Sentinel Bleeding After Pancreaticoduodenectomy: A Disregarded Sign

Introduction Delayed massive hemorrhage induced by pancreatic fistula after pancreaticoduodenectomy is a rare but life-threatening complication. The purpose of this study was to analyze the clinical course of patients with late hemorrhage, with or without sentinel bleeding, to better define treatment options in the future. Material and Methods From April 1998 to December 2006, 189 pancreaticoduodenectomies were performed. Eleven patients, including two patients referred from other hospitals, were treated with delayed massive hemorrhage occurring 5 days or more after pancreaticoduodenectomy. Sentinel bleeding was defined as minor blood loss via surgical drains or the gastrointestinal tract with an asymptomatic interval until development of hemorrhagic shock. The clinical data of patients with bleeding episodes were analyzed retrospectively. Results Eight of the 11 patients had sentinel bleeding, and seven of them had it at least 6 h before acute deterioration. Seven out of 11 patients died, five out of eight with sentinel bleeding. No differences could be detected between patients with or without sentinel bleeding before delayed massive hemorrhage. The only difference found was that non-surviving patients were significantly older than surviving patients. Delayed massive hemorrhage is a common cause of death after pancreaticoduodenostomy complicated by pancreatic fistula formation. The observation of sentinel bleeding should lead to emergency angiography and dependent from the result to emergency relaparotomy to increase the likelihood of survival.     

Homozygous microdeletion of chromosome 4q11-q12 causes severe limb-girdle muscular dystrophy type 2E with joint hyperlaxity and contractures

Microdeletion syndromes are commonly transmitted as dominant traits and are frequently associated with variably expressed pleiotropic phenotypes. Nonlethal homozygous microdeletions, on the other hand, are very rare. Here, we delineate the fifth and so far largest homozygous microdeletion in nonmalignancies of approximately 400 kb on chromosome 4q11-q12 in a large consanguineous East-Anatolian family with six affected patients. The deleted region contains the beta-sarcoglycan gene (SGCB), the predicted gene SPATA18 (spermatogenesis associated 18 homolog) and several expressed sequence tags. Patients presented with a severe and progressive Duchenne-like muscular dystrophy phenotype, a combination of hyperlaxity and joint contractures, chest pain, palpitations, and dyspnea.     

Occurence and Variability of Domoic Acid in Mussel (Mytilus galloprovincialis) Samples from the Golden Horn Estuary,Sea of Marmara (Turkey)

The occurrence and variability of domoic acid (DA) levels in wild Mytilus galloprovincialis samples, compared with the Pseudo-nitzschia spp. abundance and particulate DA (pDA) concentrations in relation to the environmental changes in the Golden Horn Estuary, Turkey from October 2018 to September 2019. Biotoxin analysis were performed by high-performance liquid chromatography with diode-array detection (HPLC–DAD). DA concentrations in particulate matter (pDA) and mussel samples were found between 0.090–0.685 µg L⁻¹ and 0.905–2.413 µg g⁻¹, respectively. Accumulation of DA in wild mussel samples could be the result of the increasing tendency of P.nitzschia spp. abundances between April and May. Maximum DA levels were detected in particulate matter when the salinity was measured as the lowest in May. Thus, it can be said that the DA production was driven by the significant salinity decrease in the GHE. This is the first attempt regarding the presence of DA in M. galloprovincialis samples collected from Turkish coasts.

     

Effect of dopamine infusion on thyroid hormone tests and prolactin levels in very low birth weight infants

Objective: To evaluate the effect of dopamine on thyroid hormone tests and prolactin (PRL) and to assess requirement for L-thyroxin (LT4).

Methods: The infants (n?=?102) were divided into three groups (Group 1; received no dopamine, Group 2 received ≤25?mg/kg cumulative dose and Group 3; received >25?mg/kg cumulative dose). Blood samples were taken at 6–8 days (timepoint 1), 13–15 days (timepoint 2), and 4–6 weeks of life (timepoint 3).

Results: Respiratory distress syndrome was higher in group 2 and 3. Patnet ductus arteriosus was higher in group 3 than in groups 1 and 2. Duration and cumulative dose in group 3 were higher than group 2. There was no difference between thyroid hormones that were taken after stopping infusion at timepoint 3 among all groups. No therapy with LT4 was needed. PRL levels were higher at timepoint 1 in group 1 than compared to group 2 and 3 (p?p?>?0.05). This difference was disappeared at following timepoints.

Conclusions: The release of TSH, FT3, FT4 and PRL were not inhibited and prophylactic thyroid hormone treatment was not required in VLBW infants receiving dopamine infusions.     

Terlipressin plus hydroxyethyl starch infusion: an effective treatment for hepatorenal syndrome

Ornipressin is a vasopressin analogue that can cause potent splanchnic vasoconstriction. It has been shown that, in combination with albumin infusion, ornipressin is able to reverse hepatorenal syndrome. However, its clinical use is limited by possible severe ischaemic complications. In our case, a 47-year-old man received a right hemihepatectomy for cholangiocellular carcinoma. On post-operative day three, he developed hepatorenal syndrome with ascites, peripheral oedema and oliguria (250-500 ml/day). Serum creatinine was increased to 3.5 mg/dl. The patient was treated with terlipressin, another vasopressin analogue with fewer side effects than ornipressin, (1 mg every 4 h intravenously) and hydroxyethyl starch (500 ml/day). Urine output increased to 3000 ml/day, serum creatinine decreased to normal range within 4 days and ascites and oedema disappeared. We hereby report the first case of successful treatment of hepatorenal syndrome with terlipressin and hydroxyethyl starch, which appears to be a safe and effective treatment.