Hemorrhagic Effusion Research Articles

Treatment for acute alcoholic-alimentary pancreatitis with peritoneal syndrome

A large number of publications on surgical treatment of acute alcohol-induced pancreatitis (AAP) with peritonitis indicates the importance of the problem and the need for a differentiated approach to treatment. The aim of this study is to determine the optimal treatment policy for acute alcohol-associated pancreatitis with peritonitis. The study included 114 male patients diagnosed with acute alcoholic pancreatitis and peritoneal sepsis, with an average age of 48.6 ± 6.4 years. They were admitted to the surgical departments of clinical hospitals between 2013 and 2023. The diagnosis of AAP was confi med based on clinical, laboratory, and instrumental findings. The classification of acute pancreatitis recommended by the National Clinical Guidelines of the Ministry of Health of the Russian Federation (2015 and 2020) has been applied. The Acute Physiology and Chronic Health Evaluation II (APACHE II) scale has been used to assess the severity and prognosis of the disease, while the Sequential Organ Failure Assessment (SOFA) scale has been used to evaluate organ failure. Based on the results, an algorithm for the treatment of acute alcoholic and alimentary pancreatitis with peritoneal syndrome has been proposed, taking into account the type of pancreatic necrosis, the extent of pancreatic damage, and the nature of fl uid accumulation. For patients with edematous pancreatitis, small-focal sterile pancreatic necrosis, and enzymatic peritonitis, percutaneous ultrasound-guided abdominal and omental drainage is recommended. In severe and moderate acute alcoholic-alimentary pancreatitis, with enzymatic peritonitis (more than 8 points on the APACHE II scale), which is manifested during diagnostic and sanitation laparoscopy by the presence of a hemorrhagic effusion and a large number of plaques of steatonecrosis on the parietal peritoneum and the large omentum, we should use an endovisual method of draining the abdominal cavity and the omentum to minimize anesthesiological and surgical aggression and to form and maintain general cavities, as well as to create good access to the pancreatic area. For patients with large-focal, infected subtotal or total pancreatic necrosis and purulent peritonitis, it is advisable to perform laparotomy, abdominalization of the pancreas, necrectomy, omentobursostomy, and drainage of purulent foci in the abdominal cavity and retroperitoneal tissue.

050. Surviving Multiple Traumas: A 37-Year-Old Male with Gunshot-Induced Hematopneumothorax and Hollow Organ Perforation

Background: Traumatic gunshot wounds to the chest and abdomen pose significant challenges in emergency surgical management. This case report presents the rapid diagnosis and successful treatment of a 37-year-old male who sustained gunshot wounds to the chest and abdomen, leading to hematopneumothorax and hollow organ perforation. Case: The patient, a 37-year-old male, was admitted to Adam Malik Hospital with shortness of breath and severe abdominal pain following a gunshot injury to the chest and lower abdomen. On primary survey, the patient exhibited tachypnea (RR 26 tpm) and hypoxia (SpO2 94% on room air), which improved with oxygen therapy. Vital signs were stable, but a left-sided hematopneumothorax and abdominal tenderness suggested hollow organ perforation. Radiological and FAST ultrasound findings confirmed the diagnosis. Emergency chest tube insertion and exploratory laparotomy were performed. The chest tube revealed hemorrhagic effusion, and laparotomy identified two small bowel perforations at 100 cm and 130 cm from the ligament of Treitz, alongside an impaled object in the mesentery. Primary suturing of the perforations was performed, and the abdomen was irrigated thoroughly. Postoperative recovery was uneventful, with the patient showing rapid clinical improvement. Conclusion: Rapid emergency surgical response led to a favorable outcome in a patient with life-threatening thoracoabdominal gunshot wounds, emphasizing the role of timely interventions in trauma care.

New strategies to classify canine pleural effusions and the diagnostic value of acute phase proteins, amylase, and adenosine deaminase in pleural exudates.

