Volume 98 ·  Issue 48 ·  2018

Chronic obstructive pulmonary disease (COPD) is still a major chronic non-communicable disease worldwide, and its high incidence and disability rate seriously affect people's health. In November 2018, COPD Global Initiative systematically summarized the research progress in the field of COPD based on the important literature published in recent years, and released the 2019 edition of COPD Global Initiative Report, which updated many aspects involving COPD risk factors, early screening and diagnosis, active prevention, management of stable phase and acute exacerbation phase, etc.^[1]The main points of its update are now interpreted as follows.

Malignant tumors are a large class of diseases that threaten human health. The advent of immune checkpoint inhibitors (ICI) such as antibodies against cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), programmed death protein 1 (PD-1) and programmed death ligand 1 (PD-L1) has opened a new chapter in tumor treatment. Although ICI significantly improved the overall survival of some patients, clinical results showed that in the vast majority of unselected solid tumors, the objective effective rate of patients receiving ICI monotherapy was only 10% to 30%, and most patients could not benefit from it, that is, primary drug resistance; Even patients with effective treatment develop disease progression, i.e., secondary drug resistance, after a period of treatment. Researchers have conducted many in-depth studies on ICI efficacy predictors, drug resistance mechanisms and countermeasures. This article reviews the efficacy predictors, primary and secondary drug resistance mechanisms and countermeasures explored in clinical and scientific research of tumor ICI treatment. Research progress, in order to provide scientific basis and clinical guidance for ICI tumor treatment.

To analyze the accuracy of cyclopexy on traumatic cyclodialysis cleft guided by anterior segment optic coherence tomography (AS-OCT).

Fifty-six eyes of 56 consecutive patients[41 males, 15 females, with a mean age of (43.14±13.85) years]who diagnosed with traumatic cyclodialysis cleft confirmed by ultrasound biomicroscopy (UBM) and underwent cyclopexy surgery at Shanxi Eye Hosiptal from July 2013 to February 2016 were included in the study. Patients were measured with the AS-OCT system before cyclopexy. AS-OCT findings of the cyclodialysis clefts were recorded. Localizing and suturing the clefts was guided by AS-OCT imaging. Preoperative and postoperative visual acuity (VA), intraocular pressure (IOP) and anterior chamber depth (ACD) were recorded and analyzed.

Imaging of preoperative AS-OCT of the 56 eyes showed an annular ciliary body detachment, a cyclodialysis cleft and shallow anterior chamber. The ciliary body detachment detected by AS-OCT showed an echo free zone between the annular ciliary body and the sclera. The cyclodialysis cleft showed a new pathway between the anterior chamber and the suprachoroidal space. AS-OCT imaging showed that the extent of cyclodialysis clefts ranged from 30 degrees to 240 degrees, which had a 0 degree to 20 degrees difference compared with UBM imaging. Localizing and suturing of the cyclodialysis clefts was guided by AS-OCT imaging. The best corrected visual acuity (BCVA) was 0.21±0.17 at baseline and 0.29±0.21 at five days postoperatively. The initial and final BCVA showed a remarkable difference after treatment (t=-4.98, P<0.01). The mean intra-ocular pressure (IOP) was (8.33±2.29) mmHg before surgery and (15.40±2.34) mmHg at five days postoperatively. There was a significant difference of IOP between preoperative and postoperative period (t=-16.590, P<0.01). The mean ACD was (1.94±0.45) mm preoperatively and (2.69±0.44) mm at five days postoperatively. There was also a significant difference of ACD between preoperative and postoperative period (t=-10.276, P<0.01). The postoperative reexamination found that ciliary body detachment or cyclodialysis clefts was not observed in the 56 eyes by AS-OCT.

As a non-invasive method, AS-OCT is accurate, correlating well with UBM in the examination of cyclodialysis cleft, and can localize the extent of clefts before cyclopexy.

To evaluate the predictive value of Wells score, revised Geneva score combined with D-dimer for the risk of pulmonary embolism in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

In this study, 234 AECOPD patients underwent CT pulmonary angiography from March 1, 2013 to December 31, 2015 in the First Affiliated Hospital of Zhengzhou University. The basic data of the patients were collected and the patients were classified into AECOPD combined with pulmonary embolism group(pulmonary embolism group) and AECOPD group according to CT pulmonary angiography results. All patients were scored by Wells score and revised Geneva score. The receiver operating characteristic (ROC) curves were generated and the Z test was applied to evaluate the predictive value by comparing the area under the ROC curves (AUC).

