A Case of Large Calcifying Fibroma of Tendo-achilles Managed by En-block Resection and Tendon Reconstruction.

Calcifying aponeurotic fibroma is a rare benign fibrous tumor with typical radiological and histopathological features seen in young children and adolescents. It commonly involves the extremities and is characterized by a very high chance of local recurrence. A complete excision of the tumor is considered to be the treatment of choice. We report a case of the tumor involving the substance of achilles tendon and extending up till its insertion in the calcaneum. To the best of our knowledge, this is the largest reported case of calcifying fibroma, with the tumor measuring 10 cm in its largest diameter. The tumor was excised in toto followed by reconstruction of the tendon defect with V-Y plasty of the native tendon and supplemented with semitendinosus and gracilis graft. There was no evidence of recurrence during the follow up period of 1 year.

Respiratory Variation in Carotid Artery Peak Systolic Velocity Is Unable to Predict Fluid Responsiveness in Spontaneously Breathing Critically Ill Patients When Assessed by Novice Physician Sonologists.

BACKGROUND: Respiratory variation in carotid artery peak systolic velocity (ΔVpeak) assessed by point-of-care ultrasound (POCUS) has been proposed as a noninvasive means to predict fluid responsiveness. We aimed to evaluate the ability of carotid ΔVpeak as assessed by novice physician sonologists to predict fluid responsiveness. METHODS: This study was conducted in 2 intensive care units. Spontaneously breathing, nonintubated patients with signs of volume depletion were included. Patients with atrial fibrillation/flutter, cardiogenic, obstructive or neurogenic shock, or those for whom further intravenous (IV) fluid administration would be harmful were excluded. Three novice physician sonologists were trained in POCUS assessment of carotid ΔVpeak. They assessed the carotid ΔVpeak in study participants prior to the administration of a 500 mL IV fluid bolus. Fluid responsiveness was defined as a ≥10% increase in cardiac index as measured using bioreactance. RESULTS: Eighty-six participants were enrolled, 50 (58.1%) were fluid responders. Carotid ΔVpeak performed poorly at predicting fluid responsiveness. Test characteristics for the optimum carotid ΔVpeak of 8.0% were: area under the receiver operating curve = 0.61 (95% CI: 0.48-0.73), sensitivity = 72.0% (95% CI: 58.3-82.56), specificity = 50.0% (95% CI: 34.5-65.5). CONCLUSIONS: Novice physician sonologists using POCUS are unable to predict fluid responsiveness using carotid ΔVpeak. Until further research identifies key limiting factors, clinicians should use caution directing IV fluid resuscitation using carotid ΔVpeak.

Change in Carotid Blood Flow and Carotid Corrected Flow Time Assessed by Novice Sonologists Fails to Determine Fluid Responsiveness in Spontaneously Breathing Intensive Care Unit Patients.

Measurement of carotid blood flow (CBF) and corrected carotid flow time (ccFT) has been proposed as a non-invasive means of determining fluid responsiveness. We evaluated the ability of CBF and ccFT as assessed by novice sonologists to determine fluid responsiveness in intensive care unit patients. Three novice physician sonologists performed carotid ultrasounds before and after a fluid bolus and calculated changes in CBF and ccFT. Fluid responsiveness was defined as a ≥10% increase in cardiac index as measured using bioreactance. Of 112 participants, 56 (50%) were fluid responders. Changes in CBF and ccFT performed poorly at determining fluid responsiveness: 19 mL/min (area under the receiver operating characteristic curve: 0.58, 95% confidence interval: 0.47-0.68) and 6 ms (0.59, 0.46-0.65) respectively. Novice physician sonologists are unable to determine fluid responsiveness using CBF or ccFT. Further research is needed to identify the key limiting factors in using carotid ultrasound to determine fluid responsiveness.

Performance of a 25% Inferior Vena Cava Collapsibility in Detecting Fluid Responsiveness When Assessed by Novice Versus Expert Physician Sonologists.

