Case study: diagnosis and operative management of de Garengeot hernia without appendectomy during the COVID-19 pandemic.

de Garengeot herniae have been reported in <100 cases in literature. They are characterized by an incarcerated femoral hernia containing the appendix. We present the case of a 45-year-old female who, upon emergency intraoperative consultation to a general surgeon while having a right groin exploration by a plastic surgeon, was found to have an appendix incarcerated within a femoral hernia. There was no evidence of appendicitis; thus, appendix was reduced and the hernia was repaired with a mesh plug. The patient did well postoperatively, with no complications and returned to complete activities. This occurred during the coronavirus disease (COVID-19) pandemic. Due to the common failure in preoperative diagnosis, it is important for surgeons to have a clinical suspicion for de Garengeot herniae for patients, presenting with a right groin bulge. Appendectomy may be safely avoided, eliminating appendectomy-associated morbidity and avoiding hospital transfer and the associated risk of COVID-19 exposure.

Shoulder Subluxation Pain as a Secondary Indication for Trapezius to Deltoid Transfer.

Brachial plexus injuries can be debilitating. We have observed that manual reduction of the patients' shoulder subluxation improves their pain and have used this as a second reason to perform the trapezius to deltoid muscle transfer beyond motion. The authors report a series of nine patients who all had significant improvement of pain in the shoulder girdle and a decrease in pain medication use after a trapezius to deltoid muscle transfer. All patients were satisfied with the outcomes and stated that they would undergo the procedure again if offered the option. The rate of major complications was low. The aim is not to describe a new technique, but to elevate a secondary indication to a primary for the trapezius to deltoid transfer beyond improving shoulder function: pain relief from chronic shoulder subluxation.

Diaphragm paralysis caused by transverse cervical artery compression of the phrenic nerve: the Red Cross syndrome.

BACKGROUND: The etiology of diaphragm paralysis is often elusive unless an iatrogenic or traumatic injury to the phrenic nerve can be clearly implicated. Until recently, there has been little interest in the pathophysiology of diaphragm paralysis since few treatment options existed. METHODS: We present three cases of symptomatic diaphragm paralysis in which a clear clinico-pathologic diagnosis could be identified, specifically a vascular compression of the phrenic nerve in the neck caused by a tortuous or adherent transverse cervical artery. RESULTS: In two patients the vascular compression followed a preceding traction injury, whereas in one patient an inter-scalene nerve block had been performed. Following vascular decompression, all three patients regained diaphragmatic motion on fluoroscopic chest radiographs, and experienced a resolution of respiratory symptoms. CONCLUSION: We suggest that vascular compression of the phrenic nerve in the neck may occur following traumatic or iatrogenic injuries, and result in symptomatic diaphragm paralysis.

Nerve allograft transplantation for functional restoration of the upper extremity: case series.

BACKGROUND: Major trauma to the spinal cord or upper extremity often results in severe sensory and motor disturbances from injuries to the brachial plexus and its insertion into the spinal cord. Functional restoration with nerve grafting neurotization and tendon transfers is the mainstay of treatment. Results may be incomplete due to a limited supply of autologous material for nerve grafts. The factors deemed most integral for success are early surgical intervention, reconstruction of all levels of injury, and maximization of the number of axonal conduits per nerve repair. OBJECTIVE: To report the second series of nerve allograft transplantation using cadaveric nerve graft and our experience with living-related nerve transplants. PARTICIPANTS: Eight patients, seven men and one woman, average age 23 years (range 18-34), with multi-level brachial plexus injuries were selected for transplantation using either cadaveric allografts or living-related donors. METHODS: Grafts were harvested and preserved in the University of Wisconsin Cold Storage Solution at 5 degrees C for up to 7 days. The immunosuppressive protocol was initiated at the time of surgery and was discontinued at approximately 1 year, or when signs of regeneration were evident. Parameters for assessment included mechanism of injury, interval between injury and treatment, level(s) of deficit, post-operative return of function, pain relief, need for revision surgery, complications, and improvement in quality of life. RESULTS: Surgery was performed using living-related donor grafts in six patients, and cadaveric grafts in two patients. Immunosuppression was tolerated for the duration of treatment in all but one patient in whom early termination occurred due to non-compliance. There were no cases of graft rejection as of most recent followup. Seven patients showed signs of regeneration, demonstrated by return of sensory and motor function and/or a migrating Tinel's sign. One patient was non-compliant with the post-operative regimen and experienced minimal return of function despite a reduction in pain. CONCLUSIONS: Despite the small number of subjects, it appears that nerve allograft transplantation may be performed safely, permitting non-prioritized repair of long-segment peripheral nerve defects and maximizing the number of axonal conduits per nerve repair. For patients with long, multi-level brachial plexus injuries or combined upper and lower extremity nerve deficits, the use of nerve allograft allows a more complete repair that may translate into greater functional restoration than autografting alone.

Staphylococcal liver abscess and acute cholecystitis in a patient with Crohn's disease receiving infliximab.

