First Robinsoniella peoriensis aortic cross homograft mycotic pseudoaneurysm: A case report and review of the literature.

Mycotic aortic aneurysm is a rare and challenging complication of aortic homografts caused by an infection and is associated with high morbidity and mortality. We report the first case of an aortic cross homograft mycotic pseudoaneurysm caused by Robinsoniella peoriensis in a 70-year-old man. Our patient underwent surgery for a recurrence of aortic cross mycotic pseudoaneurysm at the level of the aortic homograft he had had 7 years before. A clot-removal of the pseudoaneurysm was surgically carried out and the homograft was completely removed. Anaerobic culture from tissue samples yielded pure growth of a spore-forming Gram-positive rod, identified later as Robinsoniella peoriensis by 16S rRNA gene sequencing. The patient was then discharged with oral clindamycin according to the in vitro susceptibility testing. Identification of R. peoriensis might be challenging in clinical laboratories with no access to molecular methods.

Peripatellar synovitis: comparison between non-contrast-enhanced and contrast-enhanced MRI and association with pain. The MOST study.

PURPOSE: To assess the diagnostic performance of signal changes in Hoffa's fat pad (HFP) assessed on non-contrast-enhanced (CE) magnetic resonance imaging (MRI) in detecting synovitis, and the association of pain with signal changes in HFP on non-CE MRI and peripatellar synovial thickness on CE MRI. METHODS: The Multicenter Osteoarthritis (MOST) Study is an observational study of individuals who have or are at high risk for knee OA. All subjects with available non-CE and CE MRIs were included. Signal changes in HFP were scored from 0 to 3 in two regions using non-CE MRI. Synovial thickness was scored from 0 to 2 on CE MRI in five peripatellar regions. Sensitivity, specificity and accuracy of HFP signal changes were calculated considering synovial thickness on CE MRI as the reference standard. We used logistic regression to assess the associations of HFP changes (non-CE MRI) and synovial thickness (CE MRI) with pain from walking up or down stairs, after adjusting for potential confounders. RESULTS: A total of 393 subjects were included. Sensitivity of infrapatellar and intercondylar signal changes in HFP was high (71% and 88%), but specificity was low (55% and 30%). No significant associations were found between HFP changes on non-CE MRI and pain. Grade 2 synovial thickness assessed on CE MRI was significantly associated with pain after adjustments for potential confounders. CONCLUSION: Signal changes in HFP detected on non-CE MRI are a sensitive but non-specific surrogate for the assessment of synovitis. CE MRI identifies associations with pain better than non-CE MRI.

WALANT in hand surgery: Ischemic complications and their medicolegal implications in France: A systematic review of the literature and of French legal databases.

WALANT (Wide Awake Local Anesthesia No Tourniquet) presents a theoretical risk of digital ischemia due to the presence of epinephrine, associated to the local anesthetic. For this reason, in France, the market authorization prohibits the use of epinephrine in digital extremities. The main objective of the present study was to assess the risk of ischemic complications reported in literature, and then to analyze the medicolegal implications in France. A systematic literature review was performed by three independent readers, using the PubMed and Embase databases. Also, declarations of claims and legal proceedings between 2007 and 2020 in France were examined in the official national Légifrance and Doctrine databases. Eight of the 424 articles retrieved were selected. Only 3 cases of digital necrosis following local anesthesia with adrenalized lidocaine were reported. Adrenalized xylocaine may be considered in case of peripheral microcirculation disorder. From a medicolegal point of view, no complaints or medicolegal implications were associated with WALANT in France. It seems that the market authorization for adrenalized local anesthesia could be extended to use in the digital extremities. However, the lack of medical and legal data calls for caution. We therefore recommend the use of an institutional protocol specifying the cases of overdose and the patient's pathway, and training for practitioners wishing to use this technique.

A comparison of dedicated 1.0 T extremity MRI vs large-bore 1.5 T MRI for semiquantitative whole organ assessment of osteoarthritis: the MOST study.

