Volume 97  ·  Issue 15  ·  2017

Pituitary thyroid stimulating hormone (TSH) adenoma was developed by Jailer et al.^[1]It was first reported in 1960 that the clinical manifestation was hyperthyroidism (hereinafter referred to as hyperthyroidism). The first diagnosis was Graves' disease with pituitary lesions, and the symptoms of hyperthyroidism were significantly relieved after receiving radiotherapy for pituitary lesions. Therefore, it is considered that the primary lesion is located in the pituitary gland, and it is the hyperthyroidism caused by excessive secretion of TSH by the pituitary TSH adenoma. Pituitary TSH adenomas account for about 0.5% ~3.0% of pituitary adenomas^[2]The incidence is less than 1 million people^－1· Years^－1[3]It is a rare disease, common in 30-60 years old, and there is no significant difference in incidence between men and women. Although pituitary TSH adenoma is not common in patients with central hyperthyroidism, its treatment is completely different from that of primary hyperthyroidism. Using commonly used treatment measures for primary hyperthyroidism not only fails to control central hyperthyroidism, but will aggravate the risk of pituitary adenoma. Therefore, correct diagnosis is the prerequisite for appropriate treatment^[4]。 The diagnosis of pituitary TSH adenoma is difficult, and requires high level of laboratory examination, imaging diagnosis and clinician diagnosis and treatment. Due to the uneven level of hospitals in various regions of China, the phenomenon of misdiagnosis and mistreatment emerges one after another, which brings unnecessary harm to patients. Based on this situation, the diagnosis and treatment of TSH should be paid attention to and standardized.

On the occasion of the publication of the Expert Consensus on the Diagnosis and Treatment of Pituitary Thyroid Stimulating Hormone Adenoma in China (2017) (hereinafter referred to as this consensus), this article is written at the invitation of Professor Wang Renzhi, leader of China Pituitary Tumor Collaboration Group. On the one hand, I would like to congratulate the publication of this consensus. On the other hand, I would like to introduce the purpose of writing this consensus, the writing process and the problems that need to be solved in the future from the perspective of the main participants and writers, so that doctors in hospitals in various regions and levels can understand this consensus more comprehensively in clinical practice and use it more appropriately, so that it can play a greater value in clinical diagnosis and treatment, and finally achieve the purpose of improving the diagnosis and treatment level of pituitary thyroid stimulating hormone (TSH) adenoma in China.

In the first half of the 20th century, the legal professional thinking mode was advocated, and it was indestructible^[1]。 By the second half of the 20th century, the number of medical lawsuits in many countries exploded, the medical contradiction intensified day by day, and both doctors and patients fell into "litigation burden"^[2]。 Facing the challenges of the society, the legal profession and the legal circles began to change their ideas and explore to promote the judicial reform. Non-litigation and harmony have become a value orientation that human society pursues together, and the value of mutual respect and tolerance has been paid full attention to. China is no exception. In recent years, with the improvement of people's knowledge level and the enhancement of the concept of rule of law, medical disputes are also increasing constantly. How to alleviate these contradictions is also a specific problem faced by hospitals at all levels. Now on the medical dispute in our country the people's mediation and litigation mechanism of the related issues are expounded as follows.

Pituitary thyroid stimulating hormone (TSH) adenoma is a type of functional pituitary adenoma, which is the main cause of central hyperthyroidism (hereinafter referred to as hyperthyroidism). The clinical features were increased serum free thyroid hormone (FT4, FT3) levels, uninhibited serum TSH levels, accompanied by different degrees of thyrotoxicosis and goiter. TSH adenomas are rare, with an incidence of less than 1 million people^－1· Years^－1[1]0.5% to 3.0% of pituitary adenomas^[2]At present, there are few reports in domestic and foreign literatures^[3,4,5,6]。 In recent years, with the increasing sensitivity of TSH detection technology and the widespread use of imaging techniques such as magnetic resonance (MRI), the detection and diagnosis rate of TSH adenoma has increased obviously^[7]。 TSH adenomas are often misdiagnosed as primary hyperthyroidism, especially as toxic diffuse goiter (Graves disease), and are mistreated with subtotal thyroidectomy or radioiodine therapy, which instead promotes the enlargement of TSH adenomas. Therefore, it is necessary to guide and standardize the diagnosis and treatment of TSH adenoma.

