Wartime toxin exposure: recognising the silent killer

Wartime toxin exposures have been implicated in the genesis of malignancy in war veterans. Agent Orange, one toxin among many, has been linked to malignancy and the subcomponent phenoxyacetic acid has been associated with soft tissue sarcomas (STSs). This case demonstrates the association between a wartime toxin exposure (Agent Orange) and subsequent cancer development. Ultimately, we aim to highlight the importance of simple, specific questions in the patient history to account for previous wartime toxin exposures.

Old War Scar Revisited

In 1828, Jean Nicholas Marjolin, a French surgeon, first described the findings of a neoplastic development arising from a burn scar, now more commonly referred to as a Marjolin's ulcer. A Marjolin's ulcer describes malignant degeneration in any chronic wound. The majority of cases arises in burn scars and are often latent for decades. Marjolin ulcers have been widely identified in post-war time injuries. These ulcers may arise in almost any anatomical location. We report a case of an 82-year-old male that presented with a painful fluctuating mass on the right arm localized to the site of an old grenade blast injury he sustained many years earlier. While the presentation of these cases may be variable, the significance of proper management of the wounds is essential to optimal patient outcomes. An aggressive course and poor prognosis is associated with Marjolin's ulcers that degenerate into squamous cell carcinoma. Early detection and aggressive treatment/management with wide local excision and prompt coverage yield the best results when treating patients with Marjolin's ulcers.

A Boy with Relentless Pruritus: Job's Syndrome

Patient: Male, 6

Final Diagnosis: Job’s Syndrome (hyper IgE syndrome)

Symptoms: Pruritus

Medication: —

Clinical Procedure: None

Specialty: Allergology

Cannabinoid hyperemesis syndrome

The antiemetic properties of marijuana are well known, but there is increasing evidence of its paradoxical hyperemetic effects on the gastrointestinal tract and central nervous system, known as 'cannabinoid hyperemesis syndrome' (CHS). We report a case of CHS encountered in our outpatient clinic. We also completed a review of the literature using PubMed in patients over 18 years of age with CHS. Understanding the diagnostic criteria and risk factors associated with CHS may reduce the ordering of unnecessary and expensive investigations, and pursuing inappropriate medical and surgical treatments. Ultimately, abstaining from cannabis use leads to resolution of symptoms in the majority of patients.

Sternoclavicular Osteomyelitis in an Immunosuppressed Patient: A Case Report and Review of the Literature

Patient: Male, 62

Final Diagnosis: Sternoclavicular osteomyelitis

Symptoms: —

Medication: —

Clinical Procedure: Debridement

Specialty: Infectious Diseases

Optimal Preoperative Evaluation and Perioperative Care of the Geriatric Patient: A Surgeon's Perspective

The elderly preoperative patient benefits from an assessment that includes more than a routine physical examination and electrocardiogram. Such an assessment includes domains likely to affect the elderly: cognition, functionality, frailty, polypharmacy, nutrition, and social support. This fosters decisions based on functional age rather than chronologic age and on each patient as an individual. One such assessment is that promulgated by the American College of Surgeons National Surgery Quality Improvement Program/American Geriatrics Society Best Practice Guidelines. We should not miss any opportunity to improve results in this growing population of surgical patients.

Vagus nerve stimulation for partial and generalized epilepsy from infancy to adolescence

OBJECT

Vagus nerve stimulation (VNS) is approved by the FDA for the treatment of partial epilepsy in patients older than 12 years. Authors of the current study performed a large retrospective analysis and comparison of VNS outcomes in children with an age ≥ and < 12 years, including those with partial and generalized epilepsy.

METHODS

A retrospective review of the records of pediatric patients (age < 18 years) who had undergone primary VNS system implantation between 2001 and 2010 by a single pediatric neurosurgeon was undertaken. Considered data included demographics, epilepsy type (partial vs generalized), seizure frequency, seizure duration, postictal period duration, and antiepileptic medication use.

RESULTS

One hundred forty-six patients (49% female) were followed up for a mean of 41 months after VNS implantation. Thirty-two percent of patients had partial epilepsy and 68% had generalized epilepsy. After VNS system implantation, seizure frequency was reduced in 91% of patients, seizure duration in 50%, postictal period in 49%, and antiepileptic medication use in 75%. There was no significant difference in age, sex, or duration of follow-up according to epilepsy type. Neither was there any significant difference in seizure frequency reduction, seizure duration, postictal period, medication use, overall clinical improvement, or improvement in quality of life based on an age ≥ or < 12 years or epilepsy type.

CONCLUSIONS

Vagus nerve stimulation reduced both seizure frequency and antiepileptic medication use in the majority of pediatric patients regardless of sex, age cohort, or epilepsy type. Vagus nerve stimulation also reduced seizure duration and postictal period in approximately half of the pediatric patients. Contrary to expectation, children with partial epilepsy do not benefit from VNS at higher rates than those with generalized epilepsy.

Vagal nerve stimulator infection: a lead-salvage protocol

OBJECT

Vagal nerve stimulator (VNS) hardware infections are fraught with difficult management decisions. As with most implanted medical device-related infections, standard practice traditionally involves complete hardware removal, systemic antibiotic therapy, and subsequent reimplantation of the device. To avoid the potential morbidity of 2 repeat left carotid sheath surgical dissections, the authors have implemented a clinical protocol for managing VNS infections that involves generator removal and antibiotic therapy without lead removal.

METHODS

A prospective, single-surgeon database was compared with hospital billing records to identify patients who underwent primary implantation or reimplantation of a VNS lead, generator, or both, from January 2001 to May 2010, at Oregon Health & Science University. From these records, the authors identified patients with VNS hardware infections and characterized their management, using a lead salvage protocol.

