bluuebunny/crossref_metadata_2025 huggingface dataset:
Pembrolizumab for metastatic adrenocortical carcinoma with high mutational burden
Authors: Mota Jose Mauricio , Sousa Luana Guimarães , Braghiroli Maria Ignez , Siqueira Luiz Tenório , Neto João Evangelista Bezerra , Chapchap Paulo , Hoff Ana A. de Oliveira , Hoff Paulo M.
Published: December 2018

Rationale:

In the setting of metastatic or locally advanced adrenocortical carcinoma, a limited number of therapies are available and their efficacy is generally below modest. The backbone of treatment remains surgery, even for metastatic disease, whenever it is possible, and mitotane. Chemotherapy can be used with limited results. A small subset of patients with adrenocortical carcinoma may have high mutational burden and harbor mutations in mismatch-repair genes.

Patient concerns:

We report a 40-year old and a 28-year-old female patients with metastatic adrenocortical carcinoma refractory to multiple treatments.

Diagnosis:

Next-generation sequencing detected high mutational burden (>10 mutations/megabase) in both patients, one of them with MSH2 mutation.

Interventions:

They were treated with pembrolizumab (100 to 200 mg every 3 weeks).

Outcomes:

The patient harboring a MSH2 mutation experienced a long-term complete response after pembrolizumab, while the patient with high mutational burden and absence of mismatch repair deficiency did not have any response.

Lessons:

To the best of our knowledge, this is the first report in the literature of a durable complete response after pembrolizumab in a patient with metastatic adrenocortical carcinoma. Differences in therapy sequencing, possibly abscopal effect related to multiple previous radiotherapy exposition, predictive values of high mutational burden and mutations in mismatch-repair genes are discussed.
Staged reconstructive treatment for extensive irregular cicatricial alopecia after burn
Authors: Tang Songjia , Wu Xiaoxin , Sun Zhongxin , Cheng Hanxiao , Shen Haiyan , Tang Liang , Zhou Jinghe , Jia Ming , Li Jinsheng , Zhang Jufang
Published: December 2018

For extensive irregular cicatricial alopecia after burn, effective and pleasing restoration of hair-bearing scalp remains challenging. In this article, the authors presented staged reconstructive treatment for extensive irregular cicatricial alopecia with the goal to achieve better and reliable results. A retrospective review of staged reconstructive treatment performed in 16 patients with extensive irregular cicatricial alopecia after burn was conducted. In stage 1, final flaps were designed at 1st. Tissue expanders were placed into the subgaleal plane and serially inflated with normal saline. In stage 2, scarring tissues were excised and the expanded hair-bearing flaps were advanced to the defect. Hair grafts were harvested from excessive hair-bearing scalps excised from the flaps and replanted. For patients with less satisfactory results, stage 3 was performed by hair transplantation. Cicatricial area, follicular unit density, survival rate of hair grafts, and patients’ satisfaction were measured before and after each stage. Thirteen patients received 3-stage treatment, and 3 received 2-stage treatment. Significant improvements in aesthetics and patient satisfaction were achieved in all the patients. No flap necrosis, implant exposure or hematoma was observed. Ideal, aesthetic, and reliable results could be obtained using staged reconstructive treatment for patients with extensive irregular cicatricial alopecia after burn.
Modified translaryngeal tracheostomy for ventilator-dependent cardiac patients
Authors: Babaee Touraj , Tabaei Ali Sadeghpour , Moludi Jalal , Alavi Seyyed Mostafa , Tabaei Sepehr Sadeghpour
Published: December 2018

Introduction:

A significant proportion of ventilator-dependent cardiac patients need tracheostomy during intensive care unit (ICU) stay. Three different methods including traditional (surgical), percutaneous dilatation tracheostomy, translaryngeal tracheostomy (TLT), and classical Fantoni method have been developed. In this study, modified translaryngeal tracheostomy (MTLT) has been introduced to reduce and correct the technical difficulty of classical TLT through the larynx.

Materials and methods:

The patients hospitalized because of cardiac diseases whose stay in ICU and coronary care unit lasted longer than 3 weeks, and were consulted and advised for elective tracheostomy. Afterwards, MTLT was performed for all patients (the new method).

Results:

From the 159 patients, 64.2% were women. The mean age was 65.25 ± 14.35 years. There was no considerable hemorrhage (bleeding >5–10 mL). The mean values of arterial oxygen pressure, oxygen saturation, heart rate, systolic blood pressure, and a peak airway pressure before and after MTLT had a significant improvement (P < .05), which reflects a better hemodynamic state after tracheostomy. All of the tracheostomies (MTLT) were successful and without any complications. There was no considerable bleeding despite the high international normalized ratio levels.

Conclusions:

Unlike the classical Fantoni method, this study indicates that using a new improved method of tracheostomy through larynx did not impose any difficulty on retrograde passage of guide wire and this procedure could be safely conducted on patients with coagulation disorders.
Correlation analysis between SNPs in microRNA-machinery genes and tuberculosis susceptibility in the Chinese Uygur population
Authors: Cheng Hong , Li Haixia , Feng Yangchun , Zhang Zhaoxia
Published: December 2018

