2016年 · 第96卷第24期

Precision medicine refers to "tailored" medical treatment for patients using information such as their genetic composition, living environment and lifestyle, in order to obtain ideal therapeutic effects, reduce unnecessary treatment and avoid adverse reactions^[1]。 "Precision medicine" is not a brand-new concept, it originates from "individualized medicine", but due to the rapid development of biological databases, detection methods (proteomics, genomics, metabolomics, etc.) and bioinformatics analysis, the application of "precision medicine" is more widely. Precision medicine has involved pharmacogenomics, tumor diagnosis and treatment, genetic diseases, infectious diseases, cardiovascular diseases, respiratory diseases, nervous system diseases and many other aspects^[2]。 The U.S. Precision Medicine Plan released in early 2015 has two main goals. The short-term goal is more and better cancer treatments, and the long-term goal is research on the entire health and disease field^[3]。

Bone marrow cell morphology and bone marrow biopsy belong to the category of cell morphology and histopathological examination medicine, which largely depends on the subjectivity of the examiner, and is influenced by many factors such as the level of the examiner, the quality of the specimen and the examination method. It is necessary to combine a large amount of clinical data to make a comprehensive and accurate judgment. With the continuous improvement of the widespread and accuracy of high-throughput omics and targeted marker detection applications, the reliance of disease diagnosis on traditional morphological tests has decreased, making the two-way communication between morphological tests and clinical practice increasingly neglected. However, bone marrow cell morphology and bone marrow biopsy still play an irreplaceable role in the diagnosis and prognosis of blood system and related diseases. Some diseases have similar bone marrow cell morphology or bone marrow biopsy, but the clinical diagnosis is completely different; Some diseases have similar clinical manifestations, and the morphology of bone marrow cells or bone marrow biopsy is very different^[1]。 Therefore, two-way communication with the clinic is essential in the whole process of bone marrow cell morphology and bone marrow biopsy examination (before, during and after examination). The broad laboratory and clinical communication is not limited to the dialogue between clinicians and laboratory personnel, but also includes the communication between laboratory personnel and patients or family members, information on application forms, results of relevant laboratory items and interpretation of results.

The mechanism of thrombosis and hemostasis in the body involves various systems such as vascular endothelium, platelets, coagulation, anticoagulation, fibrinolysis and hemorheology, and changes in the quantity and/or function of each component will cause different degrees of thrombotic or hemorrhagic diseases. With the rapid development of laboratory medicine towards automation, specialization and informatization, and the development and application of new technologies and methods such as molecular biology and proteomics, laboratory testing of thrombosis and hemostasis plays an important role in the diagnosis and differential diagnosis of diseases, and the monitoring of efficacy of anticoagulant and thrombolytic drugs, and the clinical dependence on test results increases. However, due to the dynamic changes in the occurrence and development of thrombotic and hemorrhagic diseases, there are many influencing factors in the detection of thrombosis and hemostasis. It is very important for the laboratory to improve the internal quality control (IQC) and external quality assurance (EQA) procedures and speed up the standardization process. At the same time, it is very important to establish an active and effective communication mechanism with the clinic to ensure the reliability of the test results.

Communication is the process of passing information, thoughts, and emotions between individuals or groups for a set goal, and reaching a common agreement. It has three main elements: having a clear goal; Reach a mutual agreement; Communicate information, thoughts and emotions. The hospital is an institution composed of multiple departments. As a medical technology platform to provide services for all clinical departments and patients in the hospital, the laboratory department has the same goal as the clinical departments, that is, to provide high-quality and efficient services for patients. Therefore, it is extremely important to adopt multi-faceted communication based on the common agreement reached on this goal^[1,2]。 The International Organization for Standardization (ISO) clearly states the importance and specific requirements of clinical communication in the accreditation of medical laboratories. This article summarizes the experience of communication with clinical in the process of medical laboratory accreditation in recent years.

