Glauser, Frédéric; Barras, Anne-Catherine; Pache, Isabelle; Monti, Matteo
Abdominal paracentesis is frequently performed in the clinical setting. Every newly developed ascites need to be investigated by abdominal paracentesis. Any clinical or biological deterioration in patients with chronic ascites also requires a new paracentesis. Therapeutically abdominal paracentesis is performed for refractory or symptomatic ascites. As other invasive procedures, it is critical to master its indications, contra-indications and complications. The aim of this article is to review the basics of abdominal paracentesis in order to help physicians to carry out this technical skill.
Stafford, P. J.
A 62 year old man presented with abdominal ascites, without pleural effusion, due to peritoneal mesothelioma. He had chronic obstructive airways disease and a past history of right upper lobectomy for tuberculosis. On two occasions abdominal paracentesis was followed within 72 hours by pneumothorax. This previously unreported complication of abdominal paracentesis may be due to increased diaphragmatic excursion following the procedure and should be considered in patients with preexisting lung disease. PMID:2385561
Azuara-Blanco, A; Katz, L J
A paracentesis is performed in glaucoma procedures as a flat, beveled tract to allow access into the anterior chamber after the filtration fistula is made. Complications related to the paracentesis are infrequent because it is a self-sealing wound. The authors report a case of infectious keratitis that developed in a paracentesis tract.
Gaduputi, Vinaya; Tariq, Hassan; Chandrala, Chaitanya; Sakam, Sailaja; Abbas, Naeem; Chilimuri, Sridhar
Background Ascites remains the most common cause of hospitalization among patients with decompensated cirrhosis. Paracentesis is a relatively safe procedure with low complication rates. Computerized tomography (CT)-guided therapeutic paracentesis could be a safe and effective alternative to unaided or aided (ultrasonogram-guided) bedside paracentesis. In this retrospective study, we aimed to compare the efficacy, safety, and cost-effectiveness of CT-guided paracentesis with bedside paracentesis. Methods The period of study was from 2002 to 2012. All patients with cirrhosis who underwent therapeutic paracentesis were included in the study. These patients were divided into two groups. Group I consisted of patients who underwent CT-guided pigtail catheter insertion with ascitic fluid drainage. Group II consisted of patients who underwent beside therapeutic paracentesis after localization of fluid either by physical examination or sonographic localization. We measured the efficacy of CT-guided paracentesis and bedside paracentesis in terms of volume of fluid removed, length of stay, discharge doses of diuretics (spironolactone and furosemide) and number of days to readmission for symptomatic ascites. We also computed the cost-effectiveness of CT-guided therapeutic paracentesis when compared to a bedside procedure. Fischer exact test was used to analyze the distribution of categorical data and unpaired t-test was used for comparison of means. Results There were a total of 546 unique patients with diagnosed cirrhosis who were admitted to the hospital with symptomatic ascites and underwent therapeutic paracentesis. Two hundred and forty-seven patients underwent CT-guided paracentesis, while 272 patients underwent bedside paracentesis. There was significant inverse correlation between the amount of ascitic fluid removed and total length of stay in the hospital. We found that the volume of fluid removed via a CT-guided pigtail insertion and drainage (2.72 ± 2.02 L) is
Liver disease is a common cause of death in England and Wales, and ascites is associated with a 50% mortality rate. Most patients who present with ascites have underlying liver cirrhosis, and often require therapeutic paracentesis for symptomatic relief. This article describes a competency framework that was developed to enable advanced nurse practitioners to perform therapeutic paracentesis in an ambulatory care unit.
Gentile, S; Angelico, M; Bologna, E; Capocaccia, L
The use of paracentesis has recently been reproposed as a safe and effective alternative to diuretics for management of ascites. We have investigated the clinical and biochemical effects of large-volume paracentesis in 19 cirrhotics with tense ascites, and the relative changes in the hormones involved in sodium and water renal handling. Plasma renin activity (PRA), aldosterone (PA), and arginine vasopressin (AVP) levels and conventional liver and renal function tests were measured before and after 1, 2, and 7 days after the paracentesis. No complications were observed, but patients regained 37% of the weight lost after 1 wk. Percent weight regained was significantly and directly correlated with PA concentration measured before the paracentesis. No changes were recorded after paracentesis in biochemical and clinical data, except for a significant drop in diastolic blood pressure. No changes in AVP levels were observed. A significant increase in PA occurred after paracentesis, with a maximum peak after 48 h. The increase in PA was not accompanied by changes in PRA, but was associated with a reduction of urinary sodium excretion. A relevant fraction of body aldosterone was confined to the ascitic fluid. We conclude that the clinical results of a large-volume paracentesis can be predicted in part on the basis of PA measurement, and that removal of ascites is followed by an increase of PA of uncertain origin and effectiveness.
Keil-Ríos, Daniel; Terrazas-Solís, Hiram; González-Garay, Alejandro; Sánchez-Ávila, Juan Francisco; García-Juárez, Ignacio
The pocket ultrasound device (PUD) is a new tool that may be of use in the early detection of ascites. Abdominal ultrasound-guided paracentesis has been reported to decrease the rate of complications due to the procedure, but must be performed in a healthcare setting; this new tool may be a useful on an ambulatory basis. The aim of this study was to determine the diagnostic usefulness of the PUD in the diagnosis of ascites and the safety of guided paracentesis. We conducted a retrospective study that included adult patients suspected of having ascites and in whom an evaluation was performed with the PUD to identify it. Concordance with abdominal ultrasound (AUS) was determined with the Kappa coefficient. Sensitivity (Se), specificity (Sp) and likelihood ratios (LR) were determined and compared with physical examination, AUS, computed tomography and procurement of fluid by paracentesis. Complications resulting from the guided paracentesis were analyzed. 89 participants were included and 40 underwent a paracentesis. The PUD for ascites detection had 95.8 % Se, 81.8 % Sp, 5.27 +LR and 0.05 -LR. It had a concordance with AUS of 0.781 (p < 0.001). Technical problems during the guided paracentesis were present in only two participants (5 %) and three patients (7.5 %) developed minor complications that required no further intervention. There were no severe complications or deaths. This study suggests that the PUD is a reliable tool for ascites detection as a complement to physical examination and appears to be a safe method to perform guided paracentesis.
Widjaja, Felix F; Khairan, Paramita; Kamelia, Telly; Hasan, Irsan
Large volume paracentesis may cause paracentesis induced circulatory dysfunction (PICD). Albumin is recommended to prevent this abnormality. Meanwhile, the price of albumin is too expensive and there should be another alternative that may prevent PICD. This report aimed to compare albumin to colloids in preventing PICD. Search strategy was done using PubMed, Scopus, Proquest, dan Academic Health Complete from EBSCO with keywords of "ascites", "albumin", "colloid", "dextran", "hydroxyethyl starch", "gelatin", and "paracentesis induced circulatory dysfunction". Articles was limited to randomized clinical trial and meta-analysis with clinical question of "In hepatic cirrhotic patient undergone large volume paracentesis, whether colloids were similar to albumin to prevent PICD". We found one meta-analysis and four randomized clinical trials (RCT). A meta analysis showed that albumin was still superior of which odds ratio 0.34 (0.23-0.51). Three RCTs showed the same results and one RCT showed albumin was not superior than colloids. We conclude that colloids could not constitute albumin to prevent PICD, but colloids still have a role in patient who undergone paracentesis less than five liters.
Ambulatory emergency care units are present in many hospitals and accommodate patients who need urgent medical assessment or procedures but do not require inpatient admission to achieve this. This article reports on a project undertaken in the ambulatory care unit at the Royal United Hospital Bath, which introduced a nurse-led paracentesis service with the intention of reducing waiting times and improving the service for patients. To evaluate the effect of the project, patient satisfaction levels and waiting times were measured before and after the introduction of nurse-led paracentesis. The results confirmed a significant reduction in waiting times after the nurse-led intervention was introduced and high levels of satisfaction. The results provide evidence that nurses are acquiring the knowledge and skills required to undertake interventional procedures that improve the patient's experience while contributing to pioneering developments in ambulatory emergency care services.
Sudulagunta, Sreenivasa Rao; Sodalagunta, Mahesh Babu; Bangalore Raja, Shiva Kumar; Khorram, Hadi; Sepehrar, Mona; Noroozpour, Zahra
Background Large volume paracentesis is found to be safer and more effective for the treatment of tense ascites compared with larger-than-usual doses of diuretics according to studies. The objectives of the study was to evaluate patients with refractory ascites regarding clinical profile, technique of paracentesis, complications, amount of ascites drained, prognosis and co-morbid conditions associated with it. Methods Retrospective study was performed including patients between January 2011 and December 2013 with data pooled from total of five hospitals. A total of 4,389 paracenteses were performed on the 1,218 patients with a mean volume of 4,900 ± 2,795 mL ascitic fluid drained. Blind technique, ultrasound-guided technique of paracentesis and pig tail catheter drainage were evaluated. Diabetes mellitus data from available patients and data regarding co-morbidities were analyzed. Coagulation abnormalities in patients were studied. Results Study group age ranged from 34 to 79 years, and alcohol is the main cause of cirrhosis. Dyslipidemia was observed in 1,080 patients (88.66%). At the time of inclusion in the study, 40% of the patients had ≥ 2 other cirrhosis-related complications and 20% of the study population had ≥ 3 complications. Early complications occurred in 27.5% (337) of patients and late complications constituted 16.83% (205 patients). Conclusions Even with abnormal coagulation, paracentesis is a safe procedure. But significant co-morbidities should be addressed with care in cirrhosis patients. Ultrasound guidance during the procedure whenever required should be encouraged. PMID:27785301
Khodarahmi, Iman; Shahid, Muhammad Usman; Contractor, Sohail
We present two cases of umbilical hernia incarceration following large volume paracentesis (LVP) in patients with cirrhotic ascites. Both patients became symptomatic within 48 hours after the LVP. Although being rare, given the significantly higher mortality rate of cirrhotic patients undergoing emergent herniorrhaphy, this complication of LVP is potentially serious. Therefore, it is recommended that patients be examined closely for the presence of umbilical hernias before removal of ascitic fluid and an attempt should be made for external reduction of easily reducible hernias, if a hernia is present.
Khodarahmi, Iman; Shahid, Muhammad Usman; Contractor, Sohail
We present two cases of umbilical hernia incarceration following large volume paracentesis (LVP) in patients with cirrhotic ascites. Both patients became symptomatic within 48 hours after the LVP. Although being rare, given the significantly higher mortality rate of cirrhotic patients undergoing emergent herniorrhaphy, this complication of LVP is potentially serious. Therefore, it is recommended that patients be examined closely for the presence of umbilical hernias before removal of ascitic fluid and an attempt should be made for external reduction of easily reducible hernias, if a hernia is present. PMID:26629305
Regnier, A; Whitley, R D; Benard, P; Bonnefoi, M
The protein and PGE2 metabolite content of the aqueous humor from untreated and flunixin meglumine pretreated dogs was determined prior to and after anterior chamber paracentesis. In the untreated dogs the concentrations of protein and PGE2 metabolite in aqueous humor were greatly elevated secondary to paracentesis. Intravenously administered flunixin meglumine (1.1 mg/kg or 2.2 mg/kg) significantly reduced these inflammatory parameters, confirming that prostaglandins are involved in the stability of the blood-aqueous barrier by paracentesis in the canine eye. The clinical implication of these results is that intravenous administration of flunixin meglumine before intraocular surgery should be considered as an adjunct therapy to reduce intraoperative and postoperative uveitis.
Martin, Daniel K.; Walayat, Saqib; Jinma, Ren; Ahmed, Zohair; Ragunathan, Karthik; Dhillon, Sonu
Background The management of ascites can be problematic. This is especially true in patients with diuretic refractory ascites who develop a tense abdomen. This often results in hypotension and decreased venous return with resulting renal failure. In this paper, we further examine the risks and benefits of utilizing an indwelling peritoneal catheter to remove large-volume ascites over a 72-h period while maintaining intravascular volume and preventing renal failure. Methods We retrospectively reviewed charts and identified 36 consecutive patients undergoing continuous large-volume paracentesis with an indwelling peritoneal catheter. At the time of drain placement, no patients had signs or laboratory parameters suggestive of spontaneous bacterial peritonitis. The patients underwent ascitic fluid removal through an indwelling peritoneal catheter and were supported with scheduled albumin throughout the duration. The catheter was used to remove up to 3 L every 8 h for a maximum of 72 h. Regular laboratory and ascitic fluid testing was performed. All patients had a clinical follow-up within 3 months after the drain placement. Results An average of 16.5 L was removed over the 72-h time frame of indwelling peritoneal catheter maintenance. The albumin infusion utilized correlated to 12 mg/L removed. The average creatinine trend improved in a statistically significant manner from 1.37 on the day of admission to 1.21 on the day of drain removal. No patients developed renal failure during the hospital course. There were no documented episodes of neutrocytic ascites or bacterial peritonitis throughout the study review. Conclusion Large-volume peritoneal drainage with an indwelling peritoneal catheter is safe and effective for patients with tense ascites. Concomitant albumin infusion allows for maintenance of renal function, and no increase in infectious complications was noted. PMID:27802853
McClellan, K.; Coster, D. J.
A previously healthy 53-year-old man had keratitis of the right eye for six months, unresponsive to topical medical therapy. Acanthamoeba was grown from tissue obtained by corneal biopsy and from aqueous from an anterior chamber tap. The patient was treated with propamidine isethionate 0.1% drops and dibromopropamidine isethionate 0.15% ointment, and after two and a half months the ocular inflammation was continuing to resolve. This case supports a role for the diamidines in the treatment of acanthamoebic keratitis. Images PMID:3676141
Solà, Elsa; Sanchez-Cabús, Santiago; Rodriguez, Ezequiel; Elia, Chiara; Cela, Raquel; Moreira, Rebeca; Pose, Elisa; Sánchez-Delgado, Jordi; Cañete, Nuria; Morales-Ruiz, Manuel; Campos, Francisco; Balust, Jaume; Guevara, Mónica; García-Valdecasas, Juan Carlos; Ginès, Pere
The alfapump system has been proposed as a new treatment for the management of refractory ascites. The system removes ascites from the peritoneal cavity to urinary bladder, producing a continuous low-volume paracentesis.
Bofinger, Jason J.; Fekete, Thomas; Samuel, Rafik
Kingella kingae is a commensal of the upper respiratory tract that occasionally causes skeletal infections in children and endocarditis in children and adults. We report a case of a 55-year-old man with liver disease and tense ascites who performed a paracentesis on himself and developed K. kingae peritonitis and bacteremia. PMID:17634309
Bofinger, Jason J; Fekete, Thomas; Samuel, Rafik
Kingella kingae is a commensal of the upper respiratory tract that occasionally causes skeletal infections in children and endocarditis in children and adults. We report a case of a 55-year-old man with liver disease and tense ascites who performed a paracentesis on himself and developed K. kingae peritonitis and bacteremia.
Alper, Michael M; Smith, Laura P; Sills, Eric Scott
Objective: To summarize current views on the pathophysiology, risk factors, prevention, clinical features, and management of Ovarian Hyperstimulation Syndrome (OHSS). Design: Literature review Results: OHSS is a condition characterized by increased capillary permeability, and experimental evidence has identified a provocative link to pathologic vasoactive cytokine actions. Although the ultimate physiologic mechanism of OHSS is not yet known, there are well-known risk factors that must be considered during the administration of medications to treat infertility. Clinical features are consequences of third-spaced intravascular fluid, and OHSS may become life-threatening secondary to thromboembolism or compromised pulmonary or cardiovascular function. Cornerstones of prevention have historically included cycle cancellation, coasting, decreased dosing of human chorionic gonadotropin (hCG) trigger, use of an agonist trigger, and cryopreservation of all embryos. Newer methods of prevention include the administration of a dopamine agonist medication. Management options for OHSS include outpatient transvaginal paracentesis, outpatient transabdominal paracentesis, and inpatient hospitalization with or without paracentesis. Conclusions: OHSS continues to be a serious complication of assisted reproductive therapy (ART), with no universally agreed upon best method of prevention. Coasting and cryopreservation of all embryos are the most commonly used approaches in the literature, but cycle cancellation is the only method that can completely prevent the development of OHSS. Dopamine agonists are currently being investigated to both prevent and improve the clinical course in OHSS. Recent publications suggest that outpatient paracentesis both prevents the need for inpatient hospitalization and is a cost-effective strategy. PMID:20485578
Fontana, Luigi; Parente, Gabriella; Tassinari, Giorgio
We describe a simple test to confirm big-bubble formation in deep anterior lamellar keratoplasty by observing the position and movements of small air bubbles injected into the anterior chamber through a limbal paracentesis. The test also allows evaluation of the extension of Descemet's membrane cleavage from the posterior stroma relative to the margins of the corneal trephination.
