2015年 · 第95卷第35期

A 27-year-old male, right-handed, was transferred from another hospital to the Department of Neurosurgery, General Hospital of Tianjin Medical University with "weakness of both lower limbs for 1 week". One week before admission, the patient showed a progressive decrease in strength of both lower limbs and limited movement. By the time of admission, he could no longer walk, had no urinary incontinence or retention, and took a flat car to enter the ward. Previous history of gout for 4 years, denied history of trauma and tumor. Physical examination at admission: obese, weight about 110 kg, body mass index (BMI) 32.14, clear, no scoliosis deformity of the spine, multiple subcutaneous nodules palpable on the back of both feet, local skin slightly red, hard at touch, no obvious tenderness, muscle strength of both upper limbs grade V, muscle strength of both lower limbs grade III^–Grade, superficial hypoesthesia below the umbilical level, bilateral Pap sign (+). CT of both feet showed several round-like nodules in the subcutaneous soft tissues of the proximal parts of the 1st to 5th metatarsal bones of both feet, considering gout nodules; CT of the thoracic spine showed that T9~10 intervertebral discs occupied space inside and outside the spinal canal at the level, and extended outward along the intervertebral foramen on both sides, with the left side as the focus (FIG. 1A)； MRI of thoracic vertebra showed: T9~10 intervertebral disc level intraspinal canal extramedullary elliptical T1 and other T2 signal space-occupying lesions, showing uneven enhancement, unclear boundary with surrounding tissues, corresponding segment spinal cord compression deformation, space-occupying nature to be determined (FIG. 1B，Figure 1C)； SPECT showed that abnormal tracer concentration area was found at T9/10 level, and no obvious abnormal tracer concentration area or defect area was found in other parts of the whole body bone (Figure 1D)。 Laboratory test: blood uric acid 754 μ mol/L (normal value 140~414 μ mol/L), white blood cell count 10.4×10⁹/L [normal value (4.0~10.0) ×10⁹/L], erythrocyte count, erythrocyte sedimentation rate, blood urea nitrogen, blood creatinine, HLA-B27, rheumatoid factor, urine protein, tuberculin test and tumor markers were not abnormal. Treatment: Posterior thoracic spinal canal exploration and decompression surgery were performed under general anesthesia. All laminae of T9 and the upper 1/3 laminae of T10 were surgically removed. Exploration under microscope showed that the occupied space was located in the epidural, extending outward along the bilateral T9 and/or 10 intervertebral foramines involving the inside and outside of the spinal canal, with a volume of about 3 cm ×2 cm ×2 cm, white, granular, and smooth edges (FIG. 2A，Figure 2B), after segmented resection, it can be seen that the local dural sac swells well, and the compression of the thoracic cord is relieved. Postoperative pathological diagnosis: granular sediment mass, with a large number of foreign body giant cells in and around it, consistent with tophi (Figure 2C，Figure 2D)。 After operation, rehabilitation guidance and customized protective gear were given. After 2 weeks, the muscle strength of both lower limbs recovered to grade IV, and the blood uric acid was reexamined at 740 μ mol/L. After 4 weeks, he got out of bed and moved, improved and was discharged, and it was recommended to continue treatment to a metabolic disease specialist. After 24 months follow-up, the function of both lower limbs recovered well, and no recurrence was observed.

A 66-year-old woman was admitted for "intermittent abdominal pain with fatigue for half a year". The patient had abdominal pain intermittently without obvious trigger six months ago, which was slightly relieved after eating, accompanied by fatigue and dyspnea after activity. After admission, physical examination showed upper abdominal palpation discomfort, and no pigmentation was seen on the skin and mucosa of the whole body. Laboratory tests: Moderate anemia; Hypoalbuminemia; Positive fecal occult blood test. Gastroscopy: scattered dark spots can be seen in the whole gastric mucosa, with 2 biopsies; Dark spots were seen in the retrobulbar mucosa of the duodenum, and one piece was biopsied. Colonoscopy: Multiple nevus-like black nodules, 0.4 to 0.5 cm in size, were seen in the colon 1 to 7 cm away from the anus, and one piece was biopsied. Abdominal ultrasound: Multiple homogeneous anechoic nodules scattered under the xiphoid process, between the muscular layer of the right abdomen and the left upper abdomen and the peritoneum (FIG. 1A，FIG. 1B), the larger one is 2.2 cm ×1.5 cm, with regular shape and clear boundary, enhanced echo behind it, and rich and disordered blood flow signals can be seen inside (Figure 1C)。 Ultrasound suggested that the abdominal wall occupied multiple mass (superficial position, biopsy if necessary). Ultrasound-guided puncture biopsy of right abdominal wall mass was performed and submitted for examination. Results Return: Biopsy of gastric and duodenal retrobulbar mucosa showed malignant melanoma; The pathology of colon black spot biopsy was malignant melanoma; The pathology of abdominal wall nodule biopsy was malignant melanoma. Because no lesions were found in other parts of this patient, it was diagnosed as "primary malignant melanoma of stomach and intestine".

