2015年 · 第54卷第10期

In May 2015, the first case of imported Middle East respiratory syndrome (MERS) confirmed in China attracted great concern from people from all walks of life. Which is more contagious than MERS caused by this sudden appearance of novel coronavirus or SARS that raged that year? What exactly is pathogenicity? How can we prevent it? We will further interpret the treatment of MERS and the infectiousness of diseases that everyone is concerned about.

The Chinese Working Group on Invasive Fungal Infections first formulated the draft guidelines in 2005 and revised them three times^[1,2,3]。 The diagnostic criteria in the first three editions of the guidelines are based on the European Organization for Cancer Treatment and Research (EORTC) 2002 edition criteria^[4]For reference; With the EORTC 2008 version of the standard^[5]In 2013, the China Working Group on invasive fungal Infections revised the diagnostic guidelines for invasive fungal disease (IFD) in patients with hematological diseases^[6](hereinafter referred to as the 4th edition of the Guide), the more significant change is the addition of the "unidentified IFD" classification. This concept is innovative, but also challenging. The understanding of unidentified IFD and the implications of this new classification will now be explored.

Medical ethics education has always emphasized saving lives and healing the wounded, and the progress of modern medicine has improved the quality of life and continued to a considerable extent; However, many times, the life continued by drugs and machines has no meaning in life, especially for people with loss of consciousness, and the pain suffered by patients cannot be compensated in any meaningful way. Clinically, medical staff often face the problem of whether to start and maintain life support systems, and often need to guide and help patients and their families cope with the terminal conditions of the disease.

Lung biopsy histopathological examination is the gold standard for confirming invasive pulmonary fungal infection (IPFI)^[1,2]。 However, in clinical practice, bronchopulmonary biopsy methods such as bronchial mucosal biopsy, transbronchial transmural lung biopsy, percutaneous lung biopsy and open thoracic lung biopsy are all invasive examinations, and patients' compliance is poor, which is often intolerable by severe patients^[2,3,4]。 Respiratory cough histopathology as a noninvasive detection method for the diagnosis of pulmonary infections and neoplastic diseases^[5]。 However, so far, there are few reports of using respiratory cough histopathology to diagnose IPFI in China. This study retrospectively analyzed the clinical data of patients with IPFI diagnosed by respiratory cough histopathology, in order to improve clinicians' understanding of IPFI diagnosed by respiratory cough histopathology.

multiple primary cancer (MPC) refers to multiple primary tumors with different cell types in different organs or the same organ. It is reported in literature that the incidence of MPC is 0.73% ~11.7% in tumor patients^[1]。 According to the diagnosis time interval of two malignant tumors, they can be divided into synchronous or metachronous multiple primary cancer. The diagnosis interval of synchronous multiple primary cancer (SMPC) is within 6 months, and its incidence is low and less reported in literature. Among them, the incidence of hematological malignant tumors combined with solid tumors is lower, and only cases are reported at home and abroad^[2,3,4]In order to explore the clinical characteristics, diagnosis and treatment of this disease, 22 patients with simultaneous malignant hematological tumors combined with solid tumors treated in our hospital in the past two years were summarized and analyzed.

primary gastrointestinal lymphoma (PGIL) is a relatively rare extranodal lymphoid tissue lymphoma originating from the gastrointestinal tract^[1]Its etiology and pathogenesis remain unknown. Chromosome instability is one of the important characteristics of tumor cells. Studies have shown that dysfunction of spindle assembly checkpoint (SAC) is one of the main causes of chromosome instability. mitotic arrest deficiency protein 2 (Mad2), as the core component of SAC, has been found to be abnormally expressed in many kinds of tumor cells. It is believed that it is involved in tumor development and related to poor prognosis^[2,3]。 In order to explore the role of Mad2 in the pathogenesis of PGIL, this study examined the expression of Mad2 in PGIL tissues, and combined with Ki-67 expression, Helicobacter pylori (Hp) infection, BCL-6 gene translocation and clinical data to understand its role in the development of PGIL and its relationship with clinicopathological types and prognosis.

