2018年 · 第41卷第11期

Time flies, and it is nearly the end of the year. With the cold of early winter, the 11th issue of this magazine in 2018 met with you readers.

1994 Katzenstein and Fiorelli^[1]The concept of nonspecific interstitial pneumonia (NSIP) was proposed for the first time to describe difficult-to-classify interstitial pneumonia^[2]Subsequently, more and more research results suggest that NSIP is not a garbage-bin combination and should be regarded as an independent pathological type given the similar clinical and pathological manifestations of patients. 1998 Katzenstein and Myers^[3]NSIP was formally included in the idiopathic interstitial pneumonia (IIP) classification based on the results of previous studies. In 2002, the American thoracic society (ATS) and the European respiratory society (ERS) published an international multidisciplinary expert consensus on the classification and diagnostic criteria of IIPs^[4,5]NSIP is included in the new IIPs classification as a "temporary name". The 2008 ATS reported a comprehensive study of idiopatic nonspecific interstitial pneumonia (INSIP)^[6]Describe the status and diagnosis-related issues of INSIP, confirming that INSIP is an independent disease type^[7,8]。

Currently, glucocorticoids (hormones) are the preferred therapeutic drugs for the treatment of sarcoidosis, but alternative medications need to be considered for patients who are insensitive to glucocorticoids or have contraindications for glucocorticoid therapy. Methotrexate and azathioprine, leflunomide, mycophenolate mofetil, hydroxychloroquine, cyclosporine A, cyclophosphamide, ketoxifylline and tumor necrosis factor (TNF-α) inhibitors can be used as second-line alternative therapy for sarcoidosis^[1,2]。 Among them, methotrexate is the most widely used, but the indications, dosage, course of treatment, adverse reaction monitoring and whether folic acid supplementation is needed for methotrexate in the treatment of sarcoidosis are lacking systematic research results and international norms. To this end, the world association for sarcoidosis and other granulomatous disorders (WASOG) organized global sarcoidosis experts to formulate an international expert consensus on methotrexate for the treatment of sarcoidosis based on recent relevant clinical research evidence^[3]。 This consensus is of great significance to guide the clinical application of methotrexate. The formation process and content of the consensus are interpreted as follows for the reference of domestic clinicians.

Sarcoidosis is a systemic, non-caseous epithelioid granulomatous disease of unknown etiology that can involve multiple organs throughout the body. The lung is the most common involved part of pulmonary sarcoidosis. About 20% of patients with pulmonary sarcoidosis have fibrotic pulmonary sarcoidosis. Because of the lack of effective treatment, the mortality rate is high, which is an important factor affecting the prognosis of patients with pulmonary sarcoidosis^[1]。 In order to improve clinicians' understanding of the disease, the pathogenesis and clinical characteristics of the disease are summarized as follows.

tumor tissue can release some of its own substances, such as circulating tumor cells (CTC), circulating tumor DNA (ctDNA), circulating tumor RNA (circulating RNA, ctRNA) and exosomes, into the blood, some of which can also exist in extracellular fluids such as cerebrospinal fluid, pleural effusion and urine. The technique of tumor monitoring by detecting the above substances is commonly referred to as a liquid biopsy technique. Compared with traditional tissue biopsy, this technology is non-invasive, real-time, dynamic, and can reflect the load status of the subject's systemic tumor, and plays an increasingly important role in precision medicine.

Sleep moaning (catathrenia), also known as nocturnal moaning, is a special sleep-related phenomenon characterized by prolonged exhalation and monotonous, moaning-like sounds during sleep^[1]。 The third edition of the international classification of sleep disorders (ICSD-3) included sleep moaning as an independent sleep breathing disorder symptom or normal variant event in sleep breathing disorders^[2]。 Sleep moaning Typical polysomnography (PSG) manifests as a bradybreathing pattern, similar to central sleep apnea, including prolongation of the expiratory phase after deep inspiration, generating moans or groans during expiration, usually lasting 2 to 49 s, followed by brief deep inspiration and expiration^[3,4]。 The nature of sleep moaning is still unclear, and opinions on its etiology, pathogenesis, sleep phase of occurrence, and how to classify it are still inconsistent. The aim of this article is to discuss the above issues based on the previous literature and the latest research results, in order to guide the clinical better understanding of this disease.

Bronchoscopy and interventional therapy are widely used in clinical practice. Whether this procedure can cause chronic occupational injury, there is no relevant report at present. The purpose of this study is to understand the chronic injury situation of medical staff during long-term bronchoscopy operation.

