慢性阻塞性肺疾病(简称慢阻肺)是严重威胁人类健康的疾病,具有高患病率、高病死率、高致残率、高疾病负担的特点.慢阻肺质量控制(简称质控)指标的制定对慢阻肺诊疗的质量及均质化提升有着重大的意义.国际上英国、美国、澳大利亚的呼吸专科质控体系不同,并从不同侧重点制定了慢阻肺质控指标,对我国慢阻肺质控指标的修订有一定的借鉴作用.我国卫健委发布的慢阻肺质控指标注重慢阻肺检查和治疗的过程管理以及疾病预后.本文对国际主要国家及我国的慢阻肺质控指标进行解读,旨在为完善慢阻肺质控指标以及提高慢阻肺诊疗规范提供参考.

医疗质量是医疗安全的基石.医疗质量控制体系没有统一的模式.作者通过阐述医疗质量相关概念,概述国际呼吸专科医疗质量控制体系,提出中国呼吸专科医疗质量控制体系存在的问题及改进方向,以期不断健全和完善呼吸专科医疗质量控制体系.

目的 探索稳定期慢性阻塞性肺疾病(简称慢阻肺)患者的代谢表型分布.方法 收集2018年9月至2019年12月在北京医院呼吸与危重症医学科门诊就诊且年龄≥40岁的57例慢阻肺稳定期患者.收集变量:一般资料,症状评分[慢性阻塞性肺疾病评估测试(CAT)评分与改良英国医学研究委员会呼吸困难指数(mMRC)评分]、运动耐力测定(6 min步行试验)、肺功能检测、人体成分分析、静息能量消耗、代谢和营养的血液学指标、细胞因子等.结果 57例稳定期慢阻肺患者营养代谢表型分布:肥胖组3例(5.3％),恶病质组14例(24.6％),肌少症组10例(17.5％),30例(52.6％)患者为正常体型组,根据欧洲代谢表型的标准该研究的营养不良患病率42.1％.肥胖组慢阻肺患者的四肢骨骼肌质量[28.6(23.5,34.0)kg]、去脂肪组织质量[62.3(54.0,76.6)kg]、去脂肪组织质量指数[20.8(19.1,23.1)kg/m2]、骨矿物质含量[3.2(3.0,4.2)kg]、吸药后第1秒用力肺活量占预计值百分比(FEV1％)[56.8(40.0,56.8)]在4组中最高,而CAT评分[3.0(3.0,5.0)分]、mMRC评分[0(0,2.0)分]和BODE指数[1.0(1.0,2.0)分]在4组中最低(P<0.05).肌少症组慢阻肺患者的去脂肪组织质量指数[15.9(14.7,16.9)kg/m2]、静息能量消耗(REE)[1034.0(876.5,1156.8)kcal/d]和FEV1％[49.5(39.2,63.9)]在4组中最低,而CAT评分[13.0(6.5,17.5)分]、mMRC评分[2.0(1.5,2.0)分]和BODE指数[3.0(2.0,6.0)分]在4组中最高(P<0.05).恶病质前期和恶病质组的慢阻肺患者的体脂肪组织质量[12.0(8.2,18.9)kg]、四肢骨骼肌质量[19.8(18.1,23.2)kg]、去脂肪组织质量[46.1(43.4,52.4)kg]、内脏脂肪面积[56.6(41.8,89.1)cm2]在4组中最低(P<0.05).肿瘤坏死因子α在肌少症组最高[32.9(27.6,118.3)pg/mL](P<0.05).结论 慢性阻塞性肺疾病患者分布于各营养代谢表型,各表型之间人体成分测量差异明显.

Objective:To analyze the prevalence of malnutrition in stable-phase elderly patients with chronic obstructive pulmonary disease (COPD) using the Global Leadership Initiative on Malnutrition (GLIM) criteria.Methods:Using cross-sectional survey, 60 elderly patients with COPD in stable phase were investigated, with 72 elderly patients without COPD in the same age group selected as controls. Differences in basic characteristics, anthropometric indicators, hematology indicators and body composition were compared between the two groups. According to the GLIM diagnostic criteria for malnutrition, the first step is nutritional risk screening, the second step is to diagnose malnutrition, and the third step is to determine severe malnutrition. The prevalence of malnutrition and severe malnutrition were investigated.Results:The levels of total protein, albumin, creatinine, and lymphocyte percentage in the elderly stable COPD group were significantly lower than those in the control group. The nutritional risk and the prevalence of malnutrition in elderly COPD patients were significantly higher than those in the control group, and the prevalence of severe malnutrition was higher .Conclusions:Elderly stable COPD patients of different age groups have a higher nutritional risk. The onset age of malnutrition is younger than that of non-COPD patients and early intervention is required.

