2018年·第98卷第24期

New gastric cancer patients in my country account for about 40% of the world. According to 2015 statistics, there are 873,000 gastric cancer patients in my country^[1]。 Compared with other countries with high incidence of gastric cancer, the outstanding feature of gastric cancer patients in China is that the proportion of advanced gastric cancer is relatively high, and about 30% ~40% belong to incurable advanced gastric cancer, that is, clinical stage IV. The efficacy of these patients is extremely poor. With the popularization and application of standardized tumor treatment, early and mid-stage gastric cancer has received great attention, and the curative effect has been significantly improved. However, advanced gastric cancer, as the "last highland" in the field of gastric cancer treatment, always lacks effective treatment. This article summarizes the clinical characteristics of advanced gastric cancer in China, and puts forward the diagnosis and treatment strategies for advanced gastric cancer, hoping to be helpful for the clinical diagnosis and treatment of advanced gastric cancer in China.

At present, socialism with Chinese characteristics has entered a new era, and the main social contradiction has undergone historical new changes, which has been transformed into "the contradiction between the people's increasing demand for a better life and unbalanced and inadequate development"^[1]。 In the field of medical services, the needs of patients have also changed. New needs have developed in terms of function, quality, experience, etc., which affect medical satisfaction and doctor-patient relationship. It is a new problem faced by the field of medical services. It is of great practical significance to carry out in-depth research.

Obstructive sleep apnea (OSA) is a kind of sleep breathing disorder with sleep snoring with apnea and daytime sleepiness as the main clinical manifestations. The prevalence is 2% ~4%^[1]。 The disease can cause intermittent hypoxia, hypercapnia and disorder of sleep structure, and can lead to multiple organ and system damage such as hypertension, coronary heart disease, arrhythmia, cerebrovascular disease, cognitive dysfunction and type 2 diabetes^[2,3]。 Studies have shown that untreated patients with severe OSA have a 3.8-fold higher mortality rate than the general population^[4]。 Data from 20 domestic hospitals confirmed that the prevalence of hypertension in OSA patients in China is 49.3%, while OSA patients account for 83% of patients with refractory hypertension. Treatment of OSA has a positive effect on the reduction of blood pressure in these patients^[5]。 In addition, the OSA population was 4.33 times more likely to have stroke and 1.98 times more likely to have mortality^[6]。 OSA can cause damage to multiple systems in the body and is a veritable systemic disease^[7]。 Therefore, physicians, patients and the whole society should pay attention to the widespread and serious harm of OSA to the body.

A 56-year-old female was admitted to Peking Union Medical College Hospital on July 19, 2017 due to fear of cold for 10 years and polyuria for 6 years. Since 2007, the patient has been sensitive to cold without inducement, accompanied by edema of face, hands and feet, and fatigue. There was no fever or change in urine output. In September 2008, thyroid stimulating hormone (TSH) was 5.55 mU/L (reference range: 0.38~4.34 mU/L), free triiodothyronine (FT₃) 4.70 pmol/L (reference range: 2.76-6.30 pmol/L), free thyroxine (FT₄) 16.9 pmol/L (reference range: 10.5-24.4 pmol/L); 24 h urine free cortisol (24 h UFC) was in a normal range without special treatment. Since 2011, polyuria, polydipsia and polydipsia have occurred without trigger, and they have gradually worsened. The daily water consumption and urine volume are about 7 L, the urine volume at night is about 4 L, and nocturia is 5 to 6 times. Check blood sugar is normal; TSH 10.4 mU/L, FT₃FT₄Normal range, positive for thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TgAb); Thyroid ultrasound showed that the thyroid was enlarged, the internal echo was rough and grid-like, and the blood flow signal was abundant. Levothyroxine sodium was administered orally, gradually increasing the dose from 12.5 μ g/time, once/d to 100 μ g/time, once/d, and TSH decreased to normal after re-examination. In July 2017, the urine specific gravity was 1.005; Serum sodium 147 mmol/L (reference range: 135-145 mmol/L); erythrocyte sedimentation rate 22 mm/1 h (reference range: 0-20 mm/1 h); Enhanced magnetic resonance imaging (MRI) of the sellar region showed thickening of the pituitary stem and disappearance of short T1 signals in the posterior pituitary lobe (Figure 1)； The results of water-prohibition test are consistent with diabetes insipidus; Whole body bone imaging revealed abnormal radioactive concentration at the top of the left skull. The patient's urine output was reduced to 2~2.5 L/d and nocturia was performed once after the oral administration of desmopressin (0.05 mg/time, twice/d). Admitted for further diagnosis and treatment. Past history, personal history, marriage and childbirth history are no different, 49 years old menopause. Family history: Two older brothers suffered from autoimmune hepatitis and nephritis respectively, and one sister suffered from systemic lupus erythematosus.

