Between a Clot and a Scarred Place

Immobilized orthopedic trauma patients face an elevated risk of venous thromboembolism (VTE). We present a case in which a patient undergoing staged repair of traumatic orthopedic injuries developed deep venous thrombosis (DVT) during hospitalization, prior to repair of a lower extremity injury for which delay in operation might result in poor functional outcome. We provide an overview of recommendations regarding pharmacologic prophylaxis of VTE in orthopedic patients. We review the importance of cultivating a high index of suspicion for VTE in such patients, even when receiving appropriate prophylaxis and lacking overt symptoms. Finally, we outline the multidisciplinary decision-making process regarding optimizing care for the patient in a precarious position of developing acute VTE while awaiting urgent surgery. Specifically, we review the safety, efficacy, and management of retrievable inferior vena cava filters (rIVCF) for this population.     

Between a Rock and a Hard Place

• SFA disease has unique challenges
• A myriad of interventional techniques have been proposed to treat calcific femoral disease
• It appears a combination of atherectomy and drug elution may be the procedure of choice in these patients
• New innovative therapies may be a viable option in the future

     

Left aortic arch without a circumflex segment and a right descending aorta: a hypothetical case and a real example

We studied a case of a patent left ductus arteriosus, with a left aortic arch connected to a right descending aorta without an aortic circumflex (retroesophageal) segment. We believe this is the first world-published example of this--so far--hypothetical anomaly, included in Kirkling and Edwards classification of vascular rings. The case was a 27-year-old deaf-mute female patient with a patent left ductus arteriosus, with important left to right shunt and moderate pulmonary arterial hypertension who underwent a successful closing surgical procedure. In the aortographic study a left (normal) aortic arch was seen, which after giving off a large left ductus arteriosus, crossed to the right and connected to a right descending aorta. In the upper part of the thorax the esophagus and trachea were displaced to the right by the left aortic arch. The esophagus in the middle and the upper inferior parts of the thorax was also displaced to the right by the descending right aortic segment. Complete vascular ring was not evident. The case--although without clinical importance--reinforces the pathogenic concept of the Rathke diagram of a complete double aortic primitive arch originating the pulmonary and supraaortic vascular structures which are formed by the obliteration or disappearance of particular segments of the structure. This knowledge explains the embryogenesis of these complex anomalies. Our case is believed to be formed by the very early disappearance of a frontal portion of the primitive left dorsal aorta.     

Between a rock and a hard place: TAVR and ESRD

• Aortic stenosis in combination with end‐stage renal disease (ESRD) is a high‐risk combination for surgical valve replacement and little data exists on the role of transcatheter aortic valve replacement (TAVR)
• Pooled retrospective data from eight experienced TAVR sites suggests that TAVR can be accomplished in ESRD patients with first generation percutaneous valve at a risk similar to surgical approaches.
• Even with TAVR, valve replacement in the ESRD patient remain high risk and future improvements in technology and approaches to this poorly studied group are needed.

     

Ochronosis: a report of a case and a review of literature

A patient with alkaptonuria and ochronotic pigment deposited in articular cartilage and sclerae clinically manifested a serious osteoarthritis of the peripheral and axial joints and synchondrosis, typically involved in long lasting cases of this hereditary defect of homogentisic acid oxidase. This is the first patient with this disorder reported, where a non-cemented total knee prosthesis (PCAR) was applied on both knees. This was possible due to the good quality of the bone stock, which did not seem to be impaired by ochronosis. Our patient had no cardiac symptoms or murmurs, but had a slight calcification in the annulus of aorta observed with echocardiography, a useful new method for screening this disease manifestation. A third new aspect reported is the immunopathology of the synovial tissue. Small pieces of torn-off cartilage were seen embedded in the synovial stroma. This was associated with a slight hyperplasia of the C3bi-receptor positive and proline hydroxylase positive type A and B synovial lining cells. Perivenular infiltrates contained CD2 positive T lymphocytes, mostly belonging to the CD4 subset, and some C3bi-receptor positive monocytes. Activated CD25 positive and immunoglobulin light chain positive T and B lymphocytes were absent or few. Because modern medicine has much to offer to those suffering from this ancient inborn error of metabolism in the form of new specific diagnostic methods and new surgical modes of treatment, such as endoprosthesis surgery and cardiac valve replacement, we also present a literature overview of this interesting condition.     

以医学微生物学及免疫学系列课程建设为载体的师资队伍建设

建设高素质及优秀的教学团队,是培养高水平创新型人才的保障。在实施医学微生物学及免疫学系列课程申报与建设的实践中,使教师队伍得到锻炼和成长,迅速提高业务素质和水平,成为优秀的教学团队,为医药学人才培养做出了积极的贡献。     

Disclosing a dementia diagnosis: a review of opinion and practice, and a proposed research agenda

PURPOSE: The ethical and practical issues in disclosing a dementia diagnosis remain subjects of some debate. In this review of the literature we document previous opinion and practice in the area of diagnostic disclosure. DESIGN AND METHODS: We identified sources for this review with a MEDLINE and PsycINFO database search, followed by collection of additional articles from reference lists. RESULTS: Across sources we were able to identify a broad list of arguments both for and against diagnostic disclosure. We briefly discuss some of the ethical principles that undergird those reasons. IMPLICATIONS: Practice guidelines and professional opinion regarding disclosure appear to depart from the actual experience reported by clinicians, patients, and family members. At a more detailed level, process issues in disclosure, such as who is told, how and what they are told, and the impact of disclosure, are poorly understood. Sensitivity to individual differences may promote an optimal approach to disclosure. Research in this area is sparse and often contradictory, and throughout the review we propose research questions that, when answered, could clarify issues in disclosure that are essential to sound dementia care.