2017年 · 第97卷第26期

Chronic inflammatory diseases of the upper and lower airways refer to chronic diseases in which inflammation involves the upper and/or lower airways, including: (1) diseases dominated by the upper airways: such as allergic rhinitis (AR), non-allergic rhinitis (NAR), chronic rhinosinusitis (CRS), upper airway cough syndrome (UACS), nasal polyposis, adenoid hypertrophy, etc.; (2) The following airway-dominated diseases: such as bronchial asthma (asthma for short), bronchiectasis (bronchiectasis for short), chronic obstructive pulmonary disease (COPD for short), chronic cough, diffuse panbronchiolitis (DPB); (3) Upper-lower airway inflammation coexisting diseases: such as aspirin asthma (AIA), immobile ciliary syndrome, sinobronchial syndrome (SBS), allergic bronchopulmonary aspergillosis (ABPA), cystic fibrosis, necrotizing granulomatous vasculitis, allergic granulomatous vasculitis (Churg-Strauss syndrome, CSS), recurrent polychondritis, etc. The coexisting diseases of upper and lower airway inflammation are mostly related to genetic factors. Although the incidence in China is not as high as that of Europeans or Caucasians, it is not uncommon.

The 17-year-old male was seen in the Department of Nephrology, Peking University First Hospital on March 18, 2016 due to "polydipsia, polydipsia for 1 year, and elevated serum creatinine with hypernatremia for 3 months". The patient began to have polydipsia and polydipsia 1 year ago, drinking about 3-4 L/d of water, excessive urine output (specifics unknown), and no edema. The local hospital was diagnosed as "psychotic polydipsia", and it is recommended to appropriately limit the amount of water drinking. After taking Chinese herbal medicine for more than 3 months (to 8 months ago), he complained that during this period, his blood pressure was normal, urine output and appetite did not change significantly, and polydipsia and polydipsia improved slightly. Blood pressure 124/74 mmHg (1 mmHg =0.133 kPa) and urine specific gravity were measured six months ago<1.005, urine protein negative, urine glucose negative, urine sediment normal. Serum creatinine was 101.9 μ mol/L (normal reference value: 62-106 μ mol/L), blood urea nitrogen (BUN) was 3.28 mmol/L, blood uric acid was 631 μ mol/L (normal reference value: 150-420 μ mol/L), and the electrolyte was not checked. Benzbromarone 50 mg/time, once/d was given. On re-examination 3 months ago, it was found that serum creatinine increased by 120 μ mol/L (normal reference value: 20-115 μ mol/L), BUN 5.3 mmol/L, serum uric acid 576 μ mol/L, serum cystatin C (CysC) 1.4 mg/L, and serum albumin (ALB) 48.9 g/L; Erythrocyte sedimentation rate (ESR) 82 mm/1 h; Blood sodium 158 mmol/L, blood chloride 117.7 mmol/L, blood potassium 4.63 mmol/L, blood calcium 2.53 mmol/L, blood phosphorus 1.54 mmol/L, blood HCO₃^－24.8 mmol/L. White blood cells 10.7×10⁹/L, hemoglobin 110 g/L, platelets 156×10⁹/L. The urine specific gravity was 1.005, and the urine protein and red blood cells were negative. The urine volume was 2.6 L/d, urinary sodium was 29.3 mmol/L, urinary chloride was 22.7 mmol/L, and urinary potassium was 20.77 mmol/d. Blood immunoglobulin and complement were normal, and antinuclear antibody spectrum was negative. According to the above situation, the local hospital suspected the diagnosis of "renal tubulointerstitial disease, which is likely to be caused by Chinese herbal medicine", and no special treatment was given. It is recommended to continue to monitor the changes in renal function. The patient's thirst lessened and continued to intentionally self-control the amount of water he consumed. After that, serum creatinine fluctuated between 134 and 151 μ mol/L (normal reference value:<115 μ mol/L), BUN 15.8-9.3 mmol/L, blood uric acid 425-511 μ mol/L, blood sodium 163-174 mmol/L, blood chloride 125-133 mmol/L, blood potassium 4.89 mmol/L, blood HCO₃^－22.0 mmol/L. The blood pressure was 101/76 mmHg during the observation period, the urine volume was not recorded, and the spirit, sleep and appetite were good, but the weight decreased by 9 kg during the 2-month period.

The 51-year-old female was admitted to the Department of Endocrinology and Metabolism of Tianjin Medical University General Hospital on July 15, 2016 due to "bilateral knee pain for more than 2 years". Previously, blood pressure was found to rise for more than 10 days without treatment. Right knee arthroplasty was performed in an external hospital 10 days before admission. The patient developed bilateral knee joint pain without obvious trigger 2 years ago, which was aggravated during activity, without fever and swelling. The patient had difficulty walking, accompanied by thirst, increased nocturia and other symptoms, without nausea, vomiting, dizziness, fatigue and other discomfort. He was diagnosed with bilateral knee synovitis and osteoporosis in an external hospital, and underwent right knee arthroplasty. One week ago, the patient came to the outpatient department of our hospital. The laboratory test showed that parathyroid hormone (PTH) was 1 216.47 ng/L (reference value: 10.37~68.84 ng/L), blood calcium was 3.02 mmol/L (reference value: 2.15~2.55 mmol/L), urinary calcium was 4.03 mmol/L (reference value: 2.5~7.5 mmol/L), urinary phosphorus was 16.3 mmol/L (reference value: 23~48 mmol/L), no abdominal and lumbar pain, no digestive diseases, no skin itching and other discomfort. The patient is married at appropriate age, and the spouse and children are in good health. A family genetic history is denied.

