Volume 104 · Issue 32 · 2024

The use of arteriovenous graft (AVG) fails to meet the clinical needs in China, although it is recommended by guidelines to be the alternative access for maintenance hemodialysis (MHD) patients. Patency and complication incidence of AVG reported by recent research is superior to traditional cognition, and thus AVG should be one of main types of access in our country. Personalized selection of proper patients and grafts may improve the outcomes of AVG. In the future, outcomes of AVG must be further improved by clinical research with accurate personalized selection, basic research of precise molecule target and innovation of graft materials.

Hemodialysis remains the main kidney replacement therapy for end-stage renal disease patients worldwide. When superficial veins are exhausted or arteriovenous fistula cannot be established, arteriovenous graft fistula should be selected as the permanent dialysis access. The article elaborates on the process of arteriovenous graft fistula construction, including many technical aspects, such as preoperative evaluation, surgical plan, graft selection, preoperative preparation, and surgical procedure, which are related to surgical outcomes, complications, and long-term patency rate.

Stenosis, thrombosis, and infection are major complications of arteriovenous graft (AVG). Endovascular therapy is usually adopted for stenosis, while bypass, interposition, patch angioplasty and other surgical techniques can also be used for special sites. Interventions of AVG thrombosis include removal of thrombus and treatment of the underlying stenosis. The former includes catheter directed thrombolysis, endovascular intervention, surgical treatment, or hybrid treatment. Etiological detection before the application of empirical antibiotics is the first step of infection management. According to different infection ranges, partial graft excision and interposition, total graft excision and partial graft excision can be performed respectively. Active prevention, timely identification, and appropriate intervention of the complications can improve the long-term outcomes of AVG. Personalized interventional strategy should be employed based on the systemic evaluation.

The hepatitis B virus (HBV) is a liver-loving, double-stranded, circular DNA virus. The prevalence of hepatits B surface antigen(HBsAg)in the general population of China is approximately 6.1%, indicating a large base of HBV-infected individuals. The infection rate of HBV in the blood dialysis patient population is significantly higher than that in the general population. Kidney transplant recipients, being in an immunosuppressed state, are susceptible to HBV infection, and previous HBV infections may reactivate, affecting the long-term survival of the recipient and the transplanted kidney. To further standardize the diagnosis and treatment of HBV infection after kidney transplantation, the Transplantation Branch of the Chinese Medical Association has organized domestic experts to develop this guideline from aspects such as epidemiology, routes of HBV infection in kidney transplant recipients, indications for kidney transplantation in HBV-infected individuals, and the diagnosis, prevention, and treatment of HBV infection in kidney transplant recipients, in order to help kidney transplant professionals standardize and optimize the management of HBV infection.

An effective infectious disease surveillance and early warning system is a crucial component of public health safety and is essential for preventing and controlling outbreaks of infectious diseases. Enhancing surveillance and early warning capabilities is an urgent priority for advancing high-quality disease prevention and control efforts. Combining the research findings and practical experiences of experts in epidemiology, clinical medicine, disease prevention and control, data science, and computer science, and following multiple rounds of expert discussions, we have developed a consensus on the key technologies for a multi-point trigger intelligent surveillance and early warning system for infectious diseases. This consensus primarily covers the related concepts and definitions of the multi-point trigger intelligent surveillance and early warning system for infectious diseases, the key technical framework, sources, acquisition, and governance of multi-channel warning data, classification of early warning methods, multi-point trigger intelligent surveillance and early warning paths, multi-point trigger warning and comprehensive assessment, response to warning signals, and evaluation of early warning effectiveness. It aims to provide technical references for the construction and application of a multi-point trigger intelligent surveillance and early warning system for infectious diseases.

Aromatase inhibitors have been widely used to improve height in the world and China. However, due to their off-label use and relatively short application time, there is a lack of consistent understanding and expert consensus on the indications, efficacy, and side effects of the drugs at home and abroad. Therefore, the Growth and Development and Gonadal Diseases Committee of Chinese Aging Well Association and the Adolescent Medicine and Health Professional Committee of the Chinese Medical Doctor Association organized 28 domestic experts in growth and development, based on the clinical evidence level classification and recommendation level of the Oxford University Evidence-Based Medicine Center to establish some preliminary recommendations on the efficacy, adverse reactions, precautions, dosage, and course of use of aromatase inhibitors in treating children with short stature and improving their year-end height. Combined with the Delphi method evaluation, 14 recommendations were finally formulated to standardized the clinical application of aromatase inhibitors in improving adolescent height.

