COVID-19 vaccine equity and health equity conversations on Twitter

This study used social network analysis and trending hashtags on Twitter to identify trends related to health and vaccine equity during the Omicron wave. The analysis was conducted using consumer-friendly platforms/tools such as the Healthcare Hashtag Project and NodeXL. The study found that during the Omicron wave, there was a higher volume of tweets related to the more specific hashtag #VaccineEquity, as compared to the more general topic of #HealthEquity. The study also identified the top influencers for these hashtags and how they changed over time. The study proposes a combination of existing tools and approaches, including ontological surveillance and social network analysis, to develop proactive strategies that respond to public opinion in a timely manner. Social network analysis tools could also be useful for healthcare organizations and providers in training their staff involved in social media management to develop better social media communication strategies.

Prognostic influence of mechanical cardiopulmonary resuscitation on survival in patients with out-of-hospital cardiac arrest undergoing ECPR on VA-ECMO

Introduction

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in extracorporeal cardiopulmonary resuscitation (ECPR) in selected patients after out-of-hospital cardiac arrest (OHCA) is an established method if return of spontaneous circulation cannot be achieved. Automated chest compression devices (ACCD) facilitate transportation of patients under ongoing CPR and might improve outcome. We thus sought to evaluate prognostic influence of mechanical CPR using ACCD in patients presenting with OHCA treated with ECPR including VA-ECMO.

Methods

We retrospectively analyzed data of 171 consecutive patients treated for OHCA using ECPR in our cardiac arrest center from the years 2016 to 2022. A Cox proportional hazards model was used to identify characteristics related with survival.

Results

Of the 171 analyzed patients (84% male, mean age 56 years), 12% survived the initial hospitalization with favorable neurological outcome. The primary reason for OHCA was an acute coronary event (72%) followed by primary arrhythmia (9%) and non-ischemic cardiogenic shock (6.7%). In most cases, the collapse was witnessed (83%) and bystander CPR was performed (83%). The median time from collapse to VA-ECMO was 81 min (Q1: 69 min, Q3: 98 min). No survival benefit was seen for patients resuscitated using ACCD. Patients in whom an ACCD was used presented with overall longer times from collapse to ECMO than those who were resuscitated manually [83 min (Q1: 70 min, Q3: 98 min) vs. 69 min (Q1: 57 min, Q3: 84 min), p = 0.004].

Conclusion

No overall survival benefit of the use of ACCD before ECPR is established was found, possibly due to longer overall CPR duration. This may arguably be because of the limited availability of ACCD in pre-clinical paramedic service at the time of observation. Increasing the availability of these devices might thus improve treatment of OHCA, presumably by providing efficient CPR during transportation and transfer.

Inferior Vena Cava Filter Long Term Complications and Retrieval Techniques: A Case Series and Literature Review

INTRODUCTION AND IMPORTANCE

Long-term mechanical complications after inferior vena cava (IVC) filter placement include embedded or tilted filters, erosion of the vena cava, filter thrombosis. In the setting of caval thrombosis, patients may subsequently develop venous hypertension and post-thrombotic syndrome (PTS). Here we present three unique cases of IVC filter complications and surgical management.

CASE PRESENTATION

A 30-year-old female presented with acute abdominal pain, revealing a duodenal perforation caused by an IVC filter eroding into her duodenum. A 42-year-old female with an IVC filter in place for 20 years due to a prior pulmonary embolism underwent laser-assisted retrieval of the filter due to concerns of caval adherence. A 48-year-old male with a history of DVT, venous stasis ulcer, and an IVC filter presented for filter retrieval.

CLINICAL FINDINGS AND INVESTIGATIONS

The surgical techniques described in this report include complicated IVC filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis resulting in PTS. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience.

INTERVENTION AND OUTCOMES

The surgical techniques described in this report include complicated inferior vena cava filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience.

RELEVANCE AND IMPACT

Endovascular retrieval of long-term complicated IVC filters is challenging, but it can be a safely performed in many patients. However, open surgery may be necessary in selected patients.

Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis

Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.

Primary acinic cell carcinoma of the breast: A case report and review of literature

BACKGROUND

In the current World Health Organization classification, acinic cell carcinoma (AcCC) of the breast is considered a rare histological subtype of triple-negative breast cancer. Because of the few reports in the literature, data concerning clinical outcomes are limited. Here, we report a case of AcCC of the breast in a 48-year-old woman.

CASE SUMMARY

A 48-year-old woman with a mass in her right breast came to our hospital for further diagnosis. Mammography and an ultrasound (US) scan showed a mass in the upper inner side of the right breast. She then underwent surgery to resect the mass in her right breast. Postoperative pathological examination revealed that the tumor had abundant acinar-like structures formed by tumor cells with prominent eosinophilic granules in the cytoplasm, consistent with acinar cell carcinoma. The results of immunohistochemical analysis supported the diagnosis of breast acinar cell carcinoma. Two months later, she underwent breast-conserving surgery and sentinel lymph node biopsy. The pTNM stage was T2N0M0. After surgery, the patient received 30 radiotherapy sessions. The patient was followed up for a period of one year, and no recurrence was found.

CONCLUSION

AcCC of the breast is a rare type of malignant tumor. Because it is usually asymptomatic and can be detected by imaging studies, routine breast US or mammograms are important. However, there are no characteristic diagnostic imaging findings or clinical manifestations, so immunohistochemical examination is critical for an accurate diagnosis of AcCC of the breast.

Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®

OBJECTIVE

Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks.

METHODS

This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure.

RESULTS

Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection.

CONCLUSIONS

Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Affinity and Inactivation of Bacterial Endotoxins for Medical Device Materials

Endotoxins are high-molecular-weight complexes that contain lipopolysaccharide, protein, and phospholipid originating from the outer membrane of gram-negative bacteria. As gram-negative bacteria are naturally present in a variety of sources, endotoxins are commonly identified as contaminants in manufacturing environments. In industrial applications, endotoxin often is considered difficult to inactivate and to have a strong affinity with surfaces resulting from its hydrophobic chemical structure. This article describes the investigation of the true affinity of endotoxin, from various microbial sources in solution, for medical device material surfaces. In addition, endotoxin reduction was investigated with commonly used sterilization methods such as those based on ionizing radiation, dry and moist heat, and ethylene oxide sterilization. Endotoxin activity was found to be reduced following exposure to a range of sterilization modalities with the degree of activity reduction related to the source of endotoxin and the substrate material upon which it was present.

Intraoperative Closed Reduction of Traumatic Lateraloptosis: Operative Nuances

BACKGROUND AND IMPORTANCE

Traumatic lateral spondyloptosis, or lateraloptosis, is the complete lateral dislocation of the spine. Reduction in these dislocations presents unique challenges, especially in cases of preserved neurological function. Open techniques carry significant risks of cerebrospinal fluid leak and neurological injury. For traditional spondyloptosis, off-table closed techniques have been described but may result in loss of the reduction when the patient is transferred to the operative table. An on-table closed reduction technique has potential advantages over previously described open reduction or off-table techniques for the treatment of lateraloptosis.

CLINICAL PRESENTATION

The authors describe an on-table closed reduction technique for lateraloptosis, presenting an illustrative case in which the technique was applied. This technique is compared with alternative open and off-table reduction techniques described in the literature. The patient had good mechanical and neurological outcomes. At 14 months postoperatively, she is neurologically intact, back to work involving heavy lifting, and has only moderate back pain.

CONCLUSION

On-table closed reduction before open fixation should be considered in cases of lateraloptosis, particularly when there is preserved neurological function.

Double aneuploidy in a 2-month-old male with Edward syndrome and Klinefelter syndrome: a case report

Introduction and importance

Edward syndrome is a severe chromosomal defect that occurs as a result of non-disjunction through meiosis. It presents with cardiac septal defects, horseshoe kidneys, patent ductus arteriosus, central nervous system dysgenesis, distinctive craniofacial deformities, and overriding or overlapping fingers. Klinefelter syndrome (47, XXY) is found in 1 in 660 newborn males. It is considered to be one of the most common genetic causes of infertility. It manifests with small firm testes, androgen insufficiency, and azoospermia.

Case presentation

A 2-month-old male infant with a history of weakness in feeding, frequent convulsions, and an increase in cyanosis two days ago. There were multiple skeletal deformities and a tendency to spasm in the extremities, left ventricular atrophy, mitral atresia, atrial septal defect, ventricular septal defect with dilated right cavities, tricuspid valve regurgitation, pulmonary valve stenosis; and the aorta exits in the right ventricle. There is a widening of the subdural space, which was observed in the left frontal-parietal side with cortical atrophy in that area and a widening of the Sylvian fissure. A karyotype test confirmed the presence of Edward and Klinefelter syndromes.