Totally 32(13.7%) patients had pulmonary embolism out of the 234 AECOPD patients. The AUC by Wells score, revised Geneva score, D-dimer, Wells score + D-dimer, revised Geneva score + D-dimer were 0.869 (95% CI: 0.789-0.949), 0.710 (95% CI: 0.588-0.832), 0.866 (95% CI: 0.790-0.941), 0.926 (95% CI: 0.874-0.977), 0.855 (95% CI: 0.751-0.959). The AUC of Wells score and D-dimer were significantly greater than that of revised Geneva score (Z=2.14, 2.12, both P<0.05); the AUC of Wells score + D-dimer was significantly greater than revised Geneva score + D-dimer (Z=2.73, P<0.05).

The predictive value of Wells score + D-dimer for pulmonary embolism in AECOPD patients is higher than revised Geneva score + D-dimer.

To compare the analgesic efficacy between preoperative single-dose ketamine, a short-acting medicine and parecoxib, a long-acting medicine for reducing analgesic consumption in the first 24 h after-operation.

Eighty-one patients from Beijing Chaoyang Hospital undergoing laparoscopic uterus surgery between April and December 2015 were randomly divided into three groups: control group (group C), ketamine group (group K) and parecoxib sodium group (group P). All patients were anesthetized with general anesthesia and received sufentanil-based patient-controlled intravenous analgesia (PCIA). After induction and 10 min before incision, patients in group K, P and C were injected with intravenous 0.5 mg/kg ketamine, 40 mg parecoxib and 2 ml normal saline, respectively. The primary outcome was sufentanil consumption within 1 h and 24 h after surgery. Other outcomes included the visual analog scale (VAS) pain score at 0, 15, 30, 45min and 1, 2, 4, 8, 24 h after surgery, PCIA effective trigger times, and adverse reactions.

The postoperative sufentanil consumptions within 1 h in group K and P were(4.420±1.836)μg and (2.878±1.984)μg, respectively, and consumptions within 24 h were(28.200±3.712)μg and (25.511±4.037)μg, respectively, which were significantly less than that in group C with (6.144±2.346)μg within 1 h and (31.505±7.042)μg within 24 h (F=15.360, 8.406, all P<0.05). Patients in group P needed less sufentanil than group K in 1 h after surgery (P<0.05), however, the difference was not statistically significant in 24 h(P>0.05). The PCIA trigger times were 2(3.75) in group C, 0(1.50) in group K, and 0(1.00) in group P. Group K and P had less PCIA trigger times compared to group C (allP<0.05). Compared to group C, group K and P had lower VAS scores at 0, 15, 30 min after surgery and group P had lower VAS scores at 1, 15, 30, 45 min, 2 h after surgery, respectively (allP<0.05). There were no differences between groups in the incidence of any adverse effects(allP>0.05).

A single injection of short-acting ketamine before laparoscopic uterus surgery, has the same efficacy as long-acting parecoxib for opioid-sparing effect in the first 24 h after-operation. However, parecoxib has better analgesic effect in the early postoperative period.

To investigate the effects of nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) tube feeding on the susceptibility of pulmonary infection in long-term coma patients with stroke or traumatic brain injury.

A total of 295 candidates who were in long-term coma after stroke or traumatic brain injury but without pulmonary infection and eligible for PEG catheterization were screened prospectively between January 2014 and February 2018. The patients were divided into PEG group (86 patients) and NGT group (209 patients) according to the choice of next-of-kin. Data related to the susceptibility of pulmonary infection were collected and analyzed in the two groups one month after the catheterization.

