Volume 103 · Issue 40 · 2023

The development of respiratory medicine has evolved from the prevention and treatment of tuberculosis in 1950 s to the care of chronic obstructive pulmonary disease and corpulmonale disease in 1970 s. In the past 20 years, it has further advanced into the integration of pulmonary medicine (PM) and critical care (CC), becoming a dominant form of global disciplines in respiratory medicine. The subspecialty training system of pulmonary and critical care medicine (PCCM) is a decisive measure to ensure the standardized development of respiratory medicine, and medical intensive care unit (MICU) is the most important clinical practice field for respiratory medicine in China, which plays a crucial role in promoting the substantial construction of the critical care medical system within the PCCM subspecialty, thus contributing to the development of the discipline.

The overall prognosis of differentiated thyroid carcinoma is favorable, but some patients still progress to a locally advanced stage. At present, there are still some problems in the diagnosis and treatment of locally advanced thyroid cancer, which have not been completely clarified, and have caused some problems to the clinical treatment. This article provides a comprehensive analysis and elaboration on the selection of surgical methods for local advanced thyroid cancer, management of recurrent laryngeal nerve and trachea, timing selection of staging surgery, and targeted therapy, aiming at promoting standardized and individualized treatment for advanced thyroid cancer and improving the survival rate and quality of life.

Respiratory syncytial virus (RSV) is one of the major pathogens responsible for acute lower respiratory tract infections (LRTI) and hospitalizations in children. It is also the primary viral pathogen causing lower respiratory tract infections in children under 5 years old, posing a significant threat to child health. In order to advance RSV prevention and control efforts and comprehensively explore RSV disease burden, epidemiological patterns, development and regulation of preventive and therapeutic measures, as well as the formulation of related strategies for prevention and control, the Editorial Board of the Chinese Medical Association Chinese Medical Journal convened the "Chinese Respiratory Syncytial Virus Forum" in December 2022. Participating experts, focusing on the current research status and developmental requirements concerning respiratory syncytial virus, engaged in discussions and exchanges, culminating in the formulation of expert recommendations for the prevention and control of pediatric respiratory syncytial virus infections in China: (1) Strengthen research on RSV epidemiological characteristics and disease burden; (2) Establish a collaborative, multi-departmental, and multi-disciplinary approach for sustained, multicenter, long-term monitoring; (3) Emphasize innovation, research, development, and implementation of vaccines, monoclonal antibodies, and diagnostic methods; (4) Propel the formulation and implementation of RSV immunoprophylaxis strategies; (5) Coordinate and allocate pediatric medical and health resources rationally to prevent nosocomial infections.

The incidence and mortality of lung cancer rank first among malignant tumors in China. Among them, non-small cell lung cancer (NSCLC) is the most important pathological type, accounting for 80%-85% of lung cancer patients, including adenocarcinoma, squamous cell carcinoma and other pathological subtypes. In recent years, with the discovery of epidermal growth factor receptor (EGFR) gene and the successful development of tyrosine kinase inhibitors (TKIs), the treatment efficacy of stage Ⅳ NSCLC patients with EGFR gene sensitive mutation has been greatly improved. As of August 23, 2023, the first generation EGFR-TKIs, gefitinib, icotinib, and erlotinib; the second generation EGFR-TKIs, afatinib and dacomitinib; and the third generation EGFR-TKIs, osimertinib, almonertinib, furmonertinib and befotertinib were all approved for marketing by China National Medical Products Administration (NMPA). In addition, multiple domestic third-generation EGFR-TKIs are undergoing clinical trials, such as rezivertinib (BPI-7711), limertinib (ASK120067), and oritinib (SH-1028). Meanwhile, mobocertinib and sunvozertinib, which targets EGFR 20ins mutations, were also approved by NMPA. With the increasing variety of EGFR-TKIs approved for marketing subsequently, it brings confusion to clinicians when choosing specific medications, and there is an urgent need to develop relevant treatment guidelines. Hence, the Medical Oncology Branch of China International Exchange and Promotive Association for Medical and Health Care and the Chinese Association for Clinical Oncologists convened experts to integrate the research results of various EGFR-TKIs, and proposed the "China clinical practice guideline for epidermal growth factor receptor tyrosine kinase inhibitors in stage Ⅳ non-small cell lung cancer (version 2023)", to provide reference for better clinical practice.

