Synthetic Cannabinoid Abuse Resulting in ST-Segment Elevation Myocardial Infarction Requiring Percutaneous Coronary Intervention.

BACKGROUND: Synthetic cannabinoids (SC) are recreational designer drugs intended to mimic delta-9-tetrahydrocannabinol while surreptitiously circumventing classification by the Drug Enforcement Administration. CASE REPORT: A 50-year-old black male arrived in the Emergency Department transported by Emergency Medical Services (EMS) for altered mental status after complaining of chest pain associated with smoking SCs. EMS found the patient with an empty foil pack labeled "Scooby Snax Limited Edition Blueberry Potpourri." The patient was somnolent, but became agitated when stimulated and complained of chest pain. Vital signs were blood pressure 87/52 mm Hg and pulse 52 beats/min. The electrocardiogram demonstrated an inferior wall myocardial infarction. Coronary angiography identified an occluded obtuse marginal second branch that was successfully opened with a drug-eluting stent. The patient recovered uneventfully. Urine drug screen was negative for cocaine, and gas chromatography/mass spectrometry testing of the smoked material identified PB-22 and AMB-FUBINACA as the active ingredients. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians and cardiologists need to be aware that the mechanism of action of synthetic cannabinoids on the endocannabinoid system may result in acute ST-segment elevation myocardial infarction requiring percutaneous coronary intervention.

Superolateral hoffa fat-pad edema and patellofemoral maltracking: predictive modeling.

OBJECTIVE: Superolateral Hoffa fat-pad edema is a frequent finding with patellar maltracking and may precede clinically significant chondrosis. The purpose of this study was to clarify which patellofemoral measurements are most highly associated and to develop a prediction rule to guide clinical decision making. MATERIALS AND METHODS: Twenty-three patellofemoral measurements were performed on 71 knees retrospectively identified as having superolateral Hoffa fat-pad edema at MRI (Hoffa group) and on 45 normal knees (normal group). Univariate analysis was performed to examine the association between these measurements and Hoffa fat-pad edema. Classification and regression tree analysis with 10-fold cross validation was used to generate a prediction model. RESULTS: For 16 of the 23 patellofemoral measurements, there was a statistically significant difference (p < 0.05) between the Hoffa and normal groups. Classification and regression tree analysis identified a prediction model in which a patient is placed into the Hoffa group if one of three conditions is met: lateral patellar displacement greater than -3.6 mm and Insall-Salvati ratio greater than 0.99; lateral patellar displacement of -3.6 mm or less and Insall-Salvati ratio greater than 1.23; or lateral patellar displacement of -3.6 mm or less, Insall-Salvati ratio of 1.23 or less, and lateral trochlear inclination of 16.5° or less. In fitting of the original sample, this model had 91.6% sensitivity and 88.9% specificity for identifying the Hoffa group. When 10-fold cross validation was applied, the estimated generalizable sensitivity and specificity were 85.9% and 75.6%. CONCLUSION: Superolateral Hoffa fat-pad is strongly associated with a number of measures of patellar maltracking. A prediction model based on these measurements is accurate for differentiating knees with superolateral Hoffa fat-pad edema from normal knees.

Arthroscopic debridement of loose bodies from a popliteal cyst.

To our knowledge, arthroscopic removal of loose bodies from a popliteal cyst has never been reported in the medical literature. This article describes our technique for removing loose bodies from a popliteal cyst and verifies that the procedure can be performed safely and effectively.A 52-year-old man had progressively worsening right knee pain and swelling of 3 years' duration that had been treated conservatively for 6 months. On physical examination, there was boggy swelling, a palpable popliteal cyst, crepitus with range of motion, and diffuse discomfort and tenderness about the knee. Magnetic resonance imaging showed synovitis of unclear etiology. Arthroscopic intervention was performed after conservative measures failed. An accessory posteromedial portal was used to gain access into the popliteal cyst through the posterior joint capsule. An electrocautery device was used to penetrate into the cyst through the posterior capsule after identifying the correct location of the cyst by passing a needle percutaneously through the posterior aspect of the cyst into the joint. Multiple loose bodies along with a large cartilaginous mass were identified in the popliteal cyst and removed. The patient remained symptom free at 2-year follow-up.As long as the instruments are kept in view and medial to the midline of the knee joint, the neurovascular structures lateral to the cyst are safe. Keeping the shaver suction on low during debridement will avoid pulling in any unvisualized tissue. To avoid injury to the superficial saphenous vein and nerve when making the posterior portal, the surgeon should incise through skin only, then use blunt dissection and a blunt obturator to enter into the joint. Simple decompression of large popliteal cysts can be accomplished in a similar manner.