2014年 · 第37卷第01期

The silver snake dances to bid farewell to the old year, and the horse gallops to welcome the new year. At the beginning of the new year, we will dedicate many important articles on infection and the "Expert Consensus on Diagnosis and Treatment of Pseudomonas aeruginosa Lower Respiratory Tract Infection" to you, and sincerely wish all readers and authors a smooth and healthy work in the new year! Professor Liu Youning, the editor-in-chief of this journal, reminded all colleagues in his essay to pay attention to regular and thorough physical examination after busy work. He also extended New Year's greetings and thanked everyone. Why thank you? Please read the article "Thoughts after chest surgery".

On August 29th, 2013, I successfully performed a thoracoscopic local pneumonectomy in our hospital. Because of avoiding unnecessary worries of relatives, friends and colleagues, only a few people related to the operation knew about it before the operation, and only a few relatives and friends were notified after the operation was successfully completed. On September 18th, 20 days after surgery, I attended the annual meeting of the Respiratory Disease Branch of Chinese Medical Association held in Dalian, served as the host and gave a special report. Except for a few people, no one knew that I was "sick" to attend the meeting. As the saying goes, "paper can't hold fire". So far, more and more people have vaguely understood this matter, and some legends are somewhat unreliable. In order to repay my comrades' concern for me, and at the same time, I have taken up the space of this magazine and reported the truth to you.

Since the first SARS patient (diagnosed as "infectious atypical pneumonia" at that time) was diagnosed on December 22, 2002, the epidemic of respiratory viruses (mainly influenza viruses) in China has never stopped in the past ten years, including the SARS pandemic in 2003, the scattered epidemic of human avian influenza in 2005, the worldwide pandemic of new influenza A (H1N1) virus in 2009, the novel coronavirus infection epidemic since October 2012 and the human H7N9 avian influenza epidemic since February 2013, all of which show that respiratory viruses (mainly influenza viruses) still pose a great threat to human health and have a great impact on global social stability and economic development. Because the first target organs reached by respiratory viral infection are airways and lungs, it has always been an important topic for our medical staff engaged in the prevention and treatment of respiratory diseases.

On February 19, 2013, an 87-year-old man in Shanghai was admitted to the treatment with high fever, influenza-like symptoms and respiratory failure. The examination results showed that the influenza A virus was positive, but it could not be classified. Since then, similar severe cases have appeared continuously, and an epidemic started in the early spring of 2013. After identification, Gao et al.^[1]The pathogen was isolated from the throat swabs of three first-episode patients with the above symptoms and confirmed for the first time as a novel reassortment influenza virus formed by the reassortment of H7N3 (ZJ12 subtype), H7N9 (KO14 subtype) and H9N2 (BJ16 subtype). Since March 31, 2013, the National Health and Family Planning Commission has started to report confirmed cases of human H7N9 avian influenza daily. By November 10, 2013, 138 cases of human H7N9 avian influenza have been diagnosed in China, including 45 deaths. The geographical distribution is mainly concentrated in Shanghai, Zhejiang, Jiangsu and other Yangtze River Delta regions, but sporadic cases have also been reported in Anhui, Henan, Shandong, Hunan, Fujian, Beijing, Taipei, Guangdong and other places.

Respiratory viruses are the most common pathogens that cause respiratory diseases in humans, and it has been confirmed that more than 80% of acute respiratory infections are caused by viruses^[1]Including influenza virus, parainfluenza virus, adenovirus, rhinovirus and human metapneumovirus. The same respiratory virus can cause a variety of clinical symptoms, and different respiratory viruses can cause the same clinical symptoms. It is difficult for clinicians to distinguish accurately from clinical symptoms. Therefore, laboratory pathogen testing is very important for the final diagnosis of pathogens^[2]。

