2016年 · 第96卷第43期

Anesthesiology is in the process of transition to perioperative medicine^[1]While anesthesia in elderly patients is an important part of this transition process. The rapid aging of Chinese society has caused a sharp increase in the proportion of elderly patients undergoing surgical treatment, and the number and proportion of chronic diseases associated with elderly patients far exceed those of other age stages, which has a serious impact on the incidence of complications, mortality and postoperative outcome of perioperative elderly patients, and significantly increases the medical investment of the state and society for this population and the burden on society and families. Perioperative anesthesia management is playing an increasingly important role in reducing the incidence of complications and mortality of elderly patients. It is mainly reflected in the following aspects.

According to the Third National Retrospective Sampling Survey Report of Causes of Death, from 2004 to 2005, stroke has become the first cause of death for Chinese citizens, and its death number has exceeded that of tumors and cardiovascular diseases. According to the "China Stroke Prevention and Treatment Report 2015", about 15% of people over 40 years old in China are at high risk of stroke, and the comprehensive standardized prevalence of stroke is about 2%. Ischemic stroke is the most common type of stroke, accounting for 60% to 80% of all strokes. At present, both domestic and foreign guidelines recommend antiplatelet drug therapy for primary prevention treatment of people at high risk of stroke and secondary prevention treatment of patients with ischemic stroke^[1,2,3,4]。 According to this calculation, at least 83.2 million people in China need or are using antiplatelet drug treatment. The use of antiplatelet drugs during perioperative period in this part of the population has become an urgent clinical problem to be standardized.

The patient was a 25-year-old male. He was admitted to the Department of Neurology of the Third Hospital of Peking University in December 2015 due to "progressive weakness and numbness of both lower limbs for 1 year". One year before admission, the patient showed weakness and numbness in both lower limbs without obvious triggers, feeling of walking on cotton, and unlimited daily activities. Symptoms progressively aggravated. In the past six months, walking on the flat ground was slow, going up and down stairs was laborious, and I could not walk with my toes and heels. The symptoms are more severe at night, with slippers falling off and shoes going to bed. Slight tremor during fine activities such as holding objects in the upper limbs. No dizziness, diplopia, unclear speech, choking and coughing after drinking water, and no dyspnea. Second, stool, diet and sleep are normal. Physical health in the past, long-distance running endurance is poor, and sports can reach the standard. Deny family history of genetic diseases and similar diseases. Medical physical examination: normal development, good nutrition, no abnormalities in cardiopulmonary and abdominal examination. Physical examination of the nervous system: Shen Qing Yu Li; Cranial nerve normal; Bilateral anterior tibialis muscle and gastrocnemius muscle atrophy, normal muscle tone of limbs, proximal muscle strength of limbs grade V, distal muscle strength of both upper limbs grade V-, bilateral anterior tibialis muscle strength grade III, gastrocnemius muscle strength grade IV; Slight postural and intentional tremor in both hands; When walking, he showed a slightly bilateral cross-domain gait, with a slightly wider step base, Romberg sign (+) and one-word step sign (+), squatting was acceptable, but the toe and heel could not walk; Hypersensitivity to needle pricking below the bilateral ankle joint, normal touch, decreased position sensation and disappearance of vibration sensation of both lower limbs; The tendon reflexes of the extremities were not drawn out, and the pathological sign was (-).

A 48-year-old male was seen in Shanxi Provincial People's Hospital due to right exophthalmos for 2 months and blurred vision in his right eye for 1 month. Orbital CT examination of the patient a few days before admission showed that the right sphenoid ridge occupied extracranial and intraorbital communication (Figure 1)。 There is no obvious headache, dizziness, fatigue, nausea, loss of appetite and other symptoms recently. He had previously suffered from hepatitis B and did not receive special treatment because of normal liver function tests in the past. Physical examination: visual acuity of right eye 0.8, visual acuity of left eye 1.0, right eyeball protruding outward, no pulsatile sensation when touched, no murmur in auscultation, no abnormalities in lung and pleura visual examination, palpation, percussion and auscultation, abdominal palpation did not touch the liver and spleen, and no obvious positive signs were found in other physical examinations and specialist examinations. No abnormalities were found in liver function and routine chest X-ray after admission, and no special positive results were found in other cases. MRI of the brain showed that the tumor appeared uniform enhancement, showing "meningeal tail sign" (Figure 2)。 After the patient completed the relevant preoperative examination, on the 6th day after admission, the frontal-orbital-zygomatic approach was used to surgically remove the space. During the operation, the tumor was gray-white, with cord-like blood vessels in it, and the blood supply was extremely abundant. The boundary between the tumor and the surrounding brain tissue was clear, and there was occasional adhesion to the temporal muscle. The bone of the middle skull base was eroded and destroyed, and the bone on the lateral side of the supraorbital fissure was absent. The tumor grew into the orbit, and the intraoperative bleeding volume was large, about 4 500 ml. After total tumor tissue resection, pathological examination was performed, and the pathological diagnosis was metastatic hepatocellular carcinoma, seeFigure 3。 The serum alpha-fetoprotein (AFP) was 0.5 μ g/L (0~20). Abdominal CT examination showed low density lesions in the right lobe of the liver.

