2016年 · 第96卷第29期

Shock is a clinical manifestation of circulatory failure caused by cellular oxygen utilization disorder, and it is one of the most common clinical syndromes in critically ill patients^[1]。 Approximately 1 in 3 patients in the Critical Care Medicine Unit (ICU) develop shock^[2]。 The most critical in shock treatment is early detection of shock, definition of the type of shock, and dynamic monitoring of circulating hemodynamic information feedback therapy. In the treatment of shock, if further hemodynamic assessment is required, echocardiographic methods are preferred^[3,4]。 How to detect shock early by severe ultrasound, distinguish the type of shock and make dynamic evaluation has become the focus of clinical attention. China Critical Ultrasound Research Group (CCUSG) put forward a six-step shock assessment process guided by critical ultrasound on the basis of previous clinical research observations and clinical practice experience of critical ultrasound. Its core connotation is to follow the laws of hemodynamics, along the inferior vena cava, right ventricular function, left ventricular systolic function, left ventricular diastolic function and arterial tension. The value of the severe ultrasound-guided six-step evaluation process applied to the management of shock patients is that it can simply and quickly evaluate the patient's flow status, preload and volume responsiveness, cardiac function, peripheral vascular resistance, tissue perfusion and other all-round hemodynamic information, accurately guide clinical treatment^[5]。 Now, the precision shock treatment and how to carry out the six-step shock assessment process guided by ultrasound for severe cases are analyzed.

Spondyloarthritis (SpA) is a group of interrelated chronic inflammatory diseases characterized by inflammation of the spine, peripheral joints, and tendon attachment points, of which ankylosing spondylitis (AS) is the representative. SpA can be divided into central axial type and peripheral type according to its main affected site. Fibromyalgia (FM), often called fibromyalgia syndrome in China, is a disease characterized by chronic extensive pain and obvious physical discomfort in the whole body, often accompanied by fatigue, sleep disorders, morning stiffness, depression, anxiety and other mental symptoms. The concept and diagnostic criteria of FM are constantly evolving and changing^[1,2]It is currently believed to be a pain amplification syndrome caused by central nervous system sensitization^[3]。 FM is more common, with a prevalence of 2% to 6.4% in the general population, and only lower in rheumatic diseases than osteoarthritis^[4,5,6]。 There are many similarities in the clinical manifestations of SpA and FM. Both may have symptoms such as pain and stiffness of spinal limbs, fatigue, depression and sleep disorders, which makes the two diseases difficult to distinguish in some cases and thus misdiagnosis. In recent years, there is an increasing number of misdiagnoses of somatized symptoms of low back pain such as FM or depression or anxiety as SpA in China^[7]And it is not uncommon abroad^[8]。 However, the treatment methods of the two diseases are very different, and the prognosis is completely different, so it is important to correctly identify the two diseases clinically. In addition, long-term physical pain and functional limitation, psychological burden on prognosis and financial burden of treatment often lead to depression and anxiety in patients with SpA, especially AS^[9]Low back pain at night severely affects sleep quality^[10,11]All of these lead to SpA prone to FM, with an incidence of 12.6% ~15%^[12,13,14]While it is higher for women, up to 31.3%^[14]。 For such patients, the efficacy of SpA treatment alone is not ideal, and the efficacy of simultaneous treatment of two diseases is better. Therefore, it is clinically important to accurately identify comorbidities between SpA and FM.

