2017年 · 第97卷第36期

Pulmonary thromboembolism (PTE) is characterized by high morbidity, mortality and disability, which is a major medical problem that seriously threatens human health^[1]。 In recent years, under the continuous promotion of the National Science and Technology Support Plan from the Tenth Five-Year Plan to the Twelfth Five-Year Plan, a series of clinical research and translational medicine research related to PTE have been carried out in China, and many innovative research results have been achieved, and the level of PTE prevention and treatment has been significantly improved. Among them, the innovative "50 mg alteplase half-dose thrombolytic regimen" has been written into the American guidelines for the diagnosis and treatment of venous thromboembolism^[2]This achievement not only standardizes the diagnosis and treatment technology of PTE, but also has significant health economics benefits.

Urinary tract infection is one of the most common diseases that endanger women's health. 50% of women have at least one urinary tract infection in their lifetime, and 20% ~30% of them have multiple urinary tract infections within a year. Its incidence is second only to upper respiratory tract infection among infectious diseases, ranking second^[1,2]。 Although most urinary tract infections can be cured, if not standardized diagnosis and treatment, urinary tract infections can cause serious adverse effects on patients' health, including life-threatening bacteremia, sepsis, and chronic renal failure or even death caused by recurrence. In recent years, the incidence of multidrug resistance urinary tract infection caused by inappropriate use of antibiotics has reached 20% worldwide^[3]The treatment of urinary tract infections in the future faces severe challenges.

Organ transplantation is one of the greatest achievements in the field of medicine in the 20th century. It is known as the most dazzling jewel in the crown of medicine^[1]。 Organ transplantation combines the achievements of medicine, ethics, law and other disciplines. It is an index to measure the overall medical strength of a country or region, and it is also a symbol of the level of social development and civilization.

Pulmonary embolism is a clinical and pathophysiological syndrome of pulmonary circulation dysfunction caused by endogenous or exogenous embolus obstructing the pulmonary artery^[1]。 Among them, pulmonary thromboembolism is the most common type of pulmonary embolism, accounting for the vast majority of pulmonary embolism, so the commonly called pulmonary embolism refers to pulmonary thromboembolism. Pulmonary embolism combined with underlying diseases is very common, and these underlying diseases are often the cause or risk factors of pulmonary embolism. The more and more complex the combined underlying diseases, the greater the likelihood of developing pulmonary embolism^[2]。

The incidence of thrombotic diseases is extremely high worldwide, with high rates of disability and mortality. Antiplatelet and anticoagulant drugs are widely used in clinical practice, but different individuals have different responses to anticoagulant drugs. How to safely and effectively apply these drugs has been a hot research topic. In recent years, the use of genetic testing to guide individualized anticoagulant therapy has provided a reference for the rationality and safety of medication, and can reduce the occurrence of adverse events. The related metabolic genes and pharmacokinetics of non-vitamin K antagonist oral anticoagulants (NOACs) are briefly described below.

Warfarin is a dicoumarin anticoagulant. Because it is cheap and effective, it is often used as the first choice anticoagulant therapy for patients with pulmonary embolism, deep vein thrombosis, atrial fibrillation, etc. In view of China's huge population base and current medical conditions, warfarin will be the main anticoagulant drug for a long time.

Pulmonary thromboembolism (PTE) is a common disease, potentially fatal, accounting for the third cause of cardiovascular death^[1]。 Its onset is often hidden, and the exacerbation process is often very rapid. The mortality rate of untreated PTE patients is as high as 30%. If clinicians can diagnose and take treatment measures in time, the mortality rate can be reduced to 2% ~10%^[2]。 CT pulmonary angiography (CTPA) has the characteristics of high spatial resolution and fast scanning speed. With its widespread application, CTPA gradually replaces radionuclide ventilation perfusion imaging and pulmonary angiography, and becomes the first choice imaging method for patients with suspicious PTE^[3]Through CTPA, we can observe the position and shape of thrombosis in pulmonary artery, and also evaluate the severity of PTE by showing the position and obstruction degree of embolus in pulmonary artery^[4]。

