Iatrogenic Procedures Research Articles

Rare case of radial artery pseudoaneurysm protruding through skin after a single arterial puncture for blood-gas analysis

The pseudoaneurysm of the radial artery is an infrequent complication mainly after iatrogenic procedures, with an increased incidence over the last years. The aim of the current study was to present a rare case of a radial artery pseudoaneurysm that projected through the skin after a single arterial puncture for blood-gas analysis. A 79-year-old man, with a history of atrial fibrillation and coronary heart disease on anticoagulants, was admitted to the cardiological intermediate care unit, with pulmonary oedema due to heart failure deregulation. On the next day, his left radial artery was punctured for blood-gas analysis. No other catheterization of the vessel was executed in the following days. Six days later a pulsatile, palpable mass on the skin surface, over the site of puncture, was recognized. Subsequently a Doppler ultrasound that was performed, confirmed the diagnosis of pseudoaneurysm. The pseudoaneurysm was surgically removed under general anesthesia. The patient was hospitalized for four days for trauma monitoring and intravenous antibiotics and afterwards he was discharged from the Hospital. Three months postoperatively, no sign of recurrence was observed. The pseudoaneurysm of the radial artery is an uncommon complication that might occur even after simple iatrogenic procedures, like after a direct arterial puncture for blood-gas analysis. Therefore, specialists should always be aware of this complication in similar cases.

Phylogenetic and Molecular Analyses of More Prevalent HCV1b Subtype in the Calabria Region, Southern Italy.

Hepatitis C virus subtype 1b (HCV1b) is still the most prevalent subtype worldwide, with massive expansion due to poor health care standards, such as blood transfusion and iatrogenic procedures. Despite safe and effective new direct antiviral agents (DAA), treatment success can depend on resistance-associated substitutions (RASs) carried in target genomic regions. Herein we investigated transmission clusters and RASs among isolates from HCV1b positive subjects in the Calabria Region. Forty-one NS5B and twenty-two NS5A sequences were obtained by Sanger sequencing. Phylogenetic analysis was performed using the maximum likelihood method and resistance substitutions were analyzed with the Geno2pheno tool. Phylogenetic analysis showed sixteen statistically supported clusters, with twelve containing Italian sequences mixed with foreign HCV1b isolates and four monophyletic clusters including only sequences from Calabria. Interestingly, HCV1b spread has been maintained by sporadic infections in geographically limited areas and by dental treatment or surgical intervention in the metropolitan area. The L159F NS5B RAS was found in 15 isolates and in particular 8/15 also showed the C316N substitution. The Y93H and L31M NS5A RASs were detected in three and one isolates, respectively. The A92T NS5A RAS was found in one isolate. Overall, frequencies of detected NS5B and NS5A RASs were 36.6% and 22.7%, respectively. For the eradication of infection, improved screening policies should be considered and the prevalence of natural RASs carried on viral strains.

Fatty Density and Air

Both fat and air have lower attenuation than water on CT images. Excluding ruptured dermoid cysts, a majority of intracranial fats have no clinical significance. In contrast, intracranial air sometimes indicates serious conditions. If CT attenuation of the lesion is apparently lower than that of the orbital fat, it can be regarded as an air bubble. T1-weighted MRI is useful for differentiating fat from air. Air in the subarachnoid space, called pneumocephalus, is a significant sign of serious head injury. In such cases, there may be cerebrospinal fluid leakage, and the risk of meningitis. Iatrogenic pneumocephalus is also observed, including lumbar puncture. Air in the artery is indicative of air embolism, which is a serious condition. It is caused by trauma and iatrogenic procedures. Both, right-to-left shunt in the heart and pulmonary arteriovenous fistula are risk factors for air embolism. Small air bubbles rapidly disappear from the arterial lumen. On the other hand, air in the dural sinuses is iatrogenic but usually asymptomatic. According to anatomical characteristics, air from the left hand easily migrates into the dural sinuses via the left internal jugular vein.

Nonionic surfactant attenuates acute lung injury by restoring epithelial integrity and alveolar fluid clearance.

