Dopamine in Idiopathic Polymorphic Ventricular Tachycardia/Ventricular Fibrillation.

The role of medical therapy in the treatment of idiopathic polymorphic ventricular tachycardia (IPMVT) and idiopathic ventricular fibrillation (IVF) is not well established. Current medications in use include amiodarone, lidocaine, isoproterenol, verapamil, and quinidine. However, the use of dopamine for controlling such arrhythmias has never been described. We present an interesting case of IPMVT/IVF storm induced by short-coupled premature ventricular contractions. The arrhythmia was terminated acutely using dopamine infusion and was suppressed chronically using verapamil.

Outcome of Neglected Versus Treated Tuberculous Dactylitis in the Same Patient - A case report.

INTRODUCTION: Skeletal tuberculosis is a rare form of extrapulmonary Mycobacterium tuberculosis infection. When tubular bones are affected, it is called tuberculous dactylitis (TD). This rare entity can be seen in the hand or foot and has been mentioned in a handful of case reports. CASE REPORT: A 56-year-old female patient presented to our clinic for left hand middle finger swelling and pain of 1-year duration. Her medical history was relevant for 15 years history of progressive 4th and 5th fingers malformations that were attributed to "sarcoidosis," and for which she was treated with anti-inflammatory and low dose steroids therapy. At our clinic, physical examination was consistent with a swelling of the base of the middle finger associated with tenderness and decreased range of motion. Radiographs of the hand showed a lytic lesion involving the distal half of the first phalanx, along with blurred limits of the bone surfaces involved. An magnetic resonance imaging was ordered and showed hyper-intense signal of the first phalanx, along with subcutaneous enclosed collections on both sides of the phalanx. Surgical debridement with open biopsy and culture was done. Pathology results showed caseating granulomas, and cultures confirmed the diagnosis of TD. A computed tomography scan of the chest was done postoperatively; where few calcified nodules were noted. She also received a 9-months course of anti-tuberculous drugs and had complete cure by 9 months postoperatively. CONCLUSION: TD of the hand is a very rare entity of the spectrum of extrapulmonary M. tuberculosis infection. Clinicians should have a high index of suspicion concerning this pathology not to delay the diagnosis, which could lead to permanent deformity. Early diagnosis and treatment can significantly improve outcomes.

The Correlation Between Gender and Accessory Pathways.

Background Accessory pathways (APs) are muscular bundles capable of rapid conduction between atria and ventricles. They can be located anywhere along the atrioventricular groove or septum. The etiology of such pathways is generally unknown. This study aims to evaluate the correlation between gender, AP location, and clinical presentation. Methods This is a retrospective study of 139 patients who underwent radiofrequency ablations for newly diagnosed accessory pathways between years 2010 and 2016. Information extracted from the medical records included: age at the time of diagnosis, gender, characteristics, and anatomical location of the accessory pathways. Results A total of 139 patients with AP were enrolled in the study. The mean age of diagnosis was 32.2 ± 13.5 years. With regards to gender, APs were more common among men (p-value 0.04). Males were predominant in both the right and left AP groups (p-value 0.025), although, overall, most of the AP were left located. Also, males were more commonly diagnosed with right posteroseptal (RPS) accessory pathways while females with left lateral (LL) pathways. Concerning the clinical presentation, the manifest form was more frequent than concealed. Males were prevalent in both groups (p-value 0.38). Conclusion Gender components might have a role in the pathogenesis of AP formation.

Adrenocortical Carcinoma: A Case of Missed Diagnosis.

Incidentalomas are commonly encountered adrenal lesions. However, adrenocortical carcinoma (ACC) represents a rare etiology of adrenal incidentalomas (AI). The diagnosis of AI is generally based on laboratory data and imaging results, Fine needle aspiration (FNA) is not usually indicated in the workup of incidentaloma. In this report, we present a case of AI in which two FNA procedures failed to make the correct diagnosis of ACC.

Comparison of the Outcomes of Early Versus Late Tracheostomy in the Treatment of Critically Ill Patients: A Retrospective Multicenter Measurement Study Done in Two Hospital Centers in Lebanon.

Background  Benefits of early tracheostomy (ET) versus late tracheostomy (LT) while treating critically ill patients have been a matter of big debate in the last few years. Several meta-analyses tried to prove the benefits of ET in decreasing the duration of mechanical ventilation (MV), the length of intensive care unit (ICU) stay, and the mortality rates. However, no clear guidelines are available yet. This study will focus on comparing the outcomes of early tracheostomy versus late one. Methods This is a retrospective study done in two medical and surgical ICUs at "Sacre-Coeur Hospital" and "Rafik Hariri University Hospital" at Beirut, where we reviewed various files of patients who underwent elective tracheostomy for prolonged MV from January 2015 to June 2016. ET and LT were assumed to be procedures performed respectively before and after 10 days of MV. These two groups were subdivided based on the Acute Physiology and Chronic Health Evaluation II (APACHE II) score calculated in the first 24 hours of ICU admission. Data about short- and long-term mortality, the duration of MV, and the length of ICU stay were collected and compared. Results From a total of 45 patients, only 25 patients met the inclusion and exclusion criteria of whom 12 (48%) underwent ET and 13 (52%) patients underwent LT. In patients with APACHE II <25 (6 ET and 6 LT), ET was associated with 50% long-term mortality, 9.6 days mean duration of MV and 23 days mean length of ICU stay compared to 57% (P-value=0.05), 78 days (P-value=0.04) and 79 days (P-value=0.012) of respective parameters in LT groups. In patients with APACHE II >25 (6 ET and 7 LT), ET was associated with 50% long-term mortality, 8.6 days mean duration of MV and 24 days mean length of ICU stay compared to 84%, 105 days, 84 days of respective parameter in LT groups. Conclusions Our results are suggestive of the superiority of ET because it was associated with a reduced duration of MV, a decrease in the length of ICU stay, and, most importantly, a lower long-term mortality rate.

