Summarize the diabetes medical diagnosis and treatment standards issued by the American Diabetes Association in 2022.👀

Recently, the American Diabetes Association released the Diabetes Medical Diagnosis and Treatment Standards for 2022. With regard to the treatment of type 2 diabetes, the new version of the guidelines has made many updates, weakening the status of metformin as the first-line medication.

1. Recommendations for the treatment of type 2 diabetes.

Initial treatment: Metformin is generally used. For patients with atherosclerotic cardiovascular disease (ASCVD)/high-risk factors, heart failure and/or chronic kidney disease, GLP-1 receptor agonist or SGLT2 inhibitor is recommended as the initial treatment. According to the patient's blood sugar status, metformin is combined or not combined. Unless the patient is contraindicated or intolerant, metformin should be continued after the initial insulin therapy to continuously improve blood sugar and metabolism. 

• Compared with insulin monotherapy, metformin combined with insulin can further reduce HbA1c, reduce insulin dosage, weight gain and the risk of hypoglycemia.

For some patients, early combination therapy can be considered when starting treatment to prolong the time of treatment failure. 

When choosing hypoglycemic drugs, cardiovascular complications, the efficacy of hypoglycemic drugs, the risk of hypoglycemia, the impact on weight, cost, availability, side effects and patient wishes should be considered.

Regardless of whether the HbA1c level is up to standard, if the patient has ASCVD/high-risk factors, kidney disease or heart failure, it is recommended to use SGLT2 inhibitors and/or GLP-1 receptor agonists that have proven cardiovascular benefits.

For patients with type 2 diabetes, GLP-1 receptor agonists are better than insulin.

If insulin is used, it is recommended to combine therapy with GLP-1 receptor agonists to improve the efficacy and durability of the therapeutic effect.

Patients with type 2 diabetes who are not up to the standard should be intensively treated as soon as possible.

The treatment plan should be re-evaluated every 3-6 months, and adjusted according to needs and new influencing factors.

Clinicians should be alert to insulin overtreatment. The following conditions may indicate that there may be excessive insulin consumption. Including the basic dose of more than 0.5IU/kg, the great difference in blood glucose between bedtime and fasting or before and after meals, hypoglycemia (symptomatic or asymptomatic), and high variability. When insulin overtreatment occurs, the next step of individualized treatment should be redesigned.

2. The choice of hypoglycemic drugs for patients with ASCVD, heart failure and chronic kidney disease.

ASCVD/high-risk factors: It is recommended to use GLP-1 receptor agonist or SGLT2 inhibitor. Choose GLP-1 receptor agonists that have proven cardiovascular benefits: dulaglutide, liraglutide and semaglutide. Choose SGLT2 inhibitors that have proven cardiovascular benefits: empagliflozin and canagliflozin.

Heart failure: It is recommended to choose SGLT2 inhibitors that have been proven to be beneficial for heart failure: empagliflozin, canagliflozin, dapagliflozin and ertugliflozin.

Chronic kidney disease: 

• Patients with chronic kidney disease and proteinuria should first choose SGLT2 inhibitors that can delay the progression of chronic kidney disease: canagliflozin, empagliflozin and dapagliflozin. If SGLT2 inhibitors are contraindicated/intolerant, choose GLP1 receptor agonists with cardiovascular benefits: dulaglutide, liraglutide and semaglutide. 
• Patients with chronic kidney disease who do not have proteinuria should choose GLP-1 receptor agonists or SGLT2 inhibitors that have cardiovascular benefits.

3. The main features of hypoglycemic drugs.

Metformin: It has a higher efficacy, no risk of hypoglycemia, and does not have much effect on body weight. There are potential benefits for cardiovascular, but no obvious benefits for the progression of kidney disease and heart failure.

SGLT2 inhibitor: It has a moderate effect, has no risk of hypoglycemia, and can reduce weight. Empagliflozin and canagliflozin have cardiovascular benefits. Empagliflozin, canagliflozin, dapagliflozin and ertugliflozin are beneficial for heart failure. Canagliflozin, dapagliflozin and empagliflozin are beneficial to the progression of kidney disease.

GLP-1 receptor agonist: It has higher efficacy, no risk of hypoglycemia, and can reduce weight. Dulaglutide, liraglutide, and semaglutide have cardiovascular benefits. Neutral to heart failure. Dulaglutide, liraglutide and semaglutide are beneficial for renal endpoints.

