Thymic adenocarcinoma presenting as an incidental mediastinal mass.

BACKGROUND: Primary thymic adenocarcinoma represents an exceptionally rare malignancy, for which the cornerstone of therapy is margin-negative resection, with radiation and systemic therapy reserved for invasive and advanced disease. Thymic adenocarcinoma has not been previously reported in the setting of a concomitant malignancy, as reported herein. CASE PRESENTATION: We present a case of a 55-year-old previously healthy male diagnosed with acute myeloid leukemia, also found to have a mediastinal mass. Evaluation of the mediastinal mass with tumor markers, biopsies, and next-generation sequencing proved non-diagnostic, while he was simultaneously treated with induction chemotherapy to prevent leukemia-related blast crisis. After completing and recovering from induction chemotherapy, he underwent successful thymectomy during a chemotherapy holiday, with a margin-negative resection of thymic adenocarcinoma. He has subsequently recovered and undergone successful allogeneic hematopoietic stem cell transplant. CONCLUSIONS: We present a case of synchronous adult acute myeloid leukemia and primary thymic adenocarcinoma requiring a tailored approach for management of simultaneous malignancies.

Total anomalous origin of the coronary arteries from the pulmonary artery: a systematic review.

BACKGROUND: Although rare, coronary artery anomalies can have significant clinical implications. Total anomalous origin of the coronary arteries from the pulmonary artery (TCAPA) represents a rare subtype of coronary artery anomaly for which little is known. The aim of this review was to characterise the presentation, utilised diagnostic modalities, associated cardiac lesions, and treatment strategies in patients with TCAPA. METHODS: A systematic review was performed for cases of TCAPA using PubMed, Embase, and Web of Science. Keywords searched included "total anomalous origin of the coronary arteries from the pulmonary artery," "single ostium anomalous coronary artery from the pulmonary artery," and "anomalous origin of both coronary arteries from the pulmonary artery." RESULTS: Fifty-seven cases of TCAPA were identified in 50 manuscripts. Fifty-eight per cent of patients were male and the median age at presentation was 10 days (mean 1.71 ± 6.6 years, range 0 days-39 years). Most patients were symptomatic at the time of presentation; cyanosis (n = 22) and respiratory distress (n = 14) were the most common symptoms. Cases were most commonly diagnosed at autopsy (n = 26, 45.6%), but operative intervention was pursued in 22 cases (45.6%); aortic re-implantation (n = 14) and a Takeuchi-type repair (n = 7) were the most common routes of repair. CONCLUSIONS: The clinical presentation of patients with TCAPA was found to be variable, likely related to the presence of associated cardiac lesions. TCAPA should be considered in patients with suspected anomalous origin of the left coronary artery from the pulmonary artery for the serious consequences that can occur if not promptly corrected.

Anomalous Origin of the Circumflex or Left Anterior Descending Artery From the Pulmonary Artery.

Anomalous origin of the circumflex or left anterior descending artery from the pulmonary artery (ACxAPA and ALADAPA, respectively) are rare congenital coronary anomalies with clinical presentation varying from an asymptomatic murmur to sudden cardiac arrest. A systematic review was performed, and 46 cases of ACxAPA and 51 cases of ALADAPA were identified in 87 articles. Data were collected and analyzed from each case. A better understanding of ACxAPA/ALADAPA can provide information to providers who encounter this lesion as well as provide insight into coronary artery development which may help in the understanding of coronary artery anomalies.

Development of a porcine model of emergency resternotomy at a low-volume cardiac surgery centre.

Emergency resternotomy in the intensive care unit (ICU) is a rarely performed, yet potentially life-saving intervention. Success relies on recognition of a deteriorating clinical condition, timely deployment of equipment/personnel and rapid execution. Given how infrequently it is performed, we sought to develop a large animal model of resternotomy to prepare ICU nurses and technicians at our low-volume cardiac surgery military centre. A porcine model of resternotomy was developed at the end of an already-scheduled trauma lab. Participants worked their way through a pre-planned simulation scenario, culminating in the need for resternotomy. Pre-simulation surveys assessing knowledge and comfort level with aspects of resternotomy were compared to post-simulation surveys. Participants improved their knowledge of resternotomy by 20.4% (P < 0.0001; 14.7% for nurses and 26.9% for technicians). Improvements were seen in all aspects assessed relating to subjective comfort/preparedness of resternotomy. The model was an effective and realistic method to augment training of ICU staff about resternotomy. Costs associated with this model can be reduced when used in conjunction with large animal labs. This model should be used together with mannequin-based methods of resternotomy training to provide a realistic training environment and assessment of skills at capable institutions.

Recurrent Spontaneous Pneumothorax in a 47-Year-Old Woman.

Pneumothorax is a condition where air exists in the chest cavity, outside the lung. The causes of pneumothorax are numerous and determining the etiology can aid in treatment and prevent recurrence. We describe a 47-year-old female patient with past medical history of endometriosis who presented to the emergency room with recurrent right sided pneumothorax, its onset correlating with onset of menses. She underwent video assisted thorascopic surgery for a suspected catamenial pneumothorax whereby nodular "chocolate" appearing areas were noted on the middle lobe and multiple similar appearing lesions and fenestrations were noted on the diaphragm. A biologic mesh was affixed to the diaphragm after which mechanical and chemical pleurodesis were performed. She tolerated the procedure well and has been symptom free since. Herein, we review the pathophysiology, diagnosis, and treatment strategies for catamenial pneumothorax in the hopes of increasing awareness and understanding of this rare cause of spontaneous pneumothorax.

