Surgical Repair of Abdominal Aortic and Renal Artery Aneurysms in Takayasu's Arteritis

Takayasu''s arteritis is a large vessel vasculitis that can be a challenging diagnosis to make and has a varied clinical presentation. Management largely depends on affected vessel disease severity and individual patient considerations. The diagnosis must be considered in a young patient with large vessel aneurysms. We present a case of a 30 year-old woman of Pacific Islander descent who presented to the Tripler Army medical Center Vascular Surgery Department in Honolulu, Hawai‘i seeking repair of her abdominal aortic and renal artery aneurysms prior to conception.A 30 year-old Pacific Islander woman with a history of a saccular abdominal aortic aneurysm and renal artery aneurysms presented to our clinic seeking vascular surgery consultation prior to a planned pregnancy. She had a renal artery stent placed at an outside institution for hypertension. She met the diagnosis of Takayasu''s arteritis by Sharma''s criteria. Physical exam was significant for a palpable, pulsatile, abdominal mass and CT angiography revealed a saccular irregular-appearing infra-renal abdominal aortic aneurysm, extending to the aortic bifurcation, with a maximum diameter of 3.3 cm. A right renal artery aneurysm was also identified proximally, contiguous with the aorta, with a maximal transverse diameter of 1.7 cm. The patient underwent a supraceliac bypass to the right renal artery with a 7mm Dacron graft, as well as excision of the right renal artery aneurysm. The abdominal aortic aneurysm was replaced using a Hemashield Dacron bifurcated 14mm x 7mm bypass graft. Intraoperative measurements of the renal artery aneurysm were 1.5 x 1.5 cm and the saccular appearing distal abdominal aortic aneurysm measured 3.6 x 3.3cm. The patient was discharged from the hospital 7 days post-operatively. At 1-year follow up, CT scan of the abdominal aorta revealed the repair was without any evidence of aneurysm formation, anastomotic pseudoaneurysm formation, or areas of stenosis. She has remained normotensive with a normal serum creatinine 18 months after her repair. She has since delivered her second child.It is rare for Takayasu''s arteritis to present with aneurysmal disease. It is much more common to present with stenosis or occlusion. It has yet to be proven that Takayasu''s truly has a higher incidence in those of Asian descent. Takayasu''s can be a difficult diagnosis to make but can be aided with the use of Sharma''s criteria. Our particular patient posed unique considerations on the effects of the physiology of pregnancy on her aneurysms and repair.Managing the active phases of disease is imperative, and though medical management is first line, surgical intervention may be necessary. Surgical intervention should be performed in a quiescent period of disease if possible given that biological inflammation at the time of intervention increases the complication rate. Repair of aneurysmal disease in a young female should also be considered prior to pregnancy.     

Diagnostic image (241). A woman with malaise, periodic fever and extreme fatigue

A 51-year-old white woman with extreme fatigue, fever episodes, weight loss, leucocytosis and increased erythrocyte sedimentation rate showed diffuse high uptake of 18F-fluorodeoxyglucose in the entire aortic wall, which is characteristic of giant cell large-vessel arteritis, such as Takayasu disease.     

惠普尔养障体重症肺炎1例报告

惠普尔养障体是一种革兰阳性杆菌,属于苛养菌,临床常难以确诊。惠普尔氏病是由惠普尔养障体引起的一种慢性多系统感染性疾病,常见的靶器官是胃肠道、关节,肺部罕见受累。本文报告患者临床表现为发热、咳嗽、呼吸困难,双肺CT提示弥漫性磨玻璃影,支气管镜肺泡灌洗液宏基因测序提示为惠普尔养障体、热带念珠菌混合感染,给予美罗培南、复方磺胺甲口恶唑、氟康唑治疗好转。本文就该例惠普尔养障体肺炎病例进行报告及文献复习,旨在提高临床对惠普尔养障体感染的认识,做到早诊断、早治疗。     

