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BACKGROUND: Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or, most frequently, generalized bullous lesions. A subset of patients only develops excoriations, prurigo-like lesions, and eczematous and/or urticarial erythematous lesions. The disease, which is significantly associated with neurological disorders, has high morbidity and severely impacts the quality of life. OBJECTIVES AND METHODOLOGY: The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology sought to update the guidelines for the management of BP based on new clinical information, and new evidence on diagnostic tools and interventions. The recommendations are either evidence-based or rely on expert opinion. The degree of consent among all task force members was included. RESULTS: Treatment depends on the severity of BP and patients' comorbidities. High-potency topical corticosteroids are recommended as the mainstay of treatment whenever possible. Oral prednisone at a dose of 0.5 mg/kg/day is a recommended alternative. In case of contraindications or resistance to corticosteroids, immunosuppressive therapies, such as methotrexate, azathioprine, mycophenolate mofetil or mycophenolate acid, may be recommended. The use of doxycycline and dapsone is controversial. They may be recommended, in particular, in patients with contraindications to oral corticosteroids. B-cell-depleting therapy and intravenous immunoglobulins may be considered in treatment-resistant cases. Omalizumab and dupilumab have recently shown promising results. The final version of the guideline was consented to by several patient organizations. CONCLUSIONS: The guidelines for the management of BP were updated. They summarize evidence- and expert-based recommendations useful in clinical practice.
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Dermatología , Penfigoide Ampolloso , Venereología , Corticoesteroides/uso terapéutico , Anciano , Vesícula/tratamiento farmacológico , Humanos , Penfigoide Ampolloso/diagnóstico , Penfigoide Ampolloso/tratamiento farmacológico , Calidad de VidaRESUMEN
BACKGROUND: Drug survival rates reflect efficacy and safety and may be influenced by the availability of alternative treatment options. Little is known about time-dependent drug survival in psoriasis and the effect of increasing numbers of biologic treatment options. OBJECTIVES: To determine whether drug survival is influenced by the availability of treatment options and by factors such as gender, psoriatic arthritis or previous biologic treatment. METHODS: This observational, retrospective, multicentre cohort study analysed data from patients registered in the Austrian Psoriasis Registry (PsoRA) who were treated with biologics between 1 January 2015 and 30 November 2019. RESULTS: A total of 1572 patients who received 1848 treatment cycles were included in this analysis. The highest long-term Psoriasis Area and Severity Index improvement was observed after treatment with ixekizumab, followed by ustekinumab and secukinumab, adalimumab and etanercept. Overall, ustekinumab surpassed all other biologics in drug survival up to 48 months. However, when adjusted for biologic naïvety, its superiority vanished and drug survival rates were similar for ixekizumab (91·6%), secukinumab (90·2%) and ustekinumab (92·8%), all of them superior to adalimumab (76·5%) and etanercept (71·9%) at 12 months and beyond. Besides biologic non-naïvety (2·10, P < 0·001), the introduction of a new drug such as secukinumab or ixekizumab (relative hazard ratio 1·6, P = 0·001) and female gender (1·50, P = 0·019) increased the risk of treatment discontinuation overall, whereas psoriatic arthritis did not (1·12, P = 0·21). CONCLUSIONS: The time-dependent availability of drugs should be considered when analysing and comparing drug survival. Previous biologic exposure significantly influences drug survival. Women are more likely to stop treatment.
