Complete postsurgical left ventricular-aortic discontinuity and pseudoaneurysm formation.

BACKGROUND: Left ventricular outflow tract pseudoaneurysm is a rare but potentially fatal complication of aortic valve replacement, infective endocarditis (IE), and suture dehiscence. Left ventricular-aortic discontinuity is a severe and uncommon manifestation of IE. For patients who have a long-standing history of endocarditis, periannular lesions in the aortic valve may rupture, leading to the rare occurrence of complete, or total, left ventricular-aortic discontinuity. METHODS: We present a case of complete postoperative left ventricular-aortic discontinuity and massive circumferential left ventricular outflow tract pseudoaneurysm discovered during a 3-month follow-up visit. Appropriate consent was obtained from all parties before submission of this case report. RESULTS: Postoperative cardiac computed tomography of a patient demonstrated dehiscence of a recently placed surgical aortic valve from the left ventricular outflow tract, with massive circumferential pseudoaneurysm formation. Only a small remnant of the membranous interventricular septum connected the aortic root to the heart, informing the diagnosis of complete left ventricular-aortic discontinuity. CONCLUSION: The clinical presentation of a left ventricular outflow tract pseudoaneurysm with concomitant left ventricular-aortic discontinuity is commonly nonspecific or clinically silent; thus, it requires a high index of suspicion and use of multimodality imaging for diagnosis and management.

A RARE CASE OF RAPIDLY ENLARGING MYELOLIPOMA IN SICKLE CELL DISEASE.

OBJECTIVE: Adrenal myelolipoma (AM) is a benign tumor composed of mature fat cells and hemopoietic elements. Most AMs are incidental findings on imaging and clinically asymptomatic. The purpose of this case report is to describe a rare case of AM and explore its clinical manifestations, imaging features, and treatment. METHODS: In this study, we report a case of a rapidly growing right AM in a patient with uncontrolled hemoglobin sickle cell disease. A 38-year-old male presented to our institution's endocrine surgery clinic for evaluation of an enlarging right adrenal mass. This mass was incidentally found during an abdominal ultrasound performed for transaminitis and thrombocytopenia. Patient was asymptomatic without any abdominal discomfort, back pain, nausea, or vomiting. RESULTS: Patient was lost to follow up until 2018. Follow-up computed tomography scan in 2018 showed the right adrenal mass measuring 12.3 cm in greatest dimension with significant macroscopic fat. Given the imaging features, AM was the presumed diagnosis. However, with a medical history of uncontrolled sickle cell disease, extra-medullary hematopoiesis and rapidly growing liposarcoma could not be ruled out. Surgical excision was performed due to size and significant tumor growth. Diagnosis was confirmed with histopathology and revealed myelolipoma. CONCLUSION: Image characteristics can be helpful in diagnosis of AM; however, the appearance of this lesion on computed tomography can be similar to other adrenal gland pathologies such as liposarcoma and mass-forming extramedullary hematopoiesis. Percutaneous needle biopsy may be indicated if the diagnosis remains unclear.

Stroke as the initial presentation of Takayasu's arteritis: A case report.

In this study, we report the case of a pediatric neurology stroke patient who was ultimately diagnosed with Takayasu's Arteritis. Our case describes a 14-year-old Hispanic female with no significant past medical history who presented to an outside hospital for acute onset of confusion and right sided weakness. She was given tissue plasminogen activator (TPA) at the outside hospital and transferred as a stroke alert. Initial The NIH stroke scale (NIHSS) was 12 with primarily right sided symptoms. Physical exam was also significant for asymmetric pulses and blood pressures. Imaging was significant for multifocal stenosis. She was ultimately diagnosed with Takayasu's arteritis and treated with a multidisciplinary approach including pediatrics, neurology and rheumatology. This case represents an important differential diagnosis for pediatric stroke patients including those who have stroke as the presenting symptom of this systemic disease.

A Preoperative Cognitive Screening Test Predicts Increased Length of Stay in a Frail Population: A Retrospective Case-Control Study.

BACKGROUND: Frailty is associated with adverse perioperative outcomes including major morbidity, mortality, and increased length of stay. We sought to elucidate the role that a preoperatively assessed Mini-Cog can play in assessing the risk of adverse perioperative outcomes in a population at high risk of frailty. METHODS: In this retrospective case-control study, patients who were >60 years of age, nonambulatory, or had >5 documented medications were preoperatively assessed for handgrip strength, walking speed, and Mini-Cog score. The Emory University Clinical Data Warehouse was then used to extract this information and other perioperative data elements and outcomes data. RESULTS: Data were available for 1132 patients undergoing a wide variety of surgical procedures. For the subset of 747 patients with data for observed-to-expected length of stay, an abnormal Mini-Cog was associated with an increased odds of observed-to-expected >1 (odds ratio, 1.52; 95% CI, 1.05-2.19; P = .025). There was no association of abnormal Mini-Cog with intensive care unit length of stay >3 days (P = .182) discharge to home with self-care (P = .873) or risk of readmission (P = .104). Decreased baseline hemoglobin was associated with increased risk of 2 of the 4 outcomes studied. CONCLUSIONS: In a high-risk pool of patients, Mini-Cog may not be sensitive enough to detect significant differences for most adverse outcomes. Further work is needed to assess whether cognitive screens with greater resolution are of value in this context and to compare tools for assessing overall frailty status.

