2018年 · 第98卷第39期

Esophageal cancer is one of the eight common cancers in the world, and it is extremely difficult to cure^[1]。 The median time of postoperative recurrence was only 12 months, and more than 40% of them had local or regional recurrence. There was no uniform standard for retreatment after recurrence, and the median survival time was only 3~7 months^[2,3,4]。 According to the results of three-field lymph node dissection, the metastasis of cervical lymph node can reach about 20%^[5,6,7]。 The retreatment of cervical lymph node metastasis of esophageal cancer is difficult, and the overall response rate is only 34%^[3]。 Two-course radiotherapy for local recurrence of esophageal cancer after radiotherapy is difficult to achieve the expected dose due to the restriction of the tolerated dose of local normal tissue, and the probability of injury of normal tissue will increase when receiving the second course of radiotherapy^[8]Therefore, the second course of radiotherapy should be cautious. Lin et al.^[9]Application¹²⁵The 2-year local control rate and survival time were 26% and 10.5% in patients with recurrent esophageal cancer with cervical metastatic lymph nodes treated with radioactive seed implantation. 31.6% of patients had no recurrence within 12 months. It is suggested that radioactive seed implantation may be an effective treatment for local lymph node metastasis recurrence. However, the anatomical structure of the neck is complicated, the position of the target area is variable, and the peripheral blood vessels and nerves are abundant. It is difficult to puncture when seed implantation by conventional methods, and it is easy to damage blood vessels and other dangerous organs. In addition, because there is no standard surgical procedure, most doctors still use freehand experience implantation, resulting in inconsistent preoperative and postoperative doses, unrepeatable doses, uncontrollable doses, and difficult to popularize. How to implant cervical lymph nodes accurately has become an urgent problem to be solved. In recent years, the application of 3D printing templates has solved the problems of accurate puncture position and accurate particle dose for radioactive particle implantation^[10,11]。 Cervical lymph nodes are relatively fixed with peripheral blood vessels and nerves and other endangered organs, and their positions are superficial. The patient's position can be accurately placed as required, which is a good indication for 3D printing template-guided radioactive particle implantation. The 3D template is designed individually according to the CT images of the target area and endangered organs, and contains the anatomical position information and dosimetry information of the patient, which can effectively avoid puncture injury, improve the consistency of dose parameters before and after operation, and is simple, safe and repeatable. In order to improve the level of multidisciplinary comprehensive treatment of cervical lymph node metastasis of esophageal cancer and better standardize¹²⁵I Radioactive seed implantation for the treatment of cervical metastatic lymph nodes of esophageal cancer. Radioactive seed implantation branch of Hebei Medical Physicians Association organized multidisciplinary experts to discuss and write this article, so as to provide reference for clinical practice.

The global burden of disease study shows that hypertension has become the first contributor to disability-adjusted life years (DALY) in China, contributing 24.6% to all-cause deaths^[1,2]； Premature death years lost (YLL) caused by hypertension accounted for 64.5% and 72.8% of cardiovascular diseases and cerebrovascular diseases respectively, ranking first among all cardiovascular and cerebrovascular disease risk factors^[2]。 The proposal of the "Healthy China 2030" strategy provides basic guidelines for the prevention and control of hypertension in China, and in order to better play the guiding role of health policies in the prevention and control of hypertension, this paper systematically reviews the policies related to hypertension prevention and control issued since the launch of a new round of medical and health system reform in 2009, and puts forward relevant suggestions.