Smith, Mitchell; Durham, Janette
Transjugular intrahepatic portosystemic shunt creation is a well-established therapy for refractory variceal bleeding and refractory ascites in patients who do not tolerate repeated large volume paracentesis. Experience and technical improvements including covered stents have led to improved TIPS outcomes that have encouraged an expanded application. Evidence for other less frequent indications continues to accumulate, including the indications of primary prophylaxis in patients with high-risk acute variceal bleeding, gastric and ectopic variceal bleeding, primary treatment of medically refractory ascites, recurrent refractory ascites following liver transplantation, hepatic hydrothorax, hepatorenal syndrome, Budd-Chiari syndrome, and portal vein thrombosis. Treatment of patients with high-risk acute variceal bleeding with early TIPS and using transjugular intrahepatic portosystemic shunts as a primary therapy rather than large volume paracentesis for refractory ascites would likely be the 2 circumstances that permit expansion in the frequency of TIPS procedures. The remaining populations discussed above are relatively rare.
Venzin, C; Kook, P; Jenni, S; Wilhelm, S; Degen, T; Braun, A; Rütten, M; Glaus, T M
A six-year-old Rottweiler with chronic ascites and moderate panhypoproteinaemia that had been treated with large volume paracentesis over several months duration was diagnosed with a large bi-atrial mass and hepatic fibrosis. For palliative treatment, a peritoneo-vesical automated fluid shunt system with an integrated chargeable battery and an integrated computer to control pump function and to transmit data transcutaneously was implanted by coeliotomy. The pump was left in place for 10 weeks, eliminating the need for further paracentesis during this time. At the end of this period, no ascites was discernible and serum protein concentrations had returned to their respective reference intervals. As a complication, decubitus with skin perforation had developed above the pump. Besides palliative treatment of chronic refractory ascites, this pump may have application in other conditions characterised by chronic cavity effusion or in peritoneal dialysis.
Moore, Christopher M; Van Thiel, David H
Ascites is a pathologic accumulation of peritoneal fluidcommonly observed in decompensated cirrhotic states.Its causes are multi-factorial, but principally involve significant volume and hormonal dysregulation in the setting of portal hypertension. The diagnosis of ascites is considered in cirrhotic patients given a constellation of clinical and laboratory findings, and ultimately confirmed, with insight into etiology, by imaging and paracentesis procedures. Treatment for ascites is multi-modal including dietary sodium restriction, pharmacologic therapies, diagnostic and therapeutic paracentesis, and in certain cases transjugular intra-hepatic portosystemic shunt. Ascites is associated with numerous complications including spontaneous bacterial peritonitis, hepato-hydrothorax and hepatorenal syndrome. Given the complex nature of ascites and associatedcomplications, it is not surprising that it heralds increased morbidity and mortality in cirrhotic patients and increased cost-utilization upon the health-care system. This review will detail the pathophysiology of cirrhotic ascites, common complications derived from it, and pertinent treatment modalities. PMID:23717736
Bari, Shamsul; Malik, Ajaz A; Parray, Fazul Q; Samoon, Hamid; Munfat, Malik; Bakshi, Iftikhar H
We present a patient with slow rupture of hydatid cyst into the peritoneal cavity, presenting as massive abdominal distension and respiratory embarrassment. On paracentesis, no fluid could be drained. A small lateral incision was made under local anaesthesia to drain the 'ascites', but daughter cysts typical of hydatid came out. On laparotomy, there was a cyst in the right lobe of liver which had ruptured into the peritoneal cavity leading to secondary echinococcosis.
Adesanya, Olubukunola; Naqvi, Mubariz
We report a rare, but serious, complication of a malpositioned umbilical venous catheter in a term male infant who developed laceration, hematoma, and necrosis of liver, ascites, and left-sided obstructive uropathy secondary to extravasation of total parenteral nutrition. Abdominal paracentesis confirmed the presence of parenteral nutrition in the peritoneal cavity. Although, the umbilical venous catheterization is a common intravenous access used in neonatal intensive care units, judicious continued monitoring of its use should be practiced to avoid serious complications. PMID:27766283
Acute otitis media is the most common bacterial infection in the child under 5 years of age and the leading reason for antibiotic prescriptions in Western countries. The choice of optimal antibiotic treatment is based essentially on microbiologic epidemiologic studies. The bacteria most often responsible for otitis belong to the commensal flora of the nasopharynx. French studies using paracentesis show that the main bacteria responsible for acute otitis media are H. influenzae, S. pneumoniae and M. catarrhalis. The epidemiology of resistance to antibiotics has recently changed, with the appearance of pneumococcal strains having reduced sensitivity to penicillin, and which have played a major role in treatment failures.
Radius, R L; Finkelstein, D
We report a case of central retinal artery occlusion in an 18-year-old black woman with sickle-trait haemoglobinopathy and acute glaucoma after hyphaema. The central retinal artery occlusion occurred immediately after treatment of the glaucoma with osmotic agents, raising the possibility that they played a precipitating role. We suggest that osmotic agents be used with extreme caution in sickle patients with glaucoma. The occlusion was treated by anterior chamber paracentesis with eventual return of good vision. The reversibility of retinal and optic nerve function after total ischaemia is discussed. PMID:952815
Grzybowski, Andrzej; Ascaso, Francisco J
It is generally accepted that Jacques Daviel introduced in the 18th century the extracapsular technique of extraction of the lens while the couching method of cataract operation had already been practiced since ancient times. Present study analyses the first known cataract surgery description in three translations into English from the original Sanskrit Sushruta textbook and all the available literature on the subject. We found evidences that some sort of extraocular expulsion of lens material through a limbal puncture (paracentesis) was described by the Indian surgeon. Nevertheless, this incision cannot be considered as a classic extracapsular procedure because it was not large enough to allow the extraction of the entire lens.
Wong, Clare; Merkur, Harry
The anatomical position of the inferior epigastric artery (IEA) subjects it to risk of injury during abdominal procedures that are close to the artery, such as laparoscopic trocar insertion, insertion of intra-abdominal drains, Tenckhoff(®) catheter (peritoneal dialysis catheter) and paracentesis. This article aims to raise the awareness of the anatomical variations of the course of the IEA in relation to abdominal landmarks in order to define a safer zone for laparoscopic ancillary trocar placement. Methods of managing the IEA injury as well as techniques to minimise the risk of injury to the IEA are reviewed and discussed.
Masi, R J
A 22-year-old black female intravenous cocaine addict presented with an endophthalmitis of the right eye. Diagnostic evaluation included an immediate anterior chamber paracentesis and a delayed vitreous aspiration. Although cultures from the involved eye were negative, all 7 blood cultures grew Bacillus cereus suggesting that this organism was the responsible agent of an endogenous endophthalmitis. The patient was treated with appropriate systemic and local antibiotics with resolution of the acute inflammatory signs. However, a phthisical eye has been noted on follow-up examinations.
Miller, Joe; Uttamchandani, Deepak G.
The authors report on the design of a system which will enable real time measurements of (therapeutic) drug concentrations in the anterior chamber of the eye. Currently the concentration of therapeutic drugs in the anterior chamber is determined by analyzing samples which have been removed from the aqueous humor of laboratory animal eyes. This sampling via paracentesis can be painful and does not provide a continuous measurement. Our system will be far less invasive, removing the need for sampling via paracentesis, and also providing a continuous measurement, enabling a more complete understanding of the kinetics of ophthalmic drugs. A key component in our novel system is a specially constructed contact lens. We report on the design, optimization and manufacture of such a contact lens system capable of directing UV/VIS light in, across and out of the anterior chamber of the eye, thereby enabling absorption spectroscopy measurements of the aqueous humor to be undertaken. Design of the one piece contact lens/mirror system was achieved using the Zemax optical design software package and the lens was fabricated from synthetic fused silica. Results from modeling of the lens and experimental measurements on light propagation across the anterior chamber of animal eyes assisted by the lens will be reported.
Caraceni, Paolo; Angeli, Paolo; Prati, Daniele; Bernardi, Mauro; Liumbruno, Giancarlo M.; Bennardello, Francesco; Piccoli, Pierluigi; Velati, Claudio
The use of human albumin is common in hepatology since international scientific societies support its administration to treat or prevent severe complications of cirrhosis, such as the prevention of post-paracentesis circulatory dysfunction after large-volume paracentesis and renal failure induced by spontaneous bacterial peritonitis, and the treatment of hepatorenal syndrome in association with vasoconstrictors. However, these indications are often disregarded, mainly because the high cost of human albumin leads health authorities and hospital administrations to restrict its use. On the other hand, physicians often prescribe human albumin in patients with advanced cirrhosis for indications that are not supported by solid scientific evidence and/or are still under investigation in clinical trials. In order to implement appropriate prescription of human albumin and to avoid its futile use, the Italian Association for the Study of the Liver (AISF) and the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) nominated a panel of experts, who reviewed the available clinical literature and produced practical clinical recommendations for the use of human albumin in patients with cirrhosis. PMID:26820615
Chen, Ying-Chuan; Li, Jun-Ju; Zhu, Guan-Yu; Shi, Lin; Yang, An-Chao; Jiang, Yin; Zhang, Xin; Zhang, Jian-Guo
Nowadays, the patients with deep brain stimulation (DBS) devices are restricted to undertake 1.5T magnetic resonance imaging (MRI) according to the guideline. Nevertheless, we conducted an experiment to test pathological change near the leads in different field-strength MRI. Twenty-four male New Zealand rabbits were assigned to Group 1 (G1, n = 6, 7.0T, DBS), Group 2 (G2, n = 6, 3.0T, DBS), Group 3 (G3, n = 6, 1.5T, DBS), and Group 4 (G4, n = 6, 1.5T, paracentesis). DBS leads were implanted in G1, G2 and G3, targeting left nucleus ventralis posterior thalami. Paracentesis was performed in G4. 24 h after MRI scan, all animals were killed for examining pathological alternation (at different distance from lead) via transmission electron microscopy. Our results suggest that the severity of tissue injury correlates with the distance to electrode instead of field strength of MRI. Up to now, the reason for the restriction of MRI indicated no significantly different pathological change.
Annamalai, Alagappan; Wisdom, Lauren; Herada, Megan; Nourredin, Mazen; Ayoub, Walid; Sundaram, Vinay; Klein, Andrew; Nissen, Nicholas
Cirrhosis is a major cause of morbidity and mortality worldwide with liver transplantations as it only possible cure. In the face of a significant organ shortage many patients die waiting. A major complication of cirrhosis is the development of portal hypertension and ascites. The management of ascites has barely evolved over the last hundred years and includes only a few milestones in our treatment approach, but has overall significantly improved patient morbidity and survival. Our mainstay to ascites management includes changes in diet, diuretics, shunt procedures, and large volume paracentesis. The understanding of the pathophysiology of cirrhosis and portal hypertension has significantly improved in the last couple of decades but the changes in ascites management have not seemed to mirror this newer knowledge. We herein review the history of ascites management and discuss some its current limitations. PMID:27729954
Srinivasan, Sathish; Lyall, Douglas; Kiire, Christine
Fuchs heterochromic uveitis (FHU) in its classic presentation is a unilateral, chronic, low grade, often asymptomatic anterior uveitis. It is characterized by a classic triad of iris heterochromia, cataract and keratic precipitates. Neovascularization of the iris and the anterior chamber (AC) angle (radial and circumferential) occurs in 6–22% of cases. This angle and iris new vessels can sometimes lead to a characteristic filiform haemorrhage and formation of hyphaema after AC paracentesis and is a hallmark of FHU known as Amsler–Verrey sign. This haemorrhage has been previously associated with trivial trauma, mydriasis, applanation tonometry, gonioscopy, or it may occur spontaneously. In the setting of cataract surgery it has been previously reported with the use of a Honan balloon. We report a case of cataract and FHU where the Amsler–Verrey sign developed intraoperatively during a phacoemulsification procedure. To the best of our knowledge, this is the first documented report of this sign occurring intraoperatively during cataract surgery. PMID:22767537
Srinivasan, Sathish; Lyall, Douglas; Kiire, Christine
Fuchs heterochromic uveitis (FHU) in its classic presentation is a unilateral, chronic, low grade, often asymptomatic anterior uveitis. It is characterized by a classic triad of iris heterochromia, cataract and keratic precipitates. Neovascularization of the iris and the anterior chamber (AC) angle (radial and circumferential) occurs in 6-22% of cases. This angle and iris new vessels can sometimes lead to a characteristic filiform haemorrhage and formation of hyphaema after AC paracentesis and is a hallmark of FHU known as Amsler-Verrey sign. This haemorrhage has been previously associated with trivial trauma, mydriasis, applanation tonometry, gonioscopy, or it may occur spontaneously. In the setting of cataract surgery it has been previously reported with the use of a Honan balloon. We report a case of cataract and FHU where the Amsler-Verrey sign developed intraoperatively during a phacoemulsification procedure. To the best of our knowledge, this is the first documented report of this sign occurring intraoperatively during cataract surgery.
Williams, E. M.; Markey, C. M.; Johnson, A. M.; Morales-Ramirez, P. B.
