肺曲霉菌病30例临床分析

目的探讨肺曲霉菌病的临床特点及诊治手段,提高本病的治愈率。方法回顾性分析2007年1月至2014年4月于济宁医学院附属医院诊断为肺曲霉菌病的30例住院患者,结合文献分析,总结其临床表现、影像学特征及诊疗方法等。结果 30例患者均合并基础疾病,包括19例侵袭性肺曲霉菌病,9例曲霉菌球,2例变态反应性支气管肺曲霉菌病,其中6例经手术切除治愈;18例经药物治疗,有13例好转,5例恶化;另有6例拒绝使用抗真菌药物自动出院,1例死亡。结论肺曲霉菌病起病隐匿,早期不易引起重视,提高对该病的认识和诊断能力并及早进行治疗是降低其病死率的关键所在。     

炎症性肠病的护理干预研究进展王晶晶

炎症性肠病(IBD)具有反复发作、病程迁延、死亡率高,并伴随有腹泻、腹痛、溃疡、皮疹和关节痛等特点,可引起患者产生不良情绪,从而影响患者的生活质量水平。临床上通过相应的护理干预可显著提升患者的护理质量及有效促进患者疾病康复,可充分了解患者的身体状态以及心理状态,显著消除患者的负性情绪,以利于患者护理配合度的提升_^[1]。     

糖尿病合并肺结核护理研究进展

全球范围内糖尿病和肺结核患病率均呈逐年上升趋势,两病发病率也呈增长的趋势,发病率以每年24%的速度递增_[1]。糖尿病是结核病的易患者,导致糖尿病合并肺结核患者是非糖尿病患者的2～５倍_[2],且痰菌阳性率、空洞率、复发率高_[3]。而活动性结核病作为感染因素又可加重糖尿病并诱发酮症酸中毒等糖尿病急性并发症_[4]。糖尿病和肺结核患两病并发的患者在临床上比较常见,而且有每年增加的趋势。两病并发时相互影响病情的进展和疗效,其中,糖尿病对肺结核的影响大于结核病对糖尿病的影响_[5]。两病病情复杂,治疗上,在两病同治、控制血糖和抗结核治疗双管齐下的基础上,同时研究观察心理护理、用药护理、饮食护理及健康教育等方面对两病并发患者的影响,从而为糖尿病合并肺结核患者的临床治疗提供帮助。     

Tako-tsubo心肌病的治疗与护理进展

Tako-tsubo心肌病又名应激性心肌病、S短暂性左心室球形性综合征,是一种原因不明,以短暂、可逆的左心室功能障碍为主的心肌病。90%见于绝经后的女性患者^[1],发病前大多数有明显的精神心理压力,如丧偶、失业、手术等^[2]。该病于1990年由日本的Sato等[3]首次报道,近些年,美国和一些欧洲国家也先后在本国发现这种疾病^[4-6],我国也相继有该病例报道。其临床表现主要为胸痛、呼吸困难、急性肺水肿甚至心源性休克;心电图提示ST段抬高、T波倒置;血清心肌酶示肌钙蛋白、肌酸激酶同工酶(CK-MB)均有不同程度的升高。因此,在临床上很容易与急性心肌梗死、急性冠脉综合症相混淆,但在进一步的检查治疗中,发现其与急性心肌梗死和急性冠脉综合症有着本质区别。目前,本病尚无有效的治疗方法,主要是支持和对症治疗。部分学者认为,对Tako-tsubo心肌病患者有益的治疗方法还包括：药物治疗(β受体阻滞剂、血管紧张素转换酶抑制剂和利尿剂的长期应用)^[7]和主动脉内球囊反搏术(IABP)^[8]。现将目前Tako-tsubo心肌病的治疗和护理措施进展综述如下。     

