2018年 · 第57卷第06期

The lung is the respiratory organ of the human body, and its main function is to exchange gas with the outside world. The lungs are also a special blood-circulating organ, the only organ in the body that receives 100% cardiac output. Here, gas has life value because it meets blood, and blood completes the function of the lungs because it meets qi. In terms of the process of blood flow, the lungs are actually located between the right heart and the left heart, but at the same time, the hearts on both sides are directly connected to form an organ together. This special relationship of me in you and you in me leads to functional interdependence and mutual influence between the heart and lungs, between the heart chambers, and between the lungs and different heart chambers. Professor Liu Dawei was invited to write a monograph "Pulmonary Blood Flow: Qi Comes and Blood Comes and Qi Goes and Blood Goes", explaining the relationship and influence between them in detail, and pointing out the direction for ensuring clinical efficacy and safety.

The lung, as one of the basic organs for the existence of life, is the first thing that comes to mind as an organ of ventilation. The lungs have a huge external surface area that can be in contact with the air, but at the same time, the lungs are a special blood-circulating organ, the only organ in the body that receives 100% of cardiac output. Here, gas has the value of life because it meets blood, and blood has the full function of lungs because it meets qi.

The 2014 "Kyoto Global Consensus Report on Helicobacter Pylori Gastritis" proposed that all Helicobacter pylori (Helicobacter pylori, Hp) positive patients should receive eradication therapy unless restrictive factors are considered^[1]。 Japanese scholars expect to significantly reduce the incidence of gastric cancer by 2030, and even propose that with the eradication of Hp, Japan will eliminate gastric cancer. China is also a major country with gastric cancer. Do all infected people need to take antibacterial drugs to eradicate Hp? Other knowledge about Hp in academic circles will be introduced again.

There are 2 articles involving Helicobacter pylori in the "Focus Forum" column of the 5th issue of Chinese Journal of Internal Medicine in 2017 (Helicobacter pylori, Hp) Articles of dispute^[1,2]。 As Editor-in-Chief Jia Weiping said when opening this column, facts are the foundation, and thinking comes up with good strategies^[3]。 Academic controversy helps to improve readers' judgment skills, and we take a positive attitude of participation.

Critical ultrasonography(CUS) is different from the traditional diagnostic ultrasound, the examiner and interpreter of the image are critical care medicine physicians. The core content of CUS is to evaluate the pathophysiological changes of organs and systems and etiology changes. With the idea of critical care medicine as the soul, it can integrate the above information and clinical information, bedside real-time diagnosis and titration treatment, and evaluate the therapeutic effect so as to improve the outcome. CUS is a traditional technique which is applied as a new application method. The consensus of experts on critical ultrasonography in China released in 2016 put forward consensus suggestions on the concept, implementation and application of CUS. It should be further emphasized that the accurate and objective assessment and implementation of CUS requires the standardization of ultrasound image acquisition and the need to establish a CUS procedure. At the same time, the standardized training for CUS accepted by critical care medicine physicians requires the application of technical specifications, and the establishment of technical specifications is the basis for the quality control and continuous improvement of CUS. Chinese Critical Ultrasound Study Group and Critical Hemodynamic Therapy Collabration Group, based on the rich experience of clinical practice in critical care and research, combined with the essence of CUS, to learn the traditional ultrasonic essence, established the clinical application technical specifications of CUS, including in five parts: basic view and relevant indicators to obtain in CUS; basic norms for viscera organ assessment and special assessment; standardized processes and systematic inspection programs; examples of CUS applications; CUS training and the application of qualification certification. The establishment of applied technology standard is helpful for standardized training and clinical correct implementation. It is helpful for clinical evaluation and correct guidance treatment, and is also helpful for quality control and continuous improvement of CUS application.

The parathalamic median is supplied by the perforating thalamic artery (also known as the paracentral artery), 1976 Percheron^[1]The anatomical variation of perforating thalamic arteries is reported. Type IIB is that the common trunk of perforating arteries originates from the P1 segment of one posterior cerebellar artery (PCA), and then sends branches to supply bilateral parathalamic middle, which is called Percheron artery. Occlusion of this artery can lead to simultaneous infarction of bilateral parathalamic middle, and some may be accompanied by midbrain involvement, which is called Percheron artery infarction, which is rare in clinical practice. Two cases of Percheron arterial infarction diagnosed and treated in our hospital are reported. One case of bilateral thalamic lesions is extremely symmetrical, and it is easy to be misdiagnosed in clinic.

