2012年 · 第35卷第10期

"Expert Consensus on Diagnosis and Treatment of Mycoplasma Pneumoniae in Adults" was published in the 9th Issue of 2010 of Chinese Journal of Tuberculosis and Respiratory Medicine^[1]To remind clinicians that Mycoplasma pneumoniae has a high resistance rate to macrolides in my country, resulting in the failure of clinical treatment. Recently, the author has personally experienced several cases of mycoplasma pneumonia with typical clinical manifestations that have failed to be treated with macrolides, some of which are children under 16 years old. Now I share typical cases with readers.

In the 2005 American Thoracic Society (ATS) and American Society for Infectious Diseases (IDSA) guidelines for adult hospital-acquired pneumonia (HAP)^[1]The concept of healthcare-associated pneumonia (HCAP) was proposed for the first time, and HCAP was assigned to HAP. HCAP is defined in this guideline as the following patients with pneumonia: (1) have been hospitalized for ≥2 days in the last 90 days; (2) Long-term residence in a nursing home or chronic disease care facility; (3) have received intravenous treatment (antibiotics, chemical drugs) or wound treatment within the last 30 days; (4) Have been in a hospital or have undergone dialysis treatment. It is pointed out that the bacteria causing HCAP are mainly Gram-negative bacilli, such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae and Acinetobacter baumannii. Among the cocci, Staphylococcus aureus, especially methicillin-resistant Staphylococcus aureus (MRSA), appears to grow rapidly. It is suggested that the antibiotic selection should cover multidrug-resistant (MDR) bacteria^[1]。 Since the definition of HCAP was put forward, there have been many related studies and reviews abroad so far, and the results and opinions are also different. So, is the concept of HCAP applicable in China? Here, make some of our points.

The United States Centers for Medical Care and Medical Support Services has stopped paying hospitals compensation for certain "preventable complications" (such as catheter-related bloodstream infections, etc.), and ventilator-associated pneumonia (VAP) is likely to be the next disease to be listed on the list of discontinued payments. This has sparked resistance from critical care doctors and hospital administrators because VAP is somewhat uncertain in diagnosis and not entirely preventable. The opposition to the problem has refocused on the prevention strategy of VAP. ventilator associated trancheobronchitis (VAT), a topic raised by Europeans, has become a hot topic of research and discussion among Americans, because some research results suggest that the application of antibiotics to treat VAT can significantly reduce the incidence of VAP, reduce the dosage of antibiotics, and shorten the time of ICU stay^[1]。 Back in 2002, French scholar Nseir et al.^[2]The term nosocomial trancheobronchitis (NTB) in mechanically ventilated patients was first used, previously generally referred to as nosocomial lower respiratory tract infection. In 2005, when Nseir applied for NTB clinical trials, it was renamed VAT, which seemed to be intended to make it echo VAP, and the expression was more appropriate and concise. However, VAT and NTB are still mixed in the literature so far, and there is no clear limitation.

Aminoglycoside antibiotics have been available for 70 years and have good antibacterial activity, but their adverse reactions limit clinical use. Multi-drug resistant (MDR) bacteria, such as Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli and Acinetobacter baumannii, are much less resistant to aminoglycoside antibiotics than other antibiotics^[1]and aminoglycoside antibiotics induce bacterial resistance less than β-lactam antibiotics^[2]As a result, aminoglycoside antibiotics have once again gained the favor of clinicians. In the face of increasingly severe MDR bacterial infection, it is of great clinical significance to use aminoglycoside antibiotics rationally to reduce adverse reactions and additional damage.

Hospital-acquired pneumonia (HAP) is the most common and most harmful hospital-acquired infection in clinic. Foreign survey results show that among all hospital-acquired infections, the incidence of HAP is second only to urinary tract infections, while the incidence of HAP in ICU ranks first among all kinds of nosocomial infections, accounting for about 25% of all nosocomial infection patients in ICU. HAP not only leads to a significant prolongation of hospital stay and a substantial increase in hospital medical expenses, but also often becomes the direct cause of death in critically ill patients. The results of the survey in the United States show that HAP can prolong the average hospital stay of patients by 7 to 9 days, and increase the hospitalization cost by more than $40,000^[1,2]The cumulative consumption of medical resources is extremely astonishing. In 2008, the Infectious Disease Group of Respiratory Disease Branch of Chinese Medical Association took the lead in organizing more than 10 large teaching hospitals to jointly carry out a clinical investigation of HAP for more than 2 years. The results showed that the incidence of HAP in patients in general ward of respiratory department and respiratory ICU (RICU) was 0.88% and 15.35% respectively^[3]The average hospital stay of patients with HAP after HAP is (23.8 ± 20.5) d, of which the average course of anti-infection treatment is (19 ± 17) d, far exceeding the total average hospital stay of patients in respiratory department (13.2 ± 13.6) d. The per capita hospitalization cost of HAP patients has increased by more than 90,000 yuan compared with the per capita hospitalization cost of respiratory inpatients, of which more than 66,000 yuan of medical expenses occurred after HAP, and the average cost of anti-infective drugs used to treat HAP alone is as high as 27,000 yuan^[3]。 Such huge consumption of medical resources is actually a concentrated expression of various difficulties and challenges faced in the diagnosis and treatment of HAP at present. On the one hand, how to improve the accuracy of clinical diagnosis of HAP, how to quickly confirm the responsible pathogen of HAP and other long-term problems that have plagued clinicians have not been solved. On the other hand, the development speed of pathogenic resistance not only far exceeds the development speed of new antibacterial drugs, but also exceeds the update speed of HAP diagnosis and treatment guidelines in various countries. The current situation of "one foot high, one foot high" not only increases the risk of failure of empirical treatment, but also clinicians have begun to fall into the dilemma of "no drug available" when faced with some multidrug-resistant bacterial infections.

