2013年 · 第36卷第08期

Recently, three young doctors from the Second Military Medical UniversityLancetA short article was published in SCI complaining about the enormous pressure they faced to publish their SCI papers^[1]It has caused a lot of resonance and a lot of debate. The author would also like to express some personal opinions here, hoping to attract more attention and promote more people to participate in the re-evaluation of the doctor assessment system.

Seeking effective treatment options for patients with benign airway stenosis has been a difficult problem for respiratory doctors. There are various causes of benign airway stenosis: mucosal ischemia caused by long-term tracheal intubation, surgical injury during tracheostomy and airway reconstruction, chemical corrosion and thermal injury, various inflammatory diseases involving the airway such as Wegener's granulomatosis, sarcomatosis, airway injury after radiotherapy and granulation tissue formation caused by stent stimulation. Some of them cannot find a clear cause of airway stenosis, which is called idiopathic airway stenosis^[1]。

Sarcoidosis is a granulomatous disease with multi-system involvement, the etiology of which is not yet clear, and can involve multiple organs throughout the body. Lung and lymph node involvement was the most common, with thoracic imaging showing hilar lymph node enlargement in nearly 90% of patients. At present, there are three main conditions for the diagnosis of intrathoracic sarcoidosis: clinical symptoms and chest imaging suggest sarcoidosis, pathological confirmation of non-caseous necrotizing epithelioid granuloma, and the exclusion of other granulomatous diseases^[1]。 For patients suspected of sarcoidosis, especially for those considering hormone therapy, it is necessary to obtain a pathological diagnosis in order to exclude malignant tumors and tuberculosis. Specimens should be obtained with the least invasive means at the most accessible site. Since the lung and intramediastinal lymph nodes are the most susceptible sites, bronchoscopy and mediastinoscopy are often used to confirm the presence of non-caseous granuloma. Various methods for obtaining pathological specimens required for the diagnosis of intrathoracic sarcoidosis under endoscopy are reviewed as follows, in order to be better applied by clinicians.

Since the 1980s, the incidence of tuberculosis has risen. In 2011, there were 8.7 million new cases of tuberculosis worldwide, and the incidence of tuberculosis in China ranked second in the world^[1]。 The pathogen of tuberculosis is MTB. MTB Standard Strain H₃₇The completion of the whole genome sequencing of Rv makes the research of MTB molecular biology enter the post-genome era. Transcriptomics is a subject that studies gene transcription and transcriptional regulation in cells at the holistic level, and it is also an important means to study cell phenotype and function. At present, 36 polycistronic transcripts of MTB have been verified experimentally, including 93 operon pairs, accounting for 2.4% of all genes^[2], 82 mycobacterial promoters have been identified. The MTB genome was homologously searched for 13 sigma factors, and 15 different regulators have been found.

Since the 1980s, tuberculosis has once again become a major public health and social problem in the world. However, almost no new anti-tuberculosis drugs have emerged. The resistance of existing anti-tuberculosis drugs is becoming more and more serious, and it is urgent to develop anti-tuberculosis drugs with new mechanism of action. After nearly 20 years of unremitting efforts, several new drugs with anti-tuberculosis effects have been developed at present, and have entered various stages of clinical trials, bringing new hopes for anti-tuberculosis drug treatment. In summary, these new drugs have the following advantages: novel mechanism of action, synergistic effect with current first-and second-line drugs without antagonism, no cross-resistance or low cross-resistance rate, strong biological activity, small dosage, long half-life, low mutagenicity rate and help to shorten the course of treatment, etc. Some of these new drugs will officially enter the clinic and have a positive impact on anti-tuberculosis treatment.

