2010年 · 第33卷第07期

Since the successful study of streptomycin in 1944, tuberculosis has changed from no cure to cure, and gradually entered the era of short-course chemotherapy from long-term chemotherapy. Today, in the 21st century, the treatment of tuberculosis has become a difficult problem again. Some tuberculosis patients are treated for more than 2 years, and the root cause is MTB^[1]。

In the past five years, multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) have spread widely in South Africa, and South Africa is a high incidence area of human immunodeficiency virus (HIV) infection. They often coexist, resulting in the death of patients in a short time. The study aimed to analyze the prognosis and its associated factors in MDR-TB and XDR-TB patients in areas with high incidence of HIV infection. METHODS: A retrospective analysis of all MDR-TB and XDR-TB patients diagnosed in the Tugela Ferry region of South Africa from January 2005 to December 2007 was carried out, all of whom were treated with conventional first-line antituberculosis drugs prior to the report of drug susceptibility tests. After a definite diagnosis, MDR-TB patients were treated with kanamycin, ciprofloxacin, ethioisonicotine, ethambutol (sensitive), pyrazinamide (sensitive), terizidone or cycloserine for 6 months, after which kanamycin was discontinued for 18 months; Patients with XDR-TB were treated with a similar regimen, with only ciprofloxacin and kanamycin changed to sodium p-aminosalicylate and capreomycin. In which HIV-positive patients receive antiretroviral therapy. Results: A total of 272 MDR-TB and 382 XDR-TB patients were diagnosed. Of the 123 MDR-TB and 139 XDR-TB patients with complete case records, 85 (90%) MDR-TB and 115 (98%) XDR-TB patients were co-infected with HIV. The results of a cohort analysis of 265 MDR-TB and 374 XDR-TB patients showed an overall case fatality rate of 71% (188/265) and 83% (310/374), respectively; 106 (40%) MDR-TB and 191 (51%) XDR-TB patients died within 30 days of sputum collection, with a median survival of 60 days (95%CI39 to 174 d) and 28.5 d (95%CI20-34 d). The mean survival time of patients decreased with increasing resistance, with the longest survival time among patients resistant to isoniazid and rifampicin alone (182 d, 95%CI31 to 395 d), with the shortest mean survival time (27 d, 95%CI20-38 d). From 2005 to 2007, the mortality rate of patients decreased year by year within one year after sputum collection date, with 76%, 60% and 55% of MDR-TB patients and 85%, 84% and 75% of XDR-TB patients, respectively; Case mortality rates within 30 d also decreased year by year, 54%, 35%, and 34% for MDR-TB and 57%, 56%, and 42% for XDR-TB, respectively. Conclusions: The mortality rate of MDR-TB and XDR-TB patients is high in areas with high prevalence of HIV infection, especially within 30 days after the sputum collection day. Measures to reduce the mortality rate include early diagnosis, early administration of second-line anti-tuberculosis drugs and antiretroviral therapy.

KwaZulu-Natal, South Africa, is an endemic region of dual infection with human immunodeficiency virus (HIV) and tuberculosis. Traditional multi-drug resistant tuberculosis (MDR-TB) centralized hospitalization mode (referred to as hospitalization mode) increases the risk of nosocomial infection and also causes a heavy burden on economy and society. Therefore, there is an urgent need to promote and evaluate the community-based MDR-TB treatment model (referred to as the community model), in which patients are hospitalized for 4 weeks after obtaining drug-resistant culture results, and if there are no complications, they continue to undergo supervised chemotherapy under direct visits at the nearest primary health care facility to home, with monthly hospital follow-up. The study aimed to evaluate the early treatment effect of the community model on MDR-TB and compare it with the hospitalization model. Methods: Demographic, clinical and laboratory data of MDR-TB patients treated in a community model from March to December 2008 were recorded, as well as CD₄⁺Cell counts and antiretroviral therapy, with MDR-TB cases treated in the inpatient mode from 2001 to February 2008 as controls. Results: Among the 50 cases enrolled in the community model group, 39 cases were HIV positive, which was significantly higher than that in the inpatient model group (57 cases enrolled, 30 cases were HIV positive), but the CD between the two groups₄⁺There was no significant difference in the median cell count; The average treatment of the community model group was 84 days, which was significantly less than 106.5 days in the hospitalization model group; The average sputum smear negative conversion time in the community model group was 59 days, which was significantly less than 92 days in the hospitalization model group; The average sputum culture negative conversion time in the community model group was 85 d, which was significantly less than that in the hospitalization model group of 119 d. CONCLUSIONS: The community-based MDR-TB treatment model can accelerate the negative sputum conversion of patients and improve the early treatment effect of MDR-TB. This model is not only suitable for rural areas in South Africa, but also can be used in scale where resources allow.

