目的 探讨监测糖化血红蛋白水平(HbA1c)对糖尿病合并肺结核患者的临床价值.方法 回顾性分析2234例糖尿病合并肺结核患者的临床资料,根据入院治疗时的HbA1c水平分为血糖控制良好组(HbA1c＜8％,826例)与血糖控制不良组(HbA1c≥8％,1408例).比较两组患者临床资料、病原学药敏结果、影像学特点,分析不同糖化血红蛋白水平的糖尿病合并肺结核患者病原学药敏结果及影像学特点.结果 两组性别和年龄比较,差异均有统计学意义(P＜0.05).血糖控制不良组病原学阳性率为81.41％,高于血糖控制良好组的69.56％,差异有统计学意义(P＜0.05).血糖控制不良组空洞率为68.86％,高于血糖控制良好组的51.17％,差异有统计学意义(P＜0.05).结论 糖化血红蛋白水平有助于监测和判断糖尿病合并肺结核患者的临床情况.

目的 评估广州市耐多药肺结核治疗管理策略实施的效果,为结核病防治提供依据.方法 选取2014年7月1日至2019年12月31日于广州市胸科医院纳入耐多药肺结核高危人群筛查的2417例患者为调查对象,收集其人口学特征及临床诊疗资料,获得耐多药肺结核者671例,截止到2019年12月31日有治疗结局者352例.其中,广州户籍患者(简称"户籍患者")由专家组讨论治疗方案,纳入定点科室住院和耐多药门诊随访;非广州户籍患者(简称"非户籍患者")自行选择医院诊疗.同时,收集2018年1-5月期间162例耐多药肺结核患者医疗费用调查资料.分析调查对象治疗及转归情况,影响治疗转归的因素,以及医疗经济负担.结果 671例耐多药肺结核患者中户籍患者303例,检出率为21.37％(303/1418),低于非户籍患者的36.84％(368/999),差异有统计学意义(x2=69.93,P＜0.01).352例有治疗结局患者中治疗成功200例(56.82％),出现不良结局者152例(43.18％).单因素分析显示,户籍患者治疗成功比例(69.23％,108/156)明显高于非户籍患者(46.94％,92/196),差异有统计学意义(x2=17.59,P＜0.01);41～60岁组和≥61岁组患者出现治疗不良结局的比例明显高于治疗成功组[52.00％(78/150)vs.48.00％(72/150);56.82％(25/44)vs.43.18％(19/44)],差异有统计学意义(x2=18.45,P＜0.01);2016年1月1日及以后开始治疗的患者治疗成功的比例(61.71％,166/269)明显高于此时间以前开始治疗者(40.96％,34/83),差异有统计学意义(x2=11.13,P＜0.01).多因素logistic回归分析显示,出现治疗不良结局的危险因素为非户籍[OR(95％CI)=4.01(2.37～6.79)]、年龄＞40岁[41?60岁组:OR(95％CI) =4.08(1.05～15.96);≥61 岁组:OR(95％CI)=6.51(1.48～28.60)];而2016年1 月1 日及以后开始治疗为保护因素[OR(95％CI)=0.30(0.17～0.52)].户籍患者经济负担总费用[M(Q1,Q3)]为24 674(17 466,49 920)元,明显低于非户籍患者[100 215(63 858,133 720)元],差异有统计学意义(Z=-7.80,P＜0.01).结论 广州市耐多药肺结核管理策略可提高户籍患者治疗成功率,降低患者经济负担;建议推广对耐多药结核病患者由专家组讨论方案,定点收治和随访,减免费用等管理策略.

目的 评估不同月份痰菌结果 对含利奈唑胺方案治疗的耐多药结核病患者治疗结局预测的有效性.方法 选取广州市胸科医院肺结核科2014年10月1日—2017年11月1日使用含利奈唑胺方案治疗耐多药肺结患者,收集不同月份的痰涂片、痰培养结果 ,通过分析痰菌阴转情况,评价治疗结局预测的灵敏度、特异度和受试者工作特征曲线,比较不同月份痰菌结果 对于治疗结局的预测效率.结果 纳入47例患者中成功治疗40例;失败7例,其中2例死亡;成功率83.0％,十二月末痰培养转预测灵敏度(91.5％)、特异度(88.4％)、阳性预测值(95.0％)、ORC曲线下面积(0.832,P=0.005),优于三月末、六月末、九月末的相关指标,是最优的治疗结局预测指标.结论 比较其他月份痰菌结果 ,十二月末的痰培养阴转能更有效的预测治疗结局.