Tuberculosis (TB) is an infectious disease caused by a mycobacterial infection, with high morbidity and mortality worldwide. The pathogenesis of TB is still unclear; however, a growing body of evidence suggests that host genetic factors may play important roles in susceptibility to TB, and different gene polymorphisms in different ethnic and genetic backgrounds may lead to different effects. In view of the above theories, our research group used bioinformatics to screen for 12 single nucleotide polymorphisms (SNPs), including rs1045481, rs1045491, rs2740349, rs10719, rs642321, rs3744741, rs7813, rs3742330, rs3757, rs14035, rs720012, and rs4961280, which are derived from 6 main genes (i.e., GEMIN4, DICER1, DROSHA, DGCR8, AGO2, and RAN) acting in the microRNA-machinery pathway. We then analyzed the correlations between TB patients of Uygur in Xinjiang China and the above SNPs using a case–control study. The results showed that the genotypic distributions of rs720012 (from gene DGCR8) and rs4961280 (from gene AGO2) were not in accordance with the Hardy–Weinberg equilibrium (P < .05), so they were deleted. Subjects carrying the rs3742330 AG/GG genotype, rs1045481 GA genotype, rs1045491 CT genotype, and rs7813 AG genotype, respectively, had an increased risk of TB than individuals carrying rs3742330 AA genotype, rs1045481 GG/AA genotype, rs1045491 CC/TT genotype, and rs7813 AA/GG genotype between different groups. Expression quantitative trait loci analysis found that rs3744741 and rs2740349 from gene GEMIN4 had a regulatory effect, while rs3742330 from gene DICER1 had a reverse regulatory effect. Finally, according to the results of Linkage Disequilibrium between SNPs, the haplotype analysis showed that the haplotype of GCTAC from gene GEMIN4 had statistical differences when compared with active and inactive TB. The current experimental results provide a direction for our future research, and the research team will conduct more in-depth studies on the correlation between miRNA and TB.
Ischemia reperfusion injury in kidney transplantation
Authors: Philipponnet Carole , Aniort Julien , Garrouste Cyril , Kemeny Jean-Louis , Heng Anne-Elisabeth
Published: December 2018

Rationale:

Kidney transplantation is considered the best treatment for patients with end stage renal disease. Ischemia- reperfusion injury (IRI) is an evitable event after deceased donor transplantation and influences short term and long term graft outcome. Few data on IRI's histology in the setting of kidney transplantation are available in the literature despite its frequency and its severity.

Patient concerns:

A 64-year-old patient was admitted for his 1st kidney transplantation. There were no pre-existing immunization. The surgery proceeded without complications; with cold ischemia estimated at 37 h 50 min and warm ischemia at 44 min. The immunosuppression protocol was as follows: induction by thymoglobulins, mycophelonate mofetil, corticosteroids. Few hours after transplantation, the patient remained anuric and the biological assessment highlighted in addition to renal failure, hyperlactatemia at 5 mmol/L and a high increase in lactate deshydrogenase (LDH) at 5239 U/L. An abdominopelvic angio-scanner was performed urgently to eliminate the hypothesis of thrombosis of the artery or vein of the graft. A kidney biopsy was performed the day after the transplant and revealed massive lesions of acute tubular necrosis including apoptosis, autophagy-associated cell death, and necrosis. Microvascular dysfunction with increased vascular permeability and endothelial cell inflammation were also present. Activation of coagulation is represented by thrombi in the lumens of the glomerular capillaries.

Diagnosis:

The diagnosis was ischemia reperfusion injury responsible for delayed graft function (DGF).

Interventions:

Immunosuppressive regimen was delayed use of calcineurin inhibitors, mycophenolate mofetil, and corticosteroids.

Outcomes:

At 1 year post transplant, the patient has a renal autonomy with a graft function stable and physiological proteinuria.

Lessons:

The main clinical consequences of IRI in kidney transplant are DGF, acute and chronic graft rejection, and chronic graft dysfunction. Reducing IRI is one of the most relevant challenge in kidney transplantation.
Etiologic impact on difference on clinical outcomes of patients with heart failure after cardiac resynchronization therapy
Authors: Chen Jian-Shu , Niu Xiao-Wei , Chen Fen-mei , Yao Ya-Li
Published: December 2018

Objective:

To compare long-term clinical outcomes between patients with heart failure due to non-ischemic cardiomyopathy (NICM) and those due to ischemic cardiomyopathy (ICM) after cardiac resynchronization therapy (CRT).

Methods and Results:

EMbase, PubMed, and Cochrane Library were searched for published studies up to December 2017. Twenty-one observational studies with 12,331 patients were enrolled in the present meta-analysis. The results demonstrated that the all-cause mortality in NICM patients was significantly lower than that in ICM patients (RR 1.37, 95% CI 1.16–1.61). In terms of echocardiographic parameters, NICM patients exhibited statistically significant improvement in left ventricular ejection fraction (LVEF) (MD 2.70, 95%CI -4.13 to -1.28), and a significant decrement in left ventricular end-systolic volume (LVESV) (MD 10.41,95% CI 2.10–18.73) and left ventricular end diastolic diameter (LVEDD) (MD 7.63, 95% CI 2.59–12.68) as compared with ICM patients. No significant difference was observed in the improvement of New York Heart Association Functional Classification (MD 0.05, 95% CI -0.05 to 0.15), pulmonary arterial systolic pressure (PASP) (MD -0.61, 95% CI -4.36 to 3.14), and severity of mitral regurgitation (MD 0.00, 95% CI -0.08 to 0.07) between the 2 groups.