The patient was a 59-year-old female. He was admitted to hospital on July 13, 2015 due to numbness of his left upper limb for more than 3 months, aggravated with pain on the left side of his neck for 2 weeks. The patient developed left upper limb numbness without obvious trigger 3 months ago, no fever, nausea, headache, dizziness and other symptoms, and was not diagnosed and treated. Two weeks ago, the patient's left upper limb numbness symptom was aggravated, accompanied by pain on the left side of the neck, persistent dull pain in the standing position, no radiant pain, and improved in the recumbent position. He went to the local hospital and was treated according to "cervical spondylosis". The specifics were unknown, and the patient's symptoms did not improve. Two days ago, magnetic resonance (MR) examination in the local hospital showed that the cervical spinal cord occupied space behind the cervical 1 and cervical 2 vertebrae. Physical examination: No melanoma-like lesions were found in the skin and mucosa of the whole body, and the muscle strength of the limbs was grade IV, and the pathological signs were negative. MR examination: plain scan showed a massive lesion in the cervical spinal cord at the level of cervical 1 and cervical 2, with a size of 24 mm ×14 mm ×13 mm and a short T₁Hybrid T₂Signal shadow, regular shape, clear boundary, no obvious space occupying effect, no peritumoral edema (Figure 1)。 Diffusion weighted imaging (DWI) (b =1 000 s/mm²) showed a low signal, and the apparent diffusion coefficient (ADC) value showed a slightly higher signal (Figure 1C)。 After intravenous injection of gadopentetic acid meglumine (Gd-DTPA), C₁~ C₂The abnormal signal shadow in the horizontal cervical spinal cord was significantly enhanced (Figure 1D)。 Initial diagnosis: cavernous hemangioma with hemorrhage. Surgery and pathology: During the operation, the spinal cord was cut along the median line and the subdural space was explored. The spinal cord was enlarged at the level of cervical 1 and cervical 2, and the tumor was located in the medulla. The spinal cord was longitudinally incised along the posterior median line and separated deeper, and the tumor tissue was visible. The tumor was black, irregular in shape, adhered tightly to the surrounding tissues, substantial, and had abundant blood supply. It was removed in blocks under the microscope. Visible to the naked eye: gray-brown gray-black fragmented tissue, size 30 mm ×25 mm ×10 mm. Immunohistochemistry: S-100 positive, human melanoma antibody (HMB45), melanocyte differentiation marker (Melan-A), vascular endothelial factor (CD34), smooth muscle actin (SMA) all negative, nuclear proliferation antigen (Ki-67) 80% (Figure 2)。 Pathological diagnosis: (cervical 1-2 intramedullary space occupied) conforms to melanoma.

The prevention, treatment and rehabilitation of children's sports injuries are attracting great attention^[1]How to carry out children's sports medicine research in order to benefit the healthy development of children and avoid the negative impact of sports injury and corresponding treatment on growth and development has always been the focus and difficulty of our children's and adolescent's sports medicine research^[2]。

In China, the incidence and mortality of lung cancer rank first among all kinds of malignant tumors^[1]30% to 40% of lung cancer patients will have bone metastasis, and 22% to 59% of lung cancer patients with bone metastasis will have skeletal related events (SREs), such as cancerous bone pain, pathological fracture, spinal cord compression, hypercalcemia, etc.^[2]Not only increase the medical burden of patients, but also seriously affect the quality of life of patients. As more and more bone-targeting agents have been used for the treatment of bone metastases in recent years, bisphosphonates and denosumab have been approved in the United States and Europe for the clinical treatment of solid tumor bone metastases and the prevention of SREs. In addition, endogenous radioactive agents and targeted drugs are also continuously used for the treatment of bone metastases.

Urinary tract injury is a rare complication of gynecological surgery, but 50% ~75% of urinary tract injury comes from gynecological surgery^[1,2]Relevant litigation is higher than other comorbidities of gynecological surgery^[3]The risk of litigation is 70~90 times higher^[4]； Intraoperative detection and identification of urinary tract injuries can reduce the risk of litigation^[5]。 It is hoped that early diagnosis and early treatment can be achieved by identifying high risk factors and adequate prevention of urinary tract injury in gynecological surgery. This article reviews the prevention and diagnosis of urinary tract injuries in gynecological surgery as follows.