目的 探讨N-乙酰半胱氨酸(NAC)预防抗结核药物肝损伤作用.方法 肺结核患者196例,2HRZE/4HR+NAC(A组)及2HRZE/4HR+双环醇(B组)为观察组,2HRZE/4HR为对照组(C组),观察8周内肝损伤情况.结果 (1)A组肝损伤率17.19％,停药率45.5％,低于C组22.73％,53.3％(P=0.691,P=0.430).B组肝损伤率19.7％,低于C组22.73％(P=0.670),B组停药率76.9％,高于C组53.3％(P=0.778).A组患者肝损伤率及停药率低于B组(P=0.712,P=0.245).(2)发生肝损伤时间,A组多见于4～8周,B组多见2周内,C组3个时间段内相同.(3)各组转氨酶高值时间,A组(27.67±23.047)d较B组(19.75±16.080)d及C组(19.93±14.969)d迟.肝功能恢复时间,A组(16.83±9.998)d及C组(16.14±6.982)d较B组(22.10±19.319)d短,(P=0.469,P=0.478).结论 NAC预防性护肝作用与双环醇相似,但减少治疗中断率及延迟肝损伤发生时间,肝功能恢复时间短.

目的 了解利奈唑胺在治疗耐多药肺结核过程中出现的周围神经炎情况,为制定合理的耐多药肺结核方案提供参考.方法 选取广州市胸科医院2014年9月30日-2018年1月31日使用含利奈唑胺的抗结核治疗方案的耐多药肺结核患者47例,对治疗过程中利奈唑胺导致的周围神经炎及处理结果进行分析.结果 47例耐多药肺结核患者中出现周围神经炎24例,未出现周围神经炎23例,周围神经炎发生率为51％,两者基本资料对比未发现差异有统计学意义.利奈唑胺的累计用药时间的中位数(极小值—极大值)是150天(30-730),利奈唑胺剂量为1 200 mg/日者7例,600 mg/日者40例,两者周围神经炎的发生比例分别为4/7及20/40,未发现两者的发生比例差异有统计学意义.在发病时间上,利奈唑胺剂量为1 200 mg/日者新增病例数最多的是开始用药的0～2月,而600 mg/日者新增病例数最多的是开始用药的0～5月,其后两者新增发病例数均随时间延长而逐渐降低.发生周围神经炎的患者经停药及营养神经等综合治疗后,其转归为痊愈6例,好转10例,不变8例,无加重、死亡病例.结论 利奈唑胺在治疗耐多药肺结核过程中导致周围神经炎的比例较高,但只要及时停药及积极处理,其预后较佳.

Objective To investigate the adverse effects of linezolid treated MDR-TB and to provide the opinion for rational drug use.Methods Fourty seven MDR-TB patients hospitaled in the Department of Tuberculosis,Guangzhou Chest Hospital from October 1,2014 to March 20,2017 treated by regiman including linezolid were enrolled and linezolid-related adverse drug reaction (ADR) were analyzed.Results The median time of treatment of linezolid in 47 patients was 150 (30-730) d,and 37 cases (78.7％) had 61 cases of ADR,which mainly involving the nervous system,digestive system,blood system and skin.The adverse reactions associated with linezolid were shown as follows:24 cases of peripheral neuritis (51.1％,24/47),nausea in 15 cases (31.9％,15/47),decreased visual acuity in 11 cases (23.4％,11/47),3 cases of headache (6.4％,3/47),as well as insomnia,dizziness,skin rash,and bone marrow suppression were found in each 2 cases (4.3％,2/47).Most patients had peripheral neuritis (45.9％,17/37) and nausea (29.7％,11/37) within 0-6 months of medication.More patients had a decrease in visual acuity within 0-8 months (27.0％,10/37).The number of patients with peripheral neuritis,nausea and hypoacuity gradually decreased with the prolongation of the use of drug.Patients with ADR can take symptomatic treatment (47 cases),dose reduction (11 cases),suspend medication (3 cases),and drug withdrawal (11 cases).Among them,5 cases of peripheral neuritis,4 cases of visual deterioration,1 case of bone marrow suppression and 1 cases of nausea stopped taking medication in 37 patients with ADR,22 cases (59.5％)were improved,14 cases (37.8％) were not improved,1 cases (2.7％) was aggravated.Conclusion Linezolid has a higher rate of ADR during the long course of treatment.But it can be used safely when ADR was treated in time.

