Ruptured subcapsular hepatic hematoma complicating severe preeclampsia with haemolysis, elevated liver enzymes, low platelet count syndrome: a case report

Subcapsular liver hematoma is rare complication of severe preeclampsia and HELLP syndrome, thus making it essential for these patients to be followed up in critical and intensive care units for advanced medical support with fluid and electrolyte management and replacement of blood products while treating underlying disorders. Treatment options have to be individualised and vary from conservative management to surgical treatment including hepatic resection, hepatic artery ligation, and liver transplantation. In this paper we report a case of ruptured hepatic hematoma in a 35 year old female, few hours within delivery, a complication of severe preeclampsia and HELLP syndrom

Misoprostol for Termination of Second Trimester Pregnancy

Introductions: The termination of second trimester pregnancy is challenging due unfavorable cervix. This study evaluate the efficacy and maternal side effects of intravaginal misoprostol for termination of second trimester pregnancy.Methods: During one year period from 15th June 2011 to 14th June 2012,Department of Obstetrics and Gynaecology of Patan Hospital, women admitted for second trimester termination of pregnancy for fetal congenital anomalies and intrauterine fetal demise were studied using the International Federation of Gynaecology and Obstetrics recommended doses of vaginal misoprostol. For congenital anomalies, 400 mcg 3 hourly to a maximum of 5 doses were used. For fetal demise, gestational age of 13-17 weeks received 200 mcg every 6 hourly to a maximum of 4 doses, and 18-26 weeks dose was adjusted to 100 mcg. Main outcome measures included success rate of abortion within 48 hours, induction to delivery interval and maternal side effects.Results: There were 40 patients during study period. Success rate for termination of 2nd trimester pregnancy within 48 hours was 88.8% for congenital anomalies. For fetal demise, success of termination was 90.9% at 13-17 weeks and 100% at 18-26 weeks. Median time from induction to delivery was 26.8 hours for congenital anomalies. For fetal demise, it was 18 hours for 13-17 weeks was and 24 hours at 18 to 26 weeks respectively. Abdominal pain was seen in all doses of misoprostol.Conclusions: Vaginal misoprostol is an effective method for termination ofsecond trimester pregnancy.Keywords: misoprostol, pregnancy, second trimester terminatio

Relaparatomy after caesarean section

Introductions: Relaparotomy after caesarean section is rare and literature are scanty. The decision requires a good clinical judgment to save mother’s life. Our objective was to analyse the outcome of relaparotomy after caesarean section at Patan hospital.Methods: This was a cross sectional study done at the department of obstetrics and gynaecology, Patan Hospital, Nepal. Charts of caesarean section from January 2010 to December 2014 were reviewed to analyze the cases of relaparotomy for incidence, indication, management and outcome. Descriptive analysis was done using SPSS.Results: During 5 years, there were 17,538 caesarean deliveries, 39.15% of total 44,788 deliveries. Relaparotomy was done in 15 cases, 0.085% of 17538 caesarean. Mean age was 26.6±4.7 years, 14 (93.3%) were between 25-35 years, 12 (80%) were primigravida. Indications of relaparotomy were pyoperitonium (40%), hemoperitoneum (33.3%) and rectus sheath hematoma (26.7%). Out of 15 relaparotomy, 14 were conservative surgery and one required hysterectomy. There was no maternal mortality. Conclusions: Relaparotomyin our study the rate was eight in 10,000. Those requiring relaparatomy had fetal distress as indication for first caesarean.Keywords: caesarean section, pyoperitoneum, relaparotom

第859回 千葉医学会例会・第26回 肺癌研究施設例会 23.

PURPOSE:Perfusion analysis from first-pass contrast enhancement kinetics requires modeling tissue contrast exchange. This study presents a new approach for numerical implementation of the tissue homogeneity model, incorporating flexible distance steps along the capillary (NTHf). METHODS:The proposed NTHf model considers contrast exchange in fluid packets flowing along the capillary, incorporating flexible distance steps, thus allowing more efficient and stable calculations of the transit of tracer through the tissue. We prospectively studied 8 patients (62 ± 13 years old) with suspected CAD, who underwent first-pass perfusion CMR imaging at rest and stress prior to angiography. Myocardial blood flow (MBF) and myocardial perfusion reserve index (MPRI) were estimated using both the NTHf and the conventional adiabatic approximation of the TH models. Coronary artery lesions detected at angiography were clinically assigned to one of three categories of stenosis severity ('insignificant', 'mild to moderate' and 'severe') and related to corresponding myocardial territories. RESULTS:The mean MBF (ml/g/min) at rest/stress and MPRI were 0.80 ± 0.33/1.25 ± 0.45 and 1.68 ± 0.54 in the insignificant regions, 0.74 ± 0.21/1.09 ± 0.28 and 1.54 ± 0.46 in the mild to moderate regions, and 0.79 ± 0.28/0.63 ± 0.34 and 0.85 ± 0.48 in the severe regions, respectively. The correlation coefficients of MBFs at rest/stress and MPRI between the NTHf and AATH models were r = 0.97/0.93 and r = 0.91, respectively. CONCLUSIONS:The proposed NTHf model allows efficient quantitative analysis of the transit of tracer through tissue, particularly at higher flow. Results of initial application to MRI of myocardial perfusion in CAD are encouraging

Ursodeoxycholic Acid Therapy in Pediatric Primary Sclerosing Cholangitis : Predictors of Gamma Glutamyltransferase Normalization and Favorable Clinical Course

