Type B Aortic Dissection Complicated by Intimo-Intimal Intussusception and Extensive Intimal Denuding: Case Report with Long-term Follow-up

BACKGROUND

Acute aortic dissection rarely results in circumferential dissections of the aortic intima that may lead to intimo-intimal intussusception (IIS) with complete separation from the aortic wall. Circumferential dissection may then result in distal embolization of the involved intima and media, adding considerable complexity to the management of such cases. Despite the severity of this complication, the natural history of aortic disease following extensive intimal denuding and IIS is not well documented in the literature. Here we present a case with long-term follow-up of type B aortic dissection (TBAD) complicated by IIS and embolization of the intima into the distal aorta following thoracic endovascular aortic repair.

METHODS

Medical records and imaging studies were retrospectively reviewed with the approval of the Institutional Review Board. A single patient underwent repair of a TBAD that was complicated by IIS, with follow-up for 6 years. Aortic recovery was monitored with serial computerized tomography scans.

RESULTS

During endovascular stent deployment, the patient's dissection progressed circumferentially, leading to distal embolization of the intima and aortic occlusion. An open transabdominal aortic exploration was performed to extract the embolized intima. Despite this severe aortic structural disruption, the patient recovered well postoperatively and exhibited favorable aortic remodeling over long-term follow-up. The denuded aorta did not rupture or develop progressive worsening aneurysmal dilation and the diameter of the involved aortic segment remained stable during follow-up.

CONCLUSIONS

Acute TBADs can progress to circumferential intimal separation and IIS when managed with endovascular stenting and balloon dilation. Continued endovascular management once IIS has occurred may lead to further intimal damage, resulting in distal embolization of the intima and aortic occlusion. Thus, IIS may require conversion to open repair. However, in the event that loss of the aortic intima does occur following IIS, it is possible for the denuded aorta to recover well and remain stable with favorable remodeling over long-term follow-up.

Zeolite-loaded alginate-chitosan hydrogel beads as a topical hemostat

Hemorrhage is the leading cause of preventable death after a traumatic injury, and the largest contributor to loss of productive years of life. Hemostatic agents accelerate hemostasis and help control hemorrhage by concentrating coagulation factors, acting as procoagulants and/or interacting with erythrocytes and platelets. Hydrogel composites offer a platform for targeting both mechanical and biological hemostatic mechanisms. The goal of this work was to develop hydrogel particles composed of chitosan, alginate, and zeolite, and to assess their potential to promote blood coagulation via multiple mechanisms: erythrocyte adhesion, factor concentration, and the ability to serve as a mechanical barrier to blood loss. Several particle compositions were synthesized and characterized. Hydrogel bead composition was optimized to achieve the highest swelling capacity, greatest erythrocyte adhesion, and minimal in vitro cytotoxicity. These results suggest a polymer hydrogel-aluminosilicate composite material may serve as a platform for an effective hemostatic agent that incorporates multiple mechanisms of action. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1662-1671, 2018.

Immune reconstitution inflammatory syndrome

Antiretroviral therapy (ART) inhibits HIV replication, allowing recovery of CD4+ T cell numbers and the restoration of immune function; its introduction has led to improved outcomes for individuals with HIV infection. However, it has been observed that some individuals responding to ART experience a clinical deterioration with symptoms and signs of an inflammatory illness. Immune reconstitution inflammatory syndrome (IRIS) results from pathological immune responses occurring during immune reconstitution. IRIS is best considered a group of disorders with a wide range of clinical manifestations, incorporating disease resulting from pathological inflammation to pathogens, immune-mediated inflammatory disease and autoimmune disease. Clinical effects range from a mild, self-limiting illness to severe morbidity and mortality. Clinicians working in the field of HIV medicine can expect to encounter individuals with IRIS. In this review, we discuss definitions, describe clinical presentations, summarize research relating to pathogenesis and identify risk factors, preventive and management strategies.

Development, impact and outcomes of the Hull Bacteraemia Service

BACKGROUND

Bacteraemia is a significant cause of mortality and healthcare expenditure. Evidence suggests that consultation by an infection specialist may improve outcomes.