OBJECTIVES: Inferior vena cava collapsibility (cIVC) measured by point-of-care ultrasound (POCUS) has been proposed as a noninvasive means of assessing fluid responsiveness. We aimed to prospectively evaluate the performance of a 25% cIVC cutoff value to detect fluid responsiveness among spontaneously breathing intensive care unit (ICU) patients when assessed with POCUS by novice versus expert physician sonologists. METHODS: Prospective observational study of spontaneously breathing ICU patients. Fluid responsiveness was defined as a >10% increase in cardiac index following a 500 mL fluid bolus, measured by bioreactance. Novice sonologist measured cIVC with POCUS. Their measurements were later compared to an expert physician sonologist who independently reviewed the POCUS images and assessed cIVCs. RESULTS: Of the 85 participants, 44 (52%) were fluid responders. A 25% cIVC cutoff value performed better when assessed by expert sonologists than novice physician sonologists (receiver-operator characteristic curve, ROC = 0.82 [0.74-0.88] vs ROC = 0.69 [0.60-0.77]). CONCLUSIONS: A 25% cIVC cutoff value measured by POCUS detects fluid responsiveness. However, the experience of the physician sonologist affects test performance and should be considered when interpreting and clinically using cIVC to direct intravenous fluid resuscitation.

Uterine artery pseudoaneurysm with an anastomotic feeding vessel requiring repeat embolisation.

Uterine artery pseudoaneurysm (UAP) is a rare cause of delayed postpartum haemorrhage. Early diagnosis and endovascular management are effective in treating this condition. We present the case of a 36-year-old gravida 3, para 2 woman with delayed postpartum haemorrhage and endometritis following a spontaneous vaginal delivery. Ultrasound and catheter angiogram demonstrated a UAP arising from the distal aspect of the left uterine artery. Significant bleed persisted despite selective bilateral uterine artery embolisation. A repeat angiogram confirmed complete occlusion of bilateral uterine arteries, but abdominal aortogram demonstrated that the left ovarian artery was now feeding the pseudoaneurysm. A repeat embolisation procedure was performed to occlude the left ovarian artery. The patient was discharged the following day. Selective arterial embolisation is effective in the management of UAP. Persistent bleeding despite embolisation should raise the suspicion of anastomotic vascular supply and may require repeat embolisation.

Takayasu's arteritis and primary antiphospholipid syndrome presenting as hypertensive urgency.

A 33-year-old Caucasian man was admitted to the hospital with chest pain and hypertensive urgency. Physical examination revealed widespread arterial bruits and marked difference in blood pressure between the upper limbs. Vascular imaging showed widespread narrowing in multiple vascular territories. He met the established American College of Rheumatology criteria for Takayasu's arteritis. His resistant hypertension was considered to be a consequence of bilateral renal artery stenosis and he subsequently underwent sequential stenting of his renal arteries leading to improvement in blood pressure and reduction in the number of antihypertensive medications. Subsequent imaging revealed progression of aortic thrombus in the setting of an elevated erythrocyte sedimentation rate, and persistently elevated antiphospholipid antibodies fulfilling diagnostic criteria for primary antiphospholipid syndrome, requiring initiation of immunosuppression and anticoagulation.

Life threatening angioedema in a patient on ACE inhibitor (ACEI) confined to the upper airway.

