Volume 94  ·   Issue 15  ·  2014

As a vigorous discipline, critical care medicine in China has been enriched and developed rapidly in recent years, and has gradually played a more and more powerful role in public health emergencies in China. After the earthquake and other disasters, the first-class experts in critical care medicine in China led a large number of young and middle-aged key medical staff to rush to the disaster area at the first time. In the ruins, wilderness, field hospitals and grass-roots hospitals, they are like a special force to treat the seriously injured in disasters, saving a large number of wounded people who are hovering on the verge of life and death, and greatly reducing the disability rate of the wounded. As the rescue witnesses of public health emergencies such as SARS, Wenchuan earthquake and Xiamen BRT fire, we discuss the task, role and direction of intensive care medicine in the rescue of public health emergencies in earthquake based on our own experience and relevant literature in recent years.

China is a highly earthquake-prone area, with 7% of the land area bearing 33% of the strong earthquakes in the world^[1]。 From the Wenchuan earthquake to the Lushan earthquake, tens of thousands of people have died and hundreds of billions of property have been lost. The sudden earthquake disaster has brought us trauma and great pain, and it also warns medical staff to constantly learn experience and lessons from the disaster, especially for critical care doctors, they should constantly improve the early scientific treatment and management strategies of severe earthquake wounded, so as to learn from the past and respond calmly after similar disasters in the future, strive to minimize the casualties caused by earthquakes and effectively reduce the disability rate.

Since 2008, several strong earthquakes of high magnitude have occurred in western China such as Wenchuan in Sichuan, Yushu in Qinghai, Yiliang in Yunnan, and Lushan in Sichuan, causing huge loss of life and property. Treatment of serious earthquake injured is one of the most core tasks in earthquake relief. From Wenchuan earthquake to Yushu earthquake to Lushan earthquake, although the geographical environment, magnitude and traffic recovery of earthquakes are different, there have been many improvements and progress in the concept and practice of medical rescue for seriously injured earthquakes. Comprehensively sorting out the changes in the treatment concept, the optimization of the process and the analysis of the results in the critical treatment of the wounded in these major earthquakes, and constantly summing up the experiences and lessons will surely provide valuable guidance for improving the critical treatment actions in response to sudden disasters in the future.

To explore the value of focused critical ultrasound in the treatment of critical patients in Lushan earthquake.

The utilization of bedside ultrasound and its effects on the treatment of critical patients in Lushan earthquake were retrospectively analyzed.

After brief training of resident doctors, bedside ultrasound was performed for 107 sessions. And 97 sessions(90.7%)of ultrasound exams were valuable for diagnosis and treatment. The exams included hemodynamic monitoring for 44 sessions and bedside lung ultrasound for 58 sessions. In hemodynamic monitoring, after heart function estimation, fluid resuscitation was restarted in 8 cases(8/44, 18.2%)and terminated in 2 cases to control risks. False estimate of volume by clinical experience were 8 sessions (8/44, 18.2%). And corrections were made after ultrasound exams. A total of 18 cases(18/44, 40.9%)of hemodynamic treatments improved with the help of focused critical ultrasound. Bedside lung ultrasound was performed to monitor the change of lung water in fluid resuscitation 6 sessions and guide the pleural fluid drainage and lung recruitment before weaning 17 sessions; the BLUE-plus lung ultrasound protocol was performed for 32 sessions. And 24 cases of lung consolidation and atelectasis were found. Chest physiotherapy was then performed. The focused critical ultrasound exam was also performed to locate thrombus, biliary infection and intracranial infection, etc.

Focused critical ultrasound can provide reliable clinical information to reduce unnecessary examination and optimize therapies for Lushan earthquake victims.

To explore the intensive care unit (ICU) strategy and algorithm of treatment for critical patients from the Lushan Earthquake.

Retrospective analyses were performed on the clinical characteristics and treatments for critical patients of Lushan Earthquake occurring on April 20, 2013. A total of 18 critical patients were admitted into 3 ICUs of Sichuan Provincial People's Hospital. There were 8 females and 10 males with an average age of 46±23 years and a mean score of APACHE Ⅱ 11±6. There were extremity fractures (n=16, 88.9%), chest traumas (n=11, 61.1%), head injuries(n=8, 44.4%)and pelvic fractures (n=9, 50%). All of them received VIPC plan for early stage resuscitation and CRASHPLAN for further evaluations. And individual treatment was planned and implemented by multidisciplinary specialists.

