2014年 · 第37卷第03期

The rapid development of drug resistance between bacteria and other pathogens is a common challenge faced by human beings worldwide. The World Health Organization and authoritative health agencies in many countries have called more than once: "If you do not act now, there will be no medicine available in the future". Faced with such a severe situation, how should the government respond from the macro perspective? What should clinicians do? For more than 20 years, the author, who has taken anti-infection as the focus of his work, would like to share his personal views here for readers' reference.

Lung cancer is the most common malignant tumor in the world, and its morbidity and mortality rank first among malignant tumors. It has become a recognized killer of human health^[1]。 The prognosis of lung cancer is closely related to clinical stage. Due to the late appearance of symptoms and signs, 80% of patients have metastasis at the first visit, and the 5-year survival rate due to loss of surgery is only 16%. In contrast, the 5-year survival rate of stage I patients can reach 90%. If it can be detected in the early stage of the disease, it may effectively improve the prognosis of lung cancer patients^[2,3]。 Therefore, it is the key point of clinical work to establish a reasonable and effective screening program and carry out simple and effective screening for high-risk groups. At present, the screening methods used mainly include the following methods.

With the in-depth research on lung cancer driver genes, especially in lung adenocarcinoma, the treatment of non-small cell lung cancer (NSCLC) has entered the era of individualized targeted diagnosis and treatment. Currently, there are two clear therapeutic targets available in clinical practice, namely epidermal growth factor receptor (EGFR) gene mutation and anaplastic lymphoma kinase (ALK) gene rearrangement. The listing of tyrosine kinase inhibitors (TKIs) targeting these two gene variants has significantly improved the clinical efficacy of corresponding positive patients^[1,2]While EGFR wild-type or ALK gene rearrangement negative patients have limited benefit from it. Therefore, the diagnosis of lung cancer patients by clinicians and pathologists can no longer be satisfied with only diagnosing NSCLC or small cell lung cancer, and it is necessary to further subdivide the histopathological types. For lung cancer containing or potentially containing adenocarcinoma components, it is necessary to further clarify whether there is EGFR mutation or (and) ALK gene rearrangement.

At present, lung cancer is the leading cause of tumor-related death in the world, which seriously threatens human health. Among them, non-small cell lung cancer (NSCLC) accounts for 70% ~80%, and 80% of NSCLC patients are in the advanced stage of disease (stage IIIB ~ IV) at the time of diagnosis. Brain metastasis is a common site of metastasis in advanced NSCLC. About 10% to 25% of patients have developed central nervous system (CNS) metastasis at the time of diagnosis, and 40% to 50% of patients have developed CNS metastasis during treatment. CNS metastasis mainly includes brain metastasis and meningeal metastasis, usually manifested as increased intracranial pressure, such as nausea, vomiting and headache; The site of brain metastasis is usually located at the junction of white matter and gray matter, and functional abnormalities in a certain functional area may occur, such as abnormal movement or sensation of one limb, unstable walking, etc. Meningeal metastasis may cause meningeal irritation symptoms^[1]。 At present, the main diagnostic method for brain metastasis is head enhanced MRI to find abnormal brain parenchyma images, and the main diagnostic method for meningeal metastasis is head enhanced MRI to show abnormal thickening of leptomeninges or tumor cells found in cerebrospinal fluid. In addition to the application of dehydration drugs, hormones and antiepileptic drugs, the alternative treatments include surgery, radiotherapy and chemotherapy, among which whole brain radiotherapy is still the most important method for the treatment of brain metastasis in advanced NSCLC. In recent years, the results of several studies have shown that epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) has a good effect on patients with NSCLC with CNS metastasis.

