Extremity Edema Research Articles

#2367 Membranoproliferative glomerulonephritis preceding non-Hodgkin lymphoma recurrence : a case report

Abstract Background and Aims Glomerulonephritis (GN) have been known to be associated with both chronic lymphocytic leukemia and non-Hodgkin's lymphoma. Membranoproliferative Glomerulonephritis (MPGN) is the most commonly reported histological diagnosis in these diseases. Method This report presented a rare case of membranoproliferative glomerulonephritis preceding non- Hodgkin lymphoma recurrence. Results In September 2023, we report the case of a 75-year-old woman with Sjögren's syndrome, systemic lupus erythematosus and hypertension history. Two years prior, she developed non Hodgkin lymphoma requiring chemotherapy with cyclophosphamide, prednisone, rituximab, and vincristine. It has remained in remission. She was admitted to our department with peripheral edema complaint. Physical examination showed edema in the lower extremities. The blood pressure was 130/85 on her antihypertensive regimen. No lymphadenopathies were found. She had mild proteinuria, microhematuria and reduced estimated glomerular filtration rate. The serum creatinine level was 190 µmol/l. She had 1.8 gr/day proteinuria. Laboratory data showed decreased levels of serum C3, C4. Anti-nuclear antibody (ANA) screens were negative. The cryoglobulins test was negative. Hepatitis B, hepatitis C, and HIV serologies were negative. Renal biopsy was performed and resulted as membranoproliferative glomerulonephritis with positive IgM immunofluorescence stain (Figs 1 and 2). We therefore concluded to a membranoproliferative glomerulonephritis with monotypic immunoglobulin deposits. After investigations, she got recurrent non-Hodgkin lymphoma diagnosis. Discussion GN may precede, coexist, or follow the diagnosis of lymphoma by several years. The pathogenesis of paraneoplastic GN remains uncertain, although autoimmune mechanisms and T-lymphocyte dysfunction may be important in this respect. Conclusion Secondary membranoproliferative glomerulonephritis can be observed in non-Hodgkin lymphoma patients but there are few reports about clinical results of lymphoma treatment. There is limited information available concerning the effects of treatment of non-Hodgkin's lymphoma on the progression of non-Hodgkin's lymphoma associated membranoproliferative glomerulonephritis.

#2475 Glomerulonephritis associated with anti -TNF-α therapy

Abstract Background and Aims Biologic agents like tumor necrosis factor α inhibitors/ anti-TNF-α/, IL6 and CD80/26 are widely used in many rheumatologic diseases but these may also elicit effects on renal function. These drugs, as well as rheumatic diseases themselves, can cause autoimmune renal disorders. Though effective on the main inflammatory process the incidence of kidney injury associated with their administration is increasing. Various forms of glomerulopathies have been described in connection with biological therapy - proliferative lupus nephritis, oligo immune necrotizing crescentic glomerulonephritis, membranous glomerulonephritis, IgA nephropathy and others. Method We report the clinical and pathologic findings in two patients with Rheumatoid arthritis and Ankylosing spondylitis on biologic therapy with an anti-TNF-α agent. During the treatment they presented with nephritic syndrome requiring kidney histology. Results Case 1: The first patient is a 52-year-old man diagnosed with ankylosing spondylitis, HLA-B27 positive, 15 years before admission. Four years before admission treatment with Golimumab /anti-TNF-α/ has been initiated. During the follow-up period urine tests revealed proteinuria and hematuria, which required more detailed tests. The patient presented with clinical features of nephritic syndrome, marked lower extremity edema, hematuria, nephrotic range proteinuria, impaired hypertension control. Kidney biopsy revealed membranoproliferative glomerulonephritis. It was assumed that kidney injury was most likely associated with Golimumab therapy. Its administration was discontinued, and therapy was started with pulses of Methylprednisolone 500 mg i.v. in three consecutive days, Cyclophosphamide 500 mg i.v., repeated the second and third month, followed by low steroid doses 0,5 mg/kg with gradual tapering. Mycophenolate Mofetil 1500 mg was started from the third month. General condition and laboratory results improved considerably. The occurrence of stiffness and pain in the sacroiliac joints several months after stopping biologic treatment necessitated the inclusion of Sulfasalazine to the therapy. Initiation of therapy with another class of biologic agent, Anti-IL-17 monoclonal antibody, was discussed with the follow-up rheumatologists. Case 2: The second patient is a 66-year-old woman, with a history of hypertension and essential thrombocythemia, who was diagnosed with seropositive rheumatoid arthritis 3 years before admission, treated with Adalimumab /anti-TNF-α/. Follow-up examinations revealed low-grade proteinuria, hematuria and impaired renal function. Kidney biopsy revealed IgA nephropathy. Following the discontinuation of Adalimumab, the patient was treated with pulses of Methylprednisolone 500 mg i.v. in three consecutive days, Cyclophosphamide 500 mg i.v., repeated the second and third month, followed by low steroid doses 0,5 mg/kg with gradual tapering. Kidney function significantly improved at the third month of treatment and proteinuria was gradually reduced. Initiation of Rituximab /antiCD20/ treatment was discussed with rheumatologists. Conclusion Treatment with biological drugs can cause immune-mediated glomerular disorder/IGD/. These events are rare, and the causative effects of a specific drug is hard to establish. When a patient is suspected of having an IGD, kidney biopsy should be performed for the exact diagnosis. The drug should be discontinued, and the treatment for the new-onset renal disorder should be promptly started. A rechallenge test of the same or a similar drug should be avoided, whereas switching to a different therapy is a reasonable option.

