2013年 · 第36卷第11期

The endless deception will actually appear in "doctors", an industry closely related to life. Occasionally, the income of Jianghu doctors seeing a patient will exceed the salary of ordinary doctors for a lifetime. "Empty basin turns into a snake" and "broken coin recovery" can also be related to medical treatment. How are these things completely deviated from common sense realized? In the essay column of the editor-in-chief, Professor Liu Youning, the editor-in-chief of this magazine, starts with what he has seen and heard with his own eyes, and talks about some events that have happened in history and are gradually forgotten, so as to grasp the pulse of history and distinguish the authenticity of reality.

Around 1995, I had the honor of meeting Wang Lin in Nanchang, Jiangxi Province, and watched him perform live. Instead of watching a performance, it was more like an appraisal meeting prepared beforehand. The reason for such an appraisal meeting was that Wang Lin was already very famous in the local area at that time. Some people admired him to the extent that he was almost crazy. For example, many people firmly believed that he could take off the pants of a passerby without any contact, leaving his lower body exposed. There are also many local officials in important positions, vowing to say that one of their relatives suffered from "terminal illness" was cured by Master Wang Lin. We didn't believe in these absurdities, but we couldn't stand the persuasion and decided to learn the style of the "master" to find out.

At present, the first international expert consensus on idiopathic interstitial pneumonia (IIP)^[1]The consensus was developed by ATS and ERS in 2002. According to the pathological manifestations of the lung, IIP is divided into seven categories, namely, interstitial pneumonia vulgaris [UIP, corresponding to the clinical diagnosis of idiopathic pulmonary fibrosis (IPF)], non-specific interstitial pneumonia (NSIP), cryptogenic organizing pneumonia (COP), desquamative interstitial pneumonia (DIP), respiratory bronchiolitis with interstitial lung disease (RB-ILD), lymphocytic interstitial pneumonia (LIP), and acute interstitial pneumonia (AIP). In the past decade, with the deepening of basic and clinical research, respiratory experts have gained further understanding of interstitial lung diseases, such as the expert consensus on acute exacerbation of IPF developed in 2007^[2]Expert consensus on idiopathic nonspecific interstitial pneumonia in 2008^[3]And the 2011 Guidelines for IPF Diagnosis and Treatment^[4]But at the same time, some new problems have been encountered, such as the pathology of some surgical lung biopsy patients cannot be classified into the above seven pathological types, and some new pathological types have been discovered. In view of this, experts in the field of interstitial lung diseases believe that the classification developed in 2002 needs to be revised to better suit the needs of clinical and scientific research.

The Global Initiative For Chronic Obstructive Lung Disease (GOLD) was founded in 1998 and published The first edition of The Global Strategy For The Diagnosis, Management and Prevention of Chronic Obstructive Lung Disease (GOLD) in 2001, followed by The 2006 and 2011 editions, respectively, based on The corresponding literature. The GOLD Scientific Committee was established in 2002, and its members are responsible for assembling, evaluating and updating strategies related to COPD. In 2013, the GOLD Scientific Committee retrieved a total of 201 eligible articles published from July 1, 2011 to mid-December, 2012. After full research, 30 of them were used to partially update the 2011 edition of the global strategy for COPD. The updated contents are divided into: (1) Revision: new references are needed to revise or add new contents to the original text; (2) Determining: adding or replacing existing documents; (3) Modify the original text and give an explanation. The main revisions of the 2013 edition of the global strategy for COPD are briefly introduced as follows^[1]。

idiopathic pulmonary fibrosis (IPF) is a special type of chronic progressive fibrotic interstitial pneumonia. The etiology is unknown, and it occurs in the elderly. The lesions are confined to the lung, and the histopathological and/or imaging manifestations are usual interstitial pneumonia (UIP)^[1]。 The prevalence and mortality of IPF are increasing year by year, and the median survival time is 2~3 years. There is a lack of effective therapeutic drugs. Early diagnosis and therapeutic intervention are important for improving the prognosis of IPF patients.

Idiopathic pulmonary fibrosis (IPF) is a special type of unexplained, chronic progressive, fibrotic interstitial pneumonia, mainly occurring in the elderly, with lesions confined to the lungs, histopathology or (and) high-resolution CT (HRCT) showing the characteristics of common interstitial pneumonia (UIP), with an average survival time of only 2 to 5 years^[1]。 The etiology of IPF is unknown, the pathogenesis is unknown, the definitive diagnosis is limited, the treatment lacks effective drugs, and the prognosis is poor. In recent years, with the new understanding of the pathogenesis of IPF and the research progress of molecular cell biology, many new drugs have entered clinical trials and have been completed. However, how to face the current clinical trial results of drugs and make appropriate treatment choices is still a problem that clinicians should pay attention to.

mesenchymal stem cell (MSC) is a kind of pluripotent stem cell derived from mesoderm, which has the potential of self-replication and differentiation^[1]。 MSCs are easily isolated and cultured in vitro, have the ability to transform mesenchymal and non-mesenchymal tissue cells, and can change pathological processes by differentiating into other cells, secreting cytokines, affecting the contact mechanism between cells, and can participate in the treatment of a variety of clinical diseases.

