A rare presentation of unicentric Castleman's disease in the thigh:A case report and review of literature

BACKGROUND Castleman's disease(CD)is a rare lymphoproliferative,emulating both benign and malignant diseases.The diagnosis of CD is formulated upon the combination of clinical and laboratory criteria and ultimately confirmed by histopathological assessment.Due to its rarity,CD presents a challenge in treatment selection,with available options encompassing surgery,chemotherapy,and autologous stem cell transplantation.However,studies suggest that surgical resection of the lesion is the most effective treatment modality,especially for unicentric CD(UCD).CASE SUMMARY Here,we describe the case of a 25-year-old woman who presented with painless left thigh swelling for 10 wk.She had been following a low-fat diet to lose weight and had normal laboratory results.Magnetic resonance imaging revealed a wellcircumscribed,demarcated cystic lesion located in the left inguinal region with eccentrically positioned signal void vascular structures,measuring 4.3 cm×3 cm×3.2 cm,likely of lymphoid origin.The patient underwent surgical resection,and the final histopathology showed a vascular proliferation and hyalinization of the vessel walls,along with atretic germinal centers traversed by penetrating vessels,consistent with CD.The patient was discharged home one day after the procedure in good condition,with a follow-up appointment scheduled in our outpatient clinic.CONCLUSION Although surgical resection is the mainstay for UCD,a multidisciplinary approach is needed due the lack of specific diagnostic features and treatments.

ONE-STAGE ARTERIOVENOUS REVERSAL FOR REVASCULARIZATION OF SEVERELY ISCHEMIC LIMBS

Staged arteriovenous reversal has been successfully established forrevascularization of severely ischemic limbs since 1984. The authors tried to constrict thecentral venous limb immediately after the arteriovenous fistula formation to make the pres-sure distal to the anastomosis raising to its maximum to shorten the time required for thedistal valves to become incompetent. Thus, the revascularization of the severely ischemiclimbs may be established much sooner than the staged arteriovenous reversal, and more di-seased limbs will be saved. Forty-two patients with a total of 60 upper and lower limbshave been operated on with good results.

Outcomes of Open Surgery for Popliteal Artery Aneurysms:An 18-Year Experience in a Single Institution in Japan

Objective: To elucidate the outcomes of open surgery for popliteal artery aneurysm (PAA) in a single Japanese institution. Materials and Methods: Between 1999 and 2016, 35 patients (44 PAAs) underwent open surgery in our department. The first-line surgical strategy involved the medial approach, with excision of the aneurysm sac and autologous vein bypass grafting. Associations between the outcomes and 1) the surgical management of the aneurysmal sac (aneurysmectomy vs. ligation with bypass) and 2) the preoperative clinical symptoms were evaluated. Results: There were no aneurysm-related deaths during the follow-up period (mean, 4 years;range, 1 - 17.6 years). The 5-year primary, primary-assisted, and secondary patency rates were 67.9%, 72.7%, and 94.5%, respectively. Re-intervention was required for 19 PAAs (14 patients), including two PAAs in patients with suspected Behçet’s disease. Patency rates did not differ between the aneurysmectomy and ligation groups. Remnant sac enlargement occurred in 3 cases. Among asymptomatic patients, clinical symptoms did not deteriorate;however, the ankle brachial pressure index decreased ≥0.15 in patients with artery-graft mismatching. Conclusion: Patency rates were good, and our modified ligation with bypass procedure, which involves excising the sac as much as possible, exhibited less risk in terms of remnant sac enlargement compared to that in previous studies.

