Vein Thrombus Research Articles

Differential Prognostic Value of Extrarenal Involvement in Patients With Non-Metastatic Renal Cell Cancer.

A better definition of the prognostic significance of non-metastatic pT3a stage RCC subcategories is crucial to select the best candidate for adjuvant treatment. The aim of the study is to investigate the differential prognosis of extrarenal involvement in patients with non-metastatic pT3a RCC. From a single institutional prospective database, 451 consecutive patients treated for pT3aN0/NxM0 RCC were selected and stratified according to pT3a subtypes (perirenal fat invasion, sinus fat invasion, segmental/renal vein thrombus, ≥ 2 features). Cancer specific survival (CSS), metastasis free survival (MFS) and relapse free survival (RFS) were primary endpoints of multivariable Cox regression models. Overall, 67 (15%) patients presented with renal/segmental vein thrombus only, 185 (41%) with perirenal fat invasion, 101 (22%) with sinus fat invasion and 98 (22%) with ≥ 2 features. The presence of ≥ 2 pT3a features was associated with a higher risk of metastasis (HR=2.36; 95%CI 1.30-4.27; P value=.005), recurrence (HR=2.41; 95%CI 1.36-4.28; P value=.003) and cancer specific mortality (HR=3.54; 95%CI 1.45-8.63; P value=.005) compared to only 1 pT3a feature. Moreover, the presence of perirenal fat invasion was associated with lower CSS (HR=2.82; 95% CI 1.19-6.69; P value=.02) compared to sinus fat invasion or tumoral thrombus only. The concurrent presence of ≥ 2 pT3a features is associated to a higher risk of distant progression, relapse and cancer specific mortality, implying potential role for adjuvant therapy or a more stringent follow-up. Moreover, perirenal fat invasion is associated with worse CSS compared to other pT3a patterns taken alone.

Çok Sayıda Flebolitle İzlenen Oral Hemanjiyom

Hemangioma is a rare, non-reactive, benign vascular tumor, characterized by endothelial cell proliferations and results from vascular malformation. Hemangioma mostly occurs on head and neck skin and regresses spontaneously within 5-10 years in 50-90% of cases. However, oral lesions show less regression than skin lesions. The most commonly affected area is tongue and palatal mucosa, and rarely observed in jaw bones. Diagnosis is based on anamnesis and clinical features. Blanching of the hemangioma under pressure is characteristic clinical finding. Phlebolith is calcified thrombus in veins, venules and sinusoidal walls of hemangiomas. Head and neck phleboliths almost always indicate the soft tissue hemangioma. Phleboliths observed with hemangioma in head and neck region have distinctive appearance on panoramic radiographs. Cone-beam computed tomography provides useful information about location and distribution of phleboliths. In this case report, clinical and radiological features of oral hemangioma and many associated phleboliths are presented.

Prenatal diagnosis of a fetal inferior vena cava thrombus

Introduction: Diagnosis and management of fetal thrombosis during pregnancy is rare. Few cases of prenatally diagnosed inferior vena cava thrombi are reported and often occur with renal vein thrombi. Several maternal and fetal risk factors have been identified, including thrombophilias. Case Report: Patient is a 39-year-old G6P2123 with heterozygous Factor V Leiden with a prenatally diagnosed fetal inferior vena cava thrombus at 34 weeks of gestation during antenatal ultrasound. Her peripartum course was uncomplicated. On day 1 of life, neonatal ultrasound and computed tomography confirmed the presence of thrombus. On day 7, the neonate underwent a thrombectomy for definitive management due to risk of embolization. Conclusion: While ultrasound is not routinely used for screening for fetal thromboses, when thrombosis is diagnosed, antenatal management is complex, weighing fetal and maternal risks and benefits. Thrombectomy as definitive thrombus management is an appropriate treatment when risk of embolization exists. Imaging modalities are useful for both diagnosis and management of fetal thrombi.

