2017年 · 第97卷第37期

International Consensus on the Management of myasthenia gravis (MG) (2016)^[1]The International Consensus (hereinafter referred to as International Consensus) follows the Japanese Guide^[2]European Guide^[3,4], UK Guide^[5,6]And China Guide^[7]After the most complete and innovative treatment management consensus. This article will interpret the innovation of this consensus in MG treatment and its impact on the treatment of MG patients in China.

Uterine rupture is a serious complication of obstetrics. If it is not discovered in time and dealt with decisively, it will endanger the life of mothers and infants. Quick and timely diagnosis is of great significance to clinical active treatment. The Children's Hospital affiliated to Jiaxing University retrospectively analyzed the case data of 7 patients with uterine rupture confirmed by surgery between June 2009 and March 2016, and compared the preoperative ultrasound diagnostic images and clinical surgical results, aiming to explore the significance of ultrasound in rapid diagnosis of uterine rupture in pregnancy. The results are reported below.

The 21-year-old female was admitted to the First Affiliated Hospital of PLA General Hospital on July 13, 2015 due to repeated lumbosacral pain and multiple joint swelling and pain accompanied by fever for more than one year. The patient has experienced lumbosacral pain without trigger since February 2014, which occurs at night and can be relieved with slight activity, accompanied by morning stiffness for about 30 min. At the same time, there was intermittent fever, with a maximum body temperature of 38.5 ℃, and no chills and chills. Later, swelling and pain of shoulder and knee joints and limited movement appeared. Visited a hospital affiliated to a medical university, and was given total glycosides of paeony paeony capsules, sulfasalazine enteric-coated tablets orally and infliximab intravenously (the first dose was 3 mg·kg) according to "ankylosing spondylitis"^－1• d^－1and administered the same dose once each at the end of Week 2 and Week 6). At first, the above symptoms were significantly alleviated, but after 3 months, the symptoms worsened again, resulting in difficulty in walking and self-care. After several adjustments of the types and dosages of oral drugs, the symptoms did not improve significantly, so infliximab was adjusted to 5 mg · kg^－1• d^－1Once every 8 weeks, the course of treatment was about 1 year, and the improvement of symptoms was not obvious. During the course of the disease, in October 2014, he developed blurred vision in his right eye. He went to a hospital in Beijing and was diagnosed with papilledema and papillitis. After being injected with hormone bulbs, his symptoms improved slightly. In late June 2015, blurred vision in both eyes appeared, obviously in the right eye, and the symptoms did not improve after hormone bulb injection, followed by general numbness after sitting for a long time, transient loss of consciousness (consciousness became clear on its own for about 2 to 3 minutes) and labor in urinating and defecating. The body weight has been reduced by 15 kg in the past 1 year. The past history is not special, and his father has a history of "ankylosing spondylitis". Physical examination at admission: temperature 36.5 ℃, pulse 72 beats/min, breathing 18 beats/min, blood pressure 114/70 mmHg (1 mmHg =0.133 kPa). Edema of the right eyelid, subbulbar conjunctival hemorrhage (occurring after retrobulbar injection in the external hospital). Subcutaneous induration about 4 cm in diameter in the posterior part of the right occipital, tough in texture, no tenderness, and poor mobility; There were no obvious abnormalities in heart, lung and abdomen. Both shoulder joints are not swollen, with tenderness and limited lift. Both the bilateral four-word test and pelvic squeeze test were positive, and the straight leg elevation test was negative. The positional sensation of both lower limbs and lumbosacral region was normal, the reflexes of knee tendon and biceps tendon were not drawn out, and the Buchner sign, Babinsky sign and Hoffman sign were all negative.

The patient was a 73-year-old female with a history of primary Parkinson's disease for 8 years, mainly tremor in the limbs, switching phenomenon and dyskinesia for 1 year, and hypertension was denied. On physical examination, the muscle tone of the limbs was slightly increased, accompanied by quiescent tremor. Head MRI showed mild brain atrophy. Medications include dopaserazide tablets, carbazolidopa controlled-release tablets, entacapone, selegiline, amantadine, and pramipexole. The patient was admitted to the First Affiliated Hospital of Dalian Medical University on March 9, 2015. Surgery is strongly required due to the seriousness of drug-related complications. Bilateral microelectrode recordings were recorded once each during the operation. On the postoperative day, head CT showed obvious intracranial gas accumulation (FIG. 1A)。 Six days after surgery, head MR showed bilateral frontal subdural effusion (FIG. 1B), with a maximum width of about 1.96 cm. There was no significant electrode displacement. The patient had no new neurological symptoms and signs, and conservative treatment promoted hematoma absorption. Head MR was re-examined before program control at 4 weeks postoperatively (Figure 1C), with a large circulation mode, a pulse width of 90 μ s, a frequency of 110 Hz, and a voltage gradually increasing to 1.8 V, the patient experienced obvious stimulus-related adverse reactions as emotional uncontrolled crying. Adverse reactions disappeared after changing to small circulation stimulation mode. Three months after surgery, the head CT reexamination showed that the bilateral frontal subdural effusion was absorbed significantly (Figure 1D)。

Itraconazole (ITZ) is a second generation triazole broad-spectrum antifungal drug, which is widely used in various superficial and deep fungal diseases. It mainly acts on ergosterol synthase, a key enzyme on fungal cell membrane, and exerts antifungal effects^[1]。 Itraconazole is weakly basic, pK_a=3.7, ionizable only in acidic solution, while being fat-soluble, proteophilic and extremely low solubility in water. Because of its low solubility and good intestinal permeability, it is classified as Class II drug in the classification of biological drugs. The dissolution degree of drugs in digestive juice has a great influence on drug absorption^[2]。 Itraconazole oral liquid and capsule preparations are widely used all over the world, and oral liquid dosage forms are mainly used for patients with hematological tumors^[3]Children^[4], oral and esophageal candidiasis patients^[5]The capsule formulation is used in people with normal swallowing function. However, the bioavailability of oral itraconazole in human body is very low, especially in capsule preparations. After oral administration of 200 mg capsules in healthy adults, if all of them are absorbed, the theoretical blood concentration is about 5×10 based on 4 000 ml of blood⁴ng/ml, while the peak value of itraconazole in blood was only about 270 ng/ml^[6]。 Due to the low solubility of itraconazole itself and the first-pass effect, the drug is mostly inactivated and metabolized in the mucosa of the digestive tract and the liver. In the elderly and patients with gastrointestinal dysfunction, gastric acid secretion is reduced. Due to decreased absorption function, the effect of oral itraconazole is not good, and it is often necessary to increase the dose or prolong the course of treatment, causing psychological and economic burden. Therefore, how to improve the bioavailability of oral itraconazole has become a concern for clinicians and researchers, and in some research reports, food has a significant effect on the bioavailability of itraconazole (Table 1), the research progress in this aspect is summarized as follows.