In dogs, simplified Light's criteria can discriminate transudates from exudates. Other tests used in human medicine are pleural effusion cholesterol (CHOLPE) and butyrylcholinesterase [BChEPE], the pleural effusion/serum ratio of these analytes (CHOLratio and BChEratio), and the serum albumin minus pleural effusion albumin gradient (SEAG). We aimed to assess the diagnostic accuracies of different biomarkers in dogs with pleural effusion in differentiating exudates from transudates. Secondarily, we evaluated the potential diagnostic utility of pleural effusion acute phase proteins, amylase, and adenosine deaminase in discriminating causes of exudative effusions. Cross-sectional study including 68 client-owned dogs with pleural effusion. There were 48 exudates (10 septic, 16 neoplastic, 9 hemorrhagic, and 13 classified as other exudates) and 20 transudates. All the variables analyzed, except SEAG, were significantly different between exudates and transudates. Using the cut-off values adopted in human literature, accuracies for CHOLPE, CHOLratio, BChEPE, and BChEratio were between 82.35% and 85.29%; all values were significantly lower compared with the previously published simplified Light's criteria accuracy (i.e., 98%, p < .001 for all comparisons). We found the accuracy of the simplified Light's criteria to be similar to what has been previously reported (95.59%, p = .238). Paraoxonase-1 (PON-1PE) activity and the pleural effusion/serum paraoxonase-1 ratio (PON-1ratio) were significantly lower in exudative neoplastic effusions than in exudative hemorrhagic (p = .004 and p = .001) and septic (p = .004 and p < .001) effusions. Simplified Light's criteria were the best method for discriminating transudates from exudates, and a low PON-1PE activity and PON-1ratio in exudative effusions may suggest an underlying neoplasia.

Pleomorphic Liposarcoma Cytologically Detected in Hemosiderotic Pleural Effusion: Pitfalls Mitigated by Cytologic Clues and Cellblock Immunocytochemistry.

Sarcomatous serous effusions are uncommon and diagnostically challenging. Dedifferentiated and pleomorphic liposarcomas are rare tumors in pleural effusions revealing highly pleomorphic tumor cells mimicking carcinoma, mesothelioma, melanoma, and other sarcomas. Hematothoracic effusions further complicate the cytologic diagnosis. Correct cytologic recognition is important. We report pleomorphic liposarcoma cytologically detected in effusion fluid in a 56-year-old man who presented with a massive unilateral pleural effusion. ThinPrep showed hemorrhagic effusion fluid characterized by lysed red blood cells, foamy macrophages, and siderophages intermixed with highly pleomorphic predominantly naked mononuclear and giant nuclei. The aggregated siderophages and vacuolated macrophages could be mistaken for tumor cells, whereas the bare nuclei may be missed as nonspecific degenerate changes. Cellblock sections showed highly pleomorphic mononuclear and multinucleated giant tumor cells with diagnostic lipoblasts, intermixed with foamy macrophages and siderophages. Cellblock immunocytochemistry showed staining for vimentin and S-100 protein in the tumor cells. Other lineage-specific immunomarkers were negative. CD68 and calretinin revealed frequent background macrophages and scarce mesothelial cells. The tumor cells were negative for MDM2 and CDK4. The entertained cytopathologic diagnosis was pleomorphic liposarcoma. Core needle biopsy was procured from the mass. The histopathologic features and immunoprofile of the tissue specimen matched the cytopathologic and immunocytochemical findings confirming the cytologic diagnosis of pleomorphic liposarcoma. Pleomorphic liposarcoma is an unexpected cytologically challenging finding in effusions, particularly when compounded by pitfalls introduced by hemosiderotic fluid. Attention to certain cytologic clues mitigate pitfalls. Cellblock is a valuable diagnostic tool when integrated with relevant negative and positive immunocytochemical markers.

Complications Following XEN45 Gel Stent and Glaucoma Drainage Device Implantation During Glaucoma Fellowship.

Purpose XEN45 Gel Stent and glaucoma drainage device (GDD) implantation is safe and effective for glaucoma treatment and should be taught during glaucoma fellowship training. However, complications may still occur, with potentially sight-threatening consequences. The purpose of this study is to describe the management of complications following a series of XEN45 Gel Stent and GDDsurgeries performed over the course of glaucoma fellowship training. Methods This is a retrospective case series of XEN45 Gel Stent surgeries performed on 16 eyes and GDD surgeries performed on seven eyes. Patient demographics, disease characteristics, and complications are reviewed. The intra- and postoperative course of five select cases with complications are described in detail. Results The most frequent complications following XEN45 implantation were transient hypotony (10 eyes, 63%), reduced visual acuity (VA) (five eyes, 31%), choroidal effusion (three eyes, 19%), hyphema (two eyes, 13%), and intraocular pressure (IOP) spike (two eyes, 13%). Thirteen eyes (81%) required bleb needling, and three eyes (19%) required XEN45 replacement. Complications following GDD implantation included hypotony (three eyes, 43%), reduced VA (two eyes, 29%), choroidal effusion (two eyes, 29%), IOP spike (two eyes, 29%), implant exposure (two eyes, 29%), and shallow anterior chamber (one eye, 14%). Three eyes (43%) required revision or explantation with a secondary glaucoma surgery. One choroidal effusion following XEN45 surgery and one following GDD surgery were hemorrhagic choroidal effusions requiring surgical drainage. Conclusion Significant and potentially sight-threatening complications may occur following XEN45 Gel Stent and GDD implantation performed over the course of fellowship training. Glaucoma fellows should be ably equipped to recognize, diagnose, and manage these complications both intra- and postoperatively.