To compare the efficacy between percutaneous mechanical thrombectomy and surgical thrombectomy in the treatment of acute arteriovenous graft thrombosis (AVG).

The clinical data of acute thrombosis AVG patients treated in the Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University from January 2020 to December 2021 were retrospectively analyzed. Patients were divided into percutaneous mechanical thrombectomy group and surgical thrombectomy group according to treatment methods. Baseline information, technical success rate, complication rate, and 24-month primary and secondary patency rates of the two groups were analyzed.

A total of 130 patients aged (54.1±14.2) years were enrolled in the study, including 66 males and 64 females. There were 78 patients in the percutaneous mechanical thrombectomy group and 52 patients in surgical thrombectomy group. No statistically significant differences in gender, age, comorbidities, and lesion characteristics between the two groups were detected (all P>0.05). The technical success rate in the mechanical thrombectomy group was 98.7% (77/78), and the complication rate was 5.1% (4/78), while the technical success rate in the surgical thrombectomy group was 94.2% (49/52), and the complication rate was 9.6% (5/52). There were no statistically significant differences in the technical success rate and complication rate between the two groups (all P>0.05). The average operation time of mechanical thrombectomy was significantly shorter than that of surgical thrombectomy [(62.8±13.9) min vs (77.0±17.6) min, P<0.001]. The Kaplan-Meier survival analysis indicated the primary patency rates of the mechanical thrombectomy group at 12 and 24 months after thrombectomy were 62.8% and 38.5%, respectively, while the primary patency rates of the surgical thrombectomy group at 12 and 24 months were 57.7% and 36.5%, respectively. There was no statistically significant difference in the primary patency rate between the two groups (P=0.641). The secondary patency rates of the mechanical thrombectomy group at 12 and 24 months were 98.7% and 94.9%, respectively, while the secondary patency rates of the surgical thrombectomy group at 12 and 24 months were 92.3% and 82.7%, respectively. The secondary patency rates of the mechanical thrombectomy group were higher than those of the surgical thrombectomy group (P=0.020).

Mechanical thrombectomy is a safe and effective treatment for acute AVG thrombosis, with the advantages of shorter operation time and higher secondary patency rate compared with surgical thrombectomy.

To evaluate the prevalence, intervention methods and effect of arteriovenous graft (AVG) stenosis.

The clinical data of patients who received AVG in the Blood Purification Center, the First Affiliated Hospital of Zhengzhou University from January 2018 to December 2022 were retrospectively analyzed. The patency rate, prevalence and intervention effect of AVG stenosis were analyzed.

A total of 475 patients aged (55.5±11.8) years were included, and there were 193 male cases (40.6%) and 282 female cases (59.4%). The patients were followed up for [M (Q₁, Q₃)] 19 (12, 30) months, and the primary, assisted primary and secondary patency were 14 (5, 27), 27 (13, 55), and 59 (33, 65) months, respectively. There were 799 access events which needed intervention, with a total standardized intervention rate of 0.90 per patient-year. Totally, 431(53.9%, 431/799) stenosis events occurred in 207 AVG. Among 422 AVG stenosis events with complete clinical data, 57.8% (244/422) were multi-site stenosis and 42.2% (178/422) were single-site stenosis. The most common sites of stenosis were graft-vein anastomosis (47.6%, 340/715), venous outflows (22.7%, 162/715), and puncture zone (20.0%, 143/715). In the 414 stenosis with intact follow-up data, 90.8% (376/414) were treated by balloon angioplasty, 8.5% (35/414) received covered stent insertion, and 0.7% (3/414) were intervened by open surgery. Clinical success rate was 98.1% (406/414). The primary patency time after endovascular treatment was 6 (4, 12) months. Covered stent significantly increased post-intervention primary patency time compared withballoon angioplasty [6 (3, 7) months vs 3 (1, 4) months, P=0.020].

Stenosis is the most common complication of AVG, and the most common sites are graft-vein anastomosis, venous outflows, and puncture zone. Intervention of AVG stenosis has a high clinical success rate, and a relatively low post-intervention patency. Covered stent insertion improves the post-intervention patency of AVG, which has a poor effect using balloon expansion.

To evaluate the long-term outcomes of lower extremity arteriovenous graft (AVG) in hemodialysis patients.

