Clinical Course Of Patients Research Articles

The First Successful Living Donor Liver Transplantation for Acute-on-Chronic Liver Failure Caused by Severe Acute Necrotizing Pancreatitis: A Case Report

Liver transplantation (LT) is the only life-saving option when acute-on-chronic liver failure (ACLF) does not improve with conservative therapy. Acute pancreatitis (AP) can cause chronic liver disease progression to ACLF. However, deceased donor LT for patients with AP has had mixed results, and no consensus has been established regarding the indication for LT. We report the first successful living donor LT (LDLT) for ACLF caused by severe AP. The 38-year-old patient with alcoholic liver disease was transferred to our institute with worsening refractory ascites. During the pretransplant workup, she developed severe acute necrotizing pancreatitis, resulting in grade 3 ACLF. The patient's clinical course was further complicated by high levels of donor-specific antibodies and immune thrombocytopenia. The AP gradually improved after intensive care combined with artificial liver support. The patient successfully underwent urgent LDLT with upfront splenectomy and desensitization therapy, including plasm exchange, high-dose intravenous immunoglobulin, and anti-thymocyte globulin. No infection or recurrence of AP was observed postoperatively. We conclude that LDLT is a feasible option for ACLF patients caused by severe AP if a deceased donor is not readily available.

Choroidal Nevus Associated with Vitelliform Deposition in a Patient with Autosomal Dominant Best Dystrophy.

To describe the clinical, optical coherence tomography (OCT), fundus autofluorescence and ultrasound findings of a patient with a choroidal nevus actively exuding vitelliform material in the setting of Autosomal Dominant Best dystrophy (BD). The patient's clinical course was followed over time with ophthalmic examinations and multimodal imaging. A 71-year-old male with BD was referred for evaluation of a choroidal nevus in the right eye. Dilated fundoscopic exam showed a small pigmented choroidal nevus in the temporal periphery. Over a 3-year period the nevus developed progressive deposition of vitelliform material along its inferior border. Meanwhile, OCT and fundus photography showed only slight growth. Ultrasound showed no change in height; basal measurements were confounded by the increased vitelliform deposits. Genetic testing confirmed a heterozygous mutation in the BEST1 gene and electrophysiology was consistent with BD. Dysfunction of the retinal pigment epithelium associated with BD may cause novel presentations of other conditions such as choroidal nevi. The implications for malignant transformation of a choroidal nevus associated with vitelliform deposit accumulation in this context is unknown.

Clinical characteristics of patients with gastroesophageal reflux disease against type 2 diabetes mellitus, depending on the presence of obesity

Objective — to reveal the features of the clinical course in patients with gastroesophageal reflux disease (GERD) depending on anthropometric indicators against the background of type 2 diabetes mellitus (DM2).
 Materials and methods. The study involved 100 patients, who were divided into 3 groups: group 1 consisted of 60 patients with DM2 in combination with GERD, group 2 included 20 patients with isolated GERD, and group 3 included DM2 patients. The patients of group 1 were additionally divided into 2 subgroups: 27 subjects with normal weight and 33 subjects with excessive body weight (EBW) or obesity of various degrees. The control group consisted of 20 practically healthy people. The distribution of patients by gender and age was carried out in accordance with the standards of the international classification of age periods of the World Health Organization, revised in 2015. From the total number of patients, 44 (44%) were men and 56 (56%) were women. Body mass index (BMI) was calculated according to the Quetelet formula. Endoscopic examination of the upper part of the gastrointestinal tract with targeted biopsy was performed with an esophagogastroduodenoscope with end optics «Olympus GIF Q 150­03» (manufacturer Olympus Europa SE & CO. KG, Japan). To increase the diagnostic value of esophagogastroduodenoscopy, methods of chromoscopy and pinch biopsy of the esophageal mucosa were used.
 Results. Comparison of GERD manifestations with account of anthropometric data revealed significant differences in the subgroups with normal weight and obesity (p <0.05). Gastroenterological complaints were not registered in 6 (26.1%) patients of the obesity subgroup (DM2 + GERD + obesity) and 8 (21.6%) patients of the non‑obese subgroup (DM2 + GERD). In the subgroup with obesity (DM2 + GERD + obesity), the significant differences (p <0.001) were detected in heartburn depending on the obesity stage. Heartburn in this subgroup occurred 7.4 times more often than in patients with normal weight compared to the subgroup without obesity (odds ratio 89.13% (95%CI 12.83—137.77) χ2=35.06; р <0.0001). Cardiac symptoms in patients with increased body weight were revealed 12.3 times more often vs. subjects with BMI less than 25 kg/m2 (odds ratio 5.0 (95% CI 1.58 ‑14.10); χ2=6.95; р=0.008).
 The presence of heartburn complaints at the 2nd stage of obesity (39±5 kg/m2) and its absence at normal body mass (28±2 kg/m2), p <0.001) have been established. Analysis of the dependence of the Helicobacter pylori contamination degree on the BMI value showed no statistically significant differences between the subgroups with normal body weight and subgroup with EBW and obesity. The highest contamination degree was found in group 1 (DM2 + GERD) with the same number of positive results in both subgroups, with and without obesity.
 Conclusions. It has been established that excessive body weight and obesity significantly affect the development and progression of gastroenterological complaints in patients with DM2 combined with GERD. The heartburn was more often registered in patients with DM2 with obesity, than in those with normal weight. Comparison of GERD findings with anthropometric data revealed significant differences between the subgroups with normal body weight and obesity (р <0.05). Heartburn in the obesity subgroup occurred 7.4 times more often.

Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children’s Hospital

BackgroundAt Red Cross War Memorial Children’s Hospital (RCCH), it is the preferred practice to use non-ventriculoperitoneal (non-VP) shunts when the peritoneum is ineffective or contraindicated for cerebrospinal fluid (CSF) diversion and when endoscopy is not an option. The objective of this study is to evaluate the clinical course of patients having undergone these procedures.MethodA single-centre retrospective review at RCCH wherein 43 children with a total of 59 episodes of non-VP shunt placement over a 12-year period were identified for inclusion.ResultsTwenty-five ventriculoatrial (VA) and 32 ventriculopleural (VPL) shunts were analysed with a median age at insertion of 2.9 (0.3–14.9) and 5.3 years (0.5–13.4), respectively. The median number of previous shunt procedures prior to VA or VPL shunt insertion was 6.0 (2–28) versus 4.5 (2–17), respectively. Three VA (12.0%) and three VPL (9.4%) shunt patients were lost to follow-up. Of those remaining, 10 VA shunts (45.5%) compared to 19 (65,5%) VPL shunts required revision. One ventriculovesical shunt and one ventriculocholecystic shunt were placed in the same patient after 21 and 25 shunt-related procedures, respectively, and both were revised within 3 weeks of insertion. Median shunt survival was 8 months longer for the VA compared to the VPL shunts, being 13.5 (0–67) and 5 months (0–118), respectively. Complications for VA shunts were low, with the overall shunt sepsis rate in the VA group at 4% (n = 1) compared to 15.6% (n = 5) in the VPL group.ConclusionOur findings support that VA and VPL shunts are acceptable second-line options in an already compromised group of patients where safe treatment options are limited, provided attention is paid to the technical details specific to their placement.

Risk of transfusion-transmitted infection with severe acute respiratory syndrome coronavirus 2 from blood donors in Japan.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) essentially affects respiratory organs and tissues. SARS-CoV-2 RNAemia is often associated with more severe cases of coronavirus disease 2019 (COVID-19) compared to cases without RNAemia. To determine the impact of the pandemic on transfusion medicine, particularly transfusion-related infection, we examined the frequency of blood donation with RNAemia, the viral RNA (vRNA) concentration, and any possibility of transfusion-transmitted infection (TTI) among transfusion recipients. vRNA was examined in plasma/serum samples from 496 of 513 blood donors who reported having been infected with SARS-CoV-2 within 2 weeks of donation among a total of ca. 9.9 million blood donations in Japan between January 15, 2020, and December 31, 2021. The clinical course of patients transfused with the blood component containing vRNA was also examined. vRNA was detected in 23 of 496 samples. The median period from blood donation to COVID-19 onset was 1 day in 16 RNAemia-positive donors. Most samples had vRNA concentrations below the limit of quantification. Three patients were transfused with either a packed red blood cell or platelet concentrate that tested positive for vRNA, showing no COVID-19 symptoms and testing negative for vRNA in post-transfusion blood. The rate of RNAemia was 4.6% among blood donors who were found to be infected with SARS-CoV-2 shortly after donation, and vRNA concentrations in their donated blood were extremely low. There was no evidence of TTI in the recipients transfused with RNAemia-positive blood components. TTI risk in SARS-CoV-2 is negligible.

Glandular Crowdings in Endometrial Polyps: Clinical Follow-Up and Possible Worrisome Features.