Differential Response to Sorafenib Administration for Advanced Hepatocellular Carcinoma.

Sorafenib has been used to treat advanced hepatocellular carcinoma (aHCC). However, there is no evidence for a response of different target lesions to sorafenib administration. Therefore, we aimed to evaluate the effect of sorafenib on various aHCC target lesions. The outcomes of sorafenib treatment on aHCC, i.e., treatment response for all Child A status patients receiving the drug, were analyzed. Of 377 aHCC patients, 73 (19.3%) had complete/partial response to sorafenib, while 134 (35.4%) and 171 (45.2) had a stable or progressive disease, respectively, in the first six months. Of the evaluated metastatic lesions, 149 (39.4%), 48 (12.7%), 123 (32.5%), 98 (25.9%), 83 (22.0%), and 45 (11.9%) were present in liver, bone, lung, portal/hepatic vein thrombus, lymph nodes, and peritoneum, respectively. The overall survival and duration of treatment were 16.9 ± 18.3 and 8.1 ± 10.5 months (with median times of 11.4 and 4.6, respectively). Our analysis showed poor outcomes in macroscopic venous thrombus and bone, higher AFP, and multiple target lesions. ALBI grade A had a better outcome. Sorafenib administration showed good treatment outcomes in selected situations. PD patients with thrombus or multiple metastases should be considered for sorafenib second-line treatment. The ALBI liver function test should be selected as a treatment criterion.

Hypereosinophilic\xa0syndrome presenting as coagulopathy

BackgroundHypereosinophilic syndrome (HES) is an extremely uncommon group of disorders. It rarely presents with coagulopathy without cardiac involvement.Case presentationA 33-year-old previously healthy male with no history of atopic disease presented with abdominal pain, hematochezia, peripheral eosinophilia as high as 10,000 eos/µL, right and left portal vein, mesenteric, and splenic vein thrombi with ischemic colitis resulting in hemicolectomy and small bowel resection. Despite an extensive workup for primary and secondary etiologies of hypereosinophilia by hematology/oncology, infectious disease, rheumatology and allergy/immunology, no other clear causes were identified, and the patient was diagnosed with idiopathic HES. His eosinophilia was successfully treated with high-dose oral corticosteroids (OCS) and subsequently transitioned to anti-IL-5-receptor therapy with benralizumab. He has continued this treatment for over a year with no recurrence of eosinophilia or thrombosis while on benralizumab.ConclusionIn patients with an unexplained coagulopathy and eosinophilia, eosinophilic disorders such as HES should be considered. Corticosteroid-sparing agents, such as benralizumab show promise for successfully treating these patients.

Narrative review of portal vein thrombosis in cirrhosis: pathophysiology, diagnosis, and management from an interventional radiology perspective.

This paper examines the incidence, clinical presentation, and pathophysiology of portal vein thrombosis (PVT) in cirrhosis. Additionally, we have reviewed the literature regarding the current status of medical and interventional radiology management of PVT and have proposed a novel algorithm for the management given different clinical scenarios. Lastly two representative cases displaying endovascular treatment options are provided. Portal vein thrombus in the setting of cirrhosis is an increasingly recognized clinical issue with debate on its pathophysiology, natural course, and optimal treatment. Approximately one-third of patients are asymptomatic, and detection of the thrombus is an incidental finding on imaging performed for other reasons. In 30% to 50% of patients, PVT resolves spontaneously. However, there is increased post-transplant mortality in patients with completely occlusive PVT, therefore effective early revascularization strategies are needed for patients with complete PVT who are expected to undergo liver transplant. Additionally, no consensus has been reached regarding PVT treatment in terms of timing and type of interventions as well as type and duration of anticoagulation. Computerized literature search as well as discussion with experts in the field. Management of PVT is complex, as many variables affect which treatments can be used. Anticoagulation appears to be the optimal first-line treatment in patients with acute PVT but without bleeding varices or mesenteric ischemia. Minimally invasive treatments include various methods of mechanical thrombectomy, chemical thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization. Definitive recommendations are difficult due to lack of high quality data and continued research is needed to evaluate the efficacy of different anticoagulants as well as the timing and use of various minimally invasive therapies in specific circumstances.

