Use of a haemostatic matrix (Floseal?) does not reduce blood loss in minimally invasive total knee arthroplasty performed under continued aspirin

Background

Aspirin is being used for primary and secondary cardiovascular prevention. It has been proposed that aspirin should be discontinued 5 to 7 days before surgery. However, discontinuation might increase the risk of cardiac and thrombo-embolic co-morbidity. Aspirin also increases the risk of bleeding during and after total knee arthroplasty. This study evaluated if the intra-articular use of a haemostatic matrix (Floseal^®) might decrease blood loss in total knee arthroplasty performed under continued aspirin use.

Materials and methods

We retrospectively compared matched pairs in two groups (80 patients in each group). Patients in both groups were taking aspirin: one group was managed with conventional haemostasis (with bovie electrocoagulation), while the other group was treated with an intra-articular haemostatic matrix as an adjunct to electrocoagulation. The outcomes compared were haemoglobin and haematocrit levels at days 2 and 4 after surgery as surrogates for blood loss, transfusion rate, surgical time, and length of stay in the hospital.

Results

No differences were observed between the two groups for haemoglobin and haematocrit levels on days 2 and 4. There were no differences in transfusion rate, surgical time or length of stay in hospital between the two groups.

Discussion

The present study shows that the use of Floseal^® has no effect on reducing either visible or hidden blood loss after total knee arthroplasty with peri-operative continuation of aspirin use, as assessed by a drop in haemoglobin or haematocrit.     

Autologous transfusion of drain contents in elective primary knee arthroplasty: its value and relevance

Background

Total knee arthroplasty is associated with significant post-operative blood loss often necessitating blood transfusions. Blood transfusions may be associated with transfusion reactions and may transmit human immunodeficiency virus, hepatitis C virus and hepatitis B virus, with devastating consequences. After total knee arthroplasty, transfusion of the contents of an autologous drain is becoming common practice. The aim of our study was to look at the effectiveness of these drains in elective primary total knee arthroplasty.

Materials and methods

A prospective study was conducted including 70 non-randomised patients. A normal suction drain was used in 35 patients (group A), whereas in the other 35 patients, a CellTrans^™ drain was used (group B). All the operations were performed by four surgeons using a tourniquet with a medial parapatellar approach. Pre- and post-operative haemoglobin concentrations were recorded in both groups. A Student’s t-test was applied to determine the statistical significance of the data collected.

Results

The average fall in post-operative haemoglobin was 3.66 g/dL (SD 1.46; range, 0.6–7.0) among patients in whom the simple drain was used (group A) and 2.29 g/dL (SD 0.92; range, 0.6–5.9) among those in whom the CellTrans^™ drain was used (group B) (p<0.0001). Twenty-five units of allogeneic blood were required in group A compared to four units in group B. The rate of transfusion was 5.7% (2 patients) in the group in which CellTrans™ drain was used and 25.7% (9 patients) in the group in which a simple suction drain was used.

Discussion

Total knee arthroplasty is associated with significant post-operative blood loss despite best operative technique. Autologous reinfusion of the contents of a CellTrans^™ drain significantly reduces the rate of post-operative blood transfusion. This study indicates that the use of an autologous drain could be recommended as routine practice in primary total knee arthroplasty.     

Perioperative hyperglycemia and postoperative infection after lower limb arthroplasty

Background

One of the most serious complications after major orthopedic surgery is deep wound or periprosthetic joint infection. Various risk factors for infection after hip and knee replacement surgery have been reported, including patients'' comorbidities and surgical technique factors. We investigated whether hyperglycemia and diabetes mellitus (DM) are associated with infection that requires surgical intervention after total hip and knee arthroplasty.

Methods

We reviewed our computerized database for elective primary total hip and knee arthroplasty from 2000 to 2008. Demographic information, past medical history of patients, perioperative biochemistry, and postoperative complications were reviewed.Patients were divided into two groups: infected group (101 patients who had surgical intervention for infection at our institution within 2 years after primary surgery) and noninfected group (1847 patients with no intervention with a minimum of one year follow-up. The data were analyzed using t, chi-squared, and Fisher''s exact tests.

