Volume 96  ·  Issue 12  ·  2016

With the increasing attention of people to health and the extension of medicine, laboratory medicine as an important basis for clinical diagnosis, treatment and prognosis has also been developed rapidly. In the process of introducing, popularizing and updating modern inspection technology, the return time of inspection results is shortened, the inspection items are enriched, and the amount of inspection information per unit time is greatly increased, which affects the application effect of inspection results. After the rapid development in recent decades, the medical problems before and during analysis in the detection system have been deepened and improved continuously, so that the accuracy, stability and timeliness of the test results can meet the clinical needs. However, the content after analysis is relatively weak, and the audit of the test report still only stays at the simple check of the basic patient information and the comparison of historical results. Most of the test reports are only test reports, which do not fully reflect the description of the disease by the professional knowledge of laboratory medicine, and do not incorporate the connotation of substantive laboratory analysis and laboratory diagnosis, so that the service ability of laboratory medical knowledge is not fully reflected.

The incidence of bone metastasis in advanced breast cancer patients is 65% ~75%, while the first-episode bone metastasis in breast cancer accounts for about 27% ~50%^[1,2,3]。 Bone pain, bone injury and bone-related events (SREs) are common complications of bone metastasis from breast cancer. Bone metastasis does not directly threaten the life of patients, but bone metastasis with pain will seriously affect the quality of life of patients. Bisphosphonates inhibit osteoclast activity, reduce bone destruction, prevent and treat SREs^[4]。 Many guidelines and consensus at home and abroad regard bisphosphonates as the basic drugs for tumor bone metastasis, and the frequency of medication is once every 3 to 4 weeks. However, new data show that long-term treatment of patients with bone metastases is no less effective than once a month when the interval between bisphosphonate dosing is appropriately prolonged to once a month. Based on new data, the 2015 National Comprehensive Cancer Network (NCCN) breast cancer guidelines extend the time interval between bisphosphonate treatment^[3]。 In this regard, the 2014 European Society of Clinical Oncology (ESMO) guidelines have different positions and views^[2]。 These new studies and the recommendations of Chinese and foreign guidelines will be interpreted, in order to bring inspiration and help to the prevention and treatment of SREs in clinical breast cancer bone metastasis.

In 2008, the World Health Organization (WHO) released the fourth edition of the classification protocol for hematopoietic and lymphoid tissue tumors^[1], has been widely used all over the world. With the rapid development and application of flow cytometry, cytogenetics and molecular biology, it plays a very important role in the accurate diagnosis and classification of hematopoietic and lymphoid tissue tumors, and effectively promotes the clinical treatment and prognosis of hematopoietic and lymphoid tissue tumors. At present, morphological examination, including peripheral blood smear, bone marrow smear and bone marrow biopsy, is an indispensable means for hematopoietic and lymphoid tissue tumor examination; Almost all cases of hematopoietic and lymphoid tissue tumors were analyzed by flow cytometry for immunophenotyping; Cytogenetic technologies, including chromosome karyotyping and fluorescence in situ hybridization, are widely used for the detection of chromosome aberrations and fusion genes in patients; Molecular genetics technology, including gene amplification and sequencing technology for the detection of fusion genes and mutant genes, has become the development trend of hematopoietic and lymphoid tissue tumor diagnosis. The clinical application of the above methods and techniques has gradually developed into highly professional and complex examination items, which are of great value and sometimes even decisive significance for the diagnosis and treatment of hematopoietic and lymphoid tissue tumors.

Anemia refers to a symptom in which the amount of hemoglobin, the number of red blood cells and/or hematocrit per unit volume of peripheral blood is below the lower limit of the reference range. Anemia can be caused by systemic diseases throughout the body, and identifying the nature and etiology of anemia is essential for treatment. In recent years, the detection technology for anemia has developed rapidly. Immunological methods range from immunoelectrophoresis, enzyme-linked immunosorbent assay (ELISA), radioimmunoassay to chemiluminescence immunoassay; The separation technology ranges from cellulose acetate film, polyacrylamide gel electrophoresis to microchromatography column analysis, capillary electrophoresis, high performance liquid chromatography analysis, etc. Molecular biology, flow cytometry, chromosome analysis, etc. are also widely used in anemia detection, which provide an important basis for clinical diagnosis, differential diagnosis, treatment, prognosis judgment and curative effect monitoring.

