2017年 · 第97卷第01期

With the continuous development of economy, the continuous improvement of people's living standards and the aging of the population, people's demand for health is increasing, and medical expenses are rising. According to the World Health Organization (WHO), the world's population over 60 years old reached 900 million by 2015, and it is expected to reach 2 billion by 2050. According to the data of the sixth national census released by the National Bureau of Statistics of China^[1]As of November 1, 2010, China's total population was 1.37 billion. Among them, approximately 182 million people aged 60 and above accounted for 13.26%, an increase of 2.93% over 2000; The population aged 65 and over is 122 million, accounting for 8.87%. The problem of population aging is very prominent. At present, China is the country with the largest absolute number of elderly people in the world. It is estimated that the elderly population over 60 years old in China will increase to 245 million by 2020 and about 440 million by 2050^[2]。 Population aging is one of the important factors in the change of the disease spectrum in China. The common diseases that affect the health of our people have changed from infectious diseases in the past to chronic non-infectious diseases now, mainly including cardiovascular and cerebrovascular diseases, diabetes, chronic obstructive pulmonary disease and malignant tumors. In 2013, the National Center for Cardiovascular Diseases released the report "China Cardiovascular Disease Report 2012", which pointed out that as of 2012, the number of cardiovascular diseases in China was 290 million, and one person died of cardiovascular diseases every 10 seconds. Among cardiovascular diseases, hypertension is the most common cause, and its patients have exceeded 250 million. Hypertension causes damage to target organs such as heart, brain and kidney, seriously endangering human health^[3,4,5]。 According to China's coronary heart disease policy model, the number of cardiovascular diseases (angina pectoris, myocardial infarction, sudden death from coronary heart disease and stroke) among people aged 35-84 in China will increase by more than 50% from 2010 to 2030^[4]。 China is now the largest diabetic country in the world, with 114 million diabetic patients, and has become the fastest growing region of diabetes in the world. At present, deaths caused by chronic diseases have accounted for 85% of the total deaths in China, and the burden of diseases caused by chronic diseases accounts for 70% of the total burden of diseases. They are the main reasons for people to become poor due to diseases and fight against poverty due to diseases. If they are not effectively controlled in time, they will bring serious social and economic problems^[2,6]It is also one of the reasons for the increase of doctor-patient contradictions and doctor-patient disputes^[7]。

A 68-year-old female, Han nationality, was admitted to Beijing Jishuitan Hospital on October 28, 2011 due to progressive osteoarthralgia and proteinuria for 2 years. Two years ago, there was no inducement to appear bilateral heel and low back pain when bearing weight, which could be relieved by rest. Examination in outside hospital: blood routine was normal; urine protein (+) (+ +); normal liver function; Creatinine was 106-125 μ mol/L, urea nitrogen was 5.5-6.2 mmol/L, blood calcium was normal, blood phosphorus was 0.63-0.69 mmol/L (normal value 0.81-1.65), and blood alkaline phosphatase (ALP) was 180-235 U/L. Considering "hepatitis B virus-associated nephritis (HBV-GN) is not excluded", renal biopsy was performed, and pathological examination showed that under light microscope, 27 glomeruli, 4 ischemic sclerosis, diffuse mild hyperplasia of mesangial cells and stroma in other glomeruli, granular degeneration of renal tubular epithelial cells, partial epithelial brush margin detachment, lumen dilation, small focal atrophy of tubules, small focal mononuclear lymphocyte infiltration of renal interstitium with fibrosis, diffuse thickening of small arterial wall, and partial lumen stenosis; Immunofluorescence showed that 8 glomeruli were negative for IgG, IgA, IgM, C3, C4, C1q, FRA and HBsAg. Combined with the patient's history of hypertension, the diagnosis: hypertensive renal damage. He was treated with blood pressure control and "piperazine ferulate tablets", but the patient's urine protein continued (+) (+ +), his heel and low back pain progressively worsened, and he could not walk. And bilateral ankle joint, groin area, lower chest wall and shoulder joint pain, accompanied by difficulty in turning over and getting up. No joint swelling. Three months ago, dual-energy bone mineral density performed in a foreign hospital showed the T value of the 1st to 4th lumbar vertebrae-2.8 SD and the T value of the left femoral neck-4.5 SD, and was diagnosed as primary osteoporosis. PET-CT showed increased local metabolism with bone defects in the frontal bone, right zygomatic arch and both inferior pubic branches near the right frontal sinus; Local metabolism of multiple ribs is slightly higher; Systemic bone marrow metabolism is generally slightly increased. Biopsy of bone tissue of right ilium was performed, and no tumor cells were found in pathological examination. One month ago, the other hospital considered bone metastasis of the tumor, and gave intravenous incadronate disodium 10 mg, but the symptoms were not relieved. He was admitted to Beijing Jishuitan Hospital for further diagnosis and treatment. Height becomes 6 cm shorter. There was no significant change in body mass. Previous medical history: 20 years of history of hypertension, treatment with oral amlodipine besylate tablets 5 mg/d, good blood pressure control. Has a history of chronic hepatitis B for 19 years and started oral adefovir dipivoxil 10 mg/d 5 years ago. History of menstrual marriage and childbirth: menarche at 12 years old, menopause at 48 years old. Pregnancy 2 and natural delivery 2. Family history is not special.

