中国社区获得性肺炎病情评估标准与Fine危险分层的临床对比研究

目的 验证1998年中华医学会制订的社区获得性肺炎（CAP）诊断的治疗指南中病情评估标准筛选住院患者，判断重症肺炎的能力，为全面实施诊疗指南提供依据。方法 以2001年9月－2002年3月收治住院的137例CAP患者为对象，通过回顾性研究，应用SPSS10．0统计分析软件，比较中国CAP诊疗指南中病情评估标准与Fine危险分层的相关性；比较中国CAP病情评估标准所分各组患者在住院天数，住院费用，静脉输液天数，危险因素数目，病死率等方面的差异。结果 （1）中国病情评估标准与Fine危险分层有很好的相关性（P＜0．00，相关系数为0．601）；（2）按中国CAP病情评估标准，不符合住院标准组与符合住院标准组患者在住院天数，住院费用，静脉输液天数等方面差异有显著性（P＜0．01）；符合住院标准组与重症肺炎组在危险因素数目，病死率方面差异有显著性（P＜0．01）。结论 （1）中国CAP病情评估标准能准确区分不同风险组患者；（2）Fine分层同样适用国人；（3）中国CAP诊疗指南的病情评估标准应推广实施。     

经验性抗感染治疗急诊病房社区获得性肺炎疗效评价

目的评价急诊病房经验性抗感染治疗社区获得性肺炎（CAP）的临床疗效。方法以急诊病房CAP患者为研究对象,依据低、中、高危人群前瞻性应用抗感染治疗方案（阿奇霉素或左氧氟沙星、或联合二、三、四代头孢）,评价其疗效。结果92例患者中,男63例（68．5％）／女29例（31．5％）,年龄69．1±16．7（14～99）岁,其中CAP60例（65．2％）,CAP伴胸膜炎18例（19．6％）,慢性阻塞性肺疾病急性加重（AECOPD）伴CAP8例（8．7％）,AECOPD合并CAP伴胸膜炎4例（4．4％）,支气管扩张合并CAP2例（2．2％）。所有患者中,低危人群28例（30．4％）,中危人群34例（37．0％）,高危人群30例（32．6％）。在几种治疗方案中,7d好转率（有效／显效）为60．9％（56例）、临床治愈率为38．0％（35例）,总有效率（好转＋治愈）为98．9％（91例）。14d治愈率为47．8％（44例）,21d治愈率为10．9％（10例）。结论依据低、中、高危人群单独选择阿奇霉素或左氧氟沙星、或联合二、三、四代头孢类抗菌药物,经验性抗感染治疗CAP疗效确切可靠。     

非典型病原体所致社区获得性肺炎的临床研究

目的探讨社区获得性肺炎（community-acquired pneumonia，CAP）各种病原体的构成及非典型病原体所致CAP的临床特点，以提高诊断与治疗水平。方法收集2004年2月至2006年12月在本院诊治的成人CAP病例，采用间接免疫荧光法（检测肺炎支原体IgM抗体、肺炎衣原体IgM抗体及军团菌IgG抗体）和痰液细菌分离培养检测患者的病原体。分析CAP病原体的构成。选取31例（占27．4％）由非典型病原体（肺炎支原体、肺炎衣原体）所致CAP患者为观察组，46例（占40．7％）细菌性肺炎患者为对照组，分别对两组患者的临床表现、辅助检查、治疗及转归情况进行回顾性分析。结果肺炎支原体24例（21．2％）是最常见的病原体，其后依次为肺炎链球菌14例（12．4％）、流感嗜血杆菌9例（8．0％）、肺炎衣原体7例（6．2％）、大肠埃希菌2例（1．8％）、军团菌1例（0．8％）、卡他莫拉菌1例（0．8％）。有6例患者（5．3％）为非典型病原体与细菌混合感染。观察组的临床症状以干咳（P〈0．05）、咳白黏痰（P〈0．01）、胸闷、气促（P〈0．01）多见；观察组中外周血白细胞计数正常及中性粒细胞比例正常的患者较多（P〈0．01，P〈0．05）；观察组的胸部X线片表现以斑点状或斑片状阴影为主（P〈0．05），双肺纹理增粗明显（P〈0．05），多叶浸润比例高（P〈0．05）。结论非典型病原体（肺炎支原体、肺炎衣原体、军团菌）是CAP的主要病原体。对有这类表现的CAP患者要及早检测肺炎支原体抗体、肺炎衣原体抗体、军团菌抗体以期及早明确诊断，抗生素治疗上首选大环内酯类或喹诺酮类。     