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Productos Biológicos , Psoriasis , Adalimumab , Austria , Estudios de Cohortes , Etanercept , Femenino , Humanos , Psoriasis/tratamiento farmacológico , Sistema de Registros , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del Tratamiento , UstekinumabRESUMEN
BACKGROUND: Bullous pemphigoid (BP) is the most frequent autoimmune blistering disease mainly affecting elderly patients. Among several published risk factors, a recent post hoc analysis linked anti-BP180 autoantibodies (AABs) to fatal outcomes in BP. To date, this finding has not been confirmed independently. OBJECTIVE: To investigate the potential of anti-BP180-AAB levels as a marker of prognosis and to identify a cut-off level indicative of an increased risk for early death. Secondly, to characterize parameters associated with mortality. METHODS: Retrospective, single-centre study of BP patients diagnosed between 2001 and 2012. Analyses included epidemiological and patient- and disease-specific characteristics as well as immunological parameters at diagnosis and during follow-up. Standardized mortality ratios as well as uni- and multivariate regression analyses were calculated. RESULTS: One hundred patients (56 women, 44 men) with a median age of 81 years (interquartile range 74-86) were followed up for a median of 775 days (interquartile range 162-1617). One-year mortality rates were 25.0% implying a 2.4-fold increased risk of death compared with the general population. High anti-BP180 autoantibody levels at diagnosis (CI95 1.30-2.89; P = 0.001), dementia (CI95 1.13-6.72; P =0.03), length of hospitalization (CI95 1.16-2.41; P = 0.01) and age (CI95 1.23-4.19; P = 0.009) correlated significantly with 1-year mortality. BP180-AAB concentrations of ≥61 U/mL characterized a subgroup of patients with a particular higher risk for early death compared with the general population (CI95 1.81-3.81; P < 0.0001). CONCLUSION: In bullous pemphigoid, serum concentrations of BP180 autoantibodies at diagnosis could help to identify patients at risk for death within the first year after diagnosis (cut-off value 61 U/mL).
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Penfigoide Ampolloso , Anciano , Anciano de 80 o más Años , Autoanticuerpos , Autoantígenos , Ensayo de Inmunoadsorción Enzimática , Femenino , Humanos , Masculino , Colágenos no Fibrilares , Penfigoide Ampolloso/diagnóstico , Estudios RetrospectivosRESUMEN
BACKGROUND/OBJECTIVES: Direct closure (DC) of eyelid defects has been retrospectively shown to give excellent outcomes. We present prospective outcome data as further evidence to promote its wider use. SUBJECTS AND METHODS: A consecutive, unselected, series of patients undergoing eyelid tumour resection was studied prospectively. DC was attempted at the time of biopsy in all of them. If DC proved impossible, delayed reconstruction using other techniques was later performed. Defect size, pre- and post-operative palpebral aperture (PA) measurements and the final visit patients' and surgeons' satisfaction scores for function and appearance were recorded. RESULTS: Seventy-three eyelids of 70 patients were studied. Mean resected specimen width was 16.4 mm (4-26 mm) in the DC group, versus 23.9 mm (11-42 mm) for other, non-DC reconstructions. Primary DC was achieved in 74% of this cohort. Mean final post-operative PA measurements in the DC group were 0.7 mm vertically (p = 0.003) and 0.8 mm horizontally (p = 0.009) less than preoperatively, but there was no statistical difference (p = 0.1) in the final horizontal measurements between the operated and un-operated sides in the DC group. DC satisfaction scores were excellent for both eyelid function and appearance. CONCLUSIONS: DC of eyelid defects, irrespective of per-operative PA distortion, gives excellent late post-operative outcomes. We recommend that DC, aligning the closure tension parallel to the lid margin, is attempted whenever wound margin approximation is possible in preference to alternative reconstruction techniques, regardless of any temporary PA distortion and globe displacement that this may cause. Eyelid function and appearance recover to near normal within 2 months.
