A model for delivery of extracorporeal life support in a stand-alone veterans affairs medical center.

INTRODUCTION: For the Veterans Health Administration (VHA) to continue to perform complex cardiothoracic surgery, there must be an established pathway for providing urgent/emergent extracorporeal life support (ECLS). Partnership with a nearby tertiary care center with such expertise may be the most resource-efficient way to provide ECLS services to patients in post-cardiotomy cardiogenic shock or respiratory failure. The goal of this project was to assess the efficiency, safety, and outcomes of surgical patients who required transfer for perioperative ECLS from a single stand-alone Veterans Affairs Medical Center (VAMC) to a separate ECLS center. METHODS: Cohort consisted of all cardiothoracic surgery patients who experienced cardiogenic shock or refractory respiratory failure at the local VAMC requiring urgent or emergent institution of ECLS between 2019 and 2022. The primary outcomes are the safety and timeliness of transport. RESULTS: Mean time from the initial shock call to arrival at the ECLS center was 2.8 h. There were no complications during transfer. Six patients (86%) survived to decannulation. CONCLUSION: These results suggest that complex cardiothoracic surgery can be performed within the VHA system and when there is an indication for ECLS, those services can be safely and effectively provided at an affiliated, properly equipped center.

Subclinical Aortic Insufficiency Causing Cardiogenic Shock Years After Impella Placement.

A 28-year-old male with atrial fibrillation and thyrotoxicosis-induced heart failure underwent multiple interventions, including extracorporeal membrane oxygenation (ECMO), multiple valve repair/replacement, and Impella placement/removal. However, after a period of three years, the patient developed progressive aortic insufficiency (AI), which was attributed to damage caused by the prolonged use of the Impella device. The discussion highlights the importance of adhering to manufacturer guidelines for device use and emphasizes the need for careful examination during placement to minimize potential complications.

FundusQ-Net: A regression quality assessment deep learning algorithm for fundus images quality grading.

OBJECTIVE: Ophthalmological pathologies such as glaucoma, diabetic retinopathy and age-related macular degeneration are major causes of blindness and vision impairment. There is a need for novel decision support tools that can simplify and speed up the diagnosis of these pathologies. A key step in this process is to automatically estimate the quality of the fundus images to make sure these are interpretable by a human operator or a machine learning model. We present a novel fundus image quality scale and deep learning (DL) model that can estimate fundus image quality relative to this new scale. METHODS: A total of 1245 images were graded for quality by two ophthalmologists within the range 1-10, with a resolution of 0.5. A DL regression model was trained for fundus image quality assessment. The architecture used was Inception-V3. The model was developed using a total of 89,947 images from 6 databases, of which 1245 were labeled by the specialists and the remaining 88,702 images were used for pre-training and semi-supervised learning. The final DL model was evaluated on an internal test set (n=209) as well as an external test set (n=194). RESULTS: The final DL model, denoted FundusQ-Net, achieved a mean absolute error of 0.61 (0.54-0.68) on the internal test set. When evaluated as a binary classification model on the public DRIMDB database as an external test set the model obtained an accuracy of 99%. SIGNIFICANCE: the proposed algorithm provides a new robust tool for automated quality grading of fundus images.

A Case of Unicentric Castleman Disease with Concomitant Myasthenia Gravis and Persistent Left Superior Vena Cava.

BACKGROUND Castleman disease was first described in 1956 as mediastinal masses composed of benign lymphoid hyperplasia with germinal center formation and capillary proliferation closely resembling thymomas. It has been linked with many multi-system disorders, including myasthenia gravis. Cases of Castleman disease with corresponding myasthenia gravis have higher rates of postoperative myasthenic crisis, which are reported as high as 37.5%. We encountered a case of Castleman disease with myasthenia gravis that was discovered early and managed successfully with complete surgical resection and no postoperative myasthenic crisis. CASE REPORT A 25-year-old woman with an uncomplicated history presented with shortness of breath, numbness in hands, tiring with chewing, and fatigue. Myasthenia gravis was diagnosed with serology test results, and a 7.5×7.0-cm mediastinal mass was discovered in addition to the incidental finding of a persistent left superior vena cava, closely abutting the mass. Biopsy showed lymphoid proliferation, regressed germinal centers surrounded by small lymphocytes, and vascular proliferation, consistent with unicentric Castleman disease, hyaline-vascular type. The patient was successfully treated for Castleman disease with myasthenia gravis, and no postoperative myasthenic crisis occurred. CONCLUSIONS Castleman disease associated with myasthenia gravis can dramatically increase the risk of postoperative myasthenic crisis. Our literature review of all 16 cases of Castleman disease with myasthenia gravis since 1973 revealed that 18.75% of cases were associated with a postoperative myasthenic crisis. This association elicits the importance of prompt diagnosis of myasthenia gravis when evaluating mediastinal masses and the value of having neurology and anesthesiology staff aware of the increased risk of crisis.

A Novel Approach to Repair of Tracheal Occlusion Secondary to Percutaneous Tracheostomy Creation.

The number of endotracheal intubations increased in the United States during the COVID-19 pandemic with an associated rise in laryngotracheal injury. Our patient had a complete laryngeal occlusion just proximal to the first tracheal ring. The Neodymium-doped Yttrium Aluminum Garnet (Nd-YAG) laser is often used to resolve sub-laryngeal occlusions, and without access to the Nd-YAG laser, we had to find an alternative solution. Few centers have the access to an Nd-YAG laser, the optimal choice for sub-laryngeal occlusion and our novel approach allowed us to reestablish tracheal continuity and the patient's ability to speak.

Thoracic chordoma in a 36-year-old female.

