Hernia enlargement and pancreatitis in a patient with short bowel syndrome treated with teduglutide / Crecimiento de hernias y pancreatitis en una paciente con síndrome de intestino corto tratada con teduglutida

Introduction: teduglutide (TED) is indicated for the treatment of patients with short-bowel syndrome (SBS) who are dependent on parenteral support. Case report: we report the case of a 60-year-old woman with SBS treated with TED. She had previously undergone multiple surgical resections due to Crohn's disease. Her remnant bowel included only the duodenum and 50-60 centimeters of jejunum. The patient was dependent on intravenous fluids (2,320 mL/48 h) and had a high stoma output (3,000 mL/day). After four months of TED the jejunostomy output had decreased to 2,200 mL/day with a thicker consistency, and intravenous fluid therapy was reduced to 2,010 mL/48 h. TED was withdrawn due to acute pancreatitis and enlargement of two supraumbilical hernias with high strangulation risk. Discussion: pancreatitis has been reported in clinical studies, and determination of amylase and lipase is recommended in all patients receiving TED. In contrast, there are no recommendations for the surveillance of hernia enlargement in patients on TED therapy, but we suggest the need for surveillance based on this case report (AU)

Introducción: la teduglutida (TED) está indicada para el tratamiento de pacientes con síndrome de intestino corto (SBS) que precisen soporte parenteral. Caso clínico: mujer de 60 años con SBS tratada con TED. Previamente se había sometido a múltiples resecciones quirúrgicas por su enfermedad de Crohn. Su intestino remanente incluía el duodeno y 50-60 centímetros de yeyuno. La paciente era dependiente de líquidos por vía intravenosa (2320 ml/48 h) y tenía una ostomía de alto débito (3000 ml/día). Después de cuatro meses de TED, el débito de la yeyunostomía disminuyó a 2200 ml/día, con una consistencia más espesa, y la fluidoterapia intravenosa se redujo a 2010 ml/48 h. Se retiró la TED por pancreatitis aguda y agrandamiento de dos hernias supraumbilicales con alto riesgo de estrangulamiento. Discusión: se han descrito casos de pancreatitis en estudios previos, por lo que se recomienda la determinación de la amilasa y la lipasa en los pacientes tratados con TED. Sin embargo, no hay recomendaciones específicas sobre la vigilancia del agrandamiento de hernias, pero sugerimos su idoneidad basada en este caso clínico (AU)

Lateral herniation during treatment with collagenase Clostridium histolyticum (Xiaflex) for Peyronie's disease.

BACKGROUND: Collagenase Clostridium histolyticum (CCH), also know as Xiaflex, with penile modeling is considered to be the gold standard non-surgical option for management of Peyronie's disease and is known to be safe and efficacious. Corporal rupture is a rare but known adverse event of CCH treatment, however there are limited studies describing corporal herniation without rupture. Here we present a patient who experienced a rare complication following CCH injections for Peyronie's disease: lateral herniation of the tunica albuginea in the setting of a dorsal penile plaque. CASE PRESENTATION: A 58-year-old male presented to our clinic seeking treatment for Peyronie's disease. On exam, he was found to have a palpable dorsal plaque and > 30 degrees leftward curvature of the penis. He was deemed an appropriate candidate for and patient decided to proceed with CCH and modeling. He received 2 cycles of CCH injections (4 total CCH injections) with in-office and at-home penile modeling, per manufacturer's protocol. Two weeks following in-office modeling during his second CCH cycle, the patient reported a painless, soft swelling involving the left side of his penile shaft only occurring with erection. Exam and history were suggestive of lateral herniation rather than corporal rupture. CCH was discontinued. Patient declined further evaluation with penile ultrasound. CONCLUSIONS: This is the first case report detailing lateral herniation with CCH injections. Symptoms and exam that should raise suspicion of corporal herniation are a soft, painless mass with erection.

Tamoxifen induces the development of hernia in mice by activating MMP-2 and MMP-13 expression.

Hernia is a disease with defects in collagen synthesis/metabolism. However, the underlying mechanisms for hernia formation have not been fully defined. Tamoxifen is a selective estrogen receptor modulator and used for patients with breast cancer. Tamoxifen also has pleiotropic and side effects. Herein, we report that tamoxifen treatment resulted in an appearance of a large bulge in the low abdomen between the hind legs in male but not in female mice. The autopsy demonstrated that the low abdominal wall was broken and a large amount of intestine herniated out of the abdominal cavity. Histological analysis indicated that tamoxifen caused structural abnormalities in the low abdominal wall which were associated with decreased type II collagen content. Furthermore, we determined increased matrix metalloproteinase-2 (MMP-2) and MMP-13 expression in the tissue. In vitro, tamoxifen induced MMP-2 and MMP-13 expression in fibroblasts. The promoter activity analysis and ChIP assay demonstrate that induction of MMP-13 expression was associated with activation of JNK-AP-1 and ERK1/2 signaling pathways while induction of MMP-2 expression was related to activation of the ERK1/2 signaling pathway. Taken together, our study establishes a novel murine hernia model, defines a severe side effect of tamoxifen, and suggests a caution to male patients receiving tamoxifen treatment.

