The Role of Feral Swine in Human Aortic Infection With Brucella Species.

Brucellosis is one of the most common zoonotic infections in the world. Human infections are the result of direct exposure to infected animals or ingestion of unprocessed dairy products. While Brucella sp. infection has largely been eliminated from commercial cattle and swine with aggressive vaccination, there is a significant prevalence of Brucella sp. infection in the expanding population of feral swine in the US. We report the surgical treatment of a ruptured mycotic aneurysm of the abdominal aorta due to Brucella suis in a woman living in a rural community with a large population of feral swine. Vascular surgeons should be aware that brucellosis can result in arterial infection and should be considered in the differential diagnosis in patients with a history of exposure to feral swine or the ingestion of unprocessed dairy products.

How I do it: The neoaortoiliac system for treatment of aortoduodenal fistula after endovascular aortic repair.

The term neoaortoiliac system (NAIS) was coined by Clagett in 1993 to describe the use of the deep veins in the thigh to replace the aorta and iliac arteries in the setting of graft infection. Since that time, the NAIS procedure has been used to treat a wide array of both infectious and noninfectious conditions affecting the aortoiliac segment. In this article, we present a 10-step description of the NAIS procedure to treat an aortoduodenal fistula in a patient with an infected endovascular aneurysm repair.

The utility of the matrix format for surgical morbidity and mortality conference.

With the limitations posed by increasing work hour restrictions, surgical residency programs are focusing more on maximizing the educational benefit of their conferences. The Morbidity and Mortality (M&M) conference serves as a forum to discuss adverse events and patient care improvement using evidence-based medicine. The matrix format (MF) is an enhancement to the traditional format (TF), focusing on the case selection process and a postconference newsletter reiterating the relevant literature review and discussion points. Our institution adopted the MF to evaluate both its short- and long-term educational values. Surveys were distributed to residents and faculty within the Department of General Surgery to assess their interest and satisfaction, perception of educational value, and efficiency with the MF compared with the TF. Responses were obtained from 22/22 (100%) residents for the TF and 11/23 (48%) for the MF. Faculty responses were 19/19 (100%) and 9/16 (56%), respectively. Reasons for an overall decreased response with the MF were not investigated further, as participation was strictly voluntary. Our results confirmed an overall approval of the MF by both residents and faculty. Faculty reported an improved efficiency of the conference (P < 0.039), encompassing improved content and presentation quality. Residents reported an improved overall interest and satisfaction with the MF (P < 0.001) as well as an improvement in the educational value (P < 0.007). Residents spent less time preparing presentations and reported learning greater educational benefit to the conference when preparing their own presentations (P < 0.001). In conclusion, the MF resulted in a greater overall satisfaction for residents and attending surgeons with an increased investment by the audience and overall improvement in perceived educational benefit.

The predictive value of incidental PET/CT findings suspicious for breast cancer in women with non-breast malignancies.

BACKGROUND: On occasion, patients followed with positron emission tomographic (PET)/computed tomographic (CT) imaging for nonbreast malignancies will have incidental breast findings concerning for second primary breast cancers. The aim of this study was to determine the predictive value of PET/CT imaging to identify breast cancers in these patients. METHODS: Patients with primary nonbreast malignancies and findings concerning for second primary breast cancers were identified from a prospectively acquired nuclear medicine database from January 2005 to July 2008. Chart reviews were then performed. RESULTS: Nine hundred two women underwent PET/CT imaging to evaluate nonbreast malignancies. Nine women (1%) had concerning breast findings, and 5 (56%) had subsequent breast cancer diagnoses. The positive predictive value of PET/CT imaging in these patients was 63%. Evidence of compliance with current screening guidelines was present in only 22% of these patients. CONCLUSIONS: The data suggest that findings concerning for an additional primary breast cancer should be evaluated and that age-appropriate screening tools should not be abandoned.

Incidental PET/CT findings in the cancer patient: how should they be managed?