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Estética , Neoplasias de los Párpados/cirugía , Párpados/fisiología , Procedimientos Quirúrgicos Oftalmológicos , Neoplasias Cutáneas/cirugía , Adenocarcinoma Sebáceo/patología , Adenocarcinoma Sebáceo/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Basocelular/patología , Carcinoma Basocelular/cirugía , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Neoplasias de los Párpados/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nevo/patología , Nevo/cirugía , Estudios Prospectivos , Neoplasias Cutáneas/patología , Técnicas de Sutura , Resultado del TratamientoRESUMEN
BACKGROUND: Apremilast is a novel oral phosphodiesterase-4 inhibitor approved for psoriasis treatment. Randomized trials have documented its efficacy and safety, but data on real-world patients are scarce. OBJECTIVES: We aim to characterize psoriasis patients treated with apremilast in a real-world setting and calculate drug survival as an important measure of efficacy and compliance. METHODS: All patients with psoriasis who received apremilast between 1 April 2015 and 19 January 2017 were evaluated every 4 weeks, and we documented: age, weight, height, smoking status, family history of psoriasis, joint involvement, previous treatments, psoriasis area severity index (PASI) scores, and the onset and duration of adverse events (AE). Efficacy was analysed by PASI50, PASI75 and PASI90, reflecting the improvement of skin lesions compared to the PASI-baseline. Kaplan-Meier statistics were used for drug survival estimates. RESULTS: Forty-eight patients were included. The median apremilast drug survival was 12.5 weeks (range 1-87). Three patients (6.3%) reached PASI90, nine (18.8%) PASI75 and eight patients (16.7%) PASI50. Patient weight inversely correlated with a PASI50 response (P < 0.05, n = 37), and none of the obese patients (BMI > 30.0, n = 6) reached PASI75, compared to 32% of the non-obese patients (BMI < 30.0, n = 31). Thirty-one patients (64.6%) reported at least one AE, most frequently diarrhoea (n = 21, 43.8%), headache (n = 7, 14.6%) and joint pain (n = 5, 10.4%). CONCLUSIONS: Despite differences between real-world and trial patients, apremilast is safe and effective for the treatment of skin psoriasis in the daily practice. Up to 40% of patients will reach PASI50 or higher, but only few patients will reach PASI90. Bodyweight might affect drug efficacy.
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Antiinflamatorios no Esteroideos/uso terapéutico , Psoriasis/tratamiento farmacológico , Talidomida/análogos & derivados , Adulto , Anciano , Antiinflamatorios no Esteroideos/efectos adversos , Artralgia/inducido químicamente , Peso Corporal , Diarrea/inducido químicamente , Sustitución de Medicamentos , Femenino , Cefalea/inducido químicamente , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Obesidad/complicaciones , Estudios Prospectivos , Psoriasis/complicaciones , Índice de Severidad de la Enfermedad , Talidomida/efectos adversos , Talidomida/uso terapéutico , Factores de Tiempo , Adulto JovenRESUMEN
UNLABELLED: Mutations in the proto-oncogene c-KIT (KIT) are found in several cancers, and the site of these mutations differs markedly between cancer types. We used site directed mutagenesis to induce KIT(559), KIT(642) and KIT(816) mutations in primary human melanocytes (PHM) and we investigated the impact of each mutation on KIT function. We studied canonical KIT-signaling pathways by immunoblotting, and we used stable isotope labeling by amino acids in cell culture (SILAC) and kinase prediction models to identify kinases differently activated in respective mutants. We validated our results with the analysis of phosphorylation levels of selected substrates for each kinase. We concluded that CK1 ε and δ are more active in cell clones harboring KIT(559) and KIT(642) mutations, whereas PAK4 is more active in clones with KIT(816) mutation. Our findings might help to develop further therapeutic options for tumors with specific KIT mutations in different domains. BIOLOGICAL SIGNIFICANCE: Different types of cancers harbor mutations in the oncogene KIT. The use of small molecules inhibitors directly targeting KIT had a limited success in the treatment of patients with KIT mutant cancers. Our study describes specific phospho-proteome changes due to different KIT mutations, and provides targets of further therapeutic options.
