肝移植后肺部细菌合并真菌感染的诊治

背景：肝移植患者因常规服用免疫抑制剂,免疫力低下,极易发生肺部病原微生物感染。目的：回顾分析1例肝移植后突发肺部细菌联合真菌感染患者诊疗经过,总结相关临床治疗经验。方法：1例乙肝肝硬化失代偿期女性患者行同种异体原位肝移植后8个月余突发畏寒高热入院,经实验室检查结合胸部CT检测考虑为细菌引起的肺部感染,给予头孢哌酮钠舒巴坦钠抗菌治疗。结果与结论：治疗后临床症状缓解。1周后复查胸部CT提示：双肺下叶片状渗出较前有所吸收,但背段出现片状＂毛玻璃样改变＂,考虑合并真菌感染,停用头孢哌酮钠舒巴坦钠,改用氟康唑针,治疗1周后行胸部CT：双肺下叶背段渗出较前吸收,出院继续口服氟康唑10d,复查CT：双肺渗出性改变完全吸收。     

硬皮病继发特发性间质性肺炎合并肺癌1例

患者女性,68岁。诊断系统性硬皮病12年,双肺特发性间质性肺炎12年,口服甲泼尼龙片、雷公藤多甙片治疗,随访中发现左肺占位。CT提示双肺间质纤维化,左肺下叶背段见一团片影（图1）。行左肺下叶切除术。术后化疗和放疗。随访30个月,患者出现多次肺部感染,一直不定期复查胸部CT,术后24个月CT显示左上叶前段胸膜下新发斑片磨玻璃密度影,中心可见较多实性成分（图2）,     

肺隐球菌病临床误诊讨论

目的探讨肺隐球菌病的临床特点及诊治方法,以减少误诊。方法对我院近期收治的1例肺隐球菌病误诊病例的临床资料进行回顾性分析,并复习相关文献。结果患者因阵发性左侧背部疼痛,伴发热及咳嗽、咳痰1个月入院。曾于外院就诊,经肺部CT检查诊断为肺炎、肺结核不能排除,给予相应治疗病情加重转入我院。入院后行肺部CT检查示左肺多发渗出伴实变、下叶为著;隐球菌乳胶凝集试验(+),效价1∶480;纤维支气管镜肺活组织病理检查倾向隐球菌感染;免疫组织化学检查示CD68(组织细胞+),PAS(+),六胺银(+),抗酸(-);气管镜肺泡灌洗液检查找到新型隐球菌。确诊肺隐球菌病,予氟康唑及左氧氟沙星治疗3周后,复查胸部CT与入院时胸部CT比较肺部病灶明显吸收,出院。结论对临床表现为肺部多发渗出病灶、持续低热,且抗感染治疗效果不佳的患者应高度警惕肺隐球菌病,及时行病理检查、隐球菌乳胶凝集试验及肺泡灌洗液检查等,以减少误诊误治。     

异基因造血干细胞移植后侵袭性真菌肺部感染的CT表现

目的 分析异基因造血干细胞移植后肺部侵袭性真菌感染的CT表现及治疗过程中的影像学变化特点.方法 回顾性分析36例各种血液病患者接受异基因造血干细胞移植治疗后罹患侵袭性真菌肺部感染且生存期超过3个月者中发现胸部异常的多次CT影像资料.结果 首诊胸部CT主要征象:晕征,小叶中心结节,斑片状实变,磨玻璃样阴影,胸膜下楔形实变,空洞,肿块以及支气管气像.CT表现类型:以肺叶或肺段炎性实变或胸膜下楔形实变为主8例,以结节、肿块伴或不伴小空洞21例,弥漫性小叶中心结节为主或并少量结节、肿块3例,双肺磨玻璃样阴影4例.抗真菌治疗过程中多次CT复查:小结节、段或叶实变性炎症在2周～3个月均不同程度吸收,大结节、肿块多数出现空洞,其中12例共27个结节或肿块变为空洞,7例14个空洞出现毛刺,空洞与肺气囊并存3例,5例缩小的楔形实变与胸膜增厚融合,支气管扩张与炎性实变并存2例,1例为多发肺气囊,2例纵隔气肿,2例液气胸,2例5个结节复查时结节中心钙化.结论 异基因造血干细胞移植后真菌性肺部病变CT表现以散在多发结节、肿块、胸膜下实变常见.治疗后动态CT检查结节或肿块吸收慢且病灶易出现空洞,胸膜下病变出现胸膜粘连、气胸、脓胸,预后不良.     

