http://www.cdc.gov.tw/ct.asp?xItem=5710&ctNode=1540&mp=230

結核病診治指引(第四版)

結核病診治指引(第四版)

Anti-TB 藥物 (reference: 臨床使用抗生素手冊)
INH: 對快速增殖的細胞外結核菌特別強
RIF: 可殺死快速增殖，緩慢增殖的結核桿菌(包括吞噬細胞內), 與 enfuvirtide 無交互作用
PZA: 中性或鹼性中缺乏殺菌效力
EMB: 只有抑菌效力

Resection for pulmonary TB
MDR/XDR limited in lung
massive hemoptysis
bronchopleural fistula

TB immunity
specific CD4 T cell 釋放 IL-2, 刺激T cell 生長 specific CD4 T cell 釋放 IFN-γ, macrophage activation
Macrophage 釋放 TNF-α

結核病診治指引 (線上閱讀)
http://www.cdc.gov.tw/ct.asp?xItem=33699&ctNode=78&mp=1
近年WHO認為胸部X光診斷的信賴度不高


結核性腦膜炎 建議治療 12個月，並使用類固醇
粟粒性結核，最常侵犯肺部、肝臟、脾臟


治療
一般：INH + RMP + PZA + EMB 2 個月，再 INH + RMP + EMB 4 個月
all sensitive: INH + RMP + PZA 2 個月，再 INH + RMP 4 個月。
INH 肝毒性的危險因素：酒精性肝炎、年紀、與 RMP併用
不建議常規使用 vitamin B6

INH, RMP 空腹時服用效果較好
PZA, EMB 不受食物影響


限制傳染性結核病患搭乘大眾航空器出國出境
http://www.cdc.gov.tw/public/Attachment/99229511471.pdf

Lung cancer, squamous cell carcinoma

ERCC1 , RRM1



References:
http://www.jnccn.org/content/8/7/740.extract

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0003695one.0003695


Pathology of lung adenocarcinoma

grade 1: nonmucinous lepidic
grade 2: acinar, papillary
grade 3: solid, micropapillary

Nonmucinous BAC: more EGFR
Mucinous BAC: more K-ras
建議所有的adenocarcinoma 或 NSCLC NOS 都要測 EGFR

References:

1. http://www.cscpweb.org/Travis_Lung%20Ade.pdf

2. International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Classification of Lung Adenocarcinoma JTO 2011
http://journals.lww.com/jto/Fulltext/2011/02000/International_Association_for_the_Study_of_Lung.4.aspx





Immunohistochemical staining in lung cancer

Malignant mesothelioma: WT-1, calretinin, D2-40, cytokeratin 5/6 (+)
CEA, B72.3, Ber-EP4, MOC31 (-)
Solitary fibrous tumor: vimentin, CD34 (+), keratin (-)
Small cell lung cancer: immunoreactive for keratin, epithelial membrane antigen, TTF-1 (+)

Primary lung adenocarcinoma: TTF-1 (+), CK7 (+), CK20 (-)
Metastatic adenocarcinoma from colon: CDX-2 (+), CK7(-), CK20(+)

SCC: CK5/6 (+), p63 (+), 34βE12 (+)


DNA mutation in lung cancer
small cell lung cancer 2nd line C/T: topotecan (not irinotecan)

K-ras: chromosome 12


Tumor suppressor gene: 3p21.3 (site of RASSF1A), 3p14.2 (FHIT), 9p21 (p16), and 17p13 (p53).

KRAS Mutations in Non–Small Cell Lung Cancer

http://pats.atsjournals.org/cgi/content/abstract/6/2/201

EGFR: never smoker 多, survival 較好
KRAS : tobacco exposure, uncommon in SCC
VEGF: poor prognosis

Angiogenesis in non-small cell lung cancer: The prognostic impact of neoangiogenesis and the cytokines VEGF and bFGF in tumours and blood

http://www.lungcancerjournal.info/article/S0169-5002%2805%2900498-8/abstract

Oncogenes and Antioncogenes in Lung Tumorigenesis

http://chestjournal.chestpubs.org/content/109/5_Supplement/130S.abstract

NIPPV indication:
acute exacerbation of COPD
cardiogenic pulmonary edema
immunocompromised
soon after extubation


