2013年 · 第36卷第07期

History can occasionally be surprisingly repeated and similar. Ten years ago today, the previous government headed by Premier Wen Jiabao was facing the severe test of SARS. It just so happens that now, ten years later, the new government with * as prime minister has unexpectedly encountered H7N9 bird flu. These two public health emergencies share many similarities and have had a huge impact on society as a whole, but today's response at the government level is quite different and completely different from what it was a decade ago. Let us compare the two events from both academic and humanistic aspects, review the past and learn the new, and look forward to the future.

In recent years, clinicians in sleep disordered breathing (SDB) treatment centers have observed a special phenomenon: patients with obstructive sleep apnea syndrome (OSAS) who receive continuous positive airway pressure (CPAP) treatment have obstructive sleep apnea (OSA) events resolved, but temporary or persistent central sleep apnea (CSA) events or periodic breathing occur, this phenomenon is defined as "complex sleep apnea syndrome" (CompSAS).^[1,2]。

Human tuberculosis is characterized by tissue damage, which further leads to high morbidity and mortality and human-to-human transmission. Although the mechanism of immunopathological damage caused by MTB infection has not been elucidated^[1]However, the characteristics of extracellular matrix in human lung tissue suggest that matrix metalloproteinases (MMPs) play an important role in the^[2]And MMPs have the potential to become new diagnostic tools and therapeutic targets for tuberculosis. Therefore, we reviewed the research progress of MMPs in the field of tuberculosis, and provided reference for basic and clinical research of tuberculosis.

80% to 85% of lung cancer patients are non-small cell lung cancer (non-small cell lung cancer, NSCLC). Statistics show that in 2010, there were 222,000 new cases of lung cancer in the United States, and about 160,000 related deaths caused by lung cancer^[1]。 The mortality rate of lung cancer in China ranks first among malignant tumors, which is 30.8/100,000^[2]。

Cognitive impairment in patients with OSAHS has been gradually recognized and paid attention to by the sleep medicine community in recent ten years, and it is considered as one of the causes of adult dementia^[1]。 The exact mechanism of cognitive dysfunction in OSAHS is still unclear, and some studies suggest that inflammatory response may play a certain role in cognitive dysfunction in patients with OSAHS^[2,3]。 In this study, Montreal cognitive assessment (MoCA) Beijing version, Mini-Mental state examination (MMSE) were used to assess the cognitive impairment of patients with OSAHS, Epworth sleepiness scale (ESS) was used to assess the daytime sleepiness of patients, and serum inflammatory index high-sensitivity C-reactive protein (hs-CRP) level was measured. By comparing the correlation between inflammatory response and cognitive function score, sleep structure and hypoxia parameters in patients with OSAHS of different degrees, the role of inflammatory response in the cognitive impairment of patients with OSAHS was investigated.

nonresponding pneumonia is a clinical concept proposed in recent years, which is not uncommon in clinic, but there is still a lack of unified standard. The American Society of Infectious Diseases/American Thoracic Society (IDSA/ATS) jointly published the guidelines for the diagnosis and treatment of community-acquired pneumonia (CAP) in adults in 2007 for the first time formally proposed the concept of non-responsive pneumonia, that is, a clinical condition (worsening or unchanged clinical symptoms) in which patients with CAP do not achieve significant improvement when receiving anti-infective therapy^[1]。 In recent years, some scholars have summarized it as follows: after at least 10 days of antibiotic treatment, there are still clinical manifestations of lung infiltration and acute lung infection, and the clinical symptoms are not improved or worsened, or the imaging still shows that the lung shadow is not obviously absorbed 12 weeks after the onset of pneumonia^[2,3]。 Initial empirical anti-infective therapy was ineffective in 6% to 15% of patients with CAP^[4,5]And the case fatality rate increased from 4% to 14%^[6]。 The mortality rate of non-responsive pneumonia is 3~5 times that of CAP, which can be as high as 49%, and the mortality rate of early treatment failure is 27%^[1]。 The reason for the high mortality rate is that some patients still can't identify the pathogen based on medical history, clinical symptoms, lung imaging and routine laboratory tests, resulting in the failure of initial empirical treatment. The pathogenic and microbiological examination of CAP is difficult to complete within 48 h, making it difficult to obtain a pathogenic diagnosis, but this examination is very important^[7]。 This study investigated the value and safety of percutaneous pulmonary puncture smear, culture and pathological examination in obtaining pneumonia pathogens.

