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对于服用抗甲状腺药物，不少初治的甲亢患者会一脸茫然，不知道为什么医生再三叮嘱要进行血液反复检查。基于此，我在这里给广大病友总结一下服用抗甲状腺药物的注意事项，以消除病友们的疑问，以及帮助大家更好的进行复查。1适应症：病情轻，甲状腺轻中度肿大，年龄在20岁以下，妊娠甲亢（PTU），年老体弱或合并严重心、肝、肾疾病不能耐受手术者2反指症：对药物过敏，难以长期服药或随访，甲状腺特别肿大，腺瘤引起的甲亢。3抗甲状腺药物治疗一般需要2年，复发率较高，高达50%左右。4抗甲亢药物的副作用：粒细胞缺乏，肝损害，过敏，狼疮综合征。最严重的副作用是甲亢粒细胞缺乏，可导致高热和重症感染，甚至死亡。甲亢药导致的转氨酶升高及黄疸等肝损害也不少见。目前尚无法预先识别哪些患者对药物的副反应较大，因此需要复查。一般每2周复查一次，连续复查6次，以后可1-2月复查一次。主要复查指标是血常规和转氨酶。如果患友有服药过程中有皮肤瘙痒，或者有关节痛，牙痛，发热等应及时就医复查，切不可大意。5妊娠期甲亢药物的选择：孕早期首选低剂量丙硫氧嘧啶6β受体阻断剂：首选心得安，有支气管疾病者选择美托洛尔7硒剂补充对甲状腺突眼，甲状腺炎均有一定程度的改善。

QuestionHow is vascular dementia diagnosed and differentiated from Alzheimer disease?Making a diagnosis of vascular dementia is complicated for several reasons. First, vascular dementia has multiple causes and clinical types. Second, in contrast to Alzheimer disease, the diagnosis of vascular dementia has no pathognomonic criteria. Third, the clinical diagnostic criteria are poorly validated. Fourth, on MRI, white-matter lesions, which are related to cerebral hypoperfusion or ischemia, are nonspecific findings yet often are interpreted as diagnostic. Fifth, many patients with vascular dementia also have other causes of dementia (eg, Alzheimer disease)—so-called "mixed dementia."Several causes and presentations of vascular dementia have clinical value. Perhaps the most obvious patients are those who meet criteria for dementia and have sustained a clinical stroke—either large artery (usually cortical) or small artery (lacunes) in subcortical areas. Strokes are usually confirmed by neuroimaging (MRI is more sensitive than CT) that demonstrates either multiple infarcts or a single strategically placed infarct (eg, angular gyrus, thalamus, brain forebrain, posterior cerebral artery, or anterior cerebral artery).Patients with dementia who have evidence of cerebral infarction on MRI without clinical presentations of stroke may also have vascular dementia. Finally, chronic subcortical ischemia of small vessels in the periventricular white matter can result in the loss of neurons and supporting brain cells, leading to vascular dementia.As result of these diverse causes, the clinical presentation of vascular dementia varies considerably. Features that indicate cortical dysfunction (often caused by cerebral embolism) include executive dysfunction; aphasia, apraxia, and agnosia; hemineglect visual-spatial and construction difficulty; and anterograde amnesia. Features that indicate subcortical dysfunction (typically owing to lacunar infarcts and chronic ischemia) include focal motor signs, gait disturbance and falls, urinary tract symptoms, pseudobulbar palsy, personality changes, psychomotor retardation, and abnormal executive function. Clinically, executive dysfunction may be the earliest presenting symptom, even when cognitive impairment is mild.The temporal relationship between stroke and the onset of cognitive impairment is important in establishing the diagnosis of vascular dementia. For example, dementia occurring within 3 months of a recognized stroke or a pattern of stepwise progression of cognitive deficits strongly supports the diagnosis.A clinically useful tool for distinguishing vascular dementia from Alzheimer disease is the Hachinski Ischemic Score,[1]which assigns two points to each of the following:Abrupt onset;Fluctuating course;History of stroke;Focal neurologic symptoms; andFocal neurologic signsand one point to the following:Stepwise deterioration;Nocturnal confusion;Preservation of personality;Depression;Somatic complaints;Emotional incontinence;Hypertension; andAssociated atherosclerosis.A score of 7 or higher suggests vascular dementia, whereas a score of 4 or less suggests Alzheimer disease.Developed in association with theUCLA Alzheimer's and Dementia Care Program.