The pancreaticobiliary junction (PBJ) stands as a pivotal "hub" where the bile and pancreatic ductsmerge, directing the flow rate and direction of bile and pancreatic juice. Benign pancreaticobiliary junction diseases(BPBJD) can lead to compromised outflow of bile and pancreatic secretions, resulting in elevated pressures within the bile and pancreatic ducts, causing ductal dilation, secretion stasis, and stone formation.Furthermore, BPBJD can shift the direction of bile and pancreatic juice, inducing pancreaticobiliary reflux, bile-pancreatic reflux, or enterobiliary reflux, thereby causing both acute and chronic inflammation and tumors in the biliopancreatic system. Owing to the unique anatomical position of the PBJ and the often intricate and elusive symptoms of benign diseases in this region, clinicians might mainly address standard biliary and pancreatic diseases, overlooking the primary issues associated with the PBJ.Such oversight can yield less-than-optimal clinical outcomes. In response to this, the Gallbladder-Preserving Surgery Committee, Endoscopy Specialist Branch of Chinese Medical Doctor Association and the editorial board of the National Medical Journal of China assembled renowned domestic experts from the fields of hepatobiliary and pancreatic surgery and digestive endoscopy. Drawing upon the latest domestic and international research findings, as well as the clinical expertise of specialists from related fields within China, they have collaboratively developed an expert consensus on the endoscopic diagnosis and treatment of BPBJD. The overarching aim is to propagate and standardize the diagnosis and treatment approaches for BPBJD.

To investigate the application and effect of capillary fascia preservation between the recurrent laryngeal nerve (RLN) and common carotid artery (fascia preservation method) in nerve protection when dissecting right level Ⅵ lymph nodes for patients with papillary thyroid carcinoma.

A retrospective cohort study enrolling 195 patients with papillary thyroid carcinoma undergoing right level Ⅵ lymph node dissection in Beijing Tongren Hospital from March 2021 to August 2022 was carried out. The RLN was dissected by fascia preservation method in study group and by routine method in control group. The intraoperative electrical signal amplitude of the RLN, the number of dissected lymph nodes, and the postoperative complications were recorded and analyzed.

A total of 195 patients (study group: 94 cases, control group: 101 cases) were collected. There were 71 males and 124 females, with the median age of 32 (39, 51) years. In the study group, the total number of right level Ⅵ lymph nodes was significantly larger than the number of right Ⅵa level lymph nodes [8 (6, 11) vs 6 (4, 8), P<0.001]. There were no significant differences between the two groups in the number of level Ⅵa or level Ⅵb lymph nodes [Ⅵa: 6 (4, 8) vs 5 (3, 7), P=0.373; Ⅵb: 3 (1, 4) vs 2 (1, 4), P=0.337] and metastasis rate [Ⅵa: 51.1% (48/94) vs 52.5% (53/101), P=0.844; Ⅵb: 12.8% (12/94) vs 15.8% (16/101), P=0.541]. The ratio of electromyography (EMG) amplitude R2 in lower level Ⅵ and entry into larynx (grouped as>90%, 50%~90%,<50%) in the study group was significantly higher than that in the control group (P<0.001). No significant differences were detected between the two groups in temporary RLN paralysis [1.1% (1/94) vs 2.0% (2/101), P=1.000].

Fascia preservation method can decrease the stimulus and traction to RLN and preserve the capillary network serving RLN. It can thoroughly dissect lymph nodes and decrease the injury of RLN.

To investigate the oncological outcomes of active surveillance (AS) in patients showing thyroid nodules measuring≤1 cm with highly suspicious ultrasound features.

A prospective single-center cohort study. A total of 534 patients with highly suspicious thyroid nodules (2015 American Thyroid Association Nodule Sonographic Patterns and Risk of Malignancy: High Suspicion) were enrolled in this study, the patients received AS at Peking Union Medical College Hospital between January 2017 and November 2022 to assess oncological outcomes (disease progression, recurrence/metastasis rate, etc). The patients were followed up every 6 months for physical examination and neck ultrasound examination. And the value of tumor volume changes in evaluating tumor enlargement was explored too.

