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Journal: Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases

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Objective: To describe the clinical characteristics of acute respiratory distress syndrome (ARDS) caused by severe influenza virus in our hospital. Method: From November 2017 to February 2018, 48 patients were diagnosed with ARDS caused by influenza virus pneumonia. There characteristics, treatment, and outcomes were summarized and analyzed. According to the prognosis, the patients were divided into a survival group and a death group for comparative analysis. The multivariable logistic regression analysis was used for risk factors of hospital mortality. Result: Thirty-one patients were confirmed to have influenza A virus infection, 3 influenza B virus, 2 mixed infection, while 12 patients were diagnosed by clinical criteria. Eighteen patients died, with a mortality of 38%. Twenty-six patients (54%) were co-infected by other pathogenic microorganisms, including 17 cases of invasive aspergillus infection. Sixteen patients (33%) acquired nosocomial infection that significantly correlated with the hospital mortality, P=0.003. Multivariable logistic regression analysis showed that higher age (OR=1.086, 95% CI: 1.016-1.016), P=0.015), longer duration of flu-like symptoms to RICU time (OR=1.196, 95% CI: 1.031-1.031, P=0.018) and lower PaO(2)/FiO(2) (OR=0.973, 95% CI: 0.951-0.951, P=0.017) were independent risk factors for hospital mortality. Conclusion: In the flu season of 2017-2018, the patients of ARDS caused by severe influenza pneumonia were mainly influenza A virus, with a mortality of 38%. Co-infection was very common, especially aspergillus infection. Nosocomial infection was common and significantly correlated with high mortality. Lower PaO(2)/FiO(2), higher age and the longer duration from influenza-like symptoms to RICU was independent risk factors for high hospital mortality.

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Objective: To analyze the clinical manifestations of patients with endobronchial hamartoma(EH),and therefore to improve understanding of the disease. Methods: Data were retrospectively reviewed to describe the clinical characteristics, diagnosis procedures and prognosis of EH, including 5 patients in Beijing Anzhen Hospital, Capital Medical University from Jun 2007 to Feb 2018 and another 159 patients from Chinese and English literatures published after Jan 2000. Results: The five patients, 4 males and 1 female, aged from 46 to 69 years[mean (56±7) years], were diagnosed with EH in our hospital. There was no fever in the 5 cases, cough and expectoration in 4 cases, hemoptysis in 3 cases and asymptomatic in 1 case. Chest CT revealed that the lesions of all 5 cases were located in the right bronchial tube; 3 as high-density endobronchial mass, 1 as low-density mass, 1 as mixed density mass, and 1 as a “popcorn” lesion. Three cases were accompanied by obstructive pneumonia in the distal part of the EH and 2 cases by atelectasis. CT enhanced scan was performed in 5 cases, 2 showing no enhancement and 3 showing mild enhancement. Four cases showed polyposis under bronchoscopy, and 5 cases received bronchoscopic biopsy with 3 pathologically diagnosed as EH. Four of them received lobectomy, while 1 received removal by biopsy forceps, and all were pathologically confirmed as EH. There was no evidence of recurrence in these 5 patents with follow-up. Conclusions: EH was a rare benign bronchial tumor with nonspecific clinical and imaging manifestations. Endobronchial polyposis could be revealed by bronchoscopy, and pathological study is required to confirm the diagnosis.

