2012年 · 第35卷第04期

The author was invited to give a special report for the National Society of Microbiology on how clinicians evaluate the results of sputum bacterial culture and in vitro drug susceptibility tests, and also published a special written talk on this content in the Chinese Medical Journal^[1]。 In view of the clinical importance of this proposition and the long-existing vague understanding and debate on the related issues, the author would like to talk about my preliminary understanding of this issue again in the column of "Editor-in-Chief Essay" for criticism and reference.

The results of epidemiological investigation of COPD in China show that the prevalence of COPD in adults over 40 years old is 8.2%, of which 12.4% are males and 5.1% are females^[1]。 In this epidemiological survey population, the proportion of COPD patients with severity grade I and II (mild and moderate) was as high as 70.7%. However, these patients have almost no shortness of breath (including shortness of breath after activity), or only chronic cough, expectoration and other symptoms, and patients tend to ignore the above mild symptoms. Therefore, only 35.1% of patients have been diagnosed with COPD, and its diagnosis rate is far lower than the prevalence rate. In addition, among all patients, less than 25% have taken the initiative to see a doctor, which leads to a low diagnosis rate of COPD in my country and a treatment rate far lower than the actual prevalence rate. Patients encountered by doctors in clinical practice often seek medical advice after symptoms such as shortness of breath after activity or even shortness of breath in a quiet state. These symptomatic COPD patients, their lung function (FEV₁% of the projected value) at least less than 60%^[2]and has delayed the optimal timing of treatment. Why can't the prevention and treatment of COPD follow the prevention and treatment strategies of hypertension, coronary heart disease or diabetes, and actively start intervention and treatment when blood pressure, blood cholesterol or triglycerides and blood sugar increase, although there are no symptoms? At present, the prevention and treatment of COPD lags far behind other chronic diseases, resulting in unsatisfactory effect of COPD intervention and treatment, and the mortality rate remains high.

At present, it is believed that the immune response induced by systemic inflammatory factors in sepsis plays an extremely important role in the formation and development of organ dysfunction such as acute kidney injury. The release of a large number of inflammatory factors can cause local inflammatory response and enhanced oxidative stress. Myeloid cell trigger receptor-1 (TREM-1) is a newly discovered immunoglobulin superfamily receptor. STREM-1 is a soluble form of TREM-1, which can be released into bodily fluids with upregulated release of TREM-1. It is a biomarker of great diagnostic value for differentiating infection, and can judge the severity and prognosis of disease. This study aimed to explore the diagnostic value and significance of STREM-1 in sepsis and associated acute kidney injury.

Airway inflammatory response plays an important role in the pathogenesis of COPD. Under the action of tobacco smoke and other stimulating factors, it causes airway inflammatory cells to recruit, stimulates congenital and secondary immune responses, and then leads to thickening of tracheal wall, airway remodeling, increased bronchial smooth muscle tone, hypersecretion of mucus and loss of elastic structure of lung parenchyma, which are important basic structural lesions of COPD pathogenesis. The oxidative stress component of the stimulus can impair tissue integrity, accelerate the aging process of the lungs, and lead to reduced sensitivity to glucocorticoids in COPD patients by downregulating histone deacetylase – 2. In addition, protease/antiprotease imbalance is also an important factor that mediates the inflammatory response of COPD and leads to tissue damage. Moreover, the inflammatory response of COPD is not limited to the lungs, but a systemic and systemic inflammatory response, which can cause multiple organ damage and is associated with multiple comorbidities in COPD patients^[1]。

The first edition of the Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease has been published since 2001 "(Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, COPD Global Strategy (COPD Global Strategy for short) has been 10 years, and considerable progress has been made in COPD research in 10 years. COPD Global Strategy 2011 Revision (COPD Global Strategy Revision) officially promulgated on 29 December 2011^[1], has been significantly modified based on the original version based on the latest progress in clinical studies of COPD.

American College of Physicians (ACP), the American College of Chest Physicians (ACCP), ATS And ERS jointly released a new version of the "Clinical Practice Guidelines for the Diagnosis and Treatment of Stable Chronic Obstructive Pulmonary Disease"^[1]。 This guideline is an update of the 2007 ACP guidelines for COPD in stable phase. It is mainly aimed at all doctors engaged in clinical work of COPD. It pays more attention to clinical application and has strong practicality.

