急诊内科不常见腹痛病例临床分析

腹痛是四季多发病、常见病,更是大约20%急诊科患者主诉,引起腹痛的原因极多,临床表现也很相似,某些不常见腹痛给临床医生鉴别诊断和治疗带来了很大困难。由于导致腹痛的原因繁多,往往难以在门诊接诊的当时直接诊断,许多患者甚至需要住院进一步检查。更有甚者往往需要通过随访才能最终诊断。因此临床工作者不仅要熟练掌握常见腹痛的诊断,对不常见腹痛也应做到心中有数,以做到不至于漏诊误诊。本研究选取了我院自2007-2012年间收治的7400例腹痛病例中的110例涉及心脏科、神经科、血液科等科室的不常见甚至罕见腹痛病例,从诊断、治疗的角度总结如何在临床提高对急诊内科不常见腹痛的诊断水平。

Clinical characteristics of a group of adults with nodular lymphoid hyperplasia:A single center experience

AIM： To describe the clinical and histological characteristics of a group of adults with small-bowel nodular lymphoid hyperplasia （NLH）. METHODS： Patients were searched for five years in pathology records of our institution. The biopsy material was reassessed using strict histopathological criteria. Clinical data were obtained from medical records. RESULTS： Small-bowel NLH was diagnosed in 18 cases. The female： male ratio was 2 ： 1. The most frequent symptoms were diarrhea （72%）, involuntary weight loss （72%） and abdominal pain （61%）. Nine patients （50%） had immunodeficiency. Small-bowel bacterial overgrowth was found in three （17%） cases. At small-bowel NLH diagnosis, three （17%） had associated lymphoma： two intestinal and one extra-intestinal lymphomas. In two patients with villous atrophy and anti-endomysial antibodies the diagnosis of celiac disease was established. Giardia larnblia infection was found in only one patient with hypogammaglobulinemia （Herman＇s syndrome）. CONCLUSIONS： NLH is uncommon in adult patients. Associated diseases are immunodeficiency and lymphoid tissue malignancies.

Clinical utility of the platelet-lymphocyte ratio as a predictor of postoperative complications after radical gastrectomy for clinical T2-4 gastric cancer

AIMTo identify simple and sensitive markers for postoperative complications after gastrectomy, the predictive values were compared among candidate preoperative factors.METHODSThree-hundred and twelve patients with previously untreated clinical T2-4 gastric cancer who underwent a D2 standard gastrectomy (distal gastrectomy or total gastrectomy) were included in the analysis. Correlations between 21 parameters that can be determined by preoperative routine blood tests and clinically relevant postoperative complications (grade II or higher according to the Clavien-Dindo classification) were evaluated. The optimal cutoff values and clinical significance of the selected markers were further evaluated by subgroup analyses according to age, body mass index, operative procedure and clinical disease stage.RESULTSSixty-six patients (21.1%) experienced grade II or higher postoperative complications. The platelet-lymphocyte ratio (PLR, total lymphocyte count/platelet count × 100) exhibited the highest area under the curve value (0.639) for predicting postoperative complications among the 21 parameters, and the optimal cutoff value was determined to be 0.71 (sensitivity = 70%, specificity = 56%). In the univariate analysis, the odds ratio of a low PLR for the occurrence of postoperative complications was 2.94 (95%CI: 1.66-5.35, P < 0.001), and a multivariate binomial logistic analysis involving other potential risk factors identified a low PLR as an independent risk factor for postoperative complications (OR = 3.32, 95%CI: 1.82-6.25, P < 0.001). In subgroups classified according to age, body mass index, operative procedure and clinical disease stage, the low PLR group exhibited an increased incidence of postoperative complications.CONCLUSIONThe preoperative PLR is a simple and useful predictor of complications after curative gastrectomy in patients with clinical T2-4 gastric cancer.

T-regulatory lymphocytes in peripheral blood of gastric and colorectal cancer patients

