杭州市耐多药结核病的危险因素定性研究

目的研究杭州市耐多药结核病的危险因素。方法通过利益相关者深度访谈、二手资料收集以及案例分析收集所需信息,通过分级编码和Mindmanager 9.1.157进行分析和各因素与耐多药结核病因果关系图的构建。结果一级编码因素有:患者服药不规则和治疗方案不正确。二级编码包括药品不良反应、忘记吃药、疗程中断、心理因素、治疗方案不规范、检测信息迟滞等。三级编码因素有药品质量剂量剂型、医生技能、患者和家庭成员缺乏相关知识、督导员工作未尽职、经济困难、看病不便等数十项。部分三级编码因素还分解到四级和五级编码。编码的层级只反映各因素在因果关系图中的位置,并不代表重要程度。结论造成杭州市耐多药结核病的因素包括社会福利制度、社会歧视、工资改革、医疗体制改革、医疗和检测技术缺陷、药品质量和剂型问题等诸多方面,因此控制耐多药结核病也需要多方面共同努力。     

Multilevel factors affecting tuberculosis diagnosis and initial treatment

Objectives The study aims to assess provider adherence to national tuberculosis programme guidelines on diagnosis, initial regimens and dosages, and to examine independent effects of factors at patient, staff and hospital levels influencing adherence. Methods A review of 383 medical records of new tuberculosis (TB) patients and interviews with related staff were carried out. The study was conducted in 16 public hospitals of seven provinces of southern Thailand. The outcome variables were provider adherence to the guidelines on diagnostic procedure, initial regimen and dosage. Independent variables consisted of patient, staff and hospital factors. Multilevel logistic regression was used to identify factors associated with adherence. Results The proportions of adherence to the diagnostic procedure, initial regimen and initial dosage prescribed were 70.0%, 100.0% and 57.1%, respectively. Most of diagnosis non‐adherence was anti‐TB drugs being prescribed for smear‐negative patients without prior antibiotic trial (12.5%). The anti‐TB drug with the highest percentages of patients receiving non‐adhered dosage was ethambutol (33.6%). In contrast to single‐level analysis, which showed significant influence of up to five factors, multilevel analysis confirmed only strong effect of male patients receiving better adhered diagnosis and of non‐doctors and TB clinics providing better dosage adherence. Conclusions Adherence to TB diagnostic procedures was not good, and adherence to initial dosage, especially for ethambutol, was poor. TB clinics, the key factor of adherence, should be expanded. Female patients should be reviewed more carefully because they tend to receive poorer diagnosis adherence.     

不同来源药物治疗耐多药肺结核过程中严重不良反应发生情况分析

目的 分析耐多药肺结核患者治疗过程中药物严重不良反应发生情况,探讨不同来源（国产和进口）药物严重不良反应发生方面的差异,评价抗结核药物严重不良反应对治疗的影响。方法 2015年9-12月,由经过培训的调查人员使用统一的调查表,对7个研究地区的195例患者的病案信息进行回顾性调查。结果 研究中使用国产和进口药物患者基本情况相似,具有可比性;使用国产和进口药物患者中因不良反应引起停用相关药物率分别为16.28%和15.15%（2=0.04,P=0.84）,终止治疗率分别为8.53%和6.06%,差异无统计学意义（2=0.37,P=0.54）;两组严重不良反应发生率分别为23.26%和21.21%,差异无统计学意义（2=0.10,P=0.75）;严重不良反应发生次数前3位,使用国产药物的患者中为肝脏毒性、胃肠反应、关节痛和肌肉痛,使用进口药物的患者中为胃肠反应、精神症状、过敏反应。结论 在耐多药肺结核治疗过程中,易发生药物不良反应,但大部分患者通过调整方案仍可继续治疗。国产药物在目前使用低剂量的情况下,与高剂量进口药物安全性相近。若为保证耐多药肺结核治疗有效性,加大国产药物剂量是否会引起不良反应发生情况增加,有待进一步研究。     

