2018年 · 第57卷第08期

Fulminant myocarditis is a special type of myocarditis with sudden onset and rapid progression. It is usually caused by viral infection. Patients quickly develop severe hemodynamic disorders, hypotension/cardiogenic shock, heart failure (heart failure), etc., some of which are accompanied by fatal arrhythmias, and can be combined with respiratory and/or liver and kidney failure, and the early mortality rate is extremely high. Because the disease mostly occurs in young adults, it is an important cause of sudden death of young adults, so it is very harmful to society. In this issue, we invited Professor Hu Dayi to write a monograph "Raise awareness, enhance confidence, and effectively reduce the mortality rate of fulminant myocarditis" to explain the diagnosis and treatment of fulminant myocarditis in detail. Stay tuned.

fulminant myocarditis is a special type of myocarditis with rapid onset and rapid progression. It is usually caused by viral infection. Patients quickly develop severe hemodynamic disorders, hypotension/cardiogenic shock, heart failure (heart failure), etc., some of which are accompanied by fatal arrhythmias, and may be combined with respiratory and/or liver and kidney failure, and the early mortality rate is extremely high^[1,2,3,4]。 Fulminant myocarditis can occur at all ages, but it is mostly in young adults, which is an important cause of sudden death in young adults, so it is very harmful to society. However, for a long time, due to the lack of sufficient knowledge and understanding of the pathogenesis of fulminant myocarditis, there is no unified and standardized guiding literature in academic circles at home and abroad, so the diagnosis and treatment of fulminant myocarditis can be described as "political outcomes". Due to the lack of authoritative diagnostic criteria, it brings great obstacles to the epidemiological investigation of fulminant myocarditis. At the same time, because of the vague understanding of diagnosis and treatment, the mortality rate of fulminant myocarditis remains high. In September 2017, the Chinese Journal of Cardiovascular Diseases published the "Chinese Expert Consensus on the Diagnosis and Treatment of Fulminant Myocarditis in Adults"^[5]Although it still needs further improvement, it provides a standardized guiding literature for the clinical diagnosis and treatment of fulminant myocarditis. This is also the first time that Chinese scholars have systematically put forward the diagnosis and treatment plan of this disease internationally. The following will combine the consensus of this expert to systematically analyze the clinical characteristics of fulminant myocarditis, and focus on the application of comprehensive treatment plan based on life support in clinical treatment of fulminant myocarditis.

It has been more than 70 years since the advent of cardiac interventional electrophysiology technology, which is more than seventy years old compared with the life span of human beings. However, because the traditional method is to perform surgery under the guidance of X-ray fluoroscopy, even with the increasingly mature electrophysiology technology today, doctors still need to put on lead clothes and "reload the operation" and move forward on the top of the "line"^[1,2]。 Doctors' hard work and superb skills relieve the pain of many patients, and at the same time, they are also suffering from the serious consequences caused by X-ray radiation, which can cause radiation damage to skin, hematopoietic system, immune system, endocrine system, eyes and other tissues and organs^[3]。 Doctors have to suffer the musculoskeletal damage caused by "going into battle" to protect themselves from radiation,JAMA SurgAn article published on even called it an epidemic of intervening doctors^[4]。 At the same time, some studies have shown that if X-ray exposure reaches more than 60 minutes, the probability of malignant tumor in contact will increase by 0.03% ~0.23%^[5]； In addition, X-ray radiation can pose genetic risks such as chromosomal variation^[6]So much so that after the state advocated the "two-child" policy, it was difficult for intervening doctors to enjoy the policy dividend... This is contrary to the purpose of modern green technology trend emphasizing scientific and technological innovation and humanistic care.

Interstitial lung disease (ILD) is an important organ damage in the multisystem manifestations of connective tissue disease (CTD). It has become an important cause of death in CTD patients, and has gradually become the focus of attention of rheumatology, respiratory and critical care physicians^[1]。 The clinical manifestations of CTD-related ILD are complex and diverse. Diagnosis and disease assessment require the participation of multidisciplinary experts such as rheumatology, respiratory, imaging and pathology departments to provide a reliable basis for formulating reasonable treatment strategies. At present, there is still a lack of guiding principles for the diagnosis and treatment of CTD-related ILD for clinicians to refer to and follow, which leads to different judgments and treatment plans of different disciplines in the process of clinical diagnosis and treatment, which is not conducive to ensuring the consistency and continuity of patient treatment. It is also not conducive to the future clinical research of CTD-related ILD. To this end, the Rheumatology Related Pulmonary Vascular Interstitial Diseases Group of Rheumatologists and Immunologists Branch of Chinese Medical Doctors Association and the National Rheumatology Data Center organized domestic multidisciplinary experts from rheumatology, respiratory and imaging departments to formulate the "2018 Chinese Expert Consensus on Diagnosis and Treatment of Connective Tissue Disease Related Interstitial Lung Disease" (hereinafter referred to as this Consensus) based on international and Chinese clinical diagnosis and treatment experience and evidence, forming three primary principles and seven recommendations, aiming to improve clinicians' understanding of CTD-related ILD, gradually standardize the clinical diagnosis and treatment of CTD-related ILD in China, and finally improve the prognosis and quality of life of patients with CTD-related ILD^[2]。