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Objective: To evaluate the characteristics of exercise ventilation and gas exchange in obese and extremely obese patients by Cardiopulmonary exercise test (CPX). Methods: Restrospective anal-ysis of subjects who underwent CPET in Shengjing Hospital of China Medical University from June 2014 to June 2017. A total of 74 subjects were enrolled. According to the body mass index (BMI), 74 subjects were divided into control group(18.5 kg/m(2)≤BMI<23.9 kg/m(2)) (n=21), obese group (28.0 kg/m(2)≤BMI<40.0 kg/m(2)) (n=30) and extremely obese group(BMI≥40.0 kg/m(2))(n=23), respectively. V(O2max), V(O2max)/kg, anaerobic thresh-old(AT), oxygen pulse(V(O2)/HR), breath reserve(BR), inhale time (VTin), expiratory time(VTex) and ventilato-ry equivalent for CO(2)(EqCO(2))were measured by CPX and compared by using one-way ANOVA. Results: Compared to the control group (1 620±400) L/min, the maximal oxygen uptake(V(O2max)) in obese group(1 905±592) L/min and extremely obese group (2 131.09±541.86) L/min were significance higher (F=5.14, P<0.01). The V(O2max)/kg in obese group (19±5) L·min(-1)·kg(-1) and extremely obese groups (16±4) L·min(-1)·kg(-1) were sig-nificant lower than those in control group(27±5)L·min(-1)·kg(-1) (F=35.37,P<0.01). Compared to the control group (9.3±1.4)L·min(-1)·W(-1), the change of oxygen uptake required under certain exercise load (ΔV(O2)/ΔWR) in obese group(9.0±1.7) L·min(-1)·W(-1)and extremely obese group (8.7±2.2) L·min(-1)·W(-1) were no significant difference (F=0.67,P=0.51). The AT in obese group (1 114±391) L/min and extremely obese group (1 348±349) L/min were significant higher than those in control group (832±223) L/min (F=12.85,P<0.01). Com-pared to the control group(10±4) L·min(-1)·b(-1), V(O2)/HR in obese group (12±3) L·min(-1)·b(-1) and extremely obese group(14±3) L·min·b(-1) were significance higher (F=8.16, P<0.01). No significant difference was found between the three groups in BR, VTin, VTex and EqCO(2). Conclusion: obese and extremely obese individu-als have a decreased ablity to exercise when the body requires anaerobic metabolism to provide energy. As exercise power increases, the heart oxygen consumption per stroke and the amount of volume and oxygen re-quired for gax exchange does increase.

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Objective: To analyze the clinical features, diagnosis and differential diagnosis of diffuse pulmonary meningotheliomatosis (DPM), a rare subtype of minute pulmonary meningothelial-like nodules (MPMN), so as to improve the understanding of this disorder. Methods: The clinical data of a patient diagnosed as DPM admitted in department of Respiratory Medicine, Peking University Third Hospital in August 2016 were reported and the related literatures were reviewed. With “pulmonary meningothelial-like nodules” , “minute pulmonary meningothelial-like nodules” or “diffuse pulmonary meningotheliomatosis” as the search terms, and the search time before November 1st 2017 for Wanfangdata, China National Knowledge Infrastructure (CNKI), and PubMed.Twenty-five articles were retrieved, among which 6 English (all case reports) articles were found with the search term “diffuse pulmonary meningotheliomatosis” involving 10 cases, and the other 19 articles (1 Chinese, 18 English) about MPMN mainly discussed non-DPM cases,including 13 case reports and 6 pathological/genetic studies. Results: A 68-year old female was admitted to the hospital because of intermittent cough and expectoration for more than 3 years and aggravation for 3 weeks. Her pulmonary CT showed diffuse minute nodules distributed randomly throughout both lungs, and did not improve after treatment with oral Moxifloxacin for 2 weeks. A video-assisted thoracoscopic biopsy was performed. The specimens showed MPMN and no other lesions, which confirmed the final diagnosis of DPM. She was followed without any medication therapy and her pulmonary CT showed stabilization of the lesions one year later. DPM was considered as a rare type of MPMN. A total of 11 cases were analyzed, including 10 cases reported in the literature. The patients included 1man and 10 women, aged 51 to 75 years, with an average age of (64±8) years. Among the 11 patients, 8 denied a history of smoking or of occupational exposure, 7 presented with dyspnea, shortness of breath, or fatigue, and 8 had mild abnormalities of pulmonary function test. The pulmonary CT of all the patients showed randomly distributed, diffuse bilateral small solid or ground-glass nodules, with the diameters less than 5 millimeters, some of which were cavitated. Only 1 patient had pulmonary thromboembolism, while the other 10 did not have any other lung diseases. All the patients were histologically diagnosed, 8 by open lung biopsies, 2 by transbronchial lung biopsy, and 1 by CT-guided fine needle aspiration. Three patients were followed for 12-92 months and the lung lesions were all stable. Conclusions: As a rare subtype of MPMN, DPM lacks specificity of clinical manifestations, and presents with diffuse bilateral small solid or ground-glass nodules, distributed randomly throughout both lungs. An early correct diagnosis depends on biopsy.

