2016年 · 第39卷第07期

In the "Guidelines for the Diagnosis and Treatment of Community-acquired Pneumonia in Adults in China (2016 Edition)" published in Volume 39, Issue 4, 2016, this journal clearly classifies adult community-acquired pneumonia into bacterial pneumonia, mycoplasma or chlamydia pneumonia and viral pneumonia, emphasizing the importance and targeted treatment of viral infection in the pathogenesis of adult community-acquired pneumonia. Therefore, Professor Liu Youning, the editor-in-chief of this journal, made a further interpretation of this issue in the editor-in-chief essay column. The article mentioned that "so far, the guidelines for adult community-acquired pneumonia issued by major academic groups in the world have not deeply discussed the etiological value of viruses. The main reason may be that the existing methods are difficult to confirm that the virus detected is the causative agent of community-acquired pneumonia. In children, especially before the age of 5, viruses are more important than bacteria in community-acquired pneumonia. It is also an accepted fact that viruses decrease and bacteria increase with age. However, it is not clear how old the "breaking point" is, and whether the virus will be increasing again with aging. All these basic questions need to be further studied, and conclusions cannot be drawn before necessary research, especially as our own work is still very weak. A very important practical question is whether antibiotics, antivirals, or a combination of both should be chosen when empirically treating adult community-acquired pneumonia. The author's personal view is that unless during the epidemic period of specific viruses (such as influenza, avian influenza, adenovirus, etc.), antibiotics alone are generally chosen. Only children with mild community-acquired pneumonia and clinically compatible with virus infection can use antiviral drugs alone. Except for influenza, there are no effective drugs for other viruses common to community-acquired pneumonia. "This article has played a role in inspiring the in-depth discussion of the position of viral infection in community-acquired pneumonia and its treatment. At the same time, the article" Attention to the diagnosis and treatment of viral pneumonia in adult community-acquired pneumonia "written by Cao Bin was also published in the" Forum "column. Welcome everyone to read and participate in the discussion.

Needless to say, the importance of viral infection in community-acquired pneumonia (CAP) in children, but the etiological significance of CAP in adults has not been determined, and it is also one of the problems that are rarely mentioned or "passed by" in various diagnosis and treatment guidelines at home and abroad, so as to avoid serious discussion. Such a serious academic issue should be published in the comments and other columns more "justified". The reason why the author chose the "essay" column with the word "random talk" is that first, it can speak freely without being too rigid, and can leave a large space for discussion and debate. Second, it adopts a non-"preaching" method, which can shorten the distance with readers. Of course, it is also hoped that it can attract more readers and be willing to see more people.

staphylococcus aureus is an important pathogen of community and nosocomial infections. The emergence and increasing number of methicillin-resistant staphylococcus aureus (MRSA) has brought great challenges to anti-infective treatment. The infection caused by MRSA is difficult to treat, the prognosis is poor, and the morbidity and mortality rate remain high. The Bacterial Resistance Surveillance Project of China Bacterial Resistance Surveillance Network (CHINET) from 2005 to 2014 showed that MRSA accounted for 45% to 69% of all Staphylococcus aureus isolates in large teaching hospitals in China^{[1,2,3,4,5,6,7,8,9,10]}。 According to the Centers for Disease Control and Prevention (CDC), there were 80,461 MRSA-infected patients in the United States in 2013, including 11,285 deaths.

During the development of hypoxic pulmonary hypertension (HPH), pulmonary arterial smooth muscle cells (PASMCs) proliferate excessively and apoptosis is inhibited. The results showed that the mitochondrial membrane potential of PASMCs increased under hypoxia, resulting in the decrease of mitochondrial membrane permeability, inhibition of mitochondrial cytochrome C release and Caspase cascade reaction, and inhibition of mitochondrial-dependent apoptosis pathway^[1]。 Survivin plays the strongest role in the inhibitor of apoptosis proteins (IAP) family, and is involved in the regulation of two basic processes of life cycle, namely, inhibiting apoptosis and promoting cell proliferation^[2]。 Our previous findings suggest that survivin is effective in normoxic (21% O₂) was not expressed in cultured human pulmonary arterial smooth muscle cells (HPASMCs), but in hypoxia (2.5% O₂) expressed in cultured HPASMCs, and promoted the proliferation of HPASMCs and inhibited their apoptosis^[3]。 However, the mechanism of survivin inhibiting apoptosis of hypoxic HPAMSCs is still unclear. This study aims to explore the mechanism of survivin inhibiting apoptosis of hypoxic HPAMSCs and provide experimental basis for exploring the prevention and treatment of hypoxic pulmonary hypertension.

