Opening Aeolus' Bag of Winds: Acute Abdominal Pain in a Severely Immunosuppressed Patient

BACKGROUND

Necrotizing enterocolitis (NE) is a necrotizing disease mostly of the ileocecal region. It is a severe and potentially life-threatening complication that can affect patients undergoing chemotherapy for lymphoma. We analyze a case of NE that occurred in a patient with non-Hodgkin's lymphoma during chemotherapy with concurrent HIV infection.

CASE REPORT

We present a case of a 37-year-old woman who was admitted to our emergency department because of acute abdominal pain. Her medical history included HIV infection and B-cell immunoblastic lymphoma. For the latter, the patient was receiving rituximab cyclophosphamide hydroxydaunorubicin oncovin vincristine prednisone (R-CHOP) regimen. A complete blood count showed a low leukocyte count (40/mm³) and a low neutrophil count (32/mm³). An exploratory laparotomy with midline incision was performed. Intraoperatively, the cecum and the proximal part of the ascending colon were found to be edematous with the mesocolon being extremely gelatinous without macroscopically identified ischemia. Histopathology revealed a nonspecific infarction necrosis of the bowel wall with multiple ulcerations in the cecum, but no evidence of major vessel thrombosis. The patient had an uneventful postoperative course and was discharged in good condition on the 10th postoperative day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first reported case of NE in a patient with acquired immune-deficiency syndrome who developed the syndrome during an episode of severe neutropenia and was treated surgically. The decision to operate should be balanced between the clinical and laboratory status as well as the operative risk. Physicians should be aware of this complication of chemotherapy, especially in severely immunosuppressed patients, because it could be triggered just by an episode of neutropenia.

Concept of the aortic aneurysm repair-related surgical stress: a review of the literature

OBJECTIVE

Abdominal aorta aneurysm (AAA) is a serious threat for human life. AAA repair is a high-risk procedure which results in a severe surgical stress response. We aim to give a conceptual description of the underlying pathophysiology of stress after surgical repair of AAA.

METHODS

The MEDLINE/PubMed database was searched for publications with the medical subject heading "surgical stress" and keywords "abdominal aortic aneurysms (AAA)", or "cytokines" or "hormones" or "open repair (OR)" or "endovascular repair (EVAR)". We restricted our search to English till 2012 and only in cases of abdominal and thoracoabdominal aneurysms (TAAA).

RESULTS

We identified 93 articles that were available in English as abstracts or/and full-text articles that were deemed appropriate for our review.

CONCLUSIONS

Literature highlights no statistical significance for early acute TNF-α production in EVAR and no TNF-α production in OR. IL-6 and IL-8 levels are higher after OR especially when compared with those of EVAR. IL-10 peak was observed during ischemic phase in aneurysm surgical repair. Cortisol and epinephrine levels are higher in OR patients in comparison to EVAR patients. Finally, the incidence of systemic inflammatory response syndrome was significantly higher in OR than EVAR patients.

Impact of donor and recipient age difference on long-term allograft survival after living donor renal transplantation: analysis of 478 cases

INTRODUCTION

Either deceased or living-related renal transplantation constitutes the best therapeutic option for patients with end-stage renal disease. In this retrospective study, an attempt to identify parameters that affect allograft survival in living donor renal transplantation was made.

METHODS

Between January 2000 and July 2012, 478 adult patients received a renal transplant from a living-related donor in our center and their records were retrospectively reviewed in November 2012. Data concerning donor age, recipient age, donor/recipient age difference, donor/recipient gender, and ABO compatibility/incompatibility were recorded and associated with renal allograft survival rate.

RESULTS

Renal allograft survival rate was 96%, 89.5%, and 77.7% in the first, fifth, and 10th yr after transplantation, respectively. Only the difference between donor and recipient age was statistically significant in relation to graft survival. In cases with age difference >13 yr, graft survival rate was lower from the third yr onward.

CONCLUSIONS

Only the age difference between donor and recipient exerts an adverse impact on graft outcome after living donor renal transplantation, whereas donor age, recipient age, donor/recipient gender, and ABO incompatibility do not significantly influence renal allograft survival.

