BACKGROUND Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons.It can be spontaneous or secondary to chest trauma,es...BACKGROUND Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons.It can be spontaneous or secondary to chest trauma,esophageal perforation,medi-cally induced factors,etc.Its common symptoms are chest pain,tightness in the chest,and respiratory distress.Most mediastinal emphysema patients have mild symptoms,but severe mediastinal emphysema can cause respiratory and circulatory failure,resulting in serious consequences.CASE SUMMARY A 75-year-old man,living alone,presented with sudden onset of severe epigastric pain with chest tightness after drinking alcohol.Due to the remoteness of his residence and lack of neighbors,the patient was found by his nephew and brought to the hospital the next morning after the disease onset.Computed tomography(CT)showed free gas in the abdominal cavity,mediastinal emph-ysema,and subcutaneous pneumothorax.Upper gastrointestinal angiography showed that the esophageal mucosa was intact and the gastric antrum was perforated.Therefore,we chose to perform open gastric perforation repair on the patient under thoracic epidural anesthesia combined with intravenous anesthesia.An operative incision of the muscle layer of the patient's abdominal wall was made,and a large amount of subperitoneal gas was revealed.And a continued incision of the peritoneum revealed the presence of a perforation of approx-imately 0.5 cm in the gastric antrum,which we repaired after pathological examination.Postoperatively,the patient received high-flow oxygen and cough exercises.Chest CT was performed on the first and sixth postoperative days,and the mediastinal and subcutaneous gas was gradually reduced.CONCLUSION After gastric perforation,a large amount of free gas in the abdominal cavity can reach the mediastinum through the loose connective tissue at the esophageal hiatus of the diaphragm,and upper gastrointestinal angiography can clarify the site of perforation.In patients with mediastinal emphysema,open surgery avoids the elevation of the diaphragm caused by pneumoperitoneum compared to laparoscopic surgery and avoids increasing the mediastinal pressure.In addition,thoracic epidural anesthesia combined with intravenous anesthesia also avoids pressure on the mediastinum from mechanical ventilation.展开更多
BACKGROUND Glomerulopathy with fibrillary deposits is not uncommon in routine nephropathology practice,with amyloidosis and fibrillary glomerulonephritis being the two most frequently encountered entities.Renal amyloi...BACKGROUND Glomerulopathy with fibrillary deposits is not uncommon in routine nephropathology practice,with amyloidosis and fibrillary glomerulonephritis being the two most frequently encountered entities.Renal amyloid heavy and light chain(AHL)is relatively uncommon and its biopsy diagnosis is usually limited to cases that show strong equivalent staining for a single immunoglobulin(Ig)heavy chain and a single light chain,further supported by mass spectrometry(MS)and serum studies for monoclonal protein.But polyclonal light chain staining can pose a challenge.CASE SUMMARY Herein we present a challenging case of renal AHL with polyclonal and polytypic Ig gamma(IgG)staining pattern by immunofluorescence.The patient is a 62-yearold Caucasian male who presented to an outside institution with a serum creatinine of up to 8.1 mg/dL and nephrotic range proteinuria.Despite the finding of a polyclonal and polytypic staining pattern on immunofluorescence,ultrastructural study of the renal biopsy demonstrated the presence of fibrils with a mean diameter of 10 nm.Congo red was positive while DNAJB9 was negative.MS suggested a diagnosis of amyloid AHL type with IgG and lambda,but kappa light chains were also present supporting the immunofluorescence staining results.Serum immunofixation studies demonstrated IgG lambda monoclonal spike.The patient was started on chemotherapy.The chronic renal injury however was quite advanced and he ended up needing dialysis shortly after.CONCLUSION Tissue diagnosis of AHL amyloid can be tricky.Thorough confirmation using other available diagnostic techniques is recommended in such cases.展开更多
目的探究儿童食管异物的临床特征、围术期并发症危险因素及预防策略。方法回顾性分析2020年3月—2023年3月联勤保障部队第903医院收治的355例食管异物患儿的临床资料,根据围术期是否发生并发症,将其分为发生并发症组(101例)和未发生并...目的探究儿童食管异物的临床特征、围术期并发症危险因素及预防策略。方法回顾性分析2020年3月—2023年3月联勤保障部队第903医院收治的355例食管异物患儿的临床资料,根据围术期是否发生并发症,将其分为发生并发症组(101例)和未发生并发症组(254例)。统计食管异物患儿的临床特征及围术期并发症的危险因素,建立危险因素模型,并绘制受试者工作特征(receiver operating characteristic,ROC)曲线分析危险因素模型对食管异物患儿围术期并发症发生的预测价值。结果355例食管异物患儿围术期并发症发生101例,并发症发生率为28.45%;多因素logistic分析结果显示,年龄≤3岁、异物嵌顿时间>24 h、发热、腐蚀性异物、锐性异物、异物嵌顿在食管上段部位是食管异物患儿围术期并发症发生的危险因素(OR=2.492、2.748、2.729、2.617、2.743、2.328,P<0.05)。按照危险因素模型绘制预测食管异物患儿围术期并发症发生的ROC曲线,结果显示,当logit(P)>12.00时,曲线下面积(area under the curve,AUC)为0.873,95%CI为0.834~0.906,χ^(2)为17.778,诊断敏感度为81.19%、特异度为79.53%。结论食管异物患儿围术期并发症的发生率高,且与年龄、异物嵌顿时间、发热、腐蚀性异物、锐性异物、异物嵌顿部位密切相关,据此建立的危险因素模型可预测食管异物患儿围术期并发症及制定相关预防措施。展开更多
