Surgical management of anomalous aortic right coronary artery discovered during acute type A aortic dissection: a case report.

Anomalous aortic origin of the right coronary artery (RCA) is a rare anatomic anomaly that is present in ~1% of the general population, and is often discovered incidentally through imaging performed for another purpose. Despite being an uncommon phenomenon, aberrant right coronary arterial origins can have devastating manifestations in half of affected patients. These include myocardial infarction, arrhythmias, heart failure, syncope, and sudden cardiac death secondary to ischemia of the cardiac tissue. This report describes a case of a 48-year-old female patient that was initially found to have ST-elevation myocardial infarction. During cardiac catheterization, the patient was discovered to have a type A aortic dissection. Cardiothoracic surgery was consulted, and she was immediately transferred to the operating room for repair. During the procedure, an anomalous RCA was discovered with its origin in the dissected tissue, which was initially ligated and then bypassed using greater saphenous vein graft.

Rare case of fecaloma requiring endoscopic intervention in a 24-year-old female.

Fecalomas are a rare potential etiology for constipation experienced in children and the elderly. Large bowel obstructions due to fecalomas are preferably treated conservatively with laxatives and bowel rest. However, in the setting of severe corporostasis, more invasive procedures are required to prevent bowel ischemia and perforation. This case report describes a patient who presented to the emergency department with symptoms of large bowel obstruction and constipation, and she was found to have a fecaloma. Conservative interventions, including bowel rest and the administration of laxatives failed, prompting the need for more invasive therapies. During her admission, multiple flexible sigmoidoscopies were required to alleviate the obstruction. Ultimately, this case demonstrates an encounter of a patient with a sigmoid fecaloma from an unlikely demographic with few risk factors that required endoscopic intervention for treatment.

Rare case of pediatric trauma with hepatic injury managed using gel-foam embolization: a case report.

Nonoperative management for hepatic injuries requires observation and supportive care in the case of hemodynamically stable patients. If there is active bleeding on presentation, hepatic artery embolization is an option to achieve hemostasis in the acute setting. Although interventional radiology procedures are well documented in adults, there is limited literature regarding these procedures in the pediatric population. In this report, we present a case of a pediatric patient who sustained blunt abdominal trauma, resulting in a grade IV liver injury. Treatment involved fluoroscopically guided right hepatic segmental arterial gel-foam embolization.

An unusual case of gallstone ileus within the cecum and ascending colon: a case report.

Gallstone ileus is a rare cause of intestinal obstruction. Due to long-standing inflammation of the gallbladder, fistulization can occur within nearby structures, most commonly to the duodenum or hepatic flexure of the colon. Through these fistulas, a stone can migrate and result in a small bowel obstruction or a large bowel obstruction. This case exemplifies the diagnosis and treatment of gallstone ileus, along with potential complications due to stone migration. Early recognition and treatment of gallstone ileus is important, as stone migration can lead to increased mortality with delayed diagnosis.

Acute withdrawal in the postoperative setting in a patient taking standard therapeutic doses of pregabalin.

Pregabalin is a gamma-aminobutyric acid analog that binds to voltage-gated calcium channels within the central nervous tissues, inhibiting the release of many excitatory neurotransmitters. It is used to treat various conditions including postherpetic neuralgia and diabetic peripheral neuropathy. Recently, its use has increased as part of non-opioid pain management algorithms. Prolonged use in high doses of pregabalin is associated with physical dependency and abuse, which can be seen when the medication is abruptly stopped. This phenomenon has been seen in studies focused on patients having abused or grown dependent on pregabalin. However, this has not been documented in patients taking therapeutic levels in the perioperative setting. This case report highlights a patient who experienced acute withdrawal symptoms of pregabalin after coronary artery bypass and aortic root enlargement.

Successful surgical management of a combined abdominal and thoracic penetrating injury: a case report.

