食管胃交界腺癌的研究进展

食管胃交界腺癌（AEG）发生于食管和胃交界区域,目前尚无统一的分类标准,以解剖学为基础的Siewert分类法逐渐被临床认可。Barrett’s食管通路和胃通路是AEG的主要发病机制。手术切除是AEG的主要治疗方法,新辅助疗法的应用可在一定程度上改善患者预后,基因靶向疗法是治疗AEG的新方向。目前,东西方国家对AEG的研究结果存在争议,其病因、临床病理特点、分子生物学特点以及治疗方法等仍有待进一步研究。本文就AEG的研究进展作一综述。     

Severe hepatotoxicity with jaundice associated with paroxetine

Hepatotoxicity due to paroxetine, a selective serotonin reuptake inhibitor, is very rare, and to the best of our knowledge, only five cases of liver injury in association with paroxetine have previously been reported in the medical literature. We describe the clinical, biochemical, and pathological findings in a patient with paroxetine hepatotoxicity, which was reversed after withdrawal of the drug. The present case and the others previously reported suggest that hepatotoxicity should be taken into account as a rare complication, sometimes severe, that may occur with paroxetine.     

Sarcoma of the heart. Apropos of 2 cases

Sarcoma of the heart is a very rare condition. We present here two cases with very different clinical expression. The first patient, a 15-year old girl, presented with extremely severe ventricular arrhythmia, whereas the second patient, a 63-year old woman, mainly had signs of congestive cardiac failure. A diagnosis of cardiac tumour was made in the first case on the basis of ultrasonographic results which clearly showed the tumour developed from the walls of the left ventricle. In the second case, the tumour involved the right ventricular wall, the deformation of which was undetected by ultrasounds and only suspected at angiography. Both patients died rapidly, and the diagnosis of sarcoma was confirmed at post-mortem examination.     

Cardiac contusion: ending myocardial confusion in this capricious syndrome

Symptoms of cardiac contusion are very greatly and sometimes are non recognized or are masked by associated injury in severe chest trauma. Cardiac contusion clinically presents as a spectrum of signs and symptoms of varying severity, ranging from precordial pain, dyspnoea, and non specific ECG changes to increased serum activity of several enzymes, early severe rhythm abnormalities, severe conduction defects and death. We present a fatal case in which the definitive diagnosis of myocardial contusion has proved complex. All clinical data were suggestive of acute myocardial infarction, but the history of chest wall injury and gross and histological examination of the heart and coronary vessels led us to conclude for a cardiac contusion without myocardial infarction. In case of chest blunt trauma, the ECG should be interpreted within the context of the clinical situation, on history of chest wall injury, since a fatal myocardial contusion may occur after apparently mild injury.     

Changes in regional wall contractility induced by effort in women with normal coronary angiography --report of a clinical case]

The diagnosis of coronary artery disease in women has been thought to be more difficult than in men, owing to the lower overall prevalence of disease in women, as well as more subtle clinical presentations and unspecific changes in ST segment. The authors report a clinical case of a 61-year old woman, with low cardiovascular risk and history of atypical chest pain and a positive treadmill exercise test on the inferior leads. She did an exercise echocardiogram that revealed severe hypokinesis on the anterior wall and septum with late normalization. The patient was submitted to a coronary angiography that revealed normal arteries. An echocardiogram with hyperventilation was later performed and showed the same ischemic changes as exercise did, on the inferior leads but no regional wall motions abnormalities occurred. The patient is currently asymptomatic under calcium antagonist treatment.     

A successful bronchial thermoplasty procedure in a “very severe” asthma patient with rare complications: a case report

Introduction: Bronchial thermoplasty (BT) is a unique bronchoscopic treatment for severe asthma that utilizes radiofrequency ablation to reduce smooth muscle in the bronchial walls. Current studies mainly focused on uncontrolled severe asthma with a forced expiratory volume in 1?second (FEV₁) above 60% and associated complications, no human studies have performed on “very severe” asthma as well as its complications. Case study: We present a 60-year-old male with more than 15 years history of very severe asthma, who underwent BT. His FEV₁ was only 20.4% predicted, which would have excluded him from all prior clinical trials of BT. The first BT procedure occurred without an issue. After the second BT procedure, he experienced severe dyspnea due to an infection with a non-flu respiratory virus. This illness was complicated by the formation of a pulmonary cyst. During recovering from the third procedure, he developed stomach stones. This is mainly related with taking large amounts of hawthorn previously, also cannot exclude the role of thermal energy injury on gastrointestinal nerve function. Results: Despite these unexpected complications, his quality of life greatly improved after BT, yet his lung function did not improve. Conclusion: This case is the first to describe BT procedures in patient with this level of lung function compromise, although accompanied with rare complications; our report indicates BT may be an opportunity and choice for the “very severe” asthma patients.     

