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full issue

science
30th September
Impacted uterine myoma in a 14 week
pregnant patient
also
Dengue vs. Leptospirosis, diagnosis and
treatment from the first contact
Recurrent incisional hernia sublay repair
with fully reabsorbable monofilament mesh
– a case report
Dengue, for apparatus and systems
Bionic Pancreas and Bionic Organs – how
far we are from the success
Fragments od bacterial DNA presence in
hemodialisis patients’ blood-preliminary
report
Issue 3/2015
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Dear Colleagues,
MICHAŁ WSZOŁA MD, PhD
Editor in Chief
We are pleased to present another issue of MEDtube Science - an open access
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MEDtube Science Sep, 2015; Vol.III (3)
TABLE OF CONTENTS
Impacted uterine myoma in a 14 week pregnant patient
Agnieszka Dobrowolska-Redo, Justyna Teliga-Czajkowska, Ewa Romejko-Wolniewicz et al
PAGES 8-10
Dengue vs. Leptospirosis, diagnosis and treatment from the first contact
Luis del Carpio Orantes
PAGES 11-13
Recurrent incisional hernia sublay repair with fully reabsorbable monofilament mesh – a
case report
Magdalena Kwapisz, Michał Wszoła, Piotr Domagała et al
PAGES 14-20
Luis del Carpio Orantes
PAGES 21-24
Bionic Pancreas and Bionic Organs – how far we are from the success
Michal Wszola, Joanna Idaszek, Andrzej Berman et al
PAGES 25-27
Fragments od bacterial DNA presence in hemodialisis patients’ blood-preliminary report
Marta Serwańska-Świętek, Marzena Sikora, Bożena Interewicz et al
PAGES 28-31
science
8
Uterine myomas are some of the most
frequent neoplasms in women in the
reproductive age.
Impacted uterine myoma in a 14 week pregnant
patient
Agnieszka Dobrowolska-Redo1, Justyna Teliga-Czajkowska2#, Ewa Romejko-Wolniewicz1, Julia Zaręba-Szczudlik1, Krzysztof Czajkowski1
1.
The 2nd Department of Obstetrics and Gynecology of Warsaw Medical University, Poland
2.
Department for Didactics of Gynaecology and Obstetrics, Faculty of Health Sciences, Medical University of Warsaw, Karowa St 2, p.o. box
00-315 Warsaw, Poland. Tel. +48 22 5966 421, Fax +48 22 5966 487
#Corresponding author: Justyna Teliga-Czajkowska e-mail: [email protected] Karowa St 2, p.o. box 00-315 Warsaw, Poland
Tel. +48 22 5966 421, Fax +48 22 5966 487
RUNNING TITLE
Impacted uterine myoma
KEYWORDS
myoma, pregnancy, impacted submucosal myoma
WORD COUNT
1 437
CONFLICT OF
INTERESTS
no conflicts of interest
No supplemental data have been included with the submission
ABSTRACT
Uterine myomas are some of the most frequent neoplasms in women in the reproductive age. The frequency of
uterine myomas in pregnancy varies between 0.1 and 3.9 %. The pregnancy in a woman with uterine myomas
is usually uncomplicated, but in 10% of them, the myomas may cause symptoms. The study presents the case
of a pedunculated submucosal myoma impacted in the rectouterine pouch in a woman 14 weeks pregnant.
INTRODUCTION
U
terine myomas are some of the most frequent neoplasms in women in the reproductive
age (1,2). The frequency of uterine myomas in
pregnancy varies between 0.1 and 3.9 % (2,3,4,5).
Most of them appear without any symptoms. The
pregnancy in a woman with uterine myomas is usually
uncomplicated, but in 10% of them the myomas may
cause pain in the small pelvis, miscarriage, bleedings,
premature delivery, premature leaking of amniotic
fluid (3,4,6,7). During the delivery, the presence of
myomas may be conducive towards incorrect position of the fetus, shoulder dystocia, increased risk
of delivery with a procedure, and caesarean section.
After delivery, myomas may cause bleeding and placental tissue retention (3,4,6,7). Myomectomy during
the planned caesarean section seems to be the safe
method (8,9), while myomectomy during pregnancy
is associated with higher risk of bleeding, increased
science
9
mortality of mothers, and risk of losing the pregnancy (9). Only 2% of women require an urgent surgical
intervention during pregnancy (7). It is believed that
surgical intervention should be considered in the
case when the pain symptoms persist for 72 hours
despite analgesic treatment (5,7). Pedunculated
myomas may be particularly dangerous in case they
become wedged-in, while their removal bears a lower
risk of perioperative bleedings. The study presents
the case of a pedunculated submucosal myoma
impacted in the rectouterine pouch in a 14 weeks
pregnant woman.
CASE DESCRIPTION
The patient was a 33 year old primigravida, admitted to the hospital while 14 weeks pregnant, as an
emergency case, due to the complaints of hypogastric pains intensifying for 3 days, not disappearing
after administration of analgesic medications. Until
the complaints, the course of pregnancy had been
without complications. The ultrasound examination
in 6th week of pregnancy presented a living fetus
consistent with the pregnancy age. On the posterior
wall a pedunculated myoma 99x51 mm was discovered. In a follow-up ultrasound examination in the
12th week of pregnancy, the myoma was found to
grow, to the dimensions of 114x74mm. After admitting the patient to the Clinic, her general condition
was good, however there appeared strong pains of
the hypogastrium radiating to the anus. The blood
arterial pressure maintained at the level of 125/85
mmHg, pulse 90/minute, temperature within normal
limit. In the gynaecological examination, there was
discovered that the vaginal part was behind the pubic
symphysis of the length of 2 cm, uterus of correct
tone, and at the same time significant muscular pain
occurred when moving the uterus. The rectouterine
pouch was bulging, tender, filled with a hard tumor of
the diameter of about 10 cm – probably an impacted
myoma. The patient was informed of indications to
an urgent surgical intervention. The abdominal cavity
was opened in midline from the pubic symphysis to
the navel. During the operation, there was revealed
the pulpy body of the uterus, expanded, consistent
with the week of pregnancy. Behind the uterus, in the
rectouterine pouch, there was discovered an impacted pedunculated submucosal myoma, dimensions
15x8 cm, extruding from the posterior wall from the
area of the left horn of the uterus, pulling the uterus
posteriorly. The diameter of the peduncle was 2 cm.
Apart from that, there were also present two intramural myomas in the anterior wall, each of the diameter
of about 2 cm. Due to the difficulty in extracting the
impacted myoma, a decision was made during the
operation to additionally cut the upper border of
the wound, at the angle of 70 degrees, omitting the
navel. Through bipolar coagulation, the myoma was
removed and the peduncle was fixed with single sutures. The post-operative course was without complications. The patient was discharged on the 8th day,
in a good general condition, with live pregnancy. The
delivery was without complications, natural, at term.
DISCUSSION
Myomas, in the course of pregnancy, are diagnosed in between 0.1% to even 12.6 women (10,11).
Myomas of the size of over 3 cm are discovered in
ultrasound examinations in about 4.17% pregnancies
(4). As per the research by Muram et al. (12), 42% of
myomas are discovered during physical examinations
of pregnant women, but in the group of myomas of
the size of 3-5 cm, that rate is only 12.5%. It is getting more difficult to locate myomas together with the
progress of pregnancy. In many cases, the presence
of myoma or myomas, is discovered accidentally
during caesarean section (13). According to Muram
et al. (12), only in about 41% cases, the presence of
myomas is known to the physician supervising the
pregnancy. Pregnancy is the period when the uterus
becomes significantly enlarged, and the concentrations of hormones - both estrogens and progesterone
– are high (14). The impact of pregnancy on changing
the size of myomas, is difficult to determine. About
22% to 32% myomas are enlarged during pregnancy, while 7.8% to 19% decrease in volume (15,16).
As per the research by Hammoud et al. (2), in the
systematic ultrasound examinations between the first
half of a pregnancy and its 20th/30th week, a little
over one half of myomas shrink, on average in about
35% cases. The remaining myomas (45%) significantly expand in that period, on average by 69%. The
changes in volume may depend on the initial size of
myomas. A fast growing myoma during pregnancy
may cause strong pains, compression on the alimentary canal, and, in additional examinations, look like
an oncologically suspicious lesion (17,18). In the case
of a polycystic lesion, with uneven echogenicity, it is
only possible to distinguish between a necrotic myoma and a sarcoma, on the basis of a microscopic
examination. The presence of myomas causes a
more frequent occurrence of caesarean sections, by
about 25-100% in comparison with other patients
(4,6,19,20,21). Coronado et al. (22) analyzed the
course of pregnancies of 2065 women with myomas
and 4243 without myomas, and discovered that the
patients with myomas much more often developed
bleedings in early pregnancy (OR=1.82; 95% CI 1.053.20), premature placental abruption (OR=3.87 1.639.17), hydramnion (OR=2.44; 95% CI 1.02-5.84). The
authors also recorded disturbances during delivery
in the form of incorrect course of delivery (OR=1.85,
95% CI 1.26-2.72), frequency of breech position
(OR=3.98; 95% CI 3.07-5.16), percentage of caesarean sections (OR=6.39; 95% CI 5.46-7.50), more
frequent deliveries before the 38th week of pregnancy (OR=1.47; 95% CI 1.16-1.87), more children with
the mass of < 2500g (OR=1.99; 95% CI 1.51-2.62)
and assessed at < 7 points in the Apgar scale in the
5th minute of life (OR=2.49; 95% CI 1.49-4.15). Very
similar results in a group of 690 pregnant women
with myomas, were presented by Sheiner et al. (23).
