WONCA Online电子病例介绍——盲肠扭转

·一般情况:患者,女,46岁,因右上腹疼痛并向背部、侧胸部放射就诊,有恶心、呕吐2次.2周前行腹腔镜胆囊切除术,手术顺利无并发症,术后饮食正常.腹部疼痛时不伴有腹泻、腹胀等,无发热、寒战.既往有高血压、高胆固醇血症及胆囊病史,无吸烟及饮酒嗜好.     

Correlation of dietary intake and colorectal cancer incidence among Mexican-American migrants: the multiethnic cohort study

Studies of migrants, along with geographic and temporal variations in incidence, indicate that colorectal cancer is especially sensitive to changes in environmental factors, including, most importantly, diet. The goal of this research was to examine the changes in dietary practices that may be consistent with the changing incidence of colorectal cancer in the Los Angeles Mexican-American population. Cancer incidence and dietary intake data were available for over 35,000 Latinos of Mexican national origin currently participating in the prospective Multiethnic Cohort Study, representing the largest sample of Mexican-origin Latinos of any such study in the United States. The dataset is unique in that changes in cancer rates and in dietary behaviors across three generations could be examined. Most of the change in colorectal cancer rates occurred between the first and second generations, and, correspondingly, nearly all the dietary change also occurred between the first and second generations. Although some food traditions were retained by Mexican Americans, the dietary changes due to acculturation were significant and support an association between colorectal cancer risk and certain dietary components, notably, alcohol as a risk factor and nonstarch polysaccharides and vegetables as protective factors.     

Blunt Handlebar Injury of the Common Femoral Artery: A Case Report

Bicycle handlebar-related blunt trauma to the femoral vessels with resulting arterial injury has been described previously. However, significant injury to the ileofemoral tree with underlying arterial occlusive disease in the face of handlebar-related trauma has not been reported. We present the case of an all-terrain vehicle accident with isolated injury to the common femoral artery in a patient with underlying atherosclerotic disease.     

Platelet concentrate effects on thromboelastography

This study evaluated platelet effects on thromboelastography to determine how morphologically abnormal platelets affected native whole blood analysis. Prospective, controlled comparison. Tertiary care university hospital. Volunteer cardiac surgery patients. Fresh platelets were obtained from volunteers and were either treated normally or cryodisrupted with liquid nitrogen. Fresh platelets, liquid nitrogen-treated platelets, or an equivalent quantity of the patient's blood were added to whole blood samples obtained from cardiac surgery patients before heparinization. Thromboelastographic parameters sensitive to platelet effects were measured in each of the three groups.

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Maximum amplitude and a-angle significantly increased in the two groups receiving added platelets. There were no differences between the fresh platelet and the liquid nitrogen-treated platelet groups (Student's paired t-test). The R-time decreased significantly in both platelet-treated groups compared with the group that did not receive additional platelets. Viscoelastic changes in whole blood coagulation after the addition of platelet concentrates are not dependent on morphologically intact or functionally normal platelets. This in vitro study predicts that transfusion of poorly preserved platelet concentrates as well as fresh platelets would increase clot strength on thromboelastography if the recipient's blood were tested immediately after administration.     

Extra-abdominal desmoid tumor: an unusual subcutaneous lesion presenting as shoulder pain