Permanent intertissue implantation of radioactive particles (abbreviated as seed implantation) has become a standard treatment for early prostate cancer. The guidelines of American Cancer Society, Urology Society, Clinical Oncology Society, Radiation Oncology Society, Close Society and NCCN have been popularized and popularized as standards^[1,2,3]。 Because prostate cancer seed implantation treatment is guided by transrectal ultrasound, combined with perineal template technology, the accurate three-dimensional distribution of particles in the prostate is realized, and the dose is highly conformal, so as to increase the dose and achieve the purpose of radical cure of tumors. Because the tumors in the head and neck, chest, abdomen and pelvic cavity are affected by bone structure, gas and organ movement, it is difficult to achieve intraoperative image acquisition, three-dimensional reconstruction and guided seed implantation by ultrasound technology. In 2002, Chinese scholars creatively introduced CT guidance technology into the field of seed implantation therapy for the first time in the world. Combining 4D-CT scanning technology, punching technology and fixed needle technology to overcome the influence of gas, bone structure and organ movement, established the standard of CT guidance seed implantation therapy, greatly improved the accuracy of seed implantation therapy, broadened the application scope of seed implantation therapy, enriched and developed seed implantation brachytherapy, and published a series of research results^{[4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31]}。 However, there is no systematic research and report on the technical specifications and standards of CT guidance at present. This consensus mainly discusses the technical process of CT guidance particle implantation, and the efficacy and research results will be reported one after another with clinical research.

To explore genetic characteristic of posterior cranial fossa morphology in families of Chiari malformation type Ⅰ (CMI).

From April 2010 to May 2016, a total of 47 cases of CMI families (CMI group) and their 94 parents (CMI-P group)collected were retrospectively reviewed in Department of Spinal Surgery, Drum Tower Hospital, School of Medicine, Nanjing University.Another cohort of 50 asymptomatic adults was enrolled to serve as the control group.Patients with skull fracture or other diseases which can lead to secondary CMI were excluded.On mid-sagittal T2-weighted magnetic resonance (MR) imaging, four measurements were evaluated and compared between these three groups, including the length of cerebellar tonsillar descent, the area of posterior cranial fossa(PCF area), the area of the brain tissue in posterior cranial fossa (PCF tissue area), and the PCF crowdedness indexes (PCF tissue area/ PCF area×100%).

Totally 47 CMI patients (21 males and 26 females; mean age, 16.4 years), 94 parents (47 males and 47 females; mean age, 39.2 years) and 50 controls (23 males and 27 females; mean age, 22.3 years) were recruited in this study.Significant differences in all four indexes were found between CMI group and the control group.The length of cerebellar tonsillar descent were much bigger in CMI-P group than in the control group (1.5±2.2 mm vs -0.9±1.1 mm), with 7 cases reach the diagnostic criteria of Chiari malformation(≥5 mm) and one with syingomyelia.Compared to the control group, CMI-P group had smaller PCF area, and its PCF crowdedness indexes averaged 90.0% as between the control group (85.3%) and the CMI group (93.6%).

In CMI families, parents have similar posterior cranial fossa abnormalities with their CMI children, presenting obviously narrow and crowded.Their PCF crowdedness indexes are between normal subjects and CMI patients, and their cerebellar tonsils are lower, even some parents are also CMI patients, suggesting genetic mechanisms involved in the development of CMI.

To investigate the surgical technique and clinical efficacy of arthroscopic treatment of the elderly patients with massive rotator cuff tear.