HIV阴性儿童马尔尼菲篮状菌病2例临床分析并文献复习

 目的 总结2例人类免疫缺陷病毒（HIV）阴性儿童马尔尼菲篮状菌病（TSM）患儿的临床特征。方法 分析某儿童医院收治的2例HIV阴性TSM患儿的临床特点及实验室资料、存在的基础疾病,并复习相关文献,总结TSM感染患儿的临床特征及诊治经验。结果 2例HIV阴性TSM患儿中病例1以右下肢肿块为首发症状,1个月余后才出现发热及咳嗽,误诊为结核感染;病例2以发热、三系减少及肝脾、淋巴结大等表现起病。病例1行基因检测为STAT1基因突变,病例2有反复灰指甲及口腔溃疡病史,均行血、骨髓培养及淋巴结活检确诊。病例1先后予以伏立康唑、两性霉素B脂质体静脉滴注,伊曲康唑口服维持治疗,共治疗1年后停药;病例2一直予以伏立康唑治疗（先静脉滴注后口服）,共7个月后停药,均无复发。结论 TSM可发生在HIV阴性儿童,且可存在STAT1基因突变。对于治疗效果差的患儿,应尽早行培养或组织活检以明确诊断,并积极查找TSM可能存在的基础疾病,以到达早期诊断、早期治疗和改善预后的目的。     

Pyogenic Liver Abscess Presenting as an Initial Manifestation of Underlying Hepatocellular Cancer: A Case Report in Ethiopia

BackgroundAn adult patient presented with right abdominal pain and fever to a primary care physician and abdominal ultrasound was performed. With an initial diagnosis of a liver abscess, he was discharged from the hospital after treatment with antibiotics and drainage of the collection. However, the patient had persistent clinical findings on the same site which was later confirmed as Hepatocellular cancer.Case PresentationA 40 years old male patient who was known to have Type 2 Diabetes and Hypertension for 10 years on oral medications referred to the Gastroenterology/Hepatology unit with right upper quadrant pain, loss of appetite, nausea, vomiting of ingested matter, and significant weight loss. On further inquiry, he had been admitted six months back for similar complaints and was managed with antibiotics and drainage of an abscess collection.The multi-phasic abdominal CT scan and raised alphafetoprotein confirmed Hepatocellular Cancer which initially has presented as a pyogenic liver abscess.ConclusionHepatocellular cancer should be suspected and early diagnosis should be made in individuals presenting with a liver abscess and having risk factors for liver cancer.     

Spotted fever and murine typhus in the Negev desert region of Israel, 1981

During 1981, 52 cases of rickettsiosis caused by the spotted fever group of rickettsiae were reported in a population of 250 000 living in the Negev desert region of Israel. Retrospectively, at least 5 of these cases were serologically shown to have been caused by Rickettsia typhi, the agent of murine typhus. Most cases of rickettsial disease occurred in the summer months and one half of all cases occurred in children aged 9 years or less. While the specificity of a physician''s diagnosis of the rickettsial diseases appears to be high (i.e., few cases of other diseases are misdiagnosed as either spotted fever or murine typhus), the sensitivity of the physician''s diagnosis may be lower (i.e., many cases of these diseases presenting as fevers of unknown origin are not diagnosed as rickettsial disease). These findings may also be important for other countries of the region.     

Takayasu arteritis: a chronic vasculitis that is rare in children

Takayasu arteritis was diagnosed in two children, a 15-year-old girl and a 10-year-old boy. The girl had suffered from fatigue, malaise, abdominal pain and weight loss for several months, but no clear cause could be found. A few weeks later, when a blood pressure of 222/155 mmHg was measured, the possibility of renal artery stenosis was considered and imaging studies revealed indications for Takayasu's disease. The patient was given methylprednisolone followed by a combination of prednisone and, initially, cyclophosphamide, later methotrexate. This resulted in a clinical remission of the inflammatory process. The boy presented with increasing fatigue and variable episodes of fever. After 3 years, sarcoidosis or Castleman's disease were considered. Imaging studies revealed aortic stenosis. He underwent stenting of the involved vessel segment. Takayasu arteritis is a chronic vasculitis of unknown origin, affecting mainly the aorta and its main branches. As a result of the inflammation, stenosis, occlusion or dilatation of the involved vessels may occur and cause a wide range of symptoms. Especially in the early phase, the symptoms often are non-specific. One should look for hypertension, blood pressure differences between the two arms, decreased peripheral pulsation or bruits over the aorta and its major branches. Radiological examination may consist ofangiography, magnetic resonance imaging or CT-scans. Treatment consists of corticosteroids and other immunosuppressants, such as cyclophosphamide, methotrexate, azathioprine, and antagonists of tumour-necrosis factor alpha. In addition, balloon dilatation or stenting is often necessary.     