Maternal exposure to a brominated flame retardant and genitourinary conditions in male offspring.

BACKGROUND: The upward trend in industrial nations in the incidence of male genitourinary (GU) conditions may be attributed to increased exposure to endocrine disruptors. Polybrominated biphenyl (PBB), a brominated flame retardant, is one such suspected endocrine disruptor. OBJECTIVE: We investigated the relationship between maternal serum levels of PBBs and GU conditions among male offspring exposed in utero. METHODS: In this cohort study of sons born to women accidentally exposed to PBBs during 1973-1974, we examined self-reported data on GU conditions among male offspring in relation to maternal serum PBB levels. We used generalized estimating equations to calculate odds ratios (ORs), controlling for gestational age at birth. RESULTS: Of 464 sons, 33 reported any GU condition (13 hernias, 10 hydroceles, 9 cryptorchidism, 5 hypospadias, and 1 varicocele). Four reported both hernia and hydrocele, and one both hernia and cryptorchidism. After adjustment for gestational age at birth, sons of highly exposed women (> 5 ppb) were twice as likely to report any GU condition compared with sons of the least exposed women [< or =1 ppb; OR = 2.0; 95% confidence interval (CI), 0.8-5.1]. This risk was increased when we excluded sons born after the exposure but before the mother's serum PBB measurement (OR = 3.1; 95% CI, 1.0-9.1). We found evidence of a 3-fold increase in reported hernia or hydrocele among sons with higher PBB exposure (test of trend p-value = 0.04). Neither hypospadias nor cryptorchidism was individually associated with PBB exposure. CONCLUSIONS: Although cryptorchidism and hypospadias were not associated with in utero PBB exposure, this study suggests that other GU conditions may be associated with exposure to endocrine-disrupting chemicals during development.

Growth hormone abuse and bodybuilding as aetiological factors in the development of bilateral internal laryngocoeles. A case report.

A 36-year-old man presented with hoarseness and stridor. He was an elite professional bodybuilder and admitted to having abusing anabolic steroids and growth hormone in the recent past. A CT scan showed bilateral laryngocoeles. The patient was initially managed with intravenous corticosteroids and broad-spectrum antibiotics, and the stridor resolved sufficiently to permit discharge from the hospital. He proceeded to undergo endoscopic marsupialisation of his laryngocoeles and to date has made a full recovery. This is the first reported case where anabolic steroid and growth hormone abuse combined with an elite bodybuilder's exercise regime has been implicated in the aetiology of bilateral laryngocoeles.

Exposure-disease continuum for 2-chloro-2'-deoxyadenosine (2-CdA), a prototype teratogen: induction of lumbar hernia in the rat and species comparison for the teratogenic responses.

BACKGROUND: The purine analog 2-chloro-2'-deoxyadenosine (2-CdA) caused ocular and limb defects in the mouse and rabbit. The current study examined the teratogenic potential of this drug in the rat and compared the adverse developmental outcomes with the other species. METHODS: Timed-pregnant Sprague-Dawley rats were given a single intraperitoneal injection of various doses of 2-CdA ranging from 5-60 mg/kg, at gestational day (GD) 9.5 and GD 14. 2-CdA concentrations in maternal serum and embryos were measured by HPLC and termed fetuses were prepared for teratological examination. RESULTS: Full-litter resorption was seen in dams receiving 50 mg/kg of 2-CdA at GD 9.5, whereas post-implantation loss was significantly increased and fetal weights significantly reduced at 40 mg/kg. Gross examination of the surviving fetuses revealed microphthalmia, a shortened body trunk and lumbar hernia, manifested by a soft mass protrusion at the lumbar region on one or both sides of the spine. Incidence of these defects increased in a dose-dependent fashion. Histological examination indicated that the hernia was associated with hypoplasia of the body wall, poorly developed skeletal muscle bundles surrounding the vertebral column in the lumbar region, and an absence of the lateral muscle groups that allowed protrusion of the abdominal viscera. The lumbar hernia was generally accompanied by spina bifida, deformed ribs and a wide spectrum of soft tissue-abnormalities that included kidney, genitourinary and heart defects. At GD 14, exposure to 2-CdA at 60 mg/kg produced oligodactyly in one of six litters. CONCLUSIONS: 2-CdA produced similar ocular defects in the rat and mouse, although the incidence was much lower in the former species. In contrast, the drug-induced lumbar hernia was only seen in the rat. These apparent disparities were not readily explained by species differences in pharmacokinetic parameters. the similarities between the teratological features of 2-CdA-induced lumbar hernia in the rat and the clinical description of lumbocostovertebral syndrome, however, may provide a key to unlock the etiology of this rare birth defect in humans.

Lower eyelid herniation of orbital fat may complicate periocular corticosteroid injection.

