1/103. Intensive tandem cryofiltration apheresis and hemodialysis to treat a patient with severe calciphylaxis, cryoglobulinemia, and end-stage renal disease.This is the first report on tandem cryofiltration apheresis (CFA) and hemodialysis (HD). A 44 year old white man with Type II mixed cryoglobulinemia, hepatitis c virus (HCV), severe skin lesions, and end-stage renal disease (ESRD) on maintenance hemodialysis was air-transferred for CFA, which is only available at our medical center. The patient failed to respond to high dose steroids, immunosuppression, intravenous immunoglobulin (IVIG), and plasma exchange for the treatment of his cryoglobulinemia, and he failed alpha-interferon therapy for his HCV. On arrival, he was also found to have severe calciphylaxis secondary to ESRD with generalized, painful skin ulceration, necrosis, and penile gangrene. To treat both conditions, intensive, tandem CFA/HD was initiated. He received extensive wound care and surgical debridement. To prevent pressure ulcers and worsening of skin lesions, he was placed on the FluidAir (Kinetic Concepts Inc., San Antonio, TX) controlled air bed. The patient received 18 tandem CFA/HD treatments, and four extra HD treatments in one month. sodium citrate was used as an anticoagulant for the CFA procedure. His plasma cryoglobulin (CG) level dropped from 6,157 to 420 microg/ml, and his calciphylaxis also improved. The CFA effectively removed 93% of CG, without significant removal of IgG, IgM, IgA, albumin, and fibrinogen. No albumin or fresh frozen plasma (FFP) was required as replacement fluid for CFA. No citrate toxicity or evidence of complement activation with the cryofilter was observed. The entire CFA procedure time (3(1/2) hours) was considered. Intensive, tandem CFA/HD was performed in a critically ill patient with no apparent adverse consequences.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/103. Progressive pulmonary vascular disease after pulmonary artery banding and total correction in a case of ventricular septal defect and pulmonary hypertension.A 7-month-old infant with ventricular septal defect and pulmonary hypertension underwent pulmonary artery banding, which resulted in a decrease in the pulmonary arterial peak pressure from 102 to 54 mmHg. lung biopsy findings showed at most an early grade 3 Heath-Edwards classification, and an index of pulmonary vascular disease of 1.4, both of which indicated operability for total correction. Small pulmonary arteries less than 100 microns in diameter, however, showed marked hydropic changes in the medial smooth muscle cells. Total correction was performed at the age of 2 years, but the pulmonary arterial pressure failed to decrease. A lung biopsy taken just after the closure of the ventricular septal defect contraindicated operability due to progressive pulmonary vascular disease at a grade 6 Heath-Edwards classification and an index of pulmonary vascular disease of 2.4. The patient died at 8 months after the operation, and an autopsy revealed still more advanced pulmonary vascular disease at a grade 6 Heath-Edwards classification and an index of pulmonary vascular disease of 2.8. The pathogenesis of arterial changes is discussed.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
3/103. Prenatal pressure necrosis of the scalp.A case of full-thickness pressure necrosis of the scalp in a newborn is reported. This is a rare injury, with only four similar prior reports found in the literature. The presumed mechanism of injury is pressure of the infant's head against the mother's bony pelvis. A spectrum of injury can be seen, from temporary alopecia to complete scalp necrosis. risk factors include prolonged ruptured membranes and prolonged labor.- - - - - - - - - - ranking = 6keywords = pressure (Clic here for more details about this article) |
4/103. The application of immobilized polymyxin b fiber in the treatment of septic shock associated with severe acute pancreatitis: report of two cases.The elimination of endotoxin by direct hemoperfusion over immobilized polymyxin b fiber (PMX-F) was carried out in two patients who developed septic shock associated with severe acute pancreatitis. Parameters such as blood pressure, body temperature, and plasma endotoxin level improved after PMX-F treatment, and the infected lesions were successfully and safely removed by surgery. Although an aggressive operative strategy of debridement with ultimate closure over drains is generally associated with low mortality in patients with this devastating disease, we often hesitate to perform this operation due to the poor condition of the patient in the acute period, with multiple organ failure and/or septic shock status, and also because of the difficulty in diagnosing the pancreatic infection. In this situation, endotoxin elimination using PMX-F is a useful tool for treating secondary pancreatic infections to help the patient recover in preparation for surgery, or for treating perioperative endotoxemia.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
5/103. Midterm follow-up of necrotic bleb excision and advancement of the fornical conjunctiva.mitomycin C has improved the success rate of glaucoma filtering surgery in patients at high risk for surgical failure. However chronic hypotony is marked by decreased vision and a late-onset leaking bleb after filtration surgery using mitomycin C. Bleb excision and conjunctival advancement is the method of choice to repair bleb leakage and chronic hypotony. Five eyes from five patients were received glaucoma filtration surgery with topical mitomycin C. All of the patients' blebs were avascular and transparent. The reasons for bleb excision were two spontaneous bleb leaks, two traumatic bleb leaks and one case of severe irritation. The mean follow-up period was 18.4 /- 8.3 months (ten to 29 months). cataract surgery was combined in one eye. Postoperative intraocular pressure (IOP) increased from 2.3 /- 1.5 mmHg to 9.5 /- 3.7 mmHg at nine months postoperatively in four eyes. It went from 28 mmHg to 40 mmHg in one patient with uveitis, for whom a second trabeculectomy with mitomycin C; 0.4 mg/ml for 3 minutes, was performed. After surgery, IOP decreased to 4 mmHg in three months. Postoperative visual acuity improved four snellen lines in three eyes. A partially avascular bleb recurred in three eyes, a corneal bleb in one eye and blepharoptosis, which disappeared spontaneously at four months postoperatively, in one eye. Necrotic bleb excision and advancement of fornical conjunctiva were useful methods to increase IOP and to improve visual acuity for the patient experiencing irritation symptoms, and for leaking blebs, and hypotonic maculopathy.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
