Multisystem inflammatory syndrome in adults (MIS-A) following COVID-19 requiring venoarterial extracorporeal membrane oxygenation.

The SARS-CoV-2 virus has caused a global pandemic with serious impact around the world. Patients most commonly present with severe lung involvement and acute respiratory failure; however, multisystem inflammatory syndrome in adults (MIS-A) is a known-although rare-complication. We present a case of a 49-year-old patient who presented with combined cardiogenic and vasodilatory shock and was diagnosed with MIS-A. He initially required venoarterial extracorporeal membrane oxygenation and Impella for haemodynamic support but was able to be weaned off these devices with complete recovery of left ventricular systolic function. This case demonstrates that MIS-A may present as haemodynamic collapse in adults, but complete recovery is possible with proper haemodynamic support.

Sleep apnea, coronary artery calcium density, and cardiovascular events: results from the Multi-Ethnic Study of Atherosclerosis.

STUDY OBJECTIVES: Evaluate the association between obstructive sleep apnea (OSA), coronary artery calcium (CAC) density, and cardiovascular events in the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS: We analyzed 1,041 participants with nonzero CAC scores who had polysomnography and CAC density data from the fifth examination of the Multi-Ethnic Study of Atherosclerosis. OSA was defined as apnea-hypopnea index ≥ 15 events/h. Multivariable linear regression models were used to evaluate the independent association between OSA and CAC density. Additionally, we evaluated the impact of OSA on associations of CAC measures with incident cardiovascular disease events by testing for interaction in Cox proportional hazard regression models. RESULTS: Our analytical sample was 45% female with a mean age of 70.6 +/- 9 years. Of this sample, 36.7% (n = 383/1041) had OSA (apnea-hypopnea index ≥ 15 events/h). OSA was inversely and weakly associated with CAC density (ß = -0.09; 95% CI, -0.17 to -0.02; P = .014) and remained significantly associated after controlling for traditional cardiovascular risk factors (ß = -0.08; 95% CI, -0.16 to 0; P = .043). However, this inverse association was attenuated after controlling for body mass index (ß = -0.05; 95% CI, -0.13 to 0.02; P = .174). The mean follow-up period for cardiovascular disease events was 13.3 +/- 2.8 years. Additionally, exploratory analysis demonstrated that CAC density was independently and inversely associated with cardiovascular disease events only in the non-OSA subgroup (apnea-hypopnea index ≤ 15 events/h) (hazard ratio, 0.509; 95% CI, 0.323-0.801); P = .0035). CONCLUSIONS: OSA was associated with lower CAC density, but this association was attenuated by body mass index. Further, increased CAC density was associated with a reduced risk of cardiovascular disease events only in individuals within the non-OSA group in exploratory analysis. CITATION: Newman SB, Kundel V, Matsuzaki M, et al. Sleep apnea, coronary artery calcium density, and cardiovascular events: results from the Multi-Ethnic Study of Atherosclerosis. J Clin Sleep Med. 2021;17(10):2075-2083.

Robotic-assisted pulley technique for the ventral hernia.

When approaching complex abdominal wall hernias at either index operation or a subsequent reoperation for recurrent incarcerated abdominal wall hernias, a majority of surgeons consider mesh placement a key step in the prevention of a future recurrence. While the laparoscopic and open approaches show no significant difference in hernia recurrence, the laparoscopic approach to complex abdominal wall hernias does reduce surgical-site infection, postoperative ileus, improves short-term quality-of-life scores, and reduces hospital length of stay (Davies et al. in Am Surg 78(8):888-892, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3500604/ , 2012, McGreevy et al. in Surg Endosc 17(11):1778-1780, https://www.ncbi.nlm.nih.gov/pubmed/12958679 , 2003, Bittner et al. in Surg Endosc 33:3069-3139, https://doi.org/10.1007/s00464-019-06907-7 , 2019). In this paper, we describe a robotic approach with a pulley technique to the fixation of polypropylene mesh in complex abdominal wall reconstruction. Our primary aim is to offer a new perspective to the re-creation of challenging abdominal walls and to encourage other surgeons to gain proficiency in the robotic approach. Additionally, the material cost to the technique is lower than that of self-expanding or deployable mesh reinforcements used in other laparoscopic approaches. Over time, as an institution breaks even on the cost of a robot with their return on investment, this technique offers potential cost-saving.

