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Journal: Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases

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Objective: To analyze the polysomnography and clinical characteristics of Tibetan and Han residents with obstructive sleep apnea syndrome (OSAS) in high altitude areas of Tibet, and to explore whether nationality difference existed. Methods: The clinical data of 425 OSAS patients admitted to the Tibet Autonomous Region People’s Hospital from November 2011 to February 2018 were retrospectively analyzed, which were divided into Tibetan group and Han group. Information including sex, age, body mass index (BMI), neck circumference, waist circumference and hip circumference was collected, and apnea-hyponea index (AHI), mean oxygen saturation (MSaO(2)) during sleep, lowest oxygen saturation (LSaO(2)) during sleep, sleep phases and Epworth scores were compared between Tibetan and Han groups. Results: No significant difference was found in AHI between Tibetan and Han patients. AHI was positively correlated with BMI, neck circumference and waist circumference. Oxygen saturation in the daytime was not significantly different between groups. However, MSaO(2) and LSaO(2) during sleep were lower in Tibetan group compared with Han group (79% vs 82%, 65% vs 69%, respectively, P=0.000). Subgroup analysis showed no significant difference in MSaO(2) in mild OSAS patients, while the LSaO(2) in mild OSAS patients, the MSaO(2) and LSaO(2) in moderate and severe OSAS patients all showed significant differences between groups. Adjusted for BMI, the LSaO(2) in moderate OSAS patients, the MSaO(2) and LSaO(2) in severe OSAS patients in Tibetan group were still significantly lower than Han group. Stage-1 non-rapid eye movement was prolonged in moderate OSAS patients in Tibetan group compared with Han group (P=0.033), while other sleep phases and Epworth scores showed no significant difference between groups. Conclusion: In the circumstances of similar AHI, the MSaO(2) and LSaO(2) in moderate and severe OSAS patients were significantly lower in Tibetan group than in Han group, and the differences partially remained after adjusting for BMI, and the mechanisms needed to be further investigated in high altitude areas.

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Objective: To explore the characteristics and determining factors of attention and short-term memory impairment in young patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Methods: A total of 203 eligible patients with snoring were recruited for the study at Sleep Center, Second Affiliated Hospital of Soochow University from July 2016 to July 2017, and they were all monitored with overnight polysomnography(PSG), recording sleep parameters [NREM (Ⅰ+Ⅱ) sleep ratio, NREM Ⅲ sleep ratio, REM sleep ratio] and respiratory parameters (AHI, ODI, LSaO(2), TS90%, RRMAI). Based on apnea/hypopnea index(AHI), the patients were categorized into non-OSAHS group (030/h). All patients were assessed for sleepiness and the Motreal Cognitive Assessment (MoCA) questionnaires, Mini-mental State Examination (MMSE), Epworth Sleepiness Scale(ESS), attention and short-term memory assessment which included Trail Marking Test(TMT), digit span test(DST), and Complex Figure Test(CFT). The PSG parameters, ESS scores, total MoCA scores, attention and short-term memory were compared among groups, and a multivariate logistic regression analysis was conducted to investigate the characteristics of attention and short-term memory impairment in young patients with OSAHS and their determining factors. Results: In the overall cognitive function assessment, severe OSAHS patients’s MoCA scores were lower than those of the other two groups [27.0 (25.0, 28.0) vs 27.0 (26.0, 28.0) , 27.0 (26.0, 27.0) , P<0.01]. In the sleepiness self-assessment, severe OSAHS patients's ESS scores were significantly higher than those of the other groups (11.4±5.4 vs 5.3±4.5, 8.0±5.0, P<0.01) . In the attention tests, scores on the DST-D (8.1±1.1 vs 8.8±0.9, 8.5±1.0) and DST-B[5.5 (4.0, 7.0) vs 6.0 (5.0, 7.0) , 6.0 (5.0, 7.0) ] were significantly lower in severe OSAHS patients than in the other two groups (P<0.01) . In the memory tests, the re-drawing scores of severe OSAHS patients were significantly lower than those of the other two groups [23.0 (16.0, 27.0) vs 26.0 (24.0, 28.0) , 24.0 (20.0, 28.0) , P<0.01]. In the executive function tests, severe OSAHS patients spent much longer on both TMT-A (46.7±19.0 vs 40.2±17.4, 34.6±17.2) and TMT-B (76.9±32.6 vs 67.2±21.2, 58.6±27.5) than the other two groups (P<0.01). Multivariate logistic stepwise regression analysis showed that, AHI, ODI and NREM (Ⅰ+Ⅱ) sleep ratios were the independent determining factors. Conclusion: Attention and short-term memory functions of young patients with OSAHS were impaired. The severity of apnea and hypoxia, NREM (Ⅰ+Ⅱ) ratio were all determining factors.

