Case of anisakiasis presenting as an Amyand hernia.

This is a case of a 31-year-old male patient who presented with signs and symptoms of an incarcerated inguinal hernia. The patient's preoperative imaging showed a tubular structure in the inguinal canal and given the patient's history at presentation, there was a concern for herniation of the appendix, known as an Amyand hernia. On laparoscopy, there was no evidence of appendiceal involvement and a standard open inguinal hernia was completed. On the final pathology of the hernia sac, roundworms were identified with Y-shaped lateral cords suggesting infection by Anisakis spp. On a further interview with the patient, he revealed that he had recently travelled to Alaska and had consumed raw salmon on a fishing trip. This case demonstrates the importance of a thorough social and travel history. One should also have a low threshold to broaden the differential diagnosis when medical work-up deviates from the standard course.

Ferrier Carbocyclization-Mediated Synthesis of Enantiopure Azido Inositol Analogues.

Azide-modified inositol (InoAz) analogues are valuable as inhibitors and have shown promise as metabolic chemical reporters (MCRs) for labeling inositol-containing glycoconjugates in eukaryotic cells and potentially in mycobacteria, but the synthesis of enantiomerically pure InoAz analogues via traditional approaches is challenging. As a complementary route, here we investigated the application of the Ferrier carbocyclization reaction to the synthesis of enantiopure InoAz analogues starting from readily available azido glucosides. Using this approach combined with a para-methoxybenzyl protecting group strategy, 3-azido-3-deoxy- and 4-azido-4-deoxy-d-myo-inositol were efficiently synthesized. 5-Azido-5-deoxy-d-myo-inositol was inaccessible due to an unusual ß-elimination reaction, wherein the azide anion acted as the leaving group. The reported strategy is expected to facilitate continued development of synthetic InoAz analogues as inhibitors or MCRs of inositol-containing glycoconjugates in eukaryotic and mycobacterial systems.

Extensive multifocal mammary infarction - a case report.

BACKGROUND: Breast infarction can occur in benign breast lesions, such as fibroadenomas, as well as healthy breast tissue, typically in the gravid or lactating patient. Few theories, however, exist to explain this unusual lesion. CASE REPORT: We present a very rare case of a 27-year-old female patient with extensive, multifocal, bilateral mammary infarction. A literature search was also performed to confirm its rarity. Although solitary or limited areas of spontaneous infarction have been documented, there are no documented cases where such a large, multifocal area of involvement has occurred without obvious explanation. CONCLUSION: Extensive multifocal post-partum breast infarction is a rare occurrence that has potential long-term effects. This should be considered when taking patient history in post-partum patients, as well as those with extensive calcifications on mammogram years after giving birth.

Paradoxical hemodynamic instability complicating pericardial window surgery for cardiac tamponade in a cancer patient.

Paradoxical hemodynamic instability is defined as unexpected hemodynamic compromise that develops in a patient after pericardial fluid drainage. The overall incidence of the condition is about 5%, and it has a high in-hospital mortality rate. The condition has been reported to occur regardless of the approach that is used to drain the fluid or the underlying cause of the disease. The pathophysiology of paradoxical hemodynamic instability and the appropriate intervention are not very clear, and further studies are needed to identify appropriate preventive measures.We report a rare manifestation of paradoxical hemodynamic instability in a 65-year-old woman who had a history of stage IV lung cancer. She presented with a one-week history of pleuritic chest pain and shortness of breath on exertion. Echocardiography revealed a large circumferential pericardial effusion with right atrial and ventricular collapse during diastole, suggesting a compressive effect of the pericardial fluid; however, left ventricular systolic function was well preserved. The patient underwent the scheduled creation of a subxiphoid pericardial window. Immediately after the pericardial fluid was evacuated, her heart began to beat more vigorously, but this was abruptly followed by an episode of asystole. Pacing and medical therapy were unsuccessful in preventing repeated episodes of asystole, and the patient died.To our knowledge, this is the 2nd report of unexpected asystole after the creation of a subxiphoid pericardial window, and it is the first report of a takotsubo-like contractile pattern associated with paradoxical hemodynamic instability.

Disparities in access to video-assisted thoracic surgical lobectomy for treatment of early-stage lung cancer.