Treatment paradigms for ductus arteriosus aneurysms in adults

We report two symptomatic cases of ductus arteriosus aneurysm (DDA) in adults treated in our department over a 5-years period. One patient underwent an open off-pump surgical procedure, while the second one was treated with partial aortic arch debranching and endovascular stent-grafting. DDA in adults is an uncommon condition and can present with rupture, hoarseness or symptoms of airway obstruction. Although indications for intervention are not clearly established, most authors advocate that DDAs should be treated regardless of their size, to avoid the risk of rupture, while others reserve intervention for symptomatic patients. We report on the management of these patients and provide an updated review of the current literature.

Circulating biomarkers for abdominal aortic aneurysm: what did we learn in the last decade?

AIM

Abdominal aorta aneurysm (AAA) is a serious threat for human life, especially in such cases when it is asymptomatic until aneurysm rupture, which is a general cause of death in AAA subjects. We aim to give a conceptual description of the potential biomarkers that can correlate and predict the natural history of an AAA.

METHODS

The MEDLINE/PubMed database was searched for publications with the medical subject heading "abdominal aortic aneurysms (AAA)" and the keyword "biomarkers". We restricted our search to English till January 2012. We focused on human studies that reported aneurysm size, expansion rates and/or rupture and the studied biomarkers.

RESULTS

In this review we included 94 articles (4 reviews) that were accessible and available in English. We excluded articles referred exclusively to thoracic aneurysms and cardiac studies.

CONCLUSION

There are no specific laboratory markers that would allow one to distinguish in a simple way between aneurysm bearers and the healthy population. Serum elastase peptides seem still to be sufficient biomarkers to predict expansion and rupture, but advanced techniques (ELISA) and larger studies are needed to establish its exact role. Plasmin-antiplasmin complexes (PAP) may also have clinical potential. Newer biomarkers may also have a role, not well established yet. Beyond that, there are many limitations related to the fact that many biomarkers related with AAA outcome are not disease specific, due to their established correlation with atherosclerosis. Future research is required to establish the underlying relations between these biomarkers and their role in AAA pathophysiology.

A pathological fracture and a solitary mass in the right clavicle: an unusual first presentation of HCC and the role of immunohistochemistry

Hepatocellular carcinoma (HCC) is an aggressive malignant tumor that occurs throughout the world. Μetastases from hepatocellular carcinoma (HCC) were generally considered to be rare in the past, because the carcinoma had an aggressive clinical course. In our era, has been reported that extra-hepatic metastases occur in 13.5%-41.7% of HCC patients and this is considered as terminal-stage cancer. The prognosis for patients at this stage continues to be poor due to limited effective treatment. The common sites of extrahepatic metastases in patients with HCC are the lungs, regional lymph nodes, kidney, bone marrow and adrenals. We present here an extremely infrequent case of a patient, without known liver disease, in which the presenting symptom was a pathological-in retrospect-fracture of his right clavicle which wasn't properly evaluated, until he presented a bulky mass in the region 6 months later. For our patient, the added diagnostic difficulty alongside the unknown liver disease, has been that the clavicular metastases was the first presentation of any metastatic disease, rather than the more common sites of HCC spread to adjacent lung or lymph nodes.

H1N1v influenza vaccine in Greek medical students

BACKGROUND

We sought to investigate the penetration of the H1N1v vaccine in Greek medical students, as well as their approach to the vaccination.

METHODS

A survey was conducted among the students of the University of Athens, School of Medicine, 1 month after the initiation of the vaccination programme. Participants were asked to fill in a questionnaire regarding their status of vaccination and their approach to the H1N1v vaccine.

RESULTS

We handed a questionnaire to 1000 students (out of 1700 officially enrolled in the medical school) and retrieved 922 answers. Only 74 (8%) medical students had been vaccinated and 78 (9%) planned to (probably or definitely) do so in the future, while 641 (67%) would (probably or definitely) not get vaccinated. The highest coverage was among the sixth year students (37/234, 16%). The most common reasons for not having received the vaccine were perception of the disease as mild (387/848, 46%), and concern regarding long-term adverse events (370/848, 44%). Thirty percent (258/848) of the students doubted the vaccine's effectiveness, and 197 (23%) worried about possible short-term adverse events. One hundred and thirty-three respondents (16%) believed the whole story is a conspiracy while 102 (12%) reported to have had the flu. Almost half (43%) of the participants considered their knowledge on the subject inadequate.

CONCLUSION

Our findings confirmed the low penetration of the H1N1 vaccine in Greece, as in most European countries, even in medical students. Better education of the students and the public might aid in increasing the immunization rates.