A 58-year-old female was admitted to the hospital on 13 October 2015 due to "58 years of discovery of a buttock mass with superficial skin ulceration for 1 d". Shortly after birth, the patient was found to have a mass the size of a quail egg on the buttock, and the posterior mass increased progressively. 1 day ago, the skin on the surface of the mass was red, swollen and ulcerated, with brown and a small amount of bloody fluid flowing out. There was no fever, no lower abdominal pain, difficulty in defecation and other symptoms. Physical examination: A mass with a diameter of about 12 cm ×8 cm in the middle of the buttock, with uneven texture, cystic and solid, and poor mobility. A 1.5 cm long ulcer was seen on the surface, and there was pigmentation on the local skin. After admission, the secretions were collected and sent to bacteria for culture, which indicated the growth of Staphylococcus epidermidis, and the tumor indexes such as carcinoembryonic antigen (CEA), fetal globulin alpha (AFP) and serum carbohydrate antigen 125 (CA125) were all negative. CT of lower abdomen: A huge spindle-shaped mass was seen under the skin in the middle of the buttock, with polycystic septal changes in the lesion, and fat density, calcification and gas density shadows were seen in it. Sacrococcygeal enhanced MRI: A cystic-solid lesion with a size of 11.0 cm ×14.6 cm ×9.1 cm was seen in the central area of the sacrum and behind the urogenital diaphragm, showing polycystic changes, and the cystic part was composed of multiple ascuses surrounding the main capsule; After enhancement, the solid area in the lesion showed obvious and uniform enhancement, and the boundary with the urogenital diaphragm and pelvic floor muscles was clear. No involvement of the sacrococcygeal vertebra was observed, considering the possibility of teratoma posterior to the urogenital diaphragm (Figure 1,Figure 2，Figure 3，Figure 4，Figure 5)。 Sacrococcygeal tumor resection by parasacral posterior approach was performed on 20 Oct 2015. Routine intestinal preparation was performed. After successful general anesthesia, the patient lay prone and folded the knife position, retracted the buttocks, and incised the skin about 14 cm long along the mass rupture through the parasacrococcygeal approach. The subcutaneous tissue was incised to expose the tumor. The tumor tension was high and the capsule was weak. About 80 ml of yellow viscous capsule fluid was aspirated with a decompression needle. After the tension was reduced, there was a tough pelvic diaphragmatic fascia separating the anterior and upper part of the tumor from the rectum. Anterior and inferior are not closely related to external anal sphincter; The posterior part of the cyst wall surrounds and compresses the coccyx, but the adhesion is not tight. The gluteus maximus muscles on both sides were retracted, and the mass was carefully excised along the cyst wall. The wound surface was repeatedly washed with iodophor and physiological saline, and a drainage tube was placed after complete hemostasis. The surgical incision was closed in layers. The incision wound surface was covered with seaweed salt foam material (Wuhan Wisdi Medical Technology Co., Ltd.), sealed with semipermeable membrane, and the drainage tube was connected to the central negative pressure for negative pressure closed suction (VSD) treatment. Gross postoperative specimens: The mass was oval, with polycystic changes of different sizes, ranging from 1.5 to 5.0 cm in diameter, and gray-red organized necrotic tissue in some cystic cavities, with medium texture. Microscopic examination showed that the cyst wall was covered with pseudo-stratified ciliary columnar epithelium, squamous epithelium and transitional epithelium, and the tissue inflammation in the interstitial tissue, and multinucleated giant cells were found locally. Combined with the tumor site, it is consistent with the diagnosis of caileum cyst (Figure 6，Figure 7)。 The VSD was removed 5 days after surgery, the incision healed in the first stage, and the suture was removed 10 days after surgery. The incision healed well and there was no local recurrence at 2 months after surgery.

Glioblastoma, also known as glioblastoma multiforme (GBM), is the most malignant type of glioblastoma and the most common malignant tumor in the nervous system, accounting for about half of primary intracranial malignant tumors in adults. The prognosis of patients with GBM is still not ideal, with a median survival of only about 15 months and a 5-year survival rate<10%^[1]。 autophagy is a common phenomenon in eukaryotic cells. Through autophagy, its organelles and cytoplasm can be interpreted and recycled, thus maintaining cell self-homeostasis and promoting cell survival^[2]。 It has always been believed that radiotherapy and chemotherapy play a role by inducing apoptosis of tumor cells. In recent years, more and more studies have shown that radiotherapy and chemotherapy can not only promote apoptosis, but also induce protective autophagy in tumor cells, thus making cells resistant to radiotherapy and chemotherapy, thus ensuring cell survival, and by inhibiting this protective autophagy, the effect of radiotherapy and chemotherapy can be enhanced^[3]。 However, some studies have shown that chemoradiotherapy can also cause autophagic death, which is another way of tumor cell death caused by chemoradiotherapy^[4]。 The role of autophagy in the treatment of GBM is summarized below.