P. aeruginosa (Pseudomonas aeruginosa，P.aeruginosaPA) is a gram-negative bacillus and the most common non-fermenting bacteria in clinic. It is widely distributed in nature and can be isolated on the surface of human skin as a normal bacterial flora. It can also contaminate medical devices and even disinfectants, thus leading to iatrogenic infection. It is an important conditional pathogen of hospital-acquired infection, and has the characteristics of easy colonization, easy mutation and multi-drug resistance. The lower respiratory tract is the most common site of nosocomial bacterial infections. The infections mainly include bronchiectasis complicated with infection, chronic obstructive pulmonary disease (COPD) complicated with infection and pneumonia, etc.P aeruginosaLower respiratory tract infections caused by MDR-PA have a high mortality rate and are difficult to treat. Therefore, it is of particular importance to standardize the diagnosis and treatment of lower respiratory tract infections caused by PA.

In the past decade, the number of cases of invasive aspergillosis (IA) has increased significantly, but the drugs for the treatment of IA are relatively limited. Triazoles, polyenes and echinocanthins are the main drugs for the treatment of IA. Although the emergence of drugs such as amphotericin B, voriconazole and caspofungin improved the prognosis of IA to some extent, the mortality rate related to IA was still above 30%^[1]。 The possible reasons are that, on the one hand, many patients' primary disease is malignant tumor (solid tumor or hematological tumor) or accompanied by severe immunosuppression (bone marrow transplantation, solid organ transplantation), and their prognosis and response to treatment are poor. On the other hand, Aspergillus drug resistance also affects the therapeutic efficacy of patients^[2]。 Drawing on the good efficacy of combination therapy for other infectious diseases such as AIDS, tuberculosis and cryptococcal meningitis, people began to pay attention to the combination of different kinds of drugs to treat IA.

Chronic obstructive pulmonary disease (COPD) is a disease characterized by persistent airflow restriction, with acute exacerbations and comorbidities affecting the severity of the disease^[1]。 CT can accurately reflect the pathological changes of lung tissue, and its role in the diagnosis and assessment of COPD is increasingly obvious. The author's review of the clinical significance of CT evaluation for COPD is as follows.

bronchiectasis (bronchiectasis) is an irreversible and persistent dilatation of the bronchial wall. Bronchiectasis is a common disease among Chinese people, and there is a lack of effective treatment. Recent studies over 20 years have found that macrolide antibiotics not only have antibacterial effects, but also have anti-inflammatory and immunomodulatory effects. In recent years, the results of a number of large-scale clinical trials have confirmed that long-term low-dose macrolide antibiotics have achieved good curative effects in the treatment of chronic respiratory diseases such as diffuse panbronchitis, cystic fibrosis, and bronchial asthma, which has also made more and more people pay attention to its therapeutic potential for bronchiectasis. There are still many problems to be solved in the clinical application value of macrolide maintenance therapy for patients with bronchiectasis. The efficacy and safety of long-term low-dose macrolide antibiotics in the treatment of adult patients with bronchiectasis are reviewed as follows.

With the increasing usage of smartphones and new innovative connected devices worldwide, as well as the expansion of mobile broadband networks and services, mobile technology is becoming a major driving force in the healthcare service industry. PricewaterhouseCoopers' market analysis report predicts that by 2017, the development of the global mobile health market will bring in revenue of 23 billion US dollars, of which approximately 6.8 billion US dollars in the Asia-Pacific region and approximately 2.5 billion US dollars in China^[1]。

Cheyne-Stokes respiration (CSR) refers to a periodic breathing pattern in which breathing gradually changes from shallow to deep and fast, then from deep and fast to shallow and slow, followed by apnea for a period of time, and then repeats the above changes. CSR can occur in a variety of disease states and in the normal population, and can occur in either waking or sleeping states. Chronic congestive heart failure (CHF) is the first cause of CSR, and the prevalence of CSR increases with the exacerbation of CHF. Its existence and severity can even be used as a "mirror" of cardiac function, which also has a great influence on the prognosis of CHF patients. The definition, epidemiology, risk factors, pathogenesis, clinical manifestations and diagnosis, treatment and prognosis of CSR will now be presented.