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Melanocitos/química , Mutación , Proteoma/metabolismo , Proteínas Proto-Oncogénicas c-kit/genética , Caseína Quinasas/metabolismo , Células Cultivadas , Exones , Humanos , Melanocitos/metabolismo , Terapia Molecular Dirigida , Neoplasias/genética , Fosfoproteínas/metabolismo , Fosforilación , Proto-Oncogenes Mas , Transducción de Señal , Quinasas p21 Activadas/metabolismoRESUMEN
About one-third of cancers harbor activating mutations in rat sarcoma viral oncogene homolog (RAS) oncogenes. In melanoma, aberrant neuroblastoma-RAS (NRAS) signaling fuels tumor progression in about 20% of patients. Current therapeutics for NRAS-driven malignancies barely affect overall survival. To date, pathway interference downstream of mutant NRAS seems to be the most promising approach. In this study, data revealed that mutant NRAS induced Polo-like kinase 1 (Plk1) expression, and pharmacologic inhibition of Plk1 stabilized the size of NRAS mutant melanoma xenografts. The combination of mitogen-activated protein kinase/extracellular signal-regulated kinase kinase (MEK) and Plk1 inhibitors resulted in a significant growth reduction of NRAS mutant melanoma cells in vitro, and regression of xenografted NRAS mutant melanoma in vivo. Independent cell cycle arrest and increased induction of apoptosis underlies the synergistic effect of this combination. Data further suggest that the p53 signaling pathway is of key importance to the observed therapeutic efficacy. This study provides in vitro, in vivo, and first mechanistic data that an MEK/Plk1 inhibitor combination might be a promising treatment approach for patients with NRAS-driven melanoma. As mutant NRAS signaling is similar across different malignancies, this inhibitor combination could also offer a previously unreported treatment modality for NRAS mutant tumors of other cell origins.
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Proteínas de Ciclo Celular/metabolismo , MAP Quinasa Quinasa 1/metabolismo , Melanoma/patología , Inhibidores de Proteínas Quinasas/farmacología , Proteínas Serina-Treonina Quinasas/metabolismo , Proteínas Proto-Oncogénicas/metabolismo , Neoplasias Cutáneas/patología , Animales , Puntos de Control del Ciclo Celular/efectos de los fármacos , Proteínas de Ciclo Celular/genética , Línea Celular Tumoral , Modelos Animales de Enfermedad , Genes ras/genética , Xenoinjertos , Humanos , MAP Quinasa Quinasa 1/genética , Melanoma/metabolismo , Proteínas Serina-Treonina Quinasas/genética , Proteínas Proto-Oncogénicas/genética , Distribución Aleatoria , Ratas , Transducción de Señal/efectos de los fármacos , Transducción de Señal/genética , Neoplasias Cutáneas/metabolismo , Quinasa Tipo Polo 1RESUMEN
BACKGROUND: Mycoplasma pneumoniae, a bacterium known to be a common cause of pneumonia, has been documented to cause complications such as debilitating mucositis previously described as an atypical Stevens-Johnson syndrome without skin lesions. However, in the spectrum of epidermal dermatopathies, the condition is increasingly recognized as a separate entity, now termed M. pneumoniae-associated mucositis (MPAM). OBJECTIVES: We present a case of MPAM and systemically review the literature to discuss diagnostic and therapeutic options. METHODS: A systematic literature search was performed to find studies reporting MPAM in adults. We extracted and analysed patient demographics, disease symptomatology, diagnostic testing and treatment. RESULTS: Eleven articles, describing 12 patients and our own patient met the predefined criteria and were analysed. Respiratory, ocular and oral symptoms were present in all patients. Therapies predominantly included antibiotics (10 of 13) and immunosuppressive treatment (9 of 13) leading to complete resolution of symptoms in all patients. CONCLUSION: Our findings highlight that MPAM should be recognized as a distinct disease entity within the spectrum of epidermal dermatopathies. We discuss and show in our patient why M. pneumoniae IgA serum levels could prove to be more reliable diagnostic tools in the MPAM diagnosis than the widely used IgG and IgM titre levels.