全国结核病流行病学抽样调查及各省耐药监测中耐药结核病疫情资料分析

目的 对我国耐药肺结核的流行现状展开分析,为制定相关政策提供科学依据。 方法 分析1990、2000 和2010年三次全国结核病流行病学抽样调查资料(未包括香港、澳门和台湾地区,以下同)中不同药物的初始耐药率以及获得性耐药率的变化趋势,比较全国12个省耐药率及耐多药率的差异。 结果 根据目前我国1990、2000、2010年三次结核病流行病学抽样调查结果显示, 异烟肼和链霉素的初始耐药率呈现上升趋势(PPPP结论 为了遏制耐多药肺结核,需要尽快提高耐多药肺结核规范化治疗管理的覆盖率,通过规范化治疗来治愈耐多药肺结核患者,以控制耐多药肺结核的传染源从而降低疫情。在开展耐多药肺结核控制的同时,不可降低普通肺结核治疗管理的质量。     

Using nursing practice guidelines for the prevention of multidrug‐resistant tuberculosis among hospitalized adult patients in Bangladesh

Multidrug‐resistant tuberculosis (MDR‐TB) is one of the major public health concerns worldwide particularly in developing countries, including Bangladesh. Thus far, there are no well‐validated clinical guidelines for the prevention of MDR‐TB. This study aims to evaluate the improvement in nurses' practice using the newly developed Nursing Practice Guidelines for the Prevention of MDR‐TB (NPG: MDR‐TB) among hospitalized adult patients in Bangladesh. The guidelines were developed, disseminated and evaluated among 64 nurses by assessing nursing practice for the prevention of MDR‐TB during pre‐ and postimplementation of the guidelines. Significant differences between pretest and post‐test mean scores of nursing practice for the prevention of MDR‐TB in case finding and case holding were found in three levels of wards, including Level 0 (non‐TB), Level 1 (TB) and Level 2 (MDR‐TB) (P < 0.001). This indicated that the guidelines might be applicable to reduce the development of MDR‐TB in hospitals. However, this was a preliminary study with a limited time frame. Further evaluation is, therefore, needed.     

Americans' knowledge and perceived risk of tuberculosis

Tuberculosis (TB) has resurged as a major public health problem in the United States, but there is minimal information on the public's knowledge of TB. The general population must become aware of the seriousness of the reemergence of TB. Using data from the National Health Interview Survey Supplement, this study examined knowledge and perceived risk of TB of 14,727 U.S. respondents. Results demonstrated some general knowledge of TB, several misconceptions, and low concern regarding their risk of contracting TB. Only 10.2% of the respondents perceived risk for themselves. Respondents reported perceived knowledge of TB at a high level, while their actual knowledge was lower. Gender, education, income, and ethnicity were associated with knowledge and perceived risk. Older people responded correctly to questions about TB knowledge more often than younger people. Conclusions were that public health nursing efforts need to be redirected toward health education regarding TB risk and spread, complementing existing screening and therapy programs.     

莫西沙星对多重耐药肺结核患者血清降钙素原和sTREM-1水平的影响

目的探索莫西沙星对多重耐药肺结核(MDR-TB)患者血清降钙素原(PCT)和可溶性骨髓系细胞触发受体-1(sTREM-1)水平的影响。方法综合分析180例MDR-TB患者,随机等分为莫西沙星组和对照组,动态观察治疗后2个月和6个月血清PCT和sTREM-1水平改变,以及临床治愈情况。同时分析莫西沙星治疗后PCT和sTREM-1水平改变的相关性。结果治疗后6个月莫西沙星组累计显效率(85.6%)明显高于对照组(70.0%),差异有统计学意义(P0.05)。经治疗后,莫西沙星组患者血清sTREM-1和PCT水平明显下降,血清sTREM-1在治疗后2个月和6个月的水平明显低于对照组患者,差异有统计学意义(P0.05)。结论莫西沙星可以有效控制MRD-TB患者病情程度,并降低血清PCT和sTREM-1的水平。     