Clinical discussion

Aneuploidy is a chromosomal issue characterized by an abnormal number of a chromosome copies. The coexistence of two aneuploidies is called "double aneuploidy" which is a rare occurrence. Herein, we report a case of a 2-month-old male with Edward syndrome and Klinefelter syndrome.

Conclusion

This publication aims to highlight the challenges in diagnosing and treating a complicated genetic disease.

Cavernous hemangioma of the breast: a case report

Background

Hemangioma is a common benign tumor resulting from abnormal blood vessel growth but is infrequent in the breast. Preoperatively, it is challenging to diagnose breast hemangioma using clinical and conventional imaging modalities because of their lack of pathognomonic characteristics. An excisional biopsy can be used for tissue diagnosis in cases of diagnostic uncertainty.

Case presentation

The authors report a case of cavernous hemangioma of the breast in a 15-year-old adolescent female complaining of a rapidly enlarging firm and mobile lump in the right breast. Breast ultrasonography revealed a well-circumscribed, encapsulated, heteroechoic mass with smooth margins in the retroareolar region of the right breast. Subsequent excision of the lump revealed features of a cavernous hemangioma, and the follow-up was uneventful.

Discussion

Cavernous hemangioma of the breast is a rare entity, and its diagnosis poses a significant challenge for clinicians, as the lump may not be noticeable. The clinical diagnosis is challenging; therefore, imaging is required. Breast ultrasonography typically shows a hypoechoic lobulated mass with clear borders, although isoechoic and hyperechoic appearances are also possible. Breast mammography revealed a well-defined mass with areas of calcification. Surgical excision is often necessary when there is a discordance between imaging and histopathological findings, lesions greater than 2 cm, and atypical/malignant features.

Conclusion

Breast hemangiomas are rare benign tumors with nonspecific imaging features that require tissue sampling for diagnosis. Clinicians should be familiar with these characteristics to ensure proper management.

Metastatic thyroid follicular carcinoma presenting as pathological left clavicle fracture: An unusual skeletal metastasis at the time of diagnosis

INTRODUCTION

Thyroid carcinoma is the most common endocrine malignancy, accounting for 3 % of recent malignancies in world wide. Differentiated thyroid carcinoma constitutes 90 % thyroid malignancies, within that follicular type constitutes 10-15 %.

CLINICAL PRESENTATION

A 55-year-old female presented with left-sided neck pain and swelling over medial end of clavicle, following normal manual work. Physical examination revealed swelling on medial end of left clavicle and palpable nodule in left thyroid lobe. Imaging studies showed two nodules in both thyroid lobes with left level IV lymphadenopathy and osteolytic lesion with pathological fracture in medial end of clavicle. Histopathological evaluation confirmed well-differentiated follicular thyroid carcinoma with clavicular metastasis. The patient underwent total thyroidectomy, followed by radioiodine therapy for medial end of left clavicle.

DISCUSSION

Follicular thyroid carcinoma (FTC) is metastasis through the bloodstream, predominantly to flat bones and upper end of long bones, but clavicular deposits are very rarely reported. FNAC only diagnosed the follicular neoplasm. Further tissue evaluation needed to confirm the malignancy. Therefore, hemithyroidectomy of the lesion side is usually carried out for histopathological diagnosis. But in this case, follicular thyroid carcinoma was confirmed through core biopsy from medial end of clavicle, leading to total thyroidectomy and left cervical block dissection, followed by radioiodine therapy for metastatic clavicular involvement.

CONCLUSION

Clavicular metastasis of follicular thyroid carcinoma is very rare. Early detection and proper management of suspicious thyroid carcinoma in uncommon skeletal sites, like the clavicle, is crucial for enhancing patient outcomes, despite the rarity of follicular carcinoma metastasis to this area.

Variant of the terrible triad of the elbow, a CASE report with a review of the literature

INTRODUCTION

The terrible triad described by Hotchkiss in 1996 is a complex lesion of the elbow, following a trauma combining forced valgus and external rotation. It is a lesion that puts the elbow at risk of developing complications such as instability, stiffness, or synostosis of the proximal radio-cubital joint.

CASE REPORT

We report the case of a patient who suffered a closed trauma to the right elbow following a fall onto the palm of the hand with a valgus lateral rotation mechanism. The lesion assessment showed a B2 fracture of the distal humerus (AO classification) with a line splitting the capitulum in the frontal plane, a type 3 coronoid process fracture (Morrey/Odriscoll classification), and a posterolateral elbow dislocation. The surgical treatment followed the same principles as for the terrible triad, with a reconstruction of the lateral column by osteosynthesis of the humeral palate, followed by an internal approach for osteosynthesis of the coronoid process, with the restoration of a stable elbow without laxity in the frontal plane.

DISCUSSION

On the basis of the lesion mechanism, column theory, and the schematization of the constituent elements of elbow stability in a ring, certain lesions can be placed in the same box as the terrible triad of the elbow, which also complies with the same therapeutic implications.

CONCLUSION

Our observation underlines the possibility of the existence of lesions other than those described by Hotchkiss, which would have the same consequences: an unstable elbow with the risk of evolving into chronic instability or stiffness and whose management accepts the same management.

Metastatic spread of primary lung adenocarcinoma to the small intestine: A case report

INTRODUCTION AND IMPORTANCE

Metastasis of primary lung cancer to the small intestine is rare, and the prognosis is poor. Early diagnosis of small intestinal metastasis is difficult because the incidence of clinically obvious symptoms is low.

CASE PRESENTATION

This report described a rare case of small intestine metastasis of lung adenocarcinoma. It is worth noting that the patient was diagnosed with lung adenocarcinoma (T2aN0M0, stage IB) over a year ago. However, he complained of fever, black stools, and abdominal pain for about a year after the surgery. Enhanced CT scans showed thickening of the intestinal wall and dilatation of the lumen in the right iliac area and adjacent pelvic cavity. Capsule endoscopy identified a space-occupying lesion with hemorrhaging in the ileum. A laparotomy was subsequently performed, and the histopathological confirmation revealed a metastatic lung adenocarcinoma and immunohistochemistry further showed positive results for TTF-1 and CK7.

CLINICAL DISCUSSION

When patients with a history of primary lung cancer experience gastrointestinal symptoms, the possibility of distant metastasis of lung cancer to the digestive tract should be considered.

CONCLUSION

Due to the rarity of primary lung cancer metastasis to the small intestine, we report the case of a 64-year-old male who presented with symptoms of gastrointestinal bleeding and was ultimately diagnosed with metastasis of primary lung cancer to the small intestine. When patients with lung cancer present with gastrointestinal symptoms, we cannot rule out the possibility of distant metastasis from primary lung cancer, although this possibility is unlikely.

Complex case of ureteropelvic junction obstruction with bifid renal pelvis in ectopic kidney: A rare combination

INTRODUCTION

Renal pelvis bifidity, ectopic pelvic kidney, and ureteropelvic junction obstruction are rare urinary tract anomalies resulting from embryological developmental variations. Their coexistence in one kidney is exceedingly uncommon.

CASE PRESENTATION

An 18-year-old male with no prior medical history presented with right-sided lumbar pain. A CT scan revealed bilateral hydronephrosis, with the left kidney being malrotated and ectopically positioned in the pelvis. Dynamic renal scintigraphy confirmed bilateral ureteropelvic junction obstruction. Surgical management involved laparoscopic pyeloplasty for the right UPJ and open surgery for the left ectopic kidney with bifid pelvis.

DISCUSSION

The combination of pelvic kidney, renal pelvis bifidity, and bilateral ureteropelvic junction obstruction is exceptionally rare. Diagnosis often occurs incidentally or when symptoms related to these anomalies emerge. Imaging and dynamic renal scintigraphy play crucial roles in diagnosis. Individualized surgical management is essential for positive outcomes.

CONCLUSION

This case highlights the need for individualized management in complex urological cases involving rare anatomical variations. Surgeon experience and a comprehensive understanding of such anomalies are crucial for successful outcomes.

Postpartum hemorrhage with associated placenta previa in a kidney transplant recipient: A case report

INTRODUCTION

The efficacy and safety of uterine artery embolization (UAE) and prophylactic resuscitative endovascular balloon occlusion of the aorta (REBOA) against postpartum hemorrhage (PPH) in pregnant women after kidney transplantation have not been reported. Here, we describe a case of PPH associated with placenta previa in pregnancy following kidney transplantation, which was managed with UAE and prophylactic REBOA.

