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A 34 year old Persian woman, gravida 1, para 0, presented at 22 weeks of pregnancy with a two week history of left hip pain with no apparent precipitating event. Her past medical history included mild Multiple Sclerosis from which she was asymptomatic. She did not smoke or drink alcohol, had no history of corticosteroid, anticonvulsant or anticoagulant use and was not on any other medication. Clinical examination was unremarkable and no investigations were deemed appropriate. The working diagnosis at this stage was non-specific hip pain related to pregnancy and supportive measures were instituted.\nOver the following 12 weeks her hip pain worsened, and she started to experience pain in the contra lateral hip. Again there was no history of a traumatic event. Because of her pregnancy imaging of her hips was avoided. By 36 weeks of pregnancy she was unable to weight bear and became wheelchair bound. Pain in her hips and limitation of motion meant that a normal vaginal delivery was impossible; hence she underwent a caesarean delivery of a healthy baby at full term.\nShe was brought to the attention of the orthopaedic team when plain radiographs (see figure ) following delivery revealed a displaced intracapsular femoral neck fracture on the left and a valgus impacted right intracapsular femoral neck fracture on the right. The radiographs also revealed considerable osteopaenia. MRI (see figure ) revealed these fractures, with reduced signal on T1 and increased signal on T2 in the femoral necks in keeping with TOP.\nShe underwent closed reduction and internal fixation of the left hip. The right hip was internally fixed in situ. Two hole 135 degree dynamic hip screws were used in order to provide sufficient stability to allow immediate mobilisation despite bilateral fractures. Difficulty was encountered in ensuring that the threads of the dynamic hip screw had crossed the fracture site in the left hip as the level of the fracture was high in the femoral neck, consequently the tip of the implant had to be implanted close to the subchondral plate (see figure ).\nThe post-operative course was uncomplicated and the hip pain significantly improved immediately. Full weight bearing on the right, and partial weight bearing on the left was initiated on the first postoperative day, and maintained for the first 12 weeks. Check radiographs at 3 months showed no loss of fixation and the fractures appeared to be uniting in an adequate position. At six months she was pain free with no evidence of avascular necrosis or implant failure.

A 60-year-old female who was previously healthy with no risk factors for stroke presented with sudden onset left-sided weakness and dysphasia. National Institutes of Health Stroke Scale score on admission was 20. Brain computer tomography did not reveal any established infarct, however a computer tomography cranial angiogram showed evidence of thrombus in the proximal right middle cerebral artery (). She was treated with thrombolysis and endovascular mechanical clot removal ( and ()) with a successful outcome of recovering to a National Institutes of Health Stroke Scale score of 2 within 24 hours.\nAs a part of stroke work-up brain magnetic resonance imaging (MRI) was performed. Interestingly magnetic resonance imaging showed multiple infarcts with haemorrhages in the right middle cerebral artery territory and bilateral cerebellar hemisphere raising a possibility of an embolic source (). While reviewing the history, it became obvious that the patient had not been well for the previous four weeks prior to admission. She had a low grade pyrexia and mildly raised inflammatory markers with associated anaemia and thrombocytopenia. All the above symptoms and image findings raised the possibility of infective endocarditis.\nAn urgent echocardiogram established a mobile mass in the anterior mitral valve leaflet indicative of a vegetation which was further proven on transoesophageal echocardiography. It was a large mobile mass measuring about 11 × 4 mm and prolapsing in to the left ventricular outflow tract with mild aortic regurgitation (). She was then treated for infective endocarditis with intravenous antibiotics. Despite therapy she continued to have an intermittent fever with persistent raised inflammatory markers. However serial blood cultures and serology remained sterile. Further studies including virology, vasculitic screen (together with thrombophilia screen) and serology for atypical organisms were negative.\nHence a computer tomography of thorax, abdomen and pelvis was performed to identify an infective focus. Interestingly an underlying large pelvic mass suggestive of a right-sided ovarian tumour (9 × 9 cm) was found without any evidence of metastasis (). Imaging also revealed pulmonary, splenic and renal embolic events with evidence of infarcts. Multi systemic embolisation with poor clinical response to antibiotics raised a suspicion of non bacterial thrombotic endocarditis. Therefore low molecular weight heparin was commenced. She underwent hysterectomy with bilateral salpingo-oophorectomy and omentectomy followed by adjuvant chemotherapy. A high grade ovarian clear cell carcinoma was confirmed on histology.\nSerial repeat transthoracic and transoesophgeal echocardiography was performed to assess the size of the vegetation as a response to anticoagulation and a promising result was demonstrated ().

A 40-year-old man presented with fresh hemorrhagic stool. Colonoscopy and upper gastrointestinal endoscopy were performed, but the bleeding site was not clear in the visible range of the stomach, duodenum, and colon. On hospital day 2, capsule endoscopy was performed, and bleeding from the small intestine was detected. On hospital day 3, the patient developed shock due to massive bleeding. Hence, emergency transcatheter arterial embolization was performed. He had a history of surgery for anal atresia and small bowel stoma as a neonate, and he required hemodialysis because of chronic renal failure with bilateral kidney malformations. Computed tomography performed before transcatheter arterial embolization showed that the anatomy of the left common iliac artery was normal. However, the right external iliac artery was defective. Blood from the right common iliac artery flowed directly into a traveling vessel: the internal iliac artery. The blood vessel descended at an acute angle to the pelvic floor, and then, it rose and flowed into the femoral artery (Fig. ). We chose to insert the catheter from the left femoral artery and then further selectively advanced the catheter to the superior mesenteric artery, which is the responsible vessel for gastrointestinal bleeding. Regarding the superior mesenteric artery, the branch from the aorta was at the same level as the celiac artery, and the right hepatic artery originated from the superior mesenteric artery. But angiography did not show a clear extravasation from either branch of the superior mesenteric artery. Small intestinal endoscopy was performed on hospital day 8. However, it was impossible to advance the endoscope because the small intestinal adhesion was very strong. Thereafter, there was no massive bleeding. He was discharged home on hospital day 20 after red blood cell transfusion. Later, he was hospitalized again for small intestinal resection. In the abdominal cavity, the small intestine was firmly adhered. First, 30 cm of the adhered small intestine was resected. Then, small intestinal endoscopy was performed through the small bowel stump. There were two diverticula on the oral side, but no obvious bleeding was found. A submucosal cystic lesion was found during small intestinal resection, and it was judged to be a bleeding site due to redness.\nLater, it was confirmed that he met the diagnostic criteria for VATER association because of the deformity of the sacrum, right aplastic kidney, left hypoplastic kidney (Fig. ), and history of anal atresia.

Staged bilateral total hip arthroplasties were performed on a 55-year-old man with a neglected untreated history of DDH, who gradually developed severe bilateral hip joint arthritis. The chief complains included bilateral hips and knee joints pain on walking associated with a progressive limitation in the range of hip motion and walking ability distance day after day. The history of the present problem went back to the age 45 with an incident of the low back pain repeated at the ages 50 and 52; each time relieved by conventional bed rest and other conservative measures. The progressive changes in lumbar spine (L2-L3) including discopathies and stenosis of the spinal canal were also contributed to his limitation of walking ability for last 10 years.\nThe patient was born as the last member of a large size family of a second degree consanguineous traditional marriage, with the maternal age 43, having 3 sisters and 4 brothers without hip disease. In the past medical history, the patient presented a history of the right nasolacrimal stenosis operated at the age of 3 and 8, right inguinal hernia operated for at 1 and 3. A suspected dentine dysplasia characterized by deciduous and permanent teeth with clinically normal appearing crowns, some hypermobility and spontaneous dental abscesses started in childhood and ended with the loss of all teeth at the age of 22 to 27. An unsuccessful closed reduction of the left hip joint at the age of 11 put in spica cast from the tip of the toe up to the chest level was performed and immobilized for 9 months. A history of night bedwetting, up to the age of 11, due to urinary reflux evolving in the left renal regression and hypoplasia, accidentally revealed upon a renal infection and diagnosed by renal angiography at the age of 22. A problem of ingrown toe nail started from the age of adolescence with multiple recurrence after a surgical correction was noticed. Two attacks of the left ear Menier’s disease reported to be experienced at the age of 33 and 44 years, ended with the total hearing loss and a residual continuous tinnitus. The patient and family had a habit of W-sitting from the childhood. The patient had no history of smoking or alcohol use. NSAIDS was the only medication he received. He was married having two children, a daughter (16 years old) and a son (15 years old), none of them having hip problems.\nPhysical examination revealed marked limitation of motion with some pelvic obliquity, a positive bilateral Trendelenberg test, mild gluteal asymmetry, apparent limb length discrepancy, severe crepitation during hip flexion, and painful hip in long time standing and walking.\nThe pelvic X-ray showed false acetabulum, broken Shenton’s line which was worse on the left side, severe arthritis changes such as diminished joint space, ossified neolimbi on both sides as shown in (arrows), large osteophytes and bony spurs, loss of cartilage, massive sclerotic changes on both sides, dislocation on the left and subluxation on the right side. Increased anteversion of the femoral neck of the left side and lateral views are shown in lateral views of both hips ( and ).\nUneventful cementless total hip arthroplasties were performed on both hips. The acetabular cups were placed close to anatomic true acetabulum. Post-op anteroposterior view of the pelvis shows implantation of the femoral and acetabular components (Titanium cementless press fit). The movement occurs between a chrom-cobalt head on a highly cross linked polyethene liner ().\nThe patient got ambulated walking with crutches the day after the surgery and was able to walk without crutches six weeks after the second operation. During the first six week post-op, conventional physical therapy was instructed. No leg length discrepancy was noticed seven days after the second THR operation and remained as such thereafter (). This is demonstrated by the symmetrically located stem part of the prostheses in relation to the pubic ramus verified by equally broken Shentons’ lines shown in the post-op pelvic radiograph ().

The patient is a male in his 60s with a past medical history significant for pulmonary sarcoidosis. He was referred to neurology clinic for progressive, bilateral, lower extremity numbness which he noted first in his feet. The patient indicated the pain and tingling in his feet worsened with prolonged standing and walking. He also endorsed lower back pain on follow-up visits. MRI of the thoracic cord demonstrated a longitudinally extensive transverse myelitis. The initial workup was unrevealing for an etiology and initial suspicions were that his condition was due to neurosarcoidosis. A lumbar puncture was performed and negative. Upon further review of the spinal imaging it was thought that there may be dilatation of the spinal epidural venous plexus, which would potentially indicate a dural arteriovenous fistula. The patient was then taken for a catheter angiogram for further evaluation.\nDuring angiography, the left and right subclavian arteries were imaged to evaluate for spinal cord blood flow. An injection within the aorta was required to establish a road map for the left vertebral artery and the left vertebral artery origin from the aortic arch was found. An injection of the aortic arch origin of the vertebral artery revealed complete filling of all segments of the left vertebral artery. Retrograde filling of the left subclavian artery was seen indicating a potential dual origin from the left subclavian artery. A catheter was placed within the left subclavian and a second origin of the left vertebral artery was appreciated to originate and merge with the aortic V1 segment at the level of the C5 vertebrae (Figure ). Equal filling was seen from both the aortic and subclavian origin. No aneurysms or dissections were appreciated in either origin or at the confluence. When the right T7 spinal artery was injected, a dAVF was observed. The fistula originated from a distal branch of the spinal artery and combined with an anterior spinal vein with abnormal filling appreciated. The rest of the spinal arteries were interrogated and noted to be grossly normal without aneurysms, fistulas, or other vascular abnormalities.\nPost-procedure and follow-up\nThe patient underwent embolization of the right T7 spinal artery was performed with obliteration of the fistula (Figure ). The patient tolerated the procedure well without complication and was discharged home.