The patient was a 52-year-old male, right-handed, with a history of diabetes for 6 years and a history of smoking and drinking for more than 30 years. On August 24, 2015, he was admitted to the First Affiliated Hospital of Dalian Medical University with the main complaint of "progressive naming disorder for 4 years, aggravated with irritability for 2 years". Four years ago, family members found that the patient had difficulty in naming, mainly manifested by difficulty in naming unfamiliar things, but they could describe their uses, their ability to understand daily life was still normal, and general daily communication was acceptable. In the past 2 years, the patient's language barrier has progressively aggravated, and his listening and comprehension ability has gradually declined, mainly manifested by difficulty in naming unfamiliar things, and inability to call acquaintances by name; Can't fully understand what others are saying, can do the job, but have difficulty communicating with colleagues; Unable to fully understand the meaning of the newspaper, dysphoria to writing less commonly used words. His memory, attention and orientation have not decreased significantly, and he can still take care of himself in daily life. He can play cards and other daily activities. With the progressive aggravation of language barrier, patients gradually appear not to like to communicate with others, lazy, depressed, irritable and anxious. In the past six months, irritability and anxiety have increased due to family affairs. Cognitive function examination: Visual space, executive function, attention and orientation were not significantly affected, language and abstraction function were slightly impaired, and naming function was significantly impaired. The impairment of naming function is mainly manifested by knowing the purpose and properties of objects but not being able to name them. The impairment of language and abstraction ability is mainly manifested by the inability to retell and summarize a kind of words. Other neurological examinations showed no obvious positive localization signs. Improve head MRI, EEG, MOCA, WAB, blood routine, rheumatism immunity, folic acid, vitamin B₁₂, thyroid function test, liver and kidney function, blood glucose, blood lipids, chest X-ray and other related auxiliary examinations, but the patient refused to undergo PET or SPECT examination and MRI review for personal reasons.

The patient, a 50-year-old man, has been engaged in electric welding for 10 years. On November 21, 2015, he was admitted to the hospital with the main complaint of "head confusion for 17 days, aggravated with diplopia for 13 days". On November 4, he developed head confusion after fatigue, abnormal mental behavior (manifested as sleepiness, indifference, dislike of communication, preference to eat sweets and sugar cakes three times a day), diplopia, poor speech, dysphagia, choking and coughing after drinking water, weakness of limbs (manifested as difficulty going up and down stairs, unable to hold things), and no epileptic seizures. Since the onset of the disease, the patient has increased sleep and anorexia, and his body weight has decreased by about 5 kg. Past history: Hypertension history for more than 1 month. Personal history: Smoking for more than 20 years, about 20 cigarettes/d. Physical examination of nervous system: clear consciousness, poor spirit, poor speech, normal memory, computing power and orientation power. Diplopia in both eyes, spontaneous horizontal nystagmus on the left side, spontaneous upper right rotating nystagmus on the right side, and large nystagmus amplitude. The right corner of the mouth is lowered, the bilateral nasolabial folds are symmetrical, the soft palate is weak to the right, the uvula vertically deviates to the left, the right pharyngeal reflex disappears, and the extension of the tongue deviates to the right. The proximal muscle strength of both limbs was grade 5, the distal muscle strength was grade 3, the tendon reflex of both upper limbs was symmetrical, the knee reflex of both lower limbs was weakened, the right ankle reflex disappeared, and the left ankle reflex was weakened. The right Babinski sign was positive, the left Babinski sign was suspected positive, the right needle sensation was weaker than the left, Romberg sign (+), and there were no obvious positive signs. CT scan of the admitted chest showed multiple patches and blurred high-density shadows in both lungs, and consolidation in the middle lobe of the right lung. Cranial MRI plain scan + enhancement showed no obvious abnormalities (Figure 1)。 Results of lumbar puncture showed: pressure 105 mmH₂O (1 mmH₂0=0.009 8 kPa); Total number of cells 400 (normal value<100), no malignant cells were seen; Protein 0.66 g/L (normal value 0.15-0.45 g/L). Antibody detection of autoimmune encephalitis showed that anti-N-methyl D-aspartate receptor (NMDAR) antibody was positive in cerebrospinal fluid and negative in serum. After the treatment with human immunoglobulin and methylprednisolone sodium succinate on the same day, the patient's head was confused and limb weakness was aggravated (manifested as inability to get out of bed, inability to hold a pen and chopsticks, and inability to take care of himself), but diplopia, poor speech, dysphagia, choking and coughing after drinking water were all better than before. On December 2, the thyroid function examination showed that the thyroglobulin antibody was 154.3 U/ml (normal value 0-60 U/ml) and the thyroid peroxidase antibody was 261.3 U/ml (normal value 0-60 U/ml). The results of serum paraneoplastic antibody profiles showed: anti-RI antibody (+) and anti-Hu (+). Immediate chest CT enhancement showed irregular soft tissue mass shadow in the right hilum with mild uneven enhancement, suggesting that the middle lobe of the right lung occupied space, lung cancer was possible, and lymph node metastasis in the mediastinum and right hilum was observed. Fiberoptic bronchoscopic biopsy revealed small cell malignancy. Then the patients underwent 4 and 6 courses of chemotherapy after reexamination of chest CT enhancement, respectively, showed that the space occupied by the right hilar was reduced compared with the previous, and the soft tissue mass shadow at the right hilar was significantly reduced compared with the previous. At this time, anti-NMDAR antibody in cerebrospinal fluid was weakly positive; head¹⁸F-FDG-PET showed increased radioactivity uptake in bilateral frontal, temporal and parietal cortices with multiple basically symmetrical distributions (Figure 1)。