Although combination has become a basic principle for the treatment of active pulmonary tuberculosis, the exact efficacy of different medication regimens is still lacking in sufficient clinical data validation. This study systematically reviewed the rifampicin regimen in active pulmonary tuberculosis to assess the effect of frequency and length of treatment on the outcome of active pulmonary tuberculosis. Methods: All English, French and Spanish literature from 1965 to 2008 were searched in the PubMed, Embase and Cochrane databases, selecting active pulmonary tuberculosis treated with rifampicin, clinical trials with evidence of bacteriological diagnosis and evaluation for meta-analysis. Results: A total of 57 clinical trials were analyzed, including 312 treatment groups, 21 472 patients with active pulmonary tuberculosis. The rate of treatment failure, TB recurrence and acquired drug resistance were significantly higher with rifampicin only in the pre-treatment period (2 months) compared with the 6-month continuous treatment regimen, and this difference was more significant when the strain was resistant to isoniazid and/or streptomycin prior to treatment. Different dosing frequencies (once daily, twice weekly, and three times weekly) had no significant effect on treatment outcome. Conclusion: The shortened course of rifampicin or the resistance of strains to isoniazid and/or streptomycin significantly worsened the outcome of patients with active pulmonary tuberculosis; Different frequencies of medication have no significant difference in outcome, but due to insufficient clinical records of medication twice a week, this conclusion needs further verification.

The main purpose of implementing modern tuberculosis control strategies (DOTS strategies) is to prevent the occurrence of multidrug-resistant tuberculosis (MDR-TB), because MDR-TB is not only difficult to cure, but also has a long course of treatment, high cost and many adverse reactions. The epidemic of MDR-TB in India is very serious, but the data of MDR-TB from India is very limited. This study aims to understand the distribution characteristics of resistance to first-line and second-line anti-tuberculosis drugs in patients with retreated tuberculosis in India. Methods: Retrospective analysis of sputum MTB culture and drug susceptibility test of 2816 patients with repeated treatment of tuberculosis in Chennai Tuberculosis Research Center, South India, from 2001 to 2004. Results: 2108 cases (75%) had at least one drug resistance, among which isoniazid had the highest resistance rate (1902 cases, 67%), followed by rifampicin (1529 cases, 54%), streptomycin (1219 cases, 43%), ethambutol (841 cases, 30%), ethioisonicotine (692 cases, 25%), ofloxacin (272 cases, 9.7%) and kanamycin (184 cases, 6.5%); MDR-TB was 1498 (53.0%), extensively drug-resistant tuberculosis was 69 (4.6%), and resistance to more than one second-line antituberculosis drug was 671 (44.8%). Conclusion: Because the selected cases are mainly patients with treatment failure and chronic evacuation, the rate of multidrug resistance is high. However, the high rate of second-line antituberculosis drug resistance and extensive drug resistance in MDR-TB patients should be highly paid attention to, and the management measures for rational use of second-line antituberculosis drugs should be formulated as soon as possible.

