Research Spotlight

Martin, H. D., M. Reddy and J. Gomez-Hoyos (2015). “Deep gluteal syndrome.” Journal of hip preservation surgery 2(2): 99-107.

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Deep gluteal syndrome describes the presence of pain in the buttock caused from non-discogenic and extrapelvic entrapment of the sciatic nerve. Several structures can be involved in sciatic nerve entrapment within the gluteal space. A comprehensive history and physical examination can orientate the specific site where the sciatic nerve is entrapped, as well as several radiological signs that support the suspected diagnosis. Failure to identify the cause of pain in a timely manner can increase pain perception, and affect mental control, patient hope and consequently quality of life. This review presents a comprehensive approach to the patient with deep gluteal syndrome in order to improve the understanding of posterior hip anatomy, nerve kinematics, clinical manifestations, imaging findings, differential diagnosis and treatment considerations.

Fann, J. I., S. D. Moffatt-Bruce, J. M. DiMaio and J. A. Sanchez (2016). “Human factors and human nature in cardiothoracic surgery.” Ann Thorac Surg Apr 27 [Epub ahead of print].

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Surgical errors and adverse events include wrong or delayed operations and judgment lapses that lead to incorrect procedures 3, 4, 5, 6 and 7. It is estimated that 54% of the adverse events in patients undergoing operations surgery are preventable [7]. In patients undergoing coronary artery bypass grafting, for whom the risk-adjusted mortality rate ranges from 1.3% to 3.1%, approximately one-third of associated deaths may be preventable, with most occurring in the operating room and intensive care unit [6]. Surgical outcomes are often attributed primarily to the technical skills of the surgeon: when errors are made, the surgeon’s competence is questioned 3, 4, 8, 9 and 10. The notion that the surgeon is often held solely accountable is evidenced in the basis for surgeon rankings in public reporting.

Hebeler, K. R., J. J. Squiers, M. Arsalan, H. Baumgarten, D. O. Moore, W. H. Ryan, M. J. Mack, P. Grayburn and J. M. DiMaio (2016). “Aortic regurgitation caused by an aberrant mitral chord tethering the anterior mitral leaflet to an aortic valve cusp.” Ann Thorac Surg 101(5): e163.

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A 37-year-old man, active military, with a known heart murmur presented with new onset dyspnea on significant exertion. Transesophageal echocardiography revealed a subaortic fibrous strand connecting the A2 portion of the mitral valve to the left coronary cusp of the aortic valve, resulting in cusp prolapse and eccentric severe aortic regurgitation (Fig 1, Video). To facilitate surgical excision, transverse aortotomy was performed through an upper partial sternotomy. The abnormal chorda was resected from the underside of the aortic leaflet to the free edge of the mitral leaflet (Fig 2). After the resection, residual prolapse of the left coronary cusp was visualized, so a commissuroplasty was performed to shore up the redundant edges of the leaflet. After aortic closure, two areas of trace-to-mild aortic insufficiency, normal aortic leaflet opening motion, and trace mitral regurgitation were observed by transesophageal echocardiography. The chord was 2.5 cm long and composed of tan-white soft tissue (Fig 3) without necrosis, myxoid degeneration, calcification, or inflammation.

McCullough, P. A., M. K. Fallahzadeh and K. M. Tecson (2016). “Predicting acute kidney injury in the catheterization laboratory.” Journal of the American College of Cardiology 67(14): 1723-1724.

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There has been considerable advancement in catheters, wires, balloons, stents, and adjunctive strategies for procedures performed in the cardiac catheterization laboratory. Despite these improvements, angiographic procedures remain dependent on the use of water-soluble iodinated contrast that has inherent nephrotoxicity (1) . In addition, coronary angiography with percutaneous coronary intervention (PCI) poses additional risks of renal atheroembolism, which may occur on a subclinical basis and contribute to acute kidney injury (AKI). In the settings of acute myocardial infarction and heart failure, there are hemodynamic, neurohormonal, and cytokine mechanisms of action, which are determinants for acute tubular injury in the absence of exposure to the catheterization procedure. With this backdrop, Inohara et al. (2) in this issue of the Journal analyzed 11,041 consecutive patients enrolled in a Japanese PCI registry with the goal of validating the U.S. National Cardiovascular Data Registry’s (NCDR) CathPCI registry prediction models for AKI and the need for renal replacement therapy (dialysis). The CathPCI registry prediction model included 11 variables for AKI and 6 for AKI requiring dialysis (AKI-D) (3) . Both models were strongly influenced by 4 variables, in importance: 1) baseline renal function; 2) cardiogenic shock; 3) ST-segment elevation myocardial infarction (STEMI); and 4) heart failure. For patients without cardiogenic shock, STEMI, or heart failure, the most important predictor was baseline renal function (estimated glomerular filtration rate or chronic kidney disease [CKD] stage) followed by diabetes as shown in the first original models developed for AKI and AKI-D (4).

Campa, M., B. Mansouri, B. Wilcox and J. R. Griffin (2016). “Radiation-induced localized bullous pemphigoid in a patient with breast carcinoma.” Dermatology online journal 22(1).

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Bullous pemphigoid (BP) is a common pemphigoid disorder, which is localized in approximately 16-29% of cases. A small subset of localized BP cases is associated with prior radiation therapy, most commonly for breast carcinoma. We present a patient with an unusual presentation of localized BP after receiving partial accelerated breast irradiation (a type of brachytherapy that has a decreased amount of radiation to the skin as compared to the more common external beam radiation therapy).