Ischaemic Priapism: A Complication of Self-Administered Hyaluronic Acid Gel as an Injectable Filler for Penile Augmentation

Background: Injectable hyaluronic acid (HA) gel has emerged as a widely used soft tissue filler for surgeries. In penile reconstructivesurgery, HA gel has been employed for penile or glans augmentation in selected patients diagnosed with micropenis.This augmentation technique involves injecting the gel into submucosal tissue and increasing the size of the penis for approximately1 year. A few studies have investigated the possible complications correlated with medically assisted penile injections ofHA gel. However, no previous reports have shown the complications of self-administered HA injection. This case report aims topresent the first documented case of ischaemic priapism as a complication of self-administered HA injection.Case Presentation: We present the case of a 43-year-old male who self-administered a 20 mL injection of HA into the dorsal sideof his penis. The injected material probably reached the corpora cavernosa, leading to priapism within a few hours. However,the patient did not seek medical attention until 72 h later. The first two initial conservative attempts of blood drainage wereunsuccessful because the gel had obstructed vein drainage, causing the penis to remain in a state of priapism. The final treatmentapproach involved shunting, high enoxaparin doses and oral Effortil administration.Conclusions: While complications from medically assisted HA injections have been documented, this case report sheds light onthe complications arising from self-administered penile injections. Priapism is a severe medical condition that requires immediatetreatment to avoid potentially serious long-term consequences. Healthcare providers and patients must acknowledge itssymptoms and its appropriate course of treatment, especially in the context of penile medical injections. (AU)

Right heart echocardiographic variables and prediction of clinical severity in dogs with pulmonary stenosis.

BACKGROUND: Pulmonary stenosis (PS) usually is evaluated using echocardiography. A multiparametric approach, in addition to the maximum pressure gradient (PG), might be indicated to better characterize PS severity and address its management. HYPOTHESIS/OBJECTIVES: Our hypothesis was that right heart size and function are associated with echocardiographic and clinical severity of pulmonary stenosis in dogs. ANIMALS: Client-owned dogs with PS. METHODS: Prospective, multicenter, observational study. Enrolled dogs underwent complete echocardiographic examination. Associations among right heart echocardiographic variables, PS transvalvular PG >80 mm Hg and presence of clinical signs (exercise intolerance, syncope, right-sided congestive failure, or some combination of these) were assessed using logistic regression analysis. RESULTS: Eighty-eight dogs with PS. Twenty-eight dogs were symptomatic. Increased right ventricular end-diastolic free wall thickness (odds ratio [OR] > 100; 95% confidence interval [95%CI], 50- > 100; P = .01) and decreased aorta-to-pulmonary artery velocity time integral ratio (OR, < 0.001; 95%CI, 0.0-0.001; P = .005) were independently associated with PS PG >80 mm Hg. Decreased tricuspid annular plane systolic excursion (OR, 0.35; 95%CI, 0.15-0.77; P = .01) and increased right ventricular end-diastolic area (OR, 1.4; 95%CI, 1.08-2.02; P = .01) were independently associated with clinical severity. CONCLUSION AND CLINICAL IMPORTANCE: Structural and functional right heart echocardiographic variables are associated with echocardiographic and clinical severity in dogs with PS. A multiparametric approach is advised to better assess PS severity.

Ischaemic Priapism: A Complication of Self-Administered Hyaluronic Acid Gel as an Injectable Filler for Penile Augmentation.

BACKGROUND: Injectable hyaluronic acid (HA) gel has emerged as a widely used soft tissue filler for surgeries. In penile reconstructive surgery, HA gel has been employed for penile or glans augmentation in selected patients diagnosed with micropenis. This augmentation technique involves injecting the gel into submucosal tissue and increasing the size of the penis for approximately 1 year. A few studies have investigated the possible complications correlated with medically assisted penile injections of HA gel. However, no previous reports have shown the complications of self-administered HA injection. This case report aims to present the first documented case of ischaemic priapism as a complication of self-administered HA injection. CASE PRESENTATION: We present the case of a 43-year-old male who self-administered a 20 mL injection of HA into the dorsal side of his penis. The injected material probably reached the corpora cavernosa, leading to priapism within a few hours. However, the patient did not seek medical attention until 72 h later. The first two initial conservative attempts of blood drainage were unsuccessful because the gel had obstructed vein drainage, causing the penis to remain in a state of priapism. The final treatment approach involved shunting, high enoxaparin doses and oral Effortil administration. CONCLUSIONS: While complications from medically assisted HA injections have been documented, this case report sheds light on the complications arising from self-administered penile injections. Priapism is a severe medical condition that requires immediate treatment to avoid potentially serious long-term consequences. Healthcare providers and patients must acknowledge its symptoms and its appropriate course of treatment, especially in the context of penile medical injections.