CASE PRESENTATION

A 35-year-old, gravida 2, para 1 woman with total placenta previa presented with vaginal bleeding (460 mL) at 33 weeks and 3 days of gestation. Previously, she underwent a living-donor kidney transplantation for IgA nephropathy, and the renal artery of the transplanted kidney was anastomosed with the right internal iliac artery. An emergency cesarean section with prophylactic REBOA was performed under general anesthesia. A balloon catheter was introduced via the left femoral artery and positioned above the aortic bifurcation (Aortic zone 3). Upon confirming fetal delivery, the balloon was immediately inflated, and the total aortic occlusion time was 20 min. However, following aortic balloon deflation, atonic bleeding continued despite Bakri balloon usage and uterotonic drug administration. Subsequently, UAE was performed for the refractory PPH, the left uterine artery was embolized using a gelatin sponge, and hemostasis was successfully achieved. The patient recovered uneventfully and was discharged on postoperative day 7.

DISCUSSION AND CONCLUSION

In pregnancies following kidney transplantation, prophylactic REBOA controls bleeding; however, it decreases blood flow to the transplanted kidney. Furthermore, uterine nutrient vasculature alterations are observed, necessitating a thorough understanding of the uterine artery supply pathways during UAE.

Bouveret's syndrome: An old diagnosis. A modern multimodality approach (endoscopic and robotic surgical) of gastric outlet obstruction: Report of two cases

INTRODUCTION AND IMPORTANCE

Bouveret's syndrome is an uncommon condition characterized by the impaction of a gallstone in the pylorus or duodenum via a cholecysto-enteric fistula causing gastric outlet obstruction. We report two unusual cases of Bouveret's syndrome causing gastric outlet obstruction in two elderly patients.

CASE PRESENTATION

Two elderly female patients presented to the surgical assessment unit with features of gastric outlet obstruction. In both cases, an urgent computed tomography (CT) of the abdomen showed pneumobilia, gastric distension, and gallstones impaction at the duodenal bulb. In Patient 1, endoscopic removal of the impacted gallstones was done successfully. She was discharged three days following an uneventful recovery. In Patient 2, an endoscopic removal of a single large gallstone was attempted, which was unsuccessful. She underwent robotic gastrotomy with extraction of the large gallstone with primary repair. She was discharged on 8th postoperative day.

CLINICAL DISCUSSION

Treatment options for Bouveret's syndrome include endoscopic management and surgery. The selection of treatment options depends upon factors like the degree of obstruction, the impaction site, number, type or size of gallstones, patient co-morbidities and clinical parameters at presentation, as well as expertise available, both endoscopic and surgical.

CONCLUSIONS

Bouveret's syndrome is one of the rare complications of gallstone. Endoscopic management can be effective at removing the impacted gallstones, which is particularly helpful for those elderly patients who have multiple medical co-morbidities, as in our first patient. Surgical management like minimal invasive surgery (robotic) can be beneficial in failed endoscopic attempt of removal of stone like in the second patient.

Paget's disease of the nipple with underlying occult invasive carcinoma detected by magnetic resonance imaging and second-look ultrasound: Case report

INTRODUCTION

Paget's disease of the nipple (PDN) is a rare and often misdiagnosed condition characterized by the infiltration of adenocarcinoma cells into the nipple epidermis. It poses substantial diagnostic and therapeutic challenges due to its similarity to benign dermatological conditions and its association with in situ or invasive carcinoma.

CASE PRESENTATION

This report details the case of a 47-year-old woman with persistent nipple itching, rash, and occasional bloody discharge. No abnormalities were seen on the mammogram and ultrasound scans; punch biopsy was performed to confirm PDN. A small lesion missed by other imaging methods was detected via breast magnetic resonance imaging (MRI). A second-look ultrasound with needle localization enabled precise surgery. The pathology report after breast-conserving surgery (BCS) revealed invasive ductal carcinoma with no metastasis in the sentinel lymph node biopsy.

DISCUSSION

PDN often mimics benign skin conditions, leading to delayed diagnosis. Furthermore, timely identification is crucial as PDN is frequently associated with underlying breast malignancies. Additional imaging, such as breast MRI, is essential for comprehensive evaluation, as it can reveal hidden lesions previously undetected by conventional mammography and ultrasound. A second-look ultrasound guided needle placement for tumor localization, enhancing surgical precision, aesthetics, and reducing patient harm. Surgical management, including mastectomy, BCS with radiotherapy, and oncoplastic surgery, offers suitable options without affecting recurrence or survival in selected patients.

CONCLUSION

This case emphasizes the importance of employing additional imaging tools, such as breast MRI and second-look ultrasound for the early detection and surgical management of PDN.

Multifocal giant cell tumor of the carpus: Unusual presentation. Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Giant cell tumors (GCTs) of bone in the carpus are rare. Carpal GCTs are usually solitary lesions; multifocal involvement is exceptional. These lesions have a higher risk of local recurrence after intralesional curettage than those in other body areas.

CASE PRESENTATION

We present a case of a 28-year-old male with a six-month history of a palpable mass in the dorsal aspect of the left wrist. Physical examination revealed a 2 cm, mildly tender mass. Magnetic resonance revealed a large intermediate signal lesion involving completely hamate bone and the distal portion of the triquetrum. Histological examination confirmed a giant cell tumor of the carpus. The patient underwent en-bloc resection of the hamate bone extending to the distal part of the pyramidal. The defect was reconstructed using polymethylmethacrylate cement (PMMA), and intercarpal arthrodesis with the capitate was achieved. Follow-up at 18 months revealed a good clinical evolution, wrist range of motion of 30° of extension, 30° of flexion, and 10° of ulnar and radial deviation without evidence of tumoral recurrence.

CLINICAL DISCUSSION

The current literature suggests a high incidence of local recurrence in carpal GCT, so wide excision with carpal arthrodesis is recommended, especially in Campanacci III and multifocal involvement.

CONCLUSION

Carpal GCT is exceptional, mainly affecting the hamate, capitate, and scaphoid. Most literature supports wide excision of carpal GCT owing to the high recurrence rate with intralesional procedures.

Traumatic posterior dislocation of atlanto-axial joint with anterior arch fracture in the patient of atlanto-occipital assimilation: A case report

INTRODUCTION AND IMPORTANCE

Traumatic atlanto-axial dislocation (AAD) is relatively uncommon and can pose life-threatening risks. In this case, we describe a patient with a combination of AAD, an anterior arch fracture of the atlas, and a rare congenital anomaly known as atlanto-occipital assimilation (AOA).

CASE PRESENTATION

A 70-year-old man presented with posterior neck pain and right-sided torticollis following an accident that collision with a car while riding an electric scooter. Radiographic findings confirmed posterior AAD with anterior arch fracture of C1 in the inherent setting of AOA. The patient showed no neurologic deficit, so a closed reduction technique using Gardner-Wells tongs was attempted in an awakened state, and successful reduction could achieve without a neurologic deficit. After about three months of rigid brace application, head and neck motion was allowed, and no recurrence of dislocation or cervical pain occurred during the follow-up period of about one year.

CLINICAL DISCUSSION

Because the posterior AAD is usually accompanied by anterior arch fracture of atlas, the transverse atlantal ligament remained intact. So nonoperative management after manual reduction was possible. The presence of a C1 anterior arch fracture observed in our case can be regarded as an indicator predicting the success of closed reduction of AAD.

CONCLUSION

Our case highlighted the successful nonoperative management of traumatic posterior AAD with an accompanying anterior arch fracture of the atlas in a peculiar inherent combination of AOA through the closed reduction technique and rigid cervical brace application.

Pulmonary Dysfunction in Patients with Cirrhosis of the Liver: A Study of Pulmonary Function Tests and Arterial Blood Gases

Background and Aim

Respiratory complications in liver cirrhosis can occur due to various mechanisms, such as ascites causing restricted lung expansion and opening of intrapulmonary vascular shunts due to high portal pressures. We aimed to study the effects of the liver dysfunction on the lungs by evaluating arterial blood gas (ABG) and pulmonary function test (PFT) of all study subjects.

Subjects and Methods

A cross-sectional study was done between August 2020 and September 2022. Diagnosed cases of the liver cirrhosis were enrolled in the study after informed consent and were subjected to the following investigations: chest X-ray, oximetry, spirometry, diffusing capacity of the lung for carbon monoxide (DLCO), two-dimensional echocardiography, and ABG analysis (ABGA). The cases were divided into three groups based on their Child-Pugh staging, and statistical analysis was done on the collected data.

Results

A total of 64 (53 males and 11 females) patients with an average age of 49.82 ± 9.89 years were studied. Alcoholism was the most common cause of cirrhosis in males. Breathlessness (65.6%) and pleural effusion (26.6%) were the most common respiratory symptoms and signs, respectively. Seventeen patients had hepatic hydrothorax, eight patients had hepatopulmonary syndrome (HPS), and six patients had portopulmonary hypertension. Low pH (17.2%) and oxygen partial pressure (PaO2) (20.3%) were the most common ABGA findings. The pH, PaO2, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC), and DLCO were significantly low in Child Pugh Stage C (P < 0.05). The pH, pO2, HCO3, FEV1, FVC, FEV1/FVC, and DLCO were significantly lower in patients with HPS (P < 0.05).