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Mucositis/microbiología , Mycoplasma pneumoniae/patogenicidad , Adolescente , Adulto , Humanos , Adulto JovenRESUMEN
BACKGROUND: There are conflicting data on markers of disease progression and outcome of Merkel cell carcinoma. OBJECTIVE: We suggest to review histological and various immunohistochemical features of Merkel cell carcinoma specimens, in order to identify prognostic markers of clinical relevance. METHODS: We collected paraffin-embedded blocks from primary tumours from 26 patients diagnosed with Merkel cell carcinoma and determined the following: type and size of the tumour, number of mitoses, proliferation rate (Ki-67 antibody), (anti)-apoptosis rate (bcl-2, p53, p63 antibodies) and lymphatic vessel invasion (D2-40 antibody for podoplanin). Two authors blinded to clinical outcome, independently assessed and scored all samples. The findings were correlated with tumour progression, which was determined by local recurrence, lymph node- or distant metastases. RESULTS: During the average follow-up period of 63.4 months 12 (46%) patients had disease progression. Statistical analysis revealed Ki-67-staining (P = 0.005) as a marker of disease progression, high number of mitoses (P = 0.026) correlated with lymph node metastasis, while a tendency for increased Bcl-2 expression (P = 0.064) was found in patients with local recurrence. A higher number of invaded lymphatic capillaries showed a tendency in correlation with metastases (P = 0.072). CONCLUSION: The findings indicate that high numbers of mitoses, proliferation and survival of tumour cells as marked by Ki-67- and Bcl-2-staining, and infiltration of lymphatic vessels, might correlate with the biological behaviour of Merkel cell carcinoma.
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Carcinoma de Células de Merkel/patología , Antígeno Ki-67/metabolismo , Mitosis , Proteínas Proto-Oncogénicas c-bcl-2/metabolismo , Neoplasias Cutáneas/patología , Anciano , Anciano de 80 o más Años , Carcinoma de Células de Merkel/inmunología , Carcinoma de Células de Merkel/metabolismo , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Cutáneas/inmunología , Neoplasias Cutáneas/metabolismoRESUMEN
BACKGROUND: Interleukin-2 (IL-2) treatment for patients with metastatic melanoma has shown remarkable durable responses. Systemic administration of IL-2 may cause severe side effects, whereas local administration is considered to be a safe alternative. The lungs are common sites of metastases in melanoma patients causing considerable respiratory problems. We sought to evaluate the potential antitumoral effect of a low-dose inhalative IL-2 (lh-IL-2) regimen for patients with melanoma lung metastases. In addition, we explored the prophylactic potential of Ih-IL-2 after surgical removal of lung metastases in a study carried out in an outpatient setting. METHODS: Twenty patients with American Joint Committee on Cancer stage-IV (M1b and M1c) melanoma were enrolled in this study and treated with 3 × 3 million IU inhalative IL-2 q.d. together with monthly dacarbazine bolus injections. Five patients received lh-IL-2 after surgical resection of lung metastases to prevent recurrence of the disease (prophylaxis group, N=5). All other patients were enrolled in the treatment group (N=15). Clinical evaluations were carried out monthly and radiological follow-up was performed every third month. RESULTS: Nine patients in the treatment group had a clinical benefit with partial regression (27%) or stable disease (33%). Four patients had progression of lung metastases (26.7%) and two patients were not evaluable (13.3%). In the prophylaxis group, none of the patients developed new lung metastases during lh-IL-2 therapy. The median follow-up period was 7.8 months in the treatment group and 25.7 months in the prophylaxis group. In the majority of patients, treatment was well tolerated. CONCLUSIONS: Low-dose IL-2 inhalation might offer an effective and safe treatment option for lung metastases in melanoma patients. In addition, lh-IL-2 may have a prophylactic potential to prevent recurrence in the lungs after pulmonary melanoma metastasectomy. Administration can easily be performed in an outpatient setting, thus offering an attractive treatment option.