异基因造血干细胞移植1年后发生肺烟曲霉菌病合并闭塞性细支气管炎1例

背景:异基因造血干细胞移植是多种血液系统恶性疾病和遗传性疾病的有效治疗方法,但移植后易并发全身多脏器的病变,其中尤以肺部并发症多见.肺部并发症绝大部分为感染性疾病,小部分为非感染性疾病,两者亦可并存,但当移植病患同时发生肺部感染性疾病和非感染性疾病时,如何正确诊断和治疗尤为重要.目的:报道异基因造血干细胞移植1年后发生肺侵袭性烟曲霉菌病合并闭塞性细支气管炎1例,复习相关文献探讨其预防、临床表现和恰当的治疗方法.方法:患者异基因造血干细胞移植后373 d出现发热伴咳嗽,活动后胸闷,胸部CT提示右肺上叶前段、中叶及下叶背段可见片状阴影,进一步行右肺上叶病灶穿刺活检、培养.结果与结论:肺穿刺活检病理提示肺泡扩张,肺泡上皮增生,肺间质增厚,间质细胞增生,并见少许散在的异型淋巴样细胞,肺功能中最大通气量明显下降,残气量增加,肺活量减低,基础第1秒用力呼气容积值为59.27%.肺穿刺物培养提示烟曲霉菌生长.细胞免疫组化提示为T淋巴细胞,:CD3(+)、CD45RO(+),CD20(-),CD79a(-),MPO(-),CD34血管(-).患者确诊肺侵袭性烟曲霉菌病合并闭塞性细支气管炎,经注射用醋酸卡泊芬净+注射用伏立康唑抗真菌治疗,甲基泼尼松、硫唑嘌呤、阿奇霉素治疗闭塞性细支气管炎,治疗40 d后复查胸部CT病灶完全吸收.     

注射用头孢哌酮钠舒巴坦钠诱发老年癫痫发作剖析

目的探讨注射用头孢哌酮钠舒巴坦钠诱发老年癫痫发作的原因及处理方法。方法对收治的使用注射用头孢哌酮钠舒巴坦钠诱发癫痫发作的1例临床资料进行回顾性分析。结果本例为91岁男性,因间断咳嗽、咳痰12年,加重伴发热1 d入院。既往有慢性肾功能不全。诊断为慢性支气管炎急性发作、肺部感染,考虑患者高龄,有诱发呼吸衰竭的可能,遂予注射用头孢哌酮钠舒巴坦钠3 g、2/d静脉滴注。治疗第4天静脉滴注头孢哌酮钠舒巴坦钠过程中突发四肢及面部抽搐,意识丧失,双眼向左上方凝视,牙关紧闭,立即予对症治疗,后间断发作2次。综合分析病情,考虑患者癫痫发作与静脉滴注头孢哌酮钠舒巴坦钠有关,立即停用该药,改用比阿培南,余治疗同前,后癫痫未再发作。结论高龄并肾功能不全的患者要谨慎使用头孢哌酮钠舒巴坦钠,一旦出现不良反应,应立即停药并及时处理,以减少药物不良反应所带来的损害。     

头孢哌酮钠/舒巴坦钠治疗老年肺内感染临床疗效观察

目的评价头孢哌酮钠/舒巴坦钠治疗老年肺内感染的临床疗效和安全性。方法应用头孢哌酮钠/舒巴坦钠治疗46例老年人院内肺部感染,静滴,2.0 g/次,2次/d,疗程均为7~10 d。结果痊愈率63.04%,总有效率86.96%,痰菌清除率为88.9%。不良反应发生率为4.35%。结论头孢哌酮钠/舒巴坦钠抗菌谱广、疗效好、不良反应轻微,对治疗老年肺内感染是一种安全、有效的抗感染经验治疗药物。     

乙型肝炎相关性肺泡出血1例

正1 病例资料患者,男,49岁,因"夜间干咳1月余,咯血1周"于2017年3月6日收入广州中医药大学第一附属医院。患者于2017年2月出现无明显诱因夜间干咳,无痰,无发热恶寒,无胸闷胸痛,未作治疗;3月1日咳嗽加重,痰中带血,至外院就诊,胸部CT(图1a)提示右肺及左肺下叶多发斑片状模糊影,经抗感染(哌拉西林钠他唑巴坦钠)、止咳止血、控制血压、输血浆等对症处理后,患者仍持续咯血;3月4日复查CT(图1b)提示渗出灶扩大,血分析提示血红     

甲型H1N1流感肺炎的胸部CT表现及动态变化特点

目的 探讨甲型H1N1流感肺炎的胸部CT表现及动态变化. 方法 对60例甲型H1N1流感确诊患者进行胸部CT扫描(含HRCT),回顾性分析、比较病变的影像学特点及动态变化并进行半定量CT评分. 结果 甲型H1N1流感胸部CT表现及动态变化特点:①主要表现为片状肺实质渗出病灶,早期和吸收期主要CT表现为磨玻璃密度影;②两肺小叶性或节段性散在分布,以胸膜下和支气管周围多见,下叶较重;③肺组织、胸膜及纵隔受累可同时存在;④病程早期CT评分4.41且逐渐下降,渗出性病灶短期内吸收较快,后期遗留纤维化病变CT评分1.64分. 结论甲型H1N1流感肺炎的动态胸部CT表现具有一定特征性.熟悉其胸部CT表现有助于该病的诊断、鉴别诊断与疗效观察,但确诊需依靠流行病学史及实验室检查.     