Hemodialysis patients with lower extremity AVG from August 2015 to July 2023 in the Department of Vascular Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine were enrolled. Therapeutic effects and complications of AVG were retrospectively analyzed.

A total of 83 cases aged (58.9±13.3) years were enrolled, including 25 males and 58 females. The success rate of the operation was 100% (83/83), and no perioperative complications occurred. The follow-up time [M (Q₁, Q₃)] was 38.4 (22.6, 55.3) months, with a follow-up rate of 92.8% (77/83). There were 9 cases (11.7%) of puncture site infection, 5 cases (6.5%) of pseudoaneurysm, 2 cases (2.6%) of seroma, 3 cases (3.9%) of lower limb ischemia, 48 cases (62.3%) of stenosis and 24 cases (31.2%) of thrombosis during the follow-up period. The 6-month, 1-year, 2-year, 3-year and 5-year primary patency rates after surgery were 78.9%, 61.2%, 39.0%, 27.0% and 16.3%, respectively, assisted primary patency rates were 93.5%, 82.5%, 74.9%, 68.0% and 53.0%, respectively, and secondary patency rates were 96.1%, 94.7%, 93.1%, 91.3% and 75.3%, respectively.

For patients whose vascular resources of upper limbs are exhausted, lower extremity AVG is a safe and effective hemodialysis vascular access.

To investigate the factors affecting primary patency time in arteriovenous graft (AVG) patients receiving percutaneous transluminal balloon angioplasty (PTA).

Hemodialysis patients who underwent AVG placement at the First Affiliated Hospital of Chongqing Medical University between February 2018 and December 2021 were included. The factors including age, gender, total duration of AVG use, site of stenosis, degree of stenosis, length of stenosis, residual stenosis, and presence of thrombosis were analyzed, and influencing factors of primary patency time in AVG were determined using a multiple linear regression model.

A total of 101 patients who underwent 331 PTA treatments were enrolled, including 35 males and 66 females. The median age of patients undergoing PTA for the first time was 61 (51, 68) years, and the primary patency time after PTA was 5 (3, 10) months. The patients were followed up for (38.5±15.3) months. Multivariable linear regression analysis revealed that severe stenosis at the venous anastomosis and reflux veins (β=-2.773, 95%CI:-5.440--0.105, P=0.042), female (β=-2.247, 95%CI:-3.853--0.642, P=0.006), and previous multiple PTA treatments (β=-0.516, 95%CI:-0.978--0.054, P=0.029) were risk factors for a shorter primary patency time after PTA.

Severity of stenosis at the venous anastomosis and reflux veins of the AVG, female, and a history of multiple previous PTA treatments are associated with a shorter primary patency time in AVG patients.

To anlysis the efficacy and safety of cut-umbilical cord milking (C-UCM) compared with immediate cord clamping in preventing anemia and iron deficiency among term cesarean-delivered newborns.

A total of 485 pregnant women planning to deliver by cesarean section were recruited in this randomized controlled trial in Hunan Maternal and Child Health Hospital and Liuyang Maternal and Child Health Care Hospital from July 2016 to April 2019. A block randomization was conducted to evenly allocate them to the controlled group and the C-UCM group. In the controlled group, the cord was clamped within 30 seconds as routine. In the C-UCM group, the cord was first clamped at 25 cm from the newborn′s navel, and then the blood in the cord was gently squeezed into the newborn′s body until the cord became white and shriveled. The cord was clamped twice at 2-3 cm from the newborn′s navel subsequently. Neonatal jaundice, hyperbilirubinemia and polycythemia were monitored before discharge. After the newborns discharged, their hemoglobin, red blood cell count, hematocrit (at the age of 1, 6 and 12 months) and serum ferritin (at the age of 6 and 12 months) were followed up; body length and weight were measured; and information about their feeding and iron supplementation were collected (at the age of 1, 6, 12 and 18 months). The two groups were compared by t test, Mann-Whitney U test, χ² test, or Fisher exact probability method. The hospital was set as a random item, and the mixed effects regression model was used to evaluate the effect of C-UCM on relevant indicators of cesarean-delivered newborns.

