2015年 · 第38卷第11期

In the blink of an eye, it is nearly the end of the year, and in this autumn and winter communication period, the situation of drug-resistant bacterial infection in the lungs is becoming more and more severe. Professor Liu Youning, the editor-in-chief essay column of this issue, comments on this problem that has plagued respiratory clinical workers for many years. The writing starts from the use of foreign terms such as "multi-drug resistance", "multi-drug resistance" and "multi-drug resistance", focuses on the clinical significance of a specific type of acquired drug resistance, and emphasizes the clinical choice of therapeutic drugs after defining the mechanism of drug resistance. At the end of the article, it is briefly pointed out that it is important to understand the concept and mechanism of drug resistance, but clinical treatment should be guided in the final analysis. This article explains in simple terms and is close to clinical practice. It is recommended for relevant clinical workers to read and understand.

With the rapid development of bacterial drug resistance, there are more and more complicated terms used to describe the degree of drug resistance in microbiology. However, some terms lack international unified definition and judgment standards, and the meanings of the same term in different authors and different papers are also quite different. Most importantly, even if these drug-resistant bacteria can be accurately distinguished and classified according to those definitions, they have little reference significance for directly guiding clinical treatment. Therefore, the author suggests that these terms should not be used excessively in clinical work, and should be replaced with expression methods that can more accurately describe the characteristics and nature of bacterial drug resistance and directly guide clinical practice.

Intracranial tuberculosis is a part of extrapulmonary tuberculosis. As early as 1768, Robert Whytt proposed the concept of "brain tuberculosis"^[1]。 More than 100 years ago, "tuberculous meningitis" appeared in foreign articles^[2,3]The name of. Beginning in the 1940s, research on tuberculous meningitis began to increase significantly^[4,5]"intracranial tuberculoma" begins to appear^[6,7]"cerebral tuberculoma ( Brain tuberculoma) "^[8]"intracranial tuberculosis ( Intracranial tuberculosis) "^[9]Wait for names, naming is confusing. After the 1980s, with the development of new imaging technologies such as CT and MRI, people can observe intracranial tuberculosis lesions, including meningeal and brain parenchymal lesions with the help of CT or MRI^[10,11,12]At the same time, it has also been found that there are various intracranial tuberculosis lesions, which can be manifested as thickening of the dura mater, basal cistern meninges or pial mater, or tuberculoma; Lesions such as tuberculoma can occur in the parenchyma of the brain or in the meninges. This interleaving of lesion forms and lesion sites makes it difficult to accurately characterize a lesion with the single name "tuberculous meningitis" or "intracranial tuberculoma". Since 1990s, CNS tuberculosis has been divided into Intracranial and spinal parts abroad, and the name "Intracranial tuberculosis" has been used to describe the pathological changes of tuberculosis in various anatomical parts of the cranium^[13]。

intracranial tuberculosis is a severe central nervous system tuberculosis caused by hematogenous dissemination of Mycobacterium tuberculosis, accounting for 1.5% to 3.2% of all tuberculosis-related deaths^[1], ranking 11th in the ranking of disease disability rate and 13th in fatality rate^[2]。 Intracranial tuberculosis has become one of the important types of tuberculosis that threaten human health. In order to improve the awareness of the medical staff in China on the imaging manifestations of intracranial tuberculosis, the Tuberculosis Branch of Chinese Medical Association organized the national tuberculosis imaging and clinical experts to formulate the "Expert Consensus on Imaging Typing of Intracranial Tuberculosis".

Chronic obstructive pulmonary disease (COPD) is the most common chronic disease in respiratory departments, with a prevalence of approximately 10% in people over 40 years of age worldwide. Chronic inflammation, protease/antiprotease imbalance, oxidative stress/antioxidant stress imbalance and other mechanisms are involved in the pathogenesis of COPD, and these factors interact to promote the development of the disease. The latest research results show that endothelial cell apoptosis plays an important role in the pathogenesis of COPD. This process can be regulated by mitochondrial transcription factor (mtTFA), and epigenetics is involved in the gene regulation and modification of COPD. In this study, we analyzed the expression level of mtTFA and its methylation status in lung tissues of patients with COPD complicated with lung squamous cell carcinoma and compared it with patients without COPD.

