Left atrial thrombi following tranexamic acid in a bleeding trauma patient-A word of caution.

We describe the case of a bleeding trauma patient who received tranexamic acid (TXA) during air transport who subsequently developed multiple intra-cardiac thrombi. The administration of TXA during transport may be associated with this unusual presentation.

Contemporary results with ampullectomy for 29 "benign" neoplasms of the ampulla.

BACKGROUND: Ampullectomy may be an appropriate oncologic procedure in selected patients. Sparse data exist on procedure-related complications and the relationship between histologic analysis and outcomes. STUDY DESIGN: We retrospectively reviewed our experience with ampullectomy in 29 patients with a preoperative benign histologic diagnosis over 15 years (1991 to 2006). Presenting signs, symptoms, and preoperative diagnostic studies were reviewed. Postoperative complications and followup for recurrence were recorded. The abilities of preoperative histologic biopsy, intraoperative frozen section, and final histologic analysis to guide management and predict outcomes were determined. RESULTS: Median age was 63 years. Jaundice was present in 30% of patients. Median length of hospital stay was 9 days. Forty-five percent of patients had a complication, and there was one postoperative mortality (3%). Ampullary adenomatous neoplasms were present in 89% of patients. Preoperative biopsy had complete concordance with final pathology in 76% of patients. Preoperative biopsy and intraoperative frozen section failed to identify carcinoma in four patients. Pancreaticoduodenectomy was performed within 7 days in the postoperative period in three of these patients. After ampullectomy (median followup=16 months), recurrences were identified in two patients (8%) with benign tumors. No patients with high-grade dysplasia (n=4) have had recurrence. CONCLUSIONS: Preoperative biopsy and intraoperative frozen section analysis have limitations in the management of patients undergoing ampullectomy. High-grade dysplasia on preoperative biopsy is not an absolute contraindication to ampullectomy. Morbidity of ampullectomy is significant, but longterm outcomes of this procedure, in patients without invasive malignancy, are acceptable.

Functional outcome after redo below-knee amputation.

BACKGROUND: Nonhealing below-knee amputation (BKA) necessitates redo BKA or conversion to above-knee amputation (AKA). Outcomes after redo BKA remain poorly defined. We hypothesized that in selected patients redo BKA results in favorable functional outcomes. METHODS: Patients undergoing redo BKA at a single institution during 4 years were reviewed. A concurrent cohort proceeding directly to ipsilateral AKA served as comparative controls. RESULTS: Of 138 BKAs, 23 (17%) failed to heal primarily. Baseline demographics and medical comorbidities were similar between groups. Clinicians selected 14 for redo BKA and 9 for ipsilateral AKA. Eight (57%) of those undergoing redo BKA had a history of minor stump trauma and 13 (93%) had a palpable popliteal pulse, compared with no trauma (P = 0.007) and 4 (44%, P = 0.018) palpable popliteal pulses in the AKA group. Functionally, 86% of redo-BKA patients returned home, all eventually healed, and 86% walked, whereas none in the AKA group walked. CONCLUSIONS: In selected patients, redo BKA yields excellent functional outcomes. A history of minor stump trauma and a palpable popliteal pulse favor redo BKA compared with conversion to AKA.

Current outcomes and risk factors for the Norwood procedure.

OBJECTIVE: Tremendous strides have been made in the outcomes for hypoplastic left heart syndrome and other functional single-ventricle malformations over the past 25 years. This progress relates primarily to improvements in survival for patients undergoing the Norwood procedure. Previous reports on risk factors have been on smaller groups of patients or collected over relatively long periods of time, during which management has evolved. We analyzed our current results for the Norwood procedure with attention to risk factors for poor outcome. METHODS: A single-institution review of all patients undergoing a Norwood procedure for a single-ventricle malformation from May 1, 2001, through April 30, 2003, was performed. Patient demographics, anatomy, clinical condition, associated anomalies, operative details, and outcomes were recorded. RESULTS: Of the 111 patients, there were 23 (21%) hospital deaths. Univariate analysis revealed noncardiac abnormalities (genetic or significant extracardiac diagnosis, P = .0018), gestational age (P = .03), diagnosis of unbalanced atrioventricular septal defect (P = .017), and weight of less than 2.5 kg (P = .0072) to be related to hospital death. On multivariate analysis, only weight of less than 2.5 kg and noncardiac abnormalities were found to be independent risk factors. Patients with either of these characteristics had a hospital survival of 52% (12/23), whereas those at standard risk had a survival of 86% (76/88). CONCLUSIONS: Although improvements in management might have lessened the effect of some of the traditionally reported risk factors related to variations in the cardiovascular anatomy, noncardiac abnormalities and low birth weight remain as a future challenge for the physician caring for the patient with single-ventricle physiology.

Ganglioneuroma manifesting as an incidental adrenal mass in an adult with Turner's syndrome.

OBJECTIVE: To report a case of ganglioneuroma masquerading as an incidental adrenal mass in an adult patient with Turner's syndrome. METHODS: We present the clinical, laboratory, radiologic, and pathologic findings in this patient. RESULTS: A 31-year-old woman with Turner's syndrome who had previously been treated with growth hormone replacement had an incidentally discovered mass, apparently arising from the left adrenal gland. The mass was "silent" clinically and biochemically, but imaging characteristics were not reassuring for a benign cortical adenoma. Because of uncertainty regarding the nature of the mass, it was removed laparoscopically; during this procedure, it was noted to be intimately associated with, but anatomically distinct from, the left adrenal gland. The pathology report confirmed the presence of a benign ganglioneuroma. CONCLUSION: Although ganglioneuroma has previously been noted to be associated with Turner's syndrome (especially in pediatric patients), to the best of our knowledge this is the first report of a ganglioneuroma manifesting as an incidental adrenal mass in an adult patient with Turner's syndrome.