A targeted testing program for tuberculosis control and prevention among Baltimore city's homeless population

OBJECTIVE: To identify cases of latent tuberculosis infection (LTBI) and improve access to TB treatment among the inner-city homeless. DESIGN: This is an intervention study describing the impact of a public health program on TB prevention and control. SAMPLE: The target population for the project was residents and recent graduates of a residential addictions recovery program in a faith-based, inner-city mission. INTERVENTION: Faculty and student nurses administered purified protein derivative (PPD) tuberculin skin tests and TB symptom assessments on site to homeless Mission residents. Residents testing positive for TB infection were referred to the local city health department for follow-up. Residents placed on prophylactic therapy received intensive tracking and coaching interventions to encourage adherence to the 9-month regimen. RESULTS: Ninety-eight percent of the target population was screened for LTBI. Ninety percent of residents requiring treatment for LTBI successfully accessed treatment services. Thirty-three percent of residents completed at least 6 months of treatment. CONCLUSION: The program demonstrated a modest improvement in treatment completion among the inner-city homeless when compared with local City Health Department treatment completion rates. This program demonstrates how a faith-based organization, an academic institution, and local government can successfully partner together to meet community needs.     

Voices from the frontline: perceptions and needs of nurses involved in a nosocomial cluster of tuberculosis infection

Little is known about the psychological aspects of health care workers who contract tuberculosis (TB). This study explored the perceptions and the needs of nurses who were involved in a nosocomial cluster of TB infection in Taiwan. Using a phenomenological research design, we conducted semistructured interviews with nine participants. The data management was processed by Colaizzi's method. The result reveals that nursing staff members who occupationally contracted TB undergo two phases. From the detection of their infection to recovery, they experienced different perceptions and needs. The hospital should be mandated to accommodate nurses' varying needs accordingly. Clinical-implication-related infection control strategies, grouped into three levels of prevention, are discussed.     

2010-2012年浙江省衢州市涂阳肺结核患者结核菌株耐药状况分析

目的 分析结核分枝杆菌的耐药情况与耐药谱,为制订结核病控制对策提供依据。 方法 对2010-2012年期间在浙江省衢州市各个结核病定点医院就诊新发和复治涂阳患者进行结核杆菌培养,鉴定为结核分枝杆菌的菌株采用比例法进行6种抗结核药物[异烟肼(H)、利福平(R)、乙胺丁醇(E)、链霉素(S)、左氧氟沙星(OFX)、卡那霉素(KM)]耐药性测试。 结果 入选1169株结核分枝杆菌中,总体耐药率为22.80%,总体耐多药率为5.13%,广泛耐多药率为0.43%;单耐药谱位于前3位的是异烟肼、链霉素、氧氟沙星,多耐药谱位于前3位的是INH+SM、INH+SM+OFX、RFP +OFX;耐多药谱位于前3位的是INH+RFP+S、INH+RFP+SM+OFX和INH+RFP。 结论 耐药结核病已对衢州市结核病控制造成较大威胁,相关部门必须采取针对性的措施控制耐药结核病的流行。     

