Intraoperative Monitoring of Pulmonary Artery Physiology With Transesophageal Echocardiography in a Patient With an Extensive Pulmonary Aneurysm Undergoing Partial Nephrectomy.

Surgical patients with pulmonary hypertension present a significant challenge to the anesthesiologist. Continuous perioperative monitoring of pulmonary artery (PA) pressure is recommended and most often accomplished with a PA catheter. Placement of a PA catheter may be difficult or contraindicated, and in these cases, transesophageal echocardiography is a useful alternative to monitor dynamic PA physiology. In this case, we used intraoperative transesophageal echocardiography to detect changes in peak PA pressure and guide clinical treatment in a patient with pulmonary hypertension and an extensive PA aneurysm undergoing partial nephrectomy.

Outcomes following impaction bone grafting for treatment of unstable osteochondritis dissecans.

BACKGROUND: Many methods have been proposed to treat unstable osteochondritis dissecans (OCD). Our purpose is to report outcomes in a cohort of patients undergoing impaction bone grafting for treatment of knee OCD. METHODS: Patients undergoing impaction bone grafting for knee OCD between 1998 and 2011 were contacted and stratified into (a) those who have undergone subsequent surgery on the affected knee and (b) those who have not had revision surgery performed on the affected knee since the impaction bone grafting procedure. For those not undergoing another procedure, physical examination, radiographs, MRI, and functional outcomes (SF12, Tegner, Activity Rating Scale, and IKDC) were obtained. RESULTS: Of nine patients (10 knees) undergoing the procedure, seven (eight knees) were available for follow-up. Three had revision surgery. One had debridement due to surface overgrowth and had no symptoms 43months following debridement, while two had osteochondral allograft and autograft procedures at three and 10years after initial surgery, respectively. Four patients did not require a revision surgical procedure at average follow-up of 55.4months (range, 21-116months). All had complete MRI fill of the cartilaginous defect with less than 50% of surface irregularity and redeveloped the tidemark and a heterogeneous cartilaginous surface. Follow-up Tegner, ARS, and SF12-PCS averaged 6.8, 67.5, and 56.6, respectively. All four had good/excellent IKDC results. CONCLUSION: Impaction bone grafting can reliably restore osteocartilaginous defect produced by OCD and is a readily available and less-expensive option in treating OCD lesions. Further investigation is necessary to determine the long-term durability of the results. Level IV - Case series.

Radiofrequency Scanning for Retained Surgical Items Can Cause Electromagnetic Interference and Pacing Inhibition if an Asynchronous Pacing Mode Is Not Applied.

Radiofrequency (RF) scanning is an increasingly popular method of detecting retained surgical items. RF systems are generally regarded as safe but have the potential to cause electrical interference with pacemakers. This may lead to serious adverse events, including asystole. We present a case of an RF system used with a temporary pacemaker resulting in asystole. With the use of RF devices becoming widespread, it is important for all operating room personnel to recognize the potential for pacemaker interference from RF scanning devices and the requirements for asynchronous pacing when these devices are in use.

Sun, iron, alcohol and intrinsic liver disease: a recipe for failure.

A 62-year-old Caucasian woman, with remote history of painful skin blistering and hypertrichosis, recent history of travel to Mexico and increased alcohol consumption, presented with progressively worsening jaundice and fatigue. Physical examination was remarkable for severe generalised jaundice, scleral icterus and erythematous facial blistering and scarring. Laboratory workup revealed markedly elevated total and direct bilirubin, mildly elevated transaminases, severe iron overload and increased urine coproporphyrin. Porphyria cutanea tarda was diagnosed, and she was treated with supportive measures including hydration and alcohol cessation. Pathology of her liver demonstrated mild iron overload and severe fatty infiltration. Hospital follow-up revealed complete resolution of jaundice and fatigue and near-normalisation of liver function tests.

Pneumocystis pneumonia in a non-HIV patient on chronic corticosteroid therapy: a question of prophylaxis.