Acute pulmonary thromboembolism (PTE) is one of the acute and severe diseases in internal medicine, with high incidence, complicated clinical manifestations and easy misdiagnosis and misdiagnosis^[1,2]。 At present, the diagnosis of acute PTE mainly depends on imaging examination, including CT pulmonary angiography, pulmonary ventilation perfusion scan, etc. Biomarkers used in recent years, such as D-dimer, troponin (Tn), myoglobin, brain natriuretic peptide (BNP), cardiac fatty acid binding protein (H-FABP) and peptidin, have important significance in the clinical diagnosis, risk stratification and prognosis prediction of acute PTE. Plasma microRNA (miR) has also shown a broad application prospect in the clinical diagnosis of acute PTE. The clinical application of these biomarkers in acute PTE is briefly described below.

Venous thromboembolism (VTE) includes pulmonary thromboembolism (PTE) and deep vein thrombosis (DVT), which are considered to be manifestations of the same disease at different sites. Epidemiological surveys from North America and European countries show that the annual incidence of VTE is (104~183) /100,000, which is comparable to the annual incidence of stroke, and the annual mortality rate of PTE is about 20%^[1]。 In recent years, the importance of PTE in China has increased year by year, the diagnosis rate has gradually increased, and the missed diagnosis and misdiagnosis rate has decreased year by year. However, there is still a lack of large sample epidemiological investigation data.

Female urinary tract infection is a common infectious disease in women, and the incidence of urinary tract infection in women is nearly 10% every year^[1]Female urinary tract infection is also the most common cause of nephrology outpatient treatment, and the treatment needs to be standardized. There is still a lack of expert consensus on the diagnosis and treatment of female urinary tract infection in China. The Special Committee of Kidney Disease and Blood Purification of China Women Physicians Association formulated the Expert Consensus on Diagnosis and Treatment of Urinary Tract Infection in Chinese Women according to the special physiological structure and special physiological cycle characteristics of women, retrieved relevant international and domestic literatures and referred to the actual situation in China. This consensus is applicable to the diagnosis and treatment of common urinary infectious diseases in adult women, and does not involve urinary tuberculosis, sexually transmitted diseases and urinary tract infections in children. This consensus writing plan was organized and drafted by Professor Chen Xiangmei, chairman of the Special Committee of Kidney Disease and Blood Purification of China Women Physicians Association, and discussed and finalized by the members of the Special Committee. The consensus writer reviewed the literature and discussed the consensus draft three times, solicited comments by mail twice, and was summarized and revised by the team leader. The final draft meeting was held in Dalian, Liaoning, China on December 12, 2015.

A 51-year-old male was admitted to the Department of Endocrinology of Peking Union Medical College Hospital in April 2013, mainly because "serum alkaline phosphatase (ALP) level was found to be elevated for more than 3 years". In 2010, the patient's serum ALP level was found to be elevated, reaching 500 U/L, during physical examination in a local hospital, without special diagnosis and treatment. In January 2013, the local hospital found that parathyroid hormone (PTH) was 94.2 ng/L, and the blood calcium and phosphorus levels were within the normal range in the same period (details are unknown); Normal thyroid function; Thyroid ultrasound showed solid nodules on the dorsal side of the middle and lower right lobe of the thyroid gland, and multiple solid nodules of the thyroid gland. During the course of the disease, there was no dry mouth, polydipsia, polyuria, no history of bone pain and clinical fracture, no history of urinary stones, no acid reflux, heartburn, etc. There were no episodic headache, palpitations, sweating, no enlargement of hands and feet and facial changes, no centripetal obesity, no morning consciousness disorder, skin migration necrotizing erythema, etc. Previous hypertension for 4 years, oral medication for antihypertensive treatment (details unknown), blood pressure control can be achieved; Personal history, marriage and childbirth history is not special; Deny a history of similar disease in the family.