At present, the commonly adopted treatment measures for patients with massive pulmonary embolism include anticoagulation, thrombolysis, surgical thrombectomy, direct catheter injection into pulmonary artery thrombolysis and catheter thrombectomy. Catheter interventional therapy was first applied to massive pulmonary embolism in 1969. The application of catheter interventional therapy in patients with massive pulmonary embolism is reviewed.

idiopathic pulmonary fibrosis (IPF) accounts for about 50% ~60% of idiopathic interstitial pneumonia. The median survival time of IPF patients after diagnosis is about 2~5 years, and the five-year survival rate<20%, currently no effective therapeutic drugs^[1]。 In the past 10 years, many randomized controlled clinical trials (RCTs) have been carried out worldwide to explore new drugs for the treatment of IPF. Different primary end-points have been used in these completed IPF clinical trials^{[2,3,4,5,6,7,8,9,10]}。 In clinical trials, which indicator is selected as the primary endpoint plays an important role in inferring the causal association between intervention and efficacy. There are different perspectives on how to select an appropriate, clinically meaningful primary endpoint in IPF clinical trials^[11]No consensus has been reached. IPF investigators in the United States selected case mortality as the primary endpoint in clinical trials^[2,4,8,10]Most IPF researchers in Europe or other countries tend to choose surrogate endpoints (such as FVC) as the primary endpoints of IPF clinical trials^[3,6,9]。 Recently Raghu et al.^[12]After analyzing the primary endpoints used in IPF clinical trials over the past 10 years, it is suggested that the "clinically meaningful" primary endpoints in IPF clinical trials are all-cause mortality and all-cause non-elective hospitalization, or the primary composite endpoints are all-cause mortality and all-cause hospitalization. Raghu et al.^[12]He sharply criticized the widespread use of surrogate endpoints in the past, believing that there is no available surrogate endpoint in IPF clinical trials, and the currently used lung function index FVC is not an appropriate surrogate endpoint index. Raghu et al's discussion of the main endpoints of IPF clinical trials immediately triggered heated discussions and questions in the academic community. Many well-known IPF researchers and clinicians have written articles in mainstream professional journals in the respiratory field^{[13,14,15,16]}, put forward the following counter-arguments tit for tat.

Men have germ stem cells in their testicles, which are capable of producing new sperm in a constant stream, whereas women have germ stem cells that are only active during the embryonic period and disappear once they are born. Women have about 1 million oocytes in their ovaries at birth, and this number only decreases but not increases. By puberty, there are only about 300,000 left. From the beginning of menarche, women will choose the best one from hundreds of oocytes every month to develop into an egg, discharge the ovary and wait for conception. After that, the number of eggs gradually decreases. This statement has not changed for nearly 50 years.