CARDIOVASCULAR TOXICITY IN METASTATIC PROSTATE CANCER TREATMENT: BALANCING RISKS, TREATING CONSEQUENCES

Abstract Introduction Enzalutamide inhibits the receptor of androgen hormones. It is administered for treating metastasized prostate cancer. Enzalutamide is known to have a cardiotoxic effect. Case Report A 76 year–old man on–treatment for hypertension and overall good health underwent radical prostatectomy and bilateral ileo–obturator lymphadenectomy in 2021 for prostate cancer. In July 2023, infiltrated lymph node and lung/bone metastases were identified. Therefore, oncologist started Enzalutamide administration, i.e. Androgen Deprivation Therapy. Ecocardiography before therapy showed no alterations in cardiac morphology with normal left ventricle ejection fraction (LVEF). Three months after Enzalutamide administration, he experienced worsening dyspnea and peripheral lower extremity edema. He was admitted to the emergency Department of our hospital due to worsening dyspnea at rest, diffuse crackles and increased values in brain natriuretic peptide (BNP, 3203 pg/mL) and troponins. He was transferred to Intensive Care Unit for acute heart failure. Instrumental findings: 2D ECHOCARDIOGRAPHY: LVEF ∼20%, marked global hypocontractility at strain evaluation (GLS –9.3%); LUNG ULTRASOUND: abundant bilateral basal pleural effusion on the right extending to the middle field with atelectasis of the contiguous parenchyma; 24h Holter ECG: frequent supraventricular and ventricular ectopic arrhythmias. He begins non–invasive ventilation (NIV), high–dose diuretics, and Levosimendan. We observed amelioration in symptoms, reduction in pleural effusion, peripheral edema, and BNP levels (from 3203 pg/ml to 468.6 pg/ml). We proceed with weaning from NIV by monitoring respiratory function and performance by means of blood gas analysis. Amelioration in congestion status was evaluated by bioimpedance. After clinical stabilization, coronary angiography was performed which highlighted a bi–vessel obstructive coronary artery disease (long critical stenosis, ∼80%, on the proximal–middle section of the left anterior descending artery, ∼70% at middle section of circumflex and proximal section of first margianl). Therefore, revascularization by PCI plus DES was performed on proximal–middle LAD and on CX–MO1. Patient was discharged soon after in stable condition and underwent outpatient follow–up. Conclusions Enzalutamide might provoke important cardiotoxic effects. It might induce acute cardiac impairment and/or coronary artery diseases. Further analysis and evaluations should be performed.

A CATASTROPHIC COMPLICATION OF A CHEST TRAUMA: A CASE REPORT

Abstract A 43 year old patient came to the Emergency Department of our hospital for a cardiology visit. The EKG revealed polymorfic ventricular tachycardia with a heart rate of 160 bpm so that he was admitted to the Intensive Care Unit. In 2005, he had a post traumatic myocardial infarction after a car accident treated with the implantation of one drug eluted stent on the descending artery. Three years later, a single–chamber ICD was placed. On admission in Intensive Care Unit, cardiac auscultation revealed normal heart sounds without murmurs. No lower extremity edema was observed. A transthoracic echocardiogram showed general hypokinesis with reduced global left ventricle systolic function and no pericardial effusion (EF=20%). The patient was haemodynamically stable, the blood pressure was of 130/80 mmHg. The device was also interrogated and it showed six ineffective attempts of antitachycardia pacing. After that, the patient was given an effective intracavitary shock. Moreover, the patient underwent coronary angiography which showed no disease progression and patency of the stent previously implanted on the proximal descending artery. The electrophysiological study was performed and subsequently 3 ventricular ectopic focuses were effectively ablated. Multiple DC shocks were delivered during the procedure and the atrioventricular bundle was damaged. In consideration of the clinical features and the left ventricular reduced ejection fraction, an indication to the implantation of CRT–D was given. Conclusions This case report describes a rare complication of a blunt chest trauma. A young patient with no significant past medical history suffered a dissection of the coronary descending artery resulting in ST–elevation myocardial infarction. The mechanism of coronary occlusion following blunt chest injury may be due to: shear force applied to the coronary arteries leading to intraluminal thrombosis; vascular rupture; embolism to the coronary arteries; fissuring of an atherosclerotic plaque with dislodgment of plaque material; vascular spasm at the site of the injury. Anyway, severe left ventricular dysfunction caused the developing of polymorfic ventricular tachycardia which was unresponsive to medical treatment and was treated with ablation.