People who live or have been to the countryside, or even if they are not familiar with the countryside, can see on television that many mammals other than humans, such as cows, horses, donkeys, sheep, dogs, whose offspring such as calves, foals, lambs, etc. struggle to stand up soon after birth and can walk upright after a few hours, whereas humans are different. Newborns can't stand at all after birth, let alone walk, and don't learn to walk until they are 1 to 1.5 years old. This suggests that human pregnancies are relatively too short. Some people assume that the pregnancy period of human women is 21 months, but in reality, the pregnancy period of women is only 10 months now, so-called "ten months of pregnancy and delivery". In this sense, all births of pregnant women are now considered premature.

The results of pathological studies show that there is an association between COPD and lung cancer, which is based on the fact that smoking is a common risk factor for COPD and lung cancer, and 50% to 90% of lung cancer patients have a history of smoking. Lung cancer is also one of the important causes of death in COPD, and COPD increases the risk of lung cancer by 4.5 times; The association was stronger in the female population^[1]。 The results of basic research also confirm that COPD and lung cancer may have a common pathogenic mechanism^[2]Among the epigenetic changes, environmental factors lead to genomic changes caused by smoking-mediated oxidative stress response, which attracts more attention than genetic changes. Therefore, understanding the molecular changes of COPD susceptibility genes and conduction pathways may provide new targets for the prevention and treatment of COPD and lung cancer. The author reviews the association of epigenetic modified enzymes with COPD and lung cancer.

COPD and lung cancer are both high morbidity and mortality diseases. With the increase of tobacco consumption and the change of age structure of the world population, the incidence of COPD has reached 10%^[1], ranking fourth among the causes of death in the global population^[2]The incidence of lung cancer accounts for 12% of all tumors and is the most common malignant tumor. About 1.35 million people suffer from lung cancer worldwide every year, and about 1 million people die from lung cancer^[3]。 The incidence of lung cancer in COPD population is significantly higher, 50% ~80% of lung cancer patients are complicated with COPD, therefore, COPD is the main risk factor of lung cancer^[4]The pathogenesis of COPD and lung cancer is determined by a variety of complex mechanisms. Genes and environmental factors interact to influence the course of the disease. At present, it is believed that genetic background and chronic inflammatory response are the key factors of COPD complicated with lung cancer, and the mechanisms of elevated lung cancer risk in COPD patients mainly include the following aspects.

Pulmonary function examination is of great significance to determine airflow limitation in COPD, and the use of multi-slice spiral CT to study lung function has been affirmed by most scholars^[1,2]。 At present, the quantitative study of CT lung function mostly uses inspiratory phase and expiratory phase scanning. Because of the large exposure dose, it is harmful to patients, but the results of local level scanning are biased. In this study, low-dose multi-slice spiral CT scan was used to quantitatively analyze the lung function of patients with COPD, and compared with conventional lung function to determine clinically feasible application parameters.

COPD not only affects the lungs, but also causes systemic (or extrapulmonary) adverse effects. Osteoporosis is one of its systemic adverse effects. The results of the present study confirm that the prevalence of osteoporosis in COPD patients is significantly higher than that of peers, and oral glucocorticoids, reduced activity, smoking, malnutrition, vitamin D deficiency, advanced age, and hypoxia may be risk factors for osteoporosis in COPD patients^[1]。 Recently, some foreign scholars have reported that the elevated level of high density lipoprotein-cholesterol (HDL-ch) in COPD patients may be one of the risk factors for secondary osteoporosis^[2]。 This study investigated the relationship between HDL-ch and osteoporosis in patients with COPD by observing the changes of bone mineral density, serum HDL-ch and lung function in patients with COPD.

A 59-year-old male developed needle-like pain in his right chest without obvious trigger on June 30, 2011, which was aggravated when he inhaled, and felt chest tightness after activity, accompanied by chills, fever and a small amount of sputum and blood. He was admitted to the emergency department without special treatment. After asking for the medical history, the patient underwent colonoscopy in August 2010 due to "bloody stool" and was diagnosed with "ulcerative colitis", and was given mesalazine 5 packs/d oral treatment.

