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Background Appendectomy remains one of the most common emergency operations. Recent research supports the treatment of uncomplicated appendicitis with antibiotics alone. While nonoperative management of appendicitis may be safe in some patients, it may result in missed neoplasms. We present a case of acute appendicitis where the final pathology resulted in a diagnosis of a Burkitt-type lymphoma. Case presentation An 18-year-old male presented to the emergency department with 24 h of right lower quadrant pain with associated urinary retention, anorexia, and malaise. Past medical history was significant for intermittent diarrhea and anal fissure. He exhibited focal right lower quadrant tenderness. Workup revealed leukocytosis and CT uncovered acute appendicitis with periappendiceal abscess and no appendicolith. Laparoscopic appendectomy was performed and found acute appendicitis with associated abscess abutting the rectum and bladder. Pathology of the resected appendix reported acute appendicitis with evidence of Burkitt-type lymphoma. A PET scan did not reveal any residual disease. Hematology/oncology was consulted and chemotherapy was initiated with an excellent response. Conclusions Appendiceal lymphomas constitute less than 0.1% of gastrointestinal lymphomas. Primary appendix neoplasms are found in 0.5–1.0% of appendectomy specimens following acute appendicitis. In this case, appendectomy allowed for prompt identification and treatment of an aggressive, rapidly fatal lymphoma resulting in complete remission.

Previous research has linked death attitudes, palliative care self-efficacy, and attitudes toward care of the dying among nursing students and other nursing samples, but not among hospice nurses. The purpose of this study was to investigate these relationships among hospice nurses (N = 90). More positive attitudes toward care of the dying were associated with lower fear of death and death avoidance as well as higher neutral acceptance and escape acceptance, but not with approach acceptance. More positive attitudes toward care of the dying was associated with perceived capability to answer end-of-life concerns, but not with perceived capability to respond to end-of-life symptoms. Clinical interventions seeking to improve attitudes toward care of the dying among hospice nurses may be most effective by targeting death attitudes and improving self-efficacy in the area of discussing end-of-life concerns with patients.

We investigated the patterns of injury associated with major midface trauma. Our hypothesis is that midface injuries are associated with a decrease in certain traumatic brain injuries as well as major torso injuries. The registry of our Level I trauma center was queried for all adult patients treated over 25 years from 1989 to 2013. Patients with midface fractures were identified based on the ICD-9 code. Associated injuries were defined based both on individual ICD-9 codes as well as the Barell Injury Matrix. Injury etiology was defined based on e-codes. Univariate analysis was performed using chi-squared test, Fisher's exact test, and Wilcoxon test. A total of 29,152 patients were identified. Excluding pediatric patients, those with exclusively penetrating trauma, and patients with incomplete data, 20,971 patients were included for subsequent analysis. Midface fractures were identified in 752 patients. Patients with Le Fort fractures were more likely to be male, have a higher Injury Severity Score, a lower arrival Glasgow Coma Scale, and more likely to require intensive care unit admission and mechanical ventilation, with a longer hospital length of stay. Patients with midface fractures had significantly fewer subdural hematomas, subarachnoid hemorrhages, spine fractures, and were less likely to have associated abdominal and pelvic injuries. Patients with midface fractures were more likely to require facial reconstruction procedures and craniotomy. Patients presenting with midface fractures after blunt trauma have a distinctly different pattern of injuries. One potential mechanism for this is a deceleration effect, where midface impact and resulting fractures dissipate some of the energy.

Bariatric surgical procedures have recognized benefits for morbidly obese patients. Unfortunately, staple line leaks remain a profound complication after these procedures. Currently available intraoperative surveillance modalities have multiple drawbacks, such as requiring an available upper endoscope and experienced endoscopist. Additionally, increased procedure time and resources are needed to perform intraoperative endoscopy and maintain equipment. This is a retrospective cohort study of all bariatric patients undergoing Roux-en-Y gastric bypass or sleeve gastrectomy procedures performed by one attending surgeon at a tertiary care facility designated as a bariatric surgical center of excellence. Patients were grouped based on procedure date being before (September 2016 to mid-October 2018) or after (mid-October 2018 to March 2019) implementation of a novel intraluminal indocyanine green leak testing protocol. Diluted indocyanine green was injected via orogastric bougie intraluminally at the location of the gastric staple line and observed with near-infrared imaging from the intraperitoneal perspective for evidence of immunofluorescence extravasation. Data from the electronic medical record and bariatric surgical outcomes database were gathered to analyze the sensitivity and specificity of this new intraoperative diagnostic modality. Total of 196 patients underwent bariatric surgery with intraoperative leak testing using the gastroscopy method; of these, there were 3 false negatives and 193 true negatives. Total of 59 patients underwent bariatric surgery with intraoperative leak testing using the intraluminal ICG method; of these, there was 1 true positive, 1 false positive, 0 false negatives, and 57 true negatives. Indocyanine green leak testing had a sensitivity of 100.00% and specificity of 98.28%. Intraluminal indocyanine green is an alternative for intraoperative detection of staple line integrity during bariatric surgical procedures with comparable specificity to intraoperative gastroscopy.