Pelvic actinomycosis is an uncommon, slowly progressing granulomatous infection that has been associated with the presence of intrauterine devices. Due to its unspecific clinical and radiologic findings, it can mimic pelvic or intra-abdominal malignancy leading to mutilating surgery of high morbidity. Rarely, diagnosis is made preoperatively and in most cases surgical intervention is necessary. The patient in our case is a 42-year-old female with an IUD for 15 years diagnosed with pelvic actinomycosis. Patient was uniquely diagnosed preoperatively through paracentesis and treated conservatively with prolonged antibiotic therapy and without any type of surgical intervention. Follow-up at 1 year showed almost complete radiologic resolution of the inflammatory mass, nutritional recovery, and absence of symptoms. Pelvic actinomycosis can be successfully diagnosed and treated medically without surgical interventions. PMID:28299218
Meschino, Michael; García-Ochoa, Carlos
We present the rare case of a ruptured choledochal cyst (CC) in a young woman presenting with a two-day history of worsening upper abdominal pain. Imaging revealed a contracted gallbladder, dilated common bile duct (CBD), and a large amount of peritoneal fluid. Percutaneous paracentesis was performed, obtaining bilious fluid. Further imaging revealed cystic dilatation of the CBD and the diagnosis of rupture CC type I was made. The patient was initially managed conservatively with percutaneous drains, IV antibiotic therapy, and sphincterotomy through an ERCP. Elective cyst resection and Roux-en-Y hepatojejunostomy was performed 8 weeks later. It is important to differentiate a ruptured CC from other surgical emergencies without exploratory laparotomy. Initial conservative management could be considered, followed by elective resection once inflammation, infection, and other complications have resolved, avoiding the increased risk associated with an emergency operation or two-stage laparotomy. PMID:25713811
Massive ascites of unknown origin is an uncommon condition, which represent a diagnostic challenge. Patients with delayed diagnosis and treatment may have a poor prognosis. A 22-year-old female was referred to this hospital due to a 4-year progressive abdominal distension with massive ascites of unknown origin. By thorough investigations, she was eventually diagnosed as chronic calcified constrictive pericarditis. She received pericardiectomy and had an uneventful postoperative course. With a few day paracentesis, ascites did not progress any more. She was doing well at 5-month follow-up and has returned to work. Extracardiac manifestations, such as massive ascites and liver cirrhosis, were rare in patients with constrictive pericarditis. Pericardiectomy can be a radical solution for the treatment of chronic constrictive pericarditis. In order to avoid delayed diagnosis and treatment, physicians have to bear in mind this rare manifestation of chronic calcified constrictive pericarditis. PMID:24600502
Kogiso, Tomomi; Hashimoto, Etsuko; Ito, Taito; Hara, Toshifumi; Ikarashi, Yuichi; Kodama, Kazuhisa; Taniai, Makiko; Torii, Nobuyuki; Yoshinaga, Kentaro; Morita, Satoru; Takahashi, Yutaka; Tanaka, Junji; Sakai, Shuji; Yamamoto, Masakazu; Tokushige, Katsutoshi
A 56-year-old man was diagnosed with aplastic anemia and paroxysmal nocturnal hemoglobinuria at 43 years of age and treatment with cyclosporin A was started. Liver cirrhosis, ascites, and thrombus in the hepatic veins were found at 56 years of age and Budd-Chiari syndrome (BCS) was diagnosed according to angiography findings. He was treated with diuretics and paracentesis was performed several times, but with limited efficacy. A DenverⓇ peritoneovenous shunt (PVS) was inserted into the right jugular vein; his ascites and renal function improved immediately and his general condition has remained good for 12 months since starting the above treatment regimen. A PVS is a treatment option for ascites due to BCS. PMID:27746432
Graziosi, Luigina; Marino, Elisabetta; De Angelis, Verena; Rebonato, Alberto; Donini, Annibale
Malignant ascites is an abnormal accumulation of fluid in the peritoneal cavity of patients with intraperitoneal cancer dissemination. This clinical condition could represent the terminal evolution of a lethal disease and could influence the prognosis, severely impairing the patients' quality of life. Treatment options include a multitude of different procedures with limited efficacy and some degree of risk; diuretics, paracentesis, peritoneo-venous shunts and intraperitoneal biologic agents like anti-VEGF molecules, metalloproteinase inhibitors and immunomodulators are included. None of these approaches have been established as a standard of care because of their low efficacy or severe side effects. The last two decades saw the emergence of cytoreductive surgery with hyperthermic intraperitoneal perioperative chemotherapy (HIPEC) as a viable therapeutic approach resulting in an effective cure against refractory malignant ascites. The following describes our experiences with 3 cases together with a literature review.
Nichols-Totten, Kysha; Pollema, Travis; Moncure, Michael
Pseudoaneurysm of the inferior epigastric artery (IEA) is a recognized complication of surgery; however, it is a very rare clinical occurrence. The anatomic position of the IEA subjects patients to possible IEA injury during abdominal wall procedures that are close to the artery, such as insertions of drains, Tenckhoff catheters, laparoscopic trocars, or paracentesis. Treatment options include open surgery, percutaneous coil embolization, embolization with N-butyl cyanoacrylate, sonographic-guided thrombin injection, or sonographic-guided compression. We report the first case of a pseudoaneurysm arising from the IEA after a laparoscopic ventral hernia repair. To our knowledge, 17 IEA pseudoaneurysms have been reported, only 3 of which were spontaneous. The pseudoaneurysm in our patient was successfully treated by percutaneous injection of thrombin by interventional radiology.
Agrawal, Shefali; Vohra, Sandeep; Rawat, Sangeeta; Kashyap, Vikas
Eosinophilic gastroenteritis (EGE) is a rare condition characterized by eosinophilic infiltration of the gastrointestinal tract. Depending on the dominant layer of infiltration it is classified into three types namely, mucosal, muscularis and subserosal. The most uncommon variant is the subserosal type characterized by primarily subserosal disease, eosinophilic ascites and peripheral hypereosinophilia. The clinical features are non-specific with history of atopic predisposition and allergy. Endoscopic biopsy is frequently non-diagnostic due to an uninvolved gastrointestinal mucosa rendering its diagnosis a challenge. The mainstay of diagnosis is peripheral hypereosinophilia and eosinophil-rich ascitic fluid on diagnostic paracentesis. Oral steroid therapy is usually the first line of treatment with dramatic response. Due to a propensity for relapse, steroid-sparing therapy should be considered for relapses of EGE. We report a case of subserosal EGE with diagnostic clinical features and treatment response and review the current strategy in the management of eosinophilic ascites. PMID:27721930
Zghal, I; Malek, I; Amel, C; Soumaya, O; Bouguila, H; Nacef, L
Necrotizing viral retinitis is associated with infection by the Herpes family of viruses, especially herpes simplex virus (HSV), varicella zoster virus (VZV) and occasionally cytomegalovirus (CMV). When the diagnosis is suspected clinically, antiviral therapy must be instituted immediately. We report the case of a patient presenting with necrotizing viral retinitis 3 months following intravitreal injection of triamcinolone acetonide for diabetic macular edema. Fluorescein angiography demonstrated a superior temporal occlusive vasculitis. A diagnostic anterior chamber paracentesis was performed to obtain deoxyribo-nucleic acid (DNA) for a polymerase chain reaction (PCR) test for viral retinitis. PCR was positive for CMV. The patient was placed on intravenous ganciclovir. CMV retinitis is exceedingly rare in immunocompetent patients; however, it remains the most common cause of posterior uveitis in immunocompromised patients. The incidence of this entity remains unknown. Local immunosuppression, the dose and the frequency of injections may explain the occurrence of this severe retinitis.
Martínez, Javier; Albillos, Agustín
Ascites is a common complication of hepatic cirrhosis and portal hypertension. Patients present systemic and splanchnic circulation disorders, which cause central hypovolemia and arterial hypotension, with the subsequent activation of vasoconstrictor systems and increased renal reabsorption of sodium and water. Approximately 5%-10% of patients present refractory ascites. Refractory ascites is considered when it is not controllable with standard dietary (sodium restriction) and diuretic (furosemide up to 160 mg a day and spironolactone up to 400mg a day) treatment or when patients present adverse effects due to diuretics that impede their administration at optimum dosages. The current therapeutic options for these patients are repeated evacuative paracentesis and the percutaneous intrahepatic portosystemic shunt. Despite these treatments, refractory ascites has a poor prognosis; patients should therefore be assessed for liver transplantation.
Stirnimann, Guido; Banz, Vanessa; Storni, Federico; De Gottardi, Andrea
Cirrhotic patients with refractory ascites (RA) can be treated with repeated large volume paracentesis (LVP), with the insertion of a transjugular intrahepatic portosystemic shunt (TIPS) or with liver transplantation. However, side effects and complications of these therapeutic options, as well as organ shortage, warrant the development of novel treatments. The automated low-flow ascites pump (alfapump(®)) is a subcutaneously-implanted novel battery-driven device that pumps ascitic fluid from the peritoneal cavity into the urinary bladder. Ascites can therefore be aspirated in a time- and volume-controlled mode and evacuated by urination. Here we review the currently available data about patient selection, efficacy and safety of the alfapump and provide recommendations for the management of patients treated with this new method.
Lerman, S.; Hockwin, O.
Twenty-eight fresh donor eyes (Georgia Lions Eye Bank) ranging in age from four months to 87 years were used for an in vitro study to determine the feasibility of obtaining accurate anterior chamber diameter measurements with our Scheimpflug ultraviolet-visible slitlamp densitography apparatus. The in vivo study was performed on 16 hybrid monkeys (of varying age). These data were within 0.1 mm of measurements obtained with a modified paracentesis needle specially designed to obtain such measurements. The results of the foregoing study demonstrate that the Scheimpflug slitlamp photographic analyses can provide an accurate measurement of the anterior chamber diameter without entering the globe surgically. This will enable the surgeon to determine the diameter and order an anterior chamber IOL of a specified size prior to surgery. The authors have devised an automated program to analyze the negatives and provide direct anterior chamber diameter measurements.
Stirnimann, Guido; Banz, Vanessa; Storni, Federico; De Gottardi, Andrea
Cirrhotic patients with refractory ascites (RA) can be treated with repeated large volume paracentesis (LVP), with the insertion of a transjugular intrahepatic portosystemic shunt (TIPS) or with liver transplantation. However, side effects and complications of these therapeutic options, as well as organ shortage, warrant the development of novel treatments. The automated low-flow ascites pump (alfapump®) is a subcutaneously-implanted novel battery-driven device that pumps ascitic fluid from the peritoneal cavity into the urinary bladder. Ascites can therefore be aspirated in a time- and volume-controlled mode and evacuated by urination. Here we review the currently available data about patient selection, efficacy and safety of the alfapump and provide recommendations for the management of patients treated with this new method. PMID:28203285
Kikolski, Steven G. Aryafar, Hamed Rose, Steven C.; Roberts, Anne C.; Kinney, Thomas B.
PurposeTo investigate the efficacy and safety of the use of transjugular intrahepatic portosystemic shunt (TIPS) creation to treat cirrhosis-related chylous collections (chylothorax and chylous ascites).MethodsWe retrospectively reviewed data from four patients treated for refractory cirrhosis-related chylous collections with TIPS at our institution over an 8 year period.ResultsOne patient had chylothorax, and three patients had concomitant chylothorax and chylous ascites. There were no major complications, and the only procedure-related complications occurred in two patients who had mild, treatable hepatic encephalopathy. All patients had improvement as defined by decreased need for thoracentesis or paracentesis, with postprocedure follow-up ranging from 19 to 491 days.ConclusionTIPS is a safe procedure that is effective in the treatment of cirrhosis-related chylous collections.
Allen, H F; Grove, A S
Severe iritis which occurs within the first five days after cataract extraction may be categorized as (1) bacterial endophthalmitis, (2) toxic iritis, or (3) aseptic iritis. These entities can sometimes be distinguished because of their clinical features. If bacterial endophthalmitis is suspected, anterior chamber paracentesis should be considered and appropriate antibiotic treatment should be initiated. Acute iritis may result from the introduction of toxic agents into the eye, and may follow the use of products sterilized with ethylene oxide. Early acute aseptic iritis probably occurs more often than has previously been recognized. Response to intensive anti-inflammatory treatment is usually prompt and dramatic. The judicious use of cryoextraction and the careful manipulation of intraocular tissues may minimize the incidence and the severity of postoperative inflammation.
Williet, Nicolas; Kassir, Radwan; Cuilleron, Muriel; Dumas, Olivier; Rinaldi, Leslie; Augeul-Meunier, Karine; Cottier, Michèle; Roblin, Xavier; Phelip, Jean-Marc
A 71-year-old man, with history of plasmacytoma in relapse since one year, was hospitalized for a initial presentation of acute pancreatitis and hepatitis. Although there was a heterogeneous infiltration around the pancreas head, the diagnosis of an extramedullary localization of his plasmacytoma was not made until later. This delayed diagnosis was due to the lack of specific radiologic features and the lack of dilatation of biliary ducts at the admission. A diagnosis was made with a simple ultrasound guided paracentesis of the low abundance ascites after a transjugular hepatic biopsy, an endoscopic ultrasound-guided fine needle aspiration of the pancreatic mass, and a failed attempt of biliary drainage through endoscopic retrograde cholangiopancreatography. In order to document the difficulty of this diagnosis, characteristics of 63 patients suffering from this condition and diagnosis were identified and discussed through a systematic literature search. PMID:28246589
Beltrán, L M; García-Casasola, G
Ultrasonography in the hands of the internist can answer important clinical questions quickly at the point of patient care. This technique "enhances" the senses of the physicians and improves their ability to solve the problems of the patient. Point of care ultrasonography performed by clinicians has shown good accuracy in the diagnosis of diverse cardiac, abdominal and vascular pathologic conditions. It may also be useful for evaluation of thyroid, osteoarticular and soft tissue diseases. Furthermore, the use of ultrasound to guide invasive procedures (placement of venous catheters, thoracentesis, paracentesis) reduces the risk of complications. We present 5 cases to illustrate the usefulness of this technique in clinical practice: (i) peripartum cardiomyopathy; (ii) subclinical carotid artery atherosclerosis; (iii) asymptomatic abdominal aortic aneurysm; (iv) tendinitis of long head of biceps brachii and supraspinatus, and (v) spontaneous soleus muscle hematoma.
In most cases the outcome of impaction of the colon is favourable and with mild purging and lubrication, the mass can be broken down and the horse returned to normal health. It is important to reevaluate impaction cases which neither deteriorate or improve in a 24 hour period and to perform a paracentesis to evaluate the etiology and prognosis. A decision of euthanasia or surgical correction should be made as early as possible. Though initially stable, vital signs will deteriorate rapidly without warning. A critical evaluation of the client's farm management can prevent many impaction colics and the service practitioners provide is not complete unless the necessary changes are made. ImagesFigure 1.FIGURE 2.FIGURE 3. PMID:544003
Boey, Pui Yi; Singhal, Shweta; Perera, Shamira A; Aung, Tin
The management of acute primary angle closure is directed at lowering the intraocular pressure and relieving pupil block. Conventional treatment involves the use of medical treatment and laser peripheral iridotomy, respectively, as a means for achieving these aims. Newer therapeutic strategies have been described that are potentially useful adjuncts or alternatives to conventional treatment. Emerging strategies that lower intraocular pressure include anterior chamber paracentesis, as well as laser procedures such as iridoplasty and pupilloplasty. A possible alternative to relieving pupil block is lens extraction, and may be combined with adjunctive measures such as goniosynechiolysis and viscogoniosynechiolysis. Trabeculectomy has a limited role in the acute setting. This review paper reviews the current evidence regarding conventional and newer treatment modalities for acute primary angle closure. PMID:22536030
Bellia, Chiara; Clemente, Giuseppe; Pecoraro, Rosaria; Maida, Carlo; Simonetta, Irene; Vassallo, Valerio; Di Bona, Danilo; Gulotta, Eliana; Ciaccio, Marcello; Pinto, Antonio
Introduction Patients with chronic liver diseases are usually thin as a result of hypermetabolism and malnutrition expressed by reduced levels of leptin and impairment of other adyponectins such as visfatin. Aims We evaluated the metabolic and inflammatory effects of intravenous high-dose furosemide plus hypertonic saline solutions (HSS) compared with repeated paracentesis and a standard oral diuretic schedule, in patients with cirrhosis and refractory ascites. Methods 59 consecutive cirrhotic patients with refractory ascites unresponsive to outpatient treatment. Enrolled subjects were randomized to treatment with intravenous infusion of furosemide (125–250mg⁄bid) plus small volumes of HSS from the first day after admission until 3 days before discharge (Group A, n:38), or repeated paracentesis from the first day after admission until 3 days before discharge (Group B, n: 21). Plasma levels of ANP, BNP, Leptin, visfatin, IL-1β, TNF-a, IL-6 were measured before and after the two type of treatment. Results Subjects in group A were observed to have a significant reduction of serum levels of TNF-α, IL-1β, IL-6, ANP, BNP, and visfatin, thus regarding primary efficacy endpoints, in Group A vs. Group B we observed higher Δ-TNF-α, Δ-IL-1β, Δ-IL-6, Δ-ANP, Δ-BNP, Δ-visfatin, Δ-Leptin at discharge. Discussion Our findings underline the possible inflammatory and metabolic effect of saline overload correction in treatment of cirrhosis complications such as refractory ascites, suggesting a possible role of inflammatory and metabolic-nutritional variables as severity markers in these patients. PMID:27941973
Rozga, Jacek; Piątek, Tomasz; Małkowski, Piotr
Human serum albumin has been widely used in an array of clinical settings for nearly 7 decades. Although there is no evidence to support the use of albumin rather than crystalloid in acute volume resuscitation, many clinicians continue to use albumin because it has other important physiologic effects besides the oncotic function. In keeping with the improved understanding of albumin physiology and pathophysiology of many acute and chronic diseases, use of albumin for medical applications has increased in recent years. This, along with increased costs of manufacturing and lower production volume of medical-grade albumin, has lead to an ongoing shortage and rapid increase in albumin prices. This review is based on the analysis of major publications, related to albumin chemistry, physiology, and medical uses including guidelines developed by professional and governmental organizations. Results reflect current knowledge about the role of albumin in health and disease and relevance of albumin therapy in specific clinical settings. Albumin therapy is currently recommended in spontaneous bacterial peritonitis with ascites, refractory ascites not responsive to diuretics, large-volume paracentesis, post-paracentesis syndrome, and the treatment of hepatorenal syndrome as an adjunct to vasoconstrictors. New indications for albumin therapy are linked to the antioxidant activity of albumin and its effects on capillary integrity. In recent years, large-pore hemofiltration and albumin exchange have emerged as promising liver support therapies for liver failure and other toxic syndromes. They are designed to remove a broad range of blood-borne toxins and to restore normal functions of the circulating albumin by replacing defective forms of albumin and albumin molecules saturated with toxins with normal albumin. In view of the ongoing worldwide shortage and high cost of human albumin (native and recombinant), new usage criteria, protocols, and guidelines for appropriate utilization
Smolle, Elisabeth; Taucher, Valentin; Haybaeck, Johannes
Ovarian cancer (OC) is the eighth most lethal gynecological malignancy and the main cause of gynecological cancer death in industrialized countries. Malignant ascites is often found in OC, with about 10% of patients suffering from recurrent OC. Tumor cells in OC-associated malignant ascites promote disease recurrence and patient mortality is mainly associated with widespread metastasis to serosal surfaces and accompanying peritoneal effusions. Targeted therapies have recently been developed as novel therapeutic options for malignant ascites. The tri-functional anti-epithelial cell adhesion molecule and anti-cluster of differentiation 3 monoclonal antibody catumaxumab has been assessed in the therapy of malignant ascites, and proven to significantly reduce the ascitic flow rate when applied into the peritoneal cavity. The anti-angiogenic targeted agent bevacizumab has also shown good effects in the symptomatic treatment of malignant ascites, significantly prolonging the time until the next paracentesis. Vascular endothelial growth factor (VEGF) Trap, or aflibercept, is a fusion protein that inhibits VEGF-receptor binding. Aflibercept has proven to be effective in reduction of ascites, diminishing clinical symptoms of ascites and prolonging the time to next paracentesis. All three agents we review in the present article are effective in symptomatic control of ascites, leading to a rapid reduction of effusion and prolonging the time interval between paracenteses. However, no improvement in overall survival was observed in any of the clinical trials reported. We, thus, conclude that further investigations on larger patient series are needed to clarify whether the reduction of ascites by these targeted agents leads to a prolongation in tumor-related survival or not.