Drug-resistant tuberculosis, especially multidrug-resistant tuberculosis (MDR-TB), is a serious challenge in the control of tuberculosis. According to WHO estimates, about 510,000 cases of MDR-TB occur worldwide every year^[1]。 About 120,000 cases of MDR-TB occur in China every year^[2]。 The occurrence of drug-resistant tuberculosis is closely related to the previous irregular and irregular treatment^[2,3]。 If second-line anti-tuberculosis drugs are randomly used to MDR-TB patients without regulatory requirements, it will lead to more severe and difficult to cure extensively drug-resistant tuberculosis (XDR-TB) resistant to second-line major drugs, which will cause the spread of more drug-resistant MTB in healthy people. At present, the abuse of second-line anti-tuberculosis drugs in many areas of China is serious, and the treatment of MDR-TB is also in a blank or irregular treatment state. Therefore, the Chinese Anti-Tuberculosis Association organized relevant experts to modify, expand and improve on the basis of the "Opinions on Chemotherapy of Multidrug-Resistant Tuberculosis (Trial)" compiled in 2002^[4]Refer to WHO's "Guidelines for Programmatic Management of Drug-Resistant Tuberculosis (2008 Emergency Revision)"^[5]Combined with the actual situation in China, the "Guidelines for Chemotherapy of Drug-Resistant Tuberculosis (2009)" was prepared in 2009^[6](hereinafter referred to as the guidelines), which has guiding significance for standardizing the treatment of drug-resistant tuberculosis in China. Here, the author briefly expounds and interpretes its key contents.

To determine whether tuberculosis patients are resistant to drugs, it needs to be confirmed by laboratory drug sensitivity tests. Drug-resistant tuberculosis refers to the phenomenon that MTB infected by tuberculosis patients is confirmed to be resistant to one or more anti-tuberculosis drugs by in vitro tests. Drug-resistant tuberculosis is generally divided into four categories.

Drug-resistant tuberculosis is a major public health problem as well as a social problem. An estimated 500,000 new cases of multidrug-resistant tuberculosis (MDR-TB) occur worldwide every year^[1]About 120,000 new MDR-TB patients occur in my country every year^[2]。 In 2006, the World Health Organization (WHO) published the "Guidelines for the Programming and Management of Drug-Resistant Tuberculosis" (referred to as the 2006 Guidelines)^[3]This guideline has played a positive role in promoting the global prevention and treatment of drug-resistant tuberculosis. Extensively drug resistant tuberculosis (XDR-TB) has emerged in recent years^[4]At the same time, due to the continuous accumulation of experience in drug-resistant tuberculosis management and the application of new diagnosis, treatment and management technologies, the original 06 version of the guide has been difficult to meet the current work needs. In 2008, the WHO published "Guidelines for the Programming and Management of Drug-Resistant Tuberculosis (2008 Emergency Revision)", based on the 06 edition of the Guidelines^[5]From the perspective of national tuberculosis prevention and control planning, this guide concentrates the latest concepts and experiences of drug-resistant tuberculosis management in the world, and provides a variety of choices for drug-resistant tuberculosis prevention and control models in different regions and environments.

The epidemic of drug-resistant and multidrug-resistant tuberculosis (MDR-TB) is an important reason for the high epidemic situation of tuberculosis at present. According to the results of the national baseline survey of tuberculosis drug resistance conducted in China from 2007 to 2008, it is estimated that there are 120,000 new cases of MDR-TB in China every year, accounting for 24.0% of the total number of new cases (510,000) in the world every year, ranking second in the world. The high risk factors leading to MDR-TB include host factors such as diabetes, malnutrition, human immunodeficiency virus (HIV) infection and immunosuppressive therapy, medical factors such as irrational medication regimen, wrong dosage and irregular medication, and social factors such as low education level. However, a considerable number of patients still do not have the above conditions. More and more research results suggest that host genetic factors play an important role in the occurrence and development of tuberculosis^[1]。 The results of gene linkage analysis based on family studies and correlation analysis based on case-control studies showed that the differences in individual susceptibility or resistance to tuberculosis were related to some genes in the host. At present, on the basis of animal experiments, many candidate genes related to human tuberculosis have been screened and studied among different ethnic groups. Initial research focused on the association of these candidate genes with tuberculosis infection and susceptibility. As the conclusions of the research gradually became clear and accepted, the research focus shifted to the correlation between these genes and tuberculosis severity.

