The First-Reported Presentation of Quadruple Locations of Elastofibroma Dorsi: A Case Report and Review of the Literature.

Elastofibroma dorsi (EFD) is an uncommon benign tumor of mesenchymal origin that usually occurs in the subscapular region. Bilateral and triple EFD are frequently reported in the literature but cases with more lesions have never been described. Our patient is a 50-year-old female with quadruple locations of bilateral suprascapular and subscapular EFD who presented with left shoulder pain and swelling over the affected area. Clinical presentation, computed tomography (CT) and magnetic resonance imaging (MRI), and biopsy were consistent with EFD. Therapeutic excision was performed and successfully alleviated the patient's discomfort. This report presents the first case of quadruple locations of EFD and highlights the value of MRI in the diagnosis of EFD, especially when there are multiple masses with indistinct margins are deeply located in the chest wall.

Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review.

Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.

Creation of a dedicated line team for critically ill patients with COVID-19: A multidisciplinary approach to maximize resource utilization during the COVID-19 pandemic.

BACKGROUND: Pandemics create challenges for medical centers, which call for innovative adaptations to care for patients during the unusually high census, to distribute stress and work hours among providers, to reduce the likelihood of transmission to health care workers, and to maximize resource utilization. METHODS: We describe a multidisciplinary vascular access team's development to improve frontline providers' workflow by placing central venous and arterial catheters. Herein we describe the development, organization, and processes resulting in the rapid formation and deployment of this team, reporting on notable clinical issues encountered, which might serve as a basis for future quality improvement and investigation. We describe a retrospective, single-center descriptive study in a large, quaternary academic medical center in a major city. The COVID-19 vascular access team included physicians with specialized experience in placing invasive catheters and whose usual clinical schedule had been lessened through deferment of elective cases. The target population included patients with confirmed or suspected COVID-19 in the medical ICU (MICU) needing invasive catheter placement. The line team placed all invasive catheters on patients in the MICU with suspected or confirmed COVID-19. RESULTS AND CONCLUSIONS: Primary data collected were the number and type of catheters placed, time of team member exposure to potentially infected patients, and any complications over the first three weeks. Secondary outcomes pertained to workflow enhancement and quality improvement. 145 invasive catheters were placed on 67 patients. Of these 67 patients, 90% received arterial catheters, 64% central venous catheters, and 25% hemodialysis catheters. None of the central venous catheterizations or hemodialysis catheters were associated with early complications. Arterial line malfunction due to thrombosis was the most frequent complication. Division of labor through specialized expert procedural teams is feasible during a pandemic and offloads frontline providers while potentially conferring safety benefits.

Safety and Efficacy of Postoperative Indwelling Popliteal Nerve Catheters for Outpatient Charcot-Marie-Tooth Surgery.

BACKGROUND: Outpatient surgical deformity correction for Charcot-Marie-Tooth (CMT) disease is limited by effective postoperative pain control. Our previous institutional protocol for foot and ankle surgery in this population included preoperative single-injection nerve blocks, but patients often experienced uncontrolled pain when the block wore off postoperative day 0 or 1, resulting in high opioid requirements and unplanned emergency department visits. The use of ultrasonography-guided continuous nerve catheters in CMT patients has not previously been studied. We aimed to prospectively investigate the safety and efficacy of ultrasonography-guided indwelling popliteal catheters in CMT patients undergoing outpatient foot deformity correction surgery. METHODS: Twenty CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasonography-guided popliteal catheters. This series included 24 total outpatient procedures; 4 were staged bilateral. Indwelling popliteal catheters were maintained on discharge, providing continuous infusion until postoperative day (POD) 3, and then self-discontinued. Patients were prescribed oxycodone 5 mg (60-80 pills) as needed for breakthrough pain. Outcomes collected included daily pain scores (0-10), an opioid pill count on POD 14, and patient satisfaction ratings. Neurologic evaluation by 5-point 10g Semmes-Weinstein monofilament testing was performed preoperatively and on POD 14. RESULTS: There were no observed catheter-site infections or hematomas. Nine of the patients had pre-existing sensory deficits involving at least 2 areas on the 5-point monofilament test. Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative pain scores were typically low, with median values (interquartile ranges [IQRs]) of 3.5 (2.0-5.0) on POD 1, 2.5 (2.0-5.0) on POD 2, and 2.5 (1.0-3.75) on POD 3. At POD 14, pain was 1.0 (0-1.0). Patients consumed a median of 25 oxycodone pills (IQR 8-43) over 2 weeks, less than half the prescribed number. Patient satisfaction was high. All patients reported they would choose to have a nerve catheter again for a similar surgery. CONCLUSION: This cases series demonstrated that regional anesthesia using ultrasonography-guided indwelling popliteal catheters was safe and effective for pain control in CMT patients undergoing outpatient foot and ankle surgery. Opioid consumption was comparable to published rates following major bony procedures, and no patients required emergent treatment or hospital admission for uncontrolled pain. No new sensory deficits were detected and patients with underlying sensory deficits remained unchanged. Patients were highly satisfied. LEVEL OF EVIDENCE: Level IV, case series.