Primary bronchopulmonary cancer (hereinafter referred to as lung cancer) is a malignant tumor that seriously endangers human health. According to the data released by the World Health Organization (WHO) in 2003, lung cancer ranks first in the world in terms of morbidity (1.2 million/year) and mortality (1.1 million/year). From 2000 to 2005, the incidence of lung cancer in China increased by 116,000, and the number of deaths increased by 101,000. Peto, a famous British oncologist, predicted that if China does not control smoking and air pollution in time, by 2025, China will have more than 1 million lung cancer patients every year, becoming the world's largest lung cancer country^[1,2]。 The 5-year survival rate of lung cancer is only about 15.6%, mainly because about 75% of patients have advanced lung cancer at the time of diagnosis^[1,2]。 Lung cancer may cause poor prognosis due to insufficient early diagnosis, so it is urgent to standardize and promote early diagnosis in order to improve this situation.

lung cancer is one of the most common malignant tumors in the world, and its mortality rate ranks first among cancers. Among them, non-small cell lung cancer (NSCLC) accounts for more than 85% of lung cancer, and most of them are advanced at the time of treatment. In recent years, in the treatment of NSCLC, although the status of chemotherapy has not been fundamentally shaken, its efficacy has reached a platform, and its toxicity and adverse reactions have also limited clinical application. Targeted therapy has become one of the most concerned and promising therapeutics due to its reliable efficacy and mild toxicity and adverse reactions. The Lung Cancer Group of Respiratory Disease Branch of Chinese Medical Association and relevant experts organized by China Lung Cancer Prevention and Treatment Alliance discussed the related issues of molecular targeted therapy for advanced NSCLC, and formed an expert consensus on molecular targeted therapy for advanced NSCLC suitable for China's national conditions (2013 edition).

Background: Obesity [body mass index (BMI) ≥30 kg/m²] is one of the risk factors for bronchial asthma (asthma for short) in adults, especially in female patients. There is a theory that metabolic syndrome can be used to explain the relationship between BMI and adult asthma. The aim of this trial was to compare longitudinally the relative strength of the association between the incidence of asthma and metabolic syndrome and BMI in adults. METHODS: A total of 4 619 subjects eligible for enrollment from the Coronary Risk Development in Young Adults (CARDIA) study cohort were included in the study with a study follow-up of>25 years. New asthma event was defined as: initial self-reported newly diagnosed asthma (presence of asthma symptoms and/or use of asthma medication). The relevant data were analyzed using the Cox proportional hazards model. Results: After 25 years of follow-up, a total of 602 out of 4 619 subjects presented with new asthmatic events (417 women and 185 men). Metabolic syndrome predicted the occurrence of asthma events in women but not in men, with unadjusted hazard ratios of 1.50 (P=0.01) and 0.98 (P＝0.93)。 BMI and metabolic syndrome were similar in predicting new asthma events in female subjects. The unstatistically adjusted hazard ratio for the prediction of new asthma events in women and men by BMI was 1.19 (P<0.001) and 1.04 (P＝0.60)。 After statistical adjustment for BMI factors, the association of metabolic syndrome with asthma events in women was no longer statistically significant (P＝0.44)； In contrast, the association between BMI and female asthma events remained statistically significant after statistical adjustment for metabolic syndrome factors (P＝0.01)。 Stepwise regression model analysis showed that BMI was a stronger predictor of new asthma events than metabolic syndrome (P＝0.001)。 Conclusions: BMI is a better predictor of whether a woman will develop asthma in the future compared with metabolic syndrome.

Wine culture has a long history in China. Some people soon become red after drinking, while others still remain unchanged after drinking several glasses of white wine. Why is this?

The current accepted definition of pulmonary nodule is: a single or multiple pulmonary nodule with clear boundaries, opaque imaging, ≤3 cm in diameter, completely surrounded by pneumatic lung tissue, without atelectasis, hilar enlargement and pleural effusion^[1]。 According to whether pulmonary nodules can completely cover the lung parenchyma under CT, pulmonary nodules can be divided into solid nodules and subsolid nodules, and the latter can be subdivided into pure ground glass nodules and partially solid nodules^[2]。 Pulmonary nodules ≤8 mm were defined as subcentimeter nodules based on the size of the nodule, bounded by 8 mm. Lesions>3 cm in diameter were defined as lung masses rather than nodules, which were generally malignant according to previous studies^[3]。 When CT finds nodule density as benign calcified foci (diffuse, central, thin layer, or popcorn-like calcified form)^[4]For benign features such as intranodular fat-like low density (such as hamartoma) or arteriovenous malformation, follow-up observation or no follow-up can be performed to avoid unnecessary examination and reduce the financial burden of patients.

