Using appendiceal perforation rates to measure impact of a disaster on healthcare system effectiveness.

OBJECTIVES: To understand baseline inequities in appendiceal perforation rates and the impact of hurricane destruction on the healthcare system with respect to perforation rates and racial disparities. METHODS: We used claims data extracted from Medicaid Analytic Extract files to identify appendicitis diagnoses in children and adolescents based on International Classification of Diseases-9 codes and appendectomy procedures based on Current Procedural Terminology codes in the hurricane-affected states of Mississippi and Louisiana. County-level summary data obtained from 2005 Area Resource Files were used to determine high and low hurricane-affected areas. We estimated logistic regression models, mutually adjusting for race, sex, and age, to examine disparities and mixed logistic regression models to determine whether county-level effects contributed to perforation rates. RESULTS: There were nine counties in the high-impact area and 133 counties in the low-impact area. Living in the high- or low-impact area was not associated with a statistically different rate of perforation before or after Hurricane Katrina; however, living in the high-impact area was associated with a change from a lower risk (odds ratio [OR] 0.62) of perforation prehurricane to a higher risk (OR 1.14) posthurricane compared with those living in the low-impact areas. African Americans had statistically higher perforation rates than whites in the high-impact areas both before (OR 1.46) and after (OR 1.71) Hurricane Katrina. CONCLUSIONS: Health professionals and hospital systems were able to maintain effective levels of care before and after Hurricane Katrina; however, perforation rates in African Americans suggest ongoing racial disparities during disasters.

The Co-occurrence of Multiple Parathyroid Adenomas: A Case Report.

Solitary parathyroid adenoma is the most common cause of primary hyperparathyroidism; however, multiple parathyroid adenomas are an uncommon phenomenon. In this case report, we discuss a patient presenting with two concurrent ipsilateral parathyroid adenomas, and we review the literature. A 61-year-old African American female with a history of hypertension and kidney stones presented for the evaluation of hypercalcemia. Elevated serum calcium of 11 mg/dL was found on routine laboratory tests and low25 hydroxyvitamin-D level. Parathyroid hormone (PTH) was elevated at 172.5 pg/mL and increased to 443 pg/mL after correction of vitamin D deficiency. Renal function tests and thyroid function tests revealed normal findings. Imaging studies with 99mTc-Sestamibi scintigraphy raised concern for the possibility of either a parathyroid adenoma or hyperplasia. Minimally invasive parathyroidectomy with intraoperative PTH monitoring was planned. During surgery, the right superior parathyroid gland was found to be enlarged and was excised. However, intraoperative PTH monitoring showed an initial decrease to 203 pg/mL from a baseline of 443 pg/mL and a subsequent increase to 293 pg/mL suggesting the persistence of hyperparathyroidism. Further exploration of the neck revealed an enlarged right inferior parathyroid gland and two normal left parathyroid glands. Intraoperative PTH monitoring then revealed an appropriate decrease in PTH level to 56 pg/mL 10 minutes after excision of the right inferior parathyroid gland. More than a 50% decrease in PTH was achieved, and further exploration of the opposite side revealed no evidence of four-gland hyperplasia. Pathology reported two concurrent right superior and inferior parathyroid adenomas. Successful and curative parathyroidectomy for primary hyperparathyroidism was achieved. Although rare, multiple parathyroid adenomas occur in a significant minority of cases. Intraoperative PTH monitoring along with preoperative imaging provides guidance for curative parathyroidectomy. Additionally, more sensitive imaging such as four-dimensional computed tomography scans could lead to better localization, visualization, and identification of the second parathyroid adenoma.

Management of Symptomatic Elastofibroma Dorsi: A Case Report and Literature Review.

