2012年 · 第35卷第08期

The development of clinical medicine is very rapid, and many sub-specialties and interdisciplinary subjects have been derived on the basis of classical specialties. No matter how energetic and hard a person is, even if he tries his entire life, he can't be proficient in everything. Therefore, in large general hospitals, senior doctors, such as attending doctors and deputy chief doctors, often choose key areas of specialization in specialties and undergraduate specialties according to their own interests and work needs. As far as respiratory medicine is concerned, some people focus on lung cancer, others focus on respiratory failure and respiratory tract infections, and others focus on sleep breathing disorders, pulmonary fibrosis, COPD or bronchial asthma, etc. All well-known experts are known for having outstanding attainments in one or two sub-specialties. On the contrary, although a senior doctor has comprehensive knowledge and rich clinical experience, but has not established his own expertise, he is not valued by others, and is even easily nicknamed "all-in-one oil". But in fact, such doctors are generally welcomed by patients not only in primary hospitals, but even in large general hospitals. This article intends to discuss the importance of expanding clinical and basic knowledge with doctors who have just entered respiratory specialty in combination with the author's medical career.

nontuberculous mycobacteria (NTM) is a kind of environmental growth bacteria, which is widespread in nature and belongs to conditional pathogens. At present, about 154 species of NTM have been found in the world, among which only a very small number of pathogenic bacteria are found. The harm of NTM mainly includes nosocomial infection, chronic lung disease and immunocompromised patients, among which NTM nosocomial infection has the greatest social impact^[1]。

With the development of bacteriological and molecular biological identification technology of nontuberculous mycobacteria (NTM), the improvement of people's understanding of NTM, the prevalence of acquired immunodeficiency syndrome (AIDS) and the aging of the population, the incidence of NTM disease is increasing, and the number of cases diagnosed with NTM lung disease among sputum acid-fast bacilli positive patients is gradually increasing. In some countries and regions, the infection rate and prevalence of NTM even exceeds that of tuberculosis. The pure protein derivatives of intracellular mycobacteria (PPD ofMycobacterium intracellulareThe positive rate of PPD-B test increased from 11.2% (1971-1972) to 16.6% (1999-2000), exceeding the MTB infection rate in the same period (4.2%)^[1,2]。 The ratio of NTM to TB in a community hospital in the United States increased from 1:3.2 in 1980 to 1.6:1 in 1990^[3]。 The prevalence of NTM lung disease in Ontario, Canada increased from 9.4/100,000 in 1997 to 14.1/100,000 in 2003, and the avian-intracellular complex group (Mycobacterium avium-intracellularecomplex (MAC) and rapidly growing mycobacteria (RGM) were significantly higher than those of pulmonary tuberculosis^[4]。 Although China is one of the 22 countries with a high burden of tuberculosis in the world, the isolation rate of NTM has reached 22.9% in 2010. Therefore, NTM lung disease cannot be ignored in daily diagnosis and treatment. Regarding the diagnostic criteria of NTM lung disease, there are relevant guidelines formulated by China, the United States and Japan that can be used for reference. However, how to find patients with suspected NTM lung disease and improve the diagnostic level of NTM lung disease in the specific implementation needs to pay attention to the following aspects.

nontuberculous mycobacteria (NTM) lung disease is the most common NTM disease. In recent years, due to the prevalence of acquired immunodeficiency syndrome (AIDS) and the improvement of laboratory testing methods, the incidence of NTM pulmonary disease is increasing, which has become an important public health problem in many countries and regions^[1,2,3]。 However, because most NTM are resistant to commonly used anti-mycobacterial drugs, the treatment of NTM pulmonary disease faces many difficulties and confusions, and has attracted the attention and attention of clinicians.