The patient was a 58-year-old female. He was admitted to hospital in December 2015 due to "diarrhea for 2 months, fever and headache for 4 days". The patient developed diarrhea 2 months ago, which was yellow watery stool, 3 to 5 times a day. Three weeks ago, colonoscopy in a local hospital showed colon ulcer. The pathology was chronic inflammation of mucosa, and the diagnosis was inflammatory bowel disease. After being treated with mesalazine for anti-inflammatory and anti-infective treatment, the diarrhea improved slightly. Four days ago, the patient had a sudden fever with headache, and the laboratory test of the local hospital: white blood cells 11.1×10⁹/L, neutrophil ratio 0.725, C-reactive protein (CRP) 101.1 mg/L, erythrocyte sedimentation rate (ESR) 116 mm/1 h, the patient visited our hospital for further diagnosis and treatment. Admission physical examination: body temperature 38 ℃, pulse 107 beats/min, breathing 20 beats/min, blood pressure 103/68 mmHg (1 mmHg =0.133 kPa); No abnormalities were found in the lungs, the heart rate was 107 beats/min, the rhythm was uniform, and there was no obvious murmur; The abdomen is flat and soft, without tenderness and rebound pain; Some old rash can be seen in both lower limbs; No redness, swelling and pus were seen around the anus; The meningeal irritation sign was negative, and the pathological sign was not drawn out. Perfect relevant examinations in hospital admission: white blood cells 10.9×10⁹/L, neutrophil ratio 0.786, CRP 156.6 mg/L, ESR 115 mm/1 h; procalcitonin (PCT) 0.3 µg/L, albumin 36.1 g/L; Fecal culture, blood culture, Faida test, peripheral blood tuberculosis infection T cell spot test, tuberculin test, cytomegalovirus and Epstein-Barr virus IgM antibody, and fecal Clostridium difficile test were all negative; Tumor markers, autoantibody profiles, vasculitis antibodies, immunoglobulin quantification, complement C₃and C₄No obvious abnormalities; CT and MRI of the head, chest CT and color echocardiography showed no obvious abnormalities, and enhanced CT of the whole abdomen showed slight thickening and enhancement of the colon wall; Colonoscopy showed multiple ulcers of the whole colon, mainly longitudinal ulcers, with jumping distribution. Biopsy pathology showed chronic active inflammation of the large intestinal mucosa, occasionally crypt abscess, with non-caseous granuloma formation, acid-fast staining and polymerase chain reaction (PCR) negative for tuberculosis.

Case 1 was a 23-year-old female of social sex. Admitted with "23 years of discovery of vulvar abnormalities". When the patient was born, his family found that his vulva was of female type, and he was raised by a female. At the age of 7, his clitoris gradually enlarged, and an abnormal mass could be palpable at the labia majora, with occasional pain and discomfort. He considered himself a male and did not pay attention to it. At the age of 16, she developed breast glands. She went to a hospital for "primary amenorrhea". The karyotype was 46XY, and the abdominal color ultrasound showed no uterine and adnexal structures, so she was not treated. For further diagnosis and treatment, the outpatient department was admitted to the plastic surgery department with "sexual dysplasia". Past history and personal history are not special. The mother had no history of threatened abortion and medication during pregnancy. The parents are not close relatives, the first brother is in good health, married and has children, and denies that there are similar diseases in the family. Physical examination: blood pressure 120/90 mmHg (1 mmHg =0.133 kPa), height 178 cm, medium body shape, female posture, sparse body hair, no beard, Adam's apple development, breast development like female of the same age, clitoris hypertrophy in the shape of a small penis, labia majora and labia minora and vestibular union can be seen, urethral opening at the dorsal root of the small penis, and external vaginal opening can not be visualized (Figure 1), round and tough masses can be palpable in the bilateral inguinal area, with acceptable mobility and no tenderness. Auxiliary examination: gonadal hormone levels seeTable 1。 Blood electrolytes, adrenocorticotropic hormone (ACTH), cortisol rhythm, thyroid function [free triiodothyronine (FT₃), free thyroxine (FT₄), thyroid stimulating hormone (TSH)] was normal, and the sex-determining region on the Y chromosome (SRY) gene was positive. Ultrasound examination: uterus and bilateral ovaries were not detected, and bilateral inguinal cryptorchidism. Pituitary magnetic resonance imaging (MRI) pituitary abnormal signal shadow, Rathke cyst may. X-ray examination: Chest radiograph showed no abnormalities in heart and lung, and bone mineral density was normal. Genetic testing revealed a hemizygous insertion mutation of c.239dupGCAGCA on exon 1 of its AR gene, resulting in an integer codon mutation (Figure 2）。