糖尿病相关的足病的定义和标准(2023年更新版)

糖尿病相关的足病管理涉及多个学科,通用的专业词汇对于各学科间准确沟通交流至关重要。国际糖尿病足工作组(IWGDF)对相关文献进行了系统综述,构成了制定IWGDF指南的基础,并且明确了糖尿病相关的足病的一系列定义、标准及名词解释。本文介绍2023年IWGDF对这些定义和标准的更新,并建议在临床实践和研究中一致使用,以利于世界各地不同学科人员针对糖尿病相关的足病的专业性交流。

How severe is moderately severe acute pancreatitis? Clinical validation of revised 2012 Atlanta Classification

AIM To explore the outcomes and the appropriate treatment for patients with moderately severe acute pancreatitis(AP).METHODS Statistical analysis was performed on data from the prospectively collected database of 103 AP patients admitted to the Department of Surgery,Hospital of Lithuanian University of Health Sciences in 2008-2013. All patients were confirmed to have the diagnosis of AP during the first 24 h following admission. The severity of pancreatitis was assessed by MODS and APACHE Ⅱ scale. Clinical course was re-evaluated after 24,48 and 72 h. All patients were categorized into 3 groups based on Atlanta 2012 classification: Mild,moderately severe,and severe.Outcomes and management in moderately severe group were also compared to mild and severe cases according to Atlanta 1992 and 2012 classification.RESULTS Fifty-three-point four percent of patients had edematous while 46.6 % were diagnosed with necrotic AP. The most common cause of AP was alcohol(42.7%) followed by alimentary(26.2%),biliary(26.2%) and idiopathic(4.9%). Under Atlanta 1992 classification 56(54.4%) cases were classified as "mild" and 47(45.6%) as "severe". Using the revised classification(Atlanta 2012),the patient stratification was different: 49(47.6%) mild,27(26.2%) moderately severe and 27(26.2%) severe AP cases. The two severe groups(Atlanta 1992 and Revised Atlanta 2012) did not show statistically significant differences in clinical parameters,including ICU stay,need for interventional treatment,infected pancreatic necrosis or mortality rates. The moderately severe group of 27 patients(according to Atlanta 2012) had significantly better outcomes when compared to those 47 patients classified as severe form of AP(according to Atlanta 1992) with lower incidence of necrosis and sepsis,lower APACHE Ⅱ(P = 0.002) and MODS(P = 0.001) scores,shorter ICU stay,decreased need for interventional and surgical treatment.CONCLUSION Study shows that Atlanta 2012 criteria are more accurate,reduce unnecessary treatments for patients with mild and moderate severe pancreatitis,potentially resulting in health costs savings.

Secondary aorto-esophageal fistula after thoracic aortic aneurysm endovascular repair treated by covered esophageal stenting

Thoracic endovascular aortic repair for thoracic aortic aneurysms is an accepted alternative to open surgery, especially in patients with significant comorbidities. The procedure itself has a low risk of complications and fistulas to surrounding organs are rarely reported. An 86-year-old patient was admitted to our hospital with gastro intestinal(GI) bleeding and a suspected aortoesophageal fistula. Eight months prior, the patient had undergone a stent graft repair of a mycotic thoracic aneurysm. Computerized tomography angiography and upper GI endoscopy confirmed an aortoesophageal fistula, which was treated by esophageal stenting. With early recognition, esophageal stenting may have a role in the initial emergency control of bleeding from and palliation of aortoesophageal fistula.

Altered physiology of mesenchymal stem cells in the pathogenesis of adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis is the most common spinal deformity during puberty,especially in females.It is characterized by aberrant skeletal growth and generalized reduced bone density,which is associated with impaired bone mineral metabolism.Despite recent progress in multidisciplinary research to support various hypotheses,the pathogenesis of Adolescent idiopathic scoliosis is still not clearly understood.One of the hypothesis is to study the role of mesenchymal stem cells due to its involvement in the above-mentioned bone metabolic abnormalities.In this review,we will summarize reported literatures on the role of mesenchymal stem cells,particularly in the pathogenesis of Adolescent idiopathic scoliosis.In addition,we will describe the research on mesenchymal stem cells of Adolescent idiopathic scoliosis performed using bioinformatics tools.

