Axillary lymph node status is the most significant single prognostic factor in breast cancer, and preoperative axillary staging is essential in determining lymph node status. Axillary ultrasound scan (AUS) is the gold standard modality in preoperative staging. However, triple assessment—including clinical examination and radiological assessment with fine needle aspiration (FNA) with or without core biopsy—ensures high sensitivity.
Our study included 219 women diagnosed with invasive breast cancer between 2009 and 2010. All patients underwent a preoperative staging AUS that was graded from normal (U1) to malignant (U5). All patients with ultrasound scans graded U3 (indeterminate) and above underwent FNA that was graded from C1 (inadequate for diagnosis) to C5 (malignant). Patients diagnosed preoperatively with metastatic lymph nodes were offered axillary lymph node clearance. The rest of the patients were offered sentinel lymph node biopsy.
The 219 women were diagnosed with 228 invasive breast cancers. The mean age was 60 years (range 29-90 years). The final histology report showed metastatic axillary lymph nodes in 49 (21.5%) cases. Of these 49 cases, 22 were diagnosed preoperatively with metastatic axillary lymph node and were elected for axillary lymph node clearance, and 27 were elected for sentinel lymph node biopsy that revealed metastatic lymph nodes. AUS showed abnormal (U3/U4/U5) axillary lymph nodes in 30 of 49 (61.2%) cancer cases with an overall accuracy of 91.6%.
Combined triple assessment increases the sensitivity, negative predictive value, and overall accuracy of preoperative staging of the axilla.
Biopsy—fine needle; breast neoplasms; sentinel lymph node biopsy; ultrasonography
Thiamine is an important micronutrient, and thiamine deficiency is prevalent in patients with congestive heart failure.
Using Ovid MEDLINE, PubMed, and Excepta Medica (Embase), we conducted a systematic review and metaanalysis of randomized, double-blind, placebo-controlled trials of thiamine supplementation in patients with congestive heart failure.
Compared with placebo (2 trials, n=38), thiamine supplementation resulted in a significantly improved net change in left ventricular ejection fraction (LVEF) (3.28%, 95% confidence interval [CI]: 0.64%, 5.93%).
Compared against placebo, thiamine supplementation in 2 randomized, double-blind trials resulted in a significant improvement in net change in LVEF. While further trials are required to establish thiamine's role in patients with systolic heart failure, thiamine may help to improve LVEF in these patients.
Heart failure; stroke volume; thiamine deficiency
Acute compartment syndrome occurs when the tissue pressure within a closed muscle compartment exceeds the perfusion pressure. We observed diastolic retrograde arterial flow (DRAF) in 2 patients in the arteries proximal to compartment syndromes in injured limbs. We hypothesized that DRAF may represent an early sign of compartment pressure increments.
We mimicked compartment syndrome by using a cuff to produce external compression of the forearm at increasing pressures. We correlated the applied pressure with brachial artery blood flow, velocities, and retrograde flow. We studied the brachial artery at baseline, at external compression of 40 mmHg applied to the forearm, at forearm compression equal to the patient's diastolic blood pressure (DBP), and at forearm compression equal to the patient's mean arterial pressure (MAP). Evaluations included Doppler velocities and DRAF percentage (%). Using a ROC analysis, we selected a DRAF (%) cutoff value for the identification of patients with an applied external pressure equal to or greater than their DBP and calculated its sensitivity and specificity.
Compared with baseline, DRAF (%) was increased at 40 mmHg (P<0.05), at DBP (P<0.05), and at MAP (P<0.05). DRAF (%) was strongly correlated with applied external pressure (r=0.92, r2=0.85). DRAF 40% presented a 100% sensitivity and a 93% specificity for identifying a compression equal to or greater than the patient's DBP.
DRAF (%) strongly correlates with the degree of external pressure applied to the brachial artery, suggesting it may represent a useful tool in the detection and evaluation of compartment syndrome.
Compartment syndromes; hemodynamics; ultrasonography—Doppler
The management of enterocutaneous fistula (ECF) provides a supreme challenge for the general surgeon.
We conducted a retrospective review of all cases of patients with ECF referred to the surgical service from July 2007 to June 2011 to achieve a better understanding of the factors that predict a successful outcome.
A total of 35 patients were evaluated and managed in a systematic fashion that focused on treatment of abdominal sepsis, control of fistula output and wound management, nutritional optimization, and operative intervention when necessary. Age, gender, preoperative laboratory values, etiology of ECF, and prior abdominal surgery for ECF were reviewed and compared. Fisher exact test was used to compare patients who achieved a good outcome (n=23) to those with a poor outcome (n=12) to determine factors that might predict their ultimate result. Two factors that predicted poor outcome were the presence of abdominal malignancy (P=0.01) and ECFs that occurred in trauma patients with an open abdomen (P=0.03).
The etiology of ECF proved to be a more reliable predictor of outcome than clinical indicators.