From June 2012 to June 2015, thirty-six patients with massive rotator cuff tear were treated with arthroscopic and followed up. The visual analog scale(VAS)pain score, University of California Los Angeles (UCLA) scores, Constant scores and American Shoulder and Elbow Surgeons scale(ASES)were used before and after the arthroscopic surgery.

All the patients were followed up for average of 18.5 (12 to 30) months.Before arthroscopic surgery, the VAS, UCLA, Constant, ASES were (6.1±2.2), (10.6±4.3), (40.3±10.5) and (28.8±18.5) points; the average flexion of the shoulder was (76.5±42.6)°, the average abduction of the shoulder was (72.4±35.2)°, the average external rotation of the shoulder was(26.6±22.2)° and the average internal rotation of the shoulder was (20.2±6.2)° respectively.These scores were improved to (1.4±1.2), (30.4±5.2), (82.6±12.6), and (78.8±22.6) points, the average flexion of the shoulder was improved to (152.8±25.6)°, the average abduction of the shoulder was improved to (120.6±32.8)°, the average external rotation of the shoulder was improved to (42.6±16.2)° and the average internal rotation of the shoulder was improved to (38.4±5.6)° after one-year follow-up period.Improvement in these scores and range of motion(ROM) were significant difference(P<0.05).

Arthroscopic repair can effectively treat the eldly patient with massive rotator cuff tear and obviously improve the function of shoulder joint. The surgery has a clinical application value.

To evaluate the efficacy and safety of pedicle subtraction osteotomy for correction of severe rigid idiopathic scoliosis.

From January 2003 to December 2014, eighteen patients with severe rigid idiopathic scoliosis were treated by posterior wedge osteotomy in department of spinal surgery, the First Affiliated Hospital of Xinjiang Medical University. There were 5 males and 13 females, and the average age at was (16.9±9.1)years, and the average follow-up was 47.6 months. The coronal and sagittal Cobb′s angles, sagittal trunk shifts, apical vertebral translation, height change and fusion segments were measured on standing AP and lateral radiographs before, after surgery and the final follow-up.

The Cobb′s angle in the coronal plane was corrected from (94.3±13.3)°to (31.6±14.8)°, representing 64.8% correction rate. The Cobb′s angle in the sagittal plane was corrected from (62.5±17.8)°to (27.1±11.7)°, representing 82.6% correction rate. Coronal trunk shift was obviously improved from -29.8 mm to -3.5 mm. the average fusion segments was 13.7±1.8 ranging from 11 to 17 segments. Perioperative complications consisted of pleura injury in 4 cases, cerebrospinal fluid leakage in 2 cases transient neurological damage in 2 cases and delayed infection in 1 case.

Pedicle Subtraction Osteotomy correction by the single posterior approach is a reliable and safe surgical technique for correction of severe rigid idiopathic scoliosis.

To analyze the value of the quantitative perfusion parameters of dynamic contrast-enhanced MRI(DCE-MRI) in the pathological subtype of uterine leiomyoma.

A total of 35 cases of uterine leiomyoma confirmed by surgery and pathology were retrospectively analyzed in Shaoxing People′s Hospital from October 2015 to May 2016.All cases underwent DCE-MRI. Quantitative perfusion parameters were prospectively measured and analyzed, including transfer constant (K^trans) , efflux rate constant (K_ep), extravascular extracellular space volume ratio (V_e), blood plasma volume ratio (V_p), permeability surface area product (PS) and plasma flow (F_p) , using signal-input two-compartment tracer kinetic models (Extended Tofts model and Exchange model) in 35 leiomyoma cases.After the operation, the 35 cases were divided into three groups according to the pathological classfication , the ordinary, the cellular and the degeneration type.To analyze the differences among the three groups about the quantitative perfusion parameters of uterine leiomyoma. Compared with the gold standard of pathological findings, the ROC curves were drawn to evaluate the diagnostic efficacy of different quantitative perfusion parameters.