According to statistics, in 2013, the age-standardized prevalence of stroke in China was 11,14.8 per 100,000 people, and the age-standardized incidence rate was 246.8 per 100,000 people, which is the first cause of death in China^[1]Of which ischemic stroke accounts for 70% to 80%^[2,3]。 Therefore, the treatment ability of acute ischemic stroke (AIS) is the touchstone to test the treatment efficiency of stroke. In recent years, AIS treatment has developed rapidly, and rapid blood flow reconstruction is the core of the treatment, including recombinant tissue plasminogen activator (rt-PA), urokinase intravenous thrombolysis and mechanical thrombectomy. Patients with AIS received intravenous thrombolysis in a time-dependent manner, and the faster the thrombolysis, the better the effect^[4]； For patients with ischemic stroke onset 4.5 h, patients should be strictly screened according to the indications and contraindications, and intravenous rt-PA or urokinase thrombolytic therapy should be given as soon as possible; For patients with onset time longer than 4.5 h and onset within 6 h, patients can be strictly selected to consider intravenous urokinase thrombolysis^[5]。 The American Heart Association (AHA) recommends that patients with acute large vessel occlusion (AIS-LVO) receive endovascular therapy after intravenous thrombolysis, which is also time-sensitive^[6]。 However, in the real world, the treatment efficiency of AIS patients in China is not ideal, and the situation is grim. Relevant studies show that only 21.5% of AIS patients in China can reach emergency department within 3 hours of onset^[7], and pre-hospital delay is one of the important reasons why AIS patients cannot arrive at medical institutions where thrombolytic therapy can be performed within the time window^[8]。 The treatment of stroke can be divided into three stages: onset-call for help, call for help-go to hospital, and go to hospital-treatment^[9]While pre-hospital first aid covers the first two stages. In order to further improve the overall level of pre-hospital emergency treatment for stroke and standardize the work of pre-hospital emergency treatment, we compiled this "Guidelines for Diagnosis and Treatment of Pre-hospital Emergency Treatment for Stroke" with reference to successful experiences at home and abroad, combined with China's national conditions and the current situation of stroke treatment.

At present, pancreatic cancer has become the third leading cause of cancer death in developed countries such as Europe and America^[1]The mortality rate of pancreatic cancer in China is rising. Statistics from China Cancer Center in November 2017 show that pancreatic cancer has become the sixth leading cause of death for male cancer patients and the seventh leading cause of death for female cancer patients in China. The difficult factors in the treatment of pancreatic cancer are: (1) pancreatic cancer is aggressive, developing rapidly, and its early symptoms are hidden. Most patients have metastasized when they see a doctor, and the opportunity of radical surgical resection is lost; (2) Pancreatic cancer can surround important vascular structures such as superior mesenteric artery, vein and celiac trunk artery at the early stage of growth. Even if there is no metastasis, 30% ~40% of patients can no longer undergo radical resection at the time of diagnosis^[1,2,3]； (3) Only 5% ~12% of patients can undergo surgical resection treatment^[2]However, due to the large surgical trauma and many complications, it is difficult for patients to accept it, and because the tumor grows invasively, it is difficult to completely remove it after surgery, and it is easy to relapse after surgery, so the survival time of the patient is not significantly prolonged; (4) The efficacy of chemotherapy alone is not satisfactory. In the past, gemcitabine combined with albumin paclitaxel chemotherapy regimen was mostly used for the treatment of pancreatic cancer that cannot be surgically resected. In recent years, FOLFIRINOX regimen has been gradually used clinically to treat pancreatic cancer. Although the effect is improved compared with before, the efficacy is still not significant; (5) Although the commonly used radiotherapy methods such as conformal intensity modulated radiotherapy and cyberknife have obvious therapeutic advantages over traditional radiotherapy, the control of pancreatic cancer is still not ideal^[4]； (6)¹²⁵I Radioactive seed implantation has achieved certain clinical efficacy in the treatment of pancreatic cancer, but sometimes it is accompanied by complications such as pancreatic leakage, bleeding and radiation enteritis; (7) The temperature-based physical ablation techniques such as radiofrequency ablation, microwave ablation and argon-helium knife are "non-selective" in the destruction of tissue structure, and the ablation lesion is easy to damage the surrounding important tissue structure and easily cause serious complications^[5,6,7]Therefore, it is difficult to popularize and apply.

Since the implementation of the "comprehensive two-child" policy in China in 2015, the number of rebirths of older women has increased. Elderly pregnant women refer to pregnant women whose delivery age is ≥35 years. The proportion of elderly pregnant women in China has increased from 10.1% in 2011 to 19.9% in the first half of 2016^[1]。 Will older pregnant women increase adverse perinatal pregnancy outcomes compared with non-older pregnant women? Therefore, this study retrospectively analyzed the clinical data and pregnancy outcomes of 3 138 elderly pregnant women to explore the influence of advanced age on perinatal pregnancy outcomes.

Cardiogenic shock is the first cause of death in hospitalized patients with acute myocardial infarction^[1]。 Foreign research data show that although early reperfusion therapy and active drug therapy have been widely used in clinical practice, the prognosis of patients with cardiogenic shock has been greatly improved, but the hospitalization mortality rate remains at a high level^[2,3,4]。 There are few investigations on the clinical status of cardiogenic shock after myocardial infarction in China. This study retrospectively collected the data of patients with acute myocardial infarction combined with cardiogenic shock who attended Fuwai Hospital of Chinese Academy of Medical Sciences for emergency coronary angiography during 7 years from January 1, 2010 to December 31, 2016, and analyzed the changes of incidence, clinical complications, treatment measures and hospitalization mortality of cardiogenic shock, aiming to reveal the clinical characteristics, prognosis and changing trends of acute myocardial infarction combined with cardiogenic shock.