Objective To examine the treatment effect of nutritional support for malnutrition pulmonary tu-berculosis patients with pulmonary infection. Methods 109 adult tuberculosis patients were randomly divided into two groups. 52 patients in the treatment group were given anti-tuberculosis and anti-infection with nutrition support, and the other 57 patients in the control group were given routine treatment. Results The symptom improvement cases were 48 (92. 3％) and 39 (68. 4％) respectively in the treatment group and the control group (P=0. 006). The improvement ca-ses of chest X-ray were 33 ( 63. 5％) and 11 ( 19. 3％) respectively in the treatment group and the control group ( P<0. 001). The infection control efficiency were 92. 3％ (n=48) and 68. 4％ (n=39) respectively in the treatment group and the control group (P=0. 002). The infection control time were 8. 64 ± 3. 64 days and 13. 94 ± 5. 04 days respectively in the treatment group and the control group (P<0. 001). Conclusion Nutrition support can improve the treatment effect of malnutrition pulmonary tuberculosis patients with pulmonary infection, and shorten the time of infection control.

目的:探讨免疫调节剂在预防肺结核合并HBsAg阳性患者抗结核治疗后肝损伤发生的作用.方法:以广州市胸科医院2014年1月至2015年12月就诊的肺结核并HBsAg阳性患者136例为研究对象,将肺结核并HBV-DNA阳性患者抗结核联合抗病毒治疗的基础上,加用免疫调节剂治疗者为A组(n=21);肺结核并HBV-DNA阴性患者抗结核并加用免疫调节剂治疗者为B组(n=24).将HBV-DAN阳性患者抗结核联合抗病毒治疗未予免疫调节剂治疗者为C组(n=43);HBV-DNA阴性单纯抗结核治疗者为D组(n=48).回顾性分析各组患者治疗两个月药物性肝损伤的发生情况.结果:在HBV-DNA阳性患者人群中,A组与C组肝损伤发生率无明显差异(33.3%vs 34.9%,P>0.05);在HBV-DNA阴性患者人群中,B组肝损伤发生率虽低于D组,但无统计学意义(16.7%vs 25.0%,P>0.05).结论:肺结核并HBsAg阳性患者在抗结核治疗期间,无论HBV-DNA阳性或阴性,给予免疫调节剂治疗,对降低药物性肝损伤的发生率效果不明显.

Objective To explore the endoscopic characteristics of multidrug-resistant tuberculosis (MDR-TB) combined with tracheobronchial tuberculosis (TBTB). Methods 248 MDR-TB as study group, they hospitalized from October 1st 2008 to June 31st, 2016. 274 cases of non MDR-TB with bacteria positive as control group over 2015, all of them received bronchoscopy, sputum cultured and drug sensitivity tested of Isoniazid and Rifampicin. We analyzed the results of bronchoscopy and demographic data. Results 248 cases of MDR-TB patients, of 175 (70.56%) were diagnosed TBTB by bronchoscopy, of 73 (29.44%) without TBTB. 274 cases of non MDR-TB with bacteria positive patients, of 146 (53.28%) were diagnosed TBTB, of 128 (46.72%) non TBTB, the difference of comparisons was statistically significant (χ2 = 16.42, P = 0.000). MDR-TB combined with TBTB median age was 32 years, non MDR-TB combined with TBTB median age 42 years, the difference was statistically significant (U = 9932.00, P = 0.001). Among the MDR-TB patients, of 75 (42.86%) TBTB in the upper right bronchial, of71 (40.57%) upper left bronchus, while non MDR-TB patients, of 70 (47.95%) and 60 (41.10%), there was no statistically significant difference (χ2 = 2.44, P = 0.786). Among the MDR-TB, of 76 (43.43%) were inflammation infiltration type, of 11 (6.29%) were necrosis type, of 13 cases (7.43%) granulation proliferative type, of 72 (41.14%) were scar stricture type, of 3 (1.71%) tube wall softening type. Among the non MDR-TB, in turn, TBTB type were 50 (34.25%), 41 (28.08%), 9 (6.16%), 40 (27.40%), 5 (3.43%), the difference were statistically significant (χ2 = 30.50, P = 0.000). Conclusions The detection rate of TBTB was higher in MDR-TB patients, that common occur in younger patients. TBTB common infringe on upper right bronchial and upper left bronchus, TBTB type most are inflammatory infiltration type and scar stricture type. More attention should be paid to bronchoscopy among MDR-TB patients.