In the ordinary, cellular and degeneration type of uterine leiomyoma, K^trans value were respectively(0.684±0.341), (1.897±0.458), (0.554±0.514)/min; K_ep were respectively(1.004±0.685), (2.362±1.001), (1.274±1.093)/min; V_e were respectively 0.789%±0.186%, 0.806%±0.203%, 0.537%±0.314%; V_p were respectively 0.145%±0.196%, 0.502%±0.338%, 0.062%±0.106% and F_p were respectively(0.792±0.461), (2.426±0.509), (0.628±0.551)ml/min.Among three groups, the value of K^trans, K_ep, V_e, V_p and F_p had statistical difference(all P<0.05), the value of PS didn′t have statistical difference. The value of K^trans, K_ep, V_p and F_p in cellular type were higher than the ordinary type(all P<0.01); the value of K^trans, V_p and F_p in cellular type were higher than the degeneration type(all P<0.01); the value of V_e in ordinary type was higher than the degeneration type(P<0.05). The area under ROC curve was 0.981 for K^trans, 0.904 for K_ep, 0.622 for V_e, 0.840 for V_p and 0.994 for F_p.

The quantitative perfusion parameters of DCE-MRI , especially the value of K^trans, K_ep, V_p and F_p have a great diagnostic efficacy in the pathological classfication of uterine leiomyoma which will become a predictive factor of pathological classfication in uterine leiomyoma.

To analyze the relationship between baseline liver pathologic changes and the effectiveness of entecavir(ETV) and investigate the predictive value of baseline liver pathologic changes in determining the effectiveness of ETV, to provide reliable basis for precision medicine in patients with chronic hepatitis B(CHB).

A total of 1 366 cases with CHB were retrospectively recruited who underwent liver biopsy between January 2006 to June 2016 and were treated with ETV over 96 weeks.The relationship between baseline liver pathologic changes and the antiviral responses to ETV at 48, 96 weeks were compared.

Liver pathology was employed to make the definite inflammation grade and the fibrosis stage.According to the liver inflammation and fibrosis, patients were divided into 4 groups(G1, G2, G3, G4 and S1, S2, S3, S4 respectively). The complete response rate of G1, G2, G3 and G4 after 48 weeks ETV treatment was 26.3%(10/38), 30.9%(121/391), 35.3%(101/286), 44.4%(52/117) respectively in HBeAg positive patients and was 61.5%(24/39), 80.4%(148/184), 82.4%(201/244), 88.1%(59/67) respectively in HBeAg negative patients.There was statistical difference in the complete response rates among liver inflammation grades both in HBeAg positive patients(χ²=8.510, P<0.05) and in HBeAg negative patients(χ²=12.054, P<0.05)respectively.The differences were still statistical significant after 96 weeks ETV treatment (P<0.05). The complete response rates of S1, S2, S3 and S4 after 48 weeks ETV treatment were 39.0%(41/105), 37.8%(127/336), 30.9%(97/314), 24.7%(19/77), respectively in HBeAg positive patients and was 85.7%(30/35), 84.4%(92/109), 83.9%(162/193), 75.1%(148/197) respectively in HBeAg negative patients. Whether HBeAg was positive or not, the rates were in decline but there was no statistical difference in the complete response rates among liver fibrosis stages(χ²=7.765, P>0.05; χ²=6.729, P>0.05). The differences were still not statistical significant after 96 weeks ETV treatment (P>0.05). But after further grouping, whether HBeAg was positive or not, as the degree of fibrosis stage was aggravating, the complete response rate of G2, G3 and G4 after 48 weeks ETV treatment decreased at the same degree of inflammation grade and the differences were statistically significant (P<0.05). The differences were still statistical significant after 96 weeks ETV treatment (P<0.05).