Fatigue Performance of Fabrics of Stent-Grafts Supported with Z-Stents vs. Ringed Stents

Stent-grafts were commercialized rapidly and gained a broad clinical acceptance over the past two decades. However,relatively more recent recognition of particular stent-graft design shortcomings have been identified which need to be addressed. It appears that various stent-graft designs may be more or less resistant to metal fatigue and /or fabric abrasions which can lead to type III and type IV endoleaks over the long term. Therefore,it is necessary to investigate the fatigue performance of the most common stentgraft designs: Z-stents and ringed stents,in a long-term in vitro fatigue simulation environment. This paper aimed to analyze nondestructively( gross observations) and destructively( fabric characteristics,mechanical and chemical properties) in order to put forward suggestions to improve the fabric and stent characteristics that may prevent type III and IV endoleaks. The fabric supported with ringed stent-grafts remained nearly completely intact after 168h. However, the fabric supported with Z-stents demonstrated significant damage. Fabric characteristics and tensile strength of the fibers did not present a significant difference between the control and fatigue simulated specimens. The crystallinity declined for both specimens. The fatigue performance of fabrics supported with ringed stents appears to be superior to that supported with Z-stents. The potential for a dynamic and destructive interaction between the apices of Z-stents which can lead to fraying and /or tearing of the graft fabric must be addressed in future designs.

Incidence and Clinical Characteristics of Deep Vein Thrombosis (DVT) after Total Knee Arthroplasty (TKA) with DVT Chemoprophylaxis

Objective: Deep vein thrombosis (DVT) after total knee arthroplasty (TKA) is very common and leading cause of death due to this procedure. The objective of this study was to investigate the incidence and clinical characteristics of DVT after TKA with DVT chemoprophylaxis. Methods: This is a prospective cohort study in single institution. The patients received postoperative DVT chemoprophylaxis (low molecular weight heparin (LMWH) or Fondaparinux), followed by duplex ultrasonography to check for DVT 1 - 2 weeks after TKA. The clinical characteristics were summarized and analysed by chi-square test and regression analysis. Results: Five hundred and thirty four patients were enrolled from January 2007 to December 2010. DVT chemoprophylaxis was administered in 524 (98.1%) of the 534 patients. DVT occurred in 9 subjects (1.69%);8 subjects had DVT in the leg, and 1 subject had a pulmonary embolism. Among them, asymptomatic DVT was observed in 5 patients (0.94%). Univariate analysis showed that surgical methods (revision, P = 0.0007), body mass index (BMI) (>25, P = 0.0028), low platelet count (less than 150 × 103, P = 0.0219), time in the intensive care unit (ICU) (P < 0.0001), no administration of prophylactic LMWH (P = 0.0392), and a history of DVT (P < 0.0001) were significant risk factors of DVT. Conclusions: The incidence of DVT was 1.69% after TKA with prophylactic antithrombotic therapy. Revision surgery, BMI, low platelet count, time in ICU, absence of prophylactic LMWH and history of DVT were significant risk factors of DVT.

Pasturella multicoda infection of an abdominal aortic endograft

Both surgical and endovascular grafts have the rare risk of late secondary infection.Treatment varies based on the clinical setting,but in general the recommendations are that infected endografts be removed and reconstruction performed.In the abdominal aorta this may vary from homograft or other impregnated grafts to excision and extra-anatomic bypass.We discuss an unusual case which we believe serves as a useful review of this still debated area.A 58-year-old male presented with abdominal and back pain.Prior history was notable for human immunodeficiency virus positive status,pulmonary embolism(currently on Coumadin) and two years previously repair of a saccular infra-renal aneurysm with tube graft.The week prior to the onset of symptoms he suffered a noticeable scratch from his cat.Blood cultures were positive for pasturella multicoda.He was transferred to our institution and underwent resection and explantation,with homograft reconstruction.At one year he is alive and well.

