Abdominal Veins Research Articles

Chronic non-bacterial osteomyelitis with autoimmune hepatitis: a case report and literature review

Objective: To summarize the clinical characteristics and treatments of chronic non-bacterial osteomyelitis with autoimmune hepatitis in children. Methods: A child who had chronic non-bacterial osteomyelitis with autoimmune hepatitis was admitted to the Department of Gastroenterology of the Children's Hospital Capital Institute of Pediatrics at April 2022. The clinical data was retrospectively analyzed. Using the keywords of "chronic non-bacterial osteomyelitis""autoimmune hepatitis" in Chinese and English, the literature from database establishment to December 2022 in CNKI, Wanfang, China Biomedical Literature Database and Pubmed was searched. Combined with this case, the clinical characteristics and treatment of chronic non-bacterial osteomyelitis combined with autoimmune hepatitis were analyzed. Results: A 5 years and 3 months girl was admitted to the Department of Gastroenterology of Children's Hospital, Capital Institute of Pediatrics for "transaminase elevated for 1 year and swelling of right maxillofacial area for half a year". The physical examinations at admission found a 4.0 cm × 4.0 cm swelling area with tenderness before the right ear, abdominal distention with visible abdominal wall vein, firm and enlarged liver (10.0 cm below the xiphoid and 4.5 cm below the right ribs), and splenomegaly (Line Ⅰ 10.0 cm, Line Ⅱ 11.5 cm, and Line Ⅲ 25.0 cm). There was no redness, swelling or restriction of the limbs. Laboratory examination found abnormal liver function with alanine aminotransferase 118 U/L, aspartate aminotransferase 227 U/L, γ-glutamyltransferase 360 U/L, and positive direct anti-human globulin test; immunology test found immunoglobulin G 41.60 g/L and a homogeneous type of antinuclear antibody of 1∶1 000; the autoimmune hepatitis antibody test found a positive anti-smooth muscle antibody (1∶100). Liver biopsy showed moderate interfacial inflammation and the patient was diagnosed with autoimmune hepatitis (International Autoimmune Hepatitis Group 19). The imaging findings showed extensive involvement of the bilateral mandible, while the right side was severe. There were expansile bone changes, thinning of the bone cortex, and significant swelling of the surrounding soft tissue in the mandibular body, mandibular angle, and mandibular ramus. After treatment of glucocorticoid, the swelling of the right maxillofacial region disappeared and the transaminase returned to normal. Only one case was reported before in English and none in Chinese. The two cases were both girls whose main clinical features were joint pain and swelling. The previous case started with pain in both knee joints, and developed liver injury during treatment while this case had liver injury as the initial clinical presentation. Besides, the affected sites and degrees of arthritis in the 2 cases were different. After glucocorticoid treatment, the clinical symptoms were alleviated, and transaminases returned to normal. Conclusions: Chronic non bacterial osteomyelitis may involve the liver and manifest as autoimmune hepatitis. Glucocorticoids therapy is effective.

Application of Color Doppler with 3- and 4-Dimensional Ultrasonography in the Prenatal Evaluation of Fetal Extracardiac and Placental Abnormalities

Using color Doppler flow imaging or high-definition flow imaging with three-dimensional volume or spatio-temporal image correlation (STIC) in the glass-body mode allows displaying both gray-scale and color information of the heart cycle-related flow events and vessel spatial relationship. Conventionally, STIC in the glass-body mode has been used to examine the fetal heart and assess heart defects. Recently, a novel application of STIC in the visualization of abdominal precordial veins and intraplacental vascularization in singleton pregnancies has been reported. The aim of this present review is to discuss the use of color Doppler with three- and four-dimensional ultrasonography in the evaluation of extracardiac, placental, umbilical cord and twin abnormalities with examples. The glass-body mode is complementary to conventional 2D ultrasonography. Further studies are required to investigate use of the glass-body mode in the assessment of intraplacental vascularization in singleton and twin pregnancies.