Introduction: Acute lung injury (ALI) has a great impact and a high mortality rate in intensive care units (ICUs). Excessive air may enter the lungs, causing pulmonary air embolism (AE)-induced ALI. Some invasive iatrogenic procedures cause pulmonary AE-induced ALI, with the presentation of severe inflammatory reactions, hypoxia, and pulmonary hypertension. Pulmonary surfactants are vital in the lungs to reduce the surface tension and inflammation. Nonionic surfactants (NIS) are a kind of surfactants without electric charge on their hydrophilic parts. Studies on NIS in AE-induced ALI are limited. We aimed to study the protective effects and mechanisms of NIS in AE-induced ALI.Materials and methods: Five different groups (n = 6 in each group) were created: sham, AE, AE + NIS pretreatment (0.5 mg/kg), AE + NIS pretreatment (1 mg/kg), and AE + post-AE NIS (1 mg/kg). AE-induced ALI was introduced by the infusion of air via the pulmonary artery. Aerosolized NIS were administered via tracheostomy.Results: Pulmonary AE-induced ALI showed destruction of the alveolar cell integrity with increased pulmonary microvascular permeability, pulmonary vascular resistance, pulmonary edema, and lung inflammation. The activation of nuclear factor-κB (NF-κB) increased the expression of pro-inflammatory cytokines, and sodium-potassium-chloride co-transporter isoform 1 (NKCC1). The pretreatment with NIS (1 mg/kg) prominently maintained the integrity of the epithelial lining and suppressed the expression of NF-κB, pro-inflammatory cytokines, and NKCC1, subsequently reducing AE-induced ALI.Conclusions: NIS maintained the integrity of the epithelial lining and suppressed the expression of NF-κB, pro-inflammatory cytokines, and NKCC1, thereby reducing hyperpermeability, pulmonary edema, and inflammation in ALI.

Lumbar spinal epidural hematoma without vertebral fracture causing cauda equina syndrome

Spinal epidural hematoma (SEH) is a rare disease and may lead to spinal cord compression. It could be caused by trauma, including iatrogenic procedures such as spinal surgery or spinal anesthesia or by spontaneous events related to coagulopathy or arteriovenous malformation. Once SEH is suspected clinically and confirmed by image modalities, it should be emergently decompressed by surgical intervention. Prognosis depends on the rate of symptoms development, interval from symptom onset to surgery, level of spinal involvement, and degree of neurological deficits. Here, we report the case of a 79-year-old female who sustained a fall months before admission, presented with a 3-day history of back and bilateral lower limbs weakness. Radiography and magnetic resonance imaging demonstrated epidural hematomas at the level of T12 to L2 without associated vertebral fracture. An urgent decompressive laminectomy with blood clot removal was performed immediately. Postoperatively, her neurologic deficits improved significantly except for residual numbness.

Short and Long-term Results after Surgical Repair in Patients with Iatrogenic Biliary Injuries

Purpose: Iatrogenic bile duct injury is a complication associated with significant perioperative morbidity and mortality. The aim of this work is to analyse the results of surgical repair after biliary duct injury in our institution. Methods: This is a retrospective study from 2007 to 2019. All patients who underwent surgical repair were included. Demographic variables, type of lesions, surgical complications and evolution after surgical repair of the iatrogenic lesion were analyzed. Results: During this period a total of 41 surgical repairs were performed for iatrogenic injuries after cholecystectomy. The mean age of the patients was 57 years (28-82), 51.2% were male. Biliary iatrogenic procedures were performed laparoscopically in 78% of cases; 17.1% occurred during emergency cholecystectomy. At the initial surgery, cholecystectomy was described as a difficult procedure in 42.5% of the cases. The main indication in 78% of the patients was symptomatic cholelithiasis. In 4 patients (9.8%) an attempt at repair was made after intraoperative detection, and 10 patients (24.4%) underwent reoperation prior to referral to our unit. The highest percentage of lesions were located in the common bile duct 58.5%, according to the Strasberg classification, the most common type of lesion was E2 in 31.7% followed by E3 in 19.5%. The repair performed in 78% of the cases was hepaticojejunostomy. Postoperative complications occurred in 43.9% of patients, with severe Clavien-Dindo ≥ III complications in 17.1%. Two patients (4.8%) died postoperatively. Survival free of biliary complications was 89.8%. The median time from iatrogenic to repair was 21 days. No differences were found between patients operated on before or after 3 weeks post injury (45% vs. 42.9%; p = 0.75). Conclusion: The most frequent site of injury was the common bile duct. Hepaticojejunostomy was the most frequently technique used. Long-term results of surgical repair are satisfactory. We did not find differences between repair before three weeks or later.