Effect of Early Rehabilitation Exercise on Lower Limb Function and Psychological State After Coronary Artery Bypass Grafting: A Randomized Controlled Trial

Background: While early rehabilitation exercise has been shown to improve cardiopulmonary function and functional outcomes after revascularization in individuals who have undergone coronary artery bypass grafting (CABG), further research is still needed to fully understand the importance of psychological status and limb functional rehabilitation following CABG. Therefore, the purpose of this study was to investigate the effects of early rehabilitation exercise on lower limb function and mental health after coronary artery bypass grafting. Methods: Eighty patients who underwent CABG were randomly divided into a routine exercise group and an early rehabilitation exercise group. The degree of lower limb swelling, the amount of incision complications, the first time the patient got out of bed after the operation, the length of postoperative hospital stay, activity tolerance and postoperative psychological state were compared between the two groups. Results: The incidence of postoperative lower extremity oedema was 30% in the early rehabilitative exercise group as compared to 52.5% in the routine exercise group. Between the two groups, there was a statistically significant difference (p < 0.05) in the incidence of postoperative lower limb edema as well as the amount of swelling in the thighs and ankles on postoperative days 1, 3, and 5. In the routine exercise group, the first time the patients got out of bed was 3.45 ± 1.09 days, and the length of postoperative hospitalization was 12.75 ± 5.06 days. In the early rehabilitation exercise group, the first time the patients got out of bed was 1.93 ± 0.57 days, and the length of postoperative hospitalization was 9.50 ± 2.92 days. There were statistically significant differences in these two indices between the two groups (p < 0.05). The activity tolerance of patients in the routine exercise group was 46.10 ± 19.09 min at 2 months after surgery and 69.88 ± 19.05 min at 3 months after surgery. The activity tolerance of patients in the early rehabilitation exercise group was 56.40 ± 17.42 min at 2 months after surgery and 105 ± 23.04 min at 3 months after surgery, and there was a significant difference in activity tolerance between the two groups at these time points following surgery (p < 0.05). In addition, there were statistically significant differences in the Patient Health Questionnaire-9, Generalized Anxiety Self-Assessment Scale-7 and Pittsburgh Sleep Quality Index scores between the two groups (p < 0.05). Conclusions: Early rehabilitation exercises can promote the recovery of lower limb function after CABG to a certain extent, shorten the postoperative bed rest time and hospital stay, and effectively improve postoperative psychological well-being and sleep quality.

Edema of the upper extremity on the unaffected side in unilateral breast cancer patients.

Breast cancer-related lymphedema (BCRL) occurs usually on the affected side, and its cause and pathophysiology are well known. However, the cause of edema of the upper extremity on the unaffected side is barely known. It is often considered to be chemotherapy-induced general edema, and clinical evaluation is rarely performed in these patients. This study aimed to present the clinical characteristics of unilateral breast cancer patients with edema of upper extremity on the unaffected side, and to emphasize the importance of early diagnosis and medical interventions. This study retrospectively analyzed the medical records of unilateral breast cancer patients complaining edema of upper extremity on the unaffected side, from January 2020 to May 2021. Lymphoscintigraphy was used to assist in confirming the diagnosis of lymphedema, and Doppler ultrasonography or 3D computed tomography angiography were performed to differentiate vascular problems. Fourteen patients were enrolled in the study. Seven, 3, and 4 patients had edema of both upper extremities, edema of the upper extremity on the unaffected side only, and edema of all extremities, respectively. None of the 4 patients with edema of all extremities showed abnormal findings on examination. In patients with edema in the upper extremity on the unaffected side alone, lymphatic flow dysfunction was seen in 2 patients, and deep vein thrombosis (DVT) was diagnosed in 1. In patients with edema of both upper extremities, lymphatic flow dysfunction was seen in 2 patients, and DVT was diagnosed in 3. One patient had DVT and accompanying lymphatic flow dysfunction. Lymphedema and DVT were diagnosed in a number of patients with edema of the upper extremity on the unaffected side, and lymphedema can occur without direct injury to the lymphatic flow system. Therefore, clinicians should not overlook the fact that diseases that require early diagnosis and treatment can occur in patients with edema of the unaffected upper extremity.