The patient, a 17-year-old male, was admitted to the Department of Thoracic and Cardiac Surgery of the Second Affiliated Hospital of Suzhou University the next day after physical examination on July 25, 2015. During the course of the disease, there was no cough, expectoration, hemoptysis, dyspnea, low fever, night sweats and other discomfort. On July 3, 2011 and July 8, 2012, he underwent double bullae resection under thoracoscopic surgery (VATS) in the Department of Thoracic and Cardiac Surgery of our hospital, respectively. During this period, multiple chest X-ray and CT examinations showed no obvious positive manifestations. Physical examination of this admission: multiple old surgical scars were seen on both sides of the chest wall, and the rest was negative. Chest CT findings: plain scan showed a round soft tissue density focus in the lower lobe of the left lung, with clear edges and a size of about 2.9 cm ×3.2 cm ×2.6 cm (measured by pulmonary window). The internal density was uneven, the density at the edge of the lesion was slightly higher, with a CT value of about 32 HU, and the density in the central region was slightly lower, with a CT value of about 20 HU; The enhanced scan showed obvious uneven enhancement of the lesion, obvious annular enhancement at the edge of the lesion in the arterial phase, with a CT value of about 194 HU, striped enhancement shadow in the central area, and thickened left inferior pulmonary artery branches near the hilar side of the lesion. In the venous phase, the CT value of the marginal area of the lesion was about 164 HU, and the thicker pulmonary vein was seen adjacent to it (Figure 1)。 CT diagnosis was sclerosing hemangioma of the lower lobe of the left lung. Left lower pneumonectomy under VATS under general anesthesia. Surgical and pathological findings: Lung tissue in the lower lobe of the left lung was seen by naked eye after operation, with a size of 16 cm ×9 cm ×5 cm. A gray-white nodule was seen 3 cm away from the bronchial margin, 2 cm away from the pleura, with a diameter of 2.5 cm. The section surface was gray-white, with clear boundary and hard texture. Pathological examination: The tumor cells were epithelioid, rich in cytoplasm, round nucleus, no nuclear division, and the tumor cells were solidated and/or acinar-like arrangement (Figure 2)。 Immunohistochemical staining examination: TFE3 weak +, MyoD1 plasma +, Myogenin-, AE1/3-, Desmin-, HMB45-. Pathological diagnosis: (Left lower lung) alveolar soft tissue sarcoma (ASPS). Postoperative whole body PET-CT examination showed no abnormalities.

A 4-year-old and 7-month-old girl was admitted to the hospital due to "left limb weakness for 10 days, headache, vomiting, and mental deterioration for 3 days". The child was previously in good health and had no family history. Physical examination: drowsiness, poor spirit, uncooperative speech questions and answers, esotropia in the left eye, pupils of equal size and round, and light reflection. The muscle strength of the left limb was grade 3, and the muscle strength of the right limb was grade 5. The muscle tone was normal, and the pathological signs were not drawn out. MRI examination of the admitted skull showed that a huge irregular mass shadow was seen in the right occipital lobe, with a lesion size of about 7.8 cm ×5.3 cm ×4.8 cm. The lesion involved the temporoparietal-occipital triangle upward and the brainstem inward. The lesion T₁WI showed a slightly low signal, and there were multiple mixed high-tech stoves in it; T₂WI showed high and low mixed signals, and liquid level could be seen in it; FLAIR showed confounding signals; DWI showed a partially slightly higher signal; The enhanced scan was obviously uneven, large patchy edema was seen around the lesion, the ventricular system was compressed and accumulated water, and the midline structure shifted to the left (FIG. 1A，FIG. 1B)。

