2018年 · 第98卷第20期

Pituitary adenomas are common benign tumors in the cranium, most of which show the expansive growth characteristics of benign tumors, and most of them can be cured by surgery or drugs. However, a small number of pituitary adenomas are insensitive to conventional surgery, radiotherapy and drug therapy, and the tumor continues to grow in size. This part of the tumor is called refractory pituitary adenoma^[1,2]。 Further subarachnoid metastasis or distant metastasis is pituitary adenocarcinoma^[3]。 Whether it is refractory pituitary adenoma or pituitary adenocarcinoma, its diagnosis and treatment are very difficult. The tumor seriously affects the quality of life of patients, even threatens life, and the prognosis is extremely poor. In January 2018, the European Endocrinology Society issued the Guidelines for the Diagnosis and Treatment of Refractory Pituitary Adenomas and Pituitary Adenocarcinoma (hereinafter referred to as the Guidelines)^[4], aiming to provide standardized clinical guidance for the diagnosis, treatment and follow-up of refractory pituitary adenomas and pituitary adenocarcinomas. Summarize the important recommendations provided in the guidelines, including: (1) the diagnosis and treatment of patients with refractory pituitary adenoma and pituitary adenocarcinoma should be the responsibility of multidisciplinary collaborative (MDT) multidisciplinary teams; (2) tumor specimens need histopathological analysis, including pituitary hormones and proliferation markers, and if necessary, staining for transcription factors for correct tumor classification; (3) Temozolomide monotherapy is the first-line treatment for refractory pituitary adenoma and pituitary adenocarcinoma; The efficacy can be evaluated after 3 cycles; (4) In patients with temozolomide sensitivity, continuous treatment is recommended for at least 6 months. In addition, the guidelines provide detailed treatment recommendations for patients who relapse after temozolomide treatment, patients who are insensitive to temozolomide, and patients with systemic metastases. The interpretation and comments of the guide in this article are as follows.

Sleep apnea hypopnea syndrome (SAHS) is a common and chronic disease. In recent years, many new understandings have emerged about SAHS in the elderly, which has important guiding value for the clinical management of this type of patients^[1,2]。 First of all, sleep dyspnea in the elderly has many characteristics different from young and middle-aged patients in etiology and clinical manifestations, and its identification and clinical diagnosis and treatment are special. Secondly, does sleep breathing disorders in the elderly lead to a series of serious clinical consequences like young and middle-aged patients? Do they all require active treatment? These are uncertain. Thirdly, the occurrence of sleep breathing disorder is closely related to the life process of aging. So is sleep breathing disorder in elderly patients a continuation of the disease of young patients, or is it an independent, age-related life phenomenon? The understanding of these problems is briefly explained below.

Evidence-based practice guidelines are guiding recommendations (recommendations) based on a systematic review (body of evidence) and balancing the pros and cons of different interventions to provide the best health care for patients. In view of its importance in clinical decision-making and wide application, the formulation of guidelines has become a hot topic in medical circles at home and abroad. World Health Organization (WHO)^[1]International Guide Alliance (G-I-N)^[2]National Institute for Clinical Optimization (NICE)^[3]Rules and Guidelines Research and Evaluation Tools for the Development of Guidelines have been published (Appraisal of Guidelines Research and Evaluation in Europe, AGREE) Ⅱ^[4]Evaluate the published guidelines to recommend good quality guidelines for clinical use.

In the past 20 years, both physicians and patients have recognized the importance of clinical practice guidelines, so the number of guidelines has increased year by year. From 1993 to 2016, a total of 664 guideline articles were published in domestic medical journals, but most of them were consensus of experts, and there were few evidence-based guidelines based on systematic reviews; The average number of references for domestic guidelines is 36, compared to 400 for international guidelines; Conflict of interest is a serious problem, with 88% of guidelines having no conflict of interest statements^[1]So the quality of domestic guidelines is generally low. Moreover, there are multiple guidelines for the same problem, and the recommendations of multiple guidelines may be different, so doctors don't know how to choose. Therefore, it is very important to establish an evaluation system for the quality of guidelines, which helps clinicians to choose high-quality guidelines to guide clinical practice, and also helps guidelines formulators to formulate guidelines in a standardized way.