Conclusion

Metabolic acidosis and low FEV1/FVC and DLCO were the common findings in study subjects. Pulmonary dysfunction was common in advanced liver cirrhosis. Patients with HPS had worse ABG and PFT parameters than those without HPS.

Evaluation of diode laser efficacy in treating benign oral soft tissue masses: A case series

INTRODUCTION AND IMPORTANCE

The diode laser, with a wavelength ranging from 810 to 980 nm, is a modern treatment modality that offers significant advantages in the management of benign oral soft tissue masses. Therefore, this report aimed to assess the efficacy of diode laser application for excisional biopsy of such masses.

CASE PRESENTATION

Three female patients, aged 9, 39, and 45 years, visited the Oral Medicine Clinic with complaints of painless masses in the oral cavity persisting for two to three months. Their intraoral examination showed the presence of pedunculated or sessile exophytic lesions with a smooth surface. The lesions appeared as single, pink to red protrusions located in various sites, including the left buccal mucosa, right lateral border of the tongue, and lower gingiva.

CLINICAL DISCUSSION

Excisional biopsy of the masses was carried out in the patients using the diode laser. The surgical procedures ranged from 10 to 20 min, with minimal intraoperative bleeding and precise cutting, while no pain was reported. Postoperatively, at two weeks and four months follow-up, the intraoral wounds exhibited excellent healing without complications such as pain, bleeding, swelling, scarring, infection, or mass recurrence. The clinical diagnosis of irritational fibroma (two cases) and fibrous epulis were confirmed by histopathological examination.

CONCLUSION

Diode laser emerges as a highly efficacious method for the excisional biopsy of benign oral soft tissue masses, providing intraoperative and postoperative advantages over scalpel surgery.

Painful knee

INTRODUCTION

A bipartite patella is a rare anatomical variant of the patella. A patella bipartite is often asymptomatic and is often an incidental finding on radiological imaging. The patella remains bipartite when secondary ossification centers fail to fuse. Herein, a case of bipartite patella improved after knee arthroscopy and surgical removal.

PRESENTATION OF THE CASE

A 57-year-old male with a history of polytrauma. He complained of progressive pain in the right knee area. A radiological investigation reported a right bipartite patella. The condition improved after the open removal of the accessory patella.

DISCUSSION

This case is considered type III according to Saupe's classification. Due to its location and radiological appearance, it is a painful synchondrosis of a bipartite patella.

CONCLUSION

After the failure of conservative management, the removal of the bipartite patella was necessary and unavoidable to restore everyday activities.

Isolated renal hydatid cyst

INTRODUCTION AND IMPORTANCE

Hydatid disease, is a parasitic disease caused by the larval stage of the cestode Echinococcus granulosus. The Liver and lungs are the commonly affected organs but rarely kidney can be affected. Patient with primary renal hydatid may present with nonspecific symptoms or may be diagnosed incidentally. Imaging and serology are useful for diagnosis. The best therapy is surgery.

CASE PRESENTATION

This case is reported to discuss a 35-year-old female presented with complaints of left side flank pain and swelling. The abdominal US and CECT show renal cyst, which was nonspecific. She underwent an open surgical exploration and cystectomy plus partial pericystectomy done. Post-operative serology test show Echinococcus IgG positive. Postoperatively, the patient had an uneventful recovery and discharged with Albendazole therapy for 8 weeks.

CLINICAL DISCUSSION

Renal hydatid cyst is rare, accounting for less than 2 to 3 % of all hydatid disease. Renal hydatid cysts can remain asymptomatic for many years and then can be discovered incidentally. The diagnosis and staging of renal hydatid cysts rely heavily on imaging and serology. Hydatid disease is primarily treated surgically.

CONCLUSION

A high index of suspicion should be maintained, especially in endemic areas, to ensure timely and accurate diagnosis of renal hydatid cyst. Surgical excision remains the treatment of choice, with appropriate preoperative and postoperative anthelminthic therapy. Long-term follow-up is crucial to monitor for recurrence and associated complications.

Unusual case report of concomitant lunate and scaphoid fractures without associated dislocation in a 16-year-old male

INTRODUCTION AND IMPORTANCE

Lunate fractures without associated dislocations are rare injuries, combination scaphoid-lunate fractures without an associated dislocation are even more rare of which few are reported in the literature.

CASE PRESENTATION

This case report describes a 16-year-old otherwise healthy male with ipsilateral scaphoid and lunate fractures after punching a goalpost with his left hand, for which he had surgical management. This patient had a successful treatment with two headless compression screws through a single extended carpal tunnel approach. Surgery was performed within two weeks of injury after initially immobilized with a thumb spica splint. The postoperative period was complicated by noncompliance with weight-bearing status and missed three-month followup. However, by six months, subsequent visits demonstrated radiographic and clinical healing as well as full wrist range of motion without any other sequelae.

CLINICAL DISCUSSION

This case offers more evidence regarding this rare injury. Lunate fractures and scaphoid fractures can both be treated with open reduction and internal fixation using headless compression screws, however little evidence exists when it comes to treating them in combination.

CONCLUSION

The use of headless compression screws through a single extended carpal tunnel approach led to clinical and radiographic healing in a 16 year-old-male with combined scaphoid and lunate fractures at 6 month follow up.

Chemotherapy-induced zosteriform lichen planus following mastectomy: A rare case report

INTRODUCTION

Zosteriform Lichen Planus represents a relatively uncommon variant of LP. It is characterized by a distinctive distribution following Blaschko's line and involving multiple dermatomes, setting it apart as a unique manifestation. There have been several cases of cutaneous LP reported, but relatively few of them presented as zosteriform LP. To our knowledge, this is the first documented case of zosteriform LP as an adverse drug reaction.

PRESENTATION OF CASE

A 62-year-old female presented to the dermatology clinic with asymptomatic hyperpigmented patches that exhibited gradual spreading. The patient had a history of breast cancer and underwent a mastectomy procedure, chemotherapy, adjuvant therapy, and radiation treatment. A dermatological examination revealed the presence of multiple hyperpigmented, ill-defined macules arranged linearly on the left flank and inner thigh.

DISCUSSION

A biopsy confirmed the diagnosis as Lichen Planus. The patient's condition significantly improved following a nine-week topical steroid with dose tapering.

CONCLUSION

Zosteriform LP is a rare adverse skin reaction associated with chemotherapeutic drugs. The immunosuppression induced by chemotherapy may trigger T-cell activation, leading to a lichenoid tissue reaction. A thorough patient history assessment is essential for the management of such adverse reactions.

Treatment of giant prostatic urethral stone with prostatolithotomy case report

INTRODUCTION

The patient with prostatic urethral stones of the size mentioned in the case report is very rare, and there is no standard surgical procedure for patients with giant stones in the prostatic urethra.

PRESENTATION OF CASE

A 62-year-old male patient presented to the emergency department with complaints of dysuria and hematuria. Computed tomography showed a prostatic urethral stone measuring 78x48x56 mm. Open prostatolithotomy was performed by extending the bladder incision towards the prostate capsule and the stone was removed.

DISCUSSION

Prostate stones can be classified into two types: true prostate stones, which form within the prostate's tissues, and urethral stones, which develop in the prostatic urethra. Urethral stones can be primary (forming in the urethra) or secondary (migrating from the upper urinary tract).

CONCLUSION

Treatment options vary based on stone size and patient history, with endoscopy recommended as the primary approach. However, in cases with large stone burdens, open surgical methods may be preferred.

Choosing Juvéderm Volux™ to chin augmentation: Case report and flowchart for clinical evaluation

INTRODUCTION

The development of filler biomaterials with high hyaluronic acid concentrations, cohesiveness, and elastic modulus has become an option for chin augmentation, as the balance of these rheological properties promotes high lifting capacity, providing minimally invasive perceptible improvements in patient appearance.

PRESENTATION OF CASE

The present study reviewed clinical and anatomical aspects of patients referred for chin augmentation and created a flowchart to assertively diagnose patients with an indication of Juvéderm® Volux™ for defining the lower third of the face.

DISCUSSION

The chin is vital for facial proportions and attractiveness perception. Its relevance to facial appearance is noticed the most when chin size is less than ideal, making other facial areas seem larger or smaller. The adjacent soft tissues of the neck and jaw appear prematurely aged when chin projection or width is inadequate. Hyaluronic acid-based fillers have a confirmed history of safe and effective use for treating facial volume loss or deficiency.

