Invasive Candida Infection after Upper Gastrointestinal Tract Surgery for Gastric Cancer

Upper gastrointestinal tract (GIT) surgical procedures are more likely to cause nosocomial Candida peritonitis than lower GIT procedures and they thus constitute an independent risk factor for mortality. Because of the severity of postsurgical fungal infections complications, intensivists and surgeons need to be extremely aware of their clinical importance in critically ill postsurgical intensive care unit (ICU) patients. We analyzed the clinical and microbiological data of 149 oncologic patients who were hospitalized in the ICU at Soroka Medical Center between January 2010 and January 2015 after undergoing upper GIT surgery for gastric cancer. Invasive fungal infections related to secondary peritonitis following oncologic upper GIT surgery had a higher mortality rate than patients with nonfungal postoperative infectious complications. The presence of gastroesophageal junction leakage and advanced age were found to be independent risk factors for invasive fungal infection after oncologic upper GIT surgery

An Unusual Presentation of HCC in a Patient with No Underlying Liver Disease: A Case Study

Pedunculated hepatocellular carcinoma (P-HCC) is a rare subtype of HCC. P-HCC may occur in patients without underlying liver cirrhosis and can be present with negative serum tumor markers. With a growing worldwide incidence of nonalcoholic fatty liver disease, non-cirrhotic HCC will likely become more prevalent. We report a patient presenting to the hospital with nonspecific symptoms of weight loss, abdominal discomfort, and early satiety. Abdomen palpation found a large firm mass in the right middle abdomen. Computed tomography imaging showed a large right abdominal mass without evidence of liver attachment. The patient underwent a diagnostic laparotomy where a single 17 cm exophytic mass originating from the left liver lobe was found and resected. Clear margins were attained, and pathology demonstrated HCC. Early diagnosis of HCC is critical to achieving curative treatment, and physicians should keep P-HCC in mind when presented with a similar patient

Increased Paracetamol Bioavailability after Sleeve Gastrectomy: A Crossover Pre- vs. Post-Operative Clinical Trial

Oral drug bioavailability may be significantly altered after laparoscopic sleeve gastrectomy (LSG), the most popular bariatric procedure worldwide. Paracetamol (acetaminophen) is the post-bariatric analgesic/antipyretic drug of choice. In this work we studied and analyzed the LSG effects on systemic bioavailability and pharmacokinetics of paracetamol after oral administration of solid vs. liquid dosage form. A 4-armed, pharmacokinetic, crossover trial was performed in patients enrolled for LSG. Single paracetamol dose (500 mg), as caplet (n = 7) or syrup (n = 5), was administered before vs. 4–6 months post-LSG. Bioavailability was enhanced after LSG; in the caplet groups, average AUC0–t increased from 9.1 to 18.6 µg·h/mL with AUC0–t difference of 9.5 µg·h/mL (95% CI 4.6–14.5, p = 0.003). Cmax increased from 1.8 (95% CI 1.2–2.5) to 4.2 µg/mL (3.6–4.8) after LSG (p = 0.032). In the syrup groups, AUC0–t increased from 13.4 to 25.6 µg·h/mL, with AUC0–t difference of 12.2 µg·h/mL (95% CI 0.9–23.5, p = 0.049). Cmax changed from 5.4 (95% CI 2.5–8.4) to 7.8 µg/mL (6.1–9.6), and systemic bioavailability was complete (102%) after the surgery. Overall, decreased paracetamol exposure in obesity, with recovery to normal drug levels (caplet) or even higher (syrup) post-LSG, was revealed. In conclusion, attention to paracetamol effectiveness/safety in obesity, and after bariatric surgery, is prudent

Modified ISTH pregnancy-specific DIC score in parturients with liver rupture: population-based case series

<p><b>Objectives:</b> Liver rupture and hematoma are rare life-threatening complications of pregnancy. The aims of the current study are to: (1) characterize in a population-based study all cases of liver hematoma and/or rupture; and (2) validate the utility of the International Society on Thrombosis and Haemostasis (ISTH) modified pregnancy specific disseminated intravascular coagulation (DIC) score in those cases.</p> <p><b>Study design:</b> A retrospective cohort study including all patients with liver subcapsular hematoma or rupture between the years 1996 and 2012 was conducted. Information on maternal characteristics, clinical presentation, diagnostic studies, therapeutic modalities, as well as maternal and fetal outcomes was collected. The pregnancy-specific modified ISTH DIC scores were calculated from admission to discharge, a score >26 is suggestive of DIC.</p> <p><b>Results:</b> Out of 175,000 births in our database, seven patients were identified with liver rupture or subcapsular hematoma, representing a prevalence of 4:100,000 deliveries. Of those, six had liver rupture and one had subcapsular liver hematoma. One patient died of hemorrhagic shock. Four patients underwent surgical liver packing and one also underwent hepatic artery ligation. Four out of seven patients were diagnosed during the immediate postpartum period with severe features of preeclampsia or with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Modified ISTH pregnancy-specific DIC scores were calculated for five out of seven patients, and three (60%) had a score higher than 26. Patients with higher scores received more blood product transfusions, had longer hospitalizations, and their neonates had lower 1 and 5 minutes Apgar scores.</p> <p><b>Conclusions:</b> Elevated pregnancy-specific modified ISTH DIC score (>26) in patients with liver hematoma or rupture was associated with adverse maternal and neonatal outcomes and appeared to perform well in distinguishing high and low-risk cases. Postpartum preeclampsia may be associated with severe features and a more complicated disease course.</p