Repair of an aberrant subclavian arterioesophageal fistula following esophageal stent placement

A fistula formation between the esophagus and an aberrant right subclavian artery is a rare but fatal com-plication that has been mostly described in the setting of prolonged nasogastric intubation and foreign body erosion. We report a case of a young morbidly obese patient who underwent sleeve gastrectomy that was complicated by a postoperative leak at the level of the gastroesophageal junction. A covered esophageal stent was placed endoscopically to treat the leak. The pa-tient developed massive upper gastrointestinal bleeding secondary to the erosion of the stent into an aberrant retroesophageal right subclavian artery twelve days after stent placement. She was ultimately treated by endovascular stenting of the aberrant right subclavian artery followed by thoracotomy and esophageal repair over a T-tube. This case report highlights the multidis-ciplinary approach needed to diagnose and managesuch a devastating complication. It also emphasizes the need for imaging studies prior to stent deployment to delineate the vascular anatomy and rule out the possi-bility of such an anomaly in view of the growing popu-larity of esophageal stents, especially in the setting of a leak.

Superior mesenteric venous thrombosis: Endovascular management and outcomes

BACKGROUND Superior mesenteric venous thrombosis(SMVT)is a rare but fatal condition that is typically treated initially with anticoagulation therapy,and if this fails,with endovascular interventions.However,due to its rarity,there are not many studies that have explored the effectiveness of anticoagulation and endovascular therapies in treating SMVT.AIM To evaluate patients diagnosed with SMVT who received endovascular therapy in addition to anticoagulation and report technical and clinical outcomes.METHODS A retrospective analysis of the patients who underwent endovascular treatment for SMVT at Mayo Clinic from 2000-2019 was performed.Technical success was defined as angiographic improvement in SMV flow after intervention.Primary patency was defined as the interval from reestablishing mesenteric venous flow until the first repeat thrombotic event or need for additional intervention.Secondary patency was defined as successful restoration of flow after repeat intervention until rethrombosis or last follow-up.The adverse events were reported through Clavien-Dindo classification.RESULTS Twenty-four patients were included for analysis.The median age at intervention was 60 years(35-74 years)and 16(67%)were men.Nineteen patients presented with acute thrombosis(79.2%)and 5 with chronic thrombosis with acute manifestations(20.8%).The most commonly used endovascular modalities were thrombectomy in 12 patients(50.0%)and catheter-directed thrombolysis in 10 patients(41.7%).Technical success was achieved in 18 patients(75%).The 14-d and 30-d primary patency rates were 88.9%and 83.3%,respectively.Adverse events were reported in two patients(8.3%),one marked as grade IIIB,and 1 death marked as grade V.Five-year overall survival rate was 82%(58%-100%).CONCLUSION Endovascular intervention with anticoagulation appears to be effective for managing SMVT.This treatment combination may be considered as first-line therapy for SMVT management in select patients.

Transcervical access,reversal of flow and mesh-covered stents:New options in the armamentarium of carotid artery stenting

In the last 25 years, the very existence of carotid artery stenting(CAS) has been threatened on a number of occasions. The initial disappointing results that even lead to the discontinuation of an early randomized controlled trial have improved considerably with time. Novel devices, advanced stent and equipment technology, alternative types of access and several types of filters/emboli protecting devices have been reported to reduce stroke/death rates during/after CAS and improve CAS outcomes. The present review will provide a description of the various technology advances in the field that aim to reduce stroke and death rates associated with CAS. Transcervical access, reversal of flow and mesh-covered stents are currently the most promising tools in the armamentarium of CAS.