Conversion of initially unresectable hepatocellular carcinoma (HCC) with triple-combination therapy (lenvatinib, anti-PD-1 antibodies, and transarterial therapy): A retrospective analysis.

413 Background: Combination therapy with tyrosine kinase inhibitors and anti-PD-1 antibodies can allow selected patients with initially unresectable HCC to convert to surgical resection. We evaluated conversion therapy with a triple combination of lenvatinib (LEN), anti-PD-1 antibodies and transarterial therapy. Methods: We retrospectively searched medical records from 117 consecutive patients with unresectable/advanced HCC who received triple combination therapy between Dec 2018 and Oct 2020 at Tianjin Medical University Cancer Institute & Hospital. Eligible patients were required to have potentially resectable HCC, defined as meeting ≥1 of the following criteria: 1) estimated future liver remnant after radical (R0) resection of < 40% or < 30% in patients with/without cirrhosis, respectively; 2) R0 resection technically difficult to complete; 3) Child-Pugh score ≥7, ECOG performance status ≥1; 4) tumor thrombus in the main portal vein or inferior vena cava; 5) resectable extrahepatic metastases. The primary endpoint was the proportion of patients who underwent a successful resection (conversion rate). Secondary endpoints included objective response rate (ORR), disease control rate (DCR), 6-month disease-free survival (DFS) and safety. Results: Of 37 patients included in the analysis, all received LEN and anti-PD-1 antibodies with transarterial chemoembolization (TACE, n = 22), hepatic arterial infusion chemotherapy (HAIC, n = 9) or both (n = 6). The conversion rate was 40.5% (15) and the ORR and DCR were 67.7% and 86.5% by RECIST v1.1 and 75.7% and 86.5% by mRECIST, respectively. The median conversion time was 4 months (range: 2-15). After a median postoperative follow-up time of 10 months (95% CI, 6.42-13.58), the 6-month DFS rate was 93%. Overall, 89.2% of patients had ≥1 treatment emergent adverse event (TEAE) and 29.7% experienced a Grade 3/4 TEAE, the most common was hypertension (18.9%, n = 7). Conclusions: A triple combination of LEN, anti-PD-1 antibodies and transarterial therapy was well tolerated and effective at converting potentially resectable HCC to resectable disease. These findings warrant confirmation by future prospective studies.

Right portal vein thrombosis from idiopathic cause: case report

The aim of this study was to describe the case report of a 33-year-old girl with portal vein thrombosis. J.S.D.F., 33 years old, female, previously healthy, with a personal and family history negative for thromboembolic phenomena, without comorbidities, started with severe abdominal pain in the mesogastric region, radiating to HCD and back, associated with vomiting. Smoking active for about 20 years and using OC for 2 years. In view of the symptoms, she sought emergency services, where the first suspicion would be pancreatitis. Initial tests plagued leukocytosis. GUS of the total abdomen with doppler and CT of the abdomen showed the presence of thrombus in the right portal vein, with no other alterations. Rocefin® and metronidazole as an initial measure in the service began in addition to full coagulation with Clexane®. It showed clinical and laboratory improvement, with a reduction of leukocytes. The patient remained hospitalized in a hospital for 22 days to investigate the etiological cause. After of hospitalization, the patient was released with medical discharge, with guidelines for seeking the hematology service. During the investigation consultations, the results of the requested tests were negative for the diagnostic suspicions of nocturnal paroxysmal hemoglobinuria and chronic myeloproliferative disease. After 6 months of follow-up, she was discharged from the hematology service because she did not present a suspected disease and classified the cause of thrombolytic event as idiopathic associated with the combined use of OC and smoking.

