2015年 · 第95卷第31期

Medicine is a science and art that evolves constantly with the progress of human society and the development of science and technology. It is endowed with new connotations in the evolution of human history. From the farming age, the industrialization age to the information age, medicine has its remarkable characteristics in every historical stage. In the 21st century, the deep integration of modern science and technology with information technology as the core and medicine has promoted the profound change of traditional medical concepts and medical paradigms, and opened a new medical era characterized by precision^[1,2,3,4]。

The plan for precision medicine (precision medicine) was proposed in the 2015 State of the Union address of the United States, which attracted widespread attention in the global biomedical field once it was proposed^[1]。 For a long time, due to the complexity of individuals and the uncertainty of efficacy, clinicians' diagnosis and treatment strategies for diseases are still at the stage of combining objective examination and evaluation with empirical analysis. However, with the rapid progress of genome sequencing technology and the cross application of bioinformatics and big data science, precision medicine is naturally at the forefront of tumor treatment. China is a major country of hepatocellular carcinoma (HCC, referred to as liver cancer for short). The incidence of liver cancer accounts for the fifth in the world, and the cause of death ranks the third. Among them, middle-aged people aged 35-65 are the predominant, and men are more common^[2,3]。 At present, there are many treatment options for liver cancer, including liver transplantation, liver resection, radiofrequency ablation, transarterial chemoembolization, molecular targeting, radiotherapy and systemic chemotherapy. Surgical resection is still the first choice for the treatment of liver cancer, but the recurrence rate of metastasis is as high as 61.5% after 5 years^[4]Therefore, the prevention and treatment of metastasis and recurrence is the key link to prolong the postoperative survival of liver cancer patients. Liver surgery has entered the era of modern surgery, and the concept of precision medicine has provided a brand-new idea for the diagnosis and treatment of liver cancer.

"precision medicine" is a hot word in the current medical field. At the beginning of the new year 2015, President Barack Obama announced the launch of the "Precision Medicine" program in his State of the Union address, and further explained the specifics of the program 10 days later^[1]。 At the same time, Francis Collins, director of the National Institutes of Health (NIH), wrote in the New England Journal of Medicine (The New England Journal of Medicine,NEJM) wrote a detailed account of Obama's precision medicine plan^[2]。 Obama's vision of "precision medicine" is to "make matching cancer therapies by genes as standardized as matching blood groups for blood transfusions, make finding the right dosage as simple as measuring body temperature, in short, give the right therapy to the right people at the right time, every time"^[3]。 Throughout the so-called "precision medicine" of Obama and Collins, it is based on "precise" gene sequencing, "accurately" determining the pathogenesis of tumors, "accurately" developing or matching the corresponding targeted therapeutic drugs, and finally achieving "precise" medication. In short, the American version of "precision medicine" is mainly based on tumor molecular typing and targeted therapy at the gene level.

The surgical treatment of pancreatic head cancer has a history of nearly a hundred years, and it has been very mature in basic surgical procedures and digestive tract reconstruction methods. In the past 20 years, under the guidance of evidence-based medicine theory, the disputes on the surgical indications, resection scope and complication definition standards of pancreatic head cancer have gradually reached a consensus, and the surgical technique has reached the extreme day by day. The continuous development and application of combined organ resection, combined vascular resection, expanded lymph dissection and other techniques have greatly improved the surgical resection rate, while the perioperative mortality rate and complication rate have not increased significantly, reflecting the progress of surgical technique and perioperative management. However, in contrast to the aforementioned progress, the overall prognosis of patients has not improved significantly, and the median survival of patients who can be surgically resected is only 21 months. Pancreatic cancer has the worst prognosis among all digestive tract tumors, and its diagnosis and treatment are extremely challenging. Against the above background, the treatment principle of "individualization" has been emphasized in the past 10 years, and the treatment model has gradually transitioned from "surgery first" to "multidisciplinary collaboration (MDT)", and in recent years has risen to the precision concept. Its core is still to select the right patients and administer the right treatment at the right time^[1]。 The purpose of "precision" is to maximize the benefit of patients, not only to avoid insufficient treatment, but also to avoid overtreatment.