Percutaneous Balloon Dilation in Two Dogs with Cor Triatriatum Dexter.

Percutaneous balloon dilation was performed in a Rhodesian Ridgeback and in an American Staffordshire Terrier affected by cor triatriatum dexter (CTD). Both cases had ascites without jugular venous distension or pleural effusion. In both dogs the CTD presented a perforated membrane but with different morphology: in one case the coronary sinus entered the caudal chamber of the CTD together with the caudal vena cava. In the other case, the coronary sinus communicated with the cranial chamber of the CTD together with the cranial vena cava. Percutaneous balloon dilation of the CTD was successfully performed, and both dogs had uneventful surgery recoveries. At two years of follow-up, the dogs were free from clinical signs and cardiac medication.

Transjugular Patent Ductus Arteriosus Occlusion in Seven Dogs Using the Amplatzer Vascular Plug II.

Although vascular plugs for the closure of patent ductus arteriosus (PDA) have been validated in dogs, studies are lacking on its use as a first-choice device with a transjugular approach. The present case series describes the transvenous right jugular embolization of PDA using an Amplatzer Vascular Plug II in seven dogs of different ages, breeds, and body weights. Complete closure of the PDA was demonstrated in all cases. All dogs showed significant hemodynamic reduction of pulmonary overcirculation and left heart size after the procedure and at following echocardiographic check-ups. Transjugular PDA occlusion using an Amplatzer Vascular Plug II can thus be considered as a safe alternative to the arterial or venous femoral approach using an Amplatzer canine ductal occluder (ACDO), particularly in puppies with small femoral vessels.

Abnormalities of External Jugular Veins in Bulldogs with Pulmonary Valve Stenosis.

Two French bulldogs and one English bulldog affected by pulmonary valve stenosis and referred for pulmonary balloon valvuloplasty were diagnosed with different abnormalities of the external jugular veins. The diagnosis included unilateral absence of the right external jugular vein and bilateral hypoplasia of the external jugular veins, associated with persistent left cranial vena cava. Vascular ultrasound and computed tomography were used for the diagnosis. Jugular vein anomalies can affect decision-making regarding the central venous catheterization needed to perform procedures such as pulmonary balloon valvuloplasty or central catheter placement. Based on the results of the present case series, anomalies of external jugular veins should be considered in French and English bulldogs when the external jugular veins cannot be palpated or when echocardiography shows coronary sinus dilation. Vascular ultrasound or computed tomography may help identify jugular venous anomalies and should be considered in the preoperative evaluation of bulldogs that need to undergo interventional procedures requiring transjugular catheterization.

Clinical and Electrocardiographic Findings for Predicting the Severity of Pulmonary Valve Stenosis in Dogs.

Pulmonary valve stenosis (PS) in dogs is usually suspected due to the presence of a heart murmur and clinical signs. Echocardiography is needed to confirm the diagnosis and define the severity of PS. This retrospective study evaluated the utility of clinical and electrocardiographic (ECG) findings in the prediction of PS severity. Data regarding heart murmur and ECG analysis were gathered. Ninety-seven dogs with PS were included. A murmur grade ≥IV/VI was predictive of severe PS (area under curve (AUC) = 0.71; sensitivity (Se) = 95%; specificity (Sp) = 33%; p = 0.003). In lead II, P wave amplitude >0.35 mV (AUC = 0.67; Se = 31%; Sp = 100%; p = 0.038), Q wave < 0.15 mV (AUC = 0.70; Se = 70%; Sp = 59%; p = 0.0015), R wave < 0.87 mV (AUC = 0.66; Se = 67%; Sp = 69%; p = 0.006), and S wave > 0.37 mV (AUC = 0.80; Se = 72%; Sp = 85%; p < 0.0001) were predictive of severe PS. The extent of right deviation of the mean electrical axis of the QRS complex was correlated with the pulmonary pressure gradient (r = 0.648; p < 0.0001). In conclusion, a systolic murmur with intensity ≥IV/VI, a P wave amplitude >0.35 mV, low amplitude of Q and R waves, deep S waves in lead II, and right axis deviation of the QRS complex in a young dog are predictive of severe PS.