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Objective: To compare the clinical characteristics of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) by different levels of blood eosinophil (EOS) count and to investigate the predictive value of the response to glucocorticoid treatment and the readmission rate in the patients with higher blood eosinophils. Methods: A total of 120 patients with AECOPD were admitted to the Department of Pulmonary and Critical Care Medicine in The Second Xiangya Hospital of Central South University from January 01, 2017 to December 31, 2017. Patients were divided into two groups according to their admission blood eosinophil fractions. Patients with EOS%≥2% were in the EOS group (n=56) , while patients with EOS%<2% were in the Non-EOS group (n=64) . The clinical characteristics, hospitalization treatments especially the glucocorticoid treatment response were compared, and the risk of severe acute exacerbation of the two groups including the 12-month COPD-related readmission, and time to first COPD-related readmission were also compared. Results: Compared with the Non-EOS group, the EOS group had lower values of white blood cell (WBC) , neutrophil fraction (N%) , blood neutrophil-to-lymphocyte ratio (NLR) , and C-reactive protein (CRP) . The EOS group also required shorter course of antibiotic treatment [8 (6-10) and 9 (7-11) , P=0.033]. In glucocorticoid-treated patients (n=82) , the EOS group had significantly alleviated symptoms than the Non-EOS group (patients withδCAT≥2 were 86.8% and 68.2%, respectively, P=0.046) , and the duration of hospitalization of the EOS group was shorter [9 (7-11) and 10 (9 to 13) , P=0.042]. Patients with glucocorticoid treatment in the EOS group had significantly alleviated symptoms than those without glucocorticoid treatment (patients with δCAT ≥ 2 were 86.8% and 61.1%, respectively, P=0.040) . The follow-up one year after discharge showed a higher risk of severe acute exacerbation in the EOS group [Adjust OR 2.67 (1.10-6.46), P=0.030; HR: 1.57 (1.02-2.40), P=0.040]. Conclusion: The blood eosinophil levels were useful in predicting the AECOPD patients' response to glucocorticoid treatment and the risk of severe acute exacerbations.

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Objective: To study the incremental cost-effectiveness of the second Xpert assay in detection of Mycobacterium tuberculosis (Mtb) and rifampicin (RIF) resistance. Methods: We continuously collected 2 896 specimens from suspected tuberculosis patients who had undergone 2 Xpert tests in a week from March 2015 to March 2018, including 2 402 suspected tuberculosis patients with 1 523 males and 879 females, with an average age of 50 years. Among them, 2 144 specimens of sputum and 258 cases of bronchoalveolar lavage fluid were collected. We also enrolled 494 patients with suspected extrapulmonary tuberculosis, 318 males and 176 females, with an average age of 42 years. Among them, 157 pleural effusion specimens, 106 cerebrospinal fluid specimens, 34 urine specimens and 197 pus specimens were collected. All specimens were subjected to two Xpert tests, smear microscopy, liquid rapid culture (BACTEC MGIT 960), and positively cultured bacteria were tested for drug susceptibility. Results: Among the 2 896 specimens from suspected tuberculosis patients, either one of the two Xpert test results was positive (including both tests were positive, the same below) in 1 639 patients, and 1 502 (91.6%) were positive in the first Xpert tests. The additional 137 (8.4%) test results were positive in the second tests. According to the smear test results, all specimens were divided into the smear negative group and the smear positive group. The second Xpert test was significantly higher than the smear-positive group (14.86%, 3.2%, P<0.001), and the extrapulmonary tuberculosis group was higher than the tuberculosis group (11.2%, 8.0%, P=0.12).Of the susceptibility test results, a total of 371 were rifampicin-resistant specimens. The first Xpert detected 91.4% (339/371), and the second Xpert detected the additional 8.1% (30/371).The cost increase of the second test was very significant. Tests were calculated at 650 yuan per time, the tuberculosis group was 1 184 yuan and 13 696 yuan(P<0.001); the extrapulmonary tuberculosis group was 1 755 yuan and 13 961 yuan(P<0.001). In the test of specimens of tuberculosis and extrapulmonary tuberculosis, the smear-negative specimen cost increase of the second Xpert test was lower than that of the smear-positive specimen. Conclusion: The second xpert test showed significant value-added cost-effectiveness in the diagnosis of tuberculosis.

