2015年 · 第95卷第33期

With the continuous development of information construction of medical institutions and the application of hospital information management and Internet, more and more data generated in medical work are collected and stored by hospital information system. In addition to providing useful information for doctors' clinical diagnosis and treatment, various clinical data collected by hospitals in the process of admission and treatment also provide the most realistic sample data for medical research. How to reasonably manage and apply these data is a new challenge for hospital informatization construction in the future. Therefore, the Department of Neurosurgery of Peking Union Medical College Hospital established a database of non-functional pituitary adenomas to preserve and manage the clinical data of patients completely. Pituitary adenomas are a group of benign intracranial tumors of monoclonal origin of adenopituitary gland, accounting for 10% ~15% of intracranial tumors, and are the third most common intracranial tumors, second only to gliomas and meningiomas^[1,2]。 Non-functional pituitary adenomas account for about 30% of all pituitary adenomas^[3]。 Most patients with nonfunctional pituitary microadenomas have no obvious clinical symptoms and are discovered accidentally during autopsy or CT or MRI of the head for other diseases. Symptomatic nonfunctional pituitary adenomas are usually large in volume and can involve surrounding tissues such as cavernous sinus, sphenoid sinus and suprasellar cistern. Transnasal sphenoidal pituitary adenoma resection is the preferred treatment option^[4]。 Since 2012, Peking Union Medical College Hospital has completed about 1,600 pituitary adenoma operations, including about 600 non-functional pituitary adenomas, with abundant clinical resources. Therefore, establishing a database of nonfunctional pituitary adenoma and preserving the clinical data of patients will play an important role in the clinical and basic research of nonfunctional pituitary adenoma. Our work in this area is now reported below.

A 27-year-old female was admitted to the Department of Rheumatology and Immunology of Peking Union Medical College Hospital in June 2013 due to joint pain for 9 years, fever, rash and headache for 4 months. Nine years ago, the patient developed bilateral swelling and pain of wrist, elbow, ankle, knee, multiple metacarpophalangeal joints and proximal interphalangeal joints, accompanied by morning stiffness for about 30 minutes. He was not treated regularly, and intermittently took hormones (specific dosage form unknown) and traditional Chinese medicine, but did not take immunosuppressants. Four months ago, I developed a dark red rash on my cheeks and erythema, ulceration and crusting on both lower limbs, with intermittent fever, with a maximum body temperature of 40 ℃. Without medication, my body temperature dropped to normal spontaneously in 2~3 days, with fever 1~2 times a month, accompanied by headache, mild tingling pain, without nausea, vomiting, rotation of vision, etc. He went to a local hospital and was positive for anti-nuclear antibody, anti-RNP, anti-SM, anti-RO-52 and anti-ribosomal P protein antibody. He was suspected of systemic lupus erythematosus (SLE) and was admitted for further diagnosis and treatment. Since the disease, hair loss is obvious, and body weight decreases by 20 kg. Family history: Both sister and younger sister were diagnosed with SLE, and their parents were in good health. Physical examination: body temperature 38.3 ℃, heart rate 98 beats/min, respiratory rate 18 beats/min, blood pressure 116/80 mmHg (1 mmHg =0.133 kPa); Butterfly pigmentation on both cheeks, scattered crusty rash on lower limbs; The heart rhythm was uniform, the breathing sounds of both lungs were clear, the left upper abdomen was tender, without muscle tension and rebound pain, 5 cm under the costs of the liver and 3 cm under the costs of the spleen. The right wrist joint was swollen and tender (+), the right index finger, middle finger, ring finger and the proximal interphalangeal joint of the left ring finger were swollen and tender (+), and the right knee joint was not swollen and tender (+). Soft neck, Klinefelter sign, Buchner sign (–). Both lower limbs are not swollen. Laboratory test: blood routine: white blood cells 1.52×10⁹/L, lymphocytes 0.35×10⁹/L, hemoglobin 94 g/L, platelets 134×10⁹/L; Negative urine routine; 24 h urine protein quantification 0.15 g; Liver and kidney function: alanine transferase 4 U/L, albumin 25 g/L, creatinine 45 μ mol/L, potassium 2.5 mmol/L; Hypersensitive C-reactive protein 2.95 mg/L, erythrocyte sedimentation rate (ESR) 14 mm/h, complement C3 0.227 g/L, complement C4 0.034 g/L; Immunoglobulin (Ig) G 18.30 g/L, IgA 3.01 g/L, IgM 0.7 g/L; Antinuclear antibody spot type 1:1 280 cytoplasmic type 1:640; Anti-extractable nuclear antigen (ENA) antibodies: anti-SM antibody 1:4, anti-RNP antibody 1:4, anti-SSA antibody 1:4, anti-ribosomal P protein antibody 38 000, 16 500, 15 000. anti-neutrophil cytoplasmic antibodies, anti-cardiolipin antibodies, etc. (-). Procalcitonin<500 ng/L. Electrocardiogram and cardiac ultrasound were basically normal. Abdominal B-ultrasound: diffuse lesions in both kidneys and mild hydrops in both kidneys. There were no obvious abnormalities in chest high-resolution CT and cranial enhanced MRI. Spinal cord puncture was performed, CSF pressure 115 mmH₂O (1 mmH₂O =0.0098 kPa), CSF routine: colorless and transparent, total number of cells 84×10⁶/L, total number of white blood cells 24×10⁶/L, single core 16×10⁶/L, Multi-core 8×10⁶/L. Cerebrospinal fluid biochemistry: protein 0.95 g/L, glucose 0.9 mmol/L (instant finger blood glucose 7.0 mmol/L), chlorine 131 mmol/L. Cerebrospinal fluid bacteria, fungi, viruses and other etiologic examinations (–). After that, the spinal cord puncture was re-examined twice, the routine biochemistry was roughly the same as before, and the third cerebrospinal fluid bacterial culture: Listeria monocytogenes.

