综合医院应重视肺结核患者的早期诊断和转诊

笔者曾经多次撰文，呼吁综合医院应当为搞好我国肺结核防治工作做出更大贡献，并对综合医院内肺结核的诊断和转诊进行分析。     

Factors related to health system delays in the diagnosis of pulmonary tuberculosis in Estonia.

OBJECTIVE: To estimate health system delays (HSD) in the diagnosis of pulmonary tuberculosis (PTB) and its risk factors after major social changes in Estonia, and to assess the ability of a completely reformed health care system to diagnose patients with PTB. METHODS: All newly detected symptomatic culture-positive patients with PTB aged > or = 16 years from Southern Estonia during 2002-2003 (n = 185) were interviewed. HSD was defined as the interval from a patient's first contact with a medical provider to the date of TB diagnosis. RESULTS: The factors significantly associated with HSD greater than the median (19 days) and the 75th percentile (40 days) were smear negativity, absence of cough among symptoms, absence of chest X-ray during the first visit and age > 60 years. A significantly shorter HSD was determined in non-Estonians and unemployed patients. HSD was not associated with the specialty of the doctor first contacted by the patient. CONCLUSION: This study in Southern Estonia shows that the health care system is still managing the diagnosis of PTB without significant delays, even after substantial modifications in the health care system resulting from social reform in a post-socialist country, and that family physicians can manage PTB patients successfully.     

肺结核患者生存质量测量与评价

测量并评价活动性肺结核患的生存质量。方法采用ＳＦ－３６、生存质量指数，ＫＰＳ等量表，对２２８例活动性肺结核患和２２８例正常对照进行ＱｏＬ测量与评价，并与ＱｏＬ的影响因素进行单因素分析和多因素逐步回归分析。     

Optimal number of EUS-guided fine needle passes needed to obtain a correct diagnosis

BACKGROUND: The immediate assistance of a cytologist during EUS-guided FNA is not universal. The optimal number of fine needle passes during EUS-guided FNA has not been determined in a prospective study. The aim of this study was to determine the optimal number of passes required to obtain a correct diagnosis. METHODS: Seven or more passes were made with a fine needle into a variety of lesions during EUS-guided FNA. Adequacy of the aspirate, diagnosis, and a "certainty score" were recorded after each pass and interpreted sequentially by a cytopathologist. Surgical histopathology and 1-year clinical follow-up were used as reference standards. The percentage of correctly diagnosed cases was calculated and stratified according to organ, disease group, and EUS characteristics of the lesion. RESULTS: Lesions from 95 patients were categorized into the following locations: pancreas, lymph node, and miscellaneous. The sensitivity and specificity for 7 passes from the pancreas and miscellaneous lesion groups were, respectively, 83% and 100%. The sensitivity and specificity for 5 passes from the lymph node group were, respectively, 77% and 100%. CONCLUSIONS: During EUS-guided FNA, at least 7 passes with a fine needle into pancreatic and miscellaneous lesions, and 5 passes into lymph nodes are needed to ensure a high degree of certainty for making a correct diagnosis.     

Patient and health care system delays in pulmonary tuberculosis diagnosis in a low-incidence state.

SETTING: Tuberculosis (TB) patients reported to the Maryland Department of Health and Mental Hygiene from 1 June 2000 to 30 November 2001. OBJECTIVE: To determine the extent of delayed diagnosis of TB and to assess patient and provider factors associated with delays. DESIGN: A prospective cohort study. RESULTS: Median patient, health care and total delays were 32, 26 and 89 days, respectively, for 158 patients. Non-white (relative hazard [RH] 0.62; 95% CI 0.39-0.98) and less educated (RH 0.43; 95% CI 0.26-0.72) patients had longer patient delays. English-speaking patients (RH 0.40; 95% CI 0.24-0.68) had increased health care delays, as did patients who received a diagnosis of a respiratory illness and non-TB antibiotics (RH 0.69; 95% CI 0.49-0.96) prior to a TB diagnosis. Patients first presenting to a private physician (51 days) rather than a hospital emergency room (18 days; RH 1.87; 95% CI 1.05-3.33) or public health clinic (10 days; RH 1.79; 95% CI 1.21-2.63) had longer health care delays. When a TB diagnostic tool (chest radiograph or AFB culture) was utilized, a more rapid diagnosis of TB was made. CONCLUSION: Education of the patient population about TB symptoms might reduce delays. Increased physician awareness of the current epidemiology of TB and better use of available diagnostic tools will reduce delays and may reduce TB transmission.     