The operations of removing myomas during pregnan-
science
cy are conducted relatively rarely, usually due to such
reasons as pains, compression on the urinary bladder
and urinary retention, fast expansion of the lesion.
The main complications of the procedures conducted during pregnancy is premature end of pregnancy
(miscarriage, premature labor) and bleeding. However, in the research conducted by Lolis et al., only
one miscarriage (5) was recorded among 13 pregnant
women subject to myomectomy. However, it should
be remembered that the very presence of myomas,
may also be conducive to miscarriages and preterm
labor (22, 24). Most cases of removal of myomas
during pregnancy appear in the case of subserous
myomas, between 14th and 19th week of pregnancy
(7,9,25). In literature, there are also described cases
of extirpating intramural myomas (25). The procedures are performed by laparotomy or laparoscopy (26).
The available literature also describes the cases of
extirpation of more than one myoma (27). A unique
situation occurs when the uterus and myoma are
impacted in the small pelvis. A typical symptom is
urinary retention and hypogastric pains (28). Similar symptoms appear in the case of a pregnancy
with the uterus with permanent retroflexion. In the
case described by us, the decision on the surgery was made due to persisting hypogastric pains,
not regressing despite administration of analgesic
medications. During the surgery, it was discovered
that those pains were caused by the herniation of the
pedunculated myoma in the rectouterine pouch and
the fact that the patient’s uterus was “pulled” posteriorly, thus limiting its mobility and growth. The pain
caused by the presence of the myoma, or resulting
from its ischemia, may be treated by means other
than surgery. The first step should be the attempt to
apply opioids, or extradural anesthesia for several
days (29, 30, 31). Surgical extirpation of myomas in
pregnancy is associated with higher risk of miscarriage and bleeding. Based on the data available,
most patients after surgery will deliver the baby in
term. The surgical treatment of patients with uterine myomas is a significant challenge, and requires
detailed analysis of indications to the surgery and the
resulting risks.
10
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
CITE THIS AS
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MEDtube Science 2015, Sep 3(3), 8 - 10
31.
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science
11
Dengue infection occurs, without doubt,
at high incidence and prevalence rates
in endemic tropical areas, including
Mexico.
Dengue vs. Leptospirosis, diagnosis and
treatment from the first contact
Luis del Carpio Orantes1
1. Department of Internal Medicine, General Hospital 71, Mexican Institute of Social Security, Veracruz, Veracruz, Mexico
#Corresponding author: Luis del Carpio Orantes, E-mail: [email protected].
RUNNING TITLE
Dengue vs. leptospirosis
KEYWORDS
dengue, leptospirosis
WORD COUNT
942
CONFLICT OF
INTERESTS
ABSTRACT
Dengue infection occurs, without doubt, at high incidence and prevalence rates in endemic tropical areas,
including Mexico. Another big issue that physicians from the emergency room are facing, are infections that
often simulate dengue symptoms, primarily through the bacterial infection caused by Leptospira, whose rate
has increased in some regions. Unfortunately, there is no specific diagnosis done in this matter. Below there
is a series of comparisons between the two infections listed. Both clinical and biochemical data has been
provided for this cause.
D
engue infection occurs, without doubt, at high
incidence and prevalence rates in endemic tropical areas, including Mexico. Despite primary
prevention programs and vector control, the infection
is hard to be eradicated and continues to claim lives
every year. Yet, different strategies are used to reduce the incidence and mortality.
Another big issue that physicians from the emergency room are facing, are infections that often simulate
dengue symptoms, primarily through the bacterial
infection caused by Leptospira, whose rate has
increased in some regions. Unfortunately, there is
no specific diagnosis done in this matter and consequently, no appropriate subsequent treatment has
been introduced to decrease the rate of mortality and
lethality in this region.
Current medical practice, based on medicine stocks,
rather than evidence caused that many doctors do
not sufficiently regulate nor standardize practices
such as „prophylactic” use of antimicrobials in all
patients with dengue or suspected dengue. In such
situation it is difficult to avoid failure to diagnose
leptospirosis symptoms properly or let it pass unnoticed. One has to remember that patient may not have
an accurate serological or microbiological diagnosis,
science
which can result from iatrogenic allergic reactions ,
bacterial resistance, use inappropriate and exaggerated antimicrobials, etc.
Although the clinical pictures are similar and can
often be confused, there are some key points that
the doctor should know and understand in his first
contact with the patient to skillfully discern the difference. Coexistence cases of dengue infection and
Leptospira are virtually not possible to be differentiated. Even though, its existence has not been recorded in the literature, it rarely occurs.
Below there is a series of comparisons between the
two infections listed. Both clinical and biochemical
data has been provided for this cause.
Currently, the primary care physician should have
the clinical acumen to suspect a possible dengue
and differentiate leptospirosis hidden symptoms, for
which there are some basics to consider. It is because the clinical picture is very similar in both cases.
However in case of Leptospira there are some key
symptoms that may arise from the clinical review.
These are: data conjunctival hemorrhage, muscle
involvement manifested as myalgia and more exaggerated toward the pelvic limbs cramps and jaundice.
Typically, the biochemical features of dengue, show
hemoconcentration, leucopenia, thrombocytopenia,
lymphocytosis, in some cases, the onset of symptoms, which usually indicate free viruses. Yet, in
cases of leptospirosis, leukocytosis combined with
thrombocytopenia, there is a suspicion of the entity,
which is related to a bacterial symptoms.
In viruses, there is usually mild transaminasemia
(rarely more than two or three times the normal
value), rarely jaundice or hiperbilirubinemia, hypoalbuminemia, rarely elevated nitrogenous can be found
(reserved for severe cases, or severe hypoperfusion
shock) and moves towards gravity are gradual,
unless the patient undergoes medical review late.
Leptospira infection, in contrast, is often initially depicted with a bulky box and severe hepatic involvement, which in severe cases (Weil’s disease) are
more apparent, with transaminasemia severe hiperbilirubinemia and acute kidney injury data with elevation of data nitrogenous and respiratory or cardiac
failure (11,17,18). Clinical hospitals often use rapid
diagnostic reagents , which help clarify the diagnostic doubt. However, in many rural hospital settings
there is a deficiency of resources, which may discern
between an entity or other, coupled with basic data
clinical laboratory. The problem may be resolved by a
study done to measure serum procalcitonine, which
normally increases in bacterial or fungal infections,
but not in viral conditions.
Due to the above factors, it was sometimes decided
to start prophylactic or preventive chemotherapy.
However it has been shown that those measures
have not had a significant impact on the resolution of
the pictures and sometimes carry adverse gastrointe-
12
stinal or allergic effects. Similarly, in identified endemic areas and where there is need for humans exposed to these areas, prophylactic doses have been
administered, yet with mixed results. For prophylaxis
it is recommended to use primarily Doxycycline
200mg per week. There is no increase in gastrointestinal symptoms, mainly nausea and vomiting, and
no greater benefit on the incidence, seroconversion
or resolution of infection is demonstrated (8,9,10).
In our environment, we have chosen to administer
parenteral crystalline sodium based penicillin or cephalosporin. However, there are no studies done to
support this practice but only to recommend initiation
of empirical antibiotic therapy in patients with high
suspicion of leptospirosis demonstrated in pictures,
which was initially classified as dengue. In this case
parameters of high clinical and biochemical suspicion
of both entities were advised to be considered. They
are summarized in table 1 and 2.
While there are pictures of severe dengue with multiorgan involvement that cannot be distinguished clinically or biochemically as leptospirosis, and to keep
such critically ill patients is justifiable treating them
with empirical antibiotic therapy, then in mild cases ,
which only show dengue fever or severe dengue, it is
not (1,2,3,4,5,6,7).
Finally, it needs to be taken into consideration that
these infections are associated with atypical paintings, which have rarely been reported in the world
literature. Medical contrast images of dengue virus
infection with leukocytosis ( some series reported up
4.4%), and worse, coexistence of both infections ,
dengue, leptospirosis but in one patient at a time ,
making it extremely difficult to differentiate and treat
them separately , especially if it comes to symptoms
or mild anicteric leptospirosis , indicating these rare
or unusual cases. Antibiotics were used to prevent
progression to multiorgan failure and death. Current
patterns of prophylaxis in endemic and high incidence of leptospirosis are based on oral doxycycline in
weekly doses, and treatment schedules are varied,
from use of crystalline sodium penicillin aminopenicillins, cephalosporins 3rd generation, doxycycline,
macrolides, quinolones, etc, lasting 7-10 days (12,
13, 14, 15, 16).
