A 10-year experience in the treatment of intraabdominal cerebrospinal fluid pseudocysts

The aim of this retrospective study was to assess a ten-year experience in the treatment of rare complications of ventriculoperitoneal shunting--intraabdominal cerebrospinal fluid pseudocysts. At this time there are no data about incidence, clinical course and treatment of these complications in Croatia. Cerebrospinal fluid (CSF) abdominal pseudocyst is an uncommon but important complication of ventriculoperitoneal shunts. Retrospective data were obtained from 5 children with abdominal CSF pseudocysts, treated between 1996 and 2007. The incidence of intraabdominal CSF pseudocysts in our study is 2.9%. All patients were girls ranged in age from 4 to 12 years old (mean 8.8 years). In most cases etiology of hydrocephalus was congenital, idiopathic. Abdominal pain and distension were the most frequent clinical finding (4/5). Although infection has been reported as responsible for pseudocyst formation, we did not found it in our series. Laparotomy with cyst wall excision and catheter replacement was performed in 2/5 cases, and only cyst fluid aspiration with catheter replacement in 3/5 cases. Recurrence of the abdominal cyst was observed in one girl who was in terminal stadium of anaplastic ependymoma. It is our opinion that only catheter replacement and cyst fluid evacuation, as one of the treatment modalities, may be successful, even in large CSF intraperitoneal pseudocysts.     

Propionibacterium acnes in the etiology of endocarditis]

Propionibacterium acnes is the gram positive anaerobic bacteria belongs to the normal skin and oral microbial flora. The participation of this microorganism in the infective endocarditis is still controversial. The aim of the study was to perform the diagnostic and therapeutic difficulties in 5 patients with infective endocarditis caused by Propionibacterium acnes. In 3 out of 5 patients the infective endocarditis developed after prosthesis valve replacement, in 2 others on the native valves. The inserted prostheses were mechanical ones, propionibacterium acnes was identified as causative organisms in all of the causes (two positive blood and/or valve culture). The bacterial strains were sensitive to the antibiotics as: penicillins, cephalosporins, clindamycin, and vancomycin, however cephalosporins used at the beginning of the treatment in 3 patients and clindamycin in 1 patient had limited clinical efficacy. Later treatment with timentin, augmentin and tienamycin was successful in 3 patients; one patient was cured with vancomycin. One patient died because of septic, embolic complication in early stage of illness. We conclude the effectiveness of penicillins in combination with clavulanic acid and tienamycin in therapy of infective endocarditis due to Propionibacterium acnes. The treatment should be lasted during 4-6 weeks.     

Treatment results of nine patients with Burkitt's lymphoma

From 6/79 until 2/86, 9 patients (median age 39) with Burkitt's lymphoma were treated. Stage D disease was seen in 7 cases, stage C in two and stage A in one. The main symptom was abdominal pain or a rapidly progressing abdominal tumor. Three patients had bone marrow involvement and two had a Burkitt's leukemia. Three had typical chromosomal aberrations. Therapy consisted of a variety of chemotherapy regimens plus additional radiotherapy and/or bulk surgery. Two patients achieved complete remissions (of 6 and 20+ months duration), and 4 partial remissions were obtained. The remaining patients had either progressive, drug resistant disease or died early. One patient is currently alive and in complete remission at 20+ months. A second patient is alive at 20+ months in partial remission with traces of IgM-paraprotein still detectable. The main causes of death were tumor-lysis syndrome (4 patients) and therapy related sepsis with progressive tumor (3 patients). This poor outcome is probably due to a high proportion of high-risk patients and suboptimal therapy for this rapidly proliferating tumor.     