Contribution of pulmonary gallium scintigraphy to the diagnosis of pulmonary tuberculosis

Radioisotope scanning of the lungs with gallium 67 was performed in 13 patients whose radiological images were suggestive of pulmonary tuberculosis. The purpose of the study was to assess the value of that method as a complement to bacteriology in active pulmonary tuberculosis. Provided the lung tissue is not totally destroyed, gallium 67 is strongly taken up by the tuberculous lesions. However, scanning cannot be regarded as a routine examination, as it is costly and delivers a non-negligible dose of radiations. All it can do is to serve as a guide for more invasive investigations.     

纤维支气管镜刷片对于辅助诊断 PPD 实验阳性患者诊断肺结核的作用分析

目的：探究芒图试验阳性患者阳性程度和患者纤维支气管镜刷片的结核分枝杆菌阳性率预测价值。方法对我院在2013年8月至2015年8月期间收治的150个芒图试验阳性患者采取纤维支气管镜刷片手术,对结核分枝杆菌分布数量展开分析,并且把芒图实验所得数据划分成弱阳性、阳性、强阳性以及水泡强阳性四个类型,分析四种类型纤维支气管镜刷片,记录结核分枝杆菌阳性率。结果150个芒图试验阳性病例中,采用纤维支气管镜刷片检测所有患者的结核分枝杆菌阳性率时发现,28个弱阳性患者中,纤维支气管镜刷片检测阳性患者1例,阳性率是3.57%;76个阳性患者中,纤维支气管镜刷片检测阳性患者3例,阳性率是3.95%;42例强阳性患者中,纤维支气管镜刷片检测阳性患者3例,阳性率为14.28%;4个水泡强阳性患者中,纤维支气管镜刷片检测阳性患者3例,阳性率为75.00%。结论芒图试验水泡强阳性患者的纤维支气管镜刷片上出现的结核分枝杆菌阳性率偏高,这样的结果对临床采用纤维支气管镜治疗肺结核病具有很高的参考作用。     

Management of pulmonary tuberculosis patients complicated with diabetes mellitus before diagnosis as pulmonary tuberculosis and feasibility of chemoprophylaxis

We studied whether diabetics who are one of the high risk groups of developing pulmonary tuberculosis had undergone chest X-ray examination periodically. The feasibility of chemoprophylaxis in diabetics was also studied by investigating whether fibrotic lesions of tuberculosis can be found on previous chest X-ray films of these patients. Of the pulmonary tuberculosis patients admitted to our hospital for treatment, 78 patients complicated with diabetes mellitus were enrolled in this study. As to the mode of detection, the majority, 63 cases, are discovered, by undergoing medical examination because of respiratory symptoms, followed by 8 patients in whom pulmonary tuberculosis was found by health examination and only 1 patient was found by the periodic observation of diabetes mellitus. Of the 57 patients receiving the original treatment for pulmonary tuberculosis preceded by the discovery of diabetes mellitus, only 15 (26%) had undergone chest X-ray examination periodically. This fact shows that physicians treating diabetes mellitus have only a little concern on tuberculosis, thus the re-training of physicians dealing with diabetics on tuberculosis is considered to be necessary. According to chest X-ray films of 21 patients who had undergone chest X-ray examination and in whom the previous films were available, there were 6 patients without any lesion of pulmonary tuberculosis, 8 patients with fibrotic lesions and 7 patients with active lesions. The 8 patients showing fibrotic lesions have developed pulmonary tuberculosis on the average 15 years after they were diagnosed with diabetes mellitus, and the fact suggests that the prevention of the development of pulmonary tuberculosis among diabetics could be possible by chemoprophylaxis.     

Symptoms in patients attending services for diagnosis of pulmonary tuberculosis in Sudan.