6/103. Stress-related primary intracerebral hemorrhage: autopsy clues to underlying mechanism.BACKGROUND: research into the causes of small-vessel stroke has been hindered by technical constraints. Cases of intracerebral hemorrhage occurring in unusual clinical contexts suggest a causal role for sudden increases in blood pressure and/or cerebral blood flow. CASE DESCRIPTION: We describe a fatal primary thalamic/brain stem hemorrhage occurring in the context of sudden emotional upset. At autopsy, the brain harbored several perforating artery fibrinoid lesions adjacent to and remote from the hematoma as well as old lacunar infarcts and healed destructive small-vessel lesions. CONCLUSIONS: We postulate that the emotional upset caused a sudden rise in blood pressure/cerebral blood flow, mediating small-vessel fibrinoid necrosis and rupture. This or a related mechanism may underlie many small-vessel strokes.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
7/103. Congenital pressure necrosis of the forearm in a newborn infant.The authors report a case of congenital pressure necrosis of the forearm presenting in a newborn infant. The patient presented with an edematous and purpuric upper extremity with no underlying vascular compromise. After demarcation of the nonviable tissue during the first month of life, the extremity was debrided, and a thin split-thickness skin graft was applied. Graft contracture over the subsequent year was released and reconstructed with a full-thickness skin graft. Patient follow-up at age 22 months demonstrated progressive return of strength and function of the extremity with restoration of soft-tissue bulk and contour. When presented with this unusual circumstance, the plastic surgeon should be familiar with its differential diagnosis and management. Conservative debridement and age-appropriate resurfacing of the remaining wound were the essential treatment principles followed in this patient.- - - - - - - - - - ranking = 5keywords = pressure (Clic here for more details about this article) |
8/103. Innominate artery rupture after transcervical drainage for descending necrotizing mediastinitis.We present a case of innominate artery rupture after descending necrotizing mediastinitis (DNM) on day 36 of cervicomediastinal drainage. The patient recovered after aortosubclavian arterial bypass grafting followed by resection of the eroded artery. Because mechanical pressure caused by drains in addition to the inflammatory process can cause major vessel erosion, prolonged transcervical tube drainage for treating descending necrotizing mediastinitis should be avoided even if the drains applied are soft and thin.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/103. Rapid aggressive soft-tissue necrosis after beetle bite can be treated by radical necrectomy and vacuum suction-assisted closure.BACKGROUND: The substance cantharidin, which is produced by a type of beetle, rapidly penetrates the epidermis and can cause severe toxicities such as skin necrosis. Optimal treatment for necrotic beetle bites has not been well defined. Conservative management has been advocated but the hospital stays are long and long-term morbidity may result, especially in multimorbid patients. OBJECTIVE: The value of aggressive surgical management of such necrotizing diseases using newly developed surgical tools is compared to the traditional more conservative approach. RESULTS: We present the case of a multimorbid 60-year-old man with a rapidly progressive necrosis of the medial thigh (measuring 30 X 15 cm), acquired during a stay in Western africa after being bitten by a beetle of the species Cantharide. The patient was treated with radical surgical debridement and continuous elimination of the wound fluid by permanent computer-controlled negative pressure with a vacuum-assisted wound-closure device. This led to the sudden relief of both local and systemic symptoms and allowed extremely early wound closure. CONCLUSIONS: Comparing literature data with the course of this combined treatment, we strongly suggest an early aggressive management with complete radical excision of necrotic tissue, conditioning of the wound bed by temporary suction-assisted vacuum closure and subsequent skin grafting with continued vacuum application. This treatment leads to immediate relief of pain and enhanced healing of this lesion even in the condition of immunosuppression in the elderly.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
10/103. necrosis of the nasal ala after improper taping of a nasogastric tube.Inserting a nasogastric tube during various abdominal procedures is a common maneuver to decompress the upper gastrointestinal tract. Improper placement and taping of the nasogastric tube results in excessive pulling on the nasal ala and subsequent pressure necrosis. This complication not only carries serious cosmetic morbidity, it is also preventable if a proper taping technique is employed.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
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