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1.  Instrumented Outpatient Anterior Cervical Discectomy and Fusion: Is it Safe? 
International Surgery  2012;97(1):86-89.
Anterior cervical discectomy and fusion procedures are one of the most common procedures performed in spinal surgery. Increasingly they are being performed on an outpatient basis. The primary impetus for performing procedures as an outpatient is potential cost savings. However, there are few studies discussing the safety of performing the procedure in an ambulatory setting. This is a retrospective review of our initial experience in performing anterior cervical discectomy and fusion procedures with instrumentation (ACDFI) in an ambulatory surgery center dedicated to spine surgery. Patients were selected for outpatient surgery if they had limited co-morbidities and the surgery involved only 1 or 2 levels. One hundred fifty-two patients underwent outpatient ACDFI during the study period (2007–2009). Six patients returned to the hospital emergency room after discharge. The reasons for evaluation included 2 for neck pain, 1 for dysphagia, 1 for vocal cord paralysis and dysphagia, 1 for nausea, and 1 for cervical swelling. Only 1 of the 6 patients required admission to the hospital. None of the 6 suffered any long-term sequelae. The overall complication rate was 3.9%. A self-reported survey was completed by 75 patients within 6 months of surgery, and there was a 100% satisfaction rate among responders. ACDFI can be performed safely on an outpatient in selected patients with a high degree of patient satisfaction. Our experience is consistent with those of previous investigators.
doi:10.9738/CC35.1
PMCID: PMC3723190  PMID: 23102004
Outpatient anterior cervical discectomy safe, Fusion, Instrumented
2.  Massive Neonatal Adrenal Enlargement Due to Cytomegaly, Persistence of the Transient Cortex, and Hyperplasia of the Permanent Cortex: Findings in Cushing Syndrome Associated With Hemihypertrophy 
We describe massive enlargement of both adrenal glands in 3 newborns, 2 girls and 1 boy. Two had hemihypertrophy and other congenital abnormalities but no identified genetic mutation; the third had genetically proven Beckwith-Wiedemann syndrome. Two had severe Cushing syndrome, the third had hypercortisolemia but no clinical Cushing syndrome. Bilateral adrenalectomy cured Cushing syndrome in the 2 with the severe symptoms; total adrenal weight was 44 and 53 gm in the patients, respectively. Unilateral adrenalectomy was performed in the third patient: the gland weighed 52 g; postoperatively, the patient's hypercortisolemia normalized and, concomitantly, the enlarged contralateral adrenal gland had a 5-fold decrease in size to slight enlargement 6 years postoperatively. Microscopically, the 3 patients had similar pathology: massive adrenal enlargement due to a combination of cytomegaly, persistence of the transient cortex, and hyperplasia of the permanent cortex. The pathological findings were most likely the result of the genetic mutation identified in 1 patient and of an unknown mutation in the remaining 2 patients.
doi:10.1097/PAS.0b013e31825d538b
PMCID: PMC3444746  PMID: 22982888
Fetal adrenal gland; neonatal Cushing syndrome; cytomegaly; hemihypertrophy; Beckwith-Wiedemann syndrome
3.  Gastric Stromal Tumors in Carney Triad Are Different Clinically, Pathologically, and Behaviorally From Sporadic Gastric Gastrointestinal Stromal Tumors: Findings in 104 Cases 
Carney triad, as originally described in 1977, was the association of 3 tumors: gastric epithelioid leiomyosarcoma [later renamed gastrointestinal stromal tumor (GIST)], extra-adrenal paraganglioma, and pulmonary chondroma. The disorder affected mostly young women and was not familial. We studied the clinical and pathologic features of the gastric neoplasm in 104 patients with the syndrome. Most (88%) were young women (mean age, 22 y), and the usual presentation was gastric bleeding. The tumors, commonly antral-based (61%), were multifocal, and ranged from 0.2 to 18.0 cm in dimension. Most (86%) featured round and polygonal (epithelioid) cells. Metastasis occurred in 49 patients (47%): to gastric lymph nodes (29%), liver (25%), and peritoneum (13%). Immunopositivity was detected in the tumors tested as follows: KIT, 100%; CD34, 75%; PKCy, 21%; PDGFRA, 90%; and smooth muscle actin, 6%. Fourteen patients (13%) died of metastatic GIST at a mean age of 45 years (range, 30 to 69 y). Estimated 10 and 40-year survivals were 100% and 73%, respectively. Median survival time was 26.5 years (range, 16 to 60 y). There was no correlation between the National Institutes of Health tumor risk classification and the tumor behavior. Compared with sporadic gastric GISTs, the gastric stromal tumor in Carney triad showed distinctive features: female predilection, young patient age, epithelioid cell predominance, multifocality, frequent lymph node metastasis, serial tumor occurrence, and unpredictable behavior. Thus, the Carney triad gastric stromal tumor is different clinically, pathologically, and behaviorally from sporadic gastric GIST.
doi:10.1097/PAS.0b013e3181c20f4f
PMCID: PMC3652406  PMID: 19935059
Carney triad; nonfamilial syndrome; gastric gastrointestinal stromal tumor; pulmonary chondroma; paraganglioma
4.  Prophylactic retrievable inferior vena cava filters in spinal cord injured patients 
Background:
Pulmonary embolus (PE) secondary to deep vein thrombosis (DVT) continues to be a major source of morbidity and mortality in trauma populations. Patients with cervical spinal cord injury (SCI) are particularly susceptible to developing this complication. Non-invasive methods of preventing SCI, such as lower extremity compression devices and anticoagulation, do not confer complete protection against DVT. Retrievable inferior vena cava filters (IVCFs) offer the advantage of both providing protection against PE and avoidance of long-term complications such as DVT, if removed in a timely fashion. Our goals in this study were to identify complications related to IVCF insertion and also to determine if prophylactic insertion of IVCF is effective in preventing PE in spinal cord injured patients.
