2016年 · 第96卷第12期

With the increasing attention of people to health and the extension of medicine, laboratory medicine as an important basis for clinical diagnosis, treatment and prognosis has also been developed rapidly. In the process of introducing, popularizing and updating modern inspection technology, the return time of inspection results is shortened, the inspection items are enriched, and the amount of inspection information per unit time is greatly increased, which affects the application effect of inspection results. After the rapid development in recent decades, the medical problems before and during analysis in the detection system have been deepened and improved continuously, so that the accuracy, stability and timeliness of the test results can meet the clinical needs. However, the content after analysis is relatively weak, and the audit of the test report still only stays at the simple check of the basic patient information and the comparison of historical results. Most of the test reports are only test reports, which do not fully reflect the description of the disease by the professional knowledge of laboratory medicine, and do not incorporate the connotation of substantive laboratory analysis and laboratory diagnosis, so that the service ability of laboratory medical knowledge is not fully reflected.

The incidence of bone metastasis in advanced breast cancer patients is 65% ~75%, while the first-episode bone metastasis in breast cancer accounts for about 27% ~50%^[1,2,3]。 Bone pain, bone injury and bone-related events (SREs) are common complications of bone metastasis from breast cancer. Bone metastasis does not directly threaten the life of patients, but bone metastasis with pain will seriously affect the quality of life of patients. Bisphosphonates inhibit osteoclast activity, reduce bone destruction, prevent and treat SREs^[4]。 Many guidelines and consensus at home and abroad regard bisphosphonates as the basic drugs for tumor bone metastasis, and the frequency of medication is once every 3 to 4 weeks. However, new data show that long-term treatment of patients with bone metastases is no less effective than once a month when the interval between bisphosphonate dosing is appropriately prolonged to once a month. Based on new data, the 2015 National Comprehensive Cancer Network (NCCN) breast cancer guidelines extend the time interval between bisphosphonate treatment^[3]。 In this regard, the 2014 European Society of Clinical Oncology (ESMO) guidelines have different positions and views^[2]。 These new studies and the recommendations of Chinese and foreign guidelines will be interpreted, in order to bring inspiration and help to the prevention and treatment of SREs in clinical breast cancer bone metastasis.

Clinical microbial morphological examination has important clinical significance for the early diagnosis of infectious diseases. It can diagnose possible infected pathogens at the first time through cytological characteristics and microbial morphological characteristics, so as to achieve the purpose of early diagnosis and early treatment, and is of great significance to improve the survival rate of patients. Traditional microbial morphological examination reports only briefly describe the microbial morphology under the microscope, and the rich etiological diagnostic connotation contained under the morphological description cannot be fully reflected, which makes it difficult for clinicians to fully understand. The reporting modes adopted by different medical units are different. When patients see a doctor in different medical units, doctors' understanding of the test results is also different, which may have an impact on the diagnosis and treatment process. The purpose of this consensus is to standardize the testing and diagnosis reporting mode, interpret the diagnosis and treatment information contained in microbial morphology to the clinic to the greatest extent, strengthen the communication between microbiological laboratory and clinic, and better provide etiological basis for early diagnosis and treatment of infectious diseases.

The diagnosis of chromosomal karyotype is to provide strong morphological evidence for the diagnosis of chromosomal diseases, genetic diseases, hematological tumors with recurrent genetic abnormalities and other diseases by counting the number of chromosomes and observing and analyzing the structure, so that children with genetic diseases can get early detection, early intervention and treatment, and it is also of important clinical significance for the evaluation of curative effect and prognosis of tumor patients^{[1,2,3,4,5,6,7,8,9,10,11,12,13,14]}。

