2017年 · 第97卷第14期

Stanford type A aortic dissection involves the whole course of the aorta, and continuing to tear the iliac vessels downward often causes arterial ischemia of the lower extremities, Lee et al.^[1]And Geirsson et al.^[2]It is reported that the incidence of this condition is 10% ~12.7%. Once the disease is dangerous, it is an independent risk factor for death after aortic dissection. The terminal event is often multiple organ dysfunction syndrome (MODS) caused by massive release of necrotic products and inflammatory factors, which often causes a huge surgical blow to patients, with huge treatment cost and extremely poor prognosis. Patients with lower limb ischemia may not only show the typical signs of thoracic and dorsal tear-like severe pain aortic dissection, but also lead to ischemia of the corresponding organs when important branches of blood vessels are involved. If the iliac and femoral arteries are involved, lower limb pain, paresthesia, weakness, decreased skin temperature and disappearance or weakening of pulse may occur. Because the symptoms of lower limb ischemia are easily masked by the symptoms of aortic dissection itself, early diagnosis and timely surgical intervention for such patients are particularly important.

Dizziness is the most common clinical symptom, involving the most diagnosis and treatment departments, and is also one of the main symptoms of emergency visits. 2009 Gopinath et al.^[1]A prospective interdisciplinary study showed that the prevalence of dizziness or vertigo in elderly patients was 36.2%, with vestibular disorders accounting for 10% and non-vestibular disorders accounting for 14.2%. For many doctors, dizziness is a seemingly "simple and familiar" symptom, but the diagnosis is relatively rough and "unfamiliar". "Simple and familiar" means that doctors often face patients with dizziness symptoms, and simply and very carelessly often diagnose so-called "vestibular peripheral/central vertigo", "vertebrobasilar insufficiency", "cervical dizziness/vertigo" or "cerebral infarction", etc., but this is not the case. Speaking of "strange" means that most doctors do not understand the etiology and composition of common dizziness diseases, nor do they know many concepts such as vestibular migraine (VM) (i.e. migraine vertigo), psychogenic dizziness (now also known as subjective dizziness or persistent postural-perceptual dizziness), and phobic postural vertigo; Secondly, "strange" means that doctors' inquiry about the medical history of dizziness patients is simple and unclear. They don't know that dizziness needs to be asked from childhood, family history, and headache history.

In recent years, with precision medicine^[1]With the proposed concept, the change of medical model, and the appearance of population aging, food safety, environment and other problems, China's medical and health undertakings are in a critical period of development^[2]It also puts forward higher requirements for the performance management of public hospitals. Hospital F is a provincial large-scale comprehensive public hospital with highly intensive professional and technical talents integrating medical treatment, teaching and scientific research. The hospital currently has more than 3,000 employees, including more than 1,000 doctors, and doctors with senior professional titles account for 40.08% of the total number of doctors. Because the hospital is a technology-intensive organization, the complexity of the post composition, the groups of the performance and the difficulty of quantifying the behavior indicators determine the difficulty of the hospital performance appraisal^[3]。 It is especially necessary to build a scientific, reasonable and operable assessment system to stimulate the enthusiasm and creativity of physicians with senior professional titles in F Hospital and promote the refined management of hospitals.

Foreign bodies in the laryngopharynx and upper esophagus are common diseases in the outpatient and emergency department of otolaryngology head and neck surgery. At present, otolaryngology head and neck surgeons still use indirect laryngoscope and fiber electronic laryngoscope to take foreign bodies in the laryngopharynx, and rigid esophagoscope to take foreign bodies in the upper esophagus. However, it is often restricted by unclear vision and weak light, or the operation requires the cooperation of two people. We comprehensively used three methods to remove foreign bodies from laryngopharynx and upper esophagus: removing foreign bodies under rigid nasal endoscope video display, removing foreign bodies under rigid nasal endoscope video display under supporting laryngoscope, and removing foreign bodies by neck incision. Among them, the innovative application of rigid nasal endoscope is intuitive and convenient, which improves the detection rate and removal rate, and also reduces iatrogenic foreign body imprisonment. The clinical data of 181 cases are retrospectively analyzed and summarized, and the reports are as follows.

A 33-year-old male was admitted to the hospital on 24 April 2016 due to "intermittent abdominal pain for 6 years, aggravated with abdominal distension for 6 months". In October 2010, the patient developed distension and pain in the left middle abdomen without trigger, no fever, stopped exhausting and defecation, and his body weight decreased by 20 kg. The erythrocyte sedimentation rate (ESR) was 24 mm/1 h, and the C-reactive protein (CRP) was 29.6 mg/L. Barium enema showed: ileocecal deformation, cecal shortening, and terminal ileal stenosis (Figure 1)。 Abdominopelvic enhanced CT reconstruction of small intestine indicated that the formation of local intestinal fistula in ileum and ileocecal region may be accompanied by peripheral fat and mesenteric lesions; There were multiple lymph nodes of varying size around the lesion, mesenteric root and retroperitoneum (Figure 2)。 The ileocecal intestinal lumen was deformed and narrowed with local superficial ulcer after colonoscopy (Figure 3)。 Laparoscopic exploration was performed in January 2011. A tumor with a diameter of 1 cm was seen in the abdominal wall of the left lower abdomen. Pathology showed: fat necrotic nodules with lymphoid tissue hyperplasia; A mass of about 15 cm in diameter can be seen retroperitoneally, which is hard in texture and easy to bleed when touched. Intraoperative freezing and postoperative pathology showed that adipose tissue was necrotic and absorbed. Considering the possibility of diagnosis of mesenteric panniculitis, with Crohn's disease not excluded, prednisone 40 mg was added orally once a day, and the dose was regularly reduced until February 2012. During this period, the abdominal pain improved and the body weight increased by 15 kg. CT reexamination in December 2011 showed that the lesion was less than before (Figure 4)。 There was no regular follow-up and maintenance medication after hormone reduction. In October 2015, the patient developed abdominal distension in the right lower abdomen, with a palpable local mass, accompanied by fatigue, and a weight loss of 20 kg. Admitted to hospital for further treatment. Previous: Appendectomy in 1990, surgical treatment for perianal lesion (specificity unknown) in 1998. Personal or family history is not special. Admission physical examination: Body mass index (BMI) 19.1 kg/m²The abdomen was flat and soft, no intestinal type was seen, no tenderness, rebound pain, no clear abdominal mass was palpable, and the intestinal sound was high-key, 8 times/min.

