目的 探讨不同疗程及给药方式的糖皮质激素治疗慢性阻塞性肺病急性加重期(AECOPD)的疗效及不良反应.方法 将97例AECOPD患者随机分为标准疗程治疗组(A组)、短疗程治疗组(B组)和序贯治疗组(C组).3组第1天均接受40 mg静脉使用甲基强的松龙,而后第2～5天口服40 mg强的松.随后第6～14天,A组口服20 mg强的松,B组口服安慰剂,C组吸入布地奈德混悬液6mg(2 mg/次,3次/d).比较3组的疗效及不良反应情况.结果 3组第1、6、15天FEV1％pred及CAT评分差异均无统计学意义(均P＞0.05);C组患者口腔真菌感染高于B组(P＜0.05),A组整体并发症发生率高于B组(P＜0.05).结论 短疗程的糖皮质激素治疗能有效改善AECOPD患者的肺功能及症状评分,同时减少糖皮质激素相关不良反应的发生.

目的 比较不同严重程度慢性阻塞性肺疾病(COPD)及COPD合并慢性肺源性心脏病患者右心室功能,评价MSCT诊断COPD合并慢性肺源性心脏病的价值.方法 对53例COPD患者(轻中度组13例、重度组22例及合并慢性肺源性心脏病组18例)和36名健康志愿者(对照组)行肺功能和MSCT检查.记录肺功能和右心室功能参数.比较各组右心室功能差异,分析COPD患者肺功能与右心室功能的相关性.分别绘制右心室每搏输出量(SV)、射血分数(EF)的ROC曲线,评价MSCT在COPD合并慢性肺源性心脏病中的诊断价值.以预试验确定的右心室SV＜48 ml或EF＜40％作为诊断慢性肺源性心脏病的标准,计算诊断敏感度和特异度.结果 4组间右心室舒张末容积(EDV)、EDV/体质量指数(BMI)、SV、SV/BMI及EF差异有统计学意义(P均＜0.05),而收缩末容积(ESV)及ESV/BMI差异无统计学意义(P均＞0.05).COPD患者右心室SV/BMI、EF与第1秒用力呼气容积(FEV1) (r=0.321、0.296,P=0.019、0.031)、第1秒用力呼气容积/用力肺活量(FEV1/FVC) (r=0.305、0.280,P=0.026、0.043)及FEV1占预计值百分比(FEV1％pred;r=0.457、0.351,P=0.001、0.001)均呈正相关.分别绘制右心室EF、SV ROC曲线,AUC分别为0.973、0.930(P均＜0.001),MSCT诊断慢性肺源性心脏病的敏感度分别为77.77％、77.77％,特异度分别为98.59％、88.63％.结论 COPD患者在未达到慢性肺源性心脏病诊断标准前右心室功能已出现减退,且其肺功能与右心室功能呈正相关.MSCT能早期发现COPD患者右心室功能不全,且对于诊断慢性肺源性心脏病具有重要价值.

目的 利用快速核酸多重检测平台检测宁波地区腹泻患者艰难梭菌(CD)的感染率及致病性(毒素A、B和二元毒素AB的携带状况),探究社区获得性艰难梭菌感染(CA-CDI)的相关因素.方法 收集2016年6-12月因腹泻就诊于宁波11家社区卫生院的门诊患者680例为研究对象.通过厌氧培养法、核酸多重检测平台快速检测法检测艰难梭菌,并对分离到的菌株进行毒素基因检测和4种抗菌药物药敏检测.同时收集患者临床资料,归纳CA-CDI的相关因素.结果 共收集646份有效腹泻标本,分离获得CD共42例(6.50％);近4周接受抗感染治疗、近8周接受化疗、4周内使用抑酸药物(PPI)是CA-CDI的相关因素.本地区社区获得性CD普遍携带两种毒素基因,41株为tcdA+/tcdB+/cdtA-,仅有1株为tcdA-/tcdB+/cdtA-.同时发现1株可能引起严重肠道病变的tcdA+/tcdB+/cdtA+的高产毒株.MOKOBIO系统对菌体直接检测法其敏感性为95.24％,特异性100.00％.所有菌株对甲硝唑和万古霉素均呈高度敏感.分离菌株对克林霉素敏感率为11.90％,对红霉素敏感占45.24％;且有45.24％对克林霉素高度耐药(MIC>128 mg/L)、54.76％的菌株对红霉素呈高度耐药(MIC>128 mg/L).结论 快速核酸多重检测平台(MOKOBIO)直接检测粪便样本敏感性、特异性良好,可提高艰难梭菌感染的诊断率,方便在基层医疗单位广泛应用.

