Zhonghua yi xue za zhi = Chinese medical journal; Free China ed最新文献

Background: The most common symptom of endometrial cancer is postmenopausal bleeding. For women who present with postmenopausal bleeding and a benign tissue diagnosis, recurrent bleeding is a worrisome problem. We evaluated such patients to search for a model of good management.

Methods: We studied women aged 50 years or over who presented with postmenopausal bleeding and underwent either dilatation and curettage (D & C) or endometrial biopsy from 1990 to 1991 at Long Island Jewish Medical Center, New Hyde Park, NY, USA. The selected patients were monitored for 5 years, until 1996. For those who had an initial benign tissue diagnosis and presented with recurrent postmenopausal bleeding in the following 5 years, we studied the differences in histologic diagnoses.

Results: Seventy-seven patients had an initial benign tissue diagnosis of postmenopausal bleeding followed by recurrent bleeding. After repeat D & C or endometrial biopsy (2-6 times), 16 patients (20.8%) had endometrial cancer or endometrial complex hyperplasia. Of the 12 patients who had two or more benign tissue diagnoses, seven (58.3%) had tumors found in subsequent surgery. The diagnoses included endometrial cancer, ovarian cancer, cervical cancer and benign tumor. Postmenopausal women aged 65 years or over had a much greater chance (13/29, 44.8%) of having endometrial cancer or complex hyperplasia than women aged below 65 years (6/48, 12.5%) who presented with recurrent postmenopausal bleeding and had an initial benign tissue diagnosis (c2 = 7.893, p = 0.0050).

Conclusions: Although the initial tissue diagnosis might be benign, the possibility of endometrial cancer or complex hyperplasia cannot be ruled out for women with recurrent postmenopausal bleeding. Diagnostic D & C or endometrial biopsy combined with other tools (vaginal ultrasound, hysteroscopy, transvaginal sonohysterography) are more reliable for evaluating women with recurrent postmenopausal bleeding than D & C or endometrial biopsy only. If these diagnostic results are negative, a total hysterectomy with bilateral salpingo-oophorectomy should be considered to reduce the risk of endometrial cancer in women who present with recurrent bleeding.

Background: Peroneal nerve palsy is the most frequently encountered mononeuropathy of the lower extremities. Although many studies advocated spontaneous resolution of peroneal nerve palsy, more recent studies confirmed obvious improvement with surgical treatment techniques.

Methods: This study reviewed the results obtained from surgically treated peroneal nerve palsy in 14 patients who were admitted to our hospital between 1990 and 1996. The patients consisted of 12 males and two females with an average age of 31 years (range, 12-68 years). Peroneal nerve palsy in these patients was caused by direct or indirect injury, as confirmed by clinical examination and electromyography. The status of the nerve was observed for at least 4 months and explored when the nerve failed to reveal evidence of recovery. The nerve was decompressed, repaired or reconstructed by nerve grafting, according to the status of the injury. Weber scales were used to assess the peripheral neuropathies preoperatively and postoperatively.

Results: At a mean of 23 months (range, 11-61 months), nerve palsy scores improved from an average of 5 points to 3.14 points. Despite the small number of patients, our results indicated that the time interval between onset of injury and date of surgical treatment (p < 0.05) was the most significant factor to influence the prognosis of surgery. Results obtained from surgery were not related to the method of treatment, length of nerve graft or mechanism of injury.

Conclusions: Because peroneal nerve palsy does not always resolve spontaneously, this study favored early surgical exploration for peroneal nerve dysfunction, based on at least 4 months of follow-up.

Background: An outbreak of hand-foot-and-mouth disease caused by enterovirus infection occurred in Taiwan in 1998 and more than 70 infants and children with fulminant courses died. We compared the cardiac manifestations of fatal cases with patients who survived the enterovirus infection.