Objective To explore the relationship of tracheobronchial tuberculosis (TBTB) and multidrug-resistant pulmonary tuberculosis (MDR-PTB).Methods A total of 344 pulmonary TB patients hospitalized in Pulmonary Tuberculosis Department of Guangzhou Chest Hospital from January 1 to December 31,2015,were selected.All of them were with positive Mycobacterium tuberculosis culture and received bronchoscopy,furthermore,drug sensitivity of isoniazid and rifampicin were tested.Data,including age,gender,bronchoscopy,initial treatment or re-treatment,pulmonary cavity,course of disease,complications,result of sputum test,etc.,were retrospectively collected using one-way analysis of variance (ANOVA) and logistic multi-factor regression analysis.Results Of the 344 patients,70 (20.35％) were MDR-PTB,274 (79.65％) were non-MDR-PTB;199 (57.85％) complicated with TBTB,and 145 (42.15％) without TBTB.Among the 70 MDR-PTB patients,53 (75.71％) were complicated with TBTB,while 17 (24.29％) without TBTB.Results of ANOVA indicated that among MDR-PTB patients,44.28％％ (31/70) with the course of the disease over 24 months,77.14％ (54/70) recurrent,pulmonary cavity were found in 81.43％ (57/70),and 75.71％ (53/70) complicated with TBTB,which were significantly higher than those of non-MDR-PTB (13.87％ (38/274),15.69％ (43/274),59.49％ (163/274) and 53.28％ (146/274),respectively) (x2 =54.34,103.99,11.64,11.50,all P＜ 0.05).According to multivariate logistic regression analysis,re-treatment TB (OR (95％CI):17.37 (8.90-33.88)),pulmonary cavity (OR (95％CI):2.91 (1.36-6.23)),and TBTB (OR (95％CI):2.70 (1.33-5.49)) were risk factors of MDR-PTB.Of the 199 patients complicated with concurrent TBTB,in 75 cases (37.69 ％) were of inflammatory infiltration type,44 (22.11％) were of ulcers necrosis type,granulation proliferation type were found in 10 cases (5.03％),63 (31.66％) were of scar stricture type,5 (2.51％) were of tube wall softening type and lymphatic fistula type were in 2 cases (1.00％);there was no relationship between TBTB types and MDR-PTB (r=0.03,P=0.717).Conclusion TBTB was a risk factor for MDR-PTB.More attention should be paid in screening MDR-PTB among TBTB patients,as well as screening TBTB in MDR-PTB patients,to facilitate early diagnosis and reasonable treatment.

Objective To study the correlation of PAZ with anti-tuberculosis treatment regimen and drug-induced liver injury in tuberculosis patients with HBV-DNA positive in order to provide an optimized treatment regimen. Methods from Jan 2013 to Dec 2014, 199 pulmonary tuberculosis with HBV-DNA positive patients and 103 pulmonary tuberculosis patients without HBV in our hospital were collected. They were assigned as follows:122 cases were anti tuberculosis treatment with antiviral therapy,64 cases were A(HRZE),58 cases were B (HRE). 77 cases were anti tuberculosis treatment but not antiviral therapy , 41 cases were C (HRZE), 36 cases were D(HRE) and 103 patients without HBV were E (HRZE, the contrast group). We had observed the liver injury for 2 months after the treatment. Results 1.Incidence of liver injury was 34.38% in group A , higher than the cases in group B(20.69%,P > 0.05). 2.Incidence of liver injury in group C was apparently higher than in group D (73.17% vs. 30.56%,P < 0.05). 3.Incidence of liver injury in group B was lower than group D (20.69% vs. 30.56%,P > 0.05)4.Incidence of liver injury in group A was lower than group C (34.38% vs. 73.17%,P < 0.05).5. Incidence of liver injury in group A was higher than group E (34.38% vs. 17.48%,P< 0.05)and there was no difference between group B and group E (20.69% vs. 17.48%,P> 0.05). Conclusion Although anti tuberculosis treatment combined with antiviral therapy can be partially reduce the incidence of liver injury and relieve the severity of liver injury in tuberculosis patients infected with HBV , but PZA toxicity to hepatocytes is a major risk factor for liver injury , and we need to change the treatment plan to reduce the occurrence of liver injury.

目的:探讨联合抗病毒治疗对肺结核并HBV-DNA阳性患者抗结核药物肝损伤的预防作用.方法:以2013年1月-2014年12月在广州市胸科医院就诊的行抗结核治疗的肺结核患者为研究对象,并分组,A组(n=64):HBV-DNA阳性,联合抗病毒治疗;B组(n=41):HBV-DNA阳性,未行抗病毒治疗;C组(n=120):并HBV感染但HBV-DNA阴性,未行抗病毒治疗;D组(n=103):无HBV感染,未行抗病毒治疗.比较各组发生肝功能损伤的情况.结果:(1)4组患者治疗2月内,A及B组肝损伤发生率分别为34.38％和73.17％(P=0.000);C组肝损伤发生率为24.17％,与A组相比(P=0.141);D组肝损伤发生率为17.48％,与A组相比(P=0.013).(2)4组出现肝损伤程度由高到低依次为:B＞C＞A＞D,B组明显高于A组(P=0.011).(3)4组肝损伤出现时间无明显差异(P=0.995).结论:肺结核并HBV-DNA阳性患者,在抗结核治疗过程中联合抗病毒治疗可有效预防药物性肝损伤;同时可降低肝损伤程度.

