2017年 · 第97卷第28期

Fulminant type 1 diabetes (FT1DM) is a new subtype of type 1 diabetes, which mostly occurs in Asian countries, with the highest incidence in Japan, followed by Korea and China, and rarely reported in European and American populations. This disease mostly starts with ketosis or ketoacidosis, which is manifested as sudden onset, severe metabolic disorder, significant increase in blood sugar and normal or mild increase in glycosylated hemoglobin (HbA1c), and can be combined with serious complications such as rhabdomyolysis, acute renal failure, cardiac arrest, cerebral edema, and multiple organ failure^[1,2]If not diagnosed and rescued in time, it often leads to the death of the patient in a short time. In addition, due to the almost complete and irreversible damage to islet function, patients require long-term insulin replacement therapy, with large blood sugar fluctuations and a significantly increased risk of hypoglycemia. Therefore, as an acute and critical disease among endocrine and metabolic diseases, FT1DM should be highly valued.

Cardiovascular disease (CVD) is the most common cause of disability and death in patients with type 2 diabetes mellitus (T2DM), and its risk of occurrence is 2-4 times higher than that of non-diabetic patients^[1]。 Glucagon-like peptide 1 (GLP-1) is an incretin whose main biological role is to participate in the regulation of blood glucose homeostasis. Natural GLP-1 is easily inactivated by dipeptidyl peptidase 4 (DPP-4) rapidly, and its half-life is only 1~2 min, so its clinical application value is limited. GLP-1 receptor agonist (GLP-1RA) is protected from rapid degradation of DPP-4 due to altered amino acid sequence. At present, there are many kinds of GLP-1RA listed abroad. Short-acting preparations include exenatide and lixisenatide, and long-acting preparations include liraglutide, exenatide weekly preparations, abiglutide, dulaglutide, etc. Among them, exenatide and liraglutide are two kinds of GLP-1RA currently on the market in China. Exenatide is the first GLP-1RA approved for marketing, with only 53% homology to the amino acid sequence of human GLP-1. Liraglutide is the second marketed GLP-1RA and has 97% homology to human GLP-1. Recent studies have shown that GLP-1RA has a protective effect on the cardiovascular system^[2]。 In this paper, the cardiovascular protective effect of GLP-1RA and its potential mechanism are described.

Intra-aortic balloon counterpulsation (IABP) is the most widely used mechanical circulation assistance device at present. It is a catheter with balloon inserted into the descending aorta distal to the left subclavian and above the renal artery through the arterial system. The balloon is inflated in the diastolic phase of the heart and deflated in the systolic phase of the heart, which plays a role in assisting the heart. In 1952, Kantrowitz's experiment provided a theoretical basis for counterpulsation technology. In 1958, Harken first proposed the concept of intra-aortic balloon counterpulsation. In the early 1960s, Class et al. began to explore the method of intra-aortic balloon counterpulsation. In 1968, Kantrowitz was first used in the treatment of cardiogenic shock and was successful^[1]。 In 1973, IABP was first used to assist cardiopulmonary bypass shutdown during cardiac surgery. With the progress of technology, the continuous improvement of counterpulsation device and balloon catheter, IABP has become more and more widely used in clinical practice, and has become an indispensable means for the treatment of severe cardiac patients. IABP has been clinically used for half a century. About 1 million patients worldwide have received adjuvant IABP therapy, and about 70,000 patients in the United States are implanted with IABP every year. There is no relevant statistical data in China.

Gaucher's disease, also known as glucoencephalosidosis, is an autosomal recessive disease of glucose and lipid metabolism. Because of the defect of β-glucocerebrosidase, the substrate glucocerebroside cannot be degraded normally, and it is stored in large quantities in monocyte-macrophage lysosomes, resulting in cell swelling. The affected tissues and organs appear pathological and progressive aggravation, mainly manifested as splenomegaly, hepatomegaly, anemia, thrombocytopenia, skeletal system injury or neurological lesions^[1,2]。 Patients are divided into three types according to whether the nervous system is involved or not and the acute or slow onset: type I (non-neurological, chronic, adult), type II (neurological-acute) and type III (neurological-subacute), among which type I is the most common type, accounting for 95%^[1]。 There are significant differences in the incidence of Gaucher's disease among different ethnic groups, and there are no accurate epidemiological survey data in China at present. In this study, the clinical data and gene mutation analysis of three families with type II Gaucher disease were carried out. After the genetic etiology was defined, the prenatal genetic diagnosis of amniotic fluid or villi provided guidance for the fertility of three families when the mother of the child was repregnant.

