2017年 · 第97卷第12期

In the history of medical development, case reports have occupied an important position and promoted the progress and development of medicine. But from the second half of the 20th century, case reporting began to decline, and medical journal editors seemed more willing to publish articles on evidence-based medicine research, while enthusiasm for case reporting gradually waned. This has caused heated discussions in the medical community: opponents believe that the quality of case reports is not high and only focuses on strange events, which may be misleading to clinical research; Proponents argue that case reporting is essential in the development of medicine, and that the ability to obtain detailed information on individual patients should be an important supplement to evidence-based medicine^[1,2]。 Either way, case reports are still very low in the evidence hierarchy. After a period of decline, beginning in the late 1990s, researchers' interest in case reporting was rekindled. In 1995, The Lancet (Lancet) magazine has opened a new chapter dedicated to case reporting. In 2007, the first international medical journal to publish only case reports was published. In the following years, similar magazines appeared^[1]。 Then, what is the position of case report in medical research, what are the advantages and disadvantages, and how can we write a case report well? We will go into more detail below.

UNESCO divides medical scientific research into three categories: basic research, applied research and experimental development research. Among them, applied research is an innovative exploration to apply research results to clinical work. Clinical observation research and field investigation research in medical research both belong to this category, and it is also a relatively simple, convenient and widely used method in clinical research. Case report is to explain rare diseases or new diagnosis or treatment methods by observing and studying special clinical cases. The Sleep Medicine Center of West China Hospital, while conducting some prospective and retrospective studies, also focuses on collecting and exploring special clinical cases, which have been reported in the international academic field^{[1,2,3,4,5,6]}。 Some cases have been published in journals with important academic influence, such asBiol Psychiatry^[6]AndThorax^[2]Etc. These cases are summarized and discussed as follows.

During the "Twelfth Five-Year Plan" period, the Ministry of Science and Technology launched the "Demonstration and Application Research of Collaborative Network Construction of Clinical Medical Research" project, which led the development direction of clinical medical research in China with the demonstration of collaborative research network construction^[1]。 Recently organized national-level projects such as "13th Five-Year Plan", "Key Project for Prevention and Control of Major Chronic Non-communicable Diseases", "Key Project for Precision Medicine Research", "Key Project for Prevention and Control of Reproductive Health and Major Birth Defects", etc., take clinical medicine collaborative research as the guiding principle for the top-level design and organization of special projects, further expanding and extending the application scope of "collaborative research". What exactly is clinical medical collaborative research, what are its basic characteristics, how is its positioning, how is it different from previous clinical research, and what is its significance? In the process of thinking and answering these questions, the author found that as a new clinical research model, clinical medical collaborative research has unique theories, methods and technologies, which need to be combed and summarized in order to better understand and organize the implementation, so that China's clinical research can better and faster adapt to the national strategy of innovation-driven development.

In recent years, the rapid development of hospital digital construction makes hospital information system increasingly become an effective means to improve the quality of medical service and enhance the ability of hospital management. However, there are some shortcomings in its rapid development, such as the existence of information islands between different systems, the business system cannot meet the increasing needs of users for data analysis and data mining, and it cannot provide necessary auxiliary decision support for hospital management and development. In 2009, the state introduced a new medical reform plan, in which the establishment of a practical and shared medical and health information system was proposed for the first time. Based on the analysis of related technologies and business functions of the hospital decision support system, this paper discusses the key technologies and concrete implementation methods of designing and developing the decision support system with data sharing, data analysis and data mining functions, as well as the changes brought by the operation management decision-making of the medical industry.

Hip fracture is a common traumatic disease in elderly patients. Such patients are often accompanied by multiple coexisting diseases and comorbidities, improper anesthesia and perioperative management, and significantly increased postoperative complications and mortality. This guidance is based on relevant literature, expert consensus and guidelines^[1,2,3,4]Formulate and put forward several recommendations to improve patient outcomes, including timing of surgery, preoperative evaluation and preparation, prevention of deep vein thrombosis, selection of anesthesia and analgesia protocols, intraoperative respiratory and circulatory management, and postoperative rehabilitation plan, so as to strengthen the perioperative management of this type of patients^[3]。

A 15-year-old male was admitted to the First Hospital of Jilin University on April 17, 2016 with "sudden abdominal pain for 1 d". Abdominal examination: tenderness in the lower abdomen with mild rebound pain and muscle tension. Whole abdominal CT showed that the distal ileum in the pelvic cavity was twisted and arranged in concentric circles, which was considered to be small intestinal obstruction, not excluding intussusception (Figure 1)。 Clinical diagnosis: intussusception. On the same day, an exploratory laparotomy was performed under general anesthesia in the emergency department. During the operation, about 100 ml of pelvic bloody exudation was found. After the exudation was sucked, further exploration was found. The distal ileum and mesangium were inserted into the distal intestinal tube, with a length of about 40 cm and could not be returned. The distal end of the intussusception intestinal tube was about 15 cm away from the ileocecal part, and the proximal intestinal tube was obviously dilated without a clear tumor. Intraoperative diagnosis of "small intestinal intussusception (ileum-ileum type)", partial small intestinal resection and intestinal anastomosis were performed. Postoperative pathological report: Pancreatic acins and ducts can be seen in the submucosa and muscle layer of ileum intestine, which is consistent with ectopic pancreas (Figure 2)。 Local mucosal epithelial loss, accompanied by a large number of acute and chronic inflammatory cell infiltration, part of the intestinal wall accompanied by bleeding, showed incomplete intestinal obstruction changes, and 4 mesenteric lymph nodes reactive hyperplasia.