A 23-year-old female, unmarried, was admitted to hospital on January 3, 2012 mainly because of "intermittent cough and expectoration for more than 4 months". The patient had "ovarian cancer" 8 years ago, surgical treatment (details unknown), pathological return was ovarian mucinous cystadenocarcinoma, postoperative chemotherapy. The patient developed cough and a little white sticky sputum after catching a cold 4 months ago, and occasionally felt shortness of breath. After symptomatic treatment, there was no improvement. Recently, the cough and sputum progressively aggravated, and there was intermittent low fever. CT of the chest in the outside hospital showed multiple cavities and cavity-like lesions in both lungs, not excluding tuberculosis. For further diagnosis and treatment, he was admitted to the tuberculosis department of our hospital on January 3, 2012. Physical examination: body temperature 36.5 ℃, heart rate 80 beats/min, respiratory rate 20 beats/min, blood pressure 110/70 mm Hg (1 mm Hg =0.133 kPa), superficial lymph nodes around the body were not palpable and swollen, and a surgical scar about 5 cm long was seen in the lower abdomen, but no positive signs were seen. Laboratory and special tests: Blood routine, renal function, blood glucose and myocardial enzymes were normal, alanine aminotransferase was 57 U/L, ESR was 40 mm/1 h, blood gas analysis showed pH value 7.467, PaCO₂36.2 mm Hg, PaO₂78.9 mm Hg. CT of the chest showed scattered patch shadows on both lungs, multiple circular translucent areas and upper middle consolidation shadows on the right lung. Admission diagnosis: (1) Secondary pulmonary tuberculosis? (2) pneumonia? (3) Lung metastatic cancer? The cough and sputum were improved after giving butacanal, rifampicin and moxifloxacin anti-tuberculosis and symptomatic supportive treatment. Gradually improve relevant inspections. Blood tumor carbohydrate antigen 19-9 (CA19-9) was 76.81 U/L, anti-tuberculosis antibody was negative, PPD test was negative, IgE was only 112 IU/ml in all rheumatism series immunization items, and all 6 sputum examinations and acid-fast staining were negative. Chest enhanced CT examination: scattered flocculent blurry shadows with multiple cavities and cavity-like lesions were seen in both lungs, and the solid part of the lesion was mild to moderate enhancement, and tuberculosis was to be excluded (Figure 1，Figure 2，Figure 3，Figure 4，Figure 5，Figure 6)。 Bronchoscopy was performed, and no abnormalities were found under the microscope. The apical and basal segments of the upper and lower lobes of the right lung were brushed, lavaged, and tuberculosis and cytology were checked. There were no positive findings in all the results. CT-guided percutaneous lung biopsy was performed on February 3, 2012, and the pathological report was mucinous adenocarcinoma on February 6, 2012 (Figure 7，Figure 8), combined with the history of ovarian cancer, lung metastases are considered.

A 13-year-old female was admitted to the hospital on 15 February 2011 mainly due to "intermittent fever with chest pain for 10 days". The patient had intermittent fever without obvious trigger 10 days ago, with a maximum body temperature of 38.5℃, occasional dry cough, accompanied by chest pain, aggravated during cough and deep inspiration, and no discomfort such as expectoration, hemoptysis and chest tightness. After symptomatic treatment such as antipyretic, analgesic and anti-infective in another hospital, he still had intermittent fever and chest pain, so an X-ray chest radiograph in the outpatient department of our hospital showed that the left hilum occupied huge space and left pleural effusion (Figure 1，Figure 2)。 Since the onset of the disease, the patient has been in good spirits, with poor sleep and appetite, normal urine and defecation, and no obvious change in weight. He was in good health and had no history of exposure to radiation and toxicants. Physical examination after admission: temperature 38.7 ℃, pulse 100 beats/min, respiratory rate 20 beats/min, blood pressure 110/70 mm Hg (1 mm Hg =0.133 kPa). The superficial lymph nodes were unpalpable and swollen, the neck was soft and unresistant, the trachea was centered, the thyroid gland was not large, the left middle and lower lungs were voided when percussed, the breathing sounds of both lungs were coarse when auscultated, and a little wet rales could be heard in the left lung, but no dry rales and pleural friction sounds were heard. The heart rhythm was uniform, and no murmur was heard in the auscultation area of each valve. The abdomen is flat and soft without tenderness, and both lower limbs are not swollen. Admission diagnosis: left hilar space to be examined, left pleural effusion.

From February 2006 to August 2010, tracheal stent was used to treat patients with lung cancer near the carina who infiltrated the trachea and left and right main bronchus and caused stenosis, and good results were achieved, which are reported below.