Surfactant Attenuates Air Embolism-Induced Lung Injury by Suppressing NKCC1 Expression and NF-\u03baB Activation

Excessive amounts of air can enter the lungs and cause air embolism (AE)-induced acute lung injury (ALI). Pulmonary AE can occur during diving, aviation, and iatrogenic invasive procedures. AE-induced lung injury presents with severe hypoxia, pulmonary hypertension, microvascular hyper-permeability, and severe inflammatory responses. Pulmonary AE-induced ALI is a serious complication resulting in significant morbidity and mortality. Surfactant is abundant in the lungs and its function is to lower surface tension. Earlier studies have explored the beneficial effects of surfactant in ALI; however, none have investigated the role of surfactant in pulmonary AE-induced ALI. Therefore, we conducted this study to determine the effects of surfactant in pulmonary AE-induced ALI. Isolated-perfused rat lungs were used as a model of pulmonary AE. The animals were divided into four groups (n = 6 per group): sham, air embolism (AE), AE + surfactant (0.5 mg/kg), and AE+ surfactant (1 mg/kg). Surfactant pretreatment was administered before the induction of pulmonary AE. Pulmonary AE was induced by the infusion of 0.7 cc air through a pulmonary artery catheter. After induction of air, pulmonary AE was presented with pulmonary edema, pulmonary microvascular hyper-permeability, and lung inflammation with neutrophilic sequestration. Activation of NF-κB was observed, along with increased expression of pro-inflammatory cytokines, and Na-K-Cl cotransporter isoform 1 (NKCC1). Surfactant suppressed the activation of NF-κB and decreased the expression of pro-inflammatory cytokines and NKCC1, thereby attenuating AE-induced lung injury. Therefore, AE-induced ALI presented with pulmonary edema, microvascular hyper-permeability, and lung inflammation. Surfactant suppressed the expressions of NF-κB, pro-inflammatory cytokines, and NKCC1, thereby attenuating AE-induced lung injury.

Pneumorrhachis causing cauda equina syndrome: a case report and literature review

BackgroundPneumorrhachis (PR) describes the rare presence of intraspinal air, mainly following traumatic or iatrogenic procedures. According to the localization of air in the spinal canal, PR has been classified into internal (subdural) and external (epidural). PR rarely manifests in neurological deficits and usually resolves spontaneously without recurrence, with air being passed directly into the bloodstream.Here, we report a case of external PR occurring spontaneously (without any underlying trauma or surgical interventions) manifesting as neurological deficits. This is an extremely rare finding with only a limited number of cases in the literature.Case presentationWe report a case of spontaneous external PR manifesting as neurological symptoms in a 62-year-old male diabetic patient with chronic low backpain who developed numbness in his perineal region mainly on the left side. His medical history was normal, without trauma or surgical intervention. Magnetic resonance imaging (MRI) and computed tomography (CT) in the past 2 years demonstrated degenerative changes in the lumbar spine, including end plates and disc spaces, with intervertebral disc vacuum phenomenon (VP); the CT additionally showed intraspinal air in the epidural space at L5-S1 levels compressing the cauda equina. A diagnosis of spontaneous external PR was made. A follow-up MRI upon exacerbation of neurological deficits showed an increase in air locule size. Our patient was managed conservatively on a nonsteroidal anti-inflammatory agent (NSAID) and was advised for regular follow-ups. No aspiration or surgery has been performed to date.ConclusionsSpontaneous external pneumorrhachis manifesting as neurological symptoms is extremely rare. Due to degenerative disc disease producing vacuum phenomenon, we propose that spontaneous PR secondary to intradiscal VP be considered as part of the differential for radicular symptoms, especially with increasing age. The most effective noninvasive investigation for the diagnosis of PR is CT. MRI is less beneficial in the case of PR as gas and calcifications are hard to distinguish, both being of low-intensity signals on all MR sequences.