CONCLUSION

Juvéderm® Volux™ is a safe, effective, and long-lasting alternative for restoring and creating facial volume and sculpting, shaping, and contouring the chin and jaw.

Umbilical Littre hernia: A rare case report of an acute abdomen

INTRODUCTION

Littre's hernia (LH) is due to the presence of a Meckel's diverticulum (MD) in a hernial sac. It is an extremely rare condition in less than 1 % of all MD cases. It is often asymptomatic and is diagnosed incidentally during routine surgery for hernia repair. Surgery is the main treatment. Although the management of uncomplicated MD remains controversial, MD's management in the setting of either bowel obstruction or of Littre's hernia is done according to the clinical principles combined with the availability of local expertise.

PRESENTATION OF CASE

We report a case of an 11-year-old boy presented to the emergency room with a diagnosis of acute obstructive syndrome. Radiological exams were inconclusive. Intra-operatively findings showed a strangulated MD trapped in a small umbilical hernia. A simple wedge resection, followed by a primary closure of the remaining defect was performed. During 12 months of observation the patient remains in good condition.

DISCUSSION

LH is an uncommon type of abdominal wall hernia. Preoperative diagnosis is difficult. Even abdominal ultrasound and computed tomography (CT) cannot reveal the right diagnosis and it is generally performed intraoperatively. The main treatment is surgery. Repair of a Littre hernia requires both management of Meckel's diverticulum and repair of the hernia with sutures or mesh.

CONCLUSION

LH is a very rare type of hernia. Diagnosis is very difficult. All surgeons should be aware of this type of hernia to avoid life-threatening complications. The application of hernia repair recommendations for children may anticipate the happening of complicated LH.

Metabolic syndrome and surgical complications: a systematic review and meta-analysis of 13 million individuals

BACKGROUND

Metabolic syndrome (MetS) is characterised by the presence of at least three of the five following components: insulin resistance, obesity, chronic hypertension, elevated serum triglycerides, and decreased high-density lipoprotein cholesterol concentrations. It is estimated to affect 1 in 3 people around the globe and is reported to affect 46% of surgical patients. For people with MetS who undergo surgery, an emerging body of literature points to significantly poorer postoperative outcomes compared with nonaffected populations. The aim of this study is to review the current evidence on the risks of surgical complications in patients with MetS compared to those without MetS.

METHODS

Systematic review and meta-analysis using PRISMA and AMSTAR reporting guidelines.

RESULTS

The meta-analysis included 63 studies involving 1 919 347 patients with MetS and 11 248 114 patients without MetS. Compared to individuals without the condition, individuals with MetS were at an increased risk of mortality (OR 1.75 95% CI: 1.36-2.24; P <0.01); all surgical site infection types as well as dehiscence (OR 1.64 95% CI: 1.52-1.77; P <0.01); cardiovascular complications (OR 1.56 95% CI: 1.41-1.73; P <0.01) including myocardial infarction, stroke, cardiac arrest, cardiac arrythmias and deep vein thrombosis; increased length of hospital stay (MD 0.65 95% CI: 0.39-0.9; P <0.01); and hospital readmission (OR 1.55 95% CI: 1.41-1.71; P <0.01).

CONCLUSION

MetS is associated with a significantly increased risk of surgical complications including mortality, surgical site infection, cardiovascular complications, increased length of stay, and hospital readmission. Despite these risks and the high prevalence of MetS in surgical populations there is a lack of evidence on interventions for reducing surgical complications in patients with MetS. The authors suggest prioritising interventions across the surgical continuum that include (1) preoperative screening for MetS; (2) surgical prehabilitation; (3) intraoperative monitoring and management; and (4) postoperative rehabilitation and follow-up.

Secondary central retinal artery occlusion due to rhino-orbital-cerebral mucormycosis in a diabetic patient: a case report

Introduction and importance

Acute sinusitis can cause intraorbital complications. Although subperiosteal abscesses generally do not cause severe vision loss, rare cases of decreased vision due to central artery or vein occlusion have been reported since 2003. Central retinal artery occlusion (CRAO) is an eye emergency that can cause sudden loss of vision. This condition is commonly found in elderly individuals with other metabolic diseases. The authors report a case of a type 2 diabetes mellitus (T2DM) patient with CRAO due to suspected rhino-orbital-cerebral mucormycosis (ROCM).

Case presentation

A 47-year-old man came with sudden blurred vision since the last week. Examination of the left eye revealed no light perception and vision, orthophoric eyeball position with restricted movement in all directions. Hypaesthesia was observed on the left side of the face. In the anterior segment, oedema of the eyelids, ptosis, conjunctival injection, ciliary injection and chemosis, clear cornea, deep anterior chamber with VH4, brown iris, crypts, no neovascularization of the iris, pupil round, mid-dilated with a diameter of 5 mm, no light reflex, relative afferent papillary defect, and NO2NC2 lens were observed. In the posterior segment, non-uniform fundal reflexes were found, as well as retinal oedema, round papillae, hyperaemic fovea reflex (cherry-red spot), and a cup-to-disc ratio that could not be evaluated. The patient was diagnosed with CRAO, orbital cellulitis, and uncontrolled T2DM. The patient was administered topical and oral antibiotics; however, there was no improvement in the left eye. ROCM was suspected.

Clinical discussion

CRAO is most often caused by embolization or thrombosis associated with atherosclerosis at the lamina cribrosa level. CRAO accompanied by ROCM infection is very rare; to establish the diagnosis, it is necessary to carry out further examinations so that administered therapy can definitely improve the patient's clinical condition. Due to resource limitation, biopsy and MRI were not performed. Surgical debridement was planned when the patient was stable, but the patient missed follow-up appointments.

Conclusion

Fungal aetiology should be considered especially in T2DM patient with CRAO that do not improve with antibiotics.

Posterior-only approach for treatment of irreducible traumatic Atlanto-axial dislocation, secondary to type-II odontoid fracture; report of a missed case, its management and review of literature

INTRODUCTION AND IMPORTANCE

Odontoid fracture (OF) is among the most common and challenging cervical spine fractures in regards to the treatment and surgical approach. Atlanto-axial dislocation (AAD) is considered a significant complication after failed non-surgical treatment of OF. Traditionally, it requires anterior odontoidectomy followed by posterior C1-C2 reduction and fusion. In latest studies, Atlanto-axial joint (AAJ) remodeling in a posterior-only approach has got attention.

CASE PRESENTATION

We herein present a 30-year-old man with missed type-II OF, presenting with irreducible anterior AAD and progressive neurological deficit. Old non-united OF with dorsal callous formation, compressing spinal cord, was detected. The patient underwent correction of the deformity and reduction of the fracture utilizing the posterior-only approach. AAJ remodeling, callous release and C1-C2 fusion was performed in standard prone position, under fluoroscopic guide and intraoperative electrophysiological monitoring. The patient had uneventful surgery and postoperative course and was neurologically intact with appropriate alignment in 6-month follow-up.

CLINICAL DISCUSSION

The irreducible AAD following type-II OF could be successfully treated with posterior-only approach (C1-C2 fusion).

CONCLUSION

Type-II OF is considered unstable requiring surgical management. Close follow-up and appropriate patient education is mandatory in non-surgical treatment. Irreducible AAD has been managed with anterior odontoid resection and posterior fusion. Several complications of anterior surgery, makes posterior-only approach a noticeable choice.

Multiple dentigerous cysts in a patient showing features of Gorlin-Goltz syndrome: A case report

INTRODUCTION AND IMPORTANCE

The association between Dentigerous cysts (DCs) and Gorlin-Goltz syndrome (GGS) was claimed theoretically in a very few reports, with very few clinical foundations. The aim of this report was to present a unique case of multiple DCs in the mandible in a patient showing features of GGS.

CASE PRESENTATION

A 63-year-old male patient presented with multiple cyst-like lesions in the mandible associated with some clinical and radiological features of GGS, and that raised the suspension of odontogenic keratocyst (OKC). The patient underwent marsupialization and enucleation of these cysts, and the histopathological examination confirmed the diagnosis of DCs.

CLINICAL DISCUSSION

In this report, the patient presented with symptoms related to multiple unilocular radiolucent lesions found in the mandible and the clinical and radiological features were highly suggestive of OKCs associated with GGS. However, the perioperative findings raised the suspicion of DCs, which was confirmed by histopathology. Interestingly, GGS is an inherited autosomal dominant disorder arising from mutations in the patched tumor suppressor gene (PTCH). Previous studies showed this gene alteration in DCs; this can possibly be implicated in the pathogenesis of the association found in this report.

