Object-To report the clinical features, surgical treatment, and long-term outcomes of adults with moyamoya phenomenon treated at a single institution in the United States.Methods-Forty-three adult patients with moyamoya disease (mean age of 40+/−11 years; range 18 to 69) were treated with encephaloduroarteriosynangiosis (EDAS). Neurologists examined patients pre-and post-operatively. Follow-up was obtained in-person or by structured telephone interview (median 41 months; range 4 to 126). The following outcomes were collected: transient ischemic attack (TIA), infarction, graft collateralization, change in cerebral perfusion, and functional level according to the modified Rankin scale (mRS). Kaplan-Meier infarction risk was calculated between operated and contralateral hemispheres.Results-The majority of patients were women (65%), Caucasian (65%), presented with ischemic symptoms (98%), and had bilateral disease (86%). Nineteen patients underwent unilateral and 24 patients bilateral EDAS (n=67). Fifty of 52 (98%) patients with available imaging developed collateral vessels, and 41 of 50 (82%) had increased perfusion on SPECT scan. The incidence of peri-procedural hemisphere infarction (<48 hours) was 3%. In the follow-up period patients experienced 10 TIAs, 6 infarcts, and 1 intracranial hemorrhage. Although the hemisphere selected for surgery was based upon patient symptoms and severity of pathology, the five year infarction free survival rate was 94% in operated hemispheres versus less than 36% in non-operated hemispheres (p=0.007). After controlling for age and sex, operative hemispheres were 89% less likely to experience infarction than contralateral hemispheres (hazard ratio: 0.11; 95% CI 0.02-0.56). Thirtyeight of 43 patients (88%) had preserved or improvement in mRS over baseline status.Conclusion-In this mixed race population of North American patients, indirect bypass promoted adequate pial collateral development and increased perfusion in the majority of adult patients with moyamoya disease. Patients had low rates of postoperative TIAs, infarction, and hemorrhage, and the majority of patients had preserved or improved functional status.

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We report the case of a 61-year old female with history of gastroesophageal reflux disease and hiatal hernia who developed hemopericardium and tamponade one day after laparoscopic hiatal hernia repair and Toupe fundoplication. The patient underwent emergent pericardiocentesis and subsequent surgical pericardial window. During surgery, a tack that had been used to secure mesh to the inferior aspect of the diaphragm was found to have penetrated the pericardium near the right ventricle. The offending foreign body was trimmed and reduced into the abdomen, and the patient recovered without further complication. A review of the literature reveals that, although rare, tamponade following diaphragmatic hernia repair and fundoplication surgery often results in fatal outcome. Tamponade must be considered in any patient who develops signs of hemodynamic instability following diaphragmatic hernia repair or fundoplication surgery, as rapid diagnosis and definitive intervention can decrease fatality from such an injury.

Substantial literature exists linking inflammation with arrhythmia, in particular with regards to serological markers of systemic inflammation. Regional inflammation can be identified using positron emission tomography (PET) with the radiotracer F18-fluorodeoxyglucose (F18-FDG). In the current series, we demonstrate novel applications of cardiac PET using F18-FDG and N13-ammonia radiotracers in the evaluation and treatment of arrhythmia associated with cardiac sarcoidosis. These applications include defining the cause of arrhythmia, identifying arrhythmias that will be amenable to medical management, and guiding therapy using serial scanning. Though these applications are promising, prospective multicenter studies are needed to provide better understanding of the utility of PET imaging in the diagnosis and treatment of arrhythmias.

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Background We sought to determine inter-rater reliability of the 2009 Appropriate Use Criteria (AUC) for radionuclide imaging (RNI) and whether physicians at various levels of training can effectively identify nuclear stress tests with inappropriate indications. Methods and Results Four hundred patients were randomly selected from a consecutive cohort of patients undergoing nuclear stress testing at an academic medical center. Raters with different levels of training (including cardiology attending physicians, cardiology fellows, internal medicine hospitalists, and internal medicine interns) classified individual nuclear stress tests using the 2009 AUC. Consensus classification by two cardiologists was considered the operational gold standard, and sensitivity and specificity of individual raters for identifying inappropriate tests was calculated. Inter-rater reliability of the AUC was assessed using Cohen’s kappa statistics for pairs of different raters. The mean age of patients was 61.5 years; 214 (54%) were female. The cardiologists rated 256 (64%) of 400 NSTs as appropriate, 68 (18%) as uncertain, 55 (14%) as inappropriate; 21 (5%) tests were unable to be classified. Inter-rater reliability for non-cardiologist raters was modest (unweighted Cohen’s kappa, 0.51, 95% confidence interval, 0.45 to 0.55). Sensitivity of individual raters for identifying inappropriate tests ranged from 47% to 82%, while specificity ranged from 85% to 97%. Conclusions Inter-rater reliability for the 2009 AUC for RNI is modest, and there is considerable variation in the ability of raters at different levels of training to identify inappropriate tests.