An Unusual Presentation of an Anomalous Left Coronary Artery Arising from the Pulmonary Artery (ALCAPA) in an Adult: Anterior Papillary Muscle Rupture Causing Severe Mitral Regurgitation

We describe a 29-year-old male, previously in good health, with no history of angina pectoris and no risk factors for ischemic heart disease presenting with biventricular failure and severe mitral valve regurgitation. There were no signs or serological test results to suggest infective endocarditis. Transthoracic echocardiography (TTE) revealed severe anterior mitral valve prolapse secondary to papillary muscle rupture, severe mitral valve regurgitation, as well as an anterior myocardial wall hypokinesis. Parasternal short-axis view showed an anomalous left coronary artery arising from the pulmonary artery (ALCAPA), which was confirmed on coronary angiography. This is an unusual presentation of ALCAPA in an adult.     

微创与开放Sweet食管切除术治疗Siewert Ⅱ型食管胃结合部腺癌的疗效比较

目的比较微创与开放Sweet食管切除术治疗Siewert Ⅱ型食管胃结合部腺癌(AEG)的疗效。方法选取2015年3月至2017年9月安徽医科大学附属省立医院收治的137例AEG患者的临床资料,根据接受手术方式的不同分为微创Sweet食管切除术(MISE)组38例,开放Sweet食管切除术(OSE)组99例。比较两组术中指标及术后疗效情况。结果与OSE组相比,MISE组术中出血量较少,手术时间更长,淋巴结清扫总数及腹腔淋巴结清扫数更多,差异有统计学意义(P <0.05)。两组共有45例(32.85%)患者术后发生2级以上并发症,均以肺部感染为最常见; 4级以上严重并发症主要为严重吻合口瘘和呼吸衰竭。OSE组2～3级并发症发生率高于MISE组,差异有统计学意义(P <0.05)。MISE组和OSE组的1年生存率分别为92.1%和87.9%,3年生存率分别为68.2%和59.6%,两组术后生存情况比较差异无统计学意义(P=0.383)。两组术后复发、转移的发生情况比较差异无统计学意义(P>0.05)。Cox回归分析结果显示,以N₀期为参考,N     

Metronidazol as a probable cause of severe liver injury

Metronidazol, a commonly used antibiotic drug, has been very rarely associated with hepatotoxicity. In particular, no reports have appeared in the literature about cases of metronidazol-associated severe hepatotoxicity, leading to liver transplantation or death. We report on a case of acute fulminant liver failure in a young woman, who had, two years previously, developed jaundice after intake of metronidazol. During the current hospitalization, metronidazol treatment had been undertaken two weeks previously and also this time the patient developed severe hepatocellular injury and cholestasis. A viral etiology was ruled out as well as vascular, metabolic and malignant etiology. Although, the cause of the liver injury in this case is not proven, the relationship between this drug and two occasions of severe liver damage, suggests a positive challenge as well as rechallenge. An International algorithm was used for the assessment of the causality of a drug in this case of acute liver injury and a "probable" classification was obtained.     

Management of pneumonia in the child 2 to 59 months of age.

The mortality from pneumonia is reduced when children with pneumonia requiring antibiotics are identified and the severity of the pneumonia assessed. Children presenting with a cough or difficult breathing have pneumonia if fast breathing is present. The severity of pneumonia is classified by the presence of chest wall indrawing, inability to drink or feed well, decreased level of consciousness or convulsions, amongst others. Using these easily observed signs, pneumonia can be classified into four grades of severity: no pneumonia (cough or cold), pneumonia, severe pneumonia and very severe pneumonia. The classification into one of these four grades of severity is extremely useful as it identifies which children require antibiotics, which antibiotics and who requires hospitalisation and supplementary oxygen. This simple case management of pneumonia can be successfully taught to any cadre of health care worker, and where implemented has been shown to reduce childhood mortality from pneumonia.     

