Volume 94  ·   Issue 05  ·  2014

Clinical practice guidelines refer to recommendations that are systematically developed for specific clinical situations to help clinicians and patients make appropriate handling. However, how to ensure the scientific, impartial and authoritative guidelines, the methodology of developing guidelines plays a crucial role. With the development and development of evidence-based medicine, the adoption of evidence-based methods to formulate guidelines has become the mainstream trend and consensus of international clinical practice guidelines. In recent years, the number of guidelines formulated in China is increasing day by day, but the quality is not uniform, and the guidelines formulated strictly according to evidence-based methods have not been paid enough attention in China^[1]。 In view of this, we recently organized experts to apply the principles and methods of evidence-based medicine to develop guidelines for the diagnosis, prevention and treatment of ventilator-associated pneumonia (VAP) (referred to as VAP guidelines) in combination with the Critical Care Medicine Branch of Chinese Medical Association^[2]This paper introduces in detail how to formulate VAP guidelines using GRADE method, and explores the feasibility of adopting GRADE method to formulate evidence-based guidelines in China, in order to improve the quality of domestic guidelines.

Ventilator-associated pneum-onia (VAP) refers to pneumonia in patients with tracheal intubation or tracheotomy 48 h after mechanical ventilation, and is one of the most common nosocomial-acquired infections in patients within the Department of Critical Care Medicine (ICU). The reported incidence and mortality of VAP are high both at home and abroad. Once VAP occurs, it is easy to cause difficulty in withdrawing, prolong the patient's ICU stay and hospital stay, increase the related medical expenses, and lead to an increase in the patient's mortality rate, which seriously affects the patient's prognosis. Early recognition and diagnosis, effective and comprehensive prevention and active and effective treatment of VAP have become urgent problems in critical care medicine. In order to standardize the diagnosis, prevention and treatment of VAP, the Critical Care Medicine Branch of Chinese Medical Association has formulated the "Guidelines for Diagnosis, Prevention and Treatment of Ventilator-Associated Pneumonia (2013)" (hereinafter referred to as the Guidelines)^[1]In view of the outstanding problems existing in the current diagnosis and treatment of VAP, this guideline summarizes and standardizes the understanding, diagnosis, prevention and treatment of VAP from different levels, and puts forward corresponding recommendations according to the principles of evidence-based medicine. This article mainly interpreted the targeted treatment of VAP in the guidelines.

In June 2013, the Critical Care Medicine Branch of Chinese Medical Association released China's first medical guideline based on the GRADE classification method-"Guidelines for the Prevention, Diagnosis and Treatment of Ventilator-Associated Pneumonia (VAP) (2013)"^[1]。 On the basis of summarizing the existing evidence-based medical evidence and combining the discussion opinions of top domestic critical care experts, the Guidelines reached a consensus on the diagnosis, prevention and treatment of ventilator-associated pneumonia (VAP), and formulated practical and standardized recommendations suitable for the prevention and treatment of VAP in China.

Ventilator-associated pneum-onia (VAP) refers to pneumonia in patients with tracheal intubation or tracheotomy 48 hours after mechanical ventilation. Pneumonia within 48 hours of withdrawal and extubation also belongs to VAP. VAP is one of the most common infectious diseases in patients undergoing mechanical ventilation in intensive care unit (ICU). It can lead to prolonged hospital stay and ICU stay of patients undergoing mechanical ventilation, increase the use of antimicrobial drugs, and seriously affect the prognosis of critically ill patients. VAP is affected by many factors in clinical manifestations, imaging manifestations and pathogenic examination, so it is difficult to grasp the diagnosis. Therefore, the Critical Care Medicine Branch of Chinese Medical Association has promulgated the diagnosis, prevention and treatment guidelines of VAP after a large number of literature reviews and summarizing domestic research and experience, trying to provide the basis and reference for clinical work.

