2017年 · 第56卷第07期

Severe bronchial asthma (hereinafter referred to as asthma) accounts for about 5% ~10% of asthma patients. Although the proportion is not high, its emergency medical treatment rate and hospitalization rate are 15 times and 20 times that of mild and moderate asthma patients, respectively. Severe asthma patients have a higher risk of disease deterioration, increased hospitalization rate and mortality rate, increased medical expenses, and seriously impaired quality of life. In recent years, through the promotion of standardized diagnosis and treatment of asthma, the overall level of asthma control has been improved to a certain extent, but there are still a few patients who can't achieve good control even after using high-dose control drugs (including combination therapy) or even oral glucocorticoid therapy. This part of patients is called "severe asthma". Improving the diagnosis and treatment level of severe asthma is of great significance to improve the overall control level and prognosis of asthma. Invite Professor Lin Jiangtao to write a monograph "Emphasis on the study of disease burden and clinical phenotype of severe bronchial asthma".

Current research shows that although most patients with bronchial asthma (hereinafter referred to as asthma) can achieve good control after existing drug treatment, about 5% ~10% of patients still have difficulty in treatment. Even if high-dose inhaled glucocorticoids (hereinafter referred to as hormones) and multiple drugs are used in combination therapy, even after systemic hormone therapy, they still show "uncontrolled" asthma, that is, "severe asthma"^[1]。

The role of right ventricular function evaluation in hemodynamic therapy has been gradually recognized and accepted, which increasingly reflects its importance in the clinical work of critical disease^[1,2]。 Although different types of shock have different pathogenesis, the evaluation and management of right ventricular function are inseparable in the treatment of each type of shock. Such as common typical obstructive shock, whether pulmonary embolism or pericardial tamponade, right heart assessment is the key; For cardiogenic shock, although left ventricular pump dysfunction is the most common, due to the mechanism of ventricular interaction, the left and right hearts interact with each other, which is inseparable from the judgment of right ventricular function; Septic shock is the most common cause of distributed shock, which not only leads to left ventricular dysfunction, but also leads to right ventricular damage. Even in seemingly relatively simple hypovolemic shock, during volume management, attention needs to be paid to the damage to the right heart caused by fluid overload. In the evaluation of right ventricular function, the shape of ventricular septum and the presence or absence of contradictory movement are very important evaluation indexes^[3,4]。

January 2017Crit CarePublished a multicenter, prospective clinical study completed by the China Critical Care Clinical Research Collaborative Group: "Can ICU physicians improve the accuracy and consistency of applying the Berlin definition in the imaging diagnosis of acute respiratory distress syndrome (ARDS) through training" [Peng JM, Qian CY, Yu XY, et al. Does training improve diagnostic accuracy and inter-rater agreement in applying the Berlin radiographic definition of acute respiratory distress syndrome? A multicenter prospective study. Crit Care, 2017, 21 (1): 12]. The study was led by Professor Du Bin, ICU, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences. For the first time, the ARDS chest X-ray example provided by the Berlin Joint Committee on the Definition of ARDS was used to evaluate the accuracy and consistency of ICU doctors' judgment on ARDS chest X-ray. At the same time, it was studied whether the training could help improve the diagnostic level of ARDS chest X-ray of ICU doctors.

Clinical work often encounters some cases of diabetes, which seem common, but in fact it is not the case. Therefore, in clinical work, we should pay attention to some special clues of the disease, trace the root cause, so as to correct the diagnosis and change the treatment plan in time. In the following two special cases, clinicians found clues from unusual clinical manifestations, actively pursued them, and persevered to find answers.

smoldering multiple myeloma (SMM) is a highly heterogeneous asymptomatic clonal plasma cell disease between monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM), including both MGUS with very low risk of progression to MM or amyloidosis and asymptomatic MM with the biological nature of malignant tumors. There is currently no reliable biomarker to accurately distinguish the subtypes with different prognosis and biological nature in SMM. In recent years, great progress has been made in the diagnosis, prognosis and treatment of SMM: light chain SMM was proposed, and the prognostic factors of SMM were screened by sensitivity detection, and the prognostic models based on biochemistry, imaging (MRI or PET-CT), cytogenetics and molecular biology were established. Particularly important, randomized controlled studies have demonstrated for the first time that early intervention can prolong the disease progression time, reduce organ damage, and improve overall survival of high-risk SMM. The hot issues and future development direction of SMM research are briefly expounded.

