2013年 · 第36卷第03期

Clinical medicine belongs to the category of empirical science, and people are not sages. It is an unbelievable myth that there has never been a misdiagnosis or missed diagnosis in a medical life. However, when recalling the past, people mostly focus on "crossing five passes and beating six generals", and rarely mention "walking to Maicheng". In fact, in the recent issues of "Editor-in-Chief Essays", the author also introduced several difficult and severe cases that I successfully diagnosed and treated to readers. In order to avoid giving readers the impression that I also like "praise and self-praise", I specially cited a patient who had been misdiagnosed recently for readers' reference.

There are many magical phenomena in nature, but people are accustomed to them. Most fish have two eyes on both sides of the head, and flounder is also a fish, but why are its two eyes on the same side? There must be some truth in this. According to research, the original flounder, like other fish, also had eyes on both sides. However, because its food chain is relatively weak in the ocean, in order to not be eaten by natural enemies, it had to hide at the bottom of the sea and cover its body with a layer of fine sand, only exposing its eyes to wait for prey and avoid natural enemies to preserve itself. In such an environment, the eyes of the flounder gradually undergo a series of changes during the long-term survival race, and the downward eye slowly moves upward until both eyes are on one side of the body (above). So this is actually the result of animal evolution and natural selection.

Proteomics is a new subject, which can detect the differential expression of proteins under normal and pathological conditions, and obtain the corresponding disease markers. Among them, humoral proteomics has a broad development prospect for discovering human disease biomarkers^[1]。 In recent years, through humoral proteomics studies such as serum, pleural effusion, cerebrospinal fluid, BALF and sputum, important functional proteins related to tuberculosis have been discovered. These proteins provide valuable clues for finding disease markers and studying the pathogenesis of tuberculosis. The author summarizes the current commonly used proteomics related techniques and the progress of humoral proteomics in tuberculosis research as follows.

The dysfunction of upper airway respiratory muscles plays an important role in the pathogenesis of OSAS, and the genioglossus muscle, as the most important upper respiratory tract dilator muscle, decreases its ability to expand during sleep. Based on the important role of muscle in maintaining the opening of the upper airway, can the muscle activity be improved by electrical stimulation, so as to achieve the therapeutic effect on OSAS? Experiments have shown that the upper airway resistance of OSAS animal models, healthy people and OSAS patients can be improved by electrical stimulation on the surface of the body or within the nerve. At the same time, there are many clinical studies focusing on the excitement induced by apnea during sleep. Studies have shown its effectiveness, but there are also related studies that have reported its side effects such as sleep arousal. Tongue muscle stimulation is the latest method to improve the function of upper respiratory muscle groups. Although snoring symptoms improved significantly, there was generally no corresponding reduction in respiratory disturbance. Therefore, electrical stimulation is not widely used in clinical practice at this stage. Nevertheless, the importance of muscle in the pathophysiology of OSAS and the role of electrical stimulation in improving the symptoms of OSAS can not be neglected. Neuromuscular electrical stimulation, as a new therapeutic method, is attracting increasing attention.

metered dose inhalers (MDI) are one of the main preparations for the treatment of bronchial asthma (asthma) and chronic obstructive pulmonary disease (COPD). MDI is directly inhaled into the airway through the oral cavity and has a rapid onset of effect, with few systemic adverse reactions. The preparation also has the characteristics of convenient carrying and low price. MDI has been used clinically for more than 50 years, and has played a huge role in the treatment of respiratory diseases such as asthma and COPD, and has also been loved by the majority of patients. However, with the development of science and the improvement of people's understanding of aerosol, it has been found that the propellant in inhaled aerosol-chlorofluoro carbon (CFC), or Freon for short, has serious environmental protection problems. At present, CFC-containing aerosols tend to be phased out^[1]。 In recent years, some foreign pharmaceutical companies have developed alternatives to CFC, and a new generation of MDI has been applied in clinical practice and achieved remarkable results. The current status and clinical research progress of MDI are summarized as follows.

Hematopoietic stem cell transplantation is one of the most effective treatment methods for hematological malignancies, which can make many patients get long-term remission or even radical cure. However, pulmonary complications after transplantation seriously affect the survival and quality of life of patients, and diffuse alveolar hemorrhage (DAH) is one of the rare but serious complications. Its incidence, pathogenesis, diagnostic criteria, risk factors, clinical manifestations and treatment methods are summarized as follows.