Ventilator-associated pneum-onia (VAP) is a common complication in patients with mechanical ventilation and one of the most common nosocomial infections in patients in the Department of Critical Care Medicine (ICU). Despite the rapid development of critical care medicine, the increasing popularity and improvement of mechanical ventilation technology, and the widespread use of broad-spectrum antibiotics, the incidence and mortality of VAP remain high^[1]。 Therefore, how to effectively prevent VAP has become an increasingly concerned issue for intensive care doctors. In 2013, the Critical Care Medicine Branch of the Chinese Medical Association formulated the Guidelines for the Diagnosis, Prevention and Treatment of VAP, in which how to prevent VAP became the focus of everyone's interest. In a sense, VAP is like many diseases such as tumor, coronary heart disease and diabetes. The significance of prevention is far greater than treatment. We should strive to achieve zero VAP infection in ICU through the implementation and implementation of active preventive measures. The prevention section of the VAP Guidelines is divided into four parts according to different content directions: device-related preventive measures, operation-related preventive measures, drug prevention and clustered preventive protocols.

With the rapid development of critical care medicine in China in recent years, the clinical treatment level of critically ill patients has made remarkable progress. More and more critically ill patients have improved their prognosis after treatment in the Department of Critical Care Medicine (ICU), and most of them need to receive mechanical ventilation treatment. Mechanical ventilation plays a vital role in ensuring oxygen metabolism and treating respiratory failure caused by different causes, and can provide time for the treatment of primary disease. And the related complications caused by it have attracted more and more attention. Among them, ventilator-associated pneumonia (VAP) is one of the most common complications.

Currently, according to ventilator-associated pneumonia (VAP) definition and patient population, the incidence of VAP globally is 6% to 52% or (1.6 to 52.7) cases per 1 000 mechanical ventilation days, and the case fatality rate is 14% to 50%. VAP leads to prolonged stay in intensive care medicine (ICU), increased hospitalization costs, and is an important cause of death in critically ill patients. In the past decade, the United States, the United Kingdom, Canada and other countries have successively issued VAP-related diagnosis and treatment guidelines^[1,2,3,4]Great progress has been made in the prevention and treatment of VAP, and the incidence rate has been declining. In the United States, there are even calls to include VAP in the government medical insurance agency's refusal to pay catalogue. However, the situation of high morbidity and mortality of VAP in China is still grim. How to contain VAP has become an important issue in the field of clinical medicine. Recently, the Critical Care Branch of Chinese Medical Association issued the "Guidelines for the Prevention, Diagnosis and Treatment of Ventilator-Associated Pneumonia (2013)"^[5](hereinafter referred to as the VAP Guide). It draws on the experience of major academic organizations at home and abroad, such as American Society of Critical Care Medicine, Thoracic Association, British Association of Antimicrobial and Chemotherapy, etc. in formulating guidelines. Based on common and hot clinical issues, combined with recent research progress, the method of evidence-based medicine is applied, and the prevention, diagnosis and treatment of ventilator-associated pneumonia are introduced in detail.

To explore the relationship of mid-trimester serum screening markers and adverse pregnancy outcomes.

We retrospectively reviewed all obstetric patients with mid-trimester screening data who delivered at our department from September 2010 to November 2012. Adjusted effects were estimated with Logistic regression analysis.

A total of 3 618 cases were enrolled. The level of free β-subunit of human chorionic gonadotropin (fβ-hCG) [≥ 2.2 (multiple of median) MOM] was associated with the risk of pregnancy-related hypertension ( OR=2.06, 95%CI 1.18-3.60, P<0.01). And fβ-hCG (≥2.2 MOM) and alpha-fetoprotein (AFP) (≥1.88 MOM) were associated with the development of placenta-related complications (P<0.01, 0.05 respectively). Additionally, maternal weight was associated with the risk of pregnancy-related hypertension and placenta-related complications (bothP<0.05).