The patient was a 32-year-old male. In August 2013, "intermittent fever, accompanied by jaundice and fatigue without obvious trigger", with a maximum body temperature of 38.8℃, went to a local hospital. Blood routine: WBC (11.27~13.81) ×10⁹/L, neutrophils (2.66-3.16) ×10⁹/L, lymphocytes (7.22-9.65) ×10⁹/L, Hb 115-126 g/L, PLT (29-86) ×10⁹/L; fibrin 1.54 g/L; Ferritin 5 851 μ g/L; CT of thorax and abdomen showed inflammation of both lungs, which was considered as infectious fever, and viral infection was not excluded. Cephalosporin antibiotics combined with ganciclovir were given symptomatic treatment such as antiviral and liver protection, but the effect was poor, the body temperature was not controlled, the fever was gradually irregular, dry cough, a small amount of white sticky sputum, and fatigue and anorexia progressively worsened. In September 2013, we consulted in the pathology department of our hospital: (left neck) lymph node lymphoid tissue reactive hyperplasia, which may be related to viral infection. It is recommended to check EBER (small RNA encoded by Epstein-Barr virus). Subsequent reexamination of blood routine in other hospital: WBC 1.38×10⁹/L, neutrophils 0.44×10⁹/L, Hb 106 g/L, PLT 130×10⁹/L; Epstein-Barr virus (EBV) -DNA 4 000 copies/ml; Blood biochemistry: ALT 575 U/L, AST 304 U/L, alkaline phosphatase 977 U/L, gamma-glutamyl transpeptidase (gamma-GT) 1 771 U/L, TBil 75.4 μ mol/L. Considering EBV infection, he was given symptomatic treatment such as antipyretic and liver protection for about 2 weeks without taking antiviral drugs. During the treatment, his body temperature completely dropped to normal, and his fatigue and anorexia were significantly improved compared with before, so he was discharged from hospital. Three days after discharge, he had fever again, up to 39℃, without fear of cold, chills and other symptoms. He was admitted to the local hospital with EBV infection, and was treated with antiviral, hepatoprotective, levofloxacin for 7 days, and hydroprednisone for 3 days. Body temperature control was not good.

fever is a common clinical symptom and a common manifestation of many diseases. Besides common infections, connective tissue diseases, tumors and other diseases, rare diseases and rare diseases need to be considered, including familial mediterranean fever (FMF). This disease is rare in China, and it is easy to be misdiagnosed or missed. A case of confirmed FMF diagnosed and treated in our department is reported, and the review literature is analyzed as follows.

