2018年 · 第41卷第08期

In this midsummer season, along with the summer heat wave, the 8th issue of this magazine in 2018 meets you readers!

Bacterial resistance is a serious threat to all human health, which has been confirmed both in the understanding of medical staff and in the World Health Organization and government documents of many countries. The author will not repeat those shocking figures: such as how many people die of drug-resistant bacterial infections every year in the world, and how many infected patients will die of no cure in China by 2050. The focus of this article is to discuss with readers how to effectively delay the spread of bacterial resistance, especially in hospitals.

The results of many foreign studies have fully shown that obstructive sleep apnea (OSA) is an important cause of various road traffic accidents^[1,2]Its harm is no less than drunk driving, which has aroused widespread concern from all walks of life, especially the attention of road traffic safety management departments and medical circles. Various monographs on sleep respiratory disease have highlighted OSA and road traffic safety^[3,4,5]。 The first case reported in our country was in 1997^[6]Later, the author also published a review in a professional journal emphasizing the need to pay close attention to this issue^[7]And dedicated a chapter to this issue in Sleep Respiratory Diseases, published in 2009^[8]。

Cognitive dysfunction is one of the common complications of obstructive sleep apnea hypopnea syndrome (OSAHS). Its incidence is high, which seriously affects the quality of life and prognosis of patients, and increases the medical burden of patients. Exploring relevant biomarkers is beneficial to early identification and early intervention. The mechanism of cognitive impairment in OSAHS has not been fully elucidated at present, and the current research mainly focuses on oxidative stress damage and inflammatory response caused by chronic intermittent hypoxia and sleep fragmentation. However, published in this issue from Xu Jiahuan et al.^[1]This paper focuses on growth hormone releasing hormone (GHRH), a peptide hormone, whose effect on cognitive function has been gradually paid attention to^[2]。 Based on the fact that GHRH in OSAHS patients may be affected by sleep structure and hypoxia, the authors compared GHRH levels in OSAHS patients with or without cognitive dysfunction, and found that it was related to cognitive dysfunction in OSAHS patients, which suggested that GHRH could be used as a candidate biomarker for moderate to severe OSAHS with cognitive dysfunction.

Hypoalbuminemia is a common pathophysiological phenomenon in critically ill patients. It is reported in the literature that the decrease of serum albumin level can affect the pharmacokinetics of antibacterial drugs with high protein binding rate, and then affect the efficacy of anti-infective treatment in critically ill patients. Therefore, when giving antibacterial drugs to critically ill patients, attention should be paid to the influence of hypoproteinemia on the dose selection and efficacy of antibacterial drugs.

Hypoelasticity of the terminal distal bronchioles causes excessive flatulence in the alveolar cavity and increased lung volume, which is the main pathological change of emphysema. Overinflated and inflated lung tissue squeezes relatively normal lung tissue, resulting in abnormal ventilation blood flow ratio, which is an important cause of respiratory dysfunction in emphysema patients. Emphysema is the most characteristic pathological change in chronic obstructive pulmonary disease (COPD). Despite the best current medical care, pulmonary rehabilitation and long-term oxygen therapy, COPD did not significantly alleviate or reverse pulmonary hyperinflation^[1]。

In recent years, the incidence of pulmonary cryptococcosis (PC) has increased year by year, but the clinical manifestations and imaging features of PC lack specificity, and some patients are prone to misdiagnosis or misdiagnosis because of difficulty in obtaining lung tissue specimens or unwillingness to undergo invasive examination. The results of many foreign studies suggest that the sensitivity and specificity of blood colloidal gold immunochromatographic assay (LFA) in diagnosing pulmonary cryptococcosis can reach 98% ~100%^[1,2]However, most of the research subjects are human immunodeficiency virus (HIV) antibody-positive patients, and related research reports of HIV antibody-negative patients are rare. In this study, the diagnostic value of LFA in patients with HIV-negative pulmonary cryptococcosis was evaluated by blood LFA detection, and the histopathological results of lung biopsy were used as the gold standard.

nodular lymphoid hyperplasia (NLH) is a rare lymphocyte proliferative disease with unknown etiology. At present, it is believed to be related to immune imbalance. It is more common in the digestive system, and the respiratory system is a relatively rare target organ. pulmonary nodular lymphoid hyperplasia (PNLH) was proposed in 1983 to describe pulmonary nodules or focal infiltration caused by reactive lymphoid tissue proliferation^[1]。 This article reports a case of pulmonary nodular lymphoid hyperplasia diagnosed and treated in our hospital in May 2014 and its follow-up until November 2017. Combined with literature review, the clinical manifestations, pathological features, diagnosis, differential diagnosis, treatment and prognosis of this disease are discussed.