A 33-year-old female was admitted to the Department of Gynecology, Minhang Branch of Zhongshan Hospital affiliated to Fudan University on October 28, 2016 due to "11 weeks of menopause and 3 weeks of nausea and vomiting". The patient received assisted reproductive technology in Ruijin Hospital affiliated to Shanghai Jiaotong University on August 23, 2016 due to "not pregnant for 8 years after marriage", and was confirmed pregnant by menstrual blood and urine human chorionic gonadotropin (HCG) examination on September 3, 2016. From 8 weeks of pregnancy, nausea, vomiting, fatigue, irregular attack time, accompanied by dizziness and mild headache, the headache position is not fixed, and it cannot be relieved after bed rest. The obstetric clinic of our hospital was diagnosed as "hyperemesis gravidarum, hypokalemia" and given intravenous fluid rehydration and oral "folic acid tablets and progesterone" treatment. The blood calcium and parathyroid function were not checked in this visit. On October 26, 2016, the B-ultrasound found that the fetal heart beat disappeared. On October 28, 2016, he was admitted to the gynecology department of our hospital and underwent curettage and curettage. The operation was smooth and the bleeding was 50 ml. On the first postoperative day, the patient had obvious headache, dizziness and the highest blood pressure 177/115 mmHg (1 mmHg =0.133 kPa). Cranial magnetic resonance imaging (MRI) showed no abnormalities. After oral administration of "amlodipine besylate", the blood pressure stabilized within the normal range and was discharged. After discharge, the symptoms of headache, nausea and vomiting did not change significantly compared with before, and frequent urination occurred. On November 15, 2016, the urine HCG was negative, and the serum and urine amylase was normal; Total abdominal CT scan showed no abnormalities; Gastroscopy: chronic superficial gastritis. On November 24, 2016, he was admitted to the Department of Gastroenterology of our hospital with "nausea and vomiting". Past history: Two years ago, he underwent hysteroscopic uterine fibroidectomy in Ruijin Hospital affiliated to Shanghai Jiaotong University due to uterine fibroids. One year ago, he continued to see the assisted reproductive center of the hospital due to the man's "weak sperm motility" and made an appointment for embryo transfer treatment.

In 1991, laparoscopy was first reported to be used in colon cancer surgery. In 2009, German scholar Hohenberger et al^[1]The principle of complete mesangial resection (CME) adapted to colon cancer was proposed, which was quickly widely accepted, and the application of laparoscopic technique in colon cancer surgery was greatly standardized in practical clinical work^[2]So that the tumor radical cure effect of abdominal colon cancer surgery is better guaranteed. At present, the effect of laparoscopic radical surgery for colorectal cancer has been verified in a large number of clinical trials, and then written into the guidelines. However, the laparoscopic surgery of colon cancer in the splenic region is still controversial in academic circles^[3]。 The splenic colon, that is, the colon in the region above the descending B junction from the distal third of the transverse colon to the descending colon, accounts for only 2% ~5% of the overall incidence of colorectal cancer due to the relatively low incidence of colon cancer in the splenic region^[4,5,6,7]Therefore, compared with right colon cancer and rectal cancer, the research on the selection of surgical approach is significantly reduced. Most literatures have been mentioned in a stroke, and there are many discrepancies in comparison. Therefore, we analyzed and summarized the previous literature, summarized the following characteristics, and provided options for exploring more suitable surgical approaches, especially laparoscopic surgical approaches.

The incidence of acute kidney injury (AKI) in intensive care units is very high, and these patients often require continuous renal replacement therapy (CRRT), where the choice of anticoagulant is very important. High risk of bleeding with systemic heparinized anticoagulation^[1,2]regional citrate anticoagulation (RCA) can significantly reduce the risk of bleeding in patients. With the updating of theory, the mastery of experience and the popularization of blood gas analyzer, RCA has been widely used^[3]It is especially suitable for patients who have a risk of bleeding and need long-term blood purification treatment. Complications can be avoided or corrected in time by monitoring metabolism-related indicators, and can be safely and effectively applied even in patients with hepatic insufficiency. 2012, Organization to Improve the Global Outcome of Kidney Disease (KDIGO) Guidelines^[4]Recommendation: As long as there is no contraindication for the use of citric acid, RCA can still be the first choice for anticoagulation in patients with severe AKI treated with CRRT even if there is no risk of bleeding or coagulation dysfunction.