2017年 · 第56卷第01期

Time flies, and in a blink of an eye we have 2017 again! I sincerely thank the readers and authors who have cared and supported this journal in the past year, as well as the editorial board and reviewers who have worked hard for this journal! In the new year, we will carefully plan and compose manuscripts, and strive to provide wonderful and practical content for our clinicians. Welcome to stay tuned.

Thyroid hormones are crucial to maternal fetus and are directly related to pregnancy outcome and the intellectual development of offspring. Previous studies of our research group showed that the prevalence of thyroid disease in women in the first trimester of pregnancy was as high as 17.6% (unpublished data). Studies at home and abroad have found that thyroid disease during pregnancy can lead to an increased risk of pregnancy complications such as miscarriage and premature delivery, and a decrease in IQ of offspring. Therefore, the prevention and treatment of thyroid diseases during pregnancy is the key issue in the field of prenatal and postnatal care at present, among which subclinical hypothyroidism (hypothyroidism) and hypothyroxinemia (low T₄The diagnostic criteria of subclinical hypothyroidism and the treatment of subclinical hypothyroidism are controversial issues.

The morbidity and mortality of atherosclerotic cardiovascular disease (ASCVD) are increasing in China, which has become an important public health problem in China. As the most widely used antiplatelet drug, aspirin has been confirmed by a large number of clinical studies in the prevention and treatment of ASCVD. "Clinical application of aspirin in atherosclerotic cardiovascular disease: Chinese expert consensus (2005)"^[1]It has been published for 10 years. In the past 10 years, a number of clinical studies and guidelines for aspirin have been published. In order to better standardize the clinical application of aspirin, combined with the latest international guidelines and China's national conditions, the Geriatrics Branch of Chinese Medical Association has taken the lead in organizing multidisciplinary experts. On the basis of the 2005 edition consensus, the consensus was revised and updated. This update is more comprehensive and detailed than the 2005 version of the consensus. The following will focus on "Clinical Application of Aspirin in Atherosclerotic Cardiovascular Diseases: Chinese Expert Consensus (2016)" (referred to as the new consensus) from three aspects.^[2]The contents are briefly interpreted.

Differentiated thyroid cancer is a special cancer with relatively indolent biological behavior, accounting for the vast majority (>90%) of thyroid cancer, and its 10-year survival rate is>90%^[1]。 According to U.S. data, the annual incidence of thyroid cancer increased from 4.9/100,000 in 1975 to 14.3/100,000 in 2009, and the vast majority of the increased cases were papillary thyroid cancer (PTC); Moreover, the data show that 23% of thyroid cancers diagnosed in 1988 were microcarcinomas smaller than 1 cm, and the incidence of microcarcinomas accounted for 39% of thyroid cancers in 2008^[2]。 According to data released by cities such as Hangzhou, Shanghai and Tianjin in China, thyroid cancer ranks third among female malignant tumors and has become the fastest-increasing malignant solid tumor. This is inseparable from the extensive development of early diagnosis techniques such as ultrasound, CT and fine needle puncture. The most obvious example is that in 1999, the Korean government launched a nationwide medical examination program, which included neck ultrasound. The results showed that the incidence of thyroid cancer increased 15-fold in 16 years, making thyroid cancer the most common cancer in South Korea in one fell swoop. In fact, the number of thyroidectomies (total or partial thyroidectomies) in the United States rose by 60% between 1996 and 2006. Thyroidectomy may bring complications, mainly parathyroid damage (3% ~5%) and recurrent laryngeal nerve damage (1% ~5%). Patients undergoing total and partial thyroidectomy must take thyroxine replacement or even suppression therapy for the rest of their lives, which itself carries certain health risks and costs. For a time, the discussion and debate about over-diagnosis and over-treatment of thyroid cancer maintained a high heat in all walks of life, which has never occurred in other cancers. As a thyroid surgeon, the author believes that from a national perspective, there are insufficient treatment, irregular treatment and overtreatment in the treatment of thyroid cancer.

