Severe Disseminated Intravascular Coagulopathy Associated With Biventricular Massive Mural Thrombi in Newly Diagnosed Non-ischemic Cardiomyopathy.

Hemostatic system abnormalities have been previously associated with congestive heart failure (CHF). Here, we report a rare case of disseminated intravascular coagulopathy (DIC) in the setting of non-ischemic cardiomyopathy with right atrial and biventricular thrombus. We present a 55-year-old female with a past medical history of bronchial asthma who presented with a six-day history of bilateral leg swelling and dry cough. Her physical examination on admission was significant for signs of biventricular heart failure. Initial workup was significant for elevated pro-brain natriuretic peptide (ProBNP), elevated transaminases, marked thrombocytopenia (19,000/mcL), and coagulopathy with international normalized ratio (INR) of 2.5 and D-dimer of 15,585 ng/mL. Transthoracic echocardiogram (TTE) showed a large mobile right atrial thrombus protruding into the right ventricle and a more adherent left ventricular (LV) thrombus with severely reduced biventricular contractility. Pan CT was done and was significant for multifocal multilobar pulmonary emboli. A lower limb venous duplex was done and revealed extensive bilateral lower limb deep venous thrombosis (DVT). This rare case demonstrates an unusual association between DIC with non-ischemic cardiomyopathy, biventricular thrombus, extensive deep vein thrombosis, and pulmonary embolism (PE). In comparison, there are multiple prior reports for DIC with CHF and LV thrombus. However, our case differs from prior reports in terms of the presence of right atrial and biventricular thrombus. The patient received antibiotics, diuretics, and cryoprecipitate in the setting of persistent low fibrinogen levels. The patient underwent Interventional radiology-guided thrombectomy for extensive pulmonary emboli followed by inferior vena cava (IVC) filter insertion, resulting in the resolution of the right atrial thrombus and extensive decrease of the pulmonary emboli burden. The patient was then given apixaban after normalization of the platelet count and fibrinogen level. Hypercoagulability workup was inconclusive. The patient was then discharged after improvement of symptoms. Early recognition of DIC and cardiac thrombi in patients with new-onset heart failure is crucial for the implementation of the correct management by thrombectomy, optimizing heart failure medications, and anticoagulation to achieve better outcomes.

Combined anterior and posterior ring fixation versus posterior ring fixation alone in the management of unstable Tile B and C pelvic ring injuries: A randomized controlled trial / 中华创伤杂志(英文版)

PURPOSE@#Combined anterior and posterior ring (APR) fixation is classically performed in Tile B2 and C1 injuries to achieve superior biomechanical stability. However, the posterior ring (PR) is the main weight bearing portion that is responsible for weight transmission from the upper parts of the body to the lower limbs through the sacrum and the linea terminalis. It is hypothesized that isolated PR fixation can achieve comparable radiological and clinical outcomes to APR fixation. Therefore, we conducted this study to compare the two fixation principles in managing Tile B2 and C1 injuries.@*METHODS@#Our study included 20 patients with Tile B2 injuries and 20 patients with Tile C1 injuries. This study was a randomized control single-blinded study via computerized random numbers with a 1:1 allocation by using random block method. The study was performed at a level one trauma center. A total of 40 patients with Tile B2 and C1 injuries underwent combined APR or isolated PR fixation (Group A and B, respectively). Matta & Tornetta radiological principles and Majeed pelvic scoring system were used for the assessment of primary outcomes and postoperative complications. Secondary outcomes included operative time, amount of blood loss, intraoperative assessment of reduction, need of another operation, length of hospital stay, ability to weight bear postoperatively and pain control metrics. We used student t-test to compare the difference in means between two groups, and Chi-square test to compare proportions between two qualitative parameters. We set the confidence interval to 95% and the margin of error accepted to 5%. So, p ≤ 0.05 was considered statistically significant.@*RESULTS@#The mean follow-up duration was 18 months. The operative time (mean difference 0.575 h) and the intraoperative blood loss (mean difference 97.5 mL) were lower in Group B. Also, despite the higher frequency of rami displacement before union in the same group, there were no significant differences in terms of radiological outcome (excellent outcome with OR = 2.357), clinical outcome (excellent outcome with OR = 2.852) and postoperative complications assessment (OR = 1.556) at last follow-up.@*CONCLUSION@#The authors concluded that isolated PR fixation could favorably manage Tile B2 and C1 pelvic ring injuries with Nakatani zone II pubic rami fractures and intact inguinal ligament. Its final radiological and clinical outcomes and postoperative complications were comparable to combined APR fixation, but with less morbidity (shorter operation time, lower amount of blood, and no records of postoperative wound infection).