pulmonary hypertension (PH) is a malignant pulmonary vascular disease characterized by increased pulmonary artery pressure and remodeling of small pulmonary vessels, which often leads to right heart failure or even death. PH involves a wide range of diseases, is harmful, and lacks effective treatment. It has become a large class of diseases that seriously endanger people's health. Traditional methods for the treatment of PH include anticoagulation, oxygen inhalation, digoxin, L-arginine (nitric oxide precursor), nitroglycerin and diuretics, etc., with limited efficacy. With calcium channel blockers, prostacyclins, endothelin receptor antagonists, and phosphodiesterase inhibitors^[1,2]The emergence of other targeted drugs has promoted the clinical treatment of PH. However, these drugs are very expensive, limiting their use in developing countries. Therefore, there is an urgent need to find new economic and effective drugs for the treatment of PH in clinic. In recent years, Chinese researchers have found that tanshinone ⅡA has a good therapeutic effect on PH and is expected to become a new and effective drug for the treatment of PH.

pulmonary hypertension (PH) is a kind of abnormal pulmonary vascular structure and/or function caused by many reasons. pulmonary vascular resistance (PVR) increases progressively, and the increase of pulmonary artery pressure exceeds a certain limit, resulting in increased right heart load and right heart dysfunction, thus causing a series of clinical manifestations. PH diagnostic criteria: mean pulmonary arterial pressure (mPAP) measured by right cardiac catheter at rest ≥25 mmHg (1 mmHg =0.133 kPa). For precapillary pulmonary hypertension, two more hemodynamic parameters should be added: PVR>3 WU and pulmonary artery wedge pressure (PAWP) ≤15 mmHg. At present, pulmonary hypertension is divided into five categories, pulmonary arterial hypertension (PAH), pulmonary hypertension due to left heart disease (LHD-PH), pulmonary hypertension due to pulmonary disease and/or hypoxia, chronic thromboembolic pulmonary hypertension (CTEPH), and pulmonary hypertension due to unspecified multifactorial mechanisms^[1,2,3]。 Different types of PH have common pathological basis in their occurrence and development, namely, pulmonary vasoconstriction, remodeling and in situ thrombosis^[4,5]。 acute vasoreactivity testing (AVT) is based on the theory of reversible pulmonary vasoconstriction, and the right cardiac catheter technique is used to monitor the hemodynamics of patients with PH. At the same time, acute drug tests are conducted to observe the effects of drugs on pulmonary and systemic hemodynamics, and to predict the efficacy and safety of long-term vasodilator therapy in patients^[6]。 In 2009, the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA) expert consensus on pulmonary hypertension recommended that patients with idiopathic pulmonary arterial hypertension (IPAH), hereditary pulmonary hypertension and appetite suppressant-related pulmonary hypertension should undergo AVT to determine whether high-dose calcium channel blockers (CCBs) are suitable for treatment. The experimental drugs include prostacyclin, nitric oxide and adenosine. The positive criteria are: mPAP decreased ≥10 mmHg, absolute value ≤40 mmHg, and cardiac output remains unchanged or increased. However, there is still no consensus on the applicable population of AVT, positive diagnostic criteria, the selection of the best experimental drug, the interval of AVT examination, and the guiding value of AVT in the diagnosis and treatment of patients with pulmonary hypertension. The research progress of AVT in PH in recent years is reviewed as follows.

Chronic obstructive pulmonary disease (COPD) has a high morbidity and mortality rate, which is mainly characterized by persistent airflow restriction and progressive development. The results of recent studies show that the occurrence of COPD is closely related to some autoimmune diseases. Antibodies to vascular endothelial cells and elastin antibodies can be detected in patients with COPD, suggesting that autoimmune reactions can be involved in the occurrence of COPD^[1,2]。