High fever is one of the symptoms of acute pulmonary thromboembolism (PTE), which often leads to delayed or even misdiagnosis. The data of a PTE patient with typical clinical manifestations and imaging features but delayed diagnosis for 5 days due to hyperthermia admitted to our hospital are briefly introduced as follows.

A 23-year-old female was admitted to our hospital on June 16, 2015 because of "1 month after 6 courses of gastric lymphoma surgery and chemotherapy, low fever and fatigue for 7 days, cough and shortness of breath after activity for 4 days". The patient underwent subtotal gastrectomy in a cancer hospital on November 28, 2014. The postoperative pathology showed diffuse large B-cell lymphoma. He underwent R-CHOP regimen (rituximab 600 mg, day 1+ vincristine 2 mg, day 2+ doxorubicin 80 mg, day 2+ cyclophosphamide 1.2 g, day 2+ prednisone 100 mg, day 2 to day 6) for 6 courses of chemotherapy, achieved complete remission and was discharged. After discharge, the general condition was acceptable, and there was no abnormality in chest CT. On June 10, 2015 (1 month after discharge), the patient developed low fever, mild dry cough and shortness of breath after activity 3 days later, and went to the cancer hospital. Blood routine showed a white blood cell count of 9.9×10⁹/L, with a lymphocyte count of 1.8×10⁹/L; Chest CT showed interstitial inflammation of both lungs (Figure 1,Figure 2,Figure 3), CT of head, neck and abdomen had no abnormalities. Outpatient intravenous drip of "levofloxacin 0.5 g/d, cefoxitin 1 g/d, methylprednisolone 80 mg/d", supplemented with oxygen inhalation and symptomatic supportive treatment, but the effect was not good. On June 16, all indexes were re-checked, and the white blood cell count was 7.2×10⁹/L, the lymphocyte count was 0.9×10⁹/L, C-reactive protein was 30.7 mg/L, and procalcitonin was in the normal range, so he was admitted to the cancer hospital again. The patient's past history was not special.

A 32-year-old male was admitted to Beijing China-Japan Friendship Hospital on October 14, 2016 due to "fever, cough and expectoration for 2 months during the treatment of acute leukemia". In April 2016, he was diagnosed with "acute myeloid leukemia type M2" in Beijing Daopei Hospital, and was given "harringtonine 6 mg/d (day 1-7), intravenous drip; cytarabine 150 mg/d (day 1-7), intravenous drip", but the effect was not good; The targeted drug Bcl-2 inhibitor Venetoclax 400 mg was administered orally once a day. On August 10, 2016, the patient developed fever with a body temperature of 39.5℃. He was re-admitted to Beijing Daopei Hospital and was treated with "cefixime", but the body temperature did not drop significantly. On August 18, 2016, the blood culture results showed positive lysis subtype of Enterobacter cloacae, which was changed to imipenem/cilastatin sodium 0.5 g, once/6 h, combined with amikacin 0.4 g, once/d, and the body temperature dropped to normal on the second day. After 1 week, the fever reappeared, and the body temperature was 37.8℃. Considering that the patient was complicated with agranulocytosis, fungal infection was not excluded. Voriconazole 200 mg, once/12 h, and sequential micafungin combined with amphotericin B liposome for injection were added. Amphotericin B liposomes were discontinued due to a massive rash on the patient's trunk, but the body temperature dropped to normal. On September 13, 2016, he had fever again, cough and expectoration, with blood in the sputum, and chest CT showed patchy consolidation of the right upper lung (Figure 1)。 On October 14, 2016, bronchoscopy showed that purulent secretion from the upper lobe of the right lung obstructed the airway, and pathological examination showed that fungal mass, tending to Aspergillus, was treated with micafungin and amphotericin B, but the patient still had intermittent fever, so he was transferred to China-Japan Friendship Hospital. Physical examination at admission: body temperature 37.0 ℃, pulse 80 beats/min, breathing 20 beats/min, blood pressure 120/70 mmHg (1 mmHg =0.133 kPa), pale complexion and conjunctiva, no ulcers and skin damage all over the body. The breathing sound of the right upper lung was low, no dry and wet rales were heard in both lungs, no abnormalities were found in heart and abdomen examination, and no edema in both lower limbs. Admission diagnosis: pulmonary fungal infection, after chemotherapy for acute myeloid leukemia (type M2).