A 50-year-old Hispanic woman presented to the medical walk-in clinic of a local community hospital complaining of shoulder pain. The problem had begun 9 months previously, and first manifested as dull right shoulder pain that developed after she carried a bag of groceries up one flight of stairs. A diagnosis of “muscle strain” and “arthritis” was made for which nonnarcotic analgesics were prescribed. The pain persisted, and 2 months later she was re-evaluated and diagnosed with degenerative joint disease. An orthopedics consultation was sought for further evaluation. During this examination, she pointed out to the physician that she had a “lump in her shoulder,” but she was informed that this was of no consequence and that her complaints were due to arthritis. Roentgenograms of the right shoulder and thoracic spine were performed and determined to be within normal limits. Once again she attempted to control the pain with nonsteroidal anti-inflammatory agents to no avail. Because the pain had become unbearable, she sought relief at the medical walk-in clinic. Physical examination was remarkable for a solitary, skin-colored, firm, deeply-seated tumor measuring 3×4 cm located over the right posterior of the deltoid. The mass was exquisitely tender to palpation and was fixed to the underlying muscle. There was a full range of motion as well as good muscle strength of the shoulder, but movement of the arm in any direction was painful. The patient subsequently underwent a deep, partial excisional biopsy of the lesion, and a firm white tumor mass of about 3 × 3 cm in size was dissected away from the deltoid muscle. Although the majority of the tumor was excised, visible portions of the lesion were not removed because they were present deep within the bulk of the muscle. Histopathologic examination revealed a large, deeply-seated poorly-circumscribed fibrous proliferation containing areas in which there were numerous spindle cells arranged in fascicles ( Figs 1, 2, and 3 ). Neither cellular atypia nor mitotic figures were seen. The diagnosis of extra-abdominal desmoid tumor was made. The patient subsequently underwent a wide re-excision of the area and tolerated the procedure well, developing normal function of the arm following surgery, although there was slight persistent tenderness of the deltoid. Because of the known association of desmoid tumors with familial polyposis coli ¹ , a barium enema was performed. No colonic polyps were demonstrated.

Figure 1 Open in figure viewer PowerPoint Histopathology of desmoid tumor at scanning magnification. There is a large, poorly-circumscribed, diffuse spindle cell proliferation that extends into the subcutis, muscle, and fascia (hematoxylin and eosin; original magnification, ×10)     

Building a multigenic model of breast cancer susceptibility: CYP17 and HSD17B1 are two important candidates

We conducted a nested case-control study to evaluate whether polymorphisms in two genes involved in estrogen metabolism, CYP17 and HSD17B1, were useful in developing a breast cancer risk model that could help discriminate women who are at higher risk of breast cancer. If polymorphisms in these genes affect the level of circulating estrogens, they may directly influence breast cancer risk. The base population for this study is a multiethnic cohort study that includes African-American, Non-Latina White, Japanese, Latina, and Native Hawaiian women. For this analysis, 1508 randomly selected controls and 850 incident breast cancer cases of the first four ethnic groups who agreed to provide a blood specimen were included (76 and 80% response rates, respectively). The CYP17 A2 allele and the HSD17B1 A allele were considered "high-risk" alleles. Subjects were then classified according to number of high-risk alleles. After adjusting for age, weight, and ethnicity, we found that carrying one or more high-risk alleles increases the risk of advanced breast cancer in a dose-response fashion. The risk among women carrying four high-risk alleles was 2.21 [95% confidence interval (CI), 0.98-5.00; P for trend = 0.03] compared with those who carried none. This risk was largely limited to women who were not taking hormone replacement therapy (relative risk, 2.60; 95% CI, 0.95-7.14) and was most pronounced among those weighing 170 pounds or less (RR, 3.05; 95% CI, 1.29-7.25). These findings suggest that breast cancer risk has a strong genetic component and supports the theory that the underlying mechanism of "complex traits" can be understood using a multigenic model of candidate genes.     

Depression in children and adolescents: Does gender make a difference?

The occurrence of depression is higher in females after puberty, suggesting a gender-related difference. This article reviews studies that have examined gender differences in the presentation and treatment of depression in adults and discusses how this information applies to depressed children and adolescents. The adult literature suggests that men and women vary in presentation of depression. In addition, differences exist in the pharmacokinetic properties of various medications, but it is unclear how they affect clinical treatment response. Studies of gender differences in child and adolescent depression are limited. Some studies suggest that differences seen in adults may also apply to children and adolescents. Studies of gender differences in treatment response are not available, however. Further study and evidence-based exploration are required to better understand gender differences in depression in children and adolescents.