Interpretation of changes and premalignant lesions in endometrial polyps can be challenging. We evaluated the clinical course of patients with focal gland crowdings in endometrial polyps via repeat biopsies and searched for possible morphological findings in the initial biopsy that may foresee a premalignant course. Specimens diagnosed as endometrial polyp and focal gland crowding in patients who had a repeat biopsy in a 1-year period were reexamined. Morphological findings in the initial biopsies were recorded. The group whose repeat biopsies were "premalignant or malignant" (Group 1), and the group with "benign" repeat biopsies (Group 2) were compared. "Endometrial polyp and gland crowdings" was diagnosed in 115 specimens of which 38 patients had repeat biopsies. Among these 8 (21%) were diagnosed as "endometrial intraepithelial neoplasia (EIN)" (Group 1) and 30 (79%) as "benign" (Group 2). Morphological features in the initial biopsies were evaluated; PAX2 loss was 6 of 8 (75%) for Group 1 and 7 of 30 (23%) for Group 2 (P = .020), and altered epithelial cytological features were present in 5 of 8 (62%) versus 4 of 30 (13%) (P = .015), both significantly higher in Group 1. Dark intraluminal secretion, intraluminal histiocytes, intraglandular epithelial proliferation, and mean diameter of crowded gland areas were not statistically different between the 2 groups. "Focal gland crowdings" in endometrial polyps do carry a risk of EIN in subsequent biopsies. We suggest that the loss/decrease of PAX2 and altered epithelial cytological features in these areas in the initial biopsy are indicative of a premalignant course.

The Clinical Relevance of an Inflamed Appendix in Crohn's Disease.

An appendectomy for appendiceal inflammation has been suggested to ameliorate the clinical course of patients with ulcerative colitis [UC]. In contrast, for Crohn's disease [CD] an inverse association has been suggested with a higher incidence of CD and worse prognosis after appendectomy. The aim of this study was to analyse the clinical relevance of an inflamed appendix in CD patients undergoing ileocaecal resection [ICR]. All consecutive patients undergoing primary ICR between 2007 and 2018 were considered for inclusion. Microscopic data of available appendiceal resection specimens [n = 99] were revised by a dedicated inflammatory bowel disease [IBD] pathologist and scored as inflamed or not inflamed. Eighteen patients had a previous appendectomy. Pathological findings were correlated with disease characteristics and recurrence rates [clinical, endoscopic, and intervention-related]. In total 117 patients were included, 77 [65.8%] females, with a median age of 30 years (interquartile range [IQR] 24-43), and a median follow up of 102 months [IQR 76-114]. Of patients without previous appendectomy [n = 99], 39% had an inflamed appendix. No significant differences in disease characteristics [eg, disease location, behaviour, time to surgery] or prognosis could be demonstrated between the two groups. In contrast, previous appendectomy [n = 18] was associated with penetrating disease and numerically shorter disease duration at the time of resection. Furthermore, a trend was seen towards a stronger association with postoperative recurrence. The current study could not confirm a different prognosis for CD patients with and without an inflamed appendix. In contrast, in patients with a previous appendectomy, a trend was seen towards increased postoperative recurrence, which might be related to the higher incidence of penetrating disease.

Factors influencing outcome in patients with perforated peptic ulcer disease at a South African tertiary hospital.

Perforated peptic ulcer (PPU) is associated with significant morbidity and mortality, particularly in low to middle income countries. This study aimed to scrutinise the clinical course of patients diagnosed with PPU and identify modifiable factors to improve outcomes. A retrospective review of the hybrid electronic medical record (HEMR) database at Grey's Hospital was performed. All patients diagnosed with PPU between January 2013 and December 2020 were entered into the study. The variables collected include age, ethnicity, comorbid profile, Boey score, type of surgery performed and complications. These factors were analysed to determine the factors responsible for morbidity and mortality. One hundred and ninety four patients were diagnosed with PPU during the study period. Six patients were treated non-operatively, all of whom survived. In the surgically treated group, omental patch repair was performed in 159 (84.5%) patients, and primary closure in 26 (13.8%) patients. The leak rate was 32% in the cohort that underwent relaparotomy and the overall mortality was 14%. There was no significant relationship between the type of repair performed and outcome. All patients had a Boey score of 1 or more. The following factors were found to increase the probability of in-hospital mortality: age > 40 years (OR: 8.49, 95% CI 2.46-29.29 p < 0.01), female gender (OR: 2.509, CI 0.98-6.37, p = 0.048), need for relaparotomy (OR: 0.398, CI 0.17-0.91, p = 0.027) and Boey score > 1 (OR: 46.437, CI 6.13-350.28, p < 0.01). A Boey score > 1 was the only variable that increased the likelihood of finding a leaking repair at relaparotomy (p < 0.01). The Boey score was a significant predictor of mortality and leak rate in our patients with PPU. Adding age as a variable may improve the ability to predict mortality in our setting, while the impact of gender and ethnicity needs further investigation.

