[Pneumomediastinum and vomiting: Which approach to diagnosis? A case report]

BACKGROUND

Spontaneous pneumomediastinum (SPM) is a rare and often unrecognized condition of which vomiting is one of the reported triggering factors. Differentiating SPM from Boerhaave's syndrome (pneumomediastinum secondary to esophageal breach) is the first step in management and prognosis.

OBSERVATION

A 27-year-old woman with systemic lupus erythematous presented to the emergency department with epigastralgia, incoercible vomiting and diarrhoea. Abdominal CT showed circumferential thickening of the duodenum and bilateral ureteritis. Chest sections showed pneumomediastinum extending to the cervical region. Therapeutic management was based on prophylactic antibiotic therapy and an absolute diet (fasting). A CT scan with upper gastrointestinal opacification was performed to prevent esophageal rupture and showed quasi-obstructive thickening of the antral mucosa. The diagnosis was lupus enteritis and pneumomediastinum was secondary to the vomiting efforts. The patient was placed on corticosteroids and a favorable outcome ensued.

CONCLUSION

Strenuous vomiting is one of the precipitating factors of SPM. Boerhaave's syndrome is the main differential diagnosis with a poor prognosis, unlike SPM, which has a good prognosis with conservative treatment.

Novel benchmark values for redo liver transplantation – does the outcome justify the effort?

Objective

In the era of organ shortage, redo liver transplantation (reLT) is frequently discussed in terms of expected poor outcome, high cost and therefore wasteful resources. However, there is a lack of benchmark data to reliably assess outcomes after reLT. The aim of this study was to define the ideal reLT case, and to establish clinically relevant benchmark values for best achievable outcome in reLT.

Methods

We collected data on reLT between January 2010 and December 2018 from 22 high volume transplant centers on three continents. Benchmark cases were defined as recipients with model of end-stage liver disease score <=25, absence of portal vein thrombosis, no mechanical ventilation before surgery, receiving a graft from a donor after brain death. In addition, early reLT including those for primary non-function (PNF) were excluded. Clinically relevant endpoints covering intra- and postoperative course were selected and complications were graded by severity using the Clavien-Dindo classification and the comprehensive complication index (CCI). The benchmark cutoff for each outcome was derived from the 75th percentile of the median values of all benchmark centers, indicating the “best achievable” result. To assess the utility of the newly established benchmark values, we analyzed patients who received reLT for PNF (non-benchmark patients).

Results

Out of 1110 reLT 413 (37.2%) qualified as benchmark cases. Benchmark values included: Length of intensive care unit and hospital stay: <=6 and <=24 days, respectively; Clavien-Dindo grade >=3a complications and the CCI at 1 year: <=76% and <=72.2, respectively; in-hospital and 1-year mortality rates: <=14.0% and <=14.3%, respectively. The cutoffs for transplant-specific complications such as biliary complications at 1 year, outflow problems at 1 year and hepatic artery thrombosis at discharge were <=27.3%, <=2.5% and <=4.8%, respectively. Patients receiving a reLT for PNF showed mean outcome values all outside the reLT benchmark values. In-hospital mortality rate was 34.4% and the mean CCI at discharge 68.8.

Conclusion

ReLT remains associated with high morbidity and mortality. The availability of benchmark values for outcome parameters of reLT may serve for comparison in any future analyses of individuals, patient groups, or centers, but also in the evaluation of new therapeutic strategies and principles.

P14.36 Characterising Meningiomas in young patients under 40

BACKGROUND

Meningiomas are the most common primary CNS tumor in adults, with a median age at diagnosis of 65 years and a female to male ratio of 2–3:1 (except in grade II, III meningiomas). Younger patients usually have a genetic background or history of prior radiation exposure. Based on population-level studies, approximately 80–85% of meningiomas are WHO grade I (benign), 15–18% grade II (atypical), and 1–3% grade III (anaplastic). This case series describes a single center experience of the presentation and pathology of meningiomas in patients under the age of 40.