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Objective: To investigate the peripheral small airway dysfunction differences between idiopathic pulmonary arterial hypertension (IPAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Methods: Impulse oscillmetory system testing (IOS) and pulmonary function testing (PFT) were performed in IPAH and CTEPH patients and 30 healthy control group. We also carried out a subgroup analysis depending on their medical history of airway diseases. Results: We included 42 IPAH and 47 CTEPH patients (with or without airways disease: 8 vs. 34 and 17 vs. 34, respectively). Compared with CTEPH patients, IPAH patients were younger but had more serious pulmonary vessel resistance and mean pulmonary arterial resistance. Compared with IPAH patients, CTEPH patients had significant impaired peripheral small airway dysfunction with decreased of MEF(50) (% pred), MMEF(75/25) evaluated by PFT and R5-R20, Δ R5-R20 and AX measured by IOS [10.6(2.0, 33.0) vs. 2.5(-5.0, 16.5); 22.1(14.0, 32.6) vs. 15.5 (7.0, 23.2); 7.64(4, 18.6) vs. 6(3, 11) respectively, all P<0.05]. Subgroup analysis revealed there were no significant peripheral small dysfunction differences in IPAH patients with or without airway diseases. CTEPH patients had a higher proportion of airway diseases and more serious peripheral dysfunction than IPAH patients with airway diseases. Compared with control healthy group, peripheral airway dysfunction was more obvious even in IPAH and CTEPH patients without airway diseases. Conclusion: Compared with IPAH, CTEPH patients were older, but had better hemodynamics and a higher proportion of airway diseases. The peripheral airway dysfunction were more serious in CTEPH patients without airway diseases than IPAH patients without airway diseases and healthy controls group.

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Objective: To investigate the characteristics of respiratory viral infections, and correlation between inflammatory cytokines and respiratory virus infections in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). Methods: A prospective cohort of patients with acute exacerbations of COPD was enrolled. The sputum of all patients were collected, and 15 respiratory viruses were detected using multi-channel real-time fluorescence quantitative PCR. The clinical characteristics associated with viral infections were analyzed. The peripheral blood of the patients was collected and cytokines including IL-6, IL-8, RANTES, IP-10, sIL-2R, IFN-γ, TNF-α in the serum were detected by ELISA. Association of these cytokines with respiratory viral infections was evaluated and a discriminant model was established. Results: A total of 99 patients with acute exacerbations of COPD were enrolled in this study. Thirty-four cases (34.3%, 34/99) were positive for viral detection. Among them, the positive rate of influenza A virus was the highest (38.2%, 13/34), followed by rhinovirus (35.3%, 12/34). Multifactor logistic regression analysis showed that, fever, COPD assessment test (CAT) score in stable stage, serum IP-10 and TNF-α levels were correlated with respiratory viral infections in patients with acute exacerbations of COPD. The levels of serum IP-10 and sIL-2R increased significantly in patients with influenza A virus. Conclusions: Respiratory viral infections were common in acute exacerbations of COPD. Influenza A virus and rhinovirus were the two most common viruses. Fever was a common symptom. Patients with severe respiratory symptoms at stable stage were susceptible to viral infection. Viral infection was associated with an increase in systemic inflammatory levels, most significantly in influenza virus infection. A discriminant model composed of fever, CAT score in stable stage, serum IP-10 and TNF-α levels can be used to predict respiratory viral infections in acute exacerbations of COPD.