Femoral vein translocation for complex hemodialysis access

ObjectiveVascular access is difficult in patients without suitable arm veins and prior graft infections. The use of femoral vein translocation (FVT) to the upper extremity or contralateral lower extremity for hemodialysis access may be associated with low infection rates and high patency rates. FVT is used for patients without central venous occlusion who have failed prior access either owing to graft infection or repetitive graft thrombosis. The largest case series consists of 30 cases. The objective of this study is to determine the infection incidence, primary patency, primary-assisted patency, and secondary patency rates among FVTs. MethodsA retrospective chart review was performed on all patients who underwent FVT by a single vascular practice over a 10-year period (2013-2023). Study variables included length to last follow-up (months), prior access, prior graft infection, comorbid conditions, primary patency, primary-assisted patency, secondary patency, postoperative steal syndrome, postoperative graft infection, postoperative harvest site complication, and postoperative lower extremity compartment syndrome. ResultsA total of 131 FVTs were performed from 2013 to 2023; 126 patients (47% male, 53% female; 76% Black, 24% White) with a mean age of 52 ± 14 years and a mean body mass index of 29 ± 8 had at least 1 month of follow-up and were included for analysis. The median follow-up was 46 months (interqurtile range, 19-72 months). The mean number of prior permanent accesses was 2.5 ± 1.4. Forty-eight percent of patients had prior graft infections. The primary, primary-assisted, and secondary patency rates were 66%, 93%, and 98%, respectively, at 6 months; 43%, 85%, and 96% at 12 months; 25%, 70%, and 92% at 24 months; 16%, 61%, and 88% at 36 months; and 14%, 56%, and 82% at 48 months. Postoperative steal syndrome and postoperative access infection requiring excision was observed 16% and 5% of patients, respectively. Harvest site complications requiring an additional procedure occurred in 19% of cases. Three patients developed lower extremity compartment syndrome postoperatively, requiring fasciotomy. Six patients developed chronic lower extremity edema after femoral vein harvest. The mean procedure time and hospital length of stay were 197 ± 40 minutes and 3.5 ± 2.8 days, respectively. ConclusionsFVT is associated with low infection rates and high long-term patency rates. Significant postoperative complications include steal syndrome and harvest site complications. FVT remains a viable option for patients who have failed prior access owing to graft infection or repetitive graft thrombosis.

Management of malignant superior vena cava syndrome.

Superior vena cava (SVC) syndrome occurs due to obstructed blood flow through the SVC. It can present clinically on a spectrum, between asymptomatic and life-threatening emergency. Patients commonly report a feeling of fullness in the head, facial, neck and upper extremity edema, and dyspnea. On imaging, patients commonly have superior mediastinal widening and pleural effusion. The majority of cases are due to malignant causes, with non-small cell lung cancer, small cell lung cancer, and lymphoma the most commonly associated malignancies. When evaluating patients, a complete staging workup is recommended, as it will determine whether treatment should be definitive/curative or palliative in intent. If the patient requires urgent treatment of venous obstruction, such as in the cases of acute central airway obstruction, severe laryngeal edema and/or coma from cerebral edema, direct opening of the occlusion by endovascular stenting and angioplasty with thrombolysis should be considered. Such an approach can provide immediate relief of symptoms before cancer-specific therapies are initiated. The intent of treatment is to manage the underlying disease while palliating symptoms. Treatment approaches most commonly employ chemotherapy and/or radiation therapy depending on the primary histology. Mildly hypofractionated radiation regimens are most commonly employed and achieve high rates of symptomatic responses generally within 2 weeks of initiating therapy.

Investigating the safety and feasibility of osteopathic manipulative medicine in hospitalized children and adolescent young adults with cancer.

Children and adolescents young adults (AYAs) undergoing treatment for oncologic diagnoses are frequently hospitalized and experience unwanted therapy-induced side effects that diminish quality of life. Osteopathic manipulative treatment (OMT) is a medical intervention that utilizes manual techniques to diagnose and treat body structures. Few studies have investigated the implementation of OMT in the pediatric oncology outpatient setting. To date, no studies have investigated the safety and feasibility of OMT in the pediatric oncology inpatient setting. The objective of this study is to investigate the safety and feasibility of OMT in the pediatric oncology inpatient setting. This is a prospective, single-institution pilot study evaluating children and AYAs aged≥2 years to≤30 years with a diagnosis of cancer hospitalized at Riley Hospital for Children (RH) from September 2022 to July 2023. Approval was obtained from the Indiana University Institutional Review Board (IRB). Patients were evaluated daily with a history and physical examination as part of routine inpatient management. Patients who reported chemotherapy side effects commonly encountered and managed in the inpatient setting, such as pain, headache, neuropathy, constipation, or nausea, were offered OMT. Patients provided written informed consent/assent prior to receiving OMT. OMT was provided by trained osteopathic medical students under the supervision of a board-certified osteopathic physician and included techniques commonly taught in first- and second-year osteopathic medical school curricula. Safety was assessed by a validated pain (FACES) scale immediately pre/post-OMT and by adverse event grading per Common Terminology Criteria for Adverse Events (CTCAE) 24 h post-OMT. All data were summarized utilizing descriptive statistics. A total of 11 patients were screened for eligibility. All patients met the eligibility criteria and were enrolled in the study. The majority of patients were male (n=7, 63.6 %) with a median age of 18.2 years at time of enrollment (range, 10.2-29.8 years). Patients had a variety of hematologic malignancies including B-cell acute lymphoblastic leukemia (ALL) (n=5, 45.5 %), T-cell ALL (n=1, 9.1 %), acute myeloid leukemia (AML) (n=2, 18.2 %), non-Hodgkin's lymphoma (n=2, 18.2 %), and Hodgkin's lymphoma (n=1, 9.1 %). All patients were actively undergoing cancer-directed therapy at the time of enrollment. There were 40 unique reasons for OMT reported and treated across 37 encounters, including musculoskeletal pain (n=23, 57.5 %), edema (n=7, 17.5 %), headache (n=5, 12.5 %), peripheral neuropathy (n=2, 5.0 %), constipation (n=2, 5.0 %), and epigastric pain not otherwise specified (n=1, 2.5 %). Validated FACES pain scores were reported in 27 encounters. Of the 10 encounters for which FACES pain scores were not reported, 8 encounters addressed lower extremity edema, 1 encounter addressed peripheral neuropathy, and 1 encounter addressed constipation. The total time of OMT was documented for 33 of the 37 encounters and averaged 9.8 min (range, 3-20 min). Hospitalized children and AYAs with cancer received OMT safely with decreased pain in their reported somatic dysfunction(s). These findings support further investigation into the safety, feasibility, and efficacy of implementing OMT in the pediatric oncology inpatient setting and to a broader inpatient pediatric oncology population.