The diagnosis of chromosomal karyotype is to provide strong morphological evidence for the diagnosis of chromosomal diseases, genetic diseases, hematological tumors with recurrent genetic abnormalities and other diseases by counting the number of chromosomes and observing and analyzing the structure, so that children with genetic diseases can get early detection, early intervention and treatment, and it is also of important clinical significance for the evaluation of curative effect and prognosis of tumor patients^{[1,2,3,4,5,6,7,8,9,10,11,12,13,14]}。

Clinical microbial morphological examination has important clinical significance for the early diagnosis of infectious diseases. It can diagnose possible infected pathogens at the first time through cytological characteristics and microbial morphological characteristics, so as to achieve the purpose of early diagnosis and early treatment, and is of great significance to improve the survival rate of patients. Traditional microbial morphological examination reports only briefly describe the microbial morphology under the microscope, and the rich etiological diagnostic connotation contained under the morphological description cannot be fully reflected, which makes it difficult for clinicians to fully understand. The reporting modes adopted by different medical units are different. When patients see a doctor in different medical units, doctors' understanding of the test results is also different, which may have an impact on the diagnosis and treatment process. The purpose of this consensus is to standardize the testing and diagnosis reporting mode, interpret the diagnosis and treatment information contained in microbial morphology to the clinic to the greatest extent, strengthen the communication between microbiological laboratory and clinic, and better provide etiological basis for early diagnosis and treatment of infectious diseases.

To retrospectively analyze the relevance between DNA topoisomerase Ⅱ alpha (TOP2A), epidermal growth factor receptor (EGFR) gene expression and efficacy of docetaxel plus epirubicin as neoadjuvant chemotherapy in triple negative breast cancer (TNBC) patients.

A total of 53 women with triple negative breast cancer who underwent docetaxel plus epirubicin as neoadjuvant chemotherapy were included in this study. The gene detection was done in the samples before chemotherapy by DNA chip technology. The relevance between TOP2A, EGFR gene expression and efficacy, pathological complete response (pCR) rate of neoadjuvant chemotherapy were retrospectively analyzed.

The high expression rate of TOP2A in all the TNBC patients was 35.8% (19/53), while the rate of EGFR was 39.6% (21/53). The overall pCR rate of TNBC patients who underwent docetaxel plus epirubicin as neoadjuvant chemotherapy was 18.9% (10/53). The pCR rate was 31.6% (6/19) in TNBC patients whose TOP2A expression was high, compared to 11.8% (4/34) in whose was low (P>0.05). The pCR rate was 28.6% (6/21) in TNBC patients whose EGFR expression was high, compared to 12.5% (4/32) in whose was low (P>0.05). The pCR rate was 75.0% (6/8) in TNBC patients whose TOP2A, EGFR expression were both high, and was significantly higher than that in all the TNBC patients (P<0.01).

Efficacy of docetaxel plus epirubicin as neoadjuvant chemotherapy in TNBC patients can be predicted by detecting TOP2A, EGFR gene expression. The result may contribute to the development of more individualized neoadjuvant chemotherapy.

To explore the expression of Ubiquitin-specific processing enzyme 37(USP 37)in breast cancer and its association with the prognosis of breast cancer.

In this study, the method of Western blot was utilized to examine the expression of USP37 protein in breast cancer fresh tissue. Immunohistochemistry (IHC) was used to determine the expression of USP37 in 533 cases of breast cancer. Receive operating characteristic (ROC) curve analysis was employed to determine a cut-off score for USP37 expression. For validation, the ROC-derived cut-off score was subjected to analysis the association of USP37 expression with cancer patient outcome and clinical characteristics.

USP37 protein was mainly located in cytoplasm of the cell, occasionally in nucleus by immunohistochemistry. In the normal breast tissue, USP37 was not expressed or with low expression level, while in the 533 cases of breast cancer, the high USP37 expression was detected in 50.7% samples (270/533) with corresponding low or negative expression rate 49.3% (263/533). We found that USP37 was highly expressed in primary breast cancer tissues compared to paired adjacent non-cancerous tissues. High expression of USP37 was associated with breast cancer node classification, molecular classification and proliferation biomarker Ki67. Both univariate and multivariate analyses further revealed that USP37 expression was an independent poor prognostic parameter for overall survival (OS), recurrence-free survival (RFS) and metastasis-free survival (MFS) in breast cancer. Furthermore, USP37 expressions divided the luminal and triple negative breast cancer into different prognosis subgroups.

Our findings first provide evidences that high expression of USP37 served as an independent molecular biomarker for poor prognosis in breast cancer.

To investigate the expression level of antisense transcript of FAS (FAS-antisense 1, FAS-AS1) in breast cancer, and its effect on the host gene soluble Fas receptor (sFas).

The expression of FAS-AS1 and sFas gene was detected in 20 cases of breast cancer tumors and breast cancer cells and their normal counterparts by using real-time quantitative polymerase chain reaction(RT-qPCR). The effects of FAS-AS1 on the expression of sFas gene in breast cancer cells were analyzed by overexpressing FAS-AS1 in breast cancer cells.