Cambrian origin of the CYP27C1-mediated vitamin A1-to-A2 switch, a key mechanism of vertebrate sensory plasticity.

The spectral composition of ambient light varies across both space and time. Many species of jawed vertebrates adapt to this variation by tuning the sensitivity of their photoreceptors via the expression of CYP27C1, an enzyme that converts vitamin A1 into vitamin A2, thereby shifting the ratio of vitamin A1-based rhodopsin to red-shifted vitamin A2-based porphyropsin in the eye. Here, we show that the sea lamprey (Petromyzon marinus), a jawless vertebrate that diverged from jawed vertebrates during the Cambrian period (approx. 500 Ma), dynamically shifts its photoreceptor spectral sensitivity via vitamin A1-to-A2 chromophore exchange as it transitions between photically divergent aquatic habitats. We further show that this shift correlates with high-level expression of the lamprey orthologue of CYP27C1, specifically in the retinal pigment epithelium as in jawed vertebrates. Our results suggest that the CYP27C1-mediated vitamin A1-to-A2 switch is an evolutionarily ancient mechanism of sensory plasticity that appeared not long after the origin of vertebrates.

Voltage-sensitive conductances increase the sensitivity of rod photoresponses following pigment bleaching.

KEY POINTS: Following substantial bleaching of the visual pigment, the desensitization of the rod photovoltage is not as substantial as the desensitization of the rod outer segment photocurrent. The block of cation conductances during the internal dialysis of Cs+ further desensitizes the photovoltage thereby eliminating its difference in desensitization with the rod outer segment photocurrent. Bleached visual pigment produced an acceleration of the rod photovoltage with respect to the outer segment photocurrent, which is eliminated upon internal dialysis of Cs+ . ABSTRACT: A majority of our visual experience occurs during the day when a substantial fraction of the visual pigment in our photoreceptor cells is bleached. Under these conditions it is widely believed that rods are saturated and do not contribute substantially to downstream signalling. However, behavioural experiments on subjects with only rod function reveals that these individuals unexpectedly retain substantial vision in daylight. We sought to understand this discrepancy by characterizing the sensitivity of rod photoresponses following exposure to bright bleaching light. Measurements of the rod outer segment photocurrent in transgenic mice, which have only rod function, revealed the well-studied reduction in the sensitivity of rod photoresponses following pigment bleaching. However, membrane voltage measurements showed that the desensitization of the photovoltage was considerably less than that of the outer segment photocurrent following equivalent pigment bleaching. This discrepancy was largely eliminated during the blockade of cation channels due to the internal dialysis of Cs+ , which increased the bleach-induced desensitization of the photovoltage and slowed its temporal characteristics. Thus, sensitization of the photovoltage by rod inner segment conductances appears to extend the operating range of rod phototransduction following pigment bleaching.