穴位敷贴联合呼吸操在COPD稳定期生活质量的研究现状

【】慢性阻塞性肺疾病(COPD)是一种气流受限不完全可逆、呈进行性发展,与肺部对有害气体或有害颗粒的异常炎症反应有关,居全球死亡原因的第四位,至2020年将位居世界疾病经济负担第5位_[1],对个人、家庭和社会都造成沉重的经济负担。对于稳定期COPD患者,现存的任何一种药物治疗都不能逆转患者肺功能长期下降的趋势_[2]。其已成为严重危害人民群众健康的重要慢性呼吸系统疾病,是一个重要的公共卫生问题_[3],中医学认为本病属“咳嗽”、“喘证”、“肺胀”、“痰饮”等范畴_[4]。近年来,中药穴位敷贴在缓解稳定期COPD患者呼吸困难症状、减少急性发作次数、提高生活质量与免疫力等方面有显著功效,是一项防治COPD的中医特色治疗方法。而呼吸操改善患者肺功能,提高其生活质量。为了解中药穴位敷贴联合呼吸操防治稳定期COPD的研究近况,本文主要从穴位敷贴治疗稳定期COPD理论依据、呼吸操锻炼的意义等对COPD稳定期患者生活质量及疗效的相关文献进作简要的总结和评述。     

侵袭性肺曲霉菌病病人的护理

侵袭性肺曲霉菌病（IPA）是怖曲霉菌病中最严重的类型,诊断困难,治疗棘手,除肺部病变外,尚可合并曲霉菌败血症和其他器官受累。近年来由于广谱抗菌药物、糖皮质激素和免疫抑制剂的大量应用、器官移植和肿瘤放、化疗的广泛开展及艾滋病的流行造成IPA的危险因素增加[1],糖尿病造成免疫妥协易继发多种感染,曲霉菌病也不例外,糖尿病应作为IPA的危险因素引起医师的重视[2]。     

肺血管炎合并肺曲霉菌病误诊为肺结核剖析

目的 探讨肺血管炎并肺曲霉菌病的临床表现及诊治要点,分析误诊原因并提出防范措施.方法 对我院收治的1例少见的肺血管炎合并肺曲霉菌病的临床资料进行回顾性分析.结果 患者因反复咳嗽、咳痰3个月,伴发热、胸痛20 d入院,有肺结核病史3年.就诊我院后经支气管镜检查、肺泡灌洗培养、抗中性粒细胞胞浆抗体、血清半乳聚集糖抗原检测及肺穿刺活检病理等检查,确诊为肺血管炎合并肺曲霉菌,予抗真菌、糖皮质激素及手术切除治疗后,病情好转出院.结论 肺血管炎并肺曲霉菌病临床少见,诊断较困难,易误漏诊,且曲霉菌病药物治疗效果欠佳,应尽早手术治疗.     

临床护士在工作中的安全感和心理复原力的相关研究

目的 探究临床护士在工作中的安全感和心理复原力的相关性。方法 选用Connor-Davidson心理复原力量表_^[1]、安全感量表两个量表_^[2],随机选取218名本院护士被试进行问卷填写。结果 ①安全感在工龄上存在显著差异；②安全感在本地与外地区分上存在显著差异；③心理复原力在工龄上存在显著差异。总体上,工龄较高,心理复原力相对较高,顺应性、坚韧性和自主性较高；④心理复原力在本地与外地区分上存在显著差异。⑤安全感和复原力两者者之间都存在显著相关,且各维度间也都存在显著相关。其中安全感、人际安全维度、确定控制与心理复原力、顺应性、坚韧性和自主性存在正相关。结论 安全感越强的护士,心理复原力越强,越容易控制工作情绪,且安全感越强,复原力越强。     

MR引导聚焦超声治疗前列腺癌的护理

MR引导聚焦超声(MR-guided focused ultrasound,MRgFUS)又称磁共振引导高强度聚焦超声(MR-guided high intensity focused ultrasound,MRgHIFU)是利用超声束可穿过软组织后聚焦在靶点的特点,通过高温效应、机械效应、空化效应使靶区瞬间产生高温,使肿瘤组织凝固坏死,并通过MR实施监控治疗的范围、位置及靶区内温度变化,从而达到治疗目的的一种治疗方法 _^[1]。前列腺癌是泌尿系统常见肿瘤,其发病率在男性恶性肿瘤中位居第二。早期前列腺癌治疗方法一般有等待性观察、前列腺癌根治术、粒子植入等治疗方法。MRgFUS是近年来开展的一项新技术,具有无创、无放射性、治疗后恢复快及无严重并发症等优点_^[1]。     

