2017年 · 第56卷第04期

Insomnia is one of the most common sleep disorders. More and more studies have shown that the incidence of cardiovascular diseases in patients with chronic insomnia has increased significantly, and most patients with cardiovascular diseases are accompanied by sleep problems. Therefore, the relationship between insomnia and cardiovascular diseases has received extensive attention in recent years. For a long time, insomnia in patients with cardiovascular diseases is often the subjective diagnosis of cardiologists, but there is little objective diagnosis, and there is a lack of systematic analysis and summary. They often rely on sedative and hypnotic drugs unilaterally, while ignoring cognitive behavioral intervention. How to evaluate, diagnose, treat and manage cardiovascular diseases complicated with sleep disorders in a standardized manner is an important issue faced by cardiologists in clinical practice. Therefore, the Double Heart Group of the General Practitioner Branch of Chinese Medical Doctors Association organized well-known experts in the fields of cardiovascular diseases and sleep to formulate the "Chinese Expert Consensus on the Diagnosis and Treatment of Cardiovascular Diseases Complicated with Insomnia" after full demonstration, combined with clinical experience and the latest research results at home and abroad, which was published in full in this issue. At the same time, we specially invited Professor Lu Lin, Dean of the Sixth Hospital of Peking University, Director of the National Clinical Medical Research Center for Mental Diseases and Director of the Mental Health Center of China Center for Disease Control and Prevention, to write a monograph for this journal "Concern about cardiovascular diseases combined with insomnia disorder". Stay tuned.

As one of the independent risk factors of cardiovascular diseases, insomnia disorder has gradually attracted the attention of health departments in various countries. The incidence of cardiovascular disease increased significantly in patients with chronic insomnia, and most patients with cardiovascular disease were accompanied by sleep problems^[1,2]。 Studies show that short sleep is significantly associated with the onset of cardiovascular disease^[3]。 For a long time, insomnia in patients with cardiovascular diseases is often the subjective diagnosis of cardiologists, but few objective diagnosis; Emphasis on case reporting, but lack of systematic analysis and summary; One-sided reliance on sedative and hypnotic drugs, while neglecting comprehensive cognitive and behavioral intervention. How to evaluate, diagnose, treat and manage cardiovascular diseases complicated with insomnia in a standard way has become an important issue for cardiologists in clinical practice.

Statins play a key role in the prevention and treatment of dyslipidemia and atherosclerotic cardiovascular disease (ASCVD). A number of randomized clinical trials in the past 20 years have laid a solid foundation for the clinical status of statins. These studies confirm that the rational use of statin therapy can significantly reduce the risk of adverse cardiovascular events in patients with dyslipidemia and ASCVD and their high-risk groups. Acute coronary syndrome (ACS) is a severe phenotype of ASCVD with a higher risk of adverse events. In order to improve the clinical outcome of such patients, some scholars have proposed the treatment method of using high-dose and high-intensity statins, which brings a lot of confusion to clinicians. How to correctly understand the statin therapy strategy of ACS patients and coronary heart disease patients undergoing percutaneous coronary intervention (PCI) is an urgent issue to be clarified.

The patient was a 30-year-old female. Because of "facial acne for 1 month", the patient inadvertently found that the skin color deepened one month before admission, mainly on the face and joint junctions, with obvious facial acne, and no symptoms such as fatigue and anorexia during the course of the disease. The blood cortisol level was less than 0.01 μ g/L in other hospitals for many times, and he was admitted to the hospital to further clarify the reason. The patient previously denied history of head surgery and head trauma, postpartum hemorrhage, and long-term glucocorticoid use. The patient is married and has 1 son. Physical examination at admission: body temperature 37 ℃, pulse 90 beats/min, breathing 16 beats/min, blood pressure 110/70 mmHg (1 mmHg =0.133 kPa). Mental clarity. Height 156 cm, weight 46 kg, BMI 18.9 kg/m²The skin color is dark yellow, mainly on the face, no obvious blackening of the oral mucosa, acne on the face, a little pigmentation on the skin of the metacarpophalangeal joints of both hands, and no abnormalities were found in heart, lung and abdomen examinations.

