2018年 · 第98卷第34期

At present, new technologies represented by artificial intelligence have brought profound changes to people's production and life, and kicked off the prelude to the fourth industrial revolution^[1]。 The application of artificial intelligence in the medical field will bring medicine into a new era-the era of intelligent medicine. Intelligent medicine, as the name implies, is the "medicine" of "intelligence". Intelligence is the means and medicine is the purpose. At present, there is no clear definition of intelligent medicine. Combining the current development trend of artificial intelligence and medical field, the concept of intelligent medicine is put forward: intelligent medicine, that is, the science of assisting or replacing human beings in medical behavior through artificial intelligence.

1967, Ashbaugh et al.^[1]Twelve patients with dyspnea of acute onset are described, all presenting with hypoxemia difficult to correct with conventional oxygen therapy accompanied by reduced respiratory compliance and diffuse exudative lesions on chest X-ray, later this series of clinical manifestations became known as acute respiratory distress syndrome (ARDS). Fifty years have passed since ARDS was first proposed.

With the gradual deepening of the cognition of the pathophysiology of acute respiratory distress syndrome (ARDS), in order to correct severe hypoxia and promote the recovery of collapsed alveoli, experts in the field of critical illness have successively put forward the views of lung opening, lung protective ventilation and prone ventilation, but the clinical application is constantly questioned. According to the guidelines or expert consensus recommendation, the implementation of ventilation strategy not only fails to benefit some patients, but often produces opposite results or even serious complications, endangering patients' lives. This is because the establishment of artificial airway and positive pressure ventilation itself can effectively improve the ventilation and partial ventilation function, and because it is contrary to negative pressure respiration in human physiological state, it will inevitably cause damage to alveoli due to excessive positive pressure level, and even lead to alveolar rupture and serious complications such as mediastinal emphysema and pneumothorax, that is, mechanical ventilation-related lung injury (VILI). In addition, the pathogenic factors of ARDS vary widely, the heterogeneity of ARDS and the polymorphism of lung lesions also suggest that a single mechanical ventilation strategy is not suitable for all patients, so individualized pulmonary protective ventilation should be performed according to pathophysiological characteristics^[1,2,3]。 The importance of individualized mechanical ventilation has also been recognized in ARDS mechanical ventilation guidelines/expert consensus published in recent two years at home and abroad^[4,5,6]。

The mortality of acute respiratory distress syndrome (ARDS) is extremely high, which is a serious threat to the life of patients^[1]。 For many years, studies related to respiratory support in ARDS only protective lung ventilation strategies^[2]and prone position ventilation^[3]Extracorporeal membrane oxygenation (ECMO) can be used as a salvage measure to replace or partially replace cardiopulmonary function in patients with extremely severe ARDS who cannot be maintained by conventional mechanical ventilation strategies, and can also help reduce the incidence of ventilator-related lung injury (VILI). In 2009, the successful experience of intravenous-intravenous ECMO (VV-ECMO) in the treatment of extremely severe ARDS caused by novel influenza A (H1N1) virus inspired its application in this field^[4,5,6,7]； Some of the main results of the concurrent CESAR study and the newly published EOLIA study also confirm the advantages of ECMO in treating patients with extremely severe ARDS^[8,9]。 This will undoubtedly promote the widespread application of this technology in China. The pathophysiology, indication grasp and key process management of VV-ECMO are described below.

Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by diffuse infiltrative lesions and progressive hypoxemia in both lungs caused by many etiologies. Its main pathophysiological manifestation is diffuse inflammatory alveolar epithelial cells and pulmonary capillary endothelial cells damage. In recent years, with the continuous deepening of research on ARDS, especially the discovery of inflammatory phenotype of ARDS in 2014, we have a further understanding of the pathophysiological characteristics of ARDS^[1]Although ARDS has common characteristics, the pathophysiological characteristics of ARDS are different due to the differences in pathogenesis caused by different risk factors. At the same time, its pathophysiological manifestations are also different at different stages of ARDS.