A 24-year-old male was seen with an occipital mass for 1 year and dizziness for 5 days. The patient had no enlargement of the mass and no pain for 1 year. 5 days ago, sudden dizziness and blurred vision came to the clinic. Physical examination showed that the occipital mass was 5 cm ×3 cm in size, tough in texture, no movement, no tenderness, and no redness and swelling of the scalp. There were no abnormalities in laboratory blood routine and tumor markers such as carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP) and CA125. CT of the brain showed a bone destruction area in the occipital scale, with regular edges and no sclerosis, and the size was 3.6 cm ×4.5 cm; Local soft tissue mass was formed, and the mass was isolow density. The CT value in the low density area was about 19 HU, and the CT value in the isolow density area was about 40 HU (FIG. 1A)。 MR examination of the brain showed that the tumor in T₁WI is an isotropic signal (FIG. 1B), T₂WI is a high and low confounding signal (Figure 1C), the tumor was not uniformly enhanced in the enhancement scan, and there was no enhancement area in the interior, and the edge was obviously enhanced (Figure 1D)； Tumor size 4.5 cm ×3.2 cm ×5.5 cm; The tumor infiltrates brain tissue and superior sagittal sinus (Figure 1D), bilateral parieto-occipital leukoedema (Figure 1C)。 Surgical findings: The median horseshoe incision approach of the posterior occipital was taken, and the skull was defected due to tumor invasion, and the dura mater was destroyed by the tumor. The dura mater was cut along the edge of the tumor. The size of the tumor is 5 cm ×4 cm ×3 cm, the texture is tough, the blood supply to the scalp side is general, the color is pale yellow, the base is attached to the falx cerebri, the blood supply to the tumor on the cerebral surface is abundant, the color is gray-red, and it invades the superior sagittal sinus and sinus sinus. The tumor extensively invaded the brain tissue, and the boundary was unclear. With the assistance of cotton pads, bipolar electrocoagulation was used to separate the tumor edge and brain tissue, and the tumor was subtotally resected in blocks. A small amount of tumor invading the superior sagittal sinus and sinus sinus remained, and it was electrocoagulated and cauterized. After hemostasis, the dura mater was repaired and sutured with artificial meninges, and the defective bone flap was repaired with titanium plate. The tumor invading the skin was carefully separated and removed along the tumor edge. Postoperative pathology showed that the epithelioid tumor cells were arranged in bundles or nests under the fibrous background, and about 50% of the tumor was necrotic; Immunohistochemistry showed that tumor cells HMB45, P63, EMA, S-100, SMA, GFAP, CK (AE1/AE3), CD99, CD34, CD10, CD1a, CD31, CD34, F8, Myogenic, MyoD1 negative, Vitmin positive; Ki-67 can reach 10% ~15% locally and 5% ~10% overall. Sclerosing epithelioid fibrosarcoma was diagnosed. Postoperatively, the patient refused radiotherapy and received only one course of chemotherapy. Brain MRI revealed recurrence after 10 months, chest CT revealed multiple nodules in both lungs after 15 months, suggesting intrapulmonary metastasis, and death after 24 months.