The Mitral INsufficiency Echocardiographic score: A severity classification of myxomatous mitral valve disease in dogs.

BACKGROUND: There is no commonly shared severity score for myxomatous mitral valve disease (MMVD) based on routinely acquired echocardiographic variables. HYPOTHESIS/OBJECTIVES: To propose an easy-to-use echocardiographic classification of severity of MMVD in dogs. ANIMALS: Five hundred and sixty dogs with MMVD. METHODS: This was a retrospective, multicenter, observational study. The proposed Mitral INsufficiency Echocardiographic (MINE) score was based on 4 echocardiographic variables: left atrium-to-aorta ratio, left ventricular end-diastolic diameter normalized for body weight, fractional shortening, and E-wave transmitral peak velocity. Specific echocardiographic cutoffs were defined based on previous prognostic studies on MMVD, and severity scores were assigned as follows: mild (score: 4-5), moderate (score: 6-7), severe (score: 8-12), late stage (score: 13-14). RESULTS: Median survival time was significantly different (P < .05) between the proposed severity classes: mild (2344 days, 95% confidence interval [CI] 1877-2810 days), moderate (1882 days, 95% CI 1341-2434 days), severe (623 days, 95% CI 432-710 days), and late stage (157 days, 95% CI 53-257 days). A MINE score >8 was predictive of cardiac death (area under the curve = 0.85; P < .0001; sensitivity 87%, specificity 73%). In the multivariable analysis, all the echocardiographic variables of the MINE score were independent predictors of death because of heart disease (P < .001). CONCLUSIONS AND CLINICAL IMPORTANCE: The MINE score is a new easy-to-use echocardiographic classification of severity of MMVD, which has been proven to be clinically effective as it is associated with survival. This classification provides prognostic information and could be useful for an objective echocardiographic assessment of MMVD.

Repair of a rectovesical fistula following laparoscopic radical prostatectomy with Martius fat pad flap interposition: a proposal of a new technique.

Rectovesical fistula (RVF) is defined as an abnormal communication between the rectum and the urinary bladder, most commonly after an iatrogenic injury during pelvic surgery. Patients with RVF may have various clinical presentations, ranging from fecaluria, pneumaturia, to urine leakage through the anus. The quality of life for patients with this pathology is adversely affected owing to the associated psychological burden. Surgery is the preferred treatment given the low success rates reported for conservative or minimally invasive approaches. Herein, we present a case of a 65-year-old man with RVF after radical prostatectomy successfully treated by a transperineal approach using a modified Martius procedure.

Left atrial anteroposterior diameter in dogs: reference interval, allometric scaling, and agreement with the left atrial-to-aortic root ratio.

Left atrial enlargement (LAE) is a well-known negative prognostic factor in dogs with myxomatous mitral valve disease (MMVD). Left atrial-to-aortic root ratio (LA/Ao) is the most commonly used method to evaluate left atrial (LA) size in dogs, while the left atrial anteroposterior diameter (LAD) has been proposed as an additional measurement of LA size in different species. The aim of this study was to establish a normal reference range of LAD normalized to body weight (LADn) in dogs using allometric scales, and to evaluate the agreement between LADn and LA/Ao in the detection of LAE in dogs with MMVD. This was a retrospective, multicenter, observational study. We included 330 healthy dogs, 30 dogs with MMVD in ACVIM stage B1, 30 dogs in ACVIM stage B2, and 30 dogs in ACVIM stage C. The reference range for the LAD, depending on body weight, was between 16.91 mm and 49.68 mm. The reference range for the LADn in healthy dogs was between 10.49 and 15.72. LADn was significantly greater in dogs with MMVD compared to healthy dogs, and a significant difference in LADn was noted between different ACVIM stages (P<0.001). The most accurate cut-off value of LADn to differentiate between dogs in groups B2 and C was 20.3 (sensitivity, 83.3%; specificity, 83.3%). There was a misclassification rate of 37% between LADn and LA/Ao in the detection of LAE in group B1. This study provides a normal reference range for LAD in dogs, which can be used as an additional tool to assess LAE in dogs with MMVD.

Combined interventional procedure and cardiopulmonary bypass surgery in a dog with cor triatriatum dexter, patent foramen ovale, and pulmonary stenosis.