The genus mycobacteria is collectively referred to as nontuberculous mycobacteria (NTM) in addition to the MTB complex and Mycobacterium leprae^[1]More than 150 species have been reported so far, and there is an increasing trend. Epidemiological sampling reports showed a marked increase in the proportion of NTM strains among suspected tuberculosis patients, from 4.9 percent in 1990 to 11.1 percent in 2000^[2]To 22.9% in 2010^[3]。

nontuberculous mycobacteria (NTM) are other mycobacteria within the genus mycobacteria other than the MTB complex and Mycobacterium leprae. To date, 154 species of NTM (www.bacterio.cict.fr/m/mycobacterium.html) and 13 subspecies have been found, most of which are rot parasites, and only a few are pathogenic to humans. NTM can invade human lung, lymph nodes, bones, joints, skin and soft tissues and other tissues and organs, and can cause systemic disseminated diseases^[1]。 In recent years, NTM disease has been increasing rapidly and has become an important public health problem that threatens human health^[2]。 In order to cope with the increasing situation of NTM disease, improve the diagnosis and prevention level of NTM disease, and reduce the threat of NTM to human life and health, after extensive consultation and repeated discussion of domestic experts and scholars on epidemiology, basic, clinical and prevention of NTM disease, the "Guidelines for Diagnosis and Treatment of NTM Disease" in China in 2000^[3]and the United States 2007 "Guidelines for the Diagnosis, Treatment and Prevention of NTM Disease"^[4]Based on this, referring to the research achievements and experience of diagnosis and treatment of NTM disease at home and abroad in recent years, the "expert consensus on diagnosis and treatment of non-tuberculous mycobacterial disease" was finally formed.

tracheobronchial tuberculosis (TBTB) refers to tuberculosis that occurs in the mucosa, submucosa, smooth muscle, cartilage and adventitia of the trachea and bronchi^[1]。

The LSR2 protein was first discovered in M. leprae (Mycobacterium leprae), composed of 89 amino acid residues, is one of the main immunogens of Mycobacterium leprae, has strong immunogenicity, can be recognized by B cells and T cells at the same time^[1,2,3]。 This antigenic protein, which is ubiquitous in mycobacteria and some actinomycetes, has a highly conserved sequence and is a histone-like DNA binding protein, which has a wide range of regulatory effects on gene expression^[4,5,6]。 The research progress of LSR2 protein is summarized as follows.

According to data provided by the World Health Organization, 1.7 million people died of tuberculosis in 2009, and more than 2 billion people worldwide (about 1/3 of the world's total population) were infected with MTB. In the past, the exact pathogenic mechanism, virulence factors and host-pathogen interaction relationship of MTB were not clear. The completion of MTB 4.4 Mb genome sequencing makes the above problems promising to be explained. H in MTB₃₇About 10% of the open reading frames in the Rv genome encode a class of proteins containing a characteristic motif at the N-terminus^[1]Because of the large number of genes encoding these proteins and the specific protein structure, they play an important role in the survival, proliferation and pathogenesis of MTB. In this paper, the research progress of the structure and function of this protein family is reviewed.

nontuberculous mycobacteria (NTM) are ubiquitous environmental pathogens, which are widely present in natural water sources and soils. NTM can be isolated from drinking water, public baths, swimming pools, hospital water supply systems, and even the water supply of hemodialysis centers. In recent years, NTM disease has been increasing rapidly and has become an important public health problem that threatens human health^[1,2,3]。 The more common ones are NTM lung disease, NTM lymphadenitis, NTM skin disease, NTM bone disease and disseminated NTM disease. Patients with NTM lung disease have systemic toxic symptoms and local clinical manifestations similar to those of tuberculosis, and can be misdiagnosed as pulmonary tuberculosis for a long time in the absence of species identification results. In order to improve the understanding of NTM lung disease, the imaging characteristics of 144 cases of NTM lung disease diagnosed and treated in Shanghai Pulmonary Hospital are analyzed as follows.

nontuberculous mycobacteria (NTM) refers to the MTB complex and other mycobacteria other than Mycobacterium leprae. So far, more than 150 species have been found, among which the avian-intracellular mycobacteria complex group (Mycobacterium avium-intracellularecomplex, MAC), Mycobacterium chelonae, Mycobacterium marseille, and Mycobacterium fortuitosum are the main common pathogenic bacteria^[1]。 NTM mainly causes lung lesions, but can also cause other lesions, such as lymphadenitis, skin and soft tissue infection, and skeletal lesions, etc. Its pathogenic characteristics and clinical symptoms are similar to those of pulmonary tuberculosis, so it is difficult to distinguish and can only be identified by laboratory^[2,3]。 We conducted bacteriotype identification and drug susceptibility tests on 110 clinical isolates of NTM from Anhui Chest Hospital, and the results are as follows.

