2015年 · 第54卷第08期

Bronchial asthma (hereinafter referred to as asthma) is a chronic respiratory diseases that seriously endangers human health. In recent years, its prevalence is increasing year by year worldwide. It is estimated that there are at least 300 million asthma patients in the world and nearly 30 million asthma patients in China. How to ensure that such a large number of patients can get scientific, reasonable and standardized treatment is a major event to ensure that patients are protected from disease harm and improve their quality of life.

In recent years, although clinical medicine, especially critical care medicine, has made great progress, severe infection is still a common disease that threatens the life of critically ill patients. How to achieve early diagnosis and early anti-infection treatment of severe infection, and to evaluate the effectiveness of anti-infection treatment and the influence of immune dysfunction on anti-infection treatment correctly^[1]It is the key to the success or failure of anti-infective treatment for severe infections.

Severe infection and septic shock are common clinical syndromes in critically ill patients and have been a great challenge for critical care medicine. In recent years, despite the continuous progress of treatment technology, the hospital mortality rate of patients with severe infection and septic shock has decreased significantly, but it is still as high as 20% ~30%^[1,2]。 Studies have shown that only 9% of patients with severe infections die within 14 days of infection, while more patients die in the later stages of infection. Therefore, it is very important to explore the reasons for the high mortality rate in the late stage of severe infection.

"Thanks to Penicillin, He will come home!" 90 Fleming discovered penicillin many years ago, marking a milestone in anti-infective treatment for humans. Its outstanding curative effect made the hygienists who treated the wounded of the U.S. military in World War II let out the above sigh. So far, many medical professionals believe that humans have found a magic weapon to deal with infections (bacteria), and some even cheer that "medical textbooks can be closed". However, the joy of mankind did not last long. With the advent of more and more new antibacterial drugs, there was an increasingly complex bacterial world and an increasingly severe situation of severe infection. We have to face the question again: In the face of infection, are we concerned about the bacteria themselves or the response of the body caused by bacterial invasion? Where should bacteria themselves be in the treatment of severe infections? This is a problem that clinicians must seriously consider when treating severe infections.

Infection is an important factor affecting the clinical outcome and prognosis of ICU patients. How to control infection quickly and effectively and apply antibacterial drugs rationally are the problems that clinicians must face. ICU patients often have organ dysfunction, hemodynamic changes and abnormal metabolic environment, which will undoubtedly change the metabolism, concentration and distribution of drugs in the body, thus affecting the efficacy of antibacterial drugs. The increase of drug-resistant bacteria in recent years also puts forward higher requirements for the use of antimicrobial drugs. Therefore, how to optimize the anti-infection treatment according to the pharmacokinetics/pharmacodynamics (PK/PD) theory in clinical practice is very important for the infection control of ICU patients.

"Heavy hammer" is an antibacterial drug use strategy proposed for severe infection, which can effectively improve the success rate of severe infection treatment in clinical practice, and is a great progress in infection treatment strategy. However, the biggest problem that may be caused by clinicians' repeated emphasis on early anti-infective treatment with a "heavy hammer" strategy is the active use of broad-spectrum antibacterial drugs, and then overuse or even abuse, resulting in inappropriate treatment and an increasingly harsh drug resistance environment. In recent years, with the gradual deepening of the understanding of severe infections and the continuous emergence of new antibacterial drugs, clinicians have also gained a new understanding and grasp of the "heavy hammer" strategy.

Neck circumference as a measure of subcutaneous fat in the upper body may reflect a dysfunctional ectopic fat deposition. Foreign studies show that neck circumference is positively correlated with visceral fat content^[1]； In severely obese people, neck circumference is more valuable than waist circumference in judging intra-abdominal fat^[2]； Neck circumference is recommended as an effective screening indicator for overweight and obesity^[3]。 Domestic small sample study found that neck circumference of overweight/obese group was larger than that of normal group in both physical examination population and diabetic patients^[4]。 This study aims to compare the neck circumference with BMI, waist circumference and waist-hip ratio (WHR) in people aged 40 years and older in the community, analyze the correlation between neck circumference and obesity and its measurement indexes, and establish new observation indexes for the prediction of central obesity.