Chordomas are rare tumors that occur in the bones of the skull base and spine, affecting 1 in 1 000 000 people per year. Thoracic chordomas comprise just 1% of chordomas. A 36-year-old female underwent a right video-assisted thoracoscopic surgical resection for a cystic mass at the level of T2-3 which was well-circumscribed. Despite efforts to achieve an intact resection, there was tumor spillage due to friability, and it was taken off the bony vertebral body with no margin. The final pathologic diagnosis was chordoma. Thoracic chordomas are rare, slow-growing, recurring neoplasms that require proper preoperative diagnostic imaging and ideally preoperative trocar computed tomography-guided biopsy from a posterior approach if anatomic access is possible. They are prone to dissemination and sarcomatous differentiation. The surgical approaches for reported thoracic chordoma tumors vary due to their rarity and the variation in tumor location and presentation.

Calcified Catheter-Related Fibrin Sheath Forms Large Intravenous Cast in Hemodialysis Patient Causing Embolic Sequelae.

Catheter-related sheath (CRS) formation secondary to chronic indwelling central venous catheters (CVC) is a well-documented complication. When these fibrin sheaths calcify, they can form a "cast" surrounding the catheter. Upon removal of the CVC, a rare complication can occur where the calcified sheath remains in situ leaving behind an intraluminal catheter-shaped cast. This report describes a case of a 57-year-old dialysis-dependent woman who was found to have a right internal jugular vein cast during the evaluation and treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. This case reviews and discusses the embolic complications suspected to be a result of this cast. Our case provides insight into the clinical course, diagnostic methods, and imaging identification of a rare pathology and its unique complications.

Adhered ECMO cannula in COVID-19 related severe acute respiratory failure.

BACKGROUND: Crescent cannula adhesion in the setting of COVID-19 respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support is a novel complication. The objective of this case presentation is to highlight this rare complication and to explore potential predisposing factors and our management strategies. CASE PRESENTATION: We present the case of a 25 y.o. patient with COVID-19 respiratory failure requiring ECMO support for 16-days in which a 32 Fr crescent cannula became adherent to the SVC and proximal jugular vein. Attempts to remove the cannula at the bedside failed due to immobility of the cannula. Ultrasound of the right neck was unremarkable, so he was taken to the hybrid OR where both TEE and fluoroscopy were unrevealing. An upper sternotomy was performed, and the superior vena cava and proximal jugular vein were dissected revealing a 2 cm segment of the distal SVC and proximal jugular vein that was densely sclerosed and adherent to the cannula. The vessel was opened across the adherent area at the level of the innominate vein and the cannula was then able to be withdrawn. The patient suffered no ill effects and had an unremarkable recovery to discharge. CONCLUSIONS: To date, there have been no reports of crescent cannula adhesion related complications. In patients with COVID-19 respiratory failure requiring ECMO, clinicians should be aware of widespread hypercoagulability and the potential of unprovoked, localized venous sclerosis and cannula adhesion. We report our technique of decannulation in the setting of cannula adhesion and hope that presentation will shed further light on this complication allowing clinicians to optimize patient care.

Immunoglobulin G4-Negative Inflammatory Pseudotumors of the Pancreas.

Inflammatory pseudotumor (IPT) can occur in any organ, but rarely shows pancreatic involvement. While surgical excision has been recommended as the primary treatment for IPT of the pancreas in the past, some authors suggest observation while medical management often results in regression. Corticosteroids, nonsteroidal anti-inflammatory drugs and immunosuppressive therapy have been used to treat IPTs. Spontaneous regression has also been reported in IPT managed without surgical intervention. A 62-year-old female was evaluated for worsening abdominal pain and a mass in the neck of the pancreas that was identified on ultrasound. Further imaging with magnetic resonance imaging revealed a pancreatic mass with dilated pancreatic duct and an atrophic parenchyma of the pancreatic neck. Her serum tumor markers were not elevated. As this lesion appeared to be resectable pancreatic cancer based on cross-sectional imaging, no biopsy was performed prior to surgical resection. Distal pancreatectomy and splenectomy was recommended and the patient desired to proceed. Her recovery was uneventful with no postoperative complications, including pancreatic fistula. Final pathology revealed a lesion consistent with the diagnosis of immunoglobulin G4 (IgG4)-negative IPT without neoplasm. IPT of the pancreas is a difficult entity to diagnose and treat due to clinical and imaging characteristics closely resembling pancreatic adenocarcinoma. Biopsy with immunohistochemical analysis can be useful in diagnosing IPT; however, symptomatic lesions and concerning findings on cross-sectional imaging may warrant more definitive surgical intervention.

Clinically diagnosed cholecystitis: a case series.

In patients presenting with classic signs and symptoms of cholecystitis, the diagnosis is made based on confirmatory imaging studies. However, the most commonly utilized imaging studies lack accuracy, especially in the case of acalculous disease. Here we discuss four cases of patients presenting with symptoms of cholecystitis. All four patients underwent multiple imaging studies, which yielded negative results. Due to persistent symptoms, the decision was made to proceed with cholecystectomy. Each patient underwent uncomplicated cholecystectomy, with resolution of symptoms post-operatively, and continued symptoms relief 6-10 months post-operatively. Cholecystitis is a clinical diagnosis. Negative imaging studies should not influence the management in a patient presenting with classic signs and symptoms of cholecystitis.

An efficient computational model to predict the synthetic utility of heterocyclic arynes.

Think before you act: a computational approach is reported for evaluating the synthetic potential of heterocyclic arynes. Routine and rapid calculations of arene dehydrogenation energies and aryne angle distortion predict the likelihood that a given hetaryne can be generated, as well as the degree of regioselectivity expected in a reaction between a given hetaryne and a nucleophilic trapping agent.