A 26-year-old male patient. He was admitted to the hospital on September 12, 2014 for the main cause of "headache for 2 weeks and limb weakness for 1 week". The patient experienced persistent distension and pain in the occipital region 2 weeks ago, and felt weakness in the limbs 1 week ago, carrying heavy objects and walking with difficulty. CT examination of the head showed high-density shadows of the superior sagittal sinus and right transverse sinus (Figure 1), cranial MRI showed multiple abnormal cortical signals, and cranial magnetic resonance venography (MRV) showed poor imaging of the superior sagittal sinus, right transverse sinus, and sigmoid sinus (Figure 2)。 He had a history of nephrotic syndrome (NS) for 2 years, and the pathological diagnosis was "minimal pathological nephropathy". He reappeared hematuria and proteinuria 1 month ago. After treatment (details unknown), he reviewed the normal range of urine routine. He is currently taking prednisolone acetate 25 mg once/d. He was admitted to the hospital with "intracranial venous sinus thrombosis, venous cerebral infarction and nephrotic syndrome". Physical examination on admission: clear and sharp, mild edema of binoptical papilla; Left upper limb muscle strength 5^–Grade, remaining limb muscle strength grade 5, pathological sign (–); Cervical resistance (+), geniothoracic trihorizontal finger, Bruzinski sign, Knigg sign (–); No abnormalities were observed. Auxiliary examination: blood biochemistry: total protein 41.1 g/L, albumin 27.0 g/L, cholesterol 5.5 mmol/L, low density lipoprotein 3.28 mmol/L; 24 h urine protein quantification 0.05 g; Coagulation function: fibrinogen 6.30 g/L, D-dimer 2.02 mg/L, antithrombin III 107.0%; Blood homocysteine 30.7 μ mol/L; Anticardiolipin antibody IgA/G/M<10 Ru/ml, anti-β₂-Glycoprotein I antibody IgA/G/M 40.0 Ru/ml. Lumbar puncture: pressure 290 mmH₂O (1 mmH₂O =0.009 8 kPa), the cerebrospinal fluid was colorless and transparent, routine and biochemically normal. Ultrasound of the jugular vein: Thrombosis distal to J3 of the right internal jugular vein (partial type). Blood, urine, fecal routine, thyroid function, tumor markers, antinuclear antibody profile, anti-neutrophil cytoplasmic antibody, protein C, protein S, glycated hemoglobin normal. After admission, batroxobin 10 U was given temporary intravenous drip to reduce fibrinogen (fiber reduction), low molecular weight heparin sodium 0.8 ml once/12 h subcutaneous injection, sequential oral anticoagulation of warfarin, maintaining INR at 2~3, intravenous drip of mannitol and glycerofructose to reduce intracranial pressure and reduce cell edema, fluid rehydration to maintain blood volume, folic acid and vitamin B at the same time₆Vitamin B₁₂Correct hyperhomocysteinemia and continue oral administration of glucocorticoids. After treatment, the patient's symptoms improved, and there was no abnormality in physical examination. Re-examination of jugular vein ultrasound showed that the abnormal signal of right jugular vein disappeared, and MRV of the head showed intracranial venous sinus thrombosis (Figure 3), after 12 d of treatment, the cerebrospinal fluid pressure of lumbar puncture was 195 mmH₂O, cerebrospinal fluid routine, biochemistry normal.

The patient was a 26-year-old female. Due to fatigue and muscle weakness of both lower limbs, I went to the local hospital for 1 month. No other manifestations such as diarrhea. Past physical fitness. Physical examination: blood pressure 100/70 mmHg (1 mmHg =0.133 kPa); Serum potassium was 2.8 mmol/L (reference value: 3.5-4.5 mmol/L), and carbon dioxide binding capacity was 36 mmol/L (reference value: 22-28 mmol/L). After intravenous and oral potassium supplementation, the serum potassium was 3.8 mmol/L, and the fatigue symptoms were relieved. Two months later, he went to the doctor again due to weakness of both lower limbs, with blood pressure 105/70 mmHg, and muscle strength of both lower limbs decreased, grade III ~ IV; Serum potassium was 3.0 mmol/L, sodium was 132 mmol/L (reference value: 135-145 mmol/L), chlorine was 91.7 mmol/L (reference value: 96-108 mmol/L), and carbon dioxide binding capacity was 36.4 mmol/L. Blood gas analysis: pH 7.46, PaCO₂38 mmHg, PaO₂98 mmHg, base remaining (BE) 8 mmol/L. Serum creatinine was 58.3 μ mol/L (reference: 44-133 μ mol/L). Urinary protein was 0.19 g/2 000 ml per day, and urinary sediment microscopy was negative; urine alpha₁-Microglobulin 170 mg/L (reference: 0-12.5 mg/L), urinary microalbumin 10.7 mg/L (reference: 0-19 mg/L). Urinary pH 8.0-8.5; 24 h urine potassium 33.4 mmol. Liver function, myocardial enzyme spectrum and albumin were normal; Full set of anti-nuclear antibody and anti-soluble antigen antibody (ANA + ENA) was negative; Immunoglobulin, cortisol, renin-aldosterone and thyroid function were normal. Follow-up medical history found that the patient had been drinking Coke for a long time for 1 year, 2 L per day. Hypokalemia caused by other common causes was excluded. Considering hypokalemia and metabolic alkalosis caused by heavy drinking of Coke, the patient was instructed to stop drinking Coke. After 1 month, the patient stopped taking potassium supplementation drugs, and the blood potassium was 4.0 mmol/L. Urinary protein was rechecked daily after 3 months 0.08 g/2 000 ml, α₁-Microglobulin 11.0 mg/L, all returned to normal.

