Percutaneous aspiration of aortic valve vegetation in a patient with aortic valve endocarditis.

Key Clinical Message: Percutaneous aspiration for debulking of vegetations in right-sided infective endocarditis has been well-described, however, this technique can be employed successfully for left-sided vegetations in select high-risk patients. Abstract: We report a case of percutaneous aspiration of an aortic valve vegetation in a patient with prosthetic valve endocarditis. This novel approach was selected after patient declined surgical intervention for an enlarging vegetation despite antibiotic therapy. The procedure was successful, resulting in the complete removal of solid vegetation without complications.

Nationwide Analysis of Hospital Admissions Prior to Hartmann's Procedure for Acute Diverticulitis.

INTRODUCTION: Diverticular disease is one of the most common gastrointestinal diseases that require hospital admission. This study aims to identify trends in prior hospital admissions for patients that ultimately require a Hartmann's procedure for complicated diverticulitis. METHODS: The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged 18 years or older admitted with an ICD-9 code for colonic diverticulitis and end colostomy creation. Patients with prior hospital admissions were identified. The primary outcome was mortality after Hartmann's procedure. Secondary outcomes were prior hospital admission and previous percutaneous drain placement. Multivariable logistic regression was performed to control for confounding factors for each outcome and results were weighted for national estimates. RESULTS: There were 90,162 patients admitted with complicated diverticulitis requiring end colostomy creation. Prior hospital admissions were found in 28.1% (n = 25,307) and 14.4% (n = 12,947) had a previous percutaneous drain placed during a prior admission. The overall mortality rate was 5.9% (n = 5314) after Hartman's procedure. The mortality rate for patients with prior hospital admissions was 8.7% (P < .001), and the mortality rate for patients with previous percutaneous drain placement was 4.3% (P < .001). After controlling for confounding factors including comorbidities, patients with prior admission had an increased risk of mortality (OR 1.48 [1.40-1.58], P < .001) and patients with previous percutaneous drain placement had a decreased risk of mortality (OR .66 [.60-.72], P < .001). CONCLUSIONS: Hospitalizations for complications of diverticulitis are a costly burden to our healthcare system. By identifying those patients at high risk for readmission and emergency surgery, perioperative outcomes may be improved.

Under the Microscope: The Evolution of Surgical Loupes.

Fine motor movements of the surgeon's hands are limited by the resolution of the eye. Surgical loupes have allowed the profession of surgery to surpass this threshold. This is a review of the historical milestones that lead up to the development of the modern-day loupes. We explore the Greco-Roman history of the magnifying lens, its subsequent application to corrective eyewear centuries later, and the multiple ground-breaking advancements of the compound lens microscope. Moreover, we review the development of pre-modern loupes as each iteration improved through time. The aim of this historical review is to kindle an appreciation for the millennia of development that led to such instrumental modern-day technology.

The Evolution of Bariatric Surgery-From Sewing Lips to Constructing the Sleeve.

Bariatric surgery remains the most durable weight loss option to address morbid obesity, providing lasting reduction of debilitating chronic comorbidities. This is a review of the historical milestones that led up to the development of this surgical practice. We explore perceptions and interventions for obesity as early as the 10th century, as well as pre-modern surgical perceptions and advancements in foregut and obesity surgery. Additionally, we recount select social and surgical landmarks in the modern bariatric era. The aim of this review is to reflect on and appreciate the centuries of progress that have led to such an instrumental branch of risk reductive surgery.

Student Perspectives on Implementing Stop the Bleed Training into Medical School Curriculum.

BACKGROUND: Following the Hartford Consensus guidelines and recommendations, third-year medical students from a single institution were offered an optional Stop the Bleed (STB) training course in August 2018. The aim of this study was to assess medical students' confidence in performing bleeding control techniques and teaching others after completing the STB course. The secondary goal was to assess student perception on integrating mandatory STB training into the medical school curriculum. MATERIALS AND METHODS: A 24-question survey using a 4-point Likert scale was administered to all medical students who completed STB training. Students were anonymously asked to self-report their confidence in performing bleeding control techniques, training others after STB training, and their perception on integrating STB training into medical school curriculum. RESULTS: After completing the STB course, 95% of students were comfortable applying a tourniquet, 92% of students were confident in packing wounds, and 99% of students could apply direct pressure to wounds to stop bleeding. Overall, 94% of students reported that STB training would be helpful for their clinical rotations. CONCLUSION: These results demonstrate that medical students are positively impacted by Stop the Bleed courses and validate that the implementation of mandatory STB courses into medical school curriculum will improve medical students' knowledge and skills for hemorrhage control.

The Grave Consequences of Late Presentation and Management of Rare Double Left Ventricle Chamber With Cardiomyopathy.

A double­chambered left ventricle is a rare congenital anomaly. We present the case of a 26-year-old man with such anomaly who presented with congestive heart failure. After this diagnosis was confirmed with echocardiography, surgical removal of the anomalous band and replacement of the regurgitant deformed mitral valve were performed. Postoperatively, the patient deteriorated, and no corrective response was associated with surgery. Herein we discuss what we have learned from this rare case and how it may apply to the management of similar cases in the future.

