Unexpected Complication Research Articles

An Unexpected Complication of Steroid Use for the Treatment of Hypertrophic Scar

Annals of Plastic Surgery: February 2005 - Volume 54 - Issue 2 - p 221-222 doi: 10.1097/01.sap.0000151752.55068.b9

Central nervous system involvement in indolent lymphomas

Central nervous system (CNS) involvement, a well-recognized complication of aggressive non-Hodgkin's lymphomas (NHL), has rarely been reported in indolent lymphomas. Large series have reported this complication in 3% of indolent NHLs, generally following histological transformation. We retrospectively reviewed the disease characteristics and clinical course in seven patients (six females, one male) with indolent B-cell lymphomas who developed CNS involvement during various stages of their illness. The median ages at diagnosis of systemic and CNS lymphoma were 60 and 63 years, respectively. Histologies were: small lymphocytic lymphoma (two), follicular lymphoma grade I (two), follicular lymphoma grade II (two) and unclear low-grade histology (one). There were diverse neurological symptoms. Two patients had parenchymal involvement, three had leptomeningial involvement and two had both. Systemic lymphoma was found in all patients, all but one having bone marrow involvement. Four patients had a transformation to high-grade histology. Six patients were treated with systemic and intra-cerebrospinal fluid chemotherapy, and two received radiotherapy as well. Five patients achieved CNS response. Survival was 1-9 years for treated patients (median 2 years). Three patients died of CNS disease. CNS involvement is a rare and unexpected complication of indolent NHL, which should be considered in the differential diagnosis of patients presenting with new neurological signs. This condition is treatable and some patients have a long clinical course.

Ovarian pregnancy resulting from cornual fistulae in a woman who had undergone bilateral salpingectomy

To report a case of ovarian pregnancy following in vitro fertilization-embryo transfer (IVF-ET) treatment for which the cornual fistulae was the most probable explanation of the cause. Case report. University department and assisted reproduction unit. A 29-year-old woman with primary infertility. Hydrosalpinx of the bilateral fallopian tubes has been noted in patients who have decreased pregnancy rates in the IVF-ET treatment cycles. Salpingectomy before IVF cycles has been suggested to increase the pregnancy rate. We report a patient who presented with bilateral hydrosalpinx for whom bilateral salpingectomy was performed before IVF treatment. Clinical pregnancy. The treatment cycle resulted in a primary ovarian pregnancy and required laparoscopic operation. A cornual fistulae was found that have might led to ectopic implantation of the embryos. Ovarian pregnancy may be an unexpected complication of those receiving bilateral salpingectomy before IVF treatment. The presence of cornual fistulae after salpingectomy was probably the cause of the ectopic pregnancy.

Analysis of Vector Integration with LM-PCR after Retroviral HSV-Tk/ΔLNGFR Gene Transfer.

The development of secondary leukemia as an unexpected complication after retroviral transfer of potentially therapeutic genes was recently reported. In the pathogenesis of this complication, the upregulation of proto-oncogenes due to random vector integration played a crucial role. Therefore, the analysis of vector integration after retroviral gene transfer could become an interesting tool for risk assessment and safety measurement. In this study, 4 patients diagnosed with chronic myelogenous leukemia (CML) and 2 patients suffering from acute myelogenous leukemia (AML) were transplanted with T-cell-depleted CD34+ enriched stem cells (HSCT) from their HLA-identical siblings without further immunosuppression. After day +60 following HSCT, they received gene-modified donor T-cells infected with the replication-deficient retrovirus SFCMM-3, expressing the herpes simplex thymidine kinase (HSV-Tk) as a suicide gene, and the truncated low affinity nerve growth factor (ΔLNGFR) to control graft versus leukemia (GvL) effects and graft versus host disease (GvHD). In order to assess the viral integration sites in the transfused gene-modified donor T-cells, we performed a ligation-mediated PCR (LM-PCR) to amplify the vector flanking sequences. Final PCR products were visualized by gel electrophoresis and silver staining. Afterwards, sequence analysis (CEQ 8000, Beckman Coulter GmbH, Krefeld, Germany) of the clonal products was carried out. Standard National Center for Biotechnology Information (NCBI) blast searches were done to identify the flanking sequences (http://www.ncbi.nlm.nih.gov/BLAST). Within the investigated gene-modified T-cells of our study population, we found several integration sites. Up to now there has been no evidence for retroviral integration in the vicinity of proto-oncogene promoters after sequence analysis and database search. Furthermore, we were able to monitor the presence of the transduced T-cells at several time points after HSCT by detecting the internal retroviral band. In conclusion, the LM-PCR is a specific method to amplify and identify the flanking sequences after retroviral gene transfer, contributing significantly to the safety of gene therapy.