Elastofibroma dorsi (ED) is a rare tumor that most often occurs in the subscapular and infrascapular region between the thoracic wall, serratus anterior, and latissimus dorsi muscle. Based on a review of the literature, ED has been deemed an extremely rare entity. However, the incidence may be greater and is difficult to determine as the majority of ED being asymptomatic and therefore undiagnosed. Surgical excision is commonly performed when patients present with pain associated with ED. This being the case, it is important to evaluate the factors contributing to the pain seen in these patients and to evaluate the risks vs benefits of intervening in symptomatic ED patients who present for possible surgical intervention. We herein report a case of bilateral ED, situated in the upper back with only the right side being symptomatic in a 56-year-old male laborer. Due to pain in the right upper back, the patient underwent surgical removal of the ED. The postoperative course was uneventful and the patient had an excellent recovery. A review of the literature showed no correlation between pain on presentation and tumor size or location. Major complications of treating these patients include seroma or hematoma formation which according to the literature can be avoided using postoperative tube drainage and compressing bandages.

Primary Splenic Epidermoid Cyst: A Case Report.

Primary splenic epidermal cysts, a type I splenic lesion, are very uncommon and usually found coincidentally. In this report, we present a primary splenic epidermal cyst that presented as a mass in the left upper quadrant associated with sharp pain, early satiety, and constipation. We review the classification of splenic cysts with a detailed look into the causes and types of type I cysts. We discuss the different treatment options, how current and past surgical options are controversial, and indications for splenectomy in spleen cysts. We explore how percutaneous drainage as a bridge to splenectomy may have been beneficial in a splenic cyst of great size. This splenic cyst was attempted laparoscopically but converted to an open splenectomy after complications. The patient recovered with no difficulties postoperatively.

A Rare Complication of Internal Jugular Vein Cannulation Following Subcutaneous Implanted Port Placement.

Port-a-Cath also known as a subcutaneous implantable catheter is a common device used in patients undergoing drug infusions. Port-a-Cath placements are widely used among cancer patients who need multiple intravenous infusions with chemotherapeutic agents. The surgical approach to implanting a Port-a-Cath is associated with risks and benefits; however, it may also be associated with serious complications. We describe a rare case of a large right-sided hemothorax following right internal jugular vein cannulation after Port-a-Cath placement. We discuss possible causes of hemothorax in this patient and describe possible factors such as abnormal anatomy of vessels and body habitus contributing to this complication. We also highlight the use of imaging such as ultrasound-guided techniques and the importance of postoperative chest radiographs to screen for possible complications.

Poorly Differentiated Large Cell Neuroendocrine Carcinoma of the Colon: A Case Report.

Colon cancer is one of the most common diagnoses of cancer and a leading cause of death in America. Large cell neuroendocrine tumors are a very uncommon type of colon cancer that tends to have a poor prognosis. Usually, these tumors are only found at the time of metastasis making them even more difficult to treat. A 65-year-old female presented with worsened generalized abdominal pain associated with abdominal distention. She had not had a bowel movement in over a week and did not have any flatulence. She had a colonoscopy four years prior that was normal. Physical examination was significant for abdominal distention and a large right-sided palpable mass in her abdomen with generalized tenderness. A CT scan showed a large irregular mass at least 9.8 x 10.5 cm at the mid to distal ascending colon resulting in significant colonic narrowing significant for a large bowel obstruction. The CT also demonstrated suspicious nodules in the lung, lesions in the liver, and lymphadenopathy. She had an exploratory laparotomy with an extended hemicolectomy to remove the mass. Pathology revealed the mass was neuroendocrine carcinoma, a large cell subtype, that was poorly differentiated with involvement of at least 32 of 34 lymph nodes. This tumor was positive for AE1/AE3, CEA, CK20, and synaptophysin. Ki-67 showed 70% positivity. TTF1 was negative and ruled out a primary lung tumor. Microsatellite immunostains were positive for MLH-1, MSH-2, MSH-6, and PMS2. The patient was started on Carboplatin AUC6 and Etoposide 100mg/m2 in three-week intervals. Pegfilgrastim was also added to her treatment plan every 21 days. This is a review of a female who presented with colonic obstruction that was found to be poorly differentiated large cell neuroendocrine carcinoma after a previous negative colonoscopy.

Cecal epiploic appendagitis: a diagnostic and therapeutic dilemma.