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Objective: To study the clinical features and the diagnosis and treatment of endogenous Klebsiella pneumoniae endophthalmitis associated with Klebsiella pneumoniae pneumonia. Methods: Three cases of endogenous Klebsiella pneumoniae endophthalmitis associated with Klebsiella pneumoniae with microbiological evidence were studied. The related literatures published from January 2008 to June 2018 were reviewed with “pneumonia” , “endogenous endophthalmitis” and “Klebsiella pneumoniae” as the keywords in CNKI, Wanfang, PubMed and Web of Science databases. Results: The 3 patients, all males, aged 54 years, 82 years and 48 years respectively. They all had a history of type 2 diabetes mellitus. Endophthalmitis occurred in one eye in all of them, and the patients had eye symptoms including eye pain, progressive loss of vision, periorbital area inflammation, conjunctivitis, weakening or disappearance of pupil light reflex, corneal edema and anterior chamber effusion. All of 3 cases had multiple patchy pulmonary lesions, and Klebsiella pneumoniae was proven to be the pathogen by blood culture. Two cases had pulmonary abscess and liver abscess, and one of them had brain abscess. A total of 28 literatures with 81 cases of endogenous Klebsiella pneumoniae endophthalmitis associated with Klebsiella pneumoniae pneumonia were retrieved from CNKI, WanFang, PubMed and Web of Science database. Conclusions:Klebsiella pneumoniae was one of the most common pathogens of pneumonia and endogenous endophthalmitis, which would seriously damage the lung and the eye. The early clinical features were not specific. Misdiagnosis or missed diagnosis might cause serious consequences. Eye pain and visual disturbance symptoms, ophthalmic examination, chest imaging, blood and aqueous humor etiology were of great value in the diagnosis of this disease.

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Objective: To describe the development of the Chronic Obstructive Pulmonary Disease Morning Symptom Diary (COPD-MSD) Chinese version and to test its reliability and validity. Methods: The COPD-MSD Chinese version was developed by the standard cross-cultural translation principle. A hundred and eight patients with COPD in stable condition from the Second Xiangya Hospital were assessed by interview with COPD-MSD Chinese version, and underwent mMRC, CAT scores and pulmonary function test.The reliability and validity were evaluated by performing correlation analysis.The stages of COPD determined by lung function were compared to observe the value of COPD-MSD Chinese version in determining disease severity. Results: The Cronbach’s alpha and retest reliability of the total scale were 0.908 and 0.927, respectively.The explanatory factor analysis was conducted using orthogonal rotation through the maximum variation principle components extraction which revealed the presence of 5 components with eigen values exceeding 1, explaining totally 74.257% of the variance, and the total score of the COPD-MSD Chinese version was significantly correlated with the mMRC and CAT scores (r=0.44 and 0.56,P<0.01), indicating that the scale of the convergence validity was good. The COPD-MSD Chinese version scores varied significantly in patients with different severity of COPD(χ(2)=9.808, P<0.05). Conclusion: The COPD-MSD Chinese version showed good reliability and validity and could be used in clinical assessment of morning symptoms in Chinese COPD patients.