A 57-year-old female was admitted to the Department of Neurology of China-Japan Friendship Hospital on August 15, 2014 due to "asymptomatic pontinopathy for 1 week". The patient had repeated fever 5 months before admission, with the highest body temperature of 39.3 ℃, without chills and chills. Blood routine was tested: white blood cells 4.92×10⁹/L, red blood cells 3.37×10¹²/L, hemoglobin 95 g/L, local treatment with cefuroxime, ribavirin, ribavirin and other treatments did not improve, and ferrous sulfate treatment was intermittently given, and hemoglobin 88 g/L was re-examined later. One week ago, the cranial MRI of the outside hospital showed that the volume of the pons was slightly enlarged, and the internal sheet was seen.₁Long T₂Signal, diffusion-weighted image hyperintensity, multiple ischemic foci in bilateral cerebral hemispheres (Figure 1)。 The patient felt fatigued from the onset of the disease, without dizziness, headache, numbness and weakness of the limbs, etc., and lost 10 kg in weight. Past physical health, menopausal for 5 years, personal history, family history is not special. Physical examination: blood pressure 120/70 mmHg (1 mmHg =0.133 kPa), consciousness, anemic appearance, unpalpable swelling of superficial lymph nodes. No dry and wet rales were heard in both lungs, the heart rate was 90 beats/min, the heart rhythm was uniform, no pathological murmur was heard, the abdomen was soft, no tenderness, the liver and spleen were not palpable, and no positive signs were found in the neurological examination.

The 47-year-old female was admitted to hospital on January 13, 2016 with intermittent pain in the left kidney area for more than 1 year. The patient developed pain in the left kidney area after exertion more than 1 year ago, and CT in the outside hospital showed a huge mass in the left adrenal gland area.

The patient, 38 years old, was seen in the outpatient clinic of the First Hospital of Jilin University in February 2014 due to "weakness of both lower limbs for more than 10 years". His mother had no special pregnancy and childbirth. She was born prematurely. She couldn't raise her head at 3 months. She could sit upright with the support of 8 months. She could climb at the age of 1 and walk at the age of 2. She had weakness in both lower limbs 10 years ago, and she could still run and jump. She could walk on a flat road. She was easy to fall when climbing stairs and had a duck-walking gait. Since then, her symptoms have gradually worsened. She couldn't run and jump, so she could only walk slowly on a flat road. No history of epilepsy. Acceptable academic performance. His parents were not intimate married and denied family genetic history. Physical examination: The mind is clear and the language is clear, there are no abnormalities in the cranial nerve examination, the muscle strength of bilateral deltoid muscles, biceps brachii, and triceps brachii is grade IV, the muscle strength of iliopsoas muscles, quadriceps femoris, biceps femoris, and tibialis anterior muscles is grade III, the muscle tension of the limbs is low, the tendon reflex and pathological reflex are not drawn out, the sensory and mutaxial physical examination is not abnormal, and there is no joint contracture. Auxiliary examination: EMG suggested myogenic lesion. Head MRI: bilateral lateral paraventricular, parietal T₁Low signal, T₂High signal, FLAIR high signal (Figure 1)。 Muscle enzyme: Creatine kinase 665 U/L (25-200 U/L).