Conclusions:

Our meta-analysis illustrated that patients with HF due to NICM tended to have better clinical outcomes and LV reverse remodeling as compared with those due to ICM. This finding may help clinicians select patients who respond favorably to CRT, though further research is required to clarify the potential confounding factors and underlying mechanisms for this phenomenon.
Risk factors for child maltreatment by the utilization of medical service and socioeconomic environment in Taiwan
Authors: Hsin Yi-Chen , Chang Yu-Ching , Lee En-Pei , Chiu Cheng-Hsun , Chou I.-.Jun , Hsia Shao-Hsuan , Lin Kuang-Lin , Lee Jung , Huang Jing-Long , Wang Chao-Jan , Wu Han-Ping
Published: December 2018

Child maltreatment is complicated by cultural, welfare, and socioeconomic factors. However, the relationship between child maltreatment and socioeconomic factors has not been completely understood. We investigated risk factors for child abuse and neglect in Taiwan.

The data in our study was obtained from Taiwan National Statistics at county level from 2004 to 2015. We included 4 areas (eastern, western, southern, northern) involving 20 cities and counties. The trends of child maltreatment rate based on different years and different areas were surveyed. In addition, panel data analysis was used to analyze the links between child maltreatment rate and socioeconomic factors.

An increasing trend of child maltreatment rate in Taiwan was observed. During the past decade, child maltreatment rate increased from 14.5 in 2004 to 23.4 cases per 10000 children in 2014. The peak, which was 43 cases per 10000 children, occurred in 2012. Significant geographical differences were observed, and the highest child maltreatment rate was seen in eastern Taiwan. Panel data analysis revealed a lag effect of the unemployment rate on child maltreatment rate at the county level: the child maltreatment rate increased by 7 percent, while the prior unemployment rate increased by one percent. In addition, the medical personnel density was related to the child maltreatment rate within the county.

Previous unemployment rate had a lag impact on child maltreatment occurrence. Unemployment rate has not only a direct impact on the economy but also sequential effects on child maltreatment.
Thrombocytopenic purpura following envenomation by the nose-horned viper (Vipera ammodytes ammodytes)
Authors: Lukšić Boris , Karabuva Svjetlana , Markić Joško , Polić Branka , Kovačević Tanja , Meštrović Julije , Križaj Igor
Published: December 2018

Rationale:

Two clinical cases are reported of envenomation by the nose-horned viper (Vipera ammodytes ammodytes) venom of a 9-year-old boy and of an 84-year-old woman.

Patient concerns:

Both patients had been bitten on their extremities by such a snake in August near Split, a town in southern Croatia.

Diagnoses:

Clinical manifestation of envenomation was severe in the case of the boy, being characterized by a severe coagulopathy. This was only just apparent in the case of the elderly woman, who suffered extensive local edema and hematoma at the site of the bite, together with a neurotoxic effect—bilateral ptosis. This was the first occasion of thrombocytopenic purpura being observed in patients envenomed by nose-horned viper venom. This unexpected clinical finding was characterized by an unusually profound thrombocytopenia of 5 and 10 × 109/L platelets of the respective patients on their admission to the hospital, together with purpura, observed on the face and thorax of both individuals. In the most serious cases, such pathology can be life threatening if not promptly recognized and treated.

Interventions:

The patients recovered quickly on receiving the specific antivenom along with all the usual supportive treatments.

Outcomes:

No serious sequels were noticed at the moment of discharge.

Lessons:

Our finding constitutes an important message to clinicians to consider the possibility of such complications in the case of nose-horned viper envenomation.
The efficacy and safety of thrombolytic agents for patients with cerebral infarction
Authors: Huang Shenghui , Jiang Junshi , Xu Zhiming , Lu Cuncun , Cao Fang , Sang Wengxia , Gong Ting , Li Yanyi
Published: December 2018

Background:

Cerebral infarction is a commonly dangerous disease also with high morbidity and mortality. Thrombolytic agent is an effective method to treat it, but their relative efficacy and safety are unclear. A network meta-analysis (NMA) will be conducted to resolve this urgent problem.

Methods:

The PubMed, Embase, and Cochrane library will be systematically search from their inception to November 2018. All randomized controlled trials (RCTs) will be included this NMA and their risk of bias will be assessed using Cochrane handbook tool. The outcomes of efficacy and safety including: Modified Rankin Scale scores, reperfusion rate, incidence of symptomatic intracerebral hemorrhage and all-cause mortality. A network meta-analysis will be performed using R x64 3.5.1 software and pairwise meta-analysis will be conducted using Stata 12.0 software (Stata Corp., College Station, Texas). Grading of Recommendations Assessment, Development and Evaluation (GRADE) will be used to assess quality of outcomes.

Results:

The results of NMA will be published in a peer-reviewed journal.

Conclusion:

The NMA will provide a comprehensive evidence summary on thrombolytic agents for patients with cerebral infarction.
Phyllodes tumor of the breast with nipple discharge
Authors: Jing Pengfei , Wei Bing , Yang Xiaoqin
Published: December 2018

Rationale:

Phyllodes tumors (PTs) of the breast are rare biphasic fibroepithelial neoplasms which usually present with unilateral palpable breast lumps. Here we reported a case of borderline PTs with multifocal intraductal lesions whose primary clinical manifestation was nipple discharge.

Patient concerns:

A rare case of PT with nipple discharge in a 26-year-old young lady accepted a wide local excision on her left breast, and the pathological examination turned out to be a malignant phyllodes tumor. After a 12-month follow-up, no local or distant recurrence was observed.

Diagnosis:

Borderline PTs with multifocal intraductal lesions

Interventions:

The patient received wide local excision with clear margin. After the operation, the patient is undergoing surveillance through ultrasonography and physical examination every 3 months.

Outcomes:

After a follow-up of 12 months, no local or distant recurrence was observed.

