Surgical Treatment of Spontaneous Superficial Temporal Artery Arteriovenous Malformation: A Case Report.

BACKGROUND An arteriovenous malformation (AVM) is an abnormal connection between an artery and a vein, bypassing the capillary network. An AVM of the superficial temporal artery (STA) can occur after trauma, iatrogenic injury, infection, or spontaneously. Spontaneous, or iatrogenic, presentations of STA AVM are thought to be rare, with very few reported cases. Symptoms include local pain, headache, tinnitus, or paresthesia, in addition to a palpable mass associated with thrill on palpation. Options for diagnosis include intra-arterial angiography, doppler ultrasound, magnetic resonance angiography (MRA), and computed tomography angiography (CTA). Current management options include surgical excision, ligation, and embolization; however, it is unknown which treatment is superior in terms of recurrence and which carries a lower risk of complications. CASE REPORT We present a case of a spontaneous STA AVM in a 76-year-old woman with past medical history significant for seasonal allergies and hyperlipidemia, who presented with pulsatile tinnitus and a palpable, tender mass located to the left temporal area. The mass had been present for several years, with gradual increase in size two to three years prior to presentation. She denied any history of trauma or procedure prior to presentation of the pulsatile mass. She underwent open excision with complete resolution of symptoms and no recurrence at 11-month follow-up. CONCLUSIONS AVM of the STA is a condition that can occur secondary to trauma, infection, iatrogenic injury, or spontaneously. Spontaneous, or iatrogenic, presentations of STA AVM are thought to be rare, with very few cases documented in the literature. Surgical treatment remains the standard of management, with options including surgical excision, ligation, or embolization.

Defining a Relationship Between Postoperative Antibiotic Use and Wound Complications in the Setting of an Uncomplicated Laparoscopic Appendectomy.

INTRODUCTION: Appendicitis is a very common diagnosis that surgeons manage daily. Some surgeons are still giving antibiotics to patients suffering from uncomplicated appendicitis in the postoperative setting, despite an abundance of evidence to support a single preoperative dose of antibiotics. In this paper, we will describe the management of post-operative antibiotics at our institutions following uncomplicated appendicitis with regard to the use of antibiotics in the post-operative setting. METHODS: A retrospective chart review was performed analyzing post-operative antibiotic use and postoperative complications in 179 patients undergoing laparoscopic appendectomy for uncomplicated appendicitis. We retrospectively examined the patients to change our future practices as we perform appendectomies routinely, and there is practice variation at our centers. Current Procedural Terminology (CPT) codes for 'laparoscopic appendectomy' were used to identify the patients within our inclusion criteria. Twenty-four patients were excluded from the analysis as they had complicated appendicitis or met other exclusion criteria. We only studied the patient with uncomplicated appendicitis, as those with complicated appendicitis have a different clinical course that involves post-operative antibiotic administration or prolonged antibiotic administration with or without drain placement. Both arms of the study were homogeneous regarding patient characteristics. An independent test of the development of wound infection for those patients receiving post-operative antibiotics versus those not receiving post-operative antibiotics was conducted using the SPC XL 2010 Microsoft Excel (Redmond, USA) add-in. A p-value of <0.05 was considered statistically significant. This included the odds ratio for the development of complications.  Results: There was no difference in the risk of infection rate in patients given post-operative antibiotics; however, given the odds ratio of 6.53, there is an association between an increased wound infection rate and patients who received post-operative antibiotics.  Discussion: An appendectomy is a standard surgical procedure for acute appendicitis. The guidelines for using pre-operative antibiotics in uncomplicated appendicitis are well established; however, there is no specific recommendation on whether to continue antibiotics post-operatively. However, there is significant provider variability on this topic. Antibiotic use post-operatively in clean-contaminated cases, such as uncomplicated acute appendicitis, has been associated with higher risks of surgical site infections.  Conclusion: The use of antibiotics post-operatively may not be indicated for uncomplicated laparoscopic appendectomy and may increase wound infections. A large-scale study including a larger population and extending it to other hospitals may increase statistical significance and help guide physician management.

Surgical management of rare benign tumors of the sternum.

