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1/83. Fatal septicaemia after fibroid embolisation.

    uterine artery embolisation is a new technique for the treatment of uterine fibroids. We report a death after this procedure.
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2/83. Multicentric warfarin-induced skin necrosis complicating heparin-induced thrombocytopenia.

    Two patients developed catastrophic multicentric skin necrosis while receiving warfarin to treat venous thromboembolism complicated by immune-mediated heparin-induced thrombocytopenia (HIT). Patient 1 developed skin necrosis involving the breasts, thighs, and face, as well as venous limb gangrene and bilateral hemorrhagic necrosis of the adrenal glands, resulting in death. The second patient developed bilateral mammary necrosis necessitating mastectomies, as well as skin necrosis involving the thigh. Neither patient had an identifiable hypercoagulable syndrome, other than HIT. HIT may represent a risk factor for the development of multicentric warfarin-induced skin necrosis (WISN).
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3/83. disseminated intravascular coagulation in a patient treated with strontium-89 for metastatic carcinoma of the prostate.

    strontium-89 is effective in the palliation of bone pain caused by skeletal metastases. Its primary side effect is mild thrombocytopenia that typically recovers in 3 or 4 months. Subclinical disseminated intravascular coagulation is reported to be present in approximately 10% to 20% of patients with advanced prostate cancer. These patients may be at increased risk for severe marrow depression after radionuclide therapy for bone pain palliation. This report describes a patient with painful bony metastases resulting from prostate carcinoma. He had a normal platelet count and no clinical evidence of a coagulation disorder at the time of strontium-89 therapy, and a severe disseminated intravascular coagulation developed and lead to death after treatment. A normal platelet count before strontium-89 therapy does not preclude subsequent disseminated intravascular coagulation, and we support the Society of nuclear medicine's bone pain treatment procedure guideline that patients referred for bone palliation should be screened for disseminated intravascular coagulation before therapy.
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4/83. Severe systemic effects of Merrem's hump-nosed viper bite.

    OBJECTIVE: To report unpredictable severe systemic effects of hump-nosed viper envenomation. SETTING: Medical unit, General hospital, Anuradhapura. methods: The clinical outcome of seven patients bitten by Merrem's hump-nosed viper were monitored until recovery or death. Limited autopsies were performed on the latter. Offending snakes were positively identified by medical officers and in one instance by a herpetologist. CONCLUSION: Merrem's hump-nosed viper bites, caused an array of potentially fatal systemic manifestations. One patient developed neurological effects, severe Raynaud's syndrome leading to ascending gangrene of distal limbs and adult repiratory distress syndrome (ARDS), in addition to the known complications of severe renal cortical necrosis and haemostatic dysfunction. Two patients who developed acute renal failure and prolonged coagulopathy recovered completely. The combination of extensive renal cortical necrosis, disseminated intravascular coagulation, and ARDS proved fatal in three.
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5/83. Respiratory failure after liver transplantation.

    A rapidly growing haemangioendothelial sarcoma of the liver in a twenty-two year old woman was treated by liver transplantation. disseminated intravascular coagulation resulted in massive blood loss during surgery, and contributed to the death of the patient from respiratory failure on the fourth post-operative day, despite continuous post-operative intermittent positive-pressure ventilation. Other factors leading to her respiratory failure are discussed. There was no evidence of dysfunction in the transplanted liver.
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6/83. Intraoperative disseminated intravascular coagulopathy.

    Perioperative management of DIC is, at best, difficult, but it is not impossible. Preventing the onset of DIC is the key and is best achieved by recognizing and correcting predisposing factors. nurses caring for critically injured patients must exercise a high index of suspicion and prepare for dealing with these risk factors. The development of a massive transfusion protocol assists in maintaining a proactive approach to managing patients in need of multiple transfusions of blood and blood components. Alternative approaches to surgical management might assist the patient by allowing the health care team to rapidly identify and correct any predisposing factors rather than allowing them to go unchecked, resulting in uncontrolled complications, such as DIC and patient death.
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7/83. Echovirus hepatic failure in infancy: report of four cases with speculation on the pathogenesis.

    Disseminated echovirus infection with fulminant hepatic failure occurs almost exclusively in newborns. Although a relatively uncommon condition, it is on occasion associated with neonatal death accompanied by diffuse and extensive hemorrhagic necrosis of the liver and adrenals as the defining finding. We report four cases of severe systemic neonatal echovirus infection and present histologic and clinical evidence to demonstrate the two histologic patterns of liver involvement; intravascular coagulation in the early clinical course and a veno-occlusive component in later stages of the disease. Viral damage to vascular endothelium and hepatic venous endothelium by a "hit-and-run" process in the early viremic phase rather than direct hepatocyte injury is postulated to be a mechanism.
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8/83. Fatal inhalational anthrax with unknown source of exposure in a 61-year-old woman in new york city.

    A 61-year-old woman who was a new york city hospital employee developed fatal inhalational anthrax, but with an unknown source of anthrax exposure. The patient presented with shortness of breath, malaise, and cough that had developed 3 days prior to admission. Within hours of presentation, she developed respiratory failure and septic shock and required mechanical ventilation and vasopressor therapy. Spiral contrast-enhanced computed tomography of the chest demonstrated large bilateral pleural effusions and hemorrhagic mediastinitis. blood cultures, as well as dna amplification by polymerase chain reaction of the blood, bronchial washings, and pleural fluid specimens, were positive for bacillus anthracis. The clinical course was complicated by liver failure, renal failure, severe metabolic acidosis, disseminated intravascular coagulopathy, and cardiac tamponade, and the patient died on the fourth hospital day. The cause of death was inhalational anthrax. Despite epidemiologic investigation, including environmental samples from the patient's residence and workplace, no mechanism for anthrax exposure has been identified.
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9/83. disseminated intravascular coagulation during total hip replacement.

    disseminated intravascular coagulation (DIC) is an extremely serious hemorrhagic disorder and one that is potentially lethal. DIC is more frequently observed as a complication of obstetric pathologies, diffused neoplasms, bacterial sepsis, blood transfusions, traumas and adipose embolias. The literature reports very few cases occurring after total hip replacement, two of which the cause of death. In all of the cases described one or boh prosthetic components are cemented. The authors report a case observed after total hip replacement in a patient submitted one year previously to contralateral hip replacement. Severe hypotension, bradychardia and profuse bleeding of the wound and from the drainages one hour after suturing constituted the initial symptom. Recognition of the clinical findings, after exclusion of a iatrogenic lesion, and subsequent treatment in intensive therapy allowed us to save the patient. The syndrome must be suspected and immediately diagnosed when profuse bleeding that cannot be related to vascular lesion is observed immediately postsurgery after cemented or hybrid hip replacement. Confirmation through hematological tests and timely treatment in a specialized center are indispensable requirements to save the life of the patient.
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10/83. Unusual intravascular material in the brain. autopsy findings in a patient treated with antihemophilic factor concentrates.

    Widespread vascular occlusion caused by unusual particulate material in the brain of a patient who was intensively treated with antihemophilic factor (AHF) concentrates prior to death is described. The intravascular particles were seen partially or completely occluding both veins and arteries of small caliber in the brain and also to a much lesser extent in other organs. The resultant small focal infarcts were predominantly distributed in the cerebral white matter. The pathogenesis of this apparently unique vascular occlusive phenomenon and its relationship, if any, to the massive AHF concentrate infusion in this patient remain unknown.
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