发热与手足口病(EV-71)合并病毒性脑炎相关性研究

目的:研究发热与手足口病(EV-71)合并病毒性脑炎相关性,为临床早期诊断重型手足口病提供指导。方法:回顾研究某院手足口病住院病人1097人,合并病毒性脑炎425例,符合入选条件374例,分析发热与病毒性脑炎相关性。结果:手足口病(EV-71)发热超过39℃2天以上和/或发热38.5℃超过3天以上,大多并发病毒性脑炎,对临床早期判断重型手足口病有指导意义,重型手足口病早期应用静注免疫球蛋白预后好。     

In vitro cultivation of the rickettsial agent of trench fever

Although trench fever appears to be endemic in many areas of the world, recognition of the disease has been handicapped by the difficulties of making a clinical diagnosis and the unavailability of a simple laboratory procedure to establish the etiology. The author describes a method for the in vitro cultivation of Rickettsia quintana that provides a relatively simple means for the laboratory diagnosis of trench fever. R. quintana can be propagated with ease from the blood of patients directly on blood agar incubated at 37°C for 12-14 days under a gas tension of 5% CO₂ in air. The number of rickettsiae circulating in the patient''s peripheral blood can be quantitated. The protracted rickettsiaemia in trench fever makes for a relatively long period during which blood culture can be usefully employed.     

388例HIV／AIDS患者临床特点与机会性感染发病谱

目的了解本地HW／AIDS患者的一般情况、传播途径,分析其临床特点,总结出本地艾滋病患者的机会性感染发病谱从而指导早期诊断和治疗。方法对长沙市传染病医院2003年4月-2009年8月底收治的388例HIV／AIDS患者进行回顾性分析。结果388例HIV／AIDS患者以农民、小城镇外出打工人员为主;主要传播途径为性传播;40．98％的患者胸片检查异常,绝大多数的患者CD4^＋T淋巴细胞〈200个／tA;最常见的临床症状为发热、体重减轻、咳嗽、慢性腹泻、皮肤病变及淋巴结肿大;机会性感染发生率为91．75％,最常见的机会性感染是口腔真菌感染（占54．12％）,肺部感染（占45．10％）（其中包括卡氏肺孢子虫肺炎及肺结核）,合并感染结核者占36．08％（包括肺结核及肺外结核）。结论本地HIV／AIDS的人群以农民、打工人员为主,传播途径主要是性传播;机会性感染以鹅口疮最为常见,其次为肺部感染,且表现为多系统、多种致病微生物并存,细菌、真菌、病毒均为常见病原,呼吸、消化系统以及皮肤软组织为常见感染部位。     

Relationship of psychiatric diagnosis and weight loss maintenance in obese breast cancer survivors

OBJECTIVE: Obese breast cancer survivors are a unique population for weight loss counseling because both obesity and a diagnosis of breast cancer can increase the risk of depression. In this pilot study, weight loss maintenance was examined in obese breast cancer survivors with relationship to psychiatric diagnosis. RESEARCH METHODS AND PROCEDURES: Forty-eight subjects were enrolled. The intervention, which used individualized counseling for diet and exercise, lasted 24 months. After a 6-month period of no contact with study subjects, a follow-up body weight was obtained at 30 months. RESULTS: The nine subjects who dropped out of the study before 12 months all failed to complete a structured psychiatric interview. Of the remaining 39 subjects, 9 had major depressive disorder, and 10 had a definable psychiatric disorder of lesser severity such as adjustment disorder. Subjects with any type of psychiatric diagnosis displayed significantly less weight loss at the 12-month time-point than those with no diagnosis (6.3% vs. 12.6% loss of baseline weight, respectively). At the 30-month follow-up visit, subjects with any psychiatric disorder had a mean weight loss of 1.2% of baseline weight compared with 7.8% weight loss in subjects with no diagnosis. DISCUSSION: These results suggest that the presence of psychiatric disorders can interfere with weight loss. Therefore, recognition and treatment of psychiatric disorders may be important in attempts at weight reduction, and this will be especially important in populations such as cancer survivors, who seem to have higher rates of depression and other disorders than the general population.     