At the 2018 Beijing International Great Wall Conference, the author asked John Warner, president of the American Heart Association, a question: "The mortality rate of cardiovascular diseases in China remains high, and the related risk factors are at a high level. What suggestions do you have to improve the incidence and mortality of cardiovascular diseases in China?" His answer is one. The country should give priority to healthy nutritional food strategies. Indeed, healthy and nutritious foods include not only high-quality meat foods, but also rich fresh fruits and vegetables. Fresh fruits, leafy greens are characterized by low sodium, high potassium and rich in folic acid.

To establish the experts consensus on diagnosis and treatment of interstitial lung disease (ILD) associated with connective tissue diseases (CTDs). A multidisciplinary consensus development panel was established. The panel of consensus was composed of 41 experts in rheumatology, pulmonology, radiology, most of whom were members of Group of Pulmonary Vascular and Interstitial Diseases Associated with Rheumatic Diseases. The consensus development panel developed 3 major principles and 7 recommendations for the diagnosis and treatment of ILD associated with CTDs. The consensus covered the early screening, diagnosing, disease monitoring and assessing, immunosuppressive and anti-fibrotic therapy with a treat-to-target approach. This consensus was intended to facilitate the decision-making and standardize the care of ILD associated with CTDs in China.

The patient was a 69-year-old female. He was consulted on April 28, 2017 due to "persistent abdominal pain for 8 h". The patient had sudden dull pain under the xiphoid process and around the umbilical cord 8 hours ago, accompanied by abdominal distension and palpitations, without chest tightness and chest pain. Previous type 2 diabetes and sinus bradycardia for many years; Thoracoscopic left lower lobectomy for left lung adenocarcinoma 1 month ago; Deny previous history of atrial fibrillation and hypertension; Denying smoking and family history of coronary heart disease. Physical examination: pulse 88 beats/min, blood pressure 145/74 mmHg (1 mmHg =0.133 kPa). The mind was clear and weak, the breathing sound of the left lower lung was low, and no obvious dry and wet rales were heard in both lungs. Three surgical wounds were seen in the axillary part of the left chest wall. Percussion heart boundary is not large. The heart rate was 105 beats/min, the rhythm was irregular, the intensity of the first heart sound was different, and no pathological murmur was heard in the auscultation area of each valve. The whole abdomen is soft, with tenderness under the xiphoid process and around the umbilical cord. The whole abdomen is percussed with drum sound and weak intestinal sound. There was no edema in both lower limbs. Electrocardiogram showed atrial fibrillation, Ⅱ, Ⅲ, aVF leads and V₄~ V₆, V₇~ V₉The ST segment elevation of the lead was 0.1~0.2 mV. Blood routine and blood gas analysis were roughly normal. C-reactive protein (CRP) 116 mg/L. Lactate dehydrogenase 400 U/L (normal reference 120-250 U/L), creatine kinase isoenzyme 6.90 μ g/L (normal reference 0-6.0 μ g/L), troponin (Tn) I 3.153 μ g/L (normal reference<0.030 μ g/L), TnT 0.320 μ g/L (Normal reference value<0.01 μ g/L). D-dimer 7.90 mg/L (normal reference 0.00-1.50 mg/L). Plain abdominal X-ray in upright position: a little intestinal gas accumulation. Abdominal ultrasonography: No obvious abnormalities were found in liver, gallbladder, pancreas, spleen, kidney and right lower abdomen. X-ray chest radiograph: nodular shadow of left lower lung, reduced permeability of left lower lung.

