2016年 · 第54卷第02期

Male, 42 years old. He was admitted to hospital on May 23, 2013 for the main cause of "lymph node enlargement in the left cervical lateral region for 1 month". In 1985, a total thyroidectomy of the left thyroid gland was performed in a local hospital for "micropapillary carcinoma of the left thyroid gland without cervical lymph node enlargement". There were no tetany and hoarseness after operation, and no thyroid stimulating hormone (TSH) suppression treatment was performed. On June 15, 2008, the patient went to another hospital because the reexamination of neck ultrasound showed "multiple solid mass occupation in the left and right lobes of thyroid gland, and the nature of the lesion in the left lobe of thyroid gland is to be determined, which is considered as malignant neoplastic lesion". On June 21, 2008, the patient underwent "bilateral total thyroidectomy + isthmus resection + bilateral cervical VI lymph node dissection" under general anesthesia. Postoperative pathological report: "Left and right papillary thyroid carcinoma. The maximum diameter of left tumor was>1.0 cm, and the maximum diameter of right tumor was 0.5 cm. The left cervical VI lymph node showed cancer metastasis (7/9) and part of parathyroid tissue was visible, but the right VI lymph node showed no cancer". Postoperatively, the patient had numbness and tetany of hands and feet. The serological results showed that parathyroid hormone was 9.34 ng/L (normal range 10-69 ng/L) and serum calcium was 1.90 mmol/L (2.1-2.6 mmol/L). TSH inhibitory therapy was performed after operation, with dose-adjusted oral administration of levothyroxine 200 μ g/d and calcium 1 000 mg (3 times/d), but not performed¹³¹I treatment. There was no history of cervical radiation exposure, neoplastic disease and thyroid disease in family. Thyroid ultrasound examination was performed after admission: changes after total thyroidectomy. Color ultrasound of cervical lymph nodes showed multiple abnormal lymph nodes in the left cervical neck with clear boundaries, disappearance of lymph node hilum structure, and cystic changes in some lymph nodes. PET-CT showed changes after total thyroidectomy, swollen lymph nodes on the left side of the neck with increased glucose metabolism, considering metastatic lymph nodes; The left upper lobe patch was not associated with increased glucose metabolism, and inflammatory lesions were considered (Figure 1)。 free thyroxine 3 (FT3), free thyroxine 4 (FT4), and blood calcium were in the normal range. TSH 7.57 mU/L (normal range 0.35-4.94 mU/L) and parathyroid hormone 10.28 ng/L. On the third day of admission, lymph node dissection was performed under general anesthesia in areas Ⅱ, Ⅲ, Ⅳ and Ⅴ of the left neck. Postoperative pathology showed metastatic carcinoma in lymph nodes (3/7) (left region) (Figure 2)。 Postoperative diagnosis: Lymph node metastasis after thyroid cancer surgery and high risk of recurrence and metastasis. After operation, levothyroxine was administered orally at 150 μ g/d, and serum TSH, FT3, FT4, thyroglobulin and thyroglobulin antibody were measured regularly. The dose of levothyroxine was adjusted to control TSH at 0.1~0.5 mU/L. On 21 Jun 2013, the patient had her first¹³¹I treatment at a dose of 192 mCi. Whole body radionuclide bone imaging after radiotherapy showed a small amount of radionuclide accumulation in the residual thyroid gland and lung apex (Figure 3)。 On 18-Oct-2013, the patient underwent again¹³¹I treatment at a dose of 192 mCi. Whole body radionuclide bone imaging again showed no obvious abnormalities (Figure 4)。¹³¹I Basal thyroglobulin in TSH inhibition within 6 months after treatment<1 μ g/L.

Warfarin is a first-line oral anticoagulant for the prevention and treatment of thromboembolic diseases. However, since the day warfarin was applied in clinic, its narrow therapeutic scope, huge individual differences in anticoagulant effect and improper anticoagulation have been plaguing every doctor who prescribes warfarin. Although the anticoagulant effect of warfarin can be clinically monitored and the dose can be adjusted by measuring prothrombin time (PT) and international normalized ratio (INR), some studies have shown that the success rate of detecting the INR value in the first 4 days of anticoagulant therapy to predict the maintenance dose is only 69%. Even if the INR reaches the therapeutic range, it does not necessarily mean that the true anticoagulant goal is achieved^[1]； Moreover, a few patients can cause bleeding due to the mutation of coagulation factor IX, although PT is not significantly prolonged^[2]； Therefore, relying only on the determination of PT and INR values to determine warfarin dose still has some lag and limitations. In addition, frequent blood draws to monitor PT and INR values not only bring pain, inconvenience and financial burden to patients, but also increase the risk of bleeding. Therefore, many researchers have been making various attempts to more accurately predict the individualized dose of warfarin. However, it was not until recent years that scholars made breakthroughs in the field of molecular biology that the polymorphisms of liver cytochrome P450 2C9 (CYP2C9), vitamin K redox reductase complex 1 (VKORC1) and other genes were related to the individual dose and anticoagulant effect of warfarin that it was gradually possible to establish a "tailor-made" individualized warfarin administration model.

A 54-year-old male was seen for "intermittent macroscopic hematuria for more than 2 months". Preoperative cystoscopy: Many superficial bladder tumors were not obvious under ordinary white light (Figure 1), while it is clearly visible when viewed under narrow-band imaging techniques (Figure 2)。

One article posted inGutAdolescent obesity can double the risk of bowel cancer in middle age, according to the research report.

A study in the United States published in the journal Cancer shows that among Cancer patients, young men who use drugs that may affect fertility may pay more attention to the fertility substance retention plan than younger women. Both men and women have lower requirements for the retention plan, suggesting that there is a need for better strategies to deal with the fertility problems of young Cancer patients.

She was sent over from another district in the UK due to orthostatic hypotension of unknown etiology. My head of the section is an expert. We gathered around her hospital bed to discuss what to do.