A rare case of neonatal-onset hepatic sinusoidal obstruction syndrome

A male infant, aged 1 month and 14 days, was admitted to the hospital due to abdominal distension lasting for 2 weeks and worsening for 3 days. The infant had a history of omphalitis. Physical examination revealed severe abdominal distension, prominent abdominal wall veins, hepatosplenomegaly, and massive ascites. There was a slight elevation in liver transaminase levels. Liver ultrasound and CT scans demonstrated the absence of visualization of the intrahepatic segment of the portal vein and the left, middle, and right veins of the liver, indicating occlusion of these vessels, along with surrounding fibrous hyperplasia. The clinical diagnosis was hepatic sinusoidal obstruction syndrome resulting from omphalitis. A large amount of bloody ascites developed after 12 days of hospitalization, resulting in hypovolemic shock and respiratory failure. The infant passed away following the family's decision to discontinue treatment. This article focuses on the diagnostic approach and multidisciplinary management of neonatal-onset hepatic sinusoidal obstruction syndrome, as well as provides insights into the differential diagnosis of hepatomegaly and ascites.

Upper Limb Deep-Vein Thrombosis Following Vaccination with Janssen Vaccine

Deep-vein thrombosis (DVT) is a vascular condition that commonly presents in the lower limb(s). Although reported, its occurrence in the upper limbs is rare. Furthermore, problems with the risk of serious adverse effects in response to vaccination against COVID-19 are relatively rare, despite the unprecedented speed of vaccine production using advanced modern technology. Although infrequent, administration of certain mRNA-based and certain viral vector vaccines have been associated with vaccine-induced thrombotic thrombocytopenia cases in an otherwise healthy patient: most commonly in the central venous sinus or abdominal splanchnic veins or lower limb. Here, we present an unusual case of post Janssen vaccination upper limb DVT, with an average platelet count.

L-amino acid oxidase-1 is involved in the gut-liver axis by regulating 5-aminolevulinic acid production in mice.

L-amino acid oxidase (LAAO) is a metabolic enzyme that converts L-amino acids into ketoacids, ammonia, and hydrogen peroxide (H2O2). The generated H2O2 has previously been shown to have antibacterial and gut microbiota-modulatory properties in LAO1 knock-out (KO) mice. Since most microbial metabolites reach the liver through the portal vein, we examined gut-liver interactions in LAO1 KO mice. We found lower total cholesterol levels, higher glutamic pyruvic transaminase (GPT) levels in the serum, and higher pro-inflammatory cytokine mRNA expression in the liver tissue. In wild-type (WT) mice, LAO1 was expressed in gut tissues (ileum and colon). Microbiome analysis revealed that the abundance of some bacteria was altered in LAO1 KO mice. However, short-chain fatty acid (SCFAs) levels in cecal feces and gut permeability did not change. Fecal microbiota transplantation (FMT) revealed that feces from LAO1 KO mice slightly stimulated pro-inflammatory cytokine expression in the liver. During metabolomic analysis, 5-Aminolevulinic acid (5-ALA) was the only metabolite found to be significantly upregulated in the portal and abdominal veins of the LAO1 KO mice. Intraperitoneal administration of 5-ALA to WT mice significantly increased IL-6 mRNA expression in the liver. These observations suggest that gut LAO1 plays a role in regulating 5-ALA production and that a high level of 5-ALA stimulates the liver to increase pro-inflammatory cytokine expression by disrupting LAO1 in mice.