Adenomyosis in mice resulting from mechanically or thermally induced endometrial–myometrial interface disruption and its possible prevention

Research questionDo uterine procedures potentially disrupting the endometrial–myometrial interface (EMI) induce adenomyosis? DesignSix prospective, randomized controlled experiments were conducted involving a total of 106 female BALB/c and 12 female C57BL/6 mice. The incidence of adenomyosis was evaluated in these two strains of mouse after mechanically induced EMI disruption (EMID), or thermally induced EMID using electrocoagulation of different intensities. Finally, the incidence was evaluated in mice that had received perioperative administration of aprepitant (an NK1R inhibitor), propranolol (a beta-blocker) or vehicle. Body weight, hot plate latency and grade of myometrial infiltration were evaluated. Histology, immunohistochemistry and histochemistry analyses were also performed. ResultsMechanical injury to the EMI caused EMID. Adenomyosis developed in the majority of mice in the EMID groups 3 months after mechanically induced EMID but did not develop in the control group (83.3% in C57BL/6 mice, P = 0.015; 100% in BALB/c mice, P = 0.0002). With thermally induced EMID, adenomyosis was found in 30% of the EMID mice 10 weeks later, but the incidence increased to 66.7% if the extent of EMID damage was increased. In mice with perioperative administration of aprepitant or propranolol, the incidence of adenomyosis was reduced from 100% to 58.3% (both P = 0.00034). ConclusionsThis study provides the first piece of experimental evidence that EMID resulting from iatrogenic uterine procedures can substantially increase the risk of developing adenomyosis, with the risk in proportion to the severity of disruption. More intriguingly, perioperative administration of an NK1R antagonist or beta-blocker significantly reduced the risk of developing adenomyosis.

Prognostic Risk Factors for Patients Receiving Airway Stent Placement

背景与目的气管支架被用于治疗各种良恶性气管疾病以及医源性操作引起的中央气道狭窄或气管瘘，其在迅速缓解症状方面具有较好的效果，但患者的长期生存仍有赖于对原发病的个体化治疗。因此，探索影响气管支架置入患者预后的相关危险因素，对于优化支架置入术以及改善患者的个体化临床管理具有帮助作用。方法回顾性研究2014年1月-2017年6月在浙江大学附属第一医院胸外科接受支气管镜下气管支架置入治疗的66例患者，分析年龄、性别、基础Charlson合并症指数（Charlson comorbidity index, CCI）、支架植入操作时长等临床指标对患者预后的影响。结果年龄、性别对患者预后没有显著影响，而CCI评分较高（P=0.045）和操作时间超过60 min（P=0.037）均为患者预后不良的独立危险因素，随后依据CCI评分和操作时长两个指标构建了患者预后的列线图预测模型，模型的受试者工作特征曲线（receiver operating characteristic curve, ROC）的曲线下面积为0.71，一致性指数为0.69。结论对于接受气管支架置入的患者，其基础的CCI评分和支架置入操作的时长对其预后判断具有一定的临床价值。

The Pathogenesis of Adenomyosis vis-à-vis Endometriosis.

Adenomyosis is used to be called endometriosis interna, and deep endometriosis is now called adenomyosis externa. Thus, there is a question as to whether adenomyosis is simply endometriosis of the uterus, either from the perspective of pathogenesis or pathophysiology. In this manuscript, a comprehensive review was performed with a literature search using PubMed for all publications in English, related to adenomyosis and endometriosis, from inception to June 20, 2019. In addition, two prevailing theories, i.e., invagination—based on tissue injury and repair (TIAR) hypothesis—and metaplasia, on adenomyosis pathogenesis, are briefly overviewed and then critically scrutinized. Both theories have apparent limitations, i.e., difficulty in falsification, explaining existing data, and making useful predictions. Based on the current understanding of wound healing, a new hypothesis, called endometrial-myometrial interface disruption (EMID), is proposed to account for adenomyosis resulting from iatrogenic trauma to EMI. The EMID hypothesis not only highlights the more salient feature, i.e., hypoxia, at the wounding site, but also incorporates epithelial mesenchymal transition, recruitment of bone-marrow-derived stem cells, and enhanced survival and dissemination of endometrial cells dispersed and displaced due to iatrogenic procedures. More importantly, the EMID hypothesis predicts that the risk of adenomyosis can be reduced if certain perioperative interventions are performed. Consequently, from a pathogenic standpoint, adenomyosis is not simply endometriosis of the uterus, and, as such, may call for interventional procedures that are somewhat different from those for endometriosis to achieve the best results.