Results

There were significantly more diabetes patients in the infected group compared with the noninfected group (22% versus 9%, p < .001). Infected patients had significantly higher perioperative blood glucose (BG) values: preoperative BG (112 ± 36 versus 105 ± 31 mg/dl, p = .043) and postoperative day (POD) 1 BG (154 ± 37 versus 138 ± 31 mg/dl, p < .001). Postoperative morning hyperglycemia (BG >200 mg/dl) increased the risk for the infection more than two-fold. Non-DM patients were three times more likely to develop the infection if their morning BG was >140 mg/dl on POD 1, p = .001. Male gender, higher body mass index, knee arthroplasty, longer operative time and hospital stay, higher comorbidity index, history of myocardial infarction, congestive heart failure, and renal insufficiency were also associated with the infection.

Conclusions

Diabetes mellitus and morning postoperative hyperglycemia were predictors for postoperative infection following total joint arthroplasty. Even patients without a diagnosis of DM who developed postoperative hyperglycemia had a significantly increased risk for the infection.     

CMS Reimbursement Reform and the Incidence of Hospital-Acquired Pulmonary Embolism or Deep Vein Thrombosis

BACKGROUND

In October 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for the marginal cost of treating certain preventable hospital-acquired conditions.

OBJECTIVE

This study evaluates whether CMS’s refusal to pay for hospital-acquired pulmonary embolism (PE) or deep vein thrombosis (DVT) resulted in a lower incidence of these conditions.

DESIGN

We employ difference-in-differences modeling using 2007–2009 data from the Nationwide Inpatient Sample, an all-payer database of inpatient discharges in the U.S. Discharges between 1 January 2007 and 30 September 2008 were considered “before payment reform;” discharges between 1 October 2008 and 31 December 2009 were considered “after payment reform.” Hierarchical regression models were fit to account for clustering of observations within hospitals.

PARTICIPANTS

The “before payment reform” and “after payment reform” incidences of PE or DVT among 65–69-year-old Medicare recipients were compared with three different control groups of: a) 60–64-year-old non-Medicare patients; b) 65–69-year-old non-Medicare patients; and c) 65–69-year-old privately insured patients. Hospital reimbursements for the control groups were not affected by payment reform.

INTERVENTION

CMS payment reform for hospital-based reimbursement of patients with hip and knee replacement surgeries.

MAIN MEASURES

The outcome was the incidence proportion of hip and knee replacement surgery admissions that developed pulmonary embolism or deep vein thrombosis.

KEY RESULTS

At baseline, pulmonary embolism or deep vein thrombosis were present in 0.81 % of all hip or knee replacement surgeries for Medicare patients aged 65–69 years old. CMS payment reform resulted in a 35 % lower incidence of hospital-acquired pulmonary embolism or deep vein thrombosis in these patients (p = 0.015). Results were robust to sensitivity analyses.

CONCLUSION

CMS’s refusal to pay for hospital-acquired conditions resulted in a lower incidence of hospital-acquired pulmonary embolism or deep vein thrombosis after hip or knee replacement surgery. Payment reform had the desired direction of effect.KEY WORDS: payment reform, pay-for-performance, hospital-acquired conditions, pulmonary embolism, deep vein thrombosis     

Does aortic valve sclerosis predicts the severity and complexity of coronary artery disease?

Aim

We assessed the association of aortic valve sclerosis (AVS) with atherosclerotic risk factors and severity and complexity of coronary artery disease (CAD).

Methods

In this retrospective study, a total of 482 eligible patients were divided into 2 groups: AVS present and AVS absent. All major cardiovascular risk factors and coronary lesion characteristics were included.

Results

Age was the only independent predictor of AVS. AVS was not independently associated with the number of obstructive vessels, degree of lesion obstruction and SYNTAX score.