The patient, a 63-year-old female, was admitted to the hospital due to "swelling and pain in both knees for 12 years" and aggravation of pain in the left knee for 2 years ". Physical examination on admission: flexion contracture and varus deformity of the left knee. Range of mobility of the left knee joint: flexion 90° and straightening 30°. X-ray showed: both knee joints were varus, skeletal articular surface sclerosis, and medial space narrowing (Figure 1)。 The admission diagnosis was: osteoarthritis of both knees. The left total knee arthroplasty was performed under general anesthesia 3 days after the perfect examination. The operation was smooth, and the postoperative X-ray reexamination showed that the prosthesis was in good position (Figure 2)。 Rivaroxaban 10 mg was routinely administered daily to prevent deep vein thrombosis after surgery. B-ultrasound of deep veins of both lower limbs revealed multiple intramuscular vein thrombosis in the left lower leg 2 days after surgery, and no blood flow signal was observed. Therefore, the oral anticoagulation of rivaroxaban was changed to subcutaneous injection of Kesai 0.6 ml twice daily. B-ultrasound examination of deep veins of both lower limbs was performed again 10 days after operation, which showed that the venous thrombosis of left lower leg improved but there was still intramuscular venous thrombosis, and no influx signal was seen. The patient requested to be discharged from the hospital, and continued to be given oral anticoagulation with rivaroxaban after discharge. He was re-admitted to the hospital 20 days after operation due to swelling and pain in the left lower limb. The B-ultrasound of the deep veins of both lower limbs revealed that there was no obvious thrombosis in the deep veins of both lower limbs, and the left popliteal fossa was aneurysmally dilated, with a size of about 4.1 cm ×3.5 cm ×2.7 cm, showing abundant vortex-like arterial blood flow signals. CT scanning angiography of the lesion showed that after left knee replacement, circular high-density shadow in the soft tissue behind the tibial plateau of the left knee, obvious compression and displacement of the adjacent blood vessels, and increased density in the medullary cavity of the tibia (Figure 3)。 Give reduced activity and observe changes in the condition. Reexamination B-ultrasound showed: aneurysm-like dilatation of the left popliteal fossa, internal thrombosis, about 4.4 cm ×3.9 cm ×3.1 cm in size, solid echo in the interior, 1.6 cm in the thicker part, and rich vortex-like kinetic blood flow signals were seen by color Doppler flow imaging (CDFI), which seemed to be connected to the popliteal artery. Then percutaneous DSA (digital subtraction angiography) arterial angiography was performed under local anesthesia, and a rupture of about 0.5 cm was seen in the anterior wall of the popliteal artery (FIG. 4A), locally forming a tumor cavity (FIG. 4B)。 Embolization was difficult during the operation, so compression bandage of the popliteal fossa of the left lower limb was given, the left lower limb was braked, and the dorsal pedis artery of the left lower limb was observed. After 48 hours, the compression gauze was removed, and the local mass of the left popliteal fossa was examined. The pulsation was obvious when palpated, and the surrounding tissues were unclear. There was no fever in the skin, vascular murmur could be seen during auscultation, and the pulsation of the left dorsal pedis artery was weak. Consult the vascular surgery department and perform surgical treatment.

