Jehovah's Witnesses are a well-known patient demographic in medicine because of their religious-based refusal of blood transfusion. This case report outlines the treatment of a Jehovah's Witness patient in need of an extensive cytoreductive surgery due to a peritoneal carcinomatosis of ovarian origin. The surgeons carried out all the recommended surgical and anaesthetic measures concluding that extensive cytoreductive surgery on a Jehovah's Witness is possible and that a complete cytoreduction can be safely performed.I Testimoni di Geova rappresentano una minoranza di pazienti che per motivi religiosi non possono accettare trasfusioni di sangue e, a seconda delle scelte individuali, anche di prodotti emoderivati come eritrociti, piastrine, globuli bianchi o plasma. L’articolo illustra il trattamento di citoriduzione condotto su una paziente affetta da carcinomatosi peritoneale di origine ovarica, allo scopo di dimostrare che seguendo correttamente i protocolli e tutte le misure preventive in campo anestesiologico e chirurgico è possibile portare a termine un intervento di questa portata. Paziente di 58 anni con ipertensione e insufficienza mitralica, lamentava dolore di carattere continuo localizzato all’addome superiore e irradiato posteriormente. All’ultrasonografia è stata rilevata una neoformazione di 15 mm di diametro localizzata tra il 7 e l’8 segmento epatico. In seguito a TC dell’addome superiore e MR colangiopancreatografia sono state individuate numerose altre lesioni in sede epatica e nella testa e coda del pancreas compatibili con diagnosi di IPMN. Il planning chirurgico prevedeva una pancreatectomia distale e, successivamente, una resezione epatica a cuneo nella sede della lesione. Durante la procedura sono state identificate delle lesioni maligne sul mesocolon trasverso. Inoltre, l’esplorazione addominale ha permesso di individuare un’ulteriore lesione in corrispondenza del 7 segmento epatico e una neoformazione maligna nell’ovaio sinistro, infiltrante sigma e retto. È stato effettuato l’esame istologico dei tessuti in sede intra-operatoria che ha permesso di porre diagnosi di adenocarcinoma di probabile origine ovarica. Infine, erano presenti lesioni non precedentemente identificate a carico del pancreas e del diaframma. Alla luce di tutto ciò si è proceduto ad una pacreaticosplenectomia con doppia resezione a cuneo del fagato, resezione del diaframma, isterectomia totale con ovariectomia bilaterale, resezione del sigma, della parete anteriore del retto e dei linfonodi aorto-iliaci e otturatori. Nel complesso l’intervento è durato 510 minuti e non è stato necessario ricorrere a trasfusioni di sangue. Dal punto di vista anestesiologico è stato necessario monitorare attentamente la paziente per tutta la durata della procedura, sostenendo lo stato emodinamico e la gittata cardiaca tramite l’infusione di soluzione glocosata al 5% e di efedrina per prevenire fenomeni di insufficienza d’organo secondari all’instaurarsi di stati ipovolemici. I parametri vitali sono stati mantenuti nella norma con pressione arteriosa tra 61 e 110 mmHg e la pressione venosa centrale tra 4 e 10 mmHg, grazie all’infusione di 4000 ml di cristalloidi e terapia fluida. La paziente è rimasta in terapia intensiva per 13 giorni dopo l’intervento. Il decorso post-operatorio è stato complicato a causa della fuoriuscita di materiale pancreatico dal drenaggio in prossimità del moncone pancreatico. In conclusione è stato portato a termine senza complicazioni uno degli interventi più estesi eseguiti su un paziente testimone di geova, dimostrando che è possibile eseguire procedure di questa portata potendo, allo stesso tempo, rispettare il credo religioso. Di fondamentale importanza sono la preparazione e l’esperienza degli operatori in sala operatoria e l’adozione di tutte le misure preventive al fine di minimizzare i rischi di perdite di sangue.