Conclusion

AVS is probably a benign marker of age-related degenerative changes in the heart independent of the severity and complexity of CAD.     

Comparison of the clinical effectiveness of zanamivir and laninamivir octanoate for children with influenza A(H3N2) and B in the 2011–2012 season

Objectives

To evaluate the clinical effectiveness of the two inhaled neuraminidase inhibitors (NAIs), zanamivir (ZN) and laninamivir octate (LO), for influenza A(H3N2) and B virus infections.

Design

A prospective, multicenter observational study was conducted from January to April in 2012.

Setting

Outpatients aged 5–18 years who had a temperature of 37.5°C or higher and were diagnosed as having influenza based on an immunochromatographic assay were enrolled.

Sample

A total of 338 patients treated with ZN and 314 patients treated with LO were compared.

Main outcome measures

The duration of fever after administration of the first dose of each NAI was evaluated as a primary endpoint. The secondary endpoint was episodes of biphasic fever.

Results

No statistically significant difference in the duration of fever was found between the ZN and LO groups (log-rank test, P = 0.117). A logistic regression model showed that episodes of biphasic fever increased by 1.19 times for every decrease of 1 year of age (P = 0.016) and that the number of biphasic fever episodes in patients treated with LO was 5.80-times greater than that in patients treated with ZN (P < 0.001).

Conclusions

Although the duration of fever in the LO group was comparable to that in the ZN group, episodes of biphasic fever were more frequent in younger children and in the LO group than in the ZN group.     

Blood management and transfusion strategies in 600 patients undergoing total joint arthroplasty: an analysis of pre-operative autologous blood donation

Background

Blood loss during total joint arthroplasty strongly influences the time to recover after surgery and the quality of the recovery. Blood conservation strategies such as pre-operative autologous blood donation and post-operative cell salvage are intended to avoid allogeneic blood transfusions and their associated risks. Although widely investigated, the real effectiveness of these alternative transfusion practices remains controversial.

Materials and methods

The surgery reports of 600 patients undergoing total joint arthroplasty (312 hip and 288 knee replacements) were retrospectively reviewed to assess transfusion needs and related blood management at our institute. Evaluation parameters included post-operative blood loss, haemoglobin concentration measured at different time points, ASA score, and blood transfusion strategies.

Results

Autologous blood donation increased the odds of receiving a red blood cell transfusion. Reinfusion by a cell salvage system of post-operative shed blood was found to limit adverse effects in cases of severe post-operative blood loss. The peri-operative net decrease in haemoglobin concentration was higher in patients who had predeposited autologous blood than in those who had not.

Discussion

The strengths of this study are the high number of cases and the standardised procedures, all operations having been performed by a single orthopaedic surgeon and a single anaesthesiologist. Our data suggest that a pre-operative autologous donation programme may often be useless, if not harmful. Conversely, the use of a cell salvage system may be effective in reducing the impact of blood transfusion on a patient’s physiological status. Basal haemoglobin concentration emerged as a useful indicator of transfusion probability in total joint replacement procedures.     

Nonarteritic anterior ischemic optic neuropathy treated with intravenous prostaglandin E1 and steroids

BACKGROUND:

Acute nonarteritic anterior ischemic optic neuropathy (NAION) is considered to be acute ischemia of the posterior ciliary arteries. Prostaglandin E1 (PGE1), a powerful microcirculation vasodilator, has been shown to improve ocular blood flow.

DESIGN:

A nonrandomized, comparative trial.

METHODS:

Eight consecutive cases of NAION were treated with intravenous steroids and PGE1. Seven control cases of NAION were treated with acetylsalicylic acid and oral steroids. Fisher’s exact test was used for statistical analysis.

RESULTS:

The visual acuity improved in seven cases of NAION treated with PGE1 and was unchanged in one. Of the seven control cases, four had no change in vision and three lost further visual acuity on follow-up visits.