The mid-trimester screening markers fβ-hCG and AFP are associated the risk of adverse pregnancy outcomes. And their value may predict the risk of adverse pregnancy outcomes.

To explore the outcomes of individualized neurosurgical treatments of spastic cerebral palsy.

A total of 452 spastic cerebral palsy patients undergoing microneurosurgery during March 2006 and December 2011 were retrospectively analyzed.Performed on the basis of clinical manifestations, comprehensive procedures included selective cutting of neck or lumbosacral dorsal root ganglia (SPR, n=182) for multiple muscle spasm, selective peripheral neurotomy (SPN, n=270) for focal muscle spasm, line tendon lengthening or cutting and orthopedic surgery (n=116) for tendon contracture plus limb deformities and carotid artery adventitia endarterectomy (n=46) for salivation plus athetoid.

The average follow-up period was 18 (10-24) months.The limb spasm relief rate of SPR was 95.6% and that of SPN 98.3%.And the postoperative symptom improvement rate of common carotid arterial adventitia stripping was 91.3%. There were 8 cases (4.4%) of recurrent spasticity after SPR and 28 (10.4%) after SPN.

Offering individualized microsurgical treatments on the basis of clinical manifestations is essential for patients with spastic cerebral palsy.

To explore the functions of temporal parietal junction (TPJ) as parts of attention networks in the pathogenesis of online game addiction using resting-state functional magnetic resonance imaging (fMRI).

A total of 17 online game addicts (OGA) were recruited as OGA group and 17 healthy controls during the same period were recruited as CON group.The neuropsychological tests were performed for all of them to compare the inter-group differences in the results of Internet Addiction Test (IAT) and attention functions.All fMRI data were preprocessed after resting-state fMRI scanning.Then left and right TPJ were selected as regions of interest (ROIs) to calculate the linear correlation between TPJ and entire brain to compare the inter-group differences.

Obvious differences existed between OGA group (71±5 scores) and CON group (19±7 scores) in the IAT results and attention function (P<0.05). Compared with the controls, right TPJ in online game addicts showed decreased functional connectivity with bilateral ventromedial prefrontal cortex (VMPFC), bilateral hippocampal gyrus and bilateral amygdaloid nucleus, but increased functional connectivity with right cuneus.However, left TPJ demonstrated decreased functional connectivity with bilateral superior frontal gyrus and bilateral middle frontal gyrus, but increased functional connectivity with bilateral cuneus (P<0.05).

Altered functional connectivity of TPJ reflected its dysfunction in online game addicts.It suggests that TPJ is an important component of attention networks participating in the generation of online game addiction.

To explore the surveillance and diagnostic values of ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) follow-ups in malignant transformation of cirrhotic nodules so as to improve the diagnostic accuracy of early hepatocellular carcinoma (HCC) with liver cirrhosis.

Retrospective analyses were conducted for US, CT and MRI features of 96 HCC patients confirmed by pathological examination or treatment.

All patients (145 lesions) underwent US, CT, MRI examinations during follow-ups.US detected 62 lesions (42.6%) and 90 lesions on enhanced CT (62.1%) presented "fast-in fast-out" enhancement, pseudocapsule, progressive enlargement or increasing numbers in a short time.And 138 nodules on MRI (95.2%) manifested as decreased T ₁WI signal, increased T₂WI and DWI signal, "nodule in nodule" on T ₂WI, fatty degeneration, change of enhancement patterns, pseudocapsule, progressive enlargement or increased number in a short time.

MRI offers obvious advantages over CT and US (P<0.05). US may serve as a routine follow-up mean for cirrhotic patients.Once lesions are found, enhanced CT and/or MRI should be performed for confirming a diagnosis.Cirrhotic patients without HCC should undergo MRI regularly to diagnose HCC earlier.

To compare and analyze the positron emission tomography (PET) images with other multi-modalities in the diagnosis of hepatic tumors.