Precision medicine is the trend of medical development in the 21st century, and precision surgery is an important part of precision medicine^[1,2]。 Achieving maxillofacial functional reconstruction and accurate restoration of patient's appearance is the goal of maxillofacial prostheticians, which requires the application of the most accurate medical technology. In the past 20 years, maxillofacial defect repair has gradually entered the digital era, from extensive experience repair to digital precise repair, which has significantly improved the treatment level^[3,4]。 This article reviews and prospects three key problems in digital precise repair of oral and maxillofacial defects.

It is generally believed that modern Western medicine began in the Renaissance, and has become more and more mature after several hundred years of development. It has gradually evolved from Bacon's "empiricism" to translational medicine, systematic medicine and social medicine model based on modern science, which covers humanistic care. These developments have brought revolutionary changes to human society, from extending life span to improving the public health system, and making great progress in disease prevention and control. Even for malignant tumors, such as melanoma, leukemia, breast cancer, lung cancer, liver cancer, etc., the early diagnosis rate and patient survival of these tumors have been encouragingly improved^[1]。 However, with the progress of Western medicine, its shortcomings are gradually revealed. It is the research aimed at these shortcomings that further promotes the development of modern medicine. Although the concept of individualized treatment has been put forward long ago, it has little effect in practical application, especially in western medicine. In the past, we put too much emphasis on guidelines, consensus, and evidence-based medicine, but ignored individual differences. The improvement of sequencing technology, the rapid development of molecular biology, immunology and other disciplines make medicine hopeful for further development and breakthroughs in our era^[2]。

Neurology itself is a combination of multiple disciplines to study nervous system and skeletal muscle diseases. It is the most active clinical medical discipline today. Therefore, its development will surely be combined with the latest ideas and technologies. Several milestones in neurology are related to the cross-fusion of research results in other disciplines, such as computed tomography (CT), X-ray transmission and integrated computer technology in the 1970s, which enabled neurologists to accurately observe the normal and abnormal morphological structures of different parts of the living brain for the first time. Magnetic resonance imaging (MRI) technology, which combines physics, mathematics and computer technology, was widely used in the late 1980s. It can more precisely observe the spinal cord structures and lesions that cannot be observed by CT technology, and can also detect cerebrospinal cord lesions earlier than CT technology, especially those in the early stage of ischemia, which greatly improves the diagnosis and treatment level of neurological diseases. Nowadays, with the progress made in the fields of neuromicropathology, molecular imaging, neurobiology, neuroimmunity, gene and proteomics, let us understand the etiology and pathogenesis of neurological diseases from various levels; The development of nerve radiation and interventional technology has provided new diagnosis and treatment methods for many diseases. The research on gene and protein molecules has promoted the development of neuropharmacology, and great progress has been made in drug research and development, all of which have provided a basis for individualized drug treatment. Stem cell technology provides new hope for the treatment of neurological diseases, and the research on neural networks and functional reconstruction, as well as the development of intelligent rehabilitation devices combined with new materials, make stroke patients expected to get more accurate neurological rehabilitation. Based on the great development of neuroscience and related disciplines, the diagnosis and treatment of neurological diseases should be integrated and accurate^[1,2]。

Today, in the 21st century, clinical oncology has made remarkable achievements. Long-term survival with tumors in many tumors is no longer a dream. The past half century has witnessed the prolongation of the survival of cancer patients, the diversification of cancer treatment methods and the individualization of cancer treatment. The emphasis on patients' quality of life is also constantly promoting the optimization of treatment methods and the research and development of new drugs. With the further development of biomedical technology, the continuous update of tumor treatment concepts and the rapid development of anti-tumor drugs, cancer patients will surely usher in a new dawn, and tumor treatment will usher in a new era-precision treatment.

Orthopedic precision medicine is based on empirical medicine and evidence-based medicine. Compared with individualized medicine, it pays more attention to the characteristics of disease depth and the high accuracy of surgery and drugs. It is more operable and implementable, and has the characteristics of forward-looking, accurate, preventive, individual, minimally invasive, comprehensive and convenient. The orthopedic precision medicine process roughly includes: gene sequencing to find therapeutic targets, big data biotechnology analysis and classification, precision surgery and drug therapy intervention, and precision rehabilitation efficacy tracking and adjustment, and finally promote precision medicine for innovative diagnosis and treatment of orthopedic diseases, so as to improve diagnosis and treatment efficiency, reduce patient pain, reduce economic expenses, and optimize resource allocation.