热毒宁联合盐酸左氧氟沙星治疗社区获得性肺炎59例的疗效观察

目的观察热毒宁联合抗菌药治疗社区获得性肺炎的临床疗效。方法将118例社区获得性肺炎（CAP）患昔随机分为治疗组和对照组。对照组为常规抗菌药治疗，治疗组为在常规抗菌药治疗的基础上，加用热毒宁注射液静脉点滴。疗程7～10d。结果治愈率治疗组为98．31％，对照组为79．66％。在控制主要症状、体征、白细胞恢复天数上，治疗组明显短于对照组，治疗效果治疗组优于对照组。结论热毒宁联合抗菌药治疗社区获得性肺炎，可以提高疗效。     

老年人社区获得性肺炎病原学的调查

目的探讨老年人社区获得性肺炎（CAP）发病相关的主要因素及病原学特点。方法对151例老年人CAP住院患者,总结其基础疾病及其病原学分布特点。结果老年人CAP住院患者多有基础疾病,病原学检查检出率为76．1％,致病菌以G-杆菌为主,检出率依次为肺炎克雷白杆菌、肺炎链球菌、铜绿假单胞菌、大肠埃希菌,流感嗜血杆菌、非典型致病菌等。结论老年人CAP住院患者基础疾病多、临床表现不典型、病原菌复杂,应当引起临床医生的高度重视。     

糖尿病患者住院医疗费用的影响因素分析

目的 了解近7年来我院住院糖尿病患者住院总费用的主要影响因素。方法 通过收集1997～2004年间在我院住院的糖尿病患者住院费用资料，采用多因素线性回归分析来探索糖尿病患者总住院费用的主要影响因素。结果 糖尿病患者次住院总费用中位数为4502．8元，次均日住院费用中位数为393．9元，多因素回归分析结果表明，住院天数、性别、年龄、付费方式、有无急慢性并发症、高血压、高脂血症等13个变量对糖尿病住院总费用影响具有统计学意义（P〈0．05）。结论 糖尿病各种急慢性并发症、合并症及医疗费用的付款方式均可影响糖尿病病人住院费用。     

中国城市成人社区获得性肺炎665例病原学多中心调查

目的 研究引起社区获得性肺炎（CAP）的病原体分布及患者入选前是否应用抗生素、肺炎患者预后研究组（PORT）分级等的情况，同时检测常见病原菌的耐药性。方法 入选2003年12月至2004年11月中国7个城市12个中心的665例CAP患者并进行病原体检测。病原体确定诊断的阳性判断标准为：（1）合格痰标本培养出1株或多株细菌；（2）血培养检出病原体；（3）间隔2～4周采集的2次标本的血清肺炎支原体、肺炎衣原体或嗜肺军团菌抗体滴度呈现4倍或4倍以上增高或降低。应用琼脂稀释法对常见病原菌进行最低抑菌浓度（MIC）检测。结果 在610例同时进行了细菌培养和血清学检测的患者中，肺炎支原体是最常见的病原体，阳性率为20．7％（126例），其后依次为肺炎链球菌10．3％（63例）、流感嗜血杆菌9．2％（56例）、肺炎衣原体6，6％（40例）、肺炎克雷伯杆菌6.1％（37例）、嗜肺军团菌5.1％（31例）、金黄色葡萄球菌3．8％（23例）、大肠杆菌1．6％（10例）、卡他莫拉菌1.3％（8例）、铜绿假单胞菌1．0％（6例）。在195例细菌培养阳性患者中，共有10．2％（62例）合并非典型病原体感染。69株肺炎链球菌，对青霉素、阿奇霉素和莫西沙星的不敏感率分别为20．3％、75．4％和4．3％。结论 非典型病原体尤其是肺炎支原体感染在CAP中占据重要地位；细菌合并非典型病原体的混合感染占10．2％。肺炎链球菌、流感嗜血杆菌仍为常见的致病细菌，我国致CAP肺炎链球菌对大环内酯类抗生素的耐药率高达75．0％以上，对青霉素的不敏感率为20，3％．     