Lessons:

The lesions of the PTs are often manifested with unilateral, palpable masses in the breast. There are very few case reports of PTs manifested with nipple discharge in the literature. We should improve the understanding of the multiple clinical manifestations of PTs.
Practice styles, knowledge and attitudes of general practitioners and gastroenterology specialists who treat gastroesophageal reflux disease
Authors: Carter Dan , Dickman Ram
Published: December 2018

As little is known on the subject, our aim was to compare practice styles, knowledge and attitudes of general practitioners (GPs), and gastroenterology specialists (GIs) regarding the treatment of gastroesophageal reflux disease (GERD).

An internet survey designed by the authors was sent nationwide and randomly to 290 GIs and 1312 GPs. We assessed for the burden of GERD, indications for referral for a GI consultation, criteria for proton pump inhibitors (PPIs) selection, and main unmet treatment needs.

Forty (14%) GIs and 132 (10%) GPs returned the questionnaire. Both groups treat 13 to 14 GERD patients weekly (mean age 41–50 years). The most common first and second line drug of choice in both groups was omeprazole and esomeprazole, respectively. GIs stated that the most important consideration for the selection of treatment was high safety profile, whereas GPs considered it to be a rapid symptomatic relief. In the case of first and second line PPI failures, GIs tended to prescribe a non PPI treatment, whereas GPs restarted esomeprazole. GIs stated that the most prevalent conceived limitations of PPI treatment were nighttime heartburn and undesirable side effects, whereas GPs considered treatment inflexibility and drug interactions.

GIs and GPs hold different practice styles, knowledge, and attitudes on the treatment of GERD. Our findings ascertain the need for the development of updated National Clinical Guidelines focusing on GERD.
Randomized study of the impact of a therapeutic education program on patients suffering from chronic low-back pain who are treated with transcutaneous electrical nerve stimulation
Authors: Garaud Thomas , Gervais Christine , Szekely Barbara , Michel-Cherqui Mireille , Dreyfus Jean-François , Fischler Marc
Published: December 2018

Background:

Transcutaneous electrical nerve stimulation (TENS) is often used for the treatment of low-back pain (LBP). However, its effectiveness is controversial.

Objective:

To determine the efficacy of TENS in the treatment LBP when associated to a therapeutic education program (TEP).

Design:

Open randomized monocentric study.

Setting:

University hospital between 2010 and 2014.

Patients:

A total of 97 patients suffering from LBP.

Interventions:

Routine care (TENS group) or routine care plus a therapeutic education program (TENS-TEP group) based on consultation support by a pain resource nurse.

Main outcome measures:

EIFEL and Dallas Pain Questionnaire scores.

Results:

Twenty-two patients (44%) were still assessable at the end-of-study visit, whereas 33 (70%) were assessable at the same time point in the TENS-TEP group (P = .013). The EIFEL score and the Dallas score had a similar evolution over time between groups (P = .18 and P = .50 respectively). Similarly, there were no significant differences between the groups with respect to resting pain scores (P = .94 for back pain and P = .16 for leg pain) and movement pain scores (P = .52 for back pain and P = .56 for leg pain). At Month 6, there was no significant difference between the groups (P = .85) with regard to analgesics and social impact. Two patients presented a serious adverse event during the study (one in each group) but non-attributable to the treatment studied.

Conclusion:

This study does not support the use of TENS in the treatment of patients with chronic LBP even though patients benefited from a therapeutic education program by a pain resource nurse. However, the higher number of premature withdrawals in the TENS group may be due to early withdrawal of patients who did not experience improvement of their symptoms.
Sudden seizure during cesarean section
Authors: Zhou Wenqin , Zhu Qing
Published: December 2018

Rationale:

A first seizure can range from a fleeting subjective experience or a twitch (myoclonic jerk) through to a tonic-clonic convulsion. A first seizure occurred in a parturient during cesarean section is very rare. We describe the case of a parturient who suffered seizure when the fetus was delivered.

Patient concerns:

Our patient is a 31-year-old parturient with a first seizure during cesarean section.

Diagnoses:

Seizure.

Interventions:

The patient received supportive therapy to maintain oxygen supply and propofol was administered to terminate seizure during cesarean section.

Outcomes:

after therapy, the patient regained full consciousness and normal spontaneous respiration. She had no recall of the seizure attack. The post-operative recovery was uneventful.

Lessons:

Symptoms during seizure are very important to diagnose. It will be both harmful to mother and the fetus, when the pregnant woman suffers seizure during pregnancy or cesarean delivery. In this situation, supportive therapy need to be immediately initiate and propofol may be the most suitable drug to terminate seizure during cesarean delivery.
Metallothioneins may be a potential prognostic biomarker for tumors
Authors: Wang Lei , Xin Fuli , Lin Nanping , Wang Yingchao , Liu Xiaolong , Liu Jingfeng
Published: December 2018

Background:

Metallothioneins (MTs) were reported to be associated with many kinds of tumors’ prognosis, although MTs expression varied greatly among tumors. To assess the prognostic value of Metallothioneins (MTs) in different kinds of tumors, comprehensive literature search was conducted to perform a meta-analysis.

Methods:

Eligible studies were identified by PubMed, MEDLINE, Web of Science (WOS), the Cochrane Library of Systematic Reviews, EMBASE, China National Knowledge Infrastructure (CNKI), WANFANG database and SinoMed database up to December 2017, which was designed to assess the prognostic value of MTs in different kinds of tumors. The main endpoint events were overall survival (OS) and disease-free survival (DFS). Hazard ratios (HRs) and its variance were retrieved from the original studies directly or calculated using Engauge Digitizer version 4.1. Random or fixed effects model meta-analysis was employed depending on the heterogeneity. Publication bias was evaluated by funnel plots, Begg and Egger tests.