OBJECTIVE: To date semiquantitative whole-organ scoring of knee osteoarthritis (OA) relies on 1.5 Tesla (T) Magnetic resonance imaging (MRI) systems. Less costly 1.0 T extremity systems have been introduced that offer superior patient comfort, but may have limitations concerning field-of-view and image quality. The aim of this study was to compare semi-quantitative (SQ) scoring on a 1.0 T system using 1.5 T MRI as the standard of reference. METHODS: The Multicenter Osteoarthritis Study (MOST) is a longitudinal study of individuals who have or are at high risk for knee OA. A sample of 53 knees was selected in which MRI was performed on a 1.0 T extremity system as well as on a 1.5 T scanner applying a comparable sequence protocol. MRIs were read according to the Whole Organ Magnetic Resonance Imaging Score (WORMS) score. Agreement was determined using weighted kappa statistics. Sensitivity, specificity and accuracy were assessed using the 1.5 T readings as the reference standard. In addition the number of non-readable features was assessed. RESULTS: Agreement (w-kappa) for seven main WORMS features (cartilage, bone marrow lesions (BMLs), osteophytes, meniscal damage and extrusion, synovitis, effusion) ranged between 0.54 (synovitis) and 0.75 (cartilage). Sensitivity ranged between 68.1% (meniscal damage) and 88.1% (effusion). Specificity ranged between 63.6% (effusion) and 96.4% (BMLs). Although the overall rate of non-readable features was very low, it was higher for the 1.0 T system (1.9% vs 0.2%). CONCLUSIONS: Semiquantitative whole organ scoring can be performed using a 1.0 T peripheral scanner with a moderate to high degree of agreement and accuracy compared to SQ assessment using a 1.5 T whole body scanner. Our results are comparable to the published inter- and intra observer exercises obtained from 1.5 T systems. Sensitivity to change of longitudinal scoring was not evaluated in this cross-sectional design and should be investigated in future validation studies.

Endovascular treatment of acute aortic isthmic rupture: concerning midterm results.

BACKGROUND: We evaluated midterm results of endovascular management of traumatic aortic isthmic ruptures. METHODS: Between 2001 and 2008, 10 patients (seven males, mean age 38 years) underwent endovascular treatment of an acute aortic rupture. Eight procedures were emergent, with four cases of hemodynamic instability with Glasgow scores of 3, 5, and 7. Associated traumas were severe brain, liver, and pelvic bone injuries. All procedures were performed with transoesophageal echocardiography monitoring. We used two AneuRx and nine Medtronic Talent or Valiant stent grafts. RESULTS: All patients survived their traumatic isthmic rupture. In nine patients, stent-graft deployment was successful. One patient experienced a distal migration needing a laparotomy and deployment of an additional new thoracic stent graft. The mean intensive care unit stay was 48 hr (range 24-168). The mean hospital stay was 11 days (range 8-43). All patients were controlled clinically and by contrast computed tomography (CT) according to the EUROSTAR protocol. There were no endoleaks, stent graft-related complications, or late deaths during a mean follow-up of 49 months. The control CT showed a lack of apposition of the proximal part of the stent graft at the inner curve of the aortic arch in three patients. CONCLUSION: The midterm results of endovascular treatment of acute traumatic aortic isthmic rupture are encouraging and compare favorably to the surgical approach. Late follow-up is required to exclude possible stent-graft complications, especially in young patients with angulated aortic arches.

Lumbosacral nerve root avulsions: MR imaging demonstration of acute abnormalities.

Most of the previously reported lumbosacral nerve root avulsions presented with pseudomeningoceles at the time of delayed initial imaging. We report a case of traumatic lumbosacral nerve root injury associated with an isolated femur fracture and demonstrate the evolution of pseudomeningoceles following nerve root avulsions and edema in the perineural fat identified on the initial MR imaging.

Forearm and vertebral bone mineral in treated and untreated hyperprolactinemic amenorrhea.

