2016年 · 第96卷第07期

It is the purpose of clinical guidelines to standardize the clinical medical behavior of medical staff and provide them with information that keeps pace with the times and guides clinical work. The premise of individualized treatment or precision medicine is also to innovate and develop on the basis of the consensus of doctors. Therefore, the compilation of guidelines must be based on the principles of evidence-based medicine, evaluate the advantages and disadvantages of relevant diagnosis and treatment methods, form recommendations and guide clinical practice.

Alzheimer's disease (AD) is the most common senile dementia. It is a primary neurodegenerative disease that occurs in old age and pre-old age. Its clinical manifestations are continuous deterioration of memory and cognitive function, progressive decline of daily life ability, and various neurological and psychiatric symptoms and behavioral disorders. mild cognitive impairment (MCI) is considered to be a high-risk state before AD. With the prolongation of human life and the aging of the population, the prevalence of AD has also increased significantly: the latest WHO report shows that there were more than 35 million patients worldwide in 2015, and it is expected to double by 2030. By 2050, 115 million people will be sick worldwide^[1]。 The prevalence rate of AD among people aged 60-69 in China is 2.30%, 70-79 is 3.97%, and over 80 is 32.00%. In 2010, the number of AD patients in China reached 5.69 million, ranking first in the world^[2]。 The most prominent pathological features in the brain of AD patients are senile plaques and neuronal fibrous tangles. The main component of senile plaques is beta-amyloid peptide (A β), while neuronal fibrous tangles are composed of hyperphosphorylated tau protein in cells. The above-mentioned pathological changes mainly involve the internal temporal lobe in the early stage, which manifests as memory impairment. As the disease progresses, the neocortex of the brain is involved, and symptoms of dementia appear. In recent years, the occipital lobe involvement of the brain and the accompanying visual symptoms have been paid more and more attention.

Glioma refers to a tumor originating from glial cells, which is the most common primary intracranial tumor. WHO Central Nervous System Tumor Classification classifies glioma into WHO grades Ⅰ ~ Ⅳ, grades Ⅰ and Ⅱ are low-grade glioma, and grades Ⅲ and Ⅳ are high-grade glioma^[1]。 This guideline mainly deals with the diagnosis and treatment of low-grade glioma, high-grade glioma, cerebral gliomatosis and ependymoma.

In the United States and other developed countries, the incidence and mortality of cardiovascular disease has decreased significantly over the past 40 years. This is related to the effective control of cardiovascular risk factors, the improvement of treatment strategies, the application of non-invasive cardiovascular imaging, etc. In particular, cardiovascular CT imaging is gradually developing towards the direction of accurate diagnosis and fine stratification of risk degree of high-risk groups of cardiovascular diseases, which has replaced some traditional examination methods with greater risk or low diagnostic accuracy. The prevalence of cardiovascular diseases in China is on the rise. This inevitably leads to the increasing use of cardiovascular CT, and the resulting ionizing radiation damage becomes a major concern. Although there is currently no direct evidence that radiation damage by CT can lead to malignancy, even small doses of ionizing radiation may be carcinogenic risk based on the idea of linear non-threshold. Therefore, the principle of as low as reasonably achievable (ALARA), which requires adequate diagnostic image quality and diagnostic accuracy at the lowest possible radiation dose, is generally accepted^[1,2,3,4]。

Finger tip dissection is a common hand injury. Finger tip replantation is the first choice for repair and reconstruction^[1,2,3,4]However, for some severed fingers with slender or seriously damaged fingertips and vascular sclerosis and degeneration in elderly patients without replantation conditions, how to repair them reasonably has always been a clinical problem. In this study, 15 cases of finger tip dissection injury were repaired with emergency V-Y advancing skin flap covering the phalanges and nail beds with nutrition reimplantation.

