Acute respiratory distress secondary to posterior mediastinal goiter: a case report

Large posterior mediastinal goiters are extremely rare. Progressive enlargement and possible compression of adjacent structures, as well as malignant potential necessitate that these goiters should be surgically excised. A review of mediastinal tumors, specifically intra-thoracic goiters is presented along with a case report of acute respiratory compromise secondary to tracheal compression by a large posterior goiter

Endovascular repair of thoracic aortic pseudoaneurysms and patch aneurysms

Pseudoaneurysms and patch aneurysms are life-threatening late complications after thoracoabdominal aortic aneurysm (TAAA) repair. We treated four patients who presented with a pseudoaneurysm or patch aneurysm involving the descending thoracic portion of a previously implanted TAAA graft. In each patient, stent grafts were placed within the existing graft to cover the aneurysm endoluminally. All patients recovered without major complications, and computed tomography performed after a mean follow-up of 51.5 ± 19.7 months showed that the repairs remained intact

Outcomes of concomitant aortic valve replacement and coronary artery bypass grafting at teaching hospitals versus nonteaching hospitals

ObjectiveHospitals with a high volume and academic status produce better patient outcomes than other hospitals after complex surgical procedures. Risk models show that concomitant aortic valve replacement and coronary artery bypass grafting pose a greater risk than isolated coronary artery bypass grafting or aortic valve replacement. We examined the relationship of hospital teaching status and the presence of a thoracic surgery residency program with aortic valve replacement/coronary artery bypass grafting outcomes.MethodsBy using the Nationwide Inpatient Sample database, we identified patients who underwent concomitant aortic valve replacement/coronary artery bypass grafting from 1998 to 2007 at nonteaching hospitals, teaching hospitals without a thoracic surgery residency program, and teaching hospitals with a thoracic surgery residency program. Multivariate analysis was performed to identify intergroup differences. Risk-adjusted multivariable logistic regression analysis was used to assess independent predictors of in-hospital mortality and complication rates.ResultsThe 3 groups of patients did not differ significantly in their baseline characteristics. Patients who underwent aortic valve replacement/coronary artery bypass grafting had higher overall risk-adjusted complication rates in nonteaching hospitals (odds ratio 1.58; 95% confidence interval, 1.39–1.80; P < .0001) and teaching hospitals without a thoracic surgery residency program (odds ratio 1.42; 95% confidence interval, 1.26–1.60; P < .0001) than in thoracic surgery residency program hospitals. However, no difference was observed in the adjusted mortality rate for nonteaching hospitals (odds ratio 0.95; 95% confidence interval, 0.87–1.04; P = .25) or teaching hospitals without a thoracic surgery residency program (odds ratio 1.00; 95% confidence interval, 0.92–1.08; P = .98) when compared with thoracic surgery residency program hospitals. Robust statistical models were used for analysis, with c-statistics of 0.98 (complications) and 0.82 (mortality).ConclusionPatients who require complex cardiac operations may have better outcomes when treated at teaching hospitals with a thoracic surgery residency program

Homograft use in reoperative aortic root and proximal aortic surgery for endocarditis: A 12-year experience in high-risk patients

ObjectivesWe examined the early and midterm outcomes of homograft use in reoperative aortic root and proximal aortic surgery for endocarditis and estimated the associated risk of postoperative reinfection.MethodsFrom January 2001 to January 2014, 355 consecutive patients underwent reoperation of the proximal thoracic aorta. Thirty-nine patients (10.9%; mean age, 55.4 ± 13.3 years) presented with active endocarditis; 30 (76.9%) had prosthetic aortic root infection with or without concomitant ascending and arch graft infection, and 9 (23.1%) had proximal ascending aortic graft infection with or without aortic valve involvement. Sixteen patients (41.0%) had genetically triggered thoracic aortic disease. Twelve patients (30.8%) had more than 1 prior sternotomy (mean, 2.4 ± 0.6).ResultsValved homografts were used to replace the aortic root in 29 patients (74.4%); nonvalved homografts were used to replace the ascending aorta in 10 patients (25.6%). Twenty-five patients (64.1%) required concomitant proximal arch replacement with a homograft, and 2 patients (5.1%) required a total arch homograft. Median cardiopulmonary bypass, cardiac ischemia, and circulatory arrest times were 186 (137-253) minutes, 113 (59-151) minutes, and 28 (16-81) minutes. Operative mortality was 10.3% (n = 4). The rate of permanent stroke was 2.6% (n = 1); 3 additional patients had transient neurologic events. One patient (1/35, 2.9%) returned with aortic valve stenosis 10 years after the homograft operation. During the follow-up period (median, 2.5 years; range, 1 month to 12.3 years), no reinfection was reported, and survival was 65.7%.ConclusionsThis is one of the largest North American single-center series of homograft use in reoperations on the proximal thoracic aorta to treat active endocarditis. In this high-risk population, homograft tissue can be used with acceptable early and midterm survival and a low risk of reinfection. When necessary, homograft tissue may be extended into the distal ascending and transverse aortic arch, with excellent results. These patients require long-term surveillance for both infection and implant durability

Primary cardiac sarcoma presenting as acute left-sided heart failure

Primary cardiac sarcomas are rare malignant tumors of the heart. Clinical features depend on the site of tumor and vary from symptoms of congestive heart failure to thromboembolism and arrhythmias. Echocardiography is helpful but definitive diagnosis is established by histopathology. Surgical resection is the mainstay of treatment, and the role of chemotherapy and radiotherapy is unclear. We report a case of primary cardiac sarcoma which presented with signs and symptoms of acute left-sided heart failure

Desmoplastic fibroma of the mandible - review of the literature and presentation of a rare case

Desmoplastic fibroma (DF) is a rare, benign but locally aggressive, intraosseous lesion with a high tendency of local recurrence. In this report the actual literature is reviewed regarding epidemiological data, pathology, clinical diagnostic criterias, therapy and prognosis. Moreover, a report of an interesting case is included localized in the mandibular corpus

A systematic review of the effects of residency training on patient outcomes

<p>Abstract</p> <p>Background</p> <p>Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes.</p> <p>Methods</p> <p>The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes.</p> <p>Results</p> <p>Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design.Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained.</p> <p>Conclusions</p> <p>The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.</p