New Surgical Technique to Induce Reversible Liver Fibrosis by Surgical Closure of Major Duodenal Orifice in Dogs

This study was conducted to induce and evaluate reversible liver fibrosis in dogs by surgical closure of the major duodenal orifice. The study was performed on six healthy local adult dogs. Reversible liver fibrosis was surgically induced in all animals by surgical closure of major duodenal papilla using absorbable suture material for 60 days. Induced liver fibrosis was assessed by clinical, ultrasonographical examination, laboratory and histological methods. The clinical manifestation of the jaundiced dogs showed reduced food intake, pale-yellowish mucus membrane, inflammatory signs of the wound site and severe postoperative pain. Biochemically, there was significantly increased values of the aspartate aminotransferase, alkaline phosphatase, alanine aminotransferase, indirect bilirubin, direct bilirubin and total bilirubin especially during the first two days after surgery followed by a gradual decrease of these values until the end of the but still higher than normal values. Ultrasonographic examinations showed abnormal changes in the liver tissue such as an increase in both size and wall thickness of the gall bladder and mottled heterogeneous appearance of the liver during the first two weeks following the surgical induction of the hepatic fibrosis. Histological evaluation of liver samples revealed showed necrosis of hepatocytes and deposition of eosinophilic material, infiltration of inflammatory cells, recent thrombus in the hepatic vein, fatty change. Slight clinical, biochemical, ultrasonographic improvement was observed at 30th post-operative day. In conclusion, surgical induction of reversible liver fibrosis in dogs was an easy technique by surgical closure of major duodenal papilla and the results were confirmed by the clinical, ultrasonographical, laboratory and histological examination.

The Use of Doppler Ultrasound to Diagnose Deep Vein Thrombosis of the Lower Limbs

In most cases of pulmonary embolism, death occurs as a result of deep vein thrombosis (DVT) of the lower extremities. Therefore, to avoid DVT complications and sequel, DVT must be diagnosed as early as possible and this can be achieved via B-mode and colour Doppler imaging. The present paper seeks to investigate the suitability of the imaging method of ultrasound for lower extremity DVT diagnosis and to explore the outcomes of the use of this method in DVT cases. To this end, the paper undertakes a retrospective descriptive study of 50 cases of ultrasound-based diagnosis of DVT at King Khalid Hospital in the period between January 2019 and August 2020. Half of the cases were subjected to compression, colour, and duplex ultrasound, 14 cases were subjected to compression and duplex ultrasound, and 11 cases were subjected to compression and colour Doppler. The mean age across all cases was 46.2±19.9 years. The majority of cases (56%) were in the age range 22-41 years old (n=28), while 28% of cases were in the age range 42-61 years old (n=14), 6% of cases were in the age range 62-81 years old (n=3), and 10% of cases were in the age range 82-102 years old (n=5). Regarding sex, females accounted for 60% of cases, while males accounted for the rest of 40%. Furthermore, in 90% of cases (n=45), just one lower extremity was affected, whereas in 10% of cases (n=5), both lower extremities were affected. Regarding thrombus location, it was found mostly in the area above the knee, particularly the popliteal vein (34%), common femoral vein (18%), and superficial femoral vein (20%). Moreover, 2% of cases presented thrombus in the calf vein. In 26% of cases, multiple veins were affected. DVT was acute in 76% of cases (n=38) and chronic in 24% of cases (n=12). It is concluded that symptomatic and at-risk cases benefit from the use of ultrasound for DVT diagnosis. The suitability of this method stems from its lack of invasiveness and capability to assess thrombus location, magnitude, and stage.