A 77-year-old female was admitted to the Department of Nephrology, Peking University First Hospital on October 28, 2014 due to "intermittent fever for 4 months, palpitations and shortness of breath after activity for 2 weeks". Four months ago, there was no obvious trigger for fever (untested, details unknown), occasionally cough, cough of white sticky sputum, and no abdominal pain. The routine test of peritoneal dialysate at Peking University First Hospital showed that the number of nucleated cells was 320×10⁶/L, multiple nuclear cells 0.80. The initial diagnosis was peritoneal dialysis-related peritonitis, and intraperitoneal injection of vancomycin (1 g/time, once every 5 days) + cefoperazone (1 g) /sulbactam (0.5 g), once/d; Oral fluconazole 150 mg once a day. The number of nucleated cells remained high [(110~450) ×10⁶/L], predominantly multinuclear cells (55%-60%), intermittently accompanied by moderate fever (38.3-38.9 ℃). High fever occurred 3 months ago, with the highest body temperature of 39.2 ℃. Multiple peritoneal dialysis routine examinations showed an increase in the number of nucleated cells (maximum 480×10⁶/L), mainly monocytes, accounting for 60%-90%. CT scan of abdominal cavity: abdominal pelvic effusion, peritoneal thickening lesions, increased fat density in the abdominal cavity, and enlarged lymph nodes in the abdominal cavity, considering the possibility of peritonitis. Positron emission computed tomography (PET-CT) showed multiple lymph nodes enlarged in right cervical area IV, hepatic hilar area, anterior abdominal aorta and left axilla, with a short diameter of 0.5~1.3 cm; The pelvic peritoneum is thickened in nodular and strip shape, and glucose metabolism is increased. Superficial lymph node ultrasound: multiple swollen lymph nodes in the left axilla, the larger one was 1.6 cm ×1.1 cm. Positive T-cell SPOT test (T-SPOT) for tuberculosis infection. Considering the high possibility of tuberculosis, experimental anti-tuberculosis therapy (isoniazid 200 mg, once a day + rifamentin 600 mg, once a week) was initiated 3 months ago (24 Jul 2014). The patient's body temperature gradually returned to normal, and the peritoneal dialysis fluid routine: the number of nucleated cells is 92×10⁶/L, mononuclear cells 43×10⁶/L. Two weeks ago, the patient had palpitations and shortness of breath after slight activity, which could be relieved after rest. There was no paroxysmal dyspnea at night, and he could lie down at night. There were no hematemesis and melena. Retest blood routine: white blood cells 2.94×10⁹/L, hemoglobin 102 g/L, platelets 118×10⁹/L; Blood biochemistry: alanine aminotransferase (ALT) 34 U/L, aspartate aminotransferase (AST) 109 U/L, albumin 30 g/L. Blood routine 1 week ago: white blood cells 2.7×10⁹/L, hemoglobin 91 g/L, platelets 140×10⁹/L, blood biochemistry: ALT 23 U/L, AST 71 U/L, albumin 28.2 g/L. Admitted for further diagnosis and treatment.

