2016年 · 第55卷第08期

On April 28th, 2016, the journal held a working meeting of the editor-in-chief and deputy editor-in-chief. Experts participating in the meeting discussed how to enhance the attraction of Chinese Journal of Internal Medicine and better play the role of academic leading and guiding clinical practice. They believed that we should pay attention to hot issues in the field of internal medicine and compose manuscripts in time, which not only provided a communication platform for different academic views, but also indicated the academic views of the editorial board. Therefore, this journal launched the "Focus Forum" column, which not only tracks and reports academic hotspots, but also strives to see through the focus. Professor Jia Weiping, the editor-in-chief of this issue, wrote a message from the editor-in-chief "Facts are the foundation, thinking about good strategies" for the opening column. Stay tuned.

On April 28, 2016, a working meeting of the editor-in-chief and deputy editor-in-chief of the Chinese Journal of Internal Medicine was held in the Chinese Medical Association. For this journal, which has been published for more than 60 years, there was a lively discussion on how to better play its role in academic leading and guiding clinical practice. The topics covered annual priorities, reader feedback, development prospects and other aspects. Inadvertently mentioned the 8th edition of the American Dietary Guidelines released not long ago^[1]The target upper limit of controlling daily dietary cholesterol intake at 300 mg was removed on the grounds that the setting of this target value lacked support from epidemiological investigations and evidence-based medical evidence, that is, there is insufficient evidence of a direct link between dietary cholesterol intake and an increased risk of cardiovascular events, and there are few interventional studies supporting that limiting dietary cholesterol intake can reduce the occurrence of adverse cardiovascular events. Just the cancellation of the upper limit of cholesterol intake has triggered new debates and hot spots about cholesterol. Coincidentally, recently, Chinese scholarsN Engl J MedA study of rosuvastatin in perioperative cardiac patients was published, which looked at the effect of cholesterol-lowering therapy on atrial fibrillation and myocardial injury after cardiac surgery. The results showed that compared with placebo, except for the statin treatment group, other benefits were not evident^[2]。

Cholesterol is one of the essential nutrients in human body. It has physiological functions such as maintaining the structure and function of biofilms, participating in the formation of brain and nerve tissues, and is also a synthetic vitamin D₃Cholic acid and sterol hormones (such as aldosterone, cortisol, testosterone, estradiol and progesterone) are important raw materials. The main sources of cholesterol in the body are synthesized in the body and taken through food. Disorders of cholesterol metabolism in the body and/or excessive intake of dietary cholesterol can cause elevated blood cholesterol levels. A large number of animal experiments and population trials have shown that abnormal elevation of blood TC and LDL-C is the primary risk factor for atherosclerosis and coronary heart disease; The change trend of total blood cholesterol level directly affects the incidence of coronary heart disease; Reducing blood cholesterol level is the fundamental measure to resolve atherosclerotic plaque and prevent and treat coronary heart disease. As one of the factors affecting blood cholesterol levels, how does dietary cholesterol affect cardiovascular disease? How much cholesterol should you consume every day? How to understand the lifting of cholesterol restrictions in the new dietary guidelines in the United States? The following will explain the research progress of dietary cholesterol intake and cardiovascular diseases.

Dyslipidemia is an important risk factor for atherosclerotic cardiovascular disease (ASCVD), and active cholesterol-lowering therapy is regarded as one of the core strategies for the prevention and treatment of ASCVD. However, the recent publication of some literatures and the one-sided interpretation of some media have made people controversial about cholesterol-lowering treatment strategies. The author will talk about his own views in combination with these topics.

Clinically, over-treatment and over-diagnosis have become the concerns of doctors and patients. For example, over-diagnosis and over-treatment of thyroid cancer, prostate cancer, asymptomatic carotid stenosis and other diseases not only make patients feel psychological fear, waste huge health resources, but also bring many treatment complications to patients, and even die due to surgical complications. So how can we reduce over-diagnosis and over-treatment?