The responses to ETV treatment are closely related with baseline liver pathology.The CHB patients with higher score of inflammation and lower score of fibrosis will have a good response to ETV treatment.The degree of inflammation grades and fibrosis stages can be used as early predictors of ETV treatment for CHB.

To investigate the degree and determinants of using ticagrelor among discharged patients with acute coronary syndrome (ACS).

Patients with ACS in Fuwai hospital who were given ticagrelor after discharge between Jan. 2015 to Jun. 2015 were analyzed.The clinical characteristics and adherence to ticagrelor of these patients were collected by reviewing the electronic medical records and telephone interview.Date were statistically-analyzed.

Among all screened 404 patients, 158 (39.1%) patients prematurely stopped ticagrelor within 12 months, while 119(29.5%) patients switched from ticagrelor to clopidogrel.Unavailable locally (34.8%), economic reasons (17.7%) and hemorrhagic events (18.4%) were the main causes of the premature discontinuation of ticagrelor.Univariate analysis showed left main disease (P=0.04) and the frequency of outpatient follow-up (P<0.01) as relative factors for prematurely stopping ticagrelor outside hospital after discharge.Multivariate analysis revealed medical insurance payment (OR 1.79, 95%CI 1.03-3.11) and the frequency of outpatient follow-up (OR 0.61, 95%CI 0.43-0.86) as independent predictors of prematurely stopping ticagrelor outside hospital.Prematurely stopping ticagrelor has no significant effect on the ischemic events (myocardial infaction or stroke) (P=0.76).

Social cinditions is the main factor for the persistence to ticagrelor among ACS patients after dischcrge.Medical insurance payment and low frequency of outpatient follow-up were independent predictors of prematurely stopping ticagrelor and it may not have impact on ischemic events.

To evaluate the clinical value of SUDOSCAN in diagnosis of diabetic distal symmetrical peripheral neuropathy.

According to the diagnostic criteria for multiple diabetic distal symmetrical peripheral neuropathy, a total of 130 patients with type 2 diabetes mellitus (T2DM) in Department of Endocrinology, the Affiliated Hospital of Qingdao University between August 2015 and July 2016 were divided into two groups, diabetic peripheral neuropathy group (DPN group, 50 cases) and non-diabetic peripheral neuropathy group (NDPN group, 80 cases). Additional 80 healthy volunteers were selected as healthy control group (NC group). SUDOSCAN was employed to detect electrochemical skin conductance (ESC, the unit was μS) of subjects′ hands and feet, and the correlation between sensory nerve conduction velocity (SCV) and ESC was analyzed as well.

The average hands ESC in NC and T2DM group were (79.1±10.4) μS and (59.7±18.1) μS, respectively; the average feet ESC were (82.0±8.2) μS and (62.1±21.8) μS, respectively (both P<0.01). The average hands ESC in DPN and NDPN group were (53.2±18.9) μS and (63.7±16.5) μS; the average feet ESC were (53.5±24.4) μS and (67.4±18.2) μS, respectively (bothP<0.05). The hands and feet ESC were positively correlated with SCV, and the correlation coefficient were 0.425 and 0.445, respectively (bothP<0.01). The area under the receiver operating characteristic curve (ROC) of hands and feet ESC to evaluate diabetic symmetrical peripheral polyneuropathy were 0.785 and 0.768 (bothP<0.01).

SUDOSCAN is a promising tool for the diagnosis of diabetic symmetrical peripheral polyneuropathy.

To invesitigate 3-year patency rate of autogenous arteriovenous fistula(AVF)in the patients with late fistula dysfunction/failure.

The prospective study was carried out in the First Hospital of Tsinghua University from March 2012 to March 2013. A total of 136 maintenance hemodialysis patients with late AVF dysfunction/faliure who received AVF repairment were enrolled in the study. All the patients were divided into three groups according to surgical procedures: venous neointimal hyperplasia (VNH) stripping group (group A), non-VNH stripping group (group B) and creation of a new AVF group (group C). Patency rate was calculated by survival analysis method, and survival curve of fistula was drawn as well.

