Mycotic Pseudoaneurysm After Kidney Transplantation: Two Case Reports.

BACKGROUND: Vascular complications after kidney transplantation may cause allograft loss. Here, we describe 2 patients with extrarenal mycotic pseudoaneurysm after kidney transplantation. PATIENTS: Patient 1 was a 54-year-old man who developed pseudoaneurysm 60 days after transplantation, and patient 2 was a 48-year-old woman who was diagnosed with a pseudoaneurysm 5 months after transplantation. RESULTS: Patient 1 had a deceased-donor kidney transplant with end-to-side external iliac arterial anastomosis that was reconstructed 8 days after transplantation owing to rupture and major bleeding. At 60 days after transplantation, he had high serum creatinine level and Doppler ultrasonography showed a pseudoaneurysm of the arterial graft anastomosis and postanastomotic renal artery stenosis. Treatment included surgical excision of the pseudoaneurysm, vascular reconstruction, and fluconazole, with mycologic culture of the resected pseudoaneurysm showing Candida albicans. Patient 2 developed nondisabling intermittent claudication at 5 months after kidney transplantation, with a pseudoaneurysm subsequently observed on Doppler ultrasonography and computerized tomographic angiography. Treatment included renal artery thrombectomy and common iliac bypass to the hilar donor renal artery with inverted ipsilateral long saphenous vein. Operative samples showed C albicans, and she was treated with fluconazole. Both patients had satisfactory outcomes, and both kidney allografts were preserved. CONCLUSIONS: Extrarenal mycotic pseudoaneurysms after kidney transplantation require a high index of suspicion for early diagnosis, and preservation of the kidney graft may be achieved with the use of surgical treatment and antifungal therapy.

Comparison of extracorporeal membrane oxygenation versus cardiopulmonary bypass for lung transplantation.

OBJECTIVE: This study compared differences in patient outcomes and operative parameters for extracorporeal membrane oxygenation (ECMO) versus cardiopulmonary bypass (CPB) in patients undergoing lung transplants. METHODS: Between January 1, 2008, and July 13, 2013, 316 patients underwent lung transplants at our institution, 102 requiring intraoperative mechanical cardiopulmonary support (CPB, n=55; ECMO, n=47). We evaluated survival, blood product transfusions, bleeding complications, graft dysfunction, and rejection. RESULTS: Intraoperatively, the CPB group required more cell saver volume (1123±701 vs 814±826 mL; P=.043), fresh-frozen plasma (3.64±5.0 vs 1.51±3.2 units; P=.014), platelets (1.38±1.6 vs 0.43±1.25 units; P=.001), and cryoprecipitate (4.89±6.3 vs 0.85±2.8 units; P<.001) than the ECMO group. Postoperatively, the CPB group received more platelets (1.09±2.6 vs 0.13±0.39 units; P=.013) and was more likely to have bleeding (15 [27.3%] vs 3 [6.4%]; P=.006) and reoperation (21 [38.2%] vs 7 [14.9%]; P=.009]. The CPB group had higher rates of primary graft dysfunction at 24 and 72 hours (41 [74.5%] vs 23 [48.9%]; P=.008; and 42 [76.4%] vs 26 [56.5%]; P=.034; respectively). There were no differences in 30-day and 1-year survivals. CONCLUSIONS: Relative to CPB, the ECMO group required fewer transfusions and had less bleeding, fewer reoperations, and less primary graft dysfunction. There were no statistically significant survival differences at 30 days or 1 year.

The role of genital pathogens in morbidity following diathermy loop excision of the transformation zone of the uterine cervix.

OBJECTIVE: To evaluate the role of genital pathogens in postoperative morbidity following diathermy loop excision of the transformation zone (LETZ) of the uterine cervix. METHODS: Patients with cervical intraepithelial neoplasia (CIN) who underwent diathermy LETZ were included in a prospective study. Cervical swabs for genital pathogens were collected before the diathermy procedure. After surgery, women were followed-up regarding the occurrence and severity of postoperative pain, bleeding, and discharge. RESULTS: Genital pathogens were present in 463 of 788 (58.8%) cases. The most frequently isolated groups of microorganisms were group B ß-hemolytic Streptococcus, α-hemolytic Streptococcus, Enterococcus species, and coliforms. In patients with genital pathogens, postoperative pain was present in 298 (37.8%), discharge in 262 (33.2%), and bleeding in 236 (29.9%) cases. In patients without genital pathogens, 199 (25.3%) experienced pain, 181 (23.0%) discharge, and 143 (18.1%) bleeding. The differences between the 2 groups were not statistically significant (χ(2) for pain=0.675; χ(2) for discharge=0.031; χ(2) for bleeding=3.444; P>0.05). CONCLUSION: Genital pathogens are very common among patients with CIN and do not affect the occurrence or severity of pain, discharge, or postoperative bleeding after diathermy LETZ.

Handling post-dental extraction patients: how to avoid trans-infection of blood-borne diseases.

PURPOSE: The aim of this study is to assess the risks of cross infection after dental extraction. A systematic approach is proposed to prevent the risks of cross contamination and infection. MATERIALS AND METHODS: A survey was conducted in which patients were asked when and where they disposed of the gauze pad applied to the socket in their mouth postoperatively and whether they had touched it at all before throwing it away. RESULTS: Of the patients, 40% threw the gauze pad in the roads' litter bins and 9.33% threw it away in the practice's bathroom; half of the patients declared that they had touched the gauze pad with their bare hands before its final removal. CONCLUSIONS: The danger of trans-infection of blood-borne diseases is evident, and a series of measures is proposed to control it. Proper patient education, use of alternative methods of stopping postoperative bleeding other than a gauze pad, appropriate scheduling of appointments of already infected patients, and widespread vaccinations are some such measures. Attention and critical evaluation of the case are necessary because the already existing policies and guidelines are always open to improvements.