A 54-year-old female, who was found to have incidental giant left ICA aneurysm on magnetic resonance imaging (MRI) scan, during the workup for headaches (). There was no history of thunderclap headache or any associated visual or neurologic symptoms to suggest aneurysm rupture. Initial angiogram for evaluation of aneurysm, demonstrated a large left ICA para-ophthalmic aneurysm, measuring around 26×19 mm with a wide neck of 14 mm (). There was a patent anterior communicating artery with brisk cross filling of the left cerebral vasculature from the contralateral right side as well as patent left PCOM artery. Considering the complex anatomy, size of aneurysm and presence of good collaterals with patent anterior and PCOM artery, a plan was made in another hospital to treat the aneurysm with parent vessel occlusion rather than flow diverter stent. Subsequently, the aneurysm was treated in October 2016. Initially, a balloon occlusion test of the left ICA was performed which was negative for any neurological change during 20 minutes of balloon occlusion with blood pressure challenge as well. Subsequently, occlusion of the left ICA proximal to the aneurysm was performed using multiple coils (, ). There was no antegrade flow into the left ICA after occlusion with a patent flow into the left cerebral hemisphere through a patent anterior and PCOM arteries (, ). Angiogram of the left vertebral artery after occlusion of left ICA showed retrograde filling of the left ICA para-ophthalmic aneurysm (, ). This was considered to occlude overtime considering the competing antegrade intracranial flow. Patient remained asymptomatic after the treatment. Follow up angiogram after 6 months and 2 years demonstrated no antegrade flow in the left ICA, however there was persistent filling of the left ICA aneurysm in a retrograde fashion through the PCOM artery (). The aneurysm was followed up for another year and showed no evidence of occlusion with similar retrograde filling through the PCOM artery with no much change in its size. At this stage, considering the persistent filling of aneurysm, treatment was contemplated and the patient was transferred to our institution. She was successfully treated with a flow diverter stent across the PCOM artery into the distal left ICA. Patient recovered well, with no obvious neurological deficit or post-operative complications. Follow up angiogram after six months of flow diverter stent demonstrated patent flow in the PCOM artery with complete occlusion of the aneurysm with no residual filling (). presents an illustration of the final treatment construct.

A 35-year-old white female who was an elite endurance athlete training for triathlons had a 3-year history of chronic left hip and groin pain which was subsequently investigated by MRI study. Her MRI of the hip and femur incidentally showed distention of the left common and external iliac veins with associated deep vein thrombosis.\nAt the time, she had no symptoms of leg pain or swelling and had no personal or family history of prior thrombotic events. She had a history of prolonged flights; however, none were taken immediately prior to her investigation. She was on oral contraceptives, which were subsequently discontinued, with no additional medications. She was a lifetime nonsmoker and had no symptoms to suggest concurrent pulmonary embolism. She had a prior hand surgery with no perioperative complications. Her examination was normal with no evidence of leg swelling or asymmetry and no evidence of postthrombotic syndrome.\nShe was started on anticoagulation and 3 weeks later had an ultrasound of her left lower limb that showed no evidence of deep vein thrombosis, which included the common femoral and external iliac veins. It was concluded that it was difficult to exclude a clot proximal to the iliac vein thus, she was continued on warfarin for 6 months. Following her anticoagulation, she underwent a MR angiogram and venogram. There was no evidence of deep vein thrombosis; however, there was significant narrowing of the upper aspect of the left common iliac vein just as it passed under the right common iliac artery prior to its joining with the right iliac vein. There was no associated dilation of the peripheral left iliac veins, and remaining veins were unremarkable for compression or malformation. These findings were highly suggestive of iliac vein compression. A thrombophilia screen was done following anticoagulation therapy, which showed the patient was heterozygous for Factor V Leiden mutation.\nSoon afterward, the patient had a pelvic venogram illustrating stenosis of the left common iliac vein consistent with external compression with some collateral veins. Pressure measurements were done across the stenosis with a mean pressure gradient of 9 mm Hg. A 14 mm × 60 mm Nitinol self-expanding stent was deployed across the stenosis and dilated with a 12 mm balloon (). Good restoration was confirmed on angiography with a mean pressure gradient of 2 mm Hg. She was given 300 mg of Plavix at the time of the procedure and continued Plavix 75 mg for a total of two months. She did well after treatment and continues to take part in her regular training with no further complications.

A 51-year-old hypertensive Pakistani male patient was admitted in the cardiac intensive care unit in King Fahd University Hospital on 30 July 2017 complaining of chest and back pain for two weeks prior to the presentation; he took nonsteroidal anti-inflammatory drugs but were not effective. Physical examination was done in the emergency department and revealed stable vital signs; the patient was conscious, moving all his limbs; there were warm palpable pulses of the upper arms.\nThe CTA of the aorta revealed a large dissection flap from the origin of the left subclavian artery extending down all the way to the level of renal arteries; there was enlargement of the false lumen at the proximal aorta with large aneurysmal dilatation (mural thrombus) and a compression of the true lumen (ascending aorta). Additionally, there was a large entry point seen 2 cm distal to the right subclavian artery. The aberrant right subclavian artery was noted crossing posterior to the trachea and arising as a last branch of the aortic arch distal to the left subclavian artery; also, the left vertebral artery was arising directly from the aortic arch. There was no other evidence of vascular dissection or occlusion below the level of the renal arteries (Figures and ).\nThe patient underwent general anesthesia for thoracic endovascular repair (TEVAR) two days after his first day of admission; the procedure was done through the right femoral approach; an angiogram was performed intraoperatively (). Stent graft with a size of 34 mm × 15 cm was used and deployed into the descending thoracic aorta; the intimal entry tear was completely covered by the stent, and the false lumen was obliterated. A postdeployment angiogram revealed successful proximal occlusion of the entry point with no perfusion of the false lumen and good flow through both carotid and left vertebral arteries as well as patent right and left subclavian arteries.\nThe patient was postoperatively moving all his limbs, and the peripheral pulses were intact. He got discharged one day after the surgery and was doing well afterward. We evaluated patient's prognosis by following up for 3 to 6 months for a chest X-ray, CTA, and CT aorta 3D reconstruction (Figures and ) which confirmed no endovascular leak as well as no ischemic or stroke signs in the clinical follow-up; we assessed the patency of the subclavian arteries by examining the bilateral upper arms' blood supply in addition to radial arteries by evaluating the pulses with no evidence of morbidity.

A 19-year-old male had a history of road traffic accident 18 months back with severe head injury and pelvic fracture. He remained in the referring hospital for three months. After discharge he remained reasonably well except for occasional episodes of anterior chest pain and dyspnea on moderate exertion.\nRecently he was admitted again through the emergency department with complain of severe chest pain along with shortness of breath. CT chest with intravenous contrast showed large aneurysm of the descending thoracic aorta distal to the origin of left subclavian artery causing compression on the origin of the left main bronchus, and on the right and left pulmonary arteries with no evidence of dissecting or contrast leak; however, the patient referred to the vascular surgical unit in our institute for further management.\nAfter admission he complained of mild shortness of breath. His vital signs and his routine blood investigation were within normal limits. His chest radiograph showed normal bilateral lung fields.\nHe underwent endoluminal thoracic aortic stenting under general anesthesia. Postoperatively the patient started to complain of severe dyspnea and was desaturating. His immediate post-procedure routine chest X-ray revealed complete collapse of the left lung []. An urgent CT chest with intravenous contrast showed endovascular stent in place, but the aneurysmal sac was completely occluding the left main bronchus with complete collapse of the left lung but with adequate perfusion. The aneurysmal sac also had a mass compression on the adjacent right main pulmonary artery, which was compressed and stretched maximum at its proximal portion [].\nPatient was stable hemodynamically and with relatively acceptable arterial blood gases.\nHe was monitored closely for possible emergency intervention with an endobronchial stent.\nAlthough placement of an endobronchial stent in the left main bronchus can open the collapsed left lung, at the same time it may increase the pressure and can occlude the compressed right pulmonary artery supplying the only aerated right lung which could cause major morbidity, so, a conservative plan was adopted.\nAfter 18 hours the apex of the left lung started to open up radiologically which showed up on the chest X-ray. Patient’s arterial blood gas was improved gradually with the improvement of the expansion of the left lung over the next few days. He was discharged on the 15th post-op day with complete expansion of the left lung []. He remained asymptomatic over the next fifteen months on his regular outpatient follow-up.

An 86-year old woman presented at the emergency department suffering from severe acute upper abdominal pain. Her past medical history included hypertension, diabetes mellitus, coronary heart disease, atrial fibrillation, chronic obstructive pulmonary disease and twenty years before she had an omphalocele repair. The patient was in a close clinical and radiological follow up for monitoring a pancreatic serous cystadenoma diagnosed incidentally with a computed tomography (CT) scan 10 years earlier. The lesion was extensively studied with magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), fine needle aspiration (FNA), serology and blood test screening. At that time she was addressed for a routine year follow up scan which she attended regularly for six years. Patient did not attend her follow up time table for the last four years. Upon admission to the emergency department, chest and abdominal x-rays were performed and turned out inconclusive. Routine laboratory studies revealed marked leukocytosis, severe anemia, and blood glucose levels exceeding 500 mg/dl. Due to inconclusive diagnosis, an intravenous contrast CT scan was ordered and revealed a large amount of free peritoneal air and free fluid. (Figure , ) Moreover, a left upper quadrant 17 cm large mass originating from the stomach was revealed along with secondary liver lesions. An urgent laparotomy showed a prepyloric ulcer perforation and a large inoperable mass arising from the pancreatic body and largely invading the posterior wall of the stomach occupying the upper abdomen with multiple hepatic secondary lesions. A liver biopsy was taken, the stomach perforation was sutured closed and a washout was performed. The histopathologic findings from the biopsy material were consisted of small and medium size cystic lesions surrounded and divided by hyalloid collagenous matrix. The cysts were lined by cuboidal epithelial cells with clear cytoplasm and round nuclei without atypical or mitotic activity as demonstrated by pathology. The glycogen content was documented by PAS positive reaction. These findings were consistent with serous microcystic adenoma of the pancreas and the malignant nature of the tumor was confirmed by the presence of the extensive invasive large inoperable pancreatic mass with hepatic metastasis. The patient after a brief period in intensive care unit for respiratory problems recovered from surgery in 10 days but died a month later because of other, unrelated, serious medical problems.