A 19-year-old male was admitted with "sensorimotor disorders of both lower limbs for 3 d". The patient experienced sudden severe abdominal pain 2 h after exercise, and then felt transient radiating pain from the abdomen to both lower limbs, followed by sensory motor disorder of both lower limbs, with the left lower limb as the most important, accompanied by urinary incontinence. The local hospital gave symptomatic and supportive treatment (the specific treatment is unknown), but the efficacy was not good after 3 days, so he went to our hospital. The patient had no low-grade fever, night sweats, back pain, sensorimotor disorders, abnormal urination and defecation, good diet and sleep, and no obvious weight change in the near future. Previous: Dark red patches were found on the left back after birth, which gradually enlarged with growth; Blood pressure was found to increase for 3 years, approximately 150/95 mmHg (1 mmHg =0.133 kPa), untreated; Denial of tuberculosis history and exposure history. Personal history and family history are not special. Physical examination: body temperature 36.7℃, heart rate 110 beats/min, breathing 28 beats/min, blood pressure 148/89 mmHg. A dark red patch of about 20 cm ×12 cm can be seen on the left lower back, with irregular shape and clear boundary, slightly fading when pressed, no mass palpable below, no tremor or vascular murmur (Figure 1)。 There was no obvious tenderness and percussion pain in the spine and paravertebral areas, and no radiation pain. Hypoesthesia below the chest 8 plane, perineum, sellar area and both lower limbs, left lower limb muscle strength grade 0, right lower limb muscle strength grade 4, knee reflex and ankle reflex were weakened; Bilateral pathological reflexes were not elicited. Laboratory tests: Blood routine, biochemistry, erythrocyte sedimentation rate, C-reactive protein, procalcitonin, tuberculin (PPD), tuberculosis antibody, tuberculosis specific antigen (T-SPOT), tumor marker (C-12), alkaline phosphatase and acid phosphatase tests showed no obvious abnormalities. Auxiliary examination: color Doppler ultrasound of skin and soft tissue: the left back was scanned with dark red patches as the center, and there was no obvious mass sound image. Chest radiograph: No obvious abnormalities were found. CT plain scan enhanced three-dimensional imaging: (1) Fat density focus in spinal canal at T4 level; (2) Soft tissue foci in spinal canal and left intervertebral foramen at T10 level, osteogenesis and bone destruction were observed in vertebral bodies and adnexal bones at T5, T8-10, and left 5th to 10th posterior ribs; (3) A large number of tortuous and thickened blood vessel shadows paravertebral, the thickened blood vessels merge with azygos veins, and vascular malformations. MRI plain scan enhanced: (1) flat T3, 4 vertebral level extramedullary lipoma; (2) T7-10 intramedullary, spinal canal, vertebral body and adnexal areas have tortuous blood vessel shadows, which are considered as the possibility of arteriovenous malformation. Digital subtraction angiography (DSA): Abnormal staining masses were seen inside and outside the spinal canal in the T7-T12 segments, and some spinal veins were thickened, suggesting a space-occupying lesion with rich blood supply (Figure 2，Figure 3，Figure 4)。 Diagnosis: Cobb syndrome. Treatment: After admission, the patient was instructed to stay in bed absolutely, given symptomatic treatment such as hormone, dehydration and nerve nutrition, actively controlled blood pressure, and underwent spinal cord function rehabilitation training. After 20 days, the patient's neurological symptoms disappeared and the spinal cord function returned to normal. One year later, he underwent spinal angiography in another hospital. During the operation, he abandoned the embolization treatment due to the difficulty of putting the microguide wire in place, so he underwent further surgical resection of the spinal cord malformed vascular mass. The postoperative effect was satisfactory, and there has been no recurrence so far.

The child was delivered by cesarean section in the obstetrics department of Wulian County People's Hospital, Rizhao City at 16: 45 on September 19, 2014 due to "premature rupture of membranes" at 38 weeks of pregnancy. She had a birth weight of 2.9 kg. She had dyspnea immediately after birth, positive three concave signs, obvious shortness of breath, and purple skin. She was immediately given oxygen, cleared the respiratory tract, and found a "cyst at the base of the tongue" during tracheal intubation, so she was transferred to the neonatology department of our hospital. Admission physical examination, resuscitation sac positive pressure ventilation, triple concave sign positive, tracheal intubation was replaced, under direct laryngoscope, a white sac about 1 cm ×2 cm in size at the base of the tongue was seen, compressing the epiglottis, shortness of breath was relieved after intubation, triple concave sign disappeared. Connecting ventilator, continuous pulse oxygen monitoring and blood gas analysis, preliminary diagnosis of tongue base cyst.

Nowadays, tissue engineering construction or regenerative medicine treatment based on single cells has failed to meet the requirements of tissue structure and physiological action simulation, tissue stability and viability maintenance. Especially in the construction of large tissues and tissues lacking nourishing blood vessels and the regeneration of ischemic necrotic tissues, the most urgent difficulty to be overcome is the establishment of good blood supply system. And well-organized blood supply nourishment is not only the key to the success of regenerative therapy^[1]It is also required that the blood vessels in them can possess diverse cellular components in and around the blood vessels under normal physiological conditions to maintain vascular function for a long time^[2]。 Based on the above facts, more and more researchers tend to combine multiple cells to meet the increasingly complex regenerative medicine treatment requirements. Among them, vascular endothelial cells are often used in combination with mesenchymal stem cells for the induction of regenerative tissue and tissue pre-vascularization. On the one hand, with the participation of endothelial cells, the formation of neovascular network means that the tissue has better blood supply nourishment and better regeneration survival; On the other hand, although endothelial cells are the most important functional cells of normal-sized blood vessels, the stability and maintenance of vascular physiological function cannot be separated from the existence of their intrinsic vascular mesenchymal stem cells.

In recent years, transcatheter arterial chemoembolization (TACE) has played an important role in the treatment of liver cancer. Novel embolic material-drug-loaded microspheres with the ability to sustain the release of anti-tumor drugs^[1], has attracted much clinical attention. This paper reviews the recent advances in the application of drug-loaded microspheres in the treatment of TACE in liver cancer.