2014年 · 第94卷第37期

At present, with the development of social economy in China, the incidence of craniocerebral trauma caused by road traffic, high altitude fall and infrastructure construction accidents is increasing day by day. China's county, county-level city and township hospitals, that is, the population in the area where primary hospitals are located, accounts for 70% ~80% of the total population of the country, and a considerable number of patients after craniocerebral trauma visit these primary hospitals. Since 2011, the coverage of new cooperative medical care has been wider, patients have paid less medical expenses, and the number of trauma patients treated in primary hospitals has greatly increased.

Systemic lupus erythematosus (SLE) is the prototype of autoimmune diseases, and its treatment concept affects the whole treatment idea of autoimmune diseases. At the European Annual Meeting of Rheumatology in June 2014, a hot topic was "treat to target in systemic lupus erythematosus, T2T/SLE", which was roughly the same as the view that the author put forward in the Chinese Medical Journal more than 3 years ago that "lupus erythematosus needs to introduce the concept of targeted treatment"^[1]。 This year, Europe proposed T2T/SLE in a high profile, suggesting that the treatment concepts and strategies of SLE are being updated, and the concept of treat to target (T2T) has gradually become the consensus of SLE treatment. Clinical disciplines involving SLE, including internal medicine, dermatology, rheumatology and immunology, and nephrology, all need to pay attention to this new concept.

The patient was a 48-year-old male. He was admitted to the Department of Rheumatology and Immunology of Peking Union Medical College Hospital in February 2012 due to skin erythema ulcer with muscle weakness for 8 months, sore throat and dysphagia for 4 months. Eight months ago, the patient developed periorbital, facial, anterior chest, and extensional erythema of both elbows, partial ulceration, accompanied by proximal muscle weakness of the limbs, difficulty in lifting the upper limbs and squating the lower limbs, accompanied by joint pain of both shoulders and wrists, without swelling and morning stiffness; The local hospital found that creatine kinase (CK) was elevated (unknown), and the electromyogram showed myogenic damage. It was diagnosed as "dermatomyositis", and the symptoms improved after treatment with prednisone 40 mg/d. Four months ago, the dose of prednisone was reduced to 10 mg/d, and the rash worsened, with sore throat and hoarseness, which gradually worsened to dysphagia. One month ago, it progressed to inability to eat or drink, accompanied by fever, body temperature 38 ℃, cough and cough a small amount of white phlegm. He went to the emergency department of Peking Union Medical College Hospital and underwent laryngoscopy: nasopharynx, posterior wall of oropharynx, purulent coating of vocal cords, albuginea (FIG. 1A)。 The indwelling gastric tube was unsuccessful and esophageal obstruction was suspected. Admitted for further diagnosis and treatment. Weight loss of 20 kg after onset. Past, personal, marriage and childbirth, and family history are not special. Physical examination at admission: body temperature 36.5℃, heart rate 90 beats/min, breathing 18 beats/min, blood pressure 95/60 mmHg (1 mmHg =0.133 kPa); Poor nutrition, thin body shape, dark red maculopapular rash in V area of face, neck and chest, and scalp desquamation. Multiple finger tips ulcers and necrosis, fresh ulcers can be seen on the back of the left hand and left elbow joint, with deep wounds and yellow purulent coating, and multiple maculopapular rash, ulcers and crusts on the right shoulder, right elbow joint, multiple proximal interphalangeal joints of the right hand, metacarpophalangeal joint, left hip, both heels and the extension of the first metatarsophalangeal joint. Deep ulcer on the posterior pharyngeal wall with yellow-white purulent coating. Snow feeling under the skin of the neck and right chest. A small amount of wet rales was smelled in both lower lungs. Heart, abdomen (–). There was no edema in both lower limbs. Proximal muscle strength of both upper limbs grade IV, proximal muscle strength of both lower limbs grade V^–Grade. Laboratory test: blood routine: white blood cells 5.45×10⁹/L, hemoglobin 111 g/L, platelets 143×10⁹/L. Blood biochemistry: alanine transferase 59 U/L, aspartate transferase 34 U/L, albumin 22 g/L, creatinine 62 μ mol/L, urea 12.25 mmol/L; CK 13 U/L, lactate dehydrogenase 293 U/L. High sensitivity C-reactive protein (hsCRP) 21.49 mg/L; Erythrocyte sedimentation rate (ESR) 77 mm/1 h; Immunoglobulin, complement and rheumatoid factor were normal; Anti-nuclear antibody, anti-extractable nuclear antigen antibody, anti-phospholipid antibody, myositis antibody spectrum was negative. Tumor screening: CA125 was slightly higher, but the rest was normal. Whole body bone scan and abdominal CT were normal. Chest CT (FIG. 2A): interstitial lesions of both lungs, bullae at the left apex, thickened pleura, subcutaneous and mediastinal emphysema of the right chest. Cardiac ultrasound: reduced left ventricular compliance, minor pericardial effusion. Pathology of pharyngeal ulcer biopsy: acute and chronic inflammation, with inflammatory exudation necrosis and fungal hyphae. Hexamine silver staining (+). Upper gastrointestinal angiography: laryngopharyngeal fistula, subcutaneous, mediastinal development (Figure 3), suspected stenosis of the lower esophagus. Swab culture at cutaneous ulcers: methicillin-sensitive Staphylococcus aureus.

