We present results from clinical, radiologic, gas exchange, lung mechanics, and fibre-optic bronchoscopy-guided transbronchial biopsies in a case of acute respiratory failure due to SARS-CoV-2 ...(Covid-19). This report highlights the pulmonary, immunological, and inflammatory changes found during acute diffuse alveolar damage and the later organizing phase. An early diffuse alveolar damage pattern with predominant epithelial involvement with active recruitment of T cells and monocytes was observed followed by a late organizing pattern with pneumocyte hyperplasia, inflammatory infiltration, prominent endotheliitis, and secondary germinal centers. The patient’s deterioration paralleling the late immuno-pathological findings based the decision to administer intravenous corticosteroids, resulting in clinical, gasometric, and radiologic improvement. We believe that real-time clinicopathological correlation, along with the description of the immunological processes at play, will contribute to the full clinical picture of Covid-19 and might lead to a more rational approach in the precise timing of anti-inflammatory, anti-cytokine, or steroid therapies.
Point-of-care ultrasound (POCUS) plays a strategic role in the diagnostic and therapeutic evaluation of critically ill patients and, especially, in those who are haemodynamically unstable. In this ...context, POCUS allows a more precise identification of the cause, its differential diagnosis, the eventual coexistence with another entity and, finally, guiding of the therapeutic approach. It implies a portable use of ultrasound in acute settings covering different specified protocols, such as echocardiography, vascular, lung or abdominal ultrasound. This article reviews POCUS application in the emergency department or the intensive care unit, focused on severely compromised patients with cardiogenic shock with an emergent bedside assessment. Considering the high mortality rate of this entity, POCUS provides the intensivist/clinician with an appropriate tool for accurate diagnoses and a timely management plan. The authors propose practical algorithms for the diagnosis of patients using POCUS in these settings. This article is part of the
Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.
BackgroundLung cancer (LC) screening improves LC survival; the best screening method in terms of improving survival is low-dose CT (LDCT), outpacing chest X-ray and sputum cytology.MethodsA consensus ...of experts in Argentina was carried out to review the literature and generate recommendations for LC screening programmes. A mixed-method study was used with three phases: (1) review of the literature; (2) modified Delphi consensus panel; and (3) development of the recommendations. The Evidence to Decision (EtD) framework was used to generate 13 evaluation criteria. Nineteen experts participated in four voting rounds. Consensus among participants was defined using the RAND/UCLA method.ResultsA total of 16 recommendations scored ≥7 points with no disagreement on any criteria. Screening for LC should be performed with LDCT annually in the population at high-risk, aged between 55 and 74 years, regardless of sex, without comorbidities with a risk of death higher than the risk of death from LC, smoking ≥30 pack-years or former smokers who quit smoking within 15 years. Screening will be considered positive when finding a solid nodule ≥6 mm in diameter (or ≥113 mm3) on baseline LDCT and 4 mm in diameter if a new nodule is identified on annual screening. A smoking cessation programme should be offered, and cardiovascular risk assessment should be performed. Institutions should have a multidisciplinary committee, have protocols for the management of symptomatic patients not included in the programme and distribute educational material.ConclusionThe recommendations provide a basis for minimum requirements from which local institutions can develop their own protocols adapted to their needs and resources.
Strategies to extend the pool of organs include and promote the use of segmental liver grafts. While performing a living donor left lateral segment (LLS) liver transplant and in split procedures, the ...hepatic artery´s division becomes critical when a dominant segment 4 artery (S4A) emerges from the left hepatic artery (LHA). We aim to describe a novel technique that consists of performing microsurgical reconstruction from the pyloric artery (PA) to S4A.
A 45-y-old living donor was evaluated to use his LLS as a graft for a pediatric recipient. During the procedure, a dominant S4A born from the LHA was dissected. To obtain an appropriate LHA length and diameter for the recipient, it was necessary to transect it. An extended right lobe split graft was used in a 61-y-old patient. The S4A born from LHA had to be sectioned during the split procedure. In both cases, segment 4 remained incompletely perfused. The PA was dissected with enough length to be rotated, to perform a microsurgical anastomosis to the S4A, recovering parenchyma's color and Doppler signal while vascular permeability was demonstrated using CT scan. There was no biliary or cut surface complication.
PA to S4A reconstruction is a simple and novel technique that can be used for LLS and extended right lobe split graft and might contribute to increase donor selection and reduce living donor and recipient S4A-related complications.