In recent years, through the study of the lesions of extrapancreatic organs in patients with autoimmune pancreatitis, people have found that the lesions have similar histopathological manifestations in different affected organs, thus recognizing this systemic disease and proposing a new disease category-IgG4-related diseases. At present, it is believed that IgG4-related disease is a systemic disease that can involve multiple organs such as pancreas, biliary tract, salivary gland, mediastinum, lung, gastrointestinal tract, kidney, skin and retroperitoneal tissue, and almost any organ in the body can occur. Different clinical signs are shown according to the lesion site, such as autoimmune pancreatitis, sclerosing cholangitis, sclerosing cholecystitis, sclerosing sialadenitis, sclerosing mediastinitis, inflammatory pseudotumor (plasma cell granuloma), interstitial pneumonia, interstitial nephritis and retroperitoneal fibrosis. Since 2003 Kamisawa et al.^[1]Since the first report of a patient with autoimmune pancreatitis accompanied by interstitial pneumonia, it has attracted great attention abroad. Reports of IgG4-related lung diseases continue to emerge, but no relevant cases have been reported in China. In recent years, the author has been fortunate to diagnose several cases of lung IgG4-related lung diseases in clinical diagnosis and consultation work. We have reason to believe that IgG4-related lung diseases in China are not rare, but due to the lack of understanding of them in the past, and their pathological histology can show many types, such as inflammatory pseudotumor and interstitial pneumonia, especially when the lungs are involved alone, it is very likely to miss the diagnosis or be classified as other diseases of unknown cause. IgG4-related diseases have a good effect on hormone therapy, and correct diagnosis can make patients get timely treatment and accurate prognosis judgment. Therefore, it is very necessary to improve their understanding. We reviewed this disease in Issue 7, 2011^[2]In this issue, Zhang Hui and others were published^[3]And Liu Yong et al.^[4]2 articles on pulmonary IgG4-associated lung disease, very timely and helpful in raising industry awareness of this disease. The above two articles are reports of IgG4-related interstitial pneumonia, and IgG4-related lung disease can be manifested in many types. In order to make readers have a more comprehensive understanding of this disease, this article is specially written to talk about the name, type and diagnosis of IgG4-related lung disease in combination with different types of typical cases.

methicillin-resistant staphylococcus aureus (MRSA) is one of the important pathogens causing nosocomial and community-related infections^[1], since its first discovery in 1961^[2]In 2010, the results of clinical isolate resistance surveillance (CHINET) in 14 different regional hospitals in 10 provinces and cities in China showed that the proportion of MRSA in 4452 clinically isolated Staphylococcus aureus (hereinafter referred to as Staphylococcus aureus) was as high as 51.7%^[3], occupying the first place among Gram-positive cocci. MRSA has become the most important gram-positive coccus in hospital-associated infections. vancomycin-resistant staphylococcus aureus (VRSA) has been reported abroad. What is even more shocking is that life-threatening community-acquired MRSA infections have been reported all over the world in recent years, and the prevention and treatment situation is extremely severe. Pneumonia is one of the most common clinical infections of MRSA, and inappropriate treatment is an important cause of high mortality. Therefore, its diagnosis and treatment are facing great challenges and need to be paid attention to.