DPP-4 inhibitor: It has moderate efficacy, no risk of hypoglycemia, and does not affect body weight. There is no benefit to cardiovascular and the progression of kidney disease. In addition, saxagliptin has a potential risk of heart failure.

Thiazolidinedione: It has a higher efficacy, no risk of hypoglycemia, and will increase weight. Pioglitazone has potential cardiovascular benefits. Thiazolidinediones increase the risk of heart failure and are not beneficial to the progression of kidney disease.

Sulfonylureas: It has a higher efficacy. It has a risk of hypoglycemia and can increase weight. It has no effect on cardiovascular, heart failure and the progression of kidney disease.

Insulin: It has a higher efficacy. It has a risk of hypoglycemia and can increase weight. It has no effect on cardiovascular, heart failure and the progression of kidney disease.

4. Adverse reactions and precautions.

Metformin: Common gastrointestinal reactions (diarrhea, nausea). It may cause vitamin B12 deficiency.

SGLT2 inhibitor: SGLT2 inhibitors need to be stopped before any elective surgery to avoid the risk of DKA (diabetic ketoacidosis). Common side effects include genitourinary system infection, hypovolemia, risk of hypotension, elevated LDL-C, and Fournier gangrene. Canagliflozin has a risk of fracture.

GLP-1 receptor agonist: Common side effects are gastrointestinal reactions (nausea, vomiting, diarrhea). FDA black box warning: risk of thyroid C-cell tumors in rodent studies. However, the relevance to humans is not clear (liraglutide, dulaglutide, exenatide sustained-release agent, semaglutide).

DPP-4 inhibitor: Clinical trials have reported pancreatitis, but the causality has not yet been clarified. If pancreatitis is suspected, the drug should be discontinued. Joint pain is also a common side effect.

Thiazolidinedione: Common side effects include water and sodium retention (edema, heart failure) and the risk of fractures. Pioglitazone and rosiglitazone are at risk of congestive heart failure. Pioglitazone has a risk of bladder cancer. Rosiglitazone may increase LDL-C.

Sulfonylureas: The first generation of sulfonylureas (tolbutamide) has an increased risk of cardiovascular death.

Insulin: Risk of hypoglycemia: human insulin> human insulin analogues.

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Some lifestyle habits that can help you prevent cancer.📆📆📆

Even though medical technology is becoming more and more advanced
nowadays, cancer is still one of the diseases that everyone is afraid of. There are more and more people suffering from cancer. Every minute around the world, many people are diagnosed with cancer or die of cancer. In addition to genetics that affect cancer, daily living habits can also affect cancer. Some bad habits can make people more prone to cancer. Here are some lifestyle habits that can help you prevent cancer.

1. Eating habits.

Many families are accustomed to a high-salt, high-sugar, and high-oil diet, which makes it easy to suffer from various chronic diseases, such as high blood pressure, diabetes, gout, and high blood lipids. At the same time, it will be more prone to cancer. Therefore, the usual diet should do the following:

1. Try to have a light diet, eat less high-fat, high-salt and pickled foods. It is best to consume no more than 6 grams of salt per day.
2. Eat moderate amounts of meat, each person consumes 50-75g of livestock and poultry meat and 50-100g of fish and shrimp every day. Appropriately reduce the intake of red meat (such as beef, pig and mutton), and eat less processed meat products (such as sausage and ham).
3. Drink less sugary drinks and eat less high-energy-density foods, such as desserts and high-fat meats.
4. Drink less alcohol. If you cannot avoid drinking, men should limit their drinking to less than 2 alcohol units per day, and women should limit their drinking to 1 alcohol unit per day (1 alcohol unit is 10 ml of pure alcohol, which is approximately equivalent to 360 ml of beer and 150 ml of wine or 45ml of white wine).
5. Eat more vegetables, fruits, whole grains and legumes, which should account for more than 2/3 of your daily diet. The more types, the better.
6. To maintain good eating habits. Eat regularly every day, eat slowly and avoid overeating.

2. Exercise.

Proper exercise can enhance physical fitness, improve immunity and enhance the body's resistance. Studies have shown that exercise can significantly reduce the incidence of 13 types of cancer. Lack of necessary exercise can reduce a person's life span by 3-5 years. This also increases the probability of cancer, heart disease and stroke by 25-50%. 