endobronchial ultrasound guided tranbronchial needle aspiration (EBUS-TBNA) is a safe and efficient method for diagnosing mediastinal diseases^[1,2,3,4]。 In recent years, EBUS-TBNA has been widely used in clinical practice. Occasionally, complications such as hemorrhage, tension pneumothorax and mediastinal infection have been reported^[4,5,6]。 This paper reports the rare complications of multiple inflammatory polyps in the trachea after EBUS-TBNA in 3 patients with lymph node tuberculosis.

idiopathic pulmonary fibrosis (IPF) is a chronic progressive fibrotic interstitial pneumonia with progressive aggravation of dyspnea, decreased pulmonary function, histopathology and/or imaging with usual interstitial pneumonia (UIP) -like characteristics, mostly in the elderly, and the lesion site is limited to the lung. At present, the etiology is unknown, the median survival time is about 2 to 3 years, and the prognosis is poor^[1]。 There are large differences in the incidence and prevalence of IPF in different countries. The incidence and prevalence of IPF in the United States were 5.8 per 100 000 and 18.2 per 100 000, respectively^[2]。 The incidence and prevalence of IPF in Canada were 9.0/100 000 and 41.8/100 000, respectively^[3]。 Estimating the actual incidence and prevalence of IPF is still a worldwide challenge due to different disease definitions, inaccurate diagnosis, heterogeneous diagnostic strategies and different data sources.

obstructive sleep apnea (OSA), as one of the common risk factors of cardiovascular and cerebrovascular diseases, has been paid more and more attention^[1]。 The latest epidemiological findings show that the incidence of moderate to severe sleep dyspnea is 49.7% in men and 23.4% in women^[2]。 The vast majority of people with sleep breathing disorders are OSA. aortic dissection (AD) is a cardiovascular disease with very high mortality rate. The mortality rate of untreated Stanford type A AD exceeds 70% within 1 week, while the 5-year survival rate of drug-treated Stanford type B AD is only 60%^[3]。 Sampol et al.^[4]A higher prevalence of OSA in AD patients was found for the first time. Since then, it has been reported that OSA is closely related to AD, and OSA may affect the occurrence, development and prognosis of AD through various pathophysiological mechanisms. However, systematic studies in this area are still rarely reported. The relationship between OSA and AD and its clinical significance are summarized below.

Air pollution has become a serious public health problem in China. The composition of air pollutants is complex, which can be divided into two categories according to their forms: particulate pollutants (mainly including inhalable particulate matter, fine particulate matter, etc.) and gaseous pollutants (mainly including sulfur dioxide, carbon monoxide, nitrogen oxides and ozone, etc.). Among them, atmospheric particulate matter (PM) is a general term for various solid particulate matter and liquid particulate matter in the atmosphere. PM can be divided according to the source into^[1,2]: (1) Direct sources: from construction sites, road construction, chimneys and fires, etc.; (2) Indirect sources: chemical substances such as sulfur dioxide and nitrogen oxides emitted by power plants, factories and automobiles contact each other in the atmosphere and chemically react, thus forming PM. According to U.S. Environmental Protection Agency's Environmental Regulatory Documents^[3]Particulate matter having an aerodynamic diameter ≤10 μ m is referred to as coarse/inhalable PM, PM₁₀), ≤2.5 μ m is called fine particulate matter (PM_2.5)。