The definition of pneumonia, the assessment of severity, and clinical standardization in the Pneumonia Etiology Research for Child Health study

To develop a case definition for the Pneumonia Etiology Research for Child Health (PERCH) project, we sought a widely acceptable classification that was linked to existing pneumonia research and focused on very severe cases. We began with the World Health Organization's classification of severe/very severe pneumonia and refined it through literature reviews and a 2-stage process of expert consultation. PERCH will study hospitalized children, aged 1-59 months, with pneumonia who present with cough or difficulty breathing and have either severe pneumonia (lower chest wall indrawing) or very severe pneumonia (central cyanosis, difficulty breastfeeding/drinking, vomiting everything, convulsions, lethargy, unconsciousness, or head nodding). It will exclude patients with recent hospitalization and children with wheeze whose indrawing resolves after bronchodilator therapy. The PERCH investigators agreed upon standard interpretations of the symptoms and signs. These will be maintained by a clinical standardization monitor who conducts repeated instruction at each site and by recurrent local training and testing.     

Acute severe cardiac failure in a myeloma patient due to proteasome inhibitor bortezomib

We present here a case of severe congestive cardiac failure, in a 47-year-old patient with myeloma who had no prior cardiac history, after receiving bortezomib. Bortezomib is a boron-containing molecule, which reversibly inhibits the proteasome, an intracellular organelle, which is central to the breakdown of ubiquitinated proteins and consequently crucial for normal cellular homeostasis. Phase II clinical trials demonstrate that it is effective for the treatment of relapsed refractory myeloma. Acute development of congestive cardiac failure associated with bortezomib therapy occurs very rarely or may be underestimated. Inhibition of proteasome activity may impair cardiac function due to accumulation of unfolded, damaged and undegraded proteins in myocytes. Patients with or without cardiac disease or previously received anthracycline-containing regimes should be closely monitored when being subjected to treatment with bortezomib.     

Primary chest wall abscess caused by Escherichia coli costochondritis

Chest wall abscess may occur as primary infection or secondary to open trauma or thoracic wall surgery. The authors describe an unusual case of Escherichia coli costochondritis occurring 2 months after a blunt chest wall trauma. Primary chest wall abscess due to E coli costochondritis has been previously reported only twice occurring after urinary tract infection. All other very few reports of E coli costochondritis have been reported only after thoracic surgical procedures. An English literature review of primary chest wall abscess showed that 4 pathogens are responsible for the majority of cases: Actinomyces, Staphylococcus aureus, Candida albicans and Salmonella. C albicans costochondritis was most commonly reported among heroin addicts. The appearance of a growing chest wall mass should always prompt a search for an infectious cause, even with little or no systemic signs and symptoms.     

Pseudoazygos lobe caused by lymph node pneumatocele

In patients with AIDS, the relatively high incidence of pulmonary tuberculosis places them at risk for more severe esophageal tuberculosis (including fistula formation), and tuberculous esophagitis in the setting of AIDS may be more common than had been thought. Tuberculous esophageal fistulae have long been described and are well known. Air tracking from the esophagus into a mediastinal lymph node is very rare and reported previously to collect in small pockets in either of two patterns: irregular (or "amorphous") or peripheral and curvilinear. Complete filling of a large lymph node by air has not previously been reported. Reported here is a case of tuberculous mediastinal lymphadenopathy in an AIDS patient in whom CT scans demonstrated fistula development between a large lymph node and adjacent esophagus; this was accompanied by total replacement of the apparently necrotic content of the node with air, surrounded by the relatively thin, smooth, residual wall of the node. A lymph nodal pneumatocele was thereby created, which has not been previously described, and is the first feature of this case. On frontal chest radiography, the lateral wall of the lymph nodal pneumatocele produced an appearance falsely akin to an azygos fissure, creating the second feature: a previously unreported cause of false appearance of an azygos lobe. It is important to consider tuberculosis when a fistula to the esophagus is demonstrated in an AIDS patient, to be aware that even a large lymph node may "shell out" entirely in that setting, and not to confuse the final resulting appearance with the normal variant it may resemble.     

Arterial thrombosis leading to intestinal infarction in a patient with Behçet's disease associated with protein C deficiency

Behçet's disease may be a possible cause of both occlusive and aneurysmal arterial involvement as well as recurrent venous thrombosis. A case of Behçet's disease complicated with vascular involvement leading to intestinal infarction is presented. A 41-yr-old man suffering from Behçet's disease for 15 yr presented with a 2-day history of severe abdominal pain and bloody diarrhea. Intestinal infarction secondary to thrombosis of the superior mesenteric artery had been diagnosed during surgical exploration 3 yr previously. He was started on anticoagulation with nutritional support. The patient was readmitted with severe diarrhea and malabsorbtion symptoms 3 yr after intestinal resection. A thrombus located in the posterior wall of the infrarenal portion of aorta was detected by aortography and ultrasonography. Although thrombosis is a relatively common complication of Behçet's disease caused by vasculitis, protein C deficiency, which is a pertinent laboratory finding in this case, might be a secondary factor in the thrombotic event. This is the first case reported of mesenteric artery thrombosis leading to bowel infarction and abdominal aorta thrombosis associated with protein C deficiency.     