A 48-year-old female was admitted to the Department of Cardiovascular Medicine of the Second Affiliated Hospital of Bengbu Medical College on June 29, 2016 with "intermittent chest tightness and palpitation for 5 months and aggravation for 3 days". The patient developed chest tightness and asthma after activity 5 months ago, no precordial pain, no radiation pain, chest tightness aggravated after activity, accompanied by nocturnal paroxysmal dyspnea, and went to the local hospital on February 4, 2016. Pericardial puncture was guided by B-ultrasound, and a total of 1 200 ml of bloody noncoagulable fluid was drained before and after. No tumor cells were found in two pericardial effusions. Biochemistry of pericardial effusion: adenosine deaminase 8.4 U/L, albumin 48 g/L, lactate dehydrogenase 181.5 U/L. On April 27, 2016, the above symptoms reappeared, and he went to the First Affiliated Hospital of Anhui Medical University. Cardiac ultrasound showed that left ventricular ejection fraction (LVEF) was 61%, no segmental movement abnormalities of left ventricular wall were found, a liquid dark area of about 7.5 mm deep was seen in the anterior wall of right ventricle, and a liquid dark area of about 9.3 mm deep was seen in the posterior wall of left ventricle. After cardiotonic diuretic treatment, he was improved and discharged. Three days ago, the patient had the above symptoms aggravated again after activity, and came to our hospital for treatment. He had poor diet and sleep, normal urination and defecation, and no obvious weight loss.

Obstructive sleep apnea syndrome (OSAS) is a sleep disorder characterized by repeated occlusion of the upper airway during sleep, resulting in intermittent hypoxia and frequent micro-arousal. It is one of the most common sleep disorders, with a prevalence of 6% ~17% in the general population^[1]。 The structural or functional abnormalities of the upper airway are one of the causes of OSAS, and local inflammation of the airway will aggravate the structural and functional abnormalities, further aggravating OSAS. Local airway inflammation in OSAS patients is the result of mechanical injury caused by repeated airway closure and snoring, intermittent hypoxia and systemic inflammation associated with obesity. A large number of studies have shown that local airway inflammation plays an important role in the pathogenesis of OSAS. At present, the detection of airway inflammation in OSAS patients is only at the experimental level, and it has not been used for clinical diagnosis, treatment and follow-up.

Clinical research is a simple scientific research carried out in a complex clinical environment. The contradiction between scientificity and feasibility is prominent. It is particularly important to obtain theory, method and technical support from the perspective of research methods. Although the existing quantitative research methods have solved many problems in clinical research, some problems can not be solved well by quantitative research or qualitative research alone, and there are still limitations. mixed methods research (MMR) is the third research paradigm that combines quantitative research and qualitative research. This method can help researchers solve some problems that cannot be completely, reasonably and comprehensively explained by qualitative or quantitative research alone. At present, although some domestic scholars have used both qualitative and quantitative research methods in research projects, they generally only combine the data obtained by the two methods simply or analyze and publish them separately, and rarely publish research design articles that organically combine them. Clinical research can apply this method to provide more scientific and feasible methodological help for clinical research design, implementation and evaluation, in order to improve the quality of clinical research. This paper introduces the progress of the application of mixed methods in clinical research, and discusses its value and application prospect in improving clinical research.

The prevalence of Obstructive sleep apnea hypopnea syndrome (OSAHS) is about 4% in men and about 2% in women^[1]。 Its pathogenesis involves inflammatory reaction, oxidative stress, immune dysfunction, metabolic abnormalities and so on. Chronic intermittent hypoxia is an important pathophysiological mechanism. In recent years, the biomarkers of OSAHS have received extensive attention^[2]。 The research progress of OSAHS-related serological markers is summarized as follows.

Renal cell carcinoma (RCC) is one of the most common tumors in urology, accounting for 2% ~3% of all malignant tumors in adults^[1]20% to 40% of kidney cancer patients undergoing radical nephrectomy will gradually relapse or metastasize^[2]。 For patients with metastatic advanced renal cell carcinoma, integrated therapy combined with targeted therapy is the main treatment mode. Immunotherapy research for renal cancer was once progressing slowly. In recent years, with the research progress of Programmed cell death 1 receptor (PD-1) /Programmed cell death 1 ligand 1 (PD-L1) pathway, its related targeted therapy has opened a new chapter for renal cancer immunotherapy. Progress in immunotherapy of renal cancer related to the PD-1/PD-L1 pathway is reviewed below.