RESULTS

In their review, the authors found a matching cohort of 206 children (age 3 months-17 years) who met the inclusion criteria. These children underwent 258 operations (including, in some children, multiple operations for generator end of life and/or lead malfunction). Six children experienced a single postimplantation infection (2.3% of the 258 operative cases), and no child experienced repeated infection. A lead-salvage protocol was used in 4 of 6 infected patients and was successful in 3 (75%), with clinical follow-up ranging from 10 months to 7.5 years. The fourth patient subsequently underwent lead removal and later reimplantation in standard fashion, with no adverse sequelae.

CONCLUSIONS

Vagal nerve stimulator lead salvage is a safe and potentially advantageous strategy in the management of VNS-related infection. Further study is necessary to validate appropriate patient selection, success rates, and risks of this approach.

Vagal nerve stimulator placement for medically refractory seizures in a child treated with phrenic nerve pacing for congenital central hypoventilation syndrome

Congenital central hypoventilation syndrome (CCHS) is a rare, idiopathic disorder characterized by a failure of automatic respiration. Abnormalities such as seizure disorder, failure to thrive, and Hirschsprung disease have been associated with CCHS. In this report, the authors discuss the use of vagal nerve stimulation (VNS) to treat a medically refractory seizure disorder in a child who had previously undergone placement of bilateral phrenic nerve stimulators for treatment of CCHS. Concomitant use of phrenic and vagal nerve stimulators has not previously been reported in the literature. No adverse reactions were noted with both devices working. Diaphragmatic pacing (DP) was clinically unaffected by VNS. The patient experienced a marked reduction in seizure frequency and severity following vagal nerve stimulator placement. Based on this case, the authors conclude that VNS is a potentially safe and efficacious treatment option for seizure disorder associated with CCHS in patients undergoing DP.

Antibiotic resistance in bacteria: novel metalloenzyme inhibitors

Beta-lactam antibiotics are among the most important drugs used to fight bacterial infection. Overuse and misuse of beta-lactam antibiotics has caused the evolution of resistance mechanisms, allowing pathogenic bacteria to survive antibiotic treatment. The major source of resistance to beta-lactam antibiotics occurs through production of enzymes called beta-lactamases capable of catalyzing hydrolysis of the beta-lactam rings in these drug compounds. The metallo-beta-lactamases have become a major threat due to their broad substrate specificities; there are no clinically useful inhibitors for these metalloenzymes. We have obtained single-stranded DNA's that are potent inhibitors of the Bacillus cereus 5/B/6 metallo-beta-lactamase. These are rapid, reversible, non-competitive inhibitors of the metalloenzyme, with K(i) and K(i)' values in the nanomolar range. The inhibition patterns and metal ion dependence of their inhibition suggest that the oligonucleotides alter the coordination of the active site metal ion(s); inhibition is efficient and highly specific. Microbiological growth experiments, using combinations of ssDNA with the beta-lactam antibiotic cephalexin, reveal that the inhibitor is capable of causing cell death in liquid cultures of both Gram-positive and Gram-negative metallo-beta-lactamase producing bacteria in the micromolar concentration range.

Adipose tissue: the new endocrine organ? A review article

Fat is either white or brown, the latter being found principally in neonates. White fat, which comprises adipocytes, pre-adipocytes, macrophages, endothelial cells, fibroblasts, and leukocytes, actively participates in hormonal and inflammatory systems. Adipokines include hormones such as leptin, adiponectin, visfatin, apelin, vaspin, hepcidine, chemerin, omentin, and inflammatory cytokines, including tumor necrosis factor alpha (TNF), monocyte chemoattractant protein-1 (MCP-1), and plasminogen activator protein (PAI). Multiple roles in metabolic and inflammatory responses have been assigned to adipokines; this review describes the molecular actions and clinical significance of the more important adipokines. The array of adipokines evidences diverse roles for adipose tissue, which looms large in the mediators of inflammation and metabolism. For this reason, treating obesity is more than a reduction of excess fat; it is also the treatment of obesity's comorbidities, many of which will some day be treated by drugs that counteract derangements induced by adipokine excesses.

Is there any role of resecting the stomach to ameliorate weight loss and sugar control in morbidly obese diabetic patients?

BACKGROUND

Among the restrictive procedures the role of restrictive vs. resecting the stomach is still ambiguous. This study evaluate which is the role of the stomach with respect to blood glucose levels (BG) and percent excess weight loss (EWL) over the 18 months after restrictive procedures in morbid obese diabetic patients.

METHODS

We retrospectively compared a group of patients who underwent partial gastrectomy (just part of the gastric body) with gastric banding (GBSR; n=27), sleeve gastrectomy (part of gastric body and complete fundus resection; LSG; n=53) to laparoscopic gastric banding (LAGB; n=100). Differences among groups at 3, 6, 12, and 18 months were evaluated by analysis of variance. The three cohorts were diabetic patients similar in BMI, age, and gender.

RESULTS

At 12 and 18 months, LSG had higher EWL (P<0.05) and lower BG (P<0.05) than did either LAGB or GBSR. There were no operative deaths.

COMPLICATIONS

LAGB-two staple-line oozing, two wound infections; LSG-one hemorrhage, two staple-line oozing, two leaks; GBSR-one hemorrhage, two wound infections. All complications were readily treated.

CONCLUSIONS

LSG provides better weight loss and glucose control at 1 year and 1.5 years after surgery than does either LAGB or GBSR, suggesting that gastric fundus resection plays an important, not yet well-defined, role.