CONCLUSION

This report presented a case of bilateral DC in the mandible in a patient showing features of GGS. Therefore, this report verified the very rare association between DC and GGS. This may help dentists and physicians in reaching an accurate and early diagnosis of GGS.

Case report - Embolic shotgun pellet to the right internal carotid artery causing hemiplegia

INTRODUCTION AND IMPORTANCE

Intravascular ballistic embolism is a rare and complex medical condition, posing diagnostic and management challenges. It involves the migration of ballistic materials within the arterial system, often stemming from neck and chest injuries.

CASE PRESENTATION

A 13-year-old boy sustained a chest injury from an air rifle, leading to a pellet embolism in the right internal carotid artery, resulting in severe cerebral infarction. Despite intervention attempts, the lodged pellet left the patient with permanent hemiplegia.

CLINICAL DISCUSSION

Intravascular ballistic embolism, although infrequent, presents diagnostic and therapeutic complexities. Embolization can manifest after a delay, with neck and chest injuries serving as common entry points. This case raised potential embolization routes through the left ventricle or a chest wound to the aortic arch or right common carotid artery. Management strategies for intravascular ballistic embolism remain debated. Some cases are conservatively treated, while others undergo surgical or radiological procedures to remove the foreign body. These interventions carry risks, such as foreign body migration and reperfusion injury.

CONCLUSION

Effectively managing intravascular ballistic embolism necessitates a deep understanding of possible embolization routes and a careful evaluation of intervention risks. Collaborative research efforts are pivotal in establishing optimal management strategies for these intricate cases.

Neglected bilateral triphalangeal of the thumb delta type in adult case: A case report

INTRODUCTION

In rare case, thumb has extra phalanges known as triphalangeal of the thumb (TPT). Patients with TPT can have difficulty doing work/activities that require high precision. Therefore, surgical intervention is essential. This report provides an approach for a patient with TPT.

PRESENTATION OF CASE

A patient with TPT who underwent removal of extra phalanges and arthrodesis of interphalangeal (IP) joints is presented. The left thumb deviated 25o to ulnar while the contralateral part deviated 15o to radial. X-ray revealed both thumbs had extra delta-shaped middle phalanges. Complete excision of extra phalanges and simple arthrodesis of IP joints with two K-wires in 10° to 15° flexion was performed. Healing process ended without any complications and the patient had an improvement.

DISCUSSION

Productive-age patients with TPT can have difficulty doing work and activities that require high precision, especially in the non-opposable type of the right hand. Furthermore, the female patient is highly emphasizing the cosmetics of her hand to increase her self-confidence. Therefore, surgical intervention is essential for this patient. We performed complete excision of extra phalanges and simple arthrodesis of IP joints with two K-wires in 10° to 20° flexion. The first K-wire is introduced intramedullary as a primary fixator for longitudinal alignment, and the second wire is inserted obliquely as an anti-rotation wire. Functional outcome was assessed after 6 months post-removal of the wire which gave a satisfying result.

CONCLUSION

TPT is a rare anomaly which surgical intervention can improve the appearance and the precision of the hand.

Exploring the uncommon: A case report on localized peritonitis caused by ingested toothpick

INTRODUCTION

Bowel perforation is a serious emergency. Occasionally, sharp objects like toothpicks can get stuck in narrow parts of the small intestine, potentially resulting in impaction, obstruction, or perforation.

PRESENTATION OF CASE

A 20-year-old male arrived at our hospital's emergency department with sudden, severe abdominal pain persisting for 24 h. On examination, his abdomen showed tenderness, and bowel sounds were reduced. Contrast-enhanced computed tomography (CECT) indicated possible small intestine inflammation due to a foreign object and a diagnostic laparoscopy revealed a hyperemic terminal ileum.

DISCUSSION

This case involves ileal perforation from an unnoticed toothpick ingestion. Detecting foreign object perforations is challenging, often leading to misdiagnoses and CT scans are the most effective for toothpick detection. Definitive diagnosis is through laparoscopy, and treatment varies between laparoscopic suturing to intestinal resection.

CONCLUSION

Healthcare providers must consider toothpick ingestion in cases of acute abdominal symptoms to avert treatment delays and potential life-threatening outcomes.

Neoadjuvant Chemotherapy Approach to Pineal Germinoma: A Case Report

Intracranial germ cell tumors (GCTs) are rare malignant tumors with a peak incidence around puberty. The pineal region is the most commonly involved area of all intracranial GCTs. Due to the heterogeneous tumor origin, subtypes, and presentation, diagnosis and management are challenging. Complicated pineal germinomas are rarely reported in the literature. Here, we report a rare case of pineal germinoma with hydrocephalus and discuss the potential treatment approach. A 20-year-old boy presented to the hospital with vomiting and a decreased level of consciousness. The brain magnetic resonance imaging (MRI) revealed a pineal tumor. A ventriculoperitoneal shunt was placed to relieve the increased intracranial pressure. The patient underwent a suboccipital craniotomy with excisional biopsy of the pineal region tumor due to its critical location, as imaging studies alone may not be sufficient to establish a definitive diagnosis. Although there has been a rise in reported cases of germinoma tumors, there is currently no standardized therapeutic approach for treating them. Therefore, more randomized controlled cohort studies are necessary to evaluate potential treatments and develop a therapeutic approach.

First reported case: Uncommon presentation of Burkitt lymphoma as perineal ulceration in a young patient

INTRODUCTION AND IMPORTANCE

Burkitt lymphoma (BL) is an aggressive subtype of non-Hodgkin lymphoma with a predilection for pediatric patients, known for its rapid growth and MYC oncogene-associated chromosomal translocations.

CASE PRESENTATION

A 33-year-old male presented with a perineal ulcerated wound, initially misdiagnosed as a musculoskeletal injury. Imaging and histopathological analysis eventually confirmed BL, leading to the initiation of high-dose chemotherapy.

CLINICAL DISCUSSION

BL is characterized by its rapid growth, typically as masses in the abdomen or jaw. Nevertheless, atypical presentations can lead to diagnostic delays, underscoring the importance of considering BL even in the absence of classic symptoms. Swift recognition and accurate diagnosis are critical for initiating timely chemotherapy. Comprehensive clinical evaluation, advanced imaging, and histopathological analysis are pivotal in confirming the diagnosis.

CONCLUSION

This unique case of BL with a perineal mass presentation emphasizes the necessity of considering BL as a potential diagnosis in atypical cases, highlighting the importance of early recognition and appropriate therapeutic strategies. Healthcare professionals should be aware of the potential for unusual BL presentations.

Rhupus syndrome. a case report of a rare combination

Introduction and importance

Rhupus syndrome is a very rare combination of systemic lupus erythematosus and rheumatoid arthritis. It is characterized by the presence of erosive arthritis with symptoms and signs of systemic lupus erythematosus. Rheumatoid nodules and neurological and renal involvement are further complications of Rhupus syndrome, leading to a worse prognosis.

Case presentation

The authors presented a young female patient diagnosed with lupus erythematosus, who laterally, developed clinical signs and biomarkers that led to the diagnosis of Rhupus syndrome. This is believed to be of relevance to the knowledge of the medical community.

Conclusion

Despite being a rare entity, it is important to know its early diagnosis, and treatment to reduce the complications.

Insomnia and sleep-disordered breathing in FKRP-related limb-girdle muscular dystrophy R9. The Norwegian LGMDR9 cohort study (2020)

Limb-girdle muscular dystrophy R9 (LGMDR9) is a progressive and disabling genetic muscle disease. Sleep is relevant in the patient care as it impacts on health, functioning, and well-being. LGMDR9 may potentially affect sleep by physical or emotional symptoms, myalgia, or sleep-disordered breathing (SDB) through cardiorespiratory involvement. The objective was to investigate the occurrence of insomnia and unrecognized or untreated SDB in LGMDR9, associated factors, and relationships with fatigue and health-related quality of life (HRQoL). All 90 adults in a Norwegian LGMDR9 cohort received questionnaires on sleep, fatigue, and HRQoL. Forty-nine of them underwent clinical assessments and 26 without mask-based therapy for respiration disorders additionally underwent polysomnography (PSG) and capnometry. Among 77 questionnaire respondents, 31% received mask-based therapy. The prevalence of insomnia was 32% of both those with and without such therapy but was significantly increased in fatigued respondents (54% vs 21%). Insomnia levels correlated inversely with mental HRQoL. Among 26 PSG candidates, an apnea-hypopnea index (AHI) ≥ 5/h was observed in 16/26 subjects (≥ 15/h in 8/26) with median 6.8 obstructive apneas and 0.2 central apneas per hour of sleep. The AHI was related to advancing age and an ejection fraction < 50%. Sleep-related hypoventilation was detected in one subject. Fatigue severity did not correlate with motor function or nocturnal metrics of respiration or sleep but with Maximal Inspiratory Pressure (r = - 0.46). The results indicate that insomnia and SDB are underrecognized comorbidities in LGMDR9 and associated with HRQoL impairment and heart failure, respectively. We propose an increased attention to insomnia and SDB in the interdisciplinary care of LGMDR9. Insomnia and pulmonary function should be examined in fatigued patients.