Abstract
S3.1 Neglected implantation mycoses, September 21, 2022, 4:45 PM - 6:15 PM
Objectives
Histoplasmosis is endemic in the central/northeast region of Argentina. No data on the incidence of ...Histoplasmosis are available in most countries. It is estimated that the incidence of this mycosis is low in solid organ transplant recipients. In endemic areas of the USA (Ohio), the incidence of histoplasmosis in kidney transplant recipients is 0.25%. The objectives of this work are to describe the epidemiology, clinical forms, and evolution of kidney transplant recipients’ diagnoses with histoplasmosis in Santa Fe city, Argentina.
Methods
A retrospective study was carried out between July 2017 and July 2020 at the Nephrology, Urology, and Cardiovascular Diseases Clinic, Santa Fe (Argentina). Demographic, clinical, and laboratory data were obtained and analyzed. Histoplasmosis diagnosis was performed by means of histopathology (intracellular yeasts), recovery of Histoplasma spp. by culture, and/or positive nested PCR specific for Histoplasma Hc100 gene. No antigen detection method was available in Argentina at the time of the study.
Results
During the 36 months of the study, 225 kidney transplantations were performed. Out of these patients, 10 were diagnosed with histoplasmosis (4.44%). All the patients were Santa Fe province inhabitants. Patients’ median age was 47 years old and 90% were male. A total of 9 patients (90%) presented the disseminated form of the disease and 1 the pulmonary form; 8 were recipients of their first transplant and 2 were second transplant recipients. All received thymoglobuline induction as immunosuppressive therapy. In all, 4 were diagnosed with histoplasmosis in their first-year post-transplantation (mostly 6-12 months) and the rest after 1-year post-transplantation. At the time of the histoplasmosis diagnosis, five patients presented glomerular filtration between 30 and 60 ml/min, two <15 ml/min, two between 30 and 15 ml/min, and only one with glomerular filtration >90 ml/min. A total of 7 retained graft function at the end of treatment, 3 lost the graft (1 due to death). Histoplasmosis diagnosis was done in skin biopsies (n = 4), bone marrow (n = 3), CNS (n = 1), kidney graft (n = 1), and respiratory sample (n = 1). Laboratory diagnosis was done by histopathology, culture, and PCR in 3 cases (30%), by culture and PCR in 2 cases (20%) and by PCR alone in 5 cases (50%). Thus, all 10 patients showed positive nested PCR results. These results were informed within 24 h of receiving the samples. Cultures were positive in 5 cases and were considered positive on average after 26 days (ranging from 15 to 44 days) of incubation. All patients received amphotericin B as initial treatment. A total of 8 patients (80%) continued treatment with itraconazole and 1 with Voriconazole. Good response was observed in 9 patients.
Conclusion
We found a high incidence of histoplasmosis in kidney transplant recipients (10 times higher than reports from other endemic areas). Disseminated histoplasmosis was found in 90% of the patients. The same percentage of patients showed compromised graft function. The diagnosis was done after 1 year of transplantation in 60% of the cases. Diagnosis by histopathology/culture showed 50% sensitivity while nested PCR showed better sensitivity and diagnostic speed.
Collateral circulation secondary to liver cirrhosis may cause the development of large PSSs that may steal flow from the main portal circulation. It is important to identify these shunts prior to, or ...during the transplant surgery because they might cause an insufficient portal flow to the implanted graft. There are few reports of “steal flow syndrome” cases in pediatrics, even in biliary atresia patients that may have portal hypoplasia as an associated malformation. We present a 12‐month‐old female who received an uneventful LDLT from her mother, and the GRWR was 4.8. During the early post‐operative period, she became hemodynamically unstable, developed ascites, and altered LFT. The post‐operative ultrasound identified reversed portal flow, finding a non‐anatomical PSS. A 3D CT scan confirmed the presence of a mesocaval shunt through the territory of the right gonadal vein, draining into the right iliac vein, with no portal inflow into the liver. The patient was re‐operated, and the shunt was ligated. An intraoperative Doppler ultrasound showed adequate portal inflow after the procedure; the patient evolved satisfactorily and was discharged home on day number 49. The aim was to report a case of post‐operative steal syndrome in a pediatric recipient due to a mesocaval shunt not diagnosed during the pretransplant evaluation.
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