MicroRNA (miRNA) belongs to a large family of non-coding RNAs. It is an endogenous small molecule RNA sequence containing 22 oligonucleotides. miRNA exists in viruses, nematodes, plants and animals, and plays a vital role in cell growth, differentiation, apoptosis, metabolism, viral infection, tumorigenesis and other physiological and pathological processes. At present, it has been found that abnormal expression of circulating miRNA appears in patients with tumors, hepatitis, diabetes and myocardial infarction. Circulating miRNA may be a new target for non-invasive tumor diagnosis. However, the role of miRNA in the occurrence and development of bacterial infectious diseases, especially tuberculosis, is still unclear^[1,2]。

Obstructive sleep apnea syndrome (OSAS) is a common sleep breathing disorder characterized by repeated partial or complete collapse of the upper airway during sleep, with clinical manifestations of increased respiratory work, decreased oxygen saturation at night, fragmented sleep and daytime drowsiness. The epidemiological characteristics of OSAS are mainly in middle-aged men, and most of them occur after menopause in women, which is closely related to obesity. Adenoid hyperplasia is the main cause of OSAS in children, and the incidence of OSAS is higher in the elderly, but the severe cases are less^[1]。 The risk of all-cause mortality and cardiovascular mortality is significantly increased in the untreated population and can lead to multi-system and multi-organ damage^[2]。 The etiology of OSAS is complex, and its main pathogenesis includes the stenosis of pharyngeal cavity and the reduction or even disappearance of corresponding compensatory mechanisms. The results of recent studies have shown that upper airway inflammation is one of the important causes of the pathogenesis of OSAS. Airway mechanical stress injury, oxidative stress response, local fat accumulation in pharyngeal cavity, smoking and esophageal reflux disease are the main causes of airway inflammation^[3]。

The incidence of echinoderm microtubule-associated protein 4 (EML4) -anaplastic lymphoma kinase (ALK) fusion gene in non-small cell lung cancer (NSCLC) is 3% ~13%^[1]This new fusion gene is a rearrangement of EML4 and ALK (2p21 and 2p23, 12 bases apart) on the short arm of chromosome 2. EML4 gene fragmentation forms exons of different lengths, which are inserted between exons 19 and 20 of the relatively conserved ALK gene to form EML4-ALK fusion gene. At present, 11 variants have been detected, among which EML4 E6-ALK E20 and EML4 E13-ALK E20 are more common^[2]。

In the molecular epidemiological study of tuberculosis, spacer oligonucleotide typing (Spoligotyping) is the main MTB genotyping method. The typing principle is that there may be differences between different strains according to the presence of multiple copies of forward repeats in the MTB genome and whether there are non-repeating spacers between specific two forward repeats. Spoligotyping typing differentiates different strains by analyzing the polymorphisms present in 43 forward repeating spacer sequences in the MTB genome, and translates the genotyping results of the strains into a 15-digit composition code according to the presence of three adjacent spacer sequences. At present, Sopligotyping typing detection mainly uses reverse linear hybridization technology, but the method is cumbersome, and the interpretation of experimental results cannot be automated. Using Luminex liquid chip technology, 43 kinds of amino-labeled oligonucleotide probes complementary to forward repeat spacer sequences were labeled in different polystyrene microspheres, and a novel method of Spoligotyping genotyping of MTB was established. The method based on liquid chip technology not only maintains the advantage of high throughput of biochip, but also has the characteristics of high sensitivity and high accuracy.