A total of 158 patients undergoing ¹⁸F fluorodeoxyglucose (FDG)-PET were enrolled along with another 55 cases with ¹¹C acetate-PET (AC-PET) imaging within 1 week.The pathological results were taken as the golden criteria.Tumor marker, contrast ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) results were collected.SPSS 19.0 was used for statistical analysis.

Contrast MRI, ultrasound and CT were more effective than PET in the differential diagnosis of hepatic tumor.FDG-PET showed a better accuracy in the diagnosis of intrahepatic cholangiocarcinomas, metastasis and rare primary hepatic carcinoma.AC-PET was a good complementary method to FDG-PET.Consideration of tumor size, amount, laboratory results and history could improve the diagnostic accuracy of PET and enhanced CT.

PET must be combined with other image modalities to differentiate hepatic tumors more effectively and accurately.

To explore the clinical features and therapeutic profiles of autoimmune dementia.

Eight hospitalized patients with autoimmune dementia during March 2011 and May 2013 were recruited and retrospectively analyzed for clinical features, as well as therapeutic and prognosis profiles.

There were 3 males and 5 females with a onset age range of 45-72 years.Their onsets varied from acute (n=3), subacute (n=1) to chronic (n=4). Six of them had a fluctuating course.The diagnoses were multiple sclerosis (n=3), paraneoplastic limbic encephalitis (n=2) and Hashimoto′s encephalopathy (n=1), microscopic polyangiitis (n=1) and unclassified autoimmune encephalopathy (n=1). Progressive memory loss without delirium was the main symptom.In addition, 3 patients suffered epilepsy, 2 with intractable hyponatremia, 4 with positive serum autoimmune or paraneoplastic antibodies, 7 with inflammatory cerebrospinal fluid, 4 with abnormal electroencephalography (EEG) and 8 with various changes on brain magnetic resonance imaging (MRI). Two patients had concurrent Hashimoto′s thyroiditis and another with small cell lung cancer.All patients improved after treatment with immunological and antineoplastic therapies.

Autoimmune dementia has complex causes with a rapidly progressive and fluctuating course.The coexisting conditions include epilepsy, hyponatremia, organ-specific autoimmunity, inflammatory spinal fluid with abnormal EEG and brain MRI findings.Immunotherapy is recommended.

To explore the electrophysiological characteristics of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes (POEMS) syndrome and its related diseases.

The electrophysiological characteristics were analyzed retrospectively from June 2000 to June 2013 in patients with POEMS syndrome, monoclonal gammopathy of undetermined significance (MGUS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Electromyography and nerve conduction examinations of median, ulnar, tibial, peroneal and sural nerves were performed.

In patients with POEMS syndrome, the amplitude of compound muscle action potential (CMAP) of tibial and peroneal nerves was lower than that of median and ulnar nerves ((1.02±0.23) vs (2.12±0.30) mV, (P<0.05)); compared with patients with CIDP, the amplitude of CMAP for POEMS patients was lower ((2.12±0.30) vs (3.94±0.52) mV, (1.02±0.23) vs (3.65±0.57) mV)(P<0.05) while terminal latency indices (TLI) was higher ((0.41±0.13) vs (0.22±0.01), (0.45±0.16) vs(0.24±0.13)) (P<0.05) and the occurring rate of conduction block (CB) and temporal dispersion (TD) was lower (P<0.05). Compared with MGUS patients, the amplitude of CMAP for POEMS patients was lower ((2.12±0.30) vs (3.81±0.83) mV, (1.02±0.23) vs (3.82±0.63) mV)(P<0.05); sensory conduction velocity of POEMS patients was faster ((33±5) vs (20±3) m/s, (28±4) vs (18±3) m/s)(P<0.05)).

Nerve conduction studies of POEMS syndrome implicate both axonal loss and demyelination.Uniform demyelination is more predominant in nerve trunk rather than distal nerve terminals.CB and TD occur less frequently and axonal loss is length-dependent.

