2015年 · 第38卷第10期

On the front page of the 13th issue of Journal of Medical Sciences, where the author serves as the editorial board, there is a long article entitled "The Confusion of Chinese Doctors: Scientific Research and Clinical Practice, Which is the Most Important?"^[1]It is very enlightening to the author. I would like to share my personal opinions with readers, and please criticize and correct me.

Hypersecretion of airway mucus is an important pathophysiological and clinical manifestation of chronic airway inflammatory diseases such as chronic obstructive pulmonary disease (COPD), bronchial asthma (asthma), bronchiectasis and pulmonary cystic fibrosis^[1]。 Recent studies have found that under the stimulation of inflammation, oxidative stress and other factors, glands and goblet cells produce and secrete excessive mucus, which is involved in the pathogenesis of chronic airway inflammatory diseases and is closely related to its clinical outcome. The important role of airway mucus hypersecretion in common respiratory diseases is reported in the literature^[2,3,4]And in clinical practice, it has been found that many patients die of airway obstruction or asphyxia caused by airway mucus hypersecretion. Therefore, it is of great clinical significance to deeply explore the pathogenesis of airway mucus hypersecretion and further clarify the relationship between airway mucus hypersecretion and chronic airway inflammatory diseases.^[1,2,3,4]。 Therefore, a consensus writing expert group composed of relevant experts from COPD Group and Asthma Group of Respiratory Disease Branch of Chinese Medical Association, referred to relevant guidelines and consensus, especially the important literature related to airway mucus hypersecretion published in recent years, formulated this consensus to provide reference for clinical practice.

There are many contents of lung function measurement, but conventional lung function only includes lung volume, ventilation and diffusion function. Among them, tidal volume, vital capacity and ventilation function parameters are mainly measured by pneumometer and/or flowmeter, and functional residual air volume (FRC) or total lung volume and diffusion function are mainly measured by gas analyzer. Traditionally, vital capacity, forced vital capacity (FVC) and related parameters were measured by a monocylinder pneumometry, the maximum expiratory flow-volume curve (MEFV curve) and related parameters were measured by a flowmeter, the FRC was measured by a functional residual air volume meter, and the carbon monoxide dispersion (D_LCO), i.e. about 4 instruments complete routine lung function measurements. Modern pulmonary function meter uses electronic flowmeter (referred to as flowmeter for short, also called flow-type pneumometer when measuring lung volume; unless otherwise specified, this article is commonly called pneumometer) to replace traditional single-barrel pneumometer (also called volume-type pneumometer) and mechanical flowmeter to measure flow and automatically calculate lung volume synchronously (the integral of flow to time is volume), and the result is displayed by computer; At present, the "pneumometer method" in a broad sense actually refers to this flowmeter method. Modern volume and flow measurements can be accomplished by a simple pulmonary function meter, or by a conventional pulmonary function meter or a body volumetric meter (somatograph), wherein the conventional pulmonary function meter is equipped with not only a flow meter, but also a sampling chamber and a gas analyzer on the air path, so that it can measure the total lung volume (or FRC) and D_LAll conventional lung function parameters including CO, that is, one device is used to replace at least 3 to 4 previous instruments to complete all measurements, among which the labeled gases of the measured volume are mainly nitrogen, helium and methane; When the mark gas for measuring the dispersion function is carbon monoxide (CO), the mark gas for measuring the volume becomes the measurement D_LCO tracer gas, so that the total lung volume (or FRC) and D can be finally completed_LSimultaneous determination of CO. In view of this, the use of traditional methods to separate the "guidelines" or "specifications" describing the determination of various parameters is no longer in line with the current situation and cannot meet the clinical needs; The authors put forward an operable application method based on the laws of respiratory physiology, the characteristics of modern instruments and the practical operation procedures, hoping to help the standardization of routine pulmonary function measurement and promote the homogenization of the measurement^[1,2]。