Correlation between Cardiac Biomarkers and Right Ventricular Dysfunction in Acute Inferior Wall Myocardial Infarction with and without Right Ventricular Myocardial Infarction

Introduction: Right Ventricular Myocardial Infarction (RVMI) along with inferior wall left ventricular (LV) dysfunction or Inferior Wall Myocardial Infarction (IWMI) is found in 30-50% of the cases. Isolated Right Ventricular (RV) dysfunction or infarction is rare except in iatrogenic (interventional) procedures. RVMI is being more commonly diagnosed retrospectively in the era of primary angioplasty, when these patients post-procedure fail to improve satisfactorily as compared to isolated IWMI patients. Clues to identify early RV involvement in acute IWMI patients will help in better management and less morbidity in this group of patients. Aim: The study was undertaken to search for any correlation between cardiac biomarkers {Troponin I (Trop I), Creatinine Kinase-MB (CK-MB), Brain Natriuretic Peptide (BNP)} and RV involvement using echocardiographic parameters in inferior Acute Myocardial Infarction (AMI), with and without associated RVMI, in patients who underwent primary Percutaneous Coronary Intervention (PCI). Materials and Methods: This was a cross-sectional study, conducted from September, 2018 to August, 2019, in the Cardiology Department of ABVIMS and Dr. Ram Manohar Hospital. A total of 294 patients, presenting with acute IWMI, were included in the study. Samples for Trop-I, CK-MB and BNP were taken immediately after admission. One hundred and thirty two patients had an associated RVMI. Two-dimensional Echocardiography was done within the first 12 hours of admission. Electrocardiography (ECG) and Echocardiography (EEG) assessments were used to determine RV involvement. Comparison was done first between patients with and without RV involvement, followed by comparison among groups for quantitative parameters, especially biomarkers, for finding correlation between biomarker levels and echocardiographic parameters (both RV and LV functions). Results: Patients presenting with IWMI with an associated RVMI had increased LV E/E’ ratio. Also, as predicted, they had a low Tricuspid Annulus Plane Systolic Excursion (TAPSE) and a low RV fractional area change, as well, due to stunning of right ventricle in the acute phase. In the group with higher BNP levels (≥400 pg/mL), the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/E’) was increased; on the other hand LV ejection fraction and TAPSE were decreased. There was negative correlation between RSm (RV systolic wave), TAPSE and BNP levels. BNP, Trop I and CK-MB levels showed a positive correlation with E/E’ at higher levels. Hypotension was more in patients presenting with RVMI, but it did not reach statistical significance. The mortality was 4.5% in the inferior Myocardial Infarction (MI) with RV involvement group versus 1.8% in isolated inferior MI group (during hospital stay). Conclusion: In acute Inferior wall MI, higher levels of BNP, CK-MB, Trop I, alone or in combination, might be used for prediction of RV involvement. BNP levels ≥400 pg/mL, Trop I levels ≥1.1 ng/mL, and CK-MB levels ≥4.5 ng/mL, along with hypotension and higher E/E’ ratio were observed in such cases and were associated with RV dysfunction and increased mortality.