During ICU stay, 7 patients(38.9%)suffered acute respiratory distress syndrome (ARDS). Among them, noninvasive ventilation (n=2) and intubation and mechanical ventilation (n=5) were implemented. Ten septic patients (55.6%) received antibiotic therapy, 6 with severe head injury accepted Lund's concept for brain protection and 13 (72.2%) underwent 20 operations. Sixteen patients(88.9%)were discharged and another 2 (11.1%) remained comatose in hospital.

Earthquake-related critical patients have complicated disease situations. And centralized salvage, optimal strategy and algorithm may improve their outcomes.

To explore the effects of varus of knee osteoarthritis (OA) on patellar position.

A total of 19 patients (27 knees) underwent the examinations of anterior-posterior, lateral knee and axis of patellar X-ray at 30°, 45°, 60° and each X-ray was measured.

The ratio between length of patellar tendon and length of patellar, vertical distance of lower edge of patellar to tibial plateau and height of patellar, distance of lower edge of medial facet of patellar to anterior angle of tibia and height of patellar were different from normal values. Patellar moved medially during the process of bending from 30°to 60°.

The patellar of knee OA patients with varus moves down and medially.

To explore the advantage, feasibility and safety of modified approach to difficult vaginal hysterectomy and provide scientific rationales for expanding its indications.

A retrospective study was conducted for 237 patients undergoing hysterectomy for benign disease of uterus (without prolapse) from January 2009 to July 2012. Both modified approach to difficult vaginal hysterectomy (TVH, n=167) and abdominal hysterectomy (TAH, n=70) were performed. Two groups were compared for epidemiological, clinical characteristics, operative duration, intraoperative blood loss volume, perioperative and postoperative complications, hospitalization duration, inflammatory response and follow-up outcomes. TVH was divided into 3 subgroups of enlarged uterus (n=100), prior pelvic surgeries/endometriosis history (n=25) and complicated cases with multiple factors (n=42). Then the surgical outcome parameters were compared for each group.

The operative duration, intraoperative blood loss volume and blood transfusion amount were significantly less in the TVH group than those in the TAH group (P<0.05). No major perioperative complications occurred in either group. There was no conversion from TVH into TAH. Inflammatory response, gastrointestinal recovery and hospitalization duration for the TVH group were significantly shorter than those of the TAH group (P<0.05). The hospitalization expense was almost the same in two groups (P>0.05). Postoperative complications and the quality of sexual health were not statistically different between two groups at 1 month and 6 months post-operation (P>0.05). The data of three TVH subgroups were collected. The complicated cases with multiple factors group had longer hospitalization duration than the enlarged uterus and the prior pelvic surgeries/endometriosis history groups (P<0.05). Similarly the volume of blood loss in the complicated cases with multiple factors group was significantly more than those of other two groups (P<0.05).

As one kind of mini-invasive surgery with less complications, higher safety and feasibility, modified approach to difficult vaginal hysterectomy offers shorter operative duration, less volume of blood loss and faster recovery.

To evaluate the clinical value of conization in the diagnosis of cervical cancer to optimize its management.

Fifty-six patients diagnosed with cervical cancer after conization at our hospital between 2008 and 2012 were reviewed. The pathological profiles of colposcopic multiple biopsies and treatment options were analyzed.

Among them, there were stage Ⅰa1 (n=39), stage Ⅰa2 (n=2) and stage Ⅰb1 (n=15). And there was not much correspondence between cervical conization and colposcopic multiple biopsies in 46 cases. Among 23 patients with stage Ⅰa1 undergoing further surgery, 12 (52.17%) had residual diseases, including CINⅠ (n=5), CINⅡ(n=3), CINⅢ(n=3). No recurrence was found in 16 cases without further surgical intervention. All cases of stages Ⅰa2 and Ⅰb1 underwent repeat surgery while 8 cases received preoperative chemotherapy, including stage Ⅰa2 (n=1) and stage Ⅰb2 (n=7).

Cold knife conization plays a very important role in the diagnosis and treatment of cervical diseases. Further treatment options should be selected individually and comprehensively based on such factors as patient age, degrees of dysplasia, surgical margin status, fertility requirements and so on.