During 12-36 months follow-up, there were 46 patients with late AVF dysfunction/faliure in group A, 38 patients in group B, and 52 pateints in group C. The AVF patency rate was 88.6% at 12th month, 77.6% at 24th month, and 57.2% at 36th month in group A; 89.3% at 12th month, 74.5% at 24th month, and 55.1% at 36th month in group B; 88.1% at 12th month, 76.8% at 24th month, and 59.0% at 36th month in group C. The AVF patency rates had no statistical difference among three groups at three time points (12th, 24th and 36th month) (P>0.05).

The patency rate was high in the patients who recieved AVF repairment. There was no significant difference in the patency rate among three different surgical treatments.

To explore the minimally invasive techniques and outcome of carotid ophthalmic artery aneurysms clipping via a frontolateral approach.

The clinical data of 95 patients with carotid ophthalmic artery aneurysms treated via frontolateral approach in the last 1.5 years in Beijing Tiantan Hospital and Beijing Anzhen Hospital were analyzed retrospectively.Before the operation, digital subtraction angiogram (DSA) was performed among all patients.The patients were divided into two groups by the lateral approach.According to preoperative classification, surgical characteristics and prognosis were summarized.

Ninety-five cases of ophthalmic aneurysms were divided into type Ⅰ of 44 cases (46.3%), type Ⅱ of 34 cases (35.7%) and type Ⅲ of 17cases (17.9%), according to the results of DSA.The diameter of aneurysm was <10 mm (35 cases), 10-25 mm (34 cases), and >25 mm (26 cases). In the 17 cases of subarachnoid hemorrhage (SAH), 8 cases were ruptured carotid-ophthalmic artery aneurysms.Among those 95 patients, 93 were clipped successfully, 2 was trapped.Multiple aneurysms in 5 cases were treated in one surgical session through the same approach.No aneurysm residual was found after postoperative CTA review.Ipsilateral vision of 3 cases were decline.Cerebral infarction was appeared in 9 cases.All the others had a good recovery.

The carotid-ophthalmic artery aneurysms could be well exposed. Microsurgery through frontolateral approach has the advantages such as minimal invasion, less effect on the patients′ look and simple procedure.The frontolateral approach is safe and effective in surgery for ophthalmic segment of the internal carotid artery aneurysms.

To investigate the clinical value of contrast-enhanced ultrasound in the diagnosis of renal masses.

A total of 50 patients with renal masses who underwent partial nephrectomy were analyzed from January 2014 to October 2016 in the Department of Urology of China-Japan Union Hospital of Jilin University.In the intraoperative contrast-enhanced ultrasound, the characteristics of ultrasound imaging were recorded including location, size, boundary, echo, real-time internal and peripheral blood and renal pelvis distance, artery, guidance on the selection of surgical methods, intraoperative real-time estimation of the extent of tumor resection.

In the 50 patients, there were 49 cases enhancement in the imaging of the cystic masses, 1 case had no enhancement.Contrast-enhanced ultrasound assisted clinical accurate positioning 34 masses which were in the renal contour and not convex.And 15 patients were found main arteries of renal occupied lesions.There were 38 cases whose distance from occupying to pelvis was more than 0.5 cm, and maintained the original operation scheme for partial nephrectomy.There were 12 cases whose distance from occupying to pelvis was less than 0.5 cm, and proceeded radical resection.

Intraoperative contrast-enhanced ultrasound can provide a more accurate imaging basis for the surgeon in partial nephrectomy.It′s of great significance for the correct choice of surgical procedures, and can reduce or avoid the occurrence of postoperative complications.

To investigate the role of FOXO3a-Bim signaling in triptolide induced bladder cancer T24 cells apoptosis.

