哮喘联盟

   摘要
   医师常常对肺炎进行经验性的诊断和治疗，但单独对肺炎进行临床评价的准确性尚不清楚。本试验在初级医疗机构中研究基于症状和体征的临床判断在诊断胸片证实的伴有急性咳嗽的肺炎患者的准确性。在12个欧洲国家内，全科医生对因急性咳嗽就诊的2810名患者，基于病史和体检结果即刻判断是否存在肺炎（“是”与“否”）。一周内，本地影像科医生对患者进行胸片检查。140名患者胸片诊断为肺炎（5%），其中41名（29%）在全科医生就诊时即已经诊断。在胸片检查未发现肺炎的2670名患者中，医生基于临床特点将其中31名患者诊断为肺炎（1%）。医生仅根据临床特征诊断的肺炎患者中，57%的患者在随后的影像学检查中得到证实（阳性预测值，PPV）。医生临床判断的阴性预测值（NPV）、敏感性和特异性分别为96%、29%和99%。医生基于经验未诊断为肺炎，但影像学诊断为肺炎的患者，与临床诊断为肺炎的患者相比，症状的严重程度较低（p<0.05）。医生临床诊断的预测价值（特别是高NPV）对常规治疗有所帮助。然而，大部分影像学诊断为肺炎的患者，在临床上未列为疑似肺炎患者。有必要在初级医疗机构中进一步支持检测临床相关性肺炎。

（林江涛 审校）
 2013 Jan 24. [Epub ahead of print]

 

Diagnosing pneumonia in patients with acute cough: clinical judgment compared to chest radiography.
 
Vugt SF, Verheij T, Jong PD, Butler C, Hood K, Coenen S, Goossens H, Little P, Broekhuizen B; on behalf of the GRACE Project Group (www.grace-lrti.org).

Source
Julius Center for Health, Sciences and Primary Care, Utrecht, The Netherlands.

Abstract 
Pneumonia is often diagnosed and treated empirically, but the accuracy of clinical assessment alone is largely unknown. We therefore set out to determine the diagnostic accuracy of clinical judgment based on signs and symptoms to detect radiographic pneumonia in patients presenting with acute cough in primary care. In 2810 patients consulting with acute cough in 12 European countries, general practitioners (GPs) recorded whether they considered pneumonia present ("yes" or "no") immediately after the history and physical examination. Chest radiography was performed within one week by local radiologists blind to other patient characteristics.140 patients had radiographic pneumonia (5%), of whom 41 (29%) had been diagnosed as such by the GP. GPs diagnosed pneumonia in 31 (1%) patients on clinical grounds who turned out not to have radiographic pneumonia (n=2670). In patients diagnosed with pneumonia by GPs on clinical grounds alone, 57% were subsequently diagnosed with radiographic pneumonia (positive predictive value, PPV). Negative predictive value (NPV), sensitivity and specificity of GPs' clinical judgment were 96%, 29% and 99% respectively. Patients with radiographic pneumonia, but who had not been diagnosed empirically by GPs, presented with less severe symptoms compared to patients with a clinical diagnosis of pneumonia (p<0.05).The predictive values of GPs' clinical judgment, particularly the high NPV's, are helpful in routine care. Nonetheless, the majority of diagnoses of radiographic pneumonias was not suspected on clinical grounds. There is a need to further support the detection of clinically relevant pneumonia in primary care.
 

 2013 Jan 24. [Epub ahead of print]