Osteoporosis is a systemic disease characterized by low bone mass and destruction of bone tissue microstructure, which leads to increased bone fragility and easy fracture. It is characterized by high incidence (84 million osteoporosis patients in China alone). With the increase of social aging population, the incidence of fractures caused by osteoporosis not only increases significantly, but also leads to an increase in medical expenses and socio-economic problems (at least 15 billion yuan is consumed in China every year).^[1]。 The medical expenses of treating osteoporosis and fractures caused by osteoporosis have exceeded those of other chronic diseases, such as cerebral infarction, myocardial infarction, breast cancer and chronic obstructive pulmonary disease. Therefore, the research on osteoporosis has attracted increasing attention.

autophagy, or self-phagocytosis, is the self-degradation of cells under stress, removing damaged or excess proteins and organelles and realizing the recycling of intracellular components. This process is strictly controlled and highly conserved in cells, and is closely related to cell growth, proliferation and tumorigenesis^[1], and play different roles in different tumors or different stages of the same tumor and in the course of radiotherapy and chemotherapy of tumors^[2]。

The patient was a 28-year-old female. Due to the right breast mass for 4 years with enlargement for 1 month, she was admitted to the Affiliated Obstetrics and Gynecology Hospital of Zhejiang University on April 29, 2013. She had a history of cesarean section 2 months ago. Physical examination: A 2.0 cm ×2.5 cm mass can be seen in the outer upper quadrant of the right breast, which is hard in texture, unclear in boundary, average in mobility, negative in dimple sign and orange peel sign, and no obvious swollen lymph nodes under both axillaries. Imaging: Breast ultrasound revealed hypoechoic foci at the junction of right breast and axilla (BI-RADS-US: category 5). Mammograms showed an isodensity mass of 1.7 cm ×1.4 cm ×1.5 cm in the upper outer quadrant of the right breast near the axilla (Figure 1), shallowly lobulated, with blurred boundaries, short burr shadows and no obvious calcification. MRI showed a mass of 2.4 cm ×2.0 cm ×1.9 cm in size near the axilla in the upper outer quadrant of the right breast, 0.9 cm from the skin, T₁WI and other signals, showing star-like changes (Figure 2), T₂WI lipid suppression sequence showed slightly high signal, and low signal shadow was seen in the center (Figure 3), diffusion-weighted imaging (DWI) showed diffusion limitation, and the apparent diffusion coefficient (ADC) value of normal breast was 1.80×10^–3mm²/s, the ADC value around the mass was 1.26×10^–3mm²/s (Figure 4,Figure 5), the dynamic enhancement scan mass enhancement was roughly uniform, and short burr shadows were seen around it, showing a plateau enhancement curve (Figure 6)。 MR imaging evaluation: mass in the upper external quadrant of the right breast (BI-RADS-MRI: category 5). Surgical and pathological results, fine needle puncture of right breast mass: patches of ductal epithelium were seen in the smear, the cytoplasm was rich in red staining, the shape was single, and the abnormality was not obvious. The possibility of low-grade special type cancer was not excluded. Freezing during operation was recommended; Hollow core needle puncture of right breast mass: granular cell tumor (GCT) of right breast is possible. During the operation, the mass was located near the edge of the gland in the outer upper quadrant of the right breast, with a clear boundary with the pectoral muscle and no obvious infiltration. It was 2.5 cm ×2.0 cm ×2.0 cm in size, hard in texture, gray-yellow in section, uneven in texture, and the surrounding gland tissue was fine granular (changes during lactation). Final diagnosis: granulosa cell tumor of the right breast (Figure 7，Figure 8)。