To explore the clinical efficacies of bevacizumab (BEV) for high-grade glioma (HGG) in Chinese patients and evaluate its profiles of adverse events and usage safety.

A total of 15 HGG cases, including glioblastoma multiform (GBM) (n=12) and anaplastic astrocytoma (AA) (n=3), were selected to receive the treatments of BEV (10 mg/kg, q2w) and temozolomid (TMZ, 150 mg/m²,5 d/28 d). Their radiological responses, clinical status, progression-free survival (PFS) and overall survival (OS) were evaluated. Also their adverse events and severity were recorded and analyzed.

According to the RANO criteria, during the short period (<3 months), 11 cases had significant radiological and clinical responses. However, only 4 cases responded during a follow-up period of beyond 3 months. Three cases had reprogression after BEV chemotherapy. At 6 months post-treatment, 8 cases (53.3%) survived without lesion progression and the median PFS was 8±5 months. During a longer follow-up (>6 months), 8 patients had tumor reprogression, including 5 deaths. The median overall survival period was 24±10 months. The adverse events included hypertension (n=2), wound-healing complication (n=1), vomiting (n=2) and cerebro-spinal fluid leakage (n=1). All complications were cured by activate supportive measures.

After BEV treatment, most patients obtain more significant short-term responses with good toleration. For re-operative cases, the usage of BEV should be deferred to one month post-operation so as to avoid the occurrence of wound-healing complications.

To evaluate the diagnostic efficiency of a T-cell interferon-γ release assay based on recombinant Mycobacterium tuberculosis(MTB)11kD protein for diagnosing tuberculosis.

This prospective study enrolled inpatients with suspected tuberculosis at PUMCH to examine the diagnostic sensitivity, specificity, predictive value (PV) and likelihood ratio (LR) of T-cell interferon-γ release assays based on recombinant MTB-11kD protein, early antigenic target-6 (ESAT-6) and culture filtrate protein-10 (CFP-10) peptides (T-SPOT. TB). Test results were compared with final clinical and microbiological diagnoses.

Among 151 inpatients with suspected tuberculosis, 33(21.9%) were microbiologically or clinically diagnosed as tuberculosis and 107(70.9%) ruled out. And the remaining 11(7.3%) patients were clinically indeterminate. The sensitivities of recombinant MTB-11kD-ELISPOT assay and T-SPOT. TB were 60.6%and 81.8%respectively (P=0.057). Whereas, the specificity of recombinant MTB-11kD-ELISPOT assay was significantly higher than that of T-SPOT. TB (84.1%vs 72.9%, P=0.046). The parallel testing increased the sensitivity to 84.9% and serial testing increased the specificity to 86.9%.

The recombinant MTB-11kD-ELISPOT assay is more specific than T-SPOT. TB. And its combination with T-SPOT. TB may improve the diagnostic efficiency for tuberculosis.

To evaluate the clinical application value of X-ray digital DTSynthesis(DTS) based on IVU (Intravenous Urography)in urinary calculi contrasted with unenhanced multidetector-row computerized tomography.

75 patients suspected of urinary calculi underwent IVU, DTS based on IVU and UMDCT. The diagnostic sensitivity, specificity, accuracy, positive predictive value and negative predictive of the three imaging ways were acquired according to operations, respectively. Chi-square test was used to evaluate the difference among the three ways.

In 75 cases, 60 cases were proved to be urinary calculi. The diagnostic sensitivity, specificity, accuracy, positive predictive value and negative predictive of IVU, DTS based on IVU, UMDCT is 70.0%, 73.3%, 70.7%, 91.3%, 37.9%; 91.7%, 86.7%, 90.7%, 96.5%, 72.2%; 96.7%, 86.7%, 94.7%, 96.7%, 86.7%, respectively. No significant differences between DTS based on IVU and UMDCT were found in sensitivity, specificity, accuracy, positive predictive value and negative predictive. Both cases are better than IVU in diagnostic ability.

There is no significant difference in diagnostic ability of urinary calculi between DTS and UMDCT. DTS can be used as a routine imaging technique in diagnosis and follow up of urinary calculi.

To subdivide the M1 stage of patients to predict better survival groups and assess the predictive factors of prognosis to select personalized cancer treatments.