Health economics evidence during guideline development^[21,22]Is advocating for reporting. From the current situation, there is still a lack of health economics research results on TUPKP itself and comparison of TUPKP with other surgical treatments; At the same time, there is a lack of real RCT or high-quality RCT between laser surgery such as DiLEP. Therefore, future research in this area is needed. Furthermore, the current state advocates the localization of recommended diagnosis and treatment equipment^[23]At present, there is still a lack of evidence on the efficacy and safety of domestic TUPKP equipment in the treatment of BPH and comparison with imported TUPKP equipment in the treatment of BPH. This is also the research direction that needs to be carried out in the future. Third, the current evidence results from domestic and foreign populations suggest that TUPKP in the treatment of BPH is particularly relevant to the clinical experience of physicians. The more clinically experienced physicians will have better results with TUPKP. Although our country has been doing fruitful work in the training of physician skills, there is still a lack of relevant research results reports on the physician population in our country. Fourthly, patient values/preferences are one of the three elements of evidence-based decision-making. The development of this guideline did not conduct a survey of patient values/preferences. Next, the team developing this guideline will conduct a survey of preferences and values of patients who have undergone TUPKP surgery to prepare for the update of this guideline. Fifth, for the high cardiovascular risk/elderly population, there is currently a lack of research on comparing TUPKP with other surgical treatments; There is still a lack of relevant research on people taking anticoagulants, which is also a work that needs to be carried out in the future.

The 2017 edition of the World Health Organization (WHO) pituitary tumor classification has been released recently^[1]In addition to the typing supplement of pituitary adenoma by emphasizing the mechanism of pituitary differentiation, the most important point is the abolition of "atypical pituitary adenoma" (APA) and the proposal of "refractory pituitary adenoma" (refractory pituitary adenoma). At present, there is no clear definition at home and abroad for the incidence, diagnostic criteria, treatment methods and follow-up of refractory pituitary adenoma and pituitary adenocarcinoma. The European Journal of Endocrinology published the Guidelines for the Diagnosis and Treatment of Refractory Pituitary Adenomas and Pituitary Adenocarcinomas of the European Endocrinology Association in Issue 1, 2018^[2]The aim is to provide clinical guidelines for the diagnosis and treatment of clinically refractory pituitary adenoma and pituitary adenocarcinoma.

Children with limb bone tumors, pathological fractures and chronic osteomyelitis are increasing year by year. Intramedullary fixation of autologous fibula graft and bone defect filling are considered to be an ideal material and surgical method, and have been widely used in clinical practice; However, partial amputation of fibula may cause different degrees of movement pain of donor ankle joint, weakening of lower limb muscle strength, and even cause ankle deformity and dysfunction. Its long-term effects have been paid more and more attention^[1]。 In this study, 12 patients were surgically treated by modified periosteum-sparing fibula free graft, which is now reported below.

A 36-year-old female, primary school teacher, was admitted to the Department of Endocrinology of Peking Union Medical College Hospital on May 11, 2015 due to "face turning round and red for 4 years and menstrual disorder for 1 year". In May 2011, the patient's face became rounded and red, waist circumference increased, weight increased by 10 kg (44 kg to 54 kg) within one year without obvious inducement, accompanied by broad purple lines on the abdomen and inner thighs, vellus hair on the back, small beard on the lips, and ecchymosis easily appeared when the skin bumped. In February 2014, the patient developed menstrual disorders (menarche 12 years old, menstrual days 5-7 days, menstrual cycle 28-30 days), menstruation 1-2 days, low menstrual flow, and the cycle prolonged to 40-60 days. In April 2015, the patient visited the outpatient clinic of our hospital, and 24-hour urinary free cortisol (24-hour UFC) was checked at 2 677.09 nmol/24 h, and was admitted to our hospital for further diagnosis and treatment. Since the onset of the disease, the patient is mentally tired, his skin color is deeper than before, his diet is normal, his sleep is good, his defecation is normal, his weight has increased by 2.5 kg in the past 1 year, and his height has not become significantly shorter. There were no special findings in the remaining medical history.