The structure of the hand is delicate and complicated, with tendons, blood vessels and nerves interspersed. Once injury occurs, tissue damage is serious and pain is severe^[1]。 Patients need to endure the pain caused by the affected limb (finger) from the emergency department visit after injury to surgery. The purpose of this study was to observe the analgesic effect and adverse reactions of different doses of dezocine in emergency hand trauma, and to provide evidence for analgesia in patients with emergency hand trauma.

Case 1, male, 3 years 11 months. He complained of varus deformity of his right foot and walking weakness, which gradually worsened for 16 months. He was admitted to hospital on June 25, 2014. In August 2012, the child suffered from severe hand-foot-mouth disease encephalitis with high fever and repeated convulsions and was hospitalized in the intensive care unit of Nanjing Children's Hospital affiliated to Nanjing Medical University. The foot horseshoe varus deformity appeared about 6 months after discharge, which gradually worsened. No clubfoot manifestations at birth, excluding congenital clubfoot. Physical examination: The right foot is in the shape of inverted horseshoe, the forefoot is adducted, the gastrocnemius muscle of the right calf is atrophied compared with the left side, and the muscle elasticity is poor. Electromyographic examination after admission showed electromyographic changes of neurogenic lesion, mainly involving right L4-S1, and mildly affecting L2-L3 innervated part of the examined muscle. Preoperative total spinal cord MRI: No obvious abnormal signals were found. Right Achilles tendon lengthening and external tibialis anterior muscle placement were performed after perfect preoperative preparation. Reviewing the medical records of acute phase of hand-foot-mouth disease in August 2012, the pathogenic examination of stool specimens and throat swab specimens of children was positive for EV-71. The clinical manifestations were skin rash and febrile convulsions with confusion. Physical examination: positive meningeal irritation sign. Cerebrospinal fluid bacterial smear and culture were negative, and the number of cells was 75×10⁶/L, predominantly monocytes; Protein increased, sugar and chloride normal. MRI examination of the head and whole spinal cord was performed 1 week after neurological symptoms in the children. MRI showed that T could be seen at the medulla-pontin junction₂Symmetry point-like length T visible on WI₁Long T₂Abnormal signal shadow, clear boundary. There was no obvious thickening of the spinal cord and no obvious abnormality in shape. Thoracic 11 – 12 level spinal cord length T₂Signal (on the right). Consider inflammatory changes of spinal myeloid. Lumbar puncture at discharge showed normal cerebrospinal fluid smear, culture and cell morphology (Figure 1，Figure 2，Figure 3，Figure 4，Figure 5，Figure 6)。

There are about 185 million hepatitis C virus (HCV) infected people worldwide, of which about 350,000 die every year from complications related to HCV infection, and about 1/3 of the patients will develop liver cirrhosis or liver cancer, thus greatly increasing the mortality rate^[1,2]。 The standard treatment in the past was pegylated IFN-α (PegIFN) combined with ribavirin (RBV). The sustained viral response (SVR) rate of this therapy was 40% ~70%, and the efficacy for genotype 1 was not good. direct – acting antiviral agents (DAAs) increase SVR rates to 90%^[1]。 However, drug resistance is an important factor affecting the efficacy of DAAs. In this paper, the characteristics of drug resistance, pre-existing drug resistance and how to deal with drug resistance of DAAs are reviewed.

In recent years, with the progress of spinal fixation surgery, the development of instruments and materials, the integration of imaging technology and the emergence of 3D printing technology, the craniocervical junction fixation technology has also made great progress. Because the craniocervical junction area involves complex structures and many skeletal abnormalities, it is difficult to unify the treatment plan. In this paper, the evolution and development of various craniocervical junction fixation techniques are summarized to provide reference for clinical decision-making.

Skeleton is one of the common metastatic sites of malignant tumors. Bone disease caused by tumor metastasis is a dynamic process in which tumor cells interact with multiple cells in the bone microenvironment^[1]。 The expression of tumor cell genes is regulated by growth factors and chemokines in the bone microenvironment. Bone metastasis lesions can be divided into osteogenic, osteolytic and mixed lesions^[2]The type of lesion depends on the balance between osteoblast-mediated bone deposition and osteoclast-mediated lysis-resorption. Tumor cells and tumor bone microenvironment can release a variety of factors that directly or indirectly affect osteoblast and osteoclast generation and metabolism^[3]。