MATERIALS AND METHODS

We reviewed the Sheba Medical Center Neurosurgery and radiotherapy databases containing patients who were operated on for meningioma between the years 2011–2020. Patients under 40 were selected and information from digital medical records was gathered on these patients, including pathology reports, surgical reports, clinical and radiological data, and the use of radiotherapy or medical treatments.

RESULTS

Of 600 patients in the database, 49 patients under 40 (8.3%) were identified and 54 tumors were reviewed (five patients were operated on for multiple meningiomas). 31 patients were female (63%); 2 were under 20 years old, 15 were age 20–29 and 32 were age 30–39 at first presentation. Seven patients had received prior radiation therapy for a childhood malignancy. 28 meningiomas were histology confirmed grade I (52%), 22 were grade II (41%), 2 were grade III (4%), and 2 (4%) were grade undetermined. 22 tumors were located in the skull base (41%) and 32 (59%) in the brain convexity. Of the skull base tumors, 16 were grade I, 5 were grade II, and one was grade III. Of the convexity tumors, 12 were grade I, 16 were grade II, and 2 were grade III. Median follow-up was 35 months, and longest follow-up time was 98 months. Six patients were treated with additional radiotherapy after surgery.

CONCLUSION

Our experience with meningioma patients under 40 revealed a different grade segregation than the older population, with younger patients showing a higher incidence of grade II tumors. These tumors are generally more aggressive, and require careful resection and consideration for post-surgical radiotherapy. Further validation with population based databases is required.

From Four-Way Linking to a One Health Platform in Egypt: institutionalisation of a multidisciplinary and multisectoral One Health system

The convergence of humans, animals and our shared environment results in a dynamic in which the health of each group is inextricably linked. Taking into account the fact that the majority of emerging pathogens (e.g. highly pathogenic avian influenza [HPAI], severe acute respiratory syndrome coronavirus, Nipah virus, Middle East respiratory syndrome coronavirus) are zoonotic diseases, Egypt has established a national One Health coordination mechanism. The primary purpose of this mechanism is to provide a comprehensive, strategic approach to concurrent and future health challenges that are facing public and animal heath, including environmental impacts. In this way, the public health, animal health and environment sectors can improve disease mitigation measures, develop stronger and more stable public and animal health services, promote effective national communication strategies and improve One Health collaboration among all relevant sectors. In Egypt, the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) currently assist in hosting the country's Four-Way Linking Task Force with the participation of the convening Ministries (Ministry of Health and Population, Ministry of Environment, and Ministry of Agriculture and Land Reclamation [MOALR] - through the General Organisation for Veterinary Services and the MOALR's laboratories). In the context of the Emerging Pandemic Threats 2 Program, funded by the United States Agency for International Development (USAID), FAO plans to assist Egypt in establishing a robust, multidisciplinary and multisectoral One Health system. This system is based on the solid foundation of the Four-Way Linking Platform, which combines information from four functional streams - epidemiology, laboratories, and animal and human health. Egypt's platform will involve all sectors concerned with HPAI control and combine all stakeholders in an integrated, holistic approach to improve the detection of, response to and control of any threats at the human- animal-environment interface in Egypt.

[White hemithorax in a young women carrying coffee and milk spots]

INTRODUCTION

Neurofibromatosis type 1 (NF1) or Von Recklinghausen disease is an autosomal dominant genetic disorder with multivisceral manifestations. We report the case of a spontaneous haemothorax in a young lady wearing this genetic pathology.

CASE REPORT

A 31-year-old woman with kyphoscoliosis developed acute chest pain and dyspnea. The physical examination revealed a right pleuritic syndrome, coffee and milk spots and neurofibromas of the trunk. Biological assessment showed anemia at 6.4g/dl. Chest x-ray revealed a right side opacification. The pleural puncture showed an incoagulable hemorrhagic fluid. The chest CT scan showed no vascular abnormalities. The diagnosis of spontaneous haemothorax, revealing NF1, was retained. Transfusion and thoracic drainage were performed followed by haemostasis surgery. Pleural exploration showed pleural hematoma with regard to the 5th intercostal space. Electrocoagulation and declogging were performed. The evolution of the patient was favorable.

