 Tumoral calcinosis is a rare but well-recognized clinical and pathologic entity that is characterized by tumor-like periarticular deposits of calcium, which are most often observed in the regions of the shoulders, elbows, and hips.

 This paper describes the case of a patient who presented to the hospital with a 2-year history of swelling and firmness in his right prepatellar region, which was identified after excision as tumoral calcinosis. It also examines the three distinct clinical entities of the disease and the appropriate treatment for each one.

 Patients with tumoral calcinosis usually present with a solitary, painless, periarticular mass that may interfere with joint motion. To provide appropriate treatment, it is important to differentiate this condition from other, more common, calcium-deposition disorders of the joints. In the absence of a demonstrable metabolic derangement and in cases of severely symptomatic masses, surgical excision is the treatment of choice.

	Tumoral calcinosis is a rare but well-recognized clinical and pathologic entity characterized by tumor-like periarticular deposits of calcium, which are most often observed in the regions of the shoulders, elbows, and hips. This calcification typically takes the form of calcium hydroxyapatite crystals surrounded by a foreign body giant cell reaction and histiocytes. When Inclan and associates coined the term "tumoral calcinosis" in 1945, it was thought that this disease exclusively afflicted familial clusters and people of African descent.

 Increasing experience with tumoral calcinosis has demonstrated a more diverse clinical picture. We report a case of tumoral calcinosis in a white man who presented with a longstanding history of swelling and firmness in his right prepatellar area. We also discuss the literature regarding this condition.

	A 52-year-old white man presented with a 2-year history of swelling and firmness in his right prepatellar region. He had experienced no trauma to that area and had no similar lesions in any other part of his body. He also reported no recent pain, fevers, chills, travels, or exposure to sickness. His family, medical, surgical, and medication histories were noncontributory. His social history was remarkable for smoking a half pack of cigarettes daily.

	On physical examination, the patient was afebrile and did not appear to be in any distress. Cardiovascular, respiratory, neurologic, and abdominal examinations were unremarkable, and there was no adenopathy. Examination of his right lower extremity revealed a firm, nontender, mobile prepatellar mass, which demonstrated superficial skin ulceration. Range of motion was limited at this joint. No additional masses or skin lesions were identified anywhere else on the patient's body.

	Laboratory data included complete blood counts, chemistries with renal functions, and calcium and phosphate levels, all of which were normal. A three-view plain radiograph showed heterogeneous, amorphous calcification in the soft tissue anterior and inferior to the patella (Figure 1). There was no radiographic evidence of bony trauma, osseous erosion, joint involvement, or effusion.

	The patient underwent excision of the mass with primary closure. The operative specimen measured 6.3 x 4.0 x 1.8 cm and did not directly involve the knee or the patellofemoral joint. The gross specimen consisted of an ellipse of tan-gray skin with a centrally located, 1.5-cm raised lesion and associated underlying soft tissue, which was fibrotic, with grossly evident calcifications in need of decalcification. Microscopic examination revealed multiple discrete areas of amorphous calcifications surrounded by histiocytes and multinucleated giant cells (Figure 2). Numerous calcific particles involving the overlying skin were noted (Figure 3). At 2-year follow-up, the patient was free of recurrences and exhibited no new growths anywhere on his body.

	Tumoral calcinosis is a rare disease that has been recognized since 1899.

 Several terms in the literature are synonymous with this condition, including calcifying collagenolysis, calcifying bursitis, tumoral lipocalcinosis, Teutschlaender disease, kikuyu bursa, hip-stone disease, hydroxyapatite disease, and pseudotumoral calcinosis.

 Slightly more than 300 cases of this condition have been documented in the world literature.

	The majority of patients present with a solitary, painless, periarticular mass that can interfere with joint motion. Dystrophic periarticular soft tissue calcification with sparing of the joint is a universal finding. The lack of joint calcification helps differentiate tumoral calcinosis from calcium pyrophosphate dihydrate crystal deposition disease (pseudogout) and the intra-articular radiodense deposits of idiopathic synovial chondromatosis. The overlying skin is usually intact, but soft tissue ulceration may be seen.

	Tumoral calcinosis can manifest in three distinct clinical settings: (1) in patients with renal disease who are dependent on dialysis; (2) as a familial disorder in patients who have a phosphorus and vitamin D metabolism disorder; and (3) sporadic cases in which there is no demonstrable evidence of renal or vitamin D?related abnormalities.

 Of these three situations, renal failure and its attendant disorder of calcium and phosphorus homeostasis is the most common. Tumoral calcinosis affects men more often than women and African Americans more often than whites.

 The patient's age at presentation varies, with the condition reported in patients ranging in age from 5 months to 83 years.

	Radiographs reveal the periarticular calcified masses. Laboratory findings include derangements of serum phosphorus levels and increased serum 1,25-dihydroxy— vitamin D concentration. In sporadic cases, serum chemistries are within normal range. Definitive diagnosis is made using light microscopic examination of tissue, which shows cysts containing deposits of calcium bordered by granulation or dense fibrous tissue.

 Slavin and colleagues proposed a stage classification of the disease: stage 1 disease consists of cellular lesions without calcification; stage 2 shows cellular cystic lesions with evolving calcifications; and stage 3 reveals inactive calcifying lesions without an accompanying cellular response.