After follow-up for one month, compared with NGT group, patients in PEG group had a lower incidence of pulmonary infection (23.3% vs 37.8%, P=0.023), a later occurrence of pulmonary infection (average time: 21 days vs 13 days, P=0.034), and a less severe pulmonary infection (7.0% vs 12.9%, P=0.029). The following characteristics made patients more susceptible to pulmonary infection: age ≥ 70 years (HR=1.619, 95% CI 1.054-2.172), Charlson comorbidity index ≥ 2 points (HR=1.647, 95% CI 1.043-2.485), using of proton pump inhibitor ≥ 7 days (HR=1.725, 95% CI 1.214-2.738), and number of pressure ulcers ≥ 3 (HR=2.109, 95% CI 1.128-3.844). However, serum albumin concentration ≥35 g/L (HR=0.670, 95% CI 0.375-0.963) was a protective factor for pulmonary infections. The number of consistent pathogens cultivated from saliva, gastric juice and sputum simultaneously in NGT and PEG group was 35 strains (27.8%) and 8 strains (13.3%), respectively (P=0.029). The mortality of pulmonary infection was similar in the two groups (3.5% vs 4.3%, P=1.000), but the death due to pulmonary infection in the PEG group occur later (median time: 20 days vs 11 days, P=0.012).

PEG feeding was a preferred nutrition way which could reduce the risk of pulmonary infection more effectively than NGT feeding which might favored a retrograde gastro-pulmonary route by which pathogens colonized in stomach migrated to respiratory tract. Patients with characteristics mentioned above had the susceptibility of pulmonary infection, thus risk assessment of pulmonary infection should be conducted before selecting the catheterization method

To evaluate the results of pars plana vitrectomy (PPV) with peeling of the inner limiting membrane (ILM) in patients with laser-induced macular hole.

The clinical data of 11 patients (12 eyes) with decreased visual acuity due to laser-induced macular hole from January 2014 to December 2017 were retrospectively studied.All patients underwent routine examination, fundus photography and optical coherence tomography (OCT). Patients were observed every two weeks. PPV with ILM peeling was performed when macular hole was enlarged. Closure of macular hole, pre- and post-operation visual acuity were observed.

A total of 11 male patients (12 eyes)aged (18±4) years were included in the study.Laser instruments which lead to macular hole consisted of laser toy (3 eye), laser pen (4 eye), laser torch (1 eye) and cosmetic laser instrument (4 eyes). All patients were followed up every two weeks and evaluated by OCT. None of the macular hole was spontaneously closed in this study. All Macular holes were enlarged in 1-3 months of follow-up and underwent PPV with ILM peeling immediately. All of the macular hole with PPV and ILM peeling were completely closed. During follow-up, the best-corrected visual acuity(BCVA) of 10 eyes (10/12) were found to increase above 3 lines and BCVA of 7 eyes(7/12) were found to be more than 0.5. Only 1 eye maintained the same visual acuity after the surgery which might be due to long course, large macular hole diameter (850 μm) and serious retinal pigment epithelium (RPE) damage.

Early PPV with ILM peeling for laser induced macular hole might benefit for the closure rate of macular hole and better visual acuity prognosis.

To summarize the clinical experience of transumbilical single-port laparoscopic cholecystectomy, and evaluate its clinical utility and the feasibility of widely usage.

Between April 2012 and June 2017, 500 cases who underwent transumbilical single-port laparoscopic cholecystectomy with totally free umbilical ring by conventional instruments were enrolled. The clinical data were retrospectively analyzed.

A total of 487 patients were successfully completed the operation. In addition, 3 cases were converted to open cholecystectomy, 10 cases were converted to multi-port laparoscopy and drainage tubes were placed in 5 cases. The mean operating time of transumbilical single-port laparoscopic cholecystectomy(from the Trocars being put to the gallbladders being removed)shortened from 72.3 min to 13.2 min. The average bleeding amount was less than 10 ml. After the operation, 3 cases had delayed bile leakage and 3 cases had transient up-regulation of bilirubin at the beginning of the technique. No patients had hemorrhage and Trocar hernia. The average hospital stay of patients was 2.1 days. The cosmetic effect was remarkable during follow-up.

The transumbilical single-port laparoscopic cholecystectomy with totally free umbilical ring by conventional instruments should be widely carried out in hospitals at all levels because of its minimal postoperative pain, rapid recovery, hidden incision, low costs and low incidence of port-site hernia.

To study the damage and mechanism of intestinal mucosal barrier function in mice with ulcerative colitis induced by Dextran sulphate sodium (DSS).