CONCLUSION

Haemothorax is a rare and serious complication which may reveal NF1. It must be suspected when sudden and spontaneous white haemithorax occurs in NF1.

Activation of migration of endogenous stem cells by erythropoietin as potential rescue for neurodegenerative diseases

Neurodegenerative disorders such as Alzheimer's disease (AD) are characterized by progressive cognitive dysfunction and memory loss. There is deposition of amyloid plaques in the brain and subsequent neuronal loss. Neuroinflammation plays a key role in the pathogenesis of AD. There is still no effective curative therapy for these patients. One promising strategy involves the stimulation of endogenous stem cells. This study investigated the therapeutic effect of erythropoietin (EPO) in neurogenesis, and proved its manipulation of the endogenous mesenchymal stem cells in model of lipopolysaccharide (LPS)-induced neuroinflammation.

METHODS

Forty five adult male mice were divided equally into 3 groups: Group I (control), group II (LPS untreated group): mice were injected with single dose of lipopolysaccharide (LPS) 0.8 mg/kg intraperitoneally (ip) to induce neuroinflammation, group III (EPO treated group): in addition to (LPS) mice were further injected with EPO in dose of 40 μg/kg of body weight three times weekly for 5 consecutive weeks. Groups were tested for their locomotor activity and memory using open field test and Y-maze. Cerebral specimens were subjected to histological and morphometric studies. Glial fibrillary acidic protein (GFAP) and mesenchymal stem cell marker CD44 were assessed using immunostaining. Gene expression of brain derived neurotrophic factor (BDNF) was examined in brain tissue.

RESULTS

LPS decreased locomotor activity and percentage of correct choices in Y-maze test. Cerebral sections of LPS treated mice showed increased percentage area of dark nuclei and amyloid plaques. Multiple GFAP positive astrocytes were detected in affected cerebral sections. In addition, decrease BDNF gene expression was noted. On the other hand, EPO treated group, showed improvement in locomotor and cognitive function. Examination of the cerebral sections showed multiple neurons exhibiting less dark nuclei and less amyloid plaques in comparison to the untreated group. GFAP positive astrocytes were also reduced. Cerebral sections of the EPO treated group showed multiple branched and spindle CD44 positive cells inside and around blood vessels more than in LPS group. This immunostaining was negative in the control group. EPO administration increased BDNF gene expression.

CONCLUSION

This study proved that EPO provides excellent neuroprotective and neurotrophic effects in vivo model of LPS induced neuroinflammation. It enhances brain tissue regeneration via stimulation of endogenous mesenchymal stem cells proliferation and their migration to the site of inflammation. EPO also up regulates cerebral BDNF expression and production, which might contributes to EPO mediated neurogenesis. It also attenuates reactive gliosis thus reduces neuroinflammation. These encouraging results obtained with the use of EPO proved that it may be a promising candidate for future clinical application and treatment of neurodegenerative diseases.

[The role of imaging in thoracic tuberculosis]

Tuberculosis is an infectious disease mostly due to Mycobacterium tuberculosis. It is frequent in developing countries and its incidence is rising in developed countries. Lungs are the most involved organs of the chest but other structures can be affected. Imaging is fundamental in the management of the disease. Confirmation of diagnosis can be made only by bacteriologic and/or histologic exams. The first approach of diagnosis is based on clinical symptoms and chest X-ray signs. Radiologic signs depend on patient's age, his immune status and his previous contact with M. tuberculosis. Conventional chest X-ray remains the first-line exam to realize. It can suggest the diagnosis on the appearance and location of the lesions. CT scan is recommended for the positive diagnosis in case of discrepancy between clinical and radiographic signs, as for the diagnosis of parenchymal, vascular, lymph nodes, pleural, parietal or mediastinal complications. It is also essential for the evaluation of parenchyma sequelae. MRI and PET-scan have limited indications. The purpose of this article is to illustrate different radiological forms of chest tuberculosis, its sequelae and complications and to highlight the role of each imaging technique in the patient's management.