There were 244 women in the C-UCM group with an average age of (31.9±4.4) years, and 241 in the control group with an average age of (31.8±4.2) years (P>0.05). There was no statistically significant difference between the C-UCM group and the control group at 1, 6 and 12 months of age in hemoglobin [(123.6±14.5) vs (122.2±14.5) g/L, (115.3±9.4) vs (114.1±8.5) g/L, (115.6±9.6) vs (116.1±12.6) g/L] or anemia incidence rate [15.2% (17/112) vs 18.4% (19/103), 22.7% (34/150) vs 26.8% (44/164), 22.3% (25/112) vs 19.5% (22/113)] (all P>0.05). There was no statistically significant difference between the two groups at 6 and 12 months of age in serum ferritin [M (Q₁, Q₃), 39.9 (24.9, 61.8) vs 43.6 (25.2, 100.9) μg/L, 40.3 (25.4, 259.2) vs 40.3 (26.4, 167.6) μg/L)] or iron deficiency incidence rate [6.1% (5/82) vs 4.2% (3/72), 6.7% (5/75) vs 3.8% (3/80)] (all P>0.05). There were also no significant difference between the two groups in other indicators, such as the Z-score of weight-for-length, the incidence of neonatal jaundice, and the incidence of neonatal hyperbilirubinemia (all P>0.05). After adjusting for the relevant covariates, there were still no significant effects of C-UCM on these outcomes above.

Compared to immediate cord clamping, the intervention of gently squeezing 25 cm of the cord does not significantly reduce the risk of anemia or iron deficiency in term cesarean-delivered newborns, nor does it have a significant impact on infant growth and development. Yet this intervention does not increase the risk of jaundice or hyperbilirubinemia in newborns as well.

To construct a repetitive implantation failure (RIF)-related competitive endogenous RNA (ceRNA) regulatory network and validate with clinical samples.

RIF-related long non-coding RNA (lncRNA), microRNA (miRNA) and messenger RNA (mRNA) from the high-throughput gene expression omnibus (GEO) database Expression profile data set were obtained to construct a ceRNA regulatory network of lncRNA-miRNA-mRNA. At the same time, weighted gene co-expression network analysis (WGCNA) was used to explore hub genes in the network. This retrospective study collected RIF patients and controls (at least one pregnancy history after assisted conception) who underwent in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) for assisted pregnancy from 2020 to 2021 at the Reproductive Medicine Center of the First Affiliated Hospital of Zhengzhou University. In the endometrial tissue of patients with 1 pregnancy history, real-time fluorescence quantitative polymerase chain reaction (qRT-PCR) was used to verify the mRNA expression levels of RIF-related hub genes, and Western blotting and immunohistochemistry were used to verify protein expression levels of vascular cell adhesion molecule-1 (VCAM1).

A RIF-related ceRNA regulatory network consisting of 32 lncRNAs, 31 miRNAs and 88 mRNAs was constructed, and 7 RIF-related hub genes were identified using WGCNA. By intersecting 88 mRNAs and hub genes in the ceRNA network, two RIF-related key genes were obtained, i.e., VCAM1 and interleukin-2 receptor α (interleukin-2 receptor α, IL-2RA). In clinical verification, the ages of the control group and RIF group [M (Q₁, Q₃)] were 26.50 (25.00, 34.00) and 30.50 (25.75, 35.25) years old, respectively (P>0.05). Compared with the control group, the mRNA [0.30 (0.15, 0.42) vs 0.99 (0.69, 1.34), P=0.001] and protein expression [0.44 (0.16, 1.27) vs 2.39 (1.58, 2.58), P<0.001] of VCAM1 in the endometrium of the RIF group were both reduced.

This study uses bioinformatics analysis methods to construct a RIF-related ceRNA regulatory network, and it is confirmed through clinical samples that the expression level of VCAM1 in the endometrial tissue of RIF patients is significantly reduced.

A total of 309 (138 males and 171 females) end-stage renal disease patients who underwent implantation of early cannulation arteriovenous grafts (Acuseal) for hemodialysis in Nanfang Hospital, Southern Medical University between December 2016 and May 2021 were retrospectively included. The age of patients was (61.5±10.3) years. There were 244 patients (119 males and 125 females) who received regular follow-up. During the follow-up period, 24 patients died. Perioperative complications included graft infection (4.5%, 11/244), hematoma (4.5%, 11/244) and steal syndrome (4.1%, 10/244). No seroma or anastomotic rupture occurred. The rates of the first postoperative puncture time within 24 h, 48 h and 72 h after implantation were 42.2%(103/244), 32.4% (79/244) and 16.4% (40/244), respectively. The Kaplan-Meier survival analysis showed that the primary patency rates at 6 months and 12 months were 66.5% and 48.4%, respectively, and the secondary patency rates at 6 months and 12 months were 96.7% and 91.8%, respectively. The current study indicates that the Acuseal graft is safe for vascular access in patients requiring hemodialysis, with satisfactory patency and acceptable complication rates at 1-year follow-up.