A 28-year-old male presented with a painless swelling in the volar aspect of right mid forearm of 10 years duration with complaints of increase in size of the swelling associated with pain for the past two years. He complained of pain and paresthesia in the median nerve distribution of the right hand. The swelling measured 6 cms in length and 5 cms in width. The swelling was mobile on the transverse axis and not on the longitudinal axis. There was no motor weakness. There was normal protective sensation present in the hand. Percussion over the nerve produced positive Tinel’s sign. There was no family history of neurofibromatosis and no associated clinical features. The ultrasound showed that the mass was subcutaneous although limited and homogeneous measuring 6 cm in diameter. The patient refused to undergo MRI examination due to financial constraints. A surgical workup and a preoperative anaesthetist assessment were obtained. With a clinical diagnosis of median nerve tumor the patient was planned for excision of the tumor. The patient was explained regarding the neurological deficit following surgery and that she may need a sural nerve graft. The patient was taken up for surgery in supraclavicular block with bupivacaine and Xylocaine under tourniquet control.\nAdequate exposure of the nerve was done both proximal and distal to the tumour (). On exploration the tumour was found to be arising from the median nerve in the right mid forearm. It was a well encapsulated greyish tumour () placed in an eccentric position to the axis of the nerve (). The vascular pedicle in the proximal part of the tumour is identified first and the remaining tumour was gently resected using microsurgical techniques. The specimen was sent for histopathological examination. Histopathological examination of the masses revealed typical features of schwannoma with presence of spindle cells forming Verocay bodies and clearly identified Antony A and B areas (). At two months follow-up the patient was symptom free with mild paresthesia in his index and middle fingers. There was no motor deficit or pain and no recurrence of the lumps ().

A 29 years old male patient was taken to our emergency department within one hour of following motor vehicle accident. He complained of severe chest and back pain. On examination he was alert, conscious with pulse rate of 134 per minute, blood pressure of 86/64 mm/Hg, the extremities were cold and clammy. On auscultation, the heart sounds were audible without any adventitious sounds. The breath sounds were diminished in the left lower chest. A chest x-ray was done which revealed multiple rib fracture with mediastinal widening and left pleural effusion. In view of excruciating chest and back pain with features of hemorrhagic shock, a suspicion of aortic injury was made and hence an urgent emergency department CT scan was done after that the patient was shifted quickly to the emergency operation theater without waiting for the reports and the CT film. While shifting to the operation theater the film was obtained on the operation theater console which revealed a contained ruptured aortic rupture immediately below the level of isthmus (). An intervention cardiologist opinion was sought for endovascular stenting but in view of lacerated aorta involving more than 50% of its circumference at the site of injury, it was not possible and hence an urgent open surgical technique was advised. The patient was taken to operation theatre and intubated with single lung tube. He was positioned in right lateral position. A left posterolateral thoracotomy was done and the chest cavity was entered through the fifth intercostal space. A huge contained hematoma was noted. The patient was heparinized a plan to conduct surgery on left heart bypass on normothermia was decided. One of the 16Fr aortic cannula was inserted to the left superior pulmonary vein as outflow circuit and another 18Fr aortic cannula was inserted to the descending thoracic aorta just above the level of diaphragm as inflow circuit and the circuit was connected to the heart and lung machine. The bypass was initiated at flow rate of 1500 mL/min. A cross clamp was applied 2 cm below the origin of left subclavian artery and another aortic cross clamp was applied on the descending thoracic aorta just proximal to the thoracic aortic cannulation. Clots and debris were removed gently and it was observed that more than half of the circumference of the aortic lumen was torn approximately 5cm distal to the left subclavian artery (). The margins were trimmed and a 26 mm synthetic polyester Dacron tube interposition graft was sewn to both the ends using No 5-0 polypropylene suture, de-airing was performed by releasing the distal clamp first. The patient was weaned off gradually from the left heart bypass and the rest of the procedures were conducted uneventfully. The patient responded well and is on regular follow up for the last two years and the follow up CT scan of the repair is satisfactory ().

A 51-year-old hypertensive Pakistani male patient was admitted in the cardiac intensive care unit in King Fahd University Hospital on 30 July 2017 complaining of chest and back pain for two weeks prior to the presentation; he took nonsteroidal anti-inflammatory drugs but were not effective. Physical examination was done in the emergency department and revealed stable vital signs; the patient was conscious, moving all his limbs; there were warm palpable pulses of the upper arms.\nThe CTA of the aorta revealed a large dissection flap from the origin of the left subclavian artery extending down all the way to the level of renal arteries; there was enlargement of the false lumen at the proximal aorta with large aneurysmal dilatation (mural thrombus) and a compression of the true lumen (ascending aorta). Additionally, there was a large entry point seen 2 cm distal to the right subclavian artery. The aberrant right subclavian artery was noted crossing posterior to the trachea and arising as a last branch of the aortic arch distal to the left subclavian artery; also, the left vertebral artery was arising directly from the aortic arch. There was no other evidence of vascular dissection or occlusion below the level of the renal arteries (Figures and ).\nThe patient underwent general anesthesia for thoracic endovascular repair (TEVAR) two days after his first day of admission; the procedure was done through the right femoral approach; an angiogram was performed intraoperatively (). Stent graft with a size of 34 mm × 15 cm was used and deployed into the descending thoracic aorta; the intimal entry tear was completely covered by the stent, and the false lumen was obliterated. A postdeployment angiogram revealed successful proximal occlusion of the entry point with no perfusion of the false lumen and good flow through both carotid and left vertebral arteries as well as patent right and left subclavian arteries.\nThe patient was postoperatively moving all his limbs, and the peripheral pulses were intact. He got discharged one day after the surgery and was doing well afterward. We evaluated patient's prognosis by following up for 3 to 6 months for a chest X-ray, CTA, and CT aorta 3D reconstruction (Figures and ) which confirmed no endovascular leak as well as no ischemic or stroke signs in the clinical follow-up; we assessed the patency of the subclavian arteries by examining the bilateral upper arms' blood supply in addition to radial arteries by evaluating the pulses with no evidence of morbidity.

A 44-year-old Caucasian female referred to the ER with acute abdominal pain. Past medical history revealed no family history of colon cancer and no history of smoke. At the admission, physical examination revealed pain and tenderness in the right lower quadrant with no signs of bowel obstruction, mimicking an acute appendicitis. Laboratory investigation has not shown important pathological signs. Ultrasonography examination of the abdomen showed a contracted gallbladder with normal bile ducts, no pathologies affecting the pancreas and neither free fluid, nor signs of acute appendicitis. In consideration of the clinical status of the patient and the persistent acute abdominal pain even with a negative ultrasound, a CT scan was performed to better comprehend the nature of the underling pathology. CT scan was performed four hours after the hospital admission, and demonstrated a thickened cecal wall with a small number of pathological nearby lymph nodes, confirming the absence of peritoneal free fluid. Given the absence of radiological signs of GI perforations and of other surgical and medical emergencies, we decided to perform a colonoscopy to better understand the etiology of the underling pathology. Colonoscopy was performed 24 hours after the hospital admission and after an adequate bowel preparation and revealed a massive, ulcerated, stenotic and necrotic lesion that involved the caecum and the right colon. Biopsies of the lesion were performed and the microscopic examination showed a cell proliferation composed by large, pleomorphic cellular elements with vesicular nuclei, hyperchromatic nucleoli and eosinophilic cytoplasm, mixed with necrotic tissue. These findings were consistent with the diagnosis of poorly differentiated carcinoma ().\nFor these reasons, a laparoscopic right colectomy in an elective setting was performed, together with an accurate lymphadenectomy. Surgical exploration of the abdominal cavity confirmed the absence of peritoneal carcinosis and distant metastasis. Pathological examination of the surgical specimen revealed an ulcerated lesion of the right colon with a 6 cm diameter, composed of a whitish and compact tissue, with hard consistency and infiltrative margins that extended to the perivisceral adipose tissue. Microscopic examination discovered a poorly differentiated neoplastic epithelial tumor, rich in mitosis, with large-sized cellular elements characterized by vesicular nuclei, occasional nuclear pseudoinclusions, hyperchromatic nucleoli and eosinophilic cytoplasm and organized in chains and clusters and mixed with necrotic areas. Additionally, an inflammatory component made of lymphocytes, histiocytes and plasma cells with a polytypic expression of Immunoglobulin light chains was present. The neoplastic epithelial tumor showed the following immunohistochemical profile: positive for CK7 (focal), CAM 5.2 (focal), CKAE1/AE3 (focal), Calretinin (focal), Claudin 4, and negative for CK20, Synaptophysin, Chromogranin, CDX2, TTF-1, P63, CK5-6, CD20, CD3, CD5, CD79, MUM1, S100, ER, MART-1, EBV; proliferation cell index MIB1 was higher than 50% (). None of the 35 lymph nodes collected and examined showed presence of malignant cells. The final staging of the disease was B2 according to Astler and Coller, Stage III according to Jass and pT3 N0 Mo for the TNM classification.\nThe molecular analysis for the MSI has identified a High level of Microsatellite Instability (MSI-H) and was performed with the study of fragments with 3500 Dx Genetic Analyzer - Applied Biosystems.\nThis particular profile, especially the lack of expression of CDX2 and the positivity for Calretinin, oriented the diagnosis towards a MC rather than to a poorly differentiated carcinoma.\nSubsequently, in consideration of different variables, such as the histological characteristics, the poor degree of differentiation, the presence of vascular infiltration, the medullary histological type and the age of the patient, the patient underwent an adjuvant chemotherapy according to the FOLFOX - 4 schedule for 12 cycles (association of 5-Fluorouracil, Leucovorin, and Oxaliplatin).\nAfter 24 months from the index surgery, the patient is disease free and with a good quality of life.

A 51-year-old hypertensive Pakistani male patient was admitted in the cardiac intensive care unit in King Fahd University Hospital on 30 July 2017 complaining of chest and back pain for two weeks prior to the presentation; he took nonsteroidal anti-inflammatory drugs but were not effective. Physical examination was done in the emergency department and revealed stable vital signs; the patient was conscious, moving all his limbs; there were warm palpable pulses of the upper arms.\nThe CTA of the aorta revealed a large dissection flap from the origin of the left subclavian artery extending down all the way to the level of renal arteries; there was enlargement of the false lumen at the proximal aorta with large aneurysmal dilatation (mural thrombus) and a compression of the true lumen (ascending aorta). Additionally, there was a large entry point seen 2 cm distal to the right subclavian artery. The aberrant right subclavian artery was noted crossing posterior to the trachea and arising as a last branch of the aortic arch distal to the left subclavian artery; also, the left vertebral artery was arising directly from the aortic arch. There was no other evidence of vascular dissection or occlusion below the level of the renal arteries (Figures and ).\nThe patient underwent general anesthesia for thoracic endovascular repair (TEVAR) two days after his first day of admission; the procedure was done through the right femoral approach; an angiogram was performed intraoperatively (). Stent graft with a size of 34 mm × 15 cm was used and deployed into the descending thoracic aorta; the intimal entry tear was completely covered by the stent, and the false lumen was obliterated. A postdeployment angiogram revealed successful proximal occlusion of the entry point with no perfusion of the false lumen and good flow through both carotid and left vertebral arteries as well as patent right and left subclavian arteries.\nThe patient was postoperatively moving all his limbs, and the peripheral pulses were intact. He got discharged one day after the surgery and was doing well afterward. We evaluated patient's prognosis by following up for 3 to 6 months for a chest X-ray, CTA, and CT aorta 3D reconstruction (Figures and ) which confirmed no endovascular leak as well as no ischemic or stroke signs in the clinical follow-up; we assessed the patency of the subclavian arteries by examining the bilateral upper arms' blood supply in addition to radial arteries by evaluating the pulses with no evidence of morbidity.