A 56-year-old male was admitted to the First Affiliated Hospital of Zhejiang University on September 16, 2016 due to "diarrhea for nearly 1 year, aggravated with abdominal distension and fever for 1 month". One year ago, the patient had more stool frequency and no pus and blood. He took "berberine and probiotics" by himself, and the effect was good. Six months ago, I had a thin mucous stool, and the color of the stool was dark. One month ago, the diarrhea was aggravated, accompanied by low fever, mucous defecation 10-20 times/d, blood in the stool, abdominal distension and tenesmus. More than 20 days ago, he was hospitalized in Jinhua Hospital of Zhejiang University. Blood test routine: white blood cells 14.5×10⁹/L, C-reactive protein 66.3 mg/L; Fecal cultures: Clumomonas testosteronis. Colonoscopy: extensive lesion of left colon, ulcerative colitis (Figure 1)？ Pathology: Chronic inflammation of mucosa and inflammatory exudation necrosis; Abdominal CT: Thickening and exudation of left colon wall, inflammatory bowel disease considered (Figure 2，Figure 3)； Digital subtraction angiography (DSA): inferior mesenteric artery arteriovenous malformation (AVM), inferior mesenteric vein occlusion (Figure 4)。 After treatment with mesalazine, cefoperazone and low molecular weight heparin, the diarrhea was slightly relieved, but abdominal distension and left lower abdominal mass were gradually obvious, and the maximum daily body temperature was 37.8~38.6 ℃. The body weight has lost 6 kg in the past 1 month. A 20-year history of hypertension, blood pressure remains stable. The history of tuberculosis and surgery were denied, and the family history was not special. Physical examination: body temperature 37.9 ℃, pulse 107 beats/min, breathing 22 beats/min, blood pressure 113/83 mmHg (1 mmHg =0.133 kPa), clear mind, soft spirit, no special heart and lung, slightly swollen abdomen, intestinal mass accessible to the left lower abdomen, tenderness, no rebound pain, attenuated intestinal sound, and edema of both lower limbs.

Child, female, 8 years old. The main reason is "paroxysmal skin bleeding on the face, back, limbs and palms for half a year", and I went to the Department of Endocrinology of our hospital on August 16, 2016. Six months ago, the patient developed local diffuse bleeding on the skin of the face, back, arms, palms, fingertips and calves, which was pale red or colorless foamy liquid, and the bleeding location was uncertain, with more frequency on the face and palms (Figure 1), the amount is about a few milliliters, the bleeding stops spontaneously in an instant, and no skin damage can be seen to the naked eye after wiping. Bleeding intervals vary; Bleeding was not related to mood, activity, eating, temperature, and was not accompanied by fever, joint and muscle pain, or other discomfort symptoms. He went to many hospitals successively, and the blood, urine, fecal routine, liver and kidney function, coagulation time, autoantibodies, immunoglobulins, complement, coagulation factors, abdominal B-ultrasound and other examinations were all "normal". The diagnosis is unknown, and he has taken vitamin C, rutin and "Chinese medicine decoction", but the curative effect is not good. The patient was in good health, delivered naturally at full term, and had no history of infectious diseases such as hepatitis and tuberculosis. No intellectual disability, good academic performance, no menarche. There is no history of similar disease or hematological disorders in the family.