CITE THIS AS
MEDtube Science 2015, Jun 4(3), 11 - 13
LIST OF THE TABLES
Tab. 1. Epidemiological and clinical differences
Tab. 2. Differences and recommendations
science
13
TAB. 1. EPIDEMIOLOGICAL AND CLINICAL DIFFERENCES
Dengue
Infectious
agent
Transmission
Leptospirosis
Denguevirus (DEN- 1 to
DEN -4) RNA virus, Flavivirus family.
Strict aerobic bacteria,
spirochetes of the family,
and the genus Leptospira.
More than 200 infectious
serovars.
vector, Aedes Egypti
mosquito
Dermal or mucosal contact with sub-stances or
contaminated by the urine
of infected species other
foods.
Sharp sudden fever,
headache, muscle aches,
abdominal pain, nausea,
vomiting.
Clinical picture
Acute febrile sudden
onset accompanied by
headache, muscle aches,
retro orbital pain, nausea,
vomiting, and rash.
TAB. 2. DIFFERENCES AND RECOMMENDATIONS
* Clinical picture mild
anicteric.
* Clinical picture with
severe hepatic, renal ,
myocardial and / or neurological (Weil’s Disease)
Symptoms and signs of
increased likelihood of
leptospirosis:
exaggerated muscle pain ,
mainly in calves,
Conjunctivitis or conjunctival effusion, or
generalized scleral jaundice, hepatalgia , anuria,
acute respiratory failure
, angina by hemorrhagic
myocarditis
Suspicion clinical
Dengue
Acute febrile syndrome accompanied by headache,
retro-orbital pain,
muscle aches,
rash
Hemoconcentration (hematocrit
ratio / Hb)
Lymphocytosis
initial,
Leukopenia,
Thrombocytopenia,
Mild transaminemia
Leptospirosis
Clinically similar to
dengue.
Spill or conjunctival hemorrhage.
Intense muscle
aches, leg cramps.
Jaundice
Anuria.
Dyspnea, cyanosis. Angina
Leukocytosis
combined with
thrombocytopenia.
Azotemia
Transaminemia
severe
Hyperbilirubinemia.
Acute respiratory
failure (hypoxemia)
Diagnosis
Early Detection :
* NS1
* IgM and IgG
There is no specific
treatment.
Vigorous hydration.
Treatment
Symptomatic treatment
Advanced life support and
critical care (severe).
Various antimicrobial
* Natural Penicillins (risk of
Jarisch- Herxheimer ) .
* Aminopenicillins (ampicillin, amoxicillin).
* 3rd generation cephalosporins
(cefotaxime , ceftriaxone )
* Doxycycline
* Macrolides (azithromycin, erythromycin )
* Quinolones
Advanced life support and
intensive care in severe
cases.
1.
2.
3.
4.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Recommendation
Not start antimicrobial
Start empirical
antibiotics, even
without waiting for
a rapid diagnostic
test.
BIBLIOGRAPHY
5.
* Dark field Microscopy
(direct) in blood, CSF or
urine.
* PCR
* Microscopic agglutination test (MAT)
* IgM and IgG
Suspicion
biochemistry
Faucher JF, Hoen B, Estavoyer JM. The management of leptospirosis.
Expert Opin Pharmacother. 2004 Apr;5(4):819-27.
Suputtamongkol Y, Niwattayakul K, Suttinont C, et-al. An open,
randomized, controlled trial of penicillin, doxycycline, and cefotaxime for patients with severe leptospirosis. Clin Infect Dis. 2004 Nov
15;39(10):1417-24.
Griffith ME, Hospenthal DR, Murray CK. Antimicrobial therapy of leptospirosis. Curr Opin Infect Dis. 2006 Dec;19(6):533-7.
Phimda K, Hoontrakul S, Suttinont C, et-al. Doxycycline versus
azithromycin for treatment of leptospirosis and scrub typhus. Antimicrob Agents Chemother. 2007 Sep;51(9):3259-63.
Charan J, Saxena D, Mulla S, et-al. Antibiotics for the treatment of
leptospirosis: systematic review and meta-analysis of controlled trials.
Int J Prev Med. 2013 May;4(5):501-10.
Brett-Major DM, Coldren R. Antibiotics for leptospirosis. Cochrane
Database Syst Rev. 2012 Feb 15; 2:CD008264
Guerrier G, D’Ortenzio E. The Jarisch-Herxheimer reaction in leptospirosis: a systematic review. PLoS One. 2013; 8(3):e59266.
Guidugli F, Castro AA, Atallah AN. WITHDRAWN: Antibiotics for
preventing leptospirosis. Cochrane Database Syst Rev. 2009 Jul 8
;(3):CD001305
Brett-Major DM, Lipnick RJ. Antibiotic prophylaxis for leptospirosis.
Cochrane Database Syst Rev. 2009 Jul 8;(3):CD007342.
Bhardwaj P, Kosambiya JK, Vikas KD, et-al. Chemoprophylaxis with
doxycycline in suspected epidemic of leptospirosis during floods:
does this really work? Afr Health Sci. 2010 Jun;10(2):199-200.
Vielma, S., Muñoz, M., Pérez.Lo Presti, S. et.al. Hallazgos clínicos y
de laboratorio en pacientes con dengue. Revisión de criterios diagnósticos. Revista de la Facultad de Farmacia, Vol. 48 (1) 2006
Cabello MA, Cabral MB, Samudio M. Dengue y leptospirosis compartiendo el mismo nicho ecológico en la localidad ribereña de Carmen
del Paraná (Itapúa). Mem. Inst. Investig. Cienc. Salud, Vol. 6(1) Junio
2010: 35-40
Crociati,L.y Onofre de Medeiro Jr, H. Coinfección por leptospirosis
y dengue en un paciente de la amazonía brasileña. Rev Pan-Amaz
Saude 2010; 1(4):97-99.
Navarrete Espinosa, Joel, Acevedo Vales, Juan Antonio, Huerta
Hernández, Emilia, et-al. Prevalencia de anticuerpos contra dengue
y leptospira en la población de Jáltipan, Veracruz. Salud Pública de
México 2006, mayo-junio, 220-228.
Gonsalez CR, Casseb J, Monteiro FG, et.al. Use of doxycycline for
leptospirosis after high-risk exposure in São Paulo, Brazil. Rev Inst
Med Trop Sao Paulo. 1998 Jan-Feb; 40(1):59-61.
Edwards CN, Levett PN. Prevention and treatment of leptospirosis.
Expert Rev Anti Infect Ther. 2004 Apr; 2(2):293-8.
Dengue: Guidelines for treatment, prevention and control. Geneva:
World Health Organization, 2009.
Simmons, CP., Farrar, JJ., Van Vinh Chau, N., et-al., Dengue. N Engl J
Med 2012; 366:1423-32.
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14
Incisional hernia is a common postoperative complication of abdominal surgery, with the incidence ranging from 11%
up to 20% of all laparotomy incisions.
Recurrent incisional hernia sublay repair with
fully reabsorbable monofilament mesh – a case
report
Magdalena Kwapisz 1, Michał Wszoła1#, Piotr Domagała1, Piotr Góralski 1, Agnieszka Nalewajek 1, Anna Zuchowska2, Andrzej Chmura1, Artur
Kwiatkowski1
1.
Department of General and Transplantation Surgery, Warsaw Medical University, Warsaw, Poland
2.
Department of Clinical Radiology, Warsaw Medical University, Warsaw, Poland
# Corresponding author: Michał Wszoła MD, PhD, ul. Nowogrodzka 59 , 02-006 Warsaw, Poland. Phone:+48225021470, e-mail: michal.
[email protected]
RUNNING TITLE
Incisional hernia sublay repair
KEYWORDS
incisional hernia, recurrent hernia, hernia repair, sublay method, sublay hernioplasty, reabsorbable mesh, phasix
WORD COUNT
1 963
CONFLICT OF
INTERESTS
ABSTRACT
Incisional hernia is the most common indication for reoperation after abdominal surgery. Mesh hernioplasty is almost a
gold standard of treatment, associated with the low recurrence rate. Study presents a case of usage of a fully reabsorbable
mesh for successful sublay hernioplasty in recurrent incisional hernia with a past history of many wound complications.
INTRODUCTION
I
ncisional hernia is a common postoperative complication of abdominal surgery, with the incidence
ranging from 11% up to 20% of all laparotomy
incisions [1, 2] and the most common indication for
reoperation after laparotomy [3]. It is defined as a
defect occurring through the operative scar, caused
by a failure of the lines of closure of abdominall wall.
Thereby, it is the only hernia considered to be truly
iatrogenic. The most common incision of previous
surgery leading to incisional hernia is the infraumbilical or supraumbilical midline incision, followed by
Pfannenstiel’s incision, paramedial, lumbar and right
subcostal [4, 5]. Not only a closure technique and
suture materials have an effect on hernias incidence.
Postoperative wound infection and patient factors,
such as advanced age, obesity, diabetes mellitus,
15
tobacco abuse, hypoproteinemia, corticosteroid use
and immunosupresion are esthablished risk factors of
hernia formation likewise [4, 6, 7].