A Linked Population-Based Analysis of Severe Lower Extremity Traumas in Ontario

Background: Successful management of open tibial fractures often requires a multidisciplinary approach. Previous literature has shown that admission to a trauma centre and coordinated management of early bony fixation and soft-tissue reconstruction improve patient outcomes. The objective of this study was to describe patients who had open tibial fractures in Ontario and analyse their outcomes. Method: Linked population-based administrative data pertaining to patients who had open tibia fractures between the years 2009 and 2020 were examined. Demographic information, admission location, timing of soft-tissue reconstruction, and complication rates were collected. Results: 4240 patients were identified. The mean age was 47, and the majority were males. One-third of the patients were admitted to a trauma centre. This group were more likely to have an Injury Severity Score &gt;15, and associated neurovascular injuries of the leg. When outcomes were compared over 1 year, the trauma centre group was more likely to undergo limb amputation, but also more likely to have a soft-tissue reconstruction. The average time to soft-tissue reconstruction was 20 days. Patients receiving care in a trauma centre were more likely to have an external fixation, plastic surgery consults, and longer hospital stay. There were no differences in the odds of infection, malunion or nonunion, and 30-day mortality. Conclusions: These findings provide a comprehensive examination of the clinical course for patients experiencing open tibia fractures in Ontario. Future studies can help facilitate coordinated efforts between different specialties to expedite care and improve overall outcomes.

Utility of rotational thromboelastometry in the management of massive haemorrhage at a regional Australian hospital.

Rotational thromboelastometry (ROTEM) allows targeted and individualised blood product replacement. The study aimed to determine the impact of ROTEM-guided transfusion on the clinical course of patients with acute massive haemorrhage in a regional Australian hospital. A retrospective review of all patients with acute massive haemorrhage that compared the characteristics, blood product use, and clinical outcomes of patients with massive haemorrhage before and after the introduction of ROTEM-guided transfusion. In per-protocol analysis, the 31/97 (32%) with ROTEM-guided transfusion used less packed red blood cells (median [interquartile range]: 6 [6-8] vs. 8 [6-12] units, p = 0.03) than patients whose transfusion was not ROTEM-guided. They were also less likely to receive fresh frozen plasma (2/31 [6%] vs. 45/66 [68%], p < 0.0001) or platelets (2/31 [6%] vs. 31/66 [47%], p < 0.0001); they were, however, more likely to receive fibrinogen products (26/31 [84%] vs. 38/66 [58%], p = 0.01). Patients receiving ROTEM-guided transfusion had lower in-hospital mortality (6/31 [19%] vs. 20/66 [30%], odds ratio 0.55 [95% confidence interval]: 0.20-1.55, p = 0.26) although this did not achieve statistical significance in this small cohort. ROTEM-guided massive transfusion of patients with acute haemorrhage in this regional Australian hospital led to a reduction in packed red blood cell, fresh frozen plasma, and platelet utilisation and may also have reduced mortality.

Transfusion-Associated Reversible Cerebral Vasoconstriction Syndrome in Pediatrics: A Case Report and Review of Literature

