新发涂阳肺结核病诊断延迟分析

目的 了解新发涂阳肺结核病人诊断延迟的原因。方法 查阅6县（市）新发涂阳肺结核病人的病历，分析其延迟诊断的原因。结果 本次调查共收集诊断延迟病人108例，就诊、确诊、发现延迟的平均时间分别为4．6周、6．4周、8．7周。延迟病人首次就诊以咳嗽、咳痰、乏力为主，分别为88．9％、78．7％、37．0％。在就诊延迟者中对初始症状不重视和经济困难导致就诊延迟的分别为58．7％和34．8％。在确诊方式上，仅有10．2％的病人有痰涂片检查结果，其他均仅为X线为确诊依据。结论 病人自我保护意识较淡薄是造成就诊延迟的主要因素，而病人首次就诊症状不典型，医生重X线轻痰检的诊断方式是导致确诊延迟的主要原因。     

108例新发涂阳患者诊断延迟分析

目的：了解新发涂阳肺结核患者诊断延迟的原因，方法：查阅6县（市）新发涂阳肺结核患者的病历，分析其延迟诊断的原因，结果：调查共收集诊断延迟患者108例，就诊、确诊、发现延迟的平均时间分别为4．6周、6．4周、8．7周。延迟患者首次就诊以咳嗽，咳痰、乏力为主，分别为88．9％、78．7％、37．0％，在就诊延迟者中对初始症状不重视和经济困难导致就诊延迟的分别为58．7％和34．8％，在确诊方式上，仅有10．2％的患者有痰涂片检查结果，其他均仅以线为确诊依据。结论：患者自我保护意识较淡薄是赞赏成就诊延迟的主要因素，而中层得首次就诊断不典型，医生重X线轻痰检的诊断方式是导致确诊延迟的主要原因。     

归口管理对缩短新发涂阳肺结核诊断延迟的影响

目的　了解实施肺结核病人归口管理对涂阳肺结核病人诊断延迟的影响。方法 调查1993和 2001年肺结核病人归口管理检查和病人的卡片、病志等有关资料，分析归口管理前后诊断延迟情况。结果 归口转诊率由 48.5%，提高到 89.0%，归口到位率由 29.0%提高到 72.4%，确诊延迟率由 29.4%降到 10.6%，平均延迟天数由 22.2d降到 7.7d，就诊延迟率分别为 63.4%、68.8%和平均延迟天数分别为 48.9d、50.3d，延迟病人时间分布中 20周有一个高峰。结论 归口管理对缩短确诊延迟有明显影响，对就诊延迟无影响，加大结防宣传力度，提高群体对结防意识是缩短就诊延迟的关键。     

福建省结核病诊治延迟相关因素分析

目的　通过结核病社会评价探讨结核病诊治延迟的相关因素,为提高病人发现率提供科学依据。方法 采用定性研究和定量研究相结合的方法,对3个县肺结核病人、可疑症状者和社区居民进行调查。结果 3个县中,26.4%的病人存在就诊延迟。患者自认为病情轻(54.4%)和经济困难(33.3%)是主要原因,老年人及不知道结防机构和免费诊疗政策是主要的影响因素。59.9%的病人存在确诊延迟,病人确诊前就诊次数多是主要影响因素。96.3%的病人在确诊后1周内接受治疗。结论 减少病人就诊、确诊延迟措施:一是要加强农村结防知识宣传力度,扩大覆盖面;二是加强乡村医生结防技术培训;三是要特别关注老年人和妇女。     

南海市实施结核病控制项目效果分析

目的　评价南海市实施世界银行贷款结核病控制项目的成效。方法 因症就诊胸透筛选、痰检确诊病人,按统一化疗方案治疗,实行全程督导管理。结果 10年间共接诊可疑肺结核症状者19569人,可疑者检查率平均为0.2%,发现活动性肺结核4286例,其中涂阳2558例,涂阳病人占活动性病人59.7%,涂阳登记率从14.07/10万提高到35.66/10万;初复治涂阳比例1:0.14,初治涂阳治愈率94.3%;复治涂阳治愈率82.2%。结论 10年来结核病控制水平整体提高,是实施DOTS现代结核病控制策略的结果。     