A man in his late 50s with a history of membranoproliferative glomerulonephritis presented with fever and mild dyspnoea. He was HIV-negative and had been on corticosteroids as immunosuppression for 6 months prior to tapering them off 1 week before presentation. He was not taking prophylaxis for Pneumocystis jirovecii pneumonia. After unsuccessful treatment for community-acquired pneumonia, his condition worsened and he required intubation and mechanical ventilation. Full respiratory workup including bronchoscopy revealed P jirovecii as a source for the patient's infection. He was treated successfully with a 21-day course of trimethoprim-sulfamethoxazole  and eventually weaned off the ventilator. He has had no complications to date. In our review of this case and the existing literature, we believe that proper utilisation of prophylaxis for pneumocystis pneumonia may have prevented our patient's transfer to intensive care unit. In our article, we discuss this issue and explore current evidence for prophylaxis.

Splenic lacerations and return to play: case report of 2 professional hockey players.

BACKGROUND: Several sports medicine reviews have highlighted a 3- to 6-month time frame for return to play after splenic lacerations. These reviews are based on several well-defined grading scales for splenic injury based on computed tomography (CT). None of the articles suggest that serial CT scanning is necessary for follow-up; some even indicate that it has no role in the management of these injuries. HYPOTHESIS: With proper follow-up and possibly the use of serial CT scanning or other imaging modalities, it may be possible for athletes to safely return to play sooner than what current guidelines recommend. STUDY DESIGN: The authors present 2 cases of professional hockey players who both suffered grade III splenic lacerations while playing. METHODS: Both players were treated conservatively and monitored with serial CT scanning until radiographic and clinical findings suggested complete healing. RESULTS: Both players were able to return to full-contact professional hockey within 2 months after suffering grade III splenic lacerations. Neither athlete suffered any complications after his return. CONCLUSIONS: With CT scanning, 2 athletes were able to return to play earlier (2 months) than previously recommended (3-6 months) without compromising their safety. CLINICAL RELEVANCE: Additional cases must be examined before outlining more definitive recommendations regarding splenic lacerations in sports, but it is possible that elite athletes may return to play sooner than what the current literature recommends.

Knee popping and clicking in a pediatric athlete: meniscal injury or sports tumor?

This case report presents a teenage patient who initially was thought to have a sports-related injury but ultimately was diagnosed with a primary soft tissue tumor. A previously healthy 16-year-old softball player presented with a history of left knee joint line pain, clicking, and swelling. The patient was presumed to have a lateral meniscus tear. However, magnetic resonance imaging demonstrated an intra-articular mass. Arthroscopy revealed a 2.5- × 1.5-cm firm pedicular mass in the lateral joint. Histological exam demonstrated localized pigmented villonodular synovitis. The patient healed uneventfully and returned to sporting activities. This report re-emphasizes the possibility that "sports tumors" can mimic symptoms of a meniscal tear in young athletes.

Common leg injuries of long-distance runners: anatomical and biomechanical approach.

CONTEXT: Long-distance running (greater than 3000 m) is often recommended to maintain a healthy lifestyle. Running injury rates increase significantly when weekly mileage extends beyond 40 miles cumulatively. With the development of running analysis and other diagnostic tests, injuries to the leg secondary to bone, musculotendinous, and vascular causes can be diagnosed and successfully managed. EVIDENCE ACQUISITION: Searches used the terms running, injuries, lower extremity, leg, medial tibial stress syndrome, compartment syndrome, stress fractures, popliteal artery entrapment, gastrocnemius soleus tears, and Achilles tendinopathy. Sources included Medline, Google Scholar, and Ovid from 1970 through January 2012. RESULTS: Tibial stress fractures and medial tibial stress syndrome can sometimes be prevented and/or treated by correcting biomechanical abnormalities. Exertional compartment syndrome and popliteal artery entrapment syndrome are caused by anatomic abnormalities and are difficult to treat without surgical correction. CONCLUSION: Leg pain due to bone, musculotendinous, and vascular causes is common among long-distance runners. Knowledge of the underlying biomechanical and/or anatomic abnormality is necessary to successfully treat these conditions.