A very rare consequence of steroid therapy: Ileal perforation in a patient with familial mediterranean fever

Intestinal perforation rarely occurs in children with familial Mediterranean fever (FMF). When this does happen, it is the result of untreated intestinal obstruction caused by compression from peritoneal adhesions. Intestinal perforation is a well-known complication of steroid therapy in all ages. The duodenum is affected most frequently, but perforation may also occur in other parts of the small intestine and, very rarely, the colon. Intestinal wall changes that occur in chronic FMF may promote the harmful effects of steroids. Here we present an unexpected complication, ileal perforation, in an 8-year-old boy who was taking prednisolone for FMF-related arthritis.

Pancreatitis Caused by Rheolytic Thrombolysis: An Unexpected Complication

Two patients developed acute pancreatitis after mechanical thrombolysis with use of the AngioJet system. Patient 1 had undergone a remote complex revascularization of the lower extremities and presented with acute ischemia after thrombosis of his composite distal bypass. Patient 2 presented with superior vena cava (SVC) syndrome and had thrombosis of the SVC and innominate veins. Despite dissimilar presentations, both patients had renal insufficiency, were treated with mechanical and chemical thrombolysis, and had extensive thrombus burden. The pathophysiology of acute pancreatitis in this setting is believed to be secondary to massive hemolysis in the presence of chronic renal insufficiency. This phenomenon should be considered in patients whom develop abdominal pain after mechanical thrombolysis.

Ankle sprain: an unexpected complication

Blunt arterial injury is usually caused by high velocity trauma and can result in intimal dissection. We present a case of a professional footballer who sustained an intimal tear of the posterior tibial artery following a minor eversion injury of the ankle. The injury was noticed because of the physical demands of this patient’s profession. This was confirmed by an arteriogram and was treated with bypass surgery using an arm vein. Arterial intimal injury has not been reported previously with this type of injury. A high index of suspicion is needed to diagnose these injuries and revascularisation either by primary anastomosis or vein interposition graft is suggested.

<b>Spinal cord lesion </b>

Paraplegia and sensory disturbance are the symptoms often recognized in case of spinal cord lesion including trauma, tumor, demyelinating diseases and spinal cord infarction. In pain clinic area, neurological symptom of paraplegia may occur as an unexpected complication of the nerve block with neurolytics and it is important that we should understand pathological and anatomical basis of the spinal cord lesion. We experienced a case presenting a symptom of the paraplegia which was unexplainable for anterior spinal artery syndrome after the intercostal nerve block with neurolytics. The patient was 72 years old male with post herpetic neuralgia at the second thoracic nerve. The second intercostal nerve was blocked using 2.5 ml of 7% phenol water. Paraplegia and partial sensory disturbance below the 10th thoracic nerve were recognized after the block. We speculated the following mechanism of this complication. Phenol water partially entered into intercostal artery accompanying an intercostal nerve and drug solution spread against arterial blood flow because of the injection pressure was higher than arterial blood pressure. The drug solution entered into the intercostal artery spread to the spinal branch and the spinal cord supplied with this artery was partially damaged. There is a clear somatotopic organization of the fibers and an overlap of collaterals of ascending and descending branches of the dorsal root in the spinothalamic tract. There is also a segmental organization of the fibers in the spinothalamic tract and corticospinal tract. These tracts contain both transverse crossing fibers and uncrossing fibers. Nathan reported that the fibers subserving different sensory modalities did not 1 form the same angle with the long axis of the cord as they cross the cord. The difference in the angle of slope would lead to a different level of sensory loss for different modalities. It is considered that the sensory disturbance observed after the second intercostal nerve block appeared at the level of the 10th thoracic spinal cord level.It is important to be familiar with the anatomy of the spinal cord when performing neurolytic nerve blocks.

An unexpected surgical complication of ventricular assist device implantation identified by transesophageal echocardiography: a case report

Ventricular assist devices are used for circulatory support for patients with cardiogenic shock and refractory heart failure. Although early and late complications of left ventricular assist devices have been reported, we report a rare surgical complication of a left ventricular assist device implantation. This unexpected surgical complication was accurately identified by transesophageal echocardiography.