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Interleucina-2/administración & dosificación , Neoplasias Pulmonares/tratamiento farmacológico , Neoplasias Pulmonares/secundario , Melanoma/tratamiento farmacológico , Administración por Inhalación , Progresión de la Enfermedad , Femenino , Humanos , Interleucina-2/efectos adversos , Neoplasias Pulmonares/cirugía , Masculino , Melanoma/patología , Persona de Mediana Edad , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/efectos adversos , Resultado del TratamientoRESUMEN
INTRODUCTION: Sexually transmitted diseases are the most often registered communicable diseases in a great number of countries. The aim of this study was to analyze dynamics and distribution of gonorrhea, syphilis and scabies in Vojvodina region during the last twenty years. MATERIAL AND METHODS: Epidemiological characteristics of gonorrhea, syphilis and scabies were analyzed on the basis of data obtained from the Section of Epidemiology of the Institute of Public Health in Novi Sad. The research included the period between 1980 and 1999, with sex and age distribution of patients. Morbidity rates were given per number of inhabitants of Vojvodina. RESULTS: In the period between 1980-1999 there were 454 registered patients with the diagnosis of syphilis in Vojvodina. The morbidity ratio was highest in 1980 (3.41/100.000), and lowest in 1991 (0.24/100.000). In the twenty-year period there were more patients with gonorrhea, than patients with syphilis. There were 44.621 registered patients with gonorrhea. The maximum morbidity ratio was in 1980 (25.09/100.000), but the minimum was in 1998 (1.68/100.000). Within the examined period scabies was recorded in 56.490 patients. The highest morbidity ratio was in 1984 (232.37/100.000) and the lowest was in 1992 (73.56/100.000). DISCUSSION: The average morbidity ratio of syphilis in USA, between 1992-1994, was 11.8/100.000 and at the same time in Vojvodina it was only 0.42/100.000. In Vojvodina most patients with this disease were 20-39 years old. In the same period in USA the ratio of gonorrhea patients was 309/100.000 and in Vojvodina it was 2/100.000. In this group also, most patients were 20-39 years old. However, scabies mostly appeared at the age of 7-14. CONCLUSION: According to the obtained results, the number of registered patients with these three diseases in Vojvodina stagnates or it decreases. In order to deal with real data, it is necessary to report these diseases regularly.
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Gonorrea/epidemiología , Escabiosis/epidemiología , Sífilis/epidemiología , Adolescente , Adulto , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Yugoslavia/epidemiologíaRESUMEN
BACKGROUND: Pancreatitis after biliary stenting is a rare complication. To reduce this risk, some endoscopists routinely perform biliary sphincterotomy before stenting, but the value of this practice is not established. METHODS: The incidence of pancreatitis was reviewed in patients undergoing biliary stenting with and without a biliary sphincterotomy. RESULTS: Postprocedure pancreatitis occurred in 4 of 83 (4.8%) patients treated with transpapillary biliary stents. Patients with proximal biliary strictures were at significantly increased risk for postprocedure pancreatitis (4 of 24) versus those with distal or no strictures (0 of 59) (p = 0.006). The four patients with pancreatitis after stenting had not undergone sphincterotomy. Of those treated conservatively, two cases were graded severe (one fatal), and one was mild. The other patient was markedly symptomatic from pancreatitis, but improved dramatically after treatment with a needle-knife sphincterotomy done within 24 hours of the original ERCP. CONCLUSION: The risk of pancreatitis following transpapillary biliary stenting is increased in patients with proximal biliary strictures. Such lesions (malignant or benign) may serve as a fulcrum, leading to medial deflection of the stent and compression of the pancreatic orifice. The hypothesis that sphincterotomy may decrease the risk of biliary stent-induced obstructive pancreatitis should be tested in patients with proximal biliary strictures.