Mixed pheochromocytoma is a mixed tumor of pheochromocytoma and ganglioneuroma, ganglioneuroblastoma, neuroblastoma or peripheral nerve schwannoma, also known as combined pheochromocytoma, compound or mixed adrenal medulla tumor, which is mostly reported as a case at home and abroad. The diagnosis and treatment process of a case of pheochromocytoma complicated with ganglioneuroma is now sorted out, hoping to be helpful to understand the disease.

Primary extrahepatic portal vein obstruction (EHPVO) refers to the obstruction of the main trunk of the extrahepatic portal vein or cavernous degeneration of the portal vein caused by non-cirrhotic and non-neoplastic causes, with or without obstruction of its branches. Isolated intrahepatic portal vein, mesenteric, and splenic vein obstruction does not belong to the category of extrahepatic portal vein obstruction^[1,2,3]。 Primary EHPVO is a common cause of non-cirrhotic portal hypertension in developing countries (54%)^[1,2,4]It is also the most common cause of upper gastrointestinal bleeding in children (68% ~84%)^[1,5,6]。 However, the disease is less common in Western countries, accounting for only about 11% of the causes of portal hypertension^[1,6]。

There are many factors that lead to the formation of hypertrophic scars (HTS), and local mechanical stress is the main cause. HTS formation is a mechanical stress-induced intracellular adaptive behavior^[1]。 Mechanical stress acts on the tissue after injury, and the extracellular matrix changes its chemical composition and stiffness, initiating the repair process^[2]。 When integrin binds to specific ligands in extracellular matrix, it causes a large number of cytoskeletal proteins to recruit in cells to form adhesion spots. The formation and deformation of adhesion spots are the initiation of mechanical signal transmission. The LINC complex is located on the nuclear membrane and is a molecular structure that connects the cytoskeleton with the nuclear skeleton. Cytoskeletal proteins form a complex molecular structure network with LINC complex and nuclear skeleton, which mechanically combine the extracellular matrix and nucleus to transmit mechanical signals from the extracellular to the chromatin in the nucleus, causing the expression changes of target genes^[3]。 At the same time, mechanical stress also activates transforming growth factor (TGF) -β in the latent state in the extracellular matrix through integrin, and TGF-β enters the nucleus through the nuclear pore complex with the help of Smad, causing changes in target gene expression^[4]。 The mechanism by which mechanical stress leads to hypertrophic scarring is described below.

Noise is an important hazardous factor in production and life, which can cause health problems such as elevated blood pressure, poor mental condition, insomnia, troubles, anxiety, tinnitus and noise-induced hearing loss. According to statistics, about 1/3 of the world's population suffers from various hazards caused by noise^[1]。 Noise hazard is a key concern in the field of labor hygiene and environmental hygiene, and many research results have been produced. However, the research is mostly concentrated on factories, transportation, military, etc., and the research on hospital noise is less. This paper summarizes the research progress of hospital noise in order to provide new ideas for hospital noise research.

Currently, the global incidence of atrial fibrillation (AF) ranges from 1.5% to 2.0%. AF increases the risk of stroke, so long-term anticoagulant therapy is required for patients with AF. When AF patients have a history of heart failure (HF), chronic renal insufficiency (CKD), diabetes, stroke/transient cerebral ischemia, coronary heart disease, or are elderly, their risk of stroke and death will increase accordingly^[1]。 Rivaroxaban is a new type of oral anticoagulant, which has the characteristics of fixed dose, rapid onset of action and no need for routine coagulation monitoring. This review will focus on the overview of the study of rivaroxaban in special populations with AF (with history of HF, CKD, diabetes, stroke/transient cerebral ischemia, coronary heart disease, etc., or elderly).