To explore the independent risk factors and predictive factors of cognitive deterioration in patients of vascular cognitive impairment no dementia with subcortical ischemic vascular disease (VCIND-SIVD).

The clinical and neuropsychological characteristics of 96 VCIND-SIVD patients were collected and their cognitive states re-assessed after one year.The distribution of continuous and categorical variables was examined with univariate analysis.And Logistic regression in multivariate modeling was employed to identify the risk and predictive factors of cognitive deterioration.

After 1-year follow-up, 8 patients dropped out, 2 died and the remainder remained.There were 48 males and 38 females with an average age of 64.3±5.4 years.Among them, 17 (19.8%) deteriorated into dementia, 24 (27.9%) upgraded to normal cognition and 45 (52.3%) maintained their cognitive status.They were divided into dementia group (cognition deteriorating into dementia) and control group (elevated/sustained cognition). After univariate analysis of general information and vascular risk factors, Logistic regression demonstrated that education level (P<0.05,OR=0.7) was a preventive factor of dementia while age (P<0.05,OR=1.2), hypertension (P<0.05,OR=5.6) and high homocysteine (P<0.05,OR=4.2) were independent risk factors of dementia.After univariate analysis of neuropsychological scores, Logistic regression demonstrated that visual reproduction-immediate recall (P<0.05,OR=3.4), digit span forward (P<0.05,OR=1.2), clock drawing test (P<0.05,OR=6.8) and completion time of London tower (P<0.05,OR=5.4) were predictive factors of dementia.

VCIND-SIVD patients with low score of visual reproduction-immediate recall, digit span forward, clock drawing test and completion time of London tower should receive vigorous controls of hypertension and high homocysteine.

Summarizes the treatment effect of inflammatory abdominal aortic aneurysm (inflammatory abdominal aortic aneurysm, IAAA), and explore its therapeutic strategy.

Retrospectively analysis 17 cases of IAAA in our center from January 2002 to August 2012, 16 males, 1 female, mean age 52-79 (67±8). 4 cases were treated by conservative medical treatment, 5 cases treated by open surgery, 8 cases treated by EVAR.

During follow-up no aneurysm-related death. Follow-up for the conservative medical treatment group was a mean of (10±6) months, 1 case transit to EVAR, the aneurysm diameter of 2 cases decreased 2 mm and 4 mm, 1 case had no significant diameter change.The mean follow-up time of open group was (28±23) months, mean operation time was (4.9±0.7) hours, Mean operative blood loss was (3 300±370) ml, 1 case with postoperative anastomotic pseudoaneurysm formation.The EVAR group followed up for (20±14) months, without serious perioperative complications, 5 cases aneurysm diameter decreased (5.1±1.5) mm.

Conservative medical treatment can improve clinical symptoms of IAAA, such as inflammation, abdominal/back pain and hydronephrosis.EVAR is gradually becoming a first-line treatment of IAAA.Open surgery is still the gold standard for treatment of IAAA.Therefore, definite conclusions should be drawn from further studies.

To evaluate the effect of endovascular aneurysm repair(EVAR) of ruptured abdominal aortic aneurysm(rAAA) and to summarize the experience.

The clinical data of 13 RAAA cases(males 11, females 2, age range 69-88) undergoing EVAR from February 2002 to February 2013 were retrospectively analyzed.It consisted of 10 atherosclerotic aneurysms and 3 pseudoaneurysms.CTA was finished in all of them.And they all undergone emergency surgery.

All of the cases were successfully treated.During the perioperation , one suffered from contrast induced nephropathy and there were no deaths.During the follow-up, there were one case of type Ⅰa endoleak treated by embolism and one case of reruptured pseudoaneurysm which abandonded treatment.

Endovascular repair is the safe and effective treatment for ruptured abdominal aortic aneurysm.

To explore the clinical application of serum GP73 in the diagnosis and progress of hepatocellular carcinoma (HCC).

