Spontaneous Hepatic Hemorrhage Causing Acute Liver Failure Requiring Liver Transplant.

Spontaneous hepatic hemorrhage (SHH) is a very rare but life-threatening entity that results from a breach in the hepatic parenchyma without any external cause, the most common being hepatocellular carcinoma and hepatic adenoma. We present a case of SHH without any underlying tumor or injury. The cause in our patient remained unclear, but we hypothesize that the patient's SHH was most likely coagulopathy-related.

Safety of Utilizing Ultrasound as the Sole Modality of Follow-Up after Endovascular Aneurysm Repair.

BACKGROUND: Post endovascular aneurysm repair (EVAR), surveillance with computed tomography-aortography (CTA) remains the most common practice, per Society for Vascular Surgery (SVS) guidelines. Chronic exposure to both radiation and intravenous (IV) contrast has raised concerns about long-term CTA follow-up (FU). As we have selectively used ultrasound (US) as a sole modality for post-EVAR surveillance, we sought to review our outcomes in this subset of patients. METHODS: Retrospective review of our institution's vascular database identified 213 EVAR patients from 2013 to 2021. Fenestrated-EVAR and snorkel reconstructions were excluded. Patient demographics/outcomes, abdominal aortic aneurysm (AAA) characteristics, and FU modalities and outcomes were analyzed. Unpaired Student's t-test, ANOVA, and chi-squared test were used to assess group differences. RESULTS: Eighty-five of the 213 EVAR patients (39.9%) were lost to FU within 3 months. Among the 128 remaining patients, 91 underwent FU using initial US, while 37 patients underwent post-EVAR FU initially using CTA. There were no significant differences (P > 0.05) between patient age (75.5 ± 9.4 vs. 75.3 ± 8.5), body mass index (BMI) (27.7 ± 5.4 vs. 28.9 ± 7.4), or mean AAA size (5.6 ± 1.1 vs. 5.9 ± 1.2) in US-surveilled and computed tomography (CT)-surveilled groups, respectively. Of the 91 patients, initially surveilled with US, 15 patients demonstrated endoleak and/or AAA growth (>5 mm). The 15 patients with US-demonstrated endoleak and/or growth underwent confirmatory CTA, with 3 patients eventually requiring EVAR revision. Among 37 patients initially surveilled with CT, 10 demonstrated significant growth and 2 patients eventually required EVAR revision. There were no patients with AAA rupture during post-EVAR surveillance. FU data were analyzed among a select lower-risk group of patients (preoperative AAA diameter ≤5.5 cm, BMI ≤30, and no endoleak at completion of EVAR). Among this group, there were no surveilled patients who required EVAR reintervention, regardless of surveillance modality (US n = 32; CT n = 4). The average FU was 29.5 ± 26.4 months in the US group and 26.4 ± 22.3 months in the CT group (P > 0.05). CONCLUSIONS: Although initial CT surveillance following EVAR remains ideal, in select lower-risk patients, US is a viable alternative even for the initial post-procedure study. Advantages include decreased radiation exposure and cost. Our data suggest that US is a safe sole modality for surveillance following EVAR in selective patients.

Blood-Related Toxicity after Traumatic Brain Injury: Potential Targets for Neuroprotection.

Emergency visits, hospitalizations, and deaths due to traumatic brain injury (TBI) have increased significantly over the past few decades. While the primary early brain trauma is highly deleterious to the brain, the secondary injury post-TBI is postulated to significantly impact mortality. The presence of blood, particularly hemoglobin, and its breakdown products and key binding proteins and receptors modulating their clearance may contribute significantly to toxicity. Heme, hemin, and iron, for example, cause membrane lipid peroxidation, generate reactive oxygen species, and sensitize cells to noxious stimuli resulting in edema, cell death, and increased morbidity and mortality. A wide range of other mechanisms such as the immune system play pivotal roles in mediating secondary injury. Effective scavenging of all of these pro-oxidant and pro-inflammatory metabolites as well as controlling maladaptive immune responses is essential for limiting toxicity and secondary injury. Hemoglobin metabolism is mediated by key molecules such as haptoglobin, heme oxygenase, hemopexin, and ferritin. Genetic variability and dysfunction affecting these pathways (e.g., haptoglobin and heme oxygenase expression) have been implicated in the difference in susceptibility of individual patients to toxicity and may be target pathways for potential therapeutic interventions in TBI. Ongoing collaborative efforts are required to decipher the complexities of blood-related toxicity in TBI with an overarching goal of providing effective treatment options to all patients with TBI.

Role of the PGE2 receptor subtypes EP1, EP2, and EP3 in repetitive traumatic brain injury.

AIMS: The goal was to explore the signaling pathways of PGE2 to investigate therapeutic effects against secondary injuries following TBI. METHODS: Young (4.9 ± 1.0 months) and aged (20.4 ± 1.4 months) male wild type (WT) C57BL/6 and PGE2 EP1, 2, and 3 receptor knockout mice were selected to either receive sham or repetitive concussive head injury. Immunohistochemistry protocols with Iba1 and GFAP were performed to evaluate microgliosis and astrogliosis in the hippocampus, two critical components of neuroinflammation. Passive avoidance test measured memory function associated with the hippocampus. RESULTS: No differences in hippocampal microgliosis were found when aged EP2-/- and EP3-/- mice were compared with aged WT mice. However, the aged EP1-/- mice had 69.2 ± 7.5% less hippocampal microgliosis in the contralateral hemisphere compared with WT aged mice. Compared with aged EP2-/- and EP3-/- , EP1-/- aged mice had 78.9 ± 5.1% and 74.7 ± 6.2% less hippocampal microgliosis in the contralateral hemisphere. Within the EP1-/- mice, aged mice had 90.7 ± 2.7% and 81.1 ± 5.6% less hippocampal microgliosis compared with EP1-/- young mice in the contralateral and ipsilateral hemispheres, respectively. No differences were noted in all groups for astrogliosis. There was a significant difference in latency time within EP1-/- , EP2-/- , and EP3-/- on day 1 and day 2 in aged and young mice. CONCLUSION: These findings demonstrate that the PGE2 EP receptors may be potential therapeutic targets to treat repetitive concussions and other acute brain injuries.