创伤患者急性肾功能损伤诊断与治疗

目的：探讨患者创伤后发生急性肾损伤的患者发病率、临床特点以及发病危险因素,以便有效预防和及早治疗。方法：回顾性分析我院重症监护室2004年1月至2010年12月收治的创伤患者相关临床资料,分析创伤后急性肾损伤的发病率以及发病危险因素。结果：共有106例患者纳入我们的研究,其中47例患者创伤后并发急性肾损伤。在发生急性肾损伤患者中,平均年龄为31±19岁,84．6％为男性;其中25例为脓毒血症引起,18例是因为低血压导致急性肾功能损伤。所有患者中,24例患者出现了少尿的症状,19例患者进行了透析治疗。腹部外伤[（OR）-3．66,P-0．027]和应用呋塞来[（OR=4．10,P=0.026）]是发生急性肾损伤的危险因素。结论：急性肾损伤时创伤后的严重并发症之一,死亡率高。只有找到创伤后发生急性肾损伤的危险因素,才能有效预防和及早治疗。     

The role of cefepime, a 4th-generation cephalosporin, in treating patients with surgical sepsis]

Cefepime (Maxipime) was used in the management of 22 patients at the age of 18 to 73 years with the surgical sepsis syndrome (SAPS > 15). In 16 patients surgical sepsis was due to pancreatitis, appendititis, abdominal wound or trauma or complications after planned surgical interventions on the organs of the abdominal cavity. In the other 6 patients surgical sepsis was due to inflammatory processes in soft tissues after minor trauma. In 10 patients (group 1) cefepime was used after the pathogen verification and antibioticogram examination. In 12 patients (group 2) the antibiotic was used in the empirical therapy as the first line drug after the patients acceptance from another unit when the pathogen nature was obscure. Cefepime was administered intravenously in a dose of 2.0 g twice daily for 7 to 10 days in combination with metronidazole in a dose of 0.5 g thrice daily. After 5-6 days of the treatment the patients of group 1 were switched to the cefepime intramuscular regimen. The lethality totaled 18 per cent (4 patients). Three of them were from group 2. The patients died of progressive polyorgan insufficiency. It is characteristic that in no cases cefepime induced septic shock due to the endotoxin escape. No septicopyemia was as well observed even in the patients with verified bacteremia due to Staphylococcus aureus.     

Predictors of inferior outcome in community acquired bacterial meningitis

The aim of this study was to assess mortality and sequellae within cases from Nationwide survey of community acquired meningitis and identify risk factors for inferior outcome. Risk factors such as underlying disease (diabetes mellitus, cancer, trauma, neonatal age, splenectomy, alcoholism, sepsis, other infections), etiology, clinical symptoms and outcome (death, improvement and cured after modifications of ATB therapy, cured without change of therapy, cured with neurologic sequellae) were recorded and analysed with univariate analysis (chi2 or t test for trends, CDC Atlanta 2004). Analysing risk factors for inferior outcome (death or cured with neurologic sequellae), we compared patients who died or survived with neurologic sequellae to all patients with community acquired bacterial meningitis. Univariate analysis showed that trauma (p<0.05), alcohol abuse (p<0.05), diabetes, S. aureus (p<0.05) and gram-negative etiology (A. baumannii, Ps. aeruginosa or Enterobacteriaceae) (36% vs. 11,9%, p<0.05) were predicting inferior outcome. Analysing risk factors for treatment failure (death or failed but cured after change of antibiotic treatment) prior sepsis (34.1% vs. 13.9%, p<0.01) and gram-negative etiology (25% vs. 11.9%, p<0.02) were statistically significant predictors of treatment failure. Neisseria meningitis had less failures (p<0.05). Concerning infection associated mortality again diabetes mellitus (p<0.05), alcoholism (p<0.05) staphylococcal and gram-negative etiology (p<0.05) were significant predictors of death. N. meningitis had surprisingly less treatment failures (appropriate and rapid initial therapy). Neurologic sequellae were more common in patients with alcohol abuse (p<0.05), craniocerbral trauma (p<0.05) and less common in meningitis with pneumococcal etiology (p<0.05).     