Enzyme-linked immunosorbent assay was employed to quantitatively detect serum GP73 in 59 HCC patients, 23 cases of hepatitis B virus (HBV)-related cirrhosis and 33 normal controls.The relationship between GP73 and diagnosis as well as progress of HCC was examined.

Significant differences existed when serum GP73 was categorized by Child-Pugh class A and B (P<0.01). There was no correlation between GP73 levels and other parameters including age, gender, BCLC staging, HBV infection, tumor size, extrahepatic metastasis and tumor numbers.The serum GP73 with a mean level of [127(147) μg/L,M(QR)] in HCC patients was significantly higher than that in normal controls or those with HBV-liver cirrhosis (P<0.01). Based on the ROC curve analysis, the cut-off value was 99 μg/L with 64.4% sensitivity and 96.4% specificity.The sensitivity of diagnosing HCC with GP73 plus AFP improved(P=0.025), but not in specificity.Serum GP73 and AFP did not change greatly in terms of response assessment in mRECIST from baseline to progressive disease (P=0.959, P=0.788). No correlation existed between baseline concentration of GP73 with AFP and time to progression(r=0.119, P=0.608; r=0.142, P=0.540).

GP73 may become a potential serum marker for diagnosing HCC. And a combination of AFP yields better outcomes.The exact relationship between mRECIST and GP73 as well as AFP shall be proved by large-scale clinical trials.

To explore the effects of different doses of repeated ultrasound on the expressions of NR1 and NR2B subunits of NMDA receptor and synaptic structure so as to understand the molecular mechanisms of ultrasound on learning and memory in prenatal rats.

The pregnant rats were randomly divided into 3 groups (n=8, each) and exposed to ultrasound for 0, 4 and 20 minutes at Days 6, 12 and 18 of gestation respectively.Their offspring were tested by Morris water maze (MWM) for evaluating the learning and memory abilities at an age of 2 months.The hippocampal pyramidal cell was observed by hematoxylin and eosin staining, the expressions of NR1 and NR2B by immunohistochemistry and Western blot and the morphologies of synapse in CA1 by electron microscopy.

(1) In the water maze test, compared with the control group, the escape latency of 4 min group was significantly shorter (P<0.05) while that of 20 min group significantly longer in the 1-4 d latency (P<0.01). The time in platform quadrant (TQ) and the frequency of crossing through original platform increased in 4 min group (P<0.01). However, they decreased in the 20 min group (P<0.01); (2) in 4 min group, the density of hippocampal CA1 pyramidal cells per unit area was higher than that of the control group (P<0.05). Sparse pyramidal cells and low density were observed in the 20 min group (P<0.01); (3) compared with the control group, the expressions of total NR1, NR2B proteins in hippocampal regions significantly increased in 4 min group and both significantly decreased in 20 min (P<0.05); (4) the structure of synapses became damaged in 20min group with decreased number density and surface density.

High doses of repeated ultrasound may decrease the ability of learning and memory through a down-regulated expression of NR1 and NR2B subunits in hippocampal regions and damaging synaptic structure.However, low doses of repeated ultrasound may promote the expressions of NR1 and NR2B, maintain synaptic structure and further enhance cognitive ability in prenatal rats.

To explore the effects of low-frequency electrical stimulation (LFS) of hippocampus on the expression of GABA_A receptor α ₁ and β ₂ subunits in the kainite (KA)-kindled rats and explore its underling rescue mechanism for temporal lobe epilepsy.

The SD rats were divided into 4 groups (n=10): control group: no operation; epilepsy group: KA was stereotactically injected into rat hippocampus to establish KA-kindled model; sham-LFS group: only implanting of electrodes into hippocampus without LFS; LFS group: KA-kindled model with LFS.Then hippocampal tissues were collected and their expressions of GABA_A receptor α ₁ and β ₂ subunits measured by immunohistochemistry, quantitative-polymerase chain reaction (q-PCR) and Western blot.Nissl staining was performed to detect the number of damaged hippocampal neurons.