Suggestion:

• Perform aerobic exercises 3 times or more a week, such as jogging, swimming, skipping rope, and cycling for at least 30 minutes each time. Pay attention to warming up and stretching before and after exercise. After adapting to this exercise intensity, gradually increase the amount of exercise according to personal circumstances.

3. Sleeping.

Studies have shown that long-term lack of sleep increases the risk of cancers such as colorectal cancer, thyroid cancer and lung cancer. Studies have investigated more than 1000 cancer patients between the ages of 30 and 50 from all over the world. It was found that 99.3% of them would not rest until after the early hours of the morning for a long time. 

Suggestion:

• Children 1-2 years old: It is recommended to sleep 11-14 hours a day, but it should not be less than 9 hours or more than 16 hours.
• Children 3-5 years old: It is recommended to sleep 10-13 hours a day, but it should not be less than 8 hours or more than 14 hours.
• Children 6-13 years old: It is recommended to sleep 9-11 hours a day, but it should not be less than 7 hours or more than 12 hours.
• Adolescents aged 14-17: It is recommended to sleep 8-10 hours a day, but it should not be less than 7 hours or more than 11 hours.
• Adults aged 18-64: It is recommended to sleep 7-9 hours a day, but should not be less than 6 hours or more than 11 hours.
• Elderly people over 65: It is recommended to sleep 7-9 hours a day, but it should not be less than 5 hours or more than 9 hours.

4. Emotion.

Studies have found that experimental mice live in a pleasant environment, and their tumors are getting smaller than those in the control group, and even disappear. Positive emotions have a positive impact on the immune system and can help prevent cancer.

5. Examination.

Cancer is a chronic development process. Therefore, if cancer is detected as early as possible, there is a greater chance of recovery. Lung cancer is the cancer with the highest morbidity and mortality. However, if it is detected and treated early, the 5-year survival rate can reach 90%. Regular examination can detect cancer early and improve the cure rate of patients. In addition, people with past medical or family history should undergo more targeted examinations.

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Knowledge about streptococcal infection.📜📜📜

Streptococcus has a wide variety of bacteria and is widely distributed. Some streptococci are normal human flora, while others are pathogenic bacteria of humans. 

1. What is streptococcus?

Streptococcus is a gram-positive cocci and the bacteria are purple after Gram staining. According to whether hemolysis occurs on blood agar, Streptococcus bacteria are divided into three categories: α-hemolytic streptococcus, β-hemolytic streptococcus and γ-streptococcus.

Medically important streptococci:

1. α-hemolytic streptococcus: Streptococcus pneumoniae, Streptococcus viridans.
2. β-hemolytic streptococcus: Group A Streptococcus (also call streptococcus pyogenes), group B, group C, group D and group G streptococcus.
3. γ-streptococcus: They are generally not causing disease.

2. Common streptococcus infections:

• Streptococcus pneumoniae: Streptococcus pneumoniae is distributed in the nasopharynx of 5-10% of adults and 20-40% of children. Most of the strains are not pathogenic and only a few strains are pathogenic. It is the main pathogen of bacterial pneumonia. It causes diseases such as acute bacterial otitis media, acute bacterial sinusitis, community-acquired pneumonia and lung abscess.
• Streptococcus viridans: It is mainly distributed in the oropharynx and gastrointestinal tract. It1 is a common pathogen causing dental caries, infective endocarditis and bacteremia.
• Streptococcus pyogenes: It is mainly distributed in the throat and is the most pathogenic bacteria among streptococci. It accounts for about 90% of streptococcal infections. It is the main pathogen of acute bacterial pharyngitis and tonsillitis. It can also cause lymphangitis, acute cellulitis, acute rheumatic fever, and glomerulonephritis.

3. Commonly used antibacterial drugs for streptococcal infections.

• Penicillin is the first choice for streptococcal infections. The antibacterial activity of the first and second generation cephalosporins against Streptococcus pneumoniae is less than penicillin. The drug resistance of streptococcus is caused by genetic mutations. Streptococcus pneumoniae is also less resistant to them. Streptococcus is not sensitive to penicillin. Amoxicillin, ceftriaxone and cefotaxime will have good antibacterial activity. 
• Penicillin-resistant Streptococcus pneumoniae is highly sensitive to vancomycin, linezolid and carbapenems.
• The resistance rate of macrolides and clindamycin is high.
• Aminoglycosides have no antibacterial activity against streptococci, but have synergistic effects with β-lactam antibiotics.