From the records of 666 colorectal cancer cases treated at our hospital during January 1995 to December 2010, we analyzed the site of metastases, number of metastases, size of hepatic metastatic tumor and corresponding treatments. According to the results, we made recommendations for subdividing the M1 stage to guide individualized treatments.

The metastatic median survival of liver metastasis and non-liver metastasis were 18.7 vs 22.9 months (P=0.082). And the median survival of single organ metastasis, double organ metastasis and multiple organ metastasis were 24.8 vs 15.6 vs 10.9 months, (P<0.01). With no more than 3 liver lesions, the patients received operation or ablation therapy plus chemotherapy and their median survival was longer than those on chemotherapy only (49.6 vs 22.3 months,P<0.01).

According to metastatic characteristics, different clinical features and treatments result in significantly different survivals and prognoses in metastatic colorectal cancer patients.

To investigate the interaction between polymorphisms and environment factors in age related cataract (ARC).

Population-based case-control study. All of 448 cataract cases were selected from cataract eye database and 248 controls were recruited from Funing county. All 18 single nucleotide polymorphism (SNPs) of WRN, OGG1, BLM and ERCC6 genes were genotyped using real-time fluorescent quantitative PCR. The possible risk of ARC was estimated by unconditional Logistic regression. The interaction effects between gene-gene and gene-environment were evaluated by use of multifactor dimensionality reduction (MDR).

Risk of ARC in illiterate group was significantly increased (OR=1.53, P<0.05), compared to noilliterate group. The risk of cataract in farmers was significantly high with ORs of 3.75. Long exposure to sunlight may increase cataract risk. Factors such as smoking, drinking, hypertension had no relationship with ARC (P>0.05).WRN-rs11574311 was still associated with ARC with statistical significance after Bonferroni correction (OR=1.98, P_a<0.018). There was no evidence for any association at a significance level ofP<0.05 for the remaining alleles. MDR analysis showed a significant interaction model among the six factors: education, solar radiation,WRN-rs11574311, WRN-rs1801195, WRN-rs4733220 and BLM-rs17273206 (consistency inspection accuracy of 0.683 on average, cross validation at 10/10, P=0.005). Logistic regression model showed that the "high-risk" individuals had a significantly increased risk of ARC, compared to those "low- risk" individual classified by the MDR mode mentioned above( OR=5.51, P<0.05).

WRN-rs11574311 allele was the risk factor for ARC, and individuals who carried WRN-rs1801195, WRN-rs4733220 and BLM-rs17273206 allele and low level of education, long sunlight time significantly increased the risk of the ARC.

To verify the significance of prospective serum cancer markers clearance program for primary Venous thromboembolism(VTE) cases.

During 1 July 2010 within 31 Dec 2012, data from two Chinese vascular centers was prospective registry. All the cases diagnosed as primary VTE by first vascular physicians were underwent serum cancer markers clearance. Long term follow up was required to confirm real cancer occurrence and long term survival rate. A total of 167 cases (106 male and 61 female) were enrolled in this study. Mean age was 52±15 years old.

Eighteen cases (10.78%) were finally scanned as malignant. The sensitive of markers: Carcino-embryonic antigen (CEA) 0.67, carbohydrate antigen (CA)199 0.44, CA242 0.33, CA153 0.44, CA125 0.78, CA724 0.17, combined markers 0.94. The specificity of above markers was 0.97, 0.98, 0.98, 0.97, 0.93, 0.97 and 0.86. CA 125 showed best sensitive and specificity as a sole marker. The positive likelihood ratio for markers: CEA 24.83((95%CI 8.95-68.90), CA199 22.07(95%CI 6.43-75.78), CA242 16.56(95%CI 4.53-60.55), CA153 13.24(95%CI 4.85-36.17), CA125 10.54(95%CI 5.67-19.58), CA 724 4.97(95%CI 1.29-19.07), combined of markers 6.70(95%CI 4.44-10.12). The negative likelihood ratio for markers: CEA 0.34((95%CI 0.18-0.66), CA199 0.57(95%CI 0.37-0.86), CA242 0.68(95%CI 0.49-0.94), CA153 0.57(95%CI 0.38-0.87), CA125 0.24(95%CI 0.10-0.57), CA 724 0.86(95%CI 0.76-1.06), combined of markers 0.66(95%CI 0.01-0.44). CEA+ CA125 showed better positive and negative likelihood ratio. 6 months, 12 months and 24 months survival rate for malignant (18cases) and non-malignant(149cases) were 61.1%, 50.0%, 31.3% and 99.3%, 98.6%, 98.6% respectively.