Bronchial asthma (asthma) is one of the most common chronic respiratory diseases that seriously endangers human health and is characterized by airway inflammation and airway hyperresponsiveness. According to the Global Asthma Initiative (GINA), there are about 300 million asthma patients worldwide (about 3,000 asthma patients in China), the prevalence of asthma in different countries is 1% to 16%, and the number of asthma deaths worldwide is as high as 346,000 every year^[1,2]。 Recent findings suggest that the epithelial-to-mesenchymal transition (EMT) plays an important role in the development of asthma. EMT refers to the phenotypic conversion of differentiated epithelial cells into mesenchymal cells. When EMT occurs, the intercellular junction of epithelial cells is lacking, resulting in the separation of epithelial cells and basal cells, and obtaining mesenchymal cell-like characteristics, thus migrating to other sites^[3]。 EMT has now been confirmed to be involved in the fibrotic process of the small intestine, lens, liver, kidney and lung^[4,5,6,7,8]The role and mechanism of EMT in the development of asthma are reviewed as follows.

Lung cancer is a disease that seriously endangers human health and is one of the common malignant tumors in China. In 2015, the incidence and mortality of lung cancer ranked first among malignant tumors^[1]。 In recent years, despite the deepening of research in the field of lung cancer, human understanding of lung cancer is only the tip of the iceberg. It is still the focus and challenge of lung cancer research to clarify the mechanism of lung cancer occurrence, metastasis and drug resistance and explore new therapeutic targets. The rise of cancer stem cell theory has brought lung cancer research into the stem cell era, and will provide a new choice for the treatment of lung cancer.

A 63-year-old female was admitted to the hospital on November 11, 2015 due to "intermittent fever with cough, expectoration and shortness of breath for more than 3 months." The patient developed chills and fever after catching cold in early August 2015, with a maximum body temperature of 39.3℃, accompanied by cough, coughing a small amount of white phlegm, accompanied by fatigue and shortness of breath. There were no other systemic concomitant symptoms. After more than 1 month of infusion treatment in a local community clinic, the main drugs were "ribavirin" and "levofloxacin" (dose unknown). The patient's symptoms did not improve, and the shortness of breath gradually worsened. On September 2, 2015, I went to the local hospital. Chest CT showed multiple nodules in both lungs, some of which were fused into films, mainly distributed along the bronchial vascular bundle, and some were randomly distributed. Small cavities can be seen in some nodules (Figure 1,Figure 2,Figure 3,Figure 4)。 Preliminary diagnosis: The cause of lung shadow is to be investigated. After admission, "levofloxacin" combined with "piperacillin/tazobactam" was given intravenously for 2 weeks, and then changed to "cefoperazone/sulbactam" combined with "azithromycin" intravenously for 10 days. After admission, the patient's fever gradually improved, and the symptoms of cough, expectoration and shortness of breath were alleviated. Reexamination of chest CT (September 28, 2015) showed that the lesions were obviously absorbed and improved (Figure 5,Figure 6,Figure 7,Figure 8), and was discharged. The out-of-hospital patient continued infusion therapy (specific medication unknown), and on October 10, 2015, he had fever again without obvious trigger, with a body temperature of 39.3℃, and the remaining symptoms were the same as before. Out-of-hospital treatment was ineffective, and he went to the local hospital again on November 5, 2015. Reexamination of chest CT showed multiple patches and nodules in both lungs (Figure 9,Figure 10,Figure 11,Figure 12), compared with the chest CT on September 28, 2015, significantly progressed, and compared with September 2, 2015, the position showed migration. Again, "piperacillin/tazobactam" combined with "azithromycin" was given intravenous drip for 6 days, but the symptoms did not improve significantly. He came to our hospital for further diagnosis and treatment. Since the onset of the disease, the patient has been conscious, poor spirit, poor diet and sleep, normal defecation, and weight loss of about 5 kg. The past "hepatitis B small three yang" for more than 10 years, self-complaint has been cured. The local hospital checked hepatitis B DNA without replication, and the liver function was normal. The patient was a housewife and lived in a slightly humid environment. Having owned dogs for many years, I cleaned up the dog pen before I got a fever. Familial genetic history denied.