Lutz, Philipp; M´haimid, Mohamed; Pohlmann, Alessandra; Lehmann, Jennifer; Jansen, Christian; Schierwagen, Robert; Klein, Sabine; Strassburg, Christian P.; Spengler, Ulrich; Trebicka, Jonel
MircoRNA’s (miR) have been recognised as important modulators of gene expression and potential biomarkers. However, they have been rarely investigated in bio fluids apart from blood. We investigated the association of miR-125b and miR-155 with complications of cirrhosis. Ascites was prospectively collected from patients with cirrhosis undergoing paracentesis at our department. miR’s were determined in the supernatant using qPCR and normalized by SV-40. Clinical parameters were assessed at paracentesis and during follow-up. 76 specimens from 72 patients were analysed. MiR’s were not associated to age, sex or aetiology of cirrhosis. MiR-125b levels differed between patients with low and high MELD score, and miR-125b levels showed an inverse correlation to serum creatinine (r2 = −0.23; p = 0.05). MiR-155 was elevated in patients with spontaneous bacterial peritonitis (SBP) (n = 10; p = 0.04). MiR-155 levels differed between patients with and without 30-day survival (p = 0.02). No association of ascites levels of investigated miR’s to size of varices, episodes of gastrointestinal bleeding or hepatorenal syndrome was observed. While miR-125b levels in ascites seem to be associated with liver and renal dysfunction, miR-155 might be implicated in local immune response in SBP. PMID:28074870
Senousy, Bahaa Eldeen; Draganov, Peter V
Some patients with ascites due to liver cirrhosis become no longer responsive to diuretics. Once other causes of ascites such as portal vein thrombosis, malignancy or infection and non-compliance with medications and low sodium diet have been excluded, the diagnosis of refractory ascites can be made based on strict criteria. Patients with refractory ascites have very poor prognosis and therefore referral for consideration for liver transplantation should be initiated. Search for reversible components of the underlying liver pathology should be undertaken and targeted therapy, when available, should be considered. Currently, serial large volume paracentesis (LVP) and transjugular intrahepatic portasystemic stent-shunt (TIPS) are the two mainstay treatment options for refractory ascites. Other treatment options are available but not widely used either because they carry high morbidity and mortality (most surgical options) rates, or are new interventions that have shown promise but still need further evaluation. In this comprehensive review, we describe the evaluation and management of patients with refractory ascites from the prospective of the practicing physician. PMID:19115470
Tran, T H C; Rozenberg, F; Cassoux, N; Rao, N A; LeHoang, P; Bodaghi, B
Aim: To evaluate the diagnostic value of polymerase chain reaction (PCR) performed on aqueous humour for the detection of viral DNA in patients with necrotising herpetic retinitis. Methods: The clinical features and laboratory results of 22 patients (29 eyes) presenting with necrotising herpetic retinitis between March 1999 and June 2001 were reviewed retrospectively. Aqueous humour was obtained after anterior chamber paracentesis and PCR was performed in all cases. Results: Viral DNA was detected in the aqueous humour of 19 patients (86.4%). Epstein-Barr virus (EBV) seroconversion was evidenced in one additional patient. In the acute retinal necrosis (ARN) group (n = 19), varicella zoster virus (VZV) DNA was identified in six patients, herpes simplex virus 1 (HSV-1) DNA in two patients, herpes simplex virus 2 (HSV-2) DNA in four patients, and cytomegalovirus (CMV) genome in four patients. In the progressive outer retinal necrosis (PORN) group (n = 3), VZV DNA was detected in all patients. No sample was positive for more than one virus. Conclusions: PCR analysis of aqueous humour in patients with clinical features of necrotising viral retinitis can provide specific aetiological orientation and the method appears to be safe and highly sensitive. PMID:12488268
Verbrugge, Frederik H; Dupont, Matthias; Steels, Paul; Grieten, Lars; Malbrain, Manu; Tang, W H Wilson; Mullens, Wilfried
Current pathophysiological models of congestive heart failure unsatisfactorily explain the detrimental link between congestion and cardiorenal function. Abdominal congestion (i.e., splanchnic venous and interstitial congestion) manifests in a substantial number of patients with advanced congestive heart failure, yet is poorly defined. Compromised capacitance function of the splanchnic vasculature and deficient abdominal lymph flow resulting in interstitial edema might both be implied in the occurrence of increased cardiac filling pressures and renal dysfunction. Indeed, increased intra-abdominal pressure, as an extreme marker of abdominal congestion, is correlated with renal dysfunction in advanced congestive heart failure. Intriguing findings provide preliminary evidence that alterations in the liver and spleen contribute to systemic congestion in heart failure. Finally, gut-derived hormones might influence sodium homeostasis, whereas entrance of bowel toxins into the circulatory system, as a result of impaired intestinal barrier function secondary to congestion, might further depress cardiac as well as renal function. Those toxins are mainly produced by micro-organisms in the gut lumen, with presumably important alterations in advanced heart failure, especially when renal function is depressed. Therefore, in this state-of-the-art review, we explore the crosstalk between the abdomen, heart, and kidneys in congestive heart failure. This might offer new diagnostic opportunities as well as treatment strategies to achieve decongestion in heart failure, especially when abdominal congestion is present. Among those currently under investigation are paracentesis, ultrafiltration, peritoneal dialysis, oral sodium binders, vasodilator therapy, renal sympathetic denervation and agents targeting the gut microbiota.
Garcia-Martinez, Rita; Caraceni, Paolo; Bernardi, Mauro; Gines, Pere; Arroyo, Vicente; Jalan, Rajiv
Since the introduction of human serum albumin as a plasma expander in the 1940s, considerable research has allowed a better understanding of its biochemical properties and potential clinical benefits. Albumin has a complex structure, which is responsible for a variety of biological functions. In disease, the albumin molecule is susceptible to modifications that may alter its biological activity. During the last decades, different methods to measure albumin function have been developed. Recent studies have shown that not only albumin concentration but also albumin function is reduced in liver failure. This observation led to the concept of effective albumin concentration, which represents the fact that plasma albumin concentration does not reflect its function. Indeed, in liver disease albumin function is several times less than its concentration. In patients with cirrhosis, albumin infusion reduces mortality in patients with spontaneous bacterial peritonitis and improves outcome following large volume paracentesis. In combination with vasoconstrictors, albumin is useful in the management of patients with hepatorenal syndrome. Its role is being investigated in a large number of indications, which rely on its volume and nonvolume expansion functions such as stroke, severe sepsis, Alzheimer's disease, malaria, burns, and ovarian hyperstimulation syndrome. This review explores the above concepts, reviews the available evidence for the use of albumin in liver diseases, defines therapeutic limitations, and explores the challenges that should be addressed in future research.
Lee, June Sung
Albumin has been widely used in patients with cirrhosis in an attempt to improve circulatory and renal functions. The benefits of albumin infusions in preventing the deterioration in renal function associated with large-volume paracentesis, spontaneous bacterial peritonitis, and established hepatorenal syndrome in conjunction with a vasoconstrictor are well established. While some of these indications are supported by the results of randomized studies, others are based only on clinical experience and have not been proved in prospective studies. The paucity of well-designed trials, the high cost of albumin, the lack of a clear-cut survival benefit, and fear of transmitting unknown infections make the use of albumin controversial. The recent development of the molecular adsorbent recirculating system, an albumin dialysis, is an example of the capacity of albumin to act by mechanisms other than its oncotic effect. Efforts should be made to define the indications for albumin use, the dose required, and predictors of response, so that patients gain the maximum benefit from its administration.
Gartia, Manas R.; Misra, Santosh K.; Ye, Mao; Schwartz-Duval, Aaron; Plucinski, Lisa; Zhou, Xiangfei; Kellner, David; Labriola, Leanne T.; Pan, Dipanjan
Limited training, high cost, and low equipment mobility leads to inaccuracies in decision making and is concerning with serious ocular injuries such as suspected ruptured globe or post-operative infections. Here, we present a novel point-of-service (POS) quantitative ascorbic acid (AA) assay with use of the OcuCheck Biosensor. The present work describes the development and clinical testing of the paper-based biosensor that measures the changes in electrical resistance of the enzyme-plated interdigitated electrodes to quantify the level of AA present in ocular fluid. We have demonstrated the proof-of-concept of the biosensor testing 16 clinical samples collected from aqueous humor of patients undergoing therapeutic anterior chamber paracentesis. Comparing with gold standard colorimetric assay for AA concentration, OcuCheck showed accuracy of >80%, sensitivity of >88% and specificity of >71%. At present, there are no FDA-approved POS tests that can directly measures AA concentration levels in ocular fluid. We envisage that the device can be realized as a handheld, battery powered instrument that will have high impact on glaucoma care and point-of-care diagnostics of penetrating ocular globe injuries. PMID:26525715
Parekh, Trisha M.; Qian, You-Wen; Elghetany, M. Tarek; Schnadig, Vicki; Nawgiri, Ranjina
Background Peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS) is a rare neoplasm that typically presents as generalized lymphadenopathy. PTCL, NOS presenting as malignant ascites is rare. Methods A 61-year-old African-American man with past medical history of HCV, cryoglobulinemia, and cryptococcal pneumonia was admitted for dyspnea on exertion over a period of 1 month and new onset of abdominal distension. Results Ascites, splenomegaly, hepatomegaly and extensive lymphadenopathy were found by imaging. Paracentesis obtained 1.3 liter of abdominal fluid, the cytologic evaluation showed a monomorphic population of intermediate-sized lymphoid cells with irregular to convoluted nuclear contours. Fluid sent for flow cytometry showed an abnormal T-lymphocyte population expressing CD4, weak surface CD3 and absence of CD7. PCR studies of ascitic fluid detected a clonal T-lymphocyte population with T-cell receptor gamma gene rearrangement. Serologic testing for human T lymphotropic virus (HTLV) was positive for HTLV-II. Subsequent bone marrow biopsy revealed lymphomatous involvement. CD30 and ALK-1 immunostaining were negative. This case was classified as PTCL, NOS. Conclusions PTCL, NOS can have unusual clinical presentation such as ascites and pleural effusion, and may also occur as a complication of immunodeficiency state. Further studies are needed to determine if HCV or HTLV-II viral infection is associated with PTCL. PMID:27034820
Sederberg-Olsen, J F; Sederberg-Olsen, A E; Jensen, A M
The incidence of recurrence of secretory middle ear conditions (SMEC) in the course of the first 3 months after extrusion of a grommet was evaluated in 172 tubulated patients in relation to a number of background variables in a stepwise logistic regression analysis. The background variables were: treatment period, 3-month period (season) of extrusion, sex, age, air volume in the middle ear, diagnosis (unilateral/bilateral, suppurative/non-suppurative and consequently antibiotics), other treatment apart from a grommet (paracentesis and/or adenoidectomy), and a history of allergy. There was a definite correlation between the incidence of recurrence and the air volume in the middle ear, as determined by physical volume test, after correction for age, recurrences being most common in ears with a small middle ear volume. In addition, there was a relationship, but not as marked, between the incidence of recurrence and age after correction for the middle ear volume, recurrences being less common in older patients. None of the other background variables played a statistically significant role when correction was made for age and middle ear volume. It is recommended to practise an expectant therapeutic strategy in SMEC in order to eliminate cases with spontaneous remission. In the event of recurrence, a more liberal reinsertion of grommets is recommended for patients with small middle ear volumes, while in those with larger volumes a different aetiology should possibly be considered.
Abramov, Y; Schenker, J G; Lewin, A; Friedler, S; Nisman, B; Barak, V
The objective of this study was to follow the kinetics of four inflammatory cytokines in the plasma and ascitic fluid of seven patients who developed severe ovarian hyperstimulation syndrome (OHSS) after induction of ovulation for in-vitro fertilization. Blood samples were obtained from these patients at three different times: upon hospitalization; when significant clinical improvement was evident; and after complete resolution. Samples were analysed for interleukin-1 (IL-1), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumour necrosis factor alpha (TNF-alpha). Ascitic fluid was obtained by therapeutic paracentesis from all study patients during the active phase and analysed for these cytokines. Two control groups were available: the first included 15 women undergoing controlled ovarian stimulation for in-vitro fertilization without developing OHSS, while the second consisted of 25 healthy women not undergoing ovulation induction or any other medical treatment. High concentrations of IL-1, IL-6 and TNF-alpha were detected in all individuals upon admission for severe OHSS. Concentrations dropped significantly along with clinical improvement, reaching normal values after complete resolution. A statistically significant correlation was found between plasma cytokine concentrations and certain biological characteristics of the syndrome such as leukocytosis, increased haematocrit, and elevated plasma 17-beta-oestradiol concentrations. Ascitic fluid obtained from the study patients contained high IL-6 and IL-8 concentrations, while other cytokines were unaltered. These results suggest close association between inflammatory cytokines and the pathophysiology of the ovarian hyperstimulation syndrome.
Pérez-Cambrodí, Rafael J; Ascaso, Francisco J; Diab, Fathi; Alzamora-Rodríguez, Antonio; Grzybowski, Andrzej
The dislocation of the crystalline lens or couching technique was the predominant procedure to surgically remove cataracts until the 18th century A.D. However, in the Middle Ages, some Arab physicians tried to aspirate the opaque lens by means of a glass tube following a paracentesis. Some literary sources attributed the origins of this technique to Antyllus of Alexandria, a Greek surgeon who lived in the 2nd century A.D. in the Roman Empire. Nevertheless, this statement remains unclear and is probably the consequence of posterior interpretations or incorrect translations of the manuscripts. In recent years, the discovery of the hollow needles from Montbellet (France) and Viladamat (Spain), in archaeological settlements dated between the 1st century and 3rd century A.D., has reopened the possibility of cataract extraction as an option in the surgical management of soft cataracts in the antiquity. In any case, these findings are exceptional, and thus, probably this technique was not widely practised and very likely disparaged by the medical community.
