Severe Case of Cholestatic Hepatitis From Amoxicillin/Clavulanic Acid.

The incidence of amoxicillin/clavulanate (Augmentin) induced liver injury is relatively low when compared to other medications. Amoxicillin/clavulanic acid is one of the most frequently prescribed antibiotics by physicians and is used to treat various bacterial infections. However, amoxicillin/clavulanate can cause severe side effects, usually gastrointestinal like nausea and vomiting, rash, and sometimes hematologic like thrombocytopenia. Here, we present a case report where a 63-year-old male treated for a dog bite with amoxicillin/clavulanate acid four weeks ago presents to the hospital with severe cholestatic hepatitis, nausea, and pruritis.

Endoscopic ultrasound-guided parenchymal liver biopsy: a systematic review and meta-analysis.

BACKGROUND: Endoscopic ultrasonography (EUS)-guided liver biopsy is a novel technique to obtain adequate liver samples for diagnosis of liver parenchymal diseases. There are studies that have evaluated the feasibility and safety of EUS-guided parenchymal liver biopsy (EUS-LB), however, factors that can influence specimen quality are yet to be determined. Our aim was to determine the diagnostic accuracy of EUS-LB and evaluate factors associated with specimen quality. METHODS: We performed a detailed search of PubMed/MEDLINE and Web of Science™ databases to identify studies in which results of EUS-guided liver parenchymal biopsies were reported published up to July 2020. A random effects model was used to estimate pooled values (mean ± SE) for total specimen length (TSL) and complete portal tracts (CPT). Subgroup analyses were applied to find out the procedural factors associated with better specimen quality using Cochran's Q test. A total of 10 meta-analyses were done focusing on international studies. Total of 1326 patients who underwent EUS-LB. EUS-LBs performed for suspicion of parenchymal liver disease. Pooled mean values for TSL and CPT with subgroup analyses. RESULTS: Twenty-three studies with a total of 1326 patients were included in our meta-analysis. Overall pooled mean TSL and CPT were 45.3 ± 4.6 mm and 15.8 ± 1.5, respectively. In subgroup analysis, core biopsy needles proved to better in terms of CPT than fine-needle aspiration needles (18.4 vs 10.99, p = 0.003). FNB with slow-pull or suction technique provided a similar TSL (44.3 vs 53.9 mm, p = 0.40), however, slow-pull technique was better in terms of CPT (30 vs 14.6, p < 0.001). Heterogeneity was present among the studies. Another limitation is the low number randomized control trials. CONCLUSION: EUS-guided parenchymal liver biopsy is a good alternative to other methods of liver sampling. Using FNB needles with a slow-pull technique can provide better results.

Prevalence and Utilization of Obturator Artery Anatomic Variant in Autologous Breast Reconstruction.

BACKGROUND: The objective of this study is to quantify the prevalence and describe the utilization of an anatomic vascular variant in which the obturator artery (OA) arises from the trunk of the deep inferior epigastric artery (DIEA) in stacked/dual-pedicled autologous breast reconstruction. When this variant is identified preoperatively on computed tomography angiography (CTA), it may be utilized in a "flow-through" fashion to direct antegrade internal mammary artery (IMA) flow into a second free flap to facilitate anastomotic arrangement and optimize perfusion. METHODS: Preoperatively obtained abdomen/pelvis CTA imaging of 121 autologous breast reconstruction patients were retrospectively reviewed for the unilateral or bilateral presence of the OA branch arising from the DIEA (OA variant). The results were analyzed using descriptive statistics. RESULTS: Our analysis revealed the presence of the OA variant in 60 of the 121 (49.6%) breast reconstruction candidates, either unilaterally or bilaterally. Out of these patients, the variant was present unilaterally in 33 (55%) and bilaterally in 27 (45%) patients. Of the unilateral variants, 12 (36.4%) patients demonstrated right-sided laterality, while 21 (63.6%) patients demonstrated left-sided laterality. Clinically, this anatomic variant has been utilized in several cases of autologous breast reconstruction with flap survival in all cases. CONCLUSION: Utilization of this anatomic variant in stacked or dual-pedicled autologous breast reconstruction results in antegrade IMA perfusion of both primary and secondary flaps, as well as improved size match compared with other anastomotic options. Knowledge of the vascular anatomy and variations in the inferior epigastric system is crucial to both preventing complications and optimizing flap planning and outcome.