In March 2013, three deaths of severe pneumonia of unknown origin were reported in Shanghai, China, which was the first reported human infection with H7N9 avian influenza virus in the world^[1]。 As of September 2015, China's Health and Family Planning Commission has reported 539 cases and 227 deaths, with a case fatality rate of 42.12%^[2]Most of the deaths were combined with bacterial pneumonia, septic shock, respiratory failure and multiple organ failure (MOF). In April 2014, Fujian Province admitted a critically ill elderly patient infected with H7N9 avian influenza virus, and finally died of respiratory and circulatory failure caused by pulmonary cryptococcosis. The report is as follows.

Esophageal tuberculosis is an inflammatory granulomatous lesion of the esophageal wall caused by MTB infection. The incidence rate is low, mainly secondary, and primary esophageal tuberculosis is extremely rare. One case was diagnosed in our department in 2014, which is now reported as follows.

Broncholithiasis refers to the appearance of calcified or ossified components in the bronchial lumen, resulting in chronic cough, hemoptysis, cough stone, bronchiectasis, bronchial fistula, etc. With the further improvement of examination technology, its incidence is also on the rise. At present, there is no unified guideline for the treatment of this disease. The treatment methods are limited, the curative effect is poor, and there are many complications. We need to constantly explore and standardize new treatment methods. In this paper, the clinical diagnosis and treatment of bronchial stones were discussed based on the successful treatment of large bronchial stones in the periphery of the lung by holmium laser fractionated extraction.

Patients with chronic obstructive pulmonary disease (COPD) combined with giant bullae have decreased pulmonary ventilation function, dyspnea score, activity endurance, and quality of life. The efficacy of drug treatment is limited, the prognosis is poor, and poor pulmonary function often cannot tolerate larger thoracic surgery, and the long-term efficacy is controversial. With the development of respiratory interventional technology, trans-bronchoscopic pulmonary volume reduction (BLVR) has gradually entered clinical application because of its minimally invasive, low surgical risk and good curative effect. However, the presence of bypass ventilation in target lung lobes has obvious adverse effects on the efficacy of BLVR. The newly emerging device for detecting bypass ventilation, the Chartis system (Pulmonx Co., Ltd., USA), has made a major breakthrough in the preoperative evaluation of BLVR, increasing the success rate of surgery and maximizing the benefit of patients from BLVR. The diagnosis and treatment process of BLVR patients in our department in July 2014 and the follow-up data in the past one year are reported below.

The patient was a 60-year-old male. He was admitted to hospital on December 20, 2015 for the main reason of "intermittent cough and wheezing for 1 year, with blood in sputum for 1 month". The patient developed cough without obvious trigger 1 year ago, coughing a small amount of white phlegm, accompanied by wheezing, which was not paid attention to. After intermittent wheezing attacks, self-smell and wheezing sounds can be observed after activity. In the past month, blood in sputum appeared, accompanied by anorexia, fatigue and weight loss. Chest CT showed a massive high-density shadow in the upper lobe of the right lung with irregular edges and local "finger cuff sign" (Figure 1，Figure 2)。 The previous smoking index was 800 years, and he had not quit smoking. Physical examination: Superficial lymph nodes were not palpable and swollen, the respiratory sounds of the right upper lung were reduced, and dry and wet rales were not heard. No abnormalities were seen in the confidant. Preliminary diagnosis of admission: the cause of lung shadow to be investigated, lung cancer? Allergic bronchopulmonary aspergillosis?