The hematopoietic growth factor "erythropoietin" enhances the therapeutic effect of mesenchymal stem cells in Alzheimer's disease

Alzheimer's disease is a neurodegenerative disorder clinically characterized by cognitive dysfunction and by deposition of amyloid plaques, neurofibrillary tangles in the brain. The study investigated the therapeutic effect of combined mesenchymal stem cells and erythropoietin on Alzheimer's disease. Five groups of mice were used: control group, Alzheimer's disease was induced in four groups by a single intraperitoneal injection of 0.8 mg kg(-1) lipopolysaccharide and divided as follows: Alzheimer's disease group, mesenchymal stem cells treated group by injecting mesenchymal stem cells into the tail vein (2 x 10(6) cells), erythropoietin treated group (40 microg kg(-1) b.wt.) injected intraperitoneally 3 times/week for 5 weeks and mesenchymal stem cells and erythropoietin treated group. Locomotor activity and memory were tested using open field and Y-maze. Histological, histochemical, immunohistochemical studies, morphometric measurements were examined in brain sections of all groups. Choline transferase activity, brain derived neurotrophic factor expression and mitochondrial swellings were assessed in cerebral specimens. Lipopolysaccharide decreased locomotor activity, memory, choline transferase activity and brain derived neurotrophic factor. It increased mitochondrial swelling, apoptotic index and amyloid deposition. Combined mesenchymal stem cells and erythropoietin markedly improved all these parameters. This study proved the effective role of mesenchymal stem cells in relieving Alzheimer's disease symptoms and manifestations; it highlighted the important role of erythropoietin in the treatment of Alzheimer's disease.

Prograf five milligrams versus Tacrolimus medis in healthy volunteers: a bioequivalence study

For FDA approval, bioequivalence of a generic version of Tacrolimus must be demonstrated in a randomized, two-treatments, two-periods, two-sequences, single-dose crossover study in healthy adult volunteers. Currently there are at least 3 differents generic equivalent for Tacrolimus, that are approved by the EMA and the FDA, with a USA market share of nearly 50%. However, the market share of generic immunosuppressive drugs in the Middle East region is still very low due to the reluctance of the physician to accept Tacrolimus generics, considered to be a narrow therapeutic window drug, that are approved using the standard bioequivalence criteria of 80% to 125%. Herein we present a bioequivalence study of a new Tacrolimus generic, Tacrolimus Medis 5 mg developed by Medis Tunisia batch number 12G3003 compared with Prograf® 5 mg batch number 7202 manufactured by Astellas Toyama Co., Ltd. Japan and HIKMA Pharmaceuticals, Amman-Jordan in healthy adult volunteers using the 90%-111% criteria recommended for drugs with narrow therapeutic window. The study was, balanced, randomized, two-treatments, two-periods, two-sequences, single dose, crossover, comparative oral bioavailability study in healthy adult human volunteers. The study was carried out in accordance with the Basic Principles defined in the U.S. 21 CFR Part 312.20, the principles enunciated in the Declaration of Helsinki (World Medical Association Declaration of Helsinki). Thirty six non-smoking healthy, as determined by medical history, volunteers, 18 years and older, were included. Following randomization using a computer software (pharma solution) the volunteers were given a single oral dose of 5 milligrams following a 12 hour fast with a wash out period of 7 days. Pharmacokinetics profile with blood levels at: 0, 0.5, 1, 1.5, 2, 2.5, 3, 4, 6, 8, 10, 12, and 24 hours were performed following each dose. Tacrolimus plasma level was determined using an HPLC validated method (Transmedical For Life S.A.R.L. Beirut Lebanon), for accuracy, suitability, reproducibility, precision , long-term stability and robustness. Physical examinations, hematology, urine analysis and serum chemistry tests were performed at screening and before dosing in each period and at end of the study. Volunteers were monitored for safety and adverse events throughout the study. Both products were bioequivalent at the entire pharmacokinetic parameters tested. The LSM were 95.31%-101.21% for AUC, 94.65%-101.11% for AUC0-inf, 97.15%-100.02% for Cmax and 91.54%-103.75% for Half-life. Respectively all of which are within the EU and FDA approval limits (90-111%) indicating that the 2 products are equivalent and switchable.