Anemia refers to a symptom in which the amount of hemoglobin, the number of red blood cells and/or hematocrit per unit volume of peripheral blood is below the lower limit of the reference range. Anemia can be caused by systemic diseases throughout the body, and identifying the nature and etiology of anemia is essential for treatment. In recent years, the detection technology for anemia has developed rapidly. Immunological methods range from immunoelectrophoresis, enzyme-linked immunosorbent assay (ELISA), radioimmunoassay to chemiluminescence immunoassay; The separation technology ranges from cellulose acetate film, polyacrylamide gel electrophoresis to microchromatography column analysis, capillary electrophoresis, high performance liquid chromatography analysis, etc. Molecular biology, flow cytometry, chromosome analysis, etc. are also widely used in anemia detection, which provide an important basis for clinical diagnosis, differential diagnosis, treatment, prognosis judgment and curative effect monitoring.

In 2008, the World Health Organization (WHO) released the fourth edition of the classification protocol for hematopoietic and lymphoid tissue tumors^[1], has been widely used all over the world. With the rapid development and application of flow cytometry, cytogenetics and molecular biology, it plays a very important role in the accurate diagnosis and classification of hematopoietic and lymphoid tissue tumors, and effectively promotes the clinical treatment and prognosis of hematopoietic and lymphoid tissue tumors. At present, morphological examination, including peripheral blood smear, bone marrow smear and bone marrow biopsy, is an indispensable means for hematopoietic and lymphoid tissue tumor examination; Almost all cases of hematopoietic and lymphoid tissue tumors were analyzed by flow cytometry for immunophenotyping; Cytogenetic technologies, including chromosome karyotyping and fluorescence in situ hybridization, are widely used for the detection of chromosome aberrations and fusion genes in patients; Molecular genetics technology, including gene amplification and sequencing technology for the detection of fusion genes and mutant genes, has become the development trend of hematopoietic and lymphoid tissue tumor diagnosis. The clinical application of the above methods and techniques has gradually developed into highly professional and complex examination items, which are of great value and sometimes even decisive significance for the diagnosis and treatment of hematopoietic and lymphoid tissue tumors.

The 18-month-old male patient was in good health and had no special family history. Due to "repeated melena for more than 2 months", routine blood examination in the local hospital showed that hemoglobin was 45 g/L, and symptomatic and supportive treatment such as blood transfusion and fasting was given in the emergency department. No obvious abnormalities were found in Coombs test, anemolytic test and fluorescent spot test. Bone marrow puncture showed: proliferative anemia, iron deficiency, diagnosis of gastrointestinal bleeding, and later transferred to our hospital for treatment. After admission, abdominal enhanced CT revealed duodenal mass (Figure 1), enhanced significantly enhanced. Abdominal B-ultrasound suggests the possibility of intussusception of small intestine. A huge tumor-like protrusion with unclear pedicle width was seen under gastroscopy (Figure 2)。 On the 5th day after admission, gastroscope-assisted duodenal mass resection was performed. During the operation, a huge mass in the duodenal bulb, about 5 cm ×4 cm, with ulcer inflammation on the surface was seen. Avoiding the duodenal papilla, duodenal mass resection and duodenal repair were performed (Figure 3，Figure 4，Figure 5), with a pathological diagnosis of "juvenile polyp" (Figure 6), the postoperative recovery was acceptable, and there was no abnormality in the follow-up after discharge.