Novel presentation of a feline patient with visceral and cervical lymph node hemangiosarcoma.

To report a novel presentation of feline hemangiosarcoma. A 14-year-old spayed female feline patient diagnosed with hemangiosarcoma of the spleen and a cervical lymph node. The patient presented to the emergency service following a 1-week history of lethargy and hiding. Abdominal ultrasound revealed splenomegaly with multiple nodules and peritoneal fluid that was consistent with hemorrhagic effusion. The patient underwent a routine splenectomy and was started on doxorubicin. Histopathologic evaluation of the spleen confirmed visceral hemangiosarcoma. When the disease showed signs of progression, combination chemotherapy with cyclophosphamide and vincristine was initiated. Four months following presentation, a submandibular lymph node was removed and found to have metastatic hemangiosarcoma. From presentation to euthanasia, the patient survived 205 days. Hemangiosarcoma is a rare cancer in feline patients, with a lack of veterinary literature on its presentation and chemotherapy protocols. The subject of this case report had a novel presentation of hemangiosarcoma and responded favorably to a chemotherapy protocol not previously described for this disease.

The Distribution of Ectopic Pregnancy in Natural Pregnancy and the Comparison of Diagnostic Efficacy between Transabdominal Ultrasound and Transvaginal Ultrasound

Objective: The objective of this study was to analyze the advantages and disadvantages of transabdominal and transvaginal color Doppler ultrasound in the diagnosis of early ectopic pregnancy (EP) and to evaluate the value of two kinds of ultrasonography in the diagnosis of early EP. Patients and Methods: One hundred and ten EP patients who underwent preoperative transvaginal and transabdominal ultrasound examinations and were confirmed by surgical pathology were included in the study. The sonographic findings of different methods were analyzed, and the diagnostic effects of the two ultrasound methods were compared. Results: The positive rate of transvaginal ultrasound for EP masses was 100%, while the positive rate of transabdominal ultrasound was 67.27%, with a significant difference (P &lt; 0.0001). For 53 cases of EP located in the ampulla, the diagnostic rate of transvaginal ultrasound was 100%, while transabdominal ultrasound was only 58.49%, with a significant difference (P &lt; 0.0001). The sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound in diagnosing EP rupture were 94.44%, 58.67%, 52.31%, and 58.67%, respectively. Conclusions: The diagnostic efficacy of transvaginal ultrasound for EP is significantly better than that of transabdominal ultrasound. Therefore, for patients suspected of EP and without contraindication, transvaginal ultrasound is recommended as the first choice. Both peritoneal effusion by ultrasound and intraoperative abdominal hemorrhagic effusion had low specificity in diagnosing EP rupture. The diagnosis of EP rupture requires intraoperative direct vision.

Quantitative MRI assessment of joint effusion using T2-relaxometry at 3 Tesla: a feasibility and reproducibility study

ObjectiveT2-relaxometry could differentiate between physiological and haemorrhagic joint effusion (≥ 5% blood) in vitro. Are quantitative T2-relaxation time measurements of synovial fluid feasible and reproducible in vivo in clinically bleed-free joints of men with haemophilia?Materials and methodsIn this cross-sectional study, we measured T2-relaxation times of synovial fluid in clinically bleed-free ankles, knees or elbows of men with severe haemophilia A using a T2-mapping sequence (duration ≤ 7 min) at 3 Tesla MRI. Manual and circular regions of interest (ROI) were drawn in the synovial fluid of each joint by two independent observers to measure T2-relaxation times. Measurement feasibility was expressed as the success rate of the measurements by both observers. The interobserver and intraobserver reproducibility of the measurements were evaluated by the intraclass correlation coefficient of absolute agreement (ICC) and the limits of agreement (LoA) from Bland Altman analysis.ResultsWe evaluated 39 clinically bleed-free joints (11 ankles, 12 knees, 16 elbows) of 39 men (median age, 24 years; range 17–33) with severe haemophilia A. The success rate of the T2-measurements was ≥ 90%. Interobserver reliability was good to excellent (manual ROI: ICC = 0.92, 95% CI 0.76–0.97; circular ROI: ICC = 0.82, 95% CI 0.66–0.91) and interobserver agreement was adequate (manual ROI: LoA = 71 ms; circular ROI: LoA = 146 ms). Intraobserver reliability was good to excellent (manual ROI: ICC = 0.78, 95% CI − 0.06–0.94; circular RO: ICC = 0.99, 95% CI 0.98–0.99) and intraobserver agreement was good (manual ROI: LoA = 63 ms; circular ROI: LoA = 41 ms).ConclusionT2-relaxometry of synovial fluid in haemophilia patients is feasible with good interobserver and intraobserver reproducibility.