INTRODUCTION: ACE inhibitors accounts for 8% of all cases of angioneurotic edema and the overall incidence is 0.1 to 0.7% of patients on ACE inhibitors. It is a leading cause (20-40%) of emergency room visits in the US with angioedema. We report a case of angioedema caused by ACE inhibitors confined to the upper airway after four years on treatment with Lisinopril which persisted for three weeks and required endotracheal intubation and subsequent tracheostomy due to delayed resolution. This case is one of the rare cases presented as upper airway edema which persisted for a long time. PRESENTATION: A 60-year-old Sudanese male patient with osteoarthritis in both knees underwent bilateral total knee replacement under single-shot epidural anesthesia. He had significant past medical history of type II diabetes, bipolar affective disorder and hypertension managed with Lisinopril for the past four years. Postoperatively after 10 hours the patient desaturated and developed airway obstruction requiring intubation. Laryngoscopy revealed an edematous tongue and upper airway and vocal cords were not visualized. In view of this clinical picture a provisional diagnosis of angioedema secondary to Lisinopril was made and it was discontinued. CT scan of the neck and soft tissues revealed severe airway edema with snugly fitting endotracheal tube with no peritubal air. A repeat CT neck on the tenth postoperative day showed no signs of resolution and an elective tracheostomy was performed on the eleventh postoperative day. C1 inhibitor protein and C4 levels were assayed to exclude hereditary angioedema and were found to be within normal range. Decannulation of tracheostomy was done after airway edema resolved on the twenty-fourth postoperative day as confirmed by CT scan. Subsequently he was transferred to the ward and discharged home. CONCLUSION: ACEI induced angioedema is a well-recognized condition. Early diagnosis based on a high index of suspicion, immediate withdrawal of the offending drug followed by supportive therapy is the cornerstone of management.

Modifiable factors to decrease the cost of robotic-assisted procedures.

In 2000, the US Food and Drug Administration approved the da Vinci Surgical System® for use in the United States. Since that time, the number of surgical robotic systems throughout the United States has continued to grow. The costs for using the system include the initial purchase ($1 million to $2.3 million) plus annual maintenance fees ($100,000 to $150,000) and the cost of limited-use or disposable instruments. Increasing the number of procedures that are performed using the robotic system can decrease the per-procedure costs. Two modifiable factors that contribute to increasing the annual caseload are increasing the number of surgeons capable of using the system and having a properly educated perioperative nursing team. An educated surgical team decreases turnover time, facilitates proper flow of each surgical procedure, and is able to actively and passively solve intraoperative problems.

The role of cryosurgery of the prostate for nonsurgical candidates.

INTRODUCTION: Technological advancements have reduced the morbidity associated with cryosurgery, leading to an increased interest in this modality for the treatment of organ-confined prostate cancer. In this study, we critically examine the current role of cryoablation of the prostate to better understand how to counsel patients regarding this treatment option. METHODS: A database was compiled over a 3-year period (2008-2011) of 30 patients who underwent cryoablation for organ-confined prostate cancer. Indications for cryosurgery included primary treatment, focal treatment (institutional review board-approved prospective study), and salvage cryotherapy for radiation failure. The primary outcomes were biochemical response via prostate-specific antigen (PSA) measurement and morbidity associated with cryoablation. Cryotherapy failure was defined as an increasing postcryotherapy PSA level ≥ 2 ng/mL above the post-treatment nadir, a positive prostate biopsy, or radiographic evidence of metastatic disease. RESULTS: Of the 30 patients who underwent cryoablation from 2008 to 2011, 26 patients had complete follow-up data for analysis. Of these patients, 17 (65.38%) had total gland cryotherapy, 5 (19.23%) had salvage cryotherapy for radiation failure, and 4 (15.38%) had focal cryotherapy. The mean patient age was 68 years (54-89); median preoperative PSA was 5.5 ng/mL (1.7-15.9); median prostate volume was 35 mL (15-54); mean Gleason score was 7; and the median PSA at study conclusion was 0.7 (0.02-3.4) ng/mL. Of the 17 patients who had total prostate cryotherapy, 11 (64.7%) had significant factors precluding primary treatment by a surgical and/or radiation approach, including neurological disorders (2), morbid obesity (1), rectal cancer treated with radiation (1), kidney/pancreas transplant (2), ileoanal pouch secondary to inflammatory bowel disease (IBD) (1), renal failure (1), and age (3). There were no intra- or postoperative complications. After a median follow-up of 18 months (1-40), none of the patients with multiple comorbidities had biochemical failures. Two patients from the salvage group experienced treatment failure requiring androgen deprivation therapy. CONCLUSIONS: This critical analysis of a single-surgeon experience at a large academic prostate cancer program revealed that the contemporary role of cryosurgery is, in select patients with comorbidities, preventing surgical and/or radiation therapy. Additionally, cryosurgery has a role in treating radiation failures. Further studies are necessary to investigate focal cryotherapy as an option for primary treatment, but our preliminary results are promising, without any biochemical failures in our focal therapy cohort.