Background Reversible cerebral vasoconstriction syndrome (RCVS) is a rare complication of packed red blood cell (pRBC) transfusion primarily reported in adults with severe chronic anemia due to menorrhagia. It is characterized by a triad of rapidly changing and reversible segmental cerebral artery narrowing and dilatation, thunderclap headache, and benign cerebrospinal fluid findings. 1,2 More than 50% of patients experience blurring of vision or cortical vision loss, and a subset of patients develop hemiparesis or aphasia. 1 There are emerging case reports of RCVS in pediatric patients, however the literature examining this transfusion complication in children is limited. The rarity and potential severity of RCVS warrants better understanding by pediatric hematology and transfusion providers. Results We describe a previously healthy 4 year-old male who presented with pallor and laboratory parameters consistent with severe iron deficiency anemia. Chest x-ray showed cardiomegaly, and echocardiogram demonstrated pericardial effusion, moderate left ventricular dilation, and moderate coronary artery dilatation. His history was notable for an extremely selective diet and at least 50 ounces of cow's milk daily. The patient was admitted, and over the course of 3 days, he received a total of 43 mL/kg of pRBCs (602 mL total) in 8 aliquots, and his hemoglobin (Hgb) increased from 1.4 g/dL to 11.4 g/dL (Fig. 1). He then re-presented 5 days after discharge with altered mental status and malignant hypertension. Brain MRI/MRA was consistent with RCVS, with luminal irregularities in multiple anterior and posterior circulation intracranial arteries creating a beaded appearance. He was treated supportively with aggressive blood pressure control and made a complete neurologic recovery 8 days after presentation. At hematology clinic follow-up 2 months post-discharge, he remained at his typical neurologic baseline. Conclusions The connection between blood transfusion and RCVS is postulated to be due to a rapid increase in hematocrit and blood viscosity, which alters cerebral autoregulation and leads to hypertensive encephalopathy despite systemic normotension. 3 The increased viscosity may also lead to vasospasm. 3 When a patient with severe chronic anemia receives a pRBC transfusion, there is increased cerebral blood flow and viscosity, resulting in decreased vasodilation, increased vascular resistance, and cerebral vessel constriction. However, these are hypothesized mechanisms with little supportive experimental data. Vasculopathies and vasoconstrictive medications 2 are also risk factors for RCVS. There are 4 previous reported cases of pediatric RCVS associated with pRBC transfusion. 2 patients were acutely ill with complications of sickle cell anemia. 7,9 Another case occurred in a patient with systemic lupus erythematosus 8, and the fourth occurred in the setting of severe iron deficiency anemia. 5 Several features of our patient's clinical course are similar to the reported cases of transfusion-related RCVS 5 and warrant highlighting: 1) severe chronic anemia with cardiac dysfunction and 2) the large volume of transfused pRBCs over a short period resulting in a significant increase in Hgb. However, our patient developed symptoms of RCVS sooner than other published cases and did not have seizure or stroke. Pediatric guidelines recommend pRBC transfusion for Hgb levels between 5-10 g/dL, depending on the clinical scenario. 4 There are few data to guide Hgb targets for pediatric patients presenting with severe anemia. Over-transfusion does not offer physiological benefit and poses risk of transfusion-related adverse events. A case report from Dou et al 6 proposed that a &amp;gt;5 g/dL Hgb increase was associated with a greater likelihood of developing RCVS. For this patient with cardiac dysfunction and social concerns including lack of primary care, the potential benefits of achieving a higher Hgb with pRBC transfusions were prioritized. RCVS should be considered in pediatric and adult patients recently transfused for chronic severe anemia presenting with headaches or other neurological symptoms. Prompt recognition of RCVS may prevent unnecessary treatment and potentially limit risk of neurologic compromise. The role of the volume and rapidity of the pRBC transfusions in the development of RCVS warrants further study. Fig 1. Timeline of initial presentation, detailing blood transfusions

Detrimental impact of immunosuppressive burden on clinical course in patients with Cytomegalovirus infection after liver transplantation.

Cytomegalovirus (CMV)-infection and reactivation remain a relevant complication after liver transplantation (LT). The recipient and donor serum CMV-IgG-status has been established for risk stratification when choosing various pharmaceutical regimens for CMV-prophylaxis in the last two decades. However, factors influencing course of CMV-infection in LT remain largely unknown. In this study, the impact of immunosuppressive regimen was examined in a large cohort of patients. All patients that underwent primary LT between 2006 and 2018 at the Charité-Universitaetsmedizin, Berlin, were included. Clinical course as well as histological and laboratory findings of patients were analyzed our prospectively maintained database. Univariate and multivariate regression analysis for impact of variables on CMV-occurrence was conducted, and survival was examined using Kaplan-Meier analysis. Overall, 867 patients were included in the final analysis. CMV-infection was diagnosed in 325 (37.5%) patients after transplantation. Significantly improved overall survival was observed in these patients (Log rank=0.03). As shown by correlation and regression tree classification and regression tree analysis, the recipient/donor CMV-IgG-status with either positivity had the largest influence on CMV-occurrence. Analysis of immunosuppressive burden did not reveal statistical impact on CMV-infection, but statistically significant inverse correlation of cumulative tacrolimus trough levels and survival was found (Log rank<.001). Multivariate analysis confirmed these findings (p=.02). CMV-infection remains of clinical importance after LT. Undergone CMV-infection of either recipient or donor requires prophylactic treatment. Additionally, we found a highly significant, dosage-dependent impact of immunosuppression (IS) on long-term outcomes for these patients, underlying the importance of minimization of IS in liver transplant recipients.

Outcome of Adjuvant Chemo-Radiation in Operated Locally Advanced Rectal Cancer in a Tertiary Hospital in Bangladesh