Complaint and current medical history: The patient was a 59-year-old male who went to Peking University First Hospital on April 1, 2017 due to "repeated low back pain for 1.5 years and fever for 2 days". The patient had sudden left low back pain with fever 1.5 years ago. No abnormalities were found in urine routine, renal function, blood culture, kidney B-ultrasound and other examinations in the local hospital. He was considered "perirenal infection" and improved after symptomatic analgesic and anti-infective treatment. Three months later, abdominal B-ultrasound showed that the left kidney was atrophied. The serum creatinine fluctuated from 57 to 104 μ mol/L in the past 1 year, and the serum creatinine was 76 μ mol/L in the last re-examination 1 week ago. Two days ago, the patient suddenly experienced dull pain in the right middle and lower abdomen after taking a long-distance train, without nausea, vomiting, diarrhea, frequent urination, urgency, painful urination, etc. The pain did not relieve after defecation and lasted for about 1 h to relieve spontaneously. Two hours later, the patient developed persistent distension and pain in the right lower back, voluntary decrease in urine output (specificity unknown) and fever (maximum body temperature 39.2℃). Visit the outpatient clinic of our hospital, blood test routine: white blood cells 10.14×10⁹/L ↑ (3.5-9.5×10⁹/L), neutrophils 7.8×10⁹/L ↑ (1.8-6.3×10⁹/L), monocytes 1.39×10⁹/L ↑ (0.1-0.6×10⁹/L), hemoglobin 114 g/L↓ (130-175 g/L), platelets 181×10⁹/L (125-350×10⁹/L); Urinary routine: urinary protein 2+, urinary red blood cells 2~4/HP, white blood cells 1~3/HP, granular tube type 2~4/LP; Biochemical examination showed: serum creatinine 346 μ mol/L↑, urea nitrogen 9.3 mmol/L↑, serum creatinine 3.8 mmol/L, lactate dehydrogenase 696 IU/L↑ (100-240 IU/L); Coagulation indicators showed: prothrombin time 13.8 s ↑ (9.0~11.5 s), activated partial thromboplastin time (APTT) 36.2 s (26.9~37.9 s), fibrinogen quantitation (FIB) 4.57 g/L↑ (2~4 g/L), D-dimer 1.73 mg/L↑ (<0.24 mg/L), fibrinogen degradation products (FDP) 11.5 mg/L↑ (0-5 mg/L). Abdominal B-ultrasound showed very hypoechoic nodules on the right kidney and atrophy of the left kidney. Abdominal CT scan showed multiple slightly lower density foci in the parenchyma of the right kidney, the nature of which was to be determined, and the left kidney atrophy. Admitted to hospital for further treatment. Since the onset of the disease, the patient's urine output has decreased significantly, and there is no significant change in spirit, sleep, appetite and weight.

The 25-year-old female was seen in the emergency department of ophthalmology department of our hospital on November 30, 2016 because she did not see for 2 days after hyaluronic acid injection in her right forehead. The patient contacted the online "plastic surgeon" 2 days ago to perform hyaluronic acid injection on the right forehead in the local hotel. The hyaluronic acid injection equipment, injection dosage and injection technique were unknown. Complete ptosis of the right eye appeared immediately after the injection, which was not paid attention to by the patient. Two days later, the patient found that his right eye was invisible and his eyeball rotation was impaired, so he went to the emergency department of ophthalmology department of our hospital.

Community-acquired pneumonia (CAP) is characterized by high morbidity and mortality in immunocompromised hosts (ICH), and empirical antimicrobial therapy is usually recommended with limited efficacy. So far, there have been few studies on ICH-CAP, and almost all prospective clinical studies of CAP have excluded this population^[1,2]； Treatment recommendations for this group of patients are also not included in guidelines for the management of CAP by the American Society of Infectious Diseases and the Chest Association^[3]。 The relevant research is systematically reviewed and summarized as follows.