中山市老年肺结核患病情况分析

目的　探讨中山市老年肺结核患病情况。方法 为因症就诊及转诊到我所的疑似肺结核病人进行抗酸杆菌涂片检查和X线胸片检查 ,对诊断为肺结核的病人资料进行统计分析。结果 老年肺结核所占比例为 2 4 .2 % ,涂阳比例为 79.5%。结论 需重视老年肺结核病的控制工作。     

河南省结核病控制现状分析

目的　分析河南省结核病控制现状。方法 根据全省项目报表及各县年报表分析病人的发现和治疗情况。结果 至2000年河南省DOTS策略人口覆盖率达67.7%。项目区涂阳肺结核病人新登记率、传染源发现率及新发活动性病人中涂阳百分比分别为:15.4/10万、33.5%和40.0%,分别为非项目区的1.73、1.74和1.40倍。结论 进一步提高涂阳肺结核病人的发现水平是河南省结核病控制工作的当务之急。     

江苏无锡市农村地区提高传染性肺结核病人发现水平的探讨

目的　探讨农村地区如何提高传染性肺结核病人发现率。方法 在乡镇卫生院设立结防门诊和查痰点,采取发放经费、转诊病人、加强痰检质控、督导检查等干预措施,提高涂阳病人发现率。结果 5年来共发放23.70万元结防经费。涂阳、新发涂阳登记率逐年上升,乡镇卫生院检出涂阳病人数大幅度升高,登记涂阳病人卫生院平均报告率为62.7%。结论 乡镇卫生院是农村地区结核病预防和控制工作中的一支重要力量,在提高结核病例发现水平中可发挥重要作用。     

福清市设立乡镇初筛点提高结核病人发现探讨

目的　探讨在乡镇卫生院设立初筛点提高结核病发现率。方法 将全市22个乡镇(农场)分成6个初筛点,由其中1个中心卫生院负责痰涂片、X线检查,经市(县)结防科定诊。结果 2003年6个初筛点可疑症状者就诊率1.93%,查痰率85.8%,涂阳病人占67.2%,涂阳新登记率40.6/10万,分别比2002年提高了91.1%,14.4%,60.4%,20.1%。结论 通过乡镇初筛既可提高结核病服务的可行性,又能提高涂阳病例发现。     

深圳市某看守所结核病调查结果分析

目的了解羁押人群结核病发病情况,为今后羁押人群结核病防治工作的开展提供理论依据。方法对深圳市某看守所4 228名羁押人员进行胸部X线缩影片筛查,可疑肺部阴影者全部行X线胸片复查和痰涂片3次检查。结果X线胸片异常阴影92例,其中稳定性病灶34例（37.0%）,活动性病灶50例（54.3%）（6例新发涂阳肺结核）,8例感染病灶。44例涂阴肺结核病人中,入看守所前有结核病史11例（25%）;6例新发涂阳肺结核均有症状,44例涂阴肺结核中,有症状者17例（38.6%）;活动性病灶、临床症状和最终确诊时间均大多发生在入看守所后26个月和612个月2个时间段内。结论看守所羁押人员结核病患病率显著高于社区,且症状不典型,存在延迟诊断的问题。     

A study of patient's and doctor's delay in patients with pulmonary tuberculosis discovered by visiting doctors with symptoms in particular on doctor's delay