Acute bacterial pharyngitis and tonsillitis:

The common pathogen is group A hemolytic streptococcus. Penicillin is the first choice. Optional amoxicillin. Amoxicillin/clavulanic acid should not be used. This is mainly because hemolytic streptococcus does not produce β-lactamase, and clavulanic acid is useless at all. Since non-suppurative complications (acute rheumatic fever and glomerulonephritis) can occur after infection of group A hemolytic streptococcus, antibacterial treatment is aimed at removing bacteria and the course of treatment takes 10 days.

Acute bacterial otitis media and acute bacterial sinusitis:

The common pathogens are Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae. The first choice is amoxicillin or amoxicillin/clavulanic acid. 

Mainly reasons:

• Anti-Gram-positive bacteria activity (group A hemolytic streptococcus, streptococcus pneumoniae): amoxicillin ≈ penicillin.
• Anti-Gram-negative bacteria activity (Moraxella catarrhalis, Haemophilus influenzae): amoxicillin/clavulanic acid> amoxicillin> penicillin.

	Common pathogens	Antibacterial drugs
Acute bacterial pharyngitis and tonsillitis	Group A hemolytic streptococcus	l   Penicillin, amoxicillin. l   Patients who are allergic to penicillin can choose tetracyclines or fluoroquinolones that are sensitive to hemolytic streptococci (such as levofloxacin, moxifloxacin).
Acute cellulitis and lymphangitis.	Group A hemolytic streptococcus	l   Penicillin, amoxicillin. l   Amoxicillin/clavulanic acid, ceftriaxone.
Acute bacterial otitis media.	Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae.	l   Amoxicillin. l   If Moraxella catarrhalis and Haemophilus influenzae which producing β-lactamase strains are common in the local area, amoxicillin/clavulanic acid should be used. l   If the patient has no effect after taking the medicine for 3 days, it should be considered as possible penicillin-resistant Streptococcus pneumoniae infection. Ceftriaxone should be used.
Acute bacterial sinusitis.	Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae.	l   Amoxicillin/clavulanic acid.
Infective endocarditis	Streptococcus viridans.	l   Penicillin is used in combination with gentamicin. l   Combine ceftriaxone or cefotaxime with gentamicin.
Purulent meningitis (age < 1 month)	Group B hemolytic streptococcus, Escherichia coli, Listeria and Klebsiella pneumoniae.	l   Combine ceftriaxone or cefotaxime with ampicillin. l   Gentamicin is combined with ampicillin.

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Have you ever used corticosteroids ointments❓❓❓

Topical glucocorticoid is a very commonly used topical drug. Some people think that it is a panacea that can cure skin diseases such as itching, redness and swelling. However, some people refuse to use it because it contains steroids. The following are some practical knowledge about topical glucocorticoids.

1. Classification and intensity.

According to the different types and concentrations of glucocorticoids, topical glucocorticoids can be divided into 4 categories: super strong, strong, medium and weak. The same glucocorticoid has different strengths at different concentrations.

Commonly used topical glucocorticoids
Super strong	Clobetasol propionate	0.02%	1.    It is suitable for severe and hypertrophic skin lesions. 2.      Not for use in children <12 years old. 3.    Do not use on soft skin area. 4.    Long-term use in a small area. 5.    Do not exceed 50g per week. 6.    Continuous medication should not exceed 2-3 weeks. 7.    * They can be used with caution in children.
	Betamethasone valerate	0.1%
	Halometasone	0.05%
	Halcinonide	0.1%
	Fluocinolone	0.2%
Strong	Beclomethasone dipropionate	0.025%
	Betamethasone valerate	0.05%
	Fluocinolone	0.025%
	*Fluticasone propionate	0.05%
	*Mometasone furoate	0.1%
Medium	Prednisolone acetate	0.5%	1.    Suitable for mild to moderate skin lesions. 2.    It should not be used for a long time in a large area. 3.    It can be applied continuously for 4-6 weeks. 4.    Children <12 years old try not to use it continuously for more than 2 weeks.
	Dexamethasone acetate	0.05%
	Clobetasone butyrate	0.05%
	Hydrocortisone butyrate	1%
	Triamcinolone acetonide	0.025%
	Fludrocortisone acetate	0.025%
	Fluocinolone acetonide	0.01%
Weak	Hydrocortisone acetate	1%	1.    Suitable for mild to moderate skin lesions. 2.    Apply to the soft skin areas. 3.    Suitable for children <12 years old. 4.    It can be used in a larger area in a short time. 5.    It can be used for a long time if necessary.
	Methylprednisolone acetate	0.025%
	Desonide	0.05%
	Fluocinolone acetonide	0.0025%

Although fluticasone propionate and mometasone furoate are both strong glucocorticoids, they are less absorbed throughout the body when used externally. They are suitable for use by the elderly, infants and in a large areas.