At present, the incidence of thyroid cancer is increasing in all countries in the world^[1,2]。 The incidence of thyroid cancer in the United States has nearly tripled in the past 40 years. If this growth rate continues, it is expected that thyroid cancer will become the fourth most common cancer in the United States by 2030^[3,4]。 Statistics from the Korea Cancer Registry show that the incidence of thyroid cancer in South Korea increased nearly 10-fold between 1999 and 2013^[5]。 The incidence of thyroid cancer in China also increased nearly three times between 1988 and 2009^[6]。 However, the mortality rate of thyroid cancer did not increase with the increase of morbidity. The mortality rate of thyroid cancer in Spain, Japan, the United States and other countries has not changed significantly in recent 40 years^[4,7]； The age-standardized mortality rate of thyroid cancer in Korea increased only slightly between 1999 and 2013^[5]。 Such conflicting findings have raised concerns in the medical community about the existence of "excessive medical behavior" in the diagnosis and treatment of thyroid cancer. Vaccarella et al.^[2]It was found that there may be "overdiagnosis" of thyroid cancer in 12 countries, including the United States, Italy and France. In particular, most patients diagnosed with thyroid cancer will undergo thyroidectomy directly, which has led to the discussion of possible "overtreatment" of thyroid cancer. papillary thyroid cancer (PTC) is the most common type of thyroid cancer. The following discusses whether there may be "excessive" in the diagnosis and treatment of PTC.

atherosclerotic cardiovascular diseases (ASCVD) are currently the leading cause of death and disability threatening human health worldwide. A large number of clinical studies have fully confirmed that statins can reduce the risk of ASCVD and improve the prognosis. Therefore, although they have only existed for more than 30 years, they have been recognized as the greatest breakthrough achieved by humanity so far in the arduous war against atherosclerosis^[1]。 However, unfortunately, the previous evidence from Chinese people is very limited, resulting in little knowledge of the application of statins in Chinese people, especially the effect and safety of reducing LDL-C, which greatly restricts its rational application in clinical practice, and there are huge hidden dangers in safe and effective drug use^[2]。

The patient was a 44-year-old male. He was admitted to the Department of Endocrinology, Zhujiang Hospital, Southern Medical University on March 4, 2016 due to "dry mouth, polydipsia and polyuria for more than 1 month". Previously, fasting blood glucose 13.77 mmol/L and serum K were checked in the local hospital⁺6.07 mmol/L. After oral hypoglycemic drugs, diuresis, glucose + insulin and other potassium-lowering treatments, the blood glucose fluctuated about 10 mmol/L after retesting, and the serum K⁺5.46 mmol/L, and the treatment effect was not good, so he went to our hospital for treatment. Physical examination on admission: vital signs were stable, there were no silt spots and ecchymates on the skin of the whole body, superficial lymph nodes were not palpable and swollen, sternum was not tender, and liver and spleen were not subcostal. The muscle strength and tone of the limbs were normal, and the pathological signs were negative. Laboratory test: white blood cells 13.16×10⁹/L [normal value (3.5~9.5) ×10⁹/L], platelets 678×10⁹/L [normal value (125~350) ×10⁹/L]; Blood biochemistry: blood potassium 6.13 mmol/L, urea 5.1 mmol/L (normal value 1.8-7.1 mmol/L), creatinine 88 μ mol/L (normal value 44-133 μ mol/L), total carbon dioxide 22.2 mmol/L (normal value 22.0-31.0 mmol/L), fasting blood glucose 15.7 mmol/L (normal value 3.6-6.2 mmol/L), insulin 5.15 mIU/L, C-peptide 1.67 μ g/L. Coagulation function: fibrinogen 8.4 g/L (normal 2.0-4.0 g/L), D-dimer 2.5 mg/L (normal 0.0-0.5 mg/L). Tumor markers and antinuclear antibody profiles were negative. Electrocardiogram: Sinus rhythm, T wave changes. Abdominal ultrasound showed no abnormalities. Intensive insulin pump therapy was given to control blood glucose. For hyperkalemia, furosemide 20 mg intravenous bolus, 10% glucose 250 ml and unfractionated insulin 8 U intravenous drip were given. Retest of electrolyte showed serum potassium 5.68 mmol/L. Repeated blood tests showed that platelets increased, fluctuating in (570~680) ×10⁹/L. Bone marrow cytology examination showed that the proliferation of bone marrow hematopoietic tissue was obviously active, with erythroid, granulocyte and megakaryocyte cells, 0~9 megakaryocytes/HP, no naive cell proliferation, and platelet aggregation, which was scattered and common, suggesting essential thrombocytemia. Although the patient has high serum potassium, he has no weakness, myalgia, bradycardia and other discomfort and hyperkalemia-specific electrocardiogram manifestations, and the patient's renal function is normal. He has not used potassium-sparing diuretics and oral potassium supplementation recently. Considering that the patient's hyperkalemia is probably pseudohyperkalemia caused by essential thrombocythemia, for further verification, serum potassium and plasma potassium were detected at the same time, and the results were 5.95 mmol/L and 4.81 mmol/L, respectively. The difference between serum potassium and plasma potassium was 1.14 mmol/L, which was in line with the diagnosis of pseudohyperkalemia. Given hydroxyurea therapy, the condition is stable at present.