There were significant decreases of GABA_A receptor α ₁ and β ₂ subunits in kindled hippocampus (P<0.01). LFS resulted in an effective rescue, but failed to reach normal levels.The damaged neurons ccould not be reversed according to Nissl staining.

The hippocampal application of LFS may protect against seizures by modulating the expressions of α ₁ and β ₂ GABA_A receptor subunits.

A 61-year-old female developed right inguinal pain without obvious trigger one month ago, which was aggravated when walking. She came to the general surgery clinic of the Second Affiliated Hospital of Suzhou University for treatment. The abdomen was flat and soft, without tenderness and rebound pain, and there was no obvious mass in the abdomen. There was no obvious lymph node enlargement in the bilateral groin. The physiological curvature of the spine was present, and no obvious scoliosis deformity was seen. Extremities are well moved and muscle strength is normal. Mild tenderness on the right side of the pubic symphysis, longitudinal buckling pain in the right lower limb (-), pelvic crush separation test (-). Good sensory mobility in both lower limbs. The peripheral blood supply is good, and the pulsation of the dorsal pedis artery is palpable. Physiological reflexes are present, but pathological reflexes are not elicited. Pelvic MRI examination in outpatient clinic showed abnormal signal of right superior pubic branch with fracture, abnormal signal of surrounding soft tissue, abnormal signal foci of bilateral ilium and sacrum, and possible metastasis. The outpatient clinic then planned to admit "pelvic bone lesions" to the orthopedic surgery department for further diagnosis and treatment. During the course of the disease, the patient was generally in good condition, without low fever, emaciation, night sweats, normal defecation, dizziness, nausea and vomiting, shortness of breath, chest tightness, abdominal distension and diarrhea. Past physical fitness. History of hypertension, coronary heart disease and diabetes is denied. Deny the history of contact with infectious diseases such as tuberculosis, schistosomiasis and typhoid fever. History of trauma denied. Married, menopausal for 6 years. Deny the history of familial genetic diseases and infectious diseases. Vital signs normal. Blood red blood cells, white blood cells, neutrophils, liver and kidney function were normal after admission, fibrinogen was 5.120 g/L, and D-dimer was 1.81 mg/L. B-ultrasound examination showed no obvious abnormalities in liver, gallbladder, spleen and pancreas, and posterior-anterior chest X-ray examination showed no obvious active lesions in the chest. Pelvic MRI showed that the bone of the right pubic branch was discontinuous, and the broken end showed uneven length T₁WI, long T₂Wi-SPAIR signal (Figure 1), displaced bone fragments and fluid effusion were seen at the broken end (Figure 2)。 MRI diagnosis of abnormal signal of right upper pubic branch with fracture, abnormal signal of surrounding soft tissue, abnormal signal foci of bilateral ilium and sacrum, and possible metastasis; Pelvic CT scan showed that the bones of the pelvis were sparse, and bilateral sacral wings showed fracture lines running up and down (FIG. 3A), the shape of the fracture line is irregular, parallel to the sacroiliac joint, involving the 1st to 2nd sacral vertebrae on the left side, and the 1st to 3rd sacral vertebrae on the right side. Local osteosclerosis is seen, and the bone on both sides of the fracture line is slightly misaligned. S1~2 intervertebral space is irregular and pneumatic, and local bone sclerosis is seen (FIG. 3B)。 Right pubic ramus bone fracture (Figure 3C), the fracture line is perpendicular to the pubic bone, slightly displaced inward, free bone fragments are seen locally, and the soft tissue around the pubic symphysis and the right external obturator muscle are swollen. CT diagnosis of bilateral sacral wing, right pubic branch failure fracture, local callus formation, right external obturator muscle and pubic symphysis surrounding soft tissue swelling. Pathology: Partial tissue biopsy of the pathological fracture end of the right superior pubic branch showed mature trabecular bone and a small amount of cartilage tissue (Figure 4)。 The patient's condition did not deteriorate after 9 months of follow-up.