Review on gall bladder myeloid sarcoma: a great masquerader.

Pain in abdomen has wide differentials and narrowing down the clinical possibilities depends on type of pain, location, characterization which is usually assisted by imaging studies. Cholecystitis and cholelithiasis are amongst the common causes of acute abdomen. This study reviews the literature for the clinical characteristics, differential diagnosis, treatment and prognosis of reported cases of gallbladder myeloid sarcoma (GB-MS) who presented with abdominal symptoms. A total of 17 cases of GB-MS were studied. The median age was 52 years with age range of 23 to 84 years. All except 1 patient presented with abdominal symptoms. Based on imaging or pathological studies, 3 cases were initially confused with gallbladder lymphoma or cancer. Only 5 patients were treated with AML like chemotherapy. Treatment given included combinations of surgery, chemotherapy, and radiotherapy. None of the cases underwent HSCT for GB-MS. Seven patients were alive till the time of last F/U, 9 succumbed to death while F/U of 1 patient was not available. Irrespective of treatment protocol followed suggesting the poor prognosis in GB-MS cases. In conclusion, acute abdomen complicating blood malignancies is life threatening and can be devastating if not detected and treated in a timely fashion.

Male Breast Cancer: Reevaluate Our Opinion.

Male breast cancers (MBCs) are relatively uncommon malignancy with less than 1% incidence. MBC presents at a later age with a more advanced presentation as compared to the female breast cancer. Due to the paucity of the number of cases and trials regarding the MBC, female breast cancer treatment protocols are applied. Mastectomy and hormonal therapy remains the mainstay of treatment. Moreover, the data about prognosis of MBC remains limited.

A Description of the Vascular Anatomy of the Tensor Fascia Lata Perforator Flap Using Computed Tomography Angiography.

BACKGROUND: The perforator anatomy of the tensor fascia lata (TFL) flap has been studied using cadaver dissection; however, exact descriptions of location, size, and origin of perforator vessels using preoperative imaging modalities remain limited. The aims of this study are to describe TFL perforator anatomy using high-resolution computed tomography angiography (CTA) and to correlate these findings with landmarks for the anterolateral thigh flap to facilitate flap planning. METHODS: We identified 33 patients who previously underwent bilateral lower extremity CTAs for preoperative planning of free-flap reconstruction. The images were retrospectively reviewed, and the TFL perforator number, size, type, location, and overall pedicle origin and length were recorded. RESULTS: Thirty-three patients and 59 thighs were included in the study. There was an average of 2.5 perforators per TFL. All perforators arose from the ascending branch of the lateral circumflex femoral artery with an average pedicle length of 8.3 cm (range, 6.0-11.2 cm). Sixty-six percent of perforators were septocutaneous and 34% were musculocutaneous. The average perforator size as measured on CTA was 3 mm. The average perforator location was 10.1 cm inferior and 8.5 cm lateral to the line drawn from the anterior superior iliac spine to the superolateral patella. CONCLUSIONS: To our knowledge, this is the first study to characterize the vascular anatomy of the TFL perforator flap using high-resolution CTA and correlate this with well-established landmarks used in the planning for other thigh-based flaps. We believe data will facilitate flap design and dissection; potentially shortening operating room times, limiting exploratory incisions used to confirm the presence of thigh based perforators, and improving overall outcomes for patients.

Current Techniques for Postoperative Monitoring of Microvascular Free Flaps.