FAS-AS1 expression in breast cancer tissue and cell lines was significantly lower than that of adjacent breast tissue (P=0.000) and normal breast cells (P<0.01). However, sFasexpression in the breast cancer tissue and cell lines was significantly higher than that of adjacent breast tissue (P=0.001) and normal breast cells (P<0.01). The expression of FAS-AS1 was negatively correlated with the expression of sFas(r=-0.751, P=0.020). FAS-AS1 expression was observed to be closely correlated with tumor size (r²=0.351, P=0.025) and lymph node metastasis (r²=0.265, P=0.043). Expression of sFas and cell proliferation was significantly reduced in FAS-AS1-overexpressing MCF-7 cells (P<0.05).

FAS-AS1 is distinctly downexpressed in breast cancer, and it has certain effects on the expression of host gene sFas and breast cancer development.

To investigate the distribution of various bacteria in adenoma tissue of colorectal adenoma (T/CRA), normal colonic mucosa tissue adjacent to the adenoma (N/CRA), and healthy colonic mucosa tissue (N/H) by comparing the number of total bacteria, Bacteroides fragilis (BF), enterotoxigenic Bacteroides fragilis (ETBF), polyketide synthase (pks) gene-expressing Escherichia coli(E.coli)(pks⁺E. coli)among the above 3 types of tissues.

A total of 36 patients diagnosed with colorectal adenoma by colonoscopy and pathology in Department of Gastroenterology, Peking University People's Hospital from September 2011 to September 2013 were selected into this study. T/CRA and N/CRA tissues from the 36 patients and N/H tissues from 18 healthy controls were collected for DNA extraction. The number of total bacteria, BF, ETBF, pks⁺E. coli was detected by quantitative real time PCR, and their correlation with colorectal adenoma was analyzed.

(1) The number of total bacteria decreased gradually from N/H, N/CRA, to T/CRA, with the median values being 3.18×10^8, 1.57×10^8, and 7.91×10⁷ copies/g, respectively, and with significant difference among the three groups and between each two groups (all P<0.01). (2) The content of BF decreased gradually from N/H, N/CRA, to T/CRA, the median values being 6.03×10^5, 4.28×10^4, and 5.48×10³ copies/g, respectively, and with significant difference among the three groups and between each two groups (all P<0.01). (3) The toxin content produced by ETBF increased from N/H, N/CRA, to T/CRA, the relative expression being 1.73±0.30, 6.15±1.52, and 8.54±1.80, respectively. Significant difference was found between the T/CRA and N/H tissue (P=0.003), but not between any other two groups. (4) The expression of clbB in pks⁺E.coli was highest in T/CRA colonic tissue (2.96±0.28), followed by the N/CRA (2.79±0.19) and N/H tissue (1.06±0.08). Significant difference was found between T/CRA and N/H tissues, as well as between N/CRA and N/H tissues (both P<0.001), but not between T/CRA and N/CRA tissues.

The number of total bacteria is markedly reduced in the colonic mucosa of CRA patients compared to normal people, while the expressions of ETBF and pks⁺E.coli are significantly increased. Such changes in total bacterial, ETBF and pks⁺E.coli concentrations in colonic mucosa may be related to the tumorigenesis of colorectal adenoma.

To explore the effects of artesunate on cigarette smoke-induced lung oxidative damage in mice and the expression of Nuclear factor-E2-related factor 2 (Nrf2).

In vivo: A total of 40 female specific pathogen free BALB/c mice were divided randomly into four groups: normal group, cigarette smoke group, vehicle group and artesunate group. The latter three groups were exposed on cigarette smoke for 40 days. Vehicle (5% NaHCO₃ containing 5% dimethyl sulfoxide, 0.1 ml of each mice) or artesunate (30 mg/kg, dissolved in the 0.1 ml vehicle) was given by intraperitoneal injections before each passive smoking of the vehicle or artesunate group. Saline of 0.1ml was given to the normal and cigarette smoke groups as negative controls. Cells in bronchoalveolar lavage fluid (BALF) were collected and analyzed by absolute different cell counts. Interleukin (IL)-8 levels in BALF and 3-nitrotyrosine (NT) levels in lung tissue were tested by emzyme linked immunosorbent assay (ELISA). Malondialdehyde levels in serum, total superoxide dismutase (SOD) activity and total glutathione peroxidase (GPx) activity in lung tissue were detected. The pathological changes of lung tissues were observed by HE staining. And the expression levels of Nrf2 were measured by Westernblotting. In vitro: 16HBE cells were cultured and transfected with Nrf2 siRNA. Cigarette smoke extract (CSE) were used to stimulate the secretion of IL-8 in cells. Cells were divided into five groups: blank group, non-transfected non-artesunate group, non-transfected artesunate group, transfected non-artesunate group and transfected artesunate group. The latter four groups were incubated with CSE, and non-transfected artesunate and transfected artesunate groups were intervened with artesunate (30 μmol/L) before CSE incubation. The IL-8 levels of each group were measured using ELISA kit.