595 Penetrating Pelvic Trauma from a Crossbow Bolt: An Unusual Choice of Weapon

Abstract Introduction The crossbow was a popular weapon in medieval times due to their relative ease of use and accuracy but was superseded by firearms around the 16th century. Today, it is legal for adults in the UK to own a crossbow without a licence. Case Report A young adult male victim was brought to a Major Trauma Centre with a single lower left quadrant penetrating wound caused a crossbow bolt that was self-removed immediately after the injury. A 2.5cm entry wound was present with no exit wound. The patient was haemodynamically unstable on arrival and was transferred to theatre without imaging within 16 minutes of arrival. The main operative findings were multiple small bowel serosal tears, a full thickness small bowel injury with no contamination and a left external iliac artery injury with active bleeding which were all repaired primarily. The post-operative recovery course included occlusive left cephalic and antecubital vein thrombi and an extensive non-occlusive left common femoral vein thrombus treated with anticoagulant therapy but was otherwise unremarkable. He was discharged 10 days later with no lasting sequelae at 6-week follow up. Discussion This case highlights a rare but important and likely underreported modality of penetrating injury. Crossbow bolts have low kinetic energy compared to bullets but high penetrative force, thus little energy is transferred to surrounding tissues. Hence the main injuries caused by crossbow bolts are due to direct damage to structures they come into contact with. Although rare, trauma surgeons should be aware of the pattern of injury caused by crossbows.

Long-term follow-up of portal vein thrombosis in an American Cocker Spaniel with lobular dissecting hepatitis: a case report

BackgroundLobular dissecting hepatitis (LDH) is a rare form of canine liver cirrhosis that may be accompanied by portal hypertension in American Cocker Spaniels. In human patients with liver cirrhosis, portal vein thrombosis (PVT) is a common complication. However, PVT has not been reported in dogs with LDH. Herein, we describe the long-term follow-up of PVT in an American Cocker Spaniel with LDH.Case presentationAn 8-year-old neutered male American Cocker Spaniel presented with a 1-month history of severe abdominal effusion. The dog was histopathologically diagnosed with LDH and treated with low-dose prednisolone on day 14. On day 115, computed tomography angiography (CTA) confirmed the presence of a thrombus in the portal vein. Therefore, the dog was subcutaneously administered with the anticoagulant dalteparin, and low-dose prednisolone was continued. As a follow-up for PVT, CTA examinations were performed on days 207, 515, 886, and 1168, and the dog’s antithrombin and D-dimer levels were measured. Following anticoagulant therapy, the dog was confirmed to have gradually increased antithrombin activity and decreased D-dimer concentrations. In addition, although the thrombus was confirmed to be in the same area of the portal vein system by CTA, atrophy and increased CT values due to organization were observed during the follow-up period. The dog’s condition remained stable without clinical signs until day 1112 when it developed hepatic encephalopathy. The dog died on day 1208. On postmortem examination, histopathologically, the liver showed marked bile duct hyperplasia and fibrosis with chronic thrombus in the portal vein.ConclusionsThis case demonstrated that low-dose glucocorticoid combined with dalteparin allowed long-term follow-up of PVT in an American Cocker Spaniel with LDH.

Abstract P120: Heparin-warfarin Therapy Could Be An Alternative Treatment For Diabetes Mellitus In Addition To Being A Standard Therapy For Pulmonary Vein Thrombi.