The patient was a 41-year-old female. He was admitted to hospital on 11 September 2013 due to "recurrent abdominal pain for 9 years, aggravated for 6 months". In 2004, the patient developed periumbilical dull pain without trigger, each attack lasted for about 1~2 h, accompanied by fever and fatigue, with the highest body temperature reaching 39.4℃, no nausea and vomiting, and abdominal pain and fever were relieved after anti-infective treatment. In 2007, appendicitis was considered and appendectomy was performed, with no significant improvement in postoperative symptoms. In March 2013, the degree and frequency of abdominal pain were worse than before, with paroxysmal colic around the umbilicus and right lower abdomen, alternating diarrhea and constipation, accompanied by intermittent fever, and the highest body temperature was the same as before. In August 2013, colonoscopy in the local hospital showed multiple colon ulcers, which were considered to be Crohn's disease, and were treated with oral mesalazine, but there was no obvious effect. During the course of the disease, oral ulcer, vulvar ulcer, conjunctival sandy sensation, no photophobia, tearing, blurred vision, no rash, alopecia, photosensitivity, joint swelling and pain appeared repeatedly. Past history: Hepatitis B and C were found for more than 10 years, and the history of blood transfusion was denied. Physical examination: conjunctiva of both eyelids was congested, the superficial lymph nodes of the whole body were not palpable and swollen, no rash, no obvious abnormalities in the heart and lungs, no intestinal type in the abdomen, normal intestinal sounds, soft to touch, no mass, tenderness and rebound pain were palpable. Admitted to our hospital for further diagnosis and treatment. Complete auxiliary examination after admission, blood routine: WBC 3.14×10⁹/L, Hb 97 g/L, PLT 274×10⁹/L; Urinary routine and fecal routine were normal. Blood biochemistry: ALT 10 U/L, AST 13 U/L, total protein 79 g/L, albumin 33 g/L, TBil 9.6 μ mol/L, DBil 3.4 μ mol/L. Hepatitis B five items: HBsAg (+), anti-HBs (–), HBeAg (–), anti-HBe (+), anti-HBc (+), HBV DNA quantification<10³copies/ml; Anti-HCV (+), HCV RNA quantification 3.35×10⁶copies/ml, HCV genotype 2; T-cell SPOT test for tuberculosis infection (T – SPOT.TB) (–), PPD (–). ESR 86 mm/1h, complement C3 0.818 g/L (reference value 0.900-1.800 g/L), complement C4 0.025 g/L (reference value 0.100-0.400 g/L), IgG 14.55 g/L (reference value 7.00-17.00 g/L), IgA 2.1 g/L (reference value 0.7-4.0 g/L), IgM 22.4 g/L (reference value 0.4-2.3 g/L), IgM κ (+), cryoglobulin (+), high-sensitivity C-reactive protein (hsCRP) 12.07 mg/L; Rheumatoid factor (RF) was 17 485 U/ml (reference value 0-20 U/ml), anti-nuclear antibody (ANA), anti-soluble antigen (ENA) antibody and anti-neutrophil cytoplasmic antibody (ANCA) were all negative, and serum anti-Saccharomyces cerevisiae antibody (ASCA) -IgA 42 RU/ml. Acupuncture test (–). Chest CT: Small nodules scattered in the left tongue lobe. Gastroscopy: chronic superficial gastritis. Colonoscopy: About 20 cm from the end of the ileum, no obvious abnormalities were found in the small intestinal mucosa, the ileocecal valve was deformed, and a round ulcer was seen beside it (Figure 1), about 2.0 cm in diameter, blind bag contracture deformation, ascending colon shortening, multiple ulcers in descending colon and sigmoid colon, about 0.5~1.0 cm in diameter. (Ileocecal) Pathology: Chronic inflammation of the colon mucosa with more eosinophil infiltration in the lamina propria, and small vasculitis in the local submucosa (Figure 2), no acid-fast bacilli were found by acid-fast staining. Ophthalmologic consultation considered the possibility of allergic conjunctivitis and lymphangiectasis.

March 2015Crit CareA prospective observational study "Assessment of Human-Machine Contribution Index during Neuromodulation-Assisted Ventilation in Patients with Respiratory Failure" (Liu L, Xia F, Qiu H. Assessment of patient-ventilator breath contribution during neurally adjusted ventilatory assist in patients with acute respiratory failure. Crit Care, 2015, 19:43.), demonstrated for the first time in patients with respiratory failure that during neuromodulation assisted ventilation (NAVA), the proportion of respiratory work performed by the patient to the whole respiratory work can be assessed by calculating the human-machine contribution index (PVBC), and the assistance level of mechanical ventilation can be quantitatively assessed accordingly, so as to prevent the risk of over-assisted ventilation.