The patient was a 47-year-old female. He was admitted to hospital in May 2015 because "liver space was found to occupy for 1 month". The patient found intrahepatic nodules during abdominal ultrasound during physical examination in an outside hospital, and further abdominal CT showed multiple liver occupation, the nature of which was to be determined, so he went to our hospital. Blood test routine: WBC 6.26×10⁹/L, Hb 98 g/L, PLT 420×10⁹/L; High sensitivity C-reactive protein (hsCRP) 76.23 mg/L; ESR 100 mm/1 h; Enzyme-linked immunospot assay for tuberculosis-infected T cell detection (T-SPOT.TB): No tuberculosis-infected T cells were detected; Tumor markers: CA15-3 was 26.1 U/ml, tissue polypeptide specific antigen (TPS) was 90.44 U/L, alpha-fetoprotein, carcinoembryonic antigen and CA19-9 were all normal; Coagulation function: APTT 42.0 s, prothrombin time (PT) 11.8 s (immediately and 2 h can be completely corrected); IgG antibodies of Paragonimus westernsonii, Hepatic hydatid, Cysticercosis and Clonorchis sinensis were all negative; Immunofixation electrophoresis, immunoglobulin, complement and autoantibody were all normal. No specific changes were observed in brain MRI. Ultrasound of the neck showed bilateral swollen lymph nodes in the neck. Past history: multiple polyps of gallbladder, penicillin allergy (rash after medication). Personal History: Engaged in clothing business, often traveling for business. History of marriage and giving birth and menstruation: 2 pregnancy and 1 delivery, 1 induced abortion, denying the history of metallurgical travel. Admission physical examination: vital signs stable; A lymph node the size of a peanut grain can be reached behind the left neck, which is tough in texture, without tenderness, with clear boundaries and good mobility; No abnormalities in heart and lung; Soft abdomen without mass, percussion pain in liver area (±); Both lower limbs are not swollen.

In August 2016,Diabetes Obes MetabThe clinical study "Efficacy and safety comparison of liraglutide and sitagliptin in Chinese patients with type 2 diabetes mellitus" led by Professor Mu Yiming, Department of Endocrinology, PLA General Hospital was published [Zang L, Liu Y, Geng J, et al. Efficacy and safety of liraglutide versus sitagliptin, both in combination with metformin, in Chinese patients with type 2 diabetes: a 26-week, open-label, randomized, active comparator clinical trial. Diabetes Obes Metab, 2016, 18 (8): 803-811].

Due to the huge differences in the level of economic development and diabetes management in various parts of China, the current status of blood glucose monitoring is uneven; Because of the particularity of physiology, psychology and social background, the elderly have poor compliance, cannot effectively follow the doctor's advice, and the blood glucose monitoring outside the hospital is not ideal, resulting in low blood glucose control rate and high complications^[1]； Rural diabetic patients rarely monitored blood glucose before bedtime, before meal and after meal, and the monitoring rate was average<10%, only 9.4% of patients underwent blood glucose monitoring when hypoglycemia occurred^[2]； A multicenter, prospectively designed study on the current status and intervention of self-monitoring in patients with type 2 diabetes treated with insulin (COMPASS study) showed that self-glucose monitoring (SMBG) in Chinese patients with type 2 diabetes treated with insulin was poor, with 65.8% of patients having no fixed SMBG protocol and 59.2% of patients not following the SMBG protocol recommended by their doctors. Therefore, according to the various reasons that hinder the self-management of blood sugar in different patients, it is a big challenge for us to adopt different ways of guidance and education so that patients can actively participate in the self-management of blood sugar, monitor and control blood sugar well, and improve the quality of life.

lymphocytic hypophysitis (LYH) is the most common type of primary hypophysitis and the "youngest" autoimmune endocrine disease. LYH is characterized by massive lymphocyte and plasma cell infiltration of the pituitary gland and its continuous tissues such as the pituitary stalk, neural funnel and even the hypothalamus, and is classified according to the extent of inflammatory involvement into lymphocytic adenopituititis (restricted to adenopituitary gland, LAH), lymphocytic infundibular-neuropituititis (involving posterior pituitary and infundibular, LINH) and lymphocytic panpituititis (involving anterior, posterior pituitary and infundibular, LPH)^[1]。 Bianchi et al.^[2]And Wang et al.^[3]One case of lymphocytic hypothalamitis has been reported separately. Because there are few cases reported so far, and there is a lack of obvious distinguishing markers between infundibular nerve pituitary gland and hypothalamus in anatomy, most scholars have not classified lymphocytic hypothalamitis as a subtype of LYH. We believe that it has the same pathological manifestations as LYH, and the lesion site and clinical manifestations have their own particularities, so LYH should include lymphocytic hypothalamitis.