Extensive complex thoracoabdominal aortic aneurysm salvaged by surgical graft providing landing zone for endovascular graft:A case report

BACKGROUND Surgical repair of complex abdominal aortic aneurysm is associated with a higher perioperative mortality and morbidity.The advent of endovascular aortic repair(EVAR)has reduced perioperative complications,although the utilization of such techniques is limited by lesion characteristics,such as involvement of the visceral or renal arteries(RA)and/or presence of a sealing zone.CASE SUMMARY A 60-year-old male presented with a Crawford type IV complex thoracoabdominal aortic aneurysm(CAAA)starting directly distal to the diaphragm extending to both common iliac arteries(CIAs).The CAAA consist of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level.Due to the poor performance of the patient and the expansive disease,we planned a stepwise-combined surgery and EVAR to minimize invasiveness.A branched graft was implanted after surgical debranching of the visceral and RA.Since the patient had renal and liver injury after surgery,the second stage EVAR was performed 10 mo later.The stent graft was implanted from the distal portion of surgical branched graft to both CIAs during EVAR.The patient has been uneventful for 5-years after discharge and is being followed in the outpatient clinic.CONCLUSION The current case demonstrates that the surgical graft can provide a landing zone for second stage EVAR to avoid aggressive surgery in patients with poor performance with a long hostile CAAA.

A comparison of carotid atherosclerosis in symptomatic patients between 2002-2005 and 2012-2015 cohorts using multi-contrast magnetic resonance vessel wall imaging

OBJECTIVE To compare the morphological and compositional characteristics of carotid plaques in two cohorts(2002−2005 and 2012−2015)of Chinese patients using magnetic resonance vessel wall imaging.METHODS Symptomatic patients with carotid atherosclerotic plaques who underwent carotid vessel wall magnetic resonance imaging between 2002−2005 and 2012−2015 were retrospectively recruited.Plaque morphology[including mean wall area,wall thickness,and maximum normalized wall index(NWI)]and composition[including calcification,intraplaque hemorrhage,and lipid-rich necrotic core(LRNC)]in symptomatic carotid arteries were evaluated and compared between patients in these two time periods.RESULTS A total of 258 patients,including 129 patients in the 2002−2005 cohort and 129 patients in the 2012−2015 cohort,were recruited.Statin use(49.6%vs.32.6%,P=0.004)and hypertension(76.0%vs.62.8%,P=0.015)were significantly more common in the 2012-2015 cohort than in the 2002−2005 cohort.Patients in the 2012−2015 cohort also exhibited significantly low plaque burden parameters(all P<0.05),as well as a lower prevalence(68.2%vs.89.9%,P<0.001)and volume percentages of LRNC(11.2%±14.2%vs.25.7%±17.7%,P<0.001).These differences remained significant after adjustment for clinical factors.The differences in the volume percentages of LRNC also remained significant after an additional adjustment for maximum NWI(P<0.001).CONCLUSIONS Patients in the 2012−2015 cohort had a lower plaque burden and volume percentages of LRNC in symptomatic carotid arteries than those in the 2002−2005 cohort.These findings indicate that carotid plaques in the recent cohort had a lower severity and vulnerability.

Effect of urgent carotid endarterectomy on operative risk and benefit

Objectives:The time of Carotid intervention for recently symptomatic,severe carotid stenosis which cause a transient ischemic attack or minor stroke is still a controversial issue.Early studies showed that carotid endarterectomy(CEA)caused a high risk if performed within days follow an acute ischemic stroke.However,The National Stroke Strategy posted by UK Department of Health advocated that this situation should be regarded as an emergency procedure,and carotid intervention should ideally be performed within 48 hours.We designed this study to discuss the effect of urgent CEA on operative risk and benefit.Methods:we analyze 12 urgent CEA with primary closure performed during 1996 to 1998.All 12 patients were underwent CEA within 2 weeks,and 2 of them within 2 days.Operative risks and overall benefit from surgery were discussed in relation to the time from the last symptomatic event to CEA.Results:2 urgent CEA performed in 2 days are recovery uneventful.1 of 12 patients,who underwent urgent CEA within 2 weeks,occurred restenosis after 3 months follow up.No 30-day perioperative recurrent TIA,stroke and death.Conclusions:CEA performed within 2 weeks is feasible and reliable procedure in preventing recurrent TIA and stroke after presenting manifestations.The future aim is to perform CEA within 48 hours after TIA or stroke symptoms.