结核性大叶性肺炎2例

1病例报告例1:男,35岁。发热,T 39.8℃,咳嗽,咳少量白色泡沫痰,呼吸费力,伴右胸部憋闷不适,对症治疗10 d无效入院。查体:T 40.0℃,右上中肺野叩诊稍浊,呼吸音明显减低,可闻及少量大水泡音。胸部CT示右上中叶大叶肺炎,WBC 5.87×109/L,N 0.854,ESR 65 mm/h。入院后给予红霉素、头孢哌酮舒巴坦等治疗10 d无效。复查胸部CT示病变较前扩大。多次送检痰未见致病菌,血培养阴性,进一步行纤支镜检查示干酪性坏死。给予利福平、异烟肼、吡嗪酰胺、乙胺丁醇抗痨治疗,半个月后患者体温正常,继续抗痨治疗,3个月后复查CT,阴影完全吸收。例2:男,22…     

Variation in treatment preferences and care goals among older patients with diabetes and their physicians

BACKGROUND: Older persons with diabetes are heterogeneous with respect to life expectancy and frailty, and new guidelines recommend individualizing care. OBJECTIVES: (1) To describe variation in the preferences of older patients with diabetes regarding aggressiveness of glycemic control and avoiding diabetic complications. (2) To determine correlates of patient preferences and physician treatment goals. (3) To assess whether physicians' goals were consistent with their patients' preferences. RESEARCH DESIGN: Cross-sectional surveys and chart reviews in urban academic clinics. SUBJECTS:: Four hundred seventy-three patients with diabetes age 65 or older and 64 physicians. MEASURES: Patient preferences (utilities on a scale from 0 to 1, 0 = death, 1 = perfect health) for diabetic complications and intensity of treatment, and physician target treatment goals and ratings of aggressiveness of approach. RESULTS: Eighty percent of the patients were African American, 63% were women, average age was 73.7 +/- 5.9 years and 26% expected to live 5 years or less. Patient preferences/utilities showed significant variation: blindness 0.39 (SD, 0.32), lower leg amputation 0.45 (0.34), conventional treatment 0.76 (0.27), and intensive insulin treatment 0.64 (0.32). Physicians' hemoglobin A1c goal was < or =7% in 69% of patients. Greater estimated patient life expectancy was consistently associated with higher patient utilities and was associated with physicians' willingness to use aggressive treatments. Physicians' treatment goals and approaches were associated with patients' utilities for treatment. CONCLUSIONS: Older patients vary greatly in their preferences regarding diabetic complications and treatments. Acknowledging patient preferences, along with life goals and prognostic data, may improve quality of treatment decisions.     

慢性肾脏病患者依从性的相关因素调查及干预方法

目的:探讨慢性肾脏病患者的治疗依从性及影响因素.方法:采用自制问卷量表调查120例在我院门诊随访的慢性肾脏病患者,统计学分析患者依从性,并分析影响患者依从性的因素.结果:根据统计,26.7%慢性肾脏病患者依从性良好,20.8%患者依从性一般,52.5%患者依从性较差.影响慢性肾脏病患者依从性的因素包括:患者的年龄、经济水平、文化程度、医疗付费方式、家庭的支持.根据以上影响因素,给予适当的干预措施,随访6个月,肾功能(血肌酐或尿蛋白定量)上升15%以内判定病情稳定(占88.3%),否则为病情恶化(占11.7%).结论:慢性肾脏病患者的治疗依从性较低,对其进行健康宣教是改善患者依从性的有效方法之一.     

难治性局灶性癫痫的多学科团队模式诊疗策略

目的:探讨难治性局灶性癫痫的多学科团队模式(multidisciplinary team,MDT)诊疗策略.方法:介绍1例药物难治性颞叶癫痫,头皮脑电图监测示患者双侧颞区不同步放电,常规磁共振序列扫描未见明显异常,初步评估为患者病灶位置和侧向性不明.进行MDT讨论和后续进一步术前评估,明确患者致痫灶和治疗方法.结果:患...     