支气管肺癌(简称肺癌)已成为恶性肿瘤死亡的首要原因,2014年美国所有新发肿瘤病例中,肺癌患者病例数占14％,在男性和女性患者中仅次于前列腺癌和乳腺癌所占比例.而在同年所有因肿瘤导致死亡的患者中,肺癌所占比例为27％,远高于第二位的前列腺癌(10％)和乳腺癌(15％).截止2015年,我国有429.2万例新发肿瘤病例和281.4万例死亡病例,而肺癌是发病率最高的肿瘤,也是癌症死因之首.肺癌的5年生存率低于16％,其主要原因是约75％的肺癌患者在确诊时已是晚期.但早期肺癌治疗后5年生存率可达87.7％,患者能否手术是其长期生存的关键.因此,能否进行早期的诊断和治疗,对肺癌患者的预后极为重要.

目的 比较血清及支气管肺泡灌洗液(BALF)两种不同标本的GM试验在侵袭性肺曲霉病(IPA)早期诊断中的价值.方法 收集拟诊为IPA的26例患者为病例组,普通细菌感染性肺炎患者15例为对照组.观察两种标本GM试验I值的差异,并比较在不同诊断阈值下,血清及BALF GM试验诊断IPA的价值.通过ROC曲线分析确定血清及BALF两种标本的不同诊断阈值.结果 两组组内血清和BALF这两种不同的标本,GM试验I值存在显著性差异(均P＜0.05).在不同诊断阈值下,BALF GM试验诊断IPA的敏感度、特异度、阳性预测值、阴性预测值均优于血清.ROC曲线分析显示血清和BALF标本GM试验的诊断阈值分别为0.68、0.8,曲线下面积分别为0.809及0.894.结论 血清和BALF标本GM试验在IPA的早期诊断中都有重要的价值,但在非粒细胞缺乏的IPA患者中,BALF GM试验诊断价值可能高于血清,并且血清及BALF使用同一诊断阈值可能存在一定的不足.

目的 采用Meta分析评价CT在肺动脉高压中的诊断价值.方法 通过检索Pubmed、Elsevier和中国期刊网数据库(CNKI),获得相关中、英文文献,采用QUADAS-2工具对纳入的研究进行质量评价.采用Meta-disc 1.40软件对纳入的文献进行异质性检验,根据随机效应模型,汇总敏感度、特异度,并绘制综合受试者工作特征(SROC)曲线,计算曲线下面积.结果 共12篇文献符合要求,纳入其中8篇文献、均以肺动脉直径/升主动脉直径＞1或≥1作为肺动脉高压的诊断标准,纳入对象共计1 111例.Deeks漏斗图分析提示各文献间无明显发表偏倚(P=0.501).汇总后的敏感度、特异度分别为74％(95％可信区间:70％～77％)、81％(95％可信区间:76％～85％),SROC曲线下面积为0.853 5.结论 CT检查肺动脉直径/主动脉直径诊断肺动脉高压具有一定的临床应用价值.