The patient, a 28-year-old male, came to our hospital on December 16, 2014 due to "right thoracic and lumbar erythema for 11 years". Eleven years ago, there was no obvious trigger to appear flaky erythema in the right chest and waist, no conscious itching or pain, no fever, chills, no photosensitivity, joint pain, no oral ulcer and other discomfort since the onset. No previous formal treatment. I came to our hospital for treatment 1 year ago because of obvious enlargement of rash. The patient was in previous health and denied family history of genetic diseases and similar diseases. Physical examination: The general condition is good, the physical development is normal, there are no oral ulcers, superficial lymph nodes are not swollen, and there are no obvious abnormalities in the systematic examination. Dermatological examination: Multiple bright erythema spots with irregular shape and clear boundaries distributed along the Blaschko line with a diameter of 0.2~2.0 cm were seen on the right chest and waist. Part of the erythema surface was covered with a few adhesive scales, and the skin was depressed and atrophied around the erythema, and the peripheral capillaries were dilated without obvious sclerosis (Figure 1)。 Laboratory tests: Blood and urine routine were normal. Complement C4 0.10 g/L (normal reference value 0.17-0.40 g/L). Erythrocyte sedimentation rate, serum immunoglobulin and complement C3 were normal, and anti-nuclear antibody (ANA), anti-double stranded DNA (dsDNA), anti-Smith antibody (Sm), anti-ribonucleosome (RNP) antibody, anti-Sjogren's syndrome A (SSA/Ro) antibody, anti-Sjogren's syndrome B (SSB/La) antibody, anti-scleroderma-70 (Scl-70) antibody and anti-Jo-1 antibody were all negative. Histopathological examination of skin lesions showed: epidermal atrophy, liquefaction and degeneration of basal cells, widening of some basement membrane bands, infiltration of massive lymphocytes around intradermal blood vessels and skin appendages, and more mucin deposition between collagen fibers (Figure 2), there was no increase, thickening and homogenization of collagen. Linear cutaneous lupus erythematosus (LCLE) was diagnosed according to the clinical and histopathological changes. After topical application of 0.1% tacrolimus ointment and 0.1% tretinoin ointment for 1 month, the rash turned slightly darker and local desquamation increased. Considering that the rash did not improve significantly after topical treatment, prednisone 15 mg was taken orally once a morning, hydroxychloroquine 0.2 was taken orally twice a day, vitamin E 0.1 was taken orally once a day, compound triamcinolone acetonide ointment and 0.1% tacrolimus ointment were taken orally. After 1 month, the erythema area gradually decreased, so prednisone tablets were reduced to 10 mg orally once a morning and hydroxychloroquine 0.2 orally once a day. After 2 months, oral medication was stopped and topical medication continued. After 4 months, the erythema turned obviously darker and some rash subsided.

A 24-year-old male was admitted to the hospital due to "abdominal distension, fatigue for 1 month and jaundice for 20 days". The patient developed abdominal distension, extreme fatigue, anorexia, yellowing of skin and sclera all over the body after taking ready-for-use traditional Chinese medicine Zhuangjiefeng dispersible tablets in August 2014. Liver function was checked: alanine aminotransferase (ALT) 1 255 U/L, aspartate aminotransferase (AST) 910 U/L, total bilirubin (TBil) 82 μ mol/L, direct bilirubin (DBil) 28.5 μ mol/L, albumin 26 g/L; Coagulation: prothrombin time (PT) 31.2 s, activated partial thromboplastin time (APTT) 46.3 s, prothrombin activity (PT%) 24.0%; Hepatitis A, B, C and E virological tests were all negative (-); Serum ceruloplasmin (-). After 1 week, he developed a disturbance of consciousness, and his consciousness became clear after symptomatic and supportive treatment such as lowering intracranial pressure. Later, bone marrow smear showed hemophagous phenomenon; He was transferred to our hospital due to unknown diagnosis in other hospitals and possible combination of hemophagocytic syndrome (HPS). No previous history of liver disease and manifestations of chronic portal hypertension. Denial history of alcohol consumption and toxic exposure. Physical examination: skin sclera yellowing, subcutaneous ecchymosis, abdominal distension, total abdominal tenderness and mild rebound pain. Mobile voicing positive (+).