老年患者青霉素迟发性过敏反应1例护理

青霉素G是临床应用广泛，疗效高，毒性低的窄谱抗生素，因其可致严重的速发性过敏性休克，已引起广大医护人员的高度重视。而由青霉素G引起的迟发性过敏反应，则往往易被忽视。我科于2007年9月收治1例青霉素迟发性过敏反应老年患者，经及时治疗，精心护理后治愈。现将病例及护理体会报道如下。     

Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta‐analysis

BackgroundPatients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold‐standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other β‐lactams.MethodsWe performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta‐analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses.ResultsWe included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%–0.13%; I ² = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non‐immediate index reactions (OR = 0.05; 95% CrI = 0‐0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7–21.5; I ² = 0.3%). Performance of direct DPTs in low‐risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions.ConclusionsIn patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life‐threatening index reactions or patients with positive skin tests—who were mostly not assessed in this analysis ‐, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.     

Self-reported beta-lactam intolerance: not a class effect,dangerous to patients,and rarely allergy

Introduction: About 8% of the United States population carries an unconfirmed penicillin ‘allergy’ in their medical record. Many physicians needlessly avoid other beta-lactam use in individuals with unconfirmed penicillin allergies. There is a significantly increased risk of developing serious antibiotic-resistant infections, and increased morbidity and mortality in those who report penicillin allergy.

Areas covered: Within this study, we reviewed the relevant literature on self-reported beta-lactam allergy. We discuss how the myth of serious allergy to penicillin developed and then discuss and in detail clinically significant immunologically mediated hypersensitivity reactions. Following this discussion, we delineate the risks of not using a beta-lactam when it is the drug of choice and then discuss the epidemiology of beta-lactam-associated anaphylaxis, serious cutaneous adverse reactions, and serious systemic immunologically mediated reactions. Following these topics, we further discuss the consensus current best practices to de-label patients with reported penicillin allergy.

Expert opinion: An unconfirmed allergy to penicillin offers considerable harm to patients. Many patients have low-risk allergy symptoms to penicillin who could likely tolerate the medication without having an allergic reaction. The current best practices to de-label reported penicillin allergy is the utilization of a single dose oral challenge, with 1 h of observation, in low-risk patients.     

Diagnosing and managing food allergy in children

The prevalence of food allergy in children in the UK is now around 5%. The number of children put on restricted diets by their parents because of presumed allergy is likely to be much higher. Accurate diagnosis of food allergy is essential in order to ensure that the correct foods are carefully avoided while safe foods are not excluded unnecessarily. IgE-mediated (immediate type) reactions are the result of mast cell degranulation leading to histamine release. The typical signs of lip swelling, urticaria and possible progression to respiratory compromise (anaphylaxis) are usually clearly described, occurring within minutes of exposure to the food. Non IgE-mediated (delayed type) responses tend to start 2-6 hours, occasionally longer, after exposure and cause less specific signs/symptoms, less obviously allergic in origin. Where an immediate type allergic reaction is suspected on clinical history, allergy testing should be performed to confirm the diagnosis. This could involve either skin prick testing or specific IgE blood tests. Results must be interpreted in the context of the clinical history. The mainstay of management is allergen avoidance. The child and carers also need to know how to recognise and treat any future allergic reactions. There should be a written emergency plan in place. The plan should include advice to take a fast-acting antihistamine if any accidental exposure and reactions occur. Where there is a history of anaphylactic reaction or ongoing asthma, adrenaline auto-injectors should be prescribed as these are the major risk factors for future severe reactions. Non IgE-mediated food allergy is most common in early infancy. The diagnosis of non IgE-mediated food allergy relies on a two-stage process: strict exclusion of suspected allergen(s), only one at a time; re-challenge with suspected allergen(s), one at a time, to see if symptoms recur.     