Peritoneal Dialysis in Acute Kidney Injury: Trends in the Outcome across Time Periods

Peritoneal dialysis (PD) should be considered a suitable method of renal replacement therapy in acute kidney injury (AKI) patients. This study is the largest cohort providing patient characteristics, clinical practice, patterns and their relationship to outcomes in a developing country. Its objective was to describe the main determinants of patient and technique survival, including trends over time of PD treatment in AKI patients. This was a Brazilian prospective cohort study in which all adult AKI patients on PD were studied from January/2004 to January/2014. For comparison purposes, patients were divided into 2 groups according to the year of treatment: 2004-2008 and 2009-2014. Patient survival and technique failure (TF) were analyzed using the competing risk model of Fine and Gray. A total of 301 patients were included, 51 were transferred to hemodialysis (16.9%) during the study period. The main cause of TF was mechanical complication (47%) followed by peritonitis (41.2%). There was change in TF during the study period: compared to 2004-2008, patients treated at 2009-2014 had relative risk (RR) reduction of 0.86 (95% CI 0.77 – 0.96) and three independent risk factors were identified: period of treatment at 2009 and 2014, sepsis and age> 65 years. There were 180 deaths (59.8%) during the study. Death was the leading cause of dropout (77.9% of all cases) mainly by sepsis (58.3%), followed cardiovascular disease (36.1%). The overall patient survival was 41% at 30 days. Patient survival improved along study periods: compared to 2004-2008, patients treated at 2009-2014 had a RR reduction of 0.87 (95% CI 0.79 – 0.98). The independent risk factors for mortality were sepsis, age >70 years, ATN-ISS > 0.65 and positive fluid balance. As conclusion, we observed an improvement in patient survival and TF along the years even after correction for several confounders and using a competing risk approach.     

Diagnosis of pseudomembranous colitis.

Twenty-eight patients with histologically proved pseudomembranous colitis have been seen in one hospital since July 1975. All patients with the disease had received antibiotics, six for infections not requiring operations; the other 22 cases all occurred after major surgery. All the patients had diarrhoea; six patients also had fever with clinical signs of sepsis, and three had abdominal pain thought to be due to anastomotic dehiscence after colonic resection. Pseudomembranous colitis was associated with white blood counts over 15 000/mm3 in 17 patients and albumin concentrations of less than 30 g/1 in 18. Pseudomembranous colitis was an incidental finding at necropsy in two of six patients who had not had an operation. Of the 22 patients who had had major surgery, nine died from this complication; in all except two of these cases the diagnosis was made only at necropsy. If pseudomembranous colitis is suspected on clinical grounds or if there is an unexplained complication after colorectal surgery repeat sigmoidoscopy and testing for faecal toxins should be carried out to establish the diagnosis so that prompt supportive treatment can be given.     

有上腹部手术史的腹腔镜胆囊切除术探讨

目的:探讨有上腹部手术史的腹腔镜胆囊切除术(LC)的临床经验。方法:对87例有上腹部手术史的腹腔镜胆囊切除术的临床资料进行回顾性分析。结果:84例顺利完成腹腔镜手术,3例中转开腹手术,其中因气腹建立困难1例,胆囊三角区解剖不清2例,所有病人恢复顺利,行LC术后2～4d出院,中转开腹5～7d出院。结论:只要术前充分准备和评估,灵活选择穿刺孔,有效的腹腔粘连松解,术者具备高超的腔镜操作技术和丰富的胆道手术经验,有上腹部手术史的LC术是安全,可行的。     

