2015年 · 第95卷第30期

In the past ten years, through the vigorous promotion of many insightful people and the joint efforts of domestic medical colleagues, the diagnosis and treatment of pulmonary thromboembolism (PTE) and deep vein thrombosis (DVT) in China has undergone great changes, and the majority of patients have also benefited deeply from it; At the same time, scholars in related fields in China have carried out a series of research work, which has greatly promoted the prevention and treatment of PTE-DVT^[1,2]。 More and more researchers have looked at DVT and PTE as a whole-venous thromboembolism (VTE). As a clinical disease that is most likely to be prevented, it is very important to establish and improve the comprehensive prevention and treatment management system in hospitals.

The technical requirements for the diagnosis of pulmonary thromboembolism (PTE) are high, and the diagnosis method is not suitable for all patients; If the hospital does not have multiple PTE diagnosis technologies, it will affect the diagnosis and treatment of patients. A survey of standardized diagnosis and treatment of PTE in 10 secondary hospitals and 8 tertiary hospitals in Beijing found that 86% of PTE patients were diagnosed by CT pulmonary angiography (CTPA), and CTPA has become the main diagnosis technology of PTE; At the same time, it was found that most secondary hospitals did not have pulmonary ventilation/perfusion imaging and magnetic resonance examination techniques^[1]。 Clinically, 24.4% of patients had at least one contraindication to CTPA test^[2]Some secondary hospitals cannot make a clear diagnosis of PTE for these patients. In addition, how to judge whether they are PTE and get timely treatment for those who cannot undergo confirmation examination due to critical illness is also an important issue for us. Based on this, we initially set the PTE treatment strategy for the primary hospitals that cannot conduct confirmation examination, and elaborate it in the following levels.

The "intestinal micro-ecosystem" of the human body is composed of the intestine and huge microbial community. It is an extremely large and complex micro-ecosystem, containing 15 000~36 000 bacteria species. These bacteria together constitute the dynamic balance of gastrointestinal micro-ecology, participate in the metabolism of human material and energy, regulate the expression of human genes, regulate immunity and nutrition. Intestinal microbiosis is closely related to many diseases, such as obesity, type 2 diabetes, inflammatory bowel disease, and cardiovascular disease, among others. Previous studies have observed changes in intestinal microecology in patients with chronic kidney disease (CKD), and intestinal microecological dysregulation may further accelerate the progression of kidney disease and induce CKD-related complications^[1]。 The relationship between intestinal micro-ecology and kidney disease is described as follows.

A 63-year-old male was admitted to hospital in July 2013 due to swelling, pain and discomfort of the right testis for more than 3 months. Physical examination: the superficial lymph nodes of the whole body were not swollen; The right scrotum was obviously enlarged, with a solid mass of about 6.0 cm ×5.0 cm ×4.0 cm palpable inside, hard in texture, smooth on surface, no tenderness, unclear testicular palpation, negative light transmission test (-), and the right spermatic cord was obviously thickened, with a solid mass of about 4.0 cm ×3.0 cm ×2.5 cm palpable inside, hard in texture; There were no obvious abnormalities in the left testis and spermatic cord. Laboratory tests; Human chorionic gonadotropin, alpha-fetoprotein, carbohydrate antigen, malignant tumor specific growth factor, alkaline phosphatase and lactate dehydrogenase were all normal. Chest X-ray showed no abnormalities. B-ultrasound examination of the scrotum showed: a 5.0 cm ×4.0 cm solid mass was seen in the right testis, which was quasi-round, with clear boundaries, varying internal echo intensity and several colorful blood flows; The right spermatic cord is thickened, and a hypoechoic mass about 3.2 cm ×2.4 cm in size can be seen inside it, with clear borders. CT examination showed that there was a massive lesion in the right testis, about 4.8 cm ×4.0 cm in size, with uneven signal, and the boundary between the lesion and the surrounding tissues was still clear. Enhanced scan showed that the space-occupying lesion in the right testis was obviously uneven and enhanced, with non-enhanced areas in it; A massive lesion about 3.2 cm ×2.5 cm in size was seen in the right spermatic cord, and the enhanced scan showed that the lesion showed obvious uneven enhancement (Figure 1)； No obvious enlarged lymph nodes were found in the abdominopelvic cavity. Diagnosis of right testicular and spermatic cord tumor. Right inguinal exploration plus radical orchiectomy and spermatic cordectomy were performed under epidural anesthesia, and the operation was smooth. Pathological report: The size of the testis is about 6.0 cm ×4.0 cm ×4.0 cm, and a mass is seen during incision, with a maximum diameter of 5.0 cm. The incision surface is gray-white, hard in texture, clear in boundary, and some areas are gray-brown. A nodule can be seen at the distance of the spermatic cord 5.0 cm from the testis, and the texture of the incision surface is the same as that of the testis; Under light microscope, the basic structure of the testis was destroyed, and a large number of lymphoid cells diffusely infiltrated and grown in the tissue, lymphoepithelial lesions and mitotic images were visible (Figure 2)； Immunohistochemical staining showed that leukocyte common antigen (LCA) was positive (+ +), Bcl-2 (+ +), CD20 (+ +) (Figure 3), CD3 (background cell +), tumor cell high proliferative activity (Ki-67) (>95% +) (Figure 4), B cell specific activator protein (PAX-5) (+ /−), CD5, desmin (desmin), human placental alkaline phosphatase (PLAP), myeloperoxidase (MPO), CD34, CD10 (−). Pathological diagnosis: (right testis, spermatic cord) malignant tumor, considered as diffuse, large cell malignant lymphoma, B cell origin. Bone marrow biopsy (-). Six courses of postoperative local radiotherapy plus CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) chemotherapy were followed up for 18 months without tumor recurrence or metastasis.

