ICU应用床旁超声对胸部严重多发伤患者的诊断价值

目的：探讨重症监护病房(ICU)应用床旁超声对胸部严重多发伤患者的诊断价值。方法：以2018年4月-2019年3月我院ICU 救治的120例严重多发伤患者为研究对象,由ICU医师对所有患者进行胸部床旁超声检查,在超声检查后2h内进行胸部X线检查。以CT检查或手术探查的诊断结果为金标准,观察床旁超声与X线的检查时间、诊断结果、诊断效能,对床旁超声的诊断效能进行多因素回归分析。结果：床旁超声与X线的检查时间分别为(4.1±1.5)min、(19.0±3.3)min,床旁超声的检查时间明显短于X线( ^P<0.05);120例患者经CT检查或手术探查证实了60例阳性患者,合并胸腔积液28例、肺挫伤12例、气胸10例、心包积液7例、创伤性膈疝3例;床旁超声对胸腔积液(92.86% vs 71.43%)、肺挫伤(83.33% vs 50.00%)、气胸(90.00% vs 50.00%)、心包积液(100.00% vs 14.29%)的正确诊断符合率均明显高于X线( ^P<0.05);床旁超声检查出54例阳性患者、66例阴性患者,X线检查出49例阳性患者、71例阴性患者,床旁超声的诊断结果一致性明显高于X线(P<0.05);床旁超声的敏感度(90.00% vs 76.67%)、准确度(95.00% vs 85.83%)、阴性预测值(90.91% vs 80.28%)均明显高于X线(P<0.05),假阴性率(10.00% vs 23.33%)明显低于X线(P<0.05);就诊时间>1h、多发脏器损伤、ICU医生工作年限>5年是影响床旁超声诊断效能的独立因素( ^P<0.05)。结论：结论：ICU应用床旁超声能够快速准确地评估胸部严重多发伤患者,缩短抢救时间,提高抢救时效性。     

Is routine chest radiograph necessary after chest tube removal?

Background

Obtaining a chest radiograph (CXR) after chest tube (CT) removal to rule out a pneumothorax is a universal practice. However, the yield of this CXR has not been well documented. Additionally, most iatrogenic pneumothoraces resulting from CT removal are atmospheric in origin, asymptomatic, and can be observed. Recently, we have begun to discontinue routine CXR for CT removal. We evaluated our experience with CT removal to clarify the usefulness of routine post CT removal CXR.

Methods

After IRB approval, a retrospective study was conducted on patients who had a CT placed in the past decade. Cardiac patients requiring a CT were excluded. Patient demographics, diagnosis, treatments, and outcomes were collected. Patients were divided into two groups, those with a CXR after CT removal (Group 1) and those without (Group 2). Percentages were compared with Chi square with Yates correction.

Results

462 patients were identified (group 1 = 327, group 2 = 135). Indications for CT included; empyema (n = 176), lung resection (n = 146), pneumothorax (n = 71), pleural effusion (n = 26), spinal fusion (n = 20), trauma (n = 16), and miscellaneous (n = 7). Seven patients (2.1%) in group 1 required reinsertion for pneumothorax (n = 4), empyema (n = 2), and pleural effusion (n = 1) compared to 1 patient (0.7%) in group 2 who required reinsertion for pleural effusion. This difference was not significant (P = 0.2).

Conclusions

In non-cardiac patients with a CT, tube reinsertion is uncommon and tube replacement is secondary to symptoms. Therefore, routine post CT removal CXR is not necessary. CXR in these patients should be obtained based upon clinical indications after CT removal.     

Efficacy and safety of continuous low-irradiance photodynamic therapy in the treatment of chest wall progression of breast cancer

Background

Photodynamic therapy (PDT) is a binary therapy using a drug and high-energy light source. PDT is approved for several premalignant and malignant conditions. Recent in-vitro and animal data suggest that enhanced tumor-specific cytotoxicity can be achieved with far less collateral damage to normal surrounding tissues if PDT is administered continuously at a lower dose rate for extended periods of time. Based on these promising preclinical data, we conducted a Phase I clinical trial of continuous low-irradiance photodynamic therapy (CLIPT) using 630 nm laser energy and intravenously administered porforin sodium as the photosensitizer. We determined the maximum tolerated dose (MTD) of CLIPT on skin and tumor response in subjects with cutaneous and subcutaneous metastatic nodules who had failed radiation and surgery.

Methods

Patients with cutaneous and/or subcutaneous metastatic nodules that had failed radiation and surgery were offered enrollment into the trial. The initial study design planned for sequential cohorts of six subjects to be treated at increasing laser intensity, starting at 100 J/cm² administered continuously over 24 h (10⁻² dose rate compared with standard PDT). Dose-limiting toxicity was defined as partial or full-thickness necrosis of the surrounding tumor-free, previously irradiated skin. The MTD was defined as the highest laser energy at which ≤33% of subjects experienced the dose-limiting toxicity. Subjects received intravenous porfirmer sodium 0.8 mg/kg 48 h before commencing CLIPT. Response rates and quality of life measures were assessed.

