Sevoflurane induced diffuse alveolar haemorrhage in a young patient after orthopedic surgery: A case report

We present a very rare case of Sevoflurane Induced Diffuse Alveolar Haemorrhage in a young male patient with a closed tibial fracture after direct trauma to the right cruris. The patient was operated for tibial fracture, but diffuse alveolar haemorrhage developed after sevoflurane inhalation in the postoperative period following general anesthesia. Diffuse alveolar haemorrhage (DAH) is associated with inhalation injury from halogenated gases and reported as a unique entity in the literature that practicing clinicians should be aware of and consider in post-operative cases of acute respiratory distress. As DAH usually presents with symptoms the presence of hemoptysis, anemia, dyspnoea and radiological alveolar infiltrates, rapid detection of the aetiology and initiation of cause-directed treatment are of great importance on survival.

Abstract P6-16-01: The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01

Background: The MF07-01 trial is a multicenter phase III randomized controlled trial of treatment naive stage IV BC patients comparing loco-regional surgery (LRS) followed by appropriate systemic therapy (ST) versus ST alone.

Aims: To evaluate the importance of loco-regional tumor burden and surgery on overall survival rate in patients with de novo stage IV breast cancer.

Methods: At initial diagnosis patients were randomized 1:1 to LRS group or ST group. The surgery was a lumpectomy (L) or mastectomy (M) and sentinel lymph node biopsy (SLNB) ± axillary lymph node dissection (ALND). After surgery all patients received systemic treatment + endocrine treatment (ET) and Trastuzumab based on pathology results. The demographic, pathologic, and clinical characteristics of the patients were recorded.

Results:274 patients were accrued; 138 in the LRS group and 136 in the ST group. The groups were comparable regarding age, BMI, HER2 neu, tumor type and size, histologic grade, and bone and visceral metastasis (all p>0.05). In the LRS group 36 patients (26%) had L+ALND, 92 patients (67%) had M+ALND and 10 patients (7%) had M+SLNB, respectively.

The patients and tumor characteristicsPatients and Tumors Characteristics and Surgical TreatmentSurgerySystemic TherapyP ValueAge (mean /year±SD)51.8 ±12.651.5±13.6NSMedian follow-up (25%,75%)41.0 (24,54)37 (18,49) Tumor Size (%)   T18.7 (12) NST252.2 (72) NST321.7 (30) NST417.4 (24) NSHistologic Grade (%)   I4.4 (6)9.6 (10)NSII39.9 (55)31.7 (33)NSIII55.8 (77)58.9 (61)NS    Surgical Treatment   Lumpectomy+ ALND26 (36)--M + SLNB7 (10)--M + ALND67 (92)---SLNB17 (23)--ALND92.8 (128)--pN+89.1 (123)--30-day mortality1.4 (2)1.5 (2)0.98SLNB-Sentinel Lymph Node Biopsy; ALND-Axillary Lymph Node Dissection; M-Mastectomy

The axillary positivity rate was 89.1%. There were 76 (55%) deaths in the LRS group and 101 (74%) in the ST group during the median 40 (20-51) month follow-up. Overall survival (OS) was 34% higher in the LRS group compared to the ST group (HR: 0.66, 95%CI 0.49-0.88: p = 0.005).

Overall survival rate was higher in LN (+) (p=0.01), tumor size<5cm (p<0.0001), and high histologic grade (HG III, p<0.008) patients who underwent axillary surgery than ST group ; OS rate was with a marginal significant level in patients without axillary involvement (pN0) in the LRS group compared with ST group (p=0.05).

Conclusion: In this subgroup analysis, we observed that patients with high grade tumor, without skin or chest wall involvement and positive axilla who underwent surgery for primary breast tumor and axilla had better overall survival than ST in de novo stage IV breast. These results can be considered in clinical research design for stratification.

Citation Format: Ozmen V, Ozbas S, Karanlik H, Muslumanoglu M, Igci A, Canturk Z, Utkan NZ, Ozaslan C, Evrensel T, Uras C, Aksaz E, Soyder A, Ugurlu UM, Col C, Cabioglu N, Bozkurt B, Sezgin E, Dagoglu T, Uzunkoy A, Dulger M, Koksal N, Cengiz O, Gulluoglu B, Unal B, Atalay C, Yildirim E, Erdem E, Salimoglu S, Sezer A, Koyuncu A, Gurleyik G, Alagol H, Ulufi N, Berberoglu U, Soran A. The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-01.

