Critical evaluation and predictive value of clinical presentation in out-patients with acute community-acquired pneumonia

Diagnostic probability of community-acquired pneumonia (CAP) depends on data related to age and clinical and radiological findings. The critical evaluation of data in the literature leads to the following conclusions: 1) the prevalence of CAP in a given population with acute respiratory disease is 5% in outpatients and 10% in an emergency care unit. This could be as low as 2% in young people and even higher than 40% in hospitalized elderly patients; 2) the collection of clinical data is linked to the way the patient is examined and to the expertise of the clinician. The absolute lack of "vital signs" has a good negative predictive value in CAP; presence of unilateral crackles has a good positive predictive value; 3) there is a wide range of X-ray abnormalities: localized alveolar opacities; interstitial opacities, limited of diffused. The greatest radiological difficulties are encountered in old people with disorders including chronic respiratory or cardiac opacities and as a consequence of the high prevalence of bronchopneumonia episodes at this age; 4) among patients with lower respiratory tract (LRT) infections, the blood levels of leukocytes, CRP and procalcitonine are higher in CAP patients, mainly when their disease has a bacterial origin. Since you have not a threshold value reliably demonstrated in large populations with LRT infections or acute respiratory disease, presence or absence of these parameters could only be taken as a slight hint for a CAP diagnosis.     

Vertebroplasty success in a case of aggressive hemangioma

Vertebral hemangioma is a vascular tumor most oftenly asymptomatic and of casual radiological discovery. More rarely, it can be aggressive, causing neurological complications and therefore requiring a convenient and sustained therapy where vertebroplasty is of essential importance. In this context, we report a case of an aggressive vertebral angioma of L4 which was responsible for lumbocruralgy. She underwent verterbroplasty and then had a very good outcome. In this way we deal with the the different technics of vertebroplasty, their advantages compared to other therapeutic medical, and or surgical methods, as well as their complications.     

Dyspnoea and dysphagia in an adult caused by a tracheo-esophageal fistula

In a 64-year-old man who was suffering from chronic obstructive pulmonary disease, recurrent airway infections, dysphagia, and weight loss, achalasia was diagnosed on the basis of endoscopic and radiological examinations. Afterwards he underwent flexible bronchoscopy, which revealed a benign looking fistula between trachea and oesophagus. This appeared to be a congenital tracheo-oesophageal fistula. The fistula was closed surgically. Three months later breathlessness and a sputum-producing cough were the only remaining symptoms. This rare anomaly is mostly diagnosed during childhood, but can also manifest itself in adulthood. If a tracheo-oesophageal fistula is suspected, the diagnostic procedures of choice are a barium oesophagogram in a forward-sitting or supine position or endoscopy of the trachea. Treatment consists of division and closure of the fistula. The prognosis is good.     

Illness after travel not always due to exotic disease

It is extremely important to look for tropical and other exotic diseases in travellers who return with illness or become ill after travelling. Especially tropical diseases and exotic infectious diseases have to be excluded because of their possible fatal outcome. On the other hand, many travellers return with 'common' not-exotic illnesses not related to their journey. When in such cases attention is only given to exotic causes of their illness, diagnosis can be delayed which may be harmful. This was the case in 5 patients: a woman aged 44 years who suffered for months from bloody diarrhoea since her return from Brasil, due to a rectal adenocarcinoma, a 61-year-old man with diarrhoea upon returning from Egypt, who had hairy-cell leukaemia, a 17-year-old boy who developed a ketoacidotic diabetic crisis whilst on a journey in Uganda, but in whose case the first thoughts went to malaria, a 50-year-old man who suffered from throat pain since a journey through East Africa, during which he contracted a flu-like disease, and in whom Kahler's disease was diagnosed, and 69-year-old man suffering from recurrent fever and cough, in whom a radiological lesion was observed in the thorax which proved to be part of Wegener's disease.     