AIM: To assess the absolute number of T-regulatory cells (Tregs; CD4+CD25+Foxp3+) in the peripheral blood of gastric and colorectal cancer patients. METHODS: We enrolled 70 cancer patients (33 gastric cancer, 37 colorectal cancer) and 17 healthy volunteers. The CD3+CD4+ lymphocytes and CD4+CD25+Foxp3+ Tregs in the peripheral blood were analyzed with flow cytometry. The absolute numbers of Tregs were calculated based on the CD4+CD25+Foxp3+ cells percent-age of CD3+CD4+ cells and the absolute numbers of CD3+CD4+ cells per microliter. RESULTS: The mean number of CD4+CD25+Foxp3+ cells per microliter in colorectal cancer patients was 15.7 (SD: 21.8), for gastric cancer patients 12.2 (SD: 14.3), and for controls 17.5 (SD: 11.4). The absolute number of Tregs was significantly lower in gastric cancer patients than in controls (P = 0.026). There was no statistically significant difference for gastric vs colorectal cancer or colorectal cancer vs controls. The absolute number of Tregs was also significantly depressed in N+ vs Ncancer patients [22.0 (27.7) vs 10.1 (9.0), P = 0.013], and in the subgroup of gastric cancer patients [30.3 (27.6) vs 9.6 (8.0), P = 0.003]. No statistical difference was observed in the proportion of Tregs in the CD4+ population between the groups. CONCLUSION: The absolute number of Tregs in peripheral blood of gastric cancer but not colorectal cancer patients was significantly decreased in comparison with that in healthy controls.

ROLE OF B LYMPHOCYTE AND ITS SUBPOPULATIONS IN PATHOGENESIS OF IMMUNORELATED PANCYTOPENIA

Objective To measure the quantities and apoptosis-related protein levels of B lymphocyte in the patients with immunorelated pancytopenia （IRP） and explore the action of B lymphocyte in the pathogenic mechanism of IRP. Methods Quantifies of whole B lymphocytes and CD5^＋ B lymphocytes as well as the expressions of Fas and Bcl-2 in B lymphocytes in 35 patients with untreated IRP, 15 IRP patients in complete remission （CR）, and 10 normal controls were assayed by flow cytometry. The percentages of B lymphocyte and CD5^＋ B lymphocyte were significantly higher in untreated IRP patients than in CR IRP patients and normal controls （ P 〈 0. 05 ）, and there was no significant difference between the latter two groups （ P 〉 0. 05 ）. There was no significant difference of Fas expression in B lymphocyte among three groups （ P 〉 0. 05）. The expression of Bcl-2 in B lymphocyte was significantly higher in untreated patients than in CR patients or normal controls （ P 〈 0. 01 ）, and significantly higher in CR patients than in normal controls （ P 〈 0. 01 ）. The apoptosis. related index was significantly lower in untreated patients than in CR patients or normal controls （ P 〈 0. 05 ）, and signif. icantly lower in CR patients than in normal controls （ P 〈 0. 05 ）. The percentage of B lymphocyte was positively correlated with post-treated response time （ r = 0. 53, P 〈 0. 01 ）. Conclusion The production of auto-antibodies in IRP patients probably has some relationship with the abnormal quantifies of B lymphocyte and its subpopulations as well as with the inhibition of B lymphocyte apoptosis.

Primary 4-3-oxosteroid 5β-reductase deficiency:Two cases in China

Aldo-keto reductase 1D1(AKR1D1) deficiency,a rare but life-threatening form of bile acid deficiency,has not been previously described in China.Here,we describe the first two primary 4-3-oxosteroid 5β-reductase deficiency patients in China's Mainland diagnosed by fast atom bombardment-mass spectroscopy of urinary bile acids and confirmed by genetic analysis.A high proportion of atypical 3-oxo-4-bile acids in the urine indicated a deficiency in 4-3-oxosteroid 5β-reductase.All of the coding exons and adjacent intronic sequence of the AKR1D1 gene were sequenced using peripheral lymphocyte genomic DNA of two patients and one of the patient's parents.One patient exhibited compound heterozygous mutations:c.396C>A and c.722A>T,while the other was heterozygous for the mutation c.797G>A.Based on these mutations,a diagnosis of primary 4-3-oxosteroid 5β-reductase deficiency could be confirmed.With ursodeoxycholic acid treatment and fat-soluble vitamin supplements,liver function tests normalized rapidly,and the degree of hepatomegaly was markedly reduced in both patients.

Study on the Clinical Effectiveness of Thymectomy for Myasthenia Gravis

Objective To investigate the theoretical basis and clinical significance of thymectomy in the treatment of myasthenia gravis (MG). Methods Analyze the changes in the contents of serum AchRab and sIL-2R, lymphocyte subtypes in peripheral blood lymphocytes before and after thymectomy in 69 patients.Results In the study group significant changes were found in serum contents of AchRab and sIL-2R before and after operation and there was also remarkable change in the number and constitution of peripheral blood lymphocyte subtypes. Conclusion Thymectomy is an effective therapy for MG.