T24 cells were used and divided into control group, triptolide group(50 nmol/L), MK2206 group(50 nmol/L triptolide+ 5 μmol/L MK2206), FOXO3a-siRNA group(50 nmol/L triptolide+ 100 nmol/L FOXO3a-siRNA), Bim-siRNA group (50 nmol/L triptolide+ 100 nmol/L Bim-siRNA). MTT assay was used to analyze the cells growth inhibition.Annexin V/PI staining was implemented to detect cell apoptosis rate, the expression of p-Akt, Akt, p-FOXO3a, FOXO3a, Bim, Bax.Cleaved-caspase 3 was analyzed by Western blot.

After treatment with triptolide 25, 50, 100, 250 nmol/L, the cell growth inhibition rates at 24 hours(17%±9%, 24%±5%, 43%±8%, 61%±8%), 48 hours (20%±7%, 34%±6%, 56%±7%, 74%±5%) and 72 hours(32%±8%, 41%±7%, 69%±7%, 84%±3%) were significantly higher than control group respectively.The IC₅₀ at 24, 48, 72 hours were (113±10), (91±8), (68±5) nmol/L; the cell apoptosis rates at 24 hours (10%±4%, 15%±5%, 29%±8%, 46%±8%), 48 hours (16%±5%, 24%±6%, 40%±7%, 55%±9%) and 72 hours (27%±4%, 38%±5%, 50%±9%, 65%±8%) were significantly increased (P<0.05). Western blot showed that triptolide reduced the expression of p-Akt, p-FOXO3a and increased the expression of Bim, Bax, cleaved-caspase 3.The cell inhibition rate in Triptolide group (30%±8%) was significantly higher than that in the control group (P<0.05) and the rates in MK2206 group (54% ±6%), FOXO3a-siRNA group (18%±7%) and Bim-siRNA group (11%±6%) were also higher than the control group.Compared with the triptolide group, the inhibition rate in MK2206 group was significantly increased, but decreased in FOXO3a-siRNA group and Bim-siRNA group(P<0.05).

Triptolide induces T24 cells apoptosis through FOXO3a-Bim signaling pathway.

Case 1, male, 65 years old, was admitted to the Department of Neurology, Naval General Hospital on November 17, 2015 due to "episodic unconsciousness after eating for more than 2 months". The patient intermittently experienced dizziness after eating more than 2 months ago, followed by unconsciousness, and regained consciousness in the recumbent position for about several minutes. The self-measured blood pressure in the recumbent position was as low as 80/40 mmHg (1 mmHg =0.133 kPa), about 4 times/month. Follow-up medical history: The patient has left deviation since 2009, constipation in 2010, frequent urination and sexual dysfunction in 2012, and has not seen a doctor. Previous history of hypertension for 7 years, up to 180/110 mmHg in recumbent position, poor blood pressure control. Physical examination at admission: blood pressure 170/90 mmHg in the recumbent position, 90/60 mmHg in the standing position, and 80/50 mmHg in the recumbent position within 2 h after a meal. Forced laughter, positive palmopenial reflex, positive perioral reflex, normal muscle strength of limbs, increased muscle tone of limbs, active reflexes of bilateral biceps brachii, triceps brachii and Achilles tendon, positive bilateral Babinski sign and Chaddock sign, mutaxia and limb sensation were not abnormal. Auxiliary examination: MRI of the head showed atrophy of the pons and cerebellum, and the "cross" sign was seen in the pons (Figure 1，Figure 2)。 There were no abnormalities in blood routine, biochemistry and complete set of tumors. Video EEG examination after a full meal showed no abnormalities. Self-rated measures of anxiety and depression indicate mild depression and severe anxiety. Minimal Intelligence Status Scale (MMSE) 25 points. montreal cognitive assessment (MoCA) 18 points. Pancreatic CT showed no abnormalities. Anal sphincter electromyography (EAS-EMG) and urethral sphincter electromyography (US-EMG) showed a prolonged time limit of light contraction action potential and a simple phase of vigorous contraction recruitment potential (Table 1)。 Cutaneous sympathetic response (SSR): no waveform was elicited. Multiple system atrophy (MSA) was clinically confirmed. Treatment: Drinking water after meals, eating less carbohydrates, small meals and other changes in dietary patterns, and giving improved cocktail therapy on drugs, and the symptoms improved.

