2015年 · 第95卷第09期

Since the European Society of Critical Care Medicine (ESICM), the American Society of Critical Care Medicine (SCCM) and the International Sepsis Foundation (ISF) jointly issued the Barcelona Declaration in 2002, severe infection and septic shock have become one of the most important missions faced by global critical care medicine. Over the past decade, despite some progress in this area, global guidelines for the treatment of severe infections and septic shock were published and updated in 2004, 2008 and 2012, respectively^[1,2,3]These guidelines summarize important research results in this field worldwide, standardize clinical behavior, and improve the level of clinical treatment. However, at the same time, the incidence of severe infection and septic shock still shows a rapid upward trend, and the mortality rate is still as high as 25%^[4,5,6]。 In the treatment of severe infection and septic shock, successful control of infection is one of the most important factors to determine prognosis. Only when the infection is successfully controlled can the tissue deperfusion and shock be completely corrected and the damaged organ function can be recovered. The following focuses on several common myths in anti-infective treatment of severe infection and septic shock.

The epidemic situation of multi-drug resistant bacteria (including multi-drug resistant organisms (MDR) and pan-drug resistant (XDR)) in nosocomia is becoming increasingly severe, and it has become a global problem affecting healthcare safety^[1]。 The epidemiological data showed that the incidence of multidrug resistance was significantly higher in the ICU isolates of Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Escherichia coli (the four most common multidrug resistant gram-negative bacilli^[2,3,4,5]Severe patients with MDR bacterial infection not only increase the incidence of complications, prolong ICU stay, increase medical expenses, but also significantly increase the mortality rate^[6,7]。 Therefore, it is a major challenge for ICU physicians to understand the risk factors related to MDR bacterial infection in ICU and explore effective prevention and control measures.

Posterior circulation ischemic stroke accounts for 25% to 40% of strokes, and 70% of posterior circulation ischemic stroke is caused by arterial-arterial embolism. The vertebral artery origin (VAO) is one of the most important causes of posterior circulation ischemia because of hemodynamic disorders and other reasons where atherosclerosis is easily formed^[1]。 Studies have shown that 9% to 33% of patients with posterior circulation ischemia have vertebral artery origin stenosis (VAOS) or occlusion^[2,3]。 Using the annual incidence of the New England Posterior Circulation Ischemia Registry, 10,000 to 20,000 patients with posterior circulation ischemia in the United States are caused by VAOS each year^[4]。 However, the diagnosis and treatment of VAOS has not attracted enough attention. In order to further improve the understanding of symptomatic atherosclerotic VAOS and standardize its diagnosis and treatment, especially endovascular treatment, the Interventional Group of Stroke Prevention and Control Committee of Chinese Association of Preventive Medicine organized experts from domestic neurology, neurosurgery and vascular interventional departments to write this consensus.

A 32-year-old female, Yi nationality, was admitted to the 42nd Hospital of the People's Liberation Army on April 18, 2013 due to the discovery of vaginal mass for 4 years. The patient usually has regular menstruation and no menstrual pain. Pregnancy 8 delivered 3, spontaneous abortion and induced abortion were 5 times in total. A live female baby was delivered naturally 7 years ago, a twin male baby was delivered naturally 4 years ago, and a live male baby was delivered by caesarean section 2 years ago. Six months ago, he performed "ovarian cyst surgery" in a local hospital (details unknown). Half a month ago, an out-of-hospital ultrasound revealed another pelvic cyst. Gynecological examination after admission: normal vulvar development, married and delivered. The vagina is smooth, and a cystic mass of about 8 cm can be palpable in the middle and upper part of the right side wall, and the mass is more obvious when exerting force. The cervix is smooth, the uterus is anterior, often large, medium in quality, active, without tenderness, and there are no abnormalities in the bilateral adnexal areas. Out-of-hospital and post-admission color ultrasound showed that the right side of the pelvic cavity occupied cystic space (76 mm ×73 mm thin echo light spot), considering ovarian chocolate cyst? (Figure 1)。 Admission diagnosis: (1) Right vaginal wall cyst; (2) Right ovarian chocolate cyst? The intravaginal mass has been considered for 4 years before surgery, and the pelvic cyst detected by ultrasound is the possibility that the vaginal wall mass grows towards the pelvic cavity. Cyst removal of the right vaginal wall was performed on 22 Apr 2013 under general anesthesia after routine preoperative preparation. At the same time preparing for an exploratory laparotomy. During the operation, the middle and upper segment of the right side wall of the vagina was incised about 7 cm long. After part of the cyst was exposed, the cyst wall was incised about 2 cm. It was seen that the cyst was filled with gray-white bean dregs-like substance. After about 100 g of content was aspirated to reduce the cyst volume, the cyst wall incision was clipped and the cyst was completely stripped. The cyst cavity is closed by intermittent suturing with 3/0 absorbable thread. Because the cyst cavity is large, a rubber drainage strip is installed; The right vaginal wall was sutured intermittently with 2/0 absorbable thread. There was no palpable mass in the pelvic cavity in double diagnosis. Vaginal tamponade with large gauze compression to stop bleeding, and the operation was completed. Digital rectal examination was normal. The procedure went smoothly with about 150 ml of bleeding. Pathological diagnosis: epidermal cyst (middle and upper segment of the right wall of the vagina),Figure 2。 The postoperative recovery was smooth, pelvic ultrasound reexamination showed no abnormalities, and the hospital was discharged 5 days after operation. Discharge diagnosis: epidermal cyst of the right vaginal wall. After 2 months of follow-up, the patient had no discomfort, pelvic ultrasound showed no abnormalities, and the vaginal mucosal wound healed well.