Background: The results of animal experiments and clinical studies on pulmonary fibrosis have shown that the coagulation cascade is involved in the formation of pulmonary fibrosis, and anticoagulation therapy may be effective; In this study, warfarin sodium was used to treat patients with advanced idiopathic pulmonary fibrosis (IPF) to further understand the efficacy of anticoagulation therapy. Methods: (1) Subjects: According to the diagnostic criteria of 2011 IPF guidelines, the advanced IPF was defined as: ① aggravation of dyspnea; ②FVC decreased ≥10% from baseline or D_LCO decreased ≥15% from baseline or SaO₂Decrease ≥5% or progression of chest imaging. (2) Using a randomized double-blind, placebo-controlled method, the international normalized ratio (INR) after warfarin sodium was controlled at 2-3; The ratio of personnel in the treatment group (warfarin sodium) to the control group (placebo) was 1:1, and the study duration was 48 weeks. (3) The primary study endpoint measures were: death due to various causes, hospitalization (non-hemorrhagic disease and non-respiratory disease-related hospitalization), and FVC decrease ≥10% baseline. Results: (1) A total of 145 patients with advanced IPF (72 in warfarin sodium group and 73 in control group) were successfully enrolled from December 2009 to April 2011; Demographic characteristics and severity of lung function were comparable between groups. (2) Given that there were significantly more deaths in the warfarin sodium group than in the control group, the Data and Safety Monitoring Board (DSMB) requested that an interim evaluation of the study be convened and the study be terminated (mean follow-up time was 28 weeks, the results of the interim evaluation are shown below). (3) Occurrence of primary endpoint events: ① 23 times in warfarin sodium group and 17 times in control group (P＝0.27)； All-cause mortality was higher in the warfarin sodium group than in the control group (14:3,P＝0.005)； ② Cause of death: 11/14 deaths due to respiratory diseases in warfarin sodium group and 3/3 in control group; Cardiovascular disease-related deaths were 3 times in warfarin sodium group and 0 times in control group, respectively; ③ All-cause hospitalization rate: Warfarin sodium group was higher than that of control group (P＝0.034)； ④ Efficacy: in lung function (FVC, D_LThere was no significant difference between the warfarin sodium group and the control group. (4) Bleeding: ① Major bleeding events: 2 times and 1 time in warfarin sodium group and control group, respectively; ② Small bleeding events: 6 times and 2 times in warfarin sodium group and control group, respectively. Conclusion: Warfarin sodium does not improve the prognosis of patients with advanced IPF; Treatment with warfarin sodium resulted in more fatal events in patients with IPF without anticoagulation indications.

Many people have a vague understanding of the relationship between antibacterial drugs, antibiotics and antibacterial drugs, so there are different degrees of misuse in many occasions, including medical books, medical journals and even academic reports and lectures, which are introduced as follows.

When you see this topic, you will certainly scold me for talking nonsense or pretending to be mysterious. In fact, I couldn't tell the similarities and differences between raw plaster and plaster, and what the relationship between them was. Later, after some study, I understood the mystery.

Pneumocystis is a fungus that can cause opportunistic infections that can cause pneumocystic pneumonia (PCP) in immunosuppressed patients, most commonly in people infected with human immunodeficiency virus (HIV) or patients with acquired immunodeficiency syndrome (AIDS). PCP can also occur in non-HIV-infected immunosuppressed patients, including malignancies, organ transplants, connective tissue diseases, and malignant hematological diseases. Although Pneumocystis cannot be cultured and grown in vitro, the development of molecular biology techniques has allowed us to gain a deeper understanding of it. The advances in the diagnosis and treatment of PCP are reviewed below.

central sleep apnea (CSA) is a ventilatory dysfunction caused by lack or abnormality of respiratory drive. It is manifested by repeated weakening or cessation of breathing at night, and can be divided into primary and secondary. The occurrence of secondary CSA and the regulation of respiratory center and PaCO₂Level-related and can be further divided into non-hypercapnic and hypercapnic types. The former is common in chronic heart failure (CHF), continuous positive airway pressure (CPAP) process and high altitude state, while the latter is common in sedative drug use and neurological diseases^[1]。 The research progress of common causes and mechanisms of secondary CSA is summarized as follows.

The development of rapid and effective laboratory diagnostic technology is one of the research hotspots of tuberculosis. At present, there have been some research reports on the new technologies of nanotechnology in the laboratory diagnosis and treatment of tuberculosis. We summarize the research progress of nanotechnology in the laboratory diagnosis and treatment of tuberculosis as follows.

The incidence of pulmonary interstitial fibrosis is increasing year by year, and the traditional treatment is not effective and there are many adverse reactions. Sinomenine has anti-inflammatory, antioxidant and immunosuppressive effects. The results of recent studies show that sinomenine also has anti-renal fibrosis effects^[1]。 In this study, the effect of sinomenine on bleomycin-induced pulmonary fibrosis in mice was observed, and its possible mechanism was discussed, aiming at providing new ideas for clinical treatment of pulmonary fibrosis.