Paradoxical effects of continuous high dose gabapentin treatment on autonomic dysreflexia after complete spinal cord injury

Spinal cord injury (SCI) can have profound effects on the autonomic and cardiovascular systems, notably with injuries above high-thoracic levels that result in the development of autonomic dysreflexia (AD) characterized by volatile hypertension in response to exaggerated sympathetic reflexes triggered by afferent stimulation below the injury level. Pathophysiological changes associated with the development of AD include sprouting of both nociceptive afferents and ascending propriospinal ‘relay’ neurons below the injury, as well as dynamic changes in synaptic inputs onto sympathetic preganglionic neurons. However, it remains uncertain whether synapse formation between sprouted c-fibers and propriospinal neurons contributes to the development of exaggerated sympathetic reflexes produced during AD. We previously reported that once daily treatment with the anti-epileptic and neuropathic pain medication, gabapentin (GBP), at low dosage (50 mg/kg) mitigates experimentally induced AD soon after injections, likely by impeding glutamatergic signaling. Since much higher doses of GBP are reported to block the formation of excitatory synapses, we hypothesized that continuous, high dosage GBP treatment after SCI might prevent the formation of aforementioned aberrant synapses and, accordingly, reduce the incidence and severity of AD. Adult female rats implanted with aortic telemetry probes for hemodynamic monitoring underwent T4-transection SCI and immediately received 100 mg/kg (i.p.) of GBP and then every six hours (400 mg/kg/day) for 4-weeks after injury. We assessed daily body weight, mean arterial pressure, heart rate, frequency of spontaneous AD, and hemodynamic changes during colorectal distension (CRD) to establish whether high dose GBP treatment prophylactically mitigates both AD and associated aberrant synaptic plasticity. This regimen significantly reduced both the absolute blood pressure reached during experimentally induced AD and the time required to return to baseline afterwards. Conversely, GBP prevented return to pre-injury body weights and paradoxically increased the frequency of spontaneously occurring AD. While there were significant decreases in the densities of excitatory and inhibitory pre-synaptic markers in the lumbosacral dorsal horn following injury alone, they were unaltered by continuous GBP treatment. This indicates distinct mechanisms of action for acute GBP to mitigate induced AD whereas chronic GBP increases non-induced AD frequencies. While high dose prophylactic GBP is not recommended to treat AD, acute low dose GBP may hold therapeutic value to mitigate evoked AD, notably during iatrogenic procedures under controlled clinical conditions.

The PLART study: incidence of preterm labor and adverse pregnancy outcomes after assisted reproductive techniques-a retrospective cohort study.

Even though assisted reproductive techniques represent one of the greatest achievements in modern medicine, the risk of preterm birth related to these pregnancies is about twice as high. This must be highlighted and further investigated to optimize the management of both mothers and newborns. The purpose of this study was to compare adverse pregnancy outcomes after assisted reproductive techniques (ART) and spontaneous conceptions, focusing on the incidence of preterm births (PTB) and distinguishing between iatrogenic and spontaneous events. This retrospective cohort study analyzed single births of one Italian hospital. The incidence of PTBs in ART pregnancies, divided into iatrogenic procedures, spontaneous preterm labors and preterm premature ruptures of the membranes (pPROMs), was compared with the non-ART control group. The incidence of other adverse pregnancy outcomes and the types of delivery were also reported and compared. Of the 11,769 single births included, 2.39% were conceived by ART. The incidence of PTBs was 4.74% for spontaneous pregnancies and 12.8% for ART pregnancies (aOR 1.93; 95% CI 1.29-2.88). The percentage of iatrogenic procedures was 27.78% in the ART-PTBs' group and 30.88% in the non-ART-PTBs' controls. ART pregnancies showed an increased incidence of pPROMs (6.40% versus 2.41%), preterm labors (2.85% versus 0.93%), hypertensive disorders of the pregnancy (8.19% versus 2.32%), placenta previa (3.20% versus 0.59%), cesarean sections(28.47% versus 16.27%) and vacuum extractions (10.32% versus 5.19%). Singleton ART pregnancies have a higher risk of PTB which is mostly linked to a higher incidence of pPROMs and spontaneous preterm labor. The concurrency of a demonstrated higher risk of hypertensive gestational disorders and placenta previa suggests that placental development plays an important role in the pathogenesis of PTB.