Patients with suspected allergic reactions to COVID‐19 vaccines can be safely revaccinated after diagnostic work‐up

BackgroundWhen initiating the Danish vaccination program against COVID‐19, the incidence of anaphylaxis was estimated to be 10 times higher compared to other virus‐based vaccines. In this study, we present data on patients referred with suspected allergic reactions to COVID‐19 vaccines. The main purpose of the study is to investigate the incidence and severity of the allergic reactions, and to evaluate the safety of revaccination.MethodsAll patients in the region of Southern Denmark with case histories of allergic reactions to COVID‐19 vaccines in a defined period are included in this study. Diagnostic work up consisted of a detailed case history, evaluation of Brighton level of diagnostic certainty and World Allergy Organization grade of anaphylaxis and skin prick testing‐ and basophil histamine release testing with COVID‐19 vaccines and relevant drug excipients. Patients were revaccinated at the Allergy Center when possible.ResultsSixty‐one patients are included in this study. In 199,377 doses administered, nine patients fulfilled the criteria of anaphylaxis when using the Brighton Criteria (incidence being 45 per million). Of 55 patients with reactions to the first dose, 52 patients were revaccinated without adverse reactions. We found no proven cases of immediate anaphylaxis due to COVID‐19 vaccines. By skin prick test, we diagnosed three patients with drug excipient allergy and further a patient with mastocytosis was found.ConclusionsAnaphylactic reactions to COVID‐19 vaccines are rare and the incidence is similar to what is seen with other virus‐based vaccines. Revaccination is safe in the majority of patients; however, allergological evaluation is important since some prove to have drug excipient allergy.     

Intrapulmonary Posaconazole Penetration at the Infection Site in an Immunosuppressed Murine Model of Invasive Pulmonary Aspergillosis Receiving Oral Prophylactic Regimens

Adequate penetration to the infection/colonization site is crucial to attain optimal efficacy of posaconazole against Aspergillus fumigatus diseases. We evaluated posaconazole exposure in pulmonary epithelial lining fluid (ELF) in a murine model of invasive pulmonary aspergillosis. The posaconazole exposure (area under the plasma concentration-time curve from time zero to 24 h postinfusion [AUC_0–24]) in ELF was 20% to 31% of that in plasma for total drug after the third dose, and the relationship between plasma and ELF exposure was linear (r² = 0.97, P = 0.016).     

Allergen-induced hyperreactivity is not a feature of dermal immediate allergic reactions--in contrast to reactions of airways mucosa

Allergen challenges of airway mucosa are commonly followed by an increased sensitivity to rechallenge with allergen. In the lower airways this phenomenon has been associated with the late phase of allergic airway reactions, which in turn has been suggested as a link between anaphylaxis and continuous allergic airway disease. The aim of the present investigation was to explore further the phenomenon of allergen-induced hyperreactivity and to see whether it was possible to induce such a reaction in the skin. Twenty-six patients with seasonal allergic rhinitis due to birch and/or grass pollens were studied in the pollen-free winter months. Nine of these patients had previously demonstrated an increased reactivity following allergen challenge in the nose, and nine of the patients had cutaneous allergen-induced late-phase reactions to the allergen tested. Skin-prick tests were performed with pollen allergen, histamine, and a negative control. The areas of the weal-and-flare reactions were measured 15 min after the tests were set. Any late-phase reactions were recorded 6 hr after the skin challenge. The subjects were re-tested with allergen and histamine 24 hr after the initial prick test within the area of the corresponding weal from the previous day. In contrast to previous challenges of human airway mucosa, where the same time interval was used, we found no increased responsiveness to rechallenge as compared with the initial allergen challenge. This was true, even if only the subgroups with previously demonstrated nasal allergen-induced hyperreactivity, or cutaneous late-phase reaction were evaluated.(ABSTRACT TRUNCATED AT 250 WORDS)     

A tick-acquired red meat allergy

Allergic reaction is a common clinical picture in the Emergency Department (ED). Most allergic reactions are from food or drugs. A detailed history is an integral aspect of determining the causative agent of an allergy. Galactose-alpha-1,3-galactose (alpha-gal) allergy is a tick-acquired red meat allergy that causes delayed-onset allergic reaction or anaphylaxis due to molecular mimicry. Alpha-gal allergy may not be widely known as a cause of allergic reactions. Lack of universal awareness of this phenomenon in the ED and Urgent Care setting could lead to misdiagnosis, or delayed diagnosis. Subsequently, lack of proper instruction to avoid red meat could put patients at risk for future attacks with morbidity or mortality. We report three cases of allergic reaction presumed from red meat consumption secondary to alpha-gal allergy.     