March 2015PLoS OneA study led by Professor Li Taisheng from the Department of Infectious Medicine, Peking Union Medical College Hospital and involving seven domestic research centers "Efficacy of a second-line regimen of lopinavir enhanced by tenofovir, lamivudine and ritonavir in treated HIV-infected patients" was published online [Han Y, Li Y, Xie J, et al. Week 120 efficacy of tenofovir, lamivudine and lopinavir/R-based second-line antiretroviral therapy in treatment-experienced HIV patients. PLoS One, 2015, 10 (3): e0120705.]. This study is a prospective study and is the first to report the efficacy of a second-line treatment regimen in treated HIV-infected patients in China. The research was funded by the 12th Five-Year Plan Science and Technology Fund [2012ZX10001003 – 001].

March 2015Crit CarePublished a prospective open-label clinical study conducted by the research group of Professor Qiu Haibo, Department of Critical Care Medicine, Zhongda Hospital affiliated to Southeast University: "Setting a higher blood pressure target to improve sublingual microcirculation in patients with septic shock combined with hypertension" (Xu J, Yang Y, Qiu H. A high mean arterial pressure target is associated with improved microcirculation in septic shock patients with prior hypertension: a prospective open label study. Crit Care 2015, 19:130), this study is a prospective, single-center, interventional study that provides some theoretical basis for the development of post-resuscitation blood pressure targets in patients with septic shock with previous hypertension.

"Fever is a group of difficult diseases, which is a great challenge for physicians all the time", "It is very important for physicians to find the cause of fever in time and give it the correct treatment, but it is also very difficult"^[1]。 Patients with acute fever usually choose to see a doctor in the internal medicine department of primary hospitals first. Because there are various causes of acute fever, including dozens of infectious causes alone, the treatment of different causes is very different. Therefore, the correct preliminary differential diagnosis is very important for the correct treatment of patients and to reduce misdiagnosis, misdiagnosis and mistreatment. In clinical practice, we found that among the patients who come to the clinic due to acute fever, many patients have been transferred to many hospitals and undergone several empirical drug treatments. However, due to the lack of etiological evidence, they often fail to confirm the diagnosis for a while, worrying about anxiety caused by malignant tumors, which seriously affects their physical and mental health. In daily clinical practice, we found that the above problems are particularly prominent in the diagnosis and treatment of patients with acute fever accompanied by "infectious mononucleosis". Now, we would like to share our experience with you on several common problems.

Community-acquired pneumonia (CAP) refers to infectious inflammation of the pulmonary parenchyma (including the alveolar wall, i.e., the pulmonary interstitium in a broad sense) suffered outside the hospital, including infection with pathogens with clear incubation period, and pneumonia that develops within the incubation period after admission. CAP is a serious infectious disease, accounting for 1% of all hospitalizations. Incidence has increased significantly in recent years, with CAP increasing by 34% between 1997 and 2005 in the UK^[1]。 Atypical pathogens such as Mycoplasma pneumoniae, Legionella and Chlamydia pneumoniae are common pathogens causing CAP, which is an important problem in clinical work. The current status of atypical pathogens CAP is summarized as follows.

Coronary atherosclerotic heart disease (CAD) is currently one of the main causes of death and disability in humans. Statins have significant efficacy in the prevention and treatment of cardiovascular diseases. However, even if the maximum recommended dose of statins is given, 60% ~70% of patients with cardiovascular diseases still have less LDL-C than ideal level^[1]As well as concerns that high-dose statins can cause new onset diabetes and increase the risk of myopathy, people are constantly seeking new drugs to treat atherosclerosis. The human proprotein convertase subtilisin/kexin type 9 (PCSK9) was discovered in 2003. In the same year, French scholar Abifadel et al^[2]In patients with familial autosomal dominant hypercholesterolemia (ADH), it was found that the cause of hypercholesterolemia was not a mutation in the low-density lipoprotein receptor (LDLR) gene or apolipoprotein B (apoB) gene, but a mutation in the PCSK9 gain-of-function gene. With the deepening of research, people have found that PCSK9 plays an important regulatory role in stabilizing blood lipids. PCSK9 is closely related to the occurrence and development of atherosclerosis by increasing the degradation of LDLR and then increasing the level of LDL-C. Therefore, inhibiting the activity of PCSK9 may become a therapeutic target for the development of new drugs to reduce LDL-C. The following is a review of the mechanism of action of PCSK9, the effect of gene mutation, the relationship with atherosclerosis and the progress of clinical trials related to PCSK9 inhibitors.

Hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) are the two main types of thrombotic microvascular disease. The characteristic pathological changes are the appearance of micro-thrombosis in small blood vessels^[1]However, the pathogenesis of the two is not the same.

cardiac troponin (cTn) is a highly specific and sensitive marker detectable in blood when myocardial tissue is injured^[1]It is a good marker for the diagnosis of acute myocardial infarction (AMI) and risk stratification of heart disease^[2,3,4]。 high-sensitive cardiac troponin (hs-cTn) refers to the determination of cTn by high-sensitivity method, and its detection method has been widely used in clinical practice.

endoscopic submucosal dissection (ESD) has been widely used in China and has become the standard method for endoscopic minimally invasive treatment of gastric mucosal lesions such as early gastric cancer. However, there is no uniform standard for its perioperative medication, and there are many potential risks. In May 2015, the Digestive Endoscopy Branch of Chinese Medical Association organized an expert seminar on perioperative medication of ESD for gastric mucosal lesions in Suzhou. After full discussion by the participating experts, the expert suggestions on perioperative medication of ESD for gastric mucosal lesions in China were formed. Physicians are invited to learn from clinical practice and summarize their experience for further improvement.

The patient was a 36-year-old male. He was admitted to hospital on June 11, 2014 due to "dry mouth, blurred vision, headache for 2 weeks, aggravated for 3 days". At the end of May 2014, the patient developed dry mouth, polydipsia, and polyuria without trigger. The daily water consumption was about 4,000 ml, and nocturia was 7 to 8 times, accompanied by blurred vision, headache, nausea, and vomiting (for stomach content, the amount was about 100 ml). It was relieved after rest and was not diagnosed or treated. On June 8th, after exertion, the above symptoms reappeared and aggravated. I went to a hospital in Changping District, Beijing. My blood pressure was checked: 260/190 mmHg (1 mmHg =0.133 kPa), and my fundus examination: "binocular papilla edema", so I was admitted to the emergency department. After admission, random blood glucose: 24.9 mmol/L, serum potassium 2.7 mmol/L, urinary ketone body (–), urinary glucose (4+), urinary protein (3+), ECG showed sinus tachycardia, V₁~ V₃Lead ST elevation; CT of the brain showed that the left choroidal cyst may be widened, and the occipital cistern was widened. The blood pressure was reduced to 180~200/100~130 mmHg, and the blood sugar fluctuation was 9.2~24.8 mmol/L throughout the day. The discharge diagnosis was hypertension and hypokalemia to be investigated. After discharge, he was given oral amlodipine besylate 5 mg/d and spironolactone 20 mg/d for antihypertensive treatment. On June 10, he was admitted to the Department of Endocrinology, the First Affiliated Hospital of Xi' an Jiaotong University, and was admitted to the hospital with "diabetes, malignant hypertension and hypokalemia reasons to be investigated". Previous history of hypertension and diabetes denied. Twenty years ago, the right eye was found to be exotropic during physical examination, and it was diagnosed as "macular degeneration" without treatment. Smoking for 10 years, 20 cigarettes/d. Parents are in good health, grandmother and two aunts suffer from hypertension, and they deny family history of diabetes.

A few days ago, a randomized, multi-center, clinical trial investigated the components of blood products during blood transfusion in patients with severe trauma. The data showed that the difference between all-cause mortality at 24 h and 30 d was not statistically significant compared with the 1:1:1 ratio of plasma, platelets and red blood cells to the 1:1:2 ratio at the time of blood transfusion, but more patients in the 1:1:1 group stopped bleeding within 24 h, and fewer patients died due to bleeding (JAMA, 2015, 313: 471 – 482).

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