February 2018Semin Arthritis RheumPublished a study jointly conducted by the Department of Rheumatology and the Department of Nuclear Medicine of the PLA General Hospital "¹⁸F-FDG PET/CT can be used to differentiate idiopathic retroperitoneal fibrosis from malignant tumors surrounding the abdominal aorta "[Wang Y, Guan Z, Gao D, et al. The value of¹⁸F-FDG PET/CT in the distinction between retroperitoneal fibrosis and its malignant mimics. Semin Arthritis Rheum, 2018, 47 (4): 593-600], comparing idiopathic retroperitoneal fibrosis with malignancies surrounding the abdominal aorta¹⁸Imaging morphology and clinical characteristics of F-deoxyglucose (FDG) -positron emission computed tomography (PET) /CT provide reference for clinical diagnosis.

Infection causes dysregulation of host response and leads to organ dysfunction called sepsis, which can progress to septic shock, and the mortality rate can be as high as 50%. Early diagnosis and anti-infective treatment can improve the prognosis. Many studies have confirmed that procalcitonin (PCT) has higher sensitivity and specificity for the diagnosis of bacterial infection than C-reactive protein (CRP), leukocytes, interleukin-6, and lactic acid, and is one of the reliable indicators for the diagnosis of sepsis, and the elevated degree of PCT is related to the severity of infection and prognosis, while the decreased degree of PCT can also evaluate the anti-infective effect and be used as a reference for stopping antibiotics. Combined with cases, the advantages and limitations of PCT in anti-infective drugs for sepsis were discussed.

Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by respiratory distress and refractory hypoxemia due to diffuse injury of pulmonary microvascular endothelium and alveolar epithelium caused by various causes inside and outside the lung, resulting in pathophysiological changes such as alveolar and pulmonary interstitial edema, decreased pulmonary compliance, imbalance of pulmonary ventilation/blood flow ratio, and decreased pulmonary volume^[1,2]。 ARDS is the most common cause of dyspnea in critically ill patients and the main factor leading to poor prognosis in critically ill patients. At present, the treatment of ARDS mainly focuses on organ function support, and mechanical ventilation is its main treatment. Despite the continuous optimization of mechanical ventilation strategy, the mortality rate of ARDS is still as high as 30% ~40%^[3]。 In recent years, it has been found that hepatocyte growth factor (HGF) can promote the repair of lung tissue and reduce the inflammatory response of lung after ARDS injury^[4]。 Therefore, exploring the application of HGF in the treatment of ARDS can provide new ideas and methods for clinical treatment of ARDS.

As the most commonly used anticoagulant drug, warfarin has been used clinically for more than 40 years. It is a vitamin K antagonist (VKAs), which exerts anticoagulant effect by inhibiting the mutual conversion of vitamin K and its 2,3-epoxide^[1]。 The annual incidence of bleeding events caused by warfarin anticoagulation was 1.1% ~1.5%, of which gastrointestinal bleeding (GIB) accounted for 30% ~60%^[2]。 Nearly 1/3 of bleeding events occurred within the first month of anticoagulation therapy, and 61.1% of bleeding events occurred within the first year after anticoagulation therapy^[3]。 In recent years, the European and American Society of Digestive Endoscopy has put forward guidelines for perioperative use of endoscopic examination and treatment in patients treated with warfarin anticoagulation^[4,5]The treatment of such patients requires multidisciplinary collaboration. A questionnaire survey on the treatment of GIB caused by VKAS-related coagulation disorders found that physicians did not follow the relevant guidelines well in clinical practice, resulting in large differences in treatment options. It is recommended that physicians strengthen their knowledge and receive training in this area^[6]。 According to the clinical characteristics of warfarin-related GIB and the research progress of prevention and treatment strategies in recent years, the risk factors of warfarin-related GIB, clinical treatment outcome, endoscopic characteristics, prevention and follow-up treatment strategies of patients are discussed.