	Franco and colleagues' study of 254 hemodialysis patients identified 3 cases of tumoral calcinosis, indicating an incidence of approximately 1% in the dialysis-dependent population.

 Secondary hyperparathyroidism has been touted as an essential pathogenic factor by some authors and found by others to be noncontributory.

 Hyperphosphatemia seems to be present more consistently in dialysis-dependent patients, and the actual calcium/phosphorus level product has been implicated as the inciting factor in crystal deposition.

	Apostolou and colleagues reported successful treatment of ischial tumoral calcinosis in a dialysis-dependent patient with reduced calcium dialysate and administration of vitamin D.

 Hamada and colleagues noted this treatment method to be more effective for patients with solitary lesions and ineffective in those with multiple ones.

 Tumoral calcinosis that fails to respond to medical treatment or occurs without demonstrable metabolic derangement requires surgical excision. While surgical excision also may be necessary for severely symptomatic masses, phosphate binders that lower serum phosphorus levels have proven quite effective in treating this condition.

	Cases of familial metabolic calcinosis generally are observed in younger patients, who tend to have multiple areas of calcification. A positive family history is encountered in 30% to 40% of cases.

 The literature includes about 100 reports of familial tumoral calcinosis.

 In these reports, the disease results from disruptions in phosphate metabolism and is characterized by a high serum phosphate level and elevated 1,25-dihydroxyvitamin D. Normal renal function, elevated vitamin D levels, and an autosomal recessive inheritance pattern differentiate this variety of tumoral calcinosis from the type observed in dialysis patients. Recently, the genetic basis of familial tumoral calcinosis has been clarified. The kidneys' ability to excrete excess phosphorus from the body depends on the phosphaturic factor known as fibroblast growth factor 23 (FGF23).

 Secretion of intact FGF23 requires O-glycosylation by polypeptide N-acetylgalactosaminyltransferase 3 (GalNAc-T3) isoform.

 A mis-sense mutation in the GalNAc-T3 gene is thought to constitute the genetic basis of this disorder.

	In cases of sporadic tumoral calcinosis, trauma may be an inciting factor. Some clinicians think that elevated stromal hemosiderin levels implicate hemorrhage-related histogenesis.

 There do not appear to be any associated metabolic abnormalities, and these patients tend to be older than those with familial tumoral calcinosis. Surgical excision is the mainstay of treatment in this group of patients.

	Our case report highlights certain salient features of tumoral calcinosis. First, it recognizes the condition as a clinical diagnosis. Second, it differentiates it from other, more common, calcium-deposition disorders of the joints. Third, it highlights the importance of classifying patients into one of the three distinct clinical settings of this disease, because treatments may differ based on its biochemical pathogenesis, with medical treatment being sufficient in some cases and surgery required for others.

	The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.

		Inclan N, Leon P, Comejo MG. Tumoral calcinosis. 

		Pakasa NM, Kalengayi RM. Tumoral calcinosis: a clinicopathological study of 111 cases with emphasis on the earliest changes. 

		Polykandriotis EP, Beutel FK, Horch RE, et al. A case of familial tumoral calcinosis in a neonate and review of the literature. 

		Bhagia UT, Bertrand SL, Iwinski HJ. Tumoral calcinosis in an infant. 

		Resnick D, Niwayama G. Soft tissues. In: Resnick D, Niwayama G, eds.

. Philadelphia, Pa: Saunders; 1988:4171-4294.

		Durant DM, Riley LH 3rd, Burger PC, et al. Tumoral calcinosis of the spine: a study of 21 cases. 

		Savaci N, Avunduk MC, Tosun Z, et al. Hyperphosphatemic tumoral calcinosis. 

		Slavin RE, Wen J, Kumar D, et al. Familial tumoral calcinosis. A clinical, histopathologic, and ultrastructural study with an analysis of its calcifying process and pathogenesis. 

		Franco M, Van Elslande L, Passeron C, et al. Tumoral calcinosis in hemodialysis patients. A review of three cases. 

		Apostolou T, Tziamalis M, Christodoulidou C, et al. Regression of massive tumoral calcinosis of the ischium in a dialysis patient after treatment with reduced calcium dialysate and I.V. administration. 

		Hamada J, Tamai K, Ono W, et al. Uremic tumoral calcinosis in hemodialysis patients: clinicopathological findings and identification of calcific deposits. 

		Garringer HJ, Fisher C, Larsson TE, et al. The role of mutant UDP-N-acetyl-alpha-D-galactosamine-polypeptide N-acetylgalactosaminyltransferase 3 in regulating serum intact fibroblast growth factor 23 and matrix extracellular phosphoglycoprotein in heritable tumoral calcinosis. 

		Kato K, Jeanneau C, Tarp MA, et al. Polypeptide GalNAc-transferase T3 and familial tumoral calcinosis. Secretion of fibroblast growth factor 23 requires O-glycosylation. 

		Aprin H, Sinha A. Tumoral calcinosis. Report of a case in a one-year-old child. 