Rectal cancer is the one the common cancer in Faridpur, Bangladesh. The clinical course of patient treated with surgery alone has been characterized by a high death rate and also by the pain and disability associate with pelvic recurrence of the tumor. Adjuvant chemotherapy combined with radiation has been studied for prevention of such reoccurrence. Most of the patients at our center are those who have already been in subjected to surgery in this hospital or other private hospital in this district or other district hospital. We studied role of Oxaliplatin and Capcitabine with Radiotherapy in AJCC stage IIB to IIIC locally advanced rectal cancer and toxicities in adjuvant settings. This study was done to assess the outcome of adjuvant chemoradiation in operated locally advanced treated cancer patients. A total of 30 patients were included in between June 2016 to June 2019 in non-randomized clinical trial. About 66.6% of the patient underwent low anterior resection and 33.3% had abdominoperineal resection. Patients were treated postoperatively with Oxaliplatin and capcitabine. Radiotherapy of 45 Gy in 20 fractions were delivered in concurrently with Capcitabine 825 mg/m2 from day 1 to day 5 of Radiotherapy at National Institute of Cancer Research and Hospital, Mohakhali, Dhaka, median follow-up was 3 years. At 3 years overall survival of operated patient was 66.3% with no disease relapse. Toxicities of this schedule were mostly Anemia and Gastrointestinal mucocitis but without treatment interruption. Combination of adjuvant chemotherapy and radiotherapy is effective modality in reducing local tumour recurrence and improves survival. Bangabandhu Sheikh Mujib Med. Coll. J. 2023;2(2):101-105.

Multinodal Cervical Angiomyomatous Hamartoma.

Angiomyomatous hamartoma (AMH) is a rare benign lesion of the lymph nodes. Angiomyomatous hamartoma tends to be found in inguinal lymph nodes, and usually in a single lymph node. We present a rare care case of a 53-year-old presenting with a neck lump, found to be AMH involving multiple lymph nodes in her neck. To our knowledge, this is the first case presenting with multiple nodes in this location. There are a limited number of case reports describing magnetic resonance imaging (MRI) features of AMH lesions located in inguinal and head and neck regions. Our MRI findings revealed the mass had intermediate T1 enhancement, high T2 signal enhancement, and high post-gadolinium enhancement and fat saturation of the lesion. Angiomyomatous hamartoma is a histological diagnosis, distinguished from other similar nodal vascular lesions by a number of key features: including the presence of central nodal distribution, muscular blood vessel walls, adipose tissue, and HMB45 negative staining. Early recognition of this benign lesion may have implications for a patient's clinical course and surgical requirements.

Prevalence, causes, and clinical course of patients with surgical reintervention due to complications during cesarean section.

The objective of the study is to identify the prevalence, causes, and clinical evolution of patients with surgical reintervention due to complications during cesarean section. The file of the Toco-Surgical Unit of the Gynecological Obstetrics Hospital No. 3 of the National Medical Center "La Raza" Mexican Institute of Social Security was reviewed to know the total number of patients undergoing cesarean section from January to December 2019 and cases with reintervention due to complications during cesarean section were selected. Their general data, the cause of reintervention, stay in the intensive care unit (ICU), hospital stay, and mortality were studied. The data were analyzed with descriptive statistics using the statistical program SPSS version 20. It was found that 3371 patients underwent cesarean section, of which 1.60% (54 cases) underwent reoperation for the following reasons: Unpacking 27.79%, obstetric hemorrhage 20.37%, bleeding due to uterine atony 20.37%, hysterotomy commissure hematoma 18.52%, uterine infiltration 3.70%, vascular injury 3.70%, bladder injury 3.70%, and colonic injury 1.85%. The ICU stay was 3.79 ± 2.03 days, hospital stay was 13.67 ± 11.16 days, and mortality was 1.85%. The prevalence of reintervention was reduced, bleeding was the main cause, and the clinical evolution was satisfactory with low mortality.

Characteristics and outcomes of immunotherapy-related liver injury in patients with hepatocellular carcinoma versus other advanced solid tumours

Immune-related liver injury (irLI) is commonly observed in patients with cancer treated with immune checkpoint inhibitors (ICIs). We aimed to compare the incidence, clinical characteristics, and outcomes of irLI between patients receiving ICIs for hepatocellular carcinoma (HCC) vs. other solid tumours. Two separate cohorts were included: 375 patients with advanced/unresectable HCC, Child-Pugh A class treated with first-line atezolizumab+bevacizumab from the AB-real study, and a non-HCC cohort including 459 patients treated with first-line ICI therapy from the INVIDIa-2 multicentre study. IrLI was defined as a treatment-related increase of aminotransferase levels after exclusion of alternative aetiologies of liver injury. The incidence of irLI was adjusted for the duration of treatment exposure. In patients with HCC, the incidence of any grade irLI was 11.4% over a median treatment exposure of 4.4 months (95% CI 3.7-5.2) vs. 2.6% in the INVIDIa-2 cohort over a median treatment exposure of 12.4 months (95% CI 11.1-14.0). Exposure-adjusted-incidence of any grade irLI was 22.1 per 100-patient-years in patients with HCC and 2.1 per 100-patient-years in patients with other solid tumours (p <0.001), with median time-to-irLI of 1.4 and 4.7 months, respectively. Among patients who developed irLI, systemic corticosteroids were administered in 16.3% of patients with HCC and 75.0% of those without HCC (p<0.001), and irLI resolution was observed in 72.1% and 58.3%, respectively (p= 0.362). In patients with HCC, rates of hepatic decompensation and treatment discontinuation due to irLI were 7%. Grade 1-2 irLI was associated with improved overall survival only in patients with HCC (hazard ratio 0.53, 95% CI 0.29-0.96). Despite higher incidence and earlier onset, irLI in patients with HCC is characterised by higher rates of remission and lower requirement for corticosteroid therapy (vs. irLI in other solid tumours), low risk of hepatic decompensation and treatment discontinuation, not negatively affecting oncological outcomes. Immune-related liver injury (irLI) is common in patients with cancer receiving immune checkpoint inhibitors (ICIs), but whether irLI is more frequent or it is associated with a worse clinical course in patients with hepatocellular carcinoma (HCC), compared to other tumours, is not known. Herein, we compared characteristics and outcomes of irLI in two prospective cohorts including patients treated with ICIs for HCC or for other oncological indications. irLI is significantly more common and it occurs earlier in patients with HCC, also after adjustment for duration of treatment exposure. However, outcomes of patients with HCC who developed irLI are not negatively affected in terms of requirement for corticosteroid therapy, hepatic decompensation, treatment discontinuation and overall survival.