A case report of liver infiltration from a large renal cell carcinoma: Diagnostic and management enigma

INTRODUCTION AND IMPORTANCE

Renal cell carcinoma is the most lethal malignancy of urinary tract. Invasion of right lobe of liver by Renal cell carcinoma is rare and possess a treatment challenge. Simultaneous nephrectomy with right hepatectomy has been proposed as a part of multi-modality treatment approach. But its safety and feasibility is not well established.

CASE PRESENTATION

We herein discuss a case of 30-year old female patient who underwent simultaneous nephrectomy with right hepatectomy along with single peritoneal metastasectomy for a huge Renal cell carcinoma of right kidney and infiltrating the right lobe of liver. Intra-operatively a single peritoneal nodule was present which came positive for malignancy on frozen section. Considering young age, good performance status and oligometastatic disease definitive procedure in the form of combined right nephrectomy and right hepatectomy was performed. She was discharged from the hospital on 6th post-operative day with an uneventful post-operative course.

CLINICAL DISCUSSION

The patients with locally advanced Renal cell carcinoma with involvement of adjacent organs require en block surgical resection in combination with targeted therapy and immunotherapy. The surgical management of patients with direct liver infiltration requires a right nephrectomy with some form of liver resection based on the extent of liver involvement to achieve a margin negative resection. In our case a plan of formal right hepatectomy was made as the tumor was infiltrating into segment VI, VII, and VIII.

CONCLUSION

The combined nephrectomy and right hepatectomy is safe and feasible for this type of huge RCC invading right hepatic lobe.

Two cases of right congenital diaphragmatic hernia with stable respiratory condition: Two case reports

INTRODUCTION

Right congenital diaphragmatic defect (CDH) has been reported poor prognosis. However, laterality of the defect as the prognostic factor is recent controversial topic. We experienced two cases of right CDH with relatively stable respiratory condition and good clinical course.

PRESENTATION OF CASES

Case 1 was a girl diagnosed with right CDH by fetal ultrasonography and delivered by planned caesarian section at 37 weeks, 3 days. Fetal MRI showed liver herniation into the right thoracic cavity. High frequency oscillatory ventilation with nitric oxide gas was administered until day 5. At surgery on day 8, we found defects in the right posterolateral diaphragm and sac herniation of the right side of the liver into the right thoracic cavity. The postsurgical course was uneventful, and she was discharged on day 41. Case 2 was a girl with suspected congenital jejunal atresia after fetal ultrasonography detected polyhydramnios and dilatation. She was delivered by normal vaginal delivery at 38 weeks, 5 days, and thoraco-abdominal X ray showed right CDH but no small intestinal atresia. Surgery performed on day 3 found liver herniation into the diaphragmatic defect. Subsequently, bacterial infection occurred and was treated with the antibiotics, but her respiratory condition remained stable. She was discharged on day 49.

DISCUSSION

The volume of herniated abdominal organs is affected by the presence of a hernia sac or the size of the diaphragmatic defect.

CONCLUSION

The size of diaphragmatic defect, but not the laterality of the diaphragmatic defect, may be an important prognostic factor in right CDH.

Surgical management of a locally advanced jejunal stromal tumor: A case report of a challenging condition

INTRODUCTION AND IMPORTANCE

Locally advanced jejunal stromal tumors stand as a captivating and relatively rare entity, garnering attention for several reasons. Their inaccessible location by conventional endoscopy poses a diagnostic challenge. Further, treatment decisions necessitate a multidisciplinary approach, compounded by the absence of high-level evidence studies.

CASE PRESENTATION

A 54-year-old patient was admitted to our surgical department with abdominal pain and chronic anemia. Abdominal CT imaging confirmed the presence of a non-metastatic sizable jejunal tumor. The patient underwent laparotomy, revealing a locally advanced jejunal tumor contracting the ileum and the ascending colon. A monobloc oncological resection was performed, followed by the restoration of digestive continuity. Anatomopathological analysis delineated a locally advanced Stromal Tumor with a high risk of recurrence. The patient underwent a course of tyrosine kinase inhibitors for 3 years, with no reported recurrence during the subsequent 3-year follow-up.

DISCUSSION

Locally advanced jejunal stromal tumors are rare. Most patients present with unspecific symptoms. Diagnosis remains challenging due to their intricate anatomical location. Decisions regarding management must be deliberated within a multidisciplinary framework, tailored to each patient's unique characteristics. While combined therapeutic modalities have demonstrated efficacy in recent studies, prudence is advised given the heightened incidence of both short and long-term complications.

CONCLUSION

In the absence of randomized controlled trials, the management of locally advanced jejunal stromal tumors underscores the imperative of multidisciplinary collaboration in treatment deliberations. A wide, sometimes mutilating excision is only permissible if it is complete.

Innovative biochemisurgical treatment for stabilisation of an end-stage chronic wound in a complex vascular compromized patient

INTRODUCTION

Treating advanced peripheral arterial occlusive disease (e.g. PAOD IV) poses a significant challenge, as conventional treatments quite often fall short at this stage. However, a range of interventions can be considered to postpone amputation. This study presents an example of advanced stage of Peripheral Artery Occlusive Disease (PAOD) stage IV, encompassing a history of a high thigh amputation on the left side, coupled with pronounced wound healing disorders.

PRESENTATION OF CASE

Our patient, 55 years old, smoker and ASA Class III is in a left sided above-the knee-amputation situation. He presented to our outpatient clinic with blistering in the stump area, caused by non-proportinate pressure from the prosthesis. With an emerging septic course and advanced peripheral arterial occlusive disease (PAOD) at Fontaine class IV, revascularization was unfeasible in the left iliac artery axis and groin arteries. Additionally, a stage PAOD IV presents itself with poorly healing wounds on the right side which our patient still uses to support his transfers in and out bed and his wheelchair. Multiple surgical stump revisions and femur shortenings and diverse wound treatments were performed all were unsatisfying for patient and practitioners. We introduced a novel biochemisurgical treatment in our teaching hospital.

DISCUSSION

Desiccating-agent-A is an innovative dehydrating agent with potent desiccating characteristics upon application to organic substances. Its formulation involves blending 83% methane sulfonic acid with proton acceptors and dimethyl sulfoxide, as outlined in patent application. The case description results in an illustrated follow up period of 16 months and is presented in line with the recommendations of the consensus-based surgical case reporting guideline development.

CONCLUSION

The goal of achieving a secondary healing trend is to establish stability within the wound area or achieve complete healing. This endeavor becomes particularly intricate when severe blood circulation compromise exists. Nonetheless, progress in wound treatment measures has made it feasible to achieve this aim by fostering the formation of dry and clean necrotic tissue. This dry and clean wound is now manageable in a patient's home situation, allowing for effective care and a better chance at preventing further severe complications.

Discordant exencephaly in case of a twin delivery: a case report

Introduction and importance

Neural tube defect occurs as a result of failure of spontaneous closure of the neural tube between the third and fourth weeks of foetal life. Exencephaly is a rare malformation of the neural tube characterized by a large amount of protruding brain tissue in the absence of the calvarium.

Case presentation

The authors report a 29-year-old female, non-compliant to iron, calcium and folic acid tablets due to nauseating and itchy sensation after intake for 2 weeks, was admitted in ward Obstetrics ward in view of twin pregnancy. After proper counselling, she was advised for caesarean section, which revealed gross malformation in the form of cleft lip, cleft palate and exposed brain tissue covered by thin layer of membrane with incompletely formed cranial vault and multiple-haematoma and ulcerations in the exposed brain tissue suggestive of Exencephaly. The deformed baby survived for 2 days after birth while the other baby was grossly healthy.

Clinical discussion

Exencephaly is said to be the embryological precursor anomaly of anencephaly. Exencephaly is a type of cranial malformation that characteristically involves a large disorganized mass of brain tissue. The flat bones of calvaria are absent and the brain mass is left uncovered. This condition is incompatible with life.

Conclusion

Each and every pregnant lady must be advised to undergo ultrasonography in every trimester, especially second trimester scan (anomaly scan) to diagnose any gross congenital malformations. Each pregnant lady is suggested to take the necessary vitamins (like folic acid) to avoid any Neural tube defects.

