Ewing Sarcoma-Chest Wall Reconstruction Following Resection of Rare Primary Chest Wall Tumor.

Ewing sarcoma (ES) represents the second most common primary osseous malignancy in children and young adults, most often occurring in the diaphysis of the long bones. While rare, ES can present as an osseous tumor of the ribs and/or chest wall. These tumors are known as Askin's tumors and most commonly present with symptoms resembling pneumonia. We report the case of a 26-year-old man who was found to have a right lung mass extending into his anterolateral chest wall after presenting to the hospital for evaluation of unremitting chest pain. Biopsy was performed and the patient diagnosed with ES. After completion of neoadjuvant chemotherapy, the patient underwent resection of the right chest wall mass. The chest wall was reconstructed in a novel fashion with titanium plates and a reinforced tissue matrix patch. Due to a paucity of cases, no treatment or reconstruction algorithm currently exists for management of these malignancies.

Pleural Endometriosis: An Atypical Cause of Hemoptysis.

Endometriosis is a benign, inflammatory disease characterized by the presence of dysfunctional endometrial tissue outside the uterus. Typically confined to the pelvis, endometriosis is frequently associated with pain, dysmenorrhea, and infertility. Rarely, endometrial tissue has been documented to implant within the lung parenchyma and involve both parietal and visceral pleura of the thorax. Manifestations of thoracic endometriosis include catamenial pneumothorax, hemothorax, and hemoptysis. We present a case of thoracic endometriosis in a 43-year-old female who was found to have a loculated pleural effusion with an associated pleural nodule after gynecologic surgery. The patient underwent thoracotomy, decortication, and nodule excision. Pathology of the pleural nodule showed evidence of endometrial tissue within the parietal pleural. Thoracic endometriosis is a medical problem that is frequently undiagnosed and encountered by the practicing surgeon. Early diagnosis reduces both disease progression and late complications, allowing for early initiation of appropriate medical and surgical therapy.

Paradoxical Emboli as a Cause of Stroke.

Cerebrovascular embolic strokes are responsible for significant morbidity. 40% of strokes have no inciting cause and are thought to be the result of paradoxical emboli (PDE) passing into the arterial system by way of intra-cardiac or pulmonary vascular defects. We present two cases of PDE resulting in acute ischemic events. A 63-year-old female presented for evaluation of left upper extremity numbness. Imaging was significant for an acute right middle cerebral artery infarct and evidence of a large saddle pulmonary embolism. The patient's stroke was postulated to have been secondary to a patent foramen ovale (PFO). An 87-year-old male presented for evaluation of chest pain. The patient underwent three-vessel CABG and experienced an acute left hemispheric stroke post-operatively. Transthoracic echocardiogram demonstrated a biatrial thrombus transversing a PFO and was postulated to have been the cause. The prompt diagnosis of PDE is paramount to preventing the morbidity associated with repeat ischemic events.

Successful Cesarean Section in a COVID-19 Patient on Extracorporeal Membrane Oxygenation (ECMO).

The pandemic of COVID-19-related respiratory failure has increased utilization of ECMO in diverse patient populations. There are limited published reports of ECMO use in pregnancy, and reports of successful delivery of the fetus with survival of the mother on ECMO are exceptionally rare. We present a case of Cesarean section while on ECMO for COVID-19-related respiratory failure with survival of both mother and infant.A 37-year-old pregnant female presented with dyspnea following a positive COVID-19 test. D-Dimer and CRP were elevated and chest radiography was consistent with COVID-19 pneumonia. Her respiratory status rapidly decompensated-requiring endotracheal intubation within 6 hours of presentation, and ultimately veno-venous ECMO cannulation. Three days later, fetal heart rate decelerations prompted emergent caesarean delivery. The infant was transferred to the NICU and progressed well. The patient improved and she was decannulated on hospital day 22 (ECMO day 15) before discharge to rehab on hospital day 49.In this case, ECMO allowed survival of both mother and infant in an otherwise non-survivable respiratory failure. Consistent with existing reports, we believe ECMO is a viable strategy for refractory respiratory failure in the pregnant patient.

Acute Basilar Artery Occlusion and Death Secondary to Bilateral Vertebral Artery Dissection.

Vertebral artery dissection as a cause of basilar artery thrombosis is an exceedingly rare event that is associated with significant morbidity and poor outcomes. We present an unusual case of bilateral vertebral artery dissection and spinal cord compression in a 21-year-old male involved in a diving accident. The patient received limited antithrombotic therapy in pursuit of surgical spinal decompression, ultimately contributing to thrombosis of the basilar artery in the post-operative period and death following anterior cervical discectomy and fusion. Our goal is to highlight the severity of vertebral artery injury and the critical importance of treatment in the prevention of associated sequelae.

Large Primary Neuroendocrine Tumor of the Liver in a 57-year-Old Female Presenting With MSSA Bacteremia.