Macrì, Angelo; Vagge, Aldo; Salis, Annalisa; Fucile, Carmen; Marini, Valeria; Martelli, Antonietta; Giuffrida, Sebastiano; Iester, Michele; Damonte, Gianluca; Mattioli, Francesca
The purpose of this study was to evaluate the aqueous humor concentrations of bromfenac ophthalmic solution 0.09 % in patients undergoing phacoemulsification. Patients requiring cataract extraction received one drop (50 µL) of bromfenac 0.09 % solution in the eye to be operated, before bedtime the day before surgery or the morning of the surgery. The last administration was recorded. At the time of paracentesis, an aqueous humor sample was collected with a 30-gauge needle attached to a TB syringe and was later analyzed by high-performance liquid chromatography for drug concentration. 188 treated volunteers and 48 control, untreated, subjects were included in the study. The mean aqueous concentration of bromfenac in the treated group was 37.60 ± 68.86 and 0 nM (nmol/L) in the control group (p < 0.0001). Correlation coefficient in bromfenac group between time elapsed from instillation and drug concentration was -0.16 (p not significant). Bromfenac showed properties of good penetration and stable concentration in aqueous humor up to about 12 h after instillation.
Mao, Xiaohui; Cheng, Xuefeng; Zhang, Zheng; Wang, Zhaoyan; Wang, Zhentao
The aim of this study is to evaluate the efficacy of ethosomes encapsulated with 5-fluorouracil (5-FU) in treatment of laryngotracheal stenosis in rabbit models. The 5-FU ethosome was prepared by the thin film hydration method, and the amorphous, size distribution and the encapsulation efficiency was investigated. The tracheal mucosa were scraped about 0.5 cm with a nylon brush to induce the scar in airway grow, then models were divided into three groups: 5-FU ethosome group, 5-FU group and saline group, drug were injected into scar of every group by paracentesis guided under endoscope, respectively. The stenosis states were observed under laryngo fiberscope immediate, 7, 14 and 21 days after administrated. Airway stenosis of 5-FU ethosome group has no significant difference when compared with 5-FU group at 7 days after administration, but 5-FU ethosome significantly reduced the airway stenosis after 21-day administration when compared with 5-FU group again and has no restenosis during the period under observation. The fact that ethosomes encapsulated with 5-FU were effective for laryngotracheal stenosis suggests that it has potential as a new method for ameliorating airway stenosis originating from granulation tissue.
Miller, Joe; Wilson, William S; Blue, Robert; Wilson, Clive G; Uttamchandani, Deepak
This paper describes in detail a novel optoelectronic system designed to measure drug absorption in the anterior segment of the eye following topical application of drug formulations. This minimally invasive measurement technique offers both a method for determining drug concentration in human eyes, and demonstrates an alternative to current testing processes in model animals, which require paracentesis of the anterior chamber of the eye. The optoelectronic technique can be used with formulations, which possess appropriate spectral characteristics, namely unique absorption or fluorescence spectra. Preliminary experiments using our measurement system have been performed in rabbit and man, where we have been successful in achieving the direct measurement of topically applied brimonidine, an alpha-2 agonist used in the treatment of glaucoma. This demonstrates the feasibility of performing real-time, in vivo testing of ophthalmic drug formulations in the eye of human test subjects. We further demonstrate the novel application of the optoelectronic system for detection of topically applied UV-absorbing compounds in rabbit cadaver eyes, with a view to evaluating potential ocular sunscreen formulations. In summary, this method can be applied for the rapid comparison of the penetration of different drug formulations into the anterior eye at greatly reduced cost and time.
Meyer, Carsten H; Krohne, Tim U; Charbel Issa, Peter; Liu, Zengping; Holz, Frank G
The advantage of intravitreal injections is an immediate and increased therapeutic effect in the intended retinal tissue. The accuracy, precision and reproducibility of the delivered volume depend on the size of the syringe and the physician's manual experience. The eyelids and eyelashes are usually disinfected using a povidone-iodine solution (10%); a sterile speculum is placed and drops of povidone-iodine (5%) are applied. The use of adequate anesthetic topical lidocaine 2% is required. The injection site should be located 3.5-4 mm posterior to the limbus. The angle of the incision through the sclera may be directed in an oblique fashion of 30°. The diameter of the needle should be smaller than 25 G, and the injected volume should be limited to 0.15 ml without a routine paracentesis. The incidence of lens injury is 0.006% (2/32,318) and 0.013% (5/35,942) for rhegmatogenous retinal detachments. The rate of suspected endophthalmitis is 0.018% after bevacizumab and 0.027% after ranibizumab injections. Sterile inflammations have been observed after Avastin injections. The concentrations of vascular endothelial growth factor inhibitors decline in a monoexponential fashion. The half-life of unbound bevacizumab is 9.82 days and that of ranibizumab 7.19 days.
Sangisetty, Suma L; Miner, Thomas J
Malignant ascites indicates the presence of malignant cells in the peritoneal cavity and is a grave prognostic sign. While survival in this patient population is poor, averaging about 20 wk from time of diagnosis, quality of life can be improved through palliative procedures. Selecting the appropriate treatment modality remains a careful process, which should take into account potential risks and benefits and the life expectancy of the patient. Traditional therapies, including paracentesis, peritoneovenous shunt placement and diuretics, are successful and effective in varying degrees. After careful review of the patient’s primary tumor origin, tumor biology, tumor stage, patient performance status and comorbidities, surgical debulking and intraperitoneal chemotherapy should be considered if the benefit of therapy outweighs the risk of operation because survival curves can be extended and palliation of symptomatic malignant ascites can be achieved in select patients. In patients with peritoneal carcinomatosis who do not qualify for surgical cytoreduction but suffer from the effects of malignant ascites, intraperitoneal chemotherapy can be safely and effectively administered via laparoscopic techniques. Short operative times, short hospital stays, low complication rates and ultimately symptomatic relief are the advantages of laparoscopically administering heated intraperitoneal chemotherapy, making it not only a valuable treatment modality but also the most successful treatment modality for achieving palliative cure of malignant ascites. PMID:22590662
Chawla, H B
To produce a flat retina after an operation demands an unrestricted view of the retina during the operation, and to achieve such a view most retinal surgeons would unhesitatingly recommend the binocular indirect ophthalmoscope and scleral depression. Once the retina and all its breaks are clearly in view, the keynote of the ensuing surgery should be simplicity and safety. The former requires that the intended operation should be the least complicated available, and, should the surgical intention be frustrated, that each step should blend with the next in orderly progression, the surgeon exhausting the possibility of one step before moving on to the next and being able to recognise when the possibilities are exhausted. The latter requires experience in deciding which is in fact the least complicated operation. In general the cavity of the globe should not be entered unless the eye stands to lose more than it gains by remaining inviolate. Paracentesis, fluid release, and intravitreal air all have their place, and to avoid them gains us nothing if the retina remains detached. PMID:7115648
Hospitalized patients with cirrhosis are at increased risk of developing bacterial infections, the most common being spontaneous bacterial peritonitis (SBP) and urinary tract infections. Independent predictors of the development of bacterial infections in hospitalized cirrhotic patients are poor liver synthetic function and admission for gastrointestinal hemorrhage. Short term (seven-day) prophylaxis with norfloxacin reduces the rate of infections and improves survival and should therefore be administered to all patients with cirrhosis and variceal hemorrhage. Cirrhotic patients who develop abdominal pain, tenderness, fever, renal failure or hepatic encephalopathy should undergo diagnostic paracentesis, and those who meet the criterion for SBP (eg, an ascites neutrophil count greater than 250/mm3) should receive antibiotics, preferably a third-generation cephalosporin. In addition to antibiotic therapy, albumin infusions have been shown to reduce the risk of renal failure and mortality in patients with SBP, particularly in those with renal dysfunction and hyperbilirubinemia at the time of diagnosis. Patients who recover from an episode of SBP should be given long term prophylaxis with norfloxacin and should be assessed for liver transplantation.
Cirrhotic ascites results from sinusoidal hypertension and sodium retention, which is secondary to a decreased effective arterial blood volume. Transjugular intrahepatic portosystemic shunt (TIPS) placement is currently indicated in cirrhotic patients with refractory ascites who require large-volume paracentesis (LVP) more than two or three times per month. TIPS placement is associated with normalization of sinusoidal pressure and a significant improvement in urinary sodium excretion that correlates with suppression of plasma renin activity, which is, itself, indicative of an improvement in effective arterial blood volume. Compared with serial LVP, placement of an uncovered TIPS stent is more effective at preventing ascites from recurring; however, increased incidence of hepatic encephalopathy and shunt dysfunction rates after TIPS placement are important issues that increase its cost. Although evidence suggests that TIPS placement might result in better patient survival, this needs to be confirmed, particularly in light of the development of polytetrafluoroethylene-covered stents. Favorable results apply to centers experienced in placing the TIPS, with the aim being to decrease the portosystemic gradient to <12 mmHg but >5 mmHg. This article reviews the pathophysiologic basis for the use of a TIPS in patients with refractory ascites, the results of controlled trials comparing TIPS placement (using uncovered stents) versus LVP, and a systematic review of predictors of death after TIPS placement for refractory ascites.
Khan, Muhammad S; Misra, Santosh K; Schwartz-Duval, Aaron S; Daza, Enrique; Ostadhossein, Fatemeh; Bowman, Matthew; Jain, Akshay; Taylor, Gina; McDonagh, Deana; Labriola, Leanne T; Pan, Dipanjan
Lack of current techniques for the early monitoring of bleb leaks and other post-traumatic or post-surgical ocular injury has posed an unmet clinical need for the development of new techniques. Present evaluation techniques use either subjective or nonquantitative approaches. At present, there are no FDA approved ocular devices that can directly measure ascorbic acid (AA) concentration levels for both tear film (TF) and aqueous humor (AH) at point-of-care (POC) level. Toward this aim, we present a novel POC quantitative assay, called the ocular biosensor device, which can be used to evaluate the integrity of the anterior surface of the eye by measuring the concentration of AA in TF and AH. Herein, we utilize a novel scientific engineering approach for the development of a disposable paper based POC ocular biosensor strip. A grafted poly(styrene)-block-poly(acrylic acid) (PS-b-PAA) and graphene platelet composite with contour based μ-electrodes design (CBμE) exhibit a highly sensitive platform to perform electrochemical immunosensing technique to study clinical samples that have small volumes like tear fluid. Samples used in this study were collected clinically from subjects undergoing therapeutic anterior chamber paracentesis. The proposed biosensor reports the level of AA concentration on an electronic screen, making the results easy to read, efficient, and reliable.
Background Renal cysts are common in old patients, and usually remain untreated. Giant renal cyst measuring more than 15 cm in diameter and containing more than 1500 mls of serous fluid are rarely seen. We report a case of a 75-year-old man with a giant right renal cyst. Case presentation A 75-year-old man presented with a five years history of suprapubic pain, abdominal distension. He had no urological symptoms. Physical examination revealed a distended abdomen with shifting dullness. Routine hematology, biochemistry, and serum tumor markers were within normal limits. Erroneously diagnosed as ascites on ultrasonographic examination. Abdominal paracentesis of supposed ascites was performed. The diagnosis of giant renal cyst was finally made by Computed tomography (CT) and patient underwent continuous percutaneous catheter drainage with negative pressure, whereby 8 liters of fluid were removed with negative cytology. Subsequent Computed tomography after 6 months revealed disparition of the cysts, and the patient remained asymptomatic. Conclusion Giant renal cysts are uncommon; we conclude that the CT remains the best exam in patients evaluated for giant renal cyst. This to the best of our knowledge is the largest renal cyst in the medical literature. Studies are needed with particular attention to the factors associated with renal cyst enlargement. PMID:24428865
Tang, Rui; Tian, Xiaodong; Xie, Xuehai; Yang, Yinmo
Abstract The clinical symptoms of pylephlebitis caused by acute appendicitis are varied and atypical, which leads to delayed diagnosis and poor outcomes. Here, we report a case of intestinal necrosis caused by thrombophlebitis of the portomesenteric veins as a complication of acute appendicitis after appendectomy. The patient had acute abdominal pain with tenderness and melena on the 3rd day after appendectomy for the treatment of gangrenous appendicitis. He was diagnosed with intestinal infarction caused by thrombophlebitis of the portomesenteric veins based on enhanced CT and diagnostic abdominal paracentesis. The patient was treated by bowel excision anastomosis and thrombectomy. After postoperative antibiotic and anticoagulation treatments, the patient recovered well and was discharged 22 days after the 2nd operation. A follow-up CT scan showed no recurrence of portomesenteric veins thrombosis 3 months later. Thrombophlebitis of the portomesenteric veins is a rare but fatal complication of acute appendicitis. For all the cases with acute abdominal pain, the possibility of thrombophlebitis should be considered as a differential diagnosis. Once pylephlebitis is suspected, enhanced CT scan is helpful for early diagnosis, and sufficient control of inflammation as well as anticoagulant therapy should be performed. PMID:26091450
FERNANDES, Flávia Fonseca; ALVES, Victor Oliveira; SÁNCHEZ, Tarquino Erastides Gavilanes; de PAULA, Wagner Diniz; SANTANA, Alfredo Nicodemos Cruz
SUMMARY A previously healthy, 52-year-old woman presented with a nine months history of low fever and weight loss (> 30 kg). Physical examination disclosed generalized lymphadenopathy, skin lesions, abdominal distension, mild tachypnea and a left breast mass. Laboratory tests showed anemia; (prerenal) kidney injury, low serum albumin level; and negative serology for HIV and viral hepatitis. Computed tomography (neck/chest/abdomen) showed generalized lymph node enlargement, splenomegaly, pleural effusion and ascites. We performed thoracocentesis and paracentesis, and the findings were consistent with chylothorax and chylous ascites (with no neoplastic cells). Biopsies of the breast mass, skin and lymph nodes were performed and all of them showed large round yeast cells with multiple narrow-based budding daughter cells, characteristic of Paracoccidioides brasiliensis. Consequently, paracoccidioidomycosis was diagnosed, and liposomal amphotericin B was prescribed, as well as a high protein and low fat diet (supplemented with medium chain triglycerides). Even so, her clinical status worsened, requiring renal replacement therapy. She evolved with pneumonia, septic shock and respiratory failure and subsequently died. To our knowledge, this is the first description of a case with chylothorax and breast mass due to paracoccidioidomycosis. Additionally, we discuss: 1- the importance of the inclusion of this mycosis in the differential diagnosis of chylothorax and breast mass (breast cancer), especially in endemic areas; and 2- the possible mechanism involved in the development of chylous effusions. PMID:27410917
Tang, Rui; Tian, Xiaodong; Xie, Xuehai; Yang, Yinmo
The clinical symptoms of pylephlebitis caused by acute appendicitis are varied and atypical, which leads to delayed diagnosis and poor outcomes. Here, we report a case of intestinal necrosis caused by thrombophlebitis of the portomesenteric veins as a complication of acute appendicitis after appendectomy. The patient had acute abdominal pain with tenderness and melena on the 3rd day after appendectomy for the treatment of gangrenous appendicitis. He was diagnosed with intestinal infarction caused by thrombophlebitis of the portomesenteric veins based on enhanced CT and diagnostic abdominal paracentesis. The patient was treated by bowel excision anastomosis and thrombectomy. After postoperative antibiotic and anticoagulation treatments, the patient recovered well and was discharged 22 days after the 2nd operation. A follow-up CT scan showed no recurrence of portomesenteric veins thrombosis 3 months later. Thrombophlebitis of the portomesenteric veins is a rare but fatal complication of acute appendicitis. For all the cases with acute abdominal pain, the possibility of thrombophlebitis should be considered as a differential diagnosis. Once pylephlebitis is suspected, enhanced CT scan is helpful for early diagnosis, and sufficient control of inflammation as well as anticoagulant therapy should be performed.