Most of incisional hernia require elective surgical repair, because of becoming larger and causing morbidity complications if left untreated. A great variety of
surgical techniques have been adopted for the repair
of abdominal incisional hernias. Nowaday, the best
results are believed to be achieved by the implantation of prosthetic mesh [8] and the use of prosthetic
material is almost a standard practise. Fibrous tissue,
while growing in the porous mesh, consolidates the
abdominal wall and disperses intraabdominal pressure, to prevent a recurrence of hernia. Anatomical
repair is associated with recurrence rates about 2350% [9, 10, 11] in comparison to 1,5-10% following
prostetic mesh repair [12]. As in general, diabetes
mellitus, obesity, smoking, postoperative straining
and advanced age are also established risk factors
of recurrence [4]. Despite of its significant benefits,
a mesh should be treated as a foreign material and
susceptible to infection, sinus formation or enteric
fistulization [13]. The foreign body implantation may
lead to chronic inflammation or excessive fibrosis
and may result in increased stiffness and loss of pliability at the site of sewing [10, 14].
There is no general agreement as to the best choice
of one of many prosthetic mesh repair techniques
that have been proposed. The material can be placed
between the subcutaneus tissues of the abdominal
wall and the anterior rectus sheath (named onlay
method) as well as in the preperitoneal plane created between the rectus muscle and posterior rectus
sheath (named sublay method). This study reports a
case of usage of a fully reabsorbable Phasix Mesh for
sublay hernioplasty of recurrent incisional midline hernia after a primary surgery by Pfannenstiel’s
incision and hernioplasty with polypropylene mesh
complicated by surgical site infection.
CASE REPORT
In July 2014, 62 y.o. female admitted to the surgical
department with a complaint of the recurrent ventral
hernia and the symptoms of pain and movement
limitations while performing activities of her daily life.
She testified, that she underwent ginecological procedure by Pfannenstiel’s incision few years ago. Her
comorbidities were hypertension, diabetes mellitus
and obesity (BMI = 35).
Her past medical history revealed an incisional hernia
repaired with polypropylene mesh in January 2014,
complicated with a large hematoma (sized 200 x 120
x 90 mm). Transdermal puncture and drainage with
a subsequent antibiotic prophylaxis (ciprofloxacin)
were succesfully performed then. In March 2014,
control ultrasound examination showed giant multichamber seroma (sized 130 x 70 x 140 mm) in the
lower part of anterior abdominal wall tissues. Those
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abnormal fluid collections remained under medical
careful control. In June 2014, another antibioticoterapy (metronidazol and cefuroxime) was administered,
but pathological conditions still maintained unhealed.
As a result of her first consultation in our department,
computer tomography of the abdomen was administered. It revealed a midline gap of hypogastric linea
alba, sized 130 x 110 mm, with concomitant inflammatory infiltration of the surrounding adipose tissue.
Any pathologic fluid collection within the abdominal
cavity wasn’t found. Therapy with cefuroxime was
continued with sufficient result. Patient was qualified
for operative treatment. In May 2015, direct preoperative examination revealed palpable midline gap
sized about 13 x 8 cm [Fig. 1, 2]. Computer tomography showed midline ventral hernia (137 x 112 x 56
mm trans x cc x ap) containing mesenteric adipose
tissue and distended loops of small intestine within
numerous adhesions. The hernia gate was measured
on 104 x 75 mm [Fig. 3].
Under general anesthesia, open sublay hernioplasty
(with the mesh placed in the retromuscular space)
was performed [Video 1]. Patient was prepared and
an antimicrobial-impregnated adhesive drape was
placed over the skin of the anterior abdominal wall.
The abdomen was accessed through a midline incision, mostly through the previous scar. A single dose
of cefazolin (2,0 g intravenously) was administered
at the time of skin incision. In a first step, an inflammatory tumor around previous polypropylene mesh
was ressected and residual prosthetic material was
explanted [Fig. 4]. Peritoneal adhesions were released [Fig. 5]. Then, the sac was delineated [Fig. 6].
Its contents was reduced and discharged into the interior of the abdominal cavity. The fascial defect was
identified all around. The preperitoneal dissection of
the anterior abdominal wall, allowing for mesh to be
extended, began. When the posterior fascia has been
released, the edges of the defect were reapproximated with running non-absorbable polydioxanone (size:
1.0) sutures [Fig. 7]. After that, Phasix Mesh sized
4” x 6” (10 x 15 cm) was placed into retromuscular
space and anchored by suturing it to the rectus sheath [Fig. 8]. Additional simple sutures were placed
on either side laterally to ensure its flat position [Fig.
9]. In the next step, anterior fascia was finally reconstructed over the mesh with a running polydioxanone suture (size: 1.0) [Fig. 10, 11]. Then, hemostasis
was attained and two suction drains were placed in
subcutaneous plane superficial to the mesh. Next,
the excessive skin and subcutaneous tissue were reduced through additional incision needed in Pfannenstiel’s line. Endmost, the wound was closed [Fig.12].
In the postoperative period, patient required analgesic treatment only for 24 hours. The drains were
removed in second postoperative day and she was
discharged at the third day of hospital stay with no
direct postoperative complications.
Two weeks later, she attended a clinic as an
outpatient with delayed wound healing caused by
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seroma in the operated side. She had no fever and
microbiological test results were negative. The prophylactic therapy with Sorbact method was carried
out to prevent the wound from being infected. Patient
remained under ambulatory care with persistent
wound exudate and without its adequate healing.
After three weeks, Proteus mirabilis was identified in another microbiological tests. Then, woman
was hospitalized with diagnosis of wound infection.
Intravenous amikacine was administered. Simultaneously, negative pressure therapy was succesfully
performed. She was fully recovered at the begining of
August 2015 and with no complaints of pain or mesh
sensitivity in follow-up 2 months later [Fig. 13, 14].
DISCUSSION
The predominance of mesh reinforcement over
suture-based repair in incisional hernia surgery has
been well established in the literature. Although its incidence rate remains low, the risk of recurrence after
meshplasty is not completely eliminated. The best
technique to provide a durable correction has not
been determined. Moreover, recurrences of abdominal wall hernia as shown by the literature are rarely
induced because of failure of the mesh. In most of
cases, they occur at the mesh-tissue interface – typically at the cranial edge of the wound in the midline,
or at the lateral border of nonmidline hernias [15,
16]. It allows to suggest, that the recurrence arise
either due to technical problems with sufficient mesh
coverage or next to inadequate coverage of the defect, rather than because of the mesh material itself
[17]. The numerous approaches, types of prosthetic
materials for repair, and possible locations of mesh
placement testify to the lack of unequivocal evidence
to promote any of repair technique that have been
proposed so far.
The sublay method, popularized by Rives [18] and
Stoppa [19] in the late 1980s, uses the potential
space dissected posterior to the rectus sheath for the
mesh placement. It is considered by many surgeons
as a gold standard for open abdominal incisional
hernia repair [20, 21, 22, 23]. The recurrence rate
of preperitoneal (sublay) mesh repair mentioned in
different series varies from 2% to less than 10% [24].
Its main advantages in the reconstruction of complex
abdominal wall defects are associated with a release
of rectus abdominis muscle that provides a 2-layered closure of midline anterior fascia [25]. More
importantly, the posterior rectus sheath dissection
from the overlying muscle, provides a well-vascularized pocket for mesh placement. In contrast, the
anterior sheath is tightly adherent to the tendinous
inscriptions of the rectus muscle. It was proved by
Binnebosel at collegues on their rabbit model of open
incisional hernia repair, that mesh placed in the rectorectus space demostrates more of both type I and
type III collagen deposition in a porcine model, when
compared with its onlay position [26].
The concern with the open approach to incisional
16
hernias remains wound complications. The dissection required to proper mesh placement and reapproximate the midline can lead to significant wound
and mesh infections. In 2010, Venclauskas and
colleagues published their results of 1-year follow-up
after incisional hernia treatment. That prospective
randomized study demonstrated wound complications in 49.1% of onlay patients vs 24% of sublay
repairs. Also the incidence of seroma was significantly higher in the onlay technique (45%) when
compared with the sublay (24%) [27]. It must be
noted, that the rate of wound morbidity after incisional hernia repair depends on not only mesh material
or the technique selection, but it is connected with
patient comorbidities as well. Prior wound infection,
obesity, diabetes mellitus, heart failure, presence of
a stoma or malnutrition are well known independent
risk factors of surgical site infections [28]. It leads to
some difficulties in interpreting and comparing the
findings published in the literature.
It is believed, that placing the mesh deep in the
retrorectus plane prevents the transmittion of infection from subcutaneous tissues down to the mesh
[29]. Otherwise, there is a necessity to perform mesh
reinforcement in contaminated area in some cases.
It significantly affects the success of the operation.
When repairing a contaminated abdominal wall defect, the sublay method provides The opportunity of
rapid revascularize that prevents a material failure,
improve bacterial clearance and long-term success
of the repair [30]. Placing a mesh in a poorly vascularized area increases the risk of its early degradation
by bacterial collagenase prior to achieving neovascularization and utilization of the native host immune
system. Using a bioabsorbable or even biologic
grafts in the retrorectus compartment is hypothesized
to improve the outcomes related to recurrence rates
when contamination is present [28]. Those products
significantly raise the cost of the procedure.However, if infectious complications can be avoided, cost
would be offset by offering value to the patient.
