2014年 · 第94卷第01期

The doctor and the patient were supposed to be comrades in the same trench with the common goal of defeating the disease. However, in recent years, the relationship between doctors and patients in China has become increasingly tense, and vicious cases of injury to medical staff have occurred from time to time, which seriously disturbs the order of diagnosis and treatment in hospitals and affects the stability of society. According to the website of the National Health and Family Planning Commission (NHP), in 2012, there were 11 cases of malignant medical injuries in China, resulting in 35 casualties, including 7 deaths and 28 injuries^[1]。

A 17-year-old female was admitted to Zaozhuang Municipal Hospital on July 8, 2013 due to skin discoloration of her limbs for 2 years and skin ulceration of her lower limbs for 1 year. In June 2011, the patient showed spotty changes in the skin of his limbs without obvious trigger, with significant changes in both lower limbs, ankle and dorsum of both feet. He was diagnosed with "vasculitis syndrome" locally, and received "Voltaren and blood circulation activation and blood stasis removal" drug treatment. The symptoms were relieved, and then skin lividae appeared intermittently. In July 2012, liviana reticulata aggravated again, and the skin ulceration of both lower limbs appeared, with obvious pain, and was treated locally, the specifics are unknown. Three months later, the ulcer healed, leaving several scars on the skin. The skin on the surface of the scar was pale, which was aggravated when the weather was hot, and liviosa reticulata was relieved when the weather became cold. In March 2013, the skin of the 2nd, 3rd and 5th toes of the right foot was ulcerated and necrotized, the skin turned dark, and the reticular liviosa was aggravated again. The patient went to the local hospital and was diagnosed with systemic vasculitis and arterial occlusive disease. He was given methylprednisolone 40 mg/d for 7 days and cyclophosphamide 0.4 g once. After that, glucocorticoids were changed to oral administration, and the dose was gradually reduced to the current prednisone 20 mg/d. The effect was not good, and the toe appeared dry gangrene, so he was admitted to hospital for further treatment. There were no other discomfort such as fever, rash, repeated oral ulcers, joint pain, vulvar ulcers, etc. during the course of the disease. Physical examination: body temperature 36.4℃, blood pressure 114/75mmHg (1 mmHg =0.133 kPa), pulse 90 beats/min, glucocorticoid facial appearance, flexural artery and dorsal pedis artery beating, no dry and wet rales in both lungs, heart rate 90 beats/min, uniform rhythm, no pathological murmur, soft abdomen, no tenderness, extensive reticular liviosa-like changes in limbs and skin, low skin temperature at the ends of hands and feet, several yellow-white atrophic scars on the skin of both lower limbs, and ulceration and blackening of the 2nd, 3rd and 5th toes of the right foot (Figure 1)。 Laboratory test: blood routine: white blood cells 13.47×10⁹/L, red blood cells 4.33×10¹²/L, platelets 249×10⁹/L, hemoglobin 124 g/L; Erythrocyte sedimentation rate 9 mm/1 h, C-reactive protein 12.5 mg/L, urine routine negative, stool routine negative, lactate dehydrogenase 271.1 U/L, liver function residue normal, kidney function, ion and blood lipid normal, autoantibody spectrum negative, ANA negative, ANCA negative, anti-proliferating cell nuclear antigen antibody negative, rheumatoid factor, anti-keratin antibody, anti-cyclic citrulline antibody negative, complement and immunoglobulin normal, thyroid function normal, tumor markers negative, anticardiolipin antibody negative, lung CT, heart B-ultrasound and upper abdomen and retroperitoneal B-ultrasound were not abnormal, and both hands microcirculation examination was moderately abnormal (clarity: unclear; exudation + +); Pathological examination of skin biopsy at the rupture of the right lower limb: epidermal atrophy with keratosis, hyperplasia of subepidermal fibrous tissue. Diagnosis: vasculitis liviosa. After admission, aspirin 0.1 g, once/d, dipyridamole 25 mg 3 times/d, alprostadil and salvia miltiorrhiza were treated symptomatically, and prednisone was reduced to 15 mg once/d. The ulcerated toes were washed with 1:500 iodophor and 0.5% nitrofuracillin ointment was given for external use. The liviosa reticulata was improved after 3 weeks (Figure 2), improved and discharged.

The incidence of intertrochanteric fractures accounted for 3% ~4% of all fractures and 35.7% of perihip fractures^[1]。 Traditional conservative treatment methods such as traction are mostly used in elderly patients, but long-term bed rest is more likely to lead to a variety of serious life-threatening complications. In recent years, minimally invasive internal fixation surgery (PFNA) has become the preferred method for the treatment of intertrochanteric fractures in the elderly. However, in the course of clinical application, it was observed that although the dominant blood loss during and after operation was relatively small, the occult blood loss was more. Anemia is often one of the important reasons for the low survival rate of elderly patients with hip fracture^[2]。 In this study, the data of elderly patients with intertrochanteric fracture treated with PFNA internal fixation were analyzed, and the amount and impact of occult blood loss caused by surgery were analyzed.

Venous thromboembolism (VTE) has been widely concerned by clinicians because of its high incidence^[1]。 At present, the international standard treatment regimen for VTE is heparin combined with warfarin anticoagulation^[2]。 For patients with VTE, anticoagulant therapy can improve symptoms and prevent recurrence, but it also increases the risk of bleeding. Studies have shown that the incidence of major hemorrhage complications within 90 days of VTE patients receiving standard anticoagulant therapy can reach 2.4%^[3]。 The occurrence of bleeding events (especially major bleeding) has an important impact on the treatment effect and prognosis of patients. Therefore, it is crucial to establish a risk prediction model for VTE anticoagulant bleeding complications and pre-evaluate the bleeding risk of patients before starting treatment. For the individualized treatment of VTE, reduction of adverse reactions is crucial.

Intervertebral disc herniation is a common and frequently occurring disease in orthopedics, which seriously affects the work and life of patients. At present, its clinical efficacy is still not satisfactory^[1]。 Minimally invasive treatment is another new development field of spinal surgery in recent years. Among them, percutaneous cervical disc nucleoplasty (PCDN) has been gradually accepted by more and more patients with intervertebral disc herniation because of its advantages of less tissue damage, safer and more effective, quick recovery, simple operation and low cost, and has attracted great attention of medical workers at home and abroad.