In vivo: The total cell counts of BALF in artesunate group were significantly lower than the vehicle group [21.00(2.50)×10⁴/ml vs 35.50(2.50)×10⁴/ml, P<0.001], especially neutrophil counts [6.00(5.12)×10⁴/ml vs 13.60(5.25)×10⁴/ml, P<0.001]. The IL-8 levels in BALF, malondialdehyde levels in serum, 3-NT levels and total SOD activity in lung tissue of artesunate group were all drastically lower than those in the vehicle group [(508±55) vs (912±68) ng/L, (38.2±8.8) vs (48.7±10.6) μmol/L, (28.5±5.8) vs (50.0±9.7) μg/L and (11.8±1.8) vs (18.0±5.3) U/mg protein, respectively, allP<0.05]. No significant difference of total GPx activity existed in these four groups. And the expression level of Nrf2 in artesunate group significantly increased than that in vehicle group (P=0.008). In vitro: The IL-8 level of the non-transfected artesunate group was significantly lower than the non-transfected non-artesunate group [(352±26) vs (765±22) ng/L, P<0.001], while the IL-8 levels between the transfected artesunate and transfected non-artesunate groups had no significant difference.

Arteunate attenuates cigarette smoke-induced lung oxidative damage in mice and increases the expression level of Nrf2, and its effects might be mediated by the actions of nuclear Nrf2.

To explore the inhibitory role of suppressor of cytokine signaling 1 (SOCS1) in lipopolysaccharide (LPS)-induced mucin5AC (MUC5AC) hypersecretion and the potential mechanism involved in this process.

The human bronchial epithelial cells 16HBE were divided into 0, 0.5, 1, 6, 12 and 24 h groups according to the time of LPS challenge. In gain- and loss- of functions experiments, wild-type SOCS1 and SOCS1-targeted siRNA (SOCS1-siRNA) were synthesized to identify the function of SOCS1 in LPS-mediated MUC5AC hypersecretion, and named wild-type SOCS1 group and SOCS1-siRNA group, respectively, and the non-transfected group and non-targeted siRNA group were used as controls. In Filgotinib group, the specific inhibitor of Janus kinase 1 (JAK1), Filgotinib, was used to detect the role of JAK1/signal transducer and activator of transcription 1 (STAT1) signaling pathway in LPS challenge, and the aqueous physiological buffer group was used as the control. The production of MUC5AC protein was measured by enzyme linked immunosorbent assay (ELISA), and the amount of MUC5AC protein was normalized to the total protein in cell lysates and was expressed as μg/mg cell lysates. The proteins expressions of SOCS1, phosphorylation of JAK1 and STAT1 were measured by Western blot, and the total expression of its protein (for JAK1 and STAT1) or β-actin (for SOCS1) was used as the loading control.

Compared to 0 h group, LPS induced a robust induction in MUC5AC expression, the expression levels of MUC5AC in 0, 0.5, 1, 6, 12 and 24 h groups were (2.86±0.20), (3.42±0.29), (3.43±0.12), (10.22±0.96), (14.56±1.12), (14.15±1.34) μg/mg, in association with a decrease of SOCS1 expression. And in 6 h group, the expressions of MUC5AC and SOCS1 were both medium up-regulated (all P<0.05). Consequently, the application of LPS for 6 h was selected as the optimal responses period in the ensuing experiments. Compared to the expression of MUC5AC protein in non-transfected group, high level of SOCS1 in wild-type SOCS1 group led to a reduced phosphorylation of JAK1/STAT1, as well as Filgotinib did, thereby suppressing excessive MUC5AC production in wild-type SOCS1 group and Filgotinib group [(4.04±0.65), (7.02±0.83) vs (10.37±1.00) μg/mg] (allP<0.05). Conversely, compared to the expression of MUC5AC in non-targeted siRNA group, down-regulation of SOCS1 in SOCS1-siRNA group promoted the phosphorylation of JAK1/STAT1, and then further increased MUC5AC production [(13.69±1.32) vs (11.01±1.41) μg/mg] (allP<0.05).

These results show that SOCS1 suppresses LPS-promoted MUC5AC hypersecretion through the inhibition of JAK1/STAT1 signaling pathway.

To establish the isolation, culture and identification methods of primary rat skeletal muscle satellite cells (SMSC) and observe its characterization of differentiation in vitro.

Skeletal muscle satellite cells were obtained by tissue block culture method in combination with pre-plating techniques, and the purity of these cells was detected by both immunocytochemistry and fluorescence activated cell sorter (FACS) with Pax7 as marker of SMSC. Myogenesis of these cells was induced in differentiation medium and the mRNA expressions of myogenic differentiation gene (MyoD) and Myogenin were determined by Real-time polymerase chain reaction (PCR).

Cells crawled out from the edge of tissue blocks after 1 week of culture. After purification by pre-plating techniques, more than 97.6% of the cells expressed Pax7, a unique marker of satellite cells. The mRNA of MyoD and Myogenin showed time-specific expression in the myogenesis induction process in vitro.