Mice models of chronic ulcerative colitis induced by DSS were established. The mice were completely randomized into normal control group and DSS group, 25 mice in each group. The body weight and colon length of the mice were monitored. The pathological examination of colon tissue was confirmed the success of the model and assessed the integrity of the colonic mucosal barrier; Evan′s Blue′s intestinal permeability analysis assessed the function of colon mucosal barrier; immunofluorescence staining and Western blot were used to evaluate the expression of intestinal mucosal barrier integrity-related proteins.

Compared with the normal control group, the DSS group had lower body weight [(25.6±0.7)g vs (23.5±0.7)g, t=2.14, P<0.05], and the colon length was shorter [(7.3±0.4)cm vs (5.6±0.2)cm,t=3.975, P<0.001]; colonic pathological results showed that the intestinal mucosa became thinner and part of the intestinal mucosa was defective; Evan′s Blue instilled into the intestinal lumen was more abundant into the intestinal mucosa, and the optical density at 620 nm (OD₆₂₀)/colon tissue weight (g) was higher [(0.11±0.01) vs (0.15±0.01), t=4.174, P<0.05]; immunofluorescence and Western blot results showed lower expression of ZO-1, Claudin-1, and F-actin in colonic mucosa.

The structure and function of intestinal mucosal barrier in DSS-induced chronic ulcerative colitis mice is impaired.

To investigate the role of ERK in the apoptosis of gastric cancer cells induced by miR-433.

Lentivirus was used to transfect BGC-823 gastric cancer cell line to over-express miR-433. The blank control group (BGC-823), negative control group (BGC-823+ miR-433 negative control) and experimental group (miR-433+ miR-433, BGC-823-pMD18-T- miR-433)were set up. After treatment, the gastric cancer cell line BGC-823 was detected at 24 h, 48 h, and 72 h after culture, in vitro cell activity, cell apoptosis assays were performed by CCK-8 and Annexinv-FITC, respectively, to elucidate biological effects of miRNA-433, and After 72 h of culture, the ERK1/2 detected their protein expression were quantified by BCA method.

The growth activity of BGC-823+ miR-433 cells cultured in vitro was significantly lower than that of BGC-823 cells and BGC-823+ miR-433 negative control cells at 48 h and 72 h; BGC-823+ miR-433 cell apoptosis index was significantly increased at 24 h, 48 h, and 72 h; the expression of ERK1/2 was significantly lower than BGC-823 cells and BGC-823+ miR-433 negative contral after 72 h culture. There were no significant differences between BGC-823+ miR-433 negative control cells and BGC-823 cells.

ERK plays an important role in the apoptosis of gastric cancer cells induced by miR-433.

To discuss the whole genome-wide screening of the longevity-related gene of Uyghur population in Hotan, Xinjiang.

The whole gene scanning using genome-wide association study (GWAS) based on the pooling DNA and the SNP-Map strategy in the longevity group (≥90 years old) and control group (persons who died before 70 years old) was carried out. Then, through detecting varieties of SNP locus, the frequencies of genotype and allele were calculated by sequencing and PCR- restriction fragment length polymorphism (RFLP) method.

There was no significant difference of rs6450874, rs6800573 and rs6741735 genotypes and alleles frequency distributions between the two groups, however, there were statistical differences of rs1718307, rs4449651, rs11217987 and rs2907092 genotypes and alleles frequency distributions between the two groups. The TT genotype of rs11217987 (OR=1.462, P=0.034) and the GG genotype of rs2907092 (OR=3.000, P=0.018) were positively correlated to the longevity. And the T allele of rs11217987 (OR=1.382, 95%CI: 1.075-1.776) and the G allele of rs2907092 (OR=1.672, 95%CI: 1.267-2.205) had strong potential function to prolong life. The TT genotype of rs4449651 (OR=6.892, P=0.009) and rs1718307 (OR=4.036, P<0.001) were positively correlated to the longevity. Moreover, the T allele of both SNPs (OR=1.793, 95%CI: 1.298-2.477; OR=1.830, 95%CI: 1.391-2.407) had strong potential function to prolong life.