Ketamine induced acute systolic heart failure

Background: Studies have shown major cardiovascular effects associated with ketamine use disorder including dose-dependent negative inotropic effects. Preoperative ketamine use has been linked to ketamine-induced stress cardiomyopathy. Case presentation: A 28-year-old female with a history of recurrent cystitis and ketamine use disorder (twice weekly for 14 years) presented with bilateral lower extremity oedema and shortness of breath for 3 months. She was tachycardic with a troponin level of 0.07 ng/ml and a B-type natriuretic peptide (BNP) level of 2511 pg/ml. Electrocardiogram showed normal sinus rhythm and transthoracic echocardiography (TTE) showed left ventricular ejection fraction (EF) of 15%, dilated left ventricle, and severe tricuspid and mitral regurgitation. Computed tomography (CT) scan of the chest and abdomen showed bilateral pleural effusions with congestive hepatopathy and ascites. The patient was started on intravenous furosemide, metoprolol, and sacubitril/valsartan. Rheumatological workup including complement levels, and antinuclear anti-double-stranded DNA was negative. A repeat TTE 2 weeks later revealed an EF of 25% and moderate tricuspid regurgitation. Four months later, the EF was 54% with normal left ventricular cavity size. Conclusion: Although ketamine use disorder is increasing, data on long-term side effects is minimal. Screening for ketamine use disorders should be considered in patients presenting with acute systolic heart failure. Long-term studies are needed to evaluate the benefits of adding ketamine screening to standard urine toxicology.

The effect of physical therapy and mechanical stimulation on dysfunction of lower extremities after total pelvic exenteration in cervical carcinoma patient with rectovesicovaginal fistula induced by radiotherapy: a case report

BackgroundTotal pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes intraoperative complications and postoperative complications. These complications are responsible for the dysfunction of lower extremities, impaired quality of life, and even the high long-term morbidity rate, thus multidisciplinary cooperation and early intervention for prevention of complications are necessary. Physical therapy was found to reduce the postoperative complications and promote rehabilitation, yet the effect on how physiotherapy prevents and treats complications after total pelvic exenteration and pelvic lymphadenectomy remains unclear.Case presentationA 50-year-old Chinese woman gradually developed perianal and pelvic floor pain and discomfort, right lower limb numbness, and involuntary vaginal discharge owing to recurrence and metastasis of cervical cancer more than half a year ago. Diagnosed as rectovesicovaginal fistula caused by radiation, she received total pelvic exenteration and subsequently developed severe lower limb edema, swelling pain, obturator nerve injury, and motor dysfunction. The patient was referred to a physiotherapist who performed rehabilitation evaluation and found edema in both lower extremities, right inguinal region pain (numeric pain rate scale 5/10), decreased temperature sensation and light touch in the medial thigh of the right lower limb, decreased right hip adductor muscle strength (manual muscle test 1/5) and right hip flexor muscle strength (manual muscle test 1/5), inability actively to adduct and flex the right hip with knee extension, low de Morton mobility Index score (0/100), and low Modified Barthel Index score (35/100). Routine physiotherapy was performed in 2 weeks, including therapeutic exercises, mechanical stimulation and electrical stimulation as well as manual therapy. The outcomes showed that physiotherapy significantly reduced lower limb pain and swelling, and improved hip range of motion, motor function, and activities of daily living, but still did not prevent thrombosis.ConclusionStandardized physical therapy demonstrates the effect on postoperative complications after total pelvic exenteration and pelvic lymphadenectomy. This supports the necessity of multidisciplinary cooperation and early physiotherapy intervention. Further research is needed to determine the causes of thrombosis after standardized intervention, and more randomized controlled trials are needed to investigate the efficacy of physical therapy after total pelvic exenteration.