目的：分析2型糖尿病合并初治涂阳肺结核患者痰菌阴转情况及其影响因素。方法对住院治疗的2型糖尿病并初治涂阳的肺结核患者107例，统一予以2～3HRZE／9～10HR方案抗结核治疗，随访6个月以上，分析痰菌2个月末和6个月末的阴转情况，同时采用logistic向后逐步删除法多因素回归分析影响痰菌阴转的危险因素。结果治疗2个月末67.3％的患者痰菌阴转；6个月末89.7％的患者痰菌阴转。 logistic多因素分析显示2个月末痰菌未阴转的危险因素为糖尿病病程长（ OR＝2.524，P＝0.013）、病灶范围广（ OR＝1.136，P＝0.000）、空洞多（OR＝2.869，P＝0.010）、治疗前高水平的糖化血红蛋白（OR＝1.375，P＝0.003）、治疗2月末高水平糖化血红蛋白（OR＝2.795，P＝0.007）、治疗2个月末高水平的空腹血糖（OR＝2.493，P＝0.023）；6个月末痰菌未阴转的危险因素是病灶范围广（OR＝1.186，P＝0.034）、空洞多（OR＝2.488，P＝0.039）、2个月末痰菌阳性（ OR＝4.250，P＝0.030）。结论2型糖尿病合并初治涂阳肺结核的2个月末痰菌阴转率偏低，疾病的各宿主因素及血糖控制情况对2个月及6个月痰菌阴转存在不同影响。两病合并患者在治疗中需加强监测及管理。

目的 了解耐多药肺结核(MDR-TB)化学治疗的不良反应情况.方法 回顾性研究广州市胸科医院2008年11月至2013年7月纳入全球基金MDR-TB治疗项目并且完成疗程的96例患者.患者的治疗方案为6 Km(Am)-Z-Lfx(Ofx) PAS(Cs)-Pto/18Z-Lfx(Ofx)-PAS(Cs)-Pto.根据病历资料,收集患者的一般情况、治疗方案、药物不良反应(ADR)、处理方法,并进行分析.结果 96例患者中出现ADR 83例(86.5％),无ADR 13例(13.5％);治愈者与治疗失败者ADR的发生率分别是87.1％(54/62)和85.3％(29/34),差异无统计学意义(x2=0.06,P=0.806);在0～1个月、2～6个月的疗程治愈的患者ADR发生率分别是40.7％(22/54)和46.3％(25/54);治疗失败者分别是34.5％(10/29)和55.2％(16/29),两者比较差异无统计学意义(x2=0.31,P=0.577和x2 =0.60,P=0.441).常见的ADR是胃肠道反应、关节痛、头昏头痛、肝损伤,发生率分别是50.0％(48/96)、25.0％ (23/96)、13.5％ (13/96)、15.6％(15/96);以Cfz、Pto、PAS、Clr、Lfx、Km、Z的ADR发生率较高,分别是100％(7/7)、48.7％(39/80)、48.4％(31/64)、47.1％(8/17)、28.5％(20/70)、28.3％(17/60)、26.2％(22/84);107例次(69.5％)需停用相关的药物,替换其他药物.结论 MDR-TB治疗的ADR发生率较高、种类多,需采用正确的对策和进行规范处理.

目的探讨肺结核病变组织MMP-9表达特征,分析其表达与结核病发展的相关性。方法利用SP免疫组织化学方法,对57例肺结核病变组织和25例正常肺组织中MMP-9表达进行研究。结果MMP-9表达多呈胞浆表达。结核组MMP-9表达阳性PU值为8.966±2.91,显著高于对照组的7.657±1.585(P=0.011)。在结核组中,初治与复治之间,痰菌阳性与阴性之间,空洞与非空洞之间,不同病变范围之间MMP-9表达均差异无显著性(均P>0.05)。结论MMP-9高表达可能是肺结核病变组织区别于正常肺组织的重要特征之一,与结核病的发生相关,可作为结核病辅助诊断的标志物。

近10余年来,耐多药结核病(MDR-TB)的增多和流行是全球结核病控制面临的严重挑战和亟急待解决的难题.本院自2000年9月-2004年9月对94例耐多药肺结核患者应用卡介菌多糖核酸(斯奇康,BCG-PSN)与抗结核药联合治疗和单纯化疗进行了临床对比观察,现报告如下.