Author: Kristopher Maday PA-C

PAINE #PANCE Pearl – Pulmonary

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Question

 

57yo man is referred to your practice due to an incidental 1.1cm single pulmonary nodule found on computed tomography.  He is a never smoker and denies any known family history of lung cancer.  He has no pulmonary medical history and reports no pulmonary symptoms.

 

Image result for single pulmonary nodule ct

 

What is the next step in the management of this patient?

Answer

 

  1. The first step in the management of this patient should be investigate if there are any previous studies to compare.  This will allow us to be able to assess if any growth has taken place.  For this patient, there are no previous studies to compare.
  2. The next step would be assess malignancy risk since it is larger than 8mm.  Up to Date uses the Brock University Cancer Equation, which I happen to like as well, though there are several out there and all use clinical, historical, and radiographical criteria.
  3. Our patient has a predicted malignancy risk of 3.54% and using the below algorithm, this patient needs a follow-up CT scan in 3 months to evaluate growth.

References

  1. Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 Suppl):e93S-e120S. [pubmed]
  2. Callister ME, Baldwin DR, Akram AR, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015; 70 Suppl 2:ii1-ii54. [pubmed]
  3. McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. The New England journal of medicine. 2013; 369(10):910-9. [pubmed]
  4. Up-To-Date.  Diagnostic Evaluation of the Incidental Pulmonary Nodule.  2018.

Ep-PAINE-nym

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Westermark’s Sign

 

Other Known Aliases – none

 

Definition – focal peripheral hyperlucency resulting from collapsed vessels distal to a pulmonary thromboembolism.

 

 

Clinical Significance – Occurs as a result of oligemia of perfusion to the lung parenchyma and can be seen in up to 10% of patients with acute PTE.  Similar to Hampton’s Hump, it has a low sensitivity, but a high specificity

 

History – Named after Nils Johan Hugo Westermark (1892-1980), a Swedish radiologist who first described this finding in his 1938 paper entitled ” On the roentgen diagnosis of lung embolism”.  He was also an accomplished sailor and won a silver medal in the 1912 Olympics.

 

 

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Krishnan AS, Barrett T. Images in clinical medicine. Westermark sign in pulmonary embolism. NEJM. 2012; 366(11):e16. [pubmed]
  7. Radiopaedia.  Westermark Sign. https://radiopaedia.org/articles/westermark-sign-1
  8. Westermark N. On the roentgen diagnosis of lung embolism. Acta Radiol 1938;19:357‑72.

PAINE #PANCE Pearl – Pulmonary

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57yo man is referred to your practice due to an incidental 1.1cm single pulmonary nodule found on computed tomography.  He is a never smoker and denies any known family history of lung cancer.  He has no pulmonary medical history and reports no pulmonary symptoms.

 

Image result for single pulmonary nodule ct

 

What is the next step in the management of this patient?

Ep-PAINE-nym

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Hampton’s Hump

 

Other Known Aliases – none

 

Definition – wedge-shaped opacity in the periphery of the lung on chest radiography usually with its base along the pleural margins.

 

Clinical Significance – Occurs as a result of infarction and subsequent hemorrhage from the bronchial arteries classically due to a pulmonary embolism, but can also be from anything that causes infarction of lung parenchyma.  The sensitivity and specificity of this finding is not robust and is, by definition, a late finding that is really no longer seen in modern medicine.

 

History – Named after Aubrey Otis Hampton (1900-1955), an American radiologist who received his medical degree from Baylor University in 1925.  He rose through the ranks quickly in the field of radiology ultimately taking a position as chief of radiology at Massachussetts General in 1941.  He first described his eponymous finding in 1940 in his manuscript entitled “Correlation of postmortem chest teleroentgenograms with autopsy findings”.

Image result for Aubrey Otis Hampton

 

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Radiopaedia. Hamptons’ Hump. https://radiopaedia.org/articles/hampton-hump-2
  7. Schatzki R, Lingley JR. Aubrey O. Hampton, 1900-1955. The American journal of roentgenology, radium therapy, and nuclear medicine. 1956; 75(2):396-7. [pubmed]
  8. Ladeiras-Lopes R, Neto A, Costa C, et al. Hampton’s hump and Palla’s sign in pulmonary embolism. Circulation. 2013; 127(18):1914-5. [pubmed]
  9. Hampton AO, Castleman B.  Correlation of postmortem chest teleroentogenograms with autopsy findings.  Am J Roentgenol Radium Ther. 1940;34:305-326.

PAINE #PANCE Pearl – Surgery

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Question

 

What is the main difference between these two instruments?

 

Image result for allis clampImage result for allis clamp

 

vs

 

Image result for babcock clampImage result for babcock clamp

Answer

 

The first instrument is an Allis clamp, which has sharp teeth and can crush tissue.  It is used for grasping fascia or tissue that needs to be removed or manipulated during procedures.

 

The second instrument is a Babcock forceps,  which is non-toothed and has a wider grasping surface.  These forceps do not damage tissue and are considered non-crushing and can be used to grasp delicate tissue.  The head of the forceps is open and helps for rapid identification.

Ep-PAINE-nym

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Debakey Forceps

 

Other Known Aliases – atraumatic vascular forceps

Definition – large, coursely ribbed tissue forceps

 

Clinical Significance – used for delicate vascular surgery as these forceps do not crush or damage tissue

 

History – Named after Michael Ellis DeBakey (1908-2008), an American cardiac surgeon who received his medical degree from Tulane University School of Medicine in 1932.  He spent the majority of his career with Baylor in Texas and was prolific medical trailblazer and pioneered, among many others,:

  • The roller pump for the heart-lung machine and made open-heart surgery possible
  • Postulating the link between smoking and lung cancer
  • One of the first surgeons to perform coronary artery bypass
  • Performed the first successful carotid endarterectomy
  • Using synthetic grafts for blood vessel repair
  • Video live surgery for medical purposes

In 2005, at the age of 95, he suffered an aortic dissection (for which there is the DeBakey classfication for) and became the oldest person to survive the operation.  He died 2 months before his 100th birthday.  Dr. DeBakey received so many awards and recognition that they are too numerous to count and is arguable one of the main reasons modern cardiac surgery has advanced to where it is today.

 

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. U.S. National Library of Medicine https://www.nlm.nih.gov/news/debakey_dies.html
  7. The Michael E. BeBakey papers https://profiles.nlm.nih.gov/ps/retrieve/Narrative/FJ/p-nid/322
  8. NY Times https://www.nytimes.com/2008/07/13/health/12cnd-debakey.html
  9. Academy of Achievement http://www.achievement.org/achiever/michael-e-debakey-m-d/