The GWAS test can effectively and extensively analyze human longevity-related genes. And rs1718307, rs4449651, rs11217987 and rs2907092 are related to the longevity of Uyghur population in Hotan, Xinjiang.

To evaluate robot-assisted system YunSRobot to perform oesophagogastroduodenoscopy(EGD) in simulation model and human volunteers.

The YunSRobot was invented for soft endoscopy by our team. In this trial, gastroenterologists operated the double handles of YunSRobot to perform EGD endoscopy with Olympus GIF-H 260 in simulation model Lm103 of Koken Japan and human volunteers. The operating time, lumenal anatomic exposure, man-machine interaction and other parameters were recorded and compared with manual endoscopy.

In the endoscopy on model, each of four doctors performed 5 procedures of EGD by YunSRobot and traditional manual endoscopy, respectively. The average time of one procedure was (626.4±120.7) seconds in the robot group and (241.5±24.7) seconds in the manual group, the operating time in robot group was more than that in manual endoscopy group. (t=14.0, P<0.001). However, the robotic manipulation time of the four endoscopists was significantly shortened from the first case to the fifth case with ((783.5±154.8)s, (667.75±85.1)s, (582.0±74.7)s, (555.0±28.9)s, (543.8±29.7)s,F=15.353, P=0.03). In the endoscopy on human, three physicians operated the EGD endoscopy in 21 volunteers, each physician performed seven volunteers by YunSRobot and traditional manual endoscopy respectively. The average time of each procedure in the robot group and the manual endoscopy group was (875.6±179.8) vs (378.8±80.4)s, the operating time in robot group was also more than that in manual endoscopy group (t=10.278, P<0.001). Like the endoscopy on model, the robotic manipulation time by the three operators was significantly reduced from the first case to the seventh cases ((954.7±62.1)s, (936.7±116.9)s, (968.7±227.1)s, (1 008.0±229.4)s, (876.7±110.5)s, (735.0±149.2)s, (649.3±81.0)s,F=3.79, P=0.024). All endoscopic anatomy of EGD were clearly and skillfully observed including esophgus, cardia, fundus, body, gastric angle, antrum, pylorus, first and second parts of duodenum, and papilla in both groups. In all procedures, there were no complications.

The soft endoscopy robot YunSRobot is competent to conduct endoscopy of EGD on human. Presently the initial learning time of YunSRobot for EGD is longer than that of experienced manual endoscopy. The learning curve shows that the time of robot manipulation reduces rapidly in the initial procedures. It indicates that YunSRobot system has user-friendly functions and is easy to master.

To evaluate the performances of a "ready-to-use" liquid chromogenic medium for detecting toxigenic strains of C. difficile from stool specimens, by comparing with the reference method of combined GeneXpert detection with MALDI-TOF MS identification.

This study was a clinical application research. A total of 322 stool specimens from patients with diarrhea in Henan Provincial People′s Hospital were detected by using this liquid chromogenic mediumor by combination of GeneXpert and MALDI-TOF MS identification after CCFA culture from March to November 2017. The reference method was combined GeneXpert detection with MALDI-TOF MS identification. Data were analyzed with kappa analysis by use of SPSS 13.0. In this study, the limit of detection and anti-interference capability of chromogenic medium were determined with standard strains.

This assay had a sensitivity of 92.86% (52/56), a specificity of 96.99% (258/266), a positive predictive value of 86.67% (52/60), and a negative predictive value of 98.47% (258/262). Furthermore, this assay was well consistent with the reference method (kappa=0.874, P<0.01). The limit of detection of this assay was 10³ CFU/ml for toxigenic strain of ATCC9689, and there was no interference by non-toxigenic strain of ATCC43593 or Clostridium perfringens (ATCC13124) even.When the concentration of ATCC9689 was as low as 0.5 McFarland.

It is worth expanding clinical research for this "ready-to-use" chromogenic medium and preparing for its popularization in primary medical institutions, due to its similar performance to the reference method for detecting toxigenic strains of C. difficile, simple operation and no need of anaerobic condition.