Before 2007, solid culture and drug susceptibility test (traditional drug susceptibility test) were used to diagnose MTB resistance in laboratory worldwide. The traditional drug susceptibility test can detect the resistance of first-line anti-tuberculosis drugs (isoniazid, rifampicin, ethambutol, streptomycin) and second-line anti-tuberculosis drugs (kanamycin, ofloxacin, etc.). The results are reliable and cheap, but it takes a long time, about 2~3 months^[1,2]。 In order to improve the speed of drug resistance diagnosis, the World Health Organization successively recommended a variety of new technologies from 2007 to 2010, such as liquid culture and drug susceptibility test (liquid drug susceptibility test), molecular biology rapid drug resistance detection technology [including linear probe (LPA), automated Gene-Xpert and other technologies]. The liquid drug susceptibility test shortens the resistance diagnosis time to 1 month, and can detect the resistance of first-line and second-line anti-tuberculosis drugs. The results are reliable, but the price is relatively expensive, and it is easy to contaminate^[3]。 The linear probe technique takes 6 hours to detect drug resistance. It is suitable for smear-positive sputum specimens and cultured strains, and is suitable for use in laboratories in cities and above, but it is expensive and can only be used for drug resistance detection of isoniazid and rifampicin^[2,4]。 The automated Gene-Xpert technology takes 90 minutes to detect drug resistance. It is easy to operate and can be used in county-level laboratories. It is suitable for smear-positive and smear-negative sputum specimens (at present, domestic registration only tests smear-positive pulmonary tuberculosis for drug resistance), but it is expensive and can only detect rifampicin resistance^[5,6]。 In conclusion, different drug resistance detection technologies have their own advantages and disadvantages, and they cannot be substituted for each other.

Pediatricians have long realized that the leading pathogens of community-acquired pneumonia (CAP) in infants and children are viruses, mainly respiratory syncytial virus, parainfluenza viruses (I-III) and influenza viruses (A and B)^[1], but the incidence of adult viral pneumonia has been underestimated^[2], and considered to be an important feature that distinguishes CAP etiology in adults from children. In fact, adult viral pneumonia is not uncommon, Ruuskanen et al.^[3]It is believed that about 200 million people worldwide develop viral pneumonia every year, with children and adults accounting for 50% each. According to the results of the CAP Etiology Survey in Adults (EPIC Study) led by the U.S. Centers for Disease Control (CDC), viral pneumonia accounted for 23% of adults, bacterial pneumonia accounted for 11%, and mixed viral and bacterial infections accounted for 3%^[4]This once again proves that adult viral pneumonia is not only not uncommon, but even accounts for the first place in the pathogen spectrum of adult CAP in the United States.

pulmonary tumor thrombotic microangiopathy (PTTM) is a serious and rare complication of tumor patients, with progressive aggravation of dyspnea as the main manifestation, dangerous condition and extremely high mortality rate. At present, this disease has not been reported in China, and the possibility of missed diagnosis cannot be ruled out. Improving the understanding of the characteristics of PTTM will be very beneficial to the judgment of disease prognosis. Now review the relevant literature, and summarize the clinical, pathological, imaging features, diagnosis, differential diagnosis and treatment of PTTM as follows.

Tuberculosis is still an important infectious disease, and it is the biggest killer caused by a single infectious pathogen in the world after AIDS. According to the statistical report of the World Health Organization in 2015, there were 9.6 million new tuberculosis cases in the world in 2014, of which 1.5 million died of tuberculosis. China had 930,000 new tuberculosis patients, ranking third in the world^[1]。 In recent years, with the spread of drug-resistant tuberculosis, tuberculosis has become a major hidden danger to life safety. Therefore, it is very important to study the physiological metabolism of MTB in depth, discover new molecular targets for tuberculosis treatment, screen new drugs and prevent the spread of tuberculosis disease.

On the basis of interpretation of mechanical ventilation pressure^[1]Further interpretation of the concept of breathing forms.

In late December 2015, it took me 3 d to read through the book "The Biography of Zhong Nanshan" (written by Ye Yi, People's Publishing House, August 2014, first edition).

George Washington, the founding father of the United States, the first president and the "founding father", lived with a great honor. Many people thought he was dying, but on the contrary, he died of acute illness without warning.