Successful treatment of thrombotic thrombocytopenic purpura with plasmapheresis and anti-CD20 antibodies in a patient with immune thrombocytopenia and systemic lupus erythematosus: Case report

Rationale:Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology with diverse clinical and laboratory manifestations, including thrombocytopenia. About 25% of patients with SLE may be affected by thrombocytopenia, many of whom are asymptomatic. Some patients, however, experience platelet counts that drop quite low and predispose them to bleeding. Thrombotic thrombocytopenic purpura (TTP) is defined with a classic pentad of clinical features, such as thrombocytopenia, microangiopathic hemolytic anemia, neurological symptoms and signs, renal symptoms and signs, and fever. The association of TTP and SLE has been sporadically reported in the literature.Patient concerns and diagnosis:We describe a 16-year-old girl with SLE and immune thrombocytopenia, in whom TTP was diagnosed.Interventions and outcomes:She was treated with pulse methylprednisolone, whose platelet counts normalized after therapy with plasmapheresis and an anti-CD20 monoclonal antibody (rituximab).Conclusion:A pediatric patient with SLE and immune thrombocytopenia in whom TTP developed was treated with plasmapheresis and rituximab therapy successfully, though the patient experienced a disease relapsed after 18 months, which was controlled by the same management.     

病例讨论对实验诊断学教学中临床思维能力培养的作用

目的提高“实验诊断”的教学质量和培养学生的临床思维能力。方法理论教学结合病例分析及讨论。结果病例分析及讨论使抽象的理论内容变得生动形象,使学生的临床思维能力得到培养。结论与病例结合的教学对临床思维能力的培养有显著作用。     

Lung contusion after extracorporeal shock wave lithotripsy for pancreatic stones: A case report

Background:Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is recommended as the first-line treatment for large pancreatic stones. While complications such as post-P-ESWL pancreatitis, bleeding, infection, steinstrasse, and perforation have been reported in the past 30 years, lung contusion has never been reported. The present case demonstrates lung contusion as a complication after P-ESWL.Methods:A 48-year-old man was admitted to our department due to painful chronic pancreatitis with pancreatic duct stones. Computed tomography revealed normal lungs. P-ESWL was performed. The shock wave head contacted with right upper quadrant and the path of shock wave was at a 45° angle to the ventral midline. After P-ESWL, multiple patchy high-density shadows in the lower lobe of right lung were found, which was normal before P-ESWL. The patient had no symptoms of lung injury.Results and Conclusion:Laboratory studies revealed elevated D-dimer from 0.33 to 0.74 ug/mL, which was consistent with abnormal clotting of lung contusion. Chest computed tomography showed slight pleural effusion. Considering the interval between 2 X-rays was only 3 hours, we inferred that lung contusion was related to P-ESWL. The patient displayed stable vital signs, therefore, no specific interventions were conducted. Three days after P-ESWL, endoscopic retrograde cholangiopancreatography was performed and the lung shadows were partially absorbed. Considering the location of shock wave head, it was possible to cause lung contusion in lower lobe of right lung. More than 10,000 P-ESWL therapeutic sessions had been performed in our center since 2010, and it is the first case about lung contusion as a complication. It is also the first report to describe lung contusion after P-ESWL. Although the patient was asymptomatic, it should raise awareness of clinicians.     

Immune-checkpoint inhibitor-associated grade 3 hepatotoxicity managed with enteric-coated budesonide monotherapy: A case report

Rationale:The introduction of immune-checkpoint inhibitors (ICPI) in recent years has changed the natural course of many neoplasms. However, patients receiving these medications may present immune-mediated adverse events; management includes temporary or permanent cessation of treatment and corticosteroids, occasionally combined with other immunomodulators. Such immunosuppression, however, also has numerous adverse events and even if it is effective in controlling toxicity, it delays immunotherapy reinitiation, as current evidence requires dose tapering to ≤10 mg prednisolone equivalent before rechallenge. Enteric-coated budesonide is a corticosteroid formulation acting primarily to the intestine and liver, as a result of its extensive first-pass hepatic metabolism.Patient concerns:A 76-year-old woman treated with ipilimumab for metastatic melanoma presented with abdominal pain, vomiting, and diarrhea for at least the previous 4 days. Laboratory tests, among others, revealed elevated aminotransferases and C-reactive protein. During hospitalization, the patient also developed fever.Diagnosis:The patient, after excluding alternative causes of aminotransferase elevation, was diagnosed with grade 3 ipilimumab-associated hepatotoxicity.Interventions:Budesonide monotherapy was administered; initial daily dose was 12 mg.Outcomes:Fever subsided after the first dose of budesonide. Aminotransferases returned to normal-near normal approximately 1 month after the first dose of budesonide. After this point, daily dose was reduced by 3 mg every 2 weeks, with no clinical or biochemical relapse.Conclusions:This case of ICPI hepatitis is, to our knowledge, the first in the literature managed with budesonide monotherapy. Therefore, budesonide may be a potentially attractive option for the management of ICPI-associated liver injury in cases where corticosteroid treatment is necessary due to its safety profile and the potential advantage of faster immunotherapy rechallenge in selected patients without requiring dose tapering, in contrast to systemically acting corticosteroids. Clinical trials should be conducted in the future in order to validate or refute these findings.     