In presented case of recurrent incisional hernia with
a previous history of many wound complications, a
procedure of sublay reinforcement with fully resorbable mesh implant (Phasix Mesh) was performed.
The used material degradates through the processes
of hydrolysis and a hydrolytic enzymatic digestive
process within 12 to 18 months. There was no recurrence in 4 month follow-up observation. An episode
of surgical site infection has been effectively healed
with no futher complications.
The role of bioabsorbable implants in contaminated
cases has not been determined yet, and ongoing
prospective studies are indispensable to provide
guidance for these difficult patients. The concern for
mesh infection must be weighted against the concern
of reccurence.
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17
CONCLUSIONS
FIG. 1.
PALPABLE MIDLINE GAP
FIG. 2.
PALPABLE MIDLINE GAP
Retrorectus (sublay) method of mesh reinforcement
is preferable in incisional hernia repair, that provides
2-layered closure of the midline fascia to recreate native abdominal wall anatomy. A surgical site
infection, as well as implanted foreign body contamination, significantly increases the risk of recurrence.
Using the bioabsorbable implants, that completely
hydrolyze after providing a support throughout the
period of soft tissue healing, is suggested in contaminated area. Despite its encouraging outcomes, a cost
factor still existst and futher prospective studies are
necessary to establish its position in incisional hernia
surgery.
CITE THIS AS
MEDtube Science 2015, Sep 3(3), 14-20.
VIDEO 1. RECURRENT INCISIONAL HERNIA SUBLAY REPAIR WITH FULLY REABSORBABLE MESH
Click here to play the video.
LIST OF THE FIGURES
Fig.1: Palpable midline gap.
Fig.2: Palpable midline gap.
Fig.3: Midline ventral hernia in preoperative CT scan.
Fig.4: Ressection of inflammatory tumour around previous polypropylene mesh.
Fig.5: Release of peritoneal adhesions.
Fig.6: Hernia sac delineation.
Fig.7: Reapproximation of the posterior fascia.
Fig.8: Retrorectus mesh placement.
Fig.9: Additional suturing to ensure mesh flat
position.
Fig.10: Reconstruction of anterior fascia over the mesh.
Fig.11: Anterior abdominal wall reconstruction visu
alised in postoperative CT scan.
Fig.12: Excessive skin and subcutaneous tissue reduction through additional Pfannestiel’s incision.
Fig.13: Wound appearance in 2 – month follow-up after full recovery.
Fig.14: The appearance of anterior abdominal wall in 4 months after procedure.
FIG. 3. MIDLINE VENTRAL HERNIA IN PREOPERATIVE CT SCAN
science
FIG. 4.
RESSECTION OF INFLAMMATORY TUMOUR
AROUND PREVIOUS POLYPROPYLENE MESH
FIG. 5.
RELEASE OF PERITONEAL ADHESIONS
FIG. 6.
HERNIA SAC DELINEATION
18
FIG. 7.
REAPPROXIMATION OF THE POSTERIOR FASCIA
FIG. 8.
RETRORECTUS MESH PLACEMENT
FIG. 9. ADDITIONAL SUTURING TO ENSURE MESH FLAT POSITION
19
FIG. 10. RECONSTRUCTION OF ANTERIOR FASCIA OVER THE MESH
FIG. 11. ANTERIOR ABDOMINAL WALL RECONSTRUCTION VISUALISED IN POSTOPERATIVE CT SCAN
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FIG. 12. EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE
REDUCTION THROUGH ADDITIONAL
PFANNESTIEL’S INCISION
FIG. 13. WOUND APPEARANCE IN 2 – MONTH FOLLOW-UP AFTER FULL RECOVERY
FIG. 14. THE APPEARANCE OF ANTERIOR ABDOMINAL WALL IN 4 MONTHS AFTER PROCEDURE
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Van ‘t Riet M, Steyerberg EW, Nellensteyn J, et al. Meta-analysis of techniques for closure of midline abdominal
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Pauli EM, Rosen MJ. Open ventral hernia repair with component separation. Surg Clin N Am. 2013;93:1111–1133.
Rana KV, Singh G, Deshpande NA, et al. Postoperative complications of mesh hernioplasty for incisional hernia repair and
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Fakhar H, Bashir A, Asrar A, et al. Incisional hernia repair by
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Yahchouchy-Chouillard E, Aura T, Picone O, et al. Incisional
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Mudge M, Hughes LE. Incisional Henia: A 10 year prospective
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Voeller GR, Ramshaw B, Park AE. Incisional hernia. J Am Coll
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Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison
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Cobb WS, Kercher KW, Heniford BT. The argument for
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George CD, Ellis H. The result of incisional hernia erpair. A
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Schumpelick V, Klinge U, Junge K, et al. Incisional abdominal hernia: the open mesh repair. Langenbecks Arch Surg.
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Rives J. Major incisional hernia. In: chewal JP (ed) Surgery of
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Stoppa RE. The treatment of complicated groin and incisional
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Berry MF, Paisley S, Low DW et al. Repair of large complex
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Iqbal CW, Pham TH, Joseph A et al. Long term outcome of
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21
In daily clinical practice we are all
familiar with the word „ dengue „
making us think of an acute febrile
illness accompanied by hematologic
abnormalities, mainly leukopenia and
thrombocytopenia, that may generate plasma leakage to third space.
Luis del Carpio Orantes1
1. Department of Internal Medicine, General Hospital 71, Mexican Institute of Social Security, Veracruz, Veracruz, Mexico
#Corresponding author: Luis del Carpio Orantes, E-mail: [email protected].
RUNNING TITLE
Dengue
KEYWORDS
dengue, leptospirosis, diagnosis
WORD COUNT
1 361
CONFLICT OF
INTERESTS
ABSTRACT
In daily clinical practice we are all familiar with the word „ dengue „ making us think of an acute febrile illness.
In order to obtain an overview of the aforementioned, we look closely at and review the damage caused by
dengue to various organ systems of human body.
I
n daily clinical practice we are all familiar with the
word „ dengue „ making us think of an acute febrile
illness accompanied by hematologic abnormalities,
mainly leukopenia and thrombocytopenia, that may
generate plasma leakage to third space, however ,
some-times we face an atypical or unusual cases ,
that leaves the previous definition useless and, with
no knowledge of them, our attention may be diverted to other diseases. lost time for the diagnosis and
early treatment are the prerequisites for all medical
personnel to be aware that dengue goes beyond
a fever and thrombocytopenia , , affecting major
organs , what, if not prevented , leads to the death of
the patient and no clarification of the cases, most
of which often fulfill the criterion of severe dengue ,
according to the new WHO definition.
In order to obtain an overview of the aforementio-
ned, we look closely at and review the damage caused by dengue to various organ systems of human
body, summarized in Table 1.
Nervous System. In dengue, the involvement of the
nervous system is always constant , starting with a
holocranial and persistent headache, , relieved by
simple analgesics. Fever in children and sometimes
adults may cause seizures, cases of which are
reported, as rare or unusual cases include encephalopathy (which may be multifactorial and mental
disorders accompanied by acute electrolyte disturbances, etc.), or encephalitis, meningoen-cephalitis;
parenchymal and subarachnoid hemorrhage, related
to thrombocytopenia have also been reported. The
pathophysiology of these disorders lies in the fact
that the virus is neurotropic in nature , by capillary
bleeding , concomitant metabolic disorders and coag
science
-ulopathy type CID ( hepatic, renal , etc.) . The rarest
neurological manifestations are: Guil-lain Barre Syndrome, myelitis (acute disseminated encephalomyelitis), mononeuropathy and polyneuropathy syndrome.
There is an isolated case of phrenic neuropathy with
dia-phragmatic paralysis that resolved to cure dengue [4,6,28,29].
Ocular apparatus. It would appear that eyes have
no interaction with viral infections, how-ever in
dengue, the entities and features unique to this virus
have been identified, thus af-fecting primarily the
macula, with the so-called dengue maculopathy,
multiple case reports and series cases. Rare cases
include optic neuropathy, and vitreous retinal hemorrhages, retinal cotonosos infiltrates, foveolitis ,
among others [12,19,22,24,30].
Breathing apparatus. The most common and not
directly related to lung disease, pleural effusion is
the demonstration that rarely becomes massive and
warrant thoracentesis . However, there are atypical,
bleeding and severe cases present with pulmonary
hemor-rhage, manifested by hemoptysis to acute
respiratory failure, which may cause patient’s death
unless prompt measures are taken . In exceptional
cases of concomitant pneumonia where theetiological relationship has not been established, primary
dengue viral or second-ary bacterial, leveraging
inflammation of the lung parenchyma caused by viruses (phenom-enon observed in influenza). Isolated
case of diaphragmatic paralysis in relation to phrenic
neuropathy [27,28,31].
