2016年 · 第55卷第12期

The value of clinical practice guidelines has been deeply rooted in the hearts of people, and most doctors and patients are willing to follow the guidelines for diagnosis and treatment. However, in recent years, the number of guidelines has increased rapidly, and there are multiple guidelines for the same problem, which makes people confused about how to choose. Some experts believe that guidelines restrict individualized treatment and innovation, so they reject guidelines. How to prevent blind unconditional acceptance or total rejection of guidelines? In this issue, Professor Wang Xiaoqin of Evidence-Based Medicine Center of Fudan University wrote the article "Correct Understanding and Application of Clinical Practice Guidelines", which elaborated on related concepts, problems and application principles in the application of the guidelines, hoping to play a reference role and arouse discussion.

The value of clinical practice guidelines has been deeply rooted in the hearts of people, and most physicians and patients are willing to follow the guidelines for diagnosis and treatment. However, the number of guidelines is increasing year by year, and there are multiple guidelines for the same problem, which makes people confused about how to choose. Some experts think that guidelines restrict individualized treatment and curb innovation, so they reject guidelines. Therefore, before applying the guidelines rationally, we should first know some basic concepts and application principles, so as to prevent blind and unconditional acceptance or total denial of these extreme practices.

Proband male, 44 years old. See a doctor for "repeated acral painless ulcers for 27 years"^[1]。 At the age of 17, the proband had painless blood vesicles and skin damage in the hallux of his right foot after walking with weight. The scope gradually expanded and it was difficult to heal. The wound surface had yellow pus. The local hospital diagnosed it as "cellulitis" and the anti-infective treatment was ineffective. Two years later, the right hallux was surgically amputated and the wound healed. Subsequently, the remaining toes of the right foot, left toe, both soles and hands were swollen, the skin was thickened and ulcerated, forming painless damaging ulcers, which gradually developed to the proximal ends of the limbs, and repeated anti-infection and debridement treatments were ineffective. In 2006, bilateral high tibial amputation was performed and prosthetic limbs were installed. The friction site of prosthetic limbs was prone to skin lesions and infection, and both fingers gradually became shorter, without obvious muscle atrophy and muscle strength decrease. The proband is accompanied by fever (about 38℃) and increased skin temperature at the infected site during the onset, and the body temperature can be lowered after treatment with antibacterial drugs. The proband was unable to fasten the buttons accurately before the disease of both fingers (about 20 years old), and he was usually sweaty and had normal defecation.

The patient was a 29-year-old female. He was admitted to hospital on December 12, 2015 with rash for more than 1 month, intermittent fever for 13 days, and migratory polyarthralgia for 8 days. One month ago, there was a patchy red rash on both lower limbs and front chest without obvious trigger, which was not higher than the skin surface, accompanied by itching, without fever, dry mouth, dry eyes, oral ulcer, etc., and went to the local hospital for treatment, diagnosed with eczema, and given topical drug treatment (specific unknown), the itching was relieved compared with before. 13 days ago, after catching cold, he developed fever, fatigue, body temperature 38.5℃, no cough or expectoration, and oral vitamin C Yinqiao tablets (3 times/d, 2 tablets/time, 5 days), but the effect was not good. After that, the fever was intermittent, and the rash gradually involved both upper limbs, showing red patches, and the body temperature fluctuated from 38.5 to 39.0℃. Arthralgia in both elbows appeared 8 days ago, pain in the right gluteal area, right knee and right ankle appeared 7 days ago, and polyarticular migratory pain in the whole body appeared 6 days ago, involving both elbows, wrists, facet joints of both hands, both knees and both ankles, accompanied by fever, body temperature up to 40℃, no chills, morning stiffness, etc. Since the onset of the disease, the patient can eat and sleep, and there is no obvious weight gain or loss. Previous history: Eczema 1 year ago with pronounced pruritus (2 weeks prenatal). Married, 1 son in good health. The history of allergy, personal history, family history, and menstrual history are not special.

June 4, 2016 Official Journal of the American Academy of Gastroenterology (AGA)Clin Gastroenterol HepatolThe research "Similar intestinal flora structural characteristics in patients with diarrheal irritable bowel syndrome and depression" (Liu YX, Zhang L, Wang X, et al. Similar fecal microbiota signatures in patients with diarrhea-predominant irritable bowel syndrome and patients with depression. Clin Gastroenterol Hepatol, 2016.). It was found that patients with diarrhea-predominant irritable bowel syndrome (IBS-D) and depressed patients had similar structural characteristics of intestinal flora, and clinical pathophysiological indexes were correlated with intestinal flora disorders.

Intensifying hypoglycemic therapy to promote blood sugar control is an important measure to reduce and delay the occurrence of microvascular and macrovascular complications in diabetic patients; However, it has been found in clinical practice that intensive hypoglycemic therapy is often accompanied by the occurrence of hypoglycemia, and severe hypoglycemia is often life-threatening if it cannot be identified and treated in time. Studies have shown that the baseline incidence of hypoglycemic events in diabetic patients is 3.1 times/person-year, and the incidence of nocturnal and severe hypoglycemic events is 0.9 times/person-year and 0.3 times/person-year, respectively. Hypoglycemia increases the hospitalization rate and mortality rate of patients^[1]。 However, many medical institutions and patients do not pay attention to the manifestations and harms of hypoglycemia. In 2013, China Health Education Center conducted a questionnaire survey on 639 diabetic patients who attended tertiary A-class hospitals in six provinces in eastern, central and western China^[2]The results showed that the correct answer rate for hypoglycemia was only 18.9%. According to the data from the 2014 survey of hypoglycemia in inpatients in public hospitals at all levels in the UK, only 68% of the respondents determined that they could deal with hypoglycemia events in time, and 56% determined that they could report these events to the diabetes treatment team. A total of 12 serious adverse events of hypoglycemia were reported in 9 medical centers within one year, including 3 deaths, 3 permanent brain damage, 2 epilepsy, 2 cardiac arrest with successful resuscitation, and 2 undefined events^[3]。 Because of the high incidence and harmfulness of hypoglycemia and the insufficient understanding of hypoglycemia in medical institutions and patients, it is necessary to strengthen the training of recognition and treatment ability of hypoglycemia. The following is to help grass-roots doctors further improve their understanding of hypoglycemia through the analysis of clinical cases.