A 55-year-old male was admitted to the hospital on 17 November 2014 due to "fever with cough and expectoration for 2 weeks". On 4 November 2014, the patient developed fever without obvious trigger, with a maximum body temperature of 40 ℃, accompanied by chills, cough, and a small amount of yellow-white sputum. Blood culture in the local hospital showed Staphylococcus aureus, which was sensitive to oxacillin, linezolid and vancomycin. After anti-infective treatment (specific medication unknown), it still had persistent fever and multiple rashes and blisters all over the body. On November 8, 2014, he was seen in our hospital, and his chest CT (Figure 1，Figure 2，Figure 3，Figure 4) showed multiple patches, nodules and cord shadows of different sizes around both lungs, and some nodules showed cavities and nourishing vascular signs. Blood culture showed Staphylococcus aureus, and the diagnosis was "pneumonia, Staphylococcus aureus sepsis". After linezolid was given intravenous drip for 6 days, the skin blisters subsided and the fever was still present. Nov 15, 2014 Chest CT (Figure 5) shows patches and nodules in both lungs, which are larger and smaller than the previous part, partial consolidation of the lower lobes of both lungs, and bilateral pleural effusion; Abdominal CT showed splenomegaly, left renal pelvis, renal calyx and hydroureter, and intravenous infusion of vancomycin for 3 days showed poor effect. Past history: More than 10 years of history of type 2 diabetes, fasting blood glucose about 9 mmol/L, postprandial 2 h blood glucose about 13 mmol/L; 10-year history of hypertension; History of coronary heart disease 5 years; History of post-traumatic cerebral hemorrhage for 1 year, conservative treatment. Personal history: smoking index 60 pack years; Drinking for more than 30 years, 200 g/d of liquor. Physical examination: body temperature 38.3 ℃, pulse rate 102 beats/min, respiratory rate 26 beats/min, blood pressure 140/79 mmHg (1 mmHg =0.133 kPa), weak constitution, depression and edema of the skin all over the body, redness, swelling and ulceration of the skin of the right forearm with a diameter of about 2 cm, skin ecchyma of the left forearm with a diameter of about 6 cm, and scattered skin ulceration and crusts on the buttocks. There was no enlargement of superficial lymph nodes throughout the body. The breathing sounds of both lungs were thick, and wet rales could be heard. Both lower extremities muscle atrophy, muscle strength grade 4. Out-of-hospital blood routine showed that white blood cells were 11.53×10⁹/L, platelets were 67×10⁹/L; 2 940 mg/L for D-dimer; Blood biochemical detection showed that total protein was 46 g/L, albumin was 20 g/L, and liver and kidney function were normal; Blood gas analysis (inhaled air) showed pH 7.56, PaO₂was 67 mmHg, PaCO₂is 30 mmHg, SaO₂95%. Preliminary diagnosis of admission: sepsis, Staphylococcus aureus pneumonia, hydronephrosis (left), hydroureterosis (left).

The 5th activity of Beijing Young Respiratory Scholars Salon in 2015 was held in Chinese Medical Association on July 30, 2015, mainly to discuss non-tuberculous mycobacterial diseases. This salon activity was hosted by Chen Xiaoyou, chief physician of Beijing Chest Hospital affiliated to Capital Medical University.

"Chinese Journal of Tuberculosis and Respiratory Studies" published in the second issue of 2015, "Discussion on the Application of Aerosolized Inhaled Glucocorticoids in Acute Asthma Attacks"^[1]Article and "Reply to 'Discussion on the Application of Aerosolized Inhaled Glucocorticoids in Acute Asthmatic Attacks'"^[2](hereinafter referred to as "replies"). The article "Discussion on the Application of Aerosolized Inhaled Glucocorticoids in Acute Asthma Attacks" on "Guidelines for Prevention and Treatment of Bronchial Asthma (Definition, Diagnosis, Treatment and Management of Bronchial Asthma)"^[3]According to the instructions in the instructions for budesonide suspension for inhalation: "After inhalation of budesonide suspension, the improvement in the control of asthma symptoms appears within 2 to 8 days after initiation of treatment", it is considered that budesonide suspension should be a slow-onset drug. In the "reply", it was introduced that budesonide suspension "after 1~3 hours of inhalation, the symptoms, lung function and airway blood flow of asthma patients can be improved by stars", and it is considered that budesonide suspension takes effect after 1~3 hours of inhalation. In this regard, we believe that the following questions are worth discussing so as not to mislead readers.

This issue published a letter from Zhang Yaming, a reader, "Re-discussing the onset time of budesonide aerosol inhalation"^[1](hereinafter referred to as the letter). Some of the questions raised have been explained in detail in the article "Answering Questions from Readers such as Lu Huiyu"^[2]Not to be repeated. The responses to the new questions raised in Zhang Yaming's letter are as follows, for reference only.

On the basis of "Interpretation of Lung Volume and Ventilation Parameters", ventilation function and other common gas exchange parameters were further interpreted^[1,2]。