Intestinal fistula; parenteral nutrition—total; postoperative complications
Restorative proctocolectomy with an ileal pouch-anal anastomosis is a technically demanding procedure to treat ulcerative colitis and familial adenomatous polyposis. Since its initial description almost 30 years ago, the operation has undergone technical and perioperative modifications to improve the patient's experience.
We performed a retrospective review of the records of patients undergoing restorative proctocolectomy at the Ochsner Clinic Foundation Hospital from 2008 to 2012 and compared data from that period to data from 1989-1995 (prior to laparoscopic pouch surgery) to determine factors associated with patient outcome.
Ileal pouch-anal procedures were performed in 77 patients. The 30 male and 47 female patients ranged in age from 13 to 63 years (mean, 34.5 years). The indications for the procedure were ulcerative colitis in 62 patients, polyposis coli in 12 patients, and Crohn disease in 3 patients. Forty patients (52%) had laparoscopic-assisted procedures. The overall hospital length of stay for pouch creation averaged 6.9 days (range 3-29) and for ileostomy closure averaged 4.3 days (range 1-15). No perioperative deaths occurred within 30 days. Complications occurred in 37.7% of patients. Compared to a previous report of 72 patients from 1989 to 1995, the recent group had more laparoscopic procedures, shorter hospital stays, a smaller percentage of 3-stage procedures, and fewer general and pouch-related complications. Pouch failures were similar for both groups.
Advances in operative techniques and perioperative management have improved the outcome of restorative proctocolectomies.
Anastomosis—surgical; colonic pouches; laparoscopy; postoperative complications; proctocolectomy—restorative
Robotic-assisted surgery has evolved over the past 2 decades with constantly improving technology that assists surgeons in multiple subspecialty disciplines. The surgical requirements of lithotomy and steep Trendelenburg positions, along with the creation of a pneumoperitoneum and lack of direct access to the patient all present management challenges in gynecologic surgery. Patient positioning requirements can have significant physiologic effects and can result in many complications.
This review focuses on the anesthetic and surgical implications of robot-assisted technology in gynecologic surgery.
Good communication among team members and knowledge of the nuances of robotic surgery have the potential to improve patient outcomes, increase efficiency, and reduce complications.
Anesthesia; gynecologic surgical procedures; robotics; surgical procedures—minimally invasive
Many patients with chronic pain receive substandard analgesic therapy. Incomplete or inadequate care often stems from physician fears of patient addiction and/or drug toxicity. As a result, many chronic pain patients are undertreated and have unrelieved pain that tempts them to overuse or to abuse prescribed pharmacologic treatments. In the last few years, educational efforts have targeted physicians who treat chronic, nonmalignant pain with information to improve prescribing strategies and to appreciate side effects. Additionally, opioid prescribing guidelines and educational programs, including World Health Organization-published guidelines for the management of cancer pain in 1986 and the American Pain Society's promotion of pain as the 5th vital sign, have increased the propensity of pharmacists, physicians, and pain specialists to dispense pain treatments.
Controversial and evolving consequences from this explosion of prescription opioid use have emerged and are discussed in this review, including prescribing principles, opioid analgesic side effects, and driving concerns.
With additional appreciation for the untoward effects of chronic analgesia and a better understanding of opioid pharmacology, physicians can utilize pain management treatments in a safer and more effective manner.
Analgesics—opioid; chronic pain; medication therapy management; opioid-related disorders
Serotonin syndrome is a potentially life-threatening syndrome that is precipitated by the use of serotonergic drugs and overactivation of both the peripheral and central postsynaptic 5HT-1A and, most notably, 5HT-2A receptors. This syndrome consists of a combination of mental status changes, neuromuscular hyperactivity, and autonomic hyperactivity. Serotonin syndrome can occur via the therapeutic use of serotonergic drugs alone, an intentional overdose of serotonergic drugs, or classically, as a result of a complex drug interaction between two serotonergic drugs that work by different mechanisms. A multitude of drug combinations can result in serotonin syndrome.
This review describes the presentation and management of serotonin syndrome and discusses the drugs and interactions that can precipitate this syndrome with the goal of making physicians more alert and aware of this potentially fatal yet preventable syndrome.
Many commonly used medications have proven to be the culprits of serotonin syndrome. Proper education and awareness about serotonin syndrome will improve the accuracy of diagnosis and promote the institution of the appropriate treatment that may prevent significant morbidity and mortality.
Drug toxicity; serotonin syndrome
Sedation of children undergoing biopsies of anterior mediastinal masses can be challenging because of the absolute necessity of ensuring minimal smooth muscle relaxation and preventing airway collapse. Furthermore, positive pressure ventilation may be difficult or impossible and may also pose the additional risks of hemodynamic compromise in the pediatric patient.
We present a case series of 3 children who were successfully sedated for computed tomography (CT)-guided mediastinal biopsies with dexmedetomidine.
Dexmedetomidine, a selective alpha-2 adrenoreceptor agonist that maintains the smooth musculature of the pediatric airway, provides the ability to sustain spontaneous ventilation in patients with airway compression. Dexmedetomidine is a safe, reliable anesthetic for biopsy of children with anterior mediastinal masses.