Since 1970s, from simple bronchial smooth muscle spasm to chronic airway inflammation, human understanding of bronchial asthma (asthma for short) has undergone a fundamental change, thus laying the cornerstone of modern treatment of asthma with anti-inflammation as the main factor. Anti-inflammatory drugs with inhaled corticosteroids (ICS) as the main factor have been widely used in clinical practice, and have achieved remarkable results, which provide unquestionable evidence for the theory of airway inflammation. But can airway inflammation explain all the pathophysiological phenomena of asthma and its consequences? Can it truly reflect the whole picture of asthma? Studies have shown that the severity of airway inflammation is not correlated with asthma symptoms and lung function. Effective anti-inflammatory treatment cannot cure asthma and completely eliminate airway hyperresponsiveness. Individuals without clinical symptoms and airway inflammation may still have airway hyperresponsiveness. In the pathogenesis of asthma, there seems to be a missing link between airway inflammation and airway reactivity^[1]。

Atypical pathogens, including Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophila, play an important role in community-acquired pneumonias (CAP), and their etiological diagnosis is crucial for the treatment and prognosis of clinical SARS patients. At present, the detection of atypical pathogens has many limitations: (1) it is difficult to obtain qualified test specimens from patients with atypical pneumonia; (2) Clinical microbiology rooms where atypical pathogens are routinely cultured and detected are not common; (3) The sensitivity and specificity of current atypical pathogen detection technology are not ideal. Nonetheless, detection techniques such as molecular biology have been increasingly applied to the etiological diagnosis of atypical pathogens, which brings promise to clinical diagnosis and treatment.

neurally adjusted ventilatory assist (NAVA) is a completely new ventilation mode. Its working principle is to sense the actual ventilation needs of patients by monitoring neurorespiratory signals, and then provide physiological respiratory support. Different from the current ventilation mode, NAVA does not need to set parameters such as volume and pressure. It uses neuro-respiratory signals to control ventilator ventilation, which can not only monitor patients' ventilation needs in real time, but also realize patients' complete control of ventilator ventilation, creating another new field of mechanical ventilation.

venous thromboembolism (VTE) mainly includes deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE), which are different clinical manifestations in two different stages of the same disease course. European research data show that the number of symptomatic VTE occurs more than 1.5 million per year, and the number of VTE-related deaths is about 543,500 per year. The diagnosis of VTE in China is also increasing year by year. Several studies have shown that P-selectin, as an inflammatory factor, plays an important role in the pathogenesis of VTE, and inflammation itself is closely related to VTE. Based on the pathogenesis of VTE, we summarized the role of P-selectin in VTE and its relationship with inflammation.

The ratio of mean flow to forced vital capacity between 25% and 75% of forced exhaled air volume (FEF_25%-75%/FVC) is an indicator that reflects the relative size of airway volume. Recent studies have confirmed that the relative size of airway volume is related to airway hyperresponsiveness. In this study, the histamine challenge test was used to follow up patients with airway hyperresponsiveness for two years to explore the FEF_25%-75%Correlation of/FVC values with the onset of bronchial asthma (asthma for short) and its value in the diagnosis of asthma.

In recent years, with the continuous development of interventional pulmonology techniques, trans-bronchoscopic hypertensive balloon dilatation has become one of the effective methods for the treatment of tuberculous tracheal and bronchial scar stenosis^[1,2]。 We retrospectively analyzed the clinical data of 91 patients with tuberculous tracheal scar stenosis treated with high pressure balloon dilatation to explore the short-term and long-term efficacy and safety of high pressure balloon dilatation in the treatment of tuberculous tracheal stenosis, and evaluated its clinical application value.