Circulatory system. The circulatory system is the
first to be affected as vascular endotheli-um is
directly targeted by the virus , , resulting in thrombocytopenia, plasma leakage and circulatory collapse
(shock dengue). Similarly, another of the circulatory
system key ele-ments , the heart, is affected mainly
as myocarditis, which may manifest itself as anginal
syndrome or rhythm disturbances or cardiac conduction. The untrained eye may interpret the symptoms
as coronary artery disease or heart disease aggravated by dengue , being a reflection of the same viruses
in primary form . There are case reports, which show
rise in the enzyme levels and ST -T abnormalities,
bradyarrhythmias tachycardia, atrioventricular block
in varying degrees, mainly segment as well. Symptoms of myocarditis resemble viral myocarditis and
toxic, causing myocardial necrosis, which explains
enzymatic and electro-cardiographic abnormalities.
Report indicates ephemeral pericardial effusions,
that may exist in the context of plasma leakage or a
viral serositis at that level [2,17,23,28].
Digestive system. One of the most affected systems
after the reticuloendothelial one, some of its organs
are of particular importantce (liver and spleen) and
hence the close relationship. Always, in all cases
of dengue , severe and not severe ones, the liver
enzymes rise may be observed (primarily ALT, AST,
22
GGT, LDH) mentioning that the enzyme level is
higher than 300 IU TGP are prognostic factors for
renal failure , bleeding, and death. On the other hand
it has been shown that there exists a discriminating
factor between severe and non- severe dengue and
hypoalbuminemia as well , not as a manifestation of
the ex-pense of liver synthetic function , but capillary
plasma leakage and rarely with coagulopathy (which
regards whether this alteration in the synthesis function ) , developed serious cases of dengue hepatitis,
fulminant hepatic failure or consumptive coagulopathy mainly IDC , which in most cases are mortal.
A common manifestation is ascites and acalculous
chole-cystitis, that are part of DHF (dengue with
warning signs, according to the new WHO classi-fication) and that deserve close scrutiny because they
may be the symptoms of develop-ment to a severe
or serious condition. In a rare form of mumps, cases
of dengue, diarrhea, dengue pancreatitis have been
reported and more frequently spontaneous splenic
rupture withformation of intra and perisplenitis hematomas. Jaundice, although rare, may also occur in
cases of dengue and is not dominant over direct or
indirect hyperbilirubinemia. In a cohort study in Veracruz in 2011, 8,559 cases of dengue were studied, of
which 67 % had gastrointestinal manifestations, the
most common: nausea, abdominal pain, vomiting,
he-patomegaly, ascites and gastrointestinal bleeding
what leads to the conclusion that gastro-intestinal
manifestations are mainly accompanied with fever
[3,7,11,13,15,21].
Renal system. The most common renal manifestation is proteinuria, which may be of vary-ing degrees, from microalbuminuria to nephrotic syndrome.
secondarily, relative to the degree of shock, acute
renal failure may occur. Usually acute renal failure
is transient and do not stay long. There have been
reports of secondary glomerulonephritis and hemolytic uremic syndrome that is quite uncommon. It is
mentioned that greater proteinuria 0.55g/day may
lead to the development of a severe hemorrhagic
dengue [8,11,14,25].
Locomotor apparatus. The muscular system, which
is an important part of the musculoskel-etal system, is primarily affected and symptomatic, since
the patient always has the typical “fever bearded”,
i.e. from mild to severe muscle aches, which fortunately is usually con-trolled with simple analgesics.
However atypical or uncommon manifestations may
include myositis, rhabdomyolysis (fortunately rare
but in severe forms may contribute to acute renal
failure by myoglobinuria) and acute myopathies,
severe neuropathies and Guillain Barré syndrome
[1,9,10,11,16,18,23].
Hematologic system. Of the major biochemical
manifestations of dengue, , hematologic abnormalities are mainly 3 cell lines, it is necessary to monitor
hematocrit, hemoglobin, leukocytes and platelets,
with typical findings of dengue - elevated hematoMEDtube Science Sep, 2015; Vol.III (3)
science
23
crit, which con-firms hemoconcentration, capillary
leakage and dehydration, with the subsequent risk
of shock, leukopenia and lymphopenia characteristic
of viruses, and thrombocytopenia, which is used as
a criterion for admission or hospital discharge. In
more analytical way, altera-tions in the endothelium
have been demonstrated, with increased activation
of endothelial cells; high levels of circulating von
Willebrand factor and low levels of ADAMTS- 13
(a met-alloprotease and disintegrin regulating partly thrombogenesis) the latter are those that favor
severe thrombocytopenia and complications surrounding dengue, mainly thrombotic thrombocytopenic
purpura and hemolytic uremic syndrome. Another
complication mostly seen in children, is the secondary hemophagocytic syndrome, a range in which there
is pan-cytopenia with histiocytic infiltrate in bone
marrow, which corresponds to class II histiocyto-sis
, and clinical courses, in addition to prolonged fever (
which is characteristic ) with ab-dominal pain mainly
in school . Isolated cases of purpura fulminans with
multiple organ involvement and death. Secondary
coagulopathy [5,26,28,32].
Apparatus or
system
Typical and atypical manifestations
Ocular apparatus
•
•
•
•
•
•
Conjunctivitis
Vitreous Hemorrhage
Retinal hemorrhages
retinal Departed
Foveolitis
Maculopathy
Breathing
apparatus
•
•
•
•
•
•
Pleural effusion
Hemoptysis
Acute respiratory failure
Pneumonia
Pulmonary hemorrhage
Diaphragm Paralysis
•
•
•
Acute circulatory collapse - shock
Myocarditis (conduction and rhythm disturbances, ST-T)
Pericarditis, pericardial effusion.
Digestive system
•
•
•
•
•
•
•
•
•
•
•
Nausea and vomiting
Ascites
Hepatomegaly-hepatalgia
Gastrointestinal bleeding
Hepatitis for dengue
Acalculous cholecystitis
Mucositis
fulminant hepatic failure
Pancreatitis dengue
Mumps
splenic rupture
Renal system
•
•
•
•
•
Proteinuria - nephrotic syndrome
Glomerulonephritis
Acute renal failure
hemolytic uremic syndrome
Electrolyte Disorders
Locomotor
apparatus
•
•
•
•
Muscle aches
Myositis
Rhabdomyolysis
Acute myopathy
•
hemoconcentration (hematocrit> 20%,
ratio Ht / Hb> / = 3.5)
Leukopenia, lymphopenia
Thrombocytopenia
thrombotic thrombocytopenic purpura
hemolytic uremic syndrome
Purpura fulminans
Circulatory
system
Dermal system. The skin is not beyond dengue influence on the body . Common skin mani-festation is a
skin rash characterized by tiny hypochromic macular
lesions on an erythema-tous circular niche, known
colloquially as “white islands in a sea of red.” Followed by pruri-tus, petechiae and ecchymosis . Rarely
conjunctivitis and mucositis [20,28].
In summary, it is important to note that dengue is
not always typical, especially in terms of bleeding
or severity, and may be complicated when there is
multiorgan involvement, which leads to severe dengue cases with high mortality, that fortunately is still
rare in our envi-ronment , but in Asia and the Middle
East, is very common.
Hematology
system
CITE THIS AS
MEDtube Science 2015, Sep 3(3), 21-24
•
•
•
•
•
TAB. 1. TYPICAL (UNDERLINED ITALICS) AND ATYPICAL MANIFESTATIONS OF DENGUE
•
Dermal system
•
Apparatus or
system
Dermatitis and rash with „white islands in
a sea of red”
Itching
Typical and atypical manifestations
BIBLIOGRAPHY
Nervous System
•
•
•
•
•
•
•
•
•
•
Headache
Seizures
Mononeuropathies
Polyneuropathies
Encephalopathy, acute psychosis or dementia
encephalitis-meningitis
parenchymal hemorrhages
Subarachnoid hemorrhage
Guillain Barré Syndrome
acute encephalomyelitis
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science
25
Tissue engineering and regenerative
medicine methods are extremely
promising, in particular bioprinting of
tissues and organs, which begun to
develop at the beginning of the XXI
century. Currently, medical community, have already transplanted
trachea and bladder printed on a 3D
printer.
Bionic Pancreas and Bionic Organs – how far
we are from the success
Michal Wszola1,7#, Joanna Idaszek2, Andrzej Berman1, Alicja Kosik2, Lukasz Gorski1, Agnieszka Jozwik1, Agnieszka Dobrzyn3, Agnieszka
Cudnoch-Jędrzejewska4, Artur Kaminski5,6, Robert Wrzesien4, Marta Serwanska-Swietek1, Andrzej Chmura1, Artur Kwiatkowski1 and Wojciech
Swieszkowski2
1.
2.
3.
4.
Department of General and Transplantation Surgery, Warsaw Medical University.
Division of Material Engineering, Warsaw University of Technology, Poland.
Nencki Insitute of Experimental Biology, Polish Academy of Science, Poland.
Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, The Medical University of Warsaw,
Warsaw, Poland
National Centre for Tissue and Cell Banking, Warsaw, Poland
Department of Transplantology and Central Tissue Bank, Medical University of Warsaw, Poland
Foundation for Research and Science Development, Otwock, Poland
5.
6.
7.
8.