Example 1: A 32-year-old female was admitted to the hospital in December and May 2016 due to failure of inferior vena cava filter removal twice. The patient developed deep vein thrombosis (DVT) of the right lower extremity during pregnancy in January 2016 and a retrievable inferior vena cava (IVC) filter was placed at the local hospital. Endovascular filter removal was performed at a local hospital 3 months after filter placement, and the operation failed. The patient was then transferred to the Department of Vascular Surgery of our hospital, and the filter was removed with an endovascular gooseneck catcher, which was still unsuccessful. Abdominal CT showed that the filter was tilted, and part of the filter foot penetrated the vena cava wall (FIG. 1A)。 Considering that the patient is still young, lifetime anticoagulation is required if the filter is not removed, and multiple filter feet have penetrated the vena cava wall, one of which may damage the aorta (FIG. 1A), decided to perform laparoscopic filter removal. Diagnosis: (1) After placement of inferior vena cava retrievable filter; (2) Deep vein thrombosis of lower limbs. The patient underwent laparoscopic filter removal on December 7, 2016. Using general anesthesia, a 10, 10, 10, 5, and 5 mm cannula (Trocar) was placed in the umbilicus, midpoint of the umbilical and xiphoid process, midpoint of the umbilical and pubic symphysis, 5 cm to the right of the umbilicus, and under the xiphoid process, and the laparoscopic instrument was placed. The peritoneum was incised on the lateral side of the right paracolonic sulcus, the ascending colon and duodenum were pushed towards the midline, the kidney, renal vein and inferior vena cava were exposed, and the inferior vena cava was freed up to the tip of the filter and down to the tail of the filter. The ovarian vein and lumbar vein were clipped and severed with hemlok. The vascular occlusion band passes through the inferior vena cava and is placed at the tip and tail ends of the filter. A drainage tube about 1.5 cm long, 20 F, was cut and the tourniquet passed through this drainage tube (for blocking). After notifying the anesthesiologist, the distal and proximal ends of the inferior vena cava were blocked in turn (FIG. 1B)。 At the tip of the IVC filter, a longitudinal incision of the inferior vena cava is about 3 cm long. Because the filter hook is embedded in the wall of the inferior vena cava, the filter hook is separated with scissors. Using a catcher, the filter hook is enclosed and retrieved into the filter sheath (Figure 1C)。 IVC was rinsed with heparin water to remove intracavitary blood clots and air bubbles. The IVC incision was continuously sutured with 5-0 Prolene thread, and the proximal and distal blocking bands of the IVC were sequentially released. The operation time was 330 min, the bleeding was about 500 ml, and 4 units of suspended red blood cells were transfused. Postoperatively, low molecular weight heparin (Qizheng) was injected subcutaneously at 0.4 ml/12 h for 1 week. Hospitalized for 14 d, the patient was discharged in good condition.

A 43-year-old female was admitted to the Department of Infectious Diseases of West China Hospital of Sichuan University due to "low back pain for more than 5 months and intermittent fever for 1 month". In January 2014, the patient suffered from sudden low back pain during sleep at night, which was needle-like pain with paroxysmal attack. The pain was relieved when lying prone, and the pain was repeated, gradually appearing pain in the buttocks, posterior thighs, and lateral calves, accompanied by weakness in both lower limbs. In March, he developed weakness of both lower limbs, difficulty in standing and walking, and in April, he developed fever, with a body temperature of 40.2℃, accompanied by chills, chills, sweating, and headache. Previously, forehead pain was the main one, with an attack once a day, showing irregular fever, and at the same time, low back pain was aggravated, which was persistent, accompanied by pain and weakness in both lower limbs, and the patient could not sit up. In May, I went to a tertiary hospital, and many blood cultures were negative. Lumbar MRI showed edema of bone marrow in T11~ L5 vertebral bodies, uneven increase of intervertebral disc signal in L4~ L5, swelling of soft tissue in lumbar back, and a little fluid accumulation in the presacral space (Figure 1)。 Treated with carbapenem and vancomycin, his symptoms continued to worsen, and he was transferred to the emergency department of West China Hospital on 13 May 2014. Blood routine: Hemoglobin 90 g/L, platelet count 688×10⁹/L, white blood cell count 26.33×10⁹/L, the percentage of neutral rod-shaped nucleus granulocytes was 15.0%, and the percentage of neutral lobulated nucleus granulocytes was 70%. The erythrocyte sedimentation rate was 117 mm/h. Hepatic enzymology was normal, albumin 30.0 g/L, globulin 49.0 g/L, serum sodium 132.6 mmol/L, serum potassium 2.81 mmol/L. High sensitivity C-reactive protein 125 mg/L, procalcitonin 0.10 μ g/L, coagulation routine showed no abnormality, hepatitis B surface antibody and core antibody were positive, human immunodeficiency virus (HIV) antibody, hepatitis C antibody and syphilis antibody were negative, and cardiac color ultrasound showed no abnormality. Considering lumbar spine infection and pulmonary infection, the emergency department successively administered piperacillin/tazobactam for 7 days, moxifloxacin for 11 days + vancomycin for 7 days, and intermittently administered methylprednisolone 40 mg/d ×2 days. The patient's symptoms did not improve and he was admitted to the hospital on May 26. Past history, family history and personal history are not special. Physical examination at admission: body temperature 37 ℃, pulse 95 beats/min, breathing 20 beats/min, blood pressure 145/95 mmHg (1 mmHg =0.133 kPa). There were no abnormal signs in the heart, lung and abdomen, and the skin temperature of the bilateral lower back was slightly higher and tenderness was obvious; Lumbar spinous process tenderness and percussion pain were obvious, bilateral hypoesthesia below the inguinal area was reduced, and the muscle tone of both lower limbs was reduced. The muscle strength of the lower limbs was 2~3 in the proximal end and 4 in the distal end, mainly with weakening of knee extension and ankle dorsal extension and thumb dorsal extension. Both pathological signs and meningeal irritation signs were negative.