Familial dilated cardiomyopathy in a child: a case report

BackgroundDilated cardiomyopathy (DCM) commonly leads to heart failure (HF) and represents the most common indication for cardiac transplantation in the pediatric population. Clinical manifestations of DCM are mainly the symptoms of heart failure; it is diagnosed by EKG, chest x-ray and echocardiography. For the idiopathic and familial diseases cases of DCM, there are no definite guidelines for treatment in children as they are treated for prognostic improvement.Case presentationWe report the case of a 2-year-old girl diagnosed with dilated cardiomyopathy associated with homozygous mutation in the Myosin Light Chain 3 gene admitted for edema in lower extremities, muscle weakness, lethargy and vomiting, and she was found to be in cardiogenic shock. Chest x-ray showed cardiomegaly and EKG showed first degree atrioventricular block. Echocardiogram showed severe biventricular systolic and diastolic dysfunction. After 70 days of hospitalization, the patient went into cardiac arrest with cessation of electrical and mechanical activity of the heart, despite cardiopulmonary resuscitative efforts.ConclusionAlthough rare, pediatric DCM carries a high risk of morbidity and mortality and a lack of curative therapy.

Explant of an infected, endo-trashed IVC filter in an immunosuppressed patient with chronically occluded iliocaval stents.

In the absence of a contiguous bowel perforation or intraabdominal source, infection of a retained vena cava filter in an occluded IVC has never been described. To describe a case of an infected IVC filter in a chronically occluded iliocaval segment. Here we present a case of an immunosuppressed 35-year-old female with chronically occluded iliocaval stents and an extensive staphylococcus hominis infection of a previously endo-trashed Bard Eclipse® filter. Particular attention is paid to supportive imaging in establishing the diagnosis and technical aspects of successful device explant and retroperitoneal debridement. At 6months postoperatively, the patient was doing well without evidence of recurrent infection. Her lower extremity edema was controlled with compression alone. The main objective of this operation was source control with debridement of the infection and removal of the filter and as much of the iliac vein as safely possible. Superinfection of a previously placed iliocaval stents and inferior vena cava filter remains a concern in patients with retroperitoneal infection and chronic iliocaval occlusion. Operative explant and debridement can be safely performed in patients with favorable cardiopulmonary risk.

Assessment Modalities for Lower Extremity Edema, Lymphedema, and Lipedema: A Scoping Review.

Lower extremity swelling may be broadly characterized as due to edema, lymphedema, or lipedema. Differentiation between these three conditions is important for providing appropriate treatment. This review analyzes and compares different clinical diagnostic modalities for these conditions, with the aim of assisting in the process of choosing the most appropriate diagnostic modality by highlighting the advantages and limitations of each. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for a systematic search of peer-reviewed literature, the following diagnostic methods for lower extremity swelling were investigated: (1) ultrasound (US), (2) lymphoscintigraphy (LSG), (3) computed tomography (CT), (4) bioimpedance spectroscopy (BIS), (5) tissue dielectric constant (TDC), and (6) magnetic resonance imaging (MRI), including magnetic resonance lymphangiography (MRL). The databases used in the search were PubMed, ProQuest, CINAHL Complete, Web of Science, Embase, and Biomedical Reference Collection. After retrieving 115 studies based on predetermined inclusion criteria, a total of 31 studies were critically evaluated. The main results indicate the following: duplex US is the modality of choice to initially identify lower extremity edema such as deep venous thrombosis (DVT) and venous reflux due to its high sensitivity and specificity. CT venography of the lower extremity appears to bethe preferred option for gynecologic cancer patients with lower extremity swelling post-treatment, as it measures subcutaneous tissue volumes to look for DVTs, lymphoceles, and cancer recurrence. TDC is a recommended modality for a variety of conditions, including edema and lymphedema, in part, due to its noninvasive localized assessment capabilities and ease of use. LSG emerges as an effective imaging modality for lymphedema characterization with minimal invasiveness and high sensitivity and specificity. BIS is widely used to identify and monitor lower extremity lymphedema but has been reported to have low sensitivity and lacks the ability to account for changes in tissue composition such as fibrosis. US and MRL are favored for lipedema diagnosis, with MRL providing comprehensive anatomical and functional insights, albeit with cost and accessibility limitations compared to US. While CT, MRI, US, and TDC are all useful for differentiating lymphedema from lipedema, MRI is the preferred modality due to its anatomical and functional diagnostic capabilities. However, US is a pragmatic alternative for use with obese patients or when MRI is not an option.