9例脊椎血管瘤临床诊治效果

目的探讨脊椎血管瘤的临床特点及治疗方法。方法经临床、影像学及病理检查确诊的9例脊椎血管瘤患者，其中6例无截瘫患者行“经皮椎体成形术”治疗，3例合并不完全性截瘫患者行“前路病变椎体切除减压、植骨、内固定术”治疗。结果随访1～4．5年，患者疼痛等症状基本消失，不完全性截瘫基本恢复至正常，肿瘤未见复发。结论“经皮椎体成形术”治疗无截瘫的脊椎血管瘤能凝滞病变、固化椎体、解除症状，是一种安全有效的微创治疗方法；“前路病变椎体切除减压、植骨、内固定术”治疗合并不完全性截瘫的脊椎血管瘤，病灶清除较彻底，减压充分，截瘫恢复快，疗效良好，但出血较多，有一定手术风险。     

Clinical relevance of vertebral fractures

Existing vertebral fractures are often missed because they are clinically difficult to diagnose, because recognition of the fractures on radiological images is difficult or because the clinical relevance of the diagnosis of vertebral fractures may be underestimated by the treating physician. There is every reason to focus on the diagnosis and treatment of vertebral fractures: they are strong predictors of new vertebral and nonvertebral fractures, they are associated with significant morbidity, and, particularly importantly, effective anti-osteoporotic drugs are available. In the diagnostic work-up, vertebral morphometry in combination with dual energy X-ray absorptiometry (DEXA) can be valuable. The disadvantage of the poorer image quality, particularly in the higher thoracic region, is amply compensated for by the efficiency and diagnostic convenience to the patients and reduced exposure to radiation.     

Pediatric hospitalization for pneumococcal diseases preventable by 7-valent pneumococcal conjugate vaccine in Hong Kong

In a population-based study, we use ICD-9-CM codes to estimate the hospitalization rates for pneumococcal disease among young children in Hong Kong, 2000-2005 and the preventable burden using several outcome indicators. For children aged 相似文献   

Liver changes in HIV/AIDS]

Loss of cellular immunity accompanying the progressive HIV/AIDS disease, results in altered clinical picture and outcome of traditional infections as well as severe and often lethal illness caused by facultative pathogens. Unusual infections may call the attention to the underlining HIV disease. Liver disease appears in the great majority of HIV/AIDS patients. The authors review the viral, bacterial, fungal and protozoal infections involving the liver in AIDS. Liver biopsy has a diagnostic value beside the serology and bacteriology and may give therapeutic consequences.     

Thrombosis and cancer

Venous thromboembolic disease is a serious complication in patients with cancer. Although its incidence is not well known, the association between thromboembolic disease and cancer is frequent and is in itself an emergency. Facing clinical manifestations compatible with thromboembolic disease, it is imperative to elaborate a complete clinical history in order to know which is the tumour the patient is suffering from and if there are associated risk factors (if he is the bearer of a central venous catheter, if he is receiving treatment with chemotherapy, if his cancer has undergone a surgical intervention). Subsequently, if we hold a high suspicion of venous thromboembolic disease, treatment should be started without waiting for an immediate diagnostic confirmation. Treatment in the oncology patient is similar to that in the non-oncology patient, but greater attention should be paid to the complications deriving from the treatment, such as haemorrhaging, since this can worsen the prognosis of the patient. Due to that, efforts should be directed towards a good antithrombotic prophylaxis.     

Gene therapy of chronic granulomatous disease (CGD) by gene transfer into hematopoietic stem cells

Chronic granulomatous disease (CGD) is an inherited immunodeficiency characterized by severe recurrent bacterial and fungal infections of several organs. The disease is due to the inability of phagocytic leukocytes to generate reactive oxygen species upon phagocytosis. The defect arises as a consequence of mutations of the genes encoding for the subunits of a membrane NADPH oxidase, which catalyzes the production of superoxide anion (O2-). CGD represents an ideal candidate disorder for gene therapy, since the disease has a recessive inheritance, its phenotype is exclusively expressed in phagocytic cells, and a partial correction is likely to be effective. Given the short half-life of mature phagocytes, the optimal target cell population for gene transfer is the pluripotent hematopoietic stem cell. Transduction of CD34+ hematopoietic progenitors with retroviral vectors carrying the cDNA of the defective gene results in the correction of the enzymatic defect in myeloid cells differentiated in vitro. Still, the effective development of a clinical gene therapy protocol for this disease will await a substantial improvement in our current technology for the identification and manipulation of hematopoietic stem cells, and in our understanding of their biological and molecular properties.     