Primary neuroendocrine tumors (NETs) are rare forms of malignancy, representing just .5% of known cancers and having an overall incidence of 0.2/100,000. The most common sites of origin are bronchopulmonary and gastrointestinal, most commonly the appendix, pancreas, and ileum. We report the case of a 57-year-old female who was admitted for refractory MSSA bacteremia and several weeks of abdominal pain. CT imaging done on presentation demonstrated a 12.5 x 19.4 x 17.3 cm heterogeneous right liver mass with associated mass effect. The patient was taken to the operating room and a right hepatectomy and cholecystectomy were performed without complication. Histological examination revealed necrotic tumor in sheets and nests with marked nuclear pleomorphism. Immunohistochemistry demonstrated positive staining for pancytokeratin, synaptophysin, chromogranin, and TTF-1, consistent with undifferentiated NET. While rare, NETs can originate from a variety of organs outside the gastrointestinal and bronchopulmonary tract, including the liver.

Anticoagulant-induced hemorrhagic cholecystitis with hemobilia after deceased donor kidney transplant and literature review.

INTRODUCTION AND IMPORTANCE: Hemobilia and hemorrhagic cholecystitis are uncommon causes of right upper quadrant abdominal pain. The development of intra-gallbladder and biliary bleeding has been primarily associated with abdominal trauma, malignancy, liver transplant, and iatrogenic injury to the biliary tree and vasculature. Spontaneous anticoagulant induced hemorrhagic cholecystitis and hemobilia are incredibly rare events and have only been documented by a handful of case reports. CASE PRESENTATION: A 55-year-old male who had recently undergone a deceased-donor kidney transplant was transferred to our academic institution for evaluation of subjective fever, right upper quadrant abdominal and back pain. The patient demonstrated localized tenderness in the right abdomen and was found to have hemorrhagic cholecystitis on imaging. He subsequently underwent urgent cholecystectomy and recovered without any subsequent complications. CLINICAL DISCUSSION: Hemorrhagic cholecystitis and hemobilia are a rare cause of right-sided or generalized abdominal pain. Diagnosis is made primarily by pathognomonic findings on CT and US imaging. Prompt diagnosis is essential in preventing mortality and/or significant morbidity. The standard treatment consists of urgent/emergent cholecystectomy. CONCLUSION: A rare sequelae of anticoagulant use, intra-biliary bleeding must be considered as a differential diagnosis in anticoagulated patients presenting with right upper quadrant abdominal pain.

Readmission After Elective Ileostomy in Colorectal Surgery Is Predictable.

BACKGROUND AND OBJECTIVES: Patients who undergo colorectal surgery have high postoperative morbidity, with ileostomates being the most disadvantaged. Recent studies assessing readmission risk factors do not provide a specific prediction model and, if so, do not focus on patients who have had colorectal surgery; thus, the results of these studies have limited applicability to our specialized practice. We wanted to develop a prediction model for readmission within 30 days of discharge after ileostomy creation. METHODS: Patients who underwent elective ileostomy creation from 2013 to 2016 at the University of Florida were included in this retrospective study. Factors significantly associated with readmission within 30 days after discharge were identified by comparing a cohort that was readmitted within 30 days with one that was not. A practical, predictive model that stratified a patient's risk of readmission after the index procedure was developed. RESULTS: A total of 86 iliostomates were included; of those, 22 (26%) were readmitted within 30 days. Factors significantly associated with readmission included preoperative steroid use, history of diabetes, history of depression, lack of a hospital social worker or postoperative ostomy education, and the presence of complications after the index procedure. A model predicting readmission within 30 days of discharge that comprised the first 4 factors was developed, with a sensitivity of 73% and a specificity of 77%. CONCLUSION: Prediction of readmission in patients who undergo ileostomy creation is possible, suggesting interventions addressing predictive factors that may help decrease the readmission rate. Prospective validation of the model in a larger cohort is needed.

High-frequency rugose exopolysaccharide production by Vibrio cholerae strains isolated in Haiti.

In October, 2010, epidemic cholera was reported for the first time in Haiti in over 100 years. Establishment of cholera endemicity in Haiti will be dependent in large part on the continued presence of toxigenic V. cholerae O1 in aquatic reservoirs. The rugose phenotype of V. cholerae, characterized by exopolysaccharide production that confers resistance to environmental stress, is a potential contributor to environmental persistence. Using a microbiologic medium promoting high-frequency conversion of smooth to rugose (S-R) phenotype, 80 (46.5%) of 172 V. cholerae strains isolated from clinical and environmental sources in Haiti were able to convert to a rugose phenotype. Toxigenic V. cholerae O1 strains isolated at the beginning of the epidemic (2010) were significantly less likely to shift to a rugose phenotype than clinical strains isolated in 2012/2013, or environmental strains. Frequency of rugose conversion was influenced by incubation temperature and time. Appearance of the biofilm produced by a Haitian clinical rugose strain (altered biotype El Tor HC16R) differed from that of a typical El Tor rugose strain (N16961R) by confocal microscopy. On whole-genome SNP analysis, there was no phylogenetic clustering of strains showing an ability to shift to a rugose phenotype. Our data confirm the ability of Haitian clinical (and environmental) strains to shift to a protective rugose phenotype, and suggest that factors such as temperature influence the frequency of transition to this phenotype.