At present, the incidence of lung cancer is the first among all tumors, and its 5-year survival rate is less than 15%^[1]Literature reports that the risk of lung cancer in patients with bacterial pneumonia, tuberculosis or inflammatory lung disease is significantly increased, suggesting that the onset of lung cancer is related to chronic inflammation of the lungs.

sepsis (sepsis) is one of the most concerned problems in the field of clinical critical illness. It causes septic shock and multiple organ failure secondary to sepsis^[1,2]is one of the most common causes of death in patients^[3]。 Proteomics is a new research field in the post-gene era. The use of proteomics technology to isolate and identify differentially expressed proteins in sepsis patients' body fluids (mainly blood and urine) is beneficial to discovering biomarkers that can diagnose sepsis early. It is of great significance for early diagnosis, disease monitoring, prognosis assessment, research of sepsis pathogenesis and discovery of drug targets. The progress of sepsis and proteomics research is summarized as follows.

CD₃₉And CD₇₃It is an extracellular nucleotidase expressed in leukocytes, which can sequentially break down adenosine triphosphate (ATP) released extracellularly by injured cells, inflammatory cells and activated T cells into adenosine monophosphate (AMP) and adenosine. However, in the disease of allergic bronchial asthma (asthma for short), about CD₃₉And CD₇₃The expression level in the peripheral blood of patients and its clinical significance are rarely studied. Therefore, this study preliminarily explored CD₃₉And CD₇₃Role in allergic asthmatic diseases.

At present, it is generally believed that both sleep apnea and cardiovascular diseases are inflammatory reactive diseases. Various inflammatory markers such as cell adhesion molecule, selectin, tumor necrosis factor-α, IL-6, IL-8, C-reactive protein, etc. are closely related to vascular endothelial dysfunction and cardiovascular diseases in OSAHS patients. Previous studies have shown that after effective continuous positive airway pressure (CPAP) or surgical treatment in patients with OSAHS, the elevated inflammatory factors can be significantly reduced, suggesting that OSAHS can cause systemic inflammation, and the treatment of apnea and reversal of intermittent hypoxia/reoxygenation can reduce the inflammatory response. Williams and Steven^[1]It was found that nuclear factor-κ B is the key to vascular endothelial damage and inflammation in OSAHS patients. Nuclear factor-κ B activates and upregulates the gene expression of related inflammatory factors, forming a waterfall effect, leading to systemic inflammatory response, cell and tissue damage and organ dysfunction. The purpose of this study was to investigate the changes of inflammatory mediators in human umbilical vein endothelial cells after different modes of chronic intermittent hypoxia (CIH) exposure, to understand the differences in vascular endothelial inflammatory status after different modes of CIH exposure, and to find the relationship between reactive oxygen species clusters, nuclear factor-κ B and inflammatory factors.

ARDS is a syndrome with acute and progressive hypoxemia as the main clinical feature, and the mortality rate is as high as 50%^[1]。 "Open lung strategy" is one of the main methods for the treatment of ARDS. Optimal positive end-expiratory pressure (PEEP) is the main measure to maintain lung opening. However, the effect of PEEP on respiratory and circulatory functions is still controversial. In this study, the effects of different levels of PEEP on cardiac output, extravascular pulmonary fluid (EVLW), whole cardiac end-diastolic volume (GEDV), intrathoracic blood volume (ITBV), oxygenation index, intrapulmonary shunt (Qs/Qt), static compliance (Cst) and dynamic compliance (Cdyn) were observed in a porcine ARDS model induced by oleic acid.

Inhaled glucocorticoids (ICS) are the first choice for the control of bronchial asthma (asthma for short). Both the Global Asthma Prevention Initiative (GINA) and China's asthma prevention and treatment guidelines point out that ICS combined with long-acting β is recommended for patients with unsatisfactory control of ICS alone₂Receptor agonist (LABA) therapy was the first choice. However, their prices are relatively expensive and difficult to popularize. 2008 Guidelines for Prevention and Treatment of Bronchial Asthma^[1]It is pointed out that ICS + sustained-release theophylline drugs can be used as the first-line treatment for chronic asthma that cannot be controlled by ICS alone in poor areas of China. The results of recent studies show that CD₄^＋T cells (including Th1 cells, Th2 cells, Th17 cells and regulatory T cells) play an important role in the pathogenesis of asthma. In this study, the proportion of Th1, Th2 and Th17 cells in peripheral blood of asthmatic patients treated with ICS combined with oral theophylline was detected, which provided laboratory evidence for clinical treatment of asthma.