Tsuchida, Junko; Fujita, Shouhei; Kawano, Fumihiro; Tsukamoto, Ryoichi; Honjo, Kunpei; Naito, Shigetoshi; Ishiyama, Shun; Miyano, Shozo; Machida, Michio; Kitabatake, Toshiaki; Fujisawa, Minoru; Kojima, Kuniaki; Ogura, Kanako; Matsumoto, Toshiharu
An 85-year-old woman was admitted to our hospital for steroid therapy for relapsing nephrotic syndrome. During hospitalization, she complained of sudden epigastric pain at night. Although there were signs of peritoneal irritation, CT showed a large amount of ascitic fluid, but no free intraperitoneal gas. Gram staining of ascitic fluid obtained by abdominal paracentesis showed Gram-negative rods, which raised a strong suspicion of gastrointestinal perforation and peritonitis. Therefore, emergency surgery was performed. Exploration of the colon showed multiple sigmoid diverticula, one of which was perforated. The patient underwent an emergency Hartmann's procedure. Imaging studies failed to reveal any evidence of gastrointestinal perforation, presenting a diagnostic challenge. However, a physician performed rapid Gram staining of ascitic fluid at night when laboratory technicians were absent, had a strong suspicion of gastrointestinal perforation, and performed emergency surgery. Gram staining is superior in rapidity, and ascitic fluid Gram staining can aid in diagnosis, suggesting that it should be actively performed. We report this case, with a review of the literature on the significance of rapid diagnosis by Gram staining.
Gartia, Manas R.; Misra, Santosh K.; Ye, Mao; Schwartz-Duval, Aaron; Plucinski, Lisa; Zhou, Xiangfei; Kellner, David; Labriola, Leanne T.; Pan, Dipanjan
Limited training, high cost, and low equipment mobility leads to inaccuracies in decision making and is concerning with serious ocular injuries such as suspected ruptured globe or post-operative infections. Here, we present a novel point-of-service (POS) quantitative ascorbic acid (AA) assay with use of the OcuCheck Biosensor. The present work describes the development and clinical testing of the paper-based biosensor that measures the changes in electrical resistance of the enzyme-plated interdigitated electrodes to quantify the level of AA present in ocular fluid. We have demonstrated the proof-of-concept of the biosensor testing 16 clinical samples collected from aqueous humor of patients undergoing therapeutic anterior chamber paracentesis. Comparing with gold standard colorimetric assay for AA concentration, OcuCheck showed accuracy of >80%, sensitivity of >88% and specificity of >71%. At present, there are no FDA-approved POS tests that can directly measures AA concentration levels in ocular fluid. We envisage that the device can be realized as a handheld, battery powered instrument that will have high impact on glaucoma care and point-of-care diagnostics of penetrating ocular globe injuries.
Ward, B.; Mather, S.; Shepherd, J.; Crowther, M.; Hawkins, L.; Britton, K.; Slevin, M. L.
Seven patients with small volume ovarian carcinoma, remaining after conventional therapy with surgery and a platinum containing chemotherapy regimen, were treated with intraperitoneal monoclonal antibody guided radiotherapy. 100 mCi131I conjugated to 10 mg of monoclonal antibody were injected i.p. in 2,000 ml peritoneal dialysis fluid. Patients were evaluated 3 months later; 3 had clinical progressive disease while third look laparotomy demonstrated progressive disease in 3 of the remaining 4 patients. The seventh patient did not have a third look laparotomy and is currently inevaluable for response. Five patients with recurrent malignant ascites not controlled by diuretics or repeated paracentesis were similarly treated with 75-170 mCi131I conjugated to 10 mg monoclonal antibody. In three patients the ascites was controlled for a mean of 4 months. One patient died too early to assess the control of his ascites but tumour cells disappeared from the ascitic fluid after therapy. In the patient whose ascites were not controlled, a subpopulation of antigen-negative tumour cells was demonstrated. This study was unable to demonstrate a therapeutic benefit for i.p. injected monoclonal antibody guided radiotherapy for solid intraperitoneal tumour but suggests that it may be capable of controlling the accumulation of antigen positive malignant ascites. Images Figure 1 Figure 3 Figure 4 PMID:3219277
Ehara, Takehito; Koyama, Makoto; Nakamura, Satoshi; Takeuchi, Daisuke; Muranaka, Futoshi; Kitazawa, Masato; Miyagawa, Shinichi
Pseudo-Meigs' syndrome is used to describe cases of ascites and/or pleural effusion associated with ovarian neoplasms other than benign tumors, which improve after removal of the ovarian lesion. We present three cases of pseudo-Meigs' syndrome secondary to ovarian metastasis from colorectal cancer. In case 1, the patient has severe dyspnea and hypoxia due to massive right pleural effusion; therefore preoperative thoracic drainage was needed. In case 2, the patient needed paracentesis every two or three days to improve abdominal distension. After two courses of 5-fluorouracil, levofolinate, and oxaliplatin (mFOLFOX6), her ascites could be controlled by diuretics without aspiration and her general condition improved. Then she underwent operation. In case 3, the patient developed a massive pleural effusion and ascites coincident with a rapid enlargement of ovarian tumor after resection and adjuvant chemotherapy for rectal cancer. In all cases, pleural effusions and/or ascites resolved and general conditions and daily activities of the patients improved after oophorectomy. They are all currently in good health without recurrence of pleural effusion or ascites. In patients with suspected pseudo-Meigs' syndrome secondary to ovarian metastasis of colorectal cancer, operation including oophorectomy may reduce pleural effusions and/or ascites and improve the general condition. PMID:28373923
O'Neill, J A; Stahlman, M T; Meng, H C
Fifty-two premature, low birth weight infants presented mainly in the first week of life with sudden manifestations of intestinal ileus and an x-ray picture of pneumatosis intestinalis. Twenty-two of 32 patients treated with gastric decompression, antibiotics, intensive supportive therapy and intravenous hyperalimentation survived. Twenty other patients had progression of their disease and required operation. Twelve of these patients survived. Review of this material indicated that some medically treated patients might have survived if they had been operated upon. Indications for operation included free perforation and clinical signs of deterioration. Abdominal physical findings and x-rays were not reliable except as signs of far advanced pathology. Confirmation of ascites by paracentesis and gram stain of fluid was helpful when present. If patients were adequately treated and then developed sudden hyponatremia or progressive acidosis, they invariably had gangrenous bowel and required operation. The most striking finding was that a sudden, profound drop in the platelet count to levels below 100,000 reliably predicted the presence of gangrenous bowel and the need for operation. Other clotting studies indicated that disseminated intravascular coagulation is an important accompaniment of NNE with the complication of bowel gangrene prior to perforation. Gastrostomy and resection of involved bowel with staged anastomosis proved to be the most successful form of surgical management. Overall suvival was 66 per cent. Images Fig. 1. PMID:1164056
Stofer, Fernanda; Barretto, Maria Fernanda; Gouvea, Ana Luisa; Ribeiro, Mario; Neves, Marcio; Gismondi, Ronaldo Altenburg; Mocarzel, Luís Otavio
Patient: Male, 65 Final Diagnosis: Peritoneal amyloidosis Symptoms: Anasarca • Dyspnea • Orthopnea Medication: — Clinical Procedure: Paracentesis and peritoneal biopsy Specialty: Gastroenterology and Hepatology Objective: Unusual clinical course Background: The clinical manifestations of amyloidosis depend on the type of insoluble protein as well as the location of amyloid deposits in tissues or organs. In the gastrointestinal tract, the small intestine is the most common site of amyloid deposits, whereas peritoneal involvement and ascites are rare. Case Report: We report on a case of ascites due to peritoneal amyloidosis. A 65-year-old patient was admitted to our institution due to anasarca and pulmonary congestion, mimicking heart failure. We started the patient on diuretics and vasodilators. Despite improvement in pulmonary congestion and peripheral edema, his ascites was not reduced. Echocardiogram revealed restrictive cardiomyopathy and a speckle-tracking pattern suggestive of cardiac amyloidosis. Subcutaneous and peritoneal biopsies revealed amyloidosis. Conclusions: Amyloidosis is rare in the peritoneum and is usually asymptomatic. Ascites occurs in only 20% of patients with peritoneal amyloidosis. We searched PubMed using “ascites” and “amyloidosis” and identified only eight case reports of amyloidosis with ascites. Physicians should be particularly careful in heart failure and anasarca cases when ascites is disproportional or not responsive to diuretic treatment. To date, there is no specific treatment for peritoneal amyloidosis. PMID:27353538
Sharma, Charu; Biswas, Nihar R; Ojha, Shreesh; Velpandian, Thirumurthy
Objective Corneal permeability of drugs is an important factor used to assess the efficacy of topical preparations. Transcorneal penetration of drugs from aqueous formulation is governed by various physiological, physiochemical, and formulation factors. In the present study, we investigated the effect of formulation factors like concentration, pH, and volume of instillation across the cornea using cassette dosing technique for ophthalmic fluoroquinolones (FQs). Materials and methods Sterile cocktail formulations were prepared using four congeneric ophthalmic FQs (ofloxacin, sparfloxacin, pefloxacin mesylate, and gatifloxacin) at concentrations of 0.025%, 0.5%, and 0.1%. Each formulation was adjusted to different pH ranges (4.5, 7.0, and 8.0) and assessed for transcorneal penetration in vivo in rabbit’s cornea (n=4 eyes) at three different volumes (12.5, 25, and 50 μL). Aqueous humor was aspirated through paracentesis after applying local anesthesia at 0, 5, 15, 30, 60, 120, and 240 minutes postdosing. The biosamples collected from a total of 27 groups were analyzed using liquid chromatography–tandem mass spectroscopy to determine transcorneal permeability of all four FQs individually. Results Increase in concentration showed an increase in penetration up to 0.05%; thereafter, the effect of concentration was found to be dependent on volume of instillation as we observed a decrease in transcorneal penetration. The highest transcorneal penetration of all FQs was observed at pH 7.0 at concentration 0.05% followed by 0.025% at pH 4.5. Lastly, increasing the volume of instillation from 12.5 to 50 μL showed a significant fall in transcorneal penetration. Conclusion The study concludes that formulation factors showed discernible effect on transcorneal permeation; therefore, due emphasis should be given on drug development and design of ophthalmic formulation. PMID:26955263
Zosmer, N; Bajoria, R; Weiner, E; Rigby, M; Vaughan, J; Fisk, N M
OBJECTIVE--Fetal twin-twin transfusion syndrome (TTTS) presenting in the second trimester has been associated with almost no perinatal survival until recently, when serial drainage of amniotic fluid has improved the prognosis to 70%-80%. Most recipient twins now survive but develop cardiac dysfunction. The study was undertaken to evaluate the abnormal echocardiographic features and clinical complications of cardiac disease in the recipient twin of TTTS. DESIGN--Antenatal and postnatal echocardiographic and clinical observational study. SETTING--Antenatal studies in a tertiary referral centre. Postnatal management and follow up were performed by the same paediatric cardiologist, either at the obstetric hospital or at the regional referral centre. PATIENTS--Twin pregnancies complicated by TTTS with severe polyhydramnios diagnosed earlier than 25 weeks that proceeded until viability (n = 5). INTERVENTION--Serial fetal echocardiography with colour Doppler. Postnatal echocardiography in the first week and between two and seven months. Serial amnioreduction was performed in all pregnancies. Digoxin treatment, pericardiocentesis, paracentesis, or laser ablation of placental anastomoses was undertaken when there was hydrops. RESULTS--Increased cardiothoracic ratio and tricuspid regurgitation were seen in all recipient twins. High pulmonary artery velocities developed in three. One recipient twin died a week after delivery of endocardial fibroelastosis and infundibular pulmonary stenosis. Two other had balloon dilatation for pulmonary stenosis, one shortly after birth and one at four months. A further twin has apical thickening of the right ventricle at six months. The remaining recipient twin had normal echocardiographic findings at follow up. CONCLUSION--This report characterises for the first time a cardiac disease acquired in utero in the recipient twin in pregnancies complicated by TTTS. Clinical manifestations in utero range from mild to critical pulmonary stenosis or
Mirshahi, Alireza; Raak, Peter; Ponto, Katharina; Stoffelns, Bernhard; Lorenz, Katrin; Scharioth, Gábor B.
Purpose. To report one-year results of phacoemulsification combined with deep sclerectomy and goniosynechiolysis ab interno for chronic glaucoma associated with peripheral anterior synechiae (PAS). Methods. We retrospectively analyzed medical charts of 16 patients (20 eyes) treated by one-site combined phacoemulsification and deep sclerectomy with goniosynechiolysis ab interno. PAS were transected by a spatula introduced into the anterior chamber through a paracentesis. To account for the correlation of right and left eyes a linear mixed model with unstructured covariance structure was calculated. Results. The mean preoperative intraocular pressure (IOP) was 20.3 ± 5.2 mmHg with 2.4 ± 1.0 medications. One year postoperatively, the mean IOP was 15.3 ± 3.3 mmHg (P = 0.004, paired t-test) with 0.6 ± 1.0 medications. A postoperative IOP of ≤21 mmHg without medication was achieved in 17 of 19 eyes (89.5%) and in 12/19 eyes (63.2%) at 3 and 12 months after surgery, respectively. In the remaining eyes (10.5% at 3 months and 36.8% at 12 months), additional medication led to an IOP ≤21 mmHg or the target pressure. No case required further glaucoma surgery. In one eye, conversion of the surgery to trabeculectomy was necessary due to Descemet's window rupture. Conclusions. With goniosynechiolysis ab interno, effective and safe nonpenetrating glaucoma surgery is possible in presence of PAS. PMID:26199738
Groth, Sylvia L; Greider, Kelsi L
ABSTRACT Objective: To assess the utility of viscoelastic injection to induce bleb expansion and decrease intraocular pressure (IOP) in eyes with encapsulated glaucoma tube shunt blebs. Design: Case series. Subjects and participants: Forty-three glaucomatous eyes, including 13 eyes with congenital, 13 uveitic, 5 neovascular, 5 open angle, 4 narrow angle and 3 traumatic glaucomas. Methods, interventions or testing: All patients underwent viscoelastic flush procedure. A pre-bent 27 or 30-gauge cannula was passed through a 25-gauge paracentesis, advanced over the iris across the anterior chamber, and insinuated into the tube shunt lumen. Once the cannula was firmly lodged in position, 0.45 to 0.85 ml of viscoelastic was injected to hyperinflate the bleb. Main outcome measures: Paired t-tests were performed comparing preoperative IOP and number of medications used preoperatively vs levels measured at 1, 6, 12, 18 and 24 months. Results: Intraocular pressure was reduced from a mean preoperative level of 26.0 ± 1.2 (sem) mm Hg to 15.8 ± 1.0 at 1 month, remaining stable thereafter at each 6-month interval with 15.1 ± 1.1 mm Hg at 24 months (p < 0.0001). Medication use did not vary significantly from baseline. Pressure remained < 21 mm Hg after 2 years in 85% of eyes cannulated within 1 year of primary tube shunt implantation (n = 23), and in 62% of eyes cannulated more than 1 year after tube shunt placement (n = 20). Conclusion: Tube shunt expansion with bolus viscoelastic flush successfully restored encapsulated bleb function, providing a substantial (~10 mm Hg) IOP decrease into the mid-normal pressure range. This persisted in the majority of treated eyes for the entire study period. How to cite this article: Groth SL, Greider KL, Sponsel WE. Utility of Operative Glaucoma Tube Shunt Viscoelastic Bolus Flush. J Curr Glaucoma Pract 2015;9(3):73-76. PMID:26997840
Ilgner, Justus; Park, Jonas Jae-Hyun; Westhofen, Martin
Introduction: The master plan for innovative medical education established at RWTH Aachen Medical Faculty helped to set up an inter-disciplinary, interactive teaching environment for undergraduate medical students during their clinical course. This study presents our first experience with teaching microsurgery to medical students by means of highdefinition stereo video monitoring. Material and methods: A plastic model created for ear inspection with a handheld otoscope was modified with an exchangeable membrane resembling an eardrum plus a model of the human cochlea. We attached a 1280×1024 HD stereo camera to an operating microscope, whose images were processed online by a PC workstation. The live image was displayed by two LCD projectors @ 1280×720 pixels on a 1,25m rear-projection screen by polarized filters. Each medical student was asked to perform standard otosurgical procedures (paracentesis and insertion of grommets; insertion of a cochlear implant electrode) being guided by the HD stereoscopic video image. Results: Students quickly adopted this method of training, as all attendants shared the same high-definition stereoscopic image. The learning process of coordinating hand movement with visual feedback was regarded being challenging as well as instructive by all students. Watching the same image facilitated valuable feedback from the audience for each student performing his tasks. All students noted that this course made them feel more confident in their manual skills and that they would consider a career in a microsurgical specialty. Conclusion: High definition stereoscopy provides an easy access to microsurgical techniques for undergraduate medical students. This access not only bears the potential to compress the learning curve for junior doctors during their clinical training but also helps to attract medical students to a career in a microsurgical specialty.