A 17-year-old Malay girl was involved in a road traffic accident in which she sustained a closed right femur fracture. She was treated with intramedullary nailing of the right femur. She was well until two years after the initial trauma when she met with another road traffic accident. The patient fell off her motorcycle and was brought to our centre with severe right thigh pain. Clinically, the right thigh was deformed with no obvious open wound. There was no other associated injury and the neurovascular status was intact. A plain radiograph shown 30° varus angulation of the femoral nail in the AP view and 30° anterior angulation in the lateral view with the continuity of the nail intact (). The fracture site was noted to be not united with minimal callus formation. It was decided to remove the nail surgically. The surgery was done under regional (spinal) anaesthesia with the patient being placed in the left lateral decubitus position. A skin incision was made by a lateral approach at the fracture site under image intensifier guidance. The tissue was divided layer by layer until the fracture site and the fibrous tissue around it was cleared up.\nThe initial technique attempted was based on the principle of partially weakening the nail followed by manual straightening. The bent nail was partially resected using a jumbo cutter through the wound, then reduction was attempted using the bone holder forceps placed at the proximal and distal part of the fracture site and the strength was applied to straighten the bent nail. However, the correction failed. We then proceeded with the second technique of fully cutting the nail and then extracting it into two different pieces. The distal locking screw was removed, followed by removal of the proximal locking screw. Manual traction was applied as a distraction at the fracture site to fully visualise the apex of angulation of the bent nail. A Jumbo cutter was introduced up to the visible nail and it was sectioned by multiple bites into two parts as shown in . Continuous saline irrigation was done during the transection of the nail. The proximal part of the nail was extracted with a standard technique using extraction nail system and the distal part was extracted through the fracture site using pliers. A bone graft was done and a locking compression plate was inserted to stabilize the fractured femur. () Post-operative recuperation was uneventful and - the patient was discharged well without any complications.

A 22 year old male patient had sustained chest injury by a metal splinter under moderate velocity. He presented with an entry wound in the 9th intercostal space, anterior axillary line on the right side. He was hemodynamically stable and had no respiratory symptoms or signs and abdomen was normal. Two coordinates of X-ray chest revealed the presence of foreign body in the (R) hemithorax, we suspected that the foreign body could be in the thoracoabdominal cavity based on the mechanism of injury. CT scan confirmed our suspicion that a sharp foreign body was indeed in the (R) thoracic cavity, not close to major vessels. There was a minimal pneumothorax which was not evident clinically. This sharp foreign body mandated removal. We decided to try minimal access surgery but with full preparations for open thoracotomy in case of failure. He needed one lung ventilation as a prerequisite for thoracoscopy. Hence the procedure was done under general anesthesia and intubated with a double lumen tube. He was placed on the anterolateral right thoracotomy position. Single lung ventilation was instituted. In addition CO2 insufflation was given up to 5mm Hg, for safer initial trocar placement and better visualization of hemithorax. A 10mm camera port was placed in the (R) 5th intercostal space in the anterior axillary line. A 5 mm working port was placed in the same intercostal space. The foreign body was seen on the inferior surface of the lung and removed through the 10 mm port Figures and . The rest of the thoracic cavity and diaphragm were found to be normal. An intercostal tube was placed in the 10 mm port site. He had no adverse event intraoperatively and promptly recovered from anesthesia, with a well expanded lung that was confirmed clinically and with a bedside X ray. However, we still continued to ventilate him electively for 18 hours as our experience with one lung ventilation is limited. He was extubated and ICD removed the same day. He was discharged on the second postoperative day. He is followed up regularly and is doing well.

A 32-year-old man sustained injury to his right leg in a road traffic accident five years ago. He had mangled leg which resulted in a below knee amputation done at a local hospital. The stump had healed with secondary intention owing to insufficient soft tissue cover and infection []. He was fitted with prosthesis and was allowed ambulation. However, the loading area of the stump had repeated breakdown and the stump became extremely sensitive and painful. He was unable to wear the prosthesis and bear weight on the stump. The bone length was maintained at 12 cm below the tibial plateau and soft tissue cover was possible only at the expense of the shortening of the stump. Salvage of the stump was only possible with adequate soft tissue cover. Reconstruction of the stump was planned with anterolateral thigh flap from the opposite side. The scar tissue was excised completely till the bone. About 2 cm tibial end was projecting in the wound []. A 14 × 14cms flap along with vastus lateralis muscle was harvested with the patient in supine position. Subsequently the patient was made to lie prone for recipient vessel dissection in the popliteal fossa. Anastomosis was done end-to-end to popliteal vessels with minimal vessel diameter discrepancy []. The vastus lateralis muscle in the flap covered the bony stump and flap was insetted snugly to the defect without any redundancy. Duration of the operation was six hours. The postoperative period was uneventful, and skin grafted donor site healed satisfactorily. The patient was discharged on 16th post operative day. He was refitted with prosthesis 10 weeks after the surgery. He is a school teacher by profession and he is on the prosthesis for approximately 70 hours per week. He is symptom free at 20 months after the surgery and flap does not show any atrophy or redundancy []. He experienced remarkable improvement and can stand for 5 hours at a stretch without any pain. His pain free walking distance has increased from half a mile preoperatively to two miles post-operatively []. Although no nerve was anstomosed, the patient appreciates pain on deep pressure and can distinguish hot and cold sensation.

A 51-year-old hypertensive Pakistani male patient was admitted in the cardiac intensive care unit in King Fahd University Hospital on 30 July 2017 complaining of chest and back pain for two weeks prior to the presentation; he took nonsteroidal anti-inflammatory drugs but were not effective. Physical examination was done in the emergency department and revealed stable vital signs; the patient was conscious, moving all his limbs; there were warm palpable pulses of the upper arms.\nThe CTA of the aorta revealed a large dissection flap from the origin of the left subclavian artery extending down all the way to the level of renal arteries; there was enlargement of the false lumen at the proximal aorta with large aneurysmal dilatation (mural thrombus) and a compression of the true lumen (ascending aorta). Additionally, there was a large entry point seen 2 cm distal to the right subclavian artery. The aberrant right subclavian artery was noted crossing posterior to the trachea and arising as a last branch of the aortic arch distal to the left subclavian artery; also, the left vertebral artery was arising directly from the aortic arch. There was no other evidence of vascular dissection or occlusion below the level of the renal arteries (Figures and ).\nThe patient underwent general anesthesia for thoracic endovascular repair (TEVAR) two days after his first day of admission; the procedure was done through the right femoral approach; an angiogram was performed intraoperatively (). Stent graft with a size of 34 mm × 15 cm was used and deployed into the descending thoracic aorta; the intimal entry tear was completely covered by the stent, and the false lumen was obliterated. A postdeployment angiogram revealed successful proximal occlusion of the entry point with no perfusion of the false lumen and good flow through both carotid and left vertebral arteries as well as patent right and left subclavian arteries.\nThe patient was postoperatively moving all his limbs, and the peripheral pulses were intact. He got discharged one day after the surgery and was doing well afterward. We evaluated patient's prognosis by following up for 3 to 6 months for a chest X-ray, CTA, and CT aorta 3D reconstruction (Figures and ) which confirmed no endovascular leak as well as no ischemic or stroke signs in the clinical follow-up; we assessed the patency of the subclavian arteries by examining the bilateral upper arms' blood supply in addition to radial arteries by evaluating the pulses with no evidence of morbidity.

A 12-year-old female was referred to the Oral and Maxillofacial Surgery Department by an orthodontist regarding an ectopic upper left canine and buccal alveolar expansion from the 22 and 24. On examination there was firm, bony expansion between these teeth with associated root displacement. The 22 and 24 were not mobile. The overlying mucosa was normal and the patient was asymptomatic.\nRadiographic examination revealed an ectopic 23 which appeared to be within the maxillary sinus or a possible large cystic radiolucency surrounding the canine as well as an indistinct area of bony expansion between the 22 and 24 (). There was no evidence of root resorption of the 22 and 24. A cone beam computed tomography (CT) was carried out and showed expanded bone in the 23 region with normal trabecular pattern with intact buccal and palatal cortices, but some buccal cortical expansion. The 23 was located in the left zygomatic bone, with the crown facing buccally and causing dehiscence of the zygomatic bone. The roots were facing toward the left maxillary sinus with the dilacerated apex projecting into the sinus (). The cause of buccal alveolar expansion and migration of the 23 was unclear.\nThe patient had the 23 region explored under a general anesthetic, as well as a bone biopsy of the lesion and a left middle meatal antroscopy. The 23 was not visible during examination of the left maxillary sinus. The expanded buccal bone appeared firm but abnormal looking with slight bleeding (). A differential diagnosis of a fibroosseous lesion was made.\nHistopathology results showed vital lamellar bone with uniform osteoblast layer with minimal evidence of resorption. The soft tissue component was a mixture of adipose and highly vascular fibrous tissue. Numerous blood vessels ranged widely in size, some having muscle wall and appeared to be displacing adipose tissue. These finding were compatible with a diagnosis of an IH.\nOn review, there was no further evidence of bony expansion or active hemorrhage from the lesion. Although the 23 was positioned in the zygomatic bone, there was no cystic evidence and therefore it was not surgically removed. No further investigations were warranted as the patient was asymptomatic. The patient is currently reviewed on a 6-monthly basis with no clinical changes. No further intervention was required for this patient as she was asymptomatic.

A 7-year-old boy was referred to the Clinic of Pediatric Dentistry of our University. His mother reported that yellowish coloration of his teeth made him ashamed of smiling and damaged his relationship with other children. A detailed dental, medical, and social history was obtained from the patient. His mother reported that she and the other son were also affected by the same dental disease (), but their esthetic and functional rehabilitation was performed previously.\nClinical examination revealed a mixed dentition. The permanent maxillary central incisors and permanent maxillary and mandibular first molars were partially erupted. The patient exhibited poor oral hygiene with moderate to severe dental plaque accumulation and the gingival tissues around most of the permanent and primary teeth showed mild inflammation.\nThe patient presented short clinical crowns with a generalized yellow color in both primary and permanent teeth (Figures , , and ). The enamel surface was thin and rough, whereas the roots showed normal length and form. The pulp chambers were regular in size. Carious lesions were present in the primary maxillary right first and second molars and in the primary mandibular first and second molars. In the right side the occlusion was in Class I and in the left side it was cross bite. A deep overbite was observed with premature loss of vertical dimension. In a panoramic radiography, the thin enamel layer could not be distinguished from the underlying dentin ().\nThe treatment objectives were to improve the esthetics, eliminate the tooth sensitivity, prevent further loss of tooth structure, modify the child's attitude and behavior towards dental treatment, and improve his periodontal health. As part of the treatment plan, the treatment alternatives were explained to the child and his parents.\nThe initial treatment was early orthodontic treatment interceptive and minimal intervention. The primary maxillary right first and second molars were treated before orthodontic treatment (). The caries-preventive strategies consisted of oral hygiene instruction and dietary recommendation. The permanent maxillary central incisors were restored with composite resin to improve esthetics. The restoration improved the esthetic appearance of the smile contributing to the improvement of his behavior and social conviviality (Figures –). The patient presented incipient periodontal disease, and thus professional prophylaxis for dental plaque removal was carried out every three months. These recall visits were determined by patient's risk for caries/periodontal disease.\nThe Ethic Committee of our University approved saliva collection and mutational analysis. Saliva samples were collected from the patient, his parents, and brother for DNA analysis. The InstaGene Matrix (732-6030, Bio-Rad Laboratories, United States) protocol was used to isolate genomic DNA from saliva. All amelogenin protein coding exons sequences (exons 2, 3, 4, 5, 6, and exon 7) were amplified by Polymerase Chain Reaction (PCR) Kit (Taq DNA Polymerase, 11615-010, Invitrogen, Brazil).\nPCR amplification products were purified by use of the QIAquick PCR Purification Kit (28106, Qiagen, Germany). The primers and PCR conditions shown in were used to amplify the amelogenin gene.\nFollowing purification, PCR products were sequenced using the ABI BigDye Terminator v3.1 Cycle Sequence kit (4336917, Applied Biosystems, United States) and an ABI 3130xl Genetic Analyzer (Applied Biosystems, United States). All products were sequenced from both directions to minimize sequencing artifacts. Amelogenin gene mutations were confirmed by repeating the PCR amplification and sequencing.\nThe electropherograms were analyzed using the SeqScape Software (Applied Biosystems, United States). The resulting sequences of direct sequencing of amelogenin gene exons were compared with the amelogenin genomic reference sequence (NC_000023.10). The variations in these sequences were checked on dbSNPs database.\nMutational analysis was performed for the coding exons of the amelogenin gene and the c.261C>T mutation was detected in samples of mother, father, and brother. This alteration is a silent mutation and a single-nucleotide polymorphism (rs2106416). However, this mutation was not found in the sequence of the patient ().