To determine whether women with PRL-secreting pituitary tumors have similar decreases in cortical and trabecular bone and to determine whether bone loss associated with hyperprolactinemia is reversible, we measured forearm and vertebral bone mineral in normal women and in amenorrheic women with treated and untreated hyperprolactinemia. The mean spinal bone mineral content in hyperprolactinemic women [130 +/- 23 (+/- SD) mg/mL] was 25% lower than that in normal women (167 +/- 28 mg/mL), while the mean forearm bone mineral content (0.71 +/- 0.04 g/cm2) was similar to that in normal women (0.73 +/- 0.05 g/cm2). Women with normal serum PRL levels and regular menses after transsphenoidal surgery had slightly higher mean spinal bone mineral content (149 +/- 28 mg/mL) than women who remained amenorrheic after surgery (129 +/- 19 mg/mL), but the mean value in the cured women remained significantly lower than that in normal women. In contrast, women who had undergone successful transsphenoidal pituitary surgery had mean forearm bone mineral comparable to that in normal women. There was no correlation between vertebral and radial bone mineral in hyperprolactinemic women and no correlation between bone mineral and serum PRL, serum estradiol, or duration of amenorrhea when age was taken into account. These findings suggest that hyperprolactinemia and/or decreased gonadal function in women with PRL-secreting pituitary tumors are associated with more prominent effects on trabecular bone in the spine than on cortical bone in the wrist. In addition, the abnormal spinal bone mineral content after successful treatment suggest that normalization of estradiol and PRL secretion is not sufficient to restore bone mineral content to normal, although it may be stabilized.

Complementary saphenous grafting: long-term follow-up.

OBJECTIVE: Recently we reviewed the 10-year clinical and angiographic outcomes of sequential internal thoracic artery grafting. Most of the patients also received complementary saphenous grafts, and their overall long-term patency rates were surprisingly high. Therefore, we decided to analyze these results in more detail. METHODS: The first consecutive 500 patients having received at least one sequential internal thoracic artery graft between October 1985 and August 1991 were restudied retrospectively. The saphenous grafts were only used to achieve complete revascularization in addition to complex arterial grafting on less significant or remote coronary vessels. A total of 161 patients consented to a late angiographic restudy at a mean postoperative interval of 7.5 years (1-12.2 years). RESULTS: At 5 and 10 years postoperatively, freedom from angina was 96% and 82%, and freedom from any cardiac event was 92.8% and 69%, respectively. Only 15 (3.1%) patients needed additional revascularization (0.3% per patient-year): 4 coronary artery bypass grafting (0.8%) and 11 percutaneous transluminal coronary angioplasty (2.3%). The overall patency and intactness rates of saphenous anastomoses were 72.5% and 60.2%, respectively. There was a significant difference between the patency and intactness of sequential versus single anastomoses: 76% versus 60% and 64.5% versus 44.4%, respectively. There was no significant difference in either patency or intactness between right internal thoracic and sequential saphenous grafts anastomosed to the right coronary artery: 83.4% versus 75.2% and 77.8% versus 62.4%, respectively. The same was true for the anastomoses to the "remote area" (distal circumflex, distal right coronary artery). CONCLUSIONS: Complementary sequential saphenous grafting still deserves consideration in some patients below 70 years of age, particularly for those with disease in the "remote area": the distal circumflex and right coronary branches.

Curriculum for musculoskeletal radiology.

Although general suggestions have been made regarding a radiology residency curriculum, no specific list of entities has been offered. Over the past ten years, we have developed a resident-run morning conference in musculoskeletal radiology that is supervised by faculty and covers a specific curriculum. We offer our curriculum as an example that may assist other departments in developing their own curricula.

Satisfaction of search in diagnostic radiology.