Adrenergic alpha-2 receptor agonists; dexmedetomidine; mediastinal neoplasms
Practice standards recommend that the induction of epidural analgesia for labor begin with a test dose of local anesthetic with epinephrine. During the test dose period and following anesthetic administration, the anesthesiologist measures the parturient's pulse with continuous pulse oximetry to help detect the intravascular placement of the epidural catheter as evidenced by the abrupt onset of tachycardia.
We report the onset of tachycardia in a healthy parturient following induction of continuous epidural analgesia. The tachycardia was ultimately diagnosed as lone atrial fibrillation—a finding not previously reported in the literature.
We initially thought the diagnosis portended undetected cardiac disease, but further assessment found no cardiac abnormalities.
Analgesia—epidural; atrial fibrillation; tachycardia
Bone fracture management in third-trimester pregnant patients is rare and poorly discussed in the literature. In the case of fractures that require orthopedic surgery in near-term pregnant women, clinicians should decide between operating before or after the delivery, carefully evaluating the health of the mother and fetus.
A pregnant 41-year-old woman at 36 weeks' gestation had a traumatic midshaft displaced tibia and fibula fracture. A multispecialty team approach resulted in nonoperative treatment until delivery. The sudden spontaneous premature rupture of membranes led to a preterm cesarean section. Five days after cesarean section, the patient underwent surgery for open reduction and internal fixation with pins and plates. The patient recovered well and was discharged with her baby.
The clinical and surgical management of bone fractures in pregnant women should be determined by a multispecialty team, and a tailored intervention should be chosen for each patient.
Cesarean section; fibula; fractures—bone; pregnancy; tibia
Although crucial to the success of the US healthcare system, generic medication is not without some risks, especially when a transition is made midtreatment from a brand-name formulation to its generic counterpart. Thankfully, such a transition is usually orderly and unnoticed, without disruption to the treatment; however, this is not always the case.
This case study details an example of 1 such unfortunate disruption to treatment. A stable patient with schizophrenia was switched from brand-name Zyprexa to generic olanzapine. Within several months of the switch, the patient suffered a marked grayish discoloration of his teeth. His medication regimen was then transitioned from generic olanzapine to a new but different brand-name medication (Abilify). The transition was a success, with resolution of the adverse effect and continued stability of his mental state.
Generic olanzapine was introduced to the market in fall 2011. It remains to be seen whether this adverse effect was simply an anomaly or the beginning of a more ominous trend.
Drug toxicity; drugs—generic; psychotropic drugs
Multiple myeloma is a common disease, accounting for about 10% of hematologic malignancies in the United States. For eligible patients, the treatment of choice includes induction therapy (usually involving newer biologic agents) followed by autologous stem cell transplant; however, this treatment is generally not considered curative, and relapses usually occur. However, extramedullary relapse is an uncommon presentation, and relapses that involve the lungs have only rarely been described.
We report the case of a patient who underwent an autologous stem cell transplant for multiple myeloma and subsequently relapsed with diffuse pulmonary nodules. She then had a rapid clinical and serologic response following initiation of salvage therapy.
This case is remarkable for both the radiographic appearance of the pulmonary involvement, as well as the rapid resolution of these findings after 2 cycles of treatment with bortezomib, dexamethasone, and lenalidomide.
Multiple myeloma; multiple pulmonary nodules; plasmacytoma; recurrence; stem cell transplantation
Transcranial motor evoked potentials are used to detect iatrogenic injury to the corticospinal tracts and vascular territory of the anterior spinal artery. Tongue and lip lacerations are the most common complication of this modality. Theoretical complications include cardiac arrhythmia and seizure although there are no published reports of either.
We report a case of postoperative seizure following motor evoked potential testing in a patient without a seizure history. Although anecdotal reports exist, ours is the first known published report of seizure following transcranial electrical stimulation.
The intent of this novel report is to encourage the use of anesthetic regimens that raise seizure threshold, decrease stimulation threshold, and increase the specificity of motor evoked potentials. Providers should be prepared to treat intraoperative or perioperative seizure activity when the monitoring protocol includes transcranial motor evoked potentials.
Anesthesia; complications; evoked potentials—motor; monitoring—intraoperative; seizures
The median arcuate ligament passes superior to the origin of the celiac artery and is a continuation of the posterior diaphragm that wraps over the aorta. If it lies too low on the aorta, the ligament may cause symptoms of abdominal pain related to compression of the celiac artery.
An abdominal ultrasound in a 22-year-old woman with longstanding abdominal pain after eating showed elevated celiac artery velocities of >300 cm/s upon inspiration. Computed tomography angiography of the abdomen showed stenosis of the origin of the celiac artery and confirmed the diagnosis of median arcuate ligament syndrome. Laparoscopic release of the median arcuate ligament resulted in relief of the patient's symptoms.
The diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have a clearly established etiology.
Celiac artery; constriction—pathologic; stenosis from compression by median arcuate ligament of diaphragm
Intestinal obstruction; intestinal volvulus; volvulus of midgut