Periodic leg movements (PLMS), which are common in overnight sleep respiratory monitoring (PSG), are repetitive and stereotypical leg movements with a duration of 0.5 to 10 s and an interval of 5 to 90 s^[1]When one group (≥4) occurs, it is regarded as one periodic leg movement, and the periodic leg movement index (PLMS index, PLMI) is ≥15 times/h^[2]Is an exception.

pulmonary thromboembolism (PTE) refers to a disease caused by thrombus from the venous system or right heart obstructing the pulmonary artery or its branches. pulmonary circulation and respiratory dysfunction are the main clinical manifestations and pathophysiological features, and it is the most common type of pulmonary embolism. Patients with acute massive pulmonary embolism are prone to sudden death. Current Consensus on Treatment of Acute Pulmonary Thromboembolism^[1]And guidelines^[2]None of them describes the treatment of patients with cardiac arrest due to acute pulmonary thromboembolism. Because such cases are rare in clinical practice, cases of successful treatment can sometimes be reported in China^[3]。 We performed thrombolytic therapy during cardiopulmonary resuscitation in patients in cardiac arrest with confirmed and highly suspected acute pulmonary embolism between January 2010 and July 2013, and performed a comprehensive analysis of the results to improve awareness of the role of thrombolytic therapy in cardiopulmonary resuscitation.

Tracheal stenting is one of the most effective methods for treating airway stenosis. Placing a tracheal stent is not difficult, but how to remove the stent and the treatment of complications. Because there will be many complications after stent placement, which cannot be taken out once and for all, it is very important to take it out in time. We must strictly master the indications for stent placement and avoid abuse.

Professor Richard W. Light, an American respiratory physician, was awarded the 2009 recipients of the ATS Distinguished Achievement Awards by ATS in 2009 for his outstanding achievements in medical and research work in the field of respiratory medicine. This award is only awarded to 1~2 respiratory doctors who have made outstanding contributions every year, which shows its weight.

A 27-year-old female was seen in our hospital on July 20, 2013 due to "cough and expectoration for 1 month". One month ago, the patient developed cough and sputum without obvious inducement. The sputum was white and sticky, and the cough was unobstructed. At that time, he had chills and fever, no chest tightness, palpitations, chest pain and hemoptysis. CT in the local hospital showed a patchy shadow in the posterior basal segment of the lower lobe of the right lung. On July 1, 2013, he was hospitalized in a local hospital for 18 days, and was given piperacillin, tazobactam and ceftazidine for anti-infection. During this period, reexamination of chest CT showed that the lesions were not absorbed. Physical examination after admission: body temperature 37.2℃, pulse 85 beats/min, respiratory rate 20 beats/min, blood pressure 124/77 mmHg (1 mmHg =0.133 kPa), bilateral respiratory movement remained consistent, both lungs breathing sounds were low, no rales were heard, heart rhythm was uniform, and no obvious pathological murmur was heard in each valve auscultation area. The abdomen was flat and soft, and the liver and spleen were not touched under the costs. Admission diagnosis: nature of right lower lung lesion to be determined, tuberculosis? Fungus? Organizing pneumonia?