Idiopathic Pericarditis Leading to Hemorrhagic Pericardial Effusion- A Case Report and Review

Pericardial effusion presentation is a large spectrum that can vary from asymptomatic to cardiac tamponade. It is a relatively common syndrome and has a diverse set of etiologies including infections, malignancy, radiation/iatrogenic, pericardial injury, metabolic disturbances, endocrine disease, connective tissue disease, autoimmune disorders, trauma, or idiopathic. Pericardial drainage is recommended in most large pericardial effusions or those causing cardiac tamponade. Pericardial fluid can be either purulent, serous, serosanguinous, or hemorrhagic. In the case of hemorrhagic effusion, the common etiologies include malignancy, iatrogenic, and tuberculosis (in endemic regions). Large hemorrhagic pericardial effusions resulting from idiopathic (presumed viral) pericarditis are rare but possible. We present an interesting case of a woman with a large hemorrhagic pericardial effusion presenting as subacute cardiac tamponade caused by idiopathic pericarditis in the setting of known malignancy. This report aims to increase awareness about pericarditis as a potential cause of significant hemorrhagic pericardial effusions, rather than solely attributing them to malignancy. J MEDICINE 2024; 25: 87-89

Total hepatic inflow occlusion vs. hemihepatic inflow occlusion for laparoscopic liver resection: a systematic review and meta-analysis.

The control of bleeding during laparoscopic liver resection (LLR) is still a focus of research. However, the advantages of the main bleeding control methods, including total hepatic inflow occlusion (TIO) vs. hemihepatic inflow occlusion (HIO), during LLR remain controversial. The purpose of this meta-analysis was to compare the clinical outcomes of patients who received TIO and patients who received HIO. This meta-analysis searched the Medline, PubMed, Web of Science, Embase, Ovid, and Cochrane Library databases. The language of the studies was restricted to English, and comparative studies of patients treated with TIO and HIO during LLR were included. The primary outcome was to compare the intraoperative details, such as the operative time, occlusion time, and volume of blood loss, between the two groups. Secondary outcomes included conversion, overall complications, liver failure, biliary leakage, ascites, pleural effusion, and hospital stay. Five studies including 667 patients, 419 (62.82%) of whom received TIO and 248 (37.18%) of whom received HIO, were included in the analysis. The demographic data, including age, sex, hemoglobin, total bilirubin, albumin, and alpha-fetoprotein, were comparable. No significant differences noted in operative time, occlusion time, volume of blood loss, conversion, overall complications, liver failure, biliary leakage, hemorrhage, ascites, or pleural effusion. The hospital stay in patients who received HIO was significantly shorter than that for patients who received TIO [mean difference (MD), 0.60; 95% confidence interval (CI), 0.33-0.87; p < 0.0001; I 2 = 54%]. The blood loss of patients with liver cirrhosis in the TIO group was significantly less than that in the HIO group (MD, -107.63; 95% CI, -152.63 to -62.63; p < 0.01; I 2 = 27%). Both the TIO and HIO methods are safe and feasible for LLR. Compared with HIO, TIO seems to have less blood loss in cirrhotic patients. However, this result demands further research, especially multicenter randomized controlled trials, for verification in the future. Systematic Review Registration: https://www.crd.york.ac.uk/, Identifier PROSPERO (CRD42022382334).

#74 : Rare Presentation of Bilateral Haemorrhagic Pleural Effusions in Ovarian Hyperstimulation Syndrome

Background and Aims: Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of controlled ovarian hyperstimulation. Pleural effusions seen in OHSS usually are accompanied by marked ascites. Isolated pleural effusion without ascites is extremely rare. Here, we report a case of severe OHSS with rare presentation of isolated bilateral haemorrhagic pleural effusions following controlled ovarian hyperstimulation in in vitro fertilization (IVF). Method: We present a case of a 31-year-old lady with polycystic ovarian syndrome (PCOS) undergoing IVF where antagonist regime was used. To reduce OH SS risk, agonist trigger was given followed by cryopreservation. The patient was discharged well after oocyte retrieval. She needed admission the following day due to worsening abdominal pain. Cabergoline was started together with analgesia. On day 4 admission, she developed left haemorrhagic pleural effusion which was drained. Her condition improved initially but pleural effusion recurred after a few days and this time was bilateral. Pleural fluid drainage was repeated. Results: Patient recovered and was discharged well after 3 weeks of hospitalization. Five months later, we performed frozen embryo transfer where two day-3 embryos were transferred (both 8-cell Grade 1). She had a successful singleton pregnancy. At 38 weeks of gestation, she delivered a healthy boy weighing 3.67 kg via Caesarean section. Conclusion: Pleural effusion as sole presentation of severe OHSS is a very rare occurrence. Despite close monitoring during ovarian stimulation and rigid guidelines, OHSS still occurs. Early detection and prompt intervention by a multidisciplinary team are crucial to ensure successful management of this serious complication.