Acevedo, Juan G; Cramp, Matthew E
Hepatorenal syndrome (HRS) is a manifestation of extreme circulatory dysfunction and entails high morbidity and mortality. A new definition has been recently recommended by the International Club of Ascites, according to which HRS diagnosis relies in serum creatinine changes instead that on a fixed high value. Moreover, new data on urinary biomarkers has been recently published. In this sense, the use of urinary neutrophil gelatinase-associated lipocalin seems useful to identify patients with acute tubular necrosis and should be employed in the diagnostic algorithm. Treatment with terlipressin and albumin is the current standard of care. Recent data show that terlipressin in intravenous continuous infusion is better tolerated than intravenous boluses and has the same efficacy. Terlipressin is effective in reversing HRS in only 40%-50% of patients. Serum bilirubin and creatinine levels along with the increase in blood pressure and the presence of systemic inflammatory response syndrome have been identified as predictors of response. Clearly, there is a need for further research in novel treatments. Other treatments have been assessed such as noradrenaline, dopamine, transjugular intrahepatic portosystemic shunt, renal and liver replacement therapy, etc. Among all of them, liver transplant is the only curative option and should be considered in all patients. HRS can be prevented with volume expansion with albumin during spontaneous bacterial peritonitis and after post large volume paracentesis, and with antibiotic prophylaxis in patients with advanced cirrhosis and low proteins in the ascitic fluid. This manuscript reviews the recent advances in the diagnosis and management of this life-threatening condition. PMID:28293378
Joy, Praisy; Prithishkumar, Ivan James; Isaac, Bina
INTRODUCTION: Injury to the inferior epigastric artery (IEA) has been reported following lower abdominal wall surgical incisions, abdominal peritoneocentesis and trocar placements at laparoscopic port sites, resulting in the formation of abdominal wall haematomas that may expand considerably due to lack of tissue resistance. The aim of this study was to localise its course in relation to standard anatomic landmarks and suggest safe areas for performance of invasive procedures. MATERIALS AND METHODS: Sixty IEAs of 30 adult cadavers (male = 19; female = 11) were dissected and the course of the IEA noted in relation to the mid-inguinal point, anterior superior iliac spine (ASIS) and umbilicus. RESULTS: The mean distance of the IEA from the midline was 4.45 ± 1.42 cm at the level of the mid-inguinal point, 4.10 ± 1.15 cm at the level of ASIS and 4.49 ± 1.15 cm at the level of umbilicus. There was an average of 3.3 branches per IEA with more branches arising from its lateral aspect. The IEA was situated within one-third (32%) of the distance between the midline and the sagittal plane through ASIS at all levels. CONCLUSION: To avoid injury to IEA, trocars can be safely inserted 5.5 cm [mean + 1 standard deviation (SD)] away from the midline (or) slightly more than one-third of the distance between the midline and a sagittal plane running through ASIS. These findings may be useful not only for laparoscopic procedures but also for image-guided biopsy, abdominal paracentesis, and placement of abdominal drains. PMID:27251822
Nirmal, J; Singh, S B; Biswas, N R; Thavaraj, V; Azad, R V; Velpandian, T
Purpose We hypothesize organic cation transporters (OCT) may have a potential role in determining the pharmacokinetics and toxicity of organic cation drugs applied topically. Hence, in the present in vivo study, we attempted to evaluate the role of OCT in modulating the transport of its substrates after topical application. Methods New Zealand albino rabbits of either sex were used. Transcorneal penetration of OCT substrates tetraethylammonium and metformin after single instillation was evaluated in the absence and presence of OCT blockers (quinidine and atropine). Aqueous humor (AH) samples were collected through paracentesis amounting to 70–100 μl under topical anesthesia at various time intervals. The samples were subjected for estimation of both substrate as well as blocker concentrations using liquid chromatography mass spectrometry. Results Topical pre-treatment (30 min before substrate) of OCT blockers significantly decreased the transcorneal penetration of OCT substrates after single topical administration. The levels of blockers reaching AH in the presence of substrates were also modulated at 60 min after its administration as compared with its control. Conclusion OCT are functionally active in the uptake of their substrates from tear to AH. Therefore, OCT in the corneal epithelium may be positioned from apical to basolateral. When administering their substrates/blockers topically, both may be competing for OCT for their uptake across the cornea, thereby decreasing the corneal penetration. Hence OCT can have a potential pharmacokinetic role in modulating the ocular bioavailability of their substrates administered topically, which are used as ocular therapeutics. PMID:23846373
Moriwaki, Yoshihiro; Otani, Jun; Okuda, Junzo; Niwano, Toshiyuki; Sawada, Yoshiyuki; Nitta, Tachiko; Ohshima, Chiaki
Although massive cirrhotic ascites is generally considered a contraindication for the placement of percutaneous endoscopic gastrostomy (PEG), such patients are usually poorly nourished. Preceding paracentesis of ascites is one method for controlling ascites and allowing the safe placement of PEG, but it often results in overuse of albumin. Preceding peritoneal-venous (P-V) shunting can avoid excessive use of albumin, but this introduces the risk of infectious contamination. We encountered an 88-y-old woman with massive cirrhotic ascites, a giant esophageal hernia with dislocation of the proximal stomach into the mediastinum, hypertrophy of the lateral segment of the liver, and malnutrition who had suffered from appetite loss and a swallowing disorder for 4 mo. She underwent PEG using a staged sequential introduction method using a Funada-style gastric wall fixation kit as follows: 1) full stretching and pushing out of the stomach from the mediastinum into the peritoneal cavity by deep insertion and a turning-over procedure of the endoscope, 2) full distention by air to adhere the gastric wall to the peritoneal wall without migration of the colon, 3) four-point square fixation under gastroenterological endoscopy without migration of the visceral organ, and 4) puncture of the needle introducer of the PEG tube in the center of the fixations under repeated gastroenterological endoscopy 3 d after the fixation. She underwent P-V shunting under local anesthesia on the 28th day after placement of PEG and enteral nutrition. Her case shows that we can achieve proper enteral nutritional support even for patients with massive cirrhotic ascites.
Valerio, Christopher; Theocharidou, Eleni; Davenport, Andrew; Agarwal, Banwari
To provide an overview of the properties of human serum albumin (HSA), and to review the evidence for the use of human albumin solution (HAS) in critical illness, sepsis and cirrhosis. A MEDLINE search was performed using the terms “human albumin”, “critical illness”, “sepsis” and “cirrhosis”. The references of retrieved articles were reviewed manually. Studies published between 1980 and 2014 were selected based on quality criteria. Data extraction was performed by all authors. HSA is the main plasma protein contributing greatly to its oncotic pressure. HSA demonstrates important binding properties for endogenous and exogenous toxins, drugs and drug metabolites that account for its anti-oxidant and anti-inflammatory properties. In disease states, hypoalbuminaemia is secondary to decreased HSA production, increased loss or transcapillary leakage into the interstitial space. HSA function can be also altered in disease with reduced albumin binding capacity and increased production of modified isoforms. HAS has been used as volume expander in critical illness, but received criticism due to cost and concerns regarding safety. More recent studies confirmed the safety of HAS, but failed to show any survival benefit compared to the cheaper crystalloid fluids, therefore limiting its use. On the contrary, in cirrhosis there is robust data to support the efficacy of HAS for the prevention of circulatory dysfunction post-large volume paracentesis and in the context of spontaneous bacterial peritonitis, and for the treatment of hepato-renal syndrome and hypervolaemic hyponatraemia. It is likely that not only the oncotic properties of HAS are beneficial in cirrhosis, but also its functional properties, as HAS replaces the dysfunctional HSA. The role of HAS as the resuscitation fluid of choice in critically ill patients with cirrhosis, beyond the established indications for HAS use, should be addressed in future studies. PMID:26981172
Fukui, Hiroshi; Saito, Hidetsugu; Ueno, Yoshiyuki; Uto, Hirofumi; Obara, Katsutoshi; Sakaida, Isao; Shibuya, Akitaka; Seike, Masataka; Nagoshi, Sumiko; Segawa, Makoto; Tsubouchi, Hirohito; Moriwaki, Hisataka; Kato, Akinobu; Hashimoto, Etsuko; Michitaka, Kojiro; Murawaki, Toshikazu; Sugano, Kentaro; Watanabe, Mamoru; Shimosegawa, Tooru
The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding are the endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for
Torre Delgadillo, Aldo
Ascites is the most common complication of cirrhosis and is associated with 50% mortality at 2 years if patients do not receive orthotopic liver transplantation. Recently the International Ascites Club defined ascites into three groups: In grade I ascites fluid is detected only by ultrasound; in grade II, ascites is moderate with symmetrical distention of the abdomen; and in Grade 3 ascites is large or tense with marked abdominal distention. About 10% of patients with ascites are refractory to treatment with diuretics. In refractory ascites, patients do not respond to highest doses of diuretics (spironolactone 400 mg/day and furosemide 160 mg/ day) or develop side effects (hyperkalemia, hyponatremia, hepatic encephalopathy, or renal failure) that prohibit their use. Patients may be treated either by repeated large volume paracentesis plus albumin or transjugular intrahepatic portosystemic shunts (TIPS). Dilutional hyponatremia in cirrhotic patients is defined as serum sodium < or = 130 mEq/L in the presence of an expanded extracellular fluid volume, as indicated by the presence of ascites and/or edema. This complication of cirrhotic patients with ascites has recently gained attention given that several reports indicate that when serum sodium concentration is combined with the Model for End-Stage liver disease (MELD) it improves the prognostic accuracy of MELD score in patients awaiting orthotopic liver transplant (OLT). The first step in the management of dilutional hyponatremia is fluid restriction and discontinuation of diuretics. Water restriction at 1,000 mL/day helps prevent the progressive decrease in serum sodium concentration but usually does not correct hyponatremia in most cases. Actually are developing drugs that are active orally and act by selectively antagonizing the specific receptors (V2 receptor) of arginine vasopressin. These agents act in the distal collecting ducts of the kidneys, by increasing solute free water excretion and, thus, improving
Kameda, Toru; Taniguchi, Nobuyuki
Point-of-care abdominal ultrasound (US), which is performed by clinicians at bedside, is increasingly being used to evaluate clinical manifestations, to facilitate accurate diagnoses, and to assist procedures in emergency and critical care. Methods for the assessment of acute abdominal pain with point-of-care US must be developed according to accumulated evidence in each abdominal region. To detect hemoperitoneum, the methodology of a focused assessment with sonography for a trauma examination may also be an option in non-trauma patients. For the assessment of systemic hypoperfusion and renal dysfunction, point-of-care renal Doppler US may be an option. Utilization of point-of-care US is also considered in order to detect abdominal and pelvic lesions. It is particularly useful for the detection of gallstones and the diagnosis of acute cholecystitis. Point-of-case US is justified as the initial imaging modality for the diagnosis of ureterolithiasis and the assessment of pyelonephritis. It can be used with great accuracy to detect the presence of abdominal aortic aneurysm in symptomatic patients. It may also be useful for the diagnoses of digestive tract diseases such as appendicitis, small bowel obstruction, and gastrointestinal perforation. Additionally, point-of-care US can be a modality for assisting procedures. Paracentesis under US guidance has been shown to improve patient care. US appears to be a potential modality to verify the placement of the gastric tube. The estimation of the amount of urine with bladder US can lead to an increased success rate in small children. US-guided catheterization with transrectal pressure appears to be useful in some male patients in whom standard urethral catheterization is difficult. Although a greater accumulation of evidences is needed in some fields, point-of-care abdominal US is a promising modality to improve patient care in emergency and critical care settings.