Skeletal muscle satellite cells with high purity and strong differentiation ability can be obtained by means of tissue block culture method.

To explore the effects of different fluid resuscitation regimens on oxygen metabolism during shock stage of burn injury in swine.

Twelve Bama miniature swines were divided into crystal and colloid group (Group 1) and Parkland group (Group 2) according to the random number table. The swine models of burns shock were established. The fluid resuscitation was begun at post injury hour (PIH) 2 according to Chinese formulation or Parkland's formulation, respectively. The blood pressure, urine volume, heart rate, central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP) were recorded. The liquid volume was calculated at the first and second PIH 24. The changes in oxygen delivery (DO₂), oxygen consumption (VO₂), oxygen extraction (O₂Ext) and D-lactate (D-LA) were determined before injury and at PIH 4, 8, 24, and 48. Statistical analyses were performed.

There were no statistical differences between the two groups in blood pressure, urine volume, heart rate, CVP, PCWP in every interval (all P>0.05). The resuscitation liquid volume in the two groups during the first and second PIH 24 conformed to the domestic consensus. The VO₂ at PIH 8 was significantly higher than that of pre-burn in both groups [(190±29) vs (83±42) L·min^-1·m^-2, (149±33) vs (85±15) L·min^-1·m^-2, both P<0.05], and the VO₂ at PIH 8 was significantly higher in Group 1 than that in Group 2 (P<0.05). The DO₂ at PIH 24 in Group 1 was significantly lower than that in Group 2 [(686±72) vs (853±81) L·min^-1·m^-2,P<0.05]. There were no significant differences between the two groups in O₂Ext at any time points (all P>0.05). The D-LA at PIH 8 was significantly higher in Group 1 than that in Group 2 [(53±4) vs (45±6) mmol/L,P<0.05].

There are no significant differences in the resuscitation effects of the crystal and colloid resuscitation regimen and Parkland's formulation on oxygen metabolism during shock stage of burn injury in swine.

A 16-year-old female was admitted to the hospital mainly for "intermittent fever for 4 weeks and headache with hypertension for 2 weeks". The patient experienced intermittent fever with a maximum of 38.5℃ 4 weeks ago. I had headache 2 weeks ago, mainly forehead and occipital pain. Blood pressure 220/120 mmHg (1 mmHg =0.133 kPa) with 2 episodes of convulsions and loss of consciousness. Two weeks ago, he visited a hospital and found proteinuria, renal insufficiency, hypergammaglobulinemia, anemia and other manifestations. Abdominal enhanced CT: (1) local aneurysm formation of pancreaticoduodenal artery with mural thrombosis, irregular wall thickening of both renal arteries with stenosis; (2) splenic infarction; (3) Multiple wedge-shaped enhancement changes in both kidneys. Immune indexes: Anti-nuclear antibody, anti-double-stranded DNA antibody, anti-ENA spectrum, anti-neutrophil cytoplasmic antibody and anti-glomerular basement membrane antibody were all negative. Hepatitis B surface antibody positive. The patient had a previous history of cutaneous purpura for 8 years, and an elevated blood gamma globulin was found 4 years ago for an unknown reason. After admission to our hospital, considering that the patient has multiple system involvement manifestations, combined with abdominal CT imaging findings, the diagnosis of polyarteritis nodosa is highly likely. To confirm the diagnosis, arteriography was performed. In order to prevent contrast nephropathy, adequate hydration therapy was administered with normal saline at 1 ml · kg starting 3 h before angiography^－1• h^－1Continuous intravenous fluid rehydration until 12 h after surgery. At the same time, the patient was asked to drink moderate water, and sodium bicarbonate and acetylcysteine were given orally. Arteriographic results: Multiple aneurysms of celiac artery and renal artery vessels, the largest one was gastroduodenal aneurysm, consistent with the diagnosis of polyarteritis nodosa (Figure 1)。 Benazepril hydrochloride 10 mg was administered orally twice daily. At the same time, prednisone acetate 40 mg once daily was administered orally, and cyclophosphamide was treated, and the patient's body temperature returned to normal. Three days later, the patient had uninduced sudden hematemesis with a volume of about 1 000 ml, hypotensive shock, and hemoglobin decreased to a minimum of 57 g/L. Rescue treatment such as fluid rehydration and blood transfusion was given, and emergency arteriography was performed in the catheterization laboratory. Considering the high possibility of gastroduodenal aneurysm rupture and bleeding, gastroduodenal aneurysm interventional embolization was performed (Figure 2)。 Postoperatively, the patient's condition was stable and he did not vomit blood again. Gastroscopy: gastritis, duodenal bulge, aneurysm after treatment, no peptic ulcer (Figure 3)。 The results of all tests before and after the patient's treatment are shown inTable 1。 After discharge, the patient went to the outpatient clinic of our hospital for follow-up once a month, and was given intravenous infusion of cyclophosphamide, gradual reduction of prednisone acetate, and reduction of benazepril hydrochloride to 10 mg once a day orally. The blood pressure was well controlled, the condition was stable, and the general condition was good.