Development of Multiple Facial Lipomas During Immunotherapy for Metastatic Squamous Cell Carcinoma

An 85-year-old Caucasian male on immunotherapy for metastatic squamous cell carcinoma presented with enlarging lipomas in the area of his previous invasive squamous cell carcinoma of the lower lip and chin, status post resection, reconstruction and local radiation. The development of multiple lipomas during immunotherapy is a novel association which has yet to be reported in the literature. We discuss a putative mechanism of action of pembrolizumab-induced lipomas and describe the patient's clinical course.

Clinical profile, treatment strategy and prognostic value of intraventricular thrombus detection

Abstract Background The clinical course of patients with intraventricular thrombus (IVT) is highly variable. Controversy still exists about the length of anticoagulant treatment and its prognostic relevance. Purpose Our objective is to describe the epidemiology and clinical course of patients with IVT. Methods All patients with an echocardiographic finding of IVT in our tertiary hospital between 2005 and 2021 were retrospectively analyzed. Demographic, clinical, echocardiographic, and treatment variables were collected. Patients were followed-up to 24 months. Results A total of 195 patients with IVT were finally included. The 84.4% were male and the mean age was 65.4 ± 14.1 years. Baseline characteristics are shown in the Table. The diagnosis of IVT was mostly made in the context of an acute myocardial infarction (AMI) (55.9%), of which 60.5% had new-onset ST-segment elevation AMI and 23.5% evolved infarction. The thrombus finding was incidental in 38.0% of the cases while 5.6% debuted as stroke. Regarding the morphological characteristics, 40.5% of the thrombi were sessile, 31.2% mural shape, and 28.3% pedicled. At diagnosis, the LVEF was 38.6 ± 11.7% with an end-diastolic volume of 132.3 ± 64.2ml. Once diagnosed 86.7% of patients were on anticoagulation, 55.4% on 2PY12 inhibitor and 78.5% on acetylsalicylic acid. At 12 and 24 months, the proportion of anticoagulated patients was significantly reduced (62% and 59.4%, respectively). 24.9% continued with a P2Y12 inhibitor at 12 months and only 9% at 2 years. During follow-up, 24.4% of the patients had events at 6 months (2.4% AMI, 7.2% stroke, 2.4% systemic embolism and mortality was 14.7%). In this period there were 8.9% of hemorrhages. The proportion of ischemic events and mortality decreased at one year (5.6%) and at two years (12.1%). Complete IVT clearance was documented in 87% and the median time to resolution was 119 days [49.5-347.5]. IVT recurrence was observed in 10.7% of the cases, up to 50% detected before 2 years from diagnosis. Conclusions Most patients with IVT were diagnosed after an AMI. Despite current recommendations, more than 50% of patients continued anticoagulation at 2 years. A quarter developed events 6 months after diagnosis, and this proportion decreased significantly after this period. A recurrence rate of 10.7% was observed in our population.