Penetrating rebar injuries are extremely rare occurrences, but they are very life-threatening, particularly when involving the thoracic and abdominal cavities. The surgical approach to these traumatic injuries depends upon the length and diameter of the rebar as well as the path of penetration into the abdominal and thoracic regions. Due to the highly uncommon occurrence of penetrating rebar injuries, there is very limited information and studies pertaining to this topic in the literature. In this case report, we present a 43-year-old male patient sustaining a rebar penetrating injury, with the entry site being the left flank and the exit site being the anterior left chest. Upon arrival, the patient was emergently taken to the operating room and underwent simultaneous exploratory laparotomy and a left thoracotomy. The operation was successful in removing the rebar and the patient survived.

Rare case of an exceedingly enlarged mediastinal mass in 22-year-old male.

Masses of the mediastinum develop from anatomic structures that pass through or are normally located within this space; they may also occur secondary to metastatic spread from malignancies from other locations. The anterior compartment of the mediastinum can give rise to thymomas, which tend to be restricted to the thymus as well as nearby structures. Their symptoms are associated with their size and impact on nearby structures. This patient, a 22-year-old male with no medical history, presented to the emergency department for evaluation of a cough ongoing for 3 weeks. Chest X-ray and computed tomography (CT) scan of the thorax demonstrated a mass measuring up to 17.2 cm. Afterwards, a CT-guided biopsy was performed, which revealed findings consistent with a benign thymic neoplasm, though due to the specimen being scant, patient was referred to cardiothoracic surgery for resection and excisional biopsy of the mediastinal mass.

Delayed Presentation of Nail Gun-Associated Traumatic Pneumothorax with a Retained Foreign Body: A Case Report.

BACKGROUND Pneumatic nail guns were first introduced in the 1950's, which revolutionized the construction industry. Since that time, nail gun injuries have been reported predominantly in the extremities with rare cases of thoracic and head injuries. A nail gun can easily propel nails through human tissue with velocities varying based on propellant and object. There are limited case reports on the appropriate management of thoracic nail gun injuries. CASE REPORT A 30-year-old man presented to the Emergency Department with right-sided chest pain seven and a half hours after getting struck in the right lateral thorax with a pneumatic nail gun. The patient was hemodynamically stable and without respiratory distress. A chest X-ray was taken and showed a right pneumothorax with a retained radio-opaque object at the right lung hilum. A CT angiogram subsequently showed the object abutting the right middle lobe branch of the pulmonary artery. Cardiothoracic surgery was called and the patient was taken urgently to the operating room for right thoracotomy, finding the nail deep in the right fissure at the hilum with the nail head in contact but not puncturing the right middle lobe branch of the pulmonary artery. The patient was extubated and recovered well postoperatively. CONCLUSIONS This case demonstrates the critical nature of nail gun injuries and can better inform the trauma protocols used to treat these injuries. Even in a delayed presentation, there should be a high suspicion of traumatic lung and cardiac injuries due to the velocities obtained with pneumatic nail guns.

Peritoneal mesothelioma causing small bowel obstruction in COVID-19 positive patient.

Mesothelioma is a disease process that can present in a variety of locations including the pleural, peritoneum and pericardium. Malignant peritoneal mesothelioma has been known to be a particularly aggressive type of tumor. We report a case of a patient who presented with a small bowel obstruction whose pathology revealed peritoneal malignant mesothelioma.

Rare case of papillary fibroelastoma resection with concomitant cox-maze IV procedure.

Primary cardiac tumors represent 0.1% of all cardiac tumors, making them a rare pathologic phenomenon. The second most common cardiac tumors are papillary fibroelastomas, which also represent the most common valvular tumors. This report examines a rare case of a patient that underwent resection of papillary fibroelastoma with simultaneous Cox-Maze IV procedure for treatment of atrial fibrillation. This 67-year-old male patient was initially scheduled for transcatheter ablation for treatment of rate-controlled atrial fibrillation. During a pre-procedural trans-thoracic echocardiogram, it was discovered that the patient had a moderately sized pedunculated mass on the aortic valve, suspicious of papillary fibroelastoma. Despite the patient having no history of embolic events or aortic insufficiency from the papillary fibroelastoma, the transcatheter ablation procedure was canceled. He was referred to cardiothoracic surgery for further evaluation, and it was determined that this patient was a candidate for papillary fibroelastoma resection along with Cox-Maze IV procedure for atrial fibrillation.