Gastroparesis is a group of chronic symptomatic diseases characterized by slow gastric emptying without mechanical obstruction^[1]。 Because the pathogenesis is unknown, the treatment mode is mostly experience-based palliative treatment, which is not effective and cannot change the natural course of the disease. Fully understanding the nature of the disease is the key to the treatment of gastroparesis. Now, the research progress of the pathogenesis of gastroparesis in recent years is summarized.

malignant middle cerebral artery infarction (mMCAI) refers to the middle cerebral artery (MCA) Most or complete infarction of brain tissue in the corresponding blood supply area caused by proximal or terminal occlusion of internal carotid artery may be secondary to severe brain tissue edema and eventually cerebral hernia^[1]。 mMCAI is a typical stroke subtype of large hemispheric infarction (LHI), accounting for about 5% ~10% of ischemic stroke. It has a high mortality and disability rate, very poor prognosis, and the mortality rate of conservative treatment can reach 80%^[2]。

With the change of lifestyle and the improvement of socio-economic level, the prevalence of hyperuricemia has increased rapidly. Epidemiological surveys show that the prevalence of hyperuricemia in some cities in China has increased from 1.3% to 1.4% in the early 1980s^[1]By 2010-2014, it has increased to 11.06% ~16.90%^[2]。 More and more evidence shows that hyperuricemia is not only the pathophysiological basis of gouty arthritis, but also closely related to hypertension, obesity, cardiovascular and cerebrovascular diseases^[3]While uric acid-lowering therapy may be beneficial to the control of these diseases. The only traditional uric acid-lowering drugs are allopurinol, probenecid and benzbromarone^[4]With the attention to lowering uric acid, a variety of new drugs are developed and marketed. Mastering the mechanism of action and reasonable selection of these drugs is of great clinical significance for the control of hyperuricemia and its complications. According to the mechanism of action, these drugs can be divided into three types: uric acid production inhibitors, uric acid excretion promoters and recombinant uricases. The following is a summary of the three drugs and their representative drugs.

Mercury is a nephrotoxic heavy metal, and proteinuria caused by mercury preparations has been reported as early as 1818. Since 1980s, heavy metal toxic nephropathy has been paid attention in China, among which mercury poisoning is one of the common causes. Mercury poisoning is mainly caused by long-term inhalation of mercury vapor and mercury compound dust in production activities. In recent years, improper medication in the diagnosis and treatment of some diseases, such as oral mercury, inorganic mercury compounds and the use of mercury-containing traditional Chinese medicine remedies, can also lead to mercury accumulation in the body. It is not uncommon to use mercury-containing freckle-removing whitening cream and hair dye to cause non-occupational mercury poisoning. Glomerular disease caused by mercury poisoning most often manifests as proteinuria of varying degrees, and acute tubular necrosis can also occur. Mercury-repellent therapy can achieve complete clinical remission of mercury-toxic glomerular disease. However, the clinical manifestations of this disease lack specificity, and it is easy to be misdiagnosed, misdiagnosed and mistreated. The pathogenesis, clinical and pathological aspects, diagnosis, treatment and prognosis of mercury poisoning-related glomerular diseases are summarized as follows, so as to improve the understanding of these diseases.

Inflammatory bowel disease (IBD) is a chronic non-specific intestinal inflammatory disease. The disease is repeated and prolonged, with a certain disability rate and mortality rate, which has a great impact on the quality of life of patients and causes heavy social and economic burden^[1,2]。 In order to improve the service quality for IBD patients, especially refractory IBD patients, many domestic medical institutions have successively set up IBD diagnosis and treatment centers. Most diagnosis and treatment centers have built a multidisciplinary collaborative team led by gastroenterologists, with the participation of general surgeons, imaging doctors, pathologists and specialist nurses, set up IBD specialist clinics, and formulated IBD diagnosis and treatment routines. Many patients have benefited from it. However, a preliminary survey organized by IBD Group of Gastroenterology Branch of Chinese Medical Association found that the structure, operation and outcome evaluation indicators of IBD diagnosis and treatment centers in China are different, and there is still a certain gap with advanced IBD diagnosis and treatment centers abroad. In order to have "chapters" to follow for the establishment of new IBD diagnosis and treatment centers in China and make the established centers more standardized, the IBD group in China formulated the "Consensus on Establishing Quality Control Indicators of Inflammatory Bowel Disease Diagnosis and Treatment Centers in China" (hereinafter referred to as "Consensus Opinion") and published it in Chinese Journal of Internal Medicine, No.7, 2016^[3]。 This consensus opinion is now interpreted.

[Resource Type] Professional Resources

[Resource type] Professional journals