Patent foramen ovale: Its significance in anesthesia and intensive care: An illustrated case.

Patent foramen ovale (PFO) is defined as a valve-like opening at the level of foramen ovale or between septum primum and secundum without evidence of the anatomical defect. Paradoxical embolism (PDE) is an embolus passing through a defect PFO leading to end-organ dysfunction. PDE in septic shock is not yet reported in the literature. A 49-year male presented to the emergency department with shortness of breath since one day and pain in the left side of the chest. Chest x0 -ray revealed middle-left lobe pneumonia with pleural effusion; he was started on Co-amoxiclav, and admitted to the ward. After 6 h, his chest pain suddenly significantly increased difficulty in breathing and his oxygen saturation dropped. X-ray of the chest showed left pneumothorax, chest drain was inserted and he was intubated. He became hemodynamically unstable with maximum ventilatory support and noradrenalin. On day 4, he was found to have new pansystolic murmur in the tricuspid area. An echocardiogram revealed global hypokinesia, two mobile thrombi in the right atrial cavity, and PFO. It was noticed that his right toe had blackish discoloration. An angiogram showed occlusion of the right superficial femoral artery and immediately an embolectomy. On day 11, he was transferred to the ward. PDE needs a high index of suspicion in septic shock patients with ARDS. PDE requires PEEP adjustment, early anticoagulation, and thromboprophylaxis.

The imaging and management of nonconsecutive pars interarticularis defects: a case report and review of literature.

BACKGROUND CONTEXT: Lumbar spondylolysis is a well-recognized condition occurring in adolescents because of repetitive overuse in sports. Multiple-level spondylolysis involving consecutive lower lumbar segments are rare. Several authors have reported failure of conservative treatment in the management of multiple-level pars fractures. STUDY DESIGN: A case report and review of previous literature is presented. OBJECTIVE: The objectives of this case report were to present a rare case of pars fracture involving nonconsecutive segments and discuss image findings and treatment. METHODS: The patent's history, clinical examination, computed tomography (CT), magnetic resonance imaging (MRI) findings, and treatment are reported. We also discuss the pathogenesis, various treatment options, and review the literature. RESULTS: We present the fourth case of bilateral pars fractures involving nonconsecutive lower lumbar spine segments of L3 and L5, in a 16-year-old young adolescent footballer who presented with 4-month history of constant low back pain. After 1 year of conservative management, the more acute fractures at L3 showed complete bony union, symptomatic pain relief, and return to full sporting activity. CONCLUSION: We report a rare case of bilateral pars fractures involving nonconsecutive segments. Multiplane reconstruction of CT images and MRI are very useful in planning treatment and follow-up. Conservative management may be used to treat multilevel nonconsecutive pars fractures.

Complication rate after operative treatment of paediatric femoral neck fractures.

Paediatric fractured neck of femur injuries is rare and historically has high complication rates postoperatively. We present results from the Birmingham Children's Hospital. Fifteen displaced femoral neck fractures were identified in 14 children over a 10-year period (1997-2006). Mean age at the time of injury was 10 years (range 6-14 years). Mean follow-up was 31 months (range 6-110 months). Anatomical reduction and internal fixation was performed in all cases. Two fractures were classified as Delbet's type-I (13.3%), four type-II (26.7%), six type-III (40%) and three type-IV fractures (20%). Eleven patients were operated on within 24 h (range 4-19 h) and four after 24 h (range 2-11 days). The rate of avascular necrosis was 6.7% overall and 10% excluding pathological fractures. The rate of premature physeal closure was 33.3% overall and 40% excluding pathological fractures. Ninety-three percent of the total study population had a good result according to the Ratliff scoring system. There were no nonunions. One patient had a poor result with avascular necrosis and collapse.