CONCLUSIONS:

Intravenous PGE1 and steroids should be considered in cases of NAION to immediately restore blood flow to the optic nerve and improve visual acuity.     

Admission is not always necessary for patients with community-acquired pneumonia in risk classes IV and V diagnosed in the emergency room

OBJECTIVE:

To determine the factors that allow patients with community-acquired pneumonia who are at high risk of mortality (risk classes IV and V) to be treated at home.

DESIGN:

A prospective, observational study.

SETTING:

Six hospitals and one free-standing emergency room in Edmonton, Alberta.

PARTICIPANTS:

The present study included 2354 patients in risk classes IV and V who had a diagnosis of pneumonia made by an emergency room physician or an internist.

MEASUREMENTS:

Symptoms, signs and laboratory findings, as well as outcome measures of length of stay and mortality.

RESULTS:

Of the total study group, 319 of the patients (13.5%) were treated on an ambulatory basis. Factors predictive of admission were definite or possible pneumonia on chest radiograph as read by a radiologist, functional impairment, altered mental status, substance abuse, psychiatric disorder, abnormal white blood cell count, abnormal lymphocyte count, oxygen saturation less than 90% and antibiotic administration in the week before admission. If chest pain was present, admission was less likely. Only two of the 319 patients required subsequent admission (both had positive blood cultures) and only two died.

CONCLUSIONS:

A substantial number of patients in risk classes IV and V can be safely treated at home. Factors that help clinicians to select this subset of patients are discussed.     

The increasing prevalence of clindamycin resistance in Staphylococcus aureus isolates in children with head and neck abscesses

OBJECTIVE:

To retrospectively review trends in clindamycin resistance among Staphylococcus aureus head and neck abscesses between January 2000 and June 2008.

METHODS:

Between January 2000 and June 2008, inpatient and out-patient S aureus isolates were reviewed for antibiotic susceptibility. In particular, cultures from 153 abscesses in the head and neck region were assessed for clindamycin and methicillin resistance patterns.

RESULTS:

Annual clindamycin resistance rates for all S aureus isolates, and specifically for S aureus head and neck abscesses, revealed concerning levels of clindamycin and methicillin resistance. After 2002, the mean clindamycin resistance rate in head and neck abscesses was approximately 27%. The number of new cases of methicillin-resistant S aureus per year increased from four cases in 2000 to 44 cases in 2007.

CONCLUSION:

Antibiotic resistance should be considered following failed empirical therapy of head and neck abscesses with clindamycin.     

Rapamycin Enhances HBV Production by Inducing Cellular Autophagy

Background:

Some reports revealed that rapamycin could reactivate HBV infection. However, the mechanism has not been clearly explained.

Objectives:

In this report, we studied the mechanism by which rapamycin enhances HBV replication and expression by inducing cellular autophagy.

Materials and Methods:

HepG2.2.15 cells were treated with rapamycin to induce autophagy. Autophagosomes were observed by fluorescence microscopy and transmission electron microscopy. Autophagy marker protein LC3-Ⅱ/LC3-Ⅰwas detected by Western blotting. HBV DNA and mRNA were determined by real time PCR and Southern blotting. HBsAg was evaluated by ELISA.

Results:

In HepG2.2.15 cells, HBV DNA and HBsAg increased when host cells were treated with rapamycin and the effect was reversed by autophagy inhibitor, 3-methyladenine (3-MA).

Conclusions:

These results indicated a potential explanation for reactivation of HBV infection when patients with hepatitis receive rapamycin.     

Isolated knee monoarthritis heralding resectable non-small-cell lung cancer. A paraneoplastic syndrome not previously described

Objective

To describe isolated knee monoarthritis as a paraneoplastic syndrome heralding non‐small cell lung cancer (NSCLC), and to discuss its clinical characteristics.

Methods

Clinical records of all consecutive, new outpatients with isolated knee monoarthritis observed from January 2000 to December 2005 were reviewed. A systematic review of Medline and Cochrane Library databases was performed to identify English‐language articles related to rheumatological paraneoplastic syndromes associated with NSCLC.