A 63-year-old male was admitted to the hospital in January 2014 due to "repeated abdominal pain for 20 years, intermittent melena for 3 years, and recurrent abdominal pain for 1 week". Twenty years ago, the patient had intermittent severe pain in the left upper abdomen every 2 to 3 years, increased blood and urine amylase, and improved after drug treatment. Three years ago, the patient's gastroscopy showed spherical bulge of the gastric fundus and linear ulcer on the surface due to melena; CT showed pancreatic pseudocyst (7.9 cm ×6.5 cm), gastric fundus compression, splenic vein occlusion, and multiple collateral circulations; Diagnosis of "chronic pancreatitis (CP)", medical treatment improved, the patient refused surgery. More than a year ago, the patient underwent gastroscopy again for melena (Figure 1) shows gastric fundus bulge and gastric fundus varices; Abdominal CT showed pancreatic pseudocyst (9.3 cm ×10.2 cm); Capsule endoscopy showed edema and partial absence of jejunal mucosa; There were no abnormalities in colonoscopy; Considering "possible aspirin-related gastrointestinal bleeding", the drug treatment improved. One week ago, the patient had persistent colic in the middle and left of the upper abdomen after eating greasy food, accompanied by nausea and vomiting. Hemoglobin was 132 g/L, blood lipase was 79 U/L, and blood and urine amylase were normal. He was admitted to the hospital with "CP acute attack". Previous hypertriglyceridemia for 40 years, fenofibrate for 4 years; History of type 2 diabetes, hypertension, old myocardial infarction, percutaneous coronary intervention, oral aspirin. Has a history of smoking and no history of drinking alcohol. Physical examination at admission: vital signs were stable. Palpebral conjunctiva is pale. Soft abdomen, tenderness under the xiphoid process, no rebound pain, muscle tension, no mass, positive Murphy sign, not reaching liver and spleen, existence of liver turbidity boundary, negative mobile turbidity, bowel sound 3 times/min. There is no abnormality. After admission, the patient had obvious fatigue, no abdominal pain, hematemesis, melena, hemoglobin 68 g/L, orthocytic anemia; Positive fecal occult blood; Blood lipase 108 U/L; Biochemistry: total protein 47.6 g/L, albumin 28.9 g/L, glucose 13.2 mmol/L, urea nitrogen 9.67 mmol/L, creatinine 66 μ mol/L, triglyceride 2.8 mmol/L, total bilirubin 26.4 μ mol/L, direct bilirubin 11.3 μ mol/L, transaminase and cholesterol normal; Glycoprotein 199 normal. Preliminary diagnosis: acute onset of CP; Gastrointestinal bleeding. Perfect abdominal CT (Figure 2) shows that the pancreatic pseudocyst communicates with the gastric cavity, and there is blood accumulation in the fundus of the stomach and the lower esophagus. Therefore, the diagnosis is considered: acute attack of CP, intracystic hemorrhage of pancreatic pseudocyst and formation of gastric fistula, and gastrointestinal hemorrhage. After the general condition is stable, the body and tail of pancreas + spleen + proximal gastrectomy is performed. The diameter of the pancreatic pseudocyst was 7 cm, the diameter of the contact surface with the posterior wall of the stomach was 5 cm, and the diameter of the internal fistula was 2 mm. Pathology (Figure 3): Some hyaline degeneration, hemorrhage and necrosis of the cyst wall, destruction of pancreatic tissue and structure around the cyst wall, reduction or disappearance of acins, and only small ducts and islets remain.