2. The choice of topical glucocorticoids in various populations.

Children and the elderly: It is advisable to choose weak glucocorticoids, and use strong and super strong types with caution.

Pregnant women: Glucocorticoids should be used with caution in pregnant women. Weak or medium types can be selected when they must be used.

Soft skin areas: The face, neck, armpits, groin, inner thighs, perineum and other soft skin areas have a high drug absorption rate, so strong glucocorticoids should not be used. When it must be used, desonide, mometasone furoate and hydrocortisone can be used.

Ointment: The ointment dosage form has an encapsulating effect, which enhances the drug penetration ability. Ointment is suitable for keratinized, hypertrophic and desquamative skin, especially palms and soles. It is not recommended for non-hypertrophic, keratinized skin lesions on soft skin areas such as the face. Ointment should not be used in skin areas where babies wear diapers.

Creams, gels and solutions: They are suitable for all kinds of skin lesions and are also suitable for thick hair areas.

3. Indications.

Dermatitis, eczema, papular urticaria, erythema scaly skin disease, autoimmune skin disease, etc.

4. Contraindications.

Impetigo (bacterial infection), tinea hand and foot (fungal infection), shingles (viral infection), rosacea, acne, skin ulcers, etc. It is also not suitable for acute urticaria. The redness and itching caused by acute urticaria should be relieved with appropriate antihistamines (such as cetirizine, loratadine).

5. Dosage:

The most commonly used method for estimating the amount is the "fingertip unit"(FTU).

FTU: It refers to the amount of ointment squeezed from the ointment tube (with a diameter of 5mm) to an adult's fingertip (from the end of the index finger to the horizontal line of the first knuckle joint). A fingertip unit is about 0.5g ointment.

Estimate the skin area with the palm of your hand, and then calculate the FTU based on the area. Use about 0.5 FTU per palm area.

6. Adverse reactions.

The correct use of topical glucocorticoids is relatively safe. Long-term or large amounts of topical glucocorticoids may induce or aggravate local infections, leading to skin atrophy, telangiectasia, hirsutism, pigment changes, hormone dependence and other adverse reactions.

Patients should actively monitor for adverse reactions: The strong and super strong types are once every 2 weeks, the medium types are once every 3-4 weeks, and the weak types are once every 4-6 weeks.

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Some learning points about levothyroxine.📝📝📝

The manual for levothyroxine.

Indications:

1. Treatment of non-toxic goiter with normal thyroid function.
2. After goiter resection, prevent the recurrence of goiter.
3. Adjuvant treatment of hyperthyroidism with antithyroid drugs.
4. Suppressive treatment after thyroid cancer surgery.
5. Alternative treatment of hypothyroidism caused by various reasons.
6. Thyroid suppression test (used in diagnosis and treatment of diseases).

In addition, levothyroxine is not used for weight loss. It is because inappropriate long-term use of levothyroxine can cause various complications of hyperthyroidism and even life-threatening.

Some moderate to severe obesity patients may have subclinical hypothyroidism. Thyroid stimulating hormone is compensatory elevated, but thyroid hormone levels are normal. Consider taking a small dose of levothyroxine sodium tablets (such as 25ug/day) within a certain period of time. It can reduce the level of thyroid-stimulating hormone and increase the basal metabolic rate, which may help weight loss, but also should pay attention to adverse reactions and strengthen thyroid function.

Medicine interactions:

For drugs that affect the absorption of levothyroxine, you can increase the interval or increase the dose:

1. Cholesterol-lowering drugs: such as cholestyramine and colestipol.
2. Drugs containing aluminum, iron and calcium. Such as gastric mucosal protective agent (sucralfate), antacids (aluminum hydroxide, ferrous sulfate, calcium carbonate tablets).
3. Acid inhibitors and stomach drugs: H2 receptor blockers and proton pump inhibitors (such as ranitidine, omeprazole).
4. Anti-epileptic drugs: such as phenobarbital, phenytoin sodium, carbamazepine.
5. Anti-tuberculosis drugs: such as rifampicin.