A 37-year-old female was admitted to the Chest Pain Center of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine in February 2016 due to "sudden chest pain for 2 h"; Past physical health, denied "hypertension, coronary heart disease, diabetes" medical history and family history. Two hours before admission, there was no obvious trigger for sudden retrosternal squeezing pain, and it radiated to the left shoulder. Self-administered "analgesic tablets" were ineffective, so I came to the hospital for treatment. Physical examination showed: heart rate 90 beats/min, blood pressure 95/60 mmHg (1 mmHg =0.133 kPa), coarse respiratory sounds in both lungs, no dry and wet rales, positive Kussmaul's sign, small heart boundary, and grade 2/6 diastolic murmur in the auscultation area of mitral valve. The admission electrocardiogram showed ST segment elevation in Ⅱ, Ⅲ and avF leads (Figure 1), bedside rapid troponin was qualitatively positive. Considering acute inferior wall and right ventricular myocardial infarction, emergency coronary angiography was performed. The results showed that the intima of the left main trunk, circumflex artery and anterior descending artery was smooth and no stenosis was observed. 100% occlusion far from the proximal right coronary artery (Figure 2)。 The contrast catheter was exchanged for a guide catheter (Judkins R 3.0) and a BMW guidewire was fed to successfully pass through the occlusion section; The aspiration catheter was sent to the distal segment of the lesion along the guide wire, and after repeated aspiration, a mass "thrombus" was extracted (Figure 3), and sent for pathological examination. Re-examination showed TIMI blood flow of right coronary artery grade 3, and no plaque burden was observed in the whole course of the blood vessel (Figure 4)。 The postoperative electrocardiogram of the patient showed that the ST segment of the inferior wall lead fell back to the normal level (Figure 5)。 Considering the age of the patient, it is considered that the possibility of coronary artery embolism is high. The coagulation function of the patient was normal, and the levels of anticardiolipin antibody, protein S and protein C were normal; There was no evidence of atrial fibrillation on post-ambulatory electrocardiogram, and echocardiogram showed a hypoechoic mass about 6.5 cm ×4.6 cm ×3.0 cm in size on the left atrial side of the interatrial septum, which was soft in texture and lobulated (Figure 6), and travel between the left atrium and the mitral valve orifice with the heart beat; Anterior mitral flow was mildly restricted during diastole with a flow velocity of 1.6 m/s. The pathological findings of intracoronary embolus in the patient were "myxoma". Combined with the ultrasound results, it was considered that the myocardial infarction was caused by the partial detachment and embolization of atrial myxoma into the right coronary artery. After the patient's condition stabilized, he was transferred to the cardiac surgery department for left atrial space-occupying resection (Figure 7), and the postoperative pathology confirmed that it was consistent with the components of intracoronary embolus (Figure 8)。 Final diagnosis: (1) atrial myxoma; (2) Cardiogenic embolism: acute right ventricular and inferior wall myocardial infarction.

Holter electrocardiogram is a commonly used clinical screening method for cardiovascular diseases. By recording the ECG signals of suspicious patients in their natural life state for more than 24 hours continuously, arrhythmia events and abnormal changes of ST segment that are not easy to detect by conventional electrocardiogram can be found, and important diagnostic evaluation basis can be obtained. In recent years, the clinical application technology of dynamic electrocardiogram has been continuously updated. Through the analysis of indicators such as sinus heart rate oscillation, T-wave electrical alternation, heart rate deceleration force, heart rate variability and ECG scatter plot, it provides more comprehensive and reliable data for the diagnosis and prognosis of related diseases. Among them, the progress in the primary screening of sleep apnea syndrome (OSAHS) by detecting heart rate variability and deriving breathing curve has received a lot of attention^{[1,2,3,4,5,6,7]}。