Unchanging trend of esophagogastric junction adenocarcinoma in Korea: experience at a single institution based on Siewert's classification

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing in Western countries. It is unclear, however, whether similar changes are occurring in Asia. We therefore investigated the incidence of AEG in Korea, and assessed the clinical characteristics of three types of AEG based on Siewert's classification. We retrospectively reviewed the medical records of 16 811 patients diagnosed with esophageal squamous cell carcinoma (ESC, n= 1450) or gastric noncardiac adenocarcinoma (GNCA, n= 14 751) between 1992 and 2006. The patients were divided into three 5‐year cohorts (cohort A [1992–1996], n= 2734, cohort B [1997–2001], n= 5727, and cohort C [2002–2006], n= 8350), and the ratios of AEG (n= 610) to non‐AEG (ESC and GNCA) in each cohort were compared. Using Siewert's classification, the tumors were categorized into one of three types, and patient demographic features and 5‐year survival rates were compared. The ratio of AEG to non‐AEG cases did not change over time (0.037, 0.034, and 0.039 for cohorts A, B, and C, respectively; P= 0.40). Of the 610 patients with AEG, 23 (3.7%) had type 1 tumors, 47 (7.7%) had type 2, and 540 (88.5%) had type 3. The 5‐year survival rate of patients with type 1 AEG was much lower (4.8 ± 4.7%) than that of those with type 2 (47.9 ± 7.8%) and type 3 (47.4 ± 2.5%) tumors. Unlike in Western countries, the ratio of AEG to non‐AEG cases has not increased over time in Korea. Type 1 AEG was rarer and associated with a more unfavorable prognosis in Korea than in Western countries.     

Multinodular hepatic angioma: a rare cause of neonatal asystole. A case and review of the literature]

The clinical findings in a case with a diffuse multinodular type of angioma of the liver are reported. The clinical picture was typical: the appearance after the first week of a severe congestive failure mimicking a congenital heart disorder, of the left to right shunt type, with gross hepatomegaly of the "vascular" type with a systolo-diastolic murmur, but with no cutaneous evidence of angioma. The very severe prognosis during the first months of life of patients with this malformation, as illustrated by the 58 deaths out of the 78 cases reported in the literature, indicated ligature of the hepatic artery before the age of one month. The satisfactory outcome (with a nine months follow-up) for this case, as for the three other operated cases in the literature, leads us to conclude that this operation is indicated after a detailed arteriographic examination has been made, and provided that the other anatomical conditions are favourable.     

Necrotizing fasciitis secondary to carcinoma of the gallbladder with perforation

We present an unusual case of necrotizing fasciitis in the upper abdominal wall caused by penetrating perforation of the gallbladder. It was manifested as an elastic and reddish abdominal swelling with severe tenderness, but no peritoneal irritation. Computed tomography (CT) demonstrated water density with a slightly elevated CT value and air bubbles in the subcutaneous space. The preoperative diagnosis was subcutaneous abscess with fasciitis. At surgery, necrotizing fasciitis and subcutaneous abscess secondary to penetrating perforation of the gallbladder were revealed. Cholecystectomy and peritoneal irrigation were performed. Although no tumor was evident during surgery, a tumor located close to the perforation site was found just after the operation. Pathological examination revealed gallbladder carcinoma without stones. There have been very few previous reports of necrotizing fasciitis following gallbladder perforation. The presentation, diagnosis, and management of fasciitis, as well as carcinoma of the gallbladder with perforation, are discussed.     

Pheochromocytoma of the urinary bladder: A broad clinical spectrum

A case of pheochromocytoma of the urinary bladder is reported, and 35 previously reported cases are analyzed. This interesting entity can present with symptoms of catecholamine excess and severe hypertensive spells (often micturition-induced) or as asymptomatic hematuria without hypertension. The present case represents the severest end of the clinical spectrum, with advancing acute retinopathy and visual loss, very high blood pressure and greatly increased catecholamine excretion. Several special precautions were utilized during diagnostic studies and surgery. On the whole, prognosis is excellent in nonmalignant cases properly handled, and the location of the tumor provides opportunity for early case finding and complete cure.