A 23-year-old female was admitted to the Department of Neurology of the First Affiliated Hospital of Zhengzhou University on January 10, 2014 due to "disorder of consciousness for half a month, right limb weakness with unclear speech for 10 days". Half months before admission, the patient suddenly lost consciousness without obvious trigger, accompanied by nausea and vomiting, and the vomit was stomach content, non-jetting, without caffeine-like substances. The local hospital examined 0.5T skull MRI showed: fresh infarction in the left parieto-occipital lobe, and was treated with "mannitol needle" and other drugs. After 7 hours of onset, consciousness gradually recovered, blindness in the left eye, hemiplegia in the right limb, and motor aphasia. After 2 days, reexamination of 1.5T skull MRI showed: multiple acute infarctions in the right cerebellar hemisphere and left parieto-occipital lobe (Figure 1), 1.5T MRV showed that the superior sagittal sinus was partially unclear, and the left transverse sinus, inferior sagittal sinus and sigmoid sinus were not clearly displayed, and venous sinus thrombosis was suspected. Then he was given symptomatic and supportive treatment with anticoagulant, antiplatelet, lipid-lowering, neurotrophic and other related drugs for 10 days, and his limb weakness improved compared with before, so he was transferred to the First Affiliated Hospital of Zhengzhou University. No previous history of hypertension or diabetes. The patient gave birth to a live baby in a local hospital 50 days ago, and there was no similar patient in the family.

Osteoporosis is a disease of the skeletal system characterized by decreased bone strength and increased risk of fractures. Osteoporosis can be divided into primary osteoporosis and secondary osteoporosis, the latter being any disease and/or drug that affects bone metabolism, among which glucocorticoids (GCs) are the most common drugs. Prolonged (more than 3 months) use of any dose of GCs may lead to osteoporosis, i.e. glucocorticoid-induced osteoporosis (GIOP). The proportion of oral glucocorticoids in postmenopausal women is as high as 4.6%^[1]The incidence of fracture in patients with long-term GCs is 30% to 50%. GIOP focuses on early treatment and prevention, but at present clinicians often do not pay attention to the prevention and treatment of GIOP^[2]。 Less than 15% of patients treated with long-term GCs are given prophylactic anti-osteoporotic therapy, and there are many controversies about cement perfusion vertebroplasty for GIOP vertebral fractures.

Endometriosis (EM) has a variety of clinical manifestations due to its biological behaviors such as hyperplasia, infiltration, metastasis and recurrence, and its diagnosis and treatment are complex. There are many staging methods for EM, but there is no staging system that can comprehensively describe the characteristics of EM lesions and predict related factors such as infertility and pain. The ideal EM staging system has complex requirements: based on clinical experience and scientific basis, enjoying expert consensus, clearly defined terminology, applicable to all cases, reflecting the clinical characteristics of the disease, predicting pain relief rate, predicting fertility, predicting the risk of recurrence, guiding treatment, simple communication with patients, etc.^[1]。 This article mainly reviews the historically authoritative AFS staging system, the ENZIAN classification system describing deep infiltrating endometriosis (DIE), and the EM fertility index (EFI), which has predictive value for infertility.

APOE gene has been widely studied as the most important pathogenic gene in late-onset AD (LOAD). At the same time, recent studies have found that the mutation of the R47H site encoding the type 2 myeloid cell trigger receptor gene (TREM2) is also significantly associated with late-onset Alzheimer's disease. It is suggested that TREM2 gene can inhibit central inflammation and mediate the phagocytosis of A β and apoptotic cell debris by central monocyte phagocytosis system. However, the exact mechanism of its action is not clear at present, and the pathogenesis of its R47H mutation and LOAD pathogenesis is still to be confirmed. This paper reviews the role of TREM2 gene in central inflammation and mediating A β phagocytosis.