It is reasonable to screening malignant for "unprovoked" VTE cases. Combined multiple serum cancer markers showed best result. CA125 plus CEA showed acceptable result for some limited condition. CA50 was useless for cancer screening.

To investigate the level of Hs-CRP, Fib, IL-6, TNF-α, MDA, SOD, and analyse the correlation between the level of plasma inflammatory cytokines and clinical significance in patients with anterior ST-segment depression.

We choosed 360 patients with inferior ST Segment elavation acute myocardial infarction from May 2007 to Sep 2012 in rescue Center of Anzhen Hospital, in Anzhen Hospital, and all the patients received percutaneous coronary intervention treatment and the vascular lesions besides culprit vessel were observed. All the patients were divided into two groups: control group(n=180) and anterior ST-segment depression group(n=180). 8ml venous blood was obtained from all the patients, and then plasma were separated. The level of plasma Hs-CRP, Fib, IL-6, TNF-α, MDA, SOD were investigated by Biochemistry and ELISA. And the relativity between the level of plasma inflammatory cytokines and anterior ST-segment depression in patients with inferior acute myocardial infarction was analysed.

The proportion of double vessel coronary disease, three coronary artery lesion is higher in anterior ST-segment depression group compared with control group(P<0.01). Compared with control group, the level of Hs-CRP, Fib, IL-6, TNF-α, MDA, SOD of anterior ST-segment depression group are inclined signifancantly(P<0.01).

The level of plasma inflammatory cytokines and the degree of lipid peroxidation can reflect the severity of coronary artery disease and may have certain value in predicting the severity of disease.

To explore the immunosuppressive action of dendritic cells (DC) sensitized by oligodeoxynucleotides containing "un-methylated cytimidine-phosphodiester bond-guanylic acid" motif (CpG ODN) and CA125 on human ovarian carcinoma xenografts in nude mice.

Human peripheral blood-derived dendritic cells were isolated and identified by flow cytometry. The DC sensitized by CpG ODN and CA125 were then co-cultured with T cells and finally cytotoxic T lymphocytes (CTL) were induced. Nude mice bearing OVCAR3 transplanted tumor were immunized with induced CTL by subcutaneous injection and tumor growth and cell apoptosis observed.

Premature DC had a low expression of CD83 and CD86. In vivo,delayed growth of OVCAR3 xenografts was observed after immunotherapy with CTL induced by DC pulsed by CpG ODN and CA125. The inhibition rate of tumor was 50.71% and it was better than CpG ODN-pulsed and CA125-pulsed groups (P<0.05). Cell apoptotic rate was (29.6±3.0)% in CpG ODN+ CA125-pulsed group versus (21.8±2.7)% in CpG ODN-pulsed group. And both were more than those of unpulsed and CA125-pulsed groups(P<0.05).

CTL induced by DC sensitized by CpG ODN and CA125 can inhibit the growth of ovarian carcinoma xenografts and promote tumor cell apoptosis.

To explore the injury mechanism for white matter of spinal cord and the improvement of function after defluoriation.

A total of 120 Wistar rats were separated randomly into 4 groups (n=30 each). High flouriod group received high concentration NaF water (200 mg/L) to establish fluorosis model; control group distilled water; deflourination group high concentration NaF water (200 mg/L) for 12 weeks and then distilled water for 12 weeks; defluorination control group. The urinary contents of fluoride were detected at Weeks 4, 8 and 12. The first two groups were sacrificed at Week 12 while the other two groups at Week 24. The spinal cord functions were detected by BBB scale and incline plate test. Their cervical spinal cord tissues were collected and observed under electron microscope. The expression of myelin basic protein (MBP) in thoracic cord was detected by immunohistochemistry and Western blot. The comparison of measurement data was performed with F test and correlation analysis. Cytological changes of white matter in spinal cord were detected after chronic fluorosis.

The spinal functions of high flouriod and deflourination groups were inferior to those of the control groups. But no difference existed among the groups. Pathological manifestations of chronic white matter injury of spinal cord could be found in high flouriod and deflourination groups. The MBP expression in spinal cord of fluorosis and deflurination groups decreased in comparison with those in control groups. But no difference existed among them.