BACKGROUND: Despite a paucity of evidence-based guidelines, the use of PET/CT (positron emission tomography/computed tomography) in the management of cancer patients is increasing. As widespread clinical application increases, unexpected radiographic findings are occasionally identified. These incidental findings are often suspicious for a second primary malignancy. The purpose of this study was to determine the clinical impact of these incidental PET/CT findings. METHODS: A query of our prospectively acquired Nuclear Medicine database was performed to identify patients with a known malignancy being staged or serially imaged with PET/CT. Patients with incidental findings suggestive of a second primary malignancy were selected. Statistical analysis was performed to determine the ability of PET/CT to identify a second primary malignancy. All PET/CT were interpreted by board certified nuclear radiologists. RESULTS: Of 3,814 PET/CT scans performed on 2,219 cancer patients at our institution from January 1, 2005, to December 29, 2008, 272 patients (12% of all patients) had findings concerning for a second primary malignancy. An invasive work-up was performed on 49% (133/272) of these patients, while 15% (40/272) had no further evaluation due to an advanced primary malignancy. The remaining 36% (99/272) had no further evaluation secondary to a low clinical suspicion determined by the treating team, a clinical plan of observation, or patients lost to follow-up. Of the 133 patients evaluated further, clinicians identified a second primary malignancy in 41 patients (31%), benign disease in 62 patients (47%), and metastatic disease from their known malignancy in 30 patients (23%). The most common sites for a proven second primary malignancy were: lung (N = 10), breast (N = 7), and colon (N = 5). Investigation of these lesions was performed using several techniques, including 24 endoscopies (6 malignant). A surgical procedure was performed in 74 patients (29 malignant), and a percutaneous biopsy was performed on 34 patients (12 malignant). The overall positive predictive value for PET/CT to detect a second primary malignancy was 31% in this subgroup. At a median follow-up of 22 months, 9 of 41 patients with a second primary were dead of a malignancy, 20 were alive with disease, and 12 had no evidence of disease. CONCLUSION: Incidental PET/CT findings consistent with a second primary are occasionally encountered in cancer patients. In our data, approximately half of these findings were benign, a third were consistent with a second primary malignancy or a metastatic focus, and the remainder were never evaluated due to physician and patient decision. Advanced primary tumors are unlikely to be impacted by a second primary tumor suggesting that this subset of patients will not benefit from further investigation. Our data suggests that, despite the high rate of false positivity, incidental PET/CT findings should be investigated when the results will impact treatment algorithms. The timing and route of investigation should be dictated by clinical judgment and the status of the primary tumor. Further investigation will need to be performed to determine the long-term clinical impact of incidentally identified second primary malignancies.

A pilot study to integrate an immersive virtual patient with a breast complaint and breast examination simulator into a surgery clerkship.

BACKGROUND: We aimed to determine if an immersive virtual patient (VP) with a breast complaint and a breast mannequin could prepare third-year medical students for history-taking (HT) and clinical breast examination (CBE) on a real patient. METHODS: After standardized instruction in breast HT and CBE, students (n = 21) were randomized to either an interaction with a VP (experimental) or to no VP interaction (control) before seeing a real patient with a breast complaint. Participants completed baseline and exit surveys to assess confidence regarding their HT and CBE skills. RESULTS: Students reported greater confidence in their HT (Delta value = 1.05 +/- 1.28, P < .05) and CBE skills (Delta value = 1.14 +/- .91, P < .05) and less anxiety when performing a CBE (Delta value = -.76 +/- 1.10, P < .05). The VP intervention group had a significantly higher mean HT confidence than the control group at the conclusion of the study (4.27 +/- .47 vs 3.50 +/- .71, respectively, P < .05). CONCLUSIONS: A single interaction with a VP with a breast complaint and breast mannequin improves student confidence in breast HT during a surgery clerkship.

Early thrombosis of the superior vena cava in a patient with a central venous catheter and carcinoma of the ampulla of Vater.

Superior vena cava syndrome results from obstruction of flow through the vessel either by external compression or thrombosis. External compression by intrathoracic neoplasms is the most common etiology. Thrombosis of the vessel most often occurs in the setting of indwelling catheters or pacemakers. The diagnosis is suggested by the clinical manifestations of facial and upper extremity swelling, dyspnea, and cough. It is confirmed by CT scan showing the development of collateral flow around the lesion. In this report, we present a patient who developed superior vena cava thrombosis after undergoing a short period of central venous catheterization and a Whipple procedure for adenocarcinoma of the ampulla of Vater. The endothelial damage caused by the catheter, the low-flow state induced by the large fluid shifts during the operation, and the hypercoagulable state induced by malignancy fulfill Virchow's triad for venous thrombosis. To our knowledge, this is the first reported case of superior vena cava syndrome after the Whipple procedure with symptoms appearing after a shorter period of catheterization than previously reported in the adult literature.

Primary structure of the 2-O-methyl-alpha-L-fucose-containing side chain of the pectic polysaccharide, rhamnogalacturonan II.

A 2-O-methylfucosyl-containing heptasaccharide was released from red wine rhamnogalacturonan II (RG-II) by acid hydrolysis of the glycosidic linkage of the aceryl acid residue (AceA) and purified to homogeneity by size-exclusion and high-performance anion-exchange chromatographies. The primary structure of the heptasaccharide was determined by glycosyl-residue and glycosyl-linkage composition analyses, ESIMS, and by 1H and 13C NMR spectroscopy. The NMR data indicated that the pyranose ring of the 2,3-linked L-arabinosyl residue is conformationally flexible. The L-Arap residue was confirmed to be alpha-linked by NMR analysis of a tetraglycosyl-glycerol fragment, [alpha-L-Arap-(1-->4)-beta-D-Galp-(1-->2)-alpha-L-AcefA-(1-->3)-beta-L-Rhap-(1-->3)-Gro], generated by Smith degradation of RG-II. Our data together with the results of a previous study,(1) establish that the 2-O-Me Fuc-containing nonasaccharide side chain of wine RG-II has the structure (Api [triple bond] apiose): [see structure]. Data are presented to show that in Arabidopsis RG-II the predominant 2-O-MeFuc-containing side chain is a mono-O-acetylated heptasaccharide that lacks the non-reducing terminal beta-L-Araf and the alpha-L-Rhap residue attached to the O-3 of Arap, both of which are present on the wine nonasaccharide.