Preliminary results of surgical treatment of developmental dislocation of the hip in older children

Reduction of developmental dislocation of the hip is difficult to achieve in children after walking age and particularly in older children. In fact, at this age the important retraction of the muscles around the hip associated with a marked acetabular dysplasia and elongation of the joint capsule explain the difficulty and instability of reduction and the frequency of complications. In this study we reviewed retrospectively the clinical and radiological results of 26 developmental dislocations of the hip treated by open reduction, pelvic osteotomy and femoral shortening in 21 children aged more than 5 years. Age at surgery ranged from 5 to 11 years (mean 7.5 years) with a follow-up of 1 to 8 years (mean 2 years 7 months). According to the clinical classification of MC Kay, 17 hips had a good result while 9 hips had a fair or poor result. According to the Severin classification system 18 hips had an excellent and good radiological result. Ten hips developed an avascular necrosis of the femoral head following the reduction.     

肿瘤患者鲍氏不动杆菌医院感染的临床分析

目的探讨肿瘤患者鲍氏不动杆菌医院感染的临床特点。方法收集医院2004年1月-2010年6月,诊治的83例肿瘤患者鲍氏不动杆菌医院感染的临床资料,对其临床表现、实验室检查结果、基础疾病、菌株来源及药敏结果、肿瘤治疗及抗菌药物应用、侵入性操作、疾病的转归等进行系统分析。结果 83例肿瘤患者中以中老年患者为主,58例占69.9%;合并基础疾病113例;贫血占86.0%,肺部感染占75.9%,多部位感染占15.7%;痰液分离率76.6%,检出菌株89株,以非发酵革兰阴性杆菌为主;对检出的鲍氏不动杆菌耐药率较低的药物为阿米卡星,其耐药率20.9%,亚胺培南、头孢吡肟、头孢他啶的耐药率分别为75.5%、83.5%和84.5%;鲍氏不动杆菌检查前15 d均采用了联合抗菌治疗,4种抗菌药物联合应用占47.0%,5种抗菌药物联合应用占27.7%;平均住院时间46 d,死亡45例。结论中老年晚期肿瘤患者易发生鲍氏不动杆菌的医院感染,以肺部感染为主,耐药性严重,预后差,应给予重视。     

Continued exposure to silica after diagnosis of silicosis in Brazilian gold miners

BACKGROUND: There is a paucity of studies analyzing the effect of continued silica exposure after the onset of silicosis with regard to disease progression. The present study investigates differences in clinical and radiological presentation of silicosis among former workers with a diagnosis of silicosis, and compares workers who continued to be exposed to silica with those who stopped silica exposure after having received their diagnosis. METHODS: A sample of 83 former gold miners with a median of 21 years from the first diagnoses of silicosis, had their clinical and occupational histories taken and underwent both chest radiography (International Labor Organization standards) and spirometry. Their silica exposure was assessed and an exposure index was created. The main outcome was the radiological severity of silicosis and tuberculosis (TB). The statistical analysis was done by multiple logistic regression. RESULTS: Among the 83 miners, 44 had continued exposed to silica after being diagnosed with silicosis. Continuation of silica exposure was associated with advanced radiological images of silicosis (X-ray classification in category 3, OR = 6.42, 95% CI = 1.20-34.27), presence of coalescence and/or large opacities (OR = 3.85, CI = 1.07-13.93), and TB (OR = 4.61, 95% CI = 1.14-18.71). CONCLUSIONS: Differential survival is unlikely to explain observed differences in silicosis progression. Results reinforce the recommendation that silica exposure should be halted at an early stage whenever X-ray is suggestive of the disease.     