Mycobacteria include the MTB complex, M. leprae, and non-tuberculous mycobacteria. As of September 2014, there are 169 species of mycobacteria and their subpopulations that have been confirmed by literature reports (http: / /www.bacterio.net/mycobacterium.html). The symptoms and imaging findings of various mycobacterial infectious diseases are very similar, but the treatment is different. Rapid and accurate identification of mycobacterial species is the key to diagnose and treat various mycobacterial infectious diseases. Traditional methods for identification of mycobacterial species rely on bacteriological characteristics and biochemical reactions, which are not only time-consuming, cumbersome and less reliable. With the development of molecular biology, DNA sequencing has become the "gold standard" for bacterial identification. Methods for identifying mycobacterial species by DNA sequencing identify mycobacteria to the species level based on the species specificity of certain homologous DNA fragments of different species of mycobacteria^[1]This method has high resolution capability and can shorten the detection time. In order to improve the understanding of DNA sequencing and identification methods, the present situation and research progress in the field of mycobacterial strain identification are summarized as follows.

Lung cancer and chemotherapy are risk factors for the development of venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary thromboembolism^[1]。 The incidence of chemotherapy-associated VTE in lung cancer is about 1.9% ~24.0%^{[2,3,4,5,6,7]}, related to the study population and follow-up time. The mortality rate and medical expenses of patients with lung cancer complicated with VTE increased significantly^[5,6]。 VTE is the leading cause of death in oncology patients receiving chemotherapy after primary tumor progression^[8]。 Meta-analysis showed that heparin-based primary prophylaxis reduced the risk of chemotherapy-related VTE in lung cancer by 53%, but increased the risk of bleeding by 60%^[9]。 The American College of Chest Physicians and others do not recommend the routine use of anticoagulants for the primary prevention of chemotherapy-related VTE in lung cancer, but point out that lung cancer patients with high risk of VTE and low risk of bleeding may benefit from the primary prevention of low molecular weight heparin or low-dose unfractionated heparin^[10,11,12]。 Therefore, the risk assessment of chemotherapy-related VTE in lung cancer has improved its suitability for primary prevention to some extent. Some biomarkers and risk assessment models for chemotherapy-related VTE risk assessment in lung cancer are reviewed below.

allergic bronchopulmonary aspergillosis (ABPA) is a bronchopulmonary disease caused by the allergic reaction of the body to Aspergillus parasitic in the bronchus. In the past, ABPA was considered a rare disease. In recent years, due to the advances in serological and imaging diagnostic methods, the diagnostic rate of ABPA has increased significantly. In 2013, the International Society of Human and Animal Fungi proposed new diagnostic criteria, staging and imaging classification for ABPA^[1]The latest progress in the diagnosis and treatment of ABPA is described below.

Lung cancer is a malignant tumor with the highest mortality rate in the world, with a 5-year survival rate of about 18%. Non-small cell lung cancer (NSCLC) accounts for about 85% of lung cancer, and about 70% of patients are advanced at the time of diagnosis^[1]。 At present, the chemotherapy efficacy of advanced NSCLC has entered a plateau stage, and targeted therapy provides a new solution to break through this bottleneck. The widespread application of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKI) has successfully opened the era of targeted therapy for NSCLC. The discovery of the anaplastic lymphoma kinase (ALK) fusion gene in 2007 is another milestone in targeted therapy for NSCLC. Crizotinib is the first small molecule ALK kinase inhibitor to be developed. It was approved by the U.S. Food and Drug Administration (FDA) in 2011 for the treatment of advanced ALK-positive NSCLC. In 2014, the second ALK inhibitor, Ceritinib, was approved by the FDA for the treatment of ALK-positive patients with metastatic NSCLC who are progressive or intolerable to crizotinib treatment, but the problem of drug resistance has become the continued benefit of targeted therapy. The biggest obstacle. At present, some clinical trials of novel inhibitors or treatment strategies for ALK-positive NSCLC are continuously being carried out, and these trial data will further advance the development of targeted therapies for ALK-positive NSCLC. The current status and challenges of targeted therapy for ALK-positive NSCLC are summarized as follows.