A 36-year-old male was admitted to the hospital on 3 February 2016 due to persistent fever for 4 days and cough and sputum for 1 day. The patient developed high fever after catching a cold 4 days ago, up to 40℃, accompanied by chills, dizziness, fatigue, muscle soreness, without cough, expectoration, nausea, vomiting, chest tightness, chest pain and chills; Accompanied by diarrhea, yellow non-shaped stools, without abdominal pain. The patient's body temperature can be temporarily lowered after taking "antipyretic drugs", but it cannot be lowered to normal. One day ago, the patient was given azithromycin intravenously and cefprozil capsules orally in another hospital. The temperature did not drop and went to the emergency department of Shengjing Hospital. Moxifloxacin was given intravenous drip. The patient had a cough and yellow sticky sputum, so he was admitted to hospital. The patient had no previous history of chronic diseases and no history of infectious diseases. Drink alcohol for 10 years and deny smoking history.

A 16-year-old male was admitted to the Pancreatic Center of the First Affiliated Hospital of Nanjing Medical University on March 30, 2018 because "physical examination found that the abdominal cavity occupied 5 days". The patient was admitted to the local hospital 5 days ago due to postprandial abdominal pain, considering gastroenteritis, and was hospitalized. During this period, both abdominal color ultrasound and abdominal CT showed that the abdominal cavity occupied space. For further treatment, he came to our hospital on March 30, 2018. Has a history of allergic asthma for 2 years and improved after treatment; Has a history of chronic diarrhea for more than 1 year, and has not been systematically examined and treated. Infectious diseases, drug and food allergies, surgical trauma, blood transfusions and family history were denied. The initial diagnosis was retroperitoneal mass occupation.

Thrombotic microangiopathy (TMA) is a group of acute clinicopathological syndromes characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and ischemic organ involvement caused by various causes. Its pathological and clinical manifestations are similar, but the pathogenesis is diverse. The disease spectrum involves professional fields such as kidney disease, rheumatism, hematology, obstetrics and tumor, and the diagnosis and treatment are complicated. In recent years, with the continuous deepening of research on the pathogenesis of TMA, its diagnosis and treatment plan has made a great breakthrough, but there are still doubts. This article aims to summarize the research progress of TMA from the perspective of clinical practice, with emphasis on atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP).

With the development of biomedical research technology, new diagnosis and treatment methods are constantly emerging, and these questions should be studied and the technology to be developed should not be developed. For example, in genetic testing, embryonic stem cell research, AIDS research and organ transplantation research, there are problems of respect and protection of human dignity, interests and rights. Given the importance of ethics, ethical issues are unavoidable problems for researchers in medical research.