2018年 · 第98卷第12期

According to domestic and foreign guidelines, the clinical diagnosis of community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) does not seem difficult. Several criteria can be added together to meet the requirements, and there are many methods for etiological diagnosis. Clinical treatment is also empirical or targeted selection of anti-infective drugs. If highly drug-resistant bacteria appear, choose a possible effective drug combination or off-label medication. However, this is not the case, and the etiological diagnosis rate of CAP under the experimental conditions is only 53.1%^[1]； The autopsy results confirmed that the coincidence rate of clinical diagnosis VAP was about 69%^[2]； Coupled with the problems of colonizing bacteria and contaminating bacteria, the accuracy of etiological diagnosis at ordinary times can be imagined. We often hear such complaints: We have done it strictly according to the guidelines, all the top experts that should be invited have been invited, and all the antibacterial drugs that can be used have been used, but they are still ineffective. What should we do? The current fast-food "evidence-based medicine" evidence and the endless, constantly updated diagnosis and treatment guidelines based on it appear to be of limited value.

Extracorporeal life support (ECLS), also commonly referred to as extracorporeal membrane oxygenation (ECMO), originated from cardiopulmonary bypass and has become the most representative new treatment in the field of critical care and emergency medicine in recent years. ECMO can replace patients' heart and lung work, not only playing an important role in the treatment of heart and lung failure, but also helping many patients who have nearly died due to cardiopulmonary failure due to the primary disease to survive the most critical period, so that they can regain the opportunity to treat the primary disease. According to statistics, the number of ECMO cases nationwide reached 1,234 in 2016 (including 67 cases in Hong Kong Special Administrative Region)^[1]。 With the continuous development of ECMO technology and the continuous growth of personnel in related fields, the In Vitro Life Support Professional Committee of Chinese Medical Doctors Association was established in 2017 and immediately took the lead in formulating an expert consensus on ECMO assistance in adult circulatory failure^[2]。

Genetic testing plays an important role in the auxiliary diagnosis and medication guidance of hereditary, infectious and tumor diseases. There are many detection methods in this field, and the advantages and disadvantages of different technologies are obvious. For example, fluorescence quantitative PCR detection speed is fast, but the throughput is limited, which cannot conveniently and quickly meet the clinical demand for the detection of dozens to hundreds of sites of multiple genes. Although high-throughput sequencing has extremely high throughput, its cost, time-consuming, personnel requirements, etc. are not suitable for such detection. Therefore, new technology platforms are urgently needed to fill this gap.

extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, as a mechanical circulation assistance technology that can be inserted percutaneously, has the advantages of convenient placement, no location restriction, simultaneous biventricular combined respiratory assistance and relatively low price. In recent years, it has been applied to various acute circulatory and/or respiratory failures where conventional life support is ineffective. With the accumulation of clinical experience of ECMO for circulatory and/or respiratory assistance and the advancement of biomedical engineering technology, more portable and more stable ECMO devices have entered the clinic, and more and more critically ill patients have benefited from it^[1,2]。 According to the International Extracorporeal Life Support Organization (ELSO), as of July 2017, a total of 16 561 adult patients with circulatory failure worldwide received ECMO adjuvant therapy^[3]。 In recent years, the number of ECMO cases in China has increased rapidly. According to the statistics of Extracorporeal Circulation Branch of Chinese Society of Biomedical Engineering, the number of ECMO cases nationwide reached 1,234 in 2016^[4]。

Bronchial fistula refers to the pathological condition of abnormal passages (fistula or fistula) between the bronchus and the cavity organs or cavities such as the thoracic cavity, thoracic cavity, stomach, esophagus and even bile duct^[1]。 Pulmonary cavity is a cavity-type lesion of the lung, which refers to an air-containing space located in a mass, parenchyma or nodule of the lung. Liquefaction necrosis of lung tissue due to different reasons is the pathological basis of lung cavity formation after air entry after bronchial elimination. It is common in tuberculosis and lung cancer^[2]。 If a pathological channel in the segment and above is directly connected to the cavitary lesion of the lung, we call it a "bronchopulmonary cavitary fistula (bronchial pulmonary cavity fistula, BPCF) ". The fistula of BPCF can be seen directly under the microscope during bronchoscopy, which can be directly accessed into the lung cavity. The data of 6 patients with BPCF complicated with fungal infection are reported as follows.

The reports of abdominal aortic aneurysm (AAA) complicated with malignant tumors are uncommon, but its incidence is on the rise in recent years. The proportion of patients with AAA or malignant tumors found to be complicated with both diseases before or during operation is about 3% ~13%^[1,2]。 In the preoperative examination of AAA, it was found that about 9% to 13% of patients had abdominal malignancy^[3,4]。 Among them, colorectal cancer is the most common. Studies have shown^[5], 1.3% of patients with AAA had concomitant colorectal cancer, while 0.9% of patients with colorectal cancer had concomitant AAA. The purpose of this study was to analyze the surgical treatment strategies of AAA combined with digestive malignancies.