Abstract 17356: Recurrent Hemorrhagic Pericardial Effusion Requiring a Multimodality Imaging Approach: A Case Report

Background: A 24-year-old female with no medical history presented to the ED with chest pain and dyspnea. Vitals were notable for tachycardia to 120s. Physical examination was unremarkable. Clinical Course: Initial evaluation was notable for thrombocytopenia, NT-proBNP of 151 and high sensitivity troponin T of 18. Transthoracic echocardiogram (TTE) revealed a small pericardial effusion with tamponade physiology prompting urgent pericardiocentesis. Bloody pericardial fluid was drained and fluid studies were consistent with hemorrhagic effusion with no evidence of infection or malignancy on cytology. Surveillance TTEs showed rapid reaccumulation of pericardial fluid within 72 hours of the initial intervention. Urgent pericardial window with drain placement was performed and intraoperative transesophageal echocardiogram (TEE) revealed a right atrial (RA) mass not detected on prior TTE. Cardiac MRI confirmed the presence of a large (50 mm x 31 mm) immobile and heterogeneous mass in the superior aspect of the RA suggestive of a malignant etiology with invasion to the adjacent pericardium. Positron Emission Tomography (PET) scan demonstrated hypermetabolic activity concerning for malignancy with no evidence of mediastinal, hilar adenopathy, or distant disease. She underwent mini-sternotomy and biopsy with pathology suggestive of primary cardiac angiosarcoma. Due to the high-risk nature and location of the tumor, she was unable to undergo primary surgical resection. Neoadjuvant chemotherapy was initiated with plan for subsequent surgical reassessment. Conclusion: Workup of recurrent hemorrhagic pericardial effusions require a multimodal imaging approach.

Malignant Small Round Cell Tumor: A Rare Aggressive Malignancy-Case Report

Background: Malignant Small round Cell Tumor (MSRCT) is very rare group of tumors. Malignant cells have similar histologic appearance making it difficult to distinguish one from another, and poses a diagnostic challenge with needs for a multimodal approach. Immunohistochemistry and immunophenotyping by flow cytometry, reverse transcriptase polymer chain reaction (RT-PCR) and fluorescence in situ hybridization are needed to confirm. The appropriate and best treatment in early stages of MSRCT is early surgical excision with chemoradiotherapy based on patient specification. Inspite of all these, tumors have poor prognosis and chance of recurrence are high. Method: Case study of a 27-year-old male who presented with a non-productive cough for 4 weeks, with feverish feeling with weight loss and shortness of breath and a new onset precordial chest pain non radiating and worse on exertion. On examination his vitals were: BP 121/91 mm of hg, pulse rate 114bpm, temperature 36.3 degrees Celsius, respiratory rate 24/per min, SPO2 96%.On examination, Elevated Jugular Venous Pressure, hyperactive precordium, displaced apex beat to 6th intercostal space anterior axillary line, muffled heart sounds and bilateral lower limb edema. Respiratory exam was unremarkable. Sputum gene expert was negative for mycobacterium tuberculosis and covid 19 rapid test was negative. Chest X Ray showed cardiomegaly and a transthoracic echocardiography revealed moderate-large pericardial effusion, with mild collapse of right atrium in diastole. Pericardiocentesis done showed hemorrhagic effusion with lymphocytes cell component, patient was initiated on treatment for TB pericarditis empirically. Three months later a chest CT scan done revealed extensive mediastinal/pericardial mass with lung nodules. An ultrasound guided mediastinal/Pericardial biopsy was done, revealed a poorly differentiated small round cell carcinoma. Results: Patient expired 14 weeks from the initial onset of symptoms while awaiting immunohistochemistry studies for specific diagnosis of the tumor and oncology review. Discussion: This demonstrates the complexity of establishing differential diagnosis of MSRCT in a resource limited setting with subsequent delay in treatment initiation, heralds poor prognosis. This also confirms difficulties in establishing differential diagnosis in poorly differentiated tumor.

How fatal can untreated constipation be?