Epidemiological trend of tuberculosis in Japan has reversed recently. The incidence of pulmonary tuberculosis (PTB) patients has increased again in Japan, and many outbreaks of PTB including nosocomial outbreaks in health-care facilities have been reported. The purpose of this study is to investigate patient's delay (interval between onset of the disease and first visit to a doctor) and doctor's delay (interval between first visit to a doctor and diagnosis as TB) in patients with PTB discovered by visiting doctors with symptoms, and especially, to investigate causes of doctor's delay in details. Of 236 PTB patients who were admitted to our hospital for treatment in 1997, 118 patients (85 males, 33 females) who were detected by their symptomatic visits were enrolled in to this study. 97 were initial treatment cases and the others were re-treatment cases. Among 34 initial treatment cases who were first seen at a general hospital and diagnosed as PTB by a close medical checkup after admission to our hospital, the 50 percentile of patient's delay was 17.0 days, and the 80 percentile was 36.4 days. The 50 percentile doctor's delay was 19.6 days, and the 80 percentile was 64.2 days. The average hospital stay was 16.2 days, the 50 percentile hospital stay was 7.8 days, and 80 percentile hospital stay was 23.5 days. On the sputum test for acid fast bacilli (AFB) performed on admission to our hospital, 26(76%) out of 34 cases were positive for tubercle bacilli, with 18 cases were positive for smear and 8 cases positive for culture. Therefore, risk of nosocomial infection was suspected. Doctor's delay had been attributed mainly to insufficient medical checkup. Among 25 initial treatment cases in whom doctor's delay as more than 4 weeks, 11 cases (44%) showed delay in chest X-ray examination and 8 cases (32%) ordered no sputum examination in spite of recognition of abnormal shadows on chest X-ray. On the sputum test for AFB on admission to our hospital, 22 (88%) out of 25 cases were positive for tubercle bacilli. Therefore, it is assumed that the delay in the adequate medical checkup was accountable for the doctor's delay. Shortening of the doctor's delay could be possible if hospitals perform the sputum examination for AFB and chest X-ray examinations properly for patients with respiratory symptoms.     

A study of case findings in pulmonary tuberculosis patients

The incidence of tuberculosis patients increased again recently and many outbreaks of pulmonary tuberculosis (PTB) patients were reported. The purpose of this study is to investigate the present situation of the delay in case finding of PTB patients. 1) Of 236 PTB patients who were admitted to our hospital for treatment in 1997, 118 patients, who were detected by their symptomatic visits, were enrolled in to this study. 50 percentile patient's delay was 21.0 days, and 50 percentile doctor's delay was 7.2 days. 50 percentile total delay was 42.0 days, which was longer than about 28 days obtained by summing up the 50 percentile patient's delay and doctor's delay. The number of cases detected within 28 days was only 39 cases (33.1%). Doctor's delay was mainly attributable to the performing the examination. Regarding the relationship between the period of total delay and sputum smear positive rate, the positive rate was less than 50% when total delay was less than 4 weeks, and came to more than 60% when the delay exceeded 4 weeks. 2) Of 236 PTB patients admitted to our hospital for treatment in 1997, 49 patients had been treated at medical institutions for other diseases. The majority of the cases were diagnosed as PTB in the routine examination, but early case findings was not made, with 9.5 weeks on an average and 50 percentile total delay was 5.5 weeks. The duration of doctor's delay in undergoing examination directly related to PTB diagnosis was accountable for doctor's delay. 3) The case finding of far-advanced cavitary PTB (bI3) patients was studied. Eighty-four patients were detected by symptomatic visits, 10 patients were detected during medical treatments of other disease, and 1 patients was detected by accident. The duration of patient's delay was 5.5 months on an average, while doctor's delay was 0.3 month on an average. The bI3 patients included many social and economical weak people. The body status on admission of bI3 patients were very severe. Twenty percentile of bI3 patients died of PTB, and 14 cases of 19 dead cases died within 1 month from admission. 4) The duration of case finding of tracheobronchial tuberculosis patients was studied. 50 percentile patient's delay was 14 days, while 50 percentile doctor's delay was 145 days. The delay in examination was considered accountable for doctor's delay, with 12 cases (57%) which were treated as bronchial asthma and 6 cases (29%) in which the sputum examination for tuberculosis bacilli was not performed after the detection of chest abnormal shadows on chest X-rays. 5) The present situation of case findings in Japan was studied. Patient's delay did not improve in recent years, while doctor's delay was improve in 2000, after Declaration of State of Emergency concerning tuberculosis. 6) As the countermeasures against patient's delay, it appears necessary to continue enlightenment on PTB, and selective detection by health examination for high risk groups is necessary. As the countermeasures against doctor's delay, it appears important to recommend to all doctors to pay attention to the patients with cough and sputum and undergo sputum examination.     