A 20-year-old female was admitted for 2 weeks due to swelling and pain of the left ankle joint. Two weeks ago, the patient developed redness, swelling and pain of the left ankle joint without obvious trigger, with obvious pain at night, increased skin temperature and swelling of the heel. A nodule appeared on the inside of the heel, with obvious tenderness. There was no chronic low back and hip pain, no recurrent iritis, no swelling and pain of other peripheral joints, no fever, cough, expectoration, abdominal pain, and occasional diarrhea during the period. The mental diet was acceptable, the sleep was poor, the urine was normal, and the weight was not significantly changed. There was a history of repeated bilateral metatarsophalangeal joint swelling and pain for 6 years in the past, and it was significantly relieved after taking colchicine (1 mg for the first dose, 0.5 mg twice a day for 2 to 3 days for the next dose) at the time of the attack. Had a history of knee swelling and pain, which improved after treatment, and the specific medication was unknown. Both grandfather and father were diagnosed with a history of gout and diabetes around the age of 20. Cousin has a history of ankylosing spondylitis. Admission physical examination: swelling of left ankle joint, tenderness (+), skin color is not red, skin temperature is not high. The Achilles tendon of the left heel was swollen, and a slightly hard nodule, 0.8 cm ×0.8 cm, was palpable on the inner side of the Achilles tendon, with clear boundary, immovable, obvious tenderness and no abnormality. Auxiliary examination: white blood cells 16.50×10⁹/L, neutrophil ratio 0.877, Hb 98 g/L; No abnormalities in urine and feces routine; Free triiodothyroxine 2.58 pmol/L, free thyroxine 10.62 pmol/L, thyrotropin 1.9 mIU/L; TB antibody negative, interferon gamma 11 ng/L; Blood glucose 6.22 mmol/L, uric acid 600.8 μ mol/L, magnesium 0.64 mmol/L, cystatin C 1.29 mg/L, ALT 6.5 U/L, creatinine 83 μ mol/L (creatinine clearance 76 ml/min); ESR 36.00 mm/1 h; Anti-hemolytic streptococcin O 225.00 IU/ml, rheumatoid factor<11.4 IU/ml, CRP 6.87 mg/L; IgG 18.00 g/L; Anti-cyclic citrulline polypeptide antibody and anti-mutant citrulline vimentin antibody were negative; HLA-B₂₇Negative; Antinuclear antibody homogeneous 1:100; Anti-extractable nuclear antigen antibody negative; Blood glucose was 7.6 mmol/L before meal and 10.3 mmol/L 2 h after meal; Glycosylated hemoglobin 5.5%. Pelvic MRI revealed a small volume of fluid in bilateral hip joints. MRI of left ankle joint showed edema of bone marrow of left calcaneus, edema of Achilles tendon and peritendinous soft tissue (Figure 1)。 Dual-source CT of the ankle showed the formation of tophi around the bilateral Achilles tendon and talus (Figure 2)。 Radionuclide kidney imaging showed that the left kidney GFR 39.3 ml/min was in the lower boundary of the normal range [reference value (52.5 ± 12.5) ml/min], and the right kidney GFR 11.8 ml/min was significantly lower than the normal [reference value (52.5 ± 12.5) ml/min]. CT scan of middle and lower abdomen showed right kidney atrophy; Multiple small cysts in both kidneys; Small round shadows with slightly higher density in both kidneys, considered as complex cysts; Patchy high-density shadow of both kidneys, calcification? Stones? (Figure 3，Figure 4)。

June 2016HypertensionA large-scale population cohort study headed by Professor Huo Yong, Department of Cardiology, Peking University First Hospital, "Comparison of noninvasive central arterial pressure and peripheral blood pressure in predicting renal function decline in Chinese community population" was published [Fan F, Qi L, Jia J, et al. Noninvasive central systolic blood pressure is more strongly related to renal function decline than peripheral systolic blood pressure in a Chinese community-based population. Hypertension, 2016, 67 (6): 1166-1172].

diabetic ketoacidosis (DKA) is one of the common and serious acute complications of diabetes. Some patients presented only with diabetic ketosis. DKA often occurs in type 1 diabetes mellitus (T1DM). A 2002 survey from the United States showed that the incidence of DKA in patients with T1DM was 8 times per 100 person-years^[1]。 According to the survey in Guangdong Province, the incidence of DKA in T1DM patients reached 26.4 times/100 person-years^[2]。 Nearly 20% of T1DM have experienced hyperglycemia and DKA^[3]。 Type 2 diabetes mellitus (T2DM) often develops DKA due to acute infection, inappropriate insulin reduction or sudden interruption of treatment, improper diet, gastrointestinal diseases, stroke, myocardial infarction, trauma, surgery, pregnancy, childbirth, mental stimulation, etc.^[4]。 The incidence of DKA in pregnancy complicated diabetes mellitus and gestational diabetes mellitus in the United States is 0.5% to 3.0%^[5,6]。 The following is an analysis and summary of the diagnosis and treatment of DKA combined with the diagnosis and treatment of a patient with DKA.

Scleroderma (SSc) is a kind of autoimmune disease characterized by extensive fibrosis, vascular lesions and immune abnormalities. At present, traditional drugs such as glucocorticoids and immunosuppressants are mainly used as treatment methods, but the therapeutic effect is not ideal and there are obvious side effects. In recent years, mesenchymal stem cells (MSCs), as a new therapeutic method for refractory SSc, have provided a new direction for the treatment of SSc, and have gradually become a research hotspot. The progress and mechanism of MSCs in basic research and clinical application of scleroderma are reviewed as follows.

Recent years have seen a large amount of research indicating a high morbidity and mortality of cardiovascular disease (CVD) combined with insomnia, which leads to increasing attentions in studying the association between insomnia and CVD, such as coronary heart diseases, hypertension, heart failure, psycho-cardiology diseases and so on. Sufficient evidence shows that patients suffering from CVD are much more likely to get involved in insomnia than healthy persons. Furthermore, causing great troubles to patients with CVD, insomnia seriously influences the treatment process and prognosis of CVD. However, there is a lack of pragmatic direction for the diagnosis and treatment of this comorbidity. As a result, a specialized consensus statement offering guidance in diagnosing and treating CVD combined with insomnia, is in exigent need. This consensus, which is made by experienced experts from various relevant professional fields including cardiology, psychiatry, neurology, psychology and so forth, has summarized the recommendations for the concepts, epidemiology, pathophysiology mechanisms, diagnosis, management and the special approaches of traditional Chinese medicine in this comorbid conditions. In conclusion, it′s certain that this consensus will contribute to the practitioners in managing CVD accompanied with insomnia.

[Website]http: / /www.onlinejacc.org/

[Website]http: / /www.ccs.ca/en/