Penetrating thoracic injury from a bean bag round complicated by development of post-operative empyema.

Bean bag guns were developed as a nonlethal means for law enforcement personnel to subdue individuals. The large surface area and lower velocities of the bean bag round theoretically result in transfer of most of the energy to the skin/subcutaneous tissue and minimize the likelihood of dermal penetration, thereby 'stunning' intended victims without causing injury to deeper structures. However, this technology has been associated with significant intra-abdominal and intrathoracic injuries, skin penetration and death. We present a 59-year-old man who sustained a penetrating thoracic injury from a bean bag gun. Although the bean bag was successfully removed, the patient developed a postoperative empyema requiring operative management. We discuss the unique aspects of thoracic trauma from bean bag ballistics as well as considerations in management of patients with this uncommon mechanism of injury.

Anomalous Origin of the Right Coronary Artery From the Pulmonary Artery: A Systematic Review.

BACKGROUND: Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare congenital cardiac lesion that has been diagnosed in both children and adults with symptoms ranging from an asymptomatic murmur to sudden cardiac death. The aim of this review was to characterize published cases of ARCAPA to better understand this rare congenital coronary anomaly. METHODS: A systematic review was performed using PubMed, Embase, and Google Scholar for cases of ARCAPA. Keywords searched included: "anomalous origin of the right coronary artery from the pulmonary artery" and "ARCAPA." RESULTS: A total of 223 cases of ARCAPA were identified in 193 case reports. There was a slight male predominance (54.5%) and the median age at presentation was 14.0 years. Thirty-eight percent of patients were asymptomatic and most commonly identified during evaluation of a murmur. Angina and dyspnea were the most common presenting symptoms (22.4% and 17.0%, respectively). In symptomatic patients, a bimodal distribution of age at presentation was observed with a peak near birth and another between ages 40 and 60 years. The condition was most commonly diagnosed with coronary angiography (40.4%). Most cases were repaired surgically (72.6%) and reimplantation of the right coronary artery onto the aorta was the most common method of repair (62.3%). CONCLUSIONS: ARCAPA represents a rare coronary anomaly with great variability in clinical presentation. An understanding of the pathophysiology associated with the lesion is critical when determining treatment strategies.

Pulsed dosed delivery of oxygen in mechanically ventilated pigs with acute lung injury.

BACKGROUND: Acute lung injury (ALI) is a condition that leads to impaired oxygen delivery. We demonstrated previously that using a portable oxygen concentrator (POC) with pulsed dose delivery of oxygen is an alternative option to conserve oxygen while still maintaining adequate oxygen delivery in a mechanical model. We hypothesized that using a modified POC, pulsed dose oxygen delivery can provide adequate oxygenation in an animal model. METHODS: In a crossover study, we induced ALI in 15 pigs using an oleic acid model. We ventilated the pigs using equipment that is used by Critical Care Air Transport Teams of the US Air Force. We compared oxygen delivery using a POC in both continuous flow and pulsed dose modes, while in both volume-control and pressure-control mechanical ventilation. RESULTS: The PaO(2)/FIO(2) ratios were increased in both the continuous flow and pulsed dose delivery for volume control and pressure control. In volume control, the pulsed dose demonstrated a significant increase in the PaO(2)/FIO(2) ratio (168.8 [96.1] vs. 91.7 [65.4], p = 0.002) compared with continuous flow. However, this was not seen in pressure-control ventilation (89.0 [74.5] vs. 79.1 [65.4], p = 0.67). CONCLUSION: We were able to demonstrate that oxygen delivery using a POC in mechanically ventilated pigs with ALI is feasible. We were also able to demonstrate that pulsed dose delivery from a POC is superior to continuous flow oxygen delivery for oxygenation in ALI, when using volume control. We propose that this is a safe alternative to conserve oxygen in the transport of critically ill patients.

Open versus laparoscopic liver resection: looking beyond the immediate postoperative period.

BACKGROUND: Laparoscopic liver resection for malignant disease has shown short-term benefit. This study aimed to compare in-house, 30-day, and 1-year morbidity between laparoscopic and open liver resections. METHODS: The charts for all patients who underwent liver resection for malignant disease between April 2006 and October 2009 were reviewed. Patient, operative, and outcomes data at 30 days and 1 year were collected. RESULTS: For 76 patients, 49 open and 27 laparoscopic resections were performed. The two groups were similar in terms of age, gender, body mass index (BMI), extent of liver resection, use of ablation therapy, and tumor pathology (P > 0.05). The laparoscopic group had less blood loss (P = 0.004) and shorter hospital stays (P = 0.002). During their hospital stay, patients treated laparoscopically had fewer complications, but the difference was not significant. Home disposition was similar in the laparoscopic (96%) and open (90%) groups. More patients were readmitted at 30 days (2 vs. 9; P = 0.31) and 1 year (4 vs. 19; P = 0.04) in the open group. The all-cause 1-year mortality rates were similar between the laparoscopic and open groups (14.8% vs. 10.2%). CONCLUSION: The benefits of laparoscopic liver resection may extend beyond the initial postoperative period, with fewer readmissions despite shorter hospital stays. This also may suggest lower long-term hospital costs.

A model for a medical school surgery interest group.

The purpose of this report is to record some of the recent accomplishments of the Surgery Interest Group (SIG) at the Uniformed Services University of the Health Sciences, and to provide a framework for others to follow, with the goal of encouraging students to become interested in the exciting field of surgery. We will outline some of the events that our SIG planned and carried out in order to provide a quality experience to its members.