Results:

A total of 22 studies were enrolled in this meta-analysis, including 2843 tumor tissues (1517 were MTs negative/low, and 1326 were MTs high). Results showed that there was significant association between MTs expression and tumors’ OS (HR = 1.60; 95%CI 1.34∼1.92,P < .00001). Subgroup analysis showed that high level of MTs expression was associated with prolonged OS in liver cancer (HR = 0.65, 95%CI 0.48∼0.89,P = .007), but it was on the contrary in the tumor of ovary (HR = 1.47, 95%CI 1.01∼2.14,P = .04), bladder (HR = 1.71, 95%CI 1.21∼2.42,P = .002), intestine (HR = 3.13, 95%CI 1.97∼4.97,P < .00001), kidney (HR = 3.31, 95%CI 1.61∼6.79,P = .001). However, there was no significant association between MTs expression and OS in breast (HR = 1.02, 95%CI 0.69∼1.51,P = .93).

Conclusions:

MTs could be taken as a potential prognostic biomarker for tumors, and uniqueness of MTs prognostic value in liver cancer deserved further study.
Lactulose for the treatment of Chinese children with chronic constipation
Authors: Cao Yuan , Liu Shi-ming
Published: December 2018

Background:

This study aimed to investigate the efficacy and safety of lactulose for the treatment of Chinese children with chronic constipation.

Methods:

A total of 100 children with chronic constipation were included in this randomized controlled trial. They were equally and randomly allocated to a treatment group (n = 50) and a placebo group (n = 50). The participants in the treatment group received lactulose, while the subjects in the placebo group received placebo intervention. The children in both groups were treated for a total of 6 weeks. The primary outcome was daily stool frequency. The secondary outcomes consisted of stool consistency, measured by the Bristol Stool Form Scale, abdominal pain, flatulence, as well as the adverse events. All outcomes were measured at baseline and after 6-weeks treatment.

Results:

After 6 weeks treatment, lactulose showed better outcomes in daily stool frequency (P < .01), and stool consistency (P < .01), except the abdominal pain (P = .24), and flatulence (P = .44), compared with the placebo. Additionally, no significant differences regarding all adverse events were detected between 2 groups.

Conclusion:

The results of this study found that lactulose is efficacious for Chinese children with chronic constipation after 6-weeks of treatment.
Syncope as the initial presentation of pulmonary embolism in a young adult with testicular tumor
Authors: Song Zikai , Lv Shijie , Qin Ling , Cao Hongyan , Wu Haidi , Deng Dayong
Published: December 2018

Rationale:

Venous thrombus embolism (VTE) includes deep-vein thrombosis (DVT) and pulmonary embolism (PE) which may be an initial symptom for patients with cancer. PE has diverse clinical manifestations and is a rare complication of testicular tumor (TT).

Patient concerns:

Here, we report a 21-year-old man admitted to our hospital due to syncope.

Diagnoses:

Clinical examinations upon admission demonstrated PE resulting in syncope. Further, a malignant TT, liver metastasis, and inferior vena cava (IVC) thrombosis were diagnosed.

Interventions:

Low molecular heparin was administered immediately after PE was diagnosed.

Outcomes:

The patient suffered from cardiac arrest on hospitalization.

Lessons:

Physicians should consider the possibility of TT when a young male patient presents with syncope and is diagnosed with PE that cannot be explained by a common cause. Treatment for TT and PE should be performed as early as possible to improve the prognosis of patients combine with TT and PE.
Acute renal failure in a patient with PR3-ANCA and monoclonal immunoglobulin deposition disease
Authors: Cassol Clarissa A. , Rao Pawan K. , Braga Juarez R.
Published: December 2018

Rationale:

Acute renal failure developing over a short period of time with evidence of glomerular disease by urine sediment microscopy characterizes the clinical syndrome of rapidly progressive glomerulonephritis (RPGN), of which the most common causes are ANCA-associated glomerulonephritis (GN), immune-complex mediated GN and anti-GBM disease.

Patient concerns:

This was a middle-aged gentleman who presented with acute renal failure and a positive PR3-ANCA.

Diagnosis:

Renal biopsy showed an unusual combination of PR3-ANCA GN with focal crescents, monoclonal immunoglobulin deposition disease (MIDD) and mesangial IgA deposition on renal biopsy.

Interventions:

Serum and urine protein electrophoresis (UPEP) and immunofixation showed no detectable monoclonal paraprotein; bone marrow biopsy was negative for plasma cell neoplasia. He received high dose steroids and rituximab.

Outcomes:

The patient did not respond to treatment and progressed to end-stage renal failure within 2 months after presentation.

Lessons:

To our knowledge, the simultaneous occurrence of MIDD, PR3-ANCA and mesangial IgA has not been reported. This case highlights not only the diagnostic but also the therapeutic challenges that such a complex case presentation poses to clinicians, where the culprit may not always be what would seem most obvious (such as ANCA in a patient with RPGN) but may, in fact, be an underlying and unsuspected disease, or possibly a combination of both.
Cisplatin-induced cardiotoxicity with midrange ejection fraction
Authors: Hu Yang , Sun Bin , Zhao Bin , Mei Dan , Gu Qing , Tian Zhuang
Published: December 2018

Rationale:

Cisplatin monotherapy-induced cardiotoxicity is rare, and the prevalence remains unknown. It's extremely important to stop cisplatin when cardiotoxicity is considered.