Massive Hemoptysis in a Woman with Seizures

A 53-year-old woman presented with a productive cough, fever, chills, and night sweats of one month's duration. She reported having had lightly blood-streaked sputum initially but then experiencing massive hemoptysis (>200 mL/2 hr). Since the onset of symptoms, she had had malaise, body aches, and a 27-lb weight loss. For the last two weeks, she had also had increasing shortness of breath and pleuritic chest pain.     

Eating behaviors among low-income obese adults in the United States: Does health care provider's advice carry any weight

The U.S. Preventive Task Force recommends that all patients be screened for obesity and given appropriate weight loss advice, if needed, as nutrition counseling by primary care physicians is a key objective for Healthy People 2020. This study assesses the association between health care provider's (HCP) advice to lose weight and eating behaviors among obese individuals. Data were collected using a household survey of adults in five New Jersey cities in 2009–10. Analyses presented are limited to 548 obese participants. Negative-binomial regression analysis determined the association of participants' eating behaviors and HCP's advice to lose weight, after adjusting for the participant's attempt to lose weight and demographic variables. Despite being obese, only 48% of the participants received weight loss advice from their HCP while 68% stated they were attempting to lose weight. HCP's advice to lose weight was associated with increased salad and fruit consumption (PR 1.3, 95% CI 1.06-1.61; PR 1.23, 95% CI 1.02-1.48). Attempting to lose weight was positively associated with a higher consumption of fruit (PR 1.39, 95% CI 1.13-1.72), vegetables (PR 1.22, 95% CI 1.07-1.39), and with eating fruits and vegetables as snacks (PR 1.62, 95% CI 1.28-2.05). Attempting to lose weight was negatively associated with consumption of sweet snacks (PR 0.68, 95% CI 0.49-0.94), sugar sweetened beverages (PR 0.71, 95% CI 0.58-0.87) and fast food (PR 0.77, 95% CI 0.62-0.97). There were no significant interactions between HCP's advice and attempts to lose weight. Obese adult's attempt to lose weight, and not HCP's advice to lose weight, was a predictor for healthy eating behaviors. Interventions in medical practices should train HCPs on effective strategies for motivating obese patients to adopt healthier lifestyles.     

Clinical reasoning and decision-making in practice. A man with inexplicable joint pain and subsequent poor clinical condition

A 52-year-old man presented with polyarthritis and was negative for rheumatoid factor, anti-CCP and ANA. He was treated with low-dose methotrexate, the drug of first choice in rheumatoid arthritis. The arthritis disappeared, but the patient developed fever, progressive dyspnoea, appetite loss and weight loss. Upon hospital admission his medication was stopped and community-acquired pneumonia was diagnosed. The fever persisted despite antibiotic treatment. The tentative diagnosis of rheumatoid arthritis was changed to systemic lupus erythematosus, based on the change in clinical condition that could not be explained by polyarthritis and seroconversion to ANA- and anti-dsDNA-positive. The patient was treated with high-dose steroids and azathioprine and remained in remission for more than 1 year after treatment. The ANA test remained strongly positive, whereas anti-dsDNA was no longer detectable. This case stresses the limited value of classification criteria for the diagnosis of rheumatoid arthritis. To differentiate between rheumatoid arthritis and systemic lupus erythematosus, tests for autoantibodies against citrullinated peptides can be used. To differentiate between systemic lupus erythematosus and infection, tests for anti-dsDNA antibodies, antinuclear antibodies, C-reactive protein and complement can be used.     