Comparison between electro-acupuncture and hydrotherapy, both in combination with patient education and patient education alone, on the symptomatic treatment of osteoarthritis of the hip

OBJECTIVES: The aim of the study was to evaluate the therapeutic effect of electro-acupuncture (EA) and hydrotherapy, both in combination with patient education or with patient education alone, in the treatment of osteoarthritis in the hip. METHODS: Forty-five patients, aged 42-86 years, with radiographic changes consistent with osteoarthritis in the hip, pain related to motion, pain on load, and ache were chosen. They were randomly allocated to EA, hydrotherapy, both in combination with patient education, or patient education alone. Outcome measures were the disability rating index (DRI), global self-rating index (GSI), and visual analogue scale (VAS). Assessments were done before the intervention and immediately after the last treatment and 1, 3, and 6 months after the last treatment. RESULTS: Pain related to motion and pain on load was reduced up to 3 months after last the treatment in the hydrotherapy group and up to 6 months in the EA group. Ache during the day was significantly improved in both the EA and hydrotherapy group up to 3 months after the last treatment. Ache during the night was reduced in the hydrotherapy group up to 3 months after the last treatment and in the EA group up to 6 months after. Disability in functional activities was improved in EA and hydrotherapy groups up to 6 months after the last treatment. Quality of life was also improved in EA and hydrotherapy groups up to 3 months after the last treatment. There were no changes in the education group alone. DISCUSSION: In conclusion, EA and hydrotherapy, both in combination with patient education, induce long-lasting effects, shown by reduced pain and ache and by increased functional activity and quality of life, as demonstrated by differences in the pre- and post-treatment assessments.     

Goal setting practice in chronic low back pain. What is current practice and is it affected by beliefs and attitudes?

Introduction: Goal setting, led by the patient, is promising as an effective treatment for the management of chronic low back pain (CLBP); however, little is known about current practice. The aims of the study were to explore (1) current goal setting practice in CLBP among physiotherapists; (2) perceived barriers to goal setting in CLBP; and (3) relationship between clinician’s attitudes and beliefs and goal setting practice. Method: A cross-sectional observational survey. Results: The majority of respondents used goal setting with the main aim of facilitating self-management. The greatest number of goals were set with 50% therapist/50% patient involvement. The most common perceived barriers to goal setting related to time constraints and lack of skill and confidence. A higher biomedical score for treatment orientation of the therapist was associated with a lower patient involvement score. Conclusion: Goal setting is common practice for CLBP and is perceived as a high priority. It is more often a collaboration between therapist and patient rather than patient-led with treatment orientation of the physiotherapist a predictor of patient involvement. Education of healthcare professionals needs to include better understanding of chronic pain to orient them away from a biomedical treatment approach, as well as to enhance skills in facilitating patient involvement in goal setting.     

恶性肿瘤患儿家长心理状态分析与护理

目的:通过对恶性肿瘤患儿家长进行心理护理,增强患儿家长对恶性肿瘤治疗的信心。方法:总结我院收治2080例恶性肿瘤患儿家长存在的心理问题,针对性地对患儿家长进行心理护理。结果:700例配合医院治疗,880例抱着试一试的心理接受治疗,500例放弃治疗。结论:在不断提高小儿恶性肿瘤医疗护理水平的同时,做好患儿家长的心理护理,对患儿能接受或坚持治疗、护理起着重要作用。     

脊髓损伤致神经源性膀胱/肠道的康复评价与治疗

目的:行为管理、药物治疗及间隙性清洁导尿等,是目前脊髓损伤致神经源性膀胱和神经源性肠道的主要康复治疗措施。这些康复治疗措施应建立在对患者进行功能评定和科学管理的基础上。方法:采用康复评定Team会的形式,对具体的脊髓损伤患者的病情进行讨论,分析各项化验、检查指标,从而制定出合理的康复治疗方案,再对患者进行有针对性的康复治疗。结果:经过3个月康复治疗,患者膀胱及肠道功能恢复。结论:康复评价会是一种好办法,治疗一段时间后对患者的功能提高情况采用同期性康复评估。因此,可以对患者的处理方案进行调整。     

Chiropractic management of a patient with myasthenia gravis and vertebral subluxations.

OBJECTIVE: The chiropractic management of a patient with myasthenia gravis and vertebral subluxation is described. We discuss the pathophysiology, clinical features, and treatment of patients with these diseases. CLINICAL FEATURES: The 63-year-old male patient suffered from complaints associated with the disease myasthenia gravis along with signs of vertebral subluxation. The patient had an initial complaint of dysphagia. In addition, the patient experienced swelling of the tongue, nausea, digestive problems, weakness in the eye muscles, difficulty breathing, myopia, diplopia, and headaches. Balance and coordination problems resulted in walking difficulties. INTERVENTION AND OUTCOME: Contact specific, high-velocity, low-amplitude adjustments were applied to sites of patient subluxation. Myasthenia gravis is no longer debilitating to the patient; he is medication free and has resumed a "normal life." CONCLUSION: The clinical aspects of the disease, including the possible role of chiropractic intervention in the treatment of patients suffering from myasthenia gravis, are also discussed. This case study encourages further investigation into the holistic approach to patient management by chiropractors vis-a-vis specific adjustments of vertebral subluxation.