2015年 · 第95卷第26期

As early as the 1980s, some foreign doctors reported that individual children had multiple paraganglioma with polycythemia and malignant hypertension^[1,2]The tumor still recurred multiple times after surgical resection. In 2012, Pacak and Zhuang reported two similar patients and systematically summarized the disease and elucidated its molecular mechanism. Since then, its mystery was uncovered, so it was named "Pacak-Zhuang syndrome"^[3]。

After more than 20 years of development, although Zhejiang Province has initially established a standardized training system for residents, due to the lack of rigid regulations on teachers' admission, it only makes simple requirements in terms of academic qualifications and professional titles, which leads to inconsistent teachers' quality in various training bases, which affects the goal of homogenization of standardized training for residents in the whole province. To this end, Zhejiang Province launched a large-scale standardized training of residents in 2013, stipulating that all clinical training bases, community practice bases and theoretical teachers need to participate in teacher training. Through a series of teacher training courses and training behaviors, we will build a high-level, high-quality teacher team that is suitable for the development of standardized training of residents. The practice process of teacher training for standardized training of residents is described as follows.

Electron density deposition disease (DDD) mainly occurs in children and adolescents^[1]With limited reports at home and abroad. The clinical data of 4 patients with DDD confirmed by renal biopsy in the Second Xiangya Hospital of Central South University from January 2004 to December 2013 are reported below.

Craniocerebral trauma is a serious and critical disease in clinical practice. Its characteristics such as rapid change of disease, many complications, high rate of disability and mortality have attracted great attention in clinical practice^[1,2]。 For patients with craniocerebral trauma who have coma symptoms after operation, treatment should be carried out immediately, otherwise it will lead to serious consequences. Some data show that both hyperbaric oxygen (HBO) and right median nerve electrical stimulation (RMNS) can have a better effect on the recovery of postoperative neurological function in patients with craniocerebral trauma^[3]。 In order to explore the feasibility of HBO combined with RMNS therapy and the important value of neurological recovery after craniocerebral trauma, the clinical data and treatment effect of 62 patients with craniocerebral trauma admitted to our hospital from October 2011 to July 2013 were analyzed to evaluate the clinical value of HBO combined with RMNS therapy.

A 24-year-old male was admitted to the Department of Gastroenterology of Peking Union Medical College Hospital in April 2014 due to fever and multiple serous effusion for 2 months. The patient developed fever 2 months ago, accompanied by cough and chest tightness, with a peak body temperature of 38~39℃. The local hospital checked the serum anti-tuberculosis antibody positive, and found pleural and peritoneal effusion. Isoniazid, rifampicin, ethambutol and pyrazinamide were given quadruple anti-tuberculosis treatment for 1.5 months (during which the drug was discontinued for 1 week due to abnormal liver function). The symptoms gradually worsened, and there was skin pigmentation throughout the body, numbness at the fingertips of both hands, and blurred vision. Pleural and peritoneal effusion puncture and drainage were submitted for examination and revealed "exudate". The patient suffered from poor spirit, diet and sleep, and lost 15 kg of weight. Past history, marriage and childbirth history is not special. Personal History: The patient was from a rural area of Inner Mongolia and worked in electric welding. Family history: My mother suffered from "tuberculous pleurisy" more than 20 years ago, and she was recently active. She took rifampicin orally by herself. Physical examination: The skin of the whole body is pigmented and rough, the nails of both hands are white, a small hemangioma can be seen on the back, and multiple swollen lymph nodes can be palpable in the neck, axilla and groin on both sides, 1.0~1.5 cm in size, tough in texture, without obvious fusion. Bilateral breast symmetry, abnormal development, no tenderness, no palpable mass. The breathing sound of both lungs was thick, and the breathing sound of both lower lungs was reduced; The heart rhythm is uniform, the heart sound is strong, and there is no murmur in the precordial area; The abdomen is obviously swollen, the intestinal sound is normal, the mobile voiced sound is positive, the touch is tough, and there is a feeling of kneading the dough; No edema in both lower limbs; No neck ankylosis.