Background: Our previous study showed that warfarin or direct oral anticoagulants (DOACs) dissolved pulmonary vein thrombi (PVTs). However, in some instances, warfarin or DOACs could not dissolve PVT. It is unclear whether heparin-warfarin therapy affects PVT and diabetes mellitus (DM). Methods and Results: Our patient was a 74 year-old male. The patient had cerebral infarction one year prior; at that time, he was not treated with any medications. The patient was examined, and it was found that he had diabetes mellitus, hypertension and dyslipidemia. His HbA1c was 9.5%. The patient was treated with medications including ipraglifilozin L-proline (50 mg), sitagliptin (50 mg), repaglinide (0.25 mg) and clopidogrel (75 mg). One year after discharge, we detected PVTs in the patient’s left lower pulmonary vein (LLPV) via cardiac CT and transesophageal echocardiography (TEE). He was treated with standard doses of heparin and warfarin after stopping clopidogrel. The patient’s HbA1c was 6.2% at admission. After one month of treatment with heparin-warfarin, the PVTs were almost dissolved. The patient showed a tendency of hypoglycemia the day after admission, so the three glucose-lowering medications were discontinued within nine days. One month later, HbA1c was 6.1% without DM medications. After discharge, warfarin was continued, and blood glucose levels gradually increased. Three months later, HbA1c was 7.3%, and 4 months later, HbA1c was 7.8%, so DM medications were restarted. PVTs can release microclots, which can occlude the microvessels of all organs, leading to cell dysfunction. Heparin-warfarin can decrease microclots and reopen microvessels. Thus, blood glucose could be taken into cells, decreasing blood glucose levels. There is a possibility that DM could be prevented if we treat PVTs in their early stage. Compared to other similar cases, this patient showed hypoglycemia rather early, which might be caused by the interaction between repaglinide and clopidogrel. Conclusion: One month of heparin-warfarin therapy almost completely dissolved PVTs. During that course, DM medications were stopped in order to prevent hypoglycemia. During the next four months of warfarin therapy, the blood glucose levels gradually increased without DM medications.

Multiple thrombosis associated with Cytomegalovirus enterocolitis in an immunocompetent patient: a case report

BackgroundCytomegalovirus (CMV) is reported to have thrombogenic characteristics that activate factor X in vitro and stimulate the production of factor VIII and von Willebrand factor (vWF). Thrombosis associated with CMV infection is prevalent among immunocompromised patients and predominantly presents as a solitary large thrombus in the deep vein, pulmonary artery, splanchnic arteriovenous ducts, or other similar sites. Multiple thrombi, however, are rarely observed in such cases. Here, we report about an immunocompetent man with multiple microthrombi associated with CMV infection.Case presentationA 72-year-old Japanese man who complained of abdominal pain was hospitalized with multiple colonic stenosis. He was later diagnosed with CMV enterocolitis and treated with ganciclover from Day 27 post-admission. During hospitalization, the patient developed thrombi in his fingers. He was initially treated with anticoagulant therapy (rivaroxaban); however, the therapy was discontinued owing to a prolonged activated thromboplastin time and an elevated international normalized ratio of prothrombin time. Instead, vitamin K and fresh-frozen plasma were administered. Nevertheless, his coagulation profile remained abnormal. Eventually, he developed colonic perforation and had to undergo emergency surgery. An intraoperative specimen showed several microthrombi in the middle and small arteriovenous ducts of his small and large intestines. The patient’s coagulopathy improved preoperatively, and his overall condition improved postoperatively. Since the activation of ADAMTS13 was reduced remarkably, the thrombotic tendency was determined to be a thrombotic microangiopathy-like condition owing to increased vWF. We could not attribute the coagulopathy to any other cause except CMV infection; therefore, we concluded that this was a case of multiple thrombosis associated with CMV.ConclusionsWe present an extremely rare case of a patient with multiple thrombotic microangiopathy-like microthrombosis caused by CMV infection. Our findings suggest that CMV infection may be considered as a differential diagnosis for immunocompetent individuals who present with thrombosis of unspecified cause.