综合性卒中单元对急性卒中后肺炎影响的研究

目的研究综合性卒中单元对急性卒中后继发肺炎患者的预后、住院时间及抗生素费用的影响。方法连续收集了159例急性卒中后（发病2周内）肺炎的住院患者,随机分组,接受综合性卒中单元治疗的为卒中单元组（77例）,在神经科常规病房治疗的为对照组（82例）。评价两组患者入院时和人院后21d的美国国立卫生院卒中量表（NIHSS）、改良Rankin量表（mRS）和Barthel指数（BI）的改善情况;并比较两组的营养不良、并发症发生率、病死率、平均住院天数及抗生素费用。结果①卒中单元组入院后21d NIHSS、mRS、BI的改善值明显优于对照组[-（1．06±1．27）,0．18±1．19;-（0．12±0．33）,0．03±0．36;3．1±6．0,-（0．5±2．7）。均P〈0．01]。②卒中单元组并发症、营养不良发生率分别为59．7％,32．5％,低于对照组的75．6％,48．8％,均P〈0．05。③卒中单元组住院天数明显短于对照组[（36±17）d,（55±34）d,P〈0．01],抗生素费用明显少于对照组[（2506±893）元,（3070±1455）元,P〈0．05]。结论与在神经科常规病房治疗相比,在综合性卒中单元治疗能减少急性卒中后肺炎患者的神经功能缺损及残障程度、提高日常生活能力、减少营养不良及并发症发生率、缩短住院时间及减少抗生素费用。     

社区获得性肺炎住院患者病原体构成分析

目的了解近四年来唐山地区成人社区获得性肺炎住院患者病原谱构成。方法收集在河北联合大学附属医院呼吸内科住院治疗的400例成人社区获得性肺炎患者资料,分析其病原谱构成。1400例成人CAP住院治疗患者中,病原体阳性患者为245人,病原体检出率为61．3％。细菌培养阳性。结果细菌感染患者140人,细菌检出率为35％,其中革兰氏阳性细菌占29．9％,革兰氏阴性细菌占70．1％,最常见致病菌为肺炎克雷伯杆菌（9．8％）、肺炎链球菌（6．5％）、铜绿假单胞菌（4．5％）。血清学检测非典型病原体IgM抗体阳性患者50人,检出率为（12．5％）,病毒抗体阳性患者55人,检出率（13．8％）。结论唐山地区成人CAP患者最常见的感染类型为细菌感染、其后依次非典型性病原体感染、病毒感染,其中细菌感染以革兰氏阴性细菌为主。     