Osteoporosis is a systemic bone disease characterized by low bone mass, damaged bone microstructure, increased bone fragility and prone to fracture. The common clinical indicators for the diagnosis of osteoporosis are the occurrence of fragile fracture and/or low bone density^[1]。 Chronic obstructive pulmonary disease (COPD) is closely related to osteoporosis, which is a major complication of COPD^[2]。 It is explicitly recommended in the global strategy and guidelines for diagnosis and treatment of chronic obstructive pulmonary disease^[2,3,4]For patients with moderate to severe COPD and at risk of repeated acute exacerbation, high-dose inhaled glucocorticoids (hormones) combined with long-acting β 2-receptor agonists (LABAs) can be used for treatment. However, for patients with moderate to severe COPD, there is no clear conclusion on whether long-term inhalation of hormones can cause or aggravate osteoporosis. The relationship between COPD and osteoporosis and the effect of hormone therapy on osteoporosis are summarized as follows.

obstructive sleep apnea syndrome (OSAS) is a common sleep breathing disorder caused by repeated upper airway obstruction during sleep, which leads to repeated episodes of hypoxia. It can promote the occurrence and development of cardiovascular diseases, and its damage to pulmonary circulation has attracted more and more attention. About 30% of OSAS patients suffer from pulmonary hypertension^[1]Although continuous positive airway pressure (CPAP) can improve pulmonary artery pressure in such patients, patients' compliance with CPAP is poor, and there is a lack of simple and effective means for the treatment of OSAS-related pulmonary hypertension. The pathophysiological mechanism of OSAS is essentially the process of long-term intermittent hypoxia. The study of OSAS disease was mainly carried out by simulating the mechanism of intermittent hypoxia in animal models. It has been reported that intermittent hypoxia can cause pulmonary hypertension in mice^[2]In recent years, it has been found that intermittent hypoxia can cause oxidative stress, inflammatory reaction, increased sympathetic nerve excitability, endothelial dysfunction and hemodynamic abnormalities, which can lead to pulmonary hypertension. The related research progress of intermittent hypoxia and the pathogenesis of pulmonary hypertension is summarized as follows.

Chronic obstructive pulmonary disease (COPD) is an important disease with high morbidity and mortality in the world, causing a serious socio-economic burden. Moreover, this burden is increasing, and it is expected that slow obstructive pulmonary disease will jump to the third major disease causing death in 2020. But at the same time, COPD is also a preventable and treatable disease. Early diagnosis and rational treatment can effectively improve the quality of life of patients and reduce the social and economic burden. COPD is characterized by persistent airflow restriction, so pulmonary function testing plays a very important role in the diagnosis and severity assessment of COPD, but there are still many questions to be discussed.

continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnea hypopnea syndrome (OSAHS). However, poor adherence is one of the main problems plaguing clinicians^[1]。 In order to improve compliance, researchers have continuously explored from the aspects of changing ventilator working mode, updating man-machine connection interface, optimizing airway humidification device and psychosocial support, especially the advent of CPAP compliance automatic tracking system has made the objective evaluation of compliance a reality. The system provides information including time of use, air leakage and residual breathing events, and airway opening status at the time of breathing events^[2,3,4,5]It provides a powerful technical platform for the management of CPAP applications. The American Thoracic Society (ATS) organization expert committee issued an expert statement on automated tracking system in 2013^[6]It has important guiding significance for clinicians and the industry. There are still many challenges to correctly understand and make good use of this system.

farmer's lung disease belongs to the category of farmer's lung disease (FLD) or "greenhouse disease". It was first reported by Campbell in 1932. The incidence of the disease is high because of planting vegetables, fungi, flowers and other crops in greenhouses and raising poultry. It is mainly because of long-term labor in greenhouses with high temperature, high humidity, poor air circulation and high colony density in soil, and symptoms such as cough, dyspnea, fatigue and itchy skin can occur. If not diagnosed and treated in time, it can lead to allergic alveolitis, bronchial asthma, COPD, arthritis and skin diseases, etc. In severe cases, lung function damage, joint deformity, chronic skin diseases, etc., with poor prognosis and high disability rate, which has become an important factor affecting the quality of life and health of farmers engaged in greenhouse operations. At present, there are few reports on the epidemiology and prevention of pulmonary diseases of farmers working in greenhouses at home and abroad, but there is no diagnostic standard for farmers'"occupational diseases" in China. From August 2006 to June 2009, our hospital investigated the prevalence of allergic alveolitis among farmers engaged in greenhouse operations such as vegetables, flowers, mushroom houses and chicken and duck houses in some areas of Liaoning Province, and analyzed the related risk factors.