Iodine is an important environmental factor associated with thyroid disease. Both iodine deficiency and iodine excess increase the risk of thyroid disease. The following summarizes the monitoring results of iodine nutrition and thyroid diseases during the prevention and treatment of iodine deficiency disorder (IDD) in China over the years, the adjustment of iodine supplementation policy, the influence of iodine excess on the epidemiology of thyroid diseases, and the iodine nutrition problem of pregnant women.

Mercury and its compounds have strong neurotoxicity. Previous studies on the neurotoxicity of mercury and its compounds are more focused on the central nervous system, while studies on peripheral nerve damage caused by mercury are relatively few. Hg-induced peripheral nerve damage is usually subacute or chronic, and its pathological mechanism is not fully understood. Early studies focused on the prevalence of Minamata disease in Japan and large-scale mercury poisoning in Spain. Scattered reports are more common in related occupational diseases, adverse use of mercury-containing preparations and poisoning events. With the prevention of occupational exposure and the ban of mercury-containing drugs, mercury poisoning-related incidents are becoming fewer and fewer. However, due to the folk Chinese medicine prescriptions in our country^[1]And bad whitening cosmetics^[2]In recent years, non-occupational mercury poisoning is still not uncommon in China. The clinical manifestations of peripheral nerve damage caused by mercury poisoning are hidden. The clinical and electrophysiological characteristics of peripheral nerve damage caused by mercury and its compounds are summarized to assist in clinical diagnosis and treatment.

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death and has the largest disease burden in China. Aspirin is the most promising agent for the prevention of ASCVD in such a large population for its easy availability and relative effectiveness, although its use in primary prevention is still a subject of debate. The joint task force has reviewed the current evidence of aspirin use in healthy population and in patients with stable coronary artery disease, acute coronary syndrome, transient ischemic attack, stroke and peripheral artery disease. The consensus statement provides a practical algorithm for identifying those at a high 10-year ASCVD risk, with more than or equal to 10%, who may benefit from aspirin use. Recommendations for aspirin use in primary and secondary prevention of ASCVD in Chinese, as well as its safety and "resistance" issues, are also stated.

Non-steroidal anti-inflammatory drugs (NSAIDs) are a broad class of non glucocorticoid drugs which are extensively used in anti-inflammatory, analgesic, and antipyretic therapies. However, NSAIDs may cause many side effects, most commonly in gastrointestinal(GI) tract. Cardiovascular system, kidney, liver, central nervous system and hematopoietic system are also involved. NSAID-induced GI side effects not only endanger the patients′ health, increase mortality, but also greatly increase the cost of medical care. Therefore, how to reduce GI side effects is of particular concern to clinicians. The Chinese Rheumatism Data Center(CRDC) and Chinese Systemic Lupus Erythematosus Treatment and Research Group(CSTAR) compose a "Recommendation for the prevention and treatment of non-steroidal anti-inflammatory drug-induced gastrointestinal ulcers and its complications" , as following: (1) GI lesions are the most common side effects of NSAIDs. (2) NSAID-induced GI side effects include gastritis, esophagitis, gastric and duodenal ulcers, bleeding, perforation and obstruction. (3) With the application of capsule endoscopy and small intestinal endoscopy, growing attention is being paid to the NASID-induced small intestine mucosa damage, which is mainly erosion and ulcer. (4) Risk factors related to NSAID-induced GI ulcers include: Helicobacter pylori (Hp) infection, age> 65 years, past history of GI ulcers, high doses of NSAIDs, multiple-drug combination therapy, and comorbidities, such as cardiovascular disease and nephropathy.(5) GI and cardiovascular function should be evaluated before using NSAIDs and gastric mucosal protective agents. (6) The risk of GI ulcers and complications caused by selective cyclooxygenase-2 (COX-2) inhibitors is less than that of non-selective COX-2 inhibitors. (7)Hp eradication therapy helps to cure GI ulcers and prevent recurrence when Hp infection is positive in NSAID-induced ulcers. (8) Proton pump inhibitor (PPI) is the first choice for the prevention and treatment of NSAID-induced GI injury. Gastric mucosal protective agents also suggested.(9) H₂ receptor antagonist (H₂RA) can reduce the risk of NSAID-induced duodenal injury, however, the therapeutic effect of NSAID-induced gastric ulcer remains to be further confirmed. (10) Endoscopic treatment is the first recommendation for NSAID-induced peptic ulcers combined with upper GI bleeding, high-dose PPI effectively prevent rebleeding, reduce the possibility of surgery and mortality rate.

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