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Enfermedades de los Conductos Biliares/cirugía , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Pancreatitis/prevención & control , Esfinterotomía Endoscópica/instrumentación , Stents/efectos adversos , Adulto , Anciano , Enfermedades de los Conductos Biliares/diagnóstico , Colangiopancreatografia Retrógrada Endoscópica/métodos , Femenino , Humanos , Masculino , Pancreatitis/etiología , Pronóstico , Factores de Riesgo , Esfinterotomía Endoscópica/métodosRESUMEN
PURPOSE: To determine the feasibility of using the Amplatz thrombectomy device (ATD) to treat massive pulmonary embolism (PE). PATIENTS AND METHODS: Five patients (four men, one woman; mean age, 45.2 years) with massive PE underwent mechanical thrombectomy with the ATD, which creates a vortex that pulverizes and recirculates the clots within the pulmonary circulation. The patients were followed up for 7-18 months after thrombectomy. RESULTS: Marked improvement in pulmonary perfusion was observed in three patients at angiography and ventilation-perfusion scanning. No changes could be assessed in one patient who died shortly after the procedure. One patient developed hemoptysis during the procedure, most likely because of a reperfusion syndrome. A reduction in pulmonary artery pressure was observed in only one patient; the remaining patients had increased pressure. The four surviving patients were discharged within 8 days. CONCLUSION: Mechanical thrombectomy with the ATD provides rapid debulking of thrombus in some patients with massive PE and has the potential to improve treatment and outcomes of the most sick patients.
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Embolia Pulmonar/cirugía , Trombectomía/instrumentación , Adulto , Angiografía , Presión Sanguínea , Cateterismo de Swan-Ganz , Diseño de Equipo , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Hemoptisis/etiología , Humanos , Masculino , Persona de Mediana Edad , Arteria Pulmonar/diagnóstico por imagen , Circulación Pulmonar , Daño por Reperfusión/etiología , Tasa de Supervivencia , Trombectomía/efectos adversos , Trombectomía/métodos , Resultado del Tratamiento , Relación Ventilacion-PerfusiónRESUMEN
Bullet emboli to the heart are rare and are typically treated by operative extraction through a median sternotomy and cardiotomy. This report details the case of an 18-year-old male who sustained two gunshot wounds, one of which lodged in his left renal vein. At laparotomy, the bullet embolized to the right atrium via the inferior vena cava. Under fluoroscopic guidance the bullet was retrieved with a snare introduced percutaneously through the right internal jugular vein. Sternotomy and possible cardiopulmonary bypass were avoided.
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Embolia/cirugía , Lesiones Cardíacas/cirugía , Heridas por Arma de Fuego/cirugía , Adolescente , Embolia/etiología , Lesiones Cardíacas/complicaciones , Humanos , Venas Yugulares , Masculino , Heridas por Arma de Fuego/complicacionesRESUMEN
PURPOSE: To report the preliminary results in a trial comparing the Amplatz mechanical thrombectomy (MT) device with surgical thrombectomy (ST) to declot occluded dialysis access grafts. PATIENTS AND METHODS: Thirty-seven patients were randomly assigned by computer to either ST (n = 18) or MT (n = 19). Diagnostic fistulograms were obtained at the end of the procedure, and Doppler ultrasound was performed at 1-month follow-up. Plasma free hemoglobin levels were measured before, immediately after, and 24 hours after the procedure in the MT group. Success was defined as initial success with restoration of flow through the graft, primary patency at 30 days, and secondary patency at 30 days. RESULTS: Technical success with MT was 89%. Primary patency in the MT series was 47% and secondary 30-day patency was 68%. Technical success with ST was 83%. Primary patency in the ST series was 77% and secondary patency at 30 days was 77%. Angioplasty (n = 18) and stent placement (n = 6) were performed in the MT cases. Angioplasty was impossible in one patient. Immediately after MT, plasma free hemoglobin levels above normal were noted in 63% of the cases, but these levels were within normal levels after 24 hours in 88% of the cases. CONCLUSION: Initial success of MT in patients with occluded dialysis access grafts is comparable to that of ST. No statistically significant differences in primary or secondary patencies were seen.