Infrared pupillometry helps to detect and predict delirium in the post-anesthesia care unit.

This study evaluates the capability of pupillary parameters to detect and predict delirium in the post-anesthesia care unit (PACU-D) following general anesthesia. PACU-D may complicate and prolong the patient's postoperative course, consequently increasing hospital costs. After institutional approval, 47 patients undergoing surgical interventions with general anesthesia were included in the study. We measured the pupillary reflexes at signing of informed consent, during surgery 20 min after intubation and when the primary inhaled anesthetic was turned off, and 15 and 45 min after PACU admittance and upon discharge from the PACU. We evaluated patients for delirium using the confusion assessment method for the intensive care unit (CAM-ICU) score after 15 and 60 min in the PACU. We chose receiver operating curve (ROC) and area under the curve (AUC) to compare the performance of non-pupillary parameters to pupillary parameters, such as pupil diameter, percent constriction, and dilation velocity, to detect and predict PACU-D. Percent constriction (AUC = 0.93, optimal threshold = 18.5%) and dilation velocity (AUC = 0.93, optimal threshold = 0.35 mm/s) showed excellent ability to detect and predict delirium persisting throughout the PACU stay. These pupillary measures showed superior performance compared to other pupillary measures and features commonly associated with delirium, e.g., age (AUC = 0.73), total opioids (AUC = 0.56), or length of surgery (AUC = 0.40). Our results suggest that pupillometry and the parameters derived from the recording may identify delirious patients in the PACU. This information can help to efficiently structure their care in a timely manner, and potentially avoid adverse complications for the patient and financial consequences for the hospital.

Dopamine Transporter Activity Is Modulated by α-Synuclein.

The duration and strength of the dopaminergic signal are regulated by the dopamine transporter (DAT). Drug addiction and neurodegenerative and neuropsychiatric diseases have all been associated with altered DAT activity. The membrane localization and the activity of DAT are regulated by a number of intracellular proteins. α-Synuclein, a protein partner of DAT, is implicated in neurodegenerative disease and drug addiction. Little is known about the regulatory mechanisms of the interaction between DAT and α-synuclein, the cellular location of this interaction, and the functional consequences of this interaction on the basal, amphetamine-induced DAT-mediated dopamine efflux, and membrane microdomain distribution of the transporter. Here, we found that the majority of DAT·α-synuclein protein complexes are found at the plasma membrane of dopaminergic neurons or mammalian cells and that the amphetamine-mediated increase in DAT activity enhances the association of these proteins at the plasma membrane. Further examination of the interaction of DAT and α-synuclein revealed a transient interaction between these two proteins at the plasma membrane. Additionally, we found DAT-induced membrane depolarization enhances plasma membrane localization of α-synuclein, which in turn increases dopamine efflux and enhances DAT localization in cholesterol-rich membrane microdomains.

Dopamine Transporter Activity Is Modulated by α-synuclein.

The duration and strength of the dopaminergic signal is regulated by the dopamine transporter (DAT). Drug addiction, neurodegenerative and neuropsychiatric diseases have all been associated with altered DAT activity. The membrane localization and the activity of DAT are regulated by a number of intracellular proteins. α-synuclein, a protein partner of DAT, is implicated in neurodegenerative disease and drug addiction. Little is known about the regulatory mechanisms of the interaction between DAT and α-synuclein, the cellular location of this interaction, and the functional consequences of this interaction on the basal, amphetamine (AMPH) induced DAT-meditated DA efflux and membrane microdomain distribution of the transporter. Here, we found that the majority of DAT/α-synuclein protein complexes are found at the plasma membrane of dopaminergic neurons or mammalian cells, and that AMPH-mediated increase in DAT activity enhances the association of these proteins at the plasma membrane. Further examination of the interaction of DAT and α-synuclein revealed a transient interaction between these two proteins at the plasma membrane. Additionally, we found DAT-induced membrane depolarization enhances plasma membrane localization of α-synuclein, which in turn increases DA efflux and enhances DAT localization in cholesterol rich membrane microdomains.