White matter injury of spinal cord is present in chronic fluorosis rats. Defluoriation for a short time offers no recovery.

To observe the changes of LINGO-1 expression with time after onset in EAE mouse.

C57/BL6 mice were completely randomly divided into EAE model group(n=15), adjuvant group(n=15) and control group(n=15). LINGO-1 expression of brain tissue was detected on day 1, 7, 14, 21 and 30 after onset by RT-PCR and Western blot. RhoA and p-RhoA expression of brain tissue was analysed by Western blot.

The LINGO-1mRNA levels in EAE model group were markedly higher than control group on day 1, 7and 14 after onset (4.63±0.25, 2.72±0.12, 1.98±0.16, P<0.01,P<0.01,P<0.05). On day 30, Lingo-1 mRNA was close to control group. Expression levels of Lingo-1 protein on day 1, 7, 14, 21, 30 were higher than control group (2.11±0.15, 3.15±0.09, 2.45±0.12, 1.89±0.17, 1.21±0.05,P<0.05,P<0.01,P<0.05,P<0.05,P<0.05. The levels of p-RhoA protein increased in EAE and the peak appeared on day 1 and day 7(P<0.01). And there was no difference on RhoA expression among different groups.

LINGO-1 expression of brain tissue of EAE mouse upregulates and changes with time after onset, which may inhibit myelination by RhoA activation. In clinic, the antagonist of LINGO-1 for MS should be applied as soon as possible.

To explore the effects of 12/15-lipoxygenase antisense oligonucleotide (asON-12/15-LOX) on OGD (oxygen-glucose deprivation)-induced PPARγ (peroxisome proliferator-activated receptor γ) expression and nuclear translocation in primarily cultured cortical neurons.

After a 48-h pre-treatment of 12/15-LOX antisense oligonucleotide (asON), primarily cultured cortical neurons underwent 3-hour OGD followed by a 24-hour reperfusion. Immunoflorescent staining and Western blot were used to evaluate the expressions of 12/15-LOX and PPARγ as well as the nuclear translocation of PPARγ.

Compared with the control group, the expressions of 12/15-LOX and PPARγ whole protein were enhanced in OGD group (t=-3.72 and -6.79, P=0.03 and 0.04). And an increase of PPARγ in nucleus (t=-4.67, P=0.02) could be noted with a simultaneous reduction in cytosol (t=3.40, P=0.04) after OGD, indicating an induction of nuclear translocation by OGD. Compared with OGD group, a pre-treatment of asON-12/15-LOX dramatically attenuated OGD-induced increase in 12/15-LOX whole protein expression (t=5.03, P=0.02). Compared with OGD group, a pre-treatment of asON-12/15-LOX greatly reduced OGD-induced increase in PPARγ total protein expression (t=2.83, P=0.04) and nuclear translocation (t=7.05, P=0.01 for nuclear protein; t=-5.47, P=0.01 for cytosol protein). It indicated a possible link between 12/15-LOX and PPARγ.

12/15-LOX antisense oligonucleotide suppresses the expression and nuclear translocation of PPARγ in primarily cultured cortical neurons after OGD.

Hypertension is one of the major public health problems faced worldwide, causing more than 13% of the total deaths every year^[1]。 Many guidelines and intervention programs for the prevention and treatment of hypertension have been developed and implemented at home and abroad, but more than two-thirds of hypertensive people have not been effectively controlled^[2]。 Direct medical expenses caused by hypertension amounted to $175 billion in 2005, accounting for about 7.2% of China's total health expenditure^[3]。 Evidence shows that aggressive treatment and effective control of hypertension can avoid a large amount of associated health resource consumption^[4]。 Therefore, hypertension is not just a simple personal disease and medical problem, but also a serious public health problem and social problem. We should learn from the advanced experience of developed countries, make use of limited resources to do a good job in the prevention and treatment of hypertension, and carry out comprehensive prevention and treatment strategies in communities, mainly health education and health management.