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a common and important cause of deterioration of pulmonary function and quality of life in patients with COPD^[1]。 Timely and effective treatment of acute exacerbation is of great significance to delay the progression of COPD and improve the quality of life of patients^[2]。 COPD assessment test (CAT) is a novel health-related quality of life scale for patients with COPD^[3]At present, it is mainly used to assess the burden of symptoms and quality of life of patients with stable COPD^[2]However, there are few reports for evaluating patients with acute exacerbation of COPD, and most of them come from abroad^[4]。 This study analyzed the correlation between CAT score and inflammatory markers and dyspnea index before and after treatment in patients with acute exacerbation of COPD, aiming to explore whether CAT can be used as an index to evaluate the efficacy of acute exacerbation of COPD.

The incidence of tuberculosis and hepatitis B virus in China is high, and the probability of complication of the two diseases is about 38.6%^[1]。 The clinical cure rate of the first-line anti-tuberculosis regimen in the newly treated patients with pulmonary tuberculosis is over 90%^[2]But the incidence of liver injury within 2 months of antituberculosis therapy was about 40%. Therefore, most scholars prefer prophylactic hepatoprotective treatment when antituberculosis treatment. The purpose of this study was to investigate the preventive effects of different kinds of hepatoprotective drugs.

Cycloserine is a new second-line anti-tuberculosis drug, which is mainly used in combination with other drugs for the treatment of multidrug-resistant tuberculosis. Cycloserine inhibits the formation of bacterial cell wall mucopeptides by inhibiting D-alanine racemase and synthetase, resulting in defects in MTB cell walls, thus playing bactericidal and bacteriostatic effects^[1,2]。 We conducted a preliminary study of the pharmacokinetics of cycloserine in the lungs.

A 19-year-old male was admitted to the hospital on 27 October 2012 with "sudden right chest pain for 1 d". The patient developed right chest pain, accompanied by slight shortness of breath, while taking a bath 1 day ago, and could speak continuously into sentences without fever, cough, expectoration, dizziness and irritability. X-ray chest radiography in a local hospital showed bilateral pneumothorax, and was admitted to the thoracic surgery department of a general hospital for further treatment. The patient had previous history of apical bullous disease in both lungs; Has a history of 4 pneumothorax attacks, including 3 pneumothorax on the right side, 1 pneumothorax on the left side, and 4 pneumothorax attacks. The main treatment process of pneumothorax is as follows: (1) On December 31, 2010, due to the poor continuous closed drainage effect of the right pneumothorax, he underwent thoracoscopic right bullae resection + pleurodesis under general anesthesia; (2) On May 22, 2011, the right thoracic closed drainage was performed again due to right pneumothorax; (3) On February 29, 2012, right thoracic closed drainage was performed due to right pneumothorax, and right pleurodesis (chest injection of sapelin) was performed again 6 days later; (4) Left thoracic closed drainage was performed on October 5, 2012 due to left pneumothorax, and left pleurodesis (chest injection of sapelin) was performed on October 13, 2012; The above pneumothorax improved after treatment and was discharged. Deny history of smoking, deny history of drug allergies. Physical examination at admission: body temperature 36.5 ℃, heart rate 82 beats/min, breathing 20 beats/min, blood pressure 110/62 mmHg (1 mmHg =0.133 kPa), the patient was conscious, the trachea was centered, the respiratory sounds of both lungs were weakened, no dry and wet rales were heard, no pleural friction was heard, heart rate 82 beats/min, normal heart rhythm, no murmur and pericardial friction were heard. Two weeks later, X-ray chest radiograph showed: apical bullae of the right lung; Bilateral pneumothorax with about 55% compression of the left lung and about 45% compression of the right lung; A small amount of pleural effusion on both sides. Admission diagnosis: bilateral spontaneous pneumothorax. Bilateral closed thoracic drainage was performed, and oxygen therapy and nutritional support were given. After treatment, the patient's right pneumothorax disappeared, but the patient's left pneumothorax persisted. X-ray chest radiograph still showed a small amount of pleural effusion on the left side, left pneumothorax, left lung compression about 35%, and right lung apical bullae. After 2 weeks of continuous closed drainage, there was still air leakage in the left pneumothorax, and bubbles continued to overflow in the water seal bottle connected to the left thoracic drainage tube. It was considered that there was bronchopleural fistula, which was refractory pneumothorax. Because the patient had previously undergone left pleurodesis, and both the surgeon and the patient temporarily disagreed with the operation, the effect of closed thoracic drainage was poor. After discussion, selective bronchial occlusion (one-way valve placement in the target airway under bronchoscope guidance) was used to treat refractory pneumothorax.