Alendronate more effective than alfacalcidol in the prevention of osteoporosis in patients with rheumatic disease who are starting glucocorticoid therapy

OBJECTIVE: To compare the effects of alendronate and alfacalcidol in the prevention ofglucocorticoid-related osteoporosis in patients with a rheumatic disease. DESIGN: Randomised, double-blind, double-placebo clinical trial (www. clinicaltrials.gov; number: NCT00138983). METHODS: A total of 201 patients with rheumatic disease who were starting glucocorticoid treatment at a daily dose that was equivalent to at least 7.5 mg of prednisone were randomised to alendronate (10 mg) and a placebo capsule ofalfacalcidol daily (n = 100) or alfacalcidol (1 microg) and a placebo tablet ofalendronate daily (n = 101) for 18 months. Primary outcome was change in lumbar spine bone mineral density at 18 months. The main secondary outcome was the incidence of morphometrically confirmed vertebral deformities. RESULTS: Overall, 163 patients completed the study. The bone mineral density of the lumbar spine increased by 2.1% (95% CI: 1.1-3.1) in the alendronate group and decreased by 1.9% (95% CI: -3.I--0.7) in the alfacalcidol group. At 18 months the mean difference in change in bone mineral density between the two groups was 4.0% (95% CI: 2.4-5-5). Three patients in the alendronate group had a new vertebral deformity, compared with 8 patients in the alfacalcidol group, including 5 symptomatic vertebral fractures in 3 patients; the hazard ratio was 0.4 (95% CI: 0.1-1.4). CONCLUSION: Alendronate was more effective than alfacalcidol in preventing glucocorticoid-induced bone loss during this 18-month trial in patients with rheumatic diseases who were starting glucocorticoid treatment.     

Scurvy still exists in children: A case report

Background: Scurvy is one of the oldest diseases known to mankind. Although rare lately, the clinical suspicion arises in front of a precarious situation or deficient nutrition and food restriction secondary to a psychiatric condition, even in patients with non-specific complaints.We report the observation of a 6 -year- old boy, followed for autism since the age of 3 years and who was admitted for limping, hemorrhagic syndrome, arthritis and weakness. The diagnosis of child abuse was initially suspected but clinical and radiological abnormalities seen were characteristic of scurvy. Vitamin C level was undetectable. The child had an unbalanced diet.A favorable outcome was rapidly obtained following supplementation.Scurvy is rare, but it should be mentioned among children with psychiatric disorders, presenting with musculoskeletal manifestations or hemorrhagic syndrome.It is essential to prevent it by systematic dietary supplementation of vitamin C in children with eating difficulties.     

颈血管超声、多排螺旋CT在老年人椎动脉型颈椎病诊断中的作用与比较

目的探讨颈血管超声、多排螺旋CT（multiple slice CT,MSCT）在老年人椎动脉型颈椎病中的临床诊断价值。方法用彩超观察患者的椎动脉,结合多排螺旋CT和颈椎x线片进行检查分析,对椎动脉型颈椎病的其他检查方法进行文献复习、比较。结果颈血管超声检出椎动脉内膜、中膜增厚31例,粥样斑块7例,椎动脉狭窄、椎动脉闭塞各1例。螺旋CT检出椎动脉狭窄、椎动脉闭塞各1例。颈椎X线片所有患者均检出有不同程度的退行性病变。结论颈血管超声检查方便、无创,结合螺旋CT定位准确,检出率高,对老年人椎动脉型颈椎病的诊断具有较高的临床价值。     

Surgical treatment of secondary hyperparathyroidism in chronic renal failure. Report of 57 cases

AIM: The aim of this study was to report the experience of the department of general surgery (Aile III) Ibn Rochd Hospital in surgical management of hyperparathyroidism in patients with end-stage renal disease (ESRD). METHODS: Fifty seven patients (24 M, 33F) with hyperparathyroidism underwent surgical parathyroidectomy from 1998 to 2004. Surgical indication was established according to clinical or biological assessment. Fifty nine operations were performed (57 first-hand cervicotomies and resumptions in too cases). RESULTS: Histological examination of parathyroid gland specimens disclosed adenoma in 33 patients and hyperplasia in 14 patients. The follow-up was normal in 52 patients, marqued by cervical hematoma in 2 cases and death was deplored in 4 patients. The post-operative calcium level was in the normal range in 43 cases, low comparatively to the baseline in 12 cases and high in 2 cases. The PTH levelwas normal in 55 patients and high in two patients. Long-term outcome was evaluated in 36 patients mean follow-up (18 months). A good evolution was noted in all patient referring to clinical, biological and radiological investigations. CONCLUSION: That, in our context, surgical parathyroidectomy still an appropriate approach for the treatment of hyperparathyroidism in patients with end-stage renal disease.     