Background: Peritoneal cystic mesothelioma (PCM) is an uncommon clinical pathology. Its high rate of recurrence following partial or total resection as well as its spontaneous onset of malignancy have been well documented in a series of case studies. The medical community has yet to define standardized treatment guidelines for PCM. Case Reports: This study reviews the case of 2 patients admitted and treated for PCM. Recent studies have reported improved recurrence and survival rates achieved by means of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), especially when used as first-line treatments. However, whether or not the use of CRS and HIPEC is more effective than a surgical regimen of multiple debulking procedures, is still the subject of debate. Conclusion: CRS and HIPEC as first-line treatments have lower morbidity and mortality rates than regimens of multiple back-to-back surgical procedures, and as such, the CRS/HIPEC method appears to be the more successful approach.
Rationale: Sepsis and septic shock are associated with microcirculatory dysfunction, which is believed to contribute to sepsis-induced organ failure. Vasodilators have been proposed to improve tissue perfusion in sepsis, but the overall survival impact of this strategy is unclear. Objectives: To evaluate the impact of systemic vasodilator administration in patients with sepsis and septic shock on mortality. Methods: We conducted a meta-analysis using a random effects model. Published and unpublished randomized trials in adult patients with sepsis and septic shock were included when comparing the use of systemic vasodilators against no vasodilators. The primary outcome was 28-30-day mortality, and secondary outcomes were organ function and resource use measures. Results: We included eight randomized trials (1,076 patients). In patients randomized to vasodilator arms compared with those randomized to treatment without vasodilators, the 28-30-day mortality risk ratio was 0.74 (95% confidence interval, 0.54-1.01). In a chronological cumulative meta-analysis, the association between vasodilators and survival improved over time. In a prespecified subgroup analysis in 104 patients in two randomized trials, prostacyclin analogues were associated with a decreased rate of 28-30-day mortality among patients with sepsis and septic shock (risk ratio, 0.46; 95% confidence interval, 0.25-0.85). Conclusions: In patients with sepsis and septic shock, administration of vasodilators is not associated with decreased 28-30-day mortality, but the confidence interval suggests potential benefit, and the meta-analysis might lack power. Prostacyclin appears the most promising. The results of this meta-analysis should encourage randomized trials evaluating the impact of vasodilators on mortality in sepsis.
ABSTRACT Acute kidney injury (AKI) is a growing epidemic and is independently associated with increased risk of death, chronic kidney disease (CKD) and cardiovascular events. Randomized-controlled trials (RCTs) in this domain are notoriously challenging and many clinical studies in AKI have yielded inconclusive findings. Underlying this conundrum is the inherent heterogeneity of AKI in its etiology, presentation and course. AKI is best understood as a syndrome and identification of AKI subphenotypes is needed to elucidate the disease's myriad etiologies and to tailor effective prevention and treatment strategies. Conventional RCTs are logistically cumbersome and often feature highly selected patient populations that limit external generalizability and thus alternative trial designs should be considered when appropriate. In this narrative review of recent developments in AKI trials based on the Kidney Disease Clinical Trialists (KDCT) 2020 meeting, we discuss barriers to and strategies for improved design and implementation of clinical trials for AKI patients, including predictive and prognostic enrichment techniques, the use of pragmatic trials and adaptive trials.
Highlights•Filamentous Pf bacteriophage are produced by Pseudomonas aeruginosa•Pf phage interact with host and microbial polymers to assemble higher order structures•Pf phage increase the viscosity of polymers in cystic fibrosis airway secretions•The Pf-induced liquid crystal biofilm matrix boosts tolerance to desiccation and antibioticsSummaryBiofilms—communities of bacteria encased in a polymer-rich matrix—confer bacteria with the ability to persist in pathologic host contexts, such as the cystic fibrosis (CF) airways. How bacteria assemble polymers into biofilms is largely unknown. We find that the extracellular matrix produced by Pseudomonas aeruginosa self-assembles into a liquid crystal through entropic interactions between polymers and filamentous Pf bacteriophages, which are long, negatively charged filaments. This liquid crystalline structure enhances biofilm function by increasing adhesion and tolerance to desiccation and antibiotics. Pf bacteriophages are prevalent among P. aeruginosa clinical isolates and were detected in CF sputum. The addition of Pf bacteriophage to sputum polymers or serum was sufficient to drive their rapid assembly into viscous liquid crystals. Fd, a related bacteriophage of Escherichia coli, has similar biofilm-building capabilities. Targeting filamentous bacteriophage or the liquid crystalline organization of the biofilm matrix may represent antibacterial strategies.Graphical abstract
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