Anterior dislocation of the shoulder associated with a diaphyseal fracture of the ipsilateral humerus: a case report

Background

Anterior dislocation of the shoulder associated with a diaphyseal fracture of the ipsilateral humerus is a rare and controversial occurrence, with very few cases reported in the literature.

Case presentation

We present a case of a 39-year-old right-handed driver who presented with an anterior dislocation of the shoulder associated with a diaphyseal fracture of the ipsilateral humerus following a road traffic accident. The lateral approach to the fracture allowed us to use two forceps to gain a good grip on the proximal fragment and perform the maneuver to reduce the dislocation. The fracture was reduced and fixed with a molded Lecestre-type plate.

Conclusion

In this case, we employed the approach of initially reducing the shoulder dislocation with forceps, followed by osteosynthesis of the humeral fracture. The functional results were excellent after 6 months.

Lung cavitation to pneumothorax: A case report of the multilayered respiratory challenges in oncology patients

INTRODUCTION

The management of patients with complex oncological histories poses unique challenges, particularly when they are on targeted chemotherapy agents known for specific side effects. This case report illuminates the multifaceted complexities encountered in such scenarios, with a focus on the rare complications associated with targeted therapies.

CASE PRESENTATION

We present a 50-year-old male with an extensive oncological background, including childhood retinoblastoma and radiation-induced leiomyosarcoma. Recently diagnosed with skull base osteosarcoma, he was undergoing treatment with Regorafenib. Admitted with sepsis due to Pseudomonas aeruginosa-induced community-acquired pneumonia, his clinical course was complicated by lung cavitation leading to a spontaneous pneumothorax. This report highlights the absence of empyema, a crucial differential in the diagnosis.

DISCUSSION

This case unravels the intricate interplay between targeted chemotherapy, concurrent medications like prednisone, and their potential to cause severe complications such as pneumonia and pneumothorax. It delves into the mechanisms by which Regorafenib can lead to lung cavitation and abscess formation, a rare but significant risk. The importance of a multidisciplinary approach for prompt diagnosis and treatment, including surgical intervention, is highlighted. The pathology of the surgically resected lobe revealed metastatic high-grade leiomyosarcoma, adding another layer of complexity to the case.

CONCLUSION

This case serves as a cautionary tale highlighting the need for vigilant monitoring of patients on targeted chemotherapy agents, especially those with complex medical histories. It highlights the importance of considering potential drug-related complications and the rationale behind therapeutic choices, including antibiotic selection and surgical decision-making, in the management of acute medical conditions in these patients.

Uncommon presentation of necrotizing fasciitis affecting the breast in a young breastfeeding patient: Case report

INTRODUCTION AND IMPORTANCE

Necrotizing fasciitis is a highly dangerous infection that poses a life-threatening risk as it rapidly spreads and causes tissue necrosis in the subcutaneous tissues and fascia. Although rare, the breasts can be affected by this infection, which adds to the complexity of the condition.

CASE PRESENTATION

A 26-year-old woman who had been breastfeeding for two months presented with pain, swelling, and fever in her left breast. The left breast showed skin darkening and foul-smelling discharge. The diagnosis was septic shock due to necrotizing fasciitis. Prompt treatment included surgical debridement, broad-spectrum antibiotics, and supportive care. The patient's condition remained challenging, and the infection was caused by multi-resistant bacteria.

CLINICAL DISCUSSION

Necrotizing fasciitis is a highly severe and aggressive type of soft tissue infection. It can range from minor or mild infections of the soft tissues to severe cases involving septic shock. While it is uncommon, necrotizing fasciitis can also affect the breasts. The diagnosis of breast NF relies on a combination of clinical evaluation, culture results, laboratory findings, and imaging studies. Swift surgical interventions, along with appropriate antibiotic therapy and supportive management, are vital for the patient's survival and improved prognosis.

CONCLUSIONS

Breast necrotizing fasciitis is frequently misdiagnosed due to the presence of thick breast tissue, which creates challenges in identifying the infection between the skin and deep fascia. Swift and extensive surgical debridement, combined with the administration of broad-spectrum antibiotics, are crucial components for effectively managing and preventing the significant morbidity and mortality associated with this condition.

Abdominal pseudohernia as an exceptional complication of herpes-zoster

INTRODUCTION

Herpes zoster (HZ), caused by the reactivation of the Varicella-Zoster virus, is typically characterized by sensory complications. However, motor complications, such as abdominal pseudohernia, are rare and exceptional. This report presents a case of post-herpes zoster pseudo-hernia in a previously healthy 54-year-old man.

CASE PRESENTATION

A 54-year-old Caucasian patient developed an abdominal wall protrusion over two weeks, following a resolved herpes zoster infection. Physical examination revealed healed skin lesions and a painless protrusion on the right flank, triggered by coughing, suggesting an abdominal wall hernia. Abdominal CT scan ruled out parietal but noted asymmetry in the abdominal wall muscles, particularly thinning on the right side. The diagnosis of post-herpes zoster pseudo-hernia was established, with spontaneous resolution occurring after four months.

DISCUSSION

Herpes zoster typically manifests as a sensory condition. However, motor complications can lead to muscle weakness or paralysis. Pseudo-herniation is a rare motor complication, affecting less than 1 % of cases. It must be differentiated from true abdominal wall hernias, which require surgical intervention. Pseudo-hernia typically presents as painless abdominal bulging, often asymptomatic, but can lead to gastrointestinal issues if visceral nerves are affected. Imaging studies and EMG may be employed for diagnosis. Treatment for pseudo-hernia is conservative, addressing the underlying HZ, and the prognosis is favorable, with most cases resolving within 3 to 12 months.

CONCLUSION

Abdominal post-herpes zoster pseudo-hernia is a rare HZ complication. Recognizing this entity is crucial, as it typically resolves spontaneously without surgical intervention. This case aims to enhance awareness of this exceptional clinical manifestation.

Combined tracheoesophageal transection following a life-threatening clothesline-type blunt neck trauma: A case report

INTRODUCTION

Blunt neck trauma is an uncommon, life-threatening injury that may result in tracheoesophageal transection. The manifestations of these traumas are rather vague and nonspecific; therefore, the injury may be missed, if a careful attention is not paid.

CASE PRESENTATION

A 23-year-old young man presented with complete transection of the trachea and concurrent esophageal injury, caused by clothesline-type blunt neck trauma, while riding a motorcycle. On early examination, the patient was hemodynamically stable; however, after a few minutes, he manifested respiratory distress and progressive subcutaneous emphysema. The airway immediately was secured by inserting an endotracheal tube in distal part of the transected trachea. Afterward, the patient underwent primary repair of transected trachea and esophagus, and tracheostomy. The post-operative period was uneventful.

DISCUSSION

The blunt traumas to neck, which lead to complete transection of the trachea and the esophagus, are rare injuries. Clothesline-type injuries are the principal reasons for cricotracheal separation and further esophageal injuries. In most cases, subcutaneous emphysema is a sign of significant trauma to the aerodigestive tract. After securing the patient's airway, early surgical repair of the transected trachea and esophagus reduces the risk of further complications.

CONCLUSION

This report discusses a rare, life-threatening presentation of blunt neck trauma called clothesline-type injury, that led to complete transection of the trachea and concurrent esophageal rupture. Establishing a secure airway for those patients with tracheal injuries is required. Repairing the injured trachea and esophagus primarily at the earliest possible time can improve the patient prognosis and prevent further complications.

Successful reconstruction using three flaps combination after wide excision due to basosquamous carcinoma: A case report

INTRODUCTION

Basosquamous carcinoma (BSC) is an uncommon and malignant subtype of non-melanoma skin cancer. It has features that are halfway between basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

CASE PRESENTATION

An 87-year-old female presented with a lesion on her left cheek, nasal ala, medial canthal area, and eyelids. After investigations, which included biopsies and a computed tomography scan (CT), surgery was decided upon to completely remove the mass. A 5 × 4 cm defect after the surgery was reconstructed by mobilizing three flaps, including the McGregor flap, VY glabellar flap, and nasolabial laterally based cheek flap. The excisional biopsy detected malignancy at the lateral border of the upper lid, which led to the patient undergoing surgery to remove the tumor formation. After the second surgery, the histopathology confirmed no malignancy. The patient had functionally and aesthetically pleasing results, preserved eyelid movement and visual field. No surgical complications or recurrences occurred within the first year after the surgery.

DISCUSSION

BSC is a neoplasm without well-defined histologic characteristics or standardized treatment procedures compared to other non-melanoma skin cancers. However, several studies recommend using wide excision. In our case, Reconstructing the area was challenging due to important anatomical structures and finding tissue that matches the desired appearance, while preserving functional and aesthetic results.

CONCLUSION

In this case report, we highlight the value of reconstructing face defects after wide excision due to BSC using three flaps.