Primary benign tumors of the sternum are an exceedingly rare entity. Surgical techniques regarding intervention for these lesions are not clearly defined in the literature given their scarcity. Operative techniques include en-bloc resection of the tumor, and this has proven to be successful in preventing local recurrence despite benign nature of the lesion. Given the often extensive defect created by the excision, reconstruction is frequently necessary; depending on the size of the defect, either autologous bone grafting or the use of synthetic materials may be indicated. This study serves to present two cases of rare primary benign tumors of the sternum, giant cell tumors and osteoma spongiosum and to summarize the available literature. We present a review of the literature of 17sternal giant cell tumor cases reported so far including our patient and unique case of osteoma spongiosum of the sternum, that discusses their surgical management, as well as reconstructive techniques that provided an excellent clinical result and a lack of recurrence on long term follow-up.

Radioactive 3D printing for the production of molecular imaging phantoms.

Quality control tests of molecular imaging systems are hampered by the complexity of phantom preparation. It is proposed that radioisotopes can be directly incorporated into photo-polymer resins. Use of the radio-polymer in a 3D printer allows phantoms with more complex and reliable activity distributions to be produced whilst simplifying source preparation. Initial tests have been performed to determine the practicality of integrating Tc-99m into a photo-polymer and example phantoms produced to test suitability for quality control. Samples of build and support resins were extracted from the print cartridges of an Objet30Pro Polyjet 3D printer. The response of the resin to external factors including ionising radiation, light and dilution with Tc-99m pertechnetate were explored. After success of the initial tests the radio-polymer was used in the production of different phantoms. Radionuclide dose calibrator and gamma camera acquisitions of the phantoms were used to test accuracy of activity concentration, print consistency, uniformity and heterogeneous reproducibility. Tomographic phantoms were also produced including a uniform hot sphere, a complex configuration of spheres and interlacing torus's and a hot rod phantom. The coefficient of variation between repeat prints of a 12 g disk phantom was 0.08%. Measured activity within the disks agreed to within 98 ± 2% of the expected activity based on initial resin concentration. Gamma camera integral uniformity measured across a 3D printed flood field phantom was 5.2% compared to 6.0% measured with a commercial Co-57 flood source. Heterogeneous distributions of activity were successfully reproduced for both 2D and 3D imaging phantoms. Count concentration across regions of heterogeneity agreed with the planned activity assigned to those regions on the phantom design. 3D printing of radioactive phantoms has been successfully demonstrated and is a promising application for quality control of Positron Emission Tomography and Single Photon Emission Computed Tomography systems.

Internal hernia through the foramen of Winslow.

Foramen of Winslow hernias are one of the most uncommon types of internal hernias that a surgeon will encounter. They are often initially indolent with vague symptoms that present over an extended period of time. Unfortunately, these hernias are not often diagnosed prior to requiring emergent operative intervention. This case report describes a patient who had a long history of vague abdominal pain and radiographic evidence of a foramen of Winslow hernia 4 years prior to presenting with acute obstructive symptoms. This raises the question: Should foramen of Winslow hernias, if diagnosed early, be repaired on an elective basis?

Enzyme-based listericidal nanocomposites.

Cell lytic enzymes represent an alternative to chemical decontamination or use of antibiotics to kill pathogenic bacteria, such as listeria. A number of phage cell lytic enzymes against listeria have been isolated and possess listericidal activity; however, there has been no attempt to incorporate these enzymes onto surfaces. We report three facile routes for the surface incorporation of the listeria bacteriophage endolysin Ply500: covalent attachment onto FDA approved silica nanoparticles (SNPs), incorporation of SNP-Ply500 conjugates into a thin poly(hydroxyethyl methacrylate) film; and affinity binding to edible crosslinked starch nanoparticles via construction of a maltose binding protein fusion. These Ply500 formulations were effective in killing L. innocua (a reduced pathogenic surrogate) at challenges up to 10(5) CFU/ml both in non-growth sustaining PBS as well as under growth conditions on lettuce. This strategy represents a new route toward achieving highly selective and efficient pathogen decontamination and prevention in public infrastructure.