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Objective: To determine the pattern of respiratory pathogens at bronchiectasis exacerbation and its associations with disease severity. Methods: A total of 119 steady-state bronchiectasis patients [42 males, 77 females, age range 19 to 74 years, mean age (45±14)years], diagnosed by a compatible history combined with evidence of bronchial dilatation on high-resolution computed tomography (HRCT), were recruited prospectively from out-patient clinics in the First Affiliated Hospital of Guangzhou Medical University between September 2012 and March 2013. A comprehensive history taking, radiologic appearance, spirometry, sputum bacterial culture and 16 respiratory viruses in nasopharyngeal swabs and sputum samples by PCR assays were collected at steady-state bronchiectasis. All bronchiectasis patients were followed up one year and assessed for bacteriology, virology and systemic inflammatory indices [including white blood cell, C-reactive protein (CRP), interleukin-6, 8 and tumor necrosis factor-α] during bronchiectasis exacerbation. Results: Fifty-eight bronchiectasis patients [20 males, 38 females, age range 19 to 74 years, mean age (44±14) years] reported 100 exacerbations (1 to 5 exacerbation events per patient) during one year follow-up. Respiratory viruses were found more frequently in sputum and nasal swab during exacerbation [35.0% (35/100) and 39% (39/100)] than those during steady-state in bronchiectasis [sputum: 13.8% (8/58), nasal swab: 8.6% (5/58)] (χ(2)=8.33,χ(2)=13.51; respectively, all P<0.05). The rate of bacterial detection during exacerbation in sputum was 56% (56/100), which was not significantly different compared with those at steady-state (35/58, 60.3%;χ(2)=0.284, P=0.59). Of these respiratory infections, viral-bacterial co-infection accounted for 30% exacerbation events. The most common bacteria and viruses during exacerbation in mild bronchiectasis (n=18, with 25 exacerbation events) were Haemophilus parainfluenzae (4 cases) in sputum and influenza A in nasal swab or sputum (4 cases), respectively. In patients with moderate (n=17, with 29 exacerbation events)-severe bronchiectasis (n=23, with 46 exacerbation events), pseudomonas aeruginosa was the most common bacteria in sputum (35 cases), and the most common respiratory viruses were rhinovirus in nasal swab or sputum (11 cases). In these 100 exacerbation events, patients with bacterial and viral co-infection, pure bacteria infection, pure virus infection, no bacteria and virus infection accounted for 30, 29, 16 and 25 exacerbation events, respectively. And patients with co-infection had higher serum CRP (45±23) mg/L and IL-8 [9.0 (4.4-15.5) ng/L] (F=23.32, F=9.81,respectively; all P<0.05), and increased risk of hospitalization (30% vs. 0] compared with those in non-infectious group(χ(2)=9.0, P=0.003). Conclusions: Pseudomonas aeruginosa, rhinovirus and influenza A were common causative agents of exacerbation in bronchiectasis.In patients with moderate-severe bronchiectasis, pseudomonas aeruginosa was the most common bacterium in sputum, and the most common respiratory virus was rhinovirus in nasal swab or sputum, compared to Haemophilus parainfluenzae in sputum and influenza A in nasal swab or sputum in mild bronchiectasis. Patients with co-infection had more severe systemic inflammatory response and higher risk of hospitalization during exacerbation.

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Objective: The aim of this study was to determine the performance of the ratio of tuberculosis-specific antigen (TBAg) to phytohemagglutinin (PHA) (TBAg/PHA ratio) in T-SPOT assay in the diagnosis of active tuberculosis (ATB). Methods: Between January 2014 and January 2017, 378 Mycobacterium tuberculosis (MTB) culture positive patients (268 cases of pulmonary tuberculosis, 110 extra-pulmonary tuberculosis) and 824 healthy individuals were recruited from Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. T-SPOT assay was performed and TBAg/PHA ratio was calculated in all the participants. To validate the study, another group of 223 MTB culture positive TB patients with positive T-SPOT results were recruited from Guangzhou Chest Hospital between January 2017 and December 2017. This was a retrospective case-control study and differences between groups were analyzed using the Mann-Whitney U-test. Results: Of the 378 culture positive ATB patients, 344 patients had positive T-SPOT results. Of the 824 healthy individuals, 204 individuals had positive T-SPOT results. Using healthy individuals as the control group, the sensitivity and specificity of T-SPOT assay in the diagnosis of ATB were 91.0% (344/378) and 75.2% (620/824). Directly using T-SPOT results had a limited accuracy in distinguishing ATB from latent tuberculosis infection (LTBI). The area under the receiver operating characteristic (ROC) curve was between 0.7 and 0.8. However, a further calculation of the TBAg/PHA ratio showed a better performance than TBAg in distinguishing these two conditions, and the area under the ROC curve was 0.881 (95% CI: 0.853-0.909). If using the threshold value of 0.234, the sensitivity and specificity of the TBAg/PHA ratio in distinguishing ATB from LTBI were 69.5% (239/344) and 94.12% (192/204). The validation data showed that the performance of the TBAg/PHA ratio in distinguishing ATB from LTBI was also satisfactory, and the area under the ROC curve was 0.901 (95% CI: 0.872-0.931). Furthermore, the TBAg/PHA ratio had an important role in the diagnosis of extra-pulmonary tuberculosis. If using the threshold value of 0.234, the sensitivity and specificity of the TBAg/PHA ratio in the diagnosis of extra-pulmonary tuberculosis were 79.2% (76/96) and 94.1% (192/204). The area under the ROC curve was 0.932 (95% CI: 0.897-0.967). Conclusions: The TBAg/PHA ratio in T-SPOT assay was better than directly using T-SPOT results in distinguishing ATB from LTBI. This ratio also showed a potential use in the diagnosis of extra-pulmonary tuberculosis.