The patient was a 55-year-old male. He had a history of acute myocardial infarction and was 2 years after percutaneous coronary intervention (PCI). In October 2014, the patient suffered from severe abdominal pain and went to a local hospital for gastroscopy. Pathological biopsy showed that some glands were highly dysplasia and cancerous. The patient went to our hospital for surgical treatment, and the pathological consultation in our hospital showed moderately differentiated adenocarcinoma of the stomach. He was admitted to the hospital on 29 March 2015. On April 2, 2015, we underwent laparoscopic-assisted radical total gastrectomy and Roux-en-Y esophagojejunostomy in our hospital. Postoperatively, one drainage tube was placed in the subhepatic and splenic fossa.

The patient was a 25-year-old female. The main cause was "abdominal pain for 2 days, stopping defecation and exhaustion for 1 day", and he was admitted to our hospital for the first time on December 7, 2008. The patient first developed abdominal pain 10 years ago, and the local hospital treated it as "intestinal obstruction" and improved. Since then, I have repeated abdominal pain several times, and I am dependent on opioid analgesics. The local hospital performed laparotomy for "acute abdomen" many times, but no abnormalities were found. 2 days ago, the patient developed total abdominal paroxysmal colic due to dysmenorrhea taking "painkillers", which had nothing to do with postural changes, accompanied by nausea, vomiting, stopping defecation and exhaustion, without fever, and was admitted to our hospital with "intestinal obstruction" in the emergency department. Admission physical examination: heart rate 160 beats/min, blood pressure 150/95 mmHg (1 mmHg =0.133 kPa); Sleepiness; No obvious abnormalities in heart and lung were observed; The abdomen is flat, with multiple surgical scars, tenderness in the whole abdomen, no rebound pain and muscle tension, and hyperactivity of intestinal sounds; The muscle tone was roughly normal, and the pathological signs were negative. Auxiliary examination: There were no obvious abnormalities in blood routine and liver and kidney function, only mild hyponatremia (blood Na^＋127 mmol/L). Abdominal CT: gas and fluid accumulation in the intestine. Considered as incomplete intestinal obstruction, given conservative treatment of fasting water and fluid rehydration, abdominal pain did not improve, and morphine injection was required every 2 to 4 hours. After asking the patient's medical history, abdominal pain mostly occurs in the premenstrual or menstrual period, and emotional agitation and taking drugs can be induced. During the attack, the urine occasionally appears dark red. After this admission, the urine was burgundy red after being exposed to light for 30 min. In the family history, his mother and uncle were lost due to mental disorders. Combined with the symptoms, signs and family history of the patient, it is considered that acute intermittent porphyria is more likely. Send to Peking Union Medical College Hospital for urinary porphyrogen positive, intracellular zinc porphyrin (FEP) 3.5 μ g/g Hb (normal range ≤3 μ g/g Hb), uroporphyrin negative. The patient was diagnosed with acute intermittent porphyria. He was transferred to the hematology department on 10 December 2012 for continued treatment. On the same day, cimetidine 0.4 g intravenously once/8 h and hydrocortisone 100 mg intravenously once/12 h were given. After 2 days, the patient's mental symptoms improved, and he had defecation and exhaustion. Abdominal pain was completely relieved on 14 Dec. Hydrocortisone was reduced to 75 mg intravenously once/24 h and cimetidine was reduced to 0.6 g intravenously once/24 h until 1 week after relief. After discharge, the patient was advised to take cimetidine orally daily, but the patient only received oral cimetidine 0.2 g 2 times/d prophylaxis 7 days before menstruation. After that, for more than one year, the patient had repeated acute attacks of porphyria, which was induced by drugs, emotional agitation and fatigue. After each treatment with cimetidine, the clinical symptoms were mostly completely relieved in about 3 days. The patient was last hospitalized on 9 March 2014. 10 days before admission, he experienced abdominal pain again due to emotional agitation. The effect of oral cimetidine at home was poor, and the abdominal pain did not relieve. Admission physical examination: heart rate 150 beats/min, blood pressure 185/60 mmHg; Fuzzy consciousness; The urine is dark red. Blood biochemistry: albumin 24.3 g/L, ALT 47 U/L, lactate dehydrogenase 994 U/L, hydroxybutyrate dehydrogenase 1 017 U/L, myoglobin 176 mg/L, creatinine 716 μ mol/L, Na^＋131 mmol/L, K^＋6.05 mmol/L. On the day of admission, the patient's blood pressure and heart rate dropped rapidly, and he died of multiple organ failure two days after being transferred to ICU.