A clinical study in the collagen disease patients developed pulmonary tuberculosis during corticosteroid administration

The study subjects consisted of 14 pulmonary tuberculosis (PTB) patients with collagen disease. They are under corticosteroid treatment and the mean age is 56.4 years. The length of time from the development of collagen disease to the development of PTB averaged 4.1 years. The breakdown of collagen disease are SLE (6 patients), MCTD (3 patients), PN (2 patients), and PSS, PM, Sjogren syndrome (1 case, each). Thirteen cases were bacilli positive by the sputum examination on admission to our hospital. Chest X-ray findings on admission revealed cavitation in 3 cases and non-cavitation in 11 cases, of which 5 cases had miliary tuberculosis. Corticosteroid preparation had been administered to all of the 14 cases for more than one year. The mean dose of corticosteroid preparation administered when PTB developed was 13.9 mg (prednisolone) and it was more than 20 mg in 8 cases. The median duration from the start of the respiratory symptoms to diagnosis was 39.2 days. The delay in the discovery exceeding 1 month were seen in 9 cases. In the cases of collagen disease, when the disease course extends over a long period of time, and even when the dose of corticosteroid preparations are decreased, there is a need to be note on the risk of developing PTB. There are many non-cavitary cases with sputum smear positive. The fact suggested that an appropriate diagnosis is need so that the discovery of PTB should not be delayed.     

新发涂阳肺结核患者就诊与诊断延误对产生耐药的影响

目的了解新发涂阳肺结核患者就诊与诊断延误对产生耐药的影响,为制定耐药结核病防治策略提供科学依据。方法采取典型调查的方法。在我国东、中、西部各选1个省,每省各选择1个县作为研究现场;采用课题组编制的《新发涂阳肺结核患者诊疗过程调查表》对研究现场结核病防治机构2010年59月登记发现的329例初治涂阳肺结核患者进行面对面的问卷调查,共收回329份,有效率100．0％。对329人份痰标本进行痰培养检查,并对痰培养阳性的标本进行包括异烟肼、利福平、乙胺丁醇和链霉素4种抗结核药物的药敏试验;使用非参数检验比较耐药患者和非耐药患者的延误时间,以P〈0．05为差异有统计学意义。结果患者痰培养阳性率为88．8％（292／329）,痰培养阳性的标本中总耐药率为12．7％（37／292）,耐多药率为2．8％（8／292）。耐药患者总延误、就诊延误和诊断延误分别为37d（8～465d）、15d（0～462d）和12d（0～218d）;非耐药患者总延误、就诊延误和诊断延误分别为38d（1～597d）、16d（0～594d）和10d（0～429d）,耐药与非耐药患者在总延误、就诊延误和诊断延误水平上差异均无统计学意义（Z值分别为0．377、0．142、0．069,P值均〈0．05）。结论延误与耐药发生问没有直接的因果关系。     

