多房性囊性肾细胞癌2例报告及文献复习

目的 研究分析多房性囊性肾细胞癌（MCRCC）临床、螺旋CT和病理表现,以提高对MCRCC的认识。方法报告2例MCRCC患者的临床资料和结合文献复习,阐述该病的临床、病理及其螺旋CT表现。结果该病临床症状轻微;螺旋CT表现为多房性囊性肿物,边界清楚,囊壁可有局部增厚,间隔粗细不均,附壁及间隔结节直径〈5mm,增强后囊壁、分隔及结节中度以上强化;其病理特征为肿瘤均有包膜,由大小不等的囊腔构成,囊腔内衬单层或多层透明细胞,囊腔间隔内可见灶状透明细胞,Fuhrmam分级为Ⅰ～Ⅱ级,免疫组化显示广谱CK＋,EMA＋,CD68＋。2例均行根治性肾切除术,分别随访45个月和32个月,均无复发和转移。结论MCRCC是一种肾细胞癌的罕见亚型,属于低级别恶性肿瘤,螺旋CT和病理表现具有明显特征,早期正确诊断对治疗和预后有重要的意义。     

多房性囊性肾细胞癌临床病理分析

目的 探讨多房性囊性肾细胞癌（MCRCC）临床病理特点及鉴别诊断要点,并对国内外相关文献进行复习,以提高对MCRCC的认识和病理诊断水平.方法 分析1例MCRCC患者的临床表现、组织形态学特征及免疫组化表型,并检索国内外相关文献报道共522例,总结MCRCC的特点.结果 患者男,50岁,因体检时发现左肾占位入院,MRI、彩超及CT检查考虑为错构瘤.病理检查：大体示肿瘤位于左肾上极,有完整包膜,大小4.5 cm×4.2 cm ×4.0 cm,剖面见肿瘤由大小不等的多个囊腔构成,囊腔间隔厚薄不均,囊壁尚光滑.镜检示囊腔内衬单层透明细胞,囊腔间隔胶原纤维增生,可见灶性钙化,间隔内可见巢片状分布的透明细胞,但未形成肉眼可见的结节.细胞异型性小,细胞核Fuhrman分级：Ⅰ级.免疫组化标记显示囊腔上皮及间隔内肿瘤细胞CK和EMA阳性,CD10、RCC、Ki67和CD68阴性.行后腹腔镜下左肾根治性切除术,随访8个月,一般情况好,未见复发和转移.结论 MCRCC作为肾细胞癌的一种少见的独立亚型,完全由囊腔构成,影像学和穿刺细胞学检查等难以与囊性相关性肾病区别,因此准确的病理诊断非常必要,免疫组化标记对其诊断及鉴别诊断具有肯定价值.该肿瘤具有低度恶性潜能,预后良好,保留肾单位手术值得考虑.     

两种良性生长特性的肾细胞癌

目的:探讨两种良性生长特性的肾细胞癌的临床及病理学特点,提高对此两种肾细胞癌的诊治水平.方法:回顾性分析此两种肾细胞癌的临床和病理资料.多房性囊性肾细胞癌(MCRCC)组4例,男3例,女1例.年龄30 ～ 68岁,平均56岁.黏液性管状和梭性细胞癌(MTASCC)组3例,均为女性,年龄35 ～ 46岁,平均42岁.两组病例均为无症状肾癌,影像学检查为主要手段,其特点均为边界清楚的囊性肿瘤.结果:MCRCC组组织病理:囊壁及分隔内均可见透明细胞,透明细胞数量少,增生不活跃,未见有丝分裂像.MTASCC组组织病理:肿瘤呈三项细胞形态,包括梭形细胞、管状结构和黏液样基质.肿瘤细胞呈短梭形,大小不一,界不清,细胞核呈梭形和椭圆形,核仁明显,分裂像少见.两组病例TNM分期均为T1-2N0M0,无局部淋巴结转移或肾静脉癌栓.结论:MCRCC和MTASCC是具有良性肿瘤的临床生长特性及低度恶性的病理结果的低恶性潜能的肾细胞癌,预后良好.     

多房囊性肾细胞癌12例临床病理分析

多房囊性肾细胞癌(multilocular cystic renal cell carcinoma,MCRCC)是一种少见的临床亚型,2004年WHO将其命名为一种独立的肾癌类型.病理学定义为完全由囊腔构成的肿瘤,囊腔间隔内有小灶状透明细胞,与Ⅰ级透明细胞性肾细胞癌不能区别.在多房囊性肾细胞癌中癌细胞数量很少,诊断困难,通过免疫组化检查,囊腔间隔内的透明细胞上皮性标记物CK、EMA阳性,而组织细胞标记物CD68阴性,有助于提高疾病诊断的准确性.     