We present an unusual case of empyema of the gallbladder associated with a pyogenic liver abscess in a patient with Crohn's disease on Infliximab. It manifested by weakness, weight loss, and vague abdominal pain, which eventually localized to the right upper quadrant 4 days prior to admission. Diagnostic evaluation, which included ultrasonography and computed tomography, revealed cholelithiasis, gallbladder wall thickening, and a low-attenuation, complex mass in the left hepatic lobe. Cholecystectomy and open drainage of the liver abscess were successfully performed. There are few reports of intrahepatic abscess associated with Crohn's disease. The relationship between acute cholecystitis and Crohn's disease has also been documented. However, this report documents the unusual complication of pyogenic liver abscess secondary to acute cholecystitis in the unique population of Crohn's disease patients on Infliximab.

Frontal bone periosteal osteomas.

Osteomas are the most common tumors of the cranial vault and facial skeleton. Osteomas are usually benign in nature, commonly presenting with symptoms of facial deformity, facial pain, and headaches. Although the frontal sinus is the most frequent location of cranial osteomas, they are also occasionally seen involving only the frontal bone periosteum. This study is a retrospective series investigating the characteristics, management, and outcomes of five patients with frontal bone periosteal osteomas surgically treated with superficial osteotomies with primary closure. Medical charts were reviewed focusing on symptoms, size, radiographic findings, and disease of the periosteal osteomas. The chief complaint primarily involved a palpable deformity, which led to surgical evaluation. Radiographic studies were obtained to evaluate size and location of the frontal osteomas. Microanalysis of the specimens confirmed the presence of mature cancellous and/or cortical bone. Postoperative follow-up revealed no evidence of recurrence or complications. The superficial ostectomy technique with primary closure offers a simple, effective method for removal of frontal bone periosteal osteomas with minimal side effects.

Simvastatin suppresses LPS-induced Akt phosphorylation in the human monocyte cell line THP-1.

BACKGROUND: Activation of the small GTPase, Rac, requires post-translational modification by isoprenylation. Statins interfere with this process by blocking the synthesis of isoprenoid intermediates. The protein kinase Akt is a multifunctional regulator of cell behavior that has been linked to Rac activation. We have shown that lipopolysaccharide (LPS) stimulation leads to Rac activation in THP-1 cells. Therefore, we hypothesized that LPS stimulation would also activate Akt, a downstream effector of Rac, and that this may be blocked by statin pretreatment. MATERIALS AND METHODS: THP-1 cells were maintained in 1% fetal calf serum with or without 20 microM simvastatin for 24 h, followed by LPS stimulation for increasing time. Cytoskeletal changes were observed using Alexa-Phalloidin. Akt was immunoprecipitated from total cell lysate. Activated Akt was detected by immunoblotting with a phospho-Akt antibody and was quantified by image densitometry. RESULTS: LPS stimulation of THP-1 cells results in membrane ruffling and cell polarization. Furthermore, LPS increased Akt activation in THP-1 cells when compared with the nonstimulated controls. Akt phosphorylation peaked after 15 min of LPS stimulation and was suppressed by pretreatment with simvastatin. CONCLUSIONS: These data demonstrate that LPS stimulation leads to increased Akt phosphorylation, which can be suppressed with simvastatin pretreatment. This suggests one possible mechanism through which simvastatin could modulate LPS-induced signaling events in monocytes to improve the host response to Gram-negative infections.

Mevastatin suppresses lipopolysaccharide-induced Rac activation in the human monocyte cell line THP-1.

BACKGROUND: Rac is a member of the Rho family of small guanosine triphosphatases that regulate the actin cytoskeleton. Activation of Rac requires lipid modification that can be blocked by statins. Lipopolysaccharide-induced rearrangements in the actin cytoskeleton lead to changes in cell adhesion and motility that play a role in the cellular response to infection. The lipid products of phosphatidylinositol-3 kinase (PI3K) modulate Rac effector pathways and have been linked to the activation of the Rac-guanosine triphosphatase. We hypothesize that lipopolysaccharide stimulation leads to Rac activation and that this may be inhibited by statin pretreatment. Furthermore, signaling downstream of Rac is linked to PI3K; therefore, we hypothesize that a signaling complex between PI3K and Rac may be involved. METHODS: THP-1 cells were maintained in 1% fetal calf serum with or without 20 micromol/L mevastatin for 24 hours, followed by lipopolysaccharide stimulation. Active Rac was precipitated from THP-1 total cell lysate and then detected by immunoblotting. The PI3K-Rac complex was immunoprecipitated from total cell lysate, and the p85 regulatory subunit of PI3K was detected by immunoblotting. RESULTS: Lipopolysaccharide stimulation activated Rac. Rac activation was suppressed by pretreatment with mevastatin. The p85 subunit of PI3K was associated with Rac. CONCLUSIONS: Lipopolysaccharide stimulation leads to Rac activation in THP-1 cells, which may be suppressed with mevastatin pretreatment. There is an association between Rac and PI3K that demonstrates a role for PI3K in the activation of downstream Rac effector pathways.