Results

Over 6 years, 6654 new outpatients with different rheumatic disorders were observed. Of these, 296 (4.4%) presented with isolated monoarthritis of the knee. In five out of 296 patients (1.7%) this feature represented the initial manifestation of NSCLC. All five patients were middle‐aged men, with a long history of heavy cigarette smoking, who had a non‐erosive, isolated knee monoarthritis, with mild articular fluid collection of non‐inflammatory type. NSCLC was resectable in all patients, and knee monoarthritis remitted with no relapse confirming its paraneoplastic nature. All five patients are in good condition after a median follow up of 41 months. The literature review revealed that paraneoplastic knee monoarthritis has not previously been reported.

Conclusion

Knee monoarthritis may in some cases represent a paraneoplastic syndrome heralding NSCLC at an early stage.Small‐cell lung cancer (SCLC) is associated with various types of paraneoplastic syndromes in approximately 10–20% of cases.^1,2 Paraneoplastic syndromes associated with non‐small‐cell lung cancer (NSCLC) are less frequent and variable, but of particular interest. Given its resistance to chemotherapy, the prognosis of NSCLC is strictly dependent on the possibility of surgical removal, its early detection is thus of great importance.³Hypertrophic osteoarthropathy (HOA), observed in approximately 5% of patients, is the most frequent paraneoplastic syndrome associated with NSCLC.^1,2To the best of our knowledge, isolated knee monoarthritis not associated with HOA, as the presenting feature of NSCLC, has not previously been reported.A review of the clinical records of all outpatients presenting with isolated knee monoarthritis observed over a 6‐year period revealed that this manifestation heralded NSCLC in five patients.The aim of this study was to describe the clinical characteristics of these patients, and to discuss the differential diagnosis.     

Endobronchial closure of bronchopleural fistula using Amplatzer device

Background

Bronchopleural fistulas (BPF) are a dreaded complication after lobectomy and pneumonectomy and are associated with high morbidity and mortality. BPF are treated by a range of surgical and endoscopic techniques. Amplatzer devices (ADs), normally used for the closure of cardiac defects, may enable the minimally invasive occlusion of these defects.

Methods

Three patients with BPF were treated with the bronchoscopic closure of BPF using AD. Under general anaesthesia, the fistula was located using bronchography and the self-expanding AD was placed under direct bronchoscopic and fluoroscopic guidance into the fistula. Bronchography was used to control the complete occlusion of the BPF.

Results

Three male patients with a mean age of 63 years (range, 53-73 years) were successfully treated by AD. Two BPF occurred after lobectomy of the right lower lobe for lung cancer and one after right pneumonectomy for lung cancer. In all patients the bronchoscopic procedure was successful and symptoms of empyema and BPF showed no recurrence over a median follow-up of 22 months.

Conclusions

Endobronchial closure of BPF using AD represents a safe, effective and promising method for postoperative BPF.     

The value of thoracic computed tomography scans in clinical diagnosis: A prospective study

BACKGROUND:

Computed tomography (CT) scans are used extensively to investigate chest disease because of their cross-sectional perspective and superior contrast resolution compared with chest radiographs. These advantages lead to a more accurate imaging assessment of thoracic disease. The actual use and evaluation of the clinical impact of thoracic CT has not been assessed since scanners became widely available.

OBJECTIVE:

To identify patterns of utilization, waiting times and the impact of CT scan results on clinical diagnoses.

DESIGN:

A before and after survey of physicians who had ordered thoracic CT scans.

SETTING:

Vancouver General Hospital – a tertiary care teaching centre in Vancouver, British Columbia.

SUBJECTS:

Physicians who had ordered CT scans.

INTERVENTION:

Physicians completed a standard questionnaire before and after the CT scan result was available.

MEASUREMENTS:

Changes in the clinical diagnosis, estimates of the probabilities for the diagnosis both before and after the CT scan, and waiting times.