Free tissue transfer (FTT) is used in patients with complicated reconstructive needs; it can provide stable wound coverage, improved aesthetic appearance, and restore functional deficits. Despite the high success rates of free flaps, vascular occlusion is a significant risk leading to flap failure. Many studies have demonstrated that the salvage rate for flaps is inversely related to the time between onset of a vascular problem and its surgical correction. As a result, ongoing postoperative monitoring of free flaps for adequate perfusion is imperative to allow timely and accurate diagnosis of vascular compromise. Close monitoring and prompt notification of the physician if vascular compromise occurs are typically undertaken by first-line nurses. We conducted an integrative literature to identify and evaluate commonly used techniques for monitoring vascular free flaps during the postoperative period. We searched PubMed and Science Direct electronic databases, using the key words: "free-flap" and "monitoring." This article discusses commonly monitoring modalities, along with their advantages and limitations. Whereas large academic institutions may have an experienced nursing staff specifically trained in effective methods for monitoring free flap patients, this situation may not exist in all hospitals where free flap surgeries are performed. We describe techniques that allow easy and timely detection of flap compromise by nursing staff while reducing interuser variability.

Black Cohosh Hepatotoxicity with Autoimmune Hepatitis Presentation.

Herbal medicines have been used for the treatment of various ailments since time immemorial. Black cohosh (BC) is well known for the treatment of postmenopausal symptoms, with conflicting evidence supporting its safety and benefits. We present a rare case of BC-induced autoimmune hepatitis (AIH) with hepatotoxicity in a 69-year-old female. To our knowledge, this represents the third case of BC-induced AIH.

Reverse end-to-side nerve transfer: from animal model to clinical use.

PURPOSE: Functional recovery after peripheral nerve injury is predominantly influenced by time to reinnervation and number of regenerated motor axons. For nerve injuries in which incomplete regeneration is anticipated, a reverse end-to-side (RETS) nerve transfer might be useful to augment the regenerating nerve with additional axons and to more quickly reinnervate target muscle. This study evaluates the ability of peripheral nerve axons to regenerate across an RETS nerve transfer. We present a case report demonstrating its potential clinical applicability. METHODS: Thirty-six Lewis rats were randomized into 3 groups. In group 1 (negative control), the tibial nerve was transected and prevented from regenerating. In group 2 (positive control), the tibial and peroneal nerves were transected, and an end-to-end (ETE) nerve transfer was performed. In group 3 (experimental model), the tibial nerve and peroneal nerves were transected, and an RETS nerve transfer was performed between the proximal end of the peroneal nerve and the side of the denervated distal tibial stump. Nerve histomorphometry and perfused muscle mass were evaluated. Six Thy1-GFP transgenic Sprague Dawley rats, expressing green fluorescent protein in their neural tissues, also had the RETS procedure for evaluation with confocal microscopy. RESULTS: Nerve histomorphometry showed little to no regeneration in chronic denervation animals but statistically similar regeneration in ETE and RETS animals at 5 and 10 weeks. Muscle mass preservation was similar between ETE and RETS groups by 10 weeks and significantly better than negative controls at both time points. Nerve regeneration was robust across the RETS coaptation of Thy1-GFP rats by 5 weeks. CONCLUSIONS: Axonal regeneration occurs across an RETS coaptation. An RETS nerve transfer might augment motor recovery when less-than-optimal recovery is otherwise anticipated. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Effect of cold nerve allograft preservation on antigen presentation and rejection.

OBJECT: Nerve allotransplantation provides a temporary scaffold for host nerve regeneration and allows for the reconstruction of significant segmental nerve injuries. The need for systemic immunosuppression, however, limits the current clinical utilization of nerve allografts, although this need is reduced by the practice of cold nerve allograft preservation. Activation of T cells in response to alloantigen presentation occurs in the context of donor antigen presenting cells (direct pathway) or host antigen-presenting cells (indirect pathway). The relative role of each pathway in eliciting an alloimmune response and its potential for rejection of the nerve allograft model has not previously been investigated. The objective of this investigation was to study the effect of progressive periods of cold nerve allograft preservation on antigen presentation and the alloimmune response. METHODS: The authors used wild type C57Bl/6 (B6), BALB/c, and major histocompatibility Class II-deficient (MHC-/-) C57Bl/6 mice as both nerve allograft recipients and donors. A nonvascularized nerve allograft was used to reconstruct a 1-cm sciatic nerve gap. Progressive cold preservation of donor nerve allografts was used. Quantitative assessment was made after 3 weeks using nerve histomorphometry. RESULTS: The donor-recipient combination lacking a functional direct pathway (BALB/c host with MHC-/- graft) rejected nerve allografts as vigorously as wild-type animals. Without an intact indirect pathway (MHC-/- host with BALB/c graft), axonal regeneration was improved (p < 0.052). One week of cold allograft preservation did not improve regeneration to any significant degree in any of the donor-recipient combinations. Four weeks of cold preservation did improve regeneration significantly (p < 0.05) for all combinations compared with wild-type animals without pretreatment. However, only in the presence of an intact indirect pathway (no direct pathway) did 4 weeks of cold preservation improve regeneration significantly compared with 1 week and no preservation in the same donor-recipient combination. CONCLUSIONS: The indirect pathway may be the predominant route of antigen presentation in the unmodified host response to the nerve allograft. Prolonged duration of cold nerve allograft preservation is required to significantly attenuate the rejection response. Cold preservation for 4 weeks improves nerve regeneration with a significant effect on indirect allorecognition.