Articles

Surgical Rounds

Kamran M. H. Karimi, Clinical Instructor, Department of Surgery; Alison M. Wilson, Assistant Professor, Chair, Department of Trauma and Surgical Critical Care; H. James Williams, Professor, Department of Anatomic Pathology, West Virginia University Hospital, Morgantown, WV

Tumoral calcinosis: A rare encounter in surgical practice

		A 52-year-old man with a history of traveling to remote locations presented to his primary care physician describing intermittent midabdominal discomfort, which had started approximately 2 to 3 weeks earlier. A physical examination and routine laboratory analysis were unremarkable. Contrast-enhanced computed tomography (CT) scans of the abdomen and pelvis showed a lesion in the left adrenal gland (Figures).

 What is the lesion in the left adrenal gland most consistent with?

		Myelolipomas are benign adrenal tumors comprised of fat and bone marrow elements. They were once considered rare, with autopsy series reporting an incidence between 0.08% and 0.20%.

 The advent of routine CT scanning has shown these tumors to be more common.

 Macroscopic fat is a distinguishing characteristic of myelolipomas on CT scans. This differentiates them from adrenal adenomas, which contain microscopic fat. Adrenal myelolipomas almost always have areas of macroscopic fat with correspondingly low Hounsfield Units (HU), typically between -20 and -30 HU, which is slightly higher than that of the surrounding retroperitoneal fat.

		As the "myelo" in "myelolipoma" suggests, these tumors also contain hematopoietic elements that resemble bone, and calcifications are observed in approximately 20% of these lesions.

 Although myelolipomas are typically located in the adrenal glands, extra-adrenal lesions have been identified in the mediastinum, liver, and muscle fascia, and in the presacral, perirenal, and pararenal retroperitoneum.

 Myelolipomas are not typically associated with other disease processes.

		Clinically, myelolipomas are usually asymptomatic and hormonally nonfunctional. Larger tumors can exhibit symptoms secondary to tumor necrosis and mechanical compression, but the greatest clinical concern is hemorrhage. When these lesions grow larger than 10 cm, the risk of hemorrhage increases, and massive retroperitoneal hemorrhage and hypotensive shock are possible.

 Rarely, myelolipomas can be hormonally active, causing Cushing's syndrome, Conn's syndrome, and congenital adrenal hyperplasia.

		The natural history of adrenal myelolipomas varies. Myelolipomas are known to enlarge, but their growth rate and size vary and do not correspond with symptoms.

 Most patients with these lesions are asymptomatic and can be monitored with CT scanning and treated conservatively.

 Symptomatic tumors should be managed with adrenalectomy. Large tumors (>5 cm) also should be resected because of the risk of hemorrhage.

 In cases where there is concern regarding intraoperative hemorrhage, preoperative transcatheter embolization can be performed.

			Adusumilli S, Ramchandani P. Adrenal myelolipoma. e-medicine. Available at: 

			Tanaka T, Matsuo N, Ishikura H, et al. Adrenal myelolipoma: a case report and review of the literature. 

			Chen KT, Felix EL, Flam MS. Extraadrenal myelolipoma. 

			Singla AK, Kechejian G, Lopez MJ. Giant presacral myelolipoma. 

			Kenney PJ, Wagner BJ, Rao P, et al. Myelolipoma: CT and pathological features. 

			Hisamatsu H, Sakai H, Tsuda S, et al. Combined adrenal adenoma and myelolipoma in a patient with Cushing's syndrome: case report and review of literature. 

			Han M, Burnett AL, Fishman EK, et al. The natural history and treatment of adrenal myelolipoma. 

			El-Mekresh MM, Abdel-Gawad M, El-Diasty T, et al. Clinical, radiological and histological features of adrenal myelolipoma: review and experience with a further eight cases. 

What is the left adrenal gland lesion most consistent with?

Case report

&#8226;Think twice before investing in an EIA

At first, equity-indexed annuities (EIAs) seem to be a great deal, because they offer a guaranteed return if held to maturity. These annuities appeal to investors who want the possibility of growth, but seek downside protection. While this investment option seems to be a win-win proposition, surgeon investors should carefully consider whether this option is right for them.

An EIA is a special type of fixed-rate annuity. It pays a lower guaranteed rate than an ordinary fixed annuity (about 1.5% to 3% annually), and pays a higher rate if a stock-market index performs well in a particular year. Furthermore, if the market falls during the year, nothing is lost, but the return will be zero for that year. Like all annuities, EIA earnings are tax-deferred, so the money is not taxed until it is withdrawn.

EIAs have various crediting methods. For instance, a contract may call for crediting 50% of the market's profits. So, if the S&P 500 is up 15% for the year, you'll be credited with a 7.5% rate. Since many EIAs have rate caps, you will not earn more than a certain amount; for example, even if the index is up 30%, you may only earn 9%. While EIAs sound appealing, there are some downsides, including their complexity, money access issues, withdrawal penalties, and large commissions that chip away at returns.

Every EIA has a different crediting method, and those fine details can make a big difference in your return. Even the simplest EIA is complex, but some are so complicated that they make your head spin. It is challenging to understand how EIAs work and even harder to compare them, making it almost impossible to know if an EIA you are considering is one of the best ones.

Money access issues and withdrawal penalties

The big "if" with EIAs is that the minimum return is guaranteed only if you hold the EIA to maturity. If you do not, all bets are off and withdrawal penalties can last up to 10 years. If you need your money before the surrender period is up, you will have to pay a stiff withdrawal fee, and you may not get the guaranteed minimum rate.