Distinguishing soft tissue sarcomas of different histologic grades based on quantitative MR assessment of intratumoral heterogeneity

PurposeTo explore the role of intratumoral heterogeneity on MRI assessed by histogram analysis in differentiating soft-tissue sarcomas (STS) of different grades. Materials and MethodsPatients with primary STS undergoing MRI prior to iatrogenic procedures were included retrospectively. The histologic grade was assigned according to Federation Nationale des Centres de Lutte Contre le Cancer grading system. T1WI and T2WI were normalized by dividing mean signal intensity (SI) of contralateral/near unaffected muscles. Contrast-enhanced T1WI was normalized by computing enhancement ratio (ER) map as (SIpost-SIpre)/SIpre×100, where SIpre and SIpost represent SI of each pixel before and after enhancement. A region of interest (ROI) was manually drawn to include entire tumor area on axial slice with largest tumor diameter. Mean, mode, standard deviation, kurtosis and skewness on ROIs were extracted with ImageJ software. ANOVA/Kruskal-Wallis test was used to determine the significance of differences. ROC curve was applied for statistically significant parameters. P value ≤0.05 was considered statistically significant. ResultsAmong involved 67 patients, 8 were assigned to grade 1, 38 to grade 2 and 21 to grade 3. Skewness (P = 0.022) and kurtosis (P = 0.035) on ER maps were significantly different among STS of different grades. The optimal cutoffs of skewness and kurtosis on ER maps were -0.488 (AUC[95% CI] 0.747[0.557–0.937]; sensitivity/specificity, 62.5%/86.4%) and 0.762 (AUC[95% CI] 0.684[0.548–0.821]; sensitivity/specificity, 76.2%/56.5%), respectively. ConclusionIntratumoral heterogeneity on MRI quantitatively displayed by histogram parameters can differentiate STS of different grades. Skewness and kurtosis on ER maps show the capacity.

Phosphodiesterase-4 Inhibitor Roflumilast Attenuates Pulmonary Air Emboli–Induced Lung Injury

BackgroundPulmonary air embolism (PAE)–induced acute lung injury (ALI) can be caused by massive air entry into the lung circulation. PAE can occur during diving, aviation, and some iatrogenic invasive procedures. PAE-induced ALI presents with severe inflammation, hypoxia, and pulmonary hypertension, and it is a serious complication resulting in significant morbidity and mortality. Phosphodiesterase-4 (PDE4) inhibitors can regulate inflammation and are therefore expected to have a therapeutic effect on ALI. However, the effect of the PDE4 inhibitor roflumilast on PAE-induced ALI is unknown. MethodsThe PAE model was undertaken in isolated-perfused rat lungs. Four groups (n = 6 in each group) were defined as follows: control, PAE, PAE + roflumilast 2.5 mg/kg, and PAE + roflumilast 5 mg/kg. Induction of PAE-induced ALI was achieved via the infusion of 0.7 cc air through the pulmonary artery. Roflumilast was administered via perfusate. All groups were assessed for pulmonary microvascular permeability, lung histopathology changes, pulmonary edema (lung weight/body weight, lung wet/dry weight ratio), tumor necrosis factor alpha (TNF-α), interleukin-1β (IL-1β), IL-6, IL-17, nuclear factor–kappa B (NF-κB), and inhibitor of NF-κB alpha (IκB-α). ResultsAfter the induction of air, PAE-induced ALI presented with pulmonary edema, pulmonary microvascular hyperpermeability, and lung inflammation with neutrophilic sequestration. The PAE-induced ALI also presented with increased expressions of IL-1β, IL-6, IL-8, IL-17, TNF-α, and NF-κB and decreased expression of IκB-α. The administration of roflumilast decreased pulmonary edema, inflammation, cytokines, NF-κB, and restored IκB-α level. ConclusionsPAE-induced ALI presents with lung inflammation with neutrophilic sequestration, pulmonary edema, hyperpermeability, increased cytokine levels, and activation of the NF-κB pathway. Roflumilast attenuates lung edema and inflammation and downregulates the NF-κB pathway and cytokines.

Iatrogeniа in internist practice.