对肺结核可疑者采用症状查痰法提高患者发现率

目的探讨更全面的发现肺结核病例的检查诊断程序。方法在采用通用的胸透筛查法发现肺结核患者的基础上，采用症状查痰法，对有症状且≥3周者，直接做痰结核分枝杆菌检查，并拍摄X线胸片，对按胸透筛查法和症状查痰法发现的患者进行比较；对肺结核诊断程序改进后的结核病患者的发现情况进行分析。结果采用症状查痰法发现活动性肺结核新病例900例，比胸透筛查法多发现活动性肺结核患者73例，患者发现率提高8．8％(73／827)；发现涂阳肺结核病例262例，比胸透筛查法多发现活动性肺结核患者30例，患者发现率提高12．9％(30／232)；培养阳性肺结核病例360例，比胸透筛查法多发现患者63例，患者发现率提高21．2％(63／297)。症状查痰法发现新病例的细菌学检查阳性者的比例高于胸透筛查法，胸透筛查法发现新病例中，涂片阳性者占28．1％(232／827)，痰菌培养阳性者占35．9％(297／827)；而症状查痰法发现新病例中，涂片阳性者占29．1％(262／900)，痰菌培养阳性者占40．0％(360／900)。症状查痰法多检出的活动性肺结核患者73例中，涂阳和菌阳患者的比例均很高，分别为41．1％(30／73)和86．3％(63／73)，较胸透筛查法的检出涂阳比例(28．1％)和菌阳比例(35．9％)高。结论采用症状查痰法比胸透筛查法发现的活动性肺结核患者增加，特别是菌阳肺结核患者的发现率增加21．2％，使这些患者得到及时诊断，有利于结核病传染源的控制。     

Health-seeking behaviour among adults with prolonged cough in Vietnam

Objective To assess health‐seeking behaviour among adults with prolonged cough in a population‐based, nationally representative sample in Vietnam. Methods Cross‐sectional survey conducted from September 2006 to July 2007. All inhabitants aged ≥15 years were invited for screening for cough, history of tuberculosis (TB) treatment and chest X‐ray (CXR) examination. TB suspects, defined as any survey participant with CXR abnormalities consistent with TB, or productive cough for more than 2 weeks or TB treatment either currently or in the preceding 2 years submitted sputum specimens for smear examination and culture and provided information on health‐seeking behaviour in an in‐depth interview. Results Of 94 179 persons participating in the survey, 4.6% had prolonged productive cough. Forty‐four percentage of those had sought health care and reported pharmacies (35%), commune health posts (29%), public hospitals (24%) and private physicians (10%) as first point of contact. Only 7% had undergone sputum smear examination. Of TB suspects with prolonged productive cough, 2.9% were diagnosed with TB; 10.2% of these reported smear and 21.9% reported X‐ray examination when visiting a health care facility. The average patient delay was 4.1 weeks (95% CI: 3.9–4.4) among cough suspects and 4.0 weeks (95% CI: 3.1–4.9) among TB cases. Conclusions In this Vietnamese survey, nearly half of persons with cough for more than 2 weeks had visited a health care provider. The commonest first health facility contacted was the pharmacy. Sputum smears were rarely examined, except in the provincial TB hospital. Our findings highlight the need to improve diagnostic practices by retraining health staff on the performance of sputum examination for TB suspects.     

综合医院住院肺结核诊断现状分析

目的了解分析综合医院住院活动性肺结核患者的诊断现状。方法对2002年1月1日—2006年5月31日北京大学人民医院控感科登记的以“肺结核”为主要诊断出院的患者住院病历进行调查并进行回顾性分析,不包括陈旧性肺结核及结核性胸腔积液。结果共统计分析患者74例,其中呼吸内科报告最多,共53例(71.6%),其次为胸外科,共13例(17.6%)。有典型结核中毒症状者仅31例(41.9%),红细胞沉降率明显增快患者者占54.1%,PPD试验阳性仅54.1%。查痰率64.9%,涂阳率54.2%。患者入院至确诊时间平均为13.15 d,≤14 d者48例(64.9%),>14d者26例(35.1%)。确诊方法主要为痰抗酸杆菌阳性(共26例,占35.1%)。经各种活检确诊共27例(36.7%),其中纤维支气管镜下活检诊断8例(10.9%),经开胸肺活检确诊17例(23.0%),经肺穿刺活检确诊1例(1.4%),淋巴结活检确诊1例(1.4%),除纤维支气管镜下活检阳性率88.9%外,其余方式活检阳性率均为100%。临床诊断20例(27.0%)。结论综合医院呼吸内科处于结核病防治的第一线,目前北京大学人民医院对大部分肺结核患者在住院2周之内确诊。主要诊断方法仍为痰找抗酸杆菌阳性,但相当一部分患者通过各种方式的活检确诊。今后应进一步提高痰菌检查率和阳性率。对于诊断不清的病例应及时进行纤维支气管镜检查(包括镜下活检),必要时行肺穿刺甚至开胸肺活检。     

Should chemotherapy for pulmonary tuberculosis be started after the completion of pretreatment sputum examination?