COPD and bronchial asthma (asthma for short) are two different diseases, and the differences between them are also obvious: one is a disease that occurs in adults and is related to smoking and neutrophils, and the best treatment is the use of bronchodilators and the removal of risk factors; One is a disease of childhood origin, associated with allergies and eosinophils, and the best treatment is medication for airway inflammation. However, in clinical practice, it is sometimes not easy to not "misdiagnose" asthma as COPD, or "misdiagnose" COPD as asthma. To make matters more complicated, the coexistence of COPD and asthma^[1], also known as COPD and asthma overlap syndrome^[2]。 Through literature analysis, it can be found that due to different diagnostic criteria adopted, the prevalence of COPD and asthma coexistence also has a large difference. Reflected in clinical practice, the diagnosis of patients with COPD and asthma reflects the doctor's confusion about the diagnosis, and it is uncertain that it is asthma or COPD; Or does it mean that overlapping syndrome is a specific phenotype of COPD or asthma, and its condition is more severe and complex? This question is not easy to answer. Obviously, to identify overlapping syndromes in COPD and/or asthma populations, there needs to be a clear case definition, which unfortunately is not currently available. Current COPD guidelines and asthma guidelines both mention that both can be seen clinically, but how to define and manage it is not explained. The author talks about this issue in combination with the literature.

It is generally believed that COPD and bronchial asthma (asthma for short) are two different diseases, and there are also theories that they are different phenotypes of the same disease. In recent years, concerns have been raised about the coexistence of COPD and asthma, which is called "COPD-asthma overlap syndrome"^[1,2]Such patients have more acute exacerbations, a faster rate of lung function decline and a worse quality of life. Nonetheless, COPD-asthma overlap syndrome is not clearly defined at present, and is mostly classified as a study for the co-diagnosis of asthma and COPD in epidemiological investigation studies^[3]。 So, can COPD and asthma be co-diagnosed, and what is the implication of co-diagnosis for clinical treatment and research? The author believes that the answers to the above questions should be inspired by the purpose of the original definition of COPD and the current definitions of asthma and COPD.

The results of a multi-center large-sample survey on the etiology of community-acquired pneumonia in urban adults in China, led by Professor Liu Youning of the Infectious Disease Group of the Respiratory Disease Branch of the Chinese Medical Association, were published in this journal^[1]Then it was widely cited by domestic peers, which indicates that this research has been widely recognized and valued by everyone. The results of this study provide an important basis for the prevention and treatment of community-acquired pneumonia (CAP) in China, especially the rational application of antimicrobial drugs, and have important guiding significance for the formulation of the diagnosis and treatment guidelines of CAP in China^[2]。

At the beginning of 2006, this journal officially published the results of a one-year study on the etiology of adult community-acquired pneumonia (CAP) led by the Infectious Disease Group of the Respiratory Disease Branch of the Chinese Medical Association and conducted by more than a dozen hospitals^[1]This paper has attracted widespread attention after its publication, and has been rated as one of the 100 highly cited scientific papers in China. Looking back, the most commendable aspects of this study are mainly the serious and meticulous attitude of all the participants and the progress in the culture technology of caustic bacteria (mainly Streptococcus pneumoniae and Haemophilus influenzae). Led by Professor Chen Minjun and Professor Wang Hui, all participating research units were organized to conduct strict training on a series of technologies such as caustic bacteria collection, culture medium production, strain preservation and transportation. The results of Streptococcus pneumoniae and Haemophilus influenzae reported in this paper account for nearly 20% of the isolation of adult CAP bacteria in China, and few people can repeat them in China. This study reported for the first time that the serologically confirmed atypical pathogens in adult CAP in China exceeded the sum of isolated Streptococcus pneumoniae and even caustic bacteria. As Professor How Kwon Ying pointed out, this result has aroused doubt and controversy since its publication, and I have also answered questions similar to Professor Ho's many times orally on different occasions. After six years, thanks to Professor He, I once again proposed that as the responsible author, I should give readers some explanations.