Costimulation blockade inhibits the indirect pathway of allorecognition in nerve allograft rejection.

Nerve allografts provide a temporary scaffold for host nerve regeneration. The need for systemic immunosuppression limits clinical application. Characterization of the immunological mechanisms that induce immune hyporesponsiveness may provide a basis for optimizing immunomodulating regimens. We utilized wild-type and MHC class II-deficient mice, as both recipients and donors. Host treatment consisted of triple costimulatory blockade. Quantitative assessment was made at 3 weeks using nerve histomorphometry, and muscle testing was performed on a subset of animals at 7 weeks. Nerve allograft rejection occurred as long as either the direct or indirect pathways were functional. Indirect antigen presentation appeared to be more important. Nerve allograft rejection occurs in the absence of a normal direct or indirect immune response but may be more dependent on indirect allorecognition. The indirect pathway is required to induce costimulatory blockade immune hyporesponsiveness.

Epigenetic regulation of cardiac muscle-specific genes in H9c2 cells by Interleukin-18 and histone deacetylase inhibitor m-carboxycinnamic acid bis-hydroxamide.

Interleukin-18 (IL-18) elicited a robust hypertrophy response in H9c2 cardiomyocytes as judged by their accelerated rates of protein synthesis and increased cell size. Evidently, IL-18 treatment also induced a cardiac hypertrophy-specific program of gene expression in H9c2 cardiomyocytes since they elicited enhanced expression of atrial naturetic factor (ANF), desmin, and skeletal alpha-actin genes accompanied by a canonical switch in the transcription of alpha- and beta-myosin heavy chain (MyHC) genes. Co-treatment of H9c2 cells with m-carboxycinnamic acid bis-hydroxamide (CBHA), an inhibitor of histone deacetylases, significantly blocked both morphological and molecular manifestations of IL-18-induced cardiac hypertrophy in vitro. IL-18 treatment led to activation of phosphoinositide-3-kinase and phosphorylated Akt/protein kinase B, while CBHA blunted this pathway via inducing the expression of its upstream regulator, PTEN (phosphatase and tensin homolog). The architecture of bulk chromatin of H9c2 cells exposed to IL-18 and/or CBHA was significantly altered as judged by the extent of covalent modifications of its constituent histones. The chromatin immuno-precipitation (ChIP) assays revealed that IL-18-induced specific epigenetic changes in the chromatin of ANF, desmin, skeletal alpha-actin, and MyHC genes that were largely neutralized by CBHA. We demonstrate for the first time that 'histone code' of the entire approximately 50 kb genomic DNA encoding the alpha- and beta-MyHC genes and the intergenic DNA that generates anti-beta-MyHC RNA was uniquely modulated by pro- and anti-hypertrophy signals of IL-18 and CBHA, respectively.

Glomus tumor of the index finger.

A 41-year-old female patient presented with localized worsening subungual pain of her right index finger. Subsequent diagnostic evaluation revealed the presence of a glomus tumor. A glomus tumor is a rare tumor with a predilection for the hand. Classic symptoms include pain, pain with pressure, and pain with cold temperature. We present a completely updated literature review that addresses the epidemiology, pathology, presentation, diagnostic evaluation, classification, histology, genetics, and treatment options for glomus tumors.