A 55-year-old female, previously healthy, was admitted to the hospital on 25 April 2014 due to "upper abdominal discomfort for 3 months". The patient experienced upper abdominal discomfort, accompanied by dull pain and soreness in the lower back without obvious trigger 3 months ago, but no other discomfort. The above symptoms occur intermittently, and intermittent oral administration of "stomach medicine" can be temporarily relieved. 10 days before admission, he came to our outpatient clinic for gastroscopy, which showed chronic non-atrophic gastritis, and the nature of gastric antrum bulge remained to be investigated. He was admitted to the hospital with "gastric antrum bulge lesion". Physical examination: body temperature 36.0℃, pulse 72 beats/min, breathing 19 beats/min, blood pressure 145/91 mmHg (1 mmHg =0.133 kPa), consciousness, energy, no sclera yellowing, no anemia, no superficial lymph node enlargement, no liver palm and spider nevus, heart rate 72 beats/min, uniform rhythm, no pathological murmur, clear breathing sounds in both lungs, flat abdomen, no abdominal wall varices, no gastrointestinal pattern and peristaltic wave, soft abdomen, no tenderness, rebound pain and muscle tension, no palpable mass, no subcostal reach of liver and spleen, negative Murphy sign (-), mobile voiced sound (-), the upper boundary of the liver is located in the fifth intercostal margin of the midline of the right clavicle, and the lower boundary is located in the subcostal margin of the right quarter, percussion pain in the liver area (-), normal intestinal sounds, and no edema in both lower limbs. Admission diagnosis: Antrum protuberance lesion: stromal tumor? Leiomyoma? Ectopic pancreas? Lipoma? Auxiliary examination after admission: prothrombin time 13.2 s, partial prothrombin time 39.1 s, carcinoembryonic antigen 2.89 μ g/L, alpha-fetoprotein 5.40 μ g/L, white blood cell count 3.9×10⁹/L, neutrophil percentage 0.613, hemoglobin 118 g/L, platelet count 177×10⁹/L, hematocrit 0.354, total bilirubin 11.7 μ mol/L, alanine aminotransferase 19 U/L, aspartate aminotransferase 19 U/L, alkaline phosphatase 74 U/L, γ-glutamyltransferase 18 U/L, lipase 49 U/L, serum sodium, potassium and chlorine were all normal. On April 29, 2014, endoscopic ultrasound (EUS) showed that the posterior wall of the gastric antrum was broadly bulged, the surface mucosa was smooth, and there was no depression or glandular duct opening, with a size of about 1.5 cm ×1.5 cm ×1.2 cm. The 12 MHz microprobe scan showed that the gastric antrum bulge lesion originated from the mucosa and submucosa, with moderate echo and uneven internal echo. Several tubular anechoic structures were visible, and the larger anechoic tubular structure was about 0.22 cm ×0.30 cm in size. The hierarchical structure of muscle layer and serosa layer was clear and complete (Figure 1)。 Endoscopic mucosal resection (EMR) of gastric antrum bulge lesions was performed. After operation, the patient was given symptomatic and supportive treatment such as acid suppression and gastric mucosa protection, and the upper abdominal discomfort disappeared. Postoperative pathological diagnosis (gastric antrum) ectopic pancreas (Figure 2)。 The patient recovered and was discharged on 10 May 2014. The patient was followed up for 6 months after discharge and was in good condition.