RESULTS:

Four hundred fifty-four thoracic CT cases had completed questionnaires, of whom 80% were outpatients. A change in diagnosis was made in 48% of cases (25% with a normal CT scan and 23% with CT scan findings that indicated a different diagnosis). The largest change in probability scores for the clinical diagnosis before and after the CT scan was 43.9% for normal scans, while it was 36.3% for a different diagnosis and 26.3% for the same diagnosis. High-priority scans were associated with decreased waiting time (−7.89 days for each unit increase in priority).

CONCLUSIONS:

The CT scan results were associated with a change in diagnosis in 48% of cases. Normal scans constituted 25% of the total and had the greatest impact scores. Waiting times were highly correlated with increased urgency of the presenting problem.     

Platelet Activation in Patients with Atherosclerotic Renal Artery Stenosis Undergoing Stent Revascularization

Summary

Background and objectives

Soluble CD40 ligand (sCD40L) is a marker of platelet activation; whether platelet activation occurs in the setting of renal artery stenosis and stenting is unknown. Additionally, the effect of embolic protection devices and glycoprotein IIb/IIIa inhibitors on platelet activation during renal artery intervention is unknown.

Design, setting, participants, & measurements

Plasma levels of sCD40L were measured in healthy controls, patients with atherosclerosis without renal stenosis, and patients with renal artery stenosis before, immediately after, and 24 hours after renal artery stenting.

Results

Soluble CD40L levels were higher in renal artery stenosis patients than normal controls (347.5 ± 27.0 versus 65.2 ± 1.4 pg/ml, P < 0.001), but were similar to patients with atherosclerosis without renal artery stenosis. Platelet-rich emboli were captured in 26% (9 of 35) of embolic protection device patients, and in these patients sCD40L was elevated before the procedure. Embolic protection device use was associated with a nonsignificant increase in sCD40L, whereas sCD40L declined with abciximab after the procedure (324.9 ± 42.5 versus 188.7 ± 31.0 pg/ml, P = 0.003) and at 24 hours.

Conclusions

Atherosclerotic renal artery stenosis is associated with platelet activation, but this appears to be related to atherosclerosis, not renal artery stenosis specifically. Embolization of platelet-rich thrombi is common in renal artery stenting and is inhibited with abciximab.     

Resilience in Patients with Ischemic Heart Disease

Background

Resilience is a psychosocial factor associated with clinical outcomes in chronic diseases. The relationship between this protective factor and certain diseases, such heart diseases, is still under-explored.

Objective

The present study sought to investigate the frequency of resilience in individuals with ischemic heart disease.

Method

This was a cross-sectional study with 133 patients of both genders, aged between 35 and 65 years, treated at Rio Grande do Sul Cardiology Institute - Cardiology University Foundation, with a diagnosis of ischemic heart disease during the study period. Sixty-seven patients had a history of acute myocardial infarction. The individuals were interviewed and evaluated by the Wagnild & Young resilience scale and a sociodemographic questionnaire.

Results

Eighty-one percent of patients were classified as resilient according to the scale.

Conclusion

In the sample studied, resilience was identified in high proportion among patients with ischemic heart disease.     

Reasons for coming to hospital after treatment for community-acquired pneumonia on an ambulatory basis

BACKGROUND

Most patients with community-acquired pneumonia (CAP) are treated on an ambulatory basis.

OBJECTIVE

To evaluate the reasons for presentation to hospital after treatment for CAP on an ambulatory basis.

METHODS

The study, conducted in five hospitals in the Capital Health Region (Edmonton, Alberta), enrolled adult patients aged 17 years or older who presented with a history of having been diagnosed and treated for pneumonia within the previous month. A current diagnosis of pneumonia was based on two or more symptoms or signs of CAP, plus radiographic evidence of pneumonia.