Patients who underwent arterio-arterial graft (AAG) surgery at Beijing Haidian Hospital from March 2021 to December 2023 were prospectively included. A total of 13 cases (6 males and 7 females) aged (59±13) years were collected, with a dialysis history of 4.0 (1.8, 10.0) years. Nine cases of "bow"-type AAG and 4 cases of "α"-type AAG were established. The follow-up time was 10 (7, 16) months. The primary patency and secondary patency rates at 3, 6 and 12 months after surgery were 92.3% and 100%, 81.8% and 90.9%, 57.1% and 57.1%, respectively. Stenosis, thrombosis and infection occurred in 2, 5 and 2 cases, respectively. The current study indicates that AAG surgery is simple, minimally invasive, and has a high long-term patency rate. It can be used as a new type of vascular access for patients who fail to establish conventional dialysis access.

This paper reports the diagnosis and treatment of a patient with azoospermia and idiopathic testicular microlithiasis complicated with inflammation. A 24-year-old infertile male patient presented with pain and testicular atrophy after testicular trauma, and was diagnosed with idiopathic testicular microlithiasis (TM) with inflammation on examination, with semen analysis suggesting non-obstructive azoospermia. The biopsy of testicular incision showed fibrosis, atrophy and calcification of seminiferous tubules, and no sperm was seen. Mutation analysis of the TM-associated gene SLC34A2 did not reveal pathogenic variants. The patient receives medication, obtains sperm and gives birth naturally, and regular testicular self-examination and follow-up are recommended. The management experience of this case may provide a reference for dealing with similar complexities.

Chimeric antigen receptor T cells (CAR-T), as a novel cancer immunotherapy, have shown good efficacy in the treatment of hematological tumors. Recently, CAR-T technology has made breakthroughs in the treatment of autoimmune diseases such as systemic lupus erythematosus and immune-mediated necrotizing myositis, which can achieve long-term drug-free remission and break the situation that autoimmune diseases need long-term drug control. Therefore, CAR-T therapy is currently believed to be the most promising novel treatment for the cure of autoimmune diseases. This article summarizes the research progress of CAR-T therapy in autoimmune diseases, summarizes the ongoing related clinical trials, and the challenges and future prospects faced by CAR-T, in order to provide a basis for the research and application of CAR-T therapy in autoimmune diseases.

Interstitial lung disease (ILD) is a heterogeneous group of diseases characterized by inflammation or fibrosis of the pulmonary interstitium. The complex network of cytokines and growth factors plays an important role in the pathogenesis of ILD. Among them, the change of Janus kinase (JAK) activity can activate downstream signal transduction and transcription activator (STAT) signaling pathways, activate macrophages, increase the release of pro-inflammatory and pro-fibrotic factors, and promote the differentiation of fibroblasts into myofibroblasts, which participate in the development of ILD. JAK inhibitors (JAKi) can reduce lung inflammation and pulmonary fibrosis by blocking the JAK-STAT signaling pathway, and are expected to be used for the treatment of ILD. Basic research found that tofacitinib inhibited fibrosis and inflammatory responses in hypochlorous acid-induced systemic sclerosis-associated ILD (SSc-ILD) mice, while ruxolitinib improved the degree of pulmonary fibrosis in SSc-ILD mouse models and bleomycin mouse models. Clinical trials of JAKi in the treatment of idiopathic pulmonary fibrosis are ongoing, but from the current clinical application reports, JAKi may have potential therapeutic effects on a variety of connective tissue disease-related ILDs, including SSc-ILD, rheumatoid arthritis-related ILDs, and anti-melanoma differentiation-related gene 5 antibody-positive dermatomyositis-related ILDs, but high-level clinical trials are needed to further confirm. Given that JAKi also has strong anti-inflammatory effects, it is expected to play an active role in ILDs with obvious inflammatory responses, such as acute exacerbation of fibrotic ILD, rapidly progressing ILD and antitumor immunotherapy-related ILD.