A 55-year-old female, previously healthy, was admitted to the hospital on 25 April 2014 due to "upper abdominal discomfort for 3 months". The patient experienced upper abdominal discomfort, accompanied by dull pain and soreness in the lower back without obvious trigger 3 months ago, but no other discomfort. The above symptoms occur intermittently, and intermittent oral administration of "stomach medicine" can be temporarily relieved. 10 days before admission, he came to our outpatient clinic for gastroscopy, which showed chronic non-atrophic gastritis, and the nature of gastric antrum bulge remained to be investigated. He was admitted to the hospital with "gastric antrum bulge lesion". Physical examination: body temperature 36.0℃, pulse 72 beats/min, breathing 19 beats/min, blood pressure 145/91 mmHg (1 mmHg =0.133 kPa), consciousness, energy, no sclera yellowing, no anemia, no superficial lymph node enlargement, no liver palm and spider nevus, heart rate 72 beats/min, uniform rhythm, no pathological murmur, clear breathing sounds in both lungs, flat abdomen, no abdominal wall varices, no gastrointestinal pattern and peristaltic wave, soft abdomen, no tenderness, rebound pain and muscle tension, no palpable mass, no subcostal reach of liver and spleen, negative Murphy sign (-), mobile voiced sound (-), the upper boundary of the liver is located in the fifth intercostal margin of the midline of the right clavicle, and the lower boundary is located in the subcostal margin of the right quarter, percussion pain in the liver area (-), normal intestinal sounds, and no edema in both lower limbs. Admission diagnosis: Antrum protuberance lesion: stromal tumor? Leiomyoma? Ectopic pancreas? Lipoma? Auxiliary examination after admission: prothrombin time 13.2 s, partial prothrombin time 39.1 s, carcinoembryonic antigen 2.89 μ g/L, alpha-fetoprotein 5.40 μ g/L, white blood cell count 3.9×10⁹/L, neutrophil percentage 0.613, hemoglobin 118 g/L, platelet count 177×10⁹/L, hematocrit 0.354, total bilirubin 11.7 μ mol/L, alanine aminotransferase 19 U/L, aspartate aminotransferase 19 U/L, alkaline phosphatase 74 U/L, γ-glutamyltransferase 18 U/L, lipase 49 U/L, serum sodium, potassium and chlorine were all normal. On April 29, 2014, endoscopic ultrasound (EUS) showed that the posterior wall of the gastric antrum was broadly bulged, the surface mucosa was smooth, and there was no depression or glandular duct opening, with a size of about 1.5 cm ×1.5 cm ×1.2 cm. The 12 MHz microprobe scan showed that the gastric antrum bulge lesion originated from the mucosa and submucosa, with moderate echo and uneven internal echo. Several tubular anechoic structures were visible, and the larger anechoic tubular structure was about 0.22 cm ×0.30 cm in size. The hierarchical structure of muscle layer and serosa layer was clear and complete (Figure 1)。 Endoscopic mucosal resection (EMR) of gastric antrum bulge lesions was performed. After operation, the patient was given symptomatic and supportive treatment such as acid suppression and gastric mucosa protection, and the upper abdominal discomfort disappeared. Postoperative pathological diagnosis (gastric antrum) ectopic pancreas (Figure 2)。 The patient recovered and was discharged on 10 May 2014. The patient was followed up for 6 months after discharge and was in good condition.

A 24-year-old male was admitted to the hospital due to "abdominal distension, fatigue for 1 month and jaundice for 20 days". The patient developed abdominal distension, extreme fatigue, anorexia, yellowing of skin and sclera all over the body after taking ready-for-use traditional Chinese medicine Zhuangjiefeng dispersible tablets in August 2014. Liver function was checked: alanine aminotransferase (ALT) 1 255 U/L, aspartate aminotransferase (AST) 910 U/L, total bilirubin (TBil) 82 μ mol/L, direct bilirubin (DBil) 28.5 μ mol/L, albumin 26 g/L; Coagulation: prothrombin time (PT) 31.2 s, activated partial thromboplastin time (APTT) 46.3 s, prothrombin activity (PT%) 24.0%; Hepatitis A, B, C and E virological tests were all negative (-); Serum ceruloplasmin (-). After 1 week, he developed a disturbance of consciousness, and his consciousness became clear after symptomatic and supportive treatment such as lowering intracranial pressure. Later, bone marrow smear showed hemophagous phenomenon; He was transferred to our hospital due to unknown diagnosis in other hospitals and possible combination of hemophagocytic syndrome (HPS). No previous history of liver disease and manifestations of chronic portal hypertension. Denial history of alcohol consumption and toxic exposure. Physical examination: skin sclera yellowing, subcutaneous ecchymosis, abdominal distension, total abdominal tenderness and mild rebound pain. Mobile voicing positive (+).