This case report discusses a patient who presented with dyspnea and presyncope following the Valsalva maneuver. The patient had a history of chronic constipation and experienced difficulty defecating, leading to vigorous straining. Upon arrival at the emergency department, the patient exhibited signs of cardiac tamponade and computed tomography(CT) scan revealed high-density pericardial hemorrhagic effusion. Pericardiocentesis and surgical decompression were performed to manage the tamponade. The patient's symptoms improved and discharged in stable condition. This case highlights the potential fatal complications of constipation, emphasizing the need for a holistic approach in cardiovascular care. IMC J Med Sci. 2024; 18(1):001. DOI: https://doi.org/10.55010/imcjms.18.001 *Correspondence: Mustafa BOĞAN, Emergency Department, School of Medicine, Düzce University, Düzce, Turkey, Posta code: 81620; Email: mustafabogan@hotmail.com; ORCID: 0000-0002-3238-1827

E69 Localised intraarticular pigmented villonodular synovitis in an adolescent patient: a case-based review of the literature

Abstract Introduction Pigmented villonodular synovitis (PVNS) is a rare, locally aggressive subtype of tenosynovial giant cell tumours that affect the synovium of the joints and tendons, occurring either focally or diffusely associated with the deposition of hemosiderin into the involved joint(s) and soft tissues. Although PVNS is historically considered an inflammatory process, recent evidence suggests the possibility of a neoplastic transformation. In addition, despite being typically found as a monoarticular knee disorder, other large and small joints can also be affected. The disease is rarely reported in African children, with most reported cases not histologically confirmed. We, therefore, present the first histologically proven case of localised intraarticular PVNS in an African teenager who presented with unilateral left knee swelling and pain. Method/Setting We report the case of a 16-year-old male teenager who presented to the rheumatology clinic with a nine-month history of non-traumatic anterior left knee swelling and pain that increased over time with associated difficulty walking and standing without aid. After clinical examination and relevant investigations, Magnetic Resonant Imaging (MRI) was done to confirm our suspicion of PVNS. Findings/Treatment Examination revealed a tender, swollen knee with a fluctuant palpable infrapatellar mass. Knee arthrocentesis yielded about 200mls of non-clotted hemorrhagic effusions. The patient had an open synovectomy following MRI, which was highly suggestive of pigmented villonodular synovitis with extensive suprapatellar bursitis. Specific histological findings (below) further confirmed the diagnosis. He commenced early physiotherapy, and symptoms resolved without recurrence of swelling eleven months after surgery. Conclusion This case highlights the visual presentation of an uncommon joint disorder and suggests it is considered a differential diagnosis of non-traumatic monoarticular pain and swelling in our rheumatology clinic set-up and among teenagers in whom juvenile rheumatoid arthritis would have been the first differential. Key words: Pigmented villonodular synovitis, Synovectomy, Multinucleated giant cells Contribution statement: AA conceived the idea to write the case report, draft the first manuscript, and manage the patient. YA, HO and AF edited the manuscript, while AIL interpreted the histological findings. All the authors approved the final version of the manuscript. Disclosure statement: None declared. Ethics and patient consent: This case report adheres to the Helsinki declaration, and the patient’s parents gave written consent to publish the details of the information. Additional information: Any institution did not fund this publication. Acknowledgements: We thank Dr Isaac Akanbi and Dr Bukar for interpreting the MRI and performing the surgery.

Proton beam therapy for hepatocellular carcinoma with bile duct invasion

AimHepatocellular carcinoma (HCC) with bile duct invasion (BDI) (BDIHCC) has a poor prognosis. Moreover, due to the paucity of reports, there is no consensus regarding optimal management of this clinical condition yet. The aim of this study was to clarify the efficacy and safety of proton beam therapy (PBT) for BDIHCC.MethodsBetween 2009 and 2018, 15 patients with BDIHCC underwent PBT at our institution. The overall survival (OS), local control (LC), and progression-free survival (PFS) curves were constructed using the Kaplan-Meier method. Toxicities were assessed using the Common Terminology Criteria of Adverse Events version 4.0.ResultsThe median follow-up time was 23.4 months (range, 7.9–54.3). The median age was 71 years (range, 58–90 years). Many patients were Child A (n = 8, 53.3%) and most had solitary tumors (n = 11, 73.3%). Additionally, most patients had central type BDI (n = 11, 73%). The median tumor size was 4.0 cm (range, 1.5–8.0 cm). The 1-, 2-, and 3-year OS rates were 80.0%, 58.7% and 40.2%, respectively, and the corresponding LC and PFS rates were 93.3%, 93.3%, and 74.7% and 72.7%, 9.7%, and 0.0%, respectively. Acute grade 1/2 dermatitis (n = 7, 46.7%), and grades 2 (n = 1, 6.7%) and 3 (n = 1, 6.7%) cholangitis were observed. Late toxicities such as grade 3 gastric hemorrhage and pleural effusion were observed. No toxicities of grade 4 or higher were observed.ConclusionsPBT was feasible with tolerable toxicities for the treatment of BDIHCC.