Acute respiratory distress syndrome (ARDS) is a complex clinical disease caused by many factors inside and outside the lung (such as pneumonia, sepsis, severe trauma, inhalation). Under the action of these injury factors, the inflammatory response in the lungs and the whole body is out of control, resulting in changes in alveolar capillary endothelial cells and alveolar epithelial cells, and increased capillary permeability, thus causing a large amount of fluid to seep into the alveoli and alveolar interstitium to cause pulmonary edema. Clinically, ARDS mainly manifests as progressive respiratory distress and refractory hypoxemia. In adults, the incidence of ARDS is approximately (17.6 to 64.0) per 100,000 per year, and in intensive care units the incidence is even higher than 10%^[1]。 Currently, the treatment of ARDS is still supportive treatment based on mechanical ventilation. Low tidal volume ventilation, positive end-expiratory pressure (PEEP), prone position ventilation, and neuromuscular blockers have been shown to be effective in a selection of patients with ARDS in clinical trials. Despite this, the mortality rate in hospital is still 20% ~50% at present^[1]。 Uncontrolled infection and extrapulmonary organ failure are the leading causes of death in patients with ARDS. In addition, survivors of ARDS may be complicated by chronic lung diseases such as pulmonary fibrosis, and neuromuscular diseases such as cognitive deficits and post-traumatic stress disorder, and their long-term prognosis is still poor. Therefore, on the basis of further understanding the pathogenesis of ARDS, it is an urgent requirement and challenge for basic and clinical workers to seek more effective drug therapy and biological therapy methods to improve the prognosis of patients with ARDS. The problems of drugs and biological therapy for ARDS are described.

A 58-year-old male was admitted to hospital on May 18, 2015 due to "lymph node enlargement for more than 1 year, cough and fever for more than 4 months". The patient was found to have multiple lymph nodes swollen in the neck, axilla and groin in May 2014. The local hospital had given isoniazid, rifampicin and ethambutol anti-tuberculosis treatment for half a year without significant improvement. In January 2015, I developed a cough, cough of yellow and white phlegm, fever, and shortness of breath after activity. The local hospital gave a variety of antibiotics to treatment with poor results. After 10 days of treatment with imipenem and cilastatin sodium, the symptoms improved, and the lymph nodes shrank slightly, which increased again after discontinuation. In March of the same year, he went to the First Affiliated Hospital of Guangxi Medical University for treatment. Check white blood cells 19.2×10⁹/L, hemoglobin 90 g/L, neutrophils 15.3×10⁹/L. CT of the chest showed a large dense shadow of the right lung, effusion in the right pleural cavity, and swollen mediastinal lymph nodes. Cervical lymph node pathology showed granuloma formation, Langerhans giant cells and caseous necrosis, acid-fast staining positive bacteria, PAS staining (-), no fungi (FIG. 1A，FIG. 1B)； Negative pathogenic culture. After admission, he was treated with cefoperazone, tazobactam, moxifloxacin and fluconazole, and was treated with isoniazid, rifampicin, ethambutol, pyrazinamide and streptomycin for antituberculosis. The upper symptoms improved after treatment. Continuation of pentagrammatic anti-tuberculosis therapy outside the hospital. One month later, multiple rash and itching on the trunk and limbs appeared, cough, expectoration and fever recurred, and the lymph nodes on the left neck and axilla gradually swelled, and then he was admitted to the First Affiliated Hospital of Guangxi Medical University again. Spontaneous weight loss of 5 kg. Had shingles 1 year ago.