Intraoperative Findings and Outcome of Latarjet Procedure

Background: The purpose of this case series was to retrospectively compare radiological, clinical and functional outcomes and complications of diagnostic arthroscopy with open Latarjet procedures pre- and postoperatively within one year after surgery. Additionally we compared the pathologic findings during diagnostic arthroscopy with the radiological findings in preoperative contrast enhanced CT or MRI scans. Methods: Between 07/2009 and 11/2013 46 cases with unidirectional antero-inferior shoulder instability were enrolled, 4 cases were lost during the follow-up within one year postoperatively. Plain radiographs, contrast enhanced multislice studies, Instability Severity Index, Constant, Duplay and Rowe Scores were obtained preoperatively. Diagnostic arthroscopy was performed in all cases prior to open Latarjet procedure. At one year follow-up Constant, Duplay and Rowe Scores were obtained;position and consolidation of the coracoid transfer were assessed by conventional x-ray studies. Results: At one year follow-up a significant improvement of all scores was recorded (Constant Score 95.8 vs. 86.7;Duplay Score 93.7 vs. 25.2, Rowe Score 98.1 vs. 31.7, (p Conclusion: The Latarjet procedure is a reliable technique with very good clinical outcomes. Diagnostic arthroscopy is a valuable tool to detect HAGL- and IGHL-lesions and to visualize the engaging potential of Hill-Sachs-lesions. An additional arthroscopy may help to indicate a Latarjet procedure and to address concomitant pathologies. Level of evidence: Level IV, case series.

Cirrhotic Patients Undergoing Cardiac Surgery: Why Not to Develop a More Specific Heart-Liver Score?

Despite not included in the traditional risk scores before surgery, liver cirrhosis, especially in advanced stages, has always influenced strongly final outcome both on short and midterm in patients undergoing cardiac surgery. Growing incidence of non-alcoholic fatty liver disease interlinked with metabolic syndrome and significant advancements in medical therapy have actually increased the likelihood of cardiac surgery in cirrhotic patients. To date, Child-Pugh and MELD scores have been commonly used to predict mortality and postoperative hepatic decompensation, but on the other hand, both traditional risk scores show some limitations for evaluation of hepatopathic patients undergoing specifically cardiac surgery. In this context, a specific Heart-Liver score hasn’t been developed yet in the attempt to outline a patient profile able to face surgery, therefore addressing us to adopt the best strategy possible for each case. If CP class A or low MELD score (<11) patients tolerate cardiac surgery with a mild increase in mortality and morbidity, currently state of art recommends particular caution towards surgery idea in presence of advanced hepatic disease. As far as cardiac surgery represents the unique therapeutic strategy in several life-threatening cases, anyway surgical correction of cardiac pathology won’t guarantee an increased life expectancy in accordance with the persistent liver dysfunction. Hereby, this paper will focus on preoperative parameters that should be considered in the future realization of a Heart-Liver prognostic score for overcoming limitations and difficulties related to the impact of liver disease on final clinical outcome.

从美国外科住院医师培训制度看如何改进我国临床研究生教育

临床研究生是我国继续医学教育的重要组成部分。借助美国住院医师培训制度的经验,对改进我国临床研究生教育,提高其临床工作能力提出一些建议。改变或摒弃目前临床硕士研究生的培养模式,适当降低临床博士研究生的科研要求,加强和完善博士生的临床考试和考核制度,对增加临床博士生毕业后的临床工作能力是有益的。将目前的临床研究生教育与专科医师培养制度衔接起来亦可以作为提高临床研究生工作能力的一种方法或作为全面推行专科医师培养制度的一个过渡阶段。

从加拿大医学生外科实习谈加强对医学生临床实践能力的培养

医学教育国际化教学改革新形势下,如何加强医学生临床实践能力的培养是我们亟待思考和解决的问题。本文介绍了加拿大麦吉尔大学医学生外科实习情况,并与国内医学生临床实习情况的异同进行了比较,对加强医学生临床实践能力培养的新举措进行了探讨。