A 2-year-old American Pit Bull dog was presented for surgical evaluation of imperforate cor triatriatum dexter (CTD) and patent foramen ovale (PFO). Echocardiography identified an imperforate CTD associated with a right-to-left shunting PFO and valvular pulmonary stenosis. A 2-step interventional and surgical approach was used. Initially, a pulmonary balloon valvuloplasty was performed, and subsequently the dog underwent a surgical correction of the atrial anomaly under cardiopulmonary bypass.

Left shift of the ventricular mean electrical axis in healthy Doberman Pinschers.

In canine electrocardiography, the reference interval of the ventricular mean electrical axis (MEA) is between +40° and +100°. MEA values in dogs can be influenced by the patient position as well as by the shape of the thorax. The aim of this study was to evaluate the MEA in healthy Doberman Pinschers, hypothesizing that some present a left shift of the MEA. In this retrospective study, 41 healthy, client-owned Doberman Pinschers were included. Echocardiography and standard six-lead ECG examination were performed in all dogs. The MEA was calculated using the isoelectric method. The morphology of the QRS complex and the Q/R ratio in lead II were also evaluated. The median MEA was +45° and ranged from -45° to +90°. MEA was deviated in 16/41 dogs (39%), all presenting a left axis deviation (range, -45° to + 30°). Age was significantly associated with the MEA (P=0.008), showing a negative linear correlation. A deep Q wave in lead II was present in 26/41 (63%) dogs. The Q/R ratio was higher in dogs presenting left shift of the MEA (0.66; range, 0.28-1.35) in comparison to dogs with a MEA within reference range (0.44; range, 0.04-0.73; P<0.001). In conclusion, a significant number of healthy Doberman Pinschers present a left shift of the MEA compare to the reference range, and dogs with MEA deviation show a higher Q/R ratio in lead II. This data should be considered when electrocardiographic evaluation is performed in Doberman Pinschers.

Home monitoring of heart rate and heart rhythm with a smartphone-based ECG in dogs.

The feasibility of the home monitoring of heart rate (HR) and rhythm through ECG tracings recorded by owners with a smartphone ECG device was evaluated in dogs. Smartphone ECG tracings were recorded by owners at home using a single-lead ECG device and sent via email for interpretation. A questionnaire was prepared to assess the owner's opinion regarding this home monitoring service. Recordings were evaluated by two operators, and agreement was evaluated for HR and rhythm diagnosis. Thirty-three dogs were included. Thirty-one owners (94 per cent) felt that the recording technique was easy to learn and that the smartphone ECG device was easy to use. A total of 15 owners (45 per cent) required a second person to hold the dog during recording. Of the 150 smartphone ECG tracings that were received, 134 (89 per cent) were interpretable. The median difference between the two operators to assess the mean HR on the smartphone tracings was 10 bpm (-10, +25 bpm). Perfect agreement (κ=1) between operators was observed in the heart rhythm evaluation. Most owners sent adequate ECG tracings for interpretation via email from their smartphone. Home monitoring of HR and heart rhythm may represent an additional tool in the management of dogs with arrhythmias.

Echocardiographic evaluation of the right ventricular dimension and systolic function in dogs with pulmonary hypertension.

BACKGROUND: Right ventricular (RV) enlargement and dysfunction are associated with prognosis in humans with pulmonary hypertension (PH). HYPOTHESIS/OBJECTIVES: To assess RV size and systolic function in dogs with PH and to determine if they are associated with disease severity and right-sided congestive heart failure (R-CHF). ANIMALS: 89 dogs with PH and 74 healthy dogs. METHODS: Prospective observational study. PH was classified according to the tricuspid regurgitation pressure gradient. RV end-diastolic area (RVEDA) index was calculated as RVEDA divided by body surface area. RV systolic function was assessed with the tricuspid annular plane systolic excursion (TAPSE) and the RV fractional area change (FAC) normalized for body weight (TAPSEn and FACn, respectively). RESULTS: RVEDA index was higher in dogs with moderate PH (10.8 cm2 /m2 ; range, 6.2-14.4 cm2 /m2 ) and severe PH (12.4 cm2 /m2 ; range, 7.7-21.4 cm2 /m2 ) than in those with mild PH (8.4 cm2 /m2 ; range, 4.8-11.6 cm2 /m2 ) and control dogs (8.5 cm2 /m2 ; range, 2.8-11.6 cm2 /m2 ; P < .001). RVEDA index was significantly higher in dogs with R-CHF (13.7 cm2 /m2 ; range, 11.0-21.4 cm2 /m2 ) than in dogs without R-CHF (9.4 cm2 /m2 ; range, 4.8-17.1 cm2 /m2 ; P < .001). The severity of tricuspid regurgitation (TR) was the only independent predictor of the RVEDA index (P < .001). TAPSEn and FACn were not significantly different among varying degrees of PH severity and between dogs with and without R-CHF. CONCLUSIONS AND CLINICAL IMPORTANCE: The RVEDA index can be used to evaluate RV size in dogs. It can provide additional information in dogs with PH and predict R-CHF. Severity of TR is the main determinant of RV enlargement in dogs with PH.