BACKGROUND: Video-assisted thoracic surgical (VATS) lobectomy was originally described in 1992 and has slowly gained increasing acceptance. This study documents current utilization and outcomes for VATS versus open lobectomy in three Mid-Atlantic states. SUBJECTS AND METHODS: Inpatient discharge claims data were queried for all lobectomies performed for cancer in the Mid-Atlantic United States (New Jersey, New York, and Pennsylvania) between October 2007 and December 2008. Associations between sociodemographic factors and likelihood of undergoing VATS were tested with multiple logistic regressions. Outcomes were compared using two-sample t tests. RESULTS: There were 5489 lobectomies included. Forty-seven percent of patients were men, and 62% were ≥65 years old. Thirty-two percent (1741 of 5489) were VATS lobectomies. Men were less likely to undergo VATS (odds ratio 0.86, P=.004); those ≥65 years old were more likely to undergo VATS (odds ratio 1.34, P=.009). Uninsured patients underwent VATS less often (odds ratio 0.46, P=.01). Patients from rural areas were less likely to undergo VATS (odds ratio 0.67, P=.001), although travel distances for both groups were similar. A total of 44% of these hospitals (125 of 284) performed only open lobectomies. Patients without private insurance or Medicare were less likely to undergo a VATS lobectomy (P=0.01). In general, the likelihood of VATS lobectomy increased as hospital lobectomy volume increased. VATS patients had a shorter median length of stay (5 versus 6 days, P<.001) and a higher rate of discharge to home (92.5% versus 89.5%, P<.001). Mean total hospital costs were less for VATS patients ($49,948 versus $56,280, P<.001). In-hospital mortality was less for VATS patients (1.2% versus 2.1%, P=.013). CONCLUSION: For the period studied, patients in rural areas, in low-volume hospitals, who had Medicaid, or with lower median incomes underwent VATS lobectomy less often.

Benign metastasizing leiomyoma: a rare cause of multiple pulmonary nodules.

Benign metastasizing leiomyoma (BML) is a rare cause of pulmonary nodules that occurs when uterine leiomyomas metastasize to the lung. The management of these lesions varies from resection and hysterectomy to nonsurgical treatments such as hormonal therapy. We report a case of a 45-year-old woman with multiple nodules of the right lung identified during preoperative imaging before her hysterectomy for uterine fibroids.

Initial results of minimally invasive Ivor Lewis esophagectomy after induction chemoradiation (50.4 gy) for esophageal cancer.

OBJECTIVE: Esophageal cancer patients receiving induction chemoradiation to 41 Gy randomized to minimally invasive (MIS) esophagectomy have fewer postoperative pulmonary complications compared with those who underwent open procedures. We evaluated the feasibility of MIS Ivor Lewis esophagectomy in patients treated with induction chemoradiation to 50.4 Gy. METHODS: We retrospectively analyzed clinical data from 30 consecutive patients undergoing MIS Ivor Lewis esophagectomy after induction chemoradiation to a mean dose of 50.4 Gy by a single surgeon at a tertiary institution since 2010. Data collected included patient demographics, preoperative risk factors, neoadjuvant treatment modalities, histology, staging, operative factors, and perioperative complications. RESULTS: The mean age of the patients was 61 ± 9.5 years, and 87% were men. The dominant histology was adenocarcinoma (90%), with most tumors (70%) located at the gastroesophageal junction. A total of 22 patients (73%) presented with dysphagia, but only 15 (50%) had associated weight loss (mean 12.2% total body mass). All patients had R0 resections; mean number of resected lymph nodes was 27.1 ± 11.4. Mean operating room time was 535 ± 120 minutes, with the last 10 operations 2 hours shorter than the preceding 20. Four patients (13.3%) had major complications. including 2 (6.7%) anastomotic leaks. There was no operative mortality. CONCLUSIONS: Minimally invasive Ivor Lewis esophagectomy after chemoradiation to 50.4 Gy can be performed with decreased morbidity and mortality compared with historical series of open Ivor Lewis esophagectomy. Oncologic outcomes were acceptable as demonstrated by lymph node retrieval and complete resection rates. Operative time decreased significantly after 20 cases.