Pericardial malignant mesothelioma diagnosed in a dog by immunocytochemistry of the pericardial fluid: a case report

BackgroundPericardial effusions are one of the most common cardiac diseases in dogs. Common causes of haemorrhagic pericardial effusions include neoplasia, such as hemangiosarcoma, mesothelioma, chemodectoma, and ectopic thyroid tumours, and benign idiopathic pericardial effusion. Distinguishing among reactive mesothelial cells, malignant mesothelioma, and adenocarcinoma in body effusions is a diagnostic challenge. Therefore, the author aimed to discover whether the observed cells were reactive mesothelial, mesothelioma, or adenocarcinoma cells through immunocytochemistry using five markers (cytokeratin, vimentin, desmin, E-cadherin, and calretinin) in a canine patient.Case presentationA 2.1 kg, spayed female, 10-year-old Yorkshire Terrier dog presented to a local hospital with dyspnoea and was evaluated for pericardial effusion. The presence of pericardial fluid was confirmed, and she was referred to our hospital for further evaluation. In cytological evaluation, cells shed individually or in clusters were observed, along with numerous non-degenerative neutrophils and macrophages. The cells showed binucleation, anisocytosis, anisokaryosis, abnormal nucleoli, abundant basophilic cytoplasm, high nuclear–cytoplasmic ratio, and coarse chromatin. Large atypical multinucleate cells were also observed. Erythrophagia was observed, indicating chronic haemorrhage. Immunocytochemistry using pericardial fluid was positive for cytokeratin, vimentin, desmin, E-cadherin, and calretinin. Therefore, malignant mesothelioma was diagnosed.ConclusionsImmunocytochemistry is a very useful diagnostic technique because it can determine whether several fluorescent markers are simultaneously expressed in the same cell. Further, E-cadherin and calretinin can be used for the differential diagnosis of reactive mesothelial cells, malignant mesothelioma, and adenocarcinoma in dogs.

Predictors for the clinical prognosis of sylvian arachnoid cysts in children.

To investigate the potential factors affecting the clinical prognosis of intracranial sylvian arachnoid cysts(IAC) in children. All patients with IAC admitted to our department from January, 1, 2015 to December, 31, 2016, were retrospectively reviewed. Patients were grouped based on surgical treatment (surgery cohort vs non-surgery cohort). The clinical and image outcome of the patients were followed routinely. The clinical characteristics and the prognosis of the patients were compared in different cohorts. Binary logistic regression analysis was applied to analyze the potential factors which may post an influence on the prognosis of the patients. Of 500 patients admitted to our department for IAC, 424 patients had good prognosis and 76 had poor prognosis, with no deaths occurred during the follow-ups. 68 patients had IAC related complications and 91 patients developed new symptoms during the follow-ups. There were significant differences (P < 0.05) between the 2 cohorts in below aspects: age, gender, Galassi subtype, whether the mother was a unipara, the maximum diameter of the cysts at the first visit and the last follow-up, headache, head circumference, temporal bulge, new symptoms, cysts rupture and hemorrhage, subdural effusion, and IAC disappearance. The mean changes in the maximum diameter of the IAC for the patients were marginally higher for the surgery cohort than for the non-surgery cohort (P < 0.01). Binary logistic regression analysis suggested that the number of symptom, no new symptoms during follow-up, surgical treatment, age, maximum diameter of cysts at first diagnosis were independent risk factors affecting the prognosis of patients (P < 0.05). Patients older than 22.5 months, with the maximum diameter of IAC greater than 5.75 cm, who have multiple symptoms, born prematurely, develope new symptoms during the follow-ups and obvious symptoms after trauma need to conduct necessary surgical treatment in time. Patients with complications such as cysts rupture with hemorrhage and subdural effusion will acquire good prognosis after timely surgical treatment. IAC complete disappearance warrants no such important attention for the good prognosis.

Predictors of bleeding events in acute decompensated heart failure patients with antithrombotic therapy: AURORA study.