Тромбоз воротной вены как осложнение коронавирусной инфекции на фоне хронического вирусного гепатита

The article presents an extract from an outpatient case history card of a 47-year-old patient observed at the Central Hospital for Chronic Hepatitis C. In 2017, he received a course of therapy for this disease (Pegasis in combination with ribavirin). A sustained virological response (SVR) has been achieved. According to elastometry data dated 12/13/2017 – the degree of fibrosis F4 Metavir, 13.1 KPa. In January 2021, he suffered a coronavirus infection (according to the CT scan of the lungs, the lesion was 20 %). The disease proceeded against the background of chronic viral hepatitis C complicated by liver cirrhosis. He was treated symptomatically on an outpatient basis. He did not receive anticoagulant therapy. In February 2021, abdominal ultrasound (ABP) revealed a thrombus in the portal vein. The presence of a thrombus in the portal vein contributes to the further progression of liver cirrhosis

Substance Use Disorders in the Surgical Patient

Large bodies of evidence link alcohol consumption and substance use disorders (SUDs) with motor vehicle collisions, as well as life-threatening intentional injury. According to the substance use and mental health estimates from the 2013 National Survey on Drug Use and Health, 24.6 million individuals age 12 or older were current illicit drug users in 2013, including 2.2 million adolescents age 12 to 17, and 60.1 million individuals age 12 or older were binge drinkers in the past month. Many people with SUDs become patients; therefore, the surgeon must be able to recognize and manage many of the related issues that can ensue. This review details the definition of SUDs, basic principles of toxicology, acute management of the patient with suspected substance use intoxication or withdrawal, managing life-threatening syndromes in patients with SUDs, overdose and withdrawal syndromes of opioids, stimulants, and depressants, surgical complications of SUDs, perioperative and postoperative considerations in patients with SUDs, and consultation and referral to a toxicologist and poison control center. Figures show first- and zero-order kinetics; pupillary examination, laboratory and radiographic findings in SUDs; polymorphic ventricular tachycardia; consciousness as an interplay between arousal and awareness, an algorithm for the management of seizures, sine, mechanism of cocaine’s cardiac toxicity and hemorrhagic stroke in a cocaine abuser, necrotizing soft tissue infection, digit necrosis associated with intra-arterial injection of cocaine, scars from skin popping, nonocclusive thrombus in the left internal jugular vein, needle fracture with soft tissue dislodgment, oral contrast-enhanced computed tomographic scan showing rounded foreign bodies in the stomach, and fecal impaction associated with heroin. Tables list criteria for substance use disorders according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), frequently misused drugs, causes of death in SUD, cardiac, neurologic, and metabolic signs and symptoms caused by commonly abused substances , anion and osmolar gap equations, life-threatening manifestations of cocaine toxicity, and alcohol-related disorders. This review contains 15 figures, 8 tables, and 85 references.

Substance Use Disorders in the Surgical Patient

Large bodies of evidence link alcohol consumption and substance use disorders (SUDs) with motor vehicle collisions, as well as life-threatening intentional injury. According to the substance use and mental health estimates from the 2013 National Survey on Drug Use and Health, 24.6 million individuals age 12 or older were current illicit drug users in 2013, including 2.2 million adolescents age 12 to 17, and 60.1 million individuals age 12 or older were binge drinkers in the past month. Many people with SUDs become patients; therefore, the surgeon must be able to recognize and manage many of the related issues that can ensue. This review details the definition of SUDs, basic principles of toxicology, acute management of the patient with suspected substance use intoxication or withdrawal, managing life-threatening syndromes in patients with SUDs, overdose and withdrawal syndromes of opioids, stimulants, and depressants, surgical complications of SUDs, perioperative and postoperative considerations in patients with SUDs, and consultation and referral to a toxicologist and poison control center. Figures show first- and zero-order kinetics; pupillary examination, laboratory and radiographic findings in SUDs; polymorphic ventricular tachycardia; consciousness as an interplay between arousal and awareness, an algorithm for the management of seizures, sine, mechanism of cocaine’s cardiac toxicity and hemorrhagic stroke in a cocaine abuser, necrotizing soft tissue infection, digit necrosis associated with intra-arterial injection of cocaine, scars from skin popping, nonocclusive thrombus in the left internal jugular vein, needle fracture with soft tissue dislodgment, oral contrast-enhanced computed tomographic scan showing rounded foreign bodies in the stomach, and fecal impaction associated with heroin. Tables list criteria for substance use disorders according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), frequently misused drugs, causes of death in SUD, cardiac, neurologic, and metabolic signs and symptoms caused by commonly abused substances , anion and osmolar gap equations, life-threatening manifestations of cocaine toxicity, and alcohol-related disorders. This review contains 15 figures, 8 tables, and 85 references.