Mammalian sodium-hydrogen exchanger (Na^＋/H^＋exchanger (NHE) is a kind of protein widely existing on cell membrane and integrated on the surface of plasma membrane. It widely exists in central, intestinal and kidney organs, and participates in important physiological functions such as chemoreception and secretion of the body. By intracellular H^＋With extracellular Na^＋Carry out transmembrane exchange in equal molecular proportions to expel H^＋Thereby regulating the dynamic balance of intracellular pH. The change of intracellular pH is essential for regulating cellular chemoreceptivity, maintaining the activity of intracellular enzymes, and integrating the cytoskeleton. Since respiratory chemical regulation is the most important link of respiratory regulation, the relationship between NHE-3 and respiratory regulation and its clinical significance are summarized below.

In recent years, the incidence of idiopathic pulmonary fibrosis (IPF) has increased year by year^[1]Discussion on the pathogenesis and diagnosis and treatment of IPF has become a hot topic. The results show that abnormal coagulation system may be involved in the pathogenesis of IPF. The coagulation activity in IPF patients increases, and the anticoagulant and fibrinolytic activities decrease, which further affects the inflammatory response in the lung, causing fibrin deposition, fibroblast attachment and lung tissue remodeling in the lung, leading to fibrosis^[2]。 This study further investigated the correlation between coagulation index and lung function, so as to facilitate the disease monitoring and efficacy judgment of IPF patients.

Vitamin D is a novel neuroendocrine-immunomodulatory hormone. Studies have shown that vitamin D deficiency can increase the severity and frequency of bronchial asthma^[1]。 The prevention and treatment mechanism of early vitamin D intervention on asthma and other allergic diseases may be through transforming growth factor-β₁(TGF-β₁) Signaling by associated signaling pathways^[2]。 Tumor necrosis factor-alpha (TNF-alpha) is a deleterious proinflammatory factor^[3,4], plays a major role in airway inflammatory response and airway remodeling in asthma^[5]。 In this study, primary cultured rat airway smooth muscle cells (ASMC) were used to study the inhibitory effect of vitamin D on the growth and proliferation of TNF-α sensitized ASMC and its effect on TGF-β in asthmatic airway inflammatory response by adding TNF-α sensitized medium₁Effects of expression.

Chronic obstructive pulmonary disease (COPD) is a common and frequently occurring respiratory disease with incomplete reversibility and progressive development of airflow restriction. The results showed that when the activity of a disintegrin and metalloprotease-33 (ADAM33) was changed, it caused the function of airway smooth muscle cells and fibroblasts to change, suggesting that ADAM33 gene may be related to small airway remodeling, airway hyperresponsiveness and inflammation^[1,2]This hyperresponsive and non-specific stimulation leads to airway obstruction. The purpose of this study was to investigate the relationship between ADAM33 gene polymorphism and susceptibility in Kazakh smoking patients with COPD in Xinjiang Uygur Autonomous Region.

primary pulmonary lymphoma (PPL) is a rare malignant tumor, accounting for about 0.5% to 1% of all primary lung malignancies, 3% to 4% of extranodal lymphomas, and 1% of all non-Hodgkin's lymphomas^[1]Most of them are B-cell lymphomas occurring in low-grade malignant mucosal-associated lymphoid tissues, accounting for 70% to 80% of primary lung lymphomas^[2]While T-cell lymphoma is rarely reported. peripheral T-cell lymphoma-non otherwise specified (PTCL-NOS) is a group of T-cell lymphomas that cannot be classified into any known special type. It occurs inside and outside the lymph nodes, is obviously heterogeneous and highly aggressive, and is the most common type of peripheral T-cell lymphoma. A case of primary unspecified peripheral T-cell lymphoma of the lung diagnosed by puncture biopsy guided by nuclear magnetic resonance was reported and discussed in combination with literature review to improve clinicians' understanding of this disease.

Ossifying tracheobronchiopathy is a benign lesion with multiple nodular hyperplasia of bone or cartilage tissue under the mucosa of the trachea and bronchi and protruding towards the lumen. There are few cases of this disease reported at home and abroad, among which there are fewer patients with tuberculosis^[1,2,3,4]。 Henan Infectious Disease Hospital diagnosed and treated two patients with pulmonary tuberculosis complicated with ossifying tracheobronchopathy from May 2012 to January 2013. The clinical characteristics are reported below.