江苏省张家港市肺结核患者疾病经济负担及影响因素分析

目的了解肺结核患者疾病经济负担及影响因素,为制定结核病控制策略、提高患者治疗依从性和治疗成功率提供依据。方法以江苏省张家港市为研究现场,采用整群抽样法抽取23个样本村,以2010年1月至2013年3月期间登记报告且已完成规定抗结核疗程的340例肺结核患者为研究对象,采用自行设计的问卷,调查患者的诊治经过和相关费用,描述疾病经济负担并分析影响因素。最终有274例患者参与调查,应答率80．6％（274／340）,问卷有效率100．o％。患者因病产生的经济负担包括直接费用和间接费用两部分。直接费用包括患者因病支出的医疗费（门诊费、住院费）、患者及其陪同家属支付的食宿交通费等。间接费用指患者及其家属因本次结核病造成的误工损失费。考虑费用一般呈非正态分布,故采用均数结合中位数（P25,P75）表示费用大小。组间费用比较采两样本秩和检验（Mann-Whitney U）。结果患者人均年收入19159．9元,年收入中位数（P25,P75）15000元（4530,27500）元。因病平均支出费用18793．3元,中位数（P25,P75）9965元（3200,24400元）。人均直接费用11936．9元,中位数（P25,P75）4590元（2024,14600）元,除去医疗保险支付部分,人均自付7448．0元,中位数（P25,P75）3315元（1200,8570）元。人均间接费用6856．4元,中位数（P25,P75）1575元（0,9000）元。影响患者疾病经济负担的因素包括住院治疗（未住院治疗者平均8512．9元,中位数3800元,有住院经历者平均24381．4元,中位数15500元,Z=-8．119,P〈o．001）;服用保肝药（未服用保肝药者平均9911．8元,中位数5900元,使用保肝药者平均17075．9元,中位数8150元,Z=-2．645,P=0．008）;使用二线抗结核药（未使用二线药者平均13294．5元,中位数6785元。使用二线药者平均18065．3元,中位数10325元,Z=—2．029,P=0．043）;诊断延误时间长（首诊至确诊小于14d者平均12656．5元,中位数6110元,大于14d者平均17457．7元,中位数11065元,z=-2．970,P=0．003）。结论张家港市结核病患者的疾病经济负担较重,患者负担的费用高低与住院治疗、使用保肝药和二线药物、诊断延误等有关。     

胰岛素瘤的解剖分布特点分析

目的胰岛素瘤是最常见的胰腺神经内分泌肿瘤，因其临床表现多样，导致诊断困难。影像学诊断尤其是超声内镜(EUS)在胰岛素瘤的诊断中起着重要作用，拥有较高的敏感性和特异性。本研究拟通过明确胰岛素瘤的解剖分布特点，以期有助于提高影像学的诊断准确率和降低漏诊率，尤其是在教育和培训实践中对于EUS的学习者更具有指导价值。 方法回顾性分析解放军总医院第一医学中心病案资料数据库1993年1月至2019年11月经外科手术、病理确诊为胰岛素瘤的患者的临床资料，检索方法采取搜索术后病理诊断为"胰岛素瘤"的病例，通过查阅病例的方法，提取出胰岛素瘤的大小和解剖分布等数据，进一步分析其特点。 结果共检索到确诊为胰岛素瘤的患者116例，其中，男45例、女71例，年龄13～76岁，平均年龄(44.4±14.85)岁。胰岛素瘤单发110例(94.8%)、多发6例(5.2%)。位置分布：头颈部46例(39.7%)，单发45例、多发1例；体尾部68例(58.6%)，单发65例、多发3例；全胰腺多发2例(1.7%)。病变大小特点：最大径0.4～3.4 cm，平均大小(1.53±0.58)cm。≤1 cm 29例、>1 cm而≤1.5 cm41例、>1.5 cm而≤2.0 cm28例，≤3 cm 15例，>3 cm 3例。年龄与肿瘤的大小相关，≤44岁患者肿瘤平均大小为(1.36±0.51)cm、>44岁患者肿瘤平均大小为(1.70±0.60)cm，P<0.05。头颈部的肿瘤大于体尾部的肿瘤，头颈部肿瘤平均大小(1.66±0.63)cm，体尾部(1.42±0.52)cm，P<0.05。 结论胰岛素瘤在胰腺体尾部较头颈部更好发；绝大多数单发，但可以全胰腺多发；多数小于1.5 cm，肿瘤的大小与患者年龄和肿瘤的解剖分布相关。     

Pathogenesis of carcinoma of the papilla of Vater

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7?, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20?, MUC2?). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa.     