The patient was a 14-year-old male. He was admitted to the hospital on July 10, 2017 due to "breast development for 1 year". One year ago, when taking a bath, the patient's family found that his bilateral breast developed, which gradually increased in size in the past year. For a clear diagnosis, he went to our hospital for treatment. Past history and family history are not special. Physical examination: temperature 36.8℃, pulse 86 beats/min, breathing 22 beats/min, blood pressure 114/76 mmHg (1 mmHg =0.133 kPa), height 165 cm, weight 76.0 kg, body mass index 27.58 kg/m², abdominal obesity, no pubic hair, axillary hair, bilateral testicular volume of about 5.5 ml, penile traction length of about 7 cm, bilateral breasts as large as teacups, diameter of about 70 mm on the left side and about 60 mm on the right side, no tenderness and orange peel-like changes, small nipples, and light areola color. Laboratory tests showed that liver and kidney function, blood lipid, electrolyte and thyroid function were normal. Follicle stimulating hormone (FSH) 3.21 IU/L (male reference value 0.95-11.95 IU/L), luteinizing hormone (LH) 4.79 IU/L (male reference value 1.14-8.75 IU/L), estradiol 15.00 ng/L (male reference value 11-44 ng/L), progesterone 0.14 μ g/L (male reference value 0.1-0.2 μ g/L), testosterone 2.71 μ g/L (male reference value 1.42-9.23 μ g/L), prolactin 9.56 μ g/L (male reference value 3.46-19.40 μ g/L). 17 α-hydroxyprogesterone 0.55 μ g/L. The results of the triptorelin test and adrenocorticotropic hormone (ACTH) -cortisol rhythm are presented inTable 1，Table 2。 Breast color ultrasound examination: breast gland development, the left side is 17 mm thick and about 70 mm in diameter, the right side is 17 mm thick and about 65 mm in diameter, the structural hierarchy is not clear, the gland echo is not uniform, the strength is not equal, and the duct in the central region is not obviously dilated. Color ultrasound examination of external genitals showed that the volume of the left testis was 6 ml and the volume of the right testis was 5.4 ml. No obvious abnormalities were found in the bilateral testis, epididymis and spermatic vein. Pituitary magnetic resonance imaging (MRI) plain and enhanced scans: bulging of the upper middle edge of the pituitary gland, local early enhancement, pituitary tumor? Pituitary hyperplasia? The posterior pituitary gland is slightly larger (Figure 1）。 No obvious abnormalities were found on plain and enhanced CT scans of adrenal glands. The orthographic radiograph of the wrist joint showed 8 carpal bones, and the epiphyses at the distal end of the ulna and radius appeared, which had not been closed, which was approximately consistent with the 15-year-old bone age of the boy. Karyotype analysis: 46XY. SRY Gene Testing: Carrying male sex determining genes.

May 4, 2018,Lancet Diabetes Endocrinol"Dorzagliatin Monotherapy in Chinese Patients with Type 2 Diabetes: A Dose-Exploring, Randomized, Double-Blind, Placebo-Controlled Phase II Clinical Study" was published online led by Professor Zhu Dalong of Gulou Hospital affiliated to Nanjing University School of Medicine and jointly completed by 22 clinical research centers across the country [Zhu D, Gan S, Liu Y, et al. Dorzagliatin monotherapy in Chinese patients with type 2 diabetes: a dose-ranging, randomized, double-blind, placebo-controlled, phase 2 study. Lancet Diabetes Endocrinol, 2018 May 4. pii: S2213-8587 (18) 30105-0.]. This is the first time that the journal has published the clinical research results of original new drugs for type 2 diabetes from China.

Sepsis is an uncontrolled response of the host to infection and the development of life-threatening organ dysfunction. Septic shock is when sepsis still requires vasopressor medication to maintain mean arterial pressure ≥65 mmHg (1 mmHg =0.133 kPa) and blood lactate>2 mmol/L after active fluid resuscitation. At present, sepsis and septic shock are the leading causes of death in hospitalized patients. Although life support technology has been advancing with the rapid development of modern medicine, the mortality rate of sepsis and septic shock is still as high as 25% ~50%^[1]。 Therefore, early recognition of sepsis and timely and appropriate intervention are of great significance to improve the prognosis of sepsis.

amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease involving the anterior horn cells of the spinal cord, the motor nucleus of the brainstem and the pyramidal tract. It is manifested by progressive aggravation of muscle weakness, atrophy and pyramidal tract signs. Most patients die of respiratory failure within 3 to 5 years of onset. The etiology and pathogenic mechanism of ALS are still unknown. It is believed that the gene burden accounts for about 60% of ALS pathogenesis, while the remaining 40% is determined by environmental factors^[1]。 In recent years, with the rapid development of molecular genetics, more and more disease-causing genes have been discovered and confirmed, but the related research on environmental factors is relatively slow and difficult, and the epidemiological research results in various regions are not completely consistent. Because most of ALS are sporadic, most of them cannot find clear pathogenic genes. Therefore, it is very important to explore the environmental factors related to the onset of ALS for prevention and early intervention. The research progress in this field in recent years is summarized as follows.

Editorial Department of Chinese Journal of Internal Medicine:

Editorial Department of Chinese Journal of Internal Medicine: