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Watters T.S.,Duke University | Cardona D.M.,DUMC | Menon K.S.,Duke University | Vinson E.N.,Duke University | And 2 more authors.
American Journal of Clinical Pathology | Year: 2010

It is estimated that 35% of total hip arthroplasties (THAs) involve a second-generation metal-on-metal (MOM) prosthesis. A novel complication has appeared in a subset of patients with MOM THAs that is described as an aseptic, lymphocyte-dominated vasculitis-associated lesion (ALVAL). The clinical features of ALVAL are nonspecific, but patients complain of pain and may develop "pseudotumors." It is hypothesized that metal ions are released from the prosthesis and form haptens with native proteins that elicit a type IV hypersensitivity response in the local soft tissues. Histopathologic descriptions of ALVAL are similar to those of failed arthroplasty in general, with the addition of a dense perivascular inflammatory infiltrate that is the hallmark of ALVAL. We report 3 cases of ALVAL with clinical, radiographic, and histologic findings. Accurate assessment is crucial because an intraoperative diagnosis of chronic inflammation suggestive of ALVAL will necessitate a replacement of the prosthetic component surfaces. © American Society for Clinical Pathology.

Tsalik E.L.,DUMC | Jaggers L.B.,DUMC
American Journal of the Medical Sciences | Year: 2010

Incidental lung nodules can be due to a variety of etiologies. Management is guided by the most likely or urgent pathology, which is frequently malignancy in an elderly smoker. We present the case of a 62-year-old, long-time smoker, with an incidental lung nodule. Pursuit of the underlying etiology revealed disseminated cryptococcal and Mycobacterium avium intracellulare infections, which are most often seen in patients with advanced human immunodeficiency virusacquired immunodeficiency syndrome or other immunocompromise. This patient was ultimately determined to have idiopathic CD4 lymphocytopenia, a rare and poorly understood acquired immunodeficiency syndrome. Furthermore, Cryptococcus neoformans is well known to cause asymptomatic meningitis in immunocompetent individuals but is very rarely asymptomatic in the immunosuppressed, as was the case with this patient.

Mentz R.J.,Duke University | Fiuzat M.,DUMC | Wojdyla D.M.,Duke Clinical Research Institute | Chiswell K.,Duke Clinical Research Institute | And 3 more authors.
European Journal of Heart Failure | Year: 2012

Aims: Chronic obstructive pulmonary disease (COPD) is common in heart failure (HF) patients, yet the population is poorly characterized and associated with conflicting outcomes data. We aimed to evaluate the clinical characteristics and outcomes of HF patients with systolic dysfunction and COPD in a large acute HF registry. Methods and results: OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) was a performance-improvement registry of patients hospitalized with HF (n 48 612), which included a pre-specified subgroup of patients (n 5,701) with 60-to 90-day follow-up. We performed a retrospective analysis of the clinical characteristics and outcomes (length of stay, and in-hospital and 60-day mortality) of patients with systolic dysfunction according to baseline COPD status. COPD was present in 25 of the patients. These patients had more co-morbidities compared with patients without COPD. They were less likely to receive a beta-blocker or angiotensin-converting enzyme inhibitor during hospitalization and at discharge (P < 0.001). COPD was associated with an increased median length of stay [5 days (interquartile range 38) vs. 4 days (interquartile range 37), P < 0.0001] and increased in-hospital all-cause and non-cardiovascular (CV) mortality, with rates of 4.5 vs. 3.7 (P 0.01) and 1.0 vs. 0.6 (P 0.01), respectively, for the two endpoints, but similar 60-day mortality (6.2 vs. 6.0, P 0.28). After risk adjustment, the in-hospital non-CV mortality remained increased (odds ratio 1.65, 95 confidence interval 1.122.41; P 0.01). Conclusion: The presence of COPD in HF patients with systolic dysfunction is associated with an increased burden of co-morbidities, lower use of evidence-based HF medications, longer hospitalizations, and increased in-hospital non-CV mortality, but similar post-discharge mortality. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2012.

Easley M.E.,Duke University | Adams Jr. S.B.,DUMC | Hembree W.C.,DUMC | DeOrio J.K.,Duke University
Journal of Bone and Joint Surgery - Series A | Year: 2011

▶ Most published reports related to total ankle arthroplasty have a fair to poor-quality level of evidence. ▶ Comparative studies with a fair to good-quality level of evidence suggest that total ankle arthroplasty provides equal pain relief and possibly improved function compared with ankle arthrodesis. ▶ On the basis of the current literature, survivorship of total ankle arthroplasty implants, when measured as the retention of metal components, ranges from 70% to 98% at three to six years and from 80% to 95% at eight to twelve years. ▶ Several investigators have argued that, in the evolution of total ankle arthroplasty, some obligatory reoperation without removal of the metal implants is anticipated; examples of reoperation include relief of osseous or softtissue impingement, improvement of alignment or stability of the foot and ankle, bone-grafting for cystic lesions, and/or polyethylene exchange. ▶ A successful return to low-impact, recreational sporting activities is possible after total ankle arthroplasty. Copyright © 2011 by The Journal of Bone and Joint Surgery, Incorporated.

Lipkin M.E.,DUMC | Preminger G.M.,DUMC
Current Opinion in Urology | Year: 2012

Purpose of Review: To discuss the risk of radiation exposure to patients with nephrolithiasis. To review the risk factors for increased radiation exposure to patients during percutaneous nephrolithotomy (PNL) from fluoroscopy. To review the techniques to reduce patient radiation doses during PNL. Recent Findings: Patients with nephrolithiasis are at risk for significant radiation exposure from diagnostic imaging. Fluoroscopy used during surgical treatment of nephrolithiasis also contributes to patient radiation exposure. On average, PNL with fluoroscopy exposes patients to more radiation than a noncontrast computed tomography of the abdomen and pelvis. Risk factors for increased radiation during PNL include obesity, larger stone size and increased access tracts. Following the principles of As Low As Reasonably Achievable, use of air instead of contrast for retrograde pyelogram and use of ultrasound all reduce radiation exposure during PNL. Summary: It is important to be aware of the amount of radiation patients with nephrolithiasis receive. These patients are at risk for multiple imaging studies and multiple procedures during their lifetime. Whenever possible, the techniques outlined in this review should be implemented to reduce the amount of radiation to which patients are exposed during PNL. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.

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