A 61-year-old male suffered from uninduced upper abdominal discomfort accompanied by intermittent dull pain for 3 months. He was admitted to Subei People's Hospital of Jiangsu Province for treatment on February 26, 2013. Splenectomy and appendectomy were performed more than 20 years ago. A 6 cm long surgical scar was seen in the middle abdomen and a 5 cm long surgical scar was seen in the right lower abdomen. No obvious abnormalities were found in relevant laboratory tests and electrocardiogram. Ultrasound examination revealed a hypoechoic mass at the base of the stomach, originating in the muscular layer (Figure 1)。 Energy spectrum CT enhanced scan of the whole abdomen showed a massive soft tissue density shadow on the posterior wall of the stomach base, with a size of 26 mm ×19 mm, with clear boundary and clear envelope. The enhanced scan showed obvious uniform enhancement, no obvious enlarged lymph node shadow in the liver-stomach space and retroperitoneum, and no obvious signs of invasion in adjacent tissues and organs. It is considered that the stomach base occupies space, and stromal tumor may be (Figure 2、Figure 3、Figure 4、Figure 5)。 The energy spectrum curve showed that the normal stomach wall curve intersected with the mass curve, suggesting that the mass and the stomach wall may have different sources. Electronic gastroscopy was performed and fundus stromal tumor (muscle layer) was considered (Figure 4)。 After completing the relevant examinations, gastroscopy + laparoscopic intestinal adhesiolysis + proximal gastrectomy were performed. Laparoscopic exploration of the abdominal cavity showed that the tumor was located at the posterior wall of the gastric fundus at the entrance of the cardia, protruding out of the cavity, with a size of 3.0 cm ×2.0 cm, and extensive adhesion of the transverse colon and omentum to the abdominal wall, and the abdominal cavity adhered to the gastric fundus, so laparoscopic separation and exposure were difficult. Switched to open surgery after communicating with family members. After laparotomy, a 3 cm ×3 cm mass was palpable at the posterior wall of the gastric fundus at the entrance of the cardia. It was adhered to the top of the left diaphragm in the middle of the mass, with poor mobility and no special remaining. Intraoperatively, "gastric stromal cell tumor" was diagnosed and "proximal gastrectomy" was decided. The postoperative pathology showed that the envelope composed of fibrous tissue was seen outside the serous layer of the stomach wall, and the hyperplasia of red pulp and white pulp tissue of the spleen was seen inside it, which was considered as the spleen tissue at the fundus of the stomach (Figure 5)。

A 23-year-old female was admitted to the Department of Vascular Surgery of Peking Union Medical College Hospital for "intermittent low back pain with elevated blood pressure for 4 months and aggravated for 1 week". Past physical fitness. Physical examination: blood pressure 138/100 mmHg (1 mmHg =0.133 kPa), soft abdomen, no pulsatile mass palpable, good pulsation of bilateral, radial and dorsal pedis arteries, and no vascular murmur in bilateral renal areas. Liver and kidney function: glutamate aminotransferase 16 U/L, urea nitrogen 9.91 mmol/L, creatinine 83 μ mol/L. Erythrocyte sedimentation rate: 6 mm/h. C-reactive protein: 0.91 mg/L. Functional imaging of renal blood flow: Glomerular filtration rate (GFR) =8.31 ml/min in the right kidney and 19.39 ml/min in the left kidney. The results of rheumatism immunoassay were all negative. Computed tomography angiography (CTA) showed that the abdominal aorta showed tumor-like dilatation at the initial level of both renal arteries, with a size of about 4.5 cm ×3.5 cm. The opening segments of the celiac trunk and superior mesenteric artery were not shown, and the distal end was supplied with blood through the thickened Riolan artery arch. The initial portion of the opening of both renal arteries was severe stenosis (Figure 1)。 Admission diagnosis: Takayasu arteritis (thoracic-abdominal aortic type), pseudoaneurysm of the abdominal aorta, severe stenosis of both renal arteries, occlusion of the celiac trunk, occlusion of the superior mesenteric artery. Abdominal aorta-right renal artery autologous great saphenous vein bypass and Riolan artery arch-left renal artery bypass were performed under general anesthesia on day 17 after admission (Figure 2), endovascular repair of pseudoaneurysm of the abdominal aorta. The operation went smoothly, and low molecular weight heparin anticoagulation and aspirin antiplatelet therapy were given postoperatively. The patient recovered well after surgery and was followed up for 12 months without any discomfort and peripheral blood pressure returned to normal. The CTA at 3 and 9 months after operation showed that the abdominal aortic stent was in good position, the pseudoaneurysm disappeared, the lumen of the graft vessel was unobstructed, and no stenosis was found in each anastomosis (Figure 3)。