Evaluation of flow and structure abnormalities of splanchnic system veins in cirrhotic patients without portal hypertension

AIM

The aim of this study was to evaluate hemodynamic and anatomic alterations of the splanchnic venous system and the efficiency and safety of color Doppler radial endosonography in the assessment of cirrhotic patients by comparing Child A cirrhotic patients without portal hypertension findings versus a non-cirrhotic group.

METHODS

The study was carried out between January 2009 and February 2010; the study population was 38 cirrhotic patients without portal hypertension and 140 control patients.

RESULTS

Hepatopedal flow was monophasic in all the control patients; the flow pattern was chaotic and irregular in 8% of the cirrhotic patients; in the cirrhotic patients the portal vein diameter was increased and the flow velocity reduced; no differences in flow volume were observed between the two groups. Splenic vein diameter and flow velocity were normal. In the majority of the Child A cirrhotic patients without portal hypertension, no changes were seen in portal vein diameter or flow volume; in some patients no significant increase portal vein diameter was observed and showed the flow volumes were unchanged.

CONCLUSION

Radial Doppler endosonography may be efficient and safe for assessing the splanchnic system.

MYCOTOX® and aflatoxicosis in quails

1. This study was to evaluate the toxic effects of aflatoxin (AF) on growth performance of quail, and to determine the preventive efficacy of MYCOTOX (oxicinol, tymol, micronised yeast). 2. One hundred and eighty 1-d-old quail (Coturnix coturnix japonica) of both sexes were weighed and randomly divided into 4 experimental groups each with 5 replicates of 9 birds. 3. There were 4 dietary treatments: (1) control with 0 mg AF/kg diet and 0% MYCOTOX; (2) 0 mg AF/kg diet and 0.5% MYCOTOX; (3) 2.5 mg AF/kg diet and 0% MYCOTOX; (4) 2.5 mg AF/kg diet plus 0.5% MYCOTOX. The chicks were maintained on these treatments to 3 weeks of age. Quail consumed the diets and water ad libitum. 4. Body weight (BW) gains in groups receiving AF alone were the lowest at all periods. Feed intake was lowest in the group consuming the AF diet. The addition of MYCOTOX to the AF diet did not prevent or reduce the toxic effects of AF on feed intake at any time period. Feeding diets containing MYCOTOX alone did not change feed intake significantly. With the exception of the 1 to 7 d period, feed conversion of chicks fed the AF diet was similar to those of the other experimental groups. 5. Bursa of Fabricius weight decreased, whereas the relative weights of liver, kidney and spleen increased in quail consuming diets containing AF and AF plus MYCOTOX. Liver colour was normal in the control and MYCOTOX alone group, but was lighter in groups fed AF. 6. The results indicated that MYCOTOX was not effective in preventing the deleterious effects of AF.

Ethyl pyruvate protects colonic anastomosis from ischemia-reperfusion injury

Ethyl pyruvate is a simple derivative in Ca(+2)- and K(+)-containing balanced salt solution of pyruvate to avoid the problems associated with the instability of pyruvate in solution. It has been shown to ameliorate the effects of ischemia-reperfusion (I/R) injury in many organs. It has also been shown that I/R injury delays the healing of colonic anastomosis. In this study, the effect of ethyl pyruvate on the healing of colon anastomosis and anastomotic strength after I/R injury was investigated. Anastomosis of the colon was performed in 32 adult male Wistar albino rats divided into 4 groups of 8 individuals: (1) sham-operated control group (group 1); (2) 30 minutes of intestinal I/R by superior mesenteric artery occlusion (group 2); (3) I/R+ ethyl pyruvate (group 3), ethyl pyruvate was administered as a 50-mg/kg/d single dose; and (4) I/R+ ethyl pyruvate (group 4), ethyl pyruvate administration was repeatedly (every 6 hours) at the same dose (50 mg/kg). On the fifth postoperative day, animals were killed. Perianastomotic tissue hydroxyproline contents and anastomotic bursting pressures were measured in all groups. When the anastomotic bursting pressures and tissue hydroxyproline contents were compared, it was found that they were decreased in group 2 when compared with groups 1, 3, and 4 (P < .05). Both anastomotic bursting pressure (P = .005) and hydroxyproline content (P < .001) levels were found to be significantly increased with ethyl pyruvate administration when compared with group 2. When ethyl pyruvate administration doses were compared, a significant difference was not observed (P > .05). Ethyl pyruvate significantly prevents the delaying effect of I/R injury on anastomotic strength and healing independent from doses of administration.