Nutrition has been the topic of extensive scientific research in chronic obstructive pulmonary disease. Recent study supports that incorporation of body composition into nutritional assessment may discriminate pulmonary phenotypes, and are predictors of outcome independent of lung function impairment. In 2014, a multidisciplinary Task Force was created by the European Respiratory Society to address the statement of nutritional assessment and therapy in COPD, which presents the different metabolic phenotypes of COPD and the nutritional risk profile assessment. The metabolic phenotypes mainly take the abnormal body composition into account that is useful in clinical trial design and patient counselling. According to the current guidelines we should position nutrition intervention and the excercise training as integral part of COPD management.

Objective: To analyze the therapeutic effect and safety of daptomycin on aged patients with gram positive bacterial infection. Methods: Clinical data laboratory test results of 8 cases with gram positive bacterial infection from March 2011 to March 2017 were retrospectively analyzed. Results: All of the 8 patients were male, median age at 90 years (89~100 years), including 6 cases of CRBSI, 1 case of cSSTI and 1 case of UTI. There were 3 cases of vancomycin resistant Enterococcus faecium, 3 cases of methicillin resistant Staphylococcus epidermidis, methicillin resistant Staphylococcus haemolyticus in 1 case, 1 case of Staphylococcus capitis. Eventually, 6 patients achieved clinical cure as well as bacteriological clearance. The median time to defervescence was 3.5 days (2~5 days), and the median time of first culture negative was 3.0 days (3~7 days). Daptomycin-related adverse events included 1 case of mild skin rash and pruritus. Conclusion: Daptomycin was effective and safe in the treatment of gram positive bacterial infection.

目的 对北京地区成人呼吸道感染病毒病原体进行流行病学分析.方法 收集2014年4月至2015年3月北京医院门诊及住院的成人呼吸道急性感染患者的鼻咽拭子,应用液态芯片技术(xTAG RVP)对9种呼吸道病毒(含亚型共18种)进行检测,并分组进行统计学分析.结果 对191份样本的9种呼吸道病毒进行检测,阳性样本86例,阳性率为45.0％;病毒感染率由高到低依次为:甲型流感病毒(FluA,26.7％,51/191)、乙型流感病毒(FluB,6.8％,13/191)、肠病毒/鼻病毒(E/R,3.7％,7/191)、冠状病毒(Cor,2.6％,5/191)、呼吸道合胞病毒(RSV,2.1％,4/191)、人偏肺病毒(hMPV,2.1％,4/191)、副流感病毒(PIV,1.0％,2/191),未检出腺病毒(AdV)和人博卡病毒(HBoV);病毒感染率在门诊患者与住院患者间、男性患者与女性患者间差异无统计学意义(P＞0.05),但≤60岁组呼吸道病毒感染率显著高于＞60岁组(x2=12.264,P＜0.05).呼吸道病毒感染率各月份明显不同,以1月份感染率最高,占检出病毒总数的45.3％.结论 北京地区成人呼吸道感染病毒感染率在≤60岁组及1月份最高,病原体以FluA和FluB为主.

1病例摘要 患者,男性,60岁;主因"反复发热伴咳嗽、咳黄痰3个月"入院.患者自入院前3个月无明显诱因出现反复发热,多于下午出现,体温38℃左右,偶有38.8℃,发热时伴畏寒、食欲缺乏,间断咳嗽、咳少量黄痰.平地快走200米即感呼吸困难.否认胸闷、胸痛、咯血、盗汗、皮肤红斑、关节痛等不适.患者因发热数次就诊外院,查外周血白细胞升高,肺部影像学提示"肺炎",予利复星、头孢吡肟等药物抗感染治疗后体温能下降至正常,复查肺部影像学提示"炎症好转",停药10余天后再次出现上述症状.

1 临床资料 男性患者,45岁.因活动后气促、喘憋2个月,加重2周入院.患者2个月前出现活动后气促、喘憋,当地医院心脏超声心动图示:全心弥漫性扩大,二尖瓣大量返流,左室射血分数(EF)20％,诊断为扩张性心肌病.