PURPOSE: To report a case of lower eyelid herniation of orbital fat occurring after periocular corticosteroid injection. DESIGN: Interventional case report. METHODS: A 44-year-old man with asymmetrical pars planitis complicated by right cystoid macular edema was treated with multiple right orbital floor injections of triamcinolone through the lower eyelid. RESULTS: Right lower eyelid orbital fat herniation occurred during the course of the treatment. CONCLUSION: A herniation of orbital fat may complicate the injection of corticosteroid through the lower eyelid.

Are wound complications after a kidney transplant more common with modern immunosuppression?

BACKGROUND: The most common surgical complication after a kidney transplant is likely related to the wound. The purpose of this analysis was to determine the incidence of, and risk factors for, wound complications (e.g., infections, hernias) in kidney recipients and to assess whether newer immunosuppressive drugs increase the risk for such complications. METHODS: Between January 1, 1984 and September 30, 1998, we performed 2013 adult kidney transplants. Of these 2013 recipients, 97 (4.8%) developed either a superficial or a deep wound infection. Additionally, 73 (3.6%) recipients developed either a fascial dehiscence or a hernia of the wound. We used univariate and multivariate techniques to determine significant risk factors and outcomes. RESULTS: Mean time to development of a superficial infection (defined as located above the fascia) was 11.9 days posttransplant; to development of a deep infection (defined as located below the fascia), 39.2 days; and to development of a hernia or fascial dehiscence, 12.8 months. By multivariate analysis, the most significant risk factor for a superficial or deep wound infection was obesity (defined as body mass index>30 kg/m2) (RR=4.4, P=0.0001). Other significant risk factors were a urine leak posttransplant, any reoperation through the transplant incision, diabetes, and the use of mycophenolate mofetil (MMF) (vs. azathioprine) for maintenance immunosuppression (RR=2.43, P=0.0001). Significant risk factors for a hernia or fascial dehiscence were any reoperation through the transplant incision, increased recipient age, obesity, and the use of MMF (vs. azathioprine) for maintenance immunosuppression (RR=3.54, P=0.0004). Use of antibody induction and treatment for acute rejection were not significant risk factors for either infections or hernias. Death-censored graft survival was lower in recipients who developed a wound infection (vs. those who did not); it was not lower in recipients who developed an incisional hernia or facial dehiscence (vs. those who did not). CONCLUSIONS: Despite immunosuppression including chronic steroids, the incidence of wound infections, incisional hernias, and fascial dehiscence is low in kidney recipients. As with other types of surgery, the main risk factors for postoperative complications are obesity, reoperation, and increased age. However, in kidney recipients, use of MMF (vs. azathioprine) is an additional risk factor -one that potentially could be altered, especially in high-risk recipients.

Occurrence of genital tract abnormalities and bladder hernia in female mice exposed neonatally to tamoxifen.

Three groups of female C57BL/Tw mice given 5 daily injections of 2, 20 or 100 micrograms tamoxifen (Tx) starting on the day of birth were killed at 35 and 150 days of age. About a half of the mice killed at 150 days had been ovariectomized at 90 days. Uterine hypoplasia, myometrial involution and suppression of the uterine-gland genesis were found in the 2 age-groups of Tx-treated mice. Vaginal hypoplasia and hypospadia were common abnormalities in 150-day-old Tx-treated mice. Vaginal adenosis was encountered in 35-day-old mice treated neonatally with 20 or 100 micrograms Tx, but not in 150-day-old group. Permanent proliferation of vaginal epithelium was not induced by Tx. More than 80% of oocytes in small follicles were degenerated in Tx-exposed mice at 150 days, but not so in those at 35 days. Ovaries of neonatally Tx-exposed mice lacking corpora lutea made no luteinizing response to human chorionic gonadotropin injected prepubertally. Urinary-bladder hernia with or without caecum hernia frequently occurred in 150-day-old mice given 20 or 100 micrograms Tx. The present study revealed that neonatally administered Tx causes various abnormalities in gonad and genito-urinary tract of female C57BL/Tw mice.

[Neonatal malformations and hormone therapy during pregnancy]. / Malformazioni neonatali e terapia ormonale in gravidanza.

PIP: The use of pharmacological treatment during pregnancy has always been extremely controversial, especially if the drugs involved are sex hormones, such as diethylstilbestrol. The percentage of congenital malformations attributable to hormonal therapy during pregnancy is 3%; the period of maximum susceptibility to teratogenic agents is between the 3rd-10th week of gestation, or the period of organogenesis. The 1st reported case of congenital malformation due to hormonal therapy during pregnancy goes back to 1957; since then the literature has published more on this subject. One of the most important studies was done in 1977 by Heinonen on a group of 50,282 pregnant women; 1042 had been treated with sex hormones. 19 infants, or 18.2/1000, had cardiovascular defects. Among the remaining 49,240 patients there were 385 cardiovascular malformations, or 7.8/1000. The problem is still far from being resolved; it is up to the individual physician to give the best possible advice, after careful consideration of the clinical situation of every pregnant patient.^ieng