No single ultrasound feature can predict malignancy in thyroid nodules with acceptable diagnostic accuracy, a new systematic review and meta-analysis suggest.The findings have beenpublished online for open accessinThyroidby Luciana Reck Remonti, MD, an endocrinologist at Hospital de Clinicas de Porto Alegre, Brazil, and colleagues."Our meta-analysis evaluated the accuracy of ultrasound in predicting thyroid-nodule malignancy using the appropriate gold standard: histopathological diagnosis. Based on our results, no single ultrasound characteristic is accurate in diagnosing thyroid malignancy," Dr Remonti toldMedscape Medical News.Nonetheless, she said that ultrasound is still important for the evaluation of thyroid nodules. Although fine-needle aspiration (FNA) biopsy is considered the most accurate procedure to identify malignant nodules, to implement biopsies in all patients harboring a thyroid nodule "is too burdensome," she and her colleagues note.So "we need to be able to better select which patients need to be submitted to [FNA biopsy]," Dr Remonti said."Probably, the aggregation of ultrasound characteristics will be able to better define patients with nodules at risk," she noted, recommending that a "risk score" for thyroid malignancy, based on a number of features seen on ultrasound, be developed in the future.Asked to comment, Stephanie L Lee, MD, PhD, associate professor of medicine and director of the Thyroid Health Clinic at Boston University Medical Center, Massachusetts, toldMedscape Medical Newsthat these findings essentially confirm what is known and are in line with both the current (2009) American Thyroid Association (ATA) guidelines on thyroid nodules, as well as new ATA guidelines due out this year. (Dr Lee was on the ATA writing committee for the 2009 guidelines and the prior ones, and although she is not an author on the 2015 guidelines, she has seen them.)Essentially, Dr Lee said that the ATA approach is "if it looks worrisome — invasion outside the thyroid, unilateral adenopathy — you should biopsy all nodules." In contrast, if a nodule is simply hypoechoic, isoechoic, or spongiform, biopsy should be considered only if it reaches a certain size. "So, it's a risk stratification."Which Ultrasound Features, if Any, Predict Cancer?Dr Remonti and colleagues analyzed 52 observational studies of patients with a total 12,786 thyroid nodules that had been evaluated by ultrasound and submitted to thyroidectomy and for which histological diagnosis of surgical specimens was conducted.They also performed a separate meta-analysis on nine studies that included 1851 nodules with indeterminate cytology aspirates.All the features they evaluated — solid