Suspected cardiac masses evaluation with cardiac magnetic resonance : histological correlation and clinical outcomes

Abstract Background Cardiac masses are an heterogeneous group of very rare formations, representing a major diagnostic challenge given the difficulty in assessing their nature through imaging examinations. Cardiac Magnetic Resonance (CMR) is a noninvasive key diagnostic tool providing anatomical, functional, and tissue characteristic information. However, data validating this imaging approach are limited. Purpose analyze the clinical and CMR features of patients with benign and malignant tumors and thrombus; asses the diagnostic accuracy of CMR in comparison with the histologic examination; evaluate the prognostic rule of clinical and CMR features in predicting the primary endpoint of all cause mortality. Methods 92 Patients undergoing CMR for suspected cardiac mass between June 2004 and January 2022 were retrospectively evaluated. Patients with no mass 8 (9%) or pseudo-mass 11 (12%) were excluded. Based on CMR images, masses were divided into benign tumor, malignant tumor, and thrombus. Clinical, CMR and histological data were collected. Results 73 patients (mean age: 62±15; 51% female) with masses were finally enrolled, 27 (37%) with a diagnosis at CMR of benign tumor, 22 (30%) with malignant tumor, and 24 (33%) with thrombus. Several clinical and CMR variables were significantly associated with one type of mass rather than another. Among clinical variables the history of malignancy and smoking were seen in patients with malignant tumors (p&amp;lt;0,002) while dyspnea and chest pain were significantly found in patients with thrombi (p&amp;lt;0,016). Among CMR features high size, infiltration, pericardial repeats, pericardial effusion, signal inhomogeneity, First Pass Perfusion (FPP) and Late Gadolinium Enhancement (LGE) were associated with malignant masses (p=0.001), while reduced pre-contrast visualization, altered kinetics, low ejection fraction (EF) and long-TI were observed in thrombi (p=0.001). CMR was accurate in 91.2% (31/34) of patients in comparison with the histological examination. Accuracy for benign tumors was 91.3% (AUC=0.913), for malignant tumors 94% (AUC=0.940) and for thrombi 83% (AUC=0.833). Patients diagnosed at CMR with thrombus had similar mortality as those with benign tumor (p=0,678) while patients with malignant lesions had higher mortality (HR: 4.98 [95% CI: 1.11-22.2], p=0,035). Regardless of diagnosis at CMR, age, tumor history, mass size, signal inhomogeneity, presence of FPP, pericardial effusion, and pericardial repeats were found to predict long-term mortality (p&amp;lt;0.017). Conclusions Although CMR has high diagnostic accuracy, histologic examination remains the diagnostic gold standard in determining the type of cardiac mass. CMR is additionally useful in predicting the outcome and manage the clinical course of patients with suspected cardiac masses.

Improving risk stratification of moderate aortic stenosis

Abstract Background The clinical course of patients with moderate aortic stenosis (AS) remains ill-defined. While a watchful waiting approach is advocated by international guidelines, several studies suggest that the long-term prognosis of these patients is worse than previously considered and may even be similar to patients with severe AS. Whether these findings reflect a subgroup of moderate AS with a high comorbid burden or rapid progression to severe AS is not known. Purpose This study sought to 1) analyze the clinical course of AS throughout all stages of the disease, 2) unveil different trajectories of progression through clustering analysis, 3) explore their impact in all-cause death. Methods Patients with mild to severe AS in seriated echocardiograms (TTE) were retrospectively identified after excluding for abnormal flow conditions. Aortic peak velocity (APV) was used to monitor disease progression. A sigmoid function was used to model APV throughout time. Individual acceleration rates coefficients were calculated using random-effects models and patients were then clustered into rapid (RP) and slow progressors (SP). Results This study included 914 patients (age 76 ± 8 years, 52% female, median follow-up time 6.8 years). 483 patients were clustered as RP (53%) and 431 as SP (47%) based on their individual acceleration rate coefficients (core parameter of sigmoid model). Since the core parameter is constant throughout time and evaluations, only two consecutive TTEs per patient are needed to calculate the acceleration rate coefficient. The time interval required between these seriated TTEs varies between 9 and 14 months. No clinical variables were consistently associated with each cluster. When comparing mortality hazard rates for SP with RP across the range of APV, we found that rapid progression was persistently associated with excess mortality (HR 1.35, CI [1.07-1.69]; p=0.01; after adjusting for demographics, comorbidities, baseline AS severity, and time-dependent aortic valve replacement [AVR]). Using the upper limit of the mortality rate of a SP with an APV of 4 m/s as a reference, we found that a RP significantly exceeded this threshold with an APV velocity of only 3.2 m/s. We built a predictive model which incorporated the AS progression on top of guideline-derived AVR triggers to assign patients with a predicted probability of death ≥ 50% at 5 years to AVR. Using this model, we estimated that an extra death can be prevented for every 100 patients treated without exposing more patients to unnecessary AVR. Conclusion We identified two clusters of AS progressors, based on APV from two consecutive TTEs. RP displayed higher mortality rates across all the range of APV which can explain why same patients with moderate AS have a dismal prognosis. Since RP patients have excess adverse outcomes in early stages of AS (moderate AS), a lower APV threshold may be required to better reflect the prognosis of AS and trigger treatment.