The patient Qiu, female, 50 years old, was admitted to the Department of Neurology, Suzhou Hospital affiliated to Nanjing Medical University on May 23, 2016 due to "headache for 10 years with blurred vision in the left eye for 5 h". The patient had a history of headache for more than ten years, mainly located in the left occipital region, and in severe cases, it involved pain in the forehead and around the orbit. It occurs 3 to 5 times a year, each time lasting from several days to half a month, and the headache lasts from 4 to 72 hours at the time of the attack. It is a left pulsatile headache, accompanied by photophobia and phonophobia. It is afraid to move during the attack, and there is no visual or sensory aura before the attack. This time, due to headache 1 d later, I felt blurred vision in my left eye and went to the ophthalmology department of our hospital. I found that my left eye pupil was dilated and my intraocular pressure was normal. The corresponding ophthalmic diseases were excluded and I was transferred to the neurology department for treatment. During the course of the disease, there were no nausea, vomiting, limb twitching, limb weakness, numbness, and loss of consciousness. Constipation for many years, no abnormalities in urination, sleep at night can. Deny history of other medical diseases, infectious diseases, drug allergies and blood transfusions. Physical examination: clear consciousness, normal cognitive function, physical examination cooperation, left pupil diameter 5.0 mm, right pupil diameter 2.0 mm, direct and indirect light reflection, no abnormality in all directions of eyeball movement, no nystagmus, other cranial nerve, muscle tone, muscle strength, mutaxia, reflex, sensation, meningeal irritation signs and other examinations were not abnormal. After admission, there were no obvious abnormalities in blood routine, biochemical complete set, coagulation series, immune series and thyroid function. Lumbar puncture CSF pressure 78 mmH₂O (1 mmH₂O =0.009 8 kPa), clear and transparent color, red blood cells 0×10⁶/L, white blood cells 2×10⁶/L, total protein 195 mg/L, albumin 137 mg/L, sugar quantity 4.10 mmol/L, chloride 129.3 mmol/L. Cryptococcus neoformans was not found by ink staining. MRI + TOF-MRA of the skull showed a few lacunar foci in the right basal ganglia area. Ophthalmologic consultation measurement of intraocular pressure, fundus and optical coherence tomography (OCT) examination showed no abnormalities. There were no abnormalities in EEG. After admission, the pupil gradually recovered after 3 days of intravenous infusion of normal saline 100 ml + dexamethasone 10 mg, and the pupil diameter returned to normal after 5 days of discharge. There was no recurrence of dilated pupils after 1 month and half-year follow-up.

AS a common type I allergic disease, allergic airway diseases are mainly mediated by immunoglobulin E (IgE), among which allergic rhinitis (AR) and allergic asthma (AS) are more common. In recent years, the incidence of airway allergic diseases has been increasing rapidly, and its harm to health and the burden on society and economy have become a problem that cannot be ignored^[1]。

The pituitary stalk is an important structure connecting the pituitary gland and the hypothalamus. The most common lesion is pituitary stalk thickness (PST). pituitary stalk thickness is an imaging diagnosis, which leads to a wide spectrum of diseases. The etiological diagnosis of thickened pituitary stem has always been full of challenges due to various etiologies, hidden lesions, atypical clinical manifestations and special locations, and it is still a difficult point in the clinical work of endocrinology and neurosurgery. This article intends to summarize the progress in etiology, imaging features, clinical features, biopsy indications and prognosis of pituitary stem thickening as follows.