Drugs affected by levothyroxine:

1. Anti-diabetic drugs: Levothyroxine can reduce the effect of hypoglycemic. Therefore, patients with diabetes should increase blood glucose monitoring and adjust the dosage in time.
2. Anticoagulant: Levothyroxine can enhance the anticoagulant effect of coumarin derivatives (such as warfarin). Patients should pay attention to adjusting the dosage to prevent the risk of bleeding.

Others:

Propylthiouracil, amiodarone, iodine-containing contrast agents and β-sympathomimetic drugs, glucocorticoids, estrogen, sertraline, etc. can reduce the efficacy of the drug. Salicylate, dicoumarin, high-dose furosemide (250mg), oxytocin, phenytoin, etc. can increase the efficacy of the drug. Need to adjust the dose of levothyroxine sodium tablets as appropriate.

Foods:

Animal offal, spinach, cherries, grapes, peaches, grapefruit, soybeans, high-fiber foods, coffee, milk, yogurt, soy milk, etc.

Medication time:

Since food can affect the absorption of levothyroxine sodium tablets, it is recommended to take the dose with water every morning on an empty stomach. It can be taken immediately after getting up in the morning, but do not eat breakfast within half an hour.

If the dose of the drug is large, it is still not necessary to take it in divided doses. Try not to take the medicine before going to bed, otherwise it may increase the excitability of the body and affect the quality of sleep.

Dosage:

The blood level of thyroid stimulating hormone is a reliable basis for determining the dosage of treatment. If the child has no obvious contraindications, the full dose should be used at the beginning of treatment or the optimal dose can be reached quickly in a short period of time. However, adults should start with a small dose and gradually increase to the optimal dose every 2 to 4 weeks. Elderly patients should increase the dose more slowly.

1. Goiter (normal thyroid function): 75-200ug/day for adults, 50-150ug/day for teenagers.
2. Prevention of goiter recurrence after thyroidectomy: 75-200ug/day for adults.
3. Hypothyroidism in adults: initial dose 25-50ug/day, increase 25-50ug every 2-4 weeks, maintenance dose 125-250ug/day.
4. Hypothyroidism in children: the initial dose is 12.5-50ug/day/m² body surface area, and the maintenance dose is 100-150ug/day/m² body surface area.
5. Adjuvant treatment of anti-hyperthyroidism: 50-100ug/day. After total thyroidectomy: 150-300ug/day.
6. Thyroid suppression test: 200ug/day.

Monitor:

At the beginning of treatment and every time the dosage is adjusted, thyroid function needs to be measured every 4 to 6 weeks. Adjust the dose according to the inspection results. After the treatment reaches the standard, check again every 6 to 12 months. If the treatment is not up to standard, you should carefully look for the reasons, such as clinical compliance and medication time.

Adverse reactions:

Levothyroxine is generally well tolerated. Patients who increase the dose too quickly in the early stage of treatment or overdose may have symptoms of hyperthyroidism, such as palpitations, tremor, sweating, skin flushing, diarrhea, weight loss, menstrual disorders, insomnia and irritability.

When the patient has any adverse reactions, appropriate treatment should be given. If necessary, reduce the dose or discontinue the drug until the adverse reaction disappears and then start the treatment from a small dose.

Long-term use of levothyroxine can accelerate the bone transformation process. Elderly and postmenopausal patients with osteoporosis should pay attention to calcium and vitamin D supplementation. They should monitor the bone density regularly.

Missed medication:

The half-life of levothyroxine is 7 days and its effect is slow and lasting. The effect is significant and stable after taking the medicine one month. 

In the early treatment of hypothyroidism, if there is a missed dose, it may be considered supplementing the dose on the same day or doubling the dose the next day. If the thyroid function is relatively stable after taking the medicine regularly for a long time, it may be considered that there is no need to take supplements, and it can be maintained at the current dose.

Patients after thyroid cancer surgery should ensure that they do not miss a dose as much as possible. If a missed dose is taken, it should be refilled in time to ensure that the dose is sufficient for at least the entire week.

