2017年 · 第97卷第32期

Accelerated Rehabilitation Surgery (ERAS) is the application of a series of perioperative procedures and methods supported by evidence-based medical evidence to achieve the goals of reducing surgical stress, reducing complication rate and accelerating recovery^[1-2]。 It was first developed by Swedish doctors Wilmore and Kehlet^[3]In 2001, the application of ERAS in gastrointestinal surgery is the most successful, and in 2006, the ERAS protocol for colorectal surgery has become the basis and basis of today's ERAS^[4]。 Today, the concept of ERAS has covered all aspects of the patient's perioperative period, including preoperative education, perioperative care, optimized anesthesia and surgical procedures, postoperative labor pain, early mobilization and intestinal function recovery, etc. Its core contents mainly include five aspects: (1) optimizing analgesia, (2) early postoperative activity, (3) early postoperative eating and drinking; (4) Avoid or reduce gastrointestinal decompression, (5) Controlled fluid rehydration^[5]。

If a medical institution "violates laws, administrative regulations, rules and other regulations relating to diagnosis and treatment", it is presumed to be at fault under Article 58 of the Tort Liability Act. However, there is no clear legal definition of "diagnosis and treatment norms", and it has not appeared in the legal norms before the promulgation of the Tort Liability Law. Because it is the first application in the legal level of our country, it is difficult to be recognized as a strict legal term at present. Theory and practice are therefore controversial in understanding.

Well-functioning hemodialysis pathway is the lifeline of uremic patients, and it is the basic guarantee for patients to undergo regular dialysis to maintain their life. At present, the types of clinical application include autologous arteriovenous fistula, grafted arteriovenous fistula and deep vein catheterization. Central venous patency is necessary to establish any of the aforementioned hemodialysis pathways. For example, repeated deep vein catheterization can cause severe stenosis or occlusion of the relevant central veins of the upper and lower limbs, which makes uremic patients unable to establish hemodialysis pathways by conventional methods and fall into the desperate situation of unsustainable hemodialysis. In this study, the hemodialysis pathway was established by artificial blood vessels in the way of deep femoral artery-deep femoral artery bridging, so that the hemodialysis can continue in these patients with depleted central venous resources, which is reported below.

The patient was a female, born in October 1987, and went to the Department of Endocrinology of Peking Union Medical College Hospital on July 7, 2015 due to the discovery of "karyotype abnormality". The patient was the first birth, the first birth, the full-term natural delivery, the mother's pregnancy period was smooth, and there was no history of special drug use. Birth weight 2.9 kg, length 50 cm. It is a female vulva at birth and is raised as a girl since childhood. Speaking, walking, and height growth rates are similar to those of the same age. Intellectual development is normal. At the age of 10, he developed edema and proteinuria of both lower limbs. He was diagnosed as "nephrotic syndrome" in another hospital. He was treated with glucocorticoids, but his renal function still progressively declined, so he was treated with peritoneal dialysis. At the age of 13, he underwent one kidney transplantation in a local hospital. Postoperatively, his renal function returned to normal, and he was followed up regularly. There was no immune rejection and no recurrence of nephrotic syndrome. The patient has not had spontaneous puberty and has not been diagnosed and treated. At the age of 18, he was admitted to a foreign hospital for "breast development and primary amenorrhea", suspected of "Turner syndrome", and was given estrogen and progesterone replacement therapy for 3 months. During the medication, he had regular vaginal bleeding. After that, the patient stopped taking the drug on his own without further diagnosis and treatment. At the age of 28, the patient went to another hospital again because he had no menstrual cramps, and the karyotype was 46, XY. In order to clarify the cause, he was referred to our hospital for treatment. The patient had no siblings, parents who were not closely married, and had no family history of similar diseases. Physical examination: Height 160 cm, weight 73 kg, body mass index (BMI) 28.5 kg/m², uniformly obese, blood pressure 120/80 mmHg (1 mmHg =0.133 kPa), female appearance, without pigmentation of skin and mucous membranes throughout the body. There are no moles on the face, the hairline is not low, there are no neck webs, and there is no elbow valgus. No axillary hair. Bilateral breast Tanner stage II. There was no significant pigmentation of the skin in the perineal area, and no mass was palpable in the inguinal area. Pubic hair Tanner stage II. The female vulva, the clitoris is not large, the labia majora and minora are poorly developed, and the vagina can be detected, about 8 cm long. No skeletal deformities.