There is a close connection between the respiratory system and the circulatory system, first of all, the anatomical connection. The lungs, heart and large blood vessels (vena cava, aorta, pulmonary arteries and veins) are connected to each other, and they both belong to the thoracic internal organs; Secondly, there is a physiological relationship. The lungs, heart and large blood vessels form the pulmonary circulation pathway, which receives venous blood from the systemic circulation, and exchanges gases to form arterial blood before entering the systemic circulation. There is an interaction between respiration and cardiovascular, and changes in structure and function of one side will cause corresponding changes in the other side. In pathophysiological conditions, the result of the interaction between the two often leads to a decrease in blood oxygen delivery, which ultimately leads to tissue hypoxia and organ dysfunction. While mechanical ventilation has an impact on the respiratory system, it will inevitably have an impact on the circulatory system, thus forming a more complex interaction between respiration and cardiovascular system than in physiological respiration.

Procalcitonin (PCT) is a biomarker that can be used to assess the likelihood of bacterial infection. Using PCT to guide antibiotic therapy is a new means to reduce its abuse, which can help to reduce the risk of adverse antibiotic reactions and the emergence of multi-drug resistant bacteria. However, the interpretation of PCT levels must be closely integrated with the clinical reality and the characteristics of the detection method. In clinical practice, we should use the PCT detection method with high sensitivity, and determine the specific detection boundary value according to the actual clinical situation. The advantages and limitations of PCT level detection for guiding antibiotic therapy in patients with different clinical manifestations and different potential infections are now summarized below.

The earliest records of inhalation therapy come from ancient Egypt. Ebersberbians circa 1554 BC (Ebers papyrusIn the earliest book recording pharmaceutical knowledge in ancient Egypt, it is recorded that dyspnea is treated by inhaling scopolamine smoke. At that time, there was no special inhalation device. People roasted scopolamine leaves on bricks, so that the scopolamine in them was vaporized and inhaled by patients. In fact, the earliest records of the treatment of bronchial asthma (referred to as asthma for short) originated from China. In 2600 BC, there was a record of the use of ephedra in the Huangdi Neijing, but there was no description of inhalation therapy.

The purpose of this study was to investigate the effects of sodium tanshinone ⅡA sulfonate (STS) on right ventricular systolic blood pressure (RVSP), right ventricular hypertrophy index, lung histopathology, intracellular basal calcium concentration in distal pulmonary artery smooth muscle cells (PASMCs) in chronic hypoxic pulmonary hypertension (CHPH) models and monocrotaline-induced pulmonary hypertension rat models^2＋] i) and calcium pool manipulated calcium influx (SOCE), mRNA and protein levels of classical transient receptor potential (TRPC) channel proteins 1,6 in PASMCs, thereby exploring the therapeutic effect of STS on pulmonary hypertension and its mechanism. Targeted drugs for pulmonary hypertension are often accompanied by obvious adverse reactions, expensive and limited efficacy. Therefore, there is an urgent need for more economical and effective new drugs for the treatment of pulmonary hypertension. STS is a water-soluble product obtained by sulfonylation of tanshinone ⅡA, an active ingredient of Salvia miltiorrhiza. Recently, it has been reported that STS can effectively reverse the remodeling and proliferation of pulmonary blood vessels in animal models of chronic hypoxic pulmonary hypertension, but its mechanism is still unclear. Our previous findings show that SOCE is a major cause of calcium imbalance in PASMCs in CHPH and can cause pulmonary artery constriction and vascular remodeling. The calcium pool manipulative calcium ion channel (SOCC) is a calcium ion channel mainly composed of TRPC.

In the middle of summer, the heat is annoying. In this season of heat waves, we celebrate the 10th anniversary of the fight against SARS. Ten years ago today, clinicians faced the severe test of SARS. Now, ten years later, we are once again on the front line of the fight against H7N9 avian flu. In the essay column of the editor-in-chief of this issue, Professor Liu Youning reviewed his personal experience, reflected on the huge losses and regrets brought by SARS, summarized the experience and lessons in the process of diagnosis and treatment at that time, was pleased with the results of effective measures for national control, praised the rapid treatment process of H7N9 avian influenza and the accuracy of information, and further looked forward to the possible changes of H7N9 avian influenza, which is worthy of reading by clinicians.