Faculty Bibliography

Hemostasis is a major concern during the perioperative period. Changes in platelet aggregation and coagulation factors may contribute to the delicate balance between thrombosis and bleeding. We sought to better understand perioperative hemostasis by investigating the changes in platelet aggregation and coagulation factors during the perioperative period. We performed a prospective cohort analysis of 70 subjects undergoing non-emergent orthopedic surgery of the knee (n = 28), hip (n = 35), or spine (n = 7) between August 2011 and November 2011. Plasma was collected preoperatively (T1), 1-h intraoperatively (T2), 1-h (T3), 24-h (T4) and 48-h (T5) postoperatively. Platelet function testing was performed using whole blood impedance aggregometry. Coagulation assays were performed for factor VII, factor VIII, von Willebrand Factor (vWF), and fibrinogen. Of the 70 patients, mean age was 64.1 +/- 9.8 years, 61 % were female, and 74 % were Caucasian. Platelet activity decreased until 1 h postoperatively and then significantly increased above baseline at 24- and 48-h postoperatively. Compared to baseline, coagulation factors decreased intraoperatively. Factor VII activity continued to decrease, while FVIII, vWF, and fibrinogen all increased above baseline postoperatively. The results of our study indicate significant changes in platelet activity and coagulation factors during the perioperative period. Both platelet activity and markers of coagulation decrease during the intraoperative period and then some increase postoperatively. These changes may contribute to the hypercoagulabity and/or bleeding risk that occurs in the perioperative period. Future prospective studies aimed at correlating hemostatic changes with perioperative outcomes are warranted.

BACKGROUND: In 2012 the World Health Organization reported 8.7 million new cases of Tuberculosis worldwide, causing 1.4 million deaths (1). Despite modern drug therapy, this disease continues to present in novel ways and mimic other diseases causing misdiagnosis. AIM: We report this case to educate on the reason to suspect atypical Tuberculosis presentation, even if a common disease is diagnosed, when Tuberculosis remains in the differential. We also demonstrate that with globalization and patient moving between countries, that these presentations can occur in locations, where such atypical manifestations are very uncommon. CASE: We report on a 48 year old man with one month of malaise, fever, productive cough, night sweats, chills, pleuritic chest pain, weight loss and progressive non-painful swelling on his thorax. Initial diagnoses of interstitial pneumonia and a thoracic subcutaneous abscess were made. Needle drainage was attempted, with thick purulent material returned. When the sternum was not struck with the needle, a thoracic computed tomography scan was performed. A milliary pattern was noted in the lungs, with a large abscess present anteriorly, completely obliterating the manubrium, approaching the aorta with distant lesions. Subsequent analysis showed the material to be pan-sensitive M. Tuberculosis. CONCLUSION: The issue that this case raises is that when tuberculosi is in the differential, even common diseases may in fact be atypical manifestations of tuberculosis. In addition, when a shallow surgical procedure is going to be performed on the thoracic soft tissues, particularly when tuberculosis is suspected, imaging of the thorax should be obtained.

INTRODUCTION: Interstitial lung diseases associated with collagen vascular diseases are diverse. Among these, there is a low prevalence of bronchiolitis. We present a case with sudden onset of symptoms and significant advanced disease at the time of diagnosis. CASE PRESENTATION: This is the case of a 49 y/o female with Systemic Lupus Erythematosus (SLE) who presented complaining of exertional chest pain, shortness of breath, dry cough, and orthopnea for two weeks. The physical exam is unremarkable except for oxygen desaturation with exertion and obesity. Cardiopulmonary exam is normal. A Ct angiogram demonstrated no pulmonary embolus but was significant for diffuse thin walled cystic lung disease with interstitial fibrosis and areas of ground glass alveolitis. ANA positive C3 105 C4 13 TSH 2.23 IgG 3137mg/dl, IgA 621mg/dL, IgM 291mg/dL. Pulmonary function test showed restriction (FVC 1.64 64% FEV1 1.41 59% ratio 91) and decreased DLCO 55. Patient underwent VATS with wedge resection of Right Middle Lobe which showed follicular bronchiolitis with vague granulomatous features and multiple meningothelial-like nodules. Patient was started on prednisone, pantoprazole and albuterol. She had improvement of dyspnea and ground glass alveolitis. Fibrosis and innumerable cysts persisted. DISCUSSION: Follicular bronchiolitis is defined by the presence of hyper plastic lymphoid follicles with reactive germinal centers distributed along bronchovascular bundles. Follicular bronchiolitis results from antigenic stimulation of the bronchial associated lymphoid tissue and polyclonal lymphoid hyperplasia. Follicular bronchiolitis has been associated with numerous diseases including collagen vascular disease (most commonly Sjogrenas and Rheumatoid Arthritis), immunodeficiency states, and hypogammaglobulinemias. The typical presenting symptom is progressive breathlessness and cough although some patients may have fever. Variable pulmonary function abnormalities have been reported, including obstructive, restrictive, !