A 45-year-old male, a farmer, was admitted to the hospital on July 18, 2015 due to "repeated fever and cough for 3 years, and recurrent aggravation for 40 days". Three years ago, the patient had repeated fever, cough and expectoration without obvious inducement, mainly dry cough, with a maximum body temperature of 37.8℃. Every time he took oral anti-inflammatory drugs or went to the local hospital for infusion treatment, the fever and cough could improve, but the specific diagnosis and treatment were unknown. 40 days ago, the patient had fever and cough again, mainly low fever, with no obvious rule of fever, with the highest body temperature of 38.0℃, accompanied by night sweats, fatigue, dry cough, no expectoration, hemoptysis, chest pain, dyspnea, fatigue, anorexia, muscle pain and joint swelling and pain, and painless subcutaneous nodules in both lower limbs. He was hospitalized in a local hospital on 17 June 2015 for further treatment. Chest CT showed multiple small patches and nodular high-density shadows of different sizes in both lungs, irregular thick-walled cavities formed in massive lesions in the right lower lung, and multiple lymph nodes swollen in the mediastinum. The initial diagnosis was: (1) Secondary tuberculosis in both lungs and cavity formation in the right lower lung? (2) Lung cancer Fever and cough did not improve significantly after 15 days of quadruple anti-tuberculosis (isoniazid, rifampicin, ethambutol and pyrazinamide). Bronchial examination and right upper lobe bronchial mucosa biopsy and brushing examination were performed. Under bronchial examination, the right upper bronchus and left lower bronchus were considered to be more likely to be tuberculous. The pathological report of mucosal biopsy was "caseous necrosis under the microscope, but no tuberculous nodules, no abnormal cells and cancer cells, acid-resistant staining (-)". Continued to give quadruple anti-tuberculosis treatment for 15 days and antifungal (fluconazole) and anti-infective (cefoxitin) treatment, but the symptoms of fever and cough were not relieved. Mycobacterium tuberculosis-specific cellular immune response (-) was tested on July 8, and anti-tuberculosis treatment was discontinued. Because the patient had repeated fever and cough, it still did not improve significantly, and the peak body temperature was higher than before, with the highest body temperature of 39.0℃. Occasionally, he coughed yellow phlegm, without hemoptysis and dyspnea. Then he was transferred to our hospital for treatment on July 18th. Since the onset of the disease, the patient's body weight has decreased by 7.5 kg, and his sleep and appetite are acceptable. Previous denial of rhinitis and sinusitis, no history of exposure to tuberculosis and tuberculosis, denial of history of diabetes.

A 57-year-old male was found to have a sacrococcygeal mass for 1 week due to lumbosacral pain and distension for more than 2 months. Color ultrasound examination in the outer hospital showed that a cystic mass of about 5.4 cm ×4.7 cm could be seen in the sacrococcygeal region, with cord-like segmentation and clear boundary. Come to the First Affiliated Hospital of Zhengzhou University for treatment.

persistent postural-perceptual dizziness (PPPD) is a clinically common chronic dizziness. It is a new independent disease named by the World Health Organization in early 2014. PPPD is hardly recognized by clinicians in China, which brings difficulties to clinical diagnosis and treatment. This article reviews the historical evolution, diagnostic criteria, basic characteristics, pathogenesis and clinical treatment of PPPD.

Exosomes are extracellular vesicles secreted by a variety of living cells, containing a variety of bioactive components, playing an important role in cellular information transmission, and participating in a variety of pathophysiological processes, such as apoptosis, angiogenesis, immune regulation, tumor migration, etc^[1]。 Recent researches have shown that exosomes are closely related to Mycobacterium tuberculosis infection. The fatty arabinomannan, phosphatidylinositol mannoside and various mycobacterial proteins contained in exosomes are involved in the antigen presentation, immune response, inflammatory response and other processes of Mycobacterium tuberculosis infection, and have broad prospects in the diagnosis and treatment of diseases^[2]。 This article reviews the related studies of exosomes and Mycobacterium tuberculosis infection.

With the increase of the average life expectancy, the aging of the population, the increase of social occupation, education, economic pressure and the progress of medical technology, coupled with the liberalization of the "two-child policy" in China, the age structure of both spouses is undergoing great changes, and the proportion of advanced maternal age and advanced paternal age is gradually increasing^[1]。 At present, all countries in the world have generally classified female pregnancies aged ≥35 as advanced pregnancies, but there is no unified conclusion on advanced childbearing fathers. Some experts regard 40 as the boundary^[2,3,4]。 So far, there have been a lot of research reports on the adverse effects of advanced pregnancy on offspring^[5,6]However, research reports on older childbearing fathers are relatively rare abroad, and even only a handful in China. With the liberalization of the "two-child policy", China's population will usher in a round of rapid growth, but at the same time, with the increase of the proportion of older parents in China, the influence of older age on offspring will also increase. Because there are few studies on the adverse effects of older childbearing fathers on offspring in China, the following research on cognition of older childbearing fathers and offspring is summarized.