A 74-year-old male was seen in Tianjin Medical University General Hospital on July 19, 2012 due to "fatigue for 1 month, fever for 4 days and syncope twice". The patient had previous cerebral infarction for 3 years and old anterior wall myocardial infarction for 3 years. He developed weakness in both lower limbs 1 month before admission. He was diagnosed with cerebral infarction in another hospital and was given circulation improvement therapy and electrolyte Na was checked.^＋It was 115 mmol/L. Hypertonic saline infusion and oral salt capsule sodium supplementation were given in other hospitals, but the effect was not good. Echocardiography showed that left ventricular diastolic function was reduced, pulmonary artery pressure was not high, and coagulation function was normal. He later developed fever and syncope, and came to see a doctor for further treatment. CT examination of the head in the emergency department revealed left temporal lobe ischemia and bilateral basal ganglia lacunar foci. Physical examination after admission: body temperature 37.5 ℃, heart rate 78 beats/min, no dry and wet rales in both lungs, muscle strength of both lower limbs grade III, muscle strength of both upper limbs grade IV, laboratory examination of serum sodium 113 mmol/L, potassium 3.6 mmol/L, chlorine 82 mmol/L, liver and kidney function, myocardial enzyme and brain natriuretic peptide levels were all normal, chest CT showed right lung apical nodule shadow, the nature of which is to be determined, and cord shadow in both lungs considered chronic inflammation, so the diagnosis was considered as pulmonary infection, which may be combined with hyponatremia caused by endocrine and metabolic factors. Supplementary examination of adrenocorticotropic hormone, growth hormone and thyrotropin showed no obvious abnormality; Free T3 2.81 pmol/L, Free T4 14.97 pmol/L; Liver and kidney functions were normal; Blood cortisol 2.4 mg/L; 24 h urine sodium 219 mmol (76 mmol/L); Tumor-related examination: carcinoembryonic antigen 8.19 μ g/L, ferritin 362.95 μ g/L, prostate specific antigen 14.92 μ g/L, AFP, CA19-9 and CA242 were not abnormal; Immunohistochemical examination: antinuclear antibody 1:100, showing spot type, and no abnormalities were found in the rest; The levels of plasma renin and aldosterone in recumbent position were normal; Blood gas analysis pH 7.48, PaCO₂22 mm Hg (1 mm Hg =0.133 kPa), PaO₂78 mm Hg, HCO₃^－16.4 mmol/L. Intravenous drip of hydrocortisone succinate and hypertonic saline and oral administration of salt capsules to supplement sodium; Piperacillin and tazobactam were given anti-infective treatment for 5 days, but the effect was not good. The fever was not relieved. The patient still coughed but did not have much phlegm. Piperacillin and tazobactam were stopped, and azithromycin and ceftazidime were used for anti-infective treatment. Considering that pulmonary embolism could not be excluded, the coagulation function was re-examined. D-dimer increased from 741 μ g/L before admission to>10 000 μ g/L. Enhanced chest CT showed multiple pulmonary artery embolism in the basal segment of both lower lobes. Pulmonary embolism was diagnosed. Low molecular weight heparin calcium 0.6 ml/h was given for anticoagulation, 12 h/time, aspirin antiplatelet treatment, and vascular ultrasound of both lower limbs showed no thrombus. The protein C activity was 38.4%, and the free protein S content was 44.7%. After 1 week of low molecular weight heparin calcium application, the D-dimer was reduced to 1646 μ g/L, and the dose of low molecular weight heparin calcium was reduced to 0.6 ml/h, once/d. Reexamination of blood Na^＋121 mmol/L, stop hypertonic saline infusion and oral salt capsule sodium supplementation; Low molecular weight heparin calcium was discontinued after 3 weeks of application, and warfarin sodium was used for anticoagulation. At this time, the serum sodium was 125 mmol/L. After 10 days, the serum sodium was 140 mmol/L and D-dimer was 744 μ g/L. The free thyroid function was normal.

It has been 116 years since the advent of bronchoscope in 1897. In 1897, Gustav Killian, a German otolaryngologist known as the "Father of Bronchoscopy", first reported the use of esophagoscope to remove bone foreign bodies from the trachea of a young man, pioneering the insertion of a rigid endoscope into the trachea and the operation of the bronchus. Subsequently, the development of bronchoscopy went through three stages: traditional rigid bronchoscopy, fiberoptic bronchoscopy and electronic bronchoscopy.