Methods: A total 187 patients with enterovirus infection were treated at Taichung Veterans General Hospital between April and June 1998. Enterovirus infection was diagnosed by history, clinical features, polymerase chain reaction study and/or viral culture. Cardiac examinations including complete physical examinations, electrocardiography and echocardiography were performed on seven cases (group I) with or without central nervous system (CNS) involvement, 30 patients with CNS involvement (group II), and 150 patients without CNS involvement (group III).

Results: There were no significant differences in sex distribution, days of fever, heart rate, systemic blood pressure or time from the onset of symptoms to hospital admission among the three groups. All group I patients had features of acute congestive heart failure, pulmonary edema and neurologic signs except one who presented with right-sided heart failure and neurologic signs. The echocardiographic findings of group I were a lower fractional shortening, lower ejection fraction, and more severe and higher incidence of mitral regurgitation (p < 0.01) than in groups II and III, but there were no significant differences in end-systolic wall stress, left ventricular end-diastolic internal dimension and incidence of pericardial effusion among the three groups.

Conclusions: We conclude that seven infants and children (group I) died due to either severe cardiomyopathy or encephalopathy. The possible pathogenesis of enterovirus infection leading to death is reviewed and analyzed.

Background: Clinical tumor staging of cervical carcinoma has its limitations. The purpose of this study was to stage cervical carcinoma by magnetic resonance imaging (MRI), with an emphasis on the assessment of parametrial invasion and pelvic lymph node metastasis.

Methods: MRI was performed in 51 women with tissue-proven cervical carcinoma 2 weeks prior to surgery. Images were analyzed for parametrial invasion, pelvic lymph node metastasis and tumor stage. The results were compared with the histopathologic findings after surgery in all patients.

Results: In assessing parametrial invasion, MRI had an accuracy of 94%. In assessing pelvic lymph node metastases, MRI was accurate in 86.3% of cases. In determining stage of disease, MRI had an accuracy of 76.5%. The accuracy of MRI in differentiating localized (< or = stage IIA) from advanced disease (> or = stage IIB) was 94.1%.

Conclusions: MRI is accurate in the evaluation of parametrial invasion and lymph node metastases and in the differentiation of localized and advanced disease. MRI is beneficial in planning treatment for patients with cervical cancer.

Hepatoportal arteriovenous fistulas are usually traumatic in origin and may result in portal hypertension and serious complications. We report a 34-year-old female with a history of abdominal trauma, who developed symptoms of tarry stools and hematemesis 5 years later. Esophageal and gastric varices with bleeding were diagnosed by upper gastrointestinal endoscopy. Abdominal ultrasonography and computerized tomography favored noncirrhotic portal hypertension. An extrahepatic hepatoportal arteriovenous fistula was demonstrated by angiography. The patient underwent surgery to correct the condition. The liver had a smooth surface and both the common hepatic and gastroduodenal arteries were ligated during surgery. The postoperative course was uneventful. The varices later disappeared.

Gas within the cavernous sinus is an unusual finding. We report three patients who demonstrated gas in the cavernous sinus on computerized tomography (CT). The clinical information of these patients was reviewed for the possible source of the gas and the symptoms induced by the gas. Cavernous sinus gas was seen in two patients with sphenoid sinus fracture and in one patient after intravenous fluid infusion. None of the patients had symptoms referable to the cavernous sinus gas, but one patient had a grave prognosis due to trauma. Identification of cavernous sinus gas on CT and correlation with the clinical information is mandatory for further management.

Background: Elevated serum gamma-glutamyl transpeptidase (GGT) is often seen in patients with chronic hepatitis C virus (HCV) infection and is associated with a poor response to interferon treatment. The pathogenesis of these phenomena is unclear. Therefore, we assessed the prevalence of elevated serum GGT in Chinese patients with chronic hepatitis C and evaluated the clinical, biochemical, virologic and histologic features of this phenomenon.

Methods: One hundred and twelve patients with biopsy-proven chronic hepatitis C were enrolled. Patients who were habitual alcohol drinkers, alcoholics or had diabetes mellitus were excluded.