Editor's Choice

Evaluating interventions in applied science is difficult. The more complex the area where the intervention is to be applied, the more important it is that evaluation studies achieve comparison groups that are balanced for important but unknown factors. This means randomised trials. We report three trials this month in a particularly complex area of medicine - educational interventions. All three studies evaluated seemingly sensible ideas: educational counselling for women who had suffered an unexpected complication at delivery, education to encourage breastfeeding, and an education programme to prevent postnatal depression among women at risk. All three were well designed but none showed any significant benefit from the intervention. Dr Wing Hung Tam and colleagues from Hong Kong (pages 853–859) were clearly disappointed to find no benefit from routine educational counselling for women who had suffered unexpected adverse outcomes during childbirth. They wondered whether this might have been because the control group also got some support, or because only women with relatively mild distress agreed to participate, but the most likely reason remains that there was indeed no benefit from routine counselling at times of stress. Other studies in the puerperium have shown that similar sorts of counselling may even be detrimental, and outside pregnancy there is increasing evidence that routine counselling after such stressful events as a major road traffic accident is harmful. We should still talk to patients who have had a bad pregnancy outcome, but there is no need to go out of our way to divert resources to give them any extra feedback. Dr Labarere's group from Grenoble in France (pages 847–852) studied the effect of an educational intervention to encourage breastfeeding. We already know from other trials that providing one-to-one support to breastfeeding mothers produces a modest increase in breastfeeding success. These authors evaluated whether a 30-minute midwife-delivered educational session had any extra benefit. The answer was no. The disappointed authors cast around for any possible design faults in their trial, but their results are probably correct. They certainly accord with a number of other similar studies of breastfeeding education. Another seemingly sensible innovation was evaluated in the IDEA trial from Australia (pages 842–846). IDEA stands for “Identify women at risk of postnatal depression, Educate her about the risk, and Alert carers to the danger”. What could be more sensible? The trial was well designed, it included a large sample and the result was clear; no significant reduction in the rate of high postnatal depression score at 12 weeks post-partum. These sorts of studies are hugely important. The health service is always short of resources and it is wasteful to move staff from traditional patient care to education and counselling unless there is good evidence that doing so reduces adverse outcomes. They will encourage clinical directors and managers to get doctors and midwives back to caring for patients so they can prevent birth trauma in the first place. When managers do persuade staff back to the labour ward, how can they ensure that the staff really do deal with emergencies properly? One obvious way is to make sure that they all undergo regular obstetric “fire drill” training sessions. It seems to me that this must be a good idea. After all, other emergency services, and the army and airline pilots regularly do emergency drills. Why should obstetrics be different? Black and Brocklehurst (pages 837–841) were more sceptical. They wondered if there was any evidence that such training actually prevented adverse outcomes, or even made staff do the right thing more often. It turns out that there have been no decent quality studies. Such courses may still be effective and most people probably believe this. It is fortunate that, partly as a result of Black and Brocklehurst's research, the Department of Health has recently commissioned a group in Bristol led by Dr Bryony Strachan to conduct a high quality evaluation of individual and team drill in obstetric emergencies.

The incidence of heparin-induced thrombocytopenia in hospitalized medical patients treated with subcutaneous unfractionated heparin: a prospective cohort study

AbstractAlthough heparin-induced thrombocytopenia (HIT) is a known complication of intravenous unfractionated heparin (UFH), its incidence in medical patients treated with subcutaneous UFH is less well defined. To determine the incidence of HIT in this category of patients, the platelet count was performed at baseline and then every 3 ± 1 days in 598 consecutive patients admitted to 2 medical wards and treated with subcutaneous UFH for prophylactic (n = 360) or therapeutic (n = 238) indications. The diagnosis of HIT was accepted in the case of a platelet drop of 50% or more and either the demonstration of heparin-dependent antibodies or (when this search could not be performed) the combination of the following features: (1) the absence of any other obvious clinical explanation for thrombocytopenia, (2) the occurrence of thrombocytopenia at least 5 days after heparin start, and (3) either the normalization of the platelet count within 10 days after heparin discontinuation or the earlier patient’s death due to an unexpected thromboembolic complication. HIT developed in 5 patients (0.8%; 95% CI, 0.1%-1.6%); all of them belonged to the subgroup of patients who received heparin for prophylactic indications. The prevalence of thromboembolic complications in patients with HIT (60%) was remarkably higher than that observed in the remaining 593 patients (3.5%), leading to an odds ratio of 40.8 (95% CI, 5.2-162.8). Although the frequency of HIT in hospitalized medical patients treated with subcutaneous heparin is lower than that observed in other clinical settings, this complication is associated with a similarly high rate of thromboembolic events.

Newborn with an open posterior hip dislocation and sciatic nerve injury after intrauterine radiofrequency ablation of a sacrococcygeal teratoma

Advanced prenatal ultrasonography techniques have allowed for better understanding of the natural history, treatment, and prognosis of sacrococcygeal teratomas. Several intrauterine surgical techniques to debulk the tumor when fetal and maternal life are in jeopardy have been described. Orthopaedic impairment, such as lower extremity weakness and swelling, also has been described in association with sacrococcygeal teratomas. The authors report on a newborn in whom a large soft tissue defect overlying the posterior hip region with direct exposure of the disarticulated hip joint existed at the time of birth, which resulted from intrauterine radiofrequency ablation of a sacrococcygeal teratoma. This unexpected complication has resulted in a loss of sciatic nerve function, malformation of the acetabulum and femoral head, and loss of the left ischium, coccyx, inferior sacrum, gluteal, adductor and piriformis muscles, and posterior hip capsule. At 16 months of age, the patient has a flaccid left lower extremity with a hypoplastic hip joint. J Pediatr Surg 38:248-250. Copyright 2003, Elsevier Science (USA). All rights reserved.

