Using augmented reality as a clinical support tool to assist combat medics in the treatment of tension pneumothoraces.

This study was to extrapolate potential roles of augmented reality goggles as a clinical support tool assisting in the reduction of preventable causes of death on the battlefield. Our pilot study was designed to improve medic performance in accurately placing a large bore catheter to release tension pneumothorax (prehospital setting) while using augmented reality goggles. Thirty-four preclinical medical students recruited from Morehouse School of Medicine performed needle decompressions on human cadaver models after hearing a brief training lecture on tension pneumothorax management. Clinical vignettes identifying cadavers as having life-threatening tension pneumothoraces as a consequence of improvised explosive device attacks were used. Study group (n = 13) performed needle decompression using augmented reality goggles whereas the control group (n = 21) relied solely on memory from the lecture. The two groups were compared according to their ability to accurately complete the steps required to decompress a tension pneumothorax. The medical students using augmented reality goggle support were able to treat the tension pneumothorax on the human cadaver models more accurately than the students relying on their memory (p < 0.008). Although the augmented reality group required more time to complete the needle decompression intervention (p = 0.0684), this did not reach statistical significance.

Cecal epiploic appendagitis: a diagnostic and therapeutic dilemma.

Acute epiploic appendagitis (EA) is a rare and often misdiagnosed cause of acute abdominal pain. Though a benign and often self-limiting condition, EA's ability to mimic other disease processes makes it an important consideration in patients presenting with acute abdominal symptoms. Careful evaluation of abdominal CT scan findings is crucial in the accurate diagnosis of epiploic appendagitis, thus avoiding unnecessary surgical intervention. We report a case of a 29-year-old male presenting with a two day history of generalized abdominal pain. Physical exam revealed a diffusely tender abdomen with hypoactive bowel sounds. The patient had a leukocytosis of 18,000 and abdominal CT scan revealed right lower quadrant inflammatory changes suggestive of acute appendicitis. Laparoscopic exploration revealed an inflamed gangrenous structure adjacent to the ileocecal junction. Pathologic evaluation revealed tissue consistent with epiploic appendagitis. Retrospective review of the CT scan revealed a normal appearing appendiceal structure supero-lateral to the area of inflammation. The patient recovered uneventfully with resolving leukocytosis. We present a case of cecal epiploic appendagitis mimicking acute appendicitis and review the current literature on radiographic findings, diagnosis, and treatment of this often misdiagnosed condition. General surgeons should be aware of this self-limiting condition and consider this in the differential diagnosis.

Method for the physical analysis of drug-bone cement composite.

Skeletal metastases are often complicated by progression to impending or pathologic fracture and fixation with polymethylmethacrylate (PMMA) bone cement is used for stabilization and pain relief. Adjuvant therapy involving the delivery of PMMA composites mixed with antibiotic or chemotherapeutic agents requires an understanding of the rate of drug diffusion from the cement in addition to measurement of its mechanical properties pre- and postelution of drug. We have developed a method for the analysis of drug diffusion rate and mechanical properties of drug-cement composites using PMMA/methotrexate as a model system. The analysis method revealed the addition of methotrexate to PMMA in concentrations of 1.8 g methotrexate per 40 g PMMA did not change the compression modulus of the cement pre- or postelution of drug. The PMMA/methotrexate composites displayed an average diffusion rate of 50 ng/(mm2)(hour) during the first 6 hours, which decreased to 10 ng/(mm2)(hour) by 36 hours. Diffusion modeling predicts the 20 x 13-mm cylindrical PMMA/methotrexate samples used by the method deliver 10% of the total methotrexate content within 80 hours and 25% of the total within 133 days.

Adrenal myelolipoma: report of a case and review of the literature.

Adrenal myelolipoma is a rare benign tumor composed of mature lipomatous and hemopoietic tissue. Although it is often discovered as an incidental finding on imaging of the abdomen for some other reason or at autopsy, adrenal myelolipoma has been reported to present with symptoms such as flank pain resulting from tumor bulk, necrosis, or spontaneous retroperitoneal hemorrhage. Myelolipomas are hormonally inactive but have also been reported to coexist with other hormonally active tumors of the adrenal gland. They are usually unilateral but may be bilateral and may also develop in extraadrenal sites like the retroperitoneum, thorax, and pelvis. We report a patient with symptomatic adrenal myelolipoma diagnosed on computed tomography scan and confirmed on computed tomography-guided biopsy. The patient underwent surgical resection for symptomatic relief. We also review the literature to evaluate the presentation and optimal management of this rare adrenal tumor that is not encountered by most general surgeons and therefore not well known to most surgeons.