A 28-year-old male patient was sitting next to the driver seat in a sports utility vehicle which met with road traffic accident. The sudden deceleration injury caused both the knees of the patient to hit against the dash board. The patient was taken to a level 3 trauma center and later shifted to our level 1 trauma center after 48 h of injury. On presentation, the patient was conscious, oriented and hemodynamically stable. The right thigh was deformed, painful, had abnormal mobility around thigh, and was more shortened compared to the left lower limb which was in an attitude of external rotation, there was contusion over the right gluteal region. The radiographs [] revealed a posterior dislocation of the right hip with a posterior acetabular wall fracture, an ipsilateral fracture of the shaft of the femur, reverse oblique trochanteric fracture on the left side, and a both bones fracture of the right forearm. Being a high-energy injury and in order to study the acetabular fracture morphology in detail, a noncontrast computed tomography (CT) scan with a 3D reconstruction of the pelvis was done which revealed acetabular fracture geometry and a minimally displaced femoral neck fracture on the left side [Figure –]. On a careful review of previous radiographs, a suspicious fracture line was seen on the left side, though it was not very clear.\nThe patient underwent open reduction and internal fixation of all his fractures in the same sitting having an irreducible dislocation on one side and a femoral neck fracture on the other about 50 h from his time of sustaining injury. First with the patient in left lateral position on the right side, open reduction and internal fixation (ORIF) of the femoral shaft fracture with a locking plate and of the posterior wall acetabular fracture with a reconstruction plate and lag screws was done. A trochanteric osteotomy was also performed on the right side to aid in the fixation of the high posterosuperior acetabular wall fracture and the osteotomy subsequently fixed with three 3.5 mm cortical screws with washers. Then the patient was put over a fracture table and the ipsilateral fracture of the femoral neck and pertrochanteric fracture on the left side were treated with a dynamic condylar screw (DCS) and an additional cannulated cancellous screw []. During fluoroscopy, care was taken to ensure that all the screw threads crossed the fracture lines and compression was obtained at the neck region. Finally, the fracture of the both bones of the right forearm was fixed with low-contact dynamic compression plates (LC-DCP). It took around 6 hours for all the procedures to be completed with a blood loss of 1.2 liters and patient received 3 units of blood transfusion. Postoperatively, the patient had in bed mobilization from the second postoperative day, and started weight bearing with crutches at 12 weeks. All fractures united by 5 months, and at 28-month follow-up, the patient has no evidence of avascular necrosis, and an excellent functional outcome [Figures and ].

The third patient, a 23-year-old woman with recurrent severe depression (see under results Case 3) experienced a prolonged seizure, which was stopped by intravenous application of benzodiazepine. This event mirrored the AEs, which required medical action by a doctor as reported in Case 2.\nThe young lady was a patient with an unusually high health risk for her age because of being obese and suffering from diabetes. Epidemiological studies on the relationship between diabetes and epilepsy reached discordant conclusions. However, it has been reported that metabolic abnormalities, such as hypoglycemia and hyperglycemia, may increase the prevalence of epilepsy (). In this line, there are data-driven considerations that mechanisms for the comorbidity of obesity and epilepsy are mitochondrial dysfunction and adiponectin deficiency, which promote epilepsy, obesity, and type II diabetes mellitus (). While fundamental mechanisms of the relationship between diabetes and epilepsy remain a matter of discussion, hypoglycemia is an accepted reason for the occurrence of seizures in young patients with epilepsy (). The ECT patient reported here showed elevated blood sugar levels. However, a decline in the blood sugar level during the previous night and due to the ban of breakfast before ECT, which was applied in the early morning hours, could not be ruled out. While the occurrence of a prolonged seizure after the reduction of blood and brain sugar glucose level would be a possible explanation for our patient’s AE, its probability appears to be low. Epileptic seizures with changes in the blood sugar level are rare and not as common as previously assumed and require significant hypoglycemia to occur ().\nThe patient did not show any changes in her respiratory function during ECT despite being overweight. Her obesity might have been a risk factor for altered respiration, in particular when being related to upper airway obstruction and sleep apnea syndrome (SAS; ). SAS is well known to increase the risk of anesthesia-related AEs (; ), in particular when spontaneous breathing is needed during intravenous anesthesia. While being obese, no sleep-related respiratory disorder was present in this patient. Nevertheless, her case may remember doctors to consider SAS when examining a patient for ECT, and to use ambulatory screening instruments (; ) to assess SAS if necessary.

A 57-year-old male with stage IV metastatic esophageal adenocarcinoma who had completed a full course of chemotherapy and localized esophageal radiation about 6 months before, presented with complaints of left-sided facial pain for 3 months. The patient's pain had been progressively worsening and was significant during his chewing of solid foods, resulting in weight loss interpreted as a result of poor oral intake. The pain was described as sharp, lancinating, and throbbing, radiating to the left temple and cheek. The patient rated the severity of the facial pain as 8 out of 10 on the Numerical Pain Rating Scale.\nThe workup prior to his visit included a brain MRI and a maxillofacial CT that focused on the trigeminal nerve distribution in the brain, and facial sinuses identified no neural element involvement, metastases or bony lesions. A PET scan of the entire body at an outside hospital showed a hypermetabolic mass in the distal esophagus consistent with known adenocarcinoma.\nWith the prior diagnosis of trigeminal neuralgia, the patient had been on methadone, hydrocodone, and carbamazepine, prescribed by other providers. This combination of medications had failed to improve the pain severity. He was then referred to the center of pain management with the diagnosis of trigeminal neuralgia and continuing intractable facial pain.\nOn physical examination, the patient was in considerable distress due to the facial pain. He had a palpable trigger point over the left masseter muscle. The temporomandibular joint range of motion was within normal limits and with no associated pain. A sensory examination revealed a decreased sensation to light touch and pinprick over the left chin, the lower lip, and the lower oral mucosa, consistent with the distribution of the left inferior alveolar nerve. There was no facial asymmetry, and no other cranial nerve deficits were observed. We decided to perform a localized mandibular CT scan, on which we localized a metastatic lesion in the mandibular bone with the involvement of the inferior alveolar nerve (fig. ).\nBased on this new imaging, we reviewed his prior maxillofacial CT and PET scans. We paid specific attention to the left mandibular region because the outside facility had not mentioned an increased uptake in that region. Upon secondary review, focal uptake without any evidence of a bony lytic lesion in the left mandibular angle was noted, which likely represented evidence of early metastasis that was overlooked by prior image reading (fig. ).\nA referral to radiation oncology was issued for the localized radiation therapy of the left mandibular lesion. As part of the palliation, we decided to perform a left sphenopalatine ganglion block, which dramatically decreased the pain. The patient then received radiofrequency ablation of the left sphenopalatine ganglion based on his responses to the local anesthetic block. The combination of medications, radiofrequency, and subsequent localized radiation to the lesion provided significant pain relief. During his follow-up, he reported a pain reduction to 80% and was able to tolerate chewing the permitted semi-solid foods without pain.

A 71 year old man with signs of syncope and haemorrhagic shock secondary to massive haemetemesis was referred for emergency treatment and investigation to the 1st Department of Surgery, University of Athens Medical School in 2009. Eight years earlier the same patient, who had a known history of gastric ulcers, presented with a similar clinical picture to a different surgical unit. On admission he showed signs of haemorrhagic shock with a haemoglobin level (Hg) of 7 g dL. Emergency upper GI endoscopy was unable to identify the source of bleeding due to large volumes of blood in the stomach. Surgical treatment with a laparotomy was decided and the intraoperative findings demonstrated an acute gastric hemorrhage secondary to a massive propyloric ulcerative lesion. Resection of the lesion was decided and a distal gastrectomy and Billroth II reconstruction performed. The subsequent histology revealed a <2 cm gastrointestinal stromal tumour, with a mitotic rate of < 5 mitosis/50 per HPF, lacking necrosis and localized to the gastric mucosa. The patient made an uneventful recovery and was discharged eleven days post surgery. The patient was reviewed over the following two years and repeat endoscopies failed to reveal any signs of recurrence. The patient subsequently declined further surveillance and follow up.\nAt his readmission in 2009 the patient was primarily treated conservatively due to his hemodynamic instability. After successful resuscitation, an emergency upper GI endoscopy was performed which revealed an irregularly shaped elevated lesion on the gastrojejunostomy line and a thrombus at the center of the lesion. The hemorrhagic lesion was situated along the posterior anastomotic suture line. Multiple biopsies were performed and a definitive endoscopic haemostasis was obtained.\nPreoperative staging computed tomography (CT) showed no lymphadenopathy or hepatic metastasis and as the patient's performance status was otherwise excellent, the decision for a second operation was deemed favorable. The patient went on to have a successful completion gastrectomy with regional lymphadenectomy and the continuity of the gastrointestinal tract was maintained through the Roux-en-Y method. It is important to note that lymphadenectomy is not routinely performed in GIST as metastatic spread rarely occurs through the lymphatic system. However the unusual presentation of the case created uncertainty over the malignant potential of the tumour and the experienced surgeons deemed lymphadenectomy the most appropriate measure in this instance. Histological review of the specimen showed macroscopically an ulcerative lesion on the suture-line, measuring 0.8 cm in diameter. The cut surface was gray with a rubbery consistency. Microscopically, it was a gastrointestinal stromal tumor (figure ), composed of spindle cells with mild to moderate nuclear pleomorphism. The stroma focally had a myxoid appearance. The tumor invaded into the submucosa, showed no signs of necrosis and had positive expression of c-kit (figure ), focally positive expression of SMA, and negative expression of CD34. The postoperative course was uneventful, and the patient shows no evidence of recurrence 1 year and 6 months after the last surgery. It is noteworthy to mention that GIST in this patient occurred sporadically and that there were no clinical findings suggestive of familial GIST which can be seen in patients with neurofibramatosis type 1 (NF1) or in the Carney-Stratakis dyad.