Patient concerns:

A 53-year-old woman developed cervical cancer. She was administered cisplatin (37 mg/m2/wk) for 3 weeks, but the left ventricular ejection fraction (LVEF) declined from 70% to 48%.

Diagnosis:

Electrocardiogram showed first-degree atrioventricular block and ST-segment depression by 0.05 mv on leads II, III, and V3–5. Neither cardiac markers nor N-terminal pro-B-type natriuretic peptide (NT-pro BNP) was elevated. After a careful physical examination and laboratory investigation, we confirmed that cervical cancer did not progress and no other cause was evident. So we figured cardiotoxicity might be induced by cisplatin.

Interventions:

Cisplatin was stopped and cardioprotective therapies were given to the patient.

Outcomes:

After discontinuing cisplatin and adding cardioprotective therapies, the LVEF increased to 50% and 53%, respectively (M-mode echocardiography) after 17 and 90 days, which further confirmed our diagnosis.

Lessons:

According to this case and literature review, cisplatin-induced cardiotoxicity should be considered for the patient. When necessary, we should discontinue the suspected drug to confirm diagnosis. Cardioprotective therapies would minimize the drug-induced cardiovascular adverse events and improve patients’ outcome.
Effect of transcutaneous electrical acupoint stimulation on the EC50 of remifentanil suppressing responses to tracheal extubation in elderly patients
Authors: Yin Chun-Ping , Li Ya-Nan , Zhao Juan , Zhang Qi , Guo Yang-Yang , Gao Fang , Wang Xiu-Li , Wang Qiu-Jun
Published: December 2018

Transcutaneous electrical acupoint stimulation (TEAS) is a emerging treatment which combines transcutaneous electrical nerve stimulation with traditional acupoint therapy. The present study was aimed to evaluate the effect of TEAS on the effective concentration (EC50) of remifentanil suppressing tracheal extubation response in elderly patients.

Fifty-three patients undergoing spine surgery were randomly divided into 2 groups: control group (group C, n = 26) and transcutaneous electrical acupoint stimulation group (group TEAS, n = 27). The EC50 values for remifentanil TCI were determined using sequential method and probit analysis.

The remifentanil EC50 of that suppressed responses to extubation during anesthetic emergence was 1.20 ng/mL in group TEAS, a value that was significantly lower than the 1.64 ng/mL needed by patients in group C.

The TEAS can enhance the efficacy of remifentanil on suppressing responses to tracheal extubation in elderly patients, the EC50 of remifentanil can reduce approximately 27% compared with group C.
The impact of a heat wave on mortality in the emergency department
Authors: Oray Nese Colak , Oray Deniz , Aksay Ersin , Atilla Ridvan , Bayram Basak
Published: December 2018

Extreme heat wave increases the number of emergency department (ED) admissions and mortality rates. The purpose of our study is to investigate the effects of the heat wave experienced in Izmir province of Turkey on mortality.

During a 9-day period between 17th and 25th June 2016 (study period), air temperature values were higher than the seasonal norms in Izmir, Turkey. In this cross-sectional study, nontraumatic admissions and in-hospital mortality rates were compared this historical interval of the extreme heat wave with the same period of the previous year and the other 21 days of June 2016.

The average air temperature between 17th and 25th June 2016, was higher than the average air temperature of the previous year's same period and the average air temperature from the other 21 days of June 2016 (27.8 ± 3.6 °C, (24.5 ± 1.9°C, 24.1 ± 2.1°C, respectively) (P <.01)

During the study period, the mean number of ED visits and mortality rates were significantly higher than the previous year's same period (320 ± 30/day vs 269 ± 27/day, [P <.01], and 1.6% vs 0.7%, [P <.01]).

Although the admission rate was similar between the study period and the other 21 days of June 2016 (320 ± 30/day vs 310 ± 32/ day, [P = .445]); in-hospital mortality rate was significantly higher during study period (1.6% vs 0.7%, [P <.01]).

During the extreme heat waves, ED admissions and in-hospital mortality rates are increased. Precautions should be addressed for adaptation of people to extreme hot weather.
Is aquatic exercise more effective than land-based exercise for knee osteoarthritis?
Authors: Dong Rui , Wu Yunyao , Xu Shibing , Zhang Lei , Ying Jun , Jin Hongting , Wang Pinger , Xiao Luwei , Tong Peijian
Published: December 2018

Background:

This study aimed to systemically review the effectiveness of aquatic exercise (AQE) compared to land-based exercise (LBE) in treating knee osteoarthritis (OA).

Methods:

The Medline, Embase, Web of Science, Cochrane Central Register of Controlled Clinical Trials, CINAHL, and psyclNFO databases were comprehensively searched for randomized controlled trials (RCTs) evaluating the effectiveness of AQE and LBE for knee OA from their inception date to September 24, 2018. The risk of bias was examined using the Cochrane Collaboration Tool, and Review Manager 5.3 was used for data collation and analysis.

Results:

Eight RCTs were included, involving a total of 579 patients. The meta-analysis showed that there was no significant difference between AQE and LBE for pain relief, physical function, and improvement in the quality of life, for both short- and long-term interventions, in patients with knee OA. However, the adherence and satisfaction level for AQE was higher than for LBE. Compared to no intervention, AQE showed a mild effect for elevating activities of daily living (standardized mean difference [SMD]: −0.55, 95% confidence interval [CI] [−0.94, −0.16], P = .005) and a high effect for improving sports and recreational activities (SMD: −1.03, 95% CI [−1.82, −0.25], P = .01).