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Objective: CD(4)(+)T cells, cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed cell death-1 (PD-1) and vascular endothelial growth factor (VEGF) are associated with cancer development. The aim of the present study was to investigate the expression of CTLA-4, PD-1 and VEGF in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). Methods: From January 2017 to January 2018, a total of 47 first-visit outpatients were recruited in the Sleep and Respiratory Disorder Center of Guangdong Provincial People’s Hospital, and were divided into control group (N=17, mean age 54±12 years), mild-to-moderate OSAHS group (N=15, mean age 54±12 years) and severe OSAHS group (N=15, mean age 56±13 years). Venous blood was collected, plasma and cells were isolated, the expressions of PD-1 and CTLA-4 on the surface of CD(4)(+)T cells were detected by flow cytometry, and plasma VEGF was measured by enzyme linked immunosorbent assay. Results: The proportion of CD(4)(+)T cells in control group, mild-to-moderate OSAHS group and severe OSAHS group were respectively(38±8)%, (35±8)% and (38±6)% (F=1.228, P>0.05). The expression of CTLA-4 on CD(4)(+)T cells were respectively [1.13 (0.59~1.78)]%, [0.45 (0.16~1.43)]% and [0.87(0.47~1.46)]% (H=2.205, P>0.05). The expression of PD-1 on CD(4)(+)T cells were respectively [4.24 (2.12~6.03)]%, [3.54(2.69~5.09)]% and [3.31(1.67~8.25)]% (H=0.541, P>0.05). The concentrations of VEGF in control group, mild-to-moderate OSAHS group and severe OSAHS group were statistically different [(395.16±87.78) ng/L vs (452.85±107.97) ng/L vs (546.42±199.27) ng/L, F=4.827, P=0.013]. Compared with the control group, VEGF concentration was significantly increased in the severe OSAHS group(P<0.01). VEGF concentration was correlated negatively with the lowest SpO(2) (r (s)=-0.480,P=0.001), but positively with apnea-hypopnea index(r (s)=0.403, P=0.005), oxygen desaturation index (r (s)=0.378, P=0.010) and proportion of SpO(2) less than or equal to 90% of total sleep time(r (s)=0.547, P=0.000 3). Conclusion: There was no significant difference of PD-1 and CTLA-4 expression on CD(4)(+)T cells in patients with and without OSAHS. The expression of VEGF was elevated in OSAHS patients, and increased with the severity of OSAHS and hypoxia.

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Objective: To analyze the implementation and understanding of pulmonary rehabilitation in medical personnel at all levels of medical institutions nationwide. Methods: We used WeChat and e-channels to disseminate e-questionnaires including personal basic information and the implementation of hospital pulmonary rehabilitation (including the setting up of hospital rehabilitation, pulmonary rehabilitation-related treatment, and the composition of pulmonary rehabilitation teams), and awareness of pulmonary rehabilitation (including doctors' understanding of lung rehabilitation status, pathways, prospects, and obstacle factors). Finally, the analysis of the data was performed using SPSS 20.0 for statistical analysis. The frequency distribution and composition ratio were used to describe the distribution of each question item. Comparison among groups according to the unit level of the respondents was performed by chi-square test. P<0.05 was considered statistically significant. Results: A total of 921 medical staff from all over the country completed the survey, covering the entire country including Taiwan Province and a total of 32 provinces, municipalities, autonomous regions, and municipalities directly under the Central Government. 88.1% of medical personnel reported that their hospitals had rehabilitation departments, the difference being statistically significant (P=0.001). Doctors could understand that the most important ways of pulmonary rehabilitation knowledge were the following: expert lectures (559, 60.69%), professional literature (541, 58.74%), professional books (442, 47.99%), pulmonary rehabilitation conference (392, 42.56%), the difference being statistically significant (all P<0.05).Among the factors that impeded the implementation of pulmonary rehabilitation, the top four were lack of talent (690, 74.92%), lack of education (645, 70.03%), lack of policy support (603, 65.47%), and lack of related equipments (578, 62.76%). Conclusions: The lower the level of the hospitals, the poor the implementation and cognitive status of pulmonary rehabilitation. Promoting the training of pulmonary rehabilitation personnel and strengthening the academic exchange of pulmonary rehabilitation were good ways to strengthen the implementation of pulmonary rehabilitation and improve the understanding of pulmonary rehabilitation.