The patient, a 62-year-old female, developed right lumbar distension and pain without obvious trigger 3 days ago, without radiation pain, accompanied by nausea, and CT showed that the lower pole of the right kidney occupied space. She was seen in Shaoxing People's Hospital of Zhejiang Province on December 19, 2014. Physical examination: No percussion pain in bilateral kidney area, no tenderness in ureteral indentation. There were no abnormal findings in urine routine, and the flow red blood cell count was 197.4/μ L (normal range 0-40/μ L); There were no abnormal findings in oncology; Abdominal B-ultrasound: A hypoechoic substantial mass of 54 mm ×42 mm ×37 mm in size was detected at the lower pole of the right kidney, which protruded locally to the outside of the capsule and had irregular shape (Figure 1)； CT: A mass of about 45.7 mm ×37.4 mm in size was seen at the lower pole of the right kidney. The CT value of plain scan was about 40 HU, showing isodensity; The arterial phase was mildly enhanced, with a CT value of about 60 HU, seeming to see a pseudocapsule, and compression of the right pelvis and calyces. On December 22, he underwent "radical resection of right nephrocarcinoma" under general anesthesia and was sent for pathological examination. Gross specimen examination: the size of the right nephrectomy specimen was 140 mm ×70 mm ×60 mm, and the size of the lower pole mass was 45 mm ×40 mm ×25 mm. The section surface was gray-white and gray-yellow, partially yellow and granular, and the boundary with the surrounding kidney tissue was still clear (Figure 2)； Morphological characteristics of HE: The renal parenchyma is partially destroyed and replaced by a large number of proliferating fibrous tissue. A large number of lymphoid and plasma cell infiltration can be seen between spindle cells, which is similar to the morphological changes of inflammatory myofibroblastoma. Multiple abscesses are formed in multifocal chronic suppurative inflammation. Actinomycete mass can be seen in the center of the abscess, and the mass is surrounded by eosin radially parallel clusters (FIG. 3A，FIG. 3B)。 Pathological diagnosis: actinomycosis of the right kidney.

A 67-year-old male was admitted for "repeated vomiting for 3.5 months with emaciation". In May 2014, he came to Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine for treatment due to "repeated vomiting for 0.5 months". The vomit is the stomach content, and the amount is about 500-1 000 ml each time, 1-2 times a day. Physical examination: Vibrating water sound was accessible in the left upper abdomen, and no obvious abnormalities were found. Laboratory tests showed no abnormalities. Enhanced CT of the abdomen showed gastric cavity dilation. Gastroscopy: gastric cavity dilatation, a large amount of food residue and mucosal edema can be seen; The pyloric foramen is deformed, but it contracts well; Deep concave ulcers with a diameter of 0.8 cm were seen on the anterior and posterior walls of the duodenal bulb, respectively, with white coating on the surface, obvious congestion and edema in the peripheral mucosa, narrow junction between the bulb and the descending bulb, and the lens body barely passed through, but the descending mucosa was no different. The diagnosis was "multiple ulcer of the duodenal bulb with pyloric insufficiency obstruction" (Figure 1)。 "Inflammation" was reported by biopsy of the large curvature of the gastric antrum. The clinical diagnosis was pyloric obstruction and duodenal ulcer. He was given conservative treatment such as acid suppression and radical cure of Helicobacter pylori for 1 week, and the symptoms were relieved and he was discharged.

The main clinical manifestations of acute respiratory distress syndrome (ARDS) are refractory hypoxemia and respiratory distress. Mechanical ventilation is an important treatment for ARDS. Due to the strong respiratory distress in ARDS patients, coupled with the possible hypercapnia and alveolar collapse caused by low tidal volume ventilation strategy, the Black-Burke reflex is enhanced, and the human-machine asynchrony phenomenon is more likely to occur.