Results

Nine subjects were enrolled with chest wall progression of breast cancer following mastectomy. All had failed prior surgery and electron-beam radiation therapy. The initial two subjects were treated at 100 J/cm² and developed partial thickness skin necrosis. Dose reduction was therefore instituted, and the next cohort was treated at 50 J/cm². None of the subsequent seven subjects suffered partial or full thickness necrosis, thus establishing the MTD at 50 J/cm² over 24 h (0.5 mW irradiance). Six of the nine subjects (67%) had either a complete or partial clinical response. Of note, two subjects had significant regression of tumor nodules distant from the treatment field. Of the eight subjects whose terminal deoxynucleotidyl transferase dUTP nick end labeling assay results were available, 8 (100%) demonstrated histologic response to treatment as evidenced by either tumor apoptosis or regression. Quality of life measures were improved following treatment—particularly bleeding and pain from the tumor nodules.

Conclusions

The MTD of CLIPT was established at 50 J/cm² administered continuously over 24 h. These preliminary data suggest CLIPT may be an effective, low-morbidity therapeutic modality in the treatment of cutaneous and subcutaneous metastases of breast cancer following mastectomy. Further evaluation in a larger cohort is warranted to better assess efficacy and optimize the intervention.     

多层螺旋CT对肺撕裂伤诊断价值的研究

目的研究多层螺旋CT对肺撕裂伤(PL)的诊断价值。方法对73例PL患者的临床资料以及CT检查结果进行回顾性分析。结果 73例患者中,共累计112个病灶,病灶位置比较,差异有统计学意义(P<0.05),且肺周边区及胸膜下病灶累及一个肺叶、两个肺叶的数量多于肺中心区域(P<0.05);气液囊组的人数与其他两组相比,差异有统计学意义(P<0.01),且气液囊组的病灶数多于气囊组、血肿组(P<0.01);血肿组的病灶大小明显小于其他两组(P<0.01)。结论多层螺旋CT用于PL检查及诊断效果较佳,值得临床推广应用。     

Community-acquired pneumonia in the emergency department: an algorithm to facilitate diagnosis and guide chest CT scan indication

ObjectiveThe aim was to create and validate a community-acquired pneumonia (CAP) diagnostic algorithm to facilitate diagnosis and guide chest computed tomography (CT) scan indication in patients with CAP suspicion in Emergency Departments (ED).MethodsWe performed an analysis of CAP suspected patients enrolled in the ESCAPED study who had undergone chest CT scan and detection of respiratory pathogens through nasopharyngeal PCRs. An adjudication committee assigned the final CAP probability (reference standard). Variables associated with confirmed CAP were used to create weighted CAP diagnostic scores. We estimated the score values for which CT scans helped correctly identify CAP, therefore creating a CAP diagnosis algorithm. Algorithms were externally validated in an independent cohort of 200 patients consecutively admitted in a Swiss hospital for CAP suspicion.ResultsAmong the 319 patients included, 51% (163/319) were classified as confirmed CAP and 49% (156/319) as excluded CAP. Cough (weight = 1), chest pain (1), fever (1), positive PCR (except for rhinovirus) (1), C-reactive protein ≥50 mg/L (2) and chest X-ray parenchymal infiltrate (2) were associated with CAP. Patients with a score below 3 had a low probability of CAP (17%, 14/84), whereas those above 5 had a high probability (88%, 51/58). The algorithm (score calculation + CT scan in patients with score between 3 and 5) showed sensitivity 73% (95% CI 66–80), specificity 89% (95% CI 83–94), positive predictive value (PPV) 88% (95% CI 81–93), negative predictive value (NPV) 76% (95% CI 69–82) and area under the curve (AUC) 0.81 (95% CI 0.77–0.85). The algorithm displayed similar performance in the validation cohort (sensitivity 88% (95% CI 81–92), specificity 72% (95% CI 60–81), PPV 86% (95% CI 79–91), NPV 75% (95% CI 63–84) and AUC 0.80 (95% CI 0.73–0.87).ConclusionOur CAP diagnostic algorithm may help reduce CAP misdiagnosis and optimize the use of chest CT scan.     

成人急性粟粒性肺结核的影像诊断

目的分析32例成人急性粟粒性肺结核的X线和CT表现,提高对急性粟粒性肺结核的认识以及鉴别诊断。方法回顾分析2008～2010年收治的32例成人粟粒性肺结核患者的临床资料和影像特点。结果急性粟粒性肺结核典型影像表现为三均匀:病灶大小、密度和分布均匀。结论急性粟粒性肺结核X线和CT上有相对特征性表现,结合临床资料对该病可作出正确诊断。     

肺癌合并肺结核临床分析

目的结合实际患者对肺癌合并肺结核的临床特点进行有针对性的分析。方法对152例肺癌合并肺结核患者进行回顾性分析,并通过实际资料进行研究。结果肺癌合并肺结核患者的平均年龄在53岁左右,男性患者远多于女性患者。肺癌合并肺结核的临床表现主要是发热,咳嗽,胸闷气促等等。肺结核主要以侵润型为主,而肺癌主要以鳞癌和腺癌为主。结论中年男性是肺癌合并肺结核病症的主要人群。肺癌的临床表现、影像学表现、病理类型、临床分期和肺结核的类型无特异性。     

非梗阻性肥厚型心肌病合并阻塞性睡眠呼吸暂停综合征致顽固性胸痛一例

<正>本文报道一例表现为顽固性胸痛的非梗阻性肥厚型心肌病(hypertrophic cardiomyopathy,HCM)患者,该患者最终被诊断为同时合并阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea syndrome,OSAS),经呼吸机治疗后胸痛缓解。1临床资料患者男性,30岁。因"发现血压升高5年,反复胸闷痛3年"于2013年7月24日入院。患者5年前发现血压升高,