Conclusion:

AQE is comparable to LBE for treating knee OA.
Cardiovascular risk of sitagliptin in ischemic stroke patients with type 2 diabetes and chronic kidney disease
Authors: Liang Chung-Yu , Chen Dong-Yi , Mao Chun-Tai , Hsieh I-Chang , Hung Ming-Jui , Wang Chao-Hung , Wen Ming-Shien , Cherng Wen-Jin , Chen Tien-Hsing
Published: December 2018

Limited data are available about the cardiovascular (CV) safety and efficacy of sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, in ischemic stroke patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). Ischemic stroke patients with T2DM and CKD were selected from the Taiwan National Health Insurance Research Database (NHIRD) from March 1, 2009 to December 31, 2011. A total of 1375 patients were divided into 2 age- and gender-matched groups: patients who received sitagliptin (n = 275; 20%) and those who did not (n = 1,100). Primary major adverse cardiac and cerebrovascular events (MACCE), including ischemic stroke, hemorrhagic stroke, myocardial infarction (MI), or CV death, were evaluated. During a mean 1.07-year follow-up period, 45 patients (16.4%) in the sitagliptin group and 165 patients (15.0%) in the comparison group developed MACCEs (Hazard ratio [HR] 1.05; 95% confidence interval [CI], 0.75–1.45). Compared to the non-sitagliptin group, the sitagliptin group had a similar risk of ischemic stroke (HR 0.82; 95% CI, 0.51–1.32.), hemorrhagic stroke (HR 1.50; 95% CI, 0.58–3.82), MI (HR 1.14; 95% CI, 0.49–2.65), and CV mortality (HR 1.06; 95% CI, 0.61–1.85). The use of sitagliptin in recent ischemic stroke patients with T2DM and CKD was not associated with increased or decreased risk of adverse CV events.
Isolated pancreatic tuberculosis with elevated CA 19-9 levels masquerading as a malignancy
Authors: Sun Pi-Jiang , Lin Yan , Cui Xi-Jun
Published: December 2018

Rationale:

Primary pancreatic tuberculosis is extremely rare, it presents with non-specific clinical symptoms and imaging features; it may be falsely identified as a malignancy of the pancreas.

Patient Concerns:

A 41-year-old male with no history of tuberculosis presented to our hospital with a 2-week history of jaundice.

Diagnoses:

Abdominal computed tomography (CT) showed a heterogeneous irregular hypodense mass in the head of the pancreas causing dilatation of the common bile duct (CBD), and it was enhanced after infusion of contrast material. Serum cancer antigen (CA) 19-9 was 124 U/mL (normal: 0–40 U/mL). He was preoperatively diagnosed as having a pancreatic carcinoma.

Interventions:

A Whipple procedure (pancreaticoduodenectomy) was performed. The pancreatic tuberculosis was confirmed based on the postoperative histopathologic specimens and acid-fast stain of the drainage. Then isoniazid, rifampicin, and ethambutol were given for 6 months.

Outcomes:

The patient recovered very well. There was no evidence of tuberculosis recurrence, and the patient remained free of symptoms during the follow-up examination 1 year after surgery.

Lessons:

Pancreatic tuberculosis should be considered when the mass is located on the head of the pancreas even with elevated serum CA19-9 levels.
A comprehensive comparison of fluorescence in situ hybridization and cytology for the detection of upper urinary tract urothelial carcinoma
Authors: Jin Hongyu , Lin Tianhai , Hao Jianqi , Qiu Shi , Xu Hang , Yu Ruichao , Sun Sheng , Zhang Peng , Liu Zhenhua , Yang Lu , Liu Liangren , Han Ping , Wei Qiang
Published: December 2018

Objective:

To compare the relative effectiveness of fluorescence in situ hybridization (FISH) and cytology in diagnosing upper urinary tract urothelial carcinoma (UUT-UC) and to evaluate the advantages and potential deficiencies of FISH analysis.

Methods:

We performed a complete systematic review based on studies from PubMed/Medline, Embase, Web of Science, Ovid, Web of Knowledge, and Cochrane Library. We identified 2031 patients with strict criteria in 14 individual studies between January 2005 to November 2017 in accordance to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, we summarized the test performance using bivariate random effects models.

Results:

FISH was superior to cytology in terms of pooled sensitivities (84.0%, 95% confidence interval [CI] 74.4–90.5% vs 40.0%, 95% CI 33.6–46.7%). FISH and cytology were similar to each other in terms of pooled specificities, which were 89.5% (95% CI 85.3–92.6%) for FISH and 95.9% (95% CI 91.2–98.1%) for cytology.

Conclusion:

We confirm the superiority of FISH over cytology in terms of sensitivity and find similar diagnostic outcomes between them based on systematic analysis. Therefore, we demonstrate that FISH is extremely sensitive while still very reliable with a relatively low error rate for diagnosing UUT-UC.
MELAS and macroangiopathy
Authors: Sun Xiangrong , Jiang Guohui , Ju Xinyue , Fu Hongmei
Published: December 2018

Rationale:

Mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS) are thought to be rarely accompanied by macroangiopathy. We reported a case of MELAS that presented right distal internal carotid arterial (ICA) stenosis and reviewed 12 similar previously reported cases involving intracranial large blood vessels.

Patient concerns:

A 38-year-old man suffered from recurrent stroke-like episodes (SE) such as alternating hemiparesis (right lesion 3 years ago and current left lesion), cortical blindness and seizure for 3 years, and was previously misdiagnosed as cerebral infarction. Magnetic Resonance Angiography (MRA) and Digital Subtraction Angiography (DSA) revealed right distal ICA stenosis and sparse cortex blood vessels, which were related to the previous SE.