#Corresponding author: [email protected]
RUNNING TITLE
Bionic organs
KEYWORDS
bioprinting, 3D-bioprinting, bionic pancreas, bionic organs, artificial organs, islets transplantation
WORD COUNT
1 154
CONFLICT OF
INTERESTS
ABSTRACT
The progress in the treatment of chronic diseases of civilization that occurred in recent years, led to a significant prolongation of median survival time of the developed countries societies. Organ transplantation has
revolutionized medicine as it became possible to replace an irreversibly diseased organ. However, at the
moment we can observe a significant shortage of organs for transplantation, which forces doctors to accept
those coming from more and more expanding criteria donors. No doubt, the number of donors, at best, will
certainly not grow. Tissue engineering and regenerative medicine methods are extremely promising, in particular bioprinting of tissues and organs, which begun to develop at the beginning of the XXI century. Article
highlights possible future direction of organ transplantation.
science
T
he progress in the treatment of chronic diseases of civilization that occurred in recent years,
led to a significant prolongation of median
survival time of the developed countries societies
[1,2]. Paradoxically, it has raised more medical problems such as increased number of neurodegenerative, cardiovascular diseases [2,3] and increased demand for transplantation organs [4]. In Poland alone,
there are more than two and a half million diabetic
patients, 200,000 of which are patients with type I
diabetes [5]. According to WHO’s statistics, by 2030
these numbers will double [6]. Organ transplantation
has revolutionized medicine as it became possible to
replace an irreversibly diseased organ. However, at
the moment we can observe a significant shortage of
organs for transplantation, which forces doctors to
accept those coming from more and more expanding
criteria donors. No doubt, the number of donors, at
best, will certainly not grow. Annually, there are approximately 40 pancreas transplants in Poland. Liver
and kidney transplants are more numerous, with 300
and 1000, respectively, organs transplanted each
year. Pancreas transplantation has been a successful treatment of patients with diabetic complications
for years, limited however to relatively small number
of patients not only due to organ shortage but also
due to ischemic injury of retrieved organs [7]. Injury is even more pronounced in pancreatic tissue,
which is subjected to digestion processes in order to
isolate the islets of Langerhans, which are especially
sensitive to injury. The digestion process, by stripping the islets of their vasculature and surrounding
extracellular matrix in order to isolate them and put
into suspension, results in their hypoxic damage.
This sequence of deleterious effects is the reason
that islet transplantation has not become a common
clinical treatment modality [8]. More than 50% of
transplanted islets are lost during the first few days
post transplant. It is possible that one of the causes
of this is IBMIR - instant blood-mediated inflammatory reaction [9], leading investigators search for a
new recipient sites for islet transplantation [10,11,14].
Authors have invented, performed study and introduced into clinic as the first in the world, an innovative
method of endoscopic gastric submucosa islets
transplantation [12,13]. The damage is also caused
by deprivation of the islets of their own vasculature
and extracellular matrix. “Nude” islets has higher tendency for apoptosis, which further makes that simple
procedure very not effective. The medical world is
developing several potential paths that can solve the
problem of shortage of organs for transplantation: artificial organs [15], xenotransplantation (using organs
taken from animals) [16], tissue engineering and regenerative medicine [17]. There have been first visible
successes in using artificial organs, such as insulin
pumps [15]. But those are not able to inhibit the
development of secondary complications of diabetes, which leads to nearly 5 million deaths each year
worldwide [18]. Xenotransplantation, as a treatment
in humans, cannot be easily brought to the clinical
phase due to the still unresolved risk of transmit-
26
ting particularly dangerous zoonotic viral infections
together with the cells and organs taken from animals
[19]. Therefore, the development of new approaches
to protect newly transplanted pancreatic islets/betacells from oxidative and inflammatory stress is critical
and urgently needed. Dobrzyn et al. recently showed
that endocanabinoid system, stearoyl-CoA desaturase and Wnt singnaling play a critical role in keeping
pancreatic beta-cell identity and islet architecture
and might be used for injury treatment [20-22].
Tissue engineering and regenerative medicine methods are extremely promising, in particular bioprinting of tissues and organs, which begun to develop
at the beginning of the XXI century [23]. Currently,
medical community, have already transplanted trachea and bladder printed on a 3D printer [24,25]. In
addition, beyond the obvious purpose of transplantation, we may use bioprinted proteins, cells, tissues,
and organs in in vitro drug trials (toxicity tests), in
clinical trials and in „personalized medicine”, adapting the drug dosage to the biological capabilities
of the potential patient’s tissues. Possible rebuilding
extracellular matrix, with bioprinting, for islets and
creating a stable, well oxygenated scaffold might effectively improve islet transplants survival, make this
treatment available for a wider population of patients
and influence positively survival and quality of life of
millions of diabetic patients. Building scaffolds for
clinical use [32-34] in orthopaedics and oncologic
surgery is also developing. Recently, there has been
a significant progress in the development of scaffolds, that could constitute building blocks for organs
culture with a use of stem cells [26-28]. There have
been attempts to built scaffolds for islets transplantation that could solve problems of lack of ECM after
isolation [29]. It has been proved by Authors of this
proposal and other team independently, that islets
encapsulated in special hydrogels could be used as
a “bioink” in 3D bio-fabrication [29-30]. Nevertheless
there are several weak points to be solved if one
wants to achieve a 3Dprinted scaffold with pancreatic islets, which will be ready for transplantation
(and with islets responding to glucose stimulus). To
print islets they have to be immersed in some kind
of gel, which will have a viscosity that allows of 3D
printing but on the others hand glucose will be able
to easily go through the matrix material. This situation
only will allow islets to response properly for glucose
stimuli. So far bioengineered hydrogels like alginate,
polyglicane and many others allow to print islets and
allow to keep them alive but function of this islets are
limited [29]. Another problem that should be solved is
the lack of vasculature. All attempts are being done
with islets suspended in the hydrogel, suggesting
that after transplantation, the vasculature will ingrow into the islets somehow. Unfortunately by the
time the vasculature in-grows into the islets, most
of them are already dead, because of lack of proper
nutrition. The only answer for that problem might be
engineering scaffold with vasculature in it and with
using proper ECM for bioprinting. It is not an easy
science
27
task, but it seems that lately there has been a small
breakthrough. Researchers managed to 3D - bioprint
vessels with diameter of 0,5 mm diameter, which
were physiologically active – nutrients and oxygen
were possible to be transported through the wall and
cells of endothelium of that vessels produced steady
junction between them [31]. Such vessels would be
appropriate for islets nutrition within printed scaffolds. Improving of 3D bioprinting technology might
help to build scaffolds that will be able to be used in
clinical medicine. Of the most importance seems to
be engineering an Human Bionic Pancreas with islets
and extracellular matrix which could help become an
islet transplantation a method of treatment for definitely larger group of patients with diabetes then it is
now. Implementation of such Bionic pancreas could
lower costs paid on the treatment of diabetes mellitus and its complication and may reverse negative
trends which says that diabetes will be one of the
most common cause of death by the end of 2030 [2].
Results of that programme will give definitely a great
progress in prevention of diabetic complications and
help in treatment.
CITE THIS AS
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science
28
In 54 among 59 investigated DNA
blood samples from HD patients we
were able to detect a DNA fragment
about 790 bp in length, consistent
with the presence of 16sRNA bacterial DNA.
Fragments od bacterial DNA presence in hemodialisis patients’ blood-preliminary report
Marta Serwańska-Świętek1#, Marzena Sikora3, Bożena Interewicz3, Waldemar L Olszewski3, Andrzej Rydzewski2,4, Marek Durlik3,4
1.
2.
3.
4.
Department of General and Transplantation Surgery, Warsaw Medical University, Nowogrodzka 59th Street, 02-006 Warsaw, Poland.
Department of Internal Medicine, Nephrology and Transplantology, Central Clinical Hospital of Ministry of Internal Affairs, Warsaw, Poland
Department of Gastrointestinal Surgery and Transplantology, Central Clinical Hospital of Ministry of Internal Affairs, Poland
Institute of Experimental and Clinical Medicine, Polish Academy of Sciences, Warsaw, Poland
#Corresponding author: Marta Serwańska-Świętek, Department of General and Transplantation Surgery, Warsaw Medical University, Nowogrodzka 59th Street, 02-006 Warsaw, Poland, Tel: +48225021113, Fax: +48225022155, E-mail: [email protected]
RUNNING TITLE
Bacterial DNA in hemodialysis patients
KEYWORDS
bacterial DNA, hemodialysis, inflammation, atherosclerosis
WORD COUNT
787
CONFLICT OF
INTERESTS
ABSTRACT
Cardiovascular disease (CVD) accounts for most of morbidity and mortality in patients with end-stage renal
disease treated by chronic hemodialysis. The idea that inflammation state present in uremia plays an important
role in the development of atherosclerosis has enjoyed much attention. We have investigated therefore possible presence of bacterial DNA in the blood of chronically hemodialyzed patients. There were retrospectively
studies of 59 patients without any signs of active infection, who had been undergoing intermittent HD. In 54
among 59 investigated DNA blood samples from HD patients we were able to detect a DNA fragment about
790 bp in length, consistent with the presence of 16sRNA bacterial DNA. Bacterial DNA could not be detected
in any of the samples from control subjects. We were not able to detect bacterial DNA in any of 9 investigated
dialysate samples although in 4 blood samples of these patients bacterial DNA encoding ribosomal RNA was
observed. Bacterial DNA is detectable in blood of HD patients. This might be one of the inflammatory stimuli.