Is bacterial colonisation of the tonsillar fossa a factor in post-tonsillectomy haemorrhage?

OBJECTIVES: To identify if there is a link between bacterial colonisation of the tonsillar fossa and post-tonsillectomy haemorrhage. STUDY DESIGN AND SETTING: Prospective non-interventional study of 105 patients who underwent tonsillectomy during a seven-month period. The study took place in a secondary care centre, the West Middlesex University Hospital. PARTICIPANTS: The participants were 105 patients who consecutively underwent tonsillectomy. The exclusion criteria were any patients with suspected or known malignancy, or known bleeding dyscrasias. The participants underwent microbiological sampling of the tonsil pre-operatively. MAIN OUTCOMES MEASURES: The outcome measures were primary or secondary bleeding, defined as any evidence of haemorrhage in the tonsillar fossae. RESULTS: Twenty-four per cent of patients undergoing tonsillectomy had positive cultures from their tonsils pre-operatively. Patients with bacterial colonisation of the tonsillar fossa pre-operatively had an increased rate of post-tonsillectomy haemorrhage (odds ratio: 3.8, 1.1-12.1, 95 per cent confidence intervals, p = 0.04). CONCLUSION: This prospective study has found a relationship between bacterial colonisation of the tonsillar fossa and post-tonsillectomy haemorrhage. This suggests that there may be an argument for the use of antibiotics in those cases with positive pre-operative cultures. In view of the types of pathogens isolated, we feel that the management of a post-tonsillectomy bleed should include a beta lactamase inhibiting antibiotic.

Failure of recombinant factor VIIa in a patient with severe polymicrobial sepsis and postoperative uncontrolled intraabdominal bleeding.

BACKGROUND: This report discusses a case of unsuccessful treatment with recombinant factor VIIa (rFVIIa) in off-label use. The need for international guidelines concerning the off-label use of rFVIIa is outlined as well as the need for methods to control the efficacy of rFVIIa objectively. CASE PRESENTATION: 54 year old male with severe polymicrobial sepsis due to a perforated diverticulitis of the sigmoid colon and consecutive overt disseminated intravascular coagulation. He suffered severe intraabdominal bleeding after abdominal surgery despite conventional haemostatic support. Repeated applications of factor VIIa temporarily improved coagulation essays but did not stop clinical bleeding. The patient died in multiorgan failure due to septic and haemorrhagic shock. CONCLUSION: Off-label use of rFVIIa could result in more side effects than could be expected from literature because of a publication bias. However for most off-label applications large prospective, randomised and controlled trials to confirm the positive findings are missing. For the future, not only guidelines concerning the off-label use of rFVIIa are urgently needed but also guidelines for monitoring the efficacy of rFVIIa.

Knee and hip arthroplasty infection rates in persons with haemophilia: a 27 year single center experience during the HIV epidemic.

Total joint replacement (TJR) is an option for the management of chronic haemophilic arthropathy. Because surgery is technically challenging, there is a high rate of deep prosthetic infections, particularly in human immunodeficiency virus (HIV)-infected individuals. We determined the incidence of deep infection rates following total knee and hip arthroplasties in HIV-seropositive and HIV-seronegative persons with haemophilia. Fifty-one primary joint replacements were performed on 32 patients seen at a regional comprehensive haemophilia care center from 1975 to 2002. Thirty prostheses were placed in patients who were HIV-seropositive prior to surgery (n = 14) or seroconverted later (n = 16). Median age at the time of surgery was 33 years (range: 20-61) among 19 HIV-seropositive patients and 35 years (range: 26-74) among 13 HIV-negative patients. Median duration of follow-up was 83 months (range: 2-323). Rate of primary joint infection per artificial joint-year by HIV status was compared by Poisson regression. Main outcome measures were the incidence of primary replacement joint infections by HIV status. Deep infections developed in five (9.8%) of 51 replacement joints. There were two infections during 204.15 joint-years without HIV infection and three infections during 205.28 joint-years with HIV infection. The incidence rate of joint infection (0.98 vs. 1.46 per 100 joint-years) was not increased with HIV (relative risk, RR: 1.49, 95% CI: 0.25-8.93, P = 0.66). We conclude that HIV infection is not a contraindication to knee or hip replacement arthroplasty in the appropriate clinical setting.

A prospective study of the correlation between Chlamydia trachomatis infection and secondary bleeding following large loop excision of the transformation zone (LLETZ).

To determine the effect of Chlamydia trachomatis (CT) on the occurrence of secondary bleeding following large loop excision of the transformation zone (LLETZ), 103 patients with cervical intraepithelial neoplasia (CIN) were included in this study. In order to determine the presence of CT infection, cytological material for direct immunofluorescence analysis was obtained prior to LLETZ. After surgery, the patients were followed up for postoperative bleeding. Groups with and without postoperative bleeding were compared as regards the frequency of CT infection. Of 103 patients, 8 (7.8%) were CT positive and 95 (92.2%) were CT negative. Postoperative bleeding only occurred in 6 (2.8%) patients, all of whom were CT negative. Thus, in CT-positive patients, no secondary bleeding occurred. CT infection of the uterine cervix in patients with CIN is rare and does not appear to be important for the occurrence of postoperative bleeding after LLETZ.