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Objectives: To summarize the computed tomography angiography(CTA) features of Dieulafoy disease of the bronchus. Methods: The clinical, imaging and pathological data of Dieulafoy disease of the bronchus diagnosed in our hospital from July 4, 2010 to June 20, 2016 were retrospectively analyzed, and the CTA imaging features of the abnormal bronchial arteries were summarized. Results: There were 6 cases of bronchial Dieulafoy disease, 5 males and 1 female, with an average age of (55±15) years. Three cases had smoking history, and 2 cases had underlying diseases such as tuberculosis and acute myeloid leukemia. The common manifestations were hemoptysis, fever and pneumonia. Three patients got CTA examination, and bronchial arteries of Dieulafoy disease of the bronchus were circuitous and dilated, with the vascular diameter lager than 2 mm, no gradual narrowing but sudden truncation. Some circuitous vessels went into bronchial lumen as nodules. The bronchoscopy biopsy of 2 cases of bronchial nodules led to severe hemorrhage, with one death and one survival by successful management. Conclusions: Bronchial arteries of Dieulafoy disease of the bronchus were circuitous and dilated, and some circuitous vessels went into bronchial lumen as nodules, this demonstration can be used to diagnose Dieulafoy disease of the bronchus. For patients with hemoptysis, bronchial biopsy should only be performed after CTA examination if this disease is suspected.

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Objective: To explore the signal pathway of M2-type polarization induced by Mycobacterium tuberculosis (MTB)-specific peptide E7. Methods: Monocyte-macrophages were divided into blank control group, M1 positive stimulus group [co-stimulated with lipopolysaccharide and gamma interferon (IFN-γ)], M2 positive group(co-stimulated with IL-4 and IL-13), and E7 experimental group (with MTB-specificity polypeptide E7 stimulated). The expression of M1 type markers CD(16), IL-6, TNF-α and M2 type markers CD(163), CD(206), IL-10 were detected at 12, 18, 24 and 36 h. Furthermore, peroxisome proliferators-activated receptors-γ (PPAR-γ) blocker was used in the blank control group, M2-positive stimulus group and E7 experimental stimulus group. T test was used to compare the expression of PPAR-γ and CD(163) before and after the addition of blockers. Results: Compared with the positive control group and the blank control group, the expression of TNF-α in the E7 experimental group gradually reached the peak when macrophages were stimulated for 18 h(the relative expression was 20.02), and then the expression of TNF-α gradually decreased and the expression of CD(163) increased. The expression of CD(163) peaked at 24 h (the relative expression was 2.44). After adding the inhibitor, the expression of PPAR-γ in E7 stimulation group was lower than before blocking (before blocking 0.94±0.06, after blocking 0.69±0.09, P=0.028). CD(163) expression level was significantly lower than that before blocking (before blocking 3.95±0.61, after blocking 2.87±0.20, P=0.047). Conclusion: The MTB-specific peptide E7 induced differentiation of macrophages into M2 type, a process that may be involving PPAR-γ in just another kinase-signal transducer and activator of transcription pathway.