nontuberculous mycobacteria (NTM) and MTB belong to the same genus as mycobacteria, and their main invasive organs are also the lungs. Therefore, NTM lung disease is easily misdiagnosed as pulmonary tuberculosis in clinic, and pulmonary tuberculosis can also be complicated with NTM infection^[1]。 According to literature reports, the composition ratio of NTM strains identified from MTB isolates in China increased from 4.3% (29/682) in 1979 to 11.1% (49/441) in 2000^[2]。 In order to strengthen the differential diagnosis between NTM and pulmonary tuberculosis, we studied the clinical characteristics of 91 cases with positive NTM and MTB culture.

In recent years, the incidence of non-small cell lung cancer (NSCLC) is increasing year by year, which is a serious threat to human health. epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) has changed the therapeutic strategy of NSCLC patients. EGFR mutations are predictors of this class of drugs and play an important role in the treatment decision of NSCLC^[1]。 For advanced patients, it is difficult to obtain tumor tissue to detect EGFR mutations. Some scholars have tried to detect EGFR mutations in the body fluids of NSCLC patients, but the DNA content of tumor cells in the specimens is small and unstable, which requires high detection technology. Therefore, in this study, a corresponding smart amplification process (SMAP) system was designed to detect EGFR mutations in tumor tissues and peripheral plasma of patients with advanced NSCLC. Traditional sequencing and amplification refractory mutation system (ARMS) were used as controls, and the results were further verified by cloning sequencing, so as to explore the stability and reliability of SMAP method for detecting EGFR mutations.

A 49-year-old female, a migrant worker, was admitted to the Department of Respiratory Medicine, Beijing Tiantan Hospital on November 7, 2011 due to back pain for 1 year, which worsened in the past month, accompanied by chest tightness, choking, and choking after eating. The patient developed back pain without obvious trigger 1 year ago. The pain was located in the interscapular area, about the size of the palm, the nature was unclear, there was no dissipation, the degree of pain was not severe, and it could be relieved by itself. There were no other accompanying symptoms. The patient did not pay attention to it and did not diagnose and treat it. One month before admission, there was no obvious trigger to feel the degree of pain aggravated, the frequency of attacks also increased, and chest tightness, holding breath and choking after eating occurred. There was no cough, expectoration and blood in the sputum, and no symptoms such as low-grade fever, night sweats, fatigue and loss of appetite. X-ray chest radiograph of the outer hospital showed widening of the right superior mediastinum (Figure 1), chest CT showed multiple lymph nodes enlarged in the right upper mediastinum, and old lesions at the right lung tip (Figure 2，Figure 3，Figure 4)。 The patient was diagnosed with hypertension 2 years ago and denied history of other chronic diseases and infectious diseases.

bronchial papilloma is a rare benign tumor of the respiratory system. The lesions mainly occur in the larynx and nasopharynx, and few occur in the trachea and bronchus^[1,2]It is currently believed to be related to human papilloma virus (HPV) infection, accounting for about 0.38% of all lung tumors and about 7% to 8% of benign lung tumors^[3]。 Due to the little understanding of this disease, it is easy to be misdiagnosed as "bronchial asthma (asthma for short)" or "asthmatic bronchitis" in clinic, thus delaying the diagnosis and treatment. The diagnosis, treatment and follow-up of a patient with upper tracheal papilloma admitted to the respiratory department of the Second Hospital of Lanzhou University are analyzed as follows.

In recent years, with the prevalence of acquired immunodeficiency syndrome (AIDS), non-tuberculous mycobacteria (NTM) disseminated infection is increasing day by day, which has become a common cause of systemic bacterial infection in AIDS patients. The results of multiple epidemiological surveys have shown that there is an increase in NTM patients in human immunodeficiency virus (HIV) negative populations in some countries. Therefore, NTM disease has become a public health disease and has received more and more attention. ATS and the American Society for Infectious Diseases published "Diagnosis, Treatment, and Prevention of NTM Diseases" (2007 NTM Guidelines) in 2007^[1]The new edition of NTM guidelines provides a good reference for further understanding of NTM disease, familiarity with and mastering the diagnosis, treatment and prevention of NTM disease.