AIM

To review the characteristics and outcomes of patients seen by a newly implemented bacteraemia service.

METHODS

Retrospective review of data collected at time of consultation. Economic analyses and benchmarking of outcomes were also performed.

RESULTS

One hundred and fifty-one patients were seen by the service over an 18-month period. Staphylococcus aureus was the most common isolate and central venous lines the most common source. Antibiotics were changed and additional investigations suggested in 62% and 61% of patients, respectively. The 30-day mortality was 19%. Implementation and delivery of the service over the 18-month study period cost pound 22,663 (pound 15,109 per year). The cost per change in antibiotic prescription was pound 244. The cost per 'near-miss' detected was pound 1193. Overall mortality was no higher and possibly lower than in published studies.

CONCLUSION

We believe that this model of care may be suitable for the management of patients with bacteraemia. A study assessing the cost-effectiveness of this approach is required.

Leptospirosis: a case report of a patient with pulmonary haemorrhage successfully managed with extra corporeal membrane oxygenation

Leptospirosis is a zoonosis of worldwide significance. Pulmonary involvement is common but often mild and of little clinical significance. However, over the last two decades an increasing number of cases have been reported with pulmonary haemorrhage as a prominent feature [Carvalho CR, Bethlem EP. Pulmonary complications of leptospirosis. Clin Chest Med, 2002;23(2):469-78]. These cases are particularly challenging to treat as they often have resistant hypoxaemia despite maximal invasive mechanical ventilation. Consequently, there is a high mortality rate. Here, we present a case of severe leptospirosis complicated by massive pulmonary haemorrhage which was successfully managed by extra corporeal membrane oxygenation (ECMO).

The product of the imprinted gene IPL marks human villous cytotrophoblast and is lost in complete hydatidiform mole

The IPL/TSSC3 gene is expressed nearly exclusively from the maternal allele, and its protein product acts to limit placental growth in mice. This protein specifically marks Type II trophoblast in the labyrinthine layer of the mouse placenta. To investigate mouse-human homologies, we carried out immunohistochemistry with antibodies against human IPL. There was strong expression of IPL in villous cytotrophoblast of the human placenta, contrasting with complete lack of expression in syncytiotrophoblast. Staining for IPL was weak in cells of the villous mesenchyme and extravillous trophoblast, including the cytotrophoblast columns in the basal plate and the intervillous trophoblast islands. The IPL and p57(KIP2)/CDKN1C genes are closely linked and coordinately imprinted, and immunostaining showed that their protein products are co-expressed in villous cytotrophoblast. However, other cell types, including extravillous cytotrophoblast and cells in various non-placental tissues, expressed p57(KIP2), but not IPL. IPL protein was absent in both of two cases of androgenetic complete hydatidiform mole examined by immunostaining, and IPL mRNA was absent in an additional three cases of this neoplasm examined by northern blotting. In the mouse, Ipl-expressing cells disappear at mid- to late-gestation when placental growth ceases, but persistent IPL mRNA and protein expression was observed throughout human gestation, correlating with the continuous growth of the human placenta. These findings highlight dosage regulation of human IPL by imprinting and, more generally, suggest homology between Type II labyrinthine trophoblast in the mouse and villous cytotrophoblast in humans, both of which are proliferative stem cell-like compartments.

Pneumocystis carinii pneumonia after thoracic duct ligation and leakage

A case of Pneumocystis carinii pneumonia was induced through immunosuppression following thoracic duct ligation. The patient initially presented with an esophageal adenocarcinoma, which was totally resected. She is human immunodeficiency virus-negative and not undergoing immunosuppressive treatment.

Primary tuberculosis of the posterior oropharyngeal wall

We report a case of primary tuberculosis of the posterior oropharyngeal wall presenting with sore throat, fever and malaise. Pharyngeal tuberculosis is rare and usually occurs with primary pulmonary disease. Primary disease has been reported in small numbers in the nasopharynx and palatine tonsil but never before, to our knowledge, in the posterior oropharyngeal wall.