Objective To investigate patient factors predictive of gamma glutamyltransferase (GGT) normalization following ursodeoxycholic acid (UDCA) therapy in children with primary sclerosing cholangitis. Study design We retrospectively reviewed patient records at 46 centers. We included patients with a baseline serum GGT level >= 50 IU/L at diagnosis of primary sclerosing cholangitis who initiated UDCA therapy within 1 month and continued therapy for at least 1 year. We defined "normalization" as a GGT level Results We identified 263 patients, median age 12.1 years at diagnosis, treated with UDCA at a median dose of 15 mg/kg/d. Normalization occurred in 46%. Patients with normalization had a lower prevalence of Crohn's disease, lower total bilirubin level, lower aspartate aminotransferase to platelet ratio index, greater platelet count, and greater serum albumin level at diagnosis. The 5-year survival with native liver was 99% in those patients who achieved normalization vs 77% in those who did not. Conclusions Less than one-half of the patients treated with UDCA have a complete GGT normalization in the first year after diagnosis, but this subset of patients has a favorable 5-year outcome. Normalization is less likely in patients with a Crohn's disease phenotype or a laboratory profile suggestive of more advanced hepatobiliary fibrosis. Patients who do not achieve normalization could reasonably stop UDCA, as they are likely not receiving clinical benefit. Alternative treatments with improved efficacy are needed, particularly for patients with already-advanced disease.Peer reviewe

Consideration of a New Definition of Clinically Relevant Myocardial Infarction After Coronary Revascularization An Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions (SCAI)

Numerous definitions have been proposed for the diagnosis of myocardial infarction (MI) after coronary revascularization. The universal definition for MI designates post procedural biomarker thresholds for defining percutaneous coronary intervention (PCI)-related MI (type 4a) and coronary artery bypass grafting (CABG)-related MI (type 5), which are of uncertain prognostic importance. In addition, for both the MI types, cTn is recommended as the biomarker of choice, the prognostic significance of which is less well validated than CK-MB. Widespread adoption of a MI definition not clearly linked to subsequent adverse events such as mortality or heart failure may have serious consequences for the appropriate assessment of devices and therapies, may affect clinical care pathways, and may result in misinterpretation of physician competence. Rather than using an MI definition sensitive for small degrees of myonecrosis (the occurrence of which, based on contemporary large-scale studies, are unlikely to have important clinical consequences), it is instead recommended that a threshold level of biomarker elevation which has been strongly linked to subsequent adverse events in clinical studies be used to define a "clinically relevant MI." The present document introduces a new definition for "clinically relevant MI" after coronary revascularization (PCI or CABG), which is applicable for use in clinical trials, patient care, and quality outcomes assessment. Numerous definitions for the diagnosis of MI after coronary revascularization are in use (1). A standardized MI definition would provide uniformity for comparing clinical trial results, for assessing patient outcomes and for guiding quality improvement initiatives. In 2007, a "universal definition" for MI following coronary revascularization was proposed (2) and recently revised in 2012 (3). In this document, a PCI-related MI (type 4a) was defined as an increase in cTn to >5Â the 99th percentile of the URL during the first 48 h following PCI (in patients with normal baseline cTn concentrations), plus either: 1) evidence of prolonged ischemia as demonstrated by prolonged chest pain; or 2) ischemic ST-segment changes or new pathological Q waves; or 3) angiographic evidence of a flow limiting complication; or 4) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. MI associated with CABG (type 5) was defined as an increase in cTn to >10Â the 99th percentile URL during the first 48 h following CABG (in patients with normal baseline cTn concentrations), plus either: 1) new pathological Q waves or new LBBB; or 2) angiographically documente

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Дослідження параметра Грюнайзена ZnO при високих тисках

Дослідження термопружних властивостей кількох типів твердих тіл дуже важливо для дослідників, щоб зрозуміти структуру нижньої мантії Землі та ядра в діапазоні високих тисків. Параметр Грюнайзена відіграє дуже важливу роль у вивченні термопружних властивостей, оскільки забезпечує фундаментальну основу щодо частотного розподілу фононного спектру в твердих тілах. У дослідженні була зроблена спроба теоретично обчислити залежний від тиску параметр Грюнайзена для фаз вюрциту (B4) та кам'яної солі (B1) об'ємного та нанооксиду цинку (ZnO) приблизно до 200 ГПа. Вираз вільного об'єму для параметра Грюнайзена, отриманий Ващенком і Зубарєвим, та ізотермічні рівняння стану (EOS) використовуються для обчислення його значень. Ми виявили, що тенденція зміни параметра Грюнайзена від тиску, отримана для ZnO, подібна до тенденції, отриманої для металів згідно літературних джерел.Investigations of thermoelastic properties for several types of solids is very important for researchers to understand the earth’s lower mantle structure and core at high pressure range. The Grüneisen parameter (y) plays a very important role in the study of thermoelastic properties as it provides the fundamental basis regarding the frequency distribution of phonon spectrum in solids. In the present study, an attempt has been made to theoretically compute the pressure dependent Grüneisen parameter for wurtzite (B4) and rock salt (B1) phases of bulk and nano zinc oxide (ZnO) up to about 200 GPa. The free volume expression for the Grüneisen parameter derived by Vaschenko and Zubarev and isothermal equations of state (EOS) are used to numerate the values. We have found that the trend of variation of the Grüneisen parameter against pressure obtained for ZnO is similar to the trend obtained for other metals as per literature