The patient was admitted to the hospital on September 11, 2017, 16 hours after birth, because "the muscle tone of the limbs was increased for 16 hours". The child is the 3rd and 2nd birth, gestational age 39^＋5Zhou was delivered by vaginal delivery at 17:03 on 10 September 2017, with a birth weight of 3 450 g; Apgar score: 1 min score: 9 points (1 point deducted for crying), 5 min score: 10 points; Amniotic fluid is clear, the amount is normal, there is no umbilical cord around the neck, and there is no premature rupture of membranes; After birth, the child presented with persistent increased muscle tone of the limbs. The parents of the child are from Guizhou Province, both of Dong nationality, and they are not married by close relatives. The pregnant mother had a history of threatened abortion at 4 months of pregnancy, low risk of Down's syndrome screening, and no obvious abnormalities were found in fetal three-dimensional ultrasound; The father is in good health and has a history of smoking and drinking; The mother is in good health and has two marriage history. The first marriage has a healthy 7-year-old girl, and she had one induced abortion in 2016. The child is the first child of the mother after remarriage. Physical examination of the child: body temperature (T) 37 ℃, heart rate (P) 140 beats/min, breathing (R) 50 beats/min, blood pressure 74/38 mmHg (1 mmHg =0.133 kPa); Body mass 3 320 g, percutaneous oxygen saturation (SpO₂) 95%, head circumference 32.5 cm, body length 50 cm; Sleepiness, irritability, smooth breathing, rosy skin, normal head shape; A 3 cm ×5 cm mass can be palpable on the left top, with a clear boundary, does not cross the suture, and has a fluctuating feeling when touched; The anterior fontanel is flat and soft, about 0.5 cm ×0.5 cm in size; Facial appearance without deformity; There were no abnormalities in the heart, lungs, abdomen and external genitals. Increased muscle tone, rated as grade 4 according to the modified Ashworth classification (stiffness): hands clenched in fist shape, thumb adducted, index finger flexed tightly inside, upper limbs flexed against the chest, lower limbs rigid, and toes flexed in hook shape. The sucking reflex is weak, and the foraging and hugging reflexes are not elicited.

The latest data from the National Cancer Center show that China is a country with a high incidence of gastric cancer, and the morbidity and mortality rate rank second among all cancers^[1]The number of morbidities and deaths accounts for about 50% of the world's total. An epidemiological survey of more than 20,000 cases of gastric cancer shows that the 5-year survival rate (OS) of gastric cancer in China is only 27.4%^[2]While data from the SEER database in the United States show that the participation of postoperative adjuvant chemoradiotherapy prolongs the survival of patients with stage II to IV operable non-metastatic gastric cancer^[3]。 At present, the status of radiotherapy in the adjuvant treatment of gastric cancer in China is still controversial. Some domestic scholars believe that gastric cancer surgery in the United States has not generally reached the level of D2 radical resection, but the proportion of D2 radical resection in INT-0116 study, which established the status of adjuvant radiotherapy and chemotherapy after gastric cancer surgery, is 9.6%^[4]。 However, although D2 radical resection is recommended as the standard surgical procedure for local advanced gastric cancer in China, judging from many published articles, even in the best gastric cancer diagnosis and treatment centers in China, the proportion of actual acceptance of standard D2 radical resection in clinical practice is only about 50%. Therefore, it is very urgent to clarify the scientificity and necessity of adjuvant radiotherapy after radical gastrectomy in China.