Demonstration of the mechanism of action of biguanides

Summary Palmitic acid oxidation in rat diaphragm homogenate is depressed by biguanide concentrations that are still incapable of inhibiting oxidative phosphorylation. Glucose oxidation is not directly effected by the same biguanide concentrations: however, the inhibitory effect of palmitic acid on glucose oxidation is partly removed by biguanides. Inhibition of fatty acid oxidation, which accounts for most of the metabolic effects caused by these drugs, can be regarded as the fundamental mechanism of action of biguanides. There is some evidence suggesting that these drugs might interact with carnitine, thus preventing long-chain fatty acids from being transported across the mitochondrial membrane to the site of oxidation. Traduzione a cura degli AA.     

Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease

BACKGROUND AND AIM: Both the clinical presentation and the degree of mucosal damage in coeliac disease vary greatly. In view of conflicting information as to whether the mode of presentation correlates with the degree of villous atrophy, we reviewed a large cohort of patients with coeliac disease. PATIENTS AND METHODS: We correlated mode of presentation (classical, diarrhoea predominant or atypical/silent) with histology of duodenal biopsies and examined their trends over time. RESULTS: The cohort consisted of 499 adults, mean age 44.1 years, 68% females. The majority had silent coeliac disease (56%) and total villous atrophy (65%). There was no correlation of mode of presentation with the degree of villous atrophy (p=0.25). Sixty-eight percent of females and 58% of males had a severe villous atrophy (p=0.052). There was a significant trend over time for a greater proportion of patients presenting as atypical/silent coeliac disease and having partial villous atrophy, though the majority still had total villous atrophy. CONCLUSIONS: Among our patients the degree of villous atrophy in duodenal biopsies did not correlate with the mode of presentation, indicating that factors other than the degree of villous atrophy must account for diarrhoea in coeliac disease.     

血吸虫童虫生长发育及其机制的研究进展

血吸虫童虫是宿主免疫系统攻击的重要靶标,包括皮肤型、肺型和肝门型童虫。宿主分子对童虫生长发育具有重要作用。童虫生长发育机制包括免疫调节、信号转导、性别发育及凋亡等。肌动蛋白、组织蛋白酶、烯醇化酶和葡萄糖基转移酶等分子为血吸虫童虫生长发育的重要分子。本文对血吸虫童虫生长发育及其机制的研究进展做一综述。     

氯硝柳胺悬浮剂的毒性评价

目的评价氯硝柳胺悬浮剂的毒性，为现场大规模应用灭螺提供依据。方法按照中华人民共和国国家标准GB 15670-1995《农药登记毒理学试验方法》和鱼类毒性试验方法进行。结果经口、经皮肤的LDso雌、雄性大鼠均>5 000 mg/kg，经呼吸道的LCso雌、雄性大鼠均>5 000mg/m3，该药经口、经皮肤、经呼吸道毒性均属微毒类药物；兔眼用药后，观察期内无不良反应，对眼无刺激性；皮肤用药后对皮肤无刺激性。与氯硝柳胺原药、氯硝柳胺乙醇胺盐原药和氯硝柳胺乙醇胺盐可湿性粉剂相比，氯硝柳胺悬浮剂对鱼急性毒性最低。结论氯硝柳胺悬浮剂属微毒类药物，对鱼的毒性低于其乙醇胺盐可湿性粉剂，适合于现场应用。     

124例耐多药结核分枝杆菌基因突变特征分析

目的对临床分离的耐多药结核分枝杆菌相关基因的突变特征进行分析。方法对124例耐多药结核分枝杆菌以及50株敏感株的耐药相关基因(包括异烟肼inh A、kat G、oxyR-ahp C间隔区以及利福平rpo B)进行序列测定,分析其基因突变情况。结果异烟肼耐药inh A基因突变率为14.5%;kat G基因突变率为70.2%(87/124),主要位于315位;oxyR-ahp C间隔区突变率为15.3%;inh A、kat G两种基因同时突变率75.0%,三种基因同时突变率为89.5%。利福平rpo B基因突变的检出率高达95.2%,突变主要发生在531、526、516位点。结论我省耐多药菌异烟肼耐药相关基因最常见突变为kat G 315、inh A C-T(-15)、axyR-ahp C间隔区(-10)C-T,利福平为rpo B531、526、516。结合MDR-TB耐药相关基因的特征分析,可以建立一种快速、准确、特异的适合于我省的检测结核菌耐多药性的新方法。     