Heart failure (HF) is reported to be one of the major risks of bleeding events. On the other hand, HF patients frequently receive anticoagulants or antiplatelet therapy to manage various co-morbidities. However, predictors of bleeding events in patients with HF have rarely been reported. This study aimed to evaluate the predictors of bleeding events and relationship between bleeding events and HF re-hospitalizations. We included 1660 acute decompensated heart failure (ADHF) patients from the AURORA registry between January 2015 and December 2020. A total of 1429 patients were excluded because of history of HF admission, missing echocardiographic data at discharge, lost to follow-up, haemodialysis and no antithrombotic drugs. Finally, we evaluated 231 patients from AURORA registry. The bleeding events were defined as Type 2 to 5 bleeding according to the Bleeding Academic Research Consortium definition. We divided our patients into the bleeding group and non-bleeding group. We compared the baseline characteristics, medications, laboratory data, and echocardiographic data between the two groups. Median age was 78 (IQR 71-82) years old and male accounted for 59%. Approximately half of the patients had an antiplatelet therapy and 70% had an anticoagulant therapy. During a median follow-up of 651 (IQR 357-1139) days, 32 patients (13.8%) suffered from bleeding events. The major driver of the registered events was gastrointestinal bleeding (n=21, 65.6%), and the other events were cerebral bleeding (n=4, 12.5%), intraarticular bleeding (n=2, 6.3%), urogenital bleeding (n=2, 6.3%), haemorrhagic pericardial effusions (n=1, 3.1%), subcutaneous hematomas (n=1, 3.1%), and haemothorax (n=1, 3.1%). There was a significantly lower haemoglobin level (P<0.01), higher proportion of inferior vena cava (IVC) diameter ≥21mm (P<0.01), and higher furosemide equivalent doses per kilogram (P<0.01) in the bleeding group than non-bleeding group. A multivariate analysis revealed an equivalent dose of furosemide per kilogram ≥0.66mg/kg (hazard ratios (HR) of 2.64, 95% confidence interval (CI) 1.26-5.68, P=0.01), haemoglobin ≤10.3g/dL (HR of 2.43, 95% CI 1.14-5.03, P=0.02), and IVC diameter ≥21mm (HR of 2.79, 95% CI 1.16-6.29, P=0.02) were independently associated with bleeding events. The Kaplan-Meier analysis showed that HF re-hospitalization rates were higher in the bleeding group than non-bleeding group (P=0.04). High doses of oral loop diuretics, IVC dilatation, and anaemia were predictors of bleeding events in patients hospitalized with ADHF patients. In addition, bleeding events were associated with HF re-hospitalizations.

Abstract 10436: Spontaneous Hemopericardium After Rivaroxaban

Direct oral anticoagulants (DOACs) such as rivaroxaban have become the drugs of choice when treating a variety of conditions requiring anticoagulation. We describe a case of a patient found to have hemopericardium with tamponade physiology on a routine echo ordered for evaluation of tachycardia. A 49-year-old man with systemic hypertension was found to have a right lower lobe pulmonary embolus (PE) during a hospitalization for diabetic ketoacidosis complicated by pneumoperitoneum s/p small bowel resection. Rivaroxaban 15 mg twice daily was initiated for treatment of PE. On day 2 rivaroxaban, patient became tachycardic. Chest CT showed a small to moderate pericardial effusion with pericardial enhancement. On day 7, a echo showed trivial pericardial effusion without hemodynamic compromise. Tachycardia persisted after hospital discharge, but patient was otherwise asymptomatic. Patient transitioned to rivaroxaban 20 daily after 3 weeks. Outpatient echo done 2 months after discharge showed a large pericardial effusion with tamponade physiology. Patient was instructed to go to hospital for admission. Labs were significant for Hgb 7.8, and elevated PT 52.50, INR 4.5 and PTT 33.80. Rivaroxaban was held, and patient was given 2 units FFP, Vitamin K 10 mg oral, Kcentra 4208 units and 2 units pRBCs. Patient underwent a pericardiocentesis with removal of 600 cc of sanguineous fluid. Fluid analysis was consistent with hemorrhagic effusion. Repeat echo showed a small residual, anterior pericardial effusion with constrictive physiology. Patient was discharged on reduced dose of rivaroxaban 10 daily and Vitamin K 5 mg daily until outpatient follow up. Our case of hemopericardium occurring in a middle-aged man without confounding issues is unusual. Although hemopericardium with DOACs have been reported, the majority of cases have occurred in patients with pre-disposing risk factors. A systemic review of 26 cases by Asad, et al. described risks associated with cardiac tamponade with DOACs. The incidence of hemopericardium and tamponade appeared highest in elderly men with renal and coagulation abnormalities. Our case highlights the importance of vigilance in patients on DOACs who present with subtle symptoms suggestive of hemodynamic compromise or instability.