At present, there are many complications in the metal tracheal stent used in clinical practice. How to improve it so that it can be removed, not displaced and has few complications, so as to meet the needs of clinical work, is a topic faced by the field of respiratory intervention at present. In this study, two kinds of metal stents commonly used in clinical practice-metal bare stent and metal coated stent were improved respectively, and the related performance, complications and failure experience of the improved four kinds of metal stents were summarized, so as to provide reference for subsequent research work.

The incidence rate of granular cell tumors (GCT) accounts for 0.5% of soft tissue tumors. It can occur in any tissue and organ of the body, but it is most common in the skin and head and neck. GCT occurs in the respiratory system only accounts for 2% ~6%, and it is more common in the larynx, but rarely in the bronchus^[1]。 A case of bronchial GCT was reported to improve the understanding of this disease.

The patient was a 35-year-old female. The main cause was "intermittent edema of both lower limbs for 4 years, and lung shadows were found for 4 years". He was admitted to hospital on April 12, 2016. In August 2012, the patient was diagnosed with "nephrotic syndrome" in another hospital due to "edema of both lower limbs, hypoalbuminemia and proteinuria". During his hospitalization, chest CT showed "mass shadows in the anterior and medial segments of the upper lobe of the right lung, about 3.4 cm ×2.9 cm, small nodule-like shadows in the dorsal segment of the left lower lobe, enlargement of the right hilum, multiple nodules in the right pleura, bilateral pleural effusion, pericardial effusion, and peritoneal effusion" (Figure 1）。 The patient had no cough, expectoration, hemoptysis, chest pain, chest tightness, shortness of breath, fever, rash, joint swelling and pain and other discomfort, self-complaint of bronchoscopy showed no abnormalities, pleural effusion routine and biochemical examination revealed "leakage fluid", anti-infective treatment (medication unknown), and glucocorticoids and cyclophosphamide for nephrotic syndrome. After 2 months, reexamination of chest CT showed that the lung shadow was significantly smaller than before (Figure 2）。 In April 2013, the physical examination and X-ray chest radiograph showed "4 cm ×2.6 cm increased density in the middle lobe of the right lung, and the right costopaphragmatic angle became blunt". The patient had no discomfort and no further diagnosis and treatment. In January 2015, a reexamination of the chest CT showed that "the right thorax was small, the right mediastinum occupied a space of 7.2 cm ×3.1 cm, which was significantly larger than before, the right wall pleura was extensively thickened with protrusions, which were new than before, and there were multiple nodules in both lungs, which were more than before"; At the same time, PET-CT showed "multiple metabolically elevated nodules in the subpleural and interlobar fissures of the right lung, with standard uptake value (SUV) values of 2.3~3.8, the highest of 5.9, and scattered calcifications in the right pleura. Abnormally elevated metabolism in the right hilar and enlarged lymph nodes, with SUV values of 4.6~6.5. Considering the possibility of inflammatory granulomatous lesions, further examination is recommended to exclude sarcoidosis if necessary; micronodules and cord shadows in the lower lobe of the left lung, with low metabolism, are old lesions". In March 2016, mild edema of both lower limbs and shortness of breath after activity occurred. Chest CT examination in our outpatient clinic showed "extensive pleural nodular thickening on the right side and a small amount of pleural effusion, partial compression of right lung tissue, right mediastinum occupying about 6.7 cm ×5.8 cm, left tongue lobe and left lower lung nodule shadows, and a large amount of pericardial effusion" (Figure 3), was admitted for further diagnosis and treatment. Since the onset of the disease, the patient has clear consciousness, good spirit, good appetite and sleep, bowel movements as usual, and there is no obvious change in weight recently. In the past 4 years of "nephrotic syndrome", the pathological report of renal puncture was "atypical membranous nephropathy", and the treatment with glucocorticoids and cyclophosphamide (cumulative dose of 14 g) was given, and the monitoring of urine protein gradually turned negative. Presently take prednisone 10 mg orally, once a day. Regular menstruation, denial of smoking and drinking history, no bad habits, denial of family history of cancer and history of hereditary diseases.