A case report of warfarin induced skin necrosis

Warfarin is a common drug used in treating patients with deep-vein thrombosis, pulmonary embolism and other conditions. One of its adverse effects is warfarin-induced skin necrosis (WISN) which is a rare complication and accounts for 0.01%–0.1% of patients who received the drug. We are reporting a 60-year-old diabetic male presented to the emergency room complaining of right leg pain and swelling. On examination, the calf muscles were tender, indurated and swelled. Laboratory tests showed elevated D-dimer. Duplex ultrasound revealed a thrombus in the popliteal and tibial veins. Heparin was started and warfarin was added after 3 days. On the next day of warfarin overlap, the whole leg and ankle become dusky blue in colour. WISN is suspected and thus warfarin is stopped, after which the patient's skin gradually improved. We are assuming that improper overlap of heparin in this case resulted in such a condition.

Isolated cortical vein thrombosis complicating orbital cellulitis

Background: Orbital cellulitis is characterized by the infective inflammation of orbital structures, usually posterior to the orbital septum. Extension of infection from the paranasal sinuses is the most common etiology for orbital cellulitis. Intracranial complications of orbital cellulitis include meningitis, subdural empyema, brain abscess, and cavernous sinus thrombosis.
 Case presentation: A 33-year-old man presented with acute onset of foul-smelling mucopurulent nasal discharge and swelling of the left eye followed by altered sensorium. On examination of the left eye, chemosis, eyelid edema, and proptosis were present. Computed tomography (CT) of the brain revealed non-axial left proptosis with inflammatory reticulation in the intra- and extraconal fat alongside sinusitis. Magnetic resonance imaging of the brain confirmed the CT findings and additionally showed meningitis and subdural empyema along the left frontoparietal convexity with parenchymal signal changes, suggesting venous infarction in the left frontal lobe. Susceptibility weighted imaging (SWI) confirmed thrombus in the frontal polar vein on the left side, suggesting septic isolated septic cortical venous thrombosis (ICVT) as a complication of orbital cellulitis. Cerebrospinal fluid showed polymorphonuclear cell pleocytosis with elevated protein and lowered sugar. Blood and conjunctival swab cultures were negative. He was subsequently treated with intravenous broad-spectrum antibiotics and antifungals to which he responded and was discharged in stable condition.
 Conclusions: Our case highlights the presentation of septic ICVT complicating orbital cellulitis and paranasal sinusitis. It also underscores the higher sensitivity of SWI as a crucial tool in diagnosing ICVT. Appropriate and prompt medical treatment in orbital cellulitis can prevent further complications.

A floating thrombus detected by CT in the descending aorta in an obese patient: A possible genetic-environmental interaction

A floating thrombus in a nonaneurysmal, nonatherosclerotic aorta is a rare finding and may represent an unusual source of systemic embolism. Less than 130 cases have been reported in the literature. We describe a rare case of aortic floating thrombus in the descending aorta and the proximal portion of the suprarenal abdominal aorta detected by computed tomography angiography in a 50-year-old woman who was admitted to our emergency room with epigastric abdominal pain. The computed tomography angiography also showed some defects in the subsegmentary pulmonary artery branches along with a splenic infarction with splenic artery and vein thrombi, and a left renal thrombus. On genetic testing the patient resulted heterozygous for the polymorphism for 5,10‐methylentetrahydrofolate reductase C677T polymorphism and also with homozygous deletion alleles of the angiotensin-converting enzyme gene. The aortic floating thrombus resolved during anticoagulant therapy after 4 weeks.