A 60-year-old female, laborer by occupation, a diagnosed case of carcinoma lung with metastasis presented with chief complaints of dyspnea. The patient had massive pleural effusion []. There had been five previous episodes of pleural aspiration followed by thoracocentesis. The patient was offered thoracoscopy and talc poudrage which the patient refused so an indwelling intercostal tube insertion was planned. In order not to hamper the motility a newer economical technique was employed on the lines of indwelling pleural catheter, which not only is very expensive but also not easily available in India.\nAfter detailed informed consent, the site of icd insertion site was marked by ultrasonography in the mid axillary line. The skin was thoroughly cleaned with betadine and methylated spirit. A second point was marked 5 cm behind and above the first point and lignocaine 2% was given liberally at the point of icd insertion and subcutaneously in the line between these two points. Two subcutaneous nicks were given, the first 0.5 cm behind the point of icd insertion and the second at the second point behind and a subcutaneous tunnel was created by straight artery forceps between the two points. An 18 Fr rhemsons icd tube was taken and passed through the subcutaneous tunnel and pulled out with the artery forceps. A nick was given and the front end was inserted in the chest wall as a normal icd insertion. The rear end of the tube was cut and used as an air tight cap after reversing it []. One stitch was placed at icd site and the other at the second point []. The icd was bent and dressing applied in two layers with the upper layer in two parts so that whenever drainage was to be done [], the patient removed the distal part of dressing above and connected to a bag [] and sealed the tube with the cap after drainage of fluid. The patient was mobile without any need for carrying the icd bag with icd in situ [] continuously and remained comfortable with the tube for 4 months till the end of life. During this period the patient was called for follow up every 15 days and sterile dressing was done. No complication was encountered during the above said period.

A 60-year-old male who had a history of liver cirrhosis was referred for evaluation of a pain, swelling, and erythematous changes of the anterolateral aspect of his left leg. His symptoms started a month ago without any specific trauma. He had a history of open reduction and internal fixation performed for a tibial plateau fracture that occurred when his left knee was pinned under a tree 18 years ago. He had sciatic nerve injury at the time of the fracture. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery 8 years after the initial trauma due to a distal femur fracture and femoral artery rupture. At that time, a widespread radiopaque mass was observed on plain radiographs of left leg, and obstruction of popliteal artery with abundant collateral circulation was observed on angiography. The patient had no difficulty with his daily life functions until the aforementioned symptoms appeared, except for limited motion in the ankle and toes and sensory reduction in his foot owing to the sciatic nerve injury.\nAfter admission, the patient maintained with a long leg splint. Two weeks after the admission, the erythematous changes in the left leg localized to the anterior aspect in the middle of the leg and formed a fluid-filled, erythematous mass. A draining sinus had developed on the erythematous mass spontaneously and a thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The range of motion of the knee was 0 degrees to 100 degrees of flexion; ankle dorsiflexion was 0 degrees, ankle plantar flexion was 5 degrees, and all of the toes had clawing deformity. As for the motor strength of the ankle, the dorsiflexion was grade 0 and plantar flexion was grade 3. He had no sensation in the first web space and on the medial aspect of the foot, and had sensory reduction in the lateral, dorsal, and plantar aspects of the foot, in order of decreasing sensation.\nThe radiographs of the left leg taken 10 years ago (8 years after the initial trauma) showed a large, fusiform-shaped, radiopaque soft tissue mass in the space between the tibia and fibula that spanned from 5 cm below the proximal tibio-fibular articulation to just above the distal tibio-fibular articulation. The medial cortex of the middle third of the fibula and the posterior cortex of the distal third were sclerotic. Ten years later (18 years after the initial trauma), the patient's radiographs showed a large, fusiform-shaped soft tissue mass with extensive plaque-like and amorphous calcifications, similar to those seen in the radiographs taken 10 years earlier (Fig. ). Furthermore, we observed that calcification within the fusiform mass and in the distal part of the deep posterior compartment had increased in comparison to that seen in the radiographs taken 10 years earlier. The erosion of the medial and posterior parts of the distal two-thirds of the fibula had also increased, and a sclerotic change in the lateral cortex of the middle third of the tibia was newly observed. We performed a computed tomography (CT) scan to examine the pattern and distribution of the calcifications more closely; peripherally distributed calcification was found in the anterior compartment and in the distal part of the deep posterior compartment, and sclerotic changes were found in the tibial and fibular cortex (Fig. ). There was evidence of increased uptake between the tibia and fibula in the delayed bone phase on 3 phases of bone scan, which was determined to be caused by calcification.\nLaboratory investigations revealed that the erythrocyte sedimentation rate (ESR) was 69 mm/h and the C-reactive protein (CRP) level was 5.80 mg/dL with no fever. Serum calcium, phosphorous, and alkaline phosphatase levels were all within the normal limits.\nWe performed an incisional biopsy to differentiated soft tissue sarcoma and no viable, malignant cells were found. A thick fluid with a chalk-like material continued to be discharged through the sinus opening. We performed an extensive debridement of the anterior and deep posterior compartments to ensure definitive treatment. Intraoperative findings showed that the deep fascia was thickened, and that the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles had become necrotic and changed into a whitish, toothpaste-like material (Fig. ). Hard calcific materials resembling rice grains were spread within the necrotic muscle. Furthermore, we observed an erosion of the cortex without intramedullary involvement on the lateral tibial surface and medial fibular surface. After an en-block resection of the anterior compartment, we approached the posterior compartment through the interosseous membrane. When we opened the interosseous membrane, the turbid fluid was drained, and we found that the flexor hallucis, flexor digitorum, and tibialis posterior muscles formed a twig-shaped, hard calcification in the direction of the muscle fibers, unlike in the anterior compartment (Fig. ). Upon performing extensive debridement, we inserted a drain tube and performed primary closure. As Pseudomonas aeruginosa was identified in the intraoperative culture, we used antibiotic treatment (piperacillin-tazobactam, intravenously for 6 weeks and then ciprofloxacin, orally for 4 weeks). The fluid continued to be discharged through the drain even after the surgery; delayed wound healing occurred four weeks following the surgery, and there was no recurrence and the patients were satisfied with the result of the operation at follow-up conducted 2 years later (Fig. ).\nPathologic evaluation revealed that the anterior compartment specimen had acute and chronic inflammation with dystrophic calcification, and the posterior compartment specimen had fibrosis with dystrophic calcification; the tibial periosteum had acute and chronic inflammation with dystrophic calcification, and the tibial bone was fibrotic. These findings led to the diagnosis of calcific myonecrosis.

A 55-year-old man with no significant past medical history presented to us with 1 month history of aimless wandering movements of his left hand. He said that he felt that his left hand was not under his control. It would act on its own will, in form of levitation of the arm, purposeless groping of objects in the surroundings. His left hand would hold objects in its vicinity and start using it, for example it would start to write if a pen was present. The left hand also showed interference in the activities of the right hand. Like when he would bring the food towards his mouth with the right hand, the left hand would try and stop it. There was also history of inter-manual conflict in form that whenever he would put his reading glasses with his right hand, the left hand would remove them. When he would button his shirt with the right hand the left hand would unbutton it. When he would wear his cap with the right hand the left hand would pull off the cap and throw it on the ground. Many a times the patient had to use his right hand to control the activities of his left hand.\nOver the last 20 days the patient started feeling that even his left leg was not under his control. While sleeping in the night the left leg would move out of the blanket and would make purposeless levitation movements. Whenever he started to walk he noticed that the left leg would step backwards. Hence he had great difficulty in walking and after effort he would drag the left leg to move forward. The patient did not feel any weakness in the left leg. There was no history of cognitive decline, myoclonus, ataxia, behavior changes, weight loss. There was no history of surgical intervention, or any toxin exposure like bismuth. Examination revealed normal speech and higher mental function. The cranial nerve and motor system examination was normal. The sensory examination showed loss of cortical sensation in form of graphesthesia, loss of two point discrimination, sensory extinction on left side of body including the face. Rest of the examination was within normal limits. Over the course of stay in the hospital (next 15 days) the patient also developed truncal ataxia, cognitive impairment, left arm myoclonus. The case was discussed as progressive left alien hand and leg syndrome. The MRI brain revealed cortical hyperintensities in bilateral frontal, bilateral parietal cortex, bilateral occipital cortex and cingulate gyrus on diffusion weighted images (DWI) []. The corresponding areas were also hyperintense on fluid attenuated inversion recovery (FLAIR) sequences but less than that on DWI. The electroencephalography (EEG) done using 10-20 system showed generalized periodic triphasic sharp wave complexes of 100-150 milli second (ms) duration and inter-complex interval of 500 ms to 1 second []. The cerebrospinal fluid (CSF) analysis showed proteins 32 g/dl, sugar 73 mg/dl (blood sugar was 80 mg/dl), Chloride 102 mM/L, cells were 2/cubic millimetre (all lymphocytes). The CSF Neuron Specific Enolase (NSE) done by enhanced chemiluminescence immunoassay was raised –143.2 ng/ml (normal below 16.3 ng/ml). CSF 14-3-3 was not done due to unavailability at our center. The CSF veneral disease research laboratory (VDRL) and tuberculosis polymerase chain reaction (Tb-PCR) were negative. The thyroid profile (including T3, T4, TSH and anti-thyroid peroxidase antibodies) was normal. Computed tomography (CT) chest, abdomen was normal. Stool for occult blood was negative. Upper and lower gastrointestinal tract endoscopy was normal. Serum levels of vitamin B12 and folate were normal. Serum HIV and VDRL were non-reactive. Carcinoembryonic antigen, alpha-fetoprotein, and prostate specific antigen were within normal limits. According to the Magnetic Resonance Imaging-Creutzfeldt-Jakob disease (MRI-CJD) Consortium criteria for sCJD the patient was diagnosed as a case of probable sCJD [].[]\nTwo out of 1 and atleast one out of 2.\nTwo out of 1 and duration less than 2 years.\nThe patient was put on sodium valproate 500 mg twice a day for myoclonus and discharged. The patient and his relatives were not willing for a brain biopsy. The prognosis of the disease was explained to the relatives.

A 60-year-old woman presented to us with pain over medial aspect of right knee joint. The pain was non radiating. The pain was relieved by rest and was exacerbated by squatting and sitting cross legged. The patient had difficulty in climbing stairs. On physical examination there was tenderness along the medial aspect of knee joint and a curved scar mark was present over the anterior aspect of knee joint (). While history taking the patient told us that she had a patella fracture around 4 years back which was treated by open reduction and internal fixation and she subsequently underwent implant removal 2 years back. The patient had full range of motion (ROM) at knee joint (Figs. , ) and moderate pain was observed on medial side while flexing and extending knee joint. There was no history of any recent trauma to knee joint. A provisional diagnosis of osteoarthritis knee joint was made and weight bearing standing antero-posterior and lateral x-rays ofleft knee joint were ordered. On X-rays it was found that multiple pieces of broken circlage wire were present around knee joint and one piece had migrated posteriorly (). On examination patient did not had distal neurovascular deficit and patients pain was not related to these broken pieces, rather it was due to degenerative changes in the knee joint. It is believed that the surgeon who did implant removal removed only the K wires leaving behind the circlage wires which broke into multiple pieces over the passage of time due to the repeated stresses at knee joint. Patient was advised to undergo total knee replacement along with subsequent removal of broken hardware as potential undue complications can occur because ofbroken hardware in the form of damage to neuro vascular structure due to migration of pieces posteriorly. It was also explained to the patient that cases have been reported where broken pieces migrate to heart and sternum and produce life threatening complications. However, patient refused to undergo any type of surgery. she was warned and told to be alert whenever the nature of her pain changes or she experiences new onset of symptoms which is different in character from the pain she is experiencing now and was kept on regular follow up.