Small cell lung cancer (SCLC) is a highly aggressive disease that grows rapidly and is prone to metastasis. Patients usually respond to initial chemotherapy, but SCLC is highly susceptible to recurrence and progression, resulting in poor long-term outcomes. The advent of immunotherapy has changed the treatment pattern of SCLC. At present, some immune checkpoint inhibitors have been approved for the treatment of extensive stage SCLC, and various clinical trials are being actively carried out, showing considerable clinical benefits. Research on new immune checkpoints such as anti-T cell immunoglobulin and immunoreceptor tyrosine inhibitory motif (ITIM) domain protein antibodies is also being explored. Clinical trials of some immune combinations with anti-angiogenic drugs or radiotherapy have shown good efficacy and safety, providing new ideas for the treatment of SCLC. However, the specific mode of combination therapy needs more research to be explored, and immunotherapy still has problems such as therapeutic resistance. This article reviews the research progress of immune checkpoint inhibitors in the treatment of limited-stage and extensive-stage SCLC, explores the efficacy and adverse reactions of immunotherapy combined with other therapeutic modalities, and analyzes the challenges of SCLC immunotherapy from the aspects of finding molecular biomarkers to screen beneficial populations and overcoming immunotherapy resistance.

A 56-year-old male went to the Department of Respiratory and Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University in March 2017 with "cough and expectoration for more than 3 months and shortness of breath for more than 5 months after activity". Three months ago, I went to the local hospital for complaining of symptoms, and the CT report only showed a small nodule in the upper lobe of the right lung, but there was nothing special. After perfect bronchoscopy, the local hospital diagnosed multiple chondritis of the trachea. Later, he was transferred to the Department of Respiratory and Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University for further treatment. No obvious abnormalities were found in physical examination, laboratory examination and pulmonary function examination. CT showed that multiple cartilage ring calcification could be seen in the anterior and middle part of the trachea, and local high-density shadows could be seen protruding into the tracheal lumen, and no abnormalities were found in the tracheal membrane (Figure 1); Bronchoscopy showed multiple diffuse nodular proliferative changes in the middle and upper trachea. The nodular lesions were located at the tracheal cartilage ring, showing a star-like appearance, and there were no abnormalities in the mucosa and membrane between the tracheal cartilage ring (Figure 2). Mucosal biopsy was taken under microscope and combined with pathological slides from local hospitals. After pathological consultation, it was shown that mucosal basal cell proliferation, basement membrane thickening, massive lymphocyte infiltration and multifocal cartilage ossification were seen, which was consistent with ossifying tracheobronchiopathy. Symptomatic treatment such as cough relief, phlegm reduction and immune regulation were intermittently given, and long-term outpatient follow-up was performed, and the condition was stable. In May 2021, the patient was admitted to hospital due to aggravation of shortness of breath. There was no significant increase in bronchoscopic lesions after reexamination, and the results of alveolar lavage suggested Staphylococcus aureus infection. After anti-infection, cough and phlegm treatment, he was improved and discharged from hospital. The bronchoscopic features of ossifying tracheobronchopathy are evident. CT has important diagnostic value for this disease. The characteristic CT manifestations are multiple calcified nodules in the anterior wall of trachea, but no abnormalities are found in the membrane of trachea; Its CT findings should be differentiated from tracheal amyloidosis and recurrent polychondritis of trachea. The treatment is mainly symptomatic. If the enlargement of the lesion leads to airway stenosis, respiratory intervention is needed. Therefore, the combination of CT and bronchoscopy is an important means to identify the disease.

The patient, a 62-year-old female, visited the outpatient department of respiratory and critical care medicine of the First Affiliated Hospital of Naval Medical University on December 25, 2021 due to "cough and shortness of breath for more than 1 month". More than 1 month ago, the patient had cough and white phlegm without obvious trigger, accompanied by chest tightness and shortness of breath, obvious when moving and lying down, wheezing sounds could be heard, no chest pain, hemoptysis, and no fever. He is a farmer, has no history of smoking or drinking, and has denied a history of chronic diseases. On physical examination, bipolar wheezing sounds could be heard in the left lung. Laboratory test results: blood routine white blood cells 4.57×10⁹/L, blood neutrophils 47.0%, blood eosinophils 5.7%; Carbohydrate antigen 125 and squamous cell carcinoma-related antigen are within the normal range; Blood gas normal; The pulmonary ventilation function test was normal. Enhanced chest CT showed a soft tissue density shadow at the level of tracheal protuberance, about 1.3 cm in diameter. The CT value of plain scan was 23.5 HU, and the CT value after enhancement was 25.7 HU (Figure 1). Bronchoscopy showed a spherical neoplasm near the left main bronchial opening in the lower trachea (Figure 2). The surface mucosa of the neoplasm was smooth and the blood supply was abundant. The neoplasm was removed by trap. Pathology and immunohistochemistry confirmed that it was tracheal leiomyoma. The patient's cough and asthma improved significantly after operation, and occasionally coughed a small amount of dark red bloody sputum. He was discharged 3 days later. One outpatient CT follow-up one year later showed no tumor recurrence.