A subset of underreading errors (false-negative responses) in radiology has been attributed to "satisfaction of search," which occurs when lesions remain undetected after detection of an initial lesion. This phenomenon has not been studied in the experimental laboratory. A primary goal of this study was to develop a procedure or paradigm to study satisfaction of search. The authors measured detection accuracy for native lesions in images before and after the addition of a simulated nodular lesion. Simulated and native lesions were not spatially superimposed and the native abnormalities were physically identical with and without the nodules. Only responses related to the native lesion were analyzed. Accuracy parameters of receiver operating characteristic (ROC) curves were estimated by the method of maximum likelihood and jackknife. The average perceptual accuracy of the individual ROC curves as measured by Az and de' was significantly reduced with addition of the nodules (t = 2.364, p = 0.025, t = 2.648, p = 0.017, respectively). Az and de' parameters of the pooled ROC curve showed a similar effect (t = 1.573, p = 0.080; t = 1.934, p = 0.047, respectively). The results indicated a substantial satisfaction-of-search effect, with diminished accuracy in perception of native lesions.

Variables influencing the outcome following orthotopic liver transplantation.

Seventy-two patients who underwent orthotopic liver transplantation (OLT) were studied to identify perioperative variables that would predict survival and intraoperative blood loss. Survival and intraoperative blood loss were not affected by encephalopathy, length of donor liver ischemia, or any of the preoperative laboratory values studied. Survival was significantly decreased in patients requiring postoperative dialysis (41%) and in patients who had severe rejection requiring retransplantation (33%). Intraoperative blood loss was significantly greater in patients over 50 years of age (11.6 blood volumes) and patients with biliary atresia (8.7 blood volumes). These results may aid in choosing future recipients for orthotopic liver transplantation and in anticipating the postoperative support needed.

Reconstruction of the ascending aorta and aortic root: experience in 45 consecutive patients.

BACKGROUND: Patients with aneurysms of the ascending aorta or aortic root may have associated aortic insufficiency (AI). We reviewed our experience with aortic root remodeling and reconstruction of the sino-tubular junction. METHODS: Forty-five patients were operated on between July 1995 and September 1998. Transesophageal echocardiography showed AI grade III or IV in 15 patients. Twenty-seven patients had replacement of all three sinuses, 10 of one or two sinuses. Reconstruction of the sino-tubular junction alone was performed in 8 patients. RESULTS: There was one death at 28 days. Perioperative transesophageal echocardiography showed no or discrete AI in all patients. There has been one aortic valve replacement at day 4 postoperatively for cusp repair failure. Transesophageal echocardiography in 40 patients at a mean time of 12.5 months showed no progression of AI in 38 patients, and a grade II in 2. Clinical follow-up averaged 14.5 months. There have been three late, not procedure-related deaths. Thirty-six patients are in New York Heart Association functional class I. There have been no cases of endocarditis. CONCLUSIONS: Aortic remodeling is successful in eliminating AI in patients with aortic root disease with minimal mortality and morbidity. Early echocardiography (1 year) has shown no progression of AI in 95% of cases.

Resection of a chest chondrosarcoma invading the spine and the aorta.

A 34-year-old man presented with a large chondrosarcoma of the chest invading six ribs and the vertebral bodies of five adjacent thoracic vertebrae. En bloc resection of the tumor with six ribs, the anterior part of five vertebral bodies, and the thoracic aorta was performed through a thoracotomy and a paravertebral incision.

Ischemic gastric ulcer after coronary bypass using the right gastroepiploic artery.

The gastroepiploic artery has been widely used for complete arterial myocardial revascularization of young patients. Gastric complications related to the harvesting of this artery are exceptional. We describe here a case of ischemic gastric ulcer due to the use of a gastroepiploic artery in a patient with severe celiac trunk disease. The patient was cured by angioplasty completed by a stenting procedure.

Retrospective study of somatosensory evoked potential monitoring in deep hypothermic circulatory arrest.

BACKGROUND: We evaluated the efficiency of median-nerve somatosensory evoked potentials (SEPs) monitoring in determining the optimal level of hypothermia in 62 consecutive patients operated on under deep hypothermic circulatory arrest (CA). METHODS: CA was started at 1 degree C below the temperature at which both brainstem and cortical SEP components disappear. No additional method of cerebral protection was used. RESULTS: New neurological complications were observed in 15 patients: long-lasting in 11 and transient in 4. A retrospective analysis of SEP monitoring identified the origin of the complications in 12 cases: early CA with incomplete cooling due to emergency (3 cases); inefficient retrograde perfusion through the femoral artery during cooling due to the dissection flap effect (4 cases); embolism during rewarming (2 cases); delayed embolism (2 cases); hemorrhagic shock (1 case). In 2 cases, neurological sequelae involved the lower limbs (extracerebral origin). One case without intraoperative SEP changes was neurologically abnormal preoperatively and did not change postoperatively. There were no cases with sequelae due to excessive CA duration. CONCLUSIONS: The use of SEP monitoring to determine the optimal level of hypothermia efficiently prevents neurological sequelae of CA. It helps in monitoring the degree of cerebral protection during cooling (flap effect), and rewarming.