Special population:

At the recommended dose, levothyroxine is not teratogenic to the fetus, nor will it interfere with fetal thyroid function. Therefore, women during pregnancy and lactation cannot stop levothyroxine treatment. The dose may need to increase during pregnancy. Hypothyroidism caused by drug withdrawal has a great impact on maternal and fetal development. Levothyroxine cannot be used as an adjuvant treatment for hyperthyroidism during pregnancy, as this will increase the dose of antithyroid drugs and increase the risk of suppressing fetal thyroid function.

Patients with coronary heart disease, elderly, severe or long-term hypothyroidism must be very cautious about the dose of levothyroxine. It must be started with a small dose, the interval between dose increases should be lengthened, and the monitoring of thyroid function should be strengthened.

Patients with after thyroid cancer surgery take levothyroxine on the one hand to supplement thyroid hormones to prevent hypothyroidism, and on the other to inhibit thyroid stimulating hormone to prevent cancer recurrence.

Contraindications:

1. Allergy.
2. Untreated adrenal insufficiency, pituitary insufficiency, hyperthyroidism, coronary heart disease, angina pectoris, arteriosclerosis and high blood pressure.
3. Acute myocardial infarction, acute myocarditis.

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Vitamin D may be good for heart health.💖💖💖

After the human body is irradiated by ultraviolet rays in the sun, the skin cansynthesize an essential vitamin-vitamin D. Many people know that vitamin D is good for bones. However, recent studies have pointed out that when vitamin D is deficient, not only bone health may be affected, but also heart health. Researchers at the University of South Australia discovered genetic evidence for the first time. It proves that vitamin D deficiency can cause cardiovascular disease. People with vitamin D deficiency are more likely to develop heart disease and high blood pressure than those with normal levels of vitamin D. Cardiovascular diseases are one of the leading causes of human deaths worldwide. It is estimated to cause more than 15 million deaths each year. At the same time, cardiovascular diseases also cause huge economic losses to countries around the world. Understanding the causes of cardiovascular disease can effectively prevent it and reduce economic losses. 

For people who do not often do outdoor activities, it is easy to cause vitamin D deficiency.

Vitamin D deficiency is actually very common. Data from the United Kingdom showed that 55% of the participants had low levels of vitamin D (<50nmol/L), and 13% had severe vitamin D deficiency (<25nmol/L). Statistics show that 37% of Canadians, 23% of Australians and 24% of Americans have had low vitamin D levels. Especially for the elderly, since they may take less outdoor activities, they do not have enough time to be exposed to the sun. This prevents them from getting enough vitamin D. Although food also contains vitamin D, such as oily fish and eggs, the content of vitamin D in food is relatively low. Therefore, even through a balanced diet, there is generally not enough vitamin D. If we cannot get enough vitamin D through sunlight, we need to take supplements every day to achieve the demand. 

Vitamin D can affects cardiovascular health.

The results of the study show that if they can increase the level of vitamin D within the normal range, it should also affect the incidence of cardiovascular disease. Among the population participating in the study, individuals with vitamin D deficiency increased their vitamin D levels to at least 50 nmol/L, which is estimated to prevent 4.4% of cardiovascular disease cases. Researchers evaluated how increasing the levels of vitamin D affect cardiovascular disease risk based on how high the participants' actual the levels of vitamin D were. The study used data from nearly 300,000 people. This allows the study to provide strong statistical evidence for the link between vitamin D deficiency and cardiovascular disease. People with vitamin D deficiency are more likely to develop heart disease and high blood pressure than those with normal levels of vitamin D. For participants with the lowest levels of vitamin D, the risk of heart disease was more than twice that of those with sufficient vitamin D. The research leader thinks, "It is unethical to recruit patients with vitamin D deficiency to participate in randomized controlled trials and keep them from receiving treatment for a long time. But it is this method that can show how increasing the concentration can affect the risk of those who need it most, and don't let participants suffer any harm." Non-linear Mendelian randomization analysis supports the L-type association between serum 25-hydroxyvitamin D concentration and cardiovascular disease risk. This shows that the cardiovascular health benefits of improving vitamin D status are the strongest for those in the vitamin D deficiency range. Vitamin D supplementation may have the strongest effect on those with the lowest levels of vitamin D. The methods to eliminate vitamin D deficiency within the population can reduce the global burden of cardiovascular disease. 