Tuberculous Extensor Tenosynovitis Presenting as Huge Mass on the Dorsum of the Hand.

Infectious tuberculous tenosynovitis (TS) of the extensor tendons of the wrist is an exceptional location of musculoskeletal tuberculosis. We present a case of tuberculous extensor TS in a 52-year-old diabetic male patient presenting as a huge mass on the dorsum of the hand, in the absence of other pulmonary or extrapulmonary manifestation of tuberculosis. This report increases physicians' vigilance when dealing with patients with risk factors of tuberculosis, allowing early diagnosis and optimal treatment.

Simultaneous Bilateral Avascular Necrosis of the Femoral Heads Associated With Cocaine Use.

We present a case of a 38-year-old female patient, presenting with debilitating simultaneous bilateral avascular necrosis of the femoral head (AVNFH) 10 years after cocaine detoxification, making her wheelchair-bound for six months. This case is reported for the rarity of association of cocaine with AVNFH, and for the unique fact of the simultaneous bilateral condition occurring a long time after cocaine ingestion in the absence of other important risk factors. This report postulates cocaine as a possible cause of bilateral AVNFH, which can increase the index of suspicion of this pathology, allowing early diagnosis and better outcomes.

Recurrence of Ectopic Cushing's Syndrome 10 Years After Bilateral Adrenalectomy.

Ectopic Cushing's syndrome is a severe form of Cushing disease. Treatment usually involves the resection of the adrenocorticotropic hormone producing tumor. In certain cases, bilateral adrenalectomy is carried out as a final resort in treatment. We present a patient who had a lung carcinoid tumor, which was producing adrenocorticotropic hormone and causing ectopic Cushing's syndrome. Lung wedge resection failed to normalize cortisol level, and he had bilateral adrenalectomy. Ten years later, he had a recurrence of Cushing's disease due to lymph node metastasis of his carcinoid tumor.

The impact of BMI extremes on disease-free survival and overall survival following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are increasingly being offered to patients with peritoneal carcinomatosis (PC). On the other hand, the prevalence of obesity is also increasing and expected to reach unprecedented rates in the upcoming decades. Therefore, managing patients on either extreme of the body mass index (BMI) range is anticipated to become a routine challenge and it becomes imperative to understand the impact of BMI, as a spectrum, on the long-term outcomes of CRS and HIPEC. We aim to study the short and long-term outcomes of CRS and HIPEC in patients on both extremes of the BMI spectrum. METHODS: Patients with PC who underwent CRS and HIPEC over 10 years for ovarian, colorectal, and pseudomyxoma peritonei (PMP), and whose BMI was recorded were retrospectively included. Patients were divided based on their weight strata. The primary outcomes were disease-free survival (DFS) and overall survival (OS). RESULTS: A total of 126 patients were included. Fifty-seven point one percent were females and mean age was 59.31±1.57 years. No difference was noted between the groups in regards to demographics, perioperative characteristics, and immediate postoperative outcomes. Underweight group had a trend toward a higher peritoneal cancer index and lower rates of complete cytoreduction. Optimum BMI for OS and DFS was in the obesity range in colorectal PC, in the overweight range in ovarian PC, and in borderline obesity in PMP. Regression analysis identified underweight as an independent risk factor for shorter DFS, whereas underweight and morbid obesity were risk factors for shorter OS, after adjustment for other factors such as incomplete cytoreduction, tumor histology, and grade. CONCLUSIONS: OS and DFS vary across the BMI strata. Ovarian PC demonstrates earlier recurrence and shorter survival, whereas colorectal PC demonstrates the "obesity paradox" as patients move into the realm of obesity. BMI extremes, low or high, generally carry a poor prognosis for OS.

Outcomes of Open Versus Minimally Invasive Ivor-Lewis Esophagectomy for Cancer: A Propensity-Score Matched Analysis of NSQIP Database.

INTRODUCTION: We conducted this analysis to compare the outcomes of open transthoracic esophagectomy (OTTE) and minimally invasive transthoracic esophagectomy (MITTE) when performed for oncologic indications. METHODS: The NSQIP esophagectomy-targeted database during 2-year period was used. Only patients who underwent elective TTE for oncologic indications were included. Patients were matched per a propensity score for the likelihood of receiving OTTE versus MITTE. RESULTS: Overall, 2098 esophagectomies were reported; 576 met the inclusion criteria. A total of 161 purely OTTE patients were matched 1:1 with patients who received purely MITTE. OTTE was associated with higher reported rates of abdominal and mediastinal lymphadenectomies (LAD) (26.7% vs. 3.1% and 38.5% vs. 16.1%, respectively; p < 0.001) and had shorter mean operative time (329 vs. 414 min; p < 0.001). However, OTTE patients had higher rates of wound infection (7.5% vs. 1.9%), longer median hospitalization (10 vs. 8 days), more non-home discharges (18.0 vs. 8.1%), and a tendency toward higher rates of postoperative transfusion (13.0% vs. 6.8%; p = 0.092). The overall complications rate was higher in OTTE (46.0% vs. 33.5%; p = 0.028). No difference was noted in the rates of anastomotic leak, negative margins, reoperation, readmission, or mortality. Laparoscopic versus robotic approaches were uniformly comparable, except for higher rates of reported abdominal LAD in laparoscopic and higher rates of reported mediastinal LAD in robotic approach. CONCLUSIONS: MITTE is comparable to OTTE for oncologic indications in immediate postoperative outcomes. A concern is raised regarding the oncologic outcome given the lower reported rates of lymphadenectomies. Comparison of long-term outcomes is essential to address this concern.