OSAHS is the most common sleep-disordered breathing (SDB), with an incidence of 2% to 4% in the population^[1]。 The gold standard for diagnosing OSAHS is overnight polysomnography (PSG), which is time-consuming and laborious. Therefore, screening high-risk OSAHS patients by questionnaire is a simple and practical method. In this paper, a new simple and easy questionnaire for screening OSAHS, the Stop-Bang Questionnaire, is introduced^[2]。

Chronic obstructive pulmonary disease (COPD) is a common respiratory diseases characterized by persistent expiratory airflow restriction with progressive exacerbation, and patients have symptoms such as cough, expectoration, and exertion dyspnea. In recent years, with the continuous development of medical technology and pharmacology, inhalation administration has become the simplest and most effective route for the treatment of COPD^[1]。

An 83-year-old male was admitted to the hospital on August 19, 2012 mainly due to "fever, cough and expectoration for 14 days". The patient developed fever without obvious trigger 14 days ago, with a body temperature of 37.5℃, accompanied by cough and golden phlegm, and the symptoms gradually worsened. When the cough was severe, it was accompanied by bilateral chest pain. Cefuroxime given to the local hospital for 4 days was ineffective. Chest X-ray showed right lower lung shadow (Figure 1)。 Previous chronic bronchitis 40 years, smoking index 60 pack years. Physical examination: body temperature 37.5 ℃, pulse 70 beats/min, respiratory rate 20 beats/min, blood pressure 118/62 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. Barrel-shaped chest, percussion of both lungs showed over-voice, breathing sounds of both lungs were reduced, and wet rales could be heard in the right lower lung, but no abnormalities were observed.

Malignant tumors, especially atelectasis caused by complete occlusion of the main bronchi caused by external pressure, are in critical condition. It is very important to unblock the main bronchial passageway in time and effectively and restore lung function. The effective method is to place airway stents in time^[1]However, due to the complete occlusion of the main bronchial lumen, it is very difficult to routinely place the flexible guidewire at the front end and guide the placement of the airway stent, and the application of balloon dilation cannot effectively dilate and unblock the lumen. Therefore, it is very important to find a simple and effective method to guide the guidewire into the completely occluded lumen. Recently, two patients with complete occlusion of left main bronchus caused by malignant tumor were successfully entered into the lumen of completely occluded left main bronchus through pulmonary catheter assisted and guided wire and successfully placed airway stent. The ventilatory function of left lung was restored in time, and hypoxemia and respiratory failure were corrected. The method is simple and effective, and is reported as follows.

In 1867, the French physician Trousseau mentioned the mandala in his work. At that time, in addition to smoking from a pipe, the mandala was also made into a cigarette. Opium and belladonna were added to the recipe mentioned by Tauser in addition to mandala. In the 1860s, it was also reported that bronchial asthma (asthma) was treated by inhaling cigarettes containing arsenic.

Feng Yuxiang, commander of the Northwest Army, issued a smoking cessation order when he was stationed in Changde. One day, after the morning exercise, Feng Yuxiang strode up to the review stand and loudly announced, "From today onwards, the whole army will quit smoking. In the future, once a smoker is found, I will ask him to eat the cigarette butt." A few days later, Feng Yuxiang accidentally found a soldier hiding in a corner and smoking. He immediately reprimanded the soldier and ordered him to eat the cigarette butt in public. The soldier was very reluctant, and he kept muttering. Feng Yuxiang asked sternly, "What are you muttering about?" The soldier looked at Feng Yuxiang and said with an embarrassed expression, "Commander, my subordinates dare not speak." Feng Yuxiang said loudly, "Say! There is no one in my army who dares not speak." The soldier hesitated and said, "Commander, I saw you smoke several puffs of cigarettes when receiving guests." After the soldier said this, Feng Yuxiang immediately remembered that he had actually smoked a cigarette when he met with the commander of the neighboring army a few days ago. So he took off his cap, fell to the side, and said frankly to the soldier, "The upper beam is not straight and the lower beam is crooked, I have indeed smoked a cigarette." Then he grabbed the cigarette butt from the soldier's hand and stuffed it into his mouth. By the time the guard beside him reacted to stop him, it was too late. Feng Yuxiang had already swallowed the cigarette butt. When the smoking soldier saw it, he was so frightened that he knelt on the ground and said, "Commander, I know my mistake! I will definitely quit smoking in the future." Feng Yuxiang turned to the guard and said, "In the future, I will never smoke again. Please move all the cigarettes in my room and burn them." A box of cigarettes was burned by the guard in public. General Feng Yuxiang led by example and set an example for soldiers to quit smoking. Since then, there have been no smoking soldiers in Feng Yuxiang's troops.

Mechanical ventilation is one of the most commonly used techniques in the treatment of critical illness and respiratory failure. It has made great progress in the past 20 years, among which non-invasive ventilation is undoubtedly one of the most important advances. Modern mechanical ventilation should include invasive ventilation and non-invasive ventilation, and the complementary and cooperative application of both can maximize the effect of mechanical ventilation and reduce its adverse effects. It can be seen that mechanical ventilation has entered a new era of "combined application of non-invasive and invasive ventilation". Medical workers engaged in mechanical ventilation should be proficient in both non-invasive and invasive ventilation techniques, and reasonably choose the application of both.