Chronic obstructive pulmonary disease (COPD) is a common respiratory disease. The results of a large sample survey of people over 40 years old in China show that the prevalence of COPD is 8.2%. The onset of COPD is insidious, and most of them have no clinical symptoms or mild symptoms in the early stage. Clinicians (especially non-respiratory specialists) do not pay enough attention to it. Patients are often missed in the early stage, and they are often moderate to severe when seeking medical treatment. Therefore, the diagnosis and treatment of COPD in China is not optimistic. According to previous reports, there are significant differences in the allocation rate of pulmonary function instruments and the popularity rate of inhaled preparations in different levels of hospitals in Hunan Province. Hospitals at all levels pay insufficient attention to the health education of patients with COPD. Doctors in primary hospitals generally lack the basic knowledge of COPD diagnosis and treatment. Doctors' mastery of COPD diagnosis and treatment knowledge is closely related to their academic qualifications.

Bone morphogenetic protein 4 (BMP4) belongs to the TGF-β superfamily. At present, the role of BMP4 in adult lung inflammation is not clear. This study mainly investigates the role of BMP4 in acute and chronic airway inflammation induced by lipopolysaccharide.

The 4th Beijing Young Respiratory Scholars Salon 2015 was held on June 25th, 2015, with the theme of "Review of the 2015 American Chest Annual Conference in Denver", presided over by Dr. Huang Hui, Department of Respiratory Medicine, Peking Union Medical College Hospital.

The patient was a 57-year-old male, a farmer. He was admitted to hospital on April 12, 2014 due to "cough and cough of yellow phlegm for 24 months, dyspnea for 18 months, and aggravation for 2 days". In March 2012, the patient developed cough and yellow phlegm with no obvious trigger, accompanied by general discomfort, but no other respiratory symptoms, and was not diagnosed and treated. In January 2013, his symptoms worsened and he had difficulty breathing after movement. He went to a local hospital and the chest CT examination showed a high possibility of "tuberculosis" (Figure 1，Figure 2，Figure 3，Figure 4), no abnormalities were found in the examination of improving sputum to find acid-fast bacilli, and the experimental anti-tuberculosis treatment was not effective. In September 2013, I saw the doctor again due to aggravation of symptoms and underwent chest CT (Figure 5，Figure 6，Figure 7，Figure 8), bronchoscopy and other examinations, the diagnosis of "lung abscess, bronchiectasis and infection", and anti-infective treatments such as meropenem and levofloxacin were ineffective. On February 25, 2014, he went to a hospital in Beijing and was diagnosed with "lung abscess" by chest CT (Figure 9，Figure 10，Figure 11，Figure 12)。 On April 12, 2014, he was admitted to our hospital with cough and yellow phlegm cough accompanied by dyspnea. The patient lost about 10 kg of weight since the onset of the disease, without gastrointestinal symptoms. He had a history of diabetes for 5 years, intermittently used metformin and glimepiride, and his blood sugar control was acceptable. Smoking for more than 30 years, smoking index 60 packs per year, quit smoking for 2 years. Deny family history of genetic diseases and infectious diseases. Physical examination: body temperature 36.4℃, pulse 118 beats/min, respiratory rate 23 beats/min, blood pressure 120/85 mmHg (1 mmHg =0.133 kPa), chronic disease, thin body, asthmatic appearance, sitting breathing, no cyanosis of the skin and mucosa of the whole body, untouched and swollen superficial lymph nodes, low breathing sounds in both lungs, focusing on the left side, and scattered phlegm and wet rales can be heard in both lungs; The heart boundary was not large, the heart rate was 118 beats/min, the rhythm was uniform, and no pathological murmur was heard in the auscultation area of each valve; There were no abnormalities in the abdomen, no edema in both lower limbs, no pestle-like digits, and no abnormalities in the nervous system.

Lung cancer is the most prevalent malignant tumor in the world^[1]Trans-bronchoscopic biopsy is one of the main methods to confirm the diagnosis of lung lesions^[2]However, traditional bronchoscopy only relies on naked eye to observe endobronchial lesions, which is easy to cause missed diagnosis. probe confocal laser endomicroscopy (pCLE), known as "optical biopsy," can observe the elastic fibrous structure of the bronchi and alveoli with parallel, elliptical imaging features^[3,4,5]。 However, the pCLE image features of lung cancer have only been reported abroad^[6,7,8]And their characteristics are not the same. The purpose of this article is to investigate the imaging characteristics and safety of pCLE in lung cancer at different sites.