目的 研究比较传统培养法与实时荧光定量(PCR)法,检测机械通气患者下呼吸道感染病原菌的效果.方法 选择2013年3月-2016年1月医院ICU机械通气合并下呼吸道感染患者55例作为研究对象,通过支气管镜获得支气管肺泡灌洗液(BALF)和防污染毛刷(PSB)标本,分别采用传统培养法和实时荧光定量法检测病原菌,对两种不同检测方法进行比较分析.结果 55例患者标本中,BALF传统培养金黄色葡萄球菌、肺炎克雷伯菌、肺炎链球菌、铜绿假单胞菌、流感嗜血菌、卡他莫拉菌等阳性率均高于PSB标本培养阳性率,但差异无统计学意义;采用实时荧光定量PCR方法检测PSB标本中金黄色葡萄球菌、肺炎克雷伯菌、肺炎链球菌、铜绿假单胞菌、流感嗜血菌、卡他莫拉菌的阳性率均明显高于传统培养法检出阳性率,差异有统计学意义(P＜0.01);在检测阳性的PSB标本中,金黄色葡萄球菌、肺炎克雷伯菌、肺炎链球菌、铜绿假单胞菌、流感嗜血菌和卡他莫拉菌的浓度分别为(3.28±0.87)(6.01±0.78)(3.70±0.89)(4.90±1.15)(4.12±0.66) Log10(CFU/ml)和(4.24±0.72)Log10(CFU/ml),肺炎克雷伯菌、铜绿假单胞菌的浓度较高,与另4种菌种浓度相比,差异有统计学意义(P＜0.05).结论 机械通气下呼吸道感染患者中,以PSB标本作为病原菌检测的标本具有更高的特异性;而与传统培养相比,荧光定量PCR检测方法具有更高的敏感性,且能快速获得检测结果,对抗菌药物早期正确应用具有重要的指导意义.

OBJECTIVE To conduct the meta‐analysis of related risk factors for the Clostridium difficile infection so as to facilitate the reasonable treatment and prevention of the recurrent infections .METHODS A systematic meta‐analysis was conducted according to the PRISMA guidelines ,the databases such as MEDLINE were searched for titles and abstracts related to the subject of the C .difficile infection ,all the eligible researches were observed by using multivariate analysis model ,the data with respect to the study design ,study population ,and related risk factors were collected ,the total relative risk ratios were calculated with the use of random‐effects model ,and the extracted data were analyzed by means of Review Manager 5 .0 .RESULTS Totally 21 included researches ,with the issue time ranging from 1997 to 2015 ,covered the clinical data of 15 830 patients ,of which 3 items were the case‐control studies ,4 items were the prospective cohort studies ,2 items were the randomized controlled trial ,and 12 items were the retrospective cohort studies .The NOS score of all the included researches were more than 7 points , which was defined as the high quality studies .The analysis revealed that the most common independent risk fac‐tors for the C .difficile infection included the advanced age ( no less than 65 years old) ,use of antibiotics during the follow‐up ,use of proton‐pump inhibitors (PPIs ) ,complication of renal insufficiency ,and immunocompro‐mised state of the host .CONCLUSIONS There are a variety of risk factors associated with the recurrent C .dif fi‐cile infection ;the reasonable use of antibiotics and PPIs may contribute to the reduction of the incidence of recur‐rent C .difficile infection .

目的 CT作为一种非侵入性影像检查技术,在诊断肺动脉高压和评价右心功能方面得到了越来越多的关注.CT评价肺动脉高压大致可分为基于形态学和基于功能学.本文对CT在肺动脉高压的诊断和右心功能评价中的研究进展进行综述.

OBJECTIVE To investigate the case reports of respiratory tract Mycobacterium abscessus infection in the intensive care unit (ICU) and analyze the clinical characteristics so as to improve the clinicians'awareness of M .ab‐scessus pulmonary disease .METHODS From Jan 2014 to Mar 2014 ,the respiratory tract specimens were collected from the long‐term mechanical ventilation patients with suspected infections like fever ,malaise ,and weight loss , then the specimens were cultured ,meanwhile ,the acid‐fast staining microscopy and inoculated culture were carried out ,the strains that were cultured positive were identified by using GenoType MTBDR plus ,Genotype CM and Genotype AS probe assay as well as DNA sequencing ;the epidemiological survey was conducted . RESULTS Totally 7 patients were confirmed as the M .abscessus pulmonary disease ,of whom 5 were treated with clarithromycin ,moxifloxacin , and amikacin , and 2 were given the combination therapy of clarithromycin , moxifloxacin ,and cefoxitin .After the treatment for 4 months ,the symptoms of 6 patients were improved ,the sputum specimens were cultured negative for bacteria ,and the imaging findings were improved ;only 1 case died of the exacerbation of underlying disease ,and all the environmental specimens were cultured negative for the M .ab‐scessus .CONCLUSIONS The elderly patients undergoing the long‐term mechanical ventilation in the ICU are complicated with the M .abscessus pulmonary disease , which has become a potential threat to the patients undergoing long‐term mechanical ventilation .It is necessary to strengthen the control and prevention of nosocomial infections .