文摘BACKGROUND Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons.It can be spontaneous or secondary to chest trauma,esophageal perforation,medi-cally induced factors,etc.Its common symptoms are chest pain,tightness in the chest,and respiratory distress.Most mediastinal emphysema patients have mild symptoms,but severe mediastinal emphysema can cause respiratory and circulatory failure,resulting in serious consequences.CASE SUMMARY A 75-year-old man,living alone,presented with sudden onset of severe epigastric pain with chest tightness after drinking alcohol.Due to the remoteness of his residence and lack of neighbors,the patient was found by his nephew and brought to the hospital the next morning after the disease onset.Computed tomography(CT)showed free gas in the abdominal cavity,mediastinal emph-ysema,and subcutaneous pneumothorax.Upper gastrointestinal angiography showed that the esophageal mucosa was intact and the gastric antrum was perforated.Therefore,we chose to perform open gastric perforation repair on the patient under thoracic epidural anesthesia combined with intravenous anesthesia.An operative incision of the muscle layer of the patient's abdominal wall was made,and a large amount of subperitoneal gas was revealed.And a continued incision of the peritoneum revealed the presence of a perforation of approx-imately 0.5 cm in the gastric antrum,which we repaired after pathological examination.Postoperatively,the patient received high-flow oxygen and cough exercises.Chest CT was performed on the first and sixth postoperative days,and the mediastinal and subcutaneous gas was gradually reduced.CONCLUSION After gastric perforation,a large amount of free gas in the abdominal cavity can reach the mediastinum through the loose connective tissue at the esophageal hiatus of the diaphragm,and upper gastrointestinal angiography can clarify the site of perforation.In patients with mediastinal emphysema,open surgery avoids the elevation of the diaphragm caused by pneumoperitoneum compared to laparoscopic surgery and avoids increasing the mediastinal pressure.In addition,thoracic epidural anesthesia combined with intravenous anesthesia also avoids pressure on the mediastinum from mechanical ventilation.
文摘BACKGROUND Glomerulopathy with fibrillary deposits is not uncommon in routine nephropathology practice,with amyloidosis and fibrillary glomerulonephritis being the two most frequently encountered entities.Renal amyloid heavy and light chain(AHL)is relatively uncommon and its biopsy diagnosis is usually limited to cases that show strong equivalent staining for a single immunoglobulin(Ig)heavy chain and a single light chain,further supported by mass spectrometry(MS)and serum studies for monoclonal protein.But polyclonal light chain staining can pose a challenge.CASE SUMMARY Herein we present a challenging case of renal AHL with polyclonal and polytypic Ig gamma(IgG)staining pattern by immunofluorescence.The patient is a 62-yearold Caucasian male who presented to an outside institution with a serum creatinine of up to 8.1 mg/dL and nephrotic range proteinuria.Despite the finding of a polyclonal and polytypic staining pattern on immunofluorescence,ultrastructural study of the renal biopsy demonstrated the presence of fibrils with a mean diameter of 10 nm.Congo red was positive while DNAJB9 was negative.MS suggested a diagnosis of amyloid AHL type with IgG and lambda,but kappa light chains were also present supporting the immunofluorescence staining results.Serum immunofixation studies demonstrated IgG lambda monoclonal spike.The patient was started on chemotherapy.The chronic renal injury however was quite advanced and he ended up needing dialysis shortly after.CONCLUSION Tissue diagnosis of AHL amyloid can be tricky.Thorough confirmation using other available diagnostic techniques is recommended in such cases.
文摘目的探究儿童食管异物的临床特征、围术期并发症危险因素及预防策略。方法回顾性分析2020年3月—2023年3月联勤保障部队第903医院收治的355例食管异物患儿的临床资料,根据围术期是否发生并发症,将其分为发生并发症组(101例)和未发生并发症组(254例)。统计食管异物患儿的临床特征及围术期并发症的危险因素,建立危险因素模型,并绘制受试者工作特征(receiver operating characteristic,ROC)曲线分析危险因素模型对食管异物患儿围术期并发症发生的预测价值。结果355例食管异物患儿围术期并发症发生101例,并发症发生率为28.45%;多因素logistic分析结果显示,年龄≤3岁、异物嵌顿时间>24 h、发热、腐蚀性异物、锐性异物、异物嵌顿在食管上段部位是食管异物患儿围术期并发症发生的危险因素(OR=2.492、2.748、2.729、2.617、2.743、2.328,P<0.05)。按照危险因素模型绘制预测食管异物患儿围术期并发症发生的ROC曲线,结果显示,当logit(P)>12.00时,曲线下面积(area under the curve,AUC)为0.873,95%CI为0.834~0.906,χ^(2)为17.778,诊断敏感度为81.19%、特异度为79.53%。结论食管异物患儿围术期并发症的发生率高,且与年龄、异物嵌顿时间、发热、腐蚀性异物、锐性异物、异物嵌顿部位密切相关,据此建立的危险因素模型可预测食管异物患儿围术期并发症及制定相关预防措施。