The article presents the history of the issue, the concept of iatrogenia, possible negative consequences of the interaction of the doctor and the patient in modern conditions. The main forms of iatrogenic (psychogenic, hospital, iatrogenic diagnostic procedures, medicinal, etc.) are given. An important place is occupied by implantation of iatrogenic (patients with artificial heart valves, cardio-implanted electronic devices, coronary stents, articular endoprostheses). The most vulnerable to the development of iatrogenic are elderly and senile patients. The interdisciplinarity of the iatrogenic problem and its educational significance for therapists, general practitioners, clinical pharmacologists, pathologists. Keywords: iatrogeniа, iatrogenic events, undesirable drug reactions, мedical error.

The physician and hereditary angioedema friend or foe: 62-year diagnostic delay and iatrogenic procedures

BackgroundHereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) is a rare autosomal dominant disease characterized by episodes of acute subcutaneous swelling, and/or recurrent severe abdominal pain. The disease is potentially fatal if the upper-airway is involved. Iatrogenic harm can occur if HAE is not considered in the differential diagnosis, the specialists are not aware of the natural history, diagnosis and treatment of HAE, or as a result of unnecessary surgical and other iatrogenic interventions.Case presentationWe present the case of a 72-year-old man who began suffering recurrent abdominal pain at the age of 8 years. The pain led to frequent emergency department visits, three emergency surgical interventions, and 5 endoscopies before C1-INH-HAE was diagnosed at the age of 70. Infrequent subcutaneous swellings were attributed to unknown allergic reactions that were not related to the primary diagnosis of abdominal pain. Family history was positive for recurrent abdominal pain and angioedema but was ignored until the propositus’ grandson developed recurrent severe oro-facial edema attacks. The boy’s mother searched the worldwide web and found educational materials on a patient association website. She suggested complement C4 and C1-INH testing that led to the appropriate diagnosis of C1-INH-HAE type 1 in her son and his grandfather.ConclusionThis report emphasizes the importance of accurately evaluating personal and family history in patients with a long history of recurrent, acute, severe but medically unexplained abdominal pain and cutaneous swellings. Here, the diagnosis of HAE was overlooked for 62 years and the focus on abdominal complaints led to numerous surgical interventions without consideration of the full differential diagnosis. Screening family members from all generations for unrecognized angioedema, abdominal pain, and measurement of C1-INH and C4 are essential for accurate and timely diagnosis of HAE.

71.2 A Clinical Pathway: Identification and Management of Somatic Symptoms and Related Disorders

Somatic symptoms and related disorders (SSRDs) are often misdiagnosed as medical conditions, leading to unnecessary, costly, and potentially iatrogenic medical procedures and treatments. SSRDs are the second most common consultation request, with a prevalence of 17.5% of inpatient pediatric consultation-liaison (CL) consults. The care of youth with SSRDs varies among clinicians because of a lack of evidence-based management guidelines.

Spontaneous orbital subcutaneous emphysema mimicking lacrimal duct obstruction after sneezing: A case report

Introduction: Orbital subcutaneous emphysema after trauma has been carefully reported, but its development in the absence of trauma is rare. Case presentation: We report on a 70-year-old patient who developed unilateral orbital subcutaneous emphysema, mimicking lacrimal duct occlusion, after this man sneezed, and presented with right crepitant eyelid swelling and progressive ptosis. Orbital subcutaneous emphysema develops when air can get into the periorbital soft tissue, which presents as a result of facial bone trauma, iatrogenic procedures, and gas-forming infectious microorganisms, as seen in many published articles. It is very uncommon to see this kind of case report after sneezing; however, in our case, spontaneous orbital subcutaneous emphysema occurred after sneezing that resolved slowly after a few weeks without surgical intervention. Our patient denied any painful sensation over the right orbital area, including no visual problems with the right eye but right eyeball limited movements. It can be stressful to patients due to its symptoms but is not a true emergency. Conclusion: In this article, we should bring awareness to physicians of the possibility of a spontaneously orbital subcutaneous emphysema with complications after sneezing, yielding relevant information for patients to be informed about avoid excessive nose blowing or occluding the nose, creating controlled symptoms.