Treatment of hepatitis C virus infection in patients on maintenance hemodialysis: a single United Arab Emirates center experience

BACKGROUND

Hepatitis C is prevalent among hemodialysis patients. In patients with normal kidney function, treatment with pegylated interferon and ribavirin can lead to eradication of HCV (hepatitis C virus). But the treatment is more problematic in patients with impaired kidney function, in part due to the altered pharmacokinetics of these medications. Despite recent guidelines, the optimal strategy in this group of patients is not well defined.

METHOD

In a retrospective study, we reviewed all patients with chronic hepatitis C on hemodialysis treated at Sheikh Khalifa Medical City, in the United Arab Emirates between 2003 and 2009. The aim of our study was to determine the rate of sustained viral response (SVR) and to establish the safety and rate of dropouts in the different treatment regimens used (patients treated with peginterferon only and patients treated with peginterferon and low dose ribavirin).

RESULTS

22 patients were treated during this period. 5 patients received monotherapy with a reduced dose of peginterferon alfa 2b s.c. once weekly while 17 patients were treated with a combination of reduced dose of peginterferon alfa 2a or 2b s.c. once weekly and a low dose ribavirin (200mg/day). A SVR was achieved in 73% (16/22 patients) of the total patient population and in 76% (13/17 patients) in the sub-group of patients treated with a combination therapy. The tolerability was high. No patients had to discontinue their treatment. The use of ESA (erythropoietin stimulating agents) and G-CSF was common in the combination therapy (94% and 53% respectively).

CONCLUSION

In our study of patients on hemodialysis with chronic hepatitis C, the use of peginterferon or a combination of peginterferon with a low daily dose of ribavirin achieved a high rate of SVR and the rate of dropout was low after pursuing an aggressive management of side effects.

Impact of cold ischemia on renal transplant outcomes following donation after cardiac death

Donation after cardiac death (DCD) provides grafts in renal transplantation but is associated with increased early graft dysfunction. Cold ischemia time (CIT) is a factor that is thought to affect outcomes in renal transplantation. We sought to assess the impact of the length of CIT among our DCD cohort of renal transplants performed between April 2002 and December 2009. Since the median CIT was 15.5 hours, we formed two groups CIT < 15.5 (n = 100) and CIT > 15.5 hr (n = 98). We demonstrated an increased incidence of DGF among the extended CIT group, but the long outcomes and the mean graft function were otherwise comparable. In conclusion, CIT affects early graft function; every effort should be made to minimize it in renal transplantation using DCD kidneys.

Sequential transplant of paired kidneys following donation after cardiac death: impact of longer cold ischemia time on the second kidney on graft and patient outcome

The United Kingdom has no national sharing scheme for kidneys received from donation after cardiac death (DCD). Therefore, both kidneys retrieved by a transplant team are implanted at a single unit, often sequentially. This study analyzes the impact of a prolonged cold ischaemia time on the second transplanted kidney and the effects on short-term and long-term outcomes in all our DCD renal implants from 2002 to 2009. Cold ischaemia time was significantly longer with the second kidney (P = .04) as was delayed graft function (P = .02). Acute rejection was increased in the first transplanted kidney (P < .001). Five-year patient survival was comparable between groups, but 5-year graft survival was higher in the second transplanted group (P = .04). The results confirm that, provided recipient centers are willing to accept higher initial rates of delayed graft function, it is acceptable to transplant DCD grafts sequentially without jeopardizing long-term graft or recipient outcome.