Diagnostic and Therapeutic Challenges of Chronic Portal Vein Thrombosis Secondary to Myeloproliferative Neoplasm in Sub-Saharan Region: A Series of Cases and Literature Review

Myeloproliferative neoplasms (MPN) are the commonest causes of non-cirrhotic abdominal vein thrombosis. MPN was observed in 30-40% with Budd Chiari Syndrome (BCS) and portal vein thrombosis (PVT), whereas this is the cause in only a minority of other types of venous thrombosis. Herein, we report 10 cases of chronic PVT secondary to Janus Kinase 2 gene (JAk 2) positive myeloproliferative neoplasm (MPN). The median age was 35 years with M:F 1:1. Portal hypertension was present at presentation in all of them. Nine patients have esophageal varices, of which 6 have bleeding at presentation. Classical MPN phenotype on complete blood count (CBC) was not present in 6 of them. Management of patients with anticoagulation was difficult with 4 patients experiencing bleeding during anticoagulation, and bleeding occurring despite the target international normalized ratio (INR) in 2 of them. Portal hypertension leading to hypersplenism and hemodilution may mask erythrocytosis and thrombocytosis, which are the main criteria used to diagnose MPN. The resulting absence of a typical MPN phenotype in routine laboratory studies alongside accessibility issues, and the need for a multidisciplinary treatment approach imparts a diagnostic as well as a therapeutic challenge for chronic PVT associated with Jak 2 positive MPN in sub-Saharan patients.

Epidemiology and Outcomes of Peripheral and Non-Aortocaval Vascular Trauma in Scotland 2011 – 2018

This population based study aimed to examine the demographics, mechanisms, and outcomes of patients in Scotland suffering peripheral and non-aortocaval vascular trauma between 2011 and 2018. A retrospective observational study was conducted using prospectively collected data derived from the Scottish Trauma Audit Group (STAG) from 1 January 2011 to 31 December 2018. Peripheral and non-aortocaval vascular trauma patients were identified using Abbreviated Injury Severity (AIS) codes. Demographics, mechanisms, types of injury, severity, and outcomes were analysed. Of 30 831 patients admitted with trauma to Scottish hospitals, 569 (1.8%) patients suffered a vascular injury during the eight year study period with 275 (0.9%) patients sustaining a peripheral or non-aortocaval vascular injury. There were 221 (80%) men and 54 (20%) women with a median (range) age of 39 (14 - 88) years. Blunt trauma was responsible for 179 (65%) injuries, of which road traffic accidents were the most common mechanism. A further 67 (24%) injuries were due to penetrating trauma, of which assault was the most common cause. The most common injury was to abdominal arteries (e.g., hepatic, renal, splenic [n= 83]) with an associated mortality rate of 17%. The median (range) Injury Severity Score (ISS) was 16 (4 - 75). Sixteen (6%) patients died in the Emergency Department (ED). Two hundred and twenty-seven (83%) patients were taken to theatre during their admission with a 30 day peri-operative mortality rate of 10%, compared with an overall mortality rate of 16%. Injuries to an abdominal vein (e.g., portal, renal, splenic, superior mesenteric) had the highest number of associated deaths, with 11 (32%) of 34 cases resulting in a fatality. There is a low incidence of vascular trauma in Scotland. Blunt force was responsible for more vascular injuries than penetrating trauma. Patients with peripheral and non-aortocaval vascular injuries are likely to be severely injured and suffer a high mortality rate.