The diagnostic methods of pleural effusion are routine, biochemical, cytological, bacteriological and other examinations. Further pleural biopsy is required for pleural effusion whose cause cannot be defined by conventional diagnostic methods^[1]。 But medical thoracoscopy can directly observe the changes of pleural cavity and take the biopsy of parietal and/or visceral pleural lesions under direct vision, which is of great significance to clarify the nature of pleural effusion and diagnose pleural diseases^[2], has been recommended as a further examination method for pleural effusion that is negative for routine methods^[3]。 This study collected 85 cases of unexplained pleural effusion diagnosed by internal medicine thoracoscopy in Dalian Central Hospital. The treatment and prognosis of these patients were followed up. By comparing the changes of diagnosis before and after, the sensitivity, specificity and accuracy of unexplained pleural effusion diagnosed by internal medicine thoracoscopy and the clinical significance of follow-up were clarified.

Chronic obstructive pulmonary disease (COPD) is a disease with high morbidity and mortality, which is a serious threat to human health. Pulmonary heart disease secondary to COPD is the main cause of death and disability, and pulmonary hypertension caused by hypoxia is the core link of this process. Therefore, it is of great significance to study the pathogenesis and intervention of pulmonary hypertension caused by hypoxia. Sildenafil is the first-line drug for the treatment of arterial pulmonary hypertension, and its efficacy is positive. However, whether sildenafil can be used for the treatment of hypoxic pulmonary hypertension is still controversial. Studies on animal models of hypoxic pulmonary hypertension showed that sildenafil can significantly improve the hemodynamic parameters of hypoxic pulmonary hypertension, reduce the right heart hypertrophy index, and inhibit pulmonary artery remodeling. The proliferation and migration of pulmonary artery smooth muscle cells are the main reasons for hypoxic pulmonary vascular remodeling. The increase of intracellular calcium ions during hypoxia is the basis of its proliferation and migration. Our previous study found that the expression of classical transient receptor potential channel (TRPC) 1,6 increased in pulmonary artery smooth muscle cells during hypoxia, leading to an increase in intracellular calcium ion. Sildenafil has an effect on TRPC expression, but the mechanism is unknown. Peroxisome proliferator-activated receptor gamma (PPAR gamma) plays an important role in the development of pulmonary hypertension disease by initiating a series of signaling pathways. Therefore, this study mainly investigated whether sildenafil affects TRPC expression through cyclic guanosine phosphate (cGMP) -phosphoprotein kinase (PKG) -PPAR γ pathway under hypoxia.

Bone morphogenetic protein (BMP) family plays an important role in pulmonary hypertension, and its receptor gene mutation is associated with genetically related pulmonary hypertension and idiopathic pulmonary hypertension. Changes in BMP receptor expression have also been found in animal models of hypoxic pulmonary hypertension. Therefore, the study of bone morphogenetic protein signaling pathway plays an important role in hypoxic pulmonary hypertension. Our results suggest that different bone morphogenetic proteins play different roles, and BMP2 and BMP4 are two positive and negative regulatory factors. BMP4 promotes hypoxia-induced remodeling of pulmonary blood vessels, whereas BMP2 plays the opposite role in protecting blood vessels from excessive remodeling. After BMP4 binds to receptors, it initiates downstream signaling pathways to upregulate the expression of classical transient receptor potential channel (TRPC), thus increasing intracellular calcium ions and causing cell proliferation. The mechanism of action of BMP2 on vascular remodeling is unknown at present. The effects of BMP2 on the expression of TRPC in rat pulmonary artery smooth muscle cells, manipulative calcium influx and basal calcium in calcium pool were observed.