婴儿骨化性肾肿瘤的临床病理观察

目的探讨婴儿骨化性肾肿瘤的临床病理特点、组织起源及其诊断和鉴别诊断。方法对1例婴儿骨化性肾肿瘤的临床、影像学和病理特征进行观察并复习文献。结果患儿因肉眼血尿入院,影像学检查提示左肾下极钙化性肿物和左下肾盏、肾盂变形。大体见肿物包膜完整,灰白、灰黄色,略呈结节状,剖面质硬,灰白色,局部呈囊性,可见出血;镜下肿瘤由骨样基质、成骨样细胞和梭形细胞组成;免疫组化染色示部分成骨样细胞vimentin、EMA和CK（＋）,梭形细胞vimentin（＋）,Ki-67〉5%（＋）,且阳性细胞主要是梭形细胞。结论婴儿骨化性肾肿瘤具有独特的临床表现、影像学改变及病理特征,是一种少见的良性肾肿瘤,预后良好。     

多房囊性肾细胞癌的CT及MRI表现

目的：分析多房囊性肾细胞癌（Multilocular cystic renal cell carcinoma,MCRCC）的CT及MRI表现特征,以提高诊断水平。方法：对7例经手术病理证实为MCRCC患者的临床资料及CT、MRI表现进行回顾性分析。结果：MCRCC具有一定的特征性表现：①病灶均位于肾皮质区,呈类圆形或分叶状,境界清晰,均由多个囊腔和分隔构成;②囊壁及间隔多菲薄,形态规则,均不见附壁结节,部分可见囊壁、间隔点状钙化;③CT平扫病灶呈等或低密度,增强扫描囊壁、间隔呈进行性延迟强化,分泌期囊壁、间隔显示最清楚;④MRI T2WI能清晰显示薄而规则的囊壁及间隔,囊腔T1WI呈低信号、T2WI呈高信号,强化方式同CT。结论：CT及MRI的特征性表现对MCRCC的术前诊断具有重要作用。     

肾黏液性管状梭形细胞癌的临床病理特点

目的 探讨肾黏液性管状梭形细胞癌的临床病理特点。方法 应用常规病理、免疫组化和电镜观察2例肾黏液性管状梭形细胞癌并复习相关文献。结果 2例肿瘤均为男性，年龄37岁和82岁。肿瘤界限清楚，切面灰白色。镜下见嗜酸性胞质的低立方细胞单层排列，呈长管状或交织吻合的细管状，有的呈巢状；部分肿瘤细胞梭形，排列成束状，类似于平滑肌瘤。肿瘤间质黏液样，胞核居中，有皱折，核分裂罕见。瘤细胞间可见淋巴浆细胞及泡沫细胞。免疫组化示肿瘤细胞vimentin、EMA和AE1／AE3（＋），34β3E12、SMA、S-100、HMB45、CD15、CD20、UEA-1、CK7和CAM5．2（-）。电镜示管腔内可见短的微绒毛，有连接复合体。结论 肾黏液性管状梭形细胞癌是低度恶性的肾肿瘤，可能来源于远端肾单位。     

肾黏液性管状梭形细胞癌临床病理观察

目的 探讨肾黏液性管状梭形细胞癌的临床病理特征、诊断要点及鉴别诊断。方法 应用常规病理、免疫组化对1例肾黏液性管状梭形细胞癌进行观察、随访并复习相关文献。结果 患者女性，45岁。体检偶然发现左肾占位。大体检查见肾实质内有一个灰白色、界限清楚的类圆形结节，偏髓质分布，直径4cm，质地略脆，均匀一致；镜下见肿瘤细胞主要呈现两种结构：①类似于肾集合管的细管状结构，细胞单层立方排列；②类似于平滑肌瘤的梭形细胞结构；两种细胞均未见核分裂象；背景中显著黏液变性，并见多灶性淋巴细胞、浆细胞、泡沫细胞聚集浸润。免疫组化：EMA、CK7和Vim（＋），CK341mi2、CD15（-），CgA弱（＋），NSE和Syn（-）。随访6个月患者恢复良好。结论 肾黏液性管状梭形细胞癌是一种低度恶性、预后较好的肾上皮性肿瘤，正确诊断及鉴别诊断对临床具有重大的指导价值。     

肾及膀胱透明细胞癌一例并文献复习

【目的】探讨膀胱透明细胞癌的临床、病理、组织化学特征以及诊治方法。【方法】回顾分析I例患者临床资料,结合文献复习讨论。【结果】1例肾及膀胱肿瘤患者以血尿就诊。组织学检查膀胱肿瘤以大片透明样癌细胞、腺管样结构为特征,肾组织化学示PSA（＋）,免疫组化示：CK7、CK5／6（＋）,CEA（一）,肾肿瘤为透明细胞癌。【结论】膀胱透明细胞癌病理检查才能确诊,应与肾源型腺瘤相鉴别,治疗以根治性手术为主,预后不良。     

肾混合性上皮和间质肿瘤临床病理观察

目的 探讨肾混合性上皮和间质肿瘤的病理形态学特点、诊断及鉴别诊断.方法 应用光镜观察及免疫组化方法对1例男性肾混合性上皮和间质肿瘤进行临床病理分析,并复习文献.结果 肿瘤由上皮和间质两种成分构成,其中上皮成分主要是形态不一的腺管样结构,部分区域可见大小不等的囊,细胞无明显异型性;另见梭形细胞围绕在腺管或囊周围构成肿瘤的间叶成分,部分呈束状排列,形似平滑肌细胞,部分呈短梭形,似纤维母细胞或肌纤维母细胞样,梭形细胞轻度异型,核分裂罕见.免疫组化:上皮细胞AE1/AE3、CK7和CK34βE12(+);梭形细胞SMA(++),desmin、vimentin、ER和PR(+),CD10部分(+).结论 肾混合性上皮和间质肿瘤具有独特的组织病理学特点,预后良好,多见于女性.本例特殊之处在于患者为成年男性,且无激素类药物应用史,极为少见.该肿瘤与成人囊性肾瘤、先天性中胚层细胞肾瘤等多种肿瘤易混淆,应依据形态学特点结合免疫组化结果鉴别.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.