The child was a 2-year-old male. He was admitted to hospital with the main complaint of "finding a mass in the left scrotum for 1 d". Physical examination: body temperature 36.6 ℃, blood pressure 81/55 mmHg (1 mmHg =0.133 kPa), penis and scrotum are well developed, the mass in the left scrotum is about 1.0 cm ×1.0 cm ×1.0 cm, tough in texture, clear in boundary, no tenderness, light transmission test (-), no redness and swelling of the scrotum, bilateral testicles are located in the scrotum and accessible, the size and texture are acceptable, and the movement is good. There is no obvious mass in the bilateral groin. Laboratory tests: serum alpha-fetoprotein 2.05 μ g/L (normal 0-9 μ g/L), β human chorionic gonadotropin 0.18 U/L. Color ultrasound of the scrotum: solid mass below the left testis, hypoechoic in the middle and hyperechoic in the periphery. No obvious abnormalities were observed in the double testis, double epididymis and inguinal areas (Figure 1)； Enhanced CT: A round-like abnormal low-density shadow was seen below the testis in the left scrotum. No obvious enhancement was seen after enhancement, with clear edges and a size of about 0.86 cm ×0.86 cm ×0.68 cm. It was considered as a space-occupying lesion in the left scrotum, benign tumor, and epidermoid cyst may be (Figure 2)。

Colorectal cancer is one of the most common malignancies of the digestive tract. The worldwide incidence of colorectal cancer is the third highest among malignancies in men and the second highest among women. Changes in eating habits and lifestyle make the incidence of colorectal cancer in Asia gradually close to that in Europe and America^[1]。 Since 1991, the incidence and mortality of colorectal cancer in China have been increasing steadily. In the scope of cancer, the incidence and mortality of colorectal cancer rank fourth and fifth^[2,3]。 Colorectal cancer is essentially a genetic disease involving progressive molecular genetic changes and related histomorphological changes. The accumulation of oncogene mutations leads to spontaneous colonic epithelial cell proliferation, which usually progresses slowly over 10 to 40 years, first leading to colonic adenomas and then canceration in a few individuals^[4]Intestinal microorganisms are considered to be the etiology that may trigger the development of this series of events.

The traditional concept believes that neutrophils act as the first line of defense of the body's innate immunity by phagocytosis of exogenous pathogenic microorganisms. In 2004, Brinkmann et al.^[1]It was found that activated neutrophils can release deaggregated chromatin and intracellular proteins to the extracellular, forming a silk-like structure-neutrophil extracellular traps (NETs). Intranuclear histones and highly expressed antimicrobial peptides and granzymes in cytoplasm attach to extracellular chromatin, and cooperatively play the role of trapping and killing pathogens. Subsequently, a large number of studies have found that NETs are not only involved in the clearance of exogenous pathogens, but also involved in aseptic inflammatory processes in the body, including chronic diseases, autoimmune diseases, thrombosis, and cancer occurrence and metastasis^[1,2,3,4]。 In order to further reveal how NETs play a role in the development of these diseases, it is first necessary to confirm the massive activation of neutrophils and the release of NETs under pathological conditions. At present, the quantitative and qualitative analysis of NETs has been achieved by the detection technology, but there are some differences in sensitivity, timeliness and specificity of various methods.

Tsutsugamushi disease is a natural epidemic disease caused by infection with Rickettsia tsutsugamushi, which hosts chigger larvae and rats, and also infects humans, spreading through chiggers in long grass or dirty dirt on the floor. The infection was characterized by flu-like symptoms presenting as fever, headache, and myalgia that lasted about 1 week. In some cases, the disease can progress to severe or even multiple organ dysfunction, and even if correctly treated with doxycycline, its mortality rate should not be underestimated. Its multiple organ dysfunction can involve all major systems, the most common one is respiratory failure. If the disease progresses to this severe stage, supportive treatment such as ventilator and strengthened monitoring are urgently needed to reduce the mortality rate. At present, there have been a lot of studies on non-severe scrub typhus disease, but the diagnosis and treatment of severe scrub typhus disease is still a major clinical problem. There are reports on the diagnosis and treatment of severe cases in Southeast Asia and India, and their prognosis is not ideal. Early detection of disease progression and correct treatment is an effective means to improve prognosis. The progress of diagnosis and treatment of this disease is summarized as follows.