The main clinical features of OSAHS are disordered breathing and sleep rhythm during sleep, recurrent apnea and arousal, and in severe cases, hypertension, coronary heart disease, arrhythmia, pulmonary heart disease, stroke, type 2 diabetes, insulin resistance and progressive weight gain, etc.^[1]。 Pulmonary thromboembolism (PTE) is a disease caused by thrombus from the venous system or right heart blocking the pulmonary artery or its branches. The main clinical manifestations and pathophysiological features are pulmonary circulation (including right heart) and respiratory dysfunction^[2]。 PTE and deep vein thrombosis (DVT) are collectively referred to as venous thromboembolism (VTE), which both originate from hereditary or acquired thrombotic factors in the body. OSAHS and VTE often have common risk factors, and there may be some correlation between them. In this study, the changes of plasma P-selectin and von Willebrand factor (vWF) in patients with OSAHS and patients with OSAHS complicated with PTE were examined to explore the changes of platelet activation, vascular endothelial function and their role in pathogenesis.

Although regular, whole-course, combined and adequate systemic therapy has definite curative effect on most patients with refractory pulmonary tuberculosis, conventional chemotherapy is often difficult to close the cavity, difficult to turn negative in sputum detection, slow absorption of lesions, and poor therapeutic effect. If combined with submucosal MTB infiltration, it can destroy the normal structure of bronchial wall and cause fibrous hyperplasia. Anti-tuberculosis drugs are not easy to penetrate into the lesion, and the effect of systemic anti-tuberculosis drugs alone is not good^[1]。 For these patients, active local interventional therapy under fiberoptic bronchoscopy can protect the bronchi and lungs, and reduce the surgical operation of lung removal. The clinical data of 45 cases of refractory pulmonary tuberculosis treated with protective balloon perfusion under fiberoptic bronchoscope in Xiamen No.3 Hospital were summarized, and its effectiveness and influencing factors were retrospectively analyzed.

Guidelines for the Diagnosis and Treatment of Cough issued by China in 2009^[1]It standardizes the diagnosis and treatment of cough, plays a good role in guiding clinical practice, and benefits people greatly. However, in the process of studying the guidelines, the author thinks that the diagnostic criteria of cough variant asthma (CVA) in the guidelines are worthy of discussion.

Thank you very much Dr. Fan Huizhen for your letter, which raises very good questions, targeted, and common issues that clinicians often confuse.

functional residual capacity (FRC) refers to the amount of gas remaining in the lungs after calm expiration, which is equal to residual air volume (RC) plus supplemental expiratory volume (ERV). FRC acts as a buffer for stabilizing alveolar gas partial pressure. Without FRC, the alveoli will be completely collapsed at the end of expiration. Increased FRC indicates alveolar dilatation, and decreased FRC indicates alveolar shrinkage or collapse. FRC cannot be measured directly, but indirect methods are usually adopted, mainly including closed body tracing, closed nitrogen dilution method and closed helium dilution method (one-breath method and repeated breath method). The basic principle of the determination, whether open or closed gas dilution method, derives from the law of conservation of mass, that is, an indicator gas of a known concentration is diluted by another gas of an unknown capacity, and the unknown capacity can be obtained by measuring the concentration of the indicator gas in the diluted gas. The measurement of functional residual gas volume by plethysmography (body tracing) is the gold standard for FRC measurement at present, especially for patients with hyperinflation of the lungs and uneven gas distribution in the lungs such as COPD, its measurement is more accurate. However, body tracing is not a method for measuring indicator gas, so it should be specified.

Chen Xiaoyou (Beijing Chest Hospital Affiliated to Capital Medical University): Today's salon theme is "Diagnosis and Differential Diagnosis of Tuberculosis". Cases are provided by general hospitals, and we discuss the related issues involved in the cases.

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the important pathogenic bacteria that cause hospital-related and community-related infections. In 2010, the drug resistance surveillance results of clinical isolates in 14 hospitals in different regions of 10 provinces and cities in China showed that the proportion of MRSA in 4452 clinically isolated Staphylococcus aureus strains was as high as 51.7%, accounting for the first place among Gram-positive cocci. MRSA has become the most important gram-positive coccus in hospital-associated infections. Vancomycin-resistant Staphylococcus aureus has been reported abroad. What is even more shocking is that life-threatening community-acquired MRSA infections have been reported all over the world in recent years. The prevention and treatment situation is extremely severe. To this end, the Infectious Diseases Group of Respiratory Diseases Branch of Chinese Medical Association issued the "Expert Consensus on Diagnosis, Treatment and Prevention of Methicillin-Resistant Staphylococcus aureus Pneumonia", which gave clear guiding opinions from the definition, incidence and drug resistance of MRSA, diagnosis, empirical treatment, use of antibacterial drugs and prevention of MRSA infection, which deserves special attention.