structure, hypoechogenicity, irregular margins, absence of halo, microcalcifications, central vascularization, solitary nodule, heterogeneity, taller-than-wide shape, and absence of elasticity — were significantly associated with malignancy.However, the sensitivity of these features was somewhat low, ranging from 26.7% to 63%. Thus, using these features individually would result in 37% to 73.3% of cancers being missed, the authors explain.The features with the best specificity were microcalcifications (87.8%), central vascularization (78%), irregular margins (83.1%), and a taller-than-wide shape (96.6%).The positive likelihood ratio (ie, how many times more frequently patients with malignancy present with that particular result than does a patient without malignancy) ranged from 1.33 to 8.07, and the negative likelihood ratio went from 0.13 to 0.77.Absence of elasticity showed the best diagnostic accuracy, with a sensitivity of 87.9%, a specificity of 86.2%, and positive and negative likelihood ratios of 6.39 and 0.13, respectively.For the separate analysis of nodules with indeterminate cytology, only the presence of microcalcifications was significantly associated with malignancy, and no ultrasound variable determined the risk of malignancy with acceptable sensitivity. Among these nodules, presence of central vascularization had the best specificity (96%).Which Nodules Should Be Biopsied? Develop a Risk ScoreAccording to Dr Remonti, the findings suggest that "ultrasound characteristics should not be used to select thyroid nodules for cytological diagnosis, as none of them is capable of excluding malignancy with adequate certainty."We believe that a meta-analysis using individual patient's data is necessary, as it would be possible to aggregate several ultrasound features in order to build a risk score for thyroid malignancy. Based on this multiple-characteristics score, clinicians would be able to select nodules that do not need further evaluation."Dr Lee noted that the new ATA guidelines — just like the current ones — will include all of the features discussed in this paper except for "absence of elasticity," since elastography isn't yet widely practiced in the United States, and will also provide size criteria for which nodules should be biopsied.Regarding elastography, Dr Remonti and colleagues note that it is "a new technique and may be a good tool to select patients at increased risk for thyroid malignancy. Nevertheless, more studies are required to standardize the technique and confirm its usefulness."Dr Remonti has no relevant financial relationships. Disclosures for the coauthors are listed in the article. Dr Lee has no relevant financial relationships.Thyroid.2015;25:538-550.Article