Operative approach in traumatic injuries of the duodenum

BACKGROUND

The management of duodenal traumas remains controversial. The experience of Ankara Numune Training and Research Hospital Emergency Surgery Department with duodenal injuries during a 10-year period was analyzed to identify trends in operative management and sources of duodenum-related morbidity and mortality.

METHODS AND RESULTS

Between 1994 and 2003, 1799 patients with blunt abdominal trauma were operated on and the incidence of duodenal trauma was 2.8% (50 patients). The injuries were penetrating in 31 (62%) patients and blunt in 19 (38%). Primary repair (PR) of injury was performed in 24 (48%) patients, primary repair and tube duodenostomy (PRTd) in 8 (16%) patients, complex repair (CR) in 11 (22%) patients, and exploration only without a duodenal procedure in 5 (10%) patients. Two of the patients died during laparotomy. The mortality rate was 12% and the incidence of duodenum-related morbidity was 12%. The overall morbidity rate was 40% (20 patients). The most commonly injured portion of the duodenum was DII (58%), and the most frequent cause of duodenum-related and overall morbidity in our series was Grade III duodenal injury.

CONCLUSION

Our experience suggests that the use of primary repair in grade III injury may be associated with higher duodenum-related morbidity. Our recommendation is to use complex repair for grade III duodenal injuries.

Serum leptin, prolactin and vascular endothelial growth factor (VEGF) levels in patients with breast cancer

Angiogenesis plays an important role in tumor growth and metastasis in solid tumors. VEGF is an important regulator of tumor angiogenesis. Both leptin and prolactin have also been suggested to have roles in the regulation of angiogenic process. In our study, we measured serum leptin, prolactin and VEGF levels in 30 metastatic, 55 non-metastatic breast cancer patients and 25 control subjects. Serum leptin levels were found to be similar in non-metastatic (38.1+/-19.5 ng/ml), metastatic patients (39.6+/-16.3 ng/ml) and control subjects (35.6+/-13.9 ng/ml) (p>0.05). There was no statistically significant difference between patients with visceral metastasis (44.0+/-16.8 ng/ml) and patients with bone metastasis (35.2+/-15.0 ng/ml) (p>0.05). Serum prolactin levels were found to be similar in non-metastatic (12.2+/-10.7 ng/ml), metastatic patients (11.6+/-8.2 ng/ml) and control subjects (12.3+/-8.1 ng/ml), (p>0.05). Moreover, serum prolactin levels were not different in patients with visceral (11.4+/-8.8 ng/ml) and bone metastasis (11.8+/-8.0 ng/ml), (p>0.05). Metastatic patients had higher serum VEGF levels (249.8+/-154.9 pg/ml), when compared to the non-metastatic patients (138.7+/-59.3 pg/ml) and control subjects (108.4+/-47.7 pg/ml), (p<0.05). There was no difference in serum VEGF levels in non-metastatic patients and control subjects (p>0.05). Patients with visceral metastasis (337.0+/-168.0 pg/ml) had higher serum VEGF levels, when compared to patients with bone metastasis (162.6+71.8 pg/ml), (p<0.05). Serum VEGF activity may be used to evaluate angiogenic and metastatic activity in breast cancer patients. However, serum leptin and prolactin levels does not seem to be related with angiogenic activity and metastasis in breast cancer patients.

Metastatic carcinoma of the gallbladder due to renal cell carcinoma in the ectopic kidney

We report a rare case of secondary involvement of the gallbladder by metastatic renal cell carcinoma originating from ectopic kidney. The first diagnosis of the patient is a gallbladder carcinoma due to a polypoid mass within the gallbladder. The preoperative examinations revealed that there was also a synchronous renal cell carcinoma. The histopathologic examination of the polypoid mass and kidney after operation revealed the resected polypoid mass to be metastasis of renal cell carcinoma.