Patient, male, 67 years old. The main reason was that the bladder mass was found on physical examination and was admitted to hospital for 1 day. There was no macroscopic hematuria, no bladder irritation signs such as frequent urination, urgency and painful urination. No low back pain, fever, nausea, vomiting, dysuria and other discomfort. For further diagnosis and treatment, we came to our hospital. Color ultrasound examination of urinary tract showed that there was a substantial nodule in the right posterior wall of bladder-considering the possibility of cancer. The outpatient clinic was admitted to the hospital with "bladder mass". Previous history of hypertension for 2 years, treatment with oral antihypertensive drugs, poor blood pressure control. After admission, pelvic plain scan + enhanced CT examination showed that the soft tissue mass of the right posterior wall of the bladder was about 1.5 cm ×1.5 cm, and the mass was uniformly enhanced after enhanced scan (Figure 1)。 Physical examination: body temperature 36.6 ℃, pulse 80 beats/min, breathing 20 beats/min, blood pressure 160/95 mmHg (1 mmHg =0.133 kPa), clear mind, no positive signs in heart, lung and abdomen, no percussion pain in both kidney areas, no tenderness and rebound pain in the running area of both ureters, no swelling and no tenderness in the suprapubic bladder area.

The patient Wang Moumou, male, 48 years old, unmarried, came to the hospital for emergency department due to "acute urinary retention". The patient complained of swelling and pain at the base of the penis, accompanied by thinning of urine and dysuria for 1 h, and incarceration of the nut at the base of the penis for 16 h. Physical examination, the patient's general condition is OK, middle-aged male, anxious face, abdominal examination of liver and spleen is not reached, lower abdomen is swollen, bladder is flat and umbilical, and knocking is void. Penis examination showed that the penis was obviously swollen and purple, with a six-sided nut incarcerated at the base of the penis, and the penis distally from the nut was obviously edematous, with a diameter of 8 cm and a length of 12 cm, and the head of the penis was dark purple. Patients were admitted and diagnosed as follows: (1) Metal nut incarceration at the base of penis; (2) Acute urinary retention.

Vascular access is the "lifeline" of hemodialysis patients, and autologous arteriovenous fistula is recognized as the best vascular access^[1,2]。 The establishment of arteriovenous fistula causes iatrogenic arteriovenous short circuit. Its high flow and low resistance blood flow environment will affect the original blood flow state of cardiovascular system and induce adaptive ventricular remodeling^[3,4]。 High output heart failure is a rare complication of autologous arteriovenous fistula, and it is more common in arteriovenous fistula with high blood flow^[5,7]。 The pathogenesis of autologous arteriovenous fistula-associated high-output heart failure and its correlation with autologous arteriovenous fistula flow are unclear, but patients with high-output heart failure have a poor prognosis^[8]The disease requires clinical attention.

Immune checkpoint inhibitors such as programmed death factor-1 (PD-1) /programmed death ligand-1 (PD-L1) are a hot spot in the field of cancer therapy today. Because of its strong specificity, wide applicability and long-lasting effect, it has become a standard or emerging treatment for malignant melanoma (MM), non-small cell lung cancer (NSCLC), bladder cancer, head and neck squamous cell carcinoma, colorectal cancer (CRC), renal cell carcinoma (RCC) and gastric cancer^[1]。 Among unselected patients receiving immune-targeted therapy, only some patients had significant improvements in objective response rate (ORR) and survival outcome. Therefore, how to accurately select clinically beneficial patients has become an urgent problem to be solved in the clinical application of such preparations. At present, researchers have begun to extensively search for biomarkers (BMs) related to efficacy as treatment predictors, hoping to provide references for clinical decision-making.

Recent studies have found that brown fat exists in adults^[1]。 Another study found that in addition to white fat and brown fat, there is a third kind of fat tissue in the body, namely beige fat, which exists in the distribution position of white fat, but has similar characteristics and heat-producing function of brown fat, so it is also called white fat browning^[2]。 The browning of white fat has the function of regulating body metabolism and protecting cardiovascular diseases, which provides a new idea for the treatment of metabolic diseases such as obesity and diabetes. In this paper, the role of white fat browning in metabolic regulation and cardiovascular protection, the regulatory factors of white fat browning and its potential clinical application are described.