The patient was a 53-year-old female, a housewoman. He was admitted to the hospital on 4 May 2013 due to "intermittent cough, dyspnea after activity for 10 years and progressive aggravation of dyspnea for 5 years". Since January 2003, the patient has developed cough without obvious trigger, mainly dry cough, occasionally cough a small amount of white sticky sputum, dyspnea after activity, and no chest pain, asthma, hemoptysis and night sweats. In July 2003, I started coughing and dyspnea worsened, and hemoptysis occurred once, with a volume of about 5 ml. Chest CT examination in the local hospital showed "swollen lymph nodes in the mediastinum and hilum, small nodules and ground glass shadow lesions diffusely distributed in both lungs, with blurry edges and scattered small thin-walled cavities (lung airbags)" (FIG. 1A，FIG. 1B，Figure 1C，Figure 1DOn July 28, 2003, a mediastinoscopic lymph node biopsy was performed under general anesthesia. During mediastinoscopy, multiple lymph nodes in the neck and the right anterior trachea (the upper edge plane of the aortic arch) were enlarged. Multiple 0.5 cm ×0.5 cm lymph nodes in the neck and three 0.8 cm ×0.6 cm lymph nodes in the right anterior trachea were taken for pathological examination. The pathological report showed lymph node reactive hyperplasia, and the diagnosis was "sarcoidosis". Oral prednisolone (30 mg/d) combined with cyclophosphamide (200 mg/d) was given for 1 month. After the medication, the symptoms were relieved, so the dose of prednisolone was reduced (reduced by 10 mg every 2 weeks) to 10 mg/d, and the symptoms worsened again at night, accompanied by chest tightness, and inability to lie down to sleep. He was hospitalized again in July 2004, and was given oral prednisone 50 mg/d for 2 months. After the dose was gradually reduced to 15~20 mg/d for maintenance treatment, the symptoms were alleviated and stable, and he could tolerate general daily activities. In October 2008, the symptoms aggravated, cough and expectoration, chest tightness, dyspnea after activity progressively aggravated, and activity endurance significantly decreased. Therefore, the combined treatment with methotrexate 10 mg/week for 2 months, the symptoms were slightly alleviated, but the dyspnea after activity was not relieved. In the past 1 year, the symptoms were obviously aggravated, the activities were obviously limited, and dyspnea occurred at a slight movement. Long-term home oxygen therapy was given, and many hospitalizations were made. Since the onset of the disease, besides being diagnosed as "sarcoidosis", he has also been diagnosed with "Wegener's granuloma" and "pulmonary lymphangioleiomyomatosis". He was admitted to hospital on 4 May 2013 due to significant aggravation of dyspnea. History of enucleation of uterine fibroids and right hip trauma, and history of diabetes, hypertension and coronary heart disease were denied. Family history of hereditary disease denied.

Volume-controlled ventilation (VCV) is the earliest mechanical ventilation mode developed in the field of invasive mechanical ventilation and routinely applied in clinical practice. It is a controlled ventilation mode with preset tidal volume as the target and volume switching. It has been used in clinical practice for more than 60 years. With the continuous development of electronic engineering and computer technology and the deepening of human understanding of respiratory physiology, volume-controlled ventilation mode has been constantly improved and perfected, which has also derived many intelligent and more ideal mechanical ventilation modes, which promotes the continuous progress of mechanical ventilation technology.

The first working meeting of the 8th editorial committee of Chinese Journal of Tuberculosis and Respiratory Medicine was held in Beijing on December 21st, 2013. Professor Liu Youning, editor-in-chief, presided over the meeting. Academician Zhong Nanshan, honorary editor-in-chief, Luo Ling, deputy secretary-general of Chinese Medical Association, and Jiang Yongmao, president and editor-in-chief of the magazine, attended the meeting and delivered speeches. A total of 155 editorial board members and corresponding editorial board members attended the meeting.

The 4th Beijing Young Respiratory Scholars Salon in 2013 was held on November 28th, 2013. The theme of this salon was "Collection of Rare Diseases and Rare Diseases of the Lung", which was presided over by Dr. Shen Ning, Department of Respiratory and Critical Care Medicine, Peking University Third Hospital.

Since the advent of penicillin, human beings have achieved brilliant victories in the struggle against bacteria and other pathogens again and again. However, the problem of drug resistance of pathogens once again makes human life safety face serious threat. "If you do not act now, there will be no cure in the future!". In the "Editor-in-Chief's Essays" column, Editor-in-Chief Liu Youning expounded his personal views from the aspects of encouraging the development of new drugs, making full and rational use of existing drugs, and strictly controlling nosocomial infections. At the same time, he also analyzed the future of anti-infective treatment and strongly suggested "changing our fundamental strategy to deal with infectious diseases".