Predicting donor asystole following withdrawal of treatment in donation after cardiac death

Donation after cardiac death donation allows donor pool expansion. The period between withdrawal of treatment and donor a systole is extremely variable; its prolongation often results in unsuccessful organ procurement. We sought to assess a variety of donor variables to determine whether they predicted successful organ retrieval. We included all Donation after Cardiac Death (DCD) retrievals between 2002 and 2009, which were grouped as successful (n = 104) versus unsuccessful (n = 42). Factors that predicted unsuccessful organ procurement included older donor age, donor history of hypertension, higher at withdrawal, and absence of inotropic support. On multivariate analysis, mean arterial pressure retained its significance. Prediction of withdrawal-to-asystole time is complex, but our analysis suggested that donor blood pressure at withdrawal is an important predictor of whether retrieval would be successful.

Renal transplantation following donation after cardiac death: impact of duration from withdrawal to asystole

Donation after cardiac death (DCD) allows for expansion of the donor pool, however, the process for DCD donation can lead to a donor's physiological instability before asystole. This may have a detrimental effect on graft and patient outcomes. We analyzed all 201 DCD donations at our unit from 2002 to 2009 and compared short versus long durations to asystole around the median time (20 min). Delayed graft function was comparable between the groups (P = .13), primary nonfunction was increased in the long duration to asystole group (P < .0001), and acute rejection was increased in the short duration group (P < .001). Five year patient survival was comparable (P = .6). In conclusion, long duration asystole may have an immediate effect on graft survival, but it has no overall detrimental effect on longer-term outcomes. Further studies are required to investigate the acceptable time to wait from withdrawal to asystole.

The impact of postoperative infection on long-term outcomes in liver transplantation

INTRODUCTION

Postoperative infection (POI) prolongs inpatient stay, delays return to normal activity, and may be detrimental to long-term survival after cancer resections. This study sought to identify the impact of postoperative infection on liver transplantation outcomes.

METHODS

We analyzed our prospective database of 910 adult patients who underwent liver transplantation between 2000 and 2010 in a single UK center. POI was defined as pyrexia plus positive cultures from blood, sputum, urine, wound, or ascitic fluid. Patient demographic features and perioperative variables were analyzed for their effects on POI. The impacts of POI on overall survival (OS) and graft survival were analyzed using Kaplan-Meier curves with log-rank tests for significance, before entry into a multivariate regression analysis. We analyzed the effects of POI on the length of hospital stay (LOS) and the incidence of acute rejection episodes and readmissions within 1 year as secondary outcomes.

RESULTS

Patients who developed a postoperative chest or wound infection showed poorer OS at a mean of 7.0 versus 8.8 years (P = .009) and 7.0 versus 8.8 years (P = .003), respectively. Infection in blood, ascitic fluid, or urine showed no significant impact on survival. LOS was significantly increased among patients with a wound (median 21 vs 17 days, P = .011), a sputum (median 24 vs 17 days, P < .001), or a blood infection (median 32 vs 17 days, P < .001). Higher rates of intraoperative blood transfusion were observed among subjects who developed a chest or a wound infection. There was no difference in other variables between those who did versus did not develop an infection. Upon multivariate analysis, wound infection was the strongest independent predictor of OS (P = .007).

CONCLUSION

We demonstrated that wound or chest infections were associated with poorer OS. More aggressive prophylactic and/or therapeutic interventions targeting specific sites of infection may represent a simple and cost-effective measure to reduce hospital stay and improve OS.

Do cranial subdural hematomas migrate to the lumbar spine?

We report a patient with minor head trauma-related bilateral hemispheric subdural hematoma (SDH) and subsequent delayed spinal SDH or presumed migration to the lumbar spine. An acutely confused 88-year-old man presented to the Emergency Department after minor head trauma. Head CT scan revealed a small hemispheric SDH. The patient was admitted for observation. CT scan 6 hours later showed bilateral SDH with extension to the tentorium. Three days later SDH had resolved leaving bilateral subdural hygromas. Local leg weakness localized to the lumbar spine developed on day 6; spinal CT scan and MRI revealed a posterior L5-S1 collection. A pure subacute subdural hematoma compressing the cauda equina was drained after an L5 laminectomy. His lower leg weakness improved. The patient was discharged to rehabilitation two weeks after surgery. Patients with traumatic SDH who develop late-onset neurological deterioration attributable to any region of the spine should be evaluated for spinal SDH.