In April 2015,Lancet Diabetes EndocrinolA clinical study headed by Professor Jia Weiping, Department of Endocrinology, Sixth People's Hospital, Shanghai Jiao Tong University, "Comparison of the efficacy and safety of two intensive insulin therapy regimens in Asian patients with type 2 diabetes mellitus" was published [Jia W, Xiao X, Ji Q, et al. Comparison of thrice-daily premixed insulin (insulin lispro premix) with basal-bolus (insulin glargine once-daily plus thrice-daily prandial insulin lispro) therapy in east Asian patients with type 2 diabetes insufficiently controlled with twice-daily premixed insulin: an open-label, randomized, controlled trial. Lancet Diabetes Endocrinol, 2015, 3 (4): 254 – 262].

Aspergillus is widespread in the natural environment and can cause opportunistic infections in immunodeficient populations, mainly in patients with neutropenia and treatment with high doses of immunosuppressants. Most of the disease begins with the inhalation of Aspergillus spores in the environment from open parts of the lungs, which in turn causes local or invasive infections. In recent years, with the increase of hematological tumors or transplantation patients, the incidence of invasive aspergillosis has increased greatly, and the mortality rate is high, which has become the most important cause of infection and death in patients with acute leukemia stem cell transplantation^[1]。 Early, rapid and accurate detection of Aspergillus is of great significance for the diagnosis and treatment of patients, reducing the clinical medical burden and reducing the mortality rate of disease.

Helicobacter pylori (Helicobacter pylori, Hp) is a helical flagellated gram-negative bacterium, developed in 1982 by Australian researchers Warren and Marshall^[1]Successfully isolated and cultured from humans for the first time. The global Hp infection rate is high, reaching about 50% in Western developed countries, and more than 80% in developing countries^[2]。 Most people become infected with Hp in childhood, and the infection can last a lifetime without treatment with antimicrobial drugs^[3]。

MicroRNAs (miRNAs) are highly conserved endogenous non-protein encoding RNAs discovered in recent years, approximately 22 nucleotides long. It is formed by single-stranded RNA precursors with hairpin structure of 70-90 bases after processing by Dicer enzyme, which promotes mRNA degradation or inhibits mRNA translation by pairing with 3'-UTR of target gene, thereby realizing post-transcriptional regulation of the expression level of target gene^[1]。 Since 1993 Lee et al.^[2]The first miRNA lin – 4 was found in nematodes, and it was confirmed in subsequent studies that miRNAs exist in almost all eukaryotes, and miRNAs have become a research hotspot in the field of life sciences. More and more studies have shown that miRNAs are widely involved in various physiological and pathological processes of organisms, such as ontogenesis, cell proliferation, apoptosis and differentiation, regulation of metabolic immunity and stress response, tumor formation, etc^[3]Moreover, most types of human cancers involve abnormal expression of miRNAs, indicating that it is closely related to the pathogenesis of tumors. Some specific expressed miRNAs can be used as biomarkers for early diagnosis of tumors. In addition, personalized therapy with miRNAs and their target genes as drug targets may have important value in future clinical treatment.

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idiopathic/isolated hypogonadotropic hypogonadism (IHH) is a gradually recognized endocrine disease. Because the pathogenesis, clinical manifestations and treatment methods are complex, many clinicians have many doubts about its correct diagnosis and treatment. In order to standardize and improve the diagnosis and treatment level of IHH, the Gonadology Group of Endocrinology Branch of Chinese Medical Association organized experts to conduct a special discussion and formulated this consensus for clinical reference.

A randomized controlled trial investigated the efficacy of an inhaled small-particle glucocorticoid (ciclesonide) in refractory eosinophil asthma, with the primary endpoint being sputum eosinophil count after 8 weeks. The data showed that additional inhalation of ciclesonide sustainably inhibited airway eosinophilia, but the difference in alveolar nitric oxide reduction values did not reach statistical significance (Thorax, 2015, 70:559 – 565).