2015年 · 第95卷第32期

At present, diabetes is the third major disease in human beings besides cardiovascular and cerebrovascular diseases and malignant tumors. Statistics released by the International Diabetes Federation (IDF) in 2011 show that 10 million new cases of diabetes are added worldwide every year^[1]。 The prevalence of diabetes among people over 20 years old in China has reached 9.7%, with more than 92 million patients, ranking first in the world^[2]。 At present, it is recognized that strict blood sugar control is the most fundamental means to reduce the incidence of diabetic vascular complications. Glycosylated hemoglobin (HbA1c) is a golden index reflecting the level of long-term blood sugar control, and it is also the core index for setting blood sugar control goals. The target for glycemic control recommended by the International Diabetes Federation (IDF) and the European Association for Diabetes Research (EASD) is HbA1c<6.5%^[3]。 The American Association of Diabetes Physicians (ADA) issued guidelines for diabetes prevention and treatment in 2015^[4]And the latest "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2013 Edition)" issued by the Diabetology Branch of Chinese Medical Association^[5]In, three blood glucose control targets were proposed: (1) For most non-pregnant adult patients with type 2 diabetes, the blood glucose control target was HbA1c<7%； (2) Strict glycemic control targets (HbA1c<6.5%, or close to normal) is suitable for type 2 diabetic patients with a short course of diabetes, a long life expectancy, no diabetic complications, and no combined cardiovascular disease, provided there is no hypoglycemia or other adverse reactions; (3) Relatively loose glycemic control targets (such as HbA1c<8%) is suitable for patients with a history of severe hypoglycemia, short life expectancy, obvious diabetic microvascular or macrovascular complications, or severe systemic complications, and a long course of diabetes.

A 51-year-old male was admitted to the Department of Hepatobiliary Surgery of China-Japan Friendship Hospital due to "dull pain in the right upper abdomen with aggravation for 7 months". The abdominal pain was persistent and gradually aggravated, which had nothing to do with eating, and had no accompanying symptoms such as fever and jaundice. Past history: Congenital choledochal cyst-lateral jejunostomy 21 years ago. Six months after operation, subtotal resection of common choledochal cyst, cholecystectomy and common hepatic duct-jejunal Roux-en-Y anastomosis were performed due to recurrent cholangitis. One year after surgery, reflux cholangitis was caused by anastomotic stenosis, and common hepatic duct-jejunal anastomosis resection and reanastomosis were performed. Anastomotic stenosis with intrahepatic bile duct stones was repeated 10 years after operation. Anastomotic incision, right hepatic duct lithotomy, and Y-shaped stent placement in left and right hepatic ducts were performed again.

A 69-year-old female was admitted to the hospital in July 2010 due to repeated melena for 1 year with recurrence for half a day. Minimum hemoglobin was as low as 55 g/L during the period. The patient refused gastroscopy and was given symptomatic and supportive treatment such as hemostasis and blood transfusion. Eight years ago, the patient underwent open left radical nephrectomy and right partial hepatectomy in our hospital due to left kidney cancer and liver cancer. The pathology showed renal clear cell carcinoma and hepatocellular carcinoma. Physical examination at admission: vital signs stable, anemic appearance, accessible surgical scar in upper abdomen. Admission hemoglobin 76 g/L. CT showed: local mass of descending duodenum, adenoma or adenocarcinoma considered, please check further, right liver and left kidney postoperative changes (Figure 1)。 Gastroduodenoscopy and ultrasound gastroscopy revealed: descending duodenal neoplasms (lobulated nodular bulging neoplasms with a diameter of about 4.0 cm) (Figure 2，Figure 3)。 Pathology showed inflammatory necrotic tissue and granulation tissue hyperplasia with fungal infection (descending duodenum). Preoperative diagnosis: Duodenal tumor to be examined, metastatic tumor to be considered first, after radical left nephrectomy, after partial right hepatectomy. After perfect preoperative preparation, duodenal mass resection + intraoperative freezing was proposed. Intraoperative freezing showed metastatic clear cell carcinoma of the kidney (duodenum). Postoperative pathology showed: a piece of gray-red duodenal tissue, 5.0 cm ×3.0 cm ×1.5 cm in size, gray-red gray-yellow in section, soft in texture, and unclear in boundary. Microscopically, part of the tissue surface was covered with duodenal mucosa, part of the tissue surface was necrosis, and granulation tissue proliferation was seen below it. Tumor cells were nest-like or acinar-like distributed, separated by fine fibrous tissue containing capillaries. The cytoplasm of tumor cells was rich and translucent, and the nucleus was small and round (Figure 4)。 Immunohistochemistry showed that tumor cells were positive for vimentin (VM) and epithelial membrane antigen (EMA), partially positive for CD10 and negative for cytokeratin (CK). Pathological diagnosis: (duodenal) metastatic clear cell renal cell carcinoma. At postoperative follow-up, the patient experienced gastrointestinal bleeding again 3 and a half years after operation. The duodenal mass was examined by gastroduodenoscopy and ultrasound gastroscopy, and the biopsy pathology showed abnormal cells. Considering tumor recurrence and metastasis, the patient was given symptomatic and supportive treatment, but later lost to follow-up.

Idiopathic pulmonary fibrosis (IPF) is a chronic fibrotic interstitial pneumonia with unknown etiology and pathogenesis and progressive exacerbation of the disease; The disease often occurs in middle-aged and elderly men, and the clinical manifestations are progressive exertion dyspnea, dry cough, clubbing fingers, bursting sound in both lower lungs, lung histopathology and high-resolution chest CT show interstitial pneumonia vulgaris type, because of the lack of effective treatment, the prognosis is very poor^[1]。

Liver abscess is an infectious disease in which the liver is invaded by pathogens. The pathogens that cause liver abscess in the early stage are mainly roundworms or amoeba. With the improvement of living conditions, Escherichia coli becomes the main pathogen. The first case of Klebsiella pneumoniae liver abscess was officially reported in China in 1982^[1]Subsequently, many reports of Klebsiella pneumoniae liver abscess in Asia and Europe and the United States appeared one after another. At present, the bacterial liver abscess caused by Klebsiella pneumoniae has accounted for 43% ~66% of liver abscesses^[2]。 Studies have found that most of Klebsiella pneumoniae, which causes liver abscess, are highly mucinous and belong to highly virulent strains (hvKP). In an article published in the Lancet journal in 2012, Siu et al^[3]HVKP-induced liver abscess is considered to be a new invasive infectious disease. hvKP can not only cause liver abscess, but also cause metastatic infections, such as bacteremia, meningitis, endophthalmitis and necrotizing fasciitis, which can be life-threatening in severe cases. Li et al.^[4]It was also found that the proportion of hvKP in infections caused by Klebsiella pneumoniae increased from 25.5% in 2010 to 54.5% in 2012, which shows that the significance of hvKP is increasing. In order to improve the clinical and laboratory understanding of hvKP liver abscess, the relevant clinical and experimental research progress is summarized as follows.