The patient, a 73-year-old male, was admitted to the Department of Urology, First Hospital of Jilin University on January 21, 2018 because the right kidney cyst was found in physical examination for 4 years and enlarged for 10 days after reexamination. Four years ago, the patient underwent color ultrasound during physical examination in the local hospital and found a right kidney cyst with a diameter of about 4 cm. It was not treated. After reexamination of color ultrasound 10 days ago, it was found that the cyst was enlarged. He came to our hospital for further diagnosis and treatment. Suffering from hypertension for 30 years, taking captopril tablets orally and measuring blood pressure at ordinary times 140/90 mmHg (1 mmHg =0.133 kPa). Diabetic history for 3 years, oral metformin, usual fasting blood glucose 7.0 mmol/L. Deny family history of tumor, deny history of exposure to carcinogens.

A series of anatomical and physiological changes in digestive tract organs caused by aging, coupled with high Helicobacter pylori infection rate, smoking, stress and the use of non-steroidal anti-inflammatory drugs and antithrombotic drugs, make the risk of acid-related diseases in the elderly significantly increased. At the same time, comorbidities and their concomitant multimedication are important characteristics of elderly patients, and therefore, the combination of proton pump inhibitors with common comorbidity-related drugs is very common in elderly patients. Combination of drugs will inevitably lead to drug interactions. Pharmacokinetic interactions can occur in four stages: absorption, distribution, metabolism and excretion, among which metabolic drug-drug interactions (MDDI) have the highest incidence. When two or more drugs are administered simultaneously or sequentially, the interference of the action in the metabolic link can enhance the curative effect or even produce toxic side effects, or cause the curative effect to weaken or even fail the treatment. In view of the high use rate of proton pump inhibitors in elderly patients with comorbidities, this paper intends to briefly explain the metabolic interactions between proton pump inhibitors and common concomitant drugs, in order to provide reference for the safe, effective and rational application of proton pump inhibitors.

Acquired von Willebrand syndrome (AvWS) is a class of hemorrhagic coagulation disorders caused by secondary von Willebrand factor (vWF) structural or functional disorders. Patients often present with unexplained gastrointestinal bleeding, the etiology is easily overlooked, or misdiagnosed as von Willebrand disease (vWD)^[1]。 Common secondary causes of AvWS include lymphoproliferative disorders (48%), cardiovascular disorders (21%), myeloid proliferative disorders (15%), other neoplastic disorders (5%) and autoimmune disorders (2%)^[1]。 Among them, AvWS secondary to cardiovascular disease are associated with hemodynamic abnormalities, and their etiology is the deletion of high molecular weight (HMW) vWF multimers. AvWS may be present in approximately 79% of patients with aortic stenosis (AS)^[2]90% of patients with severe AS and 50% of patients with moderate to severe AS may have AvWS, and severe massive bleeding can be seen in about 30% to 48% of patients with severe calcified AS^[3]Such patients can also present with chronic blood loss and anemia^[4]。 In addition, AvWS associated with hemodynamic abnormalities can also be seen in other valvular heart diseases^[5]Multiple congenital heart diseases^[6]Pulmonary hypertension type I^[7]Hypertrophic obstructive cardiomyopathy^[8]and receiving left ventricular assist device therapy^[9,10]Or receive extracorporeal membrane oxygenation system therapy^[11]of patients.

On July 27-29, 2018, the 15th China International Congress of Vascular Medicine and the 15th Anniversary Celebration were held in Beijing International Convention Center. It was sponsored by the Organizing Committee of China International Congress of Vascular Medicine, China Branch of International Vascular Health Society, Chinese Medical Education Association, and the Vascular Disease Community Prevention and Treatment Center of Peking University School of Medicine, and jointly organized by Shougang Hospital of Peking University, Basic Medical School of Peking University and Vascular Medicine Professional Committee of Chinese Medical Education Association. Professor Wang Hongyu, Vice President and Director of Vascular Medicine Department of Shougang Hospital of Peking University, Director of Vascular Disease Community Prevention and Treatment Center of Peking University School of Medicine, and Chairman of Vascular Medicine Professional Committee of Chinese Medical Education Association, served as the chairman of the conference. The theme of the 2018 conference is "Artificial Intelligence and Human Heart and Vascular Health".