Acute epiploic appendagitis (EA) is a rare and often misdiagnosed cause of acute abdominal pain. Though a benign and often self-limiting condition, EA's ability to mimic other disease processes makes it an important consideration in patients presenting with acute abdominal symptoms. Careful evaluation of abdominal CT scan findings is crucial in the accurate diagnosis of epiploic appendagitis, thus avoiding unnecessary surgical intervention. We report a case of a 29-year-old male presenting with a two day history of generalized abdominal pain. Physical exam revealed a diffusely tender abdomen with hypoactive bowel sounds. The patient had a leukocytosis of 18,000 and abdominal CT scan revealed right lower quadrant inflammatory changes suggestive of acute appendicitis. Laparoscopic exploration revealed an inflamed gangrenous structure adjacent to the ileocecal junction. Pathologic evaluation revealed tissue consistent with epiploic appendagitis. Retrospective review of the CT scan revealed a normal appearing appendiceal structure supero-lateral to the area of inflammation. The patient recovered uneventfully with resolving leukocytosis. We present a case of cecal epiploic appendagitis mimicking acute appendicitis and review the current literature on radiographic findings, diagnosis, and treatment of this often misdiagnosed condition. General surgeons should be aware of this self-limiting condition and consider this in the differential diagnosis.

Adrenal myelolipoma: report of a case and review of the literature.

Adrenal myelolipoma is a rare benign tumor composed of mature lipomatous and hemopoietic tissue. Although it is often discovered as an incidental finding on imaging of the abdomen for some other reason or at autopsy, adrenal myelolipoma has been reported to present with symptoms such as flank pain resulting from tumor bulk, necrosis, or spontaneous retroperitoneal hemorrhage. Myelolipomas are hormonally inactive but have also been reported to coexist with other hormonally active tumors of the adrenal gland. They are usually unilateral but may be bilateral and may also develop in extraadrenal sites like the retroperitoneum, thorax, and pelvis. We report a patient with symptomatic adrenal myelolipoma diagnosed on computed tomography scan and confirmed on computed tomography-guided biopsy. The patient underwent surgical resection for symptomatic relief. We also review the literature to evaluate the presentation and optimal management of this rare adrenal tumor that is not encountered by most general surgeons and therefore not well known to most surgeons.

Video capsule endoscopy: clinical relevance of capsule endoscopy findings.

Video capsule endoscopy (VCE) is a novel diagnostic tool for noninvasively visualizing the lumen of the entire small intestine. It is especially useful in identifying the source of obscure small intestinal bleeding. However, VCE is not always optimal for localizing small bowel lesions. Several studies show VCE to be markedly superior to standard diagnostic techniques although the true clinical relevance of many of the capsule endoscopic findings remain unknown. We present two case reports of VCE findings that resulted in surgical intervention but were found to be benign lesions on definitive pathological examination. The actual clinical relevance of many of the lesions found on VCE thus remains to be demonstrated.

Spontaneous subcapsular splenic hematoma: a rare complication of pancreatitis.

Subcapsular hematoma of the spleen is a rare complication of pancreatitis despite its close proximity to the pancreas. Pancreatic pseudocyst involving the tail of the pancreas may erode into the splenic hilum causing hilar vessel bleeding with subcapsular dissection and hematoma formation. The management of such complication is still controversial. It has been suggested that most of these complications spontaneously regress and therefore can be managed conservatively. A case of spontaneous splenic subcapsular hematoma resulting from pancreatitis was managed conservatively with a good outcome.

Parathyroid carcinoma presenting with pathologic fracture: case report and review of the literature.

BACKGROUND: Parathyroid carcinoma is a rare neoplasm representing <1% of primary hyperparathyroidism cases. It is often not diagnosed until surgical exploration as a preoperative diagnosis is often not possible. Thus, preoperative staging for most patients is not feasible and this may compromise the treatment strategy. METHODS AND RESULTS: We report a case of a 29-year-old man presenting with avulsion fracture of the right elbow after a trivial fall. Neck exploration revealed an enlarged left lobe focally adherent to the larynx and trachea. Final pathology revealed parathyroid carcinoma with focally positive margin at the site of tracheal invasion. CONCLUSION: Parathyroid carcinoma is a rare cause of primary hyperparathyroidism. The etiology of parathyroid carcinoma is usually obscured, and the initial operation offers the best chance for cure.