A 55-year-old female was admitted to the hospital on June 10, 2011 due to "intermittent cough, expectoration, blood in sputum for 6 years, aggravated with fever for 20 days". Six years ago, the patient began to intermittently have cough, expectoration, bloodshot sputum, and occasionally low fever. The symptoms were relieved after being treated with "antibiotics" for about 2 weeks, and the onset was 1 to 2 times a year. Fever, cough and expectoration appeared again 20 days ago, with body temperature as high as 39 ℃, accompanied by mild dyspnea. Peripheral blood white blood cell count was 14.2×10 in outpatient examination⁹/L, 0.85 for neutrophils, 156 g/L for hemoglobin and 240×10 for platelets⁹/L, ESR was 18 mm/1 h and CRP was 57 mg/L. Chest CT scan showed a right hilar mass, about 4.5 cm in diameter, considering the possibility of lung cancer or lung abscess (Figure 1，Figure 2)。 "Moxifloxacin hydrochloride" 0.4 g/d intravenous drip was given, and the body temperature dropped to normal after 7 days. After 14 days, reexamination of chest CT showed that the right hilar tumor was significantly reduced (Figure 3), admitted to our hospital for further diagnosis and treatment. Past history: Right middle lobectomy 8 years ago, postoperative pathological diagnosis of pulmonary tuberculosis, postoperative triple anti-tuberculosis treatment for 3 months; Type 2 diabetes for 4 years, allergy to penicillin and cephalosporin antibiotics, no smoking history. Physical examination: body temperature 38 ℃, blood pressure 115/70 mm Hg (1 mm Hg =0.133 kPa). No yellowing and bleeding spots were observed on the skin and mucosa, and no swelling of superficial lymph nodes was observed. There were no abnormalities in the head and neck, no deformities in the thorax, clear breathing sounds in the left lung, localized dry rales can be heard in the right lung, harmonic heart rhythm, no murmur, flat and soft abdomen, no tenderness, no reach to the liver and spleen under the costs, and no abnormalities in the spine and limbs.

A 63-year-old male was admitted to Beijing Millennium Monument Hospital on April 25, 2012 due to fever, holding breath, painful urination for 20 days, cough and expectoration for half a month. 20 days ago, there was no obvious trigger for fever. The highest body temperature was 39.0℃, which was irregular fever, accompanied by chills, chills and holding breath. It was obvious after activity. He could lie down at night, accompanied by painful urination, no urgency or frequent urination. Half a month ago, he had cough, cough of yellow and white sticky phlegm, and the phlegm was not easy to cough up. There was no night sweat or fatigue. The local hospital diagnosed pneumonia and gave anti-infection and phlegm-reducing treatment for 8 days (the specific drug is unknown). The patient's cough and phlegm did not improve significantly, and holding breath was progressively aggravated. Transferred to a local municipal hospital for treatment, chest CT showed large exudation consolidation shadows in the posterior segment of the left upper lobe tip and left lower lobe, bronchial inflation signs, and a small amount of pleural effusion on the left side (Figure 1), successively treated with cefoperazone/sulbactam for 1 day and imipenem for 7 days, but still had fever, cough, expectoration and asthma. After combined treatment with linezolid, moxifloxacin and fluconazole for 4 days, the patient's conscious spirit and appetite improved slightly, but cough and sputum did not improve significantly, and dyspnea progressively aggravated. Re-examination of chest CT showed that the density of exudative lesions in the left lung was significantly higher than before, showing bronchial inflation sign, and new patch shadows and small nodule shadows in the right lung, mainly distributed along the bronchial vascular bundle (Figure 2)。 Past health, smoking index 1200 years, history of intermittent exposure to organic dyes, denial of exposure to familial genetic diseases and infectious diseases.