Cough is a common symptom in internal medicine, with many causes and a wide range of involvement, especially chronic cough without obvious abnormalities in chest imaging is easy to be neglected by patients and clinicians, many patients have been misdiagnosed as "chronic bronchitis" or "bronchitis" for a long time, a large number of antibacterial drugs and cough-reducing phlegm drugs are ineffective, or various examinations are repeatedly performed due to unclear diagnosis, which not only increases the pain of patients, but also increases the economic burden^[1]。

The central airway refers to the trachea, carina, left and right main bronchi and middle bronchi. Reduction of central airway diameter due to various reasons and clinical manifestation of dyspnea, even death of the patient, is called central tracheal stenosis (central airway stricture, CAS)^[1]。 benign central airway stricture (BCAS) refers to space-occupying or scar-spastic stenosis of the airway caused by tracheal and bronchial tuberculosis, trauma, surgery, tracheotomy, tracheal intubation, foreign bodies, benign tumors and amyloidosis, and airway collapse stenosis caused by recurrent polychondritis and thyroid cyst destruction of airway wall^[2]。 This study retrospectively analyzed the clinical data of 591 patients with CAS admitted to Tangdu Hospital in the past 5 years, which are reported below.

cryptogenic organizing pneumonia (COP) refers to a subtype of idiopathic interstitial pneumonia with unknown pathogenesis or no clinical concomitant diseases (such as infection, connective tissue disease, radiation pneumonia, etc.) and pathologically characterized by organizing pneumonia^[1,2,3]。 Due to the lack of specificity in clinical manifestations of COP, it is easy to be misdiagnosed. The clinical, imaging, pathological characteristics, treatment and follow-up results of 12 patients with COP diagnosed by pathology in PLA General Hospital are reported as follows, so as to improve clinicians' experience in early diagnosis and treatment of this disease.

Ulinastatin is a highly potent broad-spectrum hydrolase inhibitor^[1,2]Clinically, it has been widely used in the treatment of inflammatory diseases such as diffuse intravascular coagulation and acute lung injury^[3,4]However, its antioxidant effect in allergic asthma and its relationship with heme oxygenase-1 (HO-1) are still unknown. In this study, the role of ulinastatin in ovalbumin (OVA) -induced bronchial asthma (asthma) mouse model and its relationship with HO-1 were investigated from the perspective of oxidative stress, so as to provide clues for exploring new efficient and safe clinical asthma treatment drugs.

Dyspnea caused by malignant tumors invading the trachea or compressing the tracheobronchus is one of the common tumor emergencies, and it is also a common cause of death in patients with advanced cancer^[1]。 Tracheal stent implantation has become the preferred treatment for timely and effective relief of airway stenosis caused by various tumors^[2]。 The choice of anesthesia and ventilation mode during stent implantation often limits the treatment of some patients with severe airway stenosis. A patient with airway stenosis caused by esophageal cancer compressing the trachea was reported. With the support of extracorporeal membrane oxygenation (ECMO), the stent was placed through bronchoscope. The therapeutic effect was analyzed and the follow-up was performed.

The patient was a 53-year-old male with a history of rheumatoid arthritis for 8 years and was irregularly taking drugs such as fenbid, methotrexate and prednisone. No history of tuberculosis, no low fever and night sweats, etc. Five days before admission, I started to have chills and fever every afternoon, with a body temperature of 39.5℃, slight discomfort in my right upper abdomen, no nausea and vomiting, and normal stool. I was admitted to the Department of Internal Medicine of Hangzhou Red Cross Hospital with "fever to be examined". Physical examination: At admission, he was in good mental state, thin, anemic appearance, no yellowing stain on the skin and sclera, mild tenderness in the right upper abdomen, negative Murphy's sign and negative mobile voicing. Laboratory test: white blood cell count 3.1×10⁹/L, neutrophils were 0.89, lymphocytes were 0.03, hemoglobin was 107 g/L, ESR was 69 mm/1 h, fecal occult blood was negative, and Feida test was negative; Blood culture results were negative for common bacteria; X-ray chest radiograph showed no obvious abnormalities; B-ultrasound showed that the gallbladder was 7.3 cm ×4.0 cm, the wall hair was thickened and double-layered, with a thickness of 1.1 cm, and there was no effusion in the abdominal cavity; CT results were consistent with B-ultrasound, and enhanced CT showed annular enhancement of gallbladder. After admission, he was given cefoperazone sodium, sulbactam sodium and other drugs, but the symptoms and signs did not change significantly. Laparoscopic cholecystectomy was performed 10 days later. During the operation, the gallbladder size was normal, the tension was high, there was a little adhesion to the omentum, the gallbladder wall was obviously edema and congestion, the texture was brittle, there were no gallbladder stones, no ascites, no miliary nodules, and no obvious lymph node enlargement. The wall thickness of the gallbladder was about 4~5 mm, and no obvious protuberance or nodules were found. The postoperative pathological report was gallbladder tuberculosis, acid-fast staining (+), and the body temperature returned to normal after treatment with anti-tuberculosis drugs. Preoperative and postoperative multiple sputum search for acid-fast bacilli were negative, PPD test was negative, anti-tuberculosis antibody was negative, bronchoscopy after operation showed no abnormality, brush film acid-fast bacilli was negative.