Solid-pseudopapillary tumor of the pancreas masquerading as a pancreatic pseudocyst.

Solid-pseudopapillary tumor of the pancreas is a very rare low-grade malignancy, predominantly occurring in adolescent girls and young women. Accurate diagnosis of this unusual tumor is important because the prognosis after surgical resection is excellent. We report a rare case of solid-pseudopapillary tumor of the pancreas in a 22-year-old woman that was misdiagnosed as a pancreatic pseudocyst on abdominal CT scan. This case emphasizes the importance of biopsying the pseudocyst wall at the time of drainage procedure if misdiagnosis is to be avoided. CT scan findings alone can not reliably rule out malignant cystic lesions of the pancreas.

The coexistence of anaplastic and papillary carcinomas of the thyroid: a case presentation and literature review.

Papillary carcinomas of the thyroid are the most common malignant growth affecting the thyroid, currently representing 60-65 per cent of malignant thyroid neoplasm. Although the etiology of this neoplasm is unknown, they are thought to be related to neck irradiation, adenoma transformation, and Hashimoto thyroiditis. Papillary carcinomas are usually purely papillary but occasionally have areas of histologically different neoplasm, most commonly follicular. Overall, these carcinomas represent an indolent group of neoplasm and have an excellent prognosis. The occurrence of an anaplastic area in a papillary carcinoma represents the dedifferentiation of the primary neoplasm. This is an extremely rare occurrence and is considered to have negative prognostic significance. The purpose of this presentation is to discuss an unusual clinical case of a coexisting anaplastic and papillary carcinoma of the thyroid, diagnosed by fine needle aspiration (FNA) analysis presenting in a 67-year-old African-American woman. Evaluation and treatment will be discussed.

Stercoral perforation of the sigmoid colon: report of a rare case and its possible association with nonsteroidal anti-inflammatory drugs.

Stercoral perforation of the colon is a rare phenomenon with fewer than 90 cases reported in the literature to date. The pathogenesis of stercoral ulceration is thought to result from ischemic pressure necrosis of the bowel wall caused by a stercoraceous mass. Stercoral perforation in more than 90 per cent of cases involves the sigmoid or rectosigmoid colon with associated fecal mass causing localized mucosal ulceration and bowel wall thinning due to localized pressure effect. We report the case of a 45-year-old woman who presented with a 12-hour history of epigastric pain. Significant comorbidities included systemic lupus erythematosus, sarcoidosis, hypertension, and previous history of congestive heart failure. The patient was also on prednisone and a nonsteroidal anti-inflammatory drug for joint pains. On physical examination the patient had signs of generalized peritonitis. Chest X-ray showed significant free air under the diaphragm. Emergency laparotomy revealed localized perforation over the antimesenteric border of the sigmoid colon with associated stercoral mass at the site of perforation. A segmental resection of the sigmoid colon with end colostomy (Hartmann's procedure) was performed. The patient made an uneventful recovery. Stercoral perforation is often a consequence of chronic constipation; however, there are other predisposing factors as the condition is rare compared with the frequency of severe constipation. One of the hypotheses includes the association of nonsteroidal anti-inflammatory drugs (NSAIDs) with stercoral perforation of the colon. Our case report lends support to this association with NSAID use; thus there need to be greater awareness and caution when using NSAIDs in chronically constipated patients.

Malignant duodenal somatostatinoma presenting in association with von Recklinghausen disease.

Somatostatinomas are extremely rare periampullary malignant neuroendocrine tumors that may be associated with von Recklinghausen disease or type-I neurofibromatosis. Duodenal somatostatinomas are distinguished from pancreatic somatostatinomas by their frequent association with type-I neurofibromatosis and typically absence of somatostatinoma syndrome. We report a very rare and atypical case of malignant duodenal somatostatinoma presenting with somatostatinoma syndrome in association with type-I neurofibromatosis.