pulmonary veno-occlusive disease (PVOD) is a clinicopathological syndrome that can cause pulmonary hypertension. It is characterized by progressive occlusion of pulmonary venules leading to increased pulmonary vascular resistance and right heart failure^[1]。 The guidelines for pulmonary hypertension, revised at the 4th International Forum on Pulmonary Hypertension in 2008, grouped PVOD as a single subgroup of the first type of pulmonary hypertension^[2]。 The clinical manifestations of PVOD are similar to idiopathic pulmonary arterial hypertension (IPAH), which is easily misdiagnosed. 5% ~25% of IPAH may be PVOD^[3]。 PAH-specific therapy due to misdiagnosis can cause fatal pulmonary edema in patients with PVOD. In recent years, with the understanding of this disease, the number of confirmed cases has increased year by year. The research progress of this disease is briefly introduced as follows.

Flexible bronchoscope such as electronic bronchoscope or fiberoptic bronchoscope (referred to as flexible bronchoscope) is mostly used for the diagnosis of airway lesions, and the treatment under rigid bronchoscope (referred to as rigid bronchoscope) is safer and faster^[1,2,3,4]。 In recent years, the author has performed various interventional operations under the hard lens, and the clinical experience is briefly described below.

The air passage established by inserting a ventilation tube into the trachea through the upper respiratory tract or directly into the trachea is called an artificial airway. Artificial airway can not only keep the airway open, improve the ventilation function, and help to remove airway secretions, but also realize the effective connection between ventilator and patient's physiological airway, and ensure the smooth progress of invasive mechanical ventilation.

Chronic obstructive pulmonary disease (COPD) is a common public health problem among people over 40 years old in China, and the morbidity and mortality rate are increasing year by year. Therefore, it is the goal of treatment to actively control the symptoms of COPD patients and improve their lung function^[1]。 Currently used long-acting beta such as formoterol and salmeterol₂-Receptor agonists (LABAs) are capable of alleviating COPD symptoms but need to be administered twice daily. Novel ultra-long-acting beta₂-The receptor agonist indacaterol can continue to act for more than 24 hours, which is not only convenient to administer and improves patient compliance, but also can optimize clinical efficacy and prognosis by prolonging the time limit of bronchodilation^[2]So as to quickly, permanently and stably control the symptoms of dyspnea in patients with COPD, improve their lung function and hyperinflation.

The first event of Beijing Young Respiratory Scholars Salon in 2013 was held on April 25th, 2013. This event was hosted by Professor Sun Yongchang of Respiratory Department of Beijing Tongren Hospital and Professor Xu Zuojun of Respiratory Department of Peking Union Medical College Hospital. Respiratory and pathological scientists communicated face to face.

Chinese Journal of Tuberculosis and Respiratory Studies, Issue 4, 2012 published the article "Efficacy of Aerosolized Inhalation of High-dose Glucocorticoids on Acute Attacks of Moderate to Severe Bronchial Asthma in Children"^[1]In this paper, the efficacy of inhaled glucocorticoids (ICS) in the treatment of moderate to severe acute asthma attacks in children was observed, and a more effective and safe treatment plan for acute asthma attacks in children was discussed. However, after careful reading, I feel that there are several questions in this article that are worthy of discussion.

First of all, I would like to thank Dr. Xu Fengling for your attention and letter to this manuscript. Let me answer your questions one by one.

What is the most important basis for the evaluation, praise, promotion and appointment of clinicians? How should doctors deal with the relationship between clinical and scientific research? How to evaluate the value of SCI papers? In the column of "Editor-in-Chief Essays" in this issue, Editor-in-Chief Liu Youning put forward his own views on the domestic clinical talent evaluation system because he saw the reports of young doctors "complaining" and combined with the current situation of "only SCI theory" in China. It is particularly worth mentioning that in 2013, there were gratifying changes in the evaluation system of doctors in Shanghai's health sector.