A 54-year-old female patient presented to the emergency room with features of intestinal obstruction. She was constipated with evident weight loss over a period of 3 months. She was evaluated by an x-ray abdomen that revealed multiple air fluid levels and the CT – Scan of the abdomen revealed a circumferential growth involving the sigmoid colon with impending perforation and small loculated collections reaching to the superior border of urinary bladder and uterus extending to the lateral abdominal wall suggesting micro abscesses. Gastroscopy performed was normal and the colonoscopy was inconclusive due to narrowing proximal to the sigmoid colon ( and ).\nThe patient underwent exploratory laparotomy and sigmoid colectomy subsequently. The findings were an exophytic sigmoid colon tumor proliferating extraluminally with small bowel adhesions. Tumor was adherent to the lateral pelvic abdominal wall with a subcutaneous abscess pocket. Tumor perforation in sigmoid colon was noted with minimal contamination. Tumor was found infiltrating the lateral wall of uterus. No ascites, lymphadenopathy or free peritoneal/omental deposits were noted.\nThe histopathology report of the patient suggested a moderately differentiated keratinizing squamous cell carcinoma with a single sclerosed lymph node suggesting tumor metastasis with foreign body giant cell reaction ().\nThe patient underwent extensive evaluation by gynecology and urology departments to identify a possible primary source of malignancy in the urogenital tract. Their evaluations were negative. The patient did not have any skin lesions or ulcers suggesting skin primary as the source.\nThe patient recovered well from the surgery with parental nutrition support. She was ambulatory and was given oral feeds on 7th postoperative day. Subsequent CT Scan of the abdomen suggested a small fluid collection at the site of surgical anastomosis with few air pockets suggesting abscess formation/leakage. There was concomitant ascites, pleural effusion and a liver lesion noted too in the CT scan. Wound infection was treated with regular dressings initially and later vacuum dressing was applied. After improvement in health, enteral nutrition and wound, the patient was discharged for follow up in 2 weeks. The patient unfortunately passed away at her home and the information was revealed to the surgical team by the patient’s relatives.

A male patient aged 17 years and two months presented with a severe thoracolumbar SK. He was otherwise healthy but markedly overweight with a body mass index (BMI) of 37. There was no history of spinal infections or injuries and no skeletal dysplasias. There were no associated medical co-morbidities. He had been previously followed but not treated in another spinal unit since the age of 16 years during which period his kyphosis gradually progressed and became symptomatic. On presentation in our clinic, the patient complained of persistent back pain located in the thoracolumbar junction, which affected the level of his activities. The pain did not radiate to his legs and he had no neurological symptoms.\nOn clinical examination, he had a sharply angular kyphosis of 105° with the apex in the thoracolumbar junction, as well as bilateral hamstring tightness. Neurological examination was normal. There was an associated thoracolumbar scoliosis measuring 30° and no evidence of spondylolysis or spondylolisthesis. The lateral radiograph of the spine showed bridging osteophytes anteriorly across the apex of the kyphosis. Magnetic resonance imaging (MRI) of the spine was performed when he was initially seen at the age of 16 years and showed spinal cord attenuation across the thoracolumbar junction but no cord signal change, no disc herniation and no intraspinal anomalies. There was also no evidence of the bridging osteophytes on the MRI which indicates that these developed spontaneously in order to stabilize the spine as the kyphosis progressed further and the disc spaces collapsed anteriorly. The MRI did not report fusion of the posterior elements across the levels of the kyphosis, as well as congenital vertebral abnormalities.\nIndications for surgery included severe back pain refractory to conservative measures and modification of activities, as well as the extreme degree of deformity and risk for further progression possibly causing neurological complications.\nThe patient underwent kyphosis correction at the age of 17 years and 11 months when the deformity measured 115° and only corrected to 100° on a supine hyperextension radiograph against the bolster. The surgery involved a combined single-stage anterior and posterior spinal arthrodesis extending from T4 to L3 with the use of posterior pedicle hook/screw/rod instrumentation and autologous rib bone graft. The anterior approach was performed through a right thoracotomy on the convexity of the scoliosis. The diaphragm was retracted distally but not divided in order to provide access to L1. During the anterior stage, the anterior longitudinal ligament was found to be ossified from T10 to L1 with bridging osteophytes extending circumferentially from T11 to T12 at the apex of the kyphosis and displacing the major vessels anteriorly. The intervertebral discs from T9 to T12 were very stenotic and immobile. The osteophytes were excised both on the convexity and concavity of the associated thoracolumbar scoliosis. The anterior longitudinal ligament was released and complete discectomies back to the posterior longitudinal ligament were performed from T7 to L1.\nDuring the posterior exposure, the spine was found to be spontaneously fused across the apex of the kyphosis from T9 to L1. There was no evidence of congenital vertebral anomalies. Extensive posterior apical closing wedge osteotomies were performed from T7 to T12. The fused facets and ossified ligamentum flavum were excised and the spine was mobilized at completion of the anterior and posterior osteotomies. The kyphosis was corrected using a cantilever maneuver with the rods simultaneously attached from proximal to distal under intraoperative spinal cord monitoring recording motor evoked potentials (MEPs), as well as cortical and cervical somatosensory evoked potentials (SSEPs). The spinal cord monitoring signals remained stable throughout the procedure. An excellent correction of the kyphosis to 58° was achieved []. Autologous rib graft harvested during the anterior stage of the procedure was used to enhance a bony fusion across the levels of the instrumentation.\nThe patient had an uncomplicated postoperative course and mobilized following application of a spinal brace to provide additional support. He was discharged 18 days after surgery. The brace remained for four months and the patient gradually returned to normal activities including sports six months after surgery. At latest follow-up, 2.6 years following kyphosis correction, the patient had no complaints of his back; he had normal activities and a BMI of 26. Radiographs of the spine showed no evidence of pseudarthrosis and no loss of kyphosis correction or junctional deformity either proximal or distal to the instrumentation.

An 18-year-old morbidly obese male with no reported past medical history presented to the emergency room after a high-speed motor vehicle collision (MVA). He had been positioned in the middle of the backseat and was ejected from the vehicle. The injury was reported to have occurred 1 hour prior to presentation at the hospital. Field responders had placed the patient on a backboard and placed a cervical collar. He was resuscitated with intravenous fluids during transport. No manipulation of the extremities was completed prior to arrival. Upon arrival to the emergency room, he was intubated and sedated for airway protection due to low Glasgow Coma Scale. He had sustained facial lacerations and closed head trauma. CT of the abdomen and pelvis was obtained showing a dislocated left hip, with the femoral head displaced into the intrapelvic space compressing the urethra (Figures and ). There was a small bony fragment noted, representing a minor acetabulum fracture, but no evidence of proximal femur fracture. He presented in critical condition due to subdural hemorrhage and was taken emergently to the operating room for a craniotomy performed by the neurosurgical team. Due to the acuity of his head injury, no other imaging of the orthopedic injuries was obtained prior to transfer to the operating room. He was already in the operating suite after completion of the craniotomy when the orthopedic team was able to evaluate the patient. Physical exam demonstrated gross deformity of bilateral lower extremities as both legs were externally rotated and shortened. On the right thigh, there was crepitus at the distal femur suggesting a distal femur fracture. Fluoroscopic imaging was obtained intraoperatively, confirming a right distal femur fracture and left hip dislocation. After receiving clearance from the trauma surgery and neurosurgery teams for further intervention on the patient at that time, the decision was made for emergent closed reduction of the left hip under general anesthesia given the intrapelvic dislocation of the femoral head in this young patient. Given the significant displacement of the femoral head, it was discussed that open reduction may be necessary, likely via a medial approach to the hip. Given the critical condition of the patient, closed reduction was preferred, if possible. The orthopedic surgery team began the closed reduction procedure approximately 3 hours and 30 minutes after presentation to the hospital and therefore approximately 4 hours and 30 minutes after injury.\nFluoroscopy was used to aid in the closed reduction. The primary surgeon began by applying gentle traction in line with the position of the left lower extremity. Due to his massive body habitus, more forceful traction was required, and a sheet was placed across his body at the level of iliac crests with an assistant pulling countertraction. Initial attempts at closed reduction using typical reduction techniques were ineffective given the position of the dislocated femoral head within the pelvis. After several minutes of traction, fluoroscopy revealed that the femoral head was still significantly displaced medially into the patient's intrapelvic region. At this time, additional countertraction, via another sheet, was placed around the left thigh and a laterally applied force was administered by another surgeon while the primary surgeon continued to apply longitudinal traction. Based off of the presumed injury pattern of hyperabduction in a frog leg position from being thrown forward into the front seats, hyperabduction and flexion combined with longitudinal traction were utilized to slowly mobilize the dislocation outside of the pelvis. Internal rotation was also used to manipulate the femoral head inferior to the ischium followed by external rotation to move the head out of the true pelvis. After significant time and effort, fluoroscopic images demonstrated that the hip was out of the pelvis and had effectively been converted to a more commonly encountered posterior dislocation. At this point, hyperabduction was no longer necessary. Instead, longitudinal traction, hip flexion, and external rotation were utilized until an audible clunk was appreciated, and a fluoroscopic image confirmed reduction of the left femoral head (). Provisional treatment of the right distal femur fracture was then administered via skeletal traction to the right lower extremity through a tibial pin. The total operating time for the closed reduction as well as traction pin in the contralateral femur was approximately 1 hour and 15 minutes.\nAt this point, surgeons from other specialties took over care in the ongoing management of this polytraumatized patient and the urological surgery team was consulted to evaluate and manage any potential urethral injury from the dislocation. Placement of Foley in the trauma bay had been unsuccessful. After reduction of the hip, the urology team was able to place a Foley catheter without difficulty with return of normal-appearing urine without any evidence of hematuria. Given the ease of placement and benign appearance of the urine, no further imaging of the urinary tract was recommended by the urology service. The Foley catheter was removed later during hospitalization without complication.\nThe patient was admitted to the surgical intensive care unit after leaving the operating room. Postoperative radiographs and CT scan showed reduction of the left hip (Figures –). An 8 mm bony fragment from the acetabulum was again noted, which was presumed to represent an avulsion fracture from the ligamentum teres, but the scan demonstrated concentric reduction of the femoral head and no evidence of femoral fracture. Three days after presentation, the patient was weaned from sedating medications and extubated. His right lower extremity remained in skeletal traction until definitive treatment could be completed in the form of retrograde intramedullary nailing of the femur on hospital day 4, which was completed without complication. His mental status continued to improve, and he began to work with physical and occupational therapists during his admission. He was made weight bearing as tolerated on the right lower extremity but kept nonweight bearing on the left lower extremity. The patient was discharged to an acute inpatient rehab facility on hospital day 21.\nAt a follow-up visit to the orthopedic surgery clinic 9 weeks after injury, the patient reported occasional pain to the left hip and lower back after extended sitting in the wheelchair. He had continued in physical therapy as an outpatient and had been ambulating with a walker. His mental status had improved as he was now not only alert and oriented but also conversant throughout the exam. Physical exam demonstrated left hip range of motion of 0-60 degrees flexion (0-90 degrees flexion contralateral side) and 4/5 strength with hip flexion (4/5 strength hip flexion contralateral side). Distally, he was able to actively dorsiflex and plantarflex the ankle as well as flex and extend the great toe with 5/5 motor strength throughout bilateral lower extremities. Sensation was intact to light touch in superficial peroneal, deep peroneal, sural, saphenous, and plantar nerve distributions. He had 2+ dorsalis pedis and posterior tibial artery pulses. His gait was antalgic with a walker with decreased stance phase on the left leg. Radiographs showed concentric left hip with some irregularity noted in the femoral head concerning for osteonecrosis without femoral head collapse, as well as heterotopic ossification in surrounding soft tissues (). At this point, he was made weight bearing as tolerated on the left lower extremity and continued in outpatient physical therapy.\nThe patient returned to follow-up in clinic 4.5 months after injury. At that time, he reported no left hip pain at rest. He had continued in physical therapy on an outpatient basis. Physical exam was notable for improved strength with hip flexion of 5/5 in bilateral lower extremities but otherwise was unchanged from prior exam. An AP pelvis X-ray was obtained which showed maturation of the heterotopic ossification adjacent to the left hip (). Again noted was some irregularity in the femoral head but no evidence of femoral head collapse. An MRI of the pelvis was obtained 7 months postinjury, demonstrating focal areas of hypointensity on T1 images within the femoral head and inferior neck consistent with osteonecrosis, without evidence of femoral head collapse (Figures and ). Metal artifact from the right femur implant limited the ability of the MRI to evaluate the soft tissues in detail.