SAFETY AND EFFICACY OF SPLENECTOMY FOR THE TREATMENT OF CHRONIC IMMUNE THROMBOCYTOPENIA

To evaluate the short- and long-term safety and efficacy of splenectomy for the treatment of chronic immune thrombocytopenia (ITP). A cohort of ITP patients who underwent splenectomy between 2005 and 2020 was included and followed for up to 10 years. Descriptive analyses of complications (related to the procedure, infections, and thrombosis) and response to treatment were performed. Out of the 87 patients included, 80.5% were women, median age at diagnosis was 33 years (IQR 24 – 50), 28.7% had hypertension and 20.7% had antiphospholipid antibodies. The median time from diagnosis to splenectomy was 19 months (IQR 6.0 – 50.0) and median follow-up duration was 61 months (27 – 108). Post-procedure complications, such as fistula, surgical site infection and bleeding requiring transfusion, occurred in 6 (7%) patients and hospital-associated thrombosis (thrombosis occurring within 90 days after splenectomy) in 3 (3.4%). Two patients had abdominal thrombosis and 1 had abdominal and deep vein thrombosis. During the follow-up, 3 patients had infections requiring hospitalization, resulting in a 5-year cumulative risk of infections of 3.4% (95% CI 0.9 – 9.1). Regarding thrombotic events after splenectomy, the 5-year cumulative incidence was 12.6% (95 CI% 6.8 – 20.9) and the median time from splenectomy to thrombosis was 20 months (IQR 1 – 42). In the subgroup analysis, patients with cardiovascular risk factors, such as hypertension, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, and cerebrovascular disease, showed higher risk for developing a thrombotic event during follow-up. Sixty days after splenectomy, 72 patients (82.5%) had an overall response, of which 55 were complete (63.2%) and 17 partial response (19.3%). The median time for relapse was 12.5 months (IQR 4 - 45.3) and the 5-year treatment free survival was 55.3% (95% CI 45.8 – 66.4). At the end of the follow-up, 77 patients (88.5%) had partial or complete response and 2 (2.3%) had died. This study represents a cohort of patients with ITP from a single center in Brazil that evaluated the short- and long-term safety of splenectomy, in addition to its efficacy. The recent guidelines on ITP treatment recommend splenectomy as one of the main second-line therapies following failure or relapse after corticosteroid use, along with thrombopoietin receptor agonist or rituximab. The perioperative complication rate and mortality in the presented cohort were as low as those described in previous cohort studies. The institution protocol includes pre-splenectomy vaccination but not long-term antibiotic prophylaxis in adults with ITP and, even with this approach, cumulative incidence of infection requiring hospitalization in the current cohort was approximately three times lower than that in previous cohort studies. The rate of venous thromboembolism was similar to another cohort studies and seems to be associated with underlying comorbidities. Splenectomy is an efficacious well-tolerated treatment. The response rate is high, even for those requiring further ITP treatment, suggesting that splenectomy modulates future therapy response. In conclusion, splenectomy-associated rates of efficacy outweigh its rates of complications, which underscores that splenectomy should be regarded as one of the main approaches for long-term ITP remission.

Combined Transhepatic-Transsplenic Direct Intrahepatic Portocaval Shunt in a Child with Budd-Chiari Syndrome

A 6-year–old girl presented emergently with 3 episodes of hematemesis over 3 days and abdominal distension for 10 days. Physical examination revealed distended superficial abdominal veins. Ultrasonography (US) showed thrombosed hepatic veins and infrahepatic inferior vena cava (IVC) with ascites, which is diagnostic of chronic Budd-Chiari syndrome with portal hypertension. Direct intrahepatic portocaval shunt creation was planned under general anesthesia. Bilateral jugular and brachiocephalic veins were chronically occluded (Fig 1a), and femoral venography showed chronic occlusion of the IVC (Fig 1b).