Surgical Management of Cardiac Hydatid Cyst and the Residual Intramural Ectocyst.

The cardiac hydatid cyst (HC) is a rare pathology and mostly is endemic in livestock raising countries. Patients do not have a specific presentation so it is mainly a diagnosis based on imaging. Finding HC anywhere in the body warrants looking for another hydatid in other organs. This is a case report of a young male who presented with nonspecific symptoms and during diagnostic workup, it happened that he has combined hepatic and cardiac HCs. The cardiac cyst was located intramurally in the interventricular septum and expanding down mostly to the left side of the diaphragmatic surface of the heart and partly crossing intramurally to the diaphragmatic surface of the right ventricle. Emergency open-heart surgery was performed; the endocyst was removed while intramural ectocyst was drained to prevent potential future residual space.

Acute Myocardial Ischemia Secondary to Embolization of Left Atrial Myxoma to Coronary Artery.

Cardiac myxoma is the most common primary cardiac tumor. Rarely it can present with systemic or coronary embolization due to fragmentation of the tumor mass. We present a case of a young male who presented with an acute myocardial ischemia secondary to embolization of a left atrial myxoma originating from the left atrium. The patient underwent successful emergency surgical management of both the myxoma and the occlusion of the coronary artery. In this scenario, the surgery is the only effective treatment. The case also highlights the significance of performing emergency echocardiography in the setting of acute myocardial ischemia to look for possible associated pathology which can inform management plan.

Transdiaphragmatic-pericardial Hernia: Case Report of an Unusual Condition Managed by Utilization of a Robotic Surgical System.

Transdiaphragmatic hernia via the central tendon in the pericardium is a rare entity. Most often, these hernias are acquired and related to the iatrogenic creation of a transdiaphragmatic-pericardial defect. We would like to present a case of a 62-year-old male who presented with acute chest pain and was diagnosed to have a transdiaphragmatic-pericardial hernia on computed tomography. He has a history of cardiac intervention via an abdominal approach 12 years earlier. A segment of jejunum was found strangulated in the defect. We used DaVinci Xi® (Intuitive Surgical, Sunnyvale, CA) robot and were able to successfully reduce the hernia, repair the defect, and resect a short segment of jejunum which was non-viable. The utilization of a minimally invasive approach may be feasible, and the use of a robotic surgical system may enhance the surgeon's ability to repair the defect.

Combined Myocardial Bridge and Coronary Vessel Disease Requiring Coronary Artery Bypass Grafting and Myotomy of the Myocardial Bridge.

Myocardial bridging (MB) describes a band of myocardium that covers the epicardial surface of the coronary artery. This band can vary both in thickness and distance to which it covers the artery. It is broadly classified as superficial or deep, depending on the thickness of the covering muscle layer. It can be asymptomatic, or it could present with different complications. Reported complications have included ischemia and acute coronary syndromes, coronary spasm, ventricular septal rupture, and arrhythmias. MB is most commonly found in the middle segment of the left anterior descending (LAD) coronary artery. There is controversy with regard to therapy for symptomatic patients who are refractory to medical management. Percutaneous coronary intervention and surgical myotomy (unroofing) have been proposed; yet, each one has its pros and cons. MB can be associated with the development of atherosclerosis proximal to the MB segment in the involved coronary artery, and patients can present having both pathologies. We present a case series of six patients with atherosclerotic coronary lesions requiring coronary artery bypass grafting (CABG) with an accidental perioperative finding of MB, which required myotomy.

Characterization of recombinant ELMOD (cell engulfment and motility domain) proteins as GTPase-activating proteins (GAPs) for ARF family GTPases.

The ARF family of regulatory GTPases, within the RAS superfamily, is composed of ~30 members in mammals, including up to six ARF and at least 18 ARF-like (ARL) proteins. They exhibit significant structural and biochemical conservation and regulate a variety of essential cellular processes, including membrane traffic, cell division, and energy metabolism; each with links to human diseases. We previously identified members of the ELMOD family as GTPase-activating proteins (GAPs) for ARL2 that displayed crossover activity for ARFs as well. To further characterize the GAP activities of the three human ELMODs as GAPs we developed new preparations of each after overexpression in human embryonic kidney (HEK293T) cells. This allowed much higher specific activities and enhanced stability and solubility of the purified proteins. The specificities of ELMOD1-3 as GAPs for six different members of the ARF family were determined and found to display wide variations, which we believe will reveal differences in cellular functions of family members. The non-opioid sigma-1 receptor (S1R) was identified as a novel effector of GAP activity of ELMOD1-3 proteins as its direct binding to either ELMOD1 or ELMOD2 resulted in loss of GAP activity. These findings are critical to understand the roles of ELMOD proteins in cell signaling in general and in the inner ear specifically, and open the door to exploration of the regulation of their GAP activities via agonists or antagonists of the S1R.