Cardiac Involvement in Neurosarcoidosis: A Single-Center Investigation

Sarcoidosis is a multisystem inflammatory granulomatous disease. Among systemic sarcoidosis manifestations, cardiac or nervous system involvement can result in significant morbidity and mortality. We describe the overlapping incidence of cardiac sarcoidosis (CS) within a neurosarcoidosis (NS) cohort and determine the frequency of other nonsarcoid cardiac diseases in these patients. We performed a retrospective chart review of patients evaluated at the University of Utah from 2010 to 2022. Patients were included if they had (1) at least one instance of a diagnostic code for sarcoidosis in their medical record-International Classification of Diseases (ICD) 9 code 135 or ICD 10 code D86; (2) at least one outpatient visit in the Neurology Department within the University of Utah electronic health record with a diagnosis of definite, probable, or possible NS based on 2018 consensus criteria; (3) at least one outpatient visit in the Cardiology Department within the University of Utah electronic health record; and (4) ECG available in their medical record for review. Of 64 definite, probable, or possible patients with NS in the University of Utah cohort, 52 met our inclusion criteria and were included in this study. Of 52 patients with NS who met our inclusion criteria, 65.38% were female, with an average age of 60.9 years (range 38-84). More than half (58%) were obese (BMI ≥ 30). CS was diagnosed in 6 patients with NS (12%). Symptoms suggestive of possible cardiac dysfunction included lower extremity edema (50%), palpitations (46%), chest pain (44%), and shortness of breath (27%). ECG abnormalities included nonspecific T-wave change (40%) and right bundle branch block (17%). Three patients experienced ventricular tachycardia: sustained in one patient and nonsustained in 2 patients. Cardiac MRI was performed in 17 patients (32.7%) and in 3 patients (17.6%), which revealed diffuse myocardial enhancement suggesting CS. In this cohort, 12% of patients with NS also had confirmed CS. In addition, these patients had a high burden of cardiovascular disease not directly attributed to sarcoidosis. Our data suggest that patients with NS require comprehensive cardiac evaluation. Future studies are needed to clarify the extent of the direct contribution of granulomatous inflammation on the cardiovascular system from the indirect contribution of treatments such as glucocorticoids that lead to increased risk of cardiovascular disease in sarcoidosis.

Advanced osteoarthritis of the hip as reason for extensive asymmetric leg edema: a rare case report and review of the literature.

An enlarged iliopectineal bursa (IB) can cause pressure on iliofemoral veins. Clinical presentation can manifest as asymmetrical lower extremity edema. This case report demonstrates extensive asymmetrical leg edema caused by femoral vein compression based on iliopectineal bursitis (IB-itis) associated with advanced osteoarthritis (OA) of the left hip joint with an outline of relevant current literature. A female patient presented with left hip pain and edema in the leg. X-ray showed severe OA of the left hip. Computed Tomography (CT) concluded a cystic abnormality at the left iliopsoas muscle associated with the joint consistent with IB-itis, associated with a degenerative left hip joint. Hybrid total hip replacement was performed. At three-month follow-up her left leg showed no longer signs of extensive edema and she walked without the use of walking aids. IB-itis is mostly associated with rheumatoid arthritis (RA). There are no reports which only describe OA as cause of IB-itis. Extensive asymmetrical leg edema can be caused by venous compression of the femoral vein by an IB-itis. If the latter is the consequence of advanced hip OA, a total hip replacement can yield excellent clinical outcomes both functionally and with regard to the edema.

Afflatoxine Effect on Livestock Health: A Review

Aflatoxins have been the cause of numerous deaths in livestock and it also the cause for economic losses. Aflatoxins belong to a group of mycotoxins that are produced by fungi species (molds) as they grow on their substrates. The major ones are aflatoxins B1, B2, G1 and G2, thus named depending on their fluorescence under blue and green light. Aspergillus parasiticus can synthesize AFB1, AFB2, AFG1, and AFG2. AFB1=AFM1>AFG1>AFB2=AFM2>AFG2 from strongest to weakest in terms of toxicity. Pigs so affected became lethargic, did not eat, and eventually became hypothermic, icteric, and had blood in their feces. Acute aflatoxicosis is characterized by an acute hepatotoxic disease that manifests itself with depression, anorexia, jaundice, hemorrhages, edema of the lower extremities, abdominal pain and vomiting. Chronic exposure leads liver cancer. The major target organ for aflatoxins in animals is the liver. Aflatoxins are probably not major causes of livestock disease and low productivity, but are contributing factors which are likely to become more important as livestock production intensifies. The animal feeds most likely to be contaminated are maize, cottonseed, and groundnuts. These feeds are at high risk for aflatoxin contamination. Aflatoxins cannot be detected by sight or smell in contaminated food or feed. Aflatoxins are not eliminated by boiling, cooking, or by processing into compound feeds. Animal source foods, especially milk, may also contain aflatoxins if animals eat contaminated feeds. This is often the case with milk; carry-over rates are relatively high, consumption is high, and milk is often given to infants and young children who are most at-risk for negative health outcomes related to aflatoxin exposure. Affected animals may exhibit reduced feed consumption, weight loss, and reduction in production. The more significant effects in cattle may occur when animals consume lower levels of aflatoxins and chronic effects appear such as reduced reproductivity, immunosuppression, and reduced feed efficiency. An increase in dietary protein protects against adverse effects of the toxin. Feeding of extra vitamins, A and K could also decrease the detrimental effects of aflatoxins. The prevention ways are removing the sources; promotes better agricultural and storage techniques; have good resources for testing and early diagnosis; strict food quality standards; General awareness and personal protection; Better livestock feeding & management.