Anterolateral Ligament Reconstruction Practice Patterns Across the United States.

BACKGROUND: A proposed mechanism for recurrent instability following anterior cruciate ligament (ACL) reconstruction is failure of the anterolateral ligament (ALL). Presently, there are a number of approaches to treating ALL pathology. PURPOSE: To determine practice patterns among orthopaedic surgeons regarding ALL during ACL reconstruction. STUDY DESIGN: Cross-sectional study. METHODS: An online 7-question survey was sent to all physicians registered with the American Orthopaedic Society for Sports Medicine between June and July 2017. Results were analyzed with the survey website. RESULTS: Overall, 225 of 3467 surgeons responded to the survey, 86 of whom performed ALL reconstruction and completed each question in the survey. Eighty-six (38.2%) surgeons who responded to the questionnaire stated that they perform ALL reconstruction/lateral extra-articular tenodesis in conjunction with ACL reconstruction. The most common indications for ALL reconstruction were grade III pivot-shift test (46.0%) on physical examination and revision ACL reconstruction (46.0%). The most common technique used to perform ALL reconstruction was hamstring autograft (48.2%). The majority of participating surgeons (87.5%) stated that they do not make any alterations to their postoperative rehabilitation protocol after they perform ALL reconstruction. In addition, most surgeons responding to the survey (91.3%) anticipated either an increase in or the same number of ALL procedures performed in the coming year. CONCLUSION: The majority of surgeons who responded to the survey did not routinely reconstruct the ALL. Revision procedures and grade III pivot shift were the most cited indications for performing lateral augmentation. Anatomic reconstruction with hamstring was the most commonly used procedure, although there was no consensus among surgeons responding to the survey. Understanding the ALL and its contribution to knee stability is essential. For a community of physicians, it is useful to discover how fellow sports orthopaedic surgeons address ALL pathology to integrate effective and efficient treatment strategies into practice.

Evolving patterns in the diagnosis and management of allergy-mediated disorders.

BACKGROUND: This analysis explores the increasing heterogeneity of trends in allergy management under the premise that the practice of allergy has undergone significant changes in national economics, healthcare delivery, and treatment options from 2007 to 2016. METHODS: Centers for Medicare and Medicaid Services (CMS) data were obtained for: (1) temporal trends in allergy immunotherapy injection (Current Procedural Terminology [CPT] codes 95115, 95117) and testing (CPT 95004, 95024) from 2007 to 2016; (2) geographic trends; and (3) practitioners administering immunotherapy. Although there are no sublingual immunotherapy (SLIT) CPT codes, billing for unlisted allergy/immunologic services (CPT 95199) were obtained. RESULTS: Since 2007, there were 99.5 million allergy tests and 33.5 million immunotherapy injections billed to Medicare beneficiaries. Increases in testing have outpaced rising immunotherapy administration (49.7% vs 19.6% increase). Significant regional variation in testing rates was noted, with the greatest ratio of testing to immunotherapy in the South (0.35) and smallest ratio in the Northeast (0.18). The maximum unlisted allergy services billed was 594 (of which includes SLIT), compared to annual subcutaneous immunotherapy (SCIT) totals in the millions. The majority of immunotherapy in 2016 was administered by allergists/immunologists (51.6%) followed by otolaryngologists (31.2%), trends that have remained consistent since 2012. CONCLUSION: Physicians have been more aggressive in the workup of allergy-mediated disorders in recent years. Although differences in allergen load exist, there is tremendous geographic variation in the ratio of testing to immunotherapy. While the role otolaryngologists play in immunotherapy remains stable, allergists manage the majority of patients, reinforcing the importance of interdisciplinary cooperation and outreach. SLIT does not appear to play a significant role in this population.