Whether you invest a little or a lot in an EIA, the agent earns the same commission, with up to 15% being typical. You do not pay a sales charge, but the money has to come from somewhere, and it is ultimately deducted from your return. The same is true of the insurer's hefty management fees and profits. While EIAs do provide some advantages, surgeon investors planning for retirement may be better off pursuing other options.

You can achieve the same goals as an EIA, but much more cost-effectively and without tying up your money, by pursuing the following three EIA alternatives: 50/50 stock/treasury mix, variable annuities, and fixed-rate annuities.

Consider putting 50% of your nest egg in treasuries and 50% in conservative stock mutual funds. You will have a guaranteed return on half of your money and growth potential with the other half&#8212;and it is all 100% liquid. Another advantage is that a portion of mutual-fund dividends (ie, the portion generated by qualified stock dividends) are taxed at a maximum 15% rate, as are long-term capital gains distributions.

Most variable annuities now offer guaranteed lifetime income options or withdrawal options that help cushion against market risk. While a variable annuity may produce a negative return during any given year, you get the full benefit when the market is up, instead of just a portion. The best variable annuities have reasonable management fees. Some that are sold by financial advisors have no mortality and expense fees&#8212;just an asset-management fee, making them as cost-effective as mutual funds.

Fixed annuities provide a guaranteed tax-deferred yield without gimmicks. If you want to guarantee some of your principal, you can, of course, put part of your money in variable annuities and part in fixed annuities.

Before you put your money into an EIA, consider the alternatives carefully. The more you look under the hood, the less attractive EIAs will be.

 is a Registered Financial Gerontologist (RFG) and financial advisor who works with many physicians in several states. He practices in Deerfield Beach, Fla, and Forest Hills, NY, and can be reached at 

&#8226;Understanding the three faces of mutual funds

From the questions I get asked, it seems that many investors do not fully understand mutual funds, especially the differences among the three major categories they come in: open-end, closed-end, and exchange-traded funds (ETFs). Because most people invest in both stocks and bonds almost exclusively through mutual funds, it is important to understand the characteristics of all the three types.

Aside from the legal structure and other complexities, a mutual fund is a pool of investors' money managed by professional money managers following defined investment objectives and strategies. Beyond the advantages of professional management and the pooling of investments, there are two key factors that have made mutual funds the preferred investment vehicle.

First, mutual funds do not have to pay any income or capital gains taxes on their returns. Instead, they are required to distribute all their interest and dividend income and realized capital gains to their shareholders in the same year. Investors pay the taxes on those through their own tax returns, so there is no double taxation involved. Mutual funds would not have flourished without this tax treatment.

Second, with some minor exceptions and restrictions, investors can add money to or withdraw money from mutual funds at least once a day. Without this feature, mutual funds would not be as popular or convenient.

How do the three major types of mutual funds differ from one another? Answer: Primarily in the way they handle money additions and withdrawals.

Open-end mutual funds&#8212;In open-end mutual funds&#8212;by far the most popular variety&#8212;all new money goes directly into the fund and all withdrawals come directly out of the fund. Your money goes in or comes out at the end-of-day net asset value, which, stripped of all technicalities, means you buy into the existing holdings of the fund at their fair market value at the end of the day and cash out at the same price; however, you can buy or sell only once a day.

Close-end mutual funds&#8212;In closed-end mutual funds, individual investors do not deal directly with the fund. They buy shares from and sell them to other investors in the market at prices determined by supply and demand. They can buy or sell fund shares anytime during the trading hours, but the price may differ significantly from the value of the securities in the fund itself. Therefore, an investor may suffer a loss on a sale even if the value of the stocks and bonds in the fund have gone up.

ETFs&#8212;In some ways, ETFs represent the best of both worlds. They are similar to closed-end funds in that individual investors can buy or sell shares anytime during the trading hours because they have to buy or sell shares from other investors in the market. But what sets them apart from closed-end funds is that ETFs have a built-in arbitrage mechanism that generally keeps the share price in the market close to the value of the securities in the fund. In this important aspect, ETFs are similar to open-end funds, because investors are likely to get a fair price for shares at all times, except during a market crisis.

Because of the uncertainty about price, you should generally stay away from closed-end funds unless you are very knowledgeable. This is one place where truly knowledgeable investors may find great bargains.

As for choosing between ETFs and open-end funds, keep in mind that, at least for now, all ETFs are index funds. For index funds, it is often a toss up between an ETF and a similar open-end index fund. But remember, on Wall Street success always begets excess, and ETFs have fallen victim to this phenomenon. ETFs based on designer indexes are springing up like wild flowers. Make sure you understand fully the underlying index before buying an ETF based on it.

The bottom line is this: for actively managed funds, open-end funds are still the only game in town. For index funds, ETFs offer a wider variety in terms of underlying indexes, but buy an exotic variety only if you fully understand it.

&#8212;Percentage of income Americans have left for discretionary spending after paying for essentials. (

&#8212;Percentage of Americans who spend at least half of their income on housing. (

&#8212;Minimum amount Sotheby's expects Orson Welles' Academy Award for Best Screenplay for Citizen Kane to fetch at auction. (

&#8212;Shortage of employees India expects to have in the information technology sector by 2010. (

&#8212;Number of countries with a McDonald's. (

&#8212;Percentage of all Americans who have living wills. (

&#8212;Percentage of nursing home residents who have living wills. (

&#8212;Percentage of calls to local Social Security Administration offices that receive a busy signal. (

&#8212;Al Gore Jr.'s share of the Nobel Peace Prize, which he received jointly with the UN Intergovernmental Panel on Climate Change. (

&#8212;Cans of Silly String one soldier's mother has shipped to Iraq to aid in tripwire detection. (

Bulletin Board topics cover equity-indexed annuities, mutual funds, and more

Surgeon's Bulletin Board

Endoscopic clip helps achieve hemostasis—

Boston Scientific's Resolution? Clip is a preloaded, 11-mm-wide endoscopic mechanical clip used to control upper and lower GI bleeding, a potentially serious surgical complication. The clip can be opened and closed up to five times prior to deployment. In addition to lowering the rebleeding rate, clips may cause less tissue reaction. Endoscopists traditionally achieve endoscopic hemostasis using a combination of injection therapy and electrocautery. Electrocautery, however, has been associated with complications such as recurrent bleeding and delayed ulcer healing. Alternatively, endoscopic hemostasis can be achieved with mechanical clips alone or in conjunction with injection therapy. The Resolution Clip, when used with injection therapy, has been demonstrated to reduce or eliminate the need for electrocautery and dramatically reduce chances of rebleeding.

Surgical blades reduce tissue drag and provide smooth?cuts—

Personna Medical offers the Personna Plus? Surgeon's Blade, which features an exclusive Micro Coated? cutting edge, designed to glide with smooth, clean precision. Shaped by precise grinding technology, the Personna Plus sterile blade decreases tissue trauma, which promotes faster healing. The Personna Plus blade is available on Personna Plus Disposable Scalpels, Personna Safety Scalpels, and on the Personna Plus Safety Scalpel system, and it comes in all popular surgery sizes. The Personna Plus Safety Scalpel?System includes reusable metal handles with the same weight and feel as traditional scalpels?and?a disposable blade cartridge.

Monitor offers HD image quality in the OR—

Sony Electronics has introduced the LMD-2450MD 24" HD monitor, which offers 10-bit signal processing and Sony ChromaTRU? color-balance technology for ultra performance. This medical-grade, widescreen LCD monitor displays a 1920 x 1080 full HD signal, enabling the purest reproduction of images captured by today's HD surgical cameras. The LMD-2450MD provides outstanding HD image quality, detail, and clarity, with advanced color space conversion and white balance calibration technology, ensuring vivid and accurate colors. The LMD-2450MD is designed to be mounted on surgical carts and features boom arms for desktop operation with the optional SU-560 stand. It can be integrated into almost any system environment and is compatible with nearly all surgical camera systems. Common picture controls are conveniently located on the panel's front bezel and feature touch-activated backlighting. The monitor has several new functions, such as an Ethernet remove and multiformat picture display, including picture-in-picture and side-by-side. The monitor has up to 20 different user function settings, allowing surgeons to program their personal preferences.

Adhesion barrier for pelvic and abdominal surgery—

Seprafilm? Adhesion Barrier, by Genzyme Biosurgery, was designed for pelvic and abdominal surgery. This sterile, bioresorbable membrane is comprised of two chemically modified polymers (sodium hyaluronate and carboxymethylcellulose) and has been used in over 1 million patients over 10 years of clinical use. Postoperative adhesions may increase the complexity of any subsequent surgery. Seprafilm reduces the incidence, extent, and severity of postoperative adhesions between the abdominal wall and the underlying viscera and between the uterus and surrounding structures. Seprafilm is intended for use following open abdominal or pelvic surgery, serving as a site-specific, temporary adhesion barrier that physically separates tissues and organs during healing. Approximately 24 to 48 hours after placement, the Seprafilm membrane becomes a gel that is slowly resorbed by the body within 7 days, the critical tissue-healing period. Clinical trials have demonstrated that Seprafilm is safe and effective for a wide range of surgical applications.

Crocs, Inc recently introduced two new shoe models"--"the Specialist and Specialist Vent"--"to the market. These shoes are designed to meet workplace standards with a closed heel and toe design. Constructed of Croslite? material, the shoes conform to the foot and create a custom fit. They also feature a thicker metatarsal area to help protect the top of the foot and have footbed circulation nubs and a supportive arch to ensure all-day comfort. Additionally, the loose fit of the shoes allows the foot to bend and expand naturally, reducing fatigue. The shoes are odor and bacteria resistant and can be sterilized using clean water and bleach. The new Crocs shoes are available in black, chocolate, fuchsia, khaki, light blue, navy, sea blue, and white.

 does not endorse any products. All claims made are those of the manufacturers. For more detailed information, refer to package inserts or contact the firm.

Endoscopic clip helps achieve hemostasis

The earliest manifestations of hypocalcemia following thyroidectomy is

Are best diagnosed by percutaneousfine-needle?aspiration cytology

	The lesions in familial adenomatous polyposis with the smallest malignant potential are

The INCORRECT electrolyte concentration (mEq/L) in Ringer's lactate is

The most common cause of bloody stools in a 3-year-old child is

Increasing, predominantly due to increases in squamous cell carcinoma

Decreasing in parallel with gastriccarcinoma

Increasing, predominantly due to increases in upper third lesions

Increasing, predominantly due to increases in adenocarcinoma

A modified radical neck dissection spares all of the following structures EXCEPT the

Commonly appear in the cerebellopontine angle

Invade the brain early during their growth

Forty-eight hours after performing a laparoscopic cholecystectomy, a surgeon realizes that one of the clips was placed across the common bile duct. The correct approach would be

Drainage via percutaneous transhepatic cholangiogram

TIPS procedures (transjugular intrahepatic portasystemic shunts)

Control the manifestations of Budd-Chiari syndrome

Occur mostly in patients older than 50 years

Are equally frequent in right and left lobes

Both laryngospasm and carpopedal spasm are late manifestations, occurring hours, at least, after circumoral numbness. Hypocalcemia causes hyperreflexia (not hyporeflexia) by increasing neuromuscular excitability. Even if the hypocalcemia is very severe, the heart rate does not change until just prior to death.

Adrenocortical carcinoma is a virulent disease, and it is rarely curable at the time of identification. More than 90% are >6 cm when discovered. Surprisingly, 50% are hormonally active, most commonly producing Cushing's syndrome. Adrenocortical carcinoma is one of the malignancies that seed the biopsy tract, changing a conceivably curable lesion to one that cannot be cured. Thus, fine-needle aspiration is contraindicated in potentially salvageable patients. Carcinoma is one of the indications for open adrenalectomy. If the apparent pseudocapsule of the tumor is breached, malignant cells are spilled into the field, negating any possibility of cure and markedly enhancing the chances of local recurrence. Treatment of these tumors requires wide local resection with significant adjacent tissue (mesocolon, tail of pancreas, posterior stomach, and often, the adjacent kidney).

Gastric polyps are frequent manifestations. They are actually large patches of fundic gland hyperplasia, rather than adenomas, and carry no malignant potential. Duodenal and ileal polyps are, in contrast, adenomatous, and they carry the same very high malignant potential as colonic polyps. Many pathologists consider desmoids to be low-grade malignancies. They consistently recur locally and frequently transition to aggressive soft tissue sarcomas. Familial adenomatous polyposis is associated with a variety of brain tumors, virtually all of which are malignant.

All of the electrolyte concentrations are correct except chloride, which is present in Ringer's lactate at 109 mEq/L. Ringer's is an isotonic crystalloid, whose concentrations approximate those of extracellular fluid.

Anal fissures in young children are common and the result of obsessive parental attempts at toilet training. Hemorrhoids occur much later in life. Polyposis syndromes present with diarrhea at puberty, and rectal bleeding follows in the teens. Juvenile colonic polyps do cause rectal bleeding and usually cure themselves by spontaneous passage, but they are uncommon lesions. Bleeding from Meckel's diverticulum is more aggressive than bleeding with each bowel movement, and it starts much later in life. This lesion is caused by erosion of gastric mucosa contained in the diverticulum.

Adenocarcinoma of the esophagus is exploding in frequency. The incidence is up to 100 new cases/million population. Last year there were almost 15,000 new cases. Initially, the increase was thought to be due to increasing malignant degeneration in Barrett's esophagus, but more recent data suggest that there are more important genetic and epidemiologic factors. Esophageal carcinomas are less frequently squamous cell, and a lower proportion occur in the upper third.

The modified radical neck dissection spares all the listed structures except the posterior triangle lymph-node?bearing areas. The only selective neck dissections that spare these lymph nodes (level V) are the supraomohyoid and lateral neck dissections.

The most common sites of meningiomas are the cerebellopontine angles, cerebral convexities, and the parasagittal and subfrontal regions. Meningiomas are much more common in women, develop from arachnoid cap cells, and recur frequently (10% in 10 years). These lesions invade the brain very late, which frequently makes them curable.

Despite a significant stricture rate, Roux-en-Y choledochojejunostomy is the best procedure at this time. Drainage, which can be done, is not a permanent solution. Removing the clips subjects the duct to the complications of ischemia. Anastomosis of the duct to the duodenum is technically difficult under these circumstances and has a high failure rate. Loop choledochojejunostomy predisposes to cholangitis due to enteroductal reflux.

Nodular melanoma growth begins in a vertical direction, and it is this vertical growth that determines its prognosis. Lentigo maligna and superficial melanomas are superficial and develop vertical growth at a late phase. Retinal melanomas rarely metastasize to lymph nodes because of the absence of lymphatic tissue. When these lesions do metastasize, late, it is to the liver. Acral lentiginous melanomas occur in the subungual areas, skin of the palms and soles, and in African Americans, and these characteristics impair their recognition. Once identified, their behavior is not especially virulent.

Despite their effectiveness, particularly in life-threatening situations, TIPS procedures have a 50% incidence of stenosis due to neointimal hyperplasia. This can generally be corrected by angiographic intervention. TIPS procedures cause encephalopathy in one third of patients, are nonselective shunts and very effective in controlling intractable ascites. In contrast, they are totally ineffective in suprahepatic postsinusoidal causes of portal hypertension.

Eighty percent of amebic abscesses are solitary. They occur primarily in young patients (20?40 years of age), rarely cause jaundice, and overwhelmingly occur in the right lobe of the liver. Amebic abscesses respond well to amebicidal therapy (metronidazole), and may be successfully treated without drainage.

Cardiac injuries are relatively rare compared with other injuries, but they are being encountered with increasing frequency, especially at urban trauma centers. Although these injuries are life-threatening, they are not always obvious.