CLINICAL PROFILE OF ACUTE KIDNEY INJURY IN CHRONIC LIVER DISEASE, AND ITS EFFECT ON IN HOSPITAL MORTALITY

Introduction - Chronic liver disease (CLD) is a common clinical condition affecting mankind.Its association with the diseases of other important organs like kidney makes it a more devastating disease. Acute kidney injury (AKI) considerably affects the prognosis and outcome of patients with CLD, hence it is important to prevent the development of AKI and identify the precipitating factors as early as possible, so that early interventions can be done.1 A prospective observational study was done on 100 chronic liver disease patients admitted in J. A. group ofMaterial and methods - hospitals Gwalior, over a period of 22 months from Nov. 2019 to June 2021. Detailed history and physical examination, biochemical and radiological investigations were performed and data was collected using a standardised proforma. Out of the 100 patients 70 are patientsResults - are male and 30 are females. Most of the patients belonged to Child - Pugh class C (60%), followed by class B (39%) and class A (1%).Overall, alcohol was found to be the most common cause of chronic liver disease (59%), followed by hepatitis B virus infection (20%), Hepatitis C virus infection(6%), NASH related CLD(2%), portal vein thrombosis(5%), Wilson's disease (1%), unknown etiology (7%). In males, the most common cause of CLD was found to be chronic alcoholism(84.3%), followed by hepatitis B virus infection(8.6%), portal vein thrombosis and NASH related hepatitis in 2.8% each and Wilson's disease (1.4%). In females most common cause of CLD was found to be hepatitis B virus infection (46.6%),followed by hepatitis c virus infection (20%), portal vein thrombosis(10%), unknown etiology (23.3%). Ascites (78%) was the most common sign of hepatic decompensation, followed by pedal edema (67%), jaundice (52%), altered sensorium(20%), GI bleed ( 22%), dilated abdominal veins(18%), alopecia(10%). palmar erythema ( 8 %) and testicular atrophy(4%). Prevalence of AKI in CLD was found to be 30%, out of which maximum no. of patients were in AKIN stage 3(48%), frequency of stage 1 & 2 AKI was 26.6% each. The most common cause of AKI in CLD was found to be sepsis (40%), followed by GI bleed (26.7%), inappropriate use of diuretics (13. 3%), Paracentesis (6.6%)and diarrhea(10%) severe vomiting ( 3. 3%). The in hospital mortality in the patients who developed AKI was considerably higher (56.6%) than the patients who did not developed AKI (8.5%), signicant at p <0.05. CLD patients are at increased risk of developing AKI , and mortality rates areConclusion - signicantly higher in patients of CLD complicated by AKI.

COVID-19 vaccine-induced immune thrombotic thrombocytopenia

The coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) stimulated the development of highly effective vaccines that were produced with unprecedented speed with the use of new technologies. All the newly developed vaccines are highly effective with minimal adverse effects. Clinical introduction of the AstraZeneca Covid-19 vaccine has raised public alarm regarding the rare, but serious thrombotic events, known as vaccine-induced immune thrombotic thrombocytopenia (VITT). VITT is characterized clinical and laboratory syndromes like: venous (acute cerebral sinus venous thrombosis and abdominal vein thrombosis) or arterial thrombosis; mild-to-severe thrombocytopenia; positive antiplatelet factor 4 (PF4)-polyanion antibodies or anti-PF4–heparin antibodies detected by ELISA; occurring 5–30 days after ChAdOx1 nCoV-19 (AstraZeneca) or Ad26. COV2.S (Johnson & Johnson/Janssen) vaccination and elevated D-dimer. From a pathophysiological point of view, VITT is an autoimmune disease characterized by the development of antibodies that directly activate platelets, causing thrombosis in the arterial or venous systems of the body. At the same time, the components of the vaccine serve as an antigen for the formation of autoantibodies, which enhance the production of platelet factor PF4, which contributes to the formation of blood clots. It has established that intravenous use of immunoglobulin at a dose of 1 g/kg of the patient’s body weight per day, in addition to neutralizing antibodies, makes it possible to suppress VITT-mediated platelet activation. Fondaparinux, direct oral anticoagulants (DOACs), danaparoid or argatroban are the main anticoagulant drugs effective in the treatment of thrombotic conditions in VITT.