Computed tomography, radiology and echocardiography in cats naturally infected with Aelurostrongylus abstrusus.

Objectives The aims of the study were to describe the radiographic and computed tomographic features in cats naturally infected with Aelurostrongylus abstrusus, and to identify signs of pulmonary hypertension with echocardiography. Methods Fourteen cats positive on Baermann test for A abstrusus were included in the study. All cats underwent thoracic radiography, CT and echocardiography. Results The most common clinical signs were coughing (10/14) and dyspnoea (5/14). Radiographic findings included a generalised unstructured interstitial pulmonary pattern (8/14), mixed bronchointerstitioalveolar pattern (3/14) and bronchointerstitial pattern with bronchial wall thickening (3/14). Sternal lymphadenopathy was detected on thoracic radiographs in six cats. On CT, features were mixed bronchointerstitioalveolar pattern with ground-glass appearance in six cats, interstitioalveolar with multiple pulmonary nodules in five, interstitial ground-glass infiltrates in three, regional lymph node enlargement in 11 (10 sternal, three cranial mediastinal and three tracheobronchial lymph nodes) and subpleural thickening in four. None of the thoracic radiographs revealed subpleural thickening. In all cases, pulmonary vessels were normal in terms of size, shape and attenuation on both radiography and CT. Pulmonary hypertension and cardiac abnormalities were not observed in any cat during echocardiography. Conclusions and relevance CT provided a more thorough characterisation of pulmonary and mediastinal lesions compared with thoracic radiographs in cats naturally infected with A abstrusus. Although feline aelurostrongylosis has been previously associated with histopathological lesions in lung arteries, in this cohort clinical evidence of pulmonary hypertension was not documented.

Effect of potential renal acid load of foods on urinary citrate excretion in calcium renal stone formers.

The aim of this study was to investigate the influence of the potential renal acid load (PRAL) of the diet on the urinary risk factors for renal stone formation. The present series comprises 187 consecutive renal calcium stone patients (114 males, 73 females) who were studied in our stone clinic. Each patient was subjected to an investigation including a 24-h dietary record and 24-h urine sample taken over the same period. Nutrients and calories were calculated by means of food composition tables using a computerized procedure. Daily PRAL was calculated considering the mineral and protein composition of foods, the mean intestinal absorption rate for each nutrient and the metabolism of sulfur-containing amino acids. Sodium, potassium, calcium, magnesium, phosphate, oxalate, urate, citrate, and creatinine levels were measured in the urine. The mean daily PRAL was higher in male than in female patients (24.1+/-24.0 vs 16.1+/-20.1 mEq/day, P=0.000). A significantly (P=0.01) negative correlation (R=-0.18) was found between daily PRAL and daily urinary citrate, but no correlation between PRAL and urinary calcium, oxalate, and urate was shown. Daily urinary calcium (R=0.186, P=0.011) and uric acid (R=0.157, P=0.033) were significantly related to the dietary intake of protein. Daily urinary citrate was significantly related to the intakes of copper (R=0.178, P=0.015), riboflavin (R=0.20, P=0.006), piridoxine (R=0.169, P=0.021) and biotin (R=0.196, P=0.007). The regression analysis by stepwise selection confirmed the significant negative correlation between PRAL and urinary citrate (P=0.002) and the significant positive correlation between riboflavin and urinary citrate (P=0.000). Urinary citrate excretion of renal stone formers (RSFs) is highly dependent from dietary acid load. The computation of the renal acid load is advisable to investigate the role of diet in the pathogenesis of calcium stone disease and it is also a useful tool to evaluate the lithogenic potential of the diet of the individual patient.