Frequency and clinical characteristics of allergic transfusion reactions in children

Allergic transfusion reactions (ATRs)are a common form of acute transfusion reaction. It was aimed to determine the clinical characteristics and frequency of ATRs in children. This study included children who were transfused with red cell concentrate (RCC), fresh-frozen plasma (FFP), platelet concentrates(PC), apheresis granulocyte, and cryoprecipitate.The patients’ sociodemographic characteristics, the blood product that caused the reaction, the type and timing of the reaction, the patient’s age at time of reaction and their diagnosis, follow-up period, and clinical data were recorded. A total of 89703 bags of blood products were transfused to 4193 children.Two hundred eleven acute transfusion-related reactions occurred in 157 (3.74%) patients.Of these, 125 reactions (59%) were allergic. ATR occurred in 125 of 89703 infusions (0.14%).The median age of patients was 9.99 years (IQR:4.67-14.38) and ATRs occurred at a median of 30 minutes into the transfusion. Eighteen (18%) of the patients also had a history of drug reaction.When the blood products that caused ATRs were examined, 43(34.5%) occurred with apheresis and single-donor PC, 37(29.6%) with FFP, 32 (25.6%) with RCC, 10(8%) with pooled PC, 2(1.6%) with cryoprecipitate, 1(0.8%) with apheresis granulocyte.Ninety-nine(79%) of the reactions were minor allergic reactions and 26(21%) were anaphylaxis.Compared to minor allergic reactions, the proportion of PCs was statistically higher in anaphylaxis(p=0.02). Patients receiving PC should be monitored more carefully during the first half hour of transfusion. In addition, approximately one-fifth of the patients who developed ATR also had a history of drug reaction. Patients with previous reactions to drugs may be more likely to have ATR.     

Incidence of allergic reactions with fresh frozen plasma or cryo‐supernatant plasma in the treatment of thrombotic thrombocytopenic purpura

Plasma replacement for thrombotic thrombocytopenic purpura (TTP) is accomplished with various plasma products. This study sought to determine the incidence of allergic reactions with FFP or CPP as replacement in therapeutic plasma exchange (TPE). Forty‐one TTP patients were identified retrospectively who received TPE replacement with either FFP (n=21) or CPP (n=20). Anti‐histamine was administered prophylactically following the initial occurrence of an allergic reaction (urticaria, respiratory distress, or anaphylaxis with hypotension). Fifty‐one allergic reactions occurred in 65.8% of patients. Urticaria comprised 49 of 51 (96%) of reactions and respiratory distress the remaining 4%. No anaphylaxis occurred. Nineteen urticarial reactions occurred in 50% of CPP recipients compared to 71% of FFP recipients (P=0.28). Anti‐histamine breakthrough occurred in 36.3% of patients who experienced a previous allergic reaction with CPP and 37.5% with FFP (P=1.0). The overall risk of allergy per unit of plasma was 1.37% (1.23 % CPP, 1.48% FFP), comparable to estimates in non‐TTP recipients. The median number of donor exposures preceding the first allergic reaction was 35 and 32, CPP and FFP, respectively (P=0.63). The mean volume of plasma transfused prior to reaction was 9,883 mL for CPP and 9,348 mL for FFP (P=0.85). Neither product was advantageous in preventing allergic complications. Because of the large volume, the number of donor exposures, and prolonged duration of therapy, allergic reactions to plasma are common (65.8%) in the treatment of TTP. J. Clin. Apheresis. 16:134–138, 2001. © 2001 Wiley‐Liss, Inc.