Recycling of arterial grafts during reoperative coronary artery operations.

BACKGROUND: To overcome problems of lack of conduit and to maximize the number of arterial anastomoses in coronary reoperations we reused previously placed arterial grafts. METHODS: Sixteen patients were identified from February 1994 to July 1997. Mean age was 62.8 years (range, 44 to 75 years). Fifteen (94%) were in Canadian Cardiovascular Society angina class III or IV. The mean interval from primary to secondary operation was 8.5 years (range, 3 to 12 years). Eleven patients had a patent internal mammary artery graft used as the recipient for a proximal Y anastomosis. In 3 cases an arterial graft was reimplanted distally on the same coronary vessel and in 2 onto different coronary vessels. One patient had a combination of these techniques. Five patients required venous conduit. RESULTS: There were no deaths. Mean length of intensive care stay was 69 hours (range, 24 to 144) and mean hospital stay was 14 days (range, 10 to 28 days). All patients were discharged home. Follow-up averages 13 months (range, 2 to 43 months). Twelve patients (75%) are now in Canadian Cardiovascular Society angina class I and 3 (19%) in class II. CONCLUSIONS: Reusing arterial conduits during coronary reoperations is possible with minimal in-hospital morbidity and satisfactory results in terms of freedom from angina. Using these techniques can help overcome the problems of inadequate conduit and maximize the number of arterial anastomoses that can be made per patient.

The Ross operation: mid-term results.

BACKGROUND: The Ross operation, although more demanding, is now widely accepted as an alternative solution for aortic valve replacement in young adults and children. A review of our experience to assess the mid-term results with the Ross operation is presented. METHODS: From June 1991 through October 1997, 80 patients (mean age, 31 years) underwent aortic valve or root replacement with pulmonary autografts. Indications for operation were predominant aortic stenosis in 38 patients, aortic incompetence in 42 patients including endocarditis in 3 patients. Congenital lesions were present in 57 patients, either at pediatric (27 patients) or adult age (30 patients). Transthoracic echocardiography was performed preoperatively in all patients and serially after operation with the aims of measuring aortic and pulmonary annuli, evaluating transvalvular gradients and incompetence, and studying the left ventricular function. Intraoperative transesophageal echocardiography was used routinely. Complete root replacement was performed in 52 patients, intraluminal cylinder in 25 patients, and subcoronary implantation in 3 patients. RESULTS: One patient died in the early postoperative period (1.2%). There was no late death. The actuarial survival at 5 years was 98%+/-1%. All survivors remained in New York Heart Association functional class I and were free of complications and medications. No gradient or significant aortic incompetence could be demonstrated in 73 patients. One patient developed late aortic incompetence grade 3 and reoperation is considered. On the pulmonary outflow tract, 6 patients had gradients between 20 and 40 mm Hg as calculated on echocardiography. CONCLUSIONS: The pulmonary autograft gives excellent mid-term results with low mortality and no morbidity. It completely relieves the abnormal loading conditions of the left ventricle, resulting in a complete recovery of left ventricular function in most patients.

Randomized trial of intermittent antegrade warm blood versus cold crystalloid cardioplegia.