In recent years, pulmonary function test, as one of the 100 suitable technologies of the Ministry of Health for rural and urban community hospitals in ten years, has been gradually popularized and applied in the vast number of grass-roots hospitals in China. Among them, vital capacity and ventilatory function measurement are the most commonly used pulmonary function test items in clinical practice. Strict quality control is a necessary prerequisite for correctly evaluating the examination results, so as to correctly guide clinical diagnosis and treatment, otherwise it is easy to lead to missed diagnosis or misdiagnosis.

With the long-term widespread application of antimicrobial drugs in clinical practice, the problem of bacterial drug resistance is becoming increasingly serious, and human beings have faced great challenges from drug-resistant bacteria and drug-resistant bacterial infections. Compared with the rapid increase of drug-resistant bacteria, the research and development speed of antimicrobial drugs has obviously slowed down, and the possibility of new clinical drugs being launched in the next few years is less likely. On the one hand, there is a severe drug resistance situation, and on the other hand, there may be no new drugs available, which requires clinicians to re-examine existing drugs to maximize their effectiveness. The formulation of dosing regimen based on the principle of combining pharmacodynamics (PD) and pharmacokinetics (PK) of antimicrobial drugs is an important means for rational application of antimicrobial drugs.

procalcitonin (PCT), a precursor of calcitonin, is a functional protein composed of 114-116 amino acids. It is one of the markers in the diagnosis and treatment of severe bacterial infection and sepsis. In addition to the thyroid gland, macrophages and monocytes of various organs, especially the liver, can produce PCT. Bacterial endotoxin is one of the main stimulating factors inducing PCT production. PCT began to release within 4 h of exposure to infection, peaked at 8 h, and began to clear when infection was controlled. Currently, PCT is considered a secondary mediator that amplifies the inflammatory response, but its biological role and its mechanism are not fully understood^[1,2]。

The third event of Beijing Young Respiratory Scholars Salon in 2012 was held in Chinese Medical Association on April 27th, 2012. This event was hosted by Dr. Huang Hui, Department of Respiratory Medicine, Peking Union Medical College Hospital, with the theme of "Several Problems in the Diagnosis and Treatment of Pulmonary Infection Caused by Some Special Pathogens", mainly involving cytomegalovirus (CMV) pneumonia, pulmonary Aspergillus infection and cryptococcal pneumonia.

In clinical work, respiratory doctors may encounter more complex problems than other specialties, and there are more opportunities to intersect with other disciplines. Professor Liu Youning, the editor-in-chief of this journal, talked about his views in the essay column of the editor-in-chief on how to train young doctors in respiratory department, so that they can be both specialized and knowledgeable. He believes that clinical medicine is complicated and basically belongs to the category of empirical science, and it is very important to master comprehensive knowledge and skills of general internal medicine. When Professor Liu was a resident doctor, he repeatedly rotated in various wards, general outpatient clinics, emergency departments, intestinal outpatient clinics, electrocardiogram rooms, lung function rooms and bone marrow examination rooms, laying a solid foundation for general internal medicine, which laid the foundation for his later development and current achievements. Compared with foreign countries, young doctors in China generally have the problems of premature division and weak foundation of general internal medicine. Especially some graduate students, even if they have become attending doctors, their clinical abilities in general internal medicine and specialties are still very lacking. Entering a specialty too early may bring some immediate benefits to young doctors, such as being more conducive to publishing papers and promoting professional titles. However, for long-term development, it is very disadvantageous to train doctors who "know how to see a doctor" and knowledgeable medical professionals who draw analogies. The study and mastery of relevant basic knowledge is also crucial for respiratory doctors. For example, the diagnosis and treatment of respiratory failure, sleep breathing disorders and infectious diseases are inseparable from respiratory physiology, medical microbiology and clinical pharmacology of anti-infectious drugs, which is the "housekeeping" skill of respiratory doctors. Professor Liu believes that familiarity with respiratory physiology and clinical lung function is the watershed that distinguishes respiratory doctors, and it is not easy to be proficient in respiratory physiology. Besides clinical physiology, you must also master certain physics and mathematics knowledge. Therefore, Professor Liu called for the training of young doctors, solid basic skills, a scientific and orderly training process, and step-by-step progress are indispensable, and "pulling out seedlings and encouraging growth" is absolutely impossible.