Non-linear Mendelian randomization analyses support a role for vitamin D deficiency in cardiovascular disease risk.

If you want to know more detail, you can read this article.👇

Ang Zhou, Joseph B Selvanayagam, Elina Hyppönen, Non-linear Mendelian randomization analyses support a role for vitamin D deficiency in cardiovascular disease risk, European Heart Journal, 2021;, ehab809, https://doi.org/10.1093/eurheartj/ehab809

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Be careful when drinking alcohol outdoors in winter.🍺🍺🍺

In the news, people sometimes get drunk in the winter, fall asleep on the road, and then freeze to death. Some people who are still young and strong will freeze to death on the side of the road. What is going on here? Can people be frozen to death so easily? In fact, this situation is not uncommon. There will be similar news all over the world every winter, but many people may not know it.

What happened to make people drunk?

When people drink too much alcohol, they are easily paralyzed by feeling good about themselves at first. People are usually in a more excited state when they are just drunk. They will feel that they are not drunk and that all their states are normal. This is because the human body absorbs only a small dose of ethanol at this time. Small doses of ethanol can inhibit the cerebral cortex and cause the "disinhibitory excitement" of the subcortical center. Therefore, people who drink alcohol often exhibit high mood, excessive excitement and decreased control ability. 

However, as the absorbed dose of ethanol increases, the inhibitory effect will spread to the subcortical center. At this time, people turn from an excited state to a restrained state. At this time, in addition to the above symptoms will aggravate. The body will also experience symptoms such as impaired motor control ability and decreased clarity of consciousness, such as instability, confusion, lethargy and so on. 

If ethanol intake continues to increase, then it will inhibit the medulla oblongata life center. It can cause coma and even death. 

Why is it easy to freeze to death when sleeping outdoors after drinking?

In fact, This is usually caused by people underestimating the power of alcohol and lead to happen the accidents. In addition to the above, when drinking alcohol and for a short period of time after drinking, the human body will temporarily feel warm due to the effect of acetaldehyde. But in fact, the body is actually losing heat continuously at this time. As the body's heat continues to be lost, drunk people will feel colder and colder. In this case, if a person sleeps outside in the cold winter because of being drunk, it is easy to have an accident due to hypothermia.

Therefore, we must not underestimate the effects of alcohol on the human body. Never walk alone outside after excessive drinking, especially on cold winter nights.

What is alcohol dependence?

Alcohol dependence refers to the mental and physical dependence of people who drink alcohol for a long time. Mental dependence means that as long as you don't drink, you will feel restless, anxious, irritable, listless and will try everything to drink. Physical dependence refers to people who drink for a long time. Once they start to give up, the body will have a lot of discomfort, such as palpitation, headache, fatigue. Once they resume drinking, the symptoms will naturally disappear. Another feature of alcohol dependence is the continuous increase in alcohol consumption and increased tolerance. It generally takes several years to decades to reach alcohol dependence. Many people know that drinking too much is harmful to the body, but they are unable to control themselves. Occasionally reducing the amount or not drinking will cause discomfort and must drink alcohol to relieve their discomfort.

Some ways to Quit Drinking:

1. Reduce the amount of alcohol: If you drink too much, you must take it slowly to avoid withdrawal symptoms. You can choose a specific weekday to never drink and reduce the amount of alcohol you drink each time.
2. Reduce participation in drinking activities: Reduce contact with friends who drink with you and participate in their drinking activities.
3. Eat something before drinking: Eating before drinking can reduce your desire to drink, and it will also make it more difficult to get drunk.
4. Drink more water: This keeps you hydrated, and also helps your body expel toxins.
5. Self-feelings: Face your own feelings well. Explore your own inner thoughts, emotions and behaviors.
6. Refusal to drink: Bravely refuse people who invite you to drink.
7. Learn how to eliminate worries: try to understand your worries. Drinking is just an escape from the problem, and there are actually many ways to get rid of worries.
8. Consult a doctor: You should not start quitting alcohol alone. The process of quitting alcohol can be fatal. If you have withdrawal symptoms (panic, anxiety, trembling, rapid heartbeat), you should seek medical help immediately. This condition may worsen into delirium tremens, which can be fatal if not treated. 

In fact, as long as your will to quit drinking is strong enough, there are many ways to help you quit drinking. There are also some drugs that can reduce your desire for alcohol. Those drugs can make you feel discomfort when you drink alcohol.

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