science
29
INTRODUCTION
C
ardiovascular disease (CVD) accounts for most
of morbidity and mortality in patients with
end-stage renal disease treated by chronic
hemodialysis (1). Even proper management of those
patients, which helps to prevent hypertension, does
not fully answer the problem (2). Traditional risk factors do not adequately explain excess CVD observed
in ESRD patients, and paradoxically some of them
are inversely related to prevalence of CVD a phenomenon called “reverse epidemiology” (3). Thus the
idea that inflammation state present in uremia plays
an important role in the development of atherosclerosis has enjoyed much attention (4,5). This notion
has found support in reports of association between
markers of inflammation (CRP, pro-inflammatory
cytokines) and increased mortality. It was found that
30-60% of HD patients have evidence of activation
of inflammation (6). The stimulus or stimuli for such a
response were not found however. Several of them
were proposed such as reduced renal clearance of
cytokines, accumulation of AGE’s, occult inflammatory processes or infections, bioincompatibility of
dialysis membranes and exposure to endotoxins and
unspecified pro-inflammatory substances present in
dialysis fluid (7,8). Schindler et al. have reported on
the presence of short bacterial fragments in dialysate
and induction of cytokines and TLR9 by them (9).
These fragments were of sufficient small size to pass
through dialyzer membrane. We have investigated
therefore possible presence of bacterial DNA in the
blood of chronically hemodialyzed patients.
MATERIAL AND METHODS
There were retrospectively studies of 59 patients
without any signs of active infection, who had been
undergoing intermittent HD (tab. 1).
DNA samples isolated from whole blood, which were
stored at -20C as a part of an ongoing prospective study on the CRP gene polymorphism effect on
the CVD prevalence, were randomly selected. DNA
samples was also isolated from dialysate of 9 different dialysis machines.100ml of dialysate and 5 ml of
whole blood anticoagulated with 0.48% citric acid,
1.32% sodium citrate 1.47% glukose were withdrawn
before HD session. Microbiological purity of water
and dialysate was monitored according to Polish
Pharmacopeia VI regulations. Control subjects - 109
healthy volunteers (hospital staff) donated blood for
DNA isolation.
DNA was isolated using Macherey-Nagel kit according to the manufacturer procedure after pretreatment of samples by three enzymatic digestions
(Fig.1)
PCR was performed with universal primers for
16sRNA bacterial gene: forward 5’ AGT TTG ATC
CTG GCT CAG and reverse 5’ GAA CTA CCA GGG
TAT CTA AT (Oligo Poland), 5 ng of DNA, Fast Start
Taq DNA polymerase Kit, GC rich (Roche) and PCR
Anty-Inhibitor (DNA Gdańsk, Gdańsk, Poland), in final
volume of 25 µl. Amplifications were performed in
MJ Research thermocycler. We established following
conditions: 95°C for 15min, 60°C for 45s, 72°C for
10s, (95°C for 45s ,60°C for 45s, 72°C for 1 min) 35
times, and finally 72°C for 10 min. As a negative controls we used: reaction mixture without template and
DNAse treated reaction mixture. All procedures were
performed in sterile condictions to minimalise even
minor contamination of PCR mixture with exogenous
template DNA. As a positive control Staphylococcus
aureus 1/1W, Staphylococcus epidermidis 23/GS,
Staphylococcus epidermidis 78/GS, Staphylococcus
epidermidis 96/GS, Enterococcus 6/WO3, Enterococcus 1/2/WO3 and Escherichia Coli B2 strains were
used (own collection).
Products of amplification were electrophoresed on
12.5% poliacrylamide gels (ExelGel, Amersham Biosciences) and silver stained (DNA Silver Kit, Amersham Biosciences). Expected bands 789bp were
compared to 100bp ladder (Amarsham Biosciences)
with the use of GeneTools software (Syngene, England) (Fig.2).
RESULTS
In 54 among 59 investigated DNA blood samples
from HD patients we were able to detect a DNA
fragment about 790 bp in length, consistent with
the presence of 16sRNA bacterial DNA. Observed
bands were differing slightly in length and density suggesting different bacterial species as a DNA
source and different concentrations in blood (Fig. 3).
Bacterial DNA could not be detected in any of the
samples from control subjects. We were not able to
detect bacterial DNA in any of 9 investigated dialysate samples although in 4 blood samples of these
patients bacterial DNA encoding ribosomal RNA was
observed.
CONCLUSION
Bacterial DNA is detectable in blood of HD patients.
This might be one of the inflammatory stimuli. There
are several possible sources of bacterial DNA in blood of HD patients: passing of oligonucleotides through dialyzer membrane, endogenous sources (from
atherotic plaques, paradontium, nasal sinuses, veins
wall, aortic wall, dialysis fistula) or repeated introduction of bacteria into bloodstream during puncturing of
dialysis fistula. Normal skin is colonized predominantly by Gram-positive bacteria, like Staphylococcus
spp., Micrococcus spp., and coryneforms, whereas
only Acinetobacter spp. are only Gram-negative
bacteria regularly colonizing normal skin. External
factors, like topical antiseptics, however may promote skin colonization by Gram-negative bacteria.
Due to preliminary nature of this work we were not
able to ascertain neither the source DNA nor bacterial
science
30
species involved.
CITE THIS AS
LIST OF THE FIGURES
Fig. 1. DNA isolation
Fig. 2. ELEKTROPHORESIS
Fig. 3. Bacterial 16S rRNA gene
UNIVERSAL - HIGHLY CONSERVED
REGION OF DNA
FIG. 1.
DNA ISOLATION
FIG. 2.
ELEKTROPHORESIS
FIG. 3.
BACTERIAL 16S RRNA GENE UNIVERSAL - HIGHLY CONSERVED REGION OF DNA
Broad-range bacterial PCR is based on the use of primers that recognize conserved sequences of bacterial chromosomal
genes encoding ribosomal RNA (rRNA) The resulting amplified rRNA sequences also include variable regions that provide an
alternative approach for identifying theoretically all bacterial species, including those that cannot be cultivated by classical
methods.
science
31
TAB. 1. CHARACTERISTIC OF PATIENT
male gender (%)
54
age of years
62,5
Median value of CRP (ng/
ml)
6,4
median period of HD
(months)
40,4
Frequency per week
3
Lenght of HD (h)
fistulae
4-5
native arteriovenous, the double-needle
technique
machines
ultrafiltration controllers
dialysers
low-flux modyfied cellulose
dialysate
bicarbonate-buffered
The enrolment criteria
excluded patients
•
•
•
•
•
•
•
diabetes
SLE
malignancy,
HIV
severe liver disease
colitis ulcerosa
Crohn desease
BIBLIOGRAPHY
1.
2.
3.
4.
5.
6.
7.
8.
9.
Daugirdas, John T. Handbook of Dialysis 5th Edition, Wolters
Kluwer 2014
Prystacki T, Kloda K, Safranow K, Dziedziejko V, Domanski
L. Modern Management of Dialysis Center has an impact on
patients’ blood pressure and calcium-phosphorus metabolism. MEDtube Science Dec 2013; 1(1), 19-21.
Tsirpanlis G, Boufidou F, Zoga M, Triantafyllis G, Fatourou A,
Nicolaou C. Low cholesterol along with inflammation predicts
morbidity and mortality in hemodialysis patient. Hemodial Int.
2009 Apr;13(2):197-204.
Al Aly Z, Edwards JC. Vascular biology in uremia: insights into
novel mechanisms of vascular injuryAdv Chronic Kidney Dis.
2004 Jul;11(3):310-8. Review.
Wszola M, Kwiatkowski A, Nosek R et al. Chlamydia pneumoniae infection and ischemic heart disease in hemodialysis
patients. Transplant Proc. 2006 Jan-Feb;38(1):31-4.
Stenvinkel P, Heimburger O, Paultre F, Diczfalusy U, Wang T,
Berglund L, Jogestrand T: Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal
failure. Kidney Int 1999;55:1899-1911.
Zimmermann J, Herrlinger S, Pruy A, Metzger T, Wanner C:
Inflammation enhances cardiovascular risk and mortality in
hemodialysis patients. Kidney Int 1999;55:648-658.
Gupta J, Mitra N, Kanetsky PA, Devaney J, Wing MR, Reilly
M, Shah VO, Balakrishnan VS, Guzman NJ, Girndt M, Periera
BG, Feldman HI, Kusek JW, Joffe MM, Raj DS: Association
between albuminuria, kidney function, and inflammatory
biomarker profile in CKD in CRIC. Clin J Am Soc Nephrol
2012;7:1938-1946.
Schindler R, Beck W, Deppisch R, Aussieker M, Wilde A,
Göhl H, Frei U. Short bacterial DNA fragments: detection in
dialysate and induction of cytokines. J Am Soc Nephrol. 2004
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science
32
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