The patient, a 63-year-old male, underwent "combined thoracolaparoscopic resection of cardia cancer and gastroesophagothoracic anastomosis" for "poorly differentiated adenocarcinoma of the cardia". Neoadjuvant chemoradiotherapy was performed before surgery. Fever occurred on the 12th postoperative day, and chest CT was performed after oral administration of meglumine diatrizoate, which showed an air-containing cavity in the posterior mediastinum. The proximal end of this cavity communicated with the left main bronchus (Fig. 1, arrow) and the distal end communicated with the esophagogastric anastomosis (Fig. 2, arrow). Intraesophageal contrast medium was filled into the mediastinal cavity (Fig. 2, triangle). Bedside bronchoscopy showed mucosal erosion of the left main bronchial wall, covered with purulent coating, and a fistula in between (Figure 3, arrow). Diagnosis of esophageal-mediastinal-bronchial fistula, secondary mediastinitis possible. The patient's family requested conservative treatment. Two days later, the patient's condition worsened, severe pneumonia and septic shock occurred, and his family gave up treatment and voluntarily discharged the hospital. Tracheoesophageal fistula is a serious complication that may occur after surgery of esophageal and cardia tumors. It usually occurs in the left main bronchus and the middle and lower segments of trachea, and its clinical feature is choking and cough after swallowing. Upper gastrointestinal angiography, CT, MRI, bronchoscopy and gastroscopy are useful for diagnosing and distinguishing local anatomical relationships. For suitable patients, endoscopic placement of tracheal and/or esophageal stents may be a therapeutic option for fistula closure. In this patient, tracheoesophageal fistula was complicated after cardia cancer surgery. Combined with the location of the fistula, endotracheal Y-type silicone or metal-covered stent may be considered. However, the family required conservative treatment, and subsequent severe infection occurred with poor outcome.

A 31-year-old male went to the Department of Respiratory and Critical Care Medicine of the First Affiliated Hospital of University of Science and Technology of China (Anhui Provincial Hospital) for "chest pain for 1 month". The patient developed persistent dull pain in the right chest 1 month ago, which gradually worsened, without cough, hemoptysis, asthma, fever, etc. He had a history of smoking for more than 10 years, with an average of 20 cigarettes a day, and had not quit smoking. Career as a truck driver. A family genetic history is denied. CT of the patient's chest showed multiple irregular cystic lesions in both upper lungs with different sizes, accompanied by multiple nodules (Figures A ~ C), bone destruction of the sternal stem and thoracic 4 vertebrae with soft tissue density shadows, and Langerhans cell histiocytosis (LCH) is considered to be more likely. Sternal soft tissue biopsy was performed. The pathological results showed that Langerhans histiocyte proliferation with a large amount of eosinophil infiltration. Immunohistochemical results showed that CD1a (+), Langerin (+), S100 (+), CD68 (+), CD4 (+), BRAF V600E (+), CD21 (-), CD35 (-), CD (-), Ki-67 (+, about 20%). LCH is a rare disease of unknown cause characterized by infiltration and destruction of adjacent structures by Langerhans cells, the organs most commonly invaded include bones, lungs, skin, lymph nodes, and the pituitary gland. Pulmonary LCH is more common in young smokers and more common in men. It is manifested as nodular lesions in both lungs, which may be accompanied by diffuse cystic lesions, mainly in the middle and upper lung fields, and the cystic lesions may increase with the progression of the disease. This patient was a young man with a long history of heavy smoking. Multiple irregular cystic lesions with nodular shadows in both upper lungs were seen on chest CT. Finally, LCH was confirmed by tissue biopsy pathology.