Needs Assessment of Essential Anatomy: A Perspective from Anesthesiology, Emergency Medicine, ObGyn and Orthopedics Resident

IntroductionCurricular development begins with identifying a problem, followed by a needs assessment of curricular components. Changes in pedagogical approaches and reductions in curricular time for gross anatomy have been identified as problems in undergraduate medical education. The objective of this study was to conduct a needs assessment of the most essential anatomy for residents in Anesthesiology (AN), Emergency Medicine (EM), Ob/Gyn (OB), and Orthopedics (OR) at Beaumont Health in Royal Oak, MI (the teaching hospital for Oakland Univ. William Beaumont School of Medicine).MethodsResidents completed a survey to assess the clinical importance of 907 anatomical structures for the back, upper limb (UL), lower limb (LL), thorax (Thx), abdomen (Abd), pelvis and perineum (P&P), and head and neck (H&N) on a 1‐4 Likert‐scale (1=not important; 4=essential). Kruskal‐Wallis analyses with a Bonferroni correction (p<0.007) were used to assess differences of top‐level items for each region between residency groups. The 3 and 4 rating response frequencies for each structure formed a basis for classifications of importance: structures rated 3 or 4 by ≥75.0% were essential, 50.0‐74.9% more important, 25.0‐49.9% less important, 0.0‐24.9% not important.ResultsFifty‐five residents (AN, N=6; EM, N=l5; OB, N=13; OR, N=21) completed the survey. Ratings by OR residents were significantly higher for the limbs than AN, ER, and OB, and higher for the back than EM and OB. Ratings by OB residents were significantly higher for P&P than by AN and ER residents. No ratings differences were found for Thx, Abd, or H&N. Classifications of essential and more important for all structures across body regions were: AN, 71.8%; EM, 64.5%, OB: 52.0%, OR: 99.9%. Individual regions with ≥70% of structures essential or more important were: AN (Back, Thx, Abd, H&N), EM (UL, Thx, H&N), OB (Abd, P&P), OR (all regions). Regions with ≥20% of structures as not important were: AN (UL, P&P), EM (Back), OB (UL). With few exceptions, the following were classified as essential or more important: surface anatomy, meninges, heart, great vessels, respiratory tract, thoracic skeleton, peritoneum, diaphragm, abdominal veins, skull, cervical fascial spaces, cranial nerves, thyroid and parathyroid glands, and the lumbar and brachial plexuses.ConclusionsThis study conducted a needs assessment of anatomy curricular content solely from the perspective of selected non‐primary care residents at a single clinical site. Significant differences in ratings were found between residents for body regions in which residents would be expected to focus their clinical (surgical) activity (notably, OR and OB).SignificanceThis data provides insight into the importance that non‐primary care residents placed on specific anatomical structures. The authors suggest that the classifications of importance for specific anatomy by these residents were informed by their clinical perspective, and can serve as a guide for curricular development in the context of reduced contact hours, new pedagogies, and vertical integration.

Haemodynamic changes during radical nephrectomy with inferior vena cava thrombectomy: A pilot study.

Haemodynamic changes during radical nephrectomy with inferior vena cava thrombectomy: A pilot study.

Effects of methionine, leucine, and insulin on circulating concentrations and mammary extraction of energy substrates and amino acids in lactating dairy cows

The aim of this experiment was to test whether insulin potentiates the effects of two abomasally infused amino acids (AA), leucine and methionine (LM), on mammary extraction efficiency of energetic and nitrogenous nutrients. Six lactating Holstein cows (155 ± 9 DIM) were ruminally-cannulated and had the right carotid artery subcutaneously transposed. Cows were fed a 20% metabolizable protein-restricted diet and abomasally infused with water (8 L/d) or AA (Met 26 g/d, Leu 70 g/d) for 8 h/d, for 7 days. On the last day of each period, cows were intravenously infused with saline (0.9% NaCl, 110 mL/h) or subjected to 8 h hyperinsulinemic clamp (IC) alongside abomasal infusions. For IC, insulin was infused at 1 µg/kg/h. Normoglycemia was maintained by varying glucose (50% w/v in water) infusion rate based on coccygeal vein glucose concentration. Carotid arterial and subcutaneous abdominal (mammary) vein blood samples were collected at 0, 1, 2, 4, and 6 h from the start of infusions. Milk weights and samples for baseline measurements of production were taken on day 5 PM, day 6 AM and PM, and day 7 AM of the experimental period. A final milk weight and sample was taken immediately after abomasal and intravenous infusions on day 7 PM for assessing the interaction between insulin and the infused AA. The experiment had an incompletely replicated Latin square design with a 2 × 2 factorial arrangement of treatments (abomasal and intravenous infusion). Baseline milk production when cows were only receiving abomasal infusions was largely unaffected by LM, but milk protein yield tended to be decreased. On day 7, LM tended to positively increase milk fat and de novo fatty acid content, and IC tended to decrease milk protein content. Both milk urea nitrogen and plasma urea nitrogen were decreased by IC. Circulating AA concentrations in plasma were decreased by both LM and IC, but mammary extraction efficiency was affected by neither. Infusion of LM had no effect on any energy metabolite analyzed. Circulating non-esterified fatty acid concentration was decreased by IC, with no effect on mammary extraction efficiency. Mammary extraction efficiency of both acetate and β-hydroxybutyrate were decreased by IC. Overall, while both circulating concentrations of energy metabolites and amino acids were decreased in response to treatments, this was not due to improved mammary extraction efficiency.