A 52-year-old male was admitted to the Department of Encephalology, Affiliated Hospital of Tianjin Academy of Traditional Chinese Medicine on December 25, 2014 due to "disadvantageous left limb movement with disadvantageous language for 9 days". When admitted to the hospital, he saw clear spirit, poor spirit, sleep, agitation, poor movement of the left limb, conscious numbness of the right upper limb and left lower limb, poor speech, occasional choking and cough, occasional sputum, poor appetite, poor sleep, stools for 2 days, and urine adjustment. A previous history of cerebral infarction was 1 month, and a history of diabetes was 3 years. Neurological examination: left metacarpomandibular reflex (+), right Pap sign (+), specialist examination: left upper limb muscle strength grade III, left lower limb muscle strength grade I. Auxiliary examination: Head CT (December 25, 2014) showed: (1) multiple cerebral infarctions and malacia in pons, bilateral basal ganglia region-thalamus, left frontal lobe and bilateral hemioval center; (2) sparse white matter; (3) Brain atrophy. The diagnosis was "acute stage of cerebral infarction". After admission, he was treated with integrated traditional Chinese and western medicine to improve cell metabolism and circulation. Because the patient's right limb was agitated from time to time, he visited Anding Hospital many times and asked for consultation in the psychosomatic department of our hospital. He was treated with alprazolam, zopiclone, trihexyphenidyl hydrochloride, haloperidol and olanzapine for sedation, sleep aid, anticholinergic and antipsychotic treatment. However, the agitation of the limbs could not be alleviated, the movements were violent, and even the property was damaged and the limbs were bruised, so he asked for consultation on January 1, 2015. During sleep, the patient was turbid after waking up, accompanied by disorientation and restlessness, and woke up after about 5 minutes. Contact is acceptable, autonomy is incomplete, speech is unfavorable, right limb has no purpose movement, and cannot be controlled. Ask family members, the patient had been depressed and uncomfortable due to family conflicts, and then had cerebral infarction. The possibility of delirium cannot be ruled out. The prescription is as follows: oral, alprazolam tablets 0.4 mg once in the morning and afternoon, 0.8 mg before bed, sertraline hydrochloride capsules 25 mg with breakfast, increased to 50 mg with breakfast after 4 days, and trazodone hydrochloride 50 mg before bed to achieve sedation and antidepressant treatment. On January 8th, the overall symptoms of the patient were still stable, his mood improved slightly, and he could sleep. In the evening, he had transient visual hallucinations, language disorder and agitation, and it was still necessary to exclude visual hallucinations and falsehoods as delirium. The prescription is as follows: alprazolam tablets 0.2 mg once in the morning and afternoon, 0.6 mg before bedtime, sertraline hydrochloride capsules 75 mg with breakfast, trazodone hydrochloride 75 mg before bedtime, zopiclone 7.5 mg before bedtime, orally; When agitated, add 2 ml of diazepam to push slowly to achieve sedation, antidepressant and sleep-helping effects.

The blood vessel was once considered a "steel" tube. The phenomenon of vascular lumen dilatation with the increase of plaque volume in patients with atherosclerosis caused scholars to study the "vascular wall changes" in the process of disease, and then put forward the concept of "vascular remodeling". Until Gibbons et al.^[1]A more complete concept of vascular remodeling was proposed, namely, the active process of changes in the structure and function of the vascular wall under the joint action of local growth factors, vasoactive substances and mechanical stimulation of blood flow.

Negative symptoms play an important role in the evolution of the course of schizophrenia, easily accompanied by a slow loss of interest and ability during the development of the disease, ultimately leading to severe functional disability. Therefore, it is important to treat negative symptoms early. Because the biological mechanism of negative symptoms is complex, it is difficult to explain with a single biological hypothesis or genetic factors, and there is a lack of effective targeted therapy. At present, there is no satisfactory effective treatment for negative symptoms. Recent research suggests that negative symptoms of schizophrenia may be related to abnormal activation of glutamatergic system and microglia^[1,2,3]。 This article reviews the research progress of biological mechanism and drug therapy related to this part.

Both lopinavir (LPV) and ritonavir (RTV) belong to human immunodeficiency virus (HIV) protease inhibitors, and their compound preparation, lopinavir combined with low-dose ritonavir tablets (LPV/r), is a protease inhibitor drug widely used in the clinical treatment of HIV-1 infection internationally. It is currently used as one of the second-line antiretroviral drugs of choice in China. By interfering with HIV protease, the structural and functional proteins of the virus core cannot be expressed correctly, resulting in the formation of immature and non-infectious virus particles, thus achieving the effect of inhibiting HIV replication. Co-administration of LPV with low-dose RTV can significantly enhance its pharmacokinetic profile and enhance its anti-HIV-1 activity^[1]。 This article mainly reviews its clinical application from the aspects of dose and efficacy, drug resistance and adverse reactions.