以头痛为首发症状的鹦鹉热衣原体肺炎1例并文献复习

以头痛为首发症状的鹦鹉热衣原体肺炎非常罕见。本文报告1例以头痛起病的患者, 相继出现高热、咳嗽、咳痰、呼吸困难等临床表现, 胸部CT提示肺部感染, 采用宏基因组二代测序技术及结合鸟禽类接触史, 诊断鹦鹉热衣原体肺炎, 经多西环素、莫西沙星等治疗后病情好转。结合文献复习, 探讨鹦鹉热衣原体肺炎的临床特点、辅助检查及诊治方案, 旨在提高临床医生对以头痛起病的鹦鹉热衣原体肺炎的认知, 尽早诊断及治疗, 避免误诊漏诊。     

Malaise after a trip to Africa: amoebic liver abscess

During a flight to Kenya, a 42-year-old man took a therapeutic dose of chloroquine because of fever. He regularly travelled to Africa and always took chloroquine and proguanil for malaria prophylaxis. The fever disappeared but he did not fully recover. He complained of malaise and weight loss. Fourteen years previously he had suffered from amoebic dysentery. One month after the onset of the patient's complaints, an amoebic liver abscess was suspected on the basis of his medical history, an elevated ESR and a slight leukocytosis. The diagnosis was confirmed by ultrasonography and serology.     

Do working mothers raise couch potato kids? Maternal employment and children's lifestyle behaviours and weight in early childhood

Alarm about the increasing prevalence of childhood obesity has focussed attention on individual lifestyle behaviours that may contribute to unhealthy weight. More distal predictors such as maternal employment may also be implicated since working mothers have less time to supervise children's daily activities. The research reported here used two waves of data from the Longitudinal Study of Australian Children to investigate whether mothers' hours in paid work shape young children's television viewing, snacking and physical activity, and through those lifestyle behaviours, children's weight at ages 4–5 years and 6–7 years. At both ages, children's lifestyle behaviours were interrelated and associated with weight status. Cross-sectional analysis confirmed small, direct associations between longer hours of maternal employment and child weight at age 4–5 years, but not with child's weight measured two years later. In both the cross-sectional and prospective analyses, the children of mothers who worked part-time watched less television and were less likely to be overweight than children of mothers who were not employed or who worked full-time. While associations were small, they remained significant after adjustment for maternal weight, household income and other factors. The combination of direct and indirect relationships between mothers' work hours and the weight status of their young children provides additional support to calls for family-friendly work policies as an important means for promoting healthy family lifestyles and early childhood wellbeing.     

Knowing is not half the battle: Impacts of information from the National Health Screening Program in Korea

Health screening provides information on disease risk and diagnosis, but whether this promotes health is unclear. We estimate the impacts of information provided by Korea's National Health Screening Program by applying a regression discontinuity design around different biomarker thresholds of diabetes, obesity, and hyperlipidemia risk using administrative data that includes medical claims, biomarkers, and behavioral surveys over four years after screening. Generally, we find limited responses to disease risk information alone. However, we find evidence for weight loss around the high risk threshold for diabetes, where information is combined with active prompting for a secondary examination for diagnosis and treatment.     

Obésité. Pourquoi les régimes échouent-ils ?

Is there a fail and a relapse in regimen for weight loss? If yes, why? Is it due to the physician, to the diet or to the disease? First we give the data about “success” of restrictive diet and we recall that some subjects succeed to lose weight themselves. Then we show that, whatever the weight evolution, the health's benefit of regimen is not always proven. Then we overview all the mechanisms involved in the regimen's failure and in weight's relapse: behaviour, social, psychological, metabolic, hormonal, and toxic factors; but also non-nutritional etiological factors. We draw some conclusions for means and objectives in the treatment. Ways and resources must be carefully used in order to be not negative, and must be adapted for each one; objectives have to be revised: this could permit for the patient and for the physician to avoid fail in weight loss.