The earliest research on developmental brain neurotoxicity caused by general anesthetics can be traced to 1974. Quimby et al.^[1]It was reported that persistent abnormal cerebral cortical synapse formation and decline of learning and social ability in adulthood after long-term exposure to 0.01% halothane in juvenile rats. However, this study has not attracted academic attention. In 2003, Jevtovic-Todorovic et al. investigated the effects of common general anesthetics on the developmental brain. In this experiment, a "cocktail" anesthesia regimen of midazolam, isoflurane and nitrous oxide was used to anesthetize neonatal rats 7 days after delivery for 6 h. After 24 h, the neonatal rats' brains showed extensive apoptosis, hippocampal synaptic function was impaired, and the learning and memory ability of rats in adulthood was significantly reduced^[2]。 Since the results of this study were reported, the developmental brain neurotoxicity caused by general anesthetics has been widely concerned by the anesthesiology community and even the society. This review will summarize the research on developmental brain neurotoxicity caused by general anesthetics in recent years, elaborate the basic research on the effects of general anesthetics on neuronal genesis and synapse formation during neuronal development and the damage of mature neurons after division, and point out the related clinical research progress in recent years.

With the aging of China's population, the incidence of common diseases in the elderly, such as hypertension and cognitive dysfunction, has gradually increased. The number of patients with senile dementia, the terminal stage of cognitive dysfunction, has surged from 3.68 million in 1990 to 9.19 million in 2010^[1]It has become the third major disease that threatens the lives of the elderly after cardiovascular diseases and malignant tumors, bringing a heavy burden to social public health and economy. It has been studied that abnormal circadian rhythm of blood pressure in elderly hypertensive patients is associated with cognitive impairment^[2,3,4]And a large number of prospective studies suggest that antihypertensive therapy adjusting blood pressure rhythm is beneficial to delay the progression of cognitive impairment^[5,6]Therefore, the abnormal circadian rhythm of blood pressure in elderly hypertensive patients may be an important influencing factor of cognitive impairment, but the mechanism is still unclear and needs further research.

A 45-year-old male suffered from sudden headache and vomiting for 1 week. Nothing special in the past. Physical examination: clear, poor spirit, movable limbs. CT scan of the skull showed irregular high-density shadows in the left parietal occipital, edema of the surrounding brain tissue, obvious enhancement, compression of the ipsilateral ventricle, and right shift of the midline; MRI showed a 4 cm ×4 cm ×3 cm mass-like mixed signal shadow in the left parieto-occipital, T₁WI high signal, T₂WI is low signal, the boundary of the tumor is clear, and large patchy edema and irregular enhancement can be seen around it (Figure 1)； Preoperative diagnosis: left parieto-occipital glioma with hemorrhage. A 2 cm ×2 cm ×1 cm mass was seen on the left parietal, uniformly enhanced, closely related to the dura mater, and the preoperative diagnosis was meningioma. No pigmented spots were seen on the skin before surgery. The left parieto-occipital craniotomy was performed, and the parieto-occipital lobe was incised to see brown liquid flowing out, about 20 ml, and there was an abnormal blood vessel mass at the top of the cyst cavity; A brown mass was seen on the top of the left side, with medium texture, clear boundary and abundant blood supply. The base of the mass was close to the falx cerebri, and the tumor was totally removed under the microscope. Pathological diagnosis: metastatic malignant melanoma (epithelial cell type), immunohistochemistry: S-100 fraction (+), HMB45 fraction (+), Vim fraction (+), NSE (-), SY (-), CK (-), LCA (-), CD20 (-), CD79a (-), CD45RO (-), CD3 (-). After discharge, he was treated with gamma knife and died 8 months after surgery.