A 34-year-old male was admitted to the thoracic surgery department of our hospital on September 5, 2014 due to "finding the shadow of the upper lobe of the right lung for more than 1 month". Three years ago, I had thyroid surgery (pathological indication was papillary carcinoma), and there was no recurrence after surgery. Physical examination: consciousness was clear, old surgical scars were visible on the neck, no swollen lymph nodes were palpable on bilateral claviculas, no dry and wet rales were heard in both lungs, heart rate was 80 beats/min, rhythm was uniform, no pathological murmur was heard, abdomen was soft, liver and spleen were not reached under the costs, and nervous system was not abnormal. On July 28, 2014, the outpatient chest CT showed that mixed ground glass nodules were seen in the upper lobe of the right lung, the maximum diameter was 1.0 cm ×0.7 cm, the boundary was not smooth, and superficial lobules were seen. No enlarged lymph nodes were seen in the hilum and mediastinum of both lungs, and no effusion was seen in the bilateral pleural cavities. Chest CT reexamination on 11 Sep 2014 showed mixed ground glass nodules (mGGN) in the upper lobe of the right lung, similar to the anterior film (Figure 1，Figure 2)。

serotonin syndrome, also known as serotonin syndrome (SS), refers to a group of symptoms and signs caused by serotonin (5-HT) hyperfunction in the nervous system. Its main clinical manifestations are cognitive function and behavioral changes, neuromuscular abnormalities and autonomic nervous system instability, etc., and may even be life-threatening. Most of them are caused by therapeutic drugs or unexpected drug interactions^[1]。 In recent years, due to the increasing variety of antidepressants, the clinical application of selective 5-HT reuptake inhibitors (SSRIs) is increasingly widespread, and SS occurs from time to time. The recent cases of SS caused by linezolid combined with sertraline in our hospital are reported as follows to improve clinicians' awareness of the risks of combined use of the above drugs.

A 69-year-old male was admitted to the hospital on March 9, 2015 due to "cough, expectoration, blood in sputum for 9 months, wheezing and shortness of breath for 4 months". Nine months before admission, the patient developed cough and expectoration without obvious trigger. The sputum was a small amount of white foamy sputum with bright red bloodstreaks in the sputum. He went to a local hospital, and no special abnormalities were found on X-ray chest X-ray examination. He was given anti-infective treatment and was discharged after his discomfort symptoms improved slightly. Four months before admission, the patient showed wheezing and shortness of breath without obvious triggers. He went to the local hospital again, but the effect of anti-infective treatment was poor. He underwent chest CT examination, considered tracheal cancer, and was discharged without special treatment. After discharge, wheezing and shortness of breath progressively aggravated, shortness of breath in rest position at admission, and obvious limitation of activities. Previous history of hypertension for 1 year, up to 150/90 mmHg (1 mmHg =0.133 kPa), denied history of infectious diseases such as hepatitis and tuberculosis. Physical examination: The superficial lymph nodes of the whole body were unpalpable and enlarged, the breathing sounds of both lungs were weak, and the wheezing sounds of the great airways could be heard. Blood gas analysis: oxygen saturation was 93%, oxygen partial pressure was 63 mmHg, and carbon dioxide partial pressure was 43 mmHg; Blood routine: white blood cells were 7.48×10⁹/L, hemoglobin was 178 g/L, and platelet count was 308×10⁹/L, 0.53 for neutrophils; Tumor markers: neuron-specific enolase was 1.92 μ g/L, carcinoembryonic antigen was 3.58 μ g/L, and squamous cell carcinoma antigen was 0.91 μ g/L; Chest enhanced CT: Irregular soft tissue mass was seen at the tracheal carina, with unclear boundary and protruding into the lumen, about 2.5 cm ×2.2 cm, and the density was still uniform. The CT value was about 30 HU, and the CT value after enhanced scan was about 105 HU (Figure 1，Figure 2)。

This part is closely related to the second part of the explanation series^[1,2]。