两种肠内营养方案对重症急性胰腺炎患者 肠道菌群及预后的影响

目的探讨肠内免疫微生态营养和免疫增强型肠内营养方案对重症急性胰腺炎患者肠道菌群及远期预后的影响。方法选择2014年1月至2017年6月在我院就诊的重症急性胰腺炎患者156例。按照随机数字表法将患者分为A组(肠内免疫微生态营养方案组)、B组(免疫增强型肠内营养方案组)和对照组(常规肠内营养方案组),各52例。检测患者治疗前后T淋巴细胞及其亚群NK细胞、B淋巴细胞,血清免疫球蛋白及ALB、TF、PA等营养指标。同时检测患者肠道菌群,判定3组患者肠道菌失调症发生率。治疗后对患者随访6个月,记录并发症及不良预后。结果治疗后A组和B组患者患者CD+4细胞、CD+8细胞、CD+4/CD+8、NK细胞、B淋巴细胞水平显著高于治疗前,对照组患者除CD+8细胞和NK细胞外,其余各细胞水平亦显著高于治疗前(P0.05),且A组和B组患者治疗后各细胞水平高于对照组(P0.05)。治疗后A组和B组患者IgA、IgG、IgM水平显著升高,且A组和B组高于对照组(P0.05),同时3组患者治疗后ALB水平显著高于治疗前,且A、B组高于对照组,但A组和B组治疗后ALB水平比较差异无统计学意义(P0.05)。发病7～10d后,A组患者菌群失调发生率为5.77%,低于B组(19.23%)和对照组(36.54%),两两比较差异均有统计学意义(P0.05)。治疗6个月后,A组患者出现1例胰腺及胰周感染,1例MODS,0例病死;B组出现1例胰腺及胰周感染,2例MODS,3例菌血症,1例腹腔感染,2例病死;对照组出现6例胰周胰腺感染,7例MODS,5例菌血症,3例腹腔感染,3例病死。A组和B组预后显著优于对照组,且A组预后优于B组(P0.05)。结论肠内免疫微生态营养与免疫增强型肠内营养均能显著提高重症急性胰腺炎患者营养状况,提高免疫水平,且肠内免疫微生态营养在改善肠道菌群及预后方面具有更好的效果,值得临床推广。     

肾小球毛细血管内皮病合并甲状腺功能减低1例病例报道并文献复习

目的:通过分析我院收治的1例肾小球毛细血管内皮病合并甲状腺功能减退患者的诊治过程,结合相关文献,探讨此病的临床特点和诊疗方法。方法:报告北京军区总医院收治的1例肾小球毛细血管内皮病合并甲状腺功能减退病例的其临床资料及诊疗过程,并复习相关文献,对肾小球毛细血管内皮病合并甲状腺功能减退的病因、临床表现、诊断、治疗及预后进行分析,并总结其诊疗经验。结果:1例肾小球毛细血管内皮病合并甲状腺功能减退患者经综合治疗后病情好转出院,出院后继续接受对症治疗,目前患者恢复良好。结论:肾小球毛细血管内皮病的发病率低,合并甲状腺功能减退更少见,其发病原因不明,部分与药物、毒物或者病毒感染有关,多数病例对症治疗后预后较好。     

24 例眼外伤继发性青光眼的临床分析

目的:分析眼外伤继发青光眼的临床特点、病因及治疗方法,为临床治疗提供参考。方法:回顾性分析24例(24只眼)眼外伤继发青光眼患者的临床资料,分析诱发青光眼的原因、临床分型,根据具体情况选择治疗方法。结果:眼外伤诱发青光眼的原因为眼内积血11例,晶状体损伤7例,前房角挫伤4例,外伤性虹睫炎2例;单纯药物治疗4例,前房穿刺或冲洗4例,小梁切除联合丝裂霉素术10例,玻璃体切除术2例,滤过手术1例,激光周边虹膜切除术5例。治疗后随访6~12个月,眼压恢复正常率87.50%;视力下降或丧失8.33%;术中1例眼出血,1例术后晶体状浑浊加重,1例视网膜脱离。结论:眼外伤继发青光眼的临床表现复杂,治疗难度大,临床应根据患者的具体情况选择治疗措施。     

The surgical management of Melkersson-Rosenthal syndrome.