We investigated the patterns of injury associated with major midface trauma. Our hypothesis is that midface injuries are associated with a decrease in certain traumatic brain injuries as well as major torso injuries. The registry of our Level I trauma center was queried for all adult patients treated over 25 years from 1989 to 2013. Patients with midface fractures were identified based on the ICD-9 code. Associated injuries were defined based both on individual ICD-9 codes as well as the Barell Injury Matrix. Injury etiology was defined based on e-codes. Univariate analysis was performed using chi-squared test, Fisher's exact test, and Wilcoxon test. A total of 29,152 patients were identified. Excluding pediatric patients, those with exclusively penetrating trauma, and patients with incomplete data, 20,971 patients were included for subsequent analysis. Midface fractures were identified in 752 patients. Patients with Le Fort fractures were more likely to be male, have a higher Injury Severity Score, a lower arrival Glasgow Coma Scale, and more likely to require intensive care unit admission and mechanical ventilation, with a longer hospital length of stay. Patients with midface fractures had significantly fewer subdural hematomas, subarachnoid hemorrhages, spine fractures, and were less likely to have associated abdominal and pelvic injuries. Patients with midface fractures were more likely to require facial reconstruction procedures and craniotomy. Patients presenting with midface fractures after blunt trauma have a distinctly different pattern of injuries. One potential mechanism for this is a deceleration effect, where midface impact and resulting fractures dissipate some of the energy.

STUDY DESIGN: A case report of traumatic atlanto-occipital dislocation complicated by the development of anterior and posterolateral pseudomeningoceles and the late development of syringohydromyelia is presented. OBJECTIVE: To describe a unique post-traumatic and postsurgical course following atlanto-occipital dislocation. SUMMARY OF BACKGROUND DATA: Syringomyelia is a significant potential long-term complication in patients recovering from traumatic atlanto-occipital dislocation. Cord enlargement and increased T2 signal can be a marker of abnormal cerebrospinal fluid flow dynamics. This "presyrinx state" can be seen before clinical evidence of neurologic compromise. Pseudomeningocele formation after atlanto-occipital dislocation is rare, with only 3 reported cases. To our knowledge, all reported cases describe retropharyngeal pseudomeningoceles, and posterolateral pseudomeningocele as seen in this case has not previously been described. METHODS: A single case is reported with an emphasis on the imaging findings related to the patient's subsequent neurologic deterioration. RESULTS: Following a pedestrian-motor vehicle collision, the patient received initial evaluation and treatment at a local foreign medical facility, where his cervical spine was cleared. Several days following stabilizing treatment and surgery, the patient was transferred to a foreign-based United States military medical facility and ultimately to our institution, where magnetic resonance imaging demonstrated occipitocervical dissociation. The patient was taken to the operating room for surgical stabilization. Four months after his index operation, the patient underwent halo removal. Follow-up magnetic resonance imaging revealed thickening of the cervical spinal cord in conjunction with diffuse high cord T2 signal and a small low cervical segment of syringomyelia. The patient was observed with follow-up magnetic resonance imaging obtained after 1 month. At this time, the low cervical syrinx had enlarged slightly, a small thoracic syrinx was observed, and cine imaging of cerebrospinal fluid flow demonstrated obstruction at the level of the foramen magnum. The patient was taken to the operating room fordecompression of the foramen magnum and posterior fossa and duraplasty. One month later, the patient's clinical condition began to deteriorate, and repeat imaging showed continued enlargement of the patient's syrinx and hydrocephalus. He was admitted for an urgent shunt procedure but unfortunately sustained cardiorespiratory arrest while on the ward awaiting surgery. CONCLUSIONS: Atlanto-occipital dislocation is rarely survivable, and delayed diagnosis can negatively affect long-term clinical outcome. This case illustrates how, despite early signs of improvement, post-traumatic syringomyelia may occur months or even years after spinal trauma and should always be considered in patients who experience late neurologic deterioration after atlanto-occipital dislocation. Language: en