Formation and assessment of a novel surgical video atlas for thyroidectomy.

Within surgery, interactive media have previously been used to educate medical students and residents. Here, we develop and assess the efficacy of a novel surgical video atlas in teaching surgically relevant head and neck anatomy to medical students. A total thyroidectomy was recorded intraoperatively and subsequently narrated to develop a video atlas. Medical students were recruited and randomly assigned to one of the two interventions. One group was assigned to the video atlas, while the other was supplied with a traditional textbook atlas. Both groups underwent pre- and post- tests to evaluate anatomical knowledge and satisfaction. Thirty-seven students completed the study, with 18 students in the experimental group and 19 students as control. In the video atlas arm, mean pre and post-test scores were 57.2% and 84.5%, respectively. In the traditional textbook arm, the mean pre- and post-test scores were 55.3% and 76.51%, respectively. Students with the video atlas had a mean post-test score 8.07% points higher than those without (p = .035). Overall, students were significantly more satisfied with the surgical video atlas than with the standard traditional textbook. A surgical video atlas was shown to more effectively teach head and neck anatomy to medical students compared to standard textbook atlases.

Effects of enamel matrix derivative on Porphyromonas gingivalis.

BACKGROUND: Enamel matrix derivative (EMD) is used during periodontal surgery for the regeneration of periodontal tissue. It consists of the amelogenin fraction of porcine enamel matrix (AMEL) suspended in a vehicle of propylene glycol alginate (PGA). EMD-treated sites appear to heal with less inflammation. It has been suggested that antimicrobial properties of EMD might account for improved healing in vivo. The objectives of this study were: 1) to determine the antibacterial effects of EMD on the periodontal pathogen Porphyromonas gingivalis and 2) to establish the component(s) of EMD that are responsible for this effect. METHODS: The antimicrobial effects were determined in vitro using the broth dilution assay. P. gingivalis at a starting inoculum of 10(9) colony forming units/ml was treated with EMD, AMEL, and PGA in Hank's balanced salt solution (HBSS) for 1, 3, and 24 hours. The CFU/ml of P. gingivalis recovered on enriched Brucella blood agar was determined at 6 and 10 days. RESULTS: EMD (containing AMEL and PGA) or PGA alone eliminated recoverable CFUs of P. gingivalis. Interestingly, AMEL in HBSS increased recoverable CFUs from 8.62 log CFU/ml to 8.93 log CFU/ml. Further analysis of the dose response at concentrations of 0.3, 3, and 30 mg/ml of AMEL in HBSS revealed that only 30 mg/ml (clinical concentration) increased CFUs of P. gingivalis relative to baseline (from 8.8 log CFU/ml to 9.2 log CFU/ml in 3 hours). Additionally, AMEL was compared to a protein control bovine serum albumin (BSA) to determine whether this effect was unique to AMEL. A marked increase in recoverable CFUs occurred with the AMEL (increasing from 8.8 log CFU/ml to 9.47 log CFU/ml), but not with BSA. CONCLUSIONS: EMD possesses antimicrobial properties that can be attributed to the propylene glycol alginate vehicle. The amelogenin fraction of porcine enamel matrix in enamel matrix derivative (i.e., AMEL) is not antibacterial for P. gingivalis and was shown to increase recoverable CFUs.

An unusual initial manifestation of metastatic papillary thyroid carcinoma: radioiodine uptake in lymph node metastatic lesions in a patient with Graves' disease.

OBJECTIVE: To report an unusual manifestation of metastatic papillary thyroid carcinoma with functional metastatic lesions demonstrated by radioiodine scanning and to discuss the relationship of Graves' disease and thyroid carcinoma. METHODS: A case report is presented, and the current literature is reviewed. RESULTS: An 82-year-old man had symptoms and laboratory results suggestive of thyrotoxicosis. 123I thyroid uptake scanning demonstrated lateral uptake, which directed attention to the lateral aspect of the neck and resulted in subsequent identification of previously overlooked lymphadenopathy. Total thyroidectomy, including excision of the central compartment and right jugular chain lymph nodes, was performed. CONCLUSION: In two previous reports of similar cases of metastatic thyroid carcinoma, imaging was done with use of a different scanning agent. To our knowledge, this is the first published case report of functional metastatic lesions imaged with 123I before thyroidectomy. This preoperative finding facilitated clinical management of the patient's thyroid cancer and thyrotoxicosis.