 This paper discusses the case of a patient who presented to the hospital after sustaining a self-inflicted thoracoabdominal gunshot wound. It also provides a review of the literature and discusses the presentation and management of penetrating cardiac injuries.

 Cardiac injuries may occasionally have a subtle presentation, and clinicians should have a high index of suspicion for such injuries in any patient presenting with trauma to the precordial region of the chest.

	Gunshot wounds to the heart can be devastating injuries. Our report details the case of a young woman who sustained a self-inflicted gunshot wound that required cardiac repair. The patient developed an intracardiac thrombus, which resulted in a pulmonary embolism. Intracardiac thrombus with systemic embolization following cardiorrhaphy for penetrating trauma is life-threatening. Surviving patients should be monitored for delayed sequelae that require further evaluation and management. We review the literature and discuss the presentation and management of penetrating cardiac injuries.

	A 29-year-old woman presented to the hospital after sustaining a self-inflicted thoracoabdominal gunshot wound. Her vital signs were stable, with a heart rate of 103 beats per minute. A chest radiograph was normal. Evaluation using advanced trauma life support (ATLS) protocol revealed a through-and-through gunshot wound that entered to the left of the xyphoid cartilage and exited from the left lower back. A nasogastric tube revealed gross blood.

	Ertapenem sodium was administered as a preoperative antibiotic, and the patient was taken to the operating room (OR) for an exploratory celiotomy. The abdomen was explored through a midline incision, and a through-and-through stomach injury was observed. Her stomach was filled with clots, which were evacuated, and the stomach was repaired using a linear 4.0 x 4.5-mm stapler. A bleeding laceration to the left lobe of the liver also was noted, and the bleeding was controlled using a 0-chromic blunt liver suture. No other gastrointestinal injuries were observed.

	On further exploration of the tract of the injury, a small isolated clot was observed anteriorly at the junction of the left hemidiaphragm and the pericardial sac, raising a high index of suspicion for a cardiac injury. There was no evidence of cardiac tamponade, and the patient's vital signs remained stable throughout the procedure. Given the high clinical suspicion for a cardiac injury, the midline incision was converted into a thoracoabdominal incision for complete exploration of the heart and left chest. Upon opening the pericardium and removing the clot, a 1.5-cm laceration at the apex of the heart involving both ventricles was noted with active bleeding. The bleeding was controlled with digital pressure followed by an expeditious repair of the cardiac injury using 2.0 polypropylene sutures with pledgets. The pericardium was re-approximated in an interrupted fashion followed by placement of a left chest tube. The patient's vitals remained stable after her wounds were closed, and she was transported to the intensive care unit.

	On postoperative day 1, the patient was recovering well and was extubated without distress. She was placed on subcutaneous heparin, 5,000 units every 8 hours, as prophylaxis for deep vein thrombosis (DVT). On the morning of postoperative day 2, she became hypoxemic, hypotensive, and bradycardic, requiring re-intubation with a fraction of inspired oxygen of 100%. Following resuscitation with fluids, a computed tomography (CT) scan was performed, which showed a significant pulmonary embolism in the intermediate branch of the right upper lobe of the lung, no evidence of DVT, and a 1.5-cm thrombus at the apex of the left ventricle (Figure). An echocardiogram showed good cardiac function and no valvular or septal abnormalities.

	The patient was given 5,000 units of intravenous heparin and started on a heparin drip of 1,000 units per hour for full anticoagulation. She was stabilized and returned to the OR for a retained hemothorax and washout of her left chest. Upon the patient's discharge from the hospital 8 weeks after her injury, she was kept on therapeutic heparin, treated with the broad-spectrum antibiotics vancomycin and an imipenem-cilastatin combination, and given a regimen of 5 mg of warfarin daily. Postoperatively, she also received a short course of acetaminophen and codeine, along with antidepressants prescribed by her psychiatrist. She has since recovered from her injuries and is doing well, although she continues to battle with intermittent bouts of depression.

	Cardiac injuries are not altogether rare and are being observed with increasing frequently in urban trauma centers. Despite the sophistication of emergency medical services, 60% to 80% of penetrating cardiac injuries result in death at the scene or before arrival to a trauma facility.

 Patients who make it to a trauma center alive have a survival rate between 30% and 70%.

 The presentation of these cases varies considerably and can range from complete stability to cardiac tamponade leading to cardiovascular collapse and cardiac arrest.

	In acute situations, cardiac penetration may go unrecognized, and a high index of suspicion is required to establish the diagnosis. In the emergency department, the presence of a cardiac injury with cardiac tamponade can be presumed in patients presenting with a precordial wound, tachycardia, pulsus paradoxus, and Beck's triad, which includes hypotension, markedly elevated systemic venous pressure, and muffled or soft heart sounds. Beck's triad has been reported to be present in only 10% to 40% of reported cardiac injury cases.

 In cases with Beck's triad, elevation of venous pressure is the most significant diagnostic finding for pericardial tamponade.

 An electrocardiogram may also exhibit low voltage in tamponade cases; however, a common clinical mistake is to expect the presence of Kussmaul's sign, which is described as jugular venous distension upon inspiration. Although this sign has been described in cases of constrictive pericarditis, congestive heart failure, or tricuspid regurgitation, it does not occur in uncomplicated cardiac tamponade cases.