Incidence and clinical implication of nosocomial infections associated with implantable biomaterials - catheters, ventilator-associated pneumonia, urinary tract infections

Health care associated infections, the fourth leading cause of disease in industrialised countries, are a major health issue. One part of this condition is based on the increasing insertion and implantation of prosthetic medical devices, since presence of a foreign body significantly reduces the number of bacteria required to produce infection. The most significant hospital-acquired infections, based on frequency and potential severity, are those related to procedures e.g. surgical site infections and medical devices, including urinary tract infection in catheterized patients, pneumonia in patients intubated on a ventilator and bacteraemia related to intravascular catheter use. At least half of all cases of nosocomial infections are associated with medical devices.Modern medical and surgical practices have increasingly utilized implantable medical devices of various kinds. Such devices may be utilized only short-time or intermittently, for months, years or permanently. They improve the therapeutic outcome, save human lives and greatly enhance the quality of life of these patients. However, plastic devices are easily colonized with bacteria and fungi, able to be colonized by microorganisms at a rate of 0.5 cm per hour. A thick biofilm is formed within 24 hours on the entire surface of these plastic devices once inoculated even with a small initial number of bacteria.The aim of the present work is to review the current literature on causes, frequency and preventive measures against infections associated with intravascular devices, catheter-related urinary tract infection, ventilator-associated infection, and infections of other implantable medical devices. Raising awareness for infection associated with implanted medical devices, teaching and training skills of staff, and establishment of surveillance systems monitoring device-related infection seem to be the principal strategies used to achieve reduction and prevention of such infections. The intelligent use of suitable antiseptics in combination with medical devices may further support reduction and prevention of such infections. In addition to reducing the adverse clinical outcomes related with these infections, such reduction may substantially decrease the economic burden caused by device-related infection for health care systems.     

Enzyme replacement therapy for Gaucher disease introduced in late adulthood

Gaucher disease is the most prevalent lysosomal storage disorder caused by recessive mutation of the beta-glucocerebrosidase gene, which leads to massive lysosomal accumulation of glucocerebrosids especially in macrophages of bone marrow, liver and spleen. The most common presenting signs and symptoms are hepatosplenomegaly, bone pain, pathologic fractures, fatigue, bleeding tendency and recurrent infections. Regular enzyme replacement therapy which is available since 1992 in Hungary successfully reverses the symptoms of the disorder, including hematological abnormalities, bone infiltration and hepatosplenomegaly. Authors present here two cases diagnosed in late adulthood to emphasize the importance of early diagnosis and treatment.     

Role of moxifloxacin in the treatment of community-acquired pneumonia

INTRODUCTION: Community-acquired pneumonia is a common cause of morbidity and mortality throughout the world. Moxifloxacin, a new generation fluoroquinolone have become an attractive therapeutic alternative in the treatment of community-acquired pneumonia because of its excellent pharmacokinetic parameters and wide antimicrobial spectrum. AIMS: The authors reviewed the role of moxifloxacin in the treatment of community-acquired pneumonia based on their experience and the data of the literature. METHODS: The authors studied the clinical outcome of the patients treated with moxifloxacin due to community-acquired pneumonia in their hospital ward between May 1, 2002 and May 1, 2003. RESULTS: Four patients with pneumonia were treated ineffectively by moxifloxacin during a year. Serious clinical and radiological progression occurred to each patient despite moxifloxacin therapy, and two patients had to be admitted to intensive care unit. Three patients were successfully treated by 2nd or 3rd generation cephalosporin and clarithromycin, but one patient died. CONCLUSIONS: The authors call attention with these cases to the fact that in clinical trials oral moxifloxacin therapy was not more efficient either clinically or microbiologically than standard therapy in the treatment of community-acquired pneumonia. Moxifloxacin therapy is recommended to be reserved to patients allergic or not responsive to other antibiotics, and in the case of infections due to penicillin-resistant pneumococci.