Jejunal perforation complicating PEG insertion in a child

Since PEG was first described by Gauderer et al.1 in 1980, it has become one of the most important endoscopic interventions in pediatrics. Over the years, advances in technique and patient selection have resulted in favorable outcomes with minimal complications.2 This is a report of an unexpected complication of PEG placement in a child.

An unexpected complication resulting from the use of a laryngeal mask during an operation to remove a branchial cyst

An unexpected complication resulting from the use of a laryngeal mask during an operation to remove a branchial cyst

Torsion of a nongravid uterus: an unexpected complication of an ovarian cyst

Torsion of nongravid uterus is rare. Most reports occur during pregnancy. A case related to an adnexal mass, is described and the existing literature is reviewed.

Sudden Respiratory Arrest Resulting From Brainstem Embolism in a Patient Undergoing Endovascular Abdominal Aortic Aneurysm Repair

Implications Surgery on the aorta is a great challenge for the anesthesiologist, even with newly developed and less invasive stent-graft procedures. The case of a fatal cerebral embolism during endovascular repair of an abdominal aortic aneurysm is reported, and the potential mechanisms underlying this unexpected complication are discussed.

Paralytic Ileus Associated with Intracranial Diseases.

Paralytic ileus is one of the most important systemic complications associated with intracranial diseases such as subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), cerebral infarction (CI) and cerebral contusion (CC). A patient who suffers from intracranial diseases including cerebrovascular strokes has a tendedncy to be complicated by a paralytic ileus.21)22) In this paper, we present 15 cases with intracranial diseases who suffered from paralytic ileus. Indeed, various factors such as a previous history of an abdominal operation, sepsis, trauma, and drugs may contribute to the mechanism of this complication. On the other hand, nimodipine, a kind of calcium antagonist is an effective hypotensive agent without decreasing the cerebral blood flow. But an administration of this agent sometimes causes a paralytic ileus.1)2) Nimodipine were administered for all the patients of our 15 cases with hypertension. It was suggested that an administration of nimodipine was the most significant factor of the paralytic ileus of our patients. Three patients died of paralytic ileus despite the intensive conservative treatments described as below. So we must pay attention to this unexpected complication when we use this agent for those with intracranial diseases.

Australopithecus to Homo: Transformations in Body and Mind

▪ Abstract Significant changes occurred in human evolution between 2.5 and 1.8 million years ago. Stone tools first appeared, brains expanded, bodies enlarged, sexual dimorphism in body size decreased, limb proportions changed, cheek teeth reduced in size, and crania began to share more unique features with later Homo. Although the two earliest species of Homo, H. habilis and H. rudolfensis, retained many primitive features in common with australopithecine species, they both shared key unique features with later species of Homo. Two of the most conspicuous shared derived characters were the sizes of the brain and masticatory apparatus relative to body weight. Despite the shared derived characters of H. habilis and H. rudolfensis, one unexpected complication in the transition from australopithecine to Homo was that the postcranial anatomy of H. habilis retained many australopithecine characteristics. H. rudolfensis, however, seems to have had a more human-like body plan, similar to later species of Homo. H. rudolfensis may therefore represent a link between Australopithecus and Homo.

Unexpected complication of gemcitabine in a patient with non-small cell lung cancer, already treated with low-dose methotrexate for rheumatoid arthritis

Unexpected complication of gemcitabine in a patient with non-small cell lung cancer, already treated with low-dose methotrexate for rheumatoid arthritis

Myocardial perfusion in children with sickle cell anaemia

Myocardial ischaemia is an unexpected complication with potentially serious clinical damages in patients with sickle cell anaemia (SCA). Conventional techniques, such as exercise testing and echocardiography, have low sensitivity and specificity for the detection of myocardial ischaemia in patients with SCA. To assess myocardial perfusion using thallium-201 (201Tl) single-photon emission computed tomography (SPECT) in children with SCA. Eight patients (11.5 +/- 5.0 years, mean +/- SD) who were free of cardiac symptoms were studied. Myocardial perfusion was assessed by 201Tl-SPECT after stress and 3 h later after a further injection. Left ventricular ejection fraction (LVEF) was assessed by equilibrium radionuclide angiography. Myocardial perfusion was abnormal in three of eight patients: two had reversible defects and one had a fixed defect. The mean LVEF was 53 +/- 8%. There was no relationship between myocardial perfusion and LVEF. Treatment of asymptomatic myocardial ischaemia remains unclear, and more aggressive therapy of the haematological disease should be considered.