2018年·第98卷第41期

Guillain-Barré syndrome (GBS) is the most common cause of acute delayed paralysis worldwide^[1]。 GBS is somewhat self-limiting, but despite the application of immunotherapy, 25% of patients progress to severe respiratory insufficiency, 20% of patients have persistent severe disability, and approximately 5% of patients die^[2]。 On the one hand, the current diagnostic standards commonly used internationally are too strict and over-reliance on laboratory tests, resulting in delays in diagnosis and initiation of treatment for some patients^[3]。 On the other hand, non-individualized treatment plan is also the main reason for poor prognosis of some patients^[4]。 Therefore, it is necessary to correctly understand the misunderstanding of diagnosis and treatment of GBS.

Critical thinking is a form of thinking based on sufficient rationality and objective facts to conduct theoretical evaluation and objective evaluation. It is not swayed by emotional and unfounded opinions, words and deeds. Criticizing an opinion is not the same as criticizing the person who holds it. In recent years, various clinical expert consensus and clinical diagnosis and treatment guidelines have sprung up like mushrooms after a rain. There are numerous and countless, covering almost all kinds of diseases, which have a quite positive effect on standardizing clinical behavior and improving the level of diagnosis and treatment of diseases. However, these consensus or guidelines are only the experience summary of a few experts, and are often formulated on the basis of the commonality of diseases, without considering the particularity and complexity of diseases. If it is not correctly understood and practiced, it may lead to misdiagnosis and mistreatment, which may bring harm to patients. The humble opinion on the clinical expert consensus and guidelines is discussed below.

Cervical disc replacement is a common surgical method for cervical disc herniation and disc degeneration in spine surgery in recent years. The choice of indication, surgical technique, product design, patient's physical condition and other factors are the reasons for the loosening of the prosthesis^[1]。 This paper reports a case of progressive prosthesis loosening 2 years after surgery, and analyzes the causes of loosening.

A 52-year-old male patient. The main cause was "sudden numbness and weakness of the right upper limb for 1 d, aggravated with episodic convulsions for 20 h", and he was admitted to the hospital on June 30, 2016. The patient developed numbness in his right upper limb after waking up from a nap at 3 pm on June 29, 2016. His self-measured blood pressure was 140/100 mmHg (1 mmHg =0.133 kPa). He went to the Shennei emergency department of Beijing Hospital. Physical examination showed no positive signs. Cranial CT was performed (Figure 1) showed that the density of the local gyrus of the left parietal lobe was increased, and the sulcus gyrus was slightly swollen. He was discharged from hospital after being treated with oral aspirin anti-polymerization, statin lipid-lowering drugs and intravenous drip drugs to improve circulation. On the way out of the hospital, there was a sudden aggravation of numbness in the right hemibody, accompanied by weakness in the right limb, followed by a generalized seizure, which lasted about 5 minutes and then stopped. After the patient regained consciousness, he felt a headache on the left side and was sent to the emergency department of our hospital. Considering acute cerebrovascular disease and secondary epilepsy, he was given anti-epileptic treatment by intravenous pumping of sodium valproate, and there was no recurrent epilepsy. Review head MRI on 30-Jun-2016 (Figure 2) shows: a large hemorrhagic focus in the left frontoparietal lobe, the nature of which is to be determined, and the possibility of infarction with hemorrhage is high. The patient felt that the weakness of the right limb was aggravated compared with the previous day with poor speech, and was admitted to the neurology ward for further diagnosis and treatment. Past History: Physical Fitness; Smoking and drinking for more than 30 years, smoking 3~4 cigarettes/d and drinking 100~150 g/d.

A 23-year-old male developed painless full-course macroscopic hematuria for 4 d after activity, without blood clots and lumbar pain, which relieved spontaneously. Relevant examinations at the local hospital indicated that the right kidney occupied space, and the patient was admitted to Sino-Japanese Friendship Hospital of Jilin University for further definite diagnosis and treatment. After admission, routine physical examination and specialist physical examination showed no abnormal findings. Conventional ultrasound showed that the size of the right kidney was normal, and a mixed echo mass with a size of 10.9 cm ×5.5 cm ×7.4 cm and mainly hyperechoic was seen in the middle and lower renal parenchyma, with clear boundaries, envelopes and regular shape. There were many small liquefaction foci scattered in the middle and lower kidney, and the sound transmission of the liquefaction foci was poor. In addition, a large number of punctate calcifications were scattered in the middle and lower kidney parenchyma. No obvious blood flow signal was observed in different sections of the mass (Figure 1，Figure 2)。 Mild hydrops under compression of the renal pelvis, separated 1.0 cm. It is suggested that the right kidney is focal lesion, the nature of which is to be determined. Preoperative plain and enhanced CT scans showed that the middle and lower part of the right kidney showed massive shadows of abnormal density with unclear boundaries, the size was 6.4 cm ×5.9 cm ×8.5 cm. The enhanced scans showed obvious uneven enhancement of the lesions in the cortical and parenchymal phases, and the enhancement degree was slightly reduced in the excretion phase, and the lesions were slightly calcified. It suggests that the middle and lower part of the right kidney occupies space, and it is more likely to consider clear cell carcinoma. In summary, clinicians considered it to be a neoplastic lesion and performed radical right nephrectomy. After operation, the right kidney of the surgical specimen was dissected, and a tumor was found in the right kidney, with a size of 9.0 cm ×8.0 cm ×8.0 cm. The section was yellow and white, accompanied by necrosis, which seemed to have pseudocapsule. The samples were sent to pathology, and the pathological diagnosis showed focal necrosis, interstitial fibrosis, scattered sand-like calcification and inflammatory cell infiltration in the cancer tissue. Combined with the histological morphology and immunolabeling results, it was consistent with XP11.2 translocation/TFE3 gene fusion-related renal carcinoma (referred to as XP11.2 translocation renal carcinoma). The patient recovered well and was allowed to be discharged.

RecentLancetAs mentioned in the published global burden of disease, cardiovascular diseases and tumors accounted for the first and third leading causes of death in the world in 2016, respectively^[1]。 In the United States, the overall cancer mortality rate has declined since the early 1990s. The latest statistics released by the National Cancer Institute in April 2018 show that the cancer mortality rate continues to decline: from 2006 to 2015, the mortality rate of male and female cancer patients decreased by 1.8% and 1.4% each year, respectively. With the decline of mortality, the base of the population suffering from cancer increases, and it is not uncommon for cancer patients to have coronary heart disease (CHD). A study that included 6 439 women with breast cancer^[2]It was found that 45.8% of the patients were complicated with cardiovascular disease, including myocardial infarction (MI), CHD, and congestive heart failure (CHF). There are some common risk factors for tumors and CHD, such as age, smoking and obesity^[3]。 Antitumor therapy such as chemotherapy and radiotherapy may lead to vascular endothelial damage, coronary artery spasm, arterial thrombosis, etc. These factors will increase the risk of CHD in cancer patients^[4]。 When these patients treat CHD, if they choose percutaneous coronary stenting (PCI), they need to weigh the risk of thrombosis and bleeding in the subsequent treatment of tumors; If you choose coronary artery bypass grafting (CABG), you need to consider the sequence between GABG and tumor resection and the advantages and disadvantages of cardiopulmonary bypass (ECC).