The patient was a 55-year-old male. He was admitted to our hospital on December 4, 2014 due to "immobility of left lower limb for 2 days". Two days before admission, the patient suddenly experienced inconvenience of movement of the left lower limb and clumsy walking without clear trigger, which persisted without relief. MRI of the head showed acute cerebral infarction of right frontoparietal junction cortex and bilateral parietal lobes (Figure 1)。 Blood routine on December 3: white blood cells 25.9×10⁹/L, eosinophil count 13.5×10⁹/L, eosinophil ratio 0.520, Hb 126 g/L. Previous history: 1 year of eosinophilia, current oral methylprednisolone 8 mg/d. History of hypertension, diabetes and coronary heart disease was denied. Deny smoking, drinking history. Admission physical examination: body temperature 36.2℃, heart rate 80 beats/min, blood pressure 131/78 mmHg (1 mmHg =0.133 kPa), breathing 18 beats/min; Conscious and fluent in speech; Soft neck, negative meningeal irritation sign, normal high cortex function; The bilateral pupils are equal in size and round, with a diameter of 3 mm, sensitive to light reflection, full movement of both eyeballs in all directions, no diplopia and nystagmus, and the remaining cranial nerves are normal; Extremity muscle strength grade V, left biceps brachii reflex, triceps brachii reflex, radial periosteum reflex, knee tendon reflex, Achilles tendon reflex (+ + +), right biceps brachii reflex, triceps brachii reflex, radial periosteum reflex, knee tendon reflex, Achilles tendon reflex (+ +), bilateral pathological signs were negative, bilateral finger-nose test and heel-knee-tibia test were stable and accurate, and bilateral depth-shallow sensation symmetry was normal.

Kaposi's sarcoma (KS) is a rare endothelial cell-derived, vasoproliferative soft tissue malignant tumor. The iatrogenic type associated with immunosuppressive therapy is usually seen in renal allograft recipients. A case of KS after immunosuppressive therapy for membranous nephropathy is reported.

March 2016J Int AIDS SocA cross-sectional study "Prevalence of co-infection with hepatitis B and C viruses among HIV-infected people in China" led by Professor Li Taisheng from the Department of Infectious Medicine, Peking Union Medical College Hospital and involving 22 domestic research centers was published online [Xie J, Han Y, Qiu Z, et, al. Prevalence of hepatitis B and C viruses in HIV-positive patients in China: a cross-sectional study. J Int AIDS Soc, 2016, 19 (1): 20659.]. This study, funded by the "Twelfth Five-Year Plan" major science and technology project (2012ZX10001003-001) and the National Natural Science Foundation of China (81071372), reported for the first time the prevalence of HIV co-infection with hepatitis B and C viruses and the characteristics of liver diseases among untreated HIV infected patients in China.