There were 413 females and 121 males in this cohort, with a mean age of (42.6±11.8) years. During a median follow-up period of 45.6 months (ranged from 3.5 to 176.0 months), disease progression occurred in 26 patients (4.9%) with highly suspicious thyroid nodules, characterized by a minimum 3-mm increase in tumor diameter in 19 patients (3.6%) and lymph node metastases in 7 patients (1.3%). Forty-seven (8.8%) patients opted for delayed surgery, with 29 patients due to a change in preference. There was no significant differences in pathologic and follow-up outcomes between patients with disease progression and preference change. Patients aged≤40 years had a higher cumulative incidence of 5-year disease progression than those aged>40 years (4.9% vs 1.9%, P=0.060). No patients experienced distant metastases or deaths. Among the 595 high-risk thyroid nodules with continuous volume assessment results and an increase in nodule diameter of less than 3 mm (including all high-risk nodules in patients with single or multiple nodules), 184 (30.9%) and 79 (13.3%) nodules exhibited volume increases of more than 50% and 100%, respectively, in multiple measurements. Among the nodules with volume changes exceeding 50% and 100%, the proportion of nodules with a baseline tumor diameter of≤0.5 cm was significantly higher than those with a diameter of>0.5 cm, at 69.0% vs 31.0% (P<0.001) and 77.2% vs 22.8% (P<0.001), respectively.

Active surveillance in patients with highly suspicious subcentimeter thyroid nodules has good short-term oncological outcomes and can be considered a safe alternative to surgery. Due to the large variability in the measurement results of tumor volume, it is not suitable as an indicator for evaluating tumor enlargement.

To investigate the application value of near-infrared autofluorescence imaging-based convolution neural network (CNN) for automatic recognition of parathyroid gland.

The data of 83 patients who underwent thyroid papillary cancer surgery in the Department of Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University from August 2020 to March 2022 were retrospectively analyzed, and a total of 725 autofluorescence images of parathyroid gland were collected during the surgery. Meanwhile, non-parathyroid fluorescence imaging videos in the operation area of 10 patients were also collected, and 928 non-parathyroid fluorescence images were captured from those videos. The fluorescence images of parathyroid and non-parathyroid glands were directly used as input features for deep learning to construct ResNet 34, VGGNet 16 and GoogleNet models for automatic parathyroid identification. The ability of different models to identify parathyroid glands was tested by indicators such as accuracy, specificity, sensitivity, precision, receiver operating characteristic curve and area under the curve (AUC). In addition, 30 fluorescence images of parathyroid and 35 fluorescence images of non-parathyroid glands in 13 patients with papillary thyroid cancer from March to May 2022 were collected to prospectively test the best performing CNN model.

Among the 83 patients, there were 25 males and 58 females, with the mean age of (46.7±12.4) years. In the binary classification (parathyroid gland and non-parathyroid gland), the ResNet 34 model performed the best in different CNN models, the accuracy, specificity, sensitivity and precision of the identification test set were 97.6%, 96.3%, 99.3% and 95.5%, and the AUC reached 0.978 (95%CI: 0.956-0.991). In the prospective test, the prediction accuracy of the ResNet 34 model reached 93.8%, and the AUC was 0.938 (95%CI: 0.853-0.984).

The near-infrared autofluorescence imaging-based deep CNN has good application value in the automatic recognition of parathyroid gland, and can be used to assist the recognition and protection of parathyroid gland in thyroid cancer surgery.

To explore the related factors of high-volume lymph node metastasis (HVM) in multifocality papillary thyroid carcinoma (MPTC).

The clinical and pathological data of multifocality papillary thyroid carcinoma (MPTMC, d≤10 mm) and MPTC (d>10 mm) collected from Hangzhou First People′s Hospital from January 2010 to March 2023 were retrospectively analyzed. Univariate and multivariate logistic regression analysis were used to analyze the relevant factors of HVM.