Patient 1, a 40-year-old female, was seen for 8 years with polycystic spleen discovery and half a year with enlarged spleen. Physical examination: soft abdomen, palpable subcostal spleen, 5 cm for A and B lines, 10 cm for A and C lines, +10 cm for D and E lines, soft texture, no tenderness, negative for Murphy's sign. Ultrasound findings: The spleen thickness diameter was 9.4 cm, the long diameter was 18.2 cm, and the subcostal diameter was 6.5 cm. The inner boundary of the spleen reached the level of the midline of the left clavicle. Multiple cystic anechoic, honeycomb-shaped, larger long diameter was 3.1 cm (Figure 1)。 Ultrasound revealed: splenomegaly, polycystic spleen. Intraoperative findings: A huge spleen was seen in the abdominal cavity, 20 cm ×15 cm, soft in texture, with uneven surface and vesicular changes, and no obvious adhesion to the surrounding tissues. Splenectomy was performed. Postoperative pathological diagnosis: splenic lymphangioma.

allergic rhinitis (AR) is one of the most common allergic diseases, which has a high prevalence and affects a large number of people, especially children are susceptible to AR^[1]。 Patients with AR are prone to mental and behavioral disorders, and their mental and behavioral disorders can in turn affect the development and prognosis of AR patients. AR was once considered a psychosomatic disease^[2]。 With the gradual recognition of AR, people not only recognize the new concept of "one airway, one disease"^[3]But also gradually recognized the intrinsic connection between AR and mental and behavioral disorders. This article expounds the characteristics of mental and behavioral disorders associated with AR patients, biological factors of susceptibility, biological mechanisms and possible treatment options, and proposes that the mental and behavioral disorders associated with AR patients should be actively treated on the basis of anti-allergic treatment.

Cervical invasive squamous cell carcinoma (SCC) goes through a long cycle from the development to the development of cervical intraepithelial neoplasia (CIN). Therefore, the early diagnosis and treatment of SCC have become the focus of attention. The transition from epithelial cells to mesenchymal cells (EMT) is closely related to the occurrence and development of malignant tumors derived from epithelial cells. Multiple steps work together to complete the process of EMT, causing the transformation of epithelial cells to mesenchymal cells, and the polarity and mobility of cells have corresponding changes^[1,2]。 In the course of EMT, an important marker is the decrease of E-cadherin expression^[1,2]。 High mobility group protein 1 (HMGB1) has been associated with invasion and metastasis of a variety of tumors. HMGB1 can activate mitogenic activated protein kinase (MAPK), nuclear transcription factor (NF-κ B) and other pathways. These signaling pathways have been shown to be related to EMT. It is speculated that HMGB1 promotes EMT in cervical cancer through NF-κ B pathway, promotes the development of "CIN-cervical cancer", and ultimately leads to invasive cervical cancer.

Growth hormone (GH) has an anti-insulin (Ins) effect, while its action on insulin-like growth factor-1 (IGF-1) produced by the liver has insulin-like properties. Clinically, both adults with GH deficiency and patients with acromegaly caused by GH excessive secretion have a tendency to insulin resistance, indicating that the effect of GH on the effect of Ins is very complex. There may be different mechanisms by which too high or too low GH levels lead to insulin resistance. With the widespread application of recombinant human growth hormone (rhGH) in adults with growth hormone deficiency (AGHD) in recent years, its influence on insulin sensitivity has been increasingly paid attention to while improving the body composition, bone mineral density, cardiovascular risk factors, etc. Studies have shown that low-dose GH therapy can improve insulin resistance in patients with AGHD^[1]。 This article will review the relationship between rhGH therapy and insulin sensitivity.

Pancreatic cancer is a highly malignant and rapidly progressing tumor of the digestive tract, with the fourth highest mortality rate among all cancers in the western developed countries^[1]It has the characteristics of frequent recurrence and early metastasis^[2]。 Patients with pancreatic cancer have an extremely poor prognosis, with a 5-year survival rate of less than 5%. The pathogenesis of pancreatic cancer is hidden and the mortality rate is high. The main reasons are closely related to the early lymphatic and hematological metastasis and peripheral nerve invasion^[3]。 Studies have reported that pancreatic cancer cells have the biological characteristics of neurotropic growth. Once pancreatic cancer occurs nerve invasion, its mortality rate can reach 90%. Dai et al.^[4]Studies have reported that the incidence of perineural invasion (PNI) in pancreatic cancer ranges from 64% to 100%. The occurrence of PNI may be related to the anatomical structure of peripancreatic nerves, the interaction of neurofactors and the in vivo environment. In recent years, a variety of conventional imaging methods and molecular imaging techniques have been used to reveal the degree and status of PNI from different angles and levels, so as to further evaluate the development of pancreatic cancer, so as to improve the survival of patients.