Maternal and fetal arrhythmia as a sign of hemodynamic deterioration: a case report

The co-existing maternal (MA) and fetal arrythmia (FA) are associated with maternal goiter disease, chorioamnionitis, or Ballantyne’s syndrome. The aim of the study - to determine the involvement of maternal arrhythmia and fetal arrhythmia in the pathogenic scenario of hemodynamic deterioration in Ballantyne’s syndrome. Clinical case. It is presented the case of sustained several weeks of MA and FA. A pregnant woman aged 36 years was admitted to the division of maternal and fetal medicine at 34 weeks of gestation. She was gravida 4 and para 3. She had complaints of rapid heartbeat, left-side chest discomfort, and lower extremities edema. The diagnosis of maternal sinus tachycardia was supported via electrocardiography. The indices of fetal, umbilical, and uteroplacental hemodynamics detected via Doppler ultrasound were appropriate. However, fetal heart rate was 209 beats/min. The transplacental attack of oral sotalol 80 mg thrice daily was prescribed. But maternal and fetal tachycardia persisted to stay. The tricuspid regurgitation was detected via Doppler ultrasound next day. The fetus was hydropic. The male baby of 2400 g, 46 cm length, 31 cm head circumference, and Apgar score 3→5 was delivered via caesarean. The newborn was discharged in 21 days. He was admitted again in one month for rehabilitation. Maternal heart rate reduced to 72 beats/min and edema regressed in three days after birth. Conclusions. MA and FA before fetal hydrops are supposed to be the early signs of mirror syndrome. This speculation needs further investigation. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Metabolic acidemia due to saline absorption during transurethral and transcervical surgery: a report of 2 cases

BackgroundThe development of endoscopic systems that include bipolar electrocautery has enabled the use of normal saline irrigation in transurethral or transcervical endoscopic surgery. However, excessive saline absorption can cause hyperchloremic metabolic acidosis.Case presentationPatient 1: A 76-year-old man was scheduled for transurethral resection of the prostate with saline irrigation. Approximately 140 min after the surgery, abdominal distension and cervical edema were observed. Abdominal ultrasound examination indicated a subhepatic hypoechoic lesion, which suggested extravasation of saline. Arterial blood gas analysis revealed hyperchloremic metabolic acidosis. The patient was extubated 2 h after the operation with no subsequent airway problems, and the electrolyte imbalance was gradually corrected. Patient 2: A 43-year-old woman was scheduled for transcervical resection of a uterine fibroid with saline irrigation. When the drape was removed after the operation was finished, notable upper extremity edema was observed. Arterial blood gas analysis revealed hyperchloremic metabolic acidosis. The patient’s acidemia, electrolyte imbalance, and neck edema gradually resolved, and the patient was extubated 16 h after the operation without subsequent airway problems. ConclusionsAnesthesiologists should be aware of acidemia, cardiopulmonary complications, and airway obstruction caused by excessive saline absorption after saline irrigation in endoscopic surgery.

Predicting the Development of Complications After Mitral Valve Repair Using Mathematical Analysis

AIM. To study the possibilities of using risk factors, data from instrumental research methods identified at the preoperative stage as independent variables for predicting the development of complications after mitral valve surgery. MATERIAL AND METHODS. The study included 103 patients, 46 men and 57 women, who underwent surgical correction of mitral valve defect and were treated at the Cardiac Surgery Department of Chelyabinsk Regional Clinical Hospital № 1 in the period from 2014 to 2019. Among those patients, the presence of anemia at the preoperative stage (blood hemoglobin level less than 100 g/l) was detected in 13 (12,6 %) cases; obesity (BMI more than 30 kg/m2) — in 57 (55,3 %) cases; transfusion of blood and its components in anamnesis — in 14 (13,6 %) cases; type 2 diabetes mellitus — in 7 (6,8 %) cases; stroke in anamnesis — in 9 (8,7 %) cases; chronic Hepatitis C — in 6 (5,8 %) cases; HIV infection — in 4 (3,9 %) cases; antibiotic therapy before surgery was indicated in 21 (20,4 %) cases; edema of the lower extremities was detected in 40 (38,8 %) cases; an increase in body temperature before surgery — in 19 (18,4 %) cases; the presence of atrial fibrillation before surgery — in 63 (61,2 %) cases. The systematization of the source information was entered into a Microsoft Office Excel 2016 spreadsheet. Statistical analysis was carried out using the IBM SPSS Statistics v.26 program (developed by IBM Corporation). Binary logistic regression was used as a method of mathematical data analysis. Instrumental research methods: electrocardiography (ECG), echocardiography (ECHO-CG); coronary angiography was performed according to indications. RESULTS. The presence of risk factors such as anemia, obesity, as well as an increase in the size of the right atrium can be used as an independent variable to predict the development of complications. An increase in the diameter of the pulmonary artery trunk, and the presence of edema of the lower extremities reduces the risk of complications. The likelihood of developing complications after mitral valve surgery predicted by the logistic regression method was 53,4 %. The resulting model predicts the absence of complications with the likelihood of 82,5 %. The development of complications was correctly predicted in 93,3 % of cases. CONCLUSION. This model can be used as an additional tool in predicting the development of complications after mitral valve surgery.