116例耐多药肺结核患者二线抗结核药物耐药情况分析

目的 分析宁波地区耐多药结核分枝杆菌对二线抗结核药物的耐药现况,为耐多药结核病的有效防控提供科学依据。方法 从宁波市疾病预防控制中心共收集116例耐多药结核分枝杆菌临床分离株,对其进行8种二线抗结核药物左氧氟沙星、氧氟沙星、莫西沙星、卡那霉素、阿米卡星、卷曲霉素、丙硫异烟胺和对氨基水杨酸的敏感性进行检测,分析不同药物耐药率及交叉耐药情况。结果 二线抗结核药物中耐药率分别为左氧氟沙星（31.0%）、氧氟沙星（29.3%）、莫西沙星（9.4%）、卡那霉素（8.6%）、阿米卡星（7.8%）、卷曲霉素（3.4%）、丙硫异烟胺（6.0%）和对氨基水杨酸（19.8%）。初治患者对卷曲霉素的耐药率显著高于复治患者（2=4.925, P0.05）,此外卡那霉素和阿米卡星之间,氧氟沙星和左氧氟沙星之间存在完全交叉耐药。结论 耐多药肺结核患者对二线抗结核药物耐药率较高,且存在广泛耐药结核病例,应开展二线抗结核药物敏感性检测,以便给予合理治疗。     

教育管理体系对佛山市结核病医院公众结核病防治知识的影响

目的探讨我市结核病医院内部人群对大众结核病防治知识知晓率情况,为我市有效开展结核病防控健康工作提供科学依据。方法对研究人群进行分类(医技人员、院内非医技人员、外聘公司人员、患者及家属),采用结核病防治知识调查问卷,分析比较不同人群对结核病防治知识的差异,并分析其影响因素。结果调查人群结核病防治知识的总知晓率为95.34%,其中性别与户籍类型人员对知晓率无统计学意义,不同人群类别特征中总知晓率差异有统计学意义(Z=38.74,P0.05)。结论我市结核病医院内的人群对结核病防治知识知晓率较高,但需进一步提高公众结核病防治知识的知晓率。     

健康教育提高肺结核患者遵医行为的研究

目的 了解通过结核病知识的健康教育对提高肺结核患者遵嘱行为及用药依从性的效果。方法 采用多种的健康教育方法，对80例肺结核患者在住院期间及出院后进行针对性的健康教育。结果 健康教育前后病人对结核病特定知识的知晓率有显著性差异。接受教育的病人服药依从性为100%，化疗有效率为97.5%。病人对知识的知晓率、良好的遵医行为不随出院时间的延长而降低。结论 实施健康教育，不但能显著提高肺结核患者对结核病相关知识的认知，更能提高患者对治疗的依从性，同时也提高抗结核化疗的临床疗效。     

Exploring the efficacy of a case management model using DOTS in the adherence of patients with pulmonary tuberculosis

Aim. To explore the efficacy of hospitals using case management with Directly Observed Treatment – Short course (DOTS) to monitor the adherence of patients with pulmonary tuberculosis in Taiwan. Background. Non‐adherence to anti‐tuberculosis chemotherapy is the major problem in treating patients with tuberculosis. Community‐based case management coupled with DOTS has been applied to patients with tuberculosis and has resulted in good results in some countries. Taiwan has a high incidence of tuberculosis, and although it has implemented DOTS, the expected increased efficacy has not yet been realized. Design and methods. The study used a quasi‐experimental design. Using age and gender as matching factors, 96 subjects were randomly assigned to one of three groups in 2002–2003. Experimental group I was to receive DOTS case management comprising in‐hospital education, direct daily observation in the first two months and one home visit per week. Experimental group II received traditional case management comprising in‐hospital education and one home visit per month. The control group did not receive any intervention. Results. The adherence, the rate of completion, the treatment success, sputum conversion and chest X‐ray improvement of experimental group I were significantly improved compared with experimental group II and the control group. The completion rate in experimental group I was higher than the general rate for Taiwan during the past six years and the treatment success rate met the standards of the World Health Organization. Conclusion. Hospitals using case management with DOTS can improve the adherence of tuberculosis patients and the control of tuberculosis‐epidemic situations. Relevance to clinical practice. In a rapidly changing healthcare environment, clinical nurses can make a significant contribution to healthcare delivery for tuberculosis patients. This study has provided further insight into the implementation of hospital‐to‐community level case management using DOTS by nurses.     