Among 566 cases of MPTMC and 381 cases of MPTC, there were 72 males and 494 females in MPTMC, 106 males and 275 females in MPTC, respectively. The median age of the patients was 47 (39, 54) and 47 (34, 56) years, respectively, and the incidence of HVM was 4.6% (26/566) and 21.5% (82/381), respectively (χ²=64.588, P<0.001). Univariate analysis showed that in patients with MPTMC and MPTC, the incidence of HVM in males was higher than that in females [15.3% (11/72) vs 3.0% (15/494) (χ²=21.487, P<0.001) in MPTMC, 33.2% (35/106) vs 17.1% (47/275) (χ²=11.492, P=0.001) in MPTC]. The age of the HVM group was lower than that of the non-HVM group [41 (33, 50) vs 48 (39, 54) years (Z=-2.128, P=0.033) in MPTMC, 38 (29, 48) vs 48 (36, 57) years (Z=-4.987, P<0.001) in MPTC]. The maximum diameter of tumors in the HVM group were higher than those in the non-HVM group [7.0 (5.0, 10.0) mm vs 6.0 (5.0, 8.0) mm (Z=-2.558, P=0.011) in MPTMC, 17.5 (13.0, 25.0) mm vs 15.0 (12.0, 20.0) mm (Z=-2.871, P=0.004) in MPTC]. Multivariate logistic regression analysis showed that larger tumor size (OR=3.027, 2.378; 95%CI: 1.287-7.117, 1.404-4.030; P=0.011, 0.001), male (OR=5.398, 1.909; 95%CI: 2.284-12.758, 1.113-3.274; P<0.001, P=0.019), and younger age (OR=3.889, 3.136; 95%CI: 1.686-8.969, 1.837-5.355; P=0.001, P<0.001) were all risk factors for the occurrence of HVM in MPTMC and MPTC.

The proportion of HVM in MPTC patients was higher than that in MPTMC, and larger maximum diameter, male gender and younger age are related factors for HVM in MPTMC and MPTC.

To explore the molecular markers related to lymph node metastasis of prostate cancer (PCa) based on bioinformatics technology and carry out clinical verification.

The differentially expressed genes of PCa with lymph node metastasis were screened from geo data, and the hub genes of the gene co expression network were constructed. The hub genes were incorporated into the support vector machine model to evaluate its prediction efficiency. The hub genes were verified in the TCGA data set and analyzed for immune infiltration. The clinical data of 80 patients with prostate cancer in the Fourth Hospital of Hebei Medical University from January 2019 to December 2022 were collected. The logistic risk model was used to evaluate the prediction efficiency of hub gene metastasis.

Five hub genes (GSK3B, TP53, PSMC6, SUMO1, PIK3CA) were identified, and the support vector machine model constructed by them had good diagnostic value (the accuracy rate was 83.87%). TCGA validation results showed that only PSMC6 was significantly differentially expressed in PCa tissues with lymph node metastasis (P<0.001). The results of immune infiltration analysis showed that the expression of PSMC6 was significantly correlated with 9 kinds of immune cells (B cells, DC, IDC, etc.). Clinical information analysis showed that the expression of PSMC6 was significantly correlated with lymph node metastasis, PSA value, T stage and Gleason score (P<0.01). Univariate logistic results showed that T stage (OR=3.230, 95%CI:1.192-8.757, P=0.021), Gleason score (OR=4.627, 95%CI:2.212-9.677, P<0.001), PSMC6 (OR=25.235, 95%CI:5.326-119.560, P<0.001) could be used as predictors of lymph node metastasis. Multivariate logistic analysis showed that PSMC6 (OR=16.537, 95%CI:2.928-93.393, P=0.001) could be used as an independent risk factor for predicting lymph node metastasis.

PSMC6 may be used as a potential molecular marker for judging lymph node metastasis in patients with PCa.

The abdominal wall can be treated as a whole physiological and functional entity which is composed of multiple anatomical structures and planes. Surgical approaches and technical details that required are diverse in different area. Indeed, the abdominal wall is confined by several anatomical boundaries which make these surgical planes separated. If one could dissect these boundaries, then separated spaces could be connected, establishing an ample retromuscular/preperitoneal space to accommodate the mesh of ventral hernia repair. The concept of totally visceral sac separation (TVS) is achieved. The TVS concept is a summary of diverse ventral hernia repair techniques. Since its initiation and spread, this technique has been widely accepted and implemented by domestic surgeons due to its outstanding performance. This treatise will review the relevant anatomy as well assurgical tricks by the authors that aid in performing TVS. Some of the details are more tricky and harder to understand, thus this in-depth description of the technique.