轻微锻炼可以降低餐后甘油三酯水平：京都县大学Wataru Aoi及其同事2013年2月发表的文章显示，餐后1 h快走继而抵抗训练可抑制餐后甘油三酯水平增高。该研究显示，这种联合训练可使升高的餐后甘油三酯水平降低72%，而餐前开展联合训练则可使甘油三酯水平降低25%。《CT“餐巾环征”可确定高危冠脉病变》匈牙利塞麦尔维大学的Horvat与美国马萨诸塞州总医院的研究者在2012年12月《美国心脏病学杂志：影像学》上发表的文章显示，一种称为“餐巾环征（napkin-ring sign）”的环状衰减类型的冠脉斑块可识别进展性冠脉损伤，特异性达99%。

继2013年5月发布声明草案后，美国预防医学工作组(USPSTF)发布了“妊娠糖尿病筛查”的最终声明，强调有足够证据支持在孕24周后对妊娠期糖尿病(GDM)进行筛查(推荐等级B)，目前尚无更早筛查的相关证据。该声明1月13日在线发表在《内科学年鉴》（Ann Intern Med）杂志上。USPSTF前任委员北卡罗莱纳大学教堂山分校Wanda K. Nicholson博士介绍到，新声明的推荐与去年发布的草案基本一样，仅对其中的少数措辞进行了修改。该声明是对2008版声明的更新。2008版声明强调，当时并无充足证据证实在孕24周后进行GDM筛查的获益大于风险。而现在很多质量较好的大型临床试验已充分证实“与不筛查相比，在孕24周后进行GDM筛查能为母婴带来获益”。USPSTF主席Virginia A.Moyer博士称，新声明体现了“对孕产期预防产伤、先兆子痫以及巨大儿等并发症整体受益重要性看法的转变”。USPSTF确认，孕妇24周后接受GDM筛查和治疗，可使先兆子痫、巨大儿以及肩难产总体下降，从而与母婴健康中度改善相关，而筛查和治疗导致的损伤被认为非常有限。因此，工作组基本确定有中度的总体净获益。”基于对文献的系统综述，24周后筛查推荐意见被列为“B级推荐”。该最终推荐意见是对2008推荐意见的更新。当时，工作组认为推荐无症状孕妇进行筛查缺少充分证据，因此将其列为“I级推荐”。美国GDM的患病率为1%～25%，GDM女性不仅妊娠并发症发生风险会增加，还有高达60%GDM女性会在产后5~15年罹患2型糖尿病。如能及早确诊GDM，并实施良好的血糖控制，则能显著降低妊娠并发症的发生风险。因此，GDM的筛查与治疗意义重大。美国预防医学工作组旨在对现有临床试验证据进行审查与评估，以确定在孕24周前或孕24周后两个时间点进行GDM筛查的风险与获益。总体证据显示，孕24周后(通常24～28周)进行GDM筛查及治疗能显著降低先兆子痫、巨大儿及肩难产的发生风险，且对母婴的危害非常小。初级保健医生可通过二步法准确诊断孕24周后GDM，即如果50g葡萄糖负荷试验达到或超过筛查阈值[130、135或140mg/dl(7.21、7.49或7.77mmol/L)]，则再进行口服葡萄糖耐量试验。肥胖、高龄、既往有GDM病史、有糖尿病家族史、属于2型糖尿病高危种族(西班牙裔、美国土著人、南亚及东亚人、非洲裔美国人或太平洋岛裔)的女性均是GDM的高危人群。虽然高危女性可在妊娠24周前进行筛查，不过有关无症状女性早期筛查受益是否大于风险的评估证据仍然不足，因此，工作组将其列为“I级声明”。对这些高危人群，医生通常需要根据自己临床经验确定其是否需要在孕24周前进行GDM筛查。而需要强调的是，所有育龄妇女均需要采用健康生活习惯维持适宜的体重，减少未来发生GDM的潜在风险。就诊断方法而言，目前不同组织对一步法及两步法的推荐态度不同。NIH及美国妇产科医师学会推荐两步法，欧洲学会支持一步法，既往支持一步法的ADA近期发表声明称两种方法都可以。而美国预防医学工作组的新指南则并未就选择哪种方法做明确推荐。美国家庭医师协会(AAFP)和内分泌学会(ES)的推荐指南与这次更新后的USPSTF推荐意见一致。

肥胖的糖尿病前期患者进行减肥/增加体力活动或服用二甲双胍不仅可以减少他们进展为糖尿病，而且也可以充分减少心脏疾病的风险，2013年8月26日《临床内分泌与代谢杂志》在线发病的一项研究如是说。 本研究是利用核磁共振（NMR）成像与密度梯度离心（DGU）两种不同的方法，来确定：减肥/增加体力活动，使用二甲双胍或服用安慰剂，哪种方法产生了“有益的血脂”减少动脉粥样硬化的发生。 基线的体质指数是33.5至33.7之间。1年的生活方式干预后明显改善了血脂谱。服用二甲双胍也可以改善血脂，但不如生活方式明显。 戈德堡博士和他的同事们随机将1645例糖耐量受损（IGT）分为：生活方式干预组，二甲双胍850毫克每日两次组或安慰剂组。他们比较基线和1年后血液样本内血脂的水平。他们发现强化生活方式干预可减少坏的脂蛋白（极低密度脂蛋白，小而密低密度脂蛋白），增加好的脂蛋白（高密度脂蛋白）。二甲双胍适度降低坏的脂蛋白，适度增加好的脂蛋白。 强化生活方式干预组体质指数从33.5降至30.8，而二甲双胍组从33.7降至32.5。从此看来，糖尿病前期也是值得我们关注和治疗的。

记得有一次中华医学会健康大讲堂在人民大会堂举行，我（胡大一）在开场白中说 ：“中国人的健康，坏就坏在一个‘等’字。等什么？等不舒服，医学术语叫‘症状’。有了不舒服才上医院看病 ；医院也在等，等什么？等病人就诊。医院的传统模式是坐堂行医，医生是‘坐堂医生’。这两个‘等’使健康促进、健康教育、健康管理和疾病预防变得很无奈……” 预防这个词，并不是专门讲给心血管病患者听的，我们要让自己不得心血管病，这才是有效的预防。本文围绕一个“手机号”展开，告诉读者的就是如何远离心血管病，如何远离心血管病横在我们面前的死亡线。 先请记住这个“手机号”140-6-543-0-268。这里简要交代一下这个“手机号”中各个数段的含义 ：140 ：收缩压达标值 140mmHg 以下6 ：空腹血糖 6mmol/L 以下 ；糖化血红蛋白6% 以下543 ：总胆固醇值，正常人降到 5mmol/L 以下，有糖尿病或者冠心病者降到 4mmol/L 以下，同时有这两种疾病者则应降到 3mmol/L 以下0 ：零吸烟268 ：女性腰围不超过 2 尺 6 寸 ；男性腰围不超过 2 尺 8 寸如果达到上述指标，未来发生心血管病的危险会降低 90%。这是你的福，也是社会的福。希望“国人健康手机号”140-6-543-0-268 帮你降低疾病风险，提高生命质量。