Courveilhier Baumgarten Syndrome: A Rare Case Report

A 44 year old female had presented with history of abdominal distension of 20 days duration and on examination he had prominent abdominal vein and a venous hum with Ascites. He had no history of altered sensorium, melena. The clinical scenario was suggestive of Cruveilhier Baumgarten syndrome

Paediatric Thrombosis: A Five-Year Experience From A Tertiary Care Center Of Pakistan.

Advances in imaging techniques and longer survival of chronic medical conditions contribute to the increase in paediatric thrombosis. We aim to determine the incidence, underlying risk factors, management and clinical outcome of paediatric thrombosis at a multidisciplinary facility of Pakistan. A retrospectively analysis of the medical records of patients in the paediatric age group admitted at the Aga Khan University hospital from January 2013-September 2018 was performed. Site of thrombosis, associated risks factors, management options and outcome of thrombotic event were evaluated. Of the 22,320 paediatric hospitalization, 35 paediatric patients were diagnosed with thrombosis (15 cases per 10,000 admissions). The median age of the study group was 15 years and twenty patients (57%) were male. The commonest site of thrombosis was in lower limb venous 11 (31%), followed by upper limb venous thrombosis 6 (17%), abdominal vein thrombosis 7 (20%), cerebral venous thrombosis 5 (14%), pulmonary embolism and arterial thrombosis 3(9% each). Eighty three percent had underlying clinical condition including central venous catheter [CVC] (26%), malignancy and infection (14% each), antiphospholipid antibody syndrome (9%), inherited thrombophilia (9%), congenital heart disease (6%), while thrombotic thrombocytopenic purpura and autoimmune disorder (3% each). Twelve (34%) patients were treated with heparin only, 8 (23%) received heparin followed by warfarin while warfarin as a single agent was given in 2 (5.7%) patients. One patient died of pulmonary embolism while 9 (25%) had persistence or recurrence of thrombosis. Incidence of paediatric thrombosis was 0.15%. CVC placement was the most common associated risk factor. Warfarin and heparin both were found to be safe anticoagulation option. Recurrence rate was found to be high.

Point-of-care Ultrasound for the Evaluation of Acute Arterial Pathology in the Emergency Department: A Case Series.

IntroductionThe use of point-of care ultrasound (POCUS) in the evaluation of vascular emergencies including abdominal aortic aneurysm and deep vein thrombosis is well established. However, no current guidelines exist to outline the use of POCUS in the management of acute peripheral arterial pathology.Case SeriesHere, we present a case series that illustrates the utility of POCUS in the assessment of both traumatic and nontraumatic peripheral arterial disease. Direct visualization of the vasculature via B-mode, color Doppler, and pulsed-wave Doppler assisted in the diagnosis of the following: 1) an acute, post-catheterization thrombus of the proximal radial artery; 2) a complete, traumatic radial artery transection; 3) a forearm hematoma with active arterial extravasation; 4) a traumatic arteriovenous fistula; 5) an acute thrombosis of an artery bypass graft; and 6) an infected pseudoaneurysm.ConclusionThe incorporation of POCUS into patient care allowed for rapid identification of significant peripheral arterial pathology and led to changes in clinical management, expedited patient care, and circumvented potentially harmful complications.