Diagnoses:

He was diagnosed by genetic screening (a mitochondrial DNA A3243G point mutation) and presence of high lactic acidosis (4.03 mmol/L), which rose to 7.8 mmol/L after exercise.

Intervention:

The patient received Coenzyme Q10, vitamin C, L-arginine for 2 weeks and valproic acid sodium (400 mg bid) to prevent seizures till now.

Outcomes:

He is currently less active and intelligent than his peers, with occasional seizures, and needs family care.

Lessons:

Till date, there are 12 reported cases of MELAS combined with major cerebral arteries abnormalities including stenosis, dissection, occlusion, reversible vasoconstriction, aneurysms, and atherosclerosis. Hence, macroangiopathy in MELAS is not very rare. There is correlation between the affected vessels and the lesions in some cases, but not in others, which may increase the misdiagnosis rate. Hence, mitochondrial diseases cannot be excluded due to concurrent macroangiopathic lesions
Foreign body in the thoracic spine due to a nail gun penetrating injury
Authors: Chen Chi-Wei , Yang Shih-Chia , Liu Kuan-Ting , Wu Yen-Hung
Published: December 2018

Rationale:

Spinal cord injuries could be catastrophic because they may result in severe neurovascular complications. Here, we present a case of thoracic spine-penetrating injury by a nail-gun.

Patient concerns:

A 60-year-old male presented to our emergency department with complaints of progressive right chest pain for 1 week that was preceded by back pain. He had a medical history of hypertension and denied any trauma history. He had alert consciousness and stable vital signs. He was a carpenter. Upon physical and neurological examination, no obvious wounds or vesicle formation were noted, and the patient was neurologically intact.

Diagnosis:

Laboratory test results showed abnormally elevated D-dimer levels. Electrocardiography showed normal sinus rhythm. Chest radiography showed no mediastinal widening. Chest computed tomography was performed. The formal radiology report indicated a foreign body in the T4-5 spinal cord and upper back.

Interventions:

A neurosurgeon was consulted with suggestion of operation. We performed T4-5 laminectomy and foreign body removal. The foreign body, stuck to the spinal cord with dural rupture, was removed and found to be a 5 cm-long broken nail.

Outcomes:

The pain resolved immediately post operation.

Lessons:

Surgical removal of the foreign body is recommended if neurovascular complications or cerebrospinal fluid (CSF) leak is detected. Obtaining the patient's complete history, including occupation, might be helpful in determining the diagnosis. Careful interpretation of diagnostic imaging is necessary for avoiding medical disputes. Even in the absence of wounds and ecchymosis, trauma-related injury should be considered.
Acute onset of autoimmune hepatitis with sinusoidal and central vein endotheliitis, and marked involvement of activated dendritic cells
Authors: Yokomori Hiroaki , Obu Makoto , Uematsu Takayuki , Okada Takemichi , Yamazaki Hitoshi , Oda Masaya
Published: December 2018

Rationale:

Autoimmune hepatitis (AIH) is characterised by interface hepatitis. However, some acute cases exhibit atypical centrilobular necrosis with mild portal inflammation. Detailed histological and ultrastructural analyses of acute AIH are limited.

Patient concerns:

A 44-year-old female was admitted to our hospital with jaundice, general fatigue and liver dysfunction. Her transaminase levels were elevated, her immunoglobulin G level was 1735 mg/dL and her anti-nuclear titres were ×80.

Diagnosis:

AIH was diagnosed, and histochemical examination of a liver biopsy showed the presence of atypical histological features of prominent centrilobular necrosis and central vein and hepatic sinusoidal endotheliitis. Electron microscopy showed that dendritic cells (DCs) and lymphocytes were attached to disrupted liver sinusoidal endothelial cells (LSECs) in hepatic sinusoids and that DCs attached to LSECs via pseudopods in the central vein.

Interventions and outcomes:

The patient was started on 40 mg/day prednisolone to control the hepatic inflammation. Her aspartate and alanine aminotransferase levels started declining after prednisolone was initiated. Three weeks later, these levels had normalised. The dosage of prednisolone was gradually decreased as liver function improved. The patient remains under observation and continues to receive 2.5 mg prednisolone.

Lessons:

An important marker of acute AIH may be the presence of activated DCs in the hepatic sinusoids and central vein.
CT-quantified muscle and fat change in patients after surgery or endoscopic resection for early gastric cancer and its impact on long-term outcomes
Authors: Choi Moon Hyung , Kim Kyung Ah , Hwang Seong Su , Byun Jae Young
Published: December 2018

The purpose of this study was to evaluate the impact of the body composition changes on patients’ long-term outcomes after endoscopic resection or surgery for mucosal gastric cancer.

This case-control study included 96 patients who underwent endoscopic resection or surgery after propensity score matching. Areas of fat and muscle measured on CT were compared between the 2 groups. The effects of the variables on disease-free and overall survival were assessed using Cox-regression analysis and Kaplan-Meier survival analysis.

The median overall survival of the surgical and endoscopic resection groups was 91.1 and 93.9 months (P = .080). Fat area was decreased significantly more after surgery (P < .001). The number of patients with sarcopenia was increased in the surgery group. Kaplan–Meier plot showed that overall survival was significantly correlated with post-treatment sarcopenia (P = .049).

CT-based body composition analysis was helpful to evaluate the change in fat and muscle areas after treatment of early gastric cancer. The losses of fat and muscle after treatment were negatively associated with the patient overall survival.