With the extensive use of broad-spectrum antibiotics and immunosuppressants and the extensive development of organ transplantation technology, the incidence of invasive fungal infection is increasing year by year, and it has become one of the important diseases that affect the survival of patients. The lungs are the most susceptible organs to fungal attack. Microbiological examination of lower respiratory tract specimens is an important reference index to judge the pathogen of pulmonary infection. However, due to the influence of normal parasitic flora in the upper respiratory tract, the test results are often difficult to provide correct guidance and judgment. Candida is still the most common fungus that causes invasive fungal infections in humans, especially lung fungal infections. However, because Candida is the most common parasitic fungus in the upper respiratory tract, the significance of Candida isolation in the lower respiratory tract is still a controversial topic. The more common belief that Candida isolation from the lower respiratory tract is not meaningful has been challenged by clinical and basic studies in recent years.

The World Health Organization (WHO) presented a recommendation on laboratory diagnostic techniques for tuberculosis in December 2010^[1]This recommendation endorses a new rapid detection method for tuberculosis called nucleic acid amplification test (NAAT), believing that this detection method may bring revolutionary changes to the treatment and control of tuberculosis, and is an important milestone in the diagnosis and treatment of tuberculosis globally. In view of the important role of tuberculosis genetic diagnosis in the research and clinical application of tuberculosis in China at present, the author has studied the relevant research background data of WHO recommended products and investigated the current situation of tuberculosis genetic diagnosis technology application in China. Now, the relevant opinions are expounded as follows. Criticism and suggestions from domestic and foreign peers are welcome.

In the early stage, the only positive pressure ventilation modes were pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV). With the improvement of synchronization and safety requirements, the two modes gradually developed into pressure-assisted/controlled ventilation (P-A/C), volume-assisted/controlled ventilation (P-A/C, referred to as A/C for short), and constant volume and constant pressure intermittent command ventilation (IMV) and pressure-supported ventilation (PSV) modes appeared. In the past 20 years, new modes have emerged continuously, but except proportional ventilation (PAV) and neuromodulation-assisted ventilation (NAVA), which are real breakthroughs, other modes are derivatives of the above-mentioned traditional modes. Due to the immaturity of PAV and NAVA, the traditional model is still the main body of clinician application, but from the most basic VCV, PCV, PSV to various modes derived from them, their form and connotation have undergone great changes.

"A case of microscopic polyangiitis" was introduced in the case report column of Chinese Journal of Tuberculosis and Respiratory Medicine, Issue 6, 2013^[1]Thank you to the author for providing cases for everyone to learn and think about. After reading carefully, I hope that some ideas can be discussed with the author.

First of all, I would like to thank your editors for their support and help in the submission process. Your rigorous and serious attitude towards the submission content has benefited us for life. At the same time, I am also very grateful to the editorial department for the letter from the readers. We are very grateful to this teacher for his rigorous and professional enlightenment! Let's reply to the two parts of "Contents of Medical History" and "Discussion" below.

The results showed that 20% of situational recall, 15% of situational recognition, and 14% of semantic memory changes were closely related to the number of natural teeth. Older adults with the most teeth had 4% better memory than those with fewer teeth. Scientists believe that one of the reasons tooth loss affects memory is that memory is related to chewing. Chewing increases blood flow to the brain, which directly affects brain functions, including memory functions. As far as memory is concerned, sensory stimulation during jaw movement and tooth chewing directly affects the hippocampus of the brain, which is responsible for memory formation and regaining function. In the absence of teeth, the hippocampus of the brain will acquire less signals. In addition, people with missing teeth or wearing dentures will try their best to avoid eating hard-to-chew foods, especially dried fruits, which will cause the lack of nutrients such as multivitamins and certain proteins, thus affecting people's memory.