Massive hemoptysis is one of the common clinical symptoms of pulmonary tuberculosis. Because of the large amount of hemoptysis and the rapid bleeding speed, it is easy to form clots to block the bronchi, causing patients to suffocate and threaten their lives. With the extensive application of bronchoscopic interventional technique, there are more and more clinical applications of bronchoscopy to rescue asphyxia after massive hemoptysis of pulmonary tuberculosis. We used bronchoscopy to rescue 140 cases of pulmonary tuberculosis and asphyxia after massive hemoptysis, and achieved good results.

Mechanical ventilation is the most commonly used supportive treatment for patients with respiratory failure in ICU^[1]。 Under the traditional ventilation mode, the clinician subjectively selects the ventilation mode, and determines the setting of various parameters according to the characteristics and changes of the patient's condition. When the patient is not breathing spontaneously, the clinician typically selects a controlled ventilation mode (volume-controlled ventilation or pressure-controlled ventilation) and sets target minute and tidal volumes, respiratory rate, and respiration-to-respiration ratio. The initial goal is typically based on the patient's weight as well as the expected CO₂Yield setting and then adjustment to the aforementioned goals based on the results of arterial blood gas analysis. As spontaneous breathing gradually resumes, most clinicians choose either simultaneous intermittent command ventilation (SIMV) or pressure-supported ventilation mode (PSV). In PSV mode, if the patient's respiratory load and ventilation mode are acceptable, the level of pressure support gradually decreases. If the respiratory load is too high and/or the patient exhibits shallow rapid breathing, the pressure support level is increased again until the clinical condition improves.

The 10th event of Beijing Young Respiratory Scholars Salon 2012 was held on November 29, 2012. The event was hosted by Liu Guoliang, Department of Respiratory Medicine, China-Japan Friendship Hospital, Ministry of Health, with the theme of "Differential Diagnosis of Dyspnea".

The National Natural Science Foundation of China (NSFC) adheres to the strategic orientation of "supporting basic research, adhering to free exploration and playing a guiding role", which lays the foundation for enhancing China's independent innovation ability and building an innovative country. The NSFC basic funding system consists of three series: research projects, talent projects, and environmental conditions projects. The series of research projects mainly includes general projects, key projects, major projects, major research plans and international (regional) cooperative research projects. The talent project series mainly includes basic science talent training fund, youth science fund, regional science fund, outstanding youth science fund, national outstanding youth science fund and innovation research group science fund, etc. The environmental condition project series mainly includes scientific research instruments, joint funds, popular science projects, youth science and technology activities, journals, international (regional) academic conferences and cooperation and exchange projects, etc. The main funding scope of NSFC for respiratory system in the medical field (application code H01) includes diseases such as lung, airway, pulmonary circulation, mediastinum, pleura, thorax and diaphragm, as well as basic research in lung transplantation, new technologies for respiratory system diagnosis and treatment and other related sciences^[1]Respiratory tumor related research projects should be applied in Oncology (application code H16). The application, acceptance and funding status of major respiratory system project categories in 2012, as well as the precautions when applying and the funding trend in evaluation are summarized and analyzed as follows.

Clinical medicine is an empirical science, and it is inevitable that every doctor will experience misdiagnosis and missed diagnosis in the course of his growth. In the essay column of this editor-in-chief, Professor Liu Youning introduced a case of tuberculosis whose imaging, laboratory and clinical manifestations are similar to lung cancer. After joint consultation by radiology, thoracic surgery, tuberculosis and respiratory departments, on the premise of excluding lung cancer by pathological examination, experimental anti-tuberculosis treatment was finally given, and the clinical efficacy was good. In view of the diagnosis and treatment of this patient, Professor Liu Youning emphasized the differential diagnosis of atypical tuberculosis and lung cancer, pointed out that the existence of false positives and false negatives should be paid attention to in the interpretation of imaging examination results, and reminded doctors that there are often significant individual differences among patients encountered in clinical work. Its text goes from shallow to deep, whipping into the inside, which is in line with clinical practice and is worth reading.