 The aforementioned signs alone or in combination are neither very specific nor sensitive and are usually the exception rather than the rule; therefore, the absence of these clinical findings does not exclude a cardiac injury.

	Our case exemplifies the occasional subtle and deceptive nature of cardiac wounds, which can result in complications and death should the clinician fail to suspect this injury. Our patient did not present in tamponade, nor did she exhibit any signs associated with it. All patients who sustain a penetrating injury to an area inferior to the clavicle, superior to the costal margins, and medial to the midclavicular lines should be treated as though they are harboring an injury to the heart until proven otherwise; the burden of proof lies with the trauma surgeon. On occasion, the myocardial muscle along with a blood clot can seal the injury, which prevents cardiac tamponade and maintains a patient's hemodynamic stability, allowing enough time for transport to the trauma facility and early detection of the cardiac injury.

	Mortality following gunshot wounds to the heart is between 72% and 84%.

 As more physicians have become familiar with focused abdominal sonographic assessment for the evaluation of the trauma patient (FAST), cardiac tamponade has become somewhat easier to diagnose. Although the FAST technique is operator-dependent and at times limited by body habitus, excessive bowel gas, or open wounds, it serves as a rapid, noninvasive, and highly accurate diagnostic tool, which identifies life-threatening accumulations of blood in the pericardium or abdominal cavity.

 Although a learning curve is required, ultrasonography is very sensitive in detecting hemopericardium and is more specific than diagnostic pericardiocentesis, which carries a false-positive and false-negative rate of 6.4% and 19%, respectively.

 It is often wrongly stated that blood does not clot in the pericardium, yet many clinicians who care for trauma patients have observed clots in the pericardium, and the high false-negative rate of pericardiocentesis is often attributed to these clots.

 Cardiac ultrasonography has been found to have 98% accuracy, 97% specificity, and 90% sensitivity rates in detecting penetrating cardiac injuries.

 The mean examination time for a surgeon-performed cardiac ultrasound is 0.8 minutes.

 Studies have shown that echocardiography significantly reduces the time taken to diagnose cardiac or pericardial injuries and therefore confers a significant survival advantage.

	FAST was not performed in our case because the intra-abdominal wound was obvious and a celiotomy was necessary. Under these circumstances, a pericardial window is expeditious, safe, and accurate in identifying or excluding cardiac injury and is part of the trauma surgeon's armamentarium in the OR. In a series of 76 patients reported by Andrade-Alegre and Mon, no false-positives or negatives were reported with pericardial windows.

 The advantage of the pericardial window lies in its rapidity, safety, and accuracy, which is why it remains the gold standard in the evaluation of cardiac injuries. In our case, the injury created a pericardial window, but this was plugged by a visible clot intraoperatively. Given our clinical suspicion for a cardiac injury, the decision was made to obtain adequate exposure of the heart with an anterolateral thoracotomy in preparation for a cardiac repair. A median sternotomy would have been acceptable, as well. Although the patient's biventricular injury was repaired uneventfully, she encountered a rare and serious postoperative complication that often is not emphasized following penetrating cardiac injuries. A report discussing a level I trauma center's 22 years of experience with 192 penetrating cardiac trauma cases mentioned no incidence of an intracardiac thrombus.

	The postoperative complication of intracardiac thrombus with subsequent pulmonary embolization is serious and potentially life-threatening in an individual with an already compromised myocardium. Although one other case of ventricular thrombus complicating cardiac trauma has been described in the literature, there is no description of an intracardiac thrombus resulting in a pulmonary embolism following a gunshot wound to the heart.

 While cardiac evaluation for thrombus is most commonly done using two-dimensional echocardiography, our case demonstrates that CT scanning can be a useful adjunct, because it evaluates the chambers of the heart and the peripheral vasculature, allowing the lungs to be examined for emboli.

	In the setting of our patient's biventricular injury, which consisted of a clot in the left ventricle and no evidence of DVT, it is likely that the pulmonary embolism originated from a clot in her right ventricle that dislodged to the lung parenchyma as an embolus. A clot seen intraoperatively at the apex of her heart was the initial operative finding that led to the high suspicion of a cardiac injury. There was no documentation of a ventricular septal defect in any of the diagnostic studies that were performed.

	Penetrating cardiac trauma is among the most dramatic and lethal of all injuries. This case highlights the occasional subtle presentation of cardiac injuries and emphasizes the basic premise that a high index of suspicion for cardiac injury is necessary when injuries to the precordial region are identified. A better understanding of the modes of presentation and the diagnostic tools available will also lead to a rapid diagnosis and a better outcome. Following repair of a cardiac injury, close follow-up is needed, because significant complications can occur. These include the development of septal and valvular abnormalities and cardiac thromboembolism, as demonstrated by this case.

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Critical Care Medicine: Principles of Diagnosis and Management

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L. D. George Angus, Director of Trauma and Vice-Chair; Eric Seitelman, Surgical Resident; Jean-Joseph Desir, Surgical Resident; Lioudmila Haimovicci, Surgical Resident; Leonard O. Barrett, Director of Cardiothoracic Surgery; Dahua Zhou, Attending Radiologist, Department of Surgery, Nassau University Medical Center, East Meadow, NY Departments

October 2007

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