RESULTS

Seventy-five (77.3%) of the 97 patients who met the inclusion criteria had CAP, and 22 (22.7%) patients presented with a noninfectious illness. Of the patients with CAP, 25 (33.3%) met the study criteria for worsening of a comorbid illness, 23 (30.7%) had clinical failure, 16 (21.3%) had microbiological failure, six (8.0%) were noncompliant, four (5.3%) had failure of expectations and one (1.3%) had adverse effects of antimicrobial therapy.

CONCLUSIONS

Underlying diseases, exacerbations of comorbidities and complications of CAP, as well as confounders such as unusual infections and noninfectious conditions that mimic CAP, are all reasons for presenting to hospital after treatment for CAP in an ambulatory setting.     

Does thromboprophylaxis prevent venous thromboembolism after major orthopedic surgery?

OBJECTIVE:

Pulmonary embolism (PE) is an important complication of major orthopedic surgery. The aim of this study was to evaluate the incidence of venous thromboembolism (VTE) and factors influencing the development of VTE in patients undergoing major orthopedic surgery in a university hospital.

METHODS:

Patients who underwent major orthopedic surgery (hip arthroplasty, knee arthroplasty, or femur fracture repair) between February of 2006 and June of 2012 were retrospectively included in the study. The incidences of PE and deep vein thrombosis (DVT) were evaluated, as were the factors influencing their development, such as type of operation, age, and comorbidities.

RESULTS:

We reviewed the medical records of 1,306 patients. The proportions of knee arthroplasty, hip arthroplasty, and femur fracture repair were 63.4%, 29.9%, and 6.7%, respectively. The cumulative incidence of PE and DVT in patients undergoing major orthopedic surgery was 1.99% and 2.22%, respectively. Most of the patients presented with PE and DVT (61.5% and 72.4%, respectively) within the first 72 h after surgery. Patients undergoing femur fracture repair, those aged ≥ 65 years, and bedridden patients were at a higher risk for developing VTE.

CONCLUSIONS:

Our results show that VTE was a significant complication of major orthopedic surgery, despite the use of thromboprophylaxis. Clinicians should be aware of VTE, especially during the perioperative period and in bedridden, elderly patients (≥ 65 years of age).     

Isolated Tuberculosis of Transplanted Liver,A Case Report and Review of the Literature

Introduction

Recipients of liver transplantation are prone to different types of infections such as tuberculosis (TB).

Case Presentation

Herein we report a 59-year-old man with liver transplantation due to HBV cirrhosis who developed isolated hepatic TB, 18 months after OLT (orthotropic liver transplantation). He has been successfully treated with anti-TB regimen and now after 12 months he is completely symptom-free.

Conclusions

Organ transplantation and treatment of transplanted patients with immunosuppressive drugs would prone them to various unusual infections. One of these is unusual primary involvement of liver by tuberculosis which has been extremely rare in the previous reports.     

Real-time ultrasound imaging of irreversible electroporation in a porcine liver model adequately characterizes the zone of cellular necrosis

Background

Irreversible electroporation (IRE) is a largely non-thermal method for the ablation of solid tumours. The ability of ultrasound (US) to measure the size of the IRE ablation zone was studied in a porcine liver model.

Methods

Three normal pig livers were treated in vivo with a total of 22 ablations using IRE. Ultrasound was used within minutes after ablation and just prior to liver harvest at either 6 h or 24 h after the procedure. The area of cellular necrosis was measured after staining with nitroblue tetrazolium and the percentage of cell death determined by histomorphometry.

Results

Visible changes in the hepatic parenchyma were apparent by US after all 22 ablations using IRE. The mean maximum diameter of the ablation zone measured by US during the procedure was 20.1 ± 2.7 mm. This compared with a mean cellular necrosis zone maximum diameter of 20.3 ± 2.9 mm as measured histologically. The mean percentage of dead cells within the ablation zone was 77% at 6 h and 98% at 24 h after ablation.

Conclusions

Ultrasound is a useful modality for measuring the ablation zone within minutes of applying IRE to normal liver tissue. The area of parenchymal change measured by US correlates with the area of cellular necrosis.