Methods:
This was a retrospective single center study that involved cervical SCI patients who were admitted to Parkview Hospital, a level II trauma center, from January 2003 to December 2009 and underwent placement of a prophylactic IVCF within 72 hours of admission. Patients were identified from a prospectively maintained trauma registry.
Results:
During a 6-year period, 45 spinal cord injured patients were identified, who underwent placement of a prophylactic IVCF. There were 37 men and 8 women. There were no short-term complications associated with peripheral intravenous catheter (PIVC) insertion. Seventeen of the 45 (37%) patients underwent successful removal of the filter within 6–8 weeks of insertion. Twenty patients did not return for removal during the 6–8 week period for removal and eight patients were lost to follow-up. None of the patients who underwent prophylactic IVCF placement sustained a PE.
Conclusion:
Our results suggest that the use of retrievable prophylactic IVCF is a safe procedure and has the added benefit of preventing the long-term lower extremity thrombotic complications associated with their use. Even though none of the patients sustained a PE, definitive conclusions regarding the efficacy of IVCF in preventing PE could not be made due to the small sample size of our study.
doi:10.4103/2152-7806.72245
PMCID: PMC2980909  PMID: 21125013
Vena cava; spinal cord; filters; pulmonary embolus
5.  Measurement of fractionated plasma metanephrines for exclusion of pheochromocytoma: Can specificity be improved by adjustment for age? 
Background
Biochemical testing for pheochromocytoma by measurement of fractionated plasma metanephrines is limited by false positive rates of up to 18% in people without known genetic predisposition to the disease. The plasma normetanephrine fraction is responsible for most false positives and plasma normetanephrine increases with age. The objective of this study was to determine if we could improve the specificity of fractionated plasma measurements, by statistically adjusting for age.
Methods
An age-adjusted metanephrine score was derived using logistic regression from 343 subjects (including 33 people with pheochromocytoma) who underwent fractionated plasma metanephrine measurements as part of investigations for suspected pheochromocytoma at Mayo Clinic Rochester (derivation set). The performance of the age-adjusted score was validated in a dataset of 158 subjects (including patients 23 with pheochromocytoma) that underwent measurements of fractionated plasma metanephrines at Mayo Clinic the following year (validation dataset). None of the participants in the validation dataset had known genetic predisposition to pheochromocytoma.
Results
The sensitivity of the age-adjusted metanephrine score was the same as that of traditional interpretation of fractionated plasma metanephrine measurements, yielding a sensitivity of 100% (23/23, 95% confidence interval [CI] 85.7%, 100%). However, the false positive rate with traditional interpretation of fractionated plasma metanephrine measurements was 16.3% (22/135, 95% CI, 11.0%, 23.4%) and that of the age-adjusted score was significantly lower at 3.0% (4/135, 95% CI, 1.2%, 7.4%) (p < 0.001 using McNemar's test).
Conclusion
An adjustment for age in the interpretation of results of fractionated plasma metanephrines may significantly decrease false positives when using this test to exclude sporadic pheochromocytoma. Such improvements in false positive rate may result in savings of expenditures related to confirmatory imaging.
doi:10.1186/1472-6823-5-1
PMCID: PMC553971  PMID: 15737232
6.  A systematic review of the literature examining the diagnostic efficacy of measurement of fractionated plasma free metanephrines in the biochemical diagnosis of pheochromocytoma 
Background
Fractionated plasma metanephrine measurements are commonly used in biochemical testing in search of pheochromocytoma.
Methods
We aimed to critically appraise the diagnostic efficacy of fractionated plasma free metanephrine measurements in detecting pheochromocytoma. Nine electronic databases, meeting abstracts, and the Science Citation Index were searched and supplemented with previously unpublished data. Methodologic and reporting quality was independently assessed by two endocrinologists using a checklist developed by the Standards for Reporting of Diagnostic Studies Accuracy Group and data were independently abstracted.
Results
Limitations in methodologic quality were noted in all studies. In all subjects (including those with genetic predisposition): the sensitivities for detection of pheochromocytoma were 96%–100% (95% CI ranged from 82% to 100%), whereas the specificities were 85%–100% (95% CI ranged from 78% to 100%). Statistical heterogeneity was noted upon pooling positive likelihood ratios when those with predisposition to disease were included (p < 0.001). However, upon pooling the positive or negative likelihood ratios for patients with sporadic pheochromocytoma (n = 191) or those at risk for sporadic pheochromocytoma (n = 718), no statistical heterogeneity was noted (p = 0.4). For sporadic subjects, the pooled positive likelihood ratio was 5.77 (95% CI = 4.90, 6.81) and the pooled negative likelihood ratio was 0.02 (95% CI = 0.01, 0.07).
Conclusion
Negative plasma fractionated free metanephrine measurements are effective in ruling out pheochromocytoma. However, a positive test result only moderately increases suspicion of disease, particularly when screening for sporadic pheochromocytoma.
doi:10.1186/1472-6823-4-2
PMCID: PMC459231  PMID: 15225350

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