Assessment of acetabular retroversion following long term review of Salter's osteotomy.

Salter's innominate osteotomy may predispose to anterior over-coverage of the acetabulum. Over cover or retroversion has been demonstrated to be a cause of hip pain, impingement and subsequent osteoarthritis. We reviewed the long-term follow up of seventeen skeletally mature hips in sixteen patients who had previously undergone a Salter's osteotomy in childhood. The Salter pelvic osteotomy was performed at a mean average age of 5 years and follow up at a mean average age of 20 years. Patients were assessed by clinical examination for signs of impingement, Harris Hip Score and pelvic radiograph. Acetabular version was evaluated by the relationship between anterior and posterior walls of the acetabulum using templates applied to the pelvic radiograph as described by Hefti. The median acetabular cover averaged 17 degrees of anteversion with 2 patients (12%) demonstrating retroversion, neither of whom, had signs of impingement on examination. The mean average Harris Hip Score was 85 indicating a good outcome at long-term follow-up. We believe acetabular remodelling may occur with age after Salter's innominate osteotomy and have found good results in patients after skeletal maturation. Fears of long-term anterior over-coverage and retroversion with this operation may be unfounded.

Continued lumbar spinal erosion after repair of chronic contained rupture of a mycotic abdominal aortic aneurysm.

INTRODUCTION: Mycotic aneurysm of the aorta is a rare, dangerous condition. We report a case of an abdominal aortic aneurysm (AAA) caused by Candida albicans. METHODS: Case report and review of pertinent English-language literature. CASE REPORT: A 48 year-old man presented with an acute exacerbation of long-standing back pain. Examination revealed a pulsatile epigastric mass, and radiologic examinations confirmed a 9 cm chronic contained rupture of an inflammatory infrarenal AAA. At operation, no posterior aneurysm sac was found, and lumbar vertebral erosion was noted. Lower limb vascularity was secured with left axillo-bifemoral bypass. The patient presented 12 months later with severe non-mechanical back pain. Imaging confirmed continuing vertebral erosion. At laparotomy, an autologous fibula strut was used for spinal stabilization. CONCLUSION: Aggressive multimodality therapy of infected AAA and associated vertebral osteomyelitis is necessary for a successful outcome.

Late presentation of an infected carotid patch as a superficial wound nodule.

BACKGROUND: Infection of a vascular patch is an uncommon complication of carotid endarterectomy. METHODS: Case report and review of the pertinent English-language literature. CASE REPORT: A 71 year-old woman with a carotid patch infection presented with a superficial wound nodule and no false aneurysm. Diagnosis thus was delayed but was confirmed eventually with magnetic resonance imaging. Excision and saphenous vein bypass was successful. CONCLUSION: The rare complication of infection of a polyester vascular patch is described with recommendations for early diagnosis and definitive therapy.

Emphysematous pyelonephritis.

BACKGROUND: A 54-year-old nondiabetic male presented with high fever, vague lower abdominal pain and leakage of urine around his long-standing suprapubic catheter. Examination revealed pyrexia and tenderness in the right renal angle. White cell count was 22.8 x 10(9)/l. Plain abdominal X-ray showed calculi in the right kidney, ureter and bladder. Intravenous pyelogram showed gas confined to the right upper renal pelvis and perinephric space. INVESTIGATIONS: Urine and blood cultures, plain abdominal X-ray, intravenous pyelogram, abdominal ultrasound, MAG3 renogram and histopathology. DIAGNOSIS: Emphysematous pyelonephritis: class 2 or type 1. Escherichia coli was isolated from urine obtained by endoscopic drainage. MANAGEMENT: Endoscopic drainage of pus and simple nephrectomy.