The patient, a 28-year-old male, came to our hospital on December 16, 2014 due to "right thoracic and lumbar erythema for 11 years". Eleven years ago, there was no obvious trigger to appear flaky erythema in the right chest and waist, no conscious itching or pain, no fever, chills, no photosensitivity, joint pain, no oral ulcer and other discomfort since the onset. No previous formal treatment. I came to our hospital for treatment 1 year ago because of obvious enlargement of rash. The patient was in previous health and denied family history of genetic diseases and similar diseases. Physical examination: The general condition is good, the physical development is normal, there are no oral ulcers, superficial lymph nodes are not swollen, and there are no obvious abnormalities in the systematic examination. Dermatological examination: Multiple bright erythema spots with irregular shape and clear boundaries distributed along the Blaschko line with a diameter of 0.2~2.0 cm were seen on the right chest and waist. Part of the erythema surface was covered with a few adhesive scales, and the skin was depressed and atrophied around the erythema, and the peripheral capillaries were dilated without obvious sclerosis (Figure 1)。 Laboratory tests: Blood and urine routine were normal. Complement C4 0.10 g/L (normal reference value 0.17-0.40 g/L). Erythrocyte sedimentation rate, serum immunoglobulin and complement C3 were normal, and anti-nuclear antibody (ANA), anti-double stranded DNA (dsDNA), anti-Smith antibody (Sm), anti-ribonucleosome (RNP) antibody, anti-Sjogren's syndrome A (SSA/Ro) antibody, anti-Sjogren's syndrome B (SSB/La) antibody, anti-scleroderma-70 (Scl-70) antibody and anti-Jo-1 antibody were all negative. Histopathological examination of skin lesions showed: epidermal atrophy, liquefaction and degeneration of basal cells, widening of some basement membrane bands, infiltration of massive lymphocytes around intradermal blood vessels and skin appendages, and more mucin deposition between collagen fibers (Figure 2), there was no increase, thickening and homogenization of collagen. Linear cutaneous lupus erythematosus (LCLE) was diagnosed according to the clinical and histopathological changes. After topical application of 0.1% tacrolimus ointment and 0.1% tretinoin ointment for 1 month, the rash turned slightly darker and local desquamation increased. Considering that the rash did not improve significantly after topical treatment, prednisone 15 mg was taken orally once a morning, hydroxychloroquine 0.2 was taken orally twice a day, vitamin E 0.1 was taken orally once a day, compound triamcinolone acetonide ointment and 0.1% tacrolimus ointment were taken orally. After 1 month, the erythema area gradually decreased, so prednisone tablets were reduced to 10 mg orally once a morning and hydroxychloroquine 0.2 orally once a day. After 2 months, oral medication was stopped and topical medication continued. After 4 months, the erythema turned obviously darker and some rash subsided.

The 18-month-old male patient was in good health and had no special family history. Due to "repeated melena for more than 2 months", routine blood examination in the local hospital showed that hemoglobin was 45 g/L, and symptomatic and supportive treatment such as blood transfusion and fasting was given in the emergency department. No obvious abnormalities were found in Coombs test, anemolytic test and fluorescent spot test. Bone marrow puncture showed: proliferative anemia, iron deficiency, diagnosis of gastrointestinal bleeding, and later transferred to our hospital for treatment. After admission, abdominal enhanced CT revealed duodenal mass (Figure 1), enhanced significantly enhanced. Abdominal B-ultrasound suggests the possibility of intussusception of small intestine. A huge tumor-like protrusion with unclear pedicle width was seen under gastroscopy (Figure 2)。 On the 5th day after admission, gastroscope-assisted duodenal mass resection was performed. During the operation, a huge mass in the duodenal bulb, about 5 cm ×4 cm, with ulcer inflammation on the surface was seen. Avoiding the duodenal papilla, duodenal mass resection and duodenal repair were performed (Figure 3，Figure 4，Figure 5), with a pathological diagnosis of "juvenile polyp" (Figure 6), the postoperative recovery was acceptable, and there was no abnormality in the follow-up after discharge.

GERD has a high prevalence in the world, but there are some regional differences. As for the typical symptoms of GERD (such as reflux, heartburn, etc.), the prevalence is 18.1% ~27.8% in North America, 23.0% in South America, 8.8% ~25.9% in Europe, 8.7% ~33.1% in the Middle East, and 11.6% in Australia^[1]6% ~10% in Asia^[2]。 Gastroesophageal reflux symptoms can cause significant discomfort, and conservative treatment may require some patients to change their lifestyle and take drugs throughout their lives, reducing quality of life and bringing a significant economic burden. Because the research and practice of extraesophageal reflux in GERD are not systematically in-depth, its epidemiological characteristics are still unclear. The prevalence of extraesophageal symptoms of GERD can still be seen from the co-occurrence rate of GERD and asthma. GERD symptoms, abnormal pH examination, esophagitis and hiatal hernia accounted for 59.2%, 50.9%, 37.3% and 51.2% of asthma patients, respectively. The prevalence of asthma in GERD patients was 4.6%, which was higher than that in the control population 3.9%^[3]。 It is also estimated that 21% to 41% of chronic coughs are associated with GERD^[4]。 The proportion of GERD patients with chronic sinusitis was 20.7%, which was significantly higher than that of the general population (8.5%)^[5]。 The positive rate of laryngopharyngeal reflux in recumbent position was as high as 50% and that in upright position was as high as 97% in patients with polyp sinusitis and asthma^[6]。 26.6% of chronic obstructive pulmonary disease (COPD) patients had daytime and/or nighttime GERD symptoms. According to statistics, 31% of COPD acute attacks were caused by lack of regular acid suppression therapy^[7]。 The proportion of comorbid GERD in COPD population is significantly higher than that in non-COPD population, and GERD is a significant risk factor for acute COPD onset^[8]。 In addition, the comorbidity of GERD in patients with idiopathic pulmonary fibrosis was also significantly higher than that in the control population^[9]。 In summary, if all gastroesophageal reflux-related diseases are counted, the prevalence of GERD may be underestimated. GERD has become a common chronic disease in China.