Distal Fibular Metastasis of Colorectal Carcinoma: A Case Report.

Case: A 62-year-old woman presenting with ankle pain was initially treated for a non-displaced fracture. Persistent pain despite months of conservative management for her presumed injury prompted repeat radiographs which demonstrated the progression of a lytic lesion and led to an orthopedic oncology referral. Following a complete work-up, including biopsy and staging, she was diagnosed with colorectal carcinoma metastatic to the distal fibula. Conclusion: Secondary tumors of the fibula are uncommon but an important diagnosis to consider for intractable lower extremity pain especially in patients with history of malignancy or lack of age-appropriate cancer screening.

Lumbar Disc Herniation: Diagnosis and Management.

Lumbar disc herniations are common causes of lower back pain, neurological dysfunction, and buttock/leg pain. Herniation refers to the displacement of the nucleus pulposus of the intervertebral disc through the annulus fibrosus, thereby causing pressure on the neural elements. The sequalae of lumbar disc herniations range in severity from mild low back and buttock pain to severe cases of inability to ambulate and cauda equina syndrome. Diagnosis is achieved with a thorough history and physical examination along with advanced imaging. Treatment plans are dictated by corresponding patient symptoms and examination findings with their imaging. Most patients can experience relief with nonsurgical measures. However, if symptoms persist or worsen, surgery may be appropriate.

Nonsurgical Interventional Spine Pain Procedures: Outcomes and Complications.

¼: Nonsurgical interventional spine pain procedures provide an additional treatment option for lower back pain at the traditional bifurcation of conversative vs. operative management. ¼: Transforaminal epidural steroid injections, radiofrequency ablations, intrathecal drug delivery, and spinal cord stimulation were found to be effective and safe techniques when applied to their specific indication. ¼: Thermal annuloplasty and minimally invasive lumbar decompression showed mixed support. ¼: Discography, sacroiliac joint injections, and spinous process spacers lacked sufficient evidence to support efficacy. ¼: Medial branch blocks and facet joint injections were found to be useful diagnostic tools.

Acute onset of central diabetes insipidus during adolescent idiopathic scoliosis surgery.

This is a case report of a 12-year-old female with idiopathic scoliosis undergoing posterior scoliosis reconstruction that developed an acute onset of central diabetes insipidus (CDI) during surgery. The diagnosis was made as a result of an intraoperative increase in urine output to 6.82 ml/kg/hour (550 ml), a serum sodium increase from 139 to 147 mmol/L, a serum osmolality of 299 mOsmol/kg, a rapid response to vasopressin administration and a low vasopressin level of < 0.5 picograms/ml (normal, 1-5 picograms/ml). This is the first reported case of CDI with a documented low vasopressin level that has occurred in a pediatric scoliosis surgical patient.

Determining the adenoma detection rate and adenomas per colonoscopy by photography alone: proof-of-concept study.

BACKGROUND AND STUDY AIMS: The adenoma detection rate (ADR) and adenomas detected per colonoscopy (APC) are measures of the quality of mucosal inspection during colonoscopy. In a resect and discard policy, pathologic assessment for calculation of ADR and APC would not be available. The aim of this study was to determine whether ADR and APC calculation based on photography alone is adequate compared with the pathology-based gold standard. PATIENTS AND METHODS: A prospective, observational, proof-of-concept study was performed in an academic endoscopy unit. High definition photographs of consecutive polyps were taken, and pathology was estimated by the colonoscopist. Among 121 consecutive patients aged ≥ 50 years who underwent colonoscopy, 268 polyps were removed from 97 patients. Photographs of consecutive polyps were reviewed by a second endoscopist. RESULTS: The resect and discard policy applied to lesions that were ≤ 5 mm in size. When only photographs of lesions that were ultimately proven to be adenomas were included, the reviewer assessed ADR and APC to be lower than that determined by pathology (absolute reductions of 6.6 % and 0.17, and relative reductions of 12.6 % and 13.1 % in ADR and APC, respectively). When all photographs were included for calculation of ADR and APC, the reviewer determined the ADR to be 3.3 % lower (absolute reduction) and the APC to be the same as the rates determined by pathology. CONCLUSIONS: In a simulated resect and discard strategy, a high-level detector can document adequate ADR and APC by photography alone.

Intraprocedural cleansing work during colonoscopy and achievable rates of adequate preparation in an open-access endoscopy unit.

BACKGROUND: Rates of adequate bowel preparation in the 60% to 80% range continue to be reported for colonoscopy. OBJECTIVE: To describe the rate of adequate bowel preparation and intraprocedural work needed to achieve this rate in an open-access endoscopy unit. Universal split dosing and regimens tailored to medical predictors of inadequate preparation were used. DESIGN: Prospective observational study. SETTING: Academic hospital outpatient endoscopy unit and ambulatory surgery center. PATIENTS: Outpatients undergoing colonoscopy. INTERVENTIONS: Prospective assessment of preparation quality for colonoscopy during insertion and after intraprocedural cleansing in 525 patients. MAIN OUTCOME MEASUREMENTS: Rates of adequate preparation and work required to improve cleansing quality. Work time for cleaning was measured with a stopwatch. RESULTS: Adequate preparation to allow recommendation of standard screening or surveillance intervals was achieved in 96% of patients, including 6% for whom preparation was adequate only after intraprocedural cleansing work. The mean time for intraprocedural cleaning was 4.1 minutes and constituted 17% of total procedure time. Work time for cleaning and fluid volume injected increased when worse preparation grades were identified before cleaning. LIMITATIONS: Single-center study with low percentage (4%) of patients receiving Medicaid. CONCLUSION: An open-access unit using split-dose bowel cleansing preparations can achieve high rates of adequate bowel preparation for colonoscopy. Intraprocedural cleansing accounts for a substantial fraction of the total procedure time in colonoscopy and is an important contributor to high rates of adequate preparation.

Partial versus total splenectomy in children with hereditary spherocytosis.

BACKGROUND: Partial splenectomy is utilized selectively in children with hereditary spherocytosis (HS) to decrease hemolysis while maintaining immunity. Our aim was to compare outcomes between laparoscopic total splenectomy (LTS) and laparoscopic partial splenectomy (LPS). METHODS: After obtaining institutional review board approval, we reviewed the records for all children ≤18 years with HS undergoing LTS and LPS between 2002 and 2012. Wilcoxon rank-sum tests were used. RESULTS: Eighty-seven HS children underwent LTS (n = 71) and LPS (n = 16). Mean age was 7.1 ± 3.6 years (LTS) and 5.5 ± 2.8 years (LPS; P = .14). Concomitant cholecystectomy was performed in 32% of LTS and 38% of LPS cases. Operative time was 87 ± 33 minutes (LTS) and 140 ± 36 minutes (LPS; P = .0005). Duration of stay was 1.2 ± 0.5 days (LTS) and 2.4 ± 1.4 days (LPS; P = .003). Reticulocyte and hemoglobin levels improved after both operations. LPS children had lower preoperative (8.8 ± 1.9 vs 10.2 ± 1.7 g/dL; P = .0148) and postoperative (10.5 ± 1.7 vs 13.8 ± 1.1 g/dL; P < .0001) hemoglobin levels than did LTS patients. Three LPS children required transfusion (at 2, 4 and 5 postoperative years) for parvovirus-associated aplastic crises. No LTS child developed splenic function or anemia. CONCLUSION: These data demonstrate that LPS decreases hemolysis, although LTS is more effective. LPS children had lower preoperative hemoglobin levels, indicating more severe hemolysis. LPS also has greater operative time and duration of stay, disadvantages balanced by retained immunity.