A triad of facial palsy, orofacial edema, and furrowed tongue constitutes an uncommon condition known as Melkersson-Rosenthal syndrome (MRS). We report on 14 patients with Melkersson-Rosenthal syndrome. Two patients had facial palsy, 12 had orofacial edema, and 1 patient had a furrowed tongue. Nine patients were treated medically. Intralesional steroid therapy had a 75 percent recurrence rate. Systemic steroid therapy resulted in remission in two of three patients. Surgical excision and reconstruction were carried out in five patients with chronic lip or eyelid edema. This provided relief in all cases. The etiology, clinical presentation, and histologic features are discussed. Three illustrative cases are presented. An algorithm is provided that guides the surgeon with regard to both the medical and surgical treatment of the patient with Melkersson-Rosenthal syndrome.     

老年患者腹部手术后胃瘫综合征的诊治思考

目的:探讨老年患者腹部手术后胃瘫的病因、临床特点、诊断和治疗原则。方法:对9例老年患者腹部手术后胃瘫的临床资料进行回顾性分析。结果:9例老年患者依据临床表现、上消化道造影和胃镜检查确诊为术后胃瘫。经非手术治疗11-47d后,9例均治愈。结论:老年患者胃瘫是由多种因素引起的,通过上消化道造影及胃镜检查可以明确诊断,治疗上采取以营养支持为主的非手术综合治疗,一般均可治愈。     

肺炎克雷伯菌致肝脓肿侵袭综合征3例临床分析及文献复习

为提高对肺炎克雷伯菌感染所致肝脓肿侵袭综合征的临床表现及其危害的认识,回顾性分析3例确诊为肺炎克雷伯菌感染所致肝脓肿患者的临床经过、治疗反应及转归。结果发现3例患者均有肝外播散性病灶,符合肝脓肿侵袭综合征的临床特征。这3例患者为社区获得性感染,均有肝脓肿,其中2例合并眼内炎并造成失明,1例合并腰椎感染、腹主动脉感染及感染性心内膜炎。2例有糖尿病病史,1例免疫正常。结合文献复习,发现肺炎克雷伯菌感染引起肝脓肿及肝外播散性病灶,临床上称为肝脓肿侵袭综合征,大多由高毒力肺炎克雷伯菌引起,好发于糖尿病及免疫缺陷人群,也可发生于免疫正常人群,治疗困难,临床危害严重,需引起重视。     

阿泰宁（酪酸梭菌胶囊）治疗慢性结直肠炎的疗效观察

目的通过临床治疗评价阿泰宁对未确定型结肠炎（IC）和溃疡性结肠炎（UC）的疗效,探讨治疗该病的新方法。方法选择21例IC和UC患者,其中UC诊断参考中华医学会消化病分会炎症性肠病协作组提出的炎症性肠病诊断标准,给予阿泰宁口服,1次3粒,1天3次,连用4-8周。观察治疗期间的临床症状改善情况和治疗结束时进行结肠镜复查并判定其疗效。结果患者的腹泻次数由治疗前（3．60±0．94）次／d,减少到（1．5±0．71）次／d（P〈0．001）;异常便（黏液便、脓血便等）由100％下降为9．5％;腹痛由90．5％下降至14．3％;里急后重由66．7％下降至9．5％。结肠镜查,黏膜基本愈合者10例（47．6％）,黏膜炎症有改善者8例（38．1％）,无改善者3例（14．3％）。临床疗效,完全缓解10例（47．6％）;有效8例（38．1％）;无效3例（14．3％）,总有效率为85．7％。12例确诊UC患者中完全缓解6例（50％）,有效4例（33．3％）,无效2例（16．7）,总有效率为83．3％。结论阿泰宁对IC和UC患者有较好的治疗效果,能明显地改善临床症状和促进受损的肠黏膜愈合,值得推广应用。     