BACKGROUND: We performed a prospective randomized trial to compare intermittent antegrade warm blood cardioplegia with intermittent antegrade and retrograde cold crystalloid cardioplegia. METHODS: Two hundred consecutive patients scheduled for isolated coronary bypass surgical procedures were randomized into two groups: Group 1 (n = 92) received cold crystalloid cardioplegia with moderate systemic hypothermia, group 2 (n = 108) received intermittent antegrade warm blood cardioplegia with systemic normothermia. Preoperative, intraoperative, and postoperative data were prospectively collected. RESULTS: For the same median number of distal anastomoses, cardiopulmonary bypass duration and total ischemic arrest duration (57.3 +/- 20.5 versus 75 +/- 22.1 minutes, p < 0.001) were shorter in group 2 than in group 1. Apart from a higher right atrial pressure in the cold cardioplegia group, no hemodynamic difference was observed. Aspartate aminotransferase, creatine kinase-MB fraction, and cardiac troponin I levels were significantly lower in group 2 than in group 1. Outcome variables were not significantly different. CONCLUSIONS: Intermittent antegrade warm blood cardioplegia results in less myocardial cell damage than cold crystalloid cardioplegia, as assessed by the release of cardiac-specific markers. This beneficial effect has only marginal clinical consequences. Normothermic bypass has no deleterious effect on end-organ function.

Early calcific stenosis of the aortic sorin pericarbon valve implanted in the elderly.

BACKGROUND: We reviewed our experience with the Sorin Pericarbon (Sorin, Saluggia, Italy) valve implanted in the aortic position. METHODS: From January 1990 to January 1996, 143 consecutive patients had a Pericarbon valve implanted in the aortic position. The mean age was 75+/-5 years. Seventy-eight patients (55%) were in New York Heart Association (NYHA) class III or IV. Sixty patients (42%) had one or more concomitant procedures (51 coronary artery bypass grafting [CABG], 7 carotid endarterectomies, 9 others). RESULTS: The hospital mortality rate was 12% (17 of 143 patients). The follow-up was 100% complete and the median time was 42 months (range, 2 to 79 months). There were 36 late deaths, 20 being cardiac-related: 5 non-valve-related, 11 valve-related, and 4 sudden unexpected deaths. The 5-year actuarial survival was 57%+/-5%. There were 6 early valve failures related to a calcific stenosis at a median time of 36 months (range, 5 to 66 months). Three patients had to undergo another operation and one of these patients died. One patient died the day before the planned reoperation and 2 patients are followed with a symptomatic aortic stenosis but refuse reoperation. Freedom from structural deterioration was 93%+/-3% at 4 years. Echocardiographic examination was obtained in 73 patients at a median time of 42 months (range, 4 to 79 months). Four additional asymptomatic patients were found to have calcifications of their prosthesis. The 5-year freedom from thromboembolic events and from endocarditis were, respectively, 87%+/-5% and 92%+/-3%. CONCLUSION: The surprisingly high rate of early failure due to calcific stenosis and of thromboembolic events of the Pericarbon valve implanted in the aortic position in the elderly made us discontinue its use in our institution.

Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration.

We prospectively evaluated 316 caudal-approach epidural steroid injections given by staff radiologists and residents in our department over a 1-year period. Needle placement was checked with fluoroscopy and corrected if necessary. When the needle tip was within the sacral canal, nonionic contrast material was injected. If epidural contrast was not observed, the needle tip was repositioned. Of 111 procedures performed by physicians who had given fewer than 10 epidural steroid injections, 53 (47.7%) resulted in correct nonfluoroscopically directed placement of the needle. For physicians who had performed between 10 and 50 such procedures, 62 (53.4%) of 116 had correct nonfluoroscopically directed placement. For staff physicians, 55 (61.7%) of 89 placements were correct. Even when the sacral hiatus was easily palpated and a staff physician was confident that he or she was within the epidural space, fluoroscopy revealed incorrect placement 14.2% of the time (seven of 49 procedures). In addition, when the needle was positioned within the sacral canal and no blood was evident on Valsalva maneuver or aspiration, the injection was venous in 29 of 316 procedures (9.2%). The presence of blood on the needle stylus was not a reliable indicator of venous placement of the needle. Our findings indicate that fluoroscopy is essential for correct placement of epidural steroid injection. Contrast administration is necessary to avoid venous injection of steroids.