Clinical review: Critical illness polyneuropathy and myopathyhttp://ccforum.com/content/12/6/238

reduction in or absence of deep tendon reflexes
serum creatine kinase, 並非很有幫忙
Risk factor: renal failure, renal replacement therapy, hyperglycemia
Biopsy result: a. diffuse non-necrotising 'cachectic' myopathy b. myopathy with selective loss of thick (myosin) filaments c. acute necrotising myopathy

Nonpleuritic chest pain
40% thrombocytosis
unilateral pleural effusion or thickening

CT:
Rind-like pleural involvement,
mediastinal pleural involvement,
pleural nodularity
pleural thickness more than 1 cm
http://www.ejradiology.com/article/S0720-048X%2801%2900426-0/abstract


need IHC stain for diagnosis from metastatic adenocarcinoma 

Inhaled Corticosteroids

Peter J. Barnes Pharmaceuticals 2010, 3, 514-540
http://www.mdpi.com/1424-8247/3/3/514/

摘要
1. Inhaled corticosteroid: 增加 β2 receptor gene transcription，避免使用LABA後的down-regulation，prevention β agonist tolerance。
2. β2 agonist 增加 translocation of GR from cytoplasm to the nucleus，增加抗發炎的效果
合併治療可以降低ICS劑量


COPD







Histamine
H1 receptor: bronchoconstriction
H2 receptor: mucus secretion
H3 receptor: mediate modulation of cholinergic and sensory nerve.
LTD4: eosinophilic inflammation (asthma)
LTB4: chemotactic agent for neutrophil (COPD)

Leukotrience modifier Zileuton: blocks 5-lipoxygenase (arachadonic acid to LTA4)
Montelukast: inhibit leukotrienes receptor, block LTD4 ( and LTC4, LTE4), use in aspirin induced asthma





http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf



MDI 使用
shake 5 secs --- inhal deep and slow --- hold breath 4-10 secs
優點：
缺點：需要 deep and slow breath, hand-breath coordination
使用spacer 增加lung deposition。不可連按兩下以上，按兩下效果小於一下。spacer不需每次清洗。
備勞喘(連結)
http://www.tmch.org.tw/VS/pharmacy/pharmacy02-1.files/PDF/9001-Berotec%20MDI.pdf





DPI 使用
inhal quickly and deeply (2-3 secs) --- hold breath
優點：不需hand-breath coordination. Lung deposition最佳。
缺點：需要足夠 peak inspiratory flow, turbuhaler 會潮溼
同樣轉一下要吸一次藥。

Nebulizer
需要常清洗device。

Balancing the benefits and risks of inhaled long-acting beta-agonists- The influence of values

N Engl J Med 2009; 360:1592-1595

The FDA and Safe Use of Long-Acting Beta-Agonists in the Treatment of Asthma

N Engl J Med 2010; 362:1169-1171
使用 LABA 會增加 asthma-related death，如果真的需要使用在asthma control ，建議用fixed-dose combination product

Xolair is effective in allergics with a low serum IgE level.

Int Arch Allergy Immunol. 2010;152(1):71-74
Heat and moisture exchanger
http://www.rcjournal.com/cpgs/hdmvcpg.html




Reference: Murray and Nadel's Textbook of Respiratory Medicine, 5th ed.

Left lung oligemia (Westermark sign)



pulmonary embolism in left pulmonary artery


pulmonary infarction



1. Only 10% involve the upper lobe
2. pulmonary infarction 10-15%, wedge-shaped
3. Westermark’s sign (focal oligemia) Palla’s sign (prominent right descending pulmonary artery)
4. Pleural effusion
5. Elevated the diaphram

References: Radiology of Chest Diseases

Type A aortic dissection




After operation




Widened superior mediastinum, double aortic knob，displaced intimal calcification

DD with aortic aneurysm, mediastinal tumor, tortuosity of aorta



aortic dissection
http://reference.medscape.com/features/slideshow/aortic-dissection