A 46-year-old male was examined in a hospital before admission. Blood routine showed that white blood cells were 1.8×10⁹/L, hemoglobin 117 g/L, platelets 77×10⁹/L, accompanied by mild fatigue, no fever, cough, no petechia, ecchymosis, not taken seriously. Bone marrow examination in other hospital showed obvious active hyperplasia, with 32% blastocytes, so he was admitted to hospital. Bone marrow smear examination after admission revealed acute myeloid leukemia (type M6). Induction therapy was given with decitabine 35 mg/d ×7 days. On the first day after chemotherapy, the patient developed fever with a body temperature of 38.2℃. Multiple pulmonary nodules were seen on chest CT, and the results of intravenous catheter and blood culture were negative. After 3 days of anti-infective treatment with piperacillin/tazobactam combined with vancomycin, the body temperature gradually decreased. On the 4th day after chemotherapy, blood routine showed agranulocytosis and leukocytes 0.45×10⁹/L. On the 12th day after chemotherapy, the body temperature increased again, reaching a maximum of 39.2 ℃. Blood cultures for 3 consecutive days showed that Trichospora asassii was positive. Voriconazole 4 mg/kg (6 mg/kg on the first day every 12 hours) was given empirically, and the patient's body temperature did not drop. Adjust the medication and give liposomal amphotericin B 3 mg·kg^-1• d^-1。 On the 15th day after chemotherapy, serum creatinine increased from 60.4 μ mol/L to 199.8 μ mol/L, and liposomal amphotericin B decreased to 2 mg kg^-1• d^-1Combined with caspofungin 50 mg/d (70 mg on the first day) and granulocyte colony stimulating factor (G-CSF) 300 g/d to stimulate bone marrow hematopoiesis. On the 17th day after chemotherapy, the body temperature was controlled, and on the 19th day, granulocytic hematopoiesis was restored and the body temperature dropped to normal. At the same time, re-examination of bone marrow showed complete remission and renal function gradually improved. Antifungal treatment with liposomal amphotericin B combined with caspofungin continued for 3 weeks. Re-examination of chest CT showed complete dissipation of lung lesions, and voriconazole (200 mg, administered once every 12 hours) was used orally. The patient continued with consolidation chemotherapy and underwent hematopoietic stem cell transplantation 3 months later. Multiple reexaminations showed negative results for Trichosporidium asachi.

Medically, the area above 3 000 m above sea level is called plateau. The plateau area in China is vast, mainly including Qinghai-Tibet Plateau, Yunnan-Guizhou Plateau, Loess Plateau and Inner Mongolia Plateau, and its main environmental characteristics are low oxygen, low pressure and high altitude. Regardless of whether people have lived for generations or have rushed into the plateau, their system functions, metabolic levels and blood components may be reversibly or irreversibly damaged by hypobaric hypoxia^[1]。

With the development of western economy and tourism, more and more people live in the plateau. How to improve the health level of the plateau residents is an important subject. The plateau environment is a special living environment. Living on the plateau, not only may suffer from acute and chronic altitude sickness, but also other diseases are affected by the environment, which has different characteristics from the plain. The respiratory system is an open system, which is greatly influenced by the plateau environment. The relevant research is summarized as follows.

Ultrasound has the advantages of safety, portability, repeatability and real-time dynamic observation. In recent years, its clinical application in anesthesiology has gradually expanded, including guided arteriovenous puncture, nerve block, airway management, etc. Airway management is an important part of anesthesia, emergency medicine and intensive care unit work. Improper airway management will lead to aggravation of patients' condition and increased mortality. In recent years, ultrasound has shown great potential in airway management in anesthesiology department, with high clinical application value, and there is still great room for development. The application and recent progress of ultrasound in airway management are reviewed.