Chronic obstructive pulmonary disease (COPD) is a systemic disease characterized by irreversible airflow restriction and is one of the worldwide high burden diseases^[1]。 It is estimated that by 2030, COPD will rank seventh in the world for the economic burden of disease and third in the world for the cause of death^[2,3,4]。 The prevalence of COPD among people over 40 years old in China is as high as 8.2%, which seriously endangers people's health and is an important public health problem in China^[5]。 COPD manifests as dyspnea, muscle atrophy, and decreased exercise endurance^[6]These three show a vicious circle. When dyspnea is present, the patient's activity is reduced. Long-term reduction in activity will lead to skeletal muscle disuse atrophy and decrease in exercise endurance, thus further aggravating dyspnea and manifesting as progressive activity limitation.

A 47-year-old male was admitted to the hospital on July 1, 2016 due to "fever accompanied by cough and sputum for 1 month, aggravated for 1 week". The patient developed fever without obvious trigger 1 month before admission, with the highest body temperature of 38.6℃, accompanied by cough and expectoration, which was yellow sticky sputum, large amount and easy to cough up. Chest CT examination at the local hospital revealed multiple nodules in both lungs with halo signs (Figure 1，Figure 2）。 Given "cephalosporin, metronidazole, levofloxacin" anti-infective treatment (details unknown), the effect was not good, and the body temperature fluctuated between 38.1 and 38.6 ℃. One week ago, the patient's symptoms worsened, and there was blood in the sputum, which was bright red. Reexamination of the chest CT in another hospital showed that the patches in the lingual segment of the left upper lobe and the basal segment of the right lower lobe were significantly worse than before, and new patches appeared in the posterior segment of the left upper lobe tip and the anterior segment of the right upper lobe (Figure 3，Figure 4）。 The anti-infective treatment was adjusted to "melocillin sodium, metronidazole, levofloxacin" (details unknown), and the effect was not good. Admitted to our department for further diagnosis and treatment. Past history: 1 month ago, the patient developed nasal congestion, runny nose, and occasionally bloodshot, and was diagnosed with "rhinitis and paranasal sinusitis" in a foreign hospital. Personal history: Drinking alcohol for 30 years, mainly drinking liquor, with an average of 100 g/d, and not abstaining from drinking. He has smoked for 20 years, with an average of 20 cigarettes/d. He has not quit smoking, and currently he has 1 to 2 cigarettes/d. History of allergies denied. Physical examination at admission: body temperature 37.7 ℃, pulse rate 77 beats/min, respiratory rate 18 beats/min, blood pressure 149/88 mmHg (1 mmHg =0.133 kPa). Normal development, unpalpable superficial lymph nodes throughout the body. There is no cyanosis of the lips, no deformity of the nose, and no inflammation of the nasal wings. There was no tenderness in the paranasal sinuses. Percussion of both lungs showed clear sound, coarse breathing sound, and no dry and wet rales were heard; The heart boundary is not large, the heart rhythm is uniform, and no murmur is heard in the auscultation area of each valve; Soft abdomen, no tenderness, rebound pain, untouched liver and spleen. Preliminary diagnosis of admission: pneumonia in both lungs, rhinitis and paranasal sinusitis.

The 20th world congress of bronchology and interventional pulmonology 2018 (WCBIP 2018) was held on June 13-16, 2018 at Mayo Clinic in Rochester, Minnesota, USA. The conference has a total of 5 venues, with 54 themes and 36 oral presentations. In view of many hot issues in the field of respiratory intervention at present, the conference invited experts from different majors to explain from their respective angles, and interacted with the audience by on-site questioning and voting. The discussion was in-depth and enthusiastic, and the content was brilliant. Many papers of Chinese doctors were also adopted at the conference, reporting to scholars around the world the achievements of China in many fields of interventional respiratory disease in recent years. The author listened to several topics of interest on the spot, and now the relevant contents are sorted out and summarized for readers' reference.

"Effect of budesonide on airway remodeling and the expression of related inflammatory mediators in bronchial asthma mice" published in Chinese Journal of Tuberculosis and Respiratory Mediation, Issue 3, 2017^[1]This article (hereinafter referred to as "the article") aims to investigate whether budesonide can alleviate early inflammation and airway remodeling in asthma by reducing the expression of osteopontin and vascular endothelial growth factor in lung tissue of a bronchial asthma (asthma) mouse model. The suggestion in this paper that inhaled glucocorticoids (ICS) can quickly and effectively relieve acute asthma attacks is inappropriate and worthy of debate.

Thank you readers for your high attention and pertinent correction in your busy schedule. For the points to be discussed in this article, give the following explanation.