Coffman, J R
Initial examination and therapy, and the avoidance of maltreatment are emphasized. Gastric decompression is of prime importance, after which no compound should be administered via stomach tube. Where large amounts of high starch grains are fed, primary acute gastric dilatation must be differentiated from that secondary to small bowel dilatation, by immediate gastric intubation and irrigation of the cardia with lidocaine. If cessation of pain and improvement of peristalsis and general attitude follow, the former state may be assumed. If pain persists and peristalsis does not improve markedly, one should assume small bowel displacement. Rectal examination is helpful in initial evaluation: impactions, inguinal herniation and ileocaecal intussusception may be diagnosed and small bowel displacement suspected. Palpation of one or more distended loops of bowel in the ventral middle third of the abdomen indicates small bowel displacement or ileus and flaccid distension. Distinction by rectal palpation alone is difficult. Palpation of the gas-distended apex of the caecum in the middle third of the abdomen is virtually pathognomonic for 180 degrees rotation of the large bowel. Abdominal paracentesis yielding true sanguineous effusion indicates a necrotizing segment of the bowel. If negative, such a segment is absent, or there is an infarcted segment, not yet damaged to the point of leaching whole blood, or the necrotizing segment is outside the peritoneal cavity, i.e., in the thorax, intussuscepted into the caecum, or herniated into the inguinal canal. Recurrent colics frequently may be due to verminous arteritis but the relationship to diet should be investigated. Recurrent colics after grain ingestion with occult blood in the faeces may be due to ulcers; such cases respond well to grain withdrawal. The advantages and disadvantages of phenothiazine-derived tranquillizers are discussed. They are contra-indicated if there is any evidence of circulating volume insufficiency
Background The polyherbal eye drop (Itone™) is a mixture of aqueous distillates of nineteen traditionally used ingredients that sum up to impart potency to the formulation and make it a useful adjunct in various ocular pathologies. However, as there have been no controlled experimental studies accounting to the above claim, therefore, the present study was designed to evaluate the polyherbal formulation (PHF) for antiangiogenic, anti-inflammatory, anticataract, antioxidant and cytotoxicity in addition to the evaluation of intraocular penetration of PHF in rabbit eyes using LC-MS/MS. Materials and methods Antiangiogenic activity of the PHF was evaluated using in ovo chick chorio-allantoic membrane (CAM) assay and in vivo cautery induced corneal neovascularization assay in rats. Anticataract potential was evaluated using steroid induced cataract in developing chick embryos, sodium selenite induced cataract in rat pups and galactose induced cataract in rats. The antioxidant activity was evaluated using di-phenyl picryl hydrazyl (DPPH) radical scavenging assay. Anti-inflammatory activity was evaluated in vitro using inhibition of LTB4 formation in human WBCs and in vivo using carrageenan induced paw edema assay in rats. The cytotoxicity was evaluated against HeLa cancer cell lines using (3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Furthermore evaluation of the intraocular penetration of the PHF was carried out in rabbit eyes via aqueous humor paracentesis and further analysis using LC-MS/MS. Results PHF significantly inhibited VEGF induced proliferation of new blood vessels in CAM assay and inhibited the cautery induced corneal neovascularization in rats. Additionally, PHF showed noticeable delay in the progression of cataract in the selenite and galactose induced cataract models whereby the PHF treated lenses were graded for stages II and III respectively. However, the PHF did not show any anticataract activity in the hydrocortisone
Schenker, Yael; Wang, Frances; Selig, Sarah Jane; Ng, Rita
BACKGROUND Informed consent is legally and ethically required before invasive non-emergent procedures. Language barriers make obtaining informed consent more complex. OBJECTIVE Determine the impact of language barriers on documentation of informed consent among patients in a teaching hospital with on-site interpreter services. DESIGN Matched retrospective chart review study. SUBJECTS Eligible Chinese- and Spanish-speaking patients with limited English proficiency (LEP) who received a thoracentesis, paracentesis, or lumbar puncture were matched with eligible English-speaking patients by procedure, hospital service, and date of procedure. MEASUREMENTS Charts were reviewed for documentation of informed consent (IC), including a procedure note documenting an IC discussion and a signed consent form. For LEP patients, full documentation of informed consent also included evidence of interpretation, or a consent form in the patient’s primary language. RESULTS Seventy-four procedures in LEP patients were matched with 74 procedures in English speakers. Charts of English-speaking patients were more likely than those of LEP patients to contain full documentation of informed consent (53% vs 28%; odds ratio (OR): 2.81; 95% CI, 1.42–5.56; p = 0.003). Upon multivariate analysis adjusting for patient and service factors, English speakers remained more likely than LEP patients to have full documentation of informed consent (Adj OR: 3.10; 95% CI, 1.49–6.47; p = 0.003). When examining the components of informed consent, charts of English-speaking and LEP patients were similar in the proportion documenting a consent discussion; however, charts of English speakers were more likely to contain a signed consent form in any language (85% vs 70%, p = 0.03). CONCLUSIONS Despite the availability of on-site professional interpreter services, hospitalized patients who do not speak English are less likely to have documentation of informed consent for common invasive procedures
Keen, Alison; Fitzgerald, Debbie; Bryant, Andrew; Dickinson, Heather O
Background Most patients with advanced ovarian cancer and some patients with advanced endometrial cancer need repeated drainage for malignant ascites. Guidelines to advise those involved in the drainage of ascites are usually produced locally and are generally not evidence-based but mainly based on clinicians’ anecdotal evidence and experience. To discover whether there are ways of managing drains that have been demonstrated to improve the efficacy and quality of the procedure is key in making recommendations which could improve the quality of life (QOL) for women at this critical period of their lives. Objectives To evaluate the benefit and harms of different practices in the management of drains for malignant ascites in the care of women with advanced or recurrent gynaecological cancer. The review aimed to evaluate the evidence regarding the following questions; How long should the drain stay in place? Should the volume of fluid drained be replaced intravenously? Should the drain be clamped to regulate the drainage of fluid? Should any particular vital observations be regularly recorded? Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 1, 2009, Cochrane Gynaecological Cancer Group Trials Register, MEDLINE1950 to February Week 3 2009, Embase 1980 to 2009 Week 8 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of review articles and contacted experts in the field. Selection criteria We searched for randomised controlled trials (RCTs), quasi-RCTs and non-randomised studies that compared a range of interventions for management of multiple paracentesis in women with malignant ascites who had a confirmed histological diagnosis of gynaecological cancer. Data collection and analysis Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. No trials were found and therefore no data were analysed. Main results The search
Skeens, Micah A; McArthur, Jennifer; Cheifetz, Ira M; Duncan, Christine; Randolph, Adrienne G; Stanek, Joseph; Lehman, Leslie; Bajwa, Rajinder
Veno-occlusive disease (VOD) is a potentially fatal complication of hematopoietic stem cell transplantation (HSCT). Patients with VOD are often critically ill and require close collaboration between transplant physicians and intensivists. We surveyed members of a consortium of pediatric intensive care unit (PICU) and transplant physicians to assess variability in the self-reported approach to the diagnosis and management of VOD. An internet-based self-administered survey was sent to pediatric HSCT and PICU providers from September 2014 to February 2015. The survey contained questions relating to the diagnosis and treatment of VOD. The response rate was 41% of 382 providers surveyed. We found significant variability in the diagnostic and management approaches to VOD in children. Even though ultrasound is not part of the diagnostic criteria, providers reported using reversal of portal venous flow seen on abdominal ultrasound in addition to Seattle criteria (70%) or Baltimore criteria to make the diagnosis of VOD. Almost 40% of respondents did not diagnose VOD in anicteric patients (bilirubin < 2 mg/dL). Most providers (75%) initiated treatment with defibrotide at the time of diagnosis, but 14%, 7%, and 6% of the providers waited for reversal of portal venous flow, renal dysfunction, or pulmonary dysfunction, respectively, to develop before initiating therapy. Only 50% of the providers restricted fluids to 75% of the daily maintenance, whereas 21% did not restrict fluids at all. Albumin with diuretics was used by 95% of respondents. Platelets counts were maintained at 20,000 to 50,000/mm(3) and 10,000 to 20,000/mm(3) by 64% and 20% of the respondents, respectively. Paracentesis was generally initiated in the setting of oliguria or hypoxia, and nearly 50% of the providers used continuous drainage to gravity, whereas the remainder used an intermittent drainage approach. Nearly 73% of the transplant providers used VOD prophylaxis, whereas the remainder did not use any
Sheng, Qingfeng; Lv, Zhibao; Xu, Weijue; Liu, Jiangbin; Wu, Yibo; Shi, Jingyi; Xi, Zhengjun
Abstract The purpose of this study was to analyze the nature of the disease, the surgical procedures, complications, and survival of preterm infants with necrotizing enterocolitis (NEC) at our institution. Medical records of 34 preterm (gestational age <37 weeks) infants with surgical NEC were retrospectively analyzed from January 2010 to December 2014. Patients were divided into 2 groups: low birth weight (LBW, <2500 g, n = 27) and normal birth weight (NBW, ≥2500 g, n = 7). The LBW and NBW groups differed dramatically in gestational age (31.2 ± 2.2 vs. 36.3 ± 0.5 weeks), and respiratory support (55.5% vs. 0%). The median age of NEC onset was 12 and 5 postnatal days respectively. There was an inverse association between gestational age and day of NEC onset (r = −0.470). Pneumoperitoneum, positive paracentesis, and progressive clinical deterioration were the indications for laparotomy. There was no difference in the extent of disease, in the bowel involvement, in the surgical procedures, and in the postoperative complication rates between the 2 groups. The choice of procedure has often depended upon the extent of disease (enterostomy was performed in most localized and multifocal infants, simple drainage was used in 83.3% pan-intestinal patients, P < 0.001). Postoperative complications occurred in 70.5% patients. The most common complications were sepsis, intestinal stricture, and short bowel syndrome. The median hospital stay was significantly longer in the LBW group (65 vs. 19 days, P = 0.004). The overall postoperative 180-day survival rate was 70.6% (70.4% vs. 71.5%, P = 0.890, log rank test). The severity of illness was the main risk factor for mortality (8.3% in localized, 18.7% in multifocal, and 100% in pan-intestinal, P < 0.001). The short-term outcomes for surgical NEC are grave. The high mortality and postoperative complications in this study mandate urgent improvements in early recognition, expeditious
Wilhelm, Thomas; Stelzer, Tim; Wiegand, Susanne; Güldner, Christian; Teymoortash, Afshin; Günzel, Thomas; Hagen, Rudolf
Viral infections of the upper respiratory airways can lead to a delayed viral otitis media (VOM) caused by a diffusion of viruses/virus particles through the round window membrane and resulting in sensorineural hearing loss. The treatment of choice is immediate paracentesis, evacuation of all fluids from the middle ear cavity, and haemorrheological infusions. However, in some cases, persistent symptoms may be an indication for a surgical approach using mastoidectomy. In high-resolution computed tomography, an extended small-sized pneumatisation of the mastoid cells with complete shading was found in these non-responsive cases. Therefore, a direct means of inner ear affliction through weak parts of the labyrinthine bone may be hypothesised. Patients suffering from a toxic inner ear lesion (TIEL) following a common cold, treated over a 10-year period in a Tertiary Care Centre (N = 52, 57 ears), were identified and the morphological characteristics of the temporal bones of affected patients were examined by means of high-resolution computed tomography (hrCT). The findings were compared with a matched control group of 64 normal ears (CONT). Measurements included the grade of pneumatisation, distances within the temporal bones and Hounsfield units (HU) at defined anatomical structures. In the TIEL group, we found a small-sized pneumatisation in 79.4 % and a medium-sized pneumatisation in 10.9 %, thus differing from the CONT group and the literature data. Thickness of the bone wall of the lateral semicircular canal (LSC) and distances within the aditus ad antrum were significantly reduced in the TIEL group. HU's were markedly lower in the TIEL group at the precochlea, the LSC, and dorsolateral to the promentia of the LSC. There was a correlation between the HU's at the prominentia of the LSC and the hearing loss (p = 0.002). Persisting interosseous globuli, as described in 1897 by Paul Manasse, form an osseochondral network within the otic capsule and may be responsible
Wilhelm, Thomas; Stelzer, Tim; Hagen, Rudolf
Involvement of the middle ear after viral infections of the upper airways may lead to serous otitis media with effusion in the absence of bacterial infection. This can be accompanied by a concomitant shading of the mastoid air cells, which could manifest as a reduced opacity on computed tomography (CT) in the absence of a history of chronic mastoiditis or acute inflammatory signs. This can lead to a subsequent impairment of inner ear function. CT scans reveal an extended pneumatization of the temporal bones in affected patients. Inner ear hearing impairment can probably be attributed to a concomitant labyrinthine reaction-the so-called toxic inner ear lesion. If no remission occurs within 5 days after initial conservative treatment (paracentesis or hemorrheologic infusions), surgical treatment with a mastoidectomy can accelerate hearing restoration. We conducted a retrospective, nonrandomized study of short- and long-term hearing outcomes in patients with a toxic inner ear lesion who had been treated with conservative measures alone (CONS group) or with surgery (SURG group) in a tertiary care referral center. Our study group was made up of 52 consecutively presenting patients (57 ears) who had been seen over a 10-year period; there were 20 patients (21 ears) in the CONS group and 32 patients (36 ears) in the SURG group. Initially, 15 CONS patients (75%) and 18 SURG patients (56%) complained of dizziness or a balance disorder. The initial averaged sensorineural hearing loss (over 0.5, 1.0, 2.0, and 3.0 kHz) was 32.4 ± 15.6 dB in the CONS group and 35.4 ± 12.0 dB in the SURG group. At follow-up (mean: 31.7 mo), the SURG group experienced a significantly greater improvement in hearing (p = 0.025). We conclude that patients with viral otitis media and concomitant noninflammatory mastoiditis with impairment of inner ear function (sensorineural hearing loss) experience a better hearing outcome when a mastoidectomy is performed during primary treatment.
de Silva, S R; Bindra, M S
PurposeAcute submacular haemorrhage secondary to wet age-related macular degeneration (AMD) has a poor prognosis for which there is currently no 'gold standard' treatment. We evaluated the efficacy of early treatment using intravitreal triple therapy of tissue plasminogen activator (tPA), expansile gas, and an anti-VEGF agent.MethodsThis retrospective case series included eight patients presenting with acute submacular haemorrhage involving the fovea. All patients received treatment with 50 μg (0.05 ml) tPA, 0.3 ml 100% perfluoropropane (C3F8), and an anti-VEGF agent (0.05 mg Ranibizumab or 1.25 mg Bevacizumab in 0.05 ml) administered via intravitreal injection. An anterior chamber paracentesis post injection or vitreous tap was performed before injection to prevent retinal vascular occlusion secondary to raised intra-ocular pressure. Outcomes assessed were visual acuity, change in macular morphology, and complications.ResultsPatients presented promptly with delay between symptom onset and clinic review being 1.9±0.6 days (mean±SD). Treatment was delivered quickly with interval from presentation to treatment being 1.1±1.2 days. Symptom onset to treatment was 3.0±1.0 days. Subfoveal haemorrhage was effectively displaced in all patients. LogMAR visual acuity improved from 1.67±0.47 at presentation to 0.63±0.33 at final follow-up (P<0.0001), a mean of 7.9±4.8 months after treatment. Central retinal thickness improved from 658.1±174.2 μm at presentation to 316.6±142.4 μm at final follow-up (P=0.0028).ConclusionsEarly treatment of submacular haemorrhage using intravitreal tPA, C3F8, and anti-VEGF was effective in significantly improving visual acuity in this series of patients who presented soon after symptom onset. Treatment was well tolerated in this group of elderly and potentially frail patients.
El-Shabrawi, Mortada H F; Kamal, Naglaa M
Treatment of the causes of many chronic liver diseases (CLDs) may not be possible. In this case, complications must be anticipated, prevented or at least controlled by the best available therapeutic modalities. There are three main goals for the management of portal hypertension: (i) prevention of the first episode of variceal bleeding largely by non-selective β-adrenoceptor antagonists, which is not generally recommended in children; (ii) control of bleeding by using a stepwise approach from the least to most invasive strategies; (iii) and prevention of re-bleeding using bypass operations, with particular enthusiasm for the use of meso-Rex bypass in the pediatric population. Hepatic encephalopathy management also consists of three main aspects: (i) ruling out other causes of encephalopathy; (ii) identifying and treating precipitating factors; and (iii) starting empiric treatment with drugs such as lactulose, rifaximin, sodium benzoate, and flumazenil. Treatment of mild ascites and peripheral edema should begin with the restriction of sodium and water, followed by careful diuresis, then large-volume paracentesis associated with colloid volume expansion in severe cases. Empiric broad spectrum antimicrobial therapy should be used for the treatment of spontaneous bacterial peritonitis, bacterial and fungal sepsis, and cholangitis, after taking appropriate cultures, with appropriate changes in therapy after sensitivity testing. Empirical therapies continue to be the standard practice for pruritus; these consist of bile acid binding agents, phenobarbital (phenobarbitone), ursodeoxycholic acid, antihistamines, rifampin (rifampicin), and carbamazepine. Partial external biliary diversion can be used in refractory cases. Once hepatorenal syndrome is suspected, treatment should be initiated early in order to prevent the progression of renal failure; approaches consist of general supportive measures, management of concomitant complications, screening for sepsis, treatment
Spremo, S; Markić, Z; Kurbalija
shown in Table 3. Exudate in the middle ear and type B tympanogram were found in 86 ears, while in other patients dysfunction of the Eustachian tube and type C1 and C2 tympanograms were found. After 6 weeks the exudate disappeared in 16 ears and tympanogram converted in type A and type C2, while the initially found C1 tympanogram was transformed in type A in 5 of 13 ears. After 12 weeks the tympanogram type B was found in 46 ears, while in 40 ears (47%) the tympanogram was changed in type A and type C2. After 6 and 12 weeks of therapy tympanometric types were statistically examined by chi 2 test. We have found a significant difference in tympanometric types and prevalence of type A and C1 tympanograms. Paracentesis and insertion of ventilating tubes were done in 46 ears with the remaining exudate. We have found mucous exudate in 35 (76%) ears associated with retraction and scars of tympanic membrane (Table 4), what indicated that the longer duration of mucous exudate caused degenerative changes in the middle ear. Serous exudate, found in 9 ears (24%), did not affect the color and integrity of the tympanic membrane. Sensitivity of tympanometry in detection of exudate in the middle ear was 96%. Secretory otitis media is a frequent disease in childhood, that could cause functional and morphological sequelae in the middle ear. As for now, there is no unique concept of diagnosis and treatment of the disease, and it is still a current problem. We suggest a three-month evaluation of tympanometric and audiometric patterns, repeated every three weeks, in children suspected of having exudate in the middle ear. There is a large trend of spontaneous disappearance of exudate in the middle ear and changing of tympanogram type. Such children should be evaluated over the period of one year, and if there is no relapse additional treatment should not be carried out. If exudate in the middle ear persists for three months and type of the tympanogram is unchanged, myringotomy and insert