2019年 · 第42卷第11期

Colistins have been marketed in the 1950s, but due to their nephrotoxicity and neurotoxicity, and the availability of new drugs, colistins have gradually been terminated from clinical application. However, in the 21st century, colistin has been "recruited" again and has once again entered the "clinical stage". Professor Liu Youning, the editor-in-chief of this journal, elaborated on several issues that clinicians are most concerned about in his essay "Why colistin, which was eliminated in clinical practice, has regained its life", which deserves attention.

BACKGROUND AND OBJECTIVE: endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive technique for determining the nature of mediastinal lymph nodes or tumors. However, the diagnostic value of EBUS-TBNA for lymphoma is unclear. This study aims to evaluate the sensitivity and specificity of EBUS-TBNA in diagnosis of patients with suspected lymphoma by systematic literature review and meta-analysis. Methods: Two experts searched the relevant literatures in EMBASE, MEDLINE, Cochrane Library and Google Scholar databases, and evaluated the sensitivity and specificity of EBUS-TBNA for confirming the diagnosis of those patients with suspected lymphoma through the binary methodological model of QUADAS-2 and meta-analysis. Results: (1) A total of 14 studies (425 patients) were included, and the overall sensitivity of EBUS-TBNA in the diagnosis of lymphoma was 66.2% (95%CI：55%~75.8%），I²=76.2%； The specificity was 99.3% (95%CI：98.2%~99.7%），I²=40%。 For first-time lymphoma patients (13studies, 243 patients), the sensitivity of EBUS-TBNA to diagnose lymphoma was 67.1% (95% CI：54.2%~77.9%），I²=66.8%； The specificity was 99.6% (95% CI：99.1%~99.8%），I²=0%。 For patients with recurrent lymphoma (11 studies, 166 patients), the sensitivity of EBUS-TBNA for diagnosis of lymphoma was 77.8% (95%CI：68.1%~85.2%），I²=20.2%； The specificity was 99.5% (95%CI：98.9%~99.8%），I²=0%。 For patients with recurrent lymphoma, combining techniques such as rapid onsite examination (ROSE), flow cytometry and the use of thicker biopsy needles can increase the diagnostic sensitivity of EBUS-TBNA (however, there is some heterogeneity in the results between different literatures). Conclusion: EBUS-TBNA has good diagnostic sensitivity for the first diagnosis or recurrent lymphoma.

Background: Hypoxemia is the most common complication in critically ill patients during tracheal intubation and increases the risk of cardiac arrest and death. Whether positive pressure ventilation with a balloon mask during tracheal intubation in critically ill patients can prevent hypoxemia without increasing the risk of aspiration remains controversial. Methods: In a multicenter randomized trial conducted in seven intensive care units in the United States, patients who underwent tracheal intubation were randomized to receive mask ventilation during anesthesia induction and laryngoscopy and to receive no ventilation. The main outcome of the study was the lowest oxygen saturation observed within 2 min after induction of anesthesia to tracheal intubation. The secondary outcome was the incidence of severe hypoxemia, defined as oxygen saturation, during this period<80%。 Results: A total of 401 patients were included, and the minimum oxygen saturation was significantly higher in the mask-ventilated group than in the non-ventilated group, 96% (quartile range 87%-99%) and 93% (quartile range 81%-99%), respectively (P=0.01）。 Severe hypoxemia occurred in 21 (10.9%) patients in the mask ventilation group and 45 (22.8%) in the control group; The relative risk of developing severe hypoxemia was 0.48 (95%) in the mask-ventilated group compared with the non-ventilated groupCI：0.30~0.77）。 The aspiration rate during intubation was 2.5% in the mask-ventilated group and 4.0% in the non-ventilated group. There was no significant difference between the two groups (P=0.41）。 The incidence of new shadows on chest radiographs 48 h after tracheal intubation was 16.4% and 14.8%, respectively, with no significant difference between the two groups (P=0.73）。 CONCLUSIONS: Among critically ill patients undergoing tracheal intubation, patients undergoing pocket mask ventilation had higher oxygen saturation and a lower incidence of severe hypoxemia than those not undergoing ventilation.

BACKGROUND AND OBJECTIVE: Surgical lung biopsy (SLB) is the gold standard for the diagnosis of interstitial lung diseases requiring pulmonary pathological support. However, there is no direct comparative study between bronchoscopic frozen lung biopsy (TBLC) and SLB in the diagnosis of this type of interstitial lung disease. This study aims to evaluate the diagnostic value of TBLC for this type of patients by comparing the consistency of pathological diagnoses given by the same patient after receiving TBLC and continuous SLB. METHODS: A 27-month prospective study involving two medical centers enrolled patients with interstitial lung disease with non-definitive interstitial pneumonia vulgaris phenotype as determined by the first multidisciplinary assessment (MDA1) with high-resolution CT (HRCT). These patients underwent TBLC first, followed immediately by SLB under video-assisted thoracoscopy (VATS) at the same site. The pathologist of our center gives the results of pathological diagnosis and performs the second multidisciplinary assessment (MDA2) to arrive at the final diagnosis; At the same time, the specimens of TBLC and SLB are disordered (including the pairing of TBLC and SLB) and then sent to the pathologist in another hospital to give the corresponding diagnosis (TVC). The agreement (Kappa coefficient and percent agreement) of TBLC vs. SLB, MDA2 vs. TBLC, and MDA2 vs. SLB was compared. Results: (1) A total of 21 patients were included, and the long diameter of lung tissue obtained by TBLC biopsy was 7 mm (quartile 5-8 mm); The lung tissue obtained from SLB biopsy was (46.1 ± 13.8) mm. (2) The results of the consistency test were as follows: TBLC vs SLB: κ =0.22 (95%CI: 0.01~0.44), the percentage of agreement was 38% (95%CI：18~62）； MDA2 vs. TBLC: κ =0.31 (95% CI: 0.06~0.56), the percentage of agreement was 48% (95% CI：26~70）； MDA2 vs. SLB: κ =0.51 (95% CI: 0.27~0.75), the percent agreement was 62% (95% CI：38~82）。 (3) Four patients (4/21, 19%) had no pathological diagnosis by TBLC; Eleven of all 21 patients (11/21, 52%) had different treatment options due to the difference between the diagnosis given by SLB and the diagnosis given by TBLC. (4) A total of 8 cases (8/21, 38%) had consistent pathological diagnosis of TBLC and SLB, and 6 cases (4 cases UIP, 1 case RB-ILD, 1 case NSIP) had consistent pathological diagnosis of MDA2. (5) 13 cases (13/21, 61.9%) had inconsistent pathological diagnosis of TBLC and SLB biopsy, 6 cases had consistent diagnosis of MDA2 with SLB, and 3 cases had consistent diagnosis of TBLC; In another 4 cases, the diagnoses of MDA2, SLB and TBLC were inconsistent. (6) Possible reasons for inconsistent diagnosis: because the specimen of TBLC is small, it is easy to mistake other diagnoses for UIP; The distribution of lesions was inconsistent; The enrolled patients are difficult and atypical cases. Conclusion: The pathological diagnosis of interstitial lung disease obtained by bronchoscopic frozen lung biopsy and surgical lung biopsy has poor agreement; The latter had a higher coincidence rate with the diagnosis obtained after multidisciplinary evaluation.