Assessment of quality of life of parents of children with juvenile chronic arthritis

The aim of the study was to assess the quality of life (QOL) and the psychological status of parents of children with juvenile chronic arthritis (JCA). The QOL, anxiety and depression of the parents of 28 children with JCA were evaluated and compared to those of the parents of 28 healthy children. Mothers of JCA children and mothers of healthy children reported similar QOL. The reported anxiety and depression levels were similar for mothers and fathers in both groups. The parents of children with pauciarticular-type JCA reported lower QOL and higher levels of anxiety and depression than the parents of children with other types, namely polyarticular and systemic JCA. These findings may be explained by the fact that the pauciarticular patients had shorter disease duration and were less frequently seen in the outpatient clinic. The QOL of mothers of children with JCA was found to be slightly impaired in the group of children with pauciarticular JCA. Future larger studies are needed to confirm these results, as the number of subjects in the three groups was rather low. Received: 26 September 2001 / Accepted: 8 February 2002     

Numerical Simulation of the Effect of Rate of Change of Glucose on Measurement Error of Continuous Glucose Monitors

Background

A 5-day in-patient study designed to assess the accuracy of the FreeStyle Navigator® Continuous Glucose Monitoring System revealed that the level of accuracy of the continuous sensor measurements was dependent on the rate of glucose change. When the absolute rate of change was less than 1 mg•dl⁻¹•min⁻¹ (75% of the time), the median absolute relative difference (ARD) was 8.5%, with 85% of all points falling within the A zone of the Clarke error grid. When the absolute rate of change was greater than 2 mg•dl⁻¹•min⁻¹ (8% of the time), the median ARD was 17.5%, with 59% of all points falling within the Clarke A zone.

Method

Numerical simulations were performed to investigate effects of the rate of change of glucose on sensor measurement error. This approach enabled physiologically relevant distributions of glucose values to be reordered to explore the effect of different glucose rate-of-change distributions on apparent sensor accuracy.

Results

The physiological lag between blood and interstitial fluid glucose levels is sufficient to account for the observed difference in sensor accuracy between periods of stable glucose and periods of rapidly changing glucose.

Conclusions

The role of physiological lag on the apparent decrease in sensor accuracy at high glucose rates of change has implications for clinical study design, regulatory review of continuous glucose sensors, and development of performance standards for this new technology. This work demonstrates the difficulty in comparing accuracy measures between different clinical studies and highlights the need for studies to include both relevant glucose distributions and relevant glucose rate-of-change distributions.     

Study of constancy of hydrogen-consuming flora of human colon

The constancy of the hydrogen consuming flora of the human colon was studied in 15 healthy subjects via two measurements obtained 18 to 36 months apart. Hydrogen disappearance rate and the major products of H₂-consuming bacteria, methane and sulfide, were measured during incubation of fecal homogenates with excess hydrogen and sulfate. In 11/15, the hydrogen consumption rate and the predominant hydrogen-consuming pathway (methanogenesis, sulfate reduction, or neither) remained constant. However, major shifts in these pathways were observed in four subjects, with two losing and two gaining the ability to produce methane. Methanogenesis was associated with the highest hydrogen consumption rate. This study demonstrates that clinically unrecognizable, major alterations of the colonic flora occur in healthy subjects. Understanding of the factors responsible for these alterations might allow for therapeutic manipulation of the colonic flora.Supported in part by the Department of Veterans Affairs and NIDDKD RO1 DK 13309-25.