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Background Abnormal elevation in serum lipids is extremely common. Hypertriglyceridemia may be primary or a secondary disorder related to alcohol abuse, diabetes, and even pregnancy. If severe, hypertriglyceridemia can have serious medical consequences including the potentially life-threatening complication of acute pancreatitis. We present a case of a pregnant woman presenting with severe hypertriglyceridemia and acute pancreatitis eventually suffering fetal distress requiring emergent caesarean section and the use of plasmapheresis when conservative treatments failed to significantly reduce her triglyceride levels. Case Presentation 29-year-old woman G1P0 at 32 weeks gestation with a past medical history of HBV and hyperlipidemia presented with sharp right upper quadrant abdominal pain, nausea and vomiting for one day. She began having contractions, developed vaginal bleeding, and was taken for primary cesarean section due to placenta abruptia. Copious amounts of whitish, malodorous fluid was observed in the abdomen during the procedure. The patient was found to have acute pancreatitis with an initial amylase level of 251 and a lipase level of 736, peaking on the second day of admission to lipase-1625 and amylase-1499. CT scan of the abdomen and pelvis revealed severe pancreatitis with an enlarged, edematous pancreas with extensive peripancreatic inflammatory. Triglyceride levels were not measurable and the blood was noted to be grossly lipemic. The patient was started on fenofibrate, antibiotic therapy, and aggressive calcium replacement. On day 3 of the hospital stay, after no improvement in clinical status or triglyceride levels, the patient received plasmapheresis. On day 4 of the hospital stay the triglyceride level was detectable at 313. Amylase and lipase levels returned to normal levels after 1 week and the triglycerides remained between 313 and 685 during the course of the hospital stay. Conclusion Although experience with plasmapheresis in the above setting is limited, it has been shown to be a rapid and effective intervention for the emergent management of severe hypertriglyceridemia induced pancreatitis reducing triglyceride levels significantly within hours as was shown in our case. Plasmapheresis should be considered early in the course of treatment when severe hypertriglyceridemia is the cause of acute pancreatitis. Multiple sessions may be needed and the patient should be followed closely both clinically and biochemically

Introduction: Mediastinal histoplasmosis present as mediastinal adenitis, granulomas or fibrosing mediastinitis. Whether these are different faces of a continuous spectrum of disease is not yet confirmed. Below is a case of mediastinal granulomas with evolving fibrosis. An extensive literature review from 1951 to 2011, revealing over 200 cases will also be detailed. Case Presentation: A 19 year old man non-smoker presented with dyspnea, night sweats, fever and non-productive cough. Paternal history was significant for lymphomas. His lungs were clear and there were no palpable lymphadenopathies. CXR revealed a right mediastinal mass/adenopathy. Chest CT showed extensive calcified mediastinal adenopathies, soft tissue densities encircling the right main bronchus and air space disease of the RML. His PPD, HIV test and sputum AFB smears and cultures were all negative. Inspection bronchoscopy showed bulging of the main carina and narrowing of the right main bronchus. EBUS lymph node sampling as well as BAL were negative for viral, bacterial, fungal, AFB cultures and malignancies. Mediastinoscopy with biopsy showed fibrotic lymphoid tissue with areas of caseating necrotizing granulomas, fibrosis and scattered calcifications. Therapy was initiated with itraconazole. Discussion: Primary histoplasmosis is usually a self-limited respiratory infection. Coalescence of caseous mediastinal lymph nodes results in mediastinal granulomas. These presents with cough, chest pain, dysphagia, hemoptysis, and dyspnea. Compression of the SVC, esophagus, or airways, and disruption of the capsule creating fistulas may all be seen. Cultures are usually negative, as are special stains for organisms. This was the case with our patient. Imaging reveals heavy calcifications, the presence of which may obviate the need for biopsy for tissue diagnosis as per some authorities. Urinary antigen and blood or bone marrow cultures are most useful in AIDS patients with disseminated diseases. Skin tests and serologies are not useful diagnostically because of high background rates of positivity in endemic areas. Differential diagnosis includes tuberculosis, other fungal infections, lymphomas post-radiation, metastases especially mucinous adenocarcinoma, sarcoidosis, and silicosis. Most authorities believe that neither antifungal nor anti-inflammatory treatment ameliorates the outcome of fibrosing mediastinitis. Our patient had both spectrum of diseases with mediastinal fibrosis revealed by the soft tissue densities encircling the right main bronchus. This explains his presentation with a post-obstructive pneumonia. Our case brings more questions than answers. What are the optimal tests to confirm histoplasmosis? Does treatment with anti-fungals prevent the mediastinal granulomas from evolving into the more devastating late complication of mediastinal fibrosis? (Figure Presented)