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Oclusión de Injerto Vascular/terapia , Diálisis Renal , Trombectomía/instrumentación , Trombectomía/métodos , Trombosis/terapia , Derivación Arteriovenosa Quirúrgica , Prótesis Vascular , Cateterismo , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/cirugía , Humanos , Masculino , Persona de Mediana Edad , Politetrafluoroetileno , Succión/instrumentación , Succión/métodos , Trombosis/diagnóstico por imagen , Trombosis/cirugía , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía , Grado de Desobstrucción VascularRESUMEN
PURPOSE: To describe the spectrum of radiologic findings in crutch-induced axillary artery injury and the effects of its unique pathophysiology on diagnostic evaluation and treatment. METHODS: Three patients with axillary crutch-induced axillobrachial injury were studied angiographically and percutaneous intervention was performed in two cases. RESULTS: One patient required surgical bypass of a thrombosed axillary artery aneurysm. One patient responded to percutaneous transluminal angioplasty (PTA) of a focal axillary artery stenosis. One patient with an axillary artery aneurysm and distal thromboembolic disease was treated by both thrombolysis and surgical thromboembolectomy and later by PTA of an axillary artery intimal disruption. CONCLUSION: Chronic axillary crutch use may be associated with axillary artery stenosis, aneurysm formation, and secondary axillobrachial thromboembolic disease. Mural injury can be successfully treated by PTA and thromboembolic disease by thrombolytic therapy. Early identification of the axillary artery lesion is critical for long-term therapeutic results.
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Axila/irrigación sanguínea , Muletas/efectos adversos , Anciano , Aneurisma/etiología , Aneurisma/terapia , Angiografía , Angioplastia de Balón , Arterias/lesiones , Arteria Braquial/lesiones , Constricción Patológica/etiología , Constricción Patológica/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tromboembolia/etiología , Tromboembolia/terapiaRESUMEN
Splenic vein occlusion due to chronic pancreatitis may result in "left-sided portal hypertension," which is associated with gastric variceal hemorrhage. Intraoperative hemorrhage is also a major problem in this patient group, and it has been suggested that preoperative splenic arterial occlusion offers a means to diminish intraoperative blood loss. In order to assess the benefit of preoperative control of arterial inflow on intraoperative blood loss, we reviewed retrospectively 16 cases of chronic pancreatitis and associated splenic vein occlusion in patients who had splenectomy. There was a significant difference in estimated intraoperative blood loss in the two patient groups (P less than .05). Preoperative inflow control was obtained with a wedge balloon catheter or autologous clot embolization with an estimated mean blood loss of 1771 mL in seven patients. Nine patients had splenectomy without inflow control, with a mean estimated intraoperative blood loss of 3332 mL. The mean difference was 1560 mL. Preoperative control of splenic artery inflow can diminish intraoperative blood loss during splenectomy in the presence of splenic vein occlusion associated with chronic pancreatitis.
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Cateterismo/métodos , Hemorragia/prevención & control , Cuidados Preoperatorios/métodos , Esplenectomía/métodos , Arteria Esplénica/fisiopatología , Vena Esplénica , Adulto , Anciano , Enfermedad Crónica , Femenino , Humanos , Complicaciones Intraoperatorias/prevención & control , Masculino , Persona de Mediana Edad , Pancreatectomía/métodos , Pancreatitis/complicaciones , Pancreatitis/cirugía , Estudios Retrospectivos , Enfermedades Vasculares/etiología , Enfermedades Vasculares/fisiopatologíaRESUMEN
A retrospective review of 20 adult patients with splanchnic venous obstruction secondary to chronic pancreatitis was performed to identify factors important in the preoperative diagnosis and operative management of this disorder. Fifteen patients with isolated splenic vein obstruction, four with portal occlusion and one with isolated inferior mesenteric vein occlusion were studied. Chronic alcoholism was the etiology of the pancreatitis in 18 patients; two patients had a Type IV hyperlipidemia. Four patients with massive hemorrhage from gastric varices were treated with splenectomy. Most patients presented with complaints of chronic pancreatitis, requiring pancreaticojejunostomy to treat the underlying pancreatic disorder. Splenic artery inflow control was obtained preoperatively in six patients and offers a technique that is beneficial in decreasing operative blood loss. The dynamic computerized tomography (CT) scan was a valuable diagnostic tool in identifying splanchnic venous obstruction although selective angiography is required for confirmation of the diagnosis.