Weber first proposed two-point resolution (2-PD) in 1835, defining it as the minimum distance between two points that can be felt^[1]。 At present, the normal value standards of 2-PD used in China are all quoted from foreign research data, but there are few relevant studies in China. No normal values of 2-PD in the feet and lower limbs have been reported previously. We use Mayo Hospital's Aronson et al.^[2]Reported test methods for static 2-PD. The 2-PD of 128 healthy adults were investigated in order to obtain the normal range of 2-PD in China.

Case 1 was a 49-year-old male. In July 2013, he was admitted to Zaozhuang Municipal Hospital of Shandong Province for more than 10 years due to enlarged deformity of both fingers and skin ulcers. More than 10 years ago, the patient developed swelling of the metacarpophalangeal joints, proximal and distal interphalangeal joints of both hands without obvious reason, without obvious joint pain, and gradually developed enlarged deformity of both fingers, accompanied by finger ulcer, blackening of the ends of the knuckles, spontaneous necrosis and detachment of some knuckles, pus discharge, and non-union, so he underwent terminal knucklectomy in a local hospital. Postoperatively, both hands were still progressively enlarged, accompanied by repeated skin ulcers on both hands (Figure 1)。 X-ray plain films of both hands showed multiple falangeal defects and deformities in both hands, and bone destructive lesions in the falangeal bone of the left index finger. Cervical MRI showed syringomyelia at the upper margin of C2~ T4. MRI of the brain and thoracolumbar cord showed: cerebellar subtonsillar hernia, C1~ T2 vertebral level syringomyelia (Figure 2)。

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by abnormal production of autoantibodies due to excessive activation of B cells and imbalance of T lymphocytes. It causes multiple organ and system damage through immune complex deposition and lymphocyte infiltration. There are two new types of helper T cells (Th) localized in the lymphoid germinal center: follicular helper T cells (Tfh) and follicular regulatory T cells (Tfr). Tfh-Tfr balance plays a crucial role in the formation of lymphocyte germinal center, abnormal B cell activation and autoantibody production in SLE, and is closely related to the involvement of target organs such as disease activity and lupus nephritis. The latest research progress of Tfh-Tfr immune balance in SLE is reviewed below.

Heart failure is a manifestation of the development of various heart diseases to the end stage, and is the main cause of cardiovascular death^[1]Cardiac remodeling is an important pathogenesis of heart failure, and the central link of cardiac remodeling is cardiac hypertrophy^[2]。 Myocardial hypertrophy is an adaptive change of myocardial tissue to adapt to hemodynamic overload, aiming at reducing ventricular wall tension and oxygen consumption, so as to maintain normal systolic function and cardiac output. Under the continuous stimulation of various pathological factors such as ischemia and pressure overload, myocardial fibrosis is aggravated, microcirculation is damaged, which leads to tissue hypoxia, myocardial cell death, decompensation of myocardial hypertrophy, and finally deteriorates to heart failure^[3]。 Pathological myocardial hypertrophy is a kind of ventricular remodeling and cardiac insufficiency caused by hypertension, coronary heart disease and valvular heart disease. It is an independent risk factor of heart failure and an important predictor of cardiovascular morbidity and mortality^[4]Therefore, clarifying the specific pathogenesis of pathological myocardial hypertrophy is the key to the prevention and treatment of heart failure and cardiovascular diseases.

immunoglobulin G4 related disease (IgG4-RD) was first proposed in 2003^[1]The main feature is multi-organ IgG4+ cell infiltration. In recent years, with the further understanding of IgG4-RD, it has been found that the disease can involve the nervous system, that is, IgG4-related nervous system diseases. The etiology of this disease is unknown, which may be related to genetic factors. The clinical manifestations lack specificity, and the diagnosis is difficult. IgG4-related neurological diseases can involve pituitary gland, dura mater, brain parenchyma, intracranial blood vessels and other sites. This article reviews the clinical manifestations, auxiliary examinations, diagnosis, differential diagnosis and treatment of IgG4-related neurological diseases, so as to improve clinicians' understanding of the disease.