PURPOSE: Investigation on the influence of early start of chemotherapy on the results of sputum smear and culture (Ogawa medium and BACTEC MGIT960). OBJECT AND METHOD: Retrospective study for tubercle bacilli positive pulmonary tuberculosis cases in our hospital. RESULT: Starting chemotherapy before the completion of pretreatment sputum examination was found to have no adverse effect on smear positive rate and smear positive grade (246 cases), culture contamination rate on Ogawa medium and BACTEC MGIT960 (1128 sputums), culture positive rate and culture positive grade/time to confirm positive on Ogawa medium (245 cases), and culture positive rate on BACTEC MGIT960 (239 cases). Time to confirm positive on BACTEC MGIT960 was slightly, but significantly prolonged (1.16 days delay in cases with 1-3 days chemotherapy [228 cases], and 4.01 days delay in cases with 4-6 days chemotherapy [59 cases]). CONCLUSION: Unfluence of early start of chemotherapy on the results of sputum smear and culture is minor. In most of bacilli positive pulmonary tuberculosis cases chemotherapy can be started before the completion of pretreatment sputum examination.     

村医集中推荐肺结核可疑症状者检查对提高新涂阳肺结核发现率的研究

目的探讨病人主动发现的新途径,提高新涂阳肺结核发现率。方法选择2003年新涂阳登记率低于全省平均水平的30个县,由经过培训的乡村医生对肺结核可疑症状者进行摸底调查,集中组织他们到县结防科或附近的乡镇、综合医院痰检点进行免费查痰。同时,县结防科对其他非结防机构网络直报但未前来就诊的肺结核和疑似肺结核病人进行追踪调查。结果2004年11月至2005年10月,30个县共发现新涂阳肺结核病人12 091例,新涂阳登记率由项目实施前的36.21/10万,提高到49.94/10万(χ²=101.7,P<0.000 1),发现率达到86.0%。30个县共登记肺结核可疑症状者43 464例,其中村医集中推荐15 363例,占35.3%,村医推荐发现新涂阳病人3 870例,占新涂阳病人发现总数的32.0%。县结防科对传染病网络直报病人的追踪率为70.9%,追踪到位率仅33.1%。结论利用村医集中推荐肺结核可疑症状者到县结防科检查,并给予一定的激励机制,是提高病人发现的有效方法之一。     

Completeness and timeliness of treatment initiation after laboratory diagnosis of tuberculosis in Gaborone, Botswana.

SETTING: Gaborone, the capital of Botswana. OBJECTIVE: To determine the time from positive sputum smear microscopy for acid-fast bacilli (AFB) to initiation of therapy, and to identify risk factors for delays. DESIGN: Retrospective cohort study of medical records and surveillance data for patients with positive smear microscopy and newly diagnosed tuberculosis (TB) from January to May 1997. Treatment delay was defined as more than 2 weeks from the first positive sputum smear to the initiation of TB treatment. RESULTS: Of 127 patients identified, 15 (11.8%) had treatment delay, 13 (10.2%) had an incomplete workup (only one smear performed) and were not registered for TB treatment, and six (4.5%) had two or more positive smears but were not registered for TB treatment. Risk factors for treatment delay or non-registration included TB patients who had been diagnosed in a hospital outpatient setting vs. a clinic (RR 2.9, 95% CI 1.2-3.6, P = 0.02), or in a high volume vs. low volume clinic (RR 2.2, 95% CI 1.2-5.3, P = 0.01). CONCLUSION: More than a quarter of the smear-positive TB patients identified had treatment delay or no evidence of treatment initiation. Proper monitoring of laboratory sputum results and suspect TB patient registers could potentially reduce treatment delays and patient loss.