运用经典理论辨治疑难杂症

运用《黄帝内经》、《伤寒论》等经典著作理论辨治临床诸多疑难杂症,如瘙痒、汗证、臌胀、皮疹、肝癌,收效甚佳。     

现代眩晕医案中情志症名的文献分析

目的:检索1949～2010年中国出版的有关眩晕的医案文献,分析规范化后情志失常的研究,为临床病例信息调查表的制作提供可靠的依据。方法:以中国学术期刊网络出版社总库为主要来源,共检索到1 296篇符合描述眩晕症状的医案文献。运用Note Express软件和Excel 2003从医案中截取症状归类排序和频数统计,并运用统一标准的症状术语进行规范化,统计规范化后的有关情志失常的症状。结果:眩晕医案中烦躁、善怒、心烦、健忘、善悲、善忧思等18种症状共累计出现143篇,占医案总篇数13.06%,为眩晕病案中情志失常的症状进行初步症名的规范化,满足科研与临床的实际需要。结论:规范眩晕病案中情志症状名称,有助于提高诊治眩晕的可操作性和辨证论治水平。     

Intrauterine fetal death associated with Rothia dentocariosa: a case report

We report a case of intrauterine fetal death at term with a possible association to an oral bacterium, Rothia dentocariosa. A healthy primiparous woman was admitted at term with an intrauterine fetal death after an uncomplicated pregnancy. R. dentocariosa was found in the fetal blood culture.     

A prospective observational study of the safety and acceptability of vaginal hysterectomy performed in a 24-hour day case surgery setting

OBJECTIVE: To assess the safety and acceptability of vaginal hysterectomy with and without simultaneous oophorectomy in a 24-hour day case surgery setting for women with nonprolapse indications for surgery. DESIGN: Prospective observational study. SETTING: A busy teaching hospital and tertiary referral centre for Obstetrics and Gynaecology. POPULATION: Seventy-one women from one consultant's practice underwent a vaginal hysterectomy with a planned discharge within 24 hours after the procedure. All women had a body mass index less than 40 and a suitable home environment for routine day case surgery, other than that the women were from an unselected population. METHOD: Prospective observational study. MAIN OUTCOME MEASURES: The duration of the operation and mean blood loss were recorded. Any intraoperative complications were noted. In addition, the proportion of women discharged home within 24 hours of the operation was recorded together with any readmissions to hospital. Returns to theatres and any postoperative complications were also recorded. Postoperative pain scores were assessed 6 and 24 hours after procedure in selected women. RESULTS: Seventy-one vaginal hysterectomies were performed as 24-hour day case procedures. The intraoperative complication rate was 1.4%. Sixty-five women were discharged home within 24 hours (91.5%). The readmission rate within this group was 6.2%. The duration of the procedure, mean blood loss, return to theatre rate and incidence of febrile illness were comparable with rates recorded in inpatient studies. CONCLUSIONS: Vaginal hysterectomy performed as a 24-hour day case procedure appears to be as safe as traditional inpatient management, with a high rate of early discharge and a low rate of readmission. This may have additional advantages for the woman and healthcare provider alike.     

Burden of severe illness associated with laboratory confirmed influenza in adults aged 50–64 years: A rapid review

BackgroundWhile the high burden of illness caused by seasonal influenza in children and the elderly is well recognize, less is known about the burden in adults 50–64 years of age. The lack of data for this age group is a key challenge in evaluating the cost‐effectiveness of immunization programs. We aimed to assess influenza‐associated hospitalization and mortality rates and case fatality rates for hospitalized cases among adults aged 50–64 years.MethodsThis rapid review was conducted according to the PRISMA; we searched MEDLINE, EMBASE, Cochrane, Web of Science, and grey literature for articles and reports published since 2010. Studies reporting rates of hospitalization and/or mortality associated with laboratory‐confirmed influenza among adults 50–64 or 45–64 years of age for the 2010–11 through 2019–20 seasons were included.ResultsTwenty studies from 13 countries were reviewed. Reported rates of hospitalization associated with laboratory‐confirmed influenza were 5.7 to 112.8 per 100,000. Rates tended to be higher in the 2015–2019 compared with the 2010–2014 seasons and were higher in studies reporting data from high‐income versus low and middle‐income countries. Mortality rates were reported in only one study, with rates ranging from 0.8 to 3.5 per 100,000 in four different seasons. The case fatality rate among those hospitalized with influenza, as reported by population‐based studies, ranged from 1.3% to 5.6%.ConclusionsSeasonal influenza imposes a significant burden of morbidity on adults 50–64 years of age but with high heterogeneity across seasons and geographic regions. Ongoing surveillance is required to improve estimates of burden to better inform influenza vaccination and other public health policies.     

170例肝移植病例医疗质量费用分析

目的:分析肝移植病例住院费用构成并评价其医疗质量.方法:收集手术操作代码为50.5001的病案170份,采用<病例分型质量费用管理系统>软件和SAS6.1 2,进行描述性统计分析.结果与讨论:肝移植治疗水平不断提高,但费用十分昂贵,必须采取各种有效措施,降低患者负担.