实习医生规范化诊疗流行性出血热常见错误及对策探讨

目的:探讨实习医生规范化诊疗流行性出血热常见错误,并总结相关对策,为提高实习医生对流行性出血热诊断正确率提供可靠依据,保障患者疗效及生活质量。方法:对77例流行性出血热患者临床资料进行回顾性分析,内容包括误诊情况、临床表现、实验室检查项目及结果、治疗措施、治疗结果等。结果:77例流行性出血热患者经治疗后73例患者成功治愈出院,所占比例为94.81%;4例患者死亡,死亡率为5.19%。4例死亡患者均为临床误诊后未及时采用流行性出血热疾病对症治疗措施,贻误治疗时机导致死亡,死亡原因为1例严重休克、1例并发严重败血症、2例急性心力衰竭。结论:实习医生应根据患者临床表现,排除相似疾病类型,结合临床各种实验室检查结果,对患者病情进行综合判断,从而提高流行性出血热诊断正确率,降低误诊、漏诊几率,提高患者治疗效果,保障其生命安全。     

Pancreaticocolonic fistula: a complication of pancreatitis.

In three cases of pancreaticocolonic fistula presenting before the stage of exsanguinating hemorrhage of severe sepsis the problem was diagnosed on the basis of the clinical history, visualization of the terminal part of the fistula by roentgenography after a barium enema had been given and, in two cases, demonstration of the communication with the pancreatic ductal system by endoscopic retrograde pancreatography. The lesions were repaired surgically. Pancreaticocolonic fistula should be suspected in a patient with upper abdominal pain who has a history of abdominal pain and excessive alcohol consumption and in whom diarrhea and fever, hematochezia or a disappearing abdominal mass develops. Characteristically barium will collect in the terminal part of the fistula and thus permit a tentative diagnosis; the diagnosis can then be confirmed by endoscopic retrograde pancreatography. With this approach surgical treatment can be carried out earlier and the often fatal course of the disorder can be averted.     

The clinical picture of legionnaires' disease

The results of the clinico-laboratory study of 12 cases of acute pneumonia of Legionella etiology are presented. The laboratory diagnosis of Legionella infection was carried out by the study of paired sera in the passive hemagglutination test with the use of Legionella pneumophila (serotype 1) erythrocyte diagnosticum. The clinical picture of pneumonia was characterized by a severe and moderate course of the disease. Characteristic symptoms indicating the presence of indurations and infiltrations in the lung tissue were registered. Roentgenological examination revealed that the foci of pulmonary tissue infiltration appeared in the segments of the lower lobes of both lungs. In 6 patients neutrophil leukopenia, in 4 patients relative lymphocytopenia, in 5 patients monocytopenia, in 11 patients the increase of the erythrocyte sedimentation rate and in 4 patients normochromic anemia were registered. More seldom changes in the levels of residual nitrogen, urea, fibrinogen and transaminases were observed. In most cases the resolution of pneumonia was observed on weeks 2-3 of treatment. In this treatment erythromycin, rifampicin and oleandomycin, used in combination, used in combination with detoxication and infusion therapy, vitamins, vascular and other symptomatic remedies, proved to be most effective. The cases of Legionella infection under study were sporadic and epidemiologically unrelated. The severity of the course of the disease depended mainly on the general state of the patient prior to infection, age and concomitant diseases.     

Clinical Study of the Role of 64-Slice CT Cerebra Angiography in Aneurysmal Subarachnoid Hemorrhage

The objective of this study is to assess the clinical role of computed tomography angiography (CTA) in determining the etiology of aneurysmal subarachnoid hemorrhage (ASAH) and selecting the treatment options. A total of 452 patients with ASAH underwent a 64-slice CTA examination to determine the etiology and select the treatment strategies. Digital subtraction angiography (DSA) or clipping operation confirmed the detection from the CTA. The CTA results of 452 patients with ASAH were confirmed through the DSA or clipping operation and the CTA results of 451 cases were consistent with what were seen during the DSA or clipping operation. The treatment choices for 451 patients (99.8 %) were based on the CTA results. A total of 90 cases (19.9 %) underwent endovascular embolization and 362 cases (80.1 %) underwent clipping operation. The other one patient underwent endovascular embolization after the DSA examination due to insufficient information from the CTA. Also, there was one patient who was misdiagnosed in the CTA. In conclusion, a 64-slice CTA can accurately detect intracranial aneurysms and is helpful in choosing the best treatment option.