PURPOSE: To evaluate factors that influence corneal flap thickness with the Hansatome microkeratome. METHODS: One hundred thirty-two eyes of 70 patients underwent laser in situ keratomileusis (LASIK). Corneal flap thickness was measured by subtracting the intraoperative corneal bed pachymetry measurement from intraoperative total corneal pachymetry. Variables examined included plate thickness, ring size, blade use, temperature, humidity, barometric pressure, age, average keratometric power, and preoperative corneal thickness. RESULTS: Mean flap thickness using a 180-microm plate was 143 +/- 19 microm (range 61 to 207 microm). Mean flap thickness using a 160-microm plate was 119 +/- 20 microm (range 83 to 159 microm). The difference was statistically significant (P < .05). Mean flap thickness using a 180-microm plate and the same blade on the right and left eye was 151 +/- 21 microm (range 113 to 200 microm) and 137 +/- 21 microm (range 91 to 191 microm), respectively. The 14-microm difference was statistically significant (P < .001). There was a slight negative correlation of flap thickness with humidity. There was a positive correlation with preoperative corneal thickness (pachymetry). CONCLUSION: The Hansatome tended to cut thinner flaps than anticipated based on the plate used. Flaps cut on the first eye were thicker than the second eye using the same blade. Thicker corneas tended to lead to thicker flaps. There was no correlation between flap thickness and microkeratome ring size, temperature, barometric pressure, patient age, or average keratometric power.

BACKGROUND: The authors have reviewed their initial experience with laparoscopic splenectomy (LS) to identify the indications, success rate, and complications associated with this procedure compared with a series of children undergoing open splenectomy (OS) during the same time period. METHODS: The records of 51 children who underwent splenectomy from 1993 through 1998 were reviewed retrospectively. RESULTS: Thirty-five patients aged 1 to 17 years (mean, 9.4 years) underwent LS for the following indications: ITP (n = 20), sickle cell disease or thalassemia (n = 6), hereditary spherocytosis (n = 5), other hematologic disorders (n = 4). Seventeen patients aged 2 to 17 years (mean, 11.8 years) underwent OS during the same time period for ITP (n = 4), sickle cell disease or thalassemia (n = 4), hereditary spherocytosis (n = 5), and other indications (n = 4). Concomitant cholecystectomy was performed in 4 of 35 LS and 4 of 17 OS. Accessory spleens were identified in 10 of 35 LS and 2 of 17 OS cases. Eleven spleens were enlarged in the LS group, and 8 were enlarged in the OS group. One LS required conversion to an open procedure because the spleen did not fit in the bag. No other cases were converted. Median estimated blood loss was 50 mL for both the LS and OS groups. The only intraoperative complication in the LS group was a splenic capsular tear, which had no effect on the successful laparoscopic removal of the spleen. No patient in either group required a blood transfusion. The LS patients had a shorter length of hospital stay (1.8 +/- 1 versus 4.0 +/- 1 day, P = .0001). Total hospital charges were not significantly different. Follow-up ranged from 6 to 40 months. One LS patient died 47 days postoperatively from unrelated causes. Two LS patients had recurrent ITP; accessory spleens were found in one and resected laparoscopically. CONCLUSION: LS in children can be performed safely with a low conversion rate (2.9%) and is associated with a shorter hospital stay and comparable total hospital cost when compared with OS.