Video capsule endoscopy: clinical relevance of capsule endoscopy findings.

Video capsule endoscopy (VCE) is a novel diagnostic tool for noninvasively visualizing the lumen of the entire small intestine. It is especially useful in identifying the source of obscure small intestinal bleeding. However, VCE is not always optimal for localizing small bowel lesions. Several studies show VCE to be markedly superior to standard diagnostic techniques although the true clinical relevance of many of the capsule endoscopic findings remain unknown. We present two case reports of VCE findings that resulted in surgical intervention but were found to be benign lesions on definitive pathological examination. The actual clinical relevance of many of the lesions found on VCE thus remains to be demonstrated.

Spontaneous subcapsular splenic hematoma: a rare complication of pancreatitis.

Subcapsular hematoma of the spleen is a rare complication of pancreatitis despite its close proximity to the pancreas. Pancreatic pseudocyst involving the tail of the pancreas may erode into the splenic hilum causing hilar vessel bleeding with subcapsular dissection and hematoma formation. The management of such complication is still controversial. It has been suggested that most of these complications spontaneously regress and therefore can be managed conservatively. A case of spontaneous splenic subcapsular hematoma resulting from pancreatitis was managed conservatively with a good outcome.

Primary duodenal low-grade mucosa-associated lymphoid tissue lymphoma presenting with outlet obstruction.

Low-grade lymphoma arising in mucosa-associated lymphoid tissue (MALT) of the duodenum represents a very rare neoplasm. We report an unusual presentation of primary duodenal MALT lymphoma in a 78-year-old man. The patient initially presented with a suspected pulmonary embolus and was anticoagulated, which precipitated a major gastrointestinal hemorrhage. A large atypical ulcer with narrowing of the duodenum beyond the bulb was seen on endoscopy. Biopsies revealed atypical lymphoid cells. Abdominal CT scan revealed a mass in either the duodenum or head of the pancreas. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, which revealed a normal pancreatic duct with a large calculus in the common bile duct, which was extracted after sphincterotomy. Elective surgery was planned for suspected lymphoma of the duodenum. The patient developed severe nausea, vomiting, and fullness after meals. The patient underwent pancreaticoduodectomy for a neoplastic mass causing duodenal obstruction. Pathological examination of the resected specimen revealed a low-grade B-cell lymphoma (MALToma) arising in the duodenum and invading the pancreas. Flow cytometry confirmed the phenotype typical of MALT lymphoma. Celiac, peripancreatic, pelvic, and cervical nodes were also involved with tumor. Bone marrow was also positive for metastasis. The patient was postoperatively treated with chemotherapy for stage IV disease.

Unusual complications of long-term percutaneous gastrostomy tubes.

Percutaneous endoscopic gastrostomy (PEG) has been popular since it was introduced in 1980. Gastrostomy tubes left in place for long periods often result in unusual complications. Complications may also result from simply replacing a long-term indwelling tube. Five patients who had gastrostomy tubes in place for as long as 4 years are presented and their complications reviewed. Various methods used in treating these complications are discussed, and suggestions for their prevention are given. Gastrointestinal erosion and jejunal perforation following migration of the gastrostomy tube, persistent abdominal wall sinus tracts, and separation of the flange head with small bowel obstruction were encountered. Reinsertion of a gastrostomy tube through a tract prior to adequate maturation was also noted to lead to complications. Complications may result from gastrostomy tubes left in place for extended periods of time and during replacement procedures. Awareness of such complications along with education of caregivers and timely intervention by the endoscopist may prevent such occurrences. In some cases one can only hope to minimize morbidity.

Squamous cell carcinoma at herniorrhaphy and unilateral renal agenesis.