The patient was a 47-year-old male. On August 16, 2018, I went to the Second Xiangya Hospital of Central South University for treatment because of "cough and expectoration for 35 years, shortness of breath for more than 20 years after activity, and more than 2 months again". Repeated cough and sputum, shortness of breath after exertion for more than 30 years, combined with sinusitis, cold agglutinin titer ≥64, T lymphocytes (CD3⁺) proportion 46%, Th lymphocytes (CD4⁺) The ratio was 30%, and no abnormality was observed in immunoglobulin. The ratio of forced expiratory volume in the first second (FEV1) to forced vital capacity (FVC), i.e., the 1-second rate (FEV1/FVC), was 49%. Pulmonary CT showed diffuse small airway lesions in both lungs. Whole exon sequencing detected the homozygous mutation of TAP2 gene c.223_224del (p.Leu75AspfsTer91), and her sister also found the same mutation of TAP2 gene, and the diagnosis of naked lymphocyte syndrome type I and diffuse panbronchiolitis was clear. After treatment with azithromycin (0.5 g, once/d), the symptoms of cough, sputum and shortness of breath were significantly improved.

A 56-year-old female patient was presented in the Second Affiliated Hospital of Naval Medical University due to recurrence of the fifth lumbar vertebra after rectal cancer surgery. After conversion therapy, after evaluation by the multidisciplinary comprehensive therapy cooperative group, the tumor was radically resected by combined pelvic organ resection + combined anterior and posterior approach for lumbar tumor resection, reconstruction and internal fixation. He recovered well after surgery. After getting out of bed and moving, he developed lumbar discomfort. He found a localized hematoma on the lumbar wound, so he was immediately immobilized to rest in bed. The symptoms gradually improved, and no recurrence was seen after 1 year follow-up.

Ovarian aging leads to low female fertility and dysfunction of multiple systems, which affects female health and population development. Its pathogenesis is not clear, and there is no effective treatment. In recent years, it has been found that ovarian macrophages (M φ s) play an important role in maintaining ovarian physiological function, and also participate in the development of ovarian senescence. In the senescent ovarian microenvironment, ovarian M φ s differentiate and shift, secreting cytokines to promote the inflammatory response and fibrosis of the ovary, leading to follicular growth and ovarian dysfunction. In recent years, many mechanisms of M φ s and subpopulations in ovarian senescence have been discovered. In this paper, the research progress of the relationship between M φ s and ovarian senescence will be reviewed.

The external branch of the superior laryngeal nerve (EBSLN) is susceptible to damage during thyroidectomy, resulting in the inability to produce high tones after surgery, negatively affecting the patient's quality of life. Therefore, routine identification of EBSLN during surgery is essential to reduce complications of thyroidectomy. The purpose of this study was to verify the role of video-assisted surgery in the identification and protection of EBSLN during thyroidectomy, and to analyze the classification and localization of EBSLN in the positional relationship of the nerve penetration point (NEP) to the sternothyroid muscle. 134 patients with thyroid lobectomy were randomly divided into video-assisted surgery group and conventional open surgery group. The maximum diameter of thyroid mass was ≤4 cm and there was no extracapsular thyroid invasion. The researchers used video-assisted surgery to directly visually recognize EBSLN, and compared the differences in visual recognition rate and total recognition rate between the two groups. Meanwhile, the positioning of NEP was measured. The results showed that there was no statistically significant difference in baseline clinical characteristics between the two groups. Both the visual recognition rate and the total recognition rate in the video-assisted surgery group were significantly higher than those in the conventional open surgery group (91.04% vs. 77.61%, 100% vs. 89.6%). The EBSLN injury rate was 0 in both groups. The mean vertical distance (VD) of the NEP from the sternal thyroid insertion was 1.18 mm (standard deviation 1.12 mm, range 0 to 5 mm), with 88.97% of the results within this distance of 0 to 2 mm. The mean horizontal distance (HD) was 9.33 mm (standard deviation 5.03 mm, range 0 to 30 mm), and more than 92.13% of the results occurred within this range of 5 to 15 mm. Therefore, it is concluded that the visual recognition rate and total recognition rate of EBSLN in the video-assisted surgery group are higher than those in the conventional open surgery group. This method provides a good visual exposure rate of EBSLN, helping to identify and protect EBSLN during thyroidectomy.