Institutionalised isolation: tuberculosis nursing at Westwood Sanatorium, Queensland, Australia 1919–55

From the mid nineteenth to mid twentieth century sanatoria loomed large in the popular consciousness as the space for the treatment of tuberculosis (TB). A review of the historiography of sanatoria at the beginning of this paper shows that the nursing contribution to the care of TB patients is at best ignored and at worst attracts negative comment. Added to this TB nursing was not viewed as prestigious by contemporaries, leading to problems attracting recruits. Using a case study approach based on surviving archival material, this paper sets out to provide a glimpse of the work of TB nurses in a rural sanatorium at Westwood, Queensland, Australia. For the nurses geographical isolation was compounded by professional stagnation, which created a working environment influenced by friction and discord among the staff. It reveals how despite this, nurses coped with working in hostile conditions, to make the long stay of their patients, separated from their families and familiar life style more bearable.     

初治涂阳老年肺结核患者健康教育需求调查分析

目的 了解初治涂阳老年肺结核病患者对健康教育的需求.方法 收集2008年1月～2009年5月在我院确诊的年龄60岁以上、符合结核病学首次治疗规定、痰结核菌检查阳性的肺结核患者120例,采用问卷调查法.结果 绝大部分患者对结核病的有关知识很缺乏,需要医务人员实施健康教育,单项健康教育知识需求前四位分别是:所用药物的名称、剂量及服用方法,化疗药物可能引起的不良反应及毒副作用,饮食知识指导,合理安排休息与活动;健康教育需求途径患者选择最多的是"医护人员口头宣教",占88.3%.结论 本研究结果对初治涂阳老年肺结核病患者健康教育有指导作用,护士可应用本研究成果制订一份有所侧重、适合患者自身特点的健康教育计划,采用正确的护理干预手段,提高患者对医疗护理的依从性,降低其传染性,达到治愈肺结核的目的.

Abstract：

Objective To understand the health education demand of elderly smear - positive tuberculosis patients. Methods This essay surveyed 120 patients diagnosed with tuberculosis in our hospital between May 2008 and May 2009. The conditions as follows:consistent with the provisions of the first treatment in TB study; over the age of 60 years; smear - positive tuberculosis patients. The self- designed survey questionnaire was used and analyzed. Results The vast majority of the TB patients was the lack of relevant knowledge. They needed medical staff carrying out health education and popularized knowledge of TB. The former four of the idividual health education needs were the name, dosage and using method of the drug; the adverse reactions and side effects of chemotherapy drugs; knowledge and guide of the diet and how to arrange the rest and activities reasonable. Most patients (about 88.3% ) chose the" oral medical missionary"Conclusions This survey play a guiding role in selection the health education content for elderly smear - positive tuberculosis patients. Nurses could use the results of this survey to develop a focused and appropriate ordered health education programme for patients to suit their own characteristics, use the right nursing interventions to improve health nursing for the patient compliance and reduce its infectious to cure tuberculosis.     

某三级甲等医院护士肺结核相关知识及态度的调查

目的了解临床护士肺结核相关知识及态度状况,为开展有针对性的肺结核专题培训提供参考依据。方法采用便利抽样方法选取长沙市某三级甲等综合医院400名临床护士进行肺结核问卷调查。数据采用SPSS13．0软件进行处理。结果375名护士肺结核相关知识总平均分为（18．71±3．45）分,为中等水平,其中防护措施及药物控制方面得分较低,分别为（3．88±1．25）分、（4．15±1．11）分;态度总平均分为（40．08±6．01）分,对护理肺结核患者的态度呈中等水平。肺结核知识得分的主要影响因素依次为肺结核护理经验、职称及态度（P〈0．05）;肺结核态度与知识、培训情况呈正相关（r分别为0．187,0．122;P〈0．05）。结论临床护士肺结核相关知识掌握不够全面,应加强肺结核知识的培训,改善护理肺结核患者的态度,充分发挥护士在肺结核病防治工作中的作用。