2018年 · 第98卷第15期

In recent years, critical care medicine has made rapid development. In July 2008, critical care medicine was approved by the state as a secondary discipline of clinical medicine. Some scholars simply equate traditional clinical thinking with critical clinical thinking, while ignoring the professional characteristics of critical care medicine. Clinical thinking of severe disease has its particularity and professionalism, which is different from traditional clinical medicine thinking to a certain extent. Therefore, while following the traditional medical clinical thinking mode, the characteristics and ways of critical clinical thinking are worth re-thinking and summarizing. Based on the Beijing Hemodynamics Consensus^[1]Combined with the clinical practice of critical care medicine, we further summarize and put forward the following ten ways and concepts of critical care clinical thinking.

Dementia is an acquired intelligence impairment syndrome with cognitive impairment as the core symptom. Cognitive impairment can involve cognitive domains such as memory, learning, language, execution, visual space, etc. The degree of impairment is enough to interfere with daily life ability or social occupational function. It is often accompanied by mental, behavioral and personality abnormalities at a certain stage of the disease course. Therefore, the assessment of such patients typically includes cognition, social and daily activity, and psychiatric behavioral symptoms, which can be summarized as ABC. Among them, the cognitive function assessment involves the above-mentioned plurality of cognitive domains.

Auxiliary examinations for cognitive impairment diseases include body fluid examination, imaging examination, electrophysiological examination and genetic testing. Selecting appropriate auxiliary examinations can effectively assist in the diagnosis and differential diagnosis of cognitive impairment diseases and monitor the disease progress.

Head and neck cancer accounts for 30% of malignant tumors in the whole body, and surgery is the main treatment. Radiotherapy combined with chemotherapy is mainly used when locally advanced or unable to be resected surgically. Local and regional recurrence after surgery and radiotherapy is still the main cause of failure, and there is no ideal method for salvage treatment after recurrence. Radioactive seed implantation has become one of the standard treatments for early prostate cancer^[1,2,3]。 Prostate cancer seed implantation treatment is transrectal ultrasound-guided combined with pudendal template assistance, which achieves a rational spatial distribution of particles in the prostate gland, which can ensure that the seed implantation treatment is completely consistent with the preoperative plan.

The 25-year-old male was admitted to the hospital on December 23, 2016 due to "low back pain and numbness and weakness of both lower limbs for more than 2 months". When the patient was 6 years old, he had unstable walking, walking with the lateral plantar as the fulcrum, and his legs were sore. After 1 year of rest, the symptoms were relieved. At the age of 14, the patient developed enlarged deformity of interphalangeal joints of both upper limbs, accompanied by bilateral hip and knee pain, and unsteady walking. I was treated with hormone according to "rheumatoid arthritis", and the symptoms were temporarily relieved and then aggravated again (sudden discontinuation of the drug). I was treated with symptomatic treatment such as hemodialysis, traditional Chinese medicine and anti-osteoporosis, and the symptoms were relieved. At the age of 22, the patient had weakness, numbness, pain in both lower limbs, difficulty in walking, and disturbance in defecation and defecation without obvious triggers, T₁₁Sub-plane hypoesthesia. MRI showed multi-level disc herniation in the thoracic spine, and posterior thoracic decompression and internal fixation were performed in the local hospital. More than 2 months ago, the patient again experienced numbness, pain and weakness in both lower limbs, hypersensitivity below the umbilical plane, weakness in stool, and control of urine. For further diagnosis and treatment, he came to our hospital. The patient's parents were of normal height, and there was no history of close relatives in his family. Admission physical examination: height 171 cm, weight 66 kg, mild scoliosis of the spine, positive bilateral hip tenderness, swelling of both knees, wrists, metacarpophalangeal and proximal interphalangeal joints, no tenderness, limited movement of bilateral elbow and knee joints, and positive bilateral "4" sign. Hyperesthesia in the subumbilical plane, muscle strength of both lower limbs grade 3+, muscle strength of both upper limbs grade 5, bilateral knee tendon and Achilles tendon hyperreflexia, lumbar function score of 8 by the Japanese Orthopedic Society (JOA). There were no obvious abnormalities in rheumatological immunological and hematological examinations, and the preoperative imaging data were shown inFigure 1。 Admission diagnosis: multi-level disc herniation combined with spinal stenosis (thoracic vertebra, lumbar vertebra); Late-onset spinal epiphyseal dysplasia with progressive osteoarthropathy (SEDT-PA).

With the accelerating aging process of Chinese society, the number of elderly patients with neurodegenerative diseases (including Alzheimer's disease, Parkinson's disease, etc.) is increasing day by day, which has caused a serious burden and impact on China's public health system. Traditionally, senile neurodegenerative diseases are usually divided into two categories: one is the disease spectrum dominated by cognitive impairment (various types of dementia represented by Alzheimer's disease), and the other is the disease spectrum dominated by movement disorders (various types of movement disorders represented by Parkinson's disease and Parkinson's syndrome). However, in fact, many movement disorders can cause cognitive impairment, such as Parkinson's dementia, progressive supranuclear palsy dementia, etc. On the contrary, it is not uncommon for cognitive disorders to have movement disorders, such as extrapyramidal symptoms of Lewy body dementia and apraxia in patients with Alzheimer's disease.

In recent years, tumor immunotherapy has brought new hopes to patients with malignant tumors, especially the treatment of immune checkpoint inhibitors has made great progress, but there is still a lack of markers to predict efficacy. The analysis of tumor mutation burden and mismatch repair defects based on sequencing technology are the most studied immunotherapy markers at present. With the development of new generation sequencing technology, whole exon sequencing provides an opportunity for the above analysis. The role of whole exon sequencing in predicting tumor immunotherapy is reviewed as follows, and its application progress in glioma immunotherapy is analyzed.