Intestinal microorganisms include bacteria, fungi, viruses, etc. that live in human intestines. 99% of the bacteria are anaerobic bacteria, and their number is huge, far exceeding the total number of human cells^[1]。 Intestinal microorganisms play an important role in regulating human immunity and metabolism. It was previously believed that intestinal microorganisms have little effect on the brain due to the presence of the blood-brain barrier and the intestinal barrier. In recent years, more and more studies have shown that intestinal microorganisms can act on the central nervous system (CNS) through various ways, which not only affect the normal development of the nervous system, but also participate in the pathogenesis of many neuropsychiatric diseases, such as anxiety, depression, autism, schizophrenia, etc. By giving patients micro-ecological preparations such as probiotics, the clinical symptoms of patients can be improved^[2,3]； More important developments suggest that intestinal microbes may have an important relationship with neurodegenerative diseases, mainly Alzheimer's disease (AD) and Parkinson's disease (PD). This review addresses the interaction between intestinal microorganisms and the human central nervous system, their changes in old age, and the role of intestinal microorganisms in neurodegenerative diseases and related therapeutic advances.

adrenal incidentaloma (AI) refers to the tumor of the adrenal gland and the area where the adrenal gland is located accidentally found during routine physical examination by imaging methods to detect some symptoms unrelated to adrenal disease, except for the adrenal gland occupied by imaging examination during cancer staging and diagnostic examination^[1,2]。 Epidemiological data suggest that the number of patients with the disease is not small^[3,4,5]。 We summarized the case data of all AI patients who attended our department from July 1993 to July 2013, and the results showed that the number of patients attended to our department was on the rise^[6]。 Clinical studies suggest that some AI patients have abnormal hypersecretion of adrenal glands, but the clinical manifestations are not typical, and they are in subclinical state. Among them, subclinical Cushing syndrome (SCS) accounts for a large proportion^[7]。

The application of combined highly active antiretroviral therapy (HAART) can effectively inhibit HIV RNA virus in the peripheral blood of HIV-infected people to a low or even undetectable level, but patients need to take medication for life, and once the medication is stopped, the virus will immediately rebound. The reason is that HIV RNA is integrated into the genome of infected cells in the form of reverse transcription DNA to complete subsequent life cycle activities. After antiviral treatment, most of the infected cells die and are eliminated by the body, and only a small number of infected cells survive and remain in a resting state, becoming a latent HIV repository, also known as HIV DNA repository^[1]。 After drug withdrawal, HIV DNA with an intact viral genome can start transcription and translation again, causing the virus to rebound. In 1995, the Siliciano laboratory first reported resting CDs infected with HIV₄^＋T lymphocytes contain viral DNA that can be completely replicated and integrated into the human genome^[2]。

The fifth national consensus conference on the management of Helicobacter pylori (H.pylori) infection organized by Chinese Medical Association, Chinese Society of Gastroenterology, H. pylori and Peptic Ulcer Study Group was held at Hangzhou, Zhejiang Province on December 15-16, 2016.More than 80 members of the study group and experts in the field of H. pylori research and gastroenterology attended the meeting.Consensus preparatory group was established to draft the related statements.The quality of evidence and strength of recommendation were evaluated by GRADE system.The Delphi method using an anonymous electronic system was adopted to develop the consensus of relevant statements.Expert advices about the established statements were firstly consulted through the emails.After two rounds of consultation, the preliminary statements of consensus were discussed and modified in the conference item by item.A total of 21 core members voted for the final version, which contained a total of 48 statements and was divided into 6 parts, including indications for H. pylori eradication, diagnosis, treatment, H. pylori and gastric cancer, H. pylori infection in special populations, H. pylori and gastrointestinal microbiota.

Important/potential value of macrolides has been proved in the management of chronic respiratory diseases by increasing basic and clinical trials.Through three face-to-face discussions, 10 experts examined important data and drafted this consensus related to macrolides: (1) mechanism of non-antiinfective effects; (2) clinical use in chronic respiratory diseases; (3) cautions of long-term use.The mechanism out of non-antiinfective effects includes anti-inflammatory effect, modifying airway secretion, immune-regulation related to antibacterial effect, corticoid saving effect and anti-viral effect.The efficacy of long-term use of low-dose macrolides is definitely confirmed in diffuse panbronchiolitis, chronic rhinosinusitis. It is considerably used in bronchiectasia, cystic fibrosis, severe asthma and chronic obstructive pulmonary disease. Further studies should be conducted in cryptogenic organizing pneumonia and respiratory viral infection. It should be paid attention to its possible adverse effects (including drug interactions, cardiac toxicity, ototoxicity and disturbance of intestinal flora) and drug resistance in long-term use.A Chinese consensus for non-antiinfective effects and clinical use of macrolides is developed for the first time, which aims to expand their rational use and the further research.

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