Severe acute eosinophilic pneumonia (AEP) is clinically rare, and complicated with eosinophilic tension hematochemic pneumothoracic shock is even rarer. From January 1991 to January 2008, 6 cases of severe acute eosinophil pneumonia with disappearance of peripheral blood eosinophils were diagnosed in Zongrui Hospital, Ningbo City, Zhejiang Province. All of them were misdiagnosed before admission, including 5 cases of severe acute bacterial pneumonia and 1 case of cancerous tension blood hemopneumothorax. The diagnosis and treatment are reported as follows.

A 52-year-old male, who underwent left upper lobectomy for 8 months due to lung cancer and held his breath for 6 months after operation, went to the respiratory department of Peking University First Hospital on January 11, 2007. Eight months ago, the patient was diagnosed with "central squamous cell carcinoma of left lung" by chest CT and other examinations in the local hospital due to hemoptysis, and double sleeve resection of the left upper lobe, bronchi and left pulmonary artery was performed. There was no chemotherapy after the operation, and there was intermittent cough and expectoration, and occasionally blood in the sputum after severe cough. Six months ago, I was holding my breath after activity, and chest CT found "stenosis of the lower segment of the left main bronchi and shadow of the soft tissue density of the left hilar". A reexamination of the chest CT 2 months ago showed "the shadow of the left hilar soft tissue increased compared with the previous one". The patient's spirit and appetite were acceptable, his defecation was normal, and his weight did not change significantly. Excision of benign fibroma of the abdominal cavity 3 years ago. He smoked 30 packs of cigarettes per year and had quit smoking for 8 months. Physical examination: blood pressure 120/70 mm Hg (1 mm Hg =0.133 kPa), 18 breaths/min, heart rate 64 beats/min, body temperature 36 ℃. Superficial lymph nodes throughout the body were unpalpable. Tactile speech trembling on the left side of the chest was slightly enhanced, both lungs were voiceless after percussion, and the breathing sound of the left lung was low. No dry or wet rales were heard. There was no tenderness on abdominal palpation, and no subcostal palpation of liver and spleen. Admission diagnosis: Left main bronchial stenosis, after resection of left upper lobe lung cancer.

COPD is one of the important diseases that endanger human health worldwide. According to the epidemiological survey data in China, the prevalence rate of COPD among people over 40 years old is 8.2%, so it is estimated that there are about 40 million COPD patients in China. The World Health Organization predicts that COPD will rise from the 6th leading cause of death worldwide to the 3rd leading cause of death in 2020. COPD will become a serious public health problem and a heavy social and economic burden in China. Therefore, it is of great significance to understand the pathogenesis and natural course of COPD deeply.

Drug-resistant tuberculosis, especially multidrug-resistant tuberculosis (MDR-TB), is a serious challenge for tuberculosis control at present. The emergence of drug-resistant tuberculosis is closely related to the irregular treatment of patients in the past. In some areas of China, the abuse of second-line anti-tuberculosis drugs is serious, and the treatment of multi-drug-resistant tuberculosis is also not standardized. Standardizing chemotherapy methods for drug-resistant tuberculosis has become an urgent problem for tuberculosis prevention and treatment workers. Therefore, China Anti-Tuberculosis Association organized relevant experts to revise, supplement and improve the "Opinions on Chemotherapy of Multidrug-Resistant Tuberculosis (Trial)" formulated in 2002, and compiled the "Guidelines for Chemotherapy of Drug-Resistant Tuberculosis (2009)" with reference to the "Guidelines for Planning and Management of Drug-Resistant Tuberculosis (2008 Emergency Revision)" formulated by WHO and the actual situation in China, which has guiding significance for standardizing chemotherapy of drug-resistant tuberculosis in China and makes the clinical treatment of drug-resistant tuberculosis well-documented.