Spontaneous bacterial empyema in patients with liver cirrhosis in Upper Egypt: prevalence and causative organisms.

BACKGROUND: Spontaneous bacterial empyema (SBEM) is a complication in cirrhotic patients, in which a preexisting pleural effusion becomes infected. PURPOSE: The purpose was to determine the prevalence and causative organisms of SBEM among cirrhotic patients with hydrothorax. MATERIALS AND METHODS: This descriptive, cross-sectional study included 901 cirrhotic patients. All patients underwent clinical evaluation, liver function tests, chest X-ray, abdominal and chest ultrasonography, and pleural and peritoneal fluids study (when detected) including polymorphonuclear (PMN) leukocyte count, biochemical analysis, and culture by two methods: conventional and modified (inoculation of 10 mL of pleural or peritoneal fluid into a blood culture bottle). Diagnostic criteria for SBEM included positive pleural fluid culture and a PMN count of >250 cells/mm(3) or, if a negative culture, a pleural fluid PMN count of >500 cells/mm(3) and the absence of pneumonia on chest radiography. RESULTS: Of 901 cirrhotic patients, 16 cases of SBEM were diagnosed. The prevalence of SBEM was 1.8 % in cirrhotic patients and 26.2 % in patients with cirrhosis and hydrothorax. Pleural fluid culture was found to be positive by the conventional method in four (25 %) cases and by modified methods in 11 (68.8 %) cases. Escherichia coli was the most frequently isolated pathogen (six cases). The mortality rate of SBEM was 25 %. CONCLUSIONS: SBEM is a frequent complication in cirrhotic patients with hydrothorax. E. coli is the most frequent organism responsible for SBEM. The modified method of pleural fluid culture is more sensitive than the conventional method for diagnosis of SBEM.

Diagnostic value of ex vivo pleural fluid interferon-gamma versus adapted whole-blood quantiferon-TB gold in tube assays in tuberculous pleural effusion.

BACKGROUND: Noninvasive diagnosis of pleural tuberculosis (TB) remains a challenge due to the paucibacillary nature of the disease. As Mycobacterium tuberculosis (MTB)-specific T cells are recruited into pleural space in TB effusion; their indirect detection may provide useful clinical information. OBJECTIVES: Evaluation of pleural fluid interferon (INF)-γ levels vs Quantiferon-TB Gold In tube assay (QFT- IT) in blood and its adapted variants, using pleural fluid or isolated pleural fluid cells in the diagnosis of pleural TB. METHODS: Thirty-eight patients with pleural effusion of unknown etiology presented at Assiut University Hospital, Egypt, were recruited. Blood and pleural fluid were collected at presentation for INF-γ assays. Ex vivo pleural fluid INF-γ levels, QFT-IT in blood and its adapted variants were compared with final diagnosis as confirmed by other tools including blind and/or thoracoscopic pleural biopsy. RESULTS: The final clinical diagnosis was TB in 20 (53%), malignancy in 10 (26%), and effusion due to other causes in eight patients (21%). Ex vivo pleural fluid INF-γ levels accurately identified TB in all patients and were superior to the QFT-IT assays using blood or pleural fluid (70 and 78% sensitivity, with 60 and 83% specificity, respectively). QFT-IT assay applied to isolated pleural fluid cells had 100% sensitivity and 72% specificity. The optimal cut-off obtained with ROC analysis was 0.73 for TB Gold assay in blood assay, 0.82 IU/ml for the cultured pleural fluid assay, and 0.94 for isolated pleural cells assay. CONCLUSION: The ex vivo pleural fluid INF-γ level is an accurate marker for the diagnosis of pleural TB. QFT- IT assay in peripheral blood or its adapted versions of the assay using pleural fluid and/or washed pleural fluid cells had no diagnostic advantage over pleural fluid INF-γ in the diagnosis of pleural TB.

Preoperative embolization in surgical management of massive thoracic tumors.

BACKGROUND: The surgical excision of a highly vascular giant tumor may be challenging. The aim of this study was to describe our experience with preoperative percutaneous embolization of massive vascular chest tumors before surgical excision. METHODS: From 2009 to 2011, 8 cases of giant vascular thoracic tumor were treated at Assiut University Hospital, Assiut, Egypt, by preoperative embolization of the feeding arteries followed by successful excision after 48 h. RESULTS: The median age of the 8 patients was 39 years. Embolization of their tumors resulted in a reduction of tumor size, and minimal blood loss was observed perioperatively. Perilesional edema and easy differentiation of ischemic tissue facilitated complete surgical removal of the tumors. CONCLUSIONS: Preoperative embolization of giant vascular thoracic tumors is useful to decrease perioperative blood loss and facilitate total excision.