A 68-year-old female was admitted to Peking Union Medical College Hospital on March 30, 2014 due to "numbness of limbs for 4 years, aggravation with weakness of both lower limbs for 3 months". Since 2010, the patient has experienced numbness in the limbs without trigger, accompanied by fatigue, feeling of stepping on cotton, without affecting activity, without myalgia and muscle atrophy. The effect of neurotrophic drugs and acupuncture treatment is not good. In May 2011, lumbar puncture was performed in a foreign hospital. The cerebrospinal fluid paraneoplastic neurological syndrome antibody (anti-Hu.Yo.RI antibody) and oligoclonal zone (OB) were negative (-), and the myelin basic protein (MBP) was increased (12.42 μ g/L), and the IgG synthesis rate was increased (85.5 mg/24 h). Electromyography showed peripheral neurogenic damage of upper and lower limbs: the incubation period of each wave of motor evoked potential (MEP) recorded in right tibialis anterior muscle and abductor pinky muscle was prolonged, and the central conduction time was normal; The sensory conduction velocity of bilateral tibial nerve was not measured, the motor incubation period was prolonged, the conduction velocity was slowed down, and the wave amplitude was reduced; The sensory conduction velocity of right median nerve and ulnar nerve was not measured, the motor incubation period was prolonged, and the conduction velocity was slowed down; Bilateral tibial nerve H reflex, not detected by F-wave measurement. No abnormalities were found on head CT; Lumbar spine MRI: L_2～3, L_4～5, S₁Herniated disc. He was diagnosed as "chronic inflammatory demyelinating peripheral neuropathy" and was treated with intravenous human immunoglobulin (IVIG): IVIG 25 g/d ×5 d ×1 time/month ×2 months → IVIG 10 g/d ×3 d ×1 time/month ×6 months → IVIG 25 g/d ×5 d ×1 time/3 months ×2 years; In August 2012, prednisone 50 mg/d was added, and the dose was gradually reduced in early 2013. From August to September 2013, the blood test routine was normal; Erythrocyte sedimentation rate (ESR) 46 mm/1 h; Cerebrospinal fluid examination: Cerebrospinal fluid protein (CSF-Pro) 755 mg/L, other biochemistry and routine were normal. In the past 3 months, the numbness of the limbs still gradually worsened, the scope expanded, accompanied by weakness of both lower limbs, and inability to stand up after squatting. Since the onset of the disease, the general condition is good. Past history, personal history, menstrual marriage and childbirth history are not special. Family history: father died of pulmonary heart disease, mother died of gastric cancer. Physical examination: stable vital signs, walking into the ward on crutches, untouched superficial lymph nodes in the whole body, no special findings in the heart and lungs, no tenderness in the chest and ribs, no enlargement of the liver and spleen, muscle strength of both upper limbs grade V, muscle strength of both lower limbs grade IV, no tenderness in the muscles, hypotactile sensation below the elbow of both upper limbs and below the knee of both lower limbs, disappearance of tendon reflex of the limbs, no pathological reflex, meningeal irritation sign (-).

Lymph node enlargement is a common outpatient disease in primary hospitals. Lymph node puncture needle aspiration cytology is the first choice for primary outpatient doctors because of its quick and simple advantage, and it is an important means for early outpatient examination of patients with lymphoproliferative diseases and tumor metastasis. In the early stage of HIV and Treponema pallidum infection, immune cells of the body proliferate and activate to resist the invasion of HIV and Treponema pallidum. Therefore, lymph node enlargement is one of the important clinical manifestations. The cytological characteristics of lymph nodes in two patients with HIV infection and syphilis infection with lymph node enlargement as the first manifestation found in the 148th Hospital of the People's Liberation Army in recent years are reported as follows, aiming at providing clinical diagnosis basis for early diagnosis and prevention of spread of such patients.

A 60-year-old woman underwent simple right mastectomy in our hospital 9 months before admission. The postoperative pathology was considered as one of the following three types: atypical metaplastic carcinoma, well-differentiated extraosseous osteosarcoma and ossifying fasciitis. Immunohistochemical staining showed Actin (partial +), Desmin (-), S-100 (-), CK, CK-H and P63 (scattered minority +), CK-L and CK18 (-), Ki-67: 15%. It was recommended to go to another hospital for consultation of pathological results, but the diagnosis could not be confirmed due to the patient's reasons. Five months after the operation, a tumor was found at the right surgical incision without obvious trigger, the size was about 4.0 cm ×4.0 cm, painless, and the local skin was red and swollen. Subsequently, the mass gradually increased and he was re-admitted at an interval of 4 months. Physical examination showed that there was a 4.13 cm ×5.17 cm mass at the surgical incision of the right chest wall, with blurred boundary, small mobility, fixed to the pectoralis major muscle, hard texture and no tenderness. Blood biochemistry showed alkaline phosphatase: 188 U/L. Tumor markers [carcinoembryonic antigen (CEA), CA-153, CA-125, CA-199] were all normal. Chest enhanced CT examination showed a round soft tissue mass on the right chest wall, and the boundary between the lower edge of the lesion and the pectoralis major muscle was unclear. Most short diameters were seen in the bilateral axillary and mediastinum<1 cm lymph node shadow; The nodule in the lower lobe of the right lung was about 0.7 cm in diameter, and its nature was to be determined; Chest ultrasonography showed a 3.4 cm ×2.4 cm mixed echo nodule in the right chest wall, with unclear boundary and irregular shape, and abundant blood flow signals in it; Hypoechoic lymph nodes of approximately 1.7 cm ×0.9 cm were visible in the right axilla. The pathology of hollow core needle biopsy showed that spindle cells and multinucleated giant cells with active proliferation were seen, which were considered to be mesenchymal tumors (Figure 1，Figure 2，Figure 3，Figure 4)。

Virtual reality (Virtual reality) technology came into being in the 1960s of the 20th century. Its core is to generate a realistic Virtual environment with visual, auditory and tactile sensations by using various technologies, interact with the objects in it, and produce the feeling and experience of visiting the real environment in person^[1]。 Military application is the driving force to promote the development of virtual reality technology. Foreign military has developed many military simulation systems based on this technology, which can simulate actual combat to the greatest extent with low cost and realistic effect, quickly and effectively train officers and soldiers to use weapons and equipment, adapt to battlefield environment, and train military doctors and health workers in combat trauma treatment skills^[2,3]Improve the strategic and tactical accomplishments of commanders^[4]。 The application and prospect of virtual reality technology in the field of military medicine are described as follows.