A 63-year-old male was admitted to the hospital in January 2014 due to "repeated abdominal pain for 20 years, intermittent melena for 3 years, and recurrent abdominal pain for 1 week". Twenty years ago, the patient had intermittent severe pain in the left upper abdomen every 2 to 3 years, increased blood and urine amylase, and improved after drug treatment. Three years ago, the patient's gastroscopy showed spherical bulge of the gastric fundus and linear ulcer on the surface due to melena; CT showed pancreatic pseudocyst (7.9 cm ×6.5 cm), gastric fundus compression, splenic vein occlusion, and multiple collateral circulations; Diagnosis of "chronic pancreatitis (CP)", medical treatment improved, the patient refused surgery. More than a year ago, the patient underwent gastroscopy again for melena (Figure 1) shows gastric fundus bulge and gastric fundus varices; Abdominal CT showed pancreatic pseudocyst (9.3 cm ×10.2 cm); Capsule endoscopy showed edema and partial absence of jejunal mucosa; There were no abnormalities in colonoscopy; Considering "possible aspirin-related gastrointestinal bleeding", the drug treatment improved. One week ago, the patient had persistent colic in the middle and left of the upper abdomen after eating greasy food, accompanied by nausea and vomiting. Hemoglobin was 132 g/L, blood lipase was 79 U/L, and blood and urine amylase were normal. He was admitted to the hospital with "CP acute attack". Previous hypertriglyceridemia for 40 years, fenofibrate for 4 years; History of type 2 diabetes, hypertension, old myocardial infarction, percutaneous coronary intervention, oral aspirin. Has a history of smoking and no history of drinking alcohol. Physical examination at admission: vital signs were stable. Palpebral conjunctiva is pale. Soft abdomen, tenderness under the xiphoid process, no rebound pain, muscle tension, no mass, positive Murphy sign, not reaching liver and spleen, existence of liver turbidity boundary, negative mobile turbidity, bowel sound 3 times/min. There is no abnormality. After admission, the patient had obvious fatigue, no abdominal pain, hematemesis, melena, hemoglobin 68 g/L, orthocytic anemia; Positive fecal occult blood; Blood lipase 108 U/L; Biochemistry: total protein 47.6 g/L, albumin 28.9 g/L, glucose 13.2 mmol/L, urea nitrogen 9.67 mmol/L, creatinine 66 μ mol/L, triglyceride 2.8 mmol/L, total bilirubin 26.4 μ mol/L, direct bilirubin 11.3 μ mol/L, transaminase and cholesterol normal; Glycoprotein 199 normal. Preliminary diagnosis: acute onset of CP; Gastrointestinal bleeding. Perfect abdominal CT (Figure 2) shows that the pancreatic pseudocyst communicates with the gastric cavity, and there is blood accumulation in the fundus of the stomach and the lower esophagus. Therefore, the diagnosis is considered: acute attack of CP, intracystic hemorrhage of pancreatic pseudocyst and formation of gastric fistula, and gastrointestinal hemorrhage. After the general condition is stable, the body and tail of pancreas + spleen + proximal gastrectomy is performed. The diameter of the pancreatic pseudocyst was 7 cm, the diameter of the contact surface with the posterior wall of the stomach was 5 cm, and the diameter of the internal fistula was 2 mm. Pathology (Figure 3): Some hyaline degeneration, hemorrhage and necrosis of the cyst wall, destruction of pancreatic tissue and structure around the cyst wall, reduction or disappearance of acins, and only small ducts and islets remain.