Results: Forty-three (38.4%) of 112 patients had elevated serum GGT (> 60 U/l). Patients with elevated serum GGT had significantly higher serum levels of alanine and aspartate aminotransferases, alkaline phosphatase and total bilirubin, significantly higher histologic scores of liver lobular necro-inflammation and fibrosis when compared to patients with normal serum GGT. Elevated serum GGT was not correlated to serum HCV RNA titer or HCV genotype. Multivariate logistic regression analysis showed that a histologic fibrotic score > or = 2 was the only significantly independent predictor associated with elevated serum GGT. Fifty-seven of 112 patients completed a six-month course of interferon treatment. Patients with elevated serum GGT had a significantly lower sustained response rate to interferon when compared to patients with normal serum GGT (8% vs 30%, p = 0.042).

Conclusions: Elevated serum GGT in chronic hepatitis C patients was frequently associated with more severe hepatic fibrosis or cirrhosis and may, in part, account for poor response to interferon therapy.

Coronary artery to left ventricular fistula is an unusual anatomic anomaly consisting of a communication between one of the coronary arteries and the left ventricle. Only sporadic cases have been published in the literature. Diffuse multiple fistulas involving both left and right coronary arteries are even rarer. This report describes a 60-year-old woman with diffuse multiple fistulas communicating between both coronary arteries and the left ventricle. The patient manifested clinically with exertional angina and myocardial ischemia, as evidenced by a positive stress exercise test, which represents the coronary "steal" phenomenon.

Henoch-Schönlein purpura (HSP) is a systemic vasculitis with manifestations usually involving the skin, gastrointestinal tract, kidney and joints. Epididymitis is rarely seen as a complication of HSP. It is easily misdiagnosed as testicular torsion, causing the patient to undergo unnecessary surgery, because the patient may have complained of severe scrotal pain and swelling. We report a 5-year-old boy who was suffering from HSP associated with acute scrotal pain and swelling of the left testicle. No gastrointestinal signs were noted but severe joint pain, swelling and palpable skin lesions in the lower limbs and the buttocks were found. Prednisolone was prescribed and the boy recovered without surgical intervention.

Background: Polymerase chain reaction (PCR) techniques have revolutionized the diagnosis of tuberculosis (TB). PCR has significantly improved the sensitivity and specificity of existing diagnostic methods. In this study, we report our experience using a modified IS6110-based nested PCR assay for rapid diagnosis of pulmonary TB.

Methods: A total of 327 respiratory specimens from 275 patients suspected of having pulmonary TB at Taipei Veterans General Hospital were tested using the nested PCR assay, acid-fast smear and culture for the presence of Mycobacterium tuberculosis complex (MTB). Nested PCR was performed with IS6110-based primers specific for MTB. We reviewed the medical records of patients and analyzed the clinical features. The PCR results were compared with the final clinical diagnosis.

Results: We identified MTB in 167 of 327 samples by the nested PCR assay. No non-tuberculous Mycobacterium (NTM) was identified among the clinical samples. Diagnosis by PCR took about 6 hours in this study. The sensitivity and specificity compared with culture were 94.7% and 100%, respectively for the smear-positive, culture-positive samples, and 76.7% and 98.6% for the smear-negative, culture-positive samples. The overall sensitivity, specificity, positive and negative predictive values, compared with culture results, were 91.7%, 98.6%, 98.8% and 90.6%, respectively. Two specimens positive by PCR and negative by culture were taken from patients on anti-TB drug therapy. These specimens were culture-positive before anti-TB drug therapy. After resolution of the discrepancies by studying the patients' clinical data, both specificity and positive predictive value reached 100%.

Conclusions: The results indicated that this in-house nested PCR assay is a rapid and sensitive method for diagnosing pulmonary TB. It is also good for excluding infections caused by NTM.