3Department of Pathology, Brooke Army Medical Center, Fort Sam Houston, TX 78234. 41-year-old woman undergoing clinical and imaging evaluation for adrenocorticotropic hormone (ACTH)-independent Cushing’s syndrome was found to have a lipid-poor left adrenal adenoma on abdominal CT. Further evaluation with PET/CT supported a diagnosis of lipid-poor adrenal adenoma but also revealed a spiculated 3-cm soft-tissue mass in the right inguinal region that exhibited intense (standardized uptake value, 4.0) 18F-FDG activity (Fig. 1A). MRI showed the lesion to have intermediate T1 (Fig. 1B) and markedly low T2 (Fig. 1C) signal characteristics, extending through the right inguinal canal into the right lateral mons pubis (Fig. 1C). Sonography-guided core biopsy was performed, and histologic findings were consistent with endometriosis (Fig. 1D). Low T2 signal intensity characteristic of a soft-tissue lesion is of considerable aid in narrowing the radiologist’s differential diagnosis. The mnemonic CHAFT (calcification, hemosiderin, amyloid/air, fibrous lesions, and tophaceous gout) can be used to easily formulate a differential diagnosis in such lesions. Correlation with conventional radiographs and CT plays an important role in distinguishing among these entities through more precise identification of calcifications, air, and tophi. In addition, clinical presentation and anatomic location can effectively exclude tophaceous gout from differential consideration. Inguinal hernia, fibrous neoplasm, and extrapelvic endometriosis remain in the differential diagnosis. Although PET/CT is a valuable technique in evaluating for neoplasms, this case illustrates the importance of correlating increased 18F-FDG activity with cross-sectional imaging examinations. Infection, inflammation, physiologic muscular activity, brown fat, and metabolically active lesions (i.e., endometriosis) all can show markedly increased 18F-FDG uptake. Endometriosis is a common gynecologic disease affecting 1–2% of all women. Classically, it is characterized by implantation of endometrial tissue outside the uterine cavity, resulting in bleeding, cyclical pain, and scarring. Typically, endometriosis occurs within the ovaries and peritoneum [1]. However, rarer cases have been reported in the vagina, rectum, lung (potentially leading to catamenial pneumothorax), subcutaneous tissues, and inguinal canal [2, 3]. The prevailing theory to explain the mechanism of endometriosis is retrograde menstruation (implantation theory), which proposes that viable endometrial tissue is refluxed through the fallopian tube during menstruation and deposited on the peritoneal surface or pelvic organs [1]. The gubernaculum testis, which is embryologically a cord of fibrous and muscular tissue, A

Campbell SE, Reed CM, Bui-Mansfield LT, Fillman E 64-year-old woman with a history of sarcoidosis presented with back and abdominal pain and was unresponsive to nonsteroidal antiinflammatory medications. In addition, the patient complained of weakness in her right arm. Physical examination of the abdomen was unremarkable, and examination of the spine revealed normal flexion and extension and no focal tenderness. Neurologic examination revealed slightly decreased strength in the right arm and hand. A posteroanterior chest radiograph showed a bilateral diffuse reticulonodular pulmonary parenchymal pattern, right paratracheal stripe thickening, and bilateral hilar lymphadenopathy (Fig. 1A). CT of the chest confirmed bilateral hilar, right paratracheal, and subcarinal lymphadenopathy and interstitial pulmonary disease. CT also revealed widespread retroperitoneal lymphadenopathy and multiple lytic lesions within the vertebral bodies and posterior elements of the thoracolumbar spine. Subsequent MRI of the spine revealed decreased T1 signal intensity and increased T2 signal intensity scattered throughout the spine (Fig. 1B). After IV sodium gadopentate was administered to the patient, multiple brightly enhancing lesions within the vertebral bodies, pedicles, laminae, and spinous processes were identified. Diffuse leptomeningeal and nerve root enhancement and an enhancing parenchymal spinal cord mass were also present (Fig. 1C). Biopsy of a vertebral lesion revealed noncaseating granuloma consistent with sarcoidosis without evidence of malignancy (Fig. 1D). Gram stains and cultures for fungi, aerobic and anaerobic organisms, and acid-fast bacilli were all negative. The differential diagnosis for diffuse marrow infiltration, enhancing intraaxial spinal cord mass, diffuse meningeal and nerve root enhancement, and mediastinal and retroperitoneal lymphadenopathy includes metastatic disease, lymphoma, leukemia, hematogenous osteomyelitis (tuberculous, fungal), and sarcoidosis [1]. Sarcoidosis is a systemic granulomatous disease of unknown etiology that has been shown to affect nearly every organ system. Osseous involvement occurs in 1–13% of cases, typically in the small tubular bones of the hands and feet [2, 3]. Sarcoidosis may affect either the vertebral column or the spinal cord. Typical vertebral column manifestations are lytic lesions with sclerotic borders that enhance on MRI and enhancement of the intervertebral disk [1, 3–5]. Typical spinal cord manifestations are leptomeningeal enhancement, enhancing spinal cord mass, nerve root “clumping,” and enhancing nerve root [4]. The most common spinal cord manifestation is leptomeningeal disease [4]. Given the variable manifestations of sarcoidosis within the spine, this disease should be considered in the differential diagnosis along with multiple sclerosis [4]; tuberculous meningitis [4]; and widespread vertebral involvement of metastatic disease, infection, or lymphoma [1]. Sarcoidosis is typically treated with corticosteroid therapy, after which clinical symptoms and even MRI findings may completely or partially resolve in 29% of the patients [6]. Prednisone