diabetic foot (diabetic foot) has a high rate of disability and mortality, and is the main reason for hospitalization of diabetic patients. In China, diabetic foot ulcer has become the main cause of chronic wounds^[1]The annual incidence rate was 8.1%, the annual amputation rate was 5.1%, and the annual mortality rate was 14.4%^[2]。 In tertiary A hospitals, 27.3% of amputations were due to diabetic foot, accounting for 56.5% of non-traumatic amputations; In addition, diabetic foot patients spend huge amounts, approximately twice as much as non-podiatric patients^[1]。 Therefore, diabetic foot imposes a great burden on patients, families and society. Although the treatment of diabetic foot is difficult and expensive, if clinicians conduct standardized screening and management of diabetic foot, diabetic foot can be prevented and cured. The following is a clinical case, and the standardized diagnosis and treatment of diabetic foot is discussed from the identification of high-risk factors of diabetic foot, classification evaluation, diagnosis, treatment technology selection, etc. combined with the guidelines and the actual situation in China.

amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease of unknown etiology that selectively involves the anterior horn of the spinal cord, the motor nucleus of the brainstem, and the motor cortex of the brain. It is characterized by progressive exacerbation of limb weakness, muscle atrophy with pyramidal tract sign, with bulbar symptoms such as unclear speech and dysphagia. Respiratory muscle involvement may lead to dyspnea, nighttime sleep apnea, and eventually respiratory failure^[1]。 Due to the great heterogeneity of the phenotype of this disease and the lack of "gold standard" in clinical diagnosis, there is a great difference in the delay time between the onset of patients and the diagnosis, Logroscino et al.^[2]reported diagnostic delays of 240 to 389 d in different regions of continental Europe, Wijesekera et al.^[3]It is reported that the median diagnostic delay in the UK is 14.7 months, and a recent study in China shows that the median diagnostic delay in China is 14.0 months^[4]。 Therefore, the study of biomarkers of ALS is of great significance for early diagnosis and disease assessment. It is urgent to find valuable markers in clinical practice to shorten the diagnosis delay and evaluate the treatment and prognosis. Therefore, it has become one of the most important hot spots in the current ALS research field^[5]。 The research progress of gene, biochemistry, electrophysiology and imaging is briefly introduced as follows.

acute myocardial infarction (AMI) is a common critical disease in internal medicine, and its primary cause is coronary atherosclerosis heart disease (CAHD). In recent years, AMI caused by non-coronary atherosclerotic diseases has gradually received attention. From the imaging point of view, non-coronary atherosclerotic AMI mainly includes the following two conditions: (1) AMI is well diagnosed, and coronary angiography shows no obstruction of infarction-related coronary arteries. This condition is called non-obstructive coronary atherosclerotic AMI, with an incidence rate of 5% to 25%, and is more common in young people and women (18% to 35%)^[1,2,3]。 (2) Coronary angiography is abnormal, but according to clinical data, the lesion is confirmed to be non-coronary atherosclerotic disease, and the patient often suffers from systemic diseases. The potential etiology of non-coronary atherosclerotic AMI is varied, clinical characteristics and prognosis are different^[4]The etiology, epidemiological characteristics, diagnosis and treatment strategies and prognostic characteristics are summarized as follows.

IgG₄Related disease (IgG₄-related disease, IgG₄-RD) is a newly defined class of diseases that can cause multiple organ inflammation with fibrosis and sclerosis, with diffuse or focal organ enlargement as the main clinical manifestation, with or without serum IgG₄The typical histological features were lymphoplasmocyte infiltration, matted fibrosis, phlebitis obliterans, and IgG₄⁺Plasma cells are increased, and the treatment with glucocorticoids (hereinafter referred to as hormones) is effective.

With an estimated 12 million patients worldwide, autosomal dominant polycystic kidney disease (ADPKD) ranks 4th among kidney replacement therapy etiologies^[1]。 In recent years, great progress has been made in the research of ADPKD molecular genetics, biology, disease diagnosis and treatment. However, there are differences in diagnosis, evaluation, prevention and treatment among countries, and there are no widely accepted practice guidelines at present. At the end of 2014, kidney disease improving global outcome (KDIGO) convened multidisciplinary clinical experts around the world on ADPKD for a lively discussion, and reached a consensus on scientific research, clinical diagnosis and treatment, and preventive health care.

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