At present, the effective methods for treating non-small cell lung cancer (NSCLC) mainly include surgical resection, radiotherapy, chemotherapy and molecular targeted therapy. Although these methods are effective, they also have limitations and subsequent risks, including recurrence, metastasis, drug resistance and serious side effects. In recent years, with its unique advantages, tumor immunotherapy has entered people's field of vision and attracted more and more attention, and its corresponding basic research has made rapid progress. Programmed death factor 1 (PD-1) and programmed death factor ligand 1 (PD-L1), as the "star molecules" in tumor immunity, have naturally become one of the focus of research.

Pancreatic cancer is one of the most common malignant tumors in humans. Early diagnosis is very difficult. Its mortality rate is very high, and the average 5-year survival rate is less than 5%^[1]。 Statistics released by the World Health Organization show that the incidence of pancreatic cancer in the world ranks 13th among malignant tumors, but its fatality rate is the fourth^[2]。 It is difficult to diagnose CT, ultrasound and other imaging examinations commonly used in clinical practice<2 cm pancreatic tumor, and the symptoms associated with pancreatic cancer (e.g. jaundice, abdominal pain, weight loss, etc.) usually do not appear in the early stage of pancreatic cancer. When symptoms appear, 85% of patients have developed lymph node or distant metastasis, and more than 80% of pancreatic cancer is diagnosed in advanced stage, losing the opportunity for surgery, and the median survival time is about 8 months^[3,4,5,6]。 In China, with the change of environment and people's lifestyle, the prevalence of pancreatic cancer is increasing year by year^[7]。 In the past 40 years, the mortality rate of gastric cancer, lung cancer, colon cancer and prostate cancer has gradually decreased, but the overall mortality rate of pancreatic cancer has not changed significantly, indicating that the diagnosis and treatment of pancreatic cancer still need to be greatly improved^[2]。 Pancreatic cancer has the lowest relative survival rate among all cancers. The median survival time after surgical resection and adjuvant chemotherapy is about 20 months in 10% ~15% of pancreatic cancer patients with localized lesions; tumor<The 5-year survival rate of pancreatic cancer patients with 2 cm and no lymph nodes or extrapancreatic metastasis after surgical resection was 30% to 60%; If the tumor<1 cm, the postoperative 5-year survival rate can be as high as 75%^[8,9]。 Recent data from genome sequencing of primary and metastatic pancreatic cancer suggest that pancreatic cancer development is a slow process^[10]。 The development of convenient and practical serum markers has important clinical significance for the screening of early pancreatic cancer^[11]。 In recent years, domestic and foreign scholars have found that compared with normal pancreas, benign pancreatic lesions and malignant tumors of other tissue origin, anti-mucin 1 antibody (PAM4) has high specificity and sensitivity to pancreatic cancer, and may be used as a molecular marker for early diagnosis of pancreatic cancer in the future, and its application in antibody targeted imaging technology and pancreatic cancer treatment has also received wide attention.

inflammatory bowel disease (IBD) is a group of chronic non-specific inflammatory diseases of the intestine of unknown etiology, including ulcerative colitis (UC) and Corhn's disease (CD). Among them, UC lesions are mainly limited to the mucosa and submucosa of the large intestine, and the clinical manifestations are diarrhea, mucus, pus and bloody stool, and abdominal pain. The severity of the disease varies, mostly with a recurrent chronic course. Studies have shown that the risk of developing colorectal cancer in UC is more than 10 times that in healthy people, and it gradually increases with the length and intensity of the disease^[1]Therefore, understanding the pathogenesis of UC is crucial for the prevention and treatment of UC and UC-related colorectal cancer. The concept of "inflammasome" was developed by Martinon et al.^[2]First proposed in 2002, they found that the complex formed by NOD-like receptors (NLR) P1, apoptosis-associated speck-like protein containing CARD (ASC) and cysteine-containing aspartate proteolytic enzyme (caspase) can activate caspase, thus promoting the maturation and secretion of cytokines interleukin (IL) -1 β and IL-18, and participating in inflammatory response. At present, it is believed that the dysregulation of inflammasomes plays a certain role in the pathogenesis of UC. This paper reviews its role in the pathogenesis of UC.