Massive ascites as a presenting manifestation of chronic lymphocytic leukemia

Ascites is not an uncommon manifestation of certain solid tumors like gastrointestinal malignancies, ovarian cancer and breast cancer. However, it is unusual to encounter ascites in patients with hematological malignancies especially chronic leukemia. The patient described here presented with massive ascites and blood lymphocytosis. Further studies confirmed the diagnosis of chronic lymphocytic leukemia with ascites. The ascitic fluid was exudative, consisting of mature-looking B-lymphocytes, which were morphologically and immunophenotypically similar to peripheral blood and bone marrow cells. The patient was treated with chemotherapy and achieved a good response and diminution of ascitic fluid accumulation.

The Effect of Gnaphafium oxyphyllum var. natalie on Cancer and Blood Cells

Gnaphalium oxyphyllum DC is a medicinal plant whose common uses by Mexican people include the treatment of cancer. The toxicity of the aqueous and organic fractions as well as the aqueous decoction of G. oxyphyllum var. natalie F. J. Espinosa were assessed on three human cancer cell lines as well as in blood cells in healthy human lymphocyte cultures. Cytotoxic activity was assessed by the Sulforhodamine B method on HeLa （human cervical carcinoma）, T47D （human breast carcinoma） and 22Rvl （human prostate carcinoma cancer）. Colchicine was used as positive control. The decoction was also tested on lymphocytes from healthy donors through the mitotic index as biomarker. We used whole blood for these cultures and estimated the effect of the extract on platelets, leukocytes and erythrocytes. The aqueous decoction was cytotoxic （EDs0 〈 20 μg/mL） on the three cancer cell lines. The mitotic index in the exposed lymphocyte cultures did not significantly differ from the control nor the blood counts showed any difference between the experimental and control cultures. These results prove that the toxic effect of the aqueous decoction of G. oxyphyllum var. natalie is specific for cancer cell lines.

An emerging hemorrhagic fever in China caused by a novel bunyavirus SFTSV

Severe fever with thrombocytopenia syndrome(SFTS) is an emerging hemorrhagic fever in rural areas of China and is caused by a new bunyavirus,SFTSV,named after the disease.The transmission vectors and animal hosts of SFTSV are unclear.Ticks are the most likely transmission vectors and domestic animals,including goats,dogs,and cattle,are potential amplifying hosts of SFTSV.The clinical symptoms of SFTS are nonspecific,but major symptoms include fever,gastrointestinal symptoms,myalgia,dizziness,joint pain,chills,and regional lymphadenopathy.The most common abnormalities in laboratory test results are thrombocytopenia(95%),leukocytopenia(86%),and elevated levels of serum alanine aminotransferase,aspartate aminotransferase,creatine kinase,and lactate dehydrogenase.The fatality rate for SFTS is 12% on average,and the annual incidence of the disease is approximately five per 100000 of the rural population.

Efficacy and effect on serum VEGF-C of mild moxibustion plus functional exercise for upper-limb lymphedema after breast cancer surgery

Objective To observe the efficacy of mild moxibustion combined with functional exercise in the treatment of upper-limb lymphedema after breast cancer surgery and its effect on serum vascular endothelial growth factor C(VEGF-C).Methods Seventy-eight patients were divided into a control group and an observation group by the random number table method,with 39 cases in each group.The control group received functional exercise and the observation group received mild moxibustion plus functional exercise.The differences in circumference between the two upper limbs,the lymphatic flow of the affected upper limb,the disability of arm,shoulder and hand(DASH)score,the functional assessment of cancer therapy-breast(FACT-B)score and serum VEGF-C level between the two groups were compared before and after treatment.Efficacy was evaluated after treatment.Results The total effective rate was significantly higher in the observation group than in the control group(P<0.05).The difference in circumference between the two upper limbs of the two groups decreased significantly after treatment(both P<0.05),but it was significantly lower in the observation group than in the control group(P<0.05).The lymphatic flow of the affected upper limb of the two groups increased significantly after treatment(both P<0.05),but it was significantly greater in the observation group than in the control group(P<0.05).The DASH scores of the two groups decreased significantly after treatment(both P<0.05),but it was significantly lower in the observation group than in the control group(P<0.05).The FACT-B scores of the two groups increased significantly after treatment(both P<0.05),but it was significantly higher in the observation group than in the control group(P<0.05).After treatment,the serum VEGF-C level increased significantly in the observation group(P<0.05),whereas the control group did not show significant change(P>0.05).The post-treatment serum VEGF-C level was significantly higher in the observation group than in the control group(P<0.05).Conclusion The efficacy of mild moxibustion combined with functional exercise for upper-limb lymphedema after breast cancer surgery is certain,which can reduce the difference in circumference between the two upper limbs,increase the lymphatic flow of the affected upper limb,improve the limb function and the quality of life,and regulate the serum VEGF-C level.