A 21-year-old male was admitted on 30 December 2013 with "paroxysmal left epigastric pain and vomiting after eating for 13 d". Physical examination: Mild tenderness in the left upper abdomen and weakened breathing sounds in the left middle and lower lungs. Auxiliary examination: Urinary amylase: 1 013 U/L. Gastroscopy showed that the gastric cavity was torsed, and the gastric antrum was deformed and narrowed. After further imaging examination (including chest X-ray, total abdominal three-phase enhanced CT, and upper gastrointestinal tract angiography, seeFigure 1,Figure 2,Figure 3,Figure 4) The diagnosis was: left diaphragm swelling, gastric volvulus and splenic volvulus. Treatment: Abdominal pain was significantly relieved after conservative treatment after admission, but vomiting was not relieved, and the vomit did not contain bile; Endoscopic volvulus reduction was performed on the third day after admission, which ended in failure; On the 7th day of admission, surgical exploration was performed. During the operation, the left diaphragm was relaxed and swollen, the cardia moved down, the pylorus was located in the area adjacent to the esophageal hiatus in the left upper abdomen, the great curvature of the stomach was turned forward and upward and located above the small curvature of the stomach, the transverse colon was pulled upward, the spleen was located in the left middle abdomen, the spleen hilum faced outward, and the spleen rotated 180 ° clockwise, but there was no blood supply disorder. During the operation, the diagnosis of left diaphragm swollen, gastric torsion and splenic torsion was clear. Intraoperative gastroscopy after reduction showed that the gastric cavity was patent, and liquid diet began on the second day after operation. Upper gastrointestinal angiography on the sixth day after operation showed that the left diaphragm and gastric anatomical position returned to normal (Figure 5), the patient was successfully discharged on the 7th postoperative day and was followed up for 3 years without recurrence.

A 19-year-old male was admitted for "intermittent urination pain with hematuria for 1 year, recurrent and aggravated for 1 month". Blood routine: white blood cells 15.66 (normal reference value 3.5~9.5) ×10⁹/L. Urine routine: urine protein + (normal reference value-), white blood cell + + + (normal reference value-), occult blood test + + + (normal reference value-), white blood cell count 954.6 (normal reference value 0-28) /μ L, red blood cell count 381.3 (normal reference value 0-28) /μ L. The serum tumor markers were all within the normal range. Abdominal color ultrasound showed solid retroperitoneal echo (pancreatic head occupied space was not excluded). 18 Fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) (GE Discovery VCT, USA) examination showed: irregular mass in the pancreatic head area with a small number of punctate calcifications, increased radioactivity uptake, SUV_max17.38, considering the possibility of pancreatic neuroendocrine tumors (FIG. 1A，FIG. 1B)。 Abdominal CT scan showed a round soft tissue shadow at the head of the pancreas, with a CT value of about 45 HU (FIG. 2A)； After enhancement, the arterial phase was significantly enhanced, and the CT value was about 128 HU (Figure 2B)； The degree of enhancement decreased in the venous phase, and the CT value was about 107 HU (Figure 2C)； The size is about 3.8 cm ×3.4 cm ×5.0 cm, the border is clear, and the adjacent blood vessels are shifted. Consider the possibility of pancreatic head cancer. Pancreaticoduodenectomy was performed, and pancreaticoduodenectomy tissue specimens were taken. Microscopically, adenoid structures were seen in the proliferating fibrous tissue, and the cells were atypical and disordered (Figure 3) Immunohistochemistry showed: CD56 (+), CK19 (+), CK8/18 (+), Ki67 (~5%), P53 (scattered +), SYN (+), Villin (scattered +), AACT (±), AAT (±); Special staining results showed: AB/PAS (loose +). Consistent with pancreatic acinar cell carcinoma (PACC).

Non-invasive positive pressure ventilation (NPPV) is a common and usual respiratory support for patients with acute and chronic respiratory failure^[1,2]Provide positive pressure ventilation assistance to patients through non-invasive connection methods such as nasal mask, mouth and nose mask or full face mask. Because there is no artificial airway to close the respiratory circuit, NPPV is essentially a "leaky" ventilation mode. In order to achieve the ideal therapeutic effect, on the one hand, it is required that NPPV ventilator can solve how to achieve good man-machine synchronization and effective alveolar ventilation in the case of circuit leakage, that is, it is required that "the air blows well"; On the other hand, in the absence of artificial airway, how to maintain the patency of natural airway and implement effective airway maintenance is the basis, condition and prerequisite to ensure the success of NPPV treatment, that is, it is required that "the breath is clear". The problem of airway maintenance for NPPV patients is described below.

Autophagy is a survival mechanism of cells under stress. It exists in eukaryotic cells, which is mediated by lysosomes to degrade damaged organelles and long-acting proteins in cells, realize cell metabolism and renewal of organelles, promote cell survival and maintain homeostasis; However, excessive autophagy is harmful to the body, and proper autophagy regulation is a necessary condition for the formation of intracellular homeostasis^[1]。 Abnormal regulation of autophagy activity has been elucidated in a number of diseases, including malignancies, neurodegenerative diseases, infections, and inflammation. However, there are relatively few studies on autophagy in burns. This article will briefly introduce the general characteristics of autophagy and complications of severe burns, sort out the current articles on autophagy in burns, and summarize the characteristics and regularities of autophagy in burn environment, so as to provide more comprehensive theoretical support for a deeper understanding of the mechanism of autophagy after severe burns and its role in burn treatment in the future, and finally achieve reducing burn complications and improving treatment efficiency.