A 16-year-old female was admitted to the hospital mainly for "intermittent fever for 4 weeks and headache with hypertension for 2 weeks". The patient experienced intermittent fever with a maximum of 38.5℃ 4 weeks ago. I had headache 2 weeks ago, mainly forehead and occipital pain. Blood pressure 220/120 mmHg (1 mmHg =0.133 kPa) with 2 episodes of convulsions and loss of consciousness. Two weeks ago, he visited a hospital and found proteinuria, renal insufficiency, hypergammaglobulinemia, anemia and other manifestations. Abdominal enhanced CT: (1) local aneurysm formation of pancreaticoduodenal artery with mural thrombosis, irregular wall thickening of both renal arteries with stenosis; (2) splenic infarction; (3) Multiple wedge-shaped enhancement changes in both kidneys. Immune indexes: Anti-nuclear antibody, anti-double-stranded DNA antibody, anti-ENA spectrum, anti-neutrophil cytoplasmic antibody and anti-glomerular basement membrane antibody were all negative. Hepatitis B surface antibody positive. The patient had a previous history of cutaneous purpura for 8 years, and an elevated blood gamma globulin was found 4 years ago for an unknown reason. After admission to our hospital, considering that the patient has multiple system involvement manifestations, combined with abdominal CT imaging findings, the diagnosis of polyarteritis nodosa is highly likely. To confirm the diagnosis, arteriography was performed. In order to prevent contrast nephropathy, adequate hydration therapy was administered with normal saline at 1 ml · kg starting 3 h before angiography^－1• h^－1Continuous intravenous fluid rehydration until 12 h after surgery. At the same time, the patient was asked to drink moderate water, and sodium bicarbonate and acetylcysteine were given orally. Arteriographic results: Multiple aneurysms of celiac artery and renal artery vessels, the largest one was gastroduodenal aneurysm, consistent with the diagnosis of polyarteritis nodosa (Figure 1)。 Benazepril hydrochloride 10 mg was administered orally twice daily. At the same time, prednisone acetate 40 mg once daily was administered orally, and cyclophosphamide was treated, and the patient's body temperature returned to normal. Three days later, the patient had uninduced sudden hematemesis with a volume of about 1 000 ml, hypotensive shock, and hemoglobin decreased to a minimum of 57 g/L. Rescue treatment such as fluid rehydration and blood transfusion was given, and emergency arteriography was performed in the catheterization laboratory. Considering the high possibility of gastroduodenal aneurysm rupture and bleeding, gastroduodenal aneurysm interventional embolization was performed (Figure 2)。 Postoperatively, the patient's condition was stable and he did not vomit blood again. Gastroscopy: gastritis, duodenal bulge, aneurysm after treatment, no peptic ulcer (Figure 3)。 The results of all tests before and after the patient's treatment are shown inTable 1。 After discharge, the patient went to the outpatient clinic of our hospital for follow-up once a month, and was given intravenous infusion of cyclophosphamide, gradual reduction of prednisone acetate, and reduction of benazepril hydrochloride to 10 mg once a day orally. The blood pressure was well controlled, the condition was stable, and the general condition was good.

GERD has a high prevalence in the world, but there are some regional differences. As for the typical symptoms of GERD (such as reflux, heartburn, etc.), the prevalence is 18.1% ~27.8% in North America, 23.0% in South America, 8.8% ~25.9% in Europe, 8.7% ~33.1% in the Middle East, and 11.6% in Australia^[1]6% ~10% in Asia^[2]。 Gastroesophageal reflux symptoms can cause significant discomfort, and conservative treatment may require some patients to change their lifestyle and take drugs throughout their lives, reducing quality of life and bringing a significant economic burden. Because the research and practice of extraesophageal reflux in GERD are not systematically in-depth, its epidemiological characteristics are still unclear. The prevalence of extraesophageal symptoms of GERD can still be seen from the co-occurrence rate of GERD and asthma. GERD symptoms, abnormal pH examination, esophagitis and hiatal hernia accounted for 59.2%, 50.9%, 37.3% and 51.2% of asthma patients, respectively. The prevalence of asthma in GERD patients was 4.6%, which was higher than that in the control population 3.9%^[3]。 It is also estimated that 21% to 41% of chronic coughs are associated with GERD^[4]。 The proportion of GERD patients with chronic sinusitis was 20.7%, which was significantly higher than that of the general population (8.5%)^[5]。 The positive rate of laryngopharyngeal reflux in recumbent position was as high as 50% and that in upright position was as high as 97% in patients with polyp sinusitis and asthma^[6]。 26.6% of chronic obstructive pulmonary disease (COPD) patients had daytime and/or nighttime GERD symptoms. According to statistics, 31% of COPD acute attacks were caused by lack of regular acid suppression therapy^[7]。 The proportion of comorbid GERD in COPD population is significantly higher than that in non-COPD population, and GERD is a significant risk factor for acute COPD onset^[8]。 In addition, the comorbidity of GERD in patients with idiopathic pulmonary fibrosis was also significantly higher than that in the control population^[9]。 In summary, if all gastroesophageal reflux-related diseases are counted, the prevalence of GERD may be underestimated. GERD has become a common chronic disease in China.