Unilateral renal agenesis occurs infrequently. However, it has been associated with malignancies at multiple primary sites, anomalies of the genitourinary system, and supernumerary limbs. We present the case of a 60-year-old man with an incarcerated left inguinal hernia and renal insufficiency. At herniorrhaphy, he had squamous cell carcinoma in the hernia sac. A postoperative evaluation revealed unilateral renal agenesis, stage IV squamous cell carcinoma of the urinary bladder, and urolithiasis. The clinician should consider the genitourinary system as a primary site when patients present with the unusual finding of squamous cell carcinoma in the abdominal cavity and unilateral renal agenesis.

Malignant duodenal somatostatinoma presenting in association with von Recklinghausen disease.

Somatostatinomas are extremely rare periampullary malignant neuroendocrine tumors that may be associated with von Recklinghausen disease or type-I neurofibromatosis. Duodenal somatostatinomas are distinguished from pancreatic somatostatinomas by their frequent association with type-I neurofibromatosis and typically absence of somatostatinoma syndrome. We report a very rare and atypical case of malignant duodenal somatostatinoma presenting with somatostatinoma syndrome in association with type-I neurofibromatosis.

Stercoral perforation of the sigmoid colon: report of a rare case and its possible association with nonsteroidal anti-inflammatory drugs.

Stercoral perforation of the colon is a rare phenomenon with fewer than 90 cases reported in the literature to date. The pathogenesis of stercoral ulceration is thought to result from ischemic pressure necrosis of the bowel wall caused by a stercoraceous mass. Stercoral perforation in more than 90 per cent of cases involves the sigmoid or rectosigmoid colon with associated fecal mass causing localized mucosal ulceration and bowel wall thinning due to localized pressure effect. We report the case of a 45-year-old woman who presented with a 12-hour history of epigastric pain. Significant comorbidities included systemic lupus erythematosus, sarcoidosis, hypertension, and previous history of congestive heart failure. The patient was also on prednisone and a nonsteroidal anti-inflammatory drug for joint pains. On physical examination the patient had signs of generalized peritonitis. Chest X-ray showed significant free air under the diaphragm. Emergency laparotomy revealed localized perforation over the antimesenteric border of the sigmoid colon with associated stercoral mass at the site of perforation. A segmental resection of the sigmoid colon with end colostomy (Hartmann's procedure) was performed. The patient made an uneventful recovery. Stercoral perforation is often a consequence of chronic constipation; however, there are other predisposing factors as the condition is rare compared with the frequency of severe constipation. One of the hypotheses includes the association of nonsteroidal anti-inflammatory drugs (NSAIDs) with stercoral perforation of the colon. Our case report lends support to this association with NSAID use; thus there need to be greater awareness and caution when using NSAIDs in chronically constipated patients.

Debilitating lymphedema of the upper extremity after treatment of breast cancer.

Lymphedema after mastectomy occurs with a frequency as high as 30%. The incidence increases with more radical surgical dissection, as was often seen with radical mastectomies in the late 1800s. This is one aspect of breast surgery that has been greatly neglected. Surgery has often been deemed a success if the malignancy is eradicated. Patients may complain of symptoms as minor as arm heaviness to major ones such as massive chronic swelling, as was the case with our patient. The patient presented here had increasing lymphedema during a 14-year period after modified radical mastectomy and radiation therapy for advanced breast cancer. This condition had progressed to incapacitation of the extremity and a patient who as a result had become an invalid. The massively edematous extremity revealed no signs of recurrent disease or malignant degeneration. She underwent surgical intervention and physical therapy as procedures of choice to restore function.

Solid-pseudopapillary tumor of the pancreas masquerading as a pancreatic pseudocyst.

Solid-pseudopapillary tumor of the pancreas is a very rare low-grade malignancy, predominantly occurring in adolescent girls and young women. Accurate diagnosis of this unusual tumor is important because the prognosis after surgical resection is excellent. We report a rare case of solid-pseudopapillary tumor of the pancreas in a 22-year-old woman that was misdiagnosed as a pancreatic pseudocyst on abdominal CT scan. This case emphasizes the importance of biopsying the pseudocyst wall at the time of drainage procedure if misdiagnosis is to be avoided. CT scan findings alone can not reliably rule out malignant cystic lesions of the pancreas.