A midline abdominal incision: can it be that dangerous? A huge umbilical vein in a cirrhotic patient

The umbilical vein transport oxygenated blood from the placenta to the fetus. It travels through the umbilical cord, which disappears at birth. It divides in two, one part going to the liver, the other one flowing into the inferior vena cava through the ductus venosus. During labor, uterine contractions cause an increase in fetal arterial pressure, which results in a decrease in the flow of para umbilical veins. A decrease in intrahepatic blood flow in the case of liver cirrhosis increases resistance in the portal vein, resulting in portal hypertension. In order to combat portal hypertension, portosystemic shunts develop in four directions: superior (left gastric vein), inferior (via hemorrhoidal veins), posterior (left renal vein), and anterior with repermeabilization of the umbilical vein and abdominal wall veins giving Cruveilhier-Baumgarten syndrome. We report the case of a 41-year-old patient followed for a hepatic cirrhosis without obvious etiology classified as child A with portal hypertension responsible for an important splenomegaly and a hypersplenism associated with a repermeabilization of the umbilical vein, operated in our general surgery department at the University Hospital of Tangier, for a non-metastatic neuroendocrine carcinoma of the gastric antrum having benefited from an antrectomy with lymph node dissection. It should be noted that the incision was in the midline above the umbilicus strict and very careful because of the risk of damaging the umbilical vein which was of large caliber and can causing a cataclysmic and uncontrollable hemorrhage. We present the impressive image of the umbilical vein in this patient.

On the Blood Pressure in the Cardiovascular System

Background: Hemodynamics is a practical and complicated theoretical problem. The aim of this paper is to analyze the characteristics of blood pressure in the cardiovascular system changing with the mechanical parameters of blood vessels and the storage of some visceral organs. Method: The fluid network model was used for the study. The cardiovascular system was modeled as a system consisting of 20 segments of vessels. The main controlling parameters were determined first by using dimensional analysis. Then the responses of blood pressure of each segment of vessels were analyzed by changing the controlling parameters. Results: The parameters of the blood vessel of brain have the least influence on the pressures of other parts. The pressures of the system of blood vessels will decrease if some blood is stored in the liver or the abdominal vein system. Vice versa. The effects of regulation of blood on the variation of blood pressure are larger than the other controlling parameters. Conclusions: The controlling parameters of the abdominal aorta and ascending aorta affect greatly the blood pressure of each vessel.

Utility of bedside ultrasound derived hepatic and renal parenchymal flow patterns to guide management of acute kidney injury.

Ideal fluid management of critically ill patients is maintaining an adequate perfusion pressure but avoiding venous congestion. Venous excess ultrasound score (VExUS) quantifies venous congestion to guide the management of fluid balance. VExUS of abdominal veins measures fluid tolerance and helps clinicians avoid congestion. VExUS scoring predicts the development of acute kidney injury (AKI) that is a common hospital problem resulting in higher mortality and morbidity. VExUS can predict patients at risk of developing AKI post cardiac surgery. VExUS has been associated with an increase in adverse outcomes in a general intensive care population. Hepatic vein ultrasound can manifest as a sequela of right heart failure and pulmonary hypertension. Intrarenal congestion suggests poorer prognosis in heart failure patients. VExUS score has been used in decision-making to remove fluid in patients with cardiorenal syndrome. VExUS scoring may help curtail overly aggressive fluid resuscitation for patients with septic shock and help avoid iatrogenic 'salt water drowning'. We summarize the technique and clinical practice of VExUS to help guide fluid balance across different populations of critically ill patients.