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Objective: To study the role and mechanism of CD(4)(+) CD(25)(+) FoxP3(+) regulatory T cells (Tregs) in the pathophysiological process of indirect acute lung injury (iALI) in mice. Methods: The iALI model was successfully induced by shock/cecal ligation and puncture method. Sham (n=8), cecal ligation and puncture (CLP, n=10), and hemorrhage (Hem, n=12) groups were established as controls. Two experimental groups were established: CLP+Hem (n=15) without Tregs adoptive transfer (AT), and CLP+Hem with Tregs adoptive transfer (CLP+Hem+AT, n=14). The number of Tregs, subsets of lymphocytes, neutrophil activity, apoptosis, cytokine levels and histopathological changes were measured in the lung tissue of each group. The protein exudation and the expression of IL-10 in bronchoalveolar lavage fluid (BALF) were also detected. After in vitro cell co-culture, the proliferation of activated T cells and the expression of IL-10, INF-γ and iNOS protein were detected. Results: The percentage and the absolute cell number of CD(4)(+) CD(25)(+) FoxP3(+) Tregs in lung tissue of iALI mice were (2.530±0.086)%, and (1.441±0.090)×10(4)/ml, respectively, which were significantly higher than the control groups (P<0.05). Adoptive transfer of Tregs could significantly decrease CD3-positive T lymphocytes, myeloperoxidase (MPO) activity, caspase-3 activity in lung tissue as well as protein leakage in BALF (P<0.05). Meanwhile interleukin-10 (IL-10) levels in lung tissue and BALF were up-regulated from (121.4±43.76) pg/ml to (201.0±61.96) pg/ml (t=2.776, P<0.05) and (206.2±90.88) pg/ml to (339.4±109.5) pg/ml (t=2.477, P<0.05), respectively. Histopathology was also significantly improved. The proliferation of activated T lymphocytes in the adoptive transfer Treg (AT-Treg) group (n=5) was significantly lower than that in the natural regulatory T cell (N-Treg) group (n=5, t=7.485, P<0.01) and the negative control group (n=5, t=16.66, P<0.01). However, iNOS enzyme inhibitor L-NMMA could significantly reduce the T cell proliferation (P<0.05). Conclusion: CD(4)(+)CD(25)(+)FoxP3(+) Tregs could reduce inflammatory reaction in mice with iALI, and the iNOS signaling pathway may be involved in this process.

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Objective: To investigate the diagnostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin Ⅰ (TnI) for detecting right ventricular dysfunction (RVD) in patients with non-high-risk acute pulmonary thromboembolism (APE). Methods: A retrospective analysis was performed in 96 adult patients [44 males, 52 females, aged (61±14) years] with non-high-risk APE from January 2015 to June 2016. All patients were divided into RVD group and non-RVD group according to whether there was right ventricular enlargement on echocardiography. The baseline data, serumTnI and NT-proBNP levels were compared between the 2 groups and the diagnostic value of the 2 cardiac markers for RVD was analyzed. Results: There were no significant differences in age, gender, body mass index between the 2 groups (P>0.05). The creatinine clearance rate of the RVD group was lower than that of the non-RVD group [96.4 (77.5,99.6) vs 101.7 (95.1,106.5), P=0.021]. NT-proBNP [2 300 (1 056,3 396) vs 188 (61,535), P<0.01] and TnI [0.13 (0.09,0.25) vs 0.00 (0.00,0.02), P<0.01] were significant higher in the RVD group than in the non-RVD group. The univariate logistic regression analyses showed that NT-proBNP (per 100 ng/L, OR 1.199, 95%CI 1.117-1.287), TnI (per 0.01 μg/L, OR 1.164, 95%CI 1.079-1.256) and creatinine clearance rate (OR 0.968, 95% CI 0.938-0.998) were significantly associated with RVD. Multivariate regression analysis showed that NT-proBNP (per 100 ng/L, OR 1.155, 95%CI 1.074-1.241) and TnI (per 0.01 μg/L, OR 1.079, 95% CI 1.011-1.151) were independently associated with RVD. The areas under the ROC curve (AUC) of NT-proBNP, TnI, and the combination of them were 0.908 (95% CI 0.841-0.976), 0.896 (95% CI 0.826-0.966) and 0.925 (95% CI 0.862-0.988), respectively. The cut-off value of NT-proBNP was 503.5 ng/L, with a sensitivity of 85.7%, specificity of 75.4%, positive predictive value (PPV) of 66.7% and negative predictive value (NPV) of 90.2%.The cut-off value of TnI was 0.05 μg/L, and the sensitivity, specificity, PPV and NPV was 80.0%, 86.9%, 77.8% and 88.3%, respectively. The optimal probability derived from the logistic regression model in which the 2 biomarkers were the independent variables was 0.779, with a sensitivity, specificity, PPV and NPV of 65.7%, 96.7%, 92.0%, 83.1%, respectively. Conclusion: Both NT-proBNP and TnI had preferably good diagnostic value for RVD in patients with non-high-risk APE, but their clinical application needed comprehensive evaluation combined with the overall manifestations of the patients and experimental methods. The diagnostic value was higher when the 2 biomarkers were evaluated together.