OBJECTIVE: To describe the variation in clinical features of individuals presenting to a health facility with chest symptoms according to their ultimate diagnosis. METHODS: Of 16735 patients (52.6% males and 47.4% females) presenting at respiratory centres in seven states in Sudan, 5338 patients were identified with respiratory tract symptoms: 2917 (54.6%) men and 2421 (45.4%) women, with a mean age of 32 years. Those who had cough for more than 3 weeks that was not responsive to a course of antibiotics were screened by microscopy of two or three sputum specimens and chest radiography. RESULTS: A total of 504 (9.44%) were smear-positive, 259 (4.85%) were smear-negative, and 166 (3.11%) had extra-pulmonary tuberculosis, of whom 59 (1.11%) had pleural involvement; the remaining 4409 suspects (82.6%) were non-tuberculous. CONCLUSION: Tuberculosis patients had a constellation of presenting symptoms, with the principal symptom being cough for more than 3 weeks. The accompanying symptoms with greatest predicted significance were weight loss, tiredness and night sweats.     

Delays in the diagnosis and treatment of hospitalized patients with smear-positive pulmonary tuberculosis

The aim of present study was to investigate whether there was any delay in the diagnosis and treatment of inpatients with smear-positive pulmonary tuberculosis followed-up in our centre. We reviewed clinical records in February 1999 and identified 134 hospitalized patients with smear-positive pulmonary tuberculosis. Clinical files of the patients were analysed and a questionnaire was completed. Several intervals and delays were calculated. Median application interval was 17.5 days [95% confidence interval (CI) 21.3-32.4 days], median referral interval was 3.5 days (95% CI 6.8-11.4 days), median diagnosis interval was 3 days (95% CI 3.3-4.5 days) and median initiation of treatment interval was 1 day (95% CI 1.1-1.6 days). Patients delay was present in 28.4% of cases. The referral interval was longer than 2 days in 82 patients (institutional delay). Ninety-three patients (69.4%) had delays in the diagnosis and 34 patients (25.4%) had delays in the treatment. There was a doctor's delay in 119 of 134 patients (88.8%) and clinic's delay in 98 patients (73.2%). Our results have suggested that hospitalized patients with smear-positive pulmonary tuberculosis experience several delays. These delays may result in increased risk for transmission of infection. Decrease in the risk of infection for community and medical personal may only be obtained by preventing these delays.     

肺结核继发肺真菌感染的诊治进展

肺真菌感染分原发和继发感染。肺真菌原发感染很少见,而且与宿主因素可无相关性。继发感染多继发于宿主的免疫功能受损期间,如慢性消耗性疾病、粒细胞减少、长期使用免疫抑制剂、长期使用抗生素、肿瘤放化疗等。由于免疫功能受损宿主的增加、抗生素和免疫功能抑制等的广泛应用...     

肺结核临床治愈后残留空洞的诊断再评价

目的 探讨对初治肺结核临床治愈后残留空洞的诊断再评价.方法 收集2003年1月至2007年6月上海市(复旦大学附属)公共卫生临床中心和武汉市结核病防治所对初治痰菌阳性肺结核在完成短程化疗后痰菌阴转、达到临床治愈、但x线胸片检查仍残留空洞的67例患者进行支气管肺泡灌洗(BAL)和经皮肺穿刺活检(PLB),对肺结核合并疾病的诊断进行再评价.结果 67例患者BAL证实结核杆菌阴性,经过知情同意后,其中的59例患者进行了PLB 62例次,发现肺癌2例次(鳞癌1例,腺癌1例),真菌感染5例次(曲霉菌2例、隐球菌2例、白色念珠菌1例)、结核分枝杆菌阳性5例次、细菌培养阳性3例次(铜绿假单胞菌、鲍曼不动杆菌、产酸克雷伯菌各1例次).结论 即使在肺结核诊断成立并且治疗有效,对肺结核合并疾病的诊断也应该受到高度重视,临床治愈后若残留空洞,仍有必要对诊断进行评价,以免延误肺结核合并的肿瘤和感染性疾病的诊断,必要时需进行BAL或PLB明确诊断.