A 65-year-old female, a housewoman, was admitted to the hospital on 5 September 2010 due to "recurrent fever, cough, expectoration, chest pain for 4 months, aggravated for 1 d". The patient developed fever without obvious trigger 4 months ago, with a body temperature of about 38.0℃, accompanied by cough, cough of white sputum, occasionally with a little bloodshot in the sputum, no odor, small amount, and right lower chest pain, aggravated when coughing and deep breathing, no shortness of breath, no night sweats. At that time, CT examination of the lung in an outside hospital showed right lower lung abscess, and bronchoscopy showed bronchitis changes. After one month of anti-infection and phlegm-reducing treatment (details unknown), the right lower lung abscess shrank, and the condition improved and was discharged. After discharge, the patient took cefdinir and other drugs orally irregularly, but he still had repeated fever, with a maximum body temperature of 38.0℃, cough and yellow purulent sputum without odor, still had right chest pain, occasionally blood in sputum, and the amount was small, so he did not see a doctor. One day before admission, fever appeared again, body temperature reached 38.0℃, cough, expectoration, and right chest pain were worse than before, so I went to our hospital for an X-ray chest radiograph, which showed a mass of flake-like density thickening shadow in the right lower lung, and an arc-like high-density shadow was faintly visible at the edge. Considering infectious lesions combined with abscess formation, with the possibility of right pleural effusion (Figure 1)。 Since the onset of the disease, the patient has poor appetite, acceptable sleep, normal urine and defecation, and no obvious change in weight. Past history: 2-year history of diabetes, usually given insulin combined with oral hypoglycemic drugs, blood glucose was not monitored. Yu Nothing Special.

The 12th National Conference on Respiratory Diseases of Chinese Medical Association was held in Guangzhou Baiyun International Conference Center from September 15 to 18, 2011. This conference is different from the previous annual meetings in terms of the number of participants, the number of special lectures, the form of holding the conference, especially to fully mobilize the enthusiasm of various academic groups and improve the professionalism and depth of academic lectures.

Regardless of the disease, the occurrence and development of pulmonary dysfunction is a dynamic process, and accordingly, its diagnosis and grade are also different. In this paper, COPD, idiopathic pulmonary interstitial fibrosis (IPF) and pulmonary embolism (PE) are used as representatives of airway diseases, pulmonary parenchymal diseases and pulmonary vascular diseases to explain the dynamic changes, change mechanisms and diagnosis of pulmonary function.

The birth of antimicrobial drugs ended the history of incurable infectious diseases, and is recognized as the third major invention of World War II, alongside the atomic bomb and radar^[1]。 However, with the long-term use of antimicrobial drugs in clinical practice, especially the irregular abuse has led to an increasingly serious problem of bacterial resistance. The emergence of bacterial drug resistance often leads to the failure of clinical treatment, resulting in the increase of mortality, prolonged hospital stay and increased medical expenses, which has become a serious problem that threatens human health^[2]。

The 9th event of Beijing Young Respiratory Scholars Salon 2011 was held at the Chinese Medical Association on November 24th, 2011. It was presided over by Du Yuguo, deputy chief physician of Beijing Military Region General Hospital, with the theme of "Diagnosis and Treatment of Hemoptysis".

On the morning of December 29th, 2011, with light snowflakes falling in the sky, I said goodbye to my postgraduate tutor, a famous tuberculosis epidemiologist in China, former deputy chairman of the Tuberculosis Society of Chinese Medical Association, deputy editor-in-chief of Chinese Journal of Tuberculosis and Respiration, and researcher Wang Zhongren, director of the Flow Research Office of Beijing Institute of Tuberculosis, with great sadness.

COPD is a chronic progressive disease, and the effect of existing prevention and control strategies is not satisfactory. The prevalence and mortality of COPD people have not yet improved, and there is even a tendency to further aggravate. Therefore, it is crucial to actively explore new prevention and control strategies for COPD people. Academician Zhong Nanshan, the special honorary editor-in-chief of this journal, wrote a review. The article quoted the latest research data in the field of COPD, pointing out that the research energy should not be focused on middle and advanced patients, but should focus on early detection, early diagnosis and early intervention. Academician Zhong pointed out the direction of COPD research for us from the perspective of prevention and control, which is of far-reaching significance.