The patient was a man in his 80s with no remarkable medical or family history. He presented at our emergency department with swelling and pain in the right groin. The right groin showed a swelling of 10 × 10 cm. Vital signs and blood tests were normal at the visit. Abdominal contrast-enhanced CT showed prolapse of the small intestine into the right groin (Figure ). The hernia was located outside the inferior abdominal wall artery, suggesting an indirect hernia. The size of the hernia gate was 3 × 2 cm. The left side did not show any apparent hernias. On confirming that there was no apparent intestinal ischemia, manual return was performed and the patient was hospitalized for observation. He was discharged 3 days later, after confirmation that there were no complications such as intestinal ischemia. It was agreed upon that surgery would be performed at a later date on a watch-and-wait basis. TAPP was used to repair it. The operation was performed in a supine position under general anesthesia. On placing the 12-mm port in the umbilicus using the open method and examining the abdominal cavity, the coexistence of a femoral hernia as well as an indirect inguinal hernia was observed on the right side. Further observation of the left side also revealed an indirect inguinal as well as a femoral hernia (Figure ). Although the patient was asymptomatic, surgery was also indicated for the left side, and a simultaneous repair was then performed. Two 5-mm ports were placed in the left and right abdomen, respectively, and the operation was performed with three ports in total. The first repair was performed on the right hernia. The peritoneum was linearly incised from the outside of the hernia tract toward the hernia tract, and the space between the peritoneum and the preperitoneal fat was separated to form a space for placing the mesh. Exfoliation was performed to include the thigh ring. The inside was sufficiently dissected up to the rectus abdominis muscle, and the outside was sufficiently dissected to the right upper iliac spine. Thereafter, a Bard 3D Max Light ® mesh (10 × 15 cm) was placed and fixed to cover the inner inguinal ring, Hesselbach's triangle, and thigh ring completely. The incised peritoneum was surgically closed with 3-0 Vicryl sutures. The left hernia was repaired using the same procedure (Figure ). The postoperative progress of the patient was good, and he was discharged 2 days later. No complications or recurrence has been reported for 3 years since the surgery.

Our patient was a 32-year-old gravida III para II Amhara woman who came from a rural area of North West Ethiopia. Her first delivery was an uncomplicated spontaneous vaginal delivery at home at the age of 22 years. Her second delivery was a spontaneous vaginal delivery in a health center 4 years later with early neonatal death for unknown reasons. She was seen by a health professional only once during the current pregnancy, when she experienced progressive abdominal pain 4 months prior to her delivery. She was assessed in a health center and referred to a regional hospital where she underwent an ultrasound scan and was reassured. She presented to the University of Gondar Teaching Hospital with the principal complaint of shortness of breath with associated progressive abdominal distension and pain. Her last menstrual period was unknown but she reported 9 months of amenorrhea.\nOn general examination, she looked emaciated and was slightly pale. Her vital signs were within normal limits. Her cardiovascular and respiratory system did not reveal any abnormalities. On abdominal examination her symphysis fundal height was term sized, with longitudinal lie and breech presentation. The fetal heart rate was 132 beats per minute and there were no uterine contractions. On vaginal examination the cervix was closed and uneffaced. There was no vaginal bleeding. On ultrasonography examination, there was a singleton live pregnancy with excessive amniotic fluid. The placenta appeared to be attached to the serosal surface of the fundus of her uterus and her uterus was empty. The gestational age was 40 weeks by ultrasound estimation. Her preoperative hematocrit was 34%. An emergency laparotomy was performed with the impression of abdominal pregnancy. Upon opening her abdomen and entering the peritoneum, the fetus was seen in an intact amniotic sac and there was no hemoperitoneum (Fig. ).\nOn opening the amniotic sac a live female neonate was delivered weighing 2.6kg. The uterus was ruptured at the fundus and the placenta was extensively adhered to the edge of the ruptured site, the serosal surface of the uterus and to the peritoneum and had infiltrated through the myometrium (Fig. ).\nHer fallopian tubes, ovaries and other abdominal organs were normal. The amniotic sac was attached to her bowels and her anterior abdominal wall and this was removed intraoperatively with no abdominal organ damage. There was significant bleeding after the placenta was detached from her uterus which prompted total abdominal hysterectomy to secure hemostasis and to remove the ruptured uterus. Total estimated intraoperative blood loss was 2L. She was transfused with two units of whole blood intraoperatively and postoperatively and her post-transfusion hematocrit was 27% (Fig. ).\nHer uterus was subjected for histopathology and sections from the infiltrated uterine wall show normal-sized chorionic villi, fibrin and decidual stroma. The patient and neonate progressed well and were discharged.

The adverse reaction to clozapine occurred in a 57-year-old married Caucasian woman with a long history of treatment-resistant chronic schizophrenia (ICD10 F20) who has required continuing care in hospital for many years, due to the severity of her condition. She first developed schizophrenia at around the age of 18 and has received antipsychotic medication for almost 40 years. There is a family history of schizophrenia with her son and a maternal cousin both having the condition. Despite the recognized advantages of treating many patients with schizophrenia in community settings, her symptoms - both positive and negative - have been resistant to a range of treatments and as a consequence she has been in hospital since 1985. Periodically, the patient can also exhibit challenging behaviour that requires skilled nursing support; on occasion, she has required nursing in the intensive psychiatric care unit rather than the rehabilitation ward. The patient has been prescribed many different antipsychotics over the 40 year duration of her illness, including second-generation (atypical) antipsychotic medication, with unfortunately no benefit to symptoms or functioning. A trial of clozapine in June 2003 was discontinued about a month later following development of acute renal failure, when she required transfer to the general hospital unit. At that time, the renal failure was attributed to clozapine by internal medicine specialists, although the patient was also taking lithium at this time, and developed secondary lithium toxicity with a peak lithium of 2.2 mmol/L before all medication was discontinued.\nIn November 2007, after a multidisciplinary case review, it was decided that the patient might benefit from a retrial of clozapine, especially given her failure to benefit from all atypical antipsychotics available in the UK. This was considered a reasonable strategy given that the adverse renal effects seen previously when clozapine had been introduced, were thought to have been caused, or exacerbated by, lithium carbonate. Given the severe and refractory nature of the patient's condition, and taking into account the circumstances of the previous trial of clozapine, there appeared compelling grounds for a reintroduction of clozapine. The patient's concomitant medication at the time of the retrial was olanzapine 10 mg and levomepromazine 75 mg at night and sodium valproate 1100 mg per day; for acute exacerbations of psychosis, haloperidol 5 mg IM was available. This combination of medication had been utilized for several months before the clozapine retrial, without evidence of adverse effects. Before the treatment trial of clozapine, treatment with levomepromazine was discontinued. Haematology and biochemistry blood results were normal when checked 3 days before clozapine was initiated.\nClozapine was started with a dose of 12.5 mg at night. On day 2 of clozapine treatment (12.5 mg in the morning and at night), the patient complained of feeling generally unwell and on examination was tachycardic (115 beats per minute) and pyrexial (37.5°C). On day 3 (12.5 mg clozapine in the morning and at night), the patient remained tachycardic and pyrexial (38.0°C). A urine dipstick test showed a trace of protein and the presence of red blood cells (RBCs) and the patient was presumed to have a urinary tract infection and was commenced on trimethoprim, after a urine (MSSU) sample had been sent for bacteriology. On day 4, the patient's pyrexia and tachycardia persisted, and clozapine was stopped; a total of five doses of clozapine had been given. Blood biochemistry revealed a markedly elevated C-reactive protein (CRP) of 197 mg/L; differential white cell count: lymphocytes 1.04 (1.3-3.5 × 109) and neutrophils 8.2 (2.0-7.5 × 109). All other results were normal including creatinine (87 μmol/L). Midstream specimen of urine showed scanty pus cells and organisms, but no RBCs, and no growth. The following day, trimethoprim was discontinued and amoxicillin commenced for a suspected chest infection. The raised temperature settled over the next few days, although the patient remained tachycardic. Blood biochemistry on day 8 showed CRP 138 mg/L, creatinine 126 μmol/L, and an estimated glomerular filtration rate (eGFR) of 40 mL/min/1.73 m2. Biochemistry results on day 9 were creatinine 106 μmol/L, eGFR 50 mL/min/1.73 m2, and erythrocyte sedimentation rate (ESR) 70 mm/hour. Amoxicillin was discontinued after 5 days. Renal function returned to normal over the next few days.

We report the case of a 73-year-old male with bilateral THAs performed simultaneously at a different institution in 1995 using Biomet Bi-Metric stem and Ringloc cup through a posterior approach. Preoperatively, the patient had debilitating bilateral hip pain (right worse than left), and the patient reported shortening of his right leg compared to his left. The surgery was performed without complications, and the patient reported no problems with his THAs for two years with the exception that his right leg was shorter than his left. One year after surgery, the patient had a good Harris Hip Score of 87. Two years after his bilateral THAs, the patient reports developing a draining sinus tract of his left thigh () and bilateral periprosthetic infections which were not confirmed with aspiration. The patient did not want to have a revision surgery and was placed on chronic AST which was managed without the aide of infectious disease or identification of the microorganism. The patient had no risk factors for PJI.\nIn 2004, the patient was first seen in clinic and reported doing well with no hip pain but had some decreased hip range of motion and noted to have Brooker III/IV heterotopic ossification around both hips on X-ray (). He denied any systemic symptoms but was still having some drainage from the sinus of his left thigh. He was encouraged to continue his antibiotics, which at the time was amoxicillin.\nBy his next visit in 2005, the patient had started to wean himself off his amoxicillin as there had not been any drainage from his sinus tract in several months. A discussion took place with the patient in which it was explained to him that there were risks associated with discontinuing his antibiotics and that they had been beneficial in suppressing the patient's hip infection to that point in time. The patient expressed understanding and said he would continue to monitor his symptoms but was going to continue to wean himself off the antibiotics and would be sure to follow up if there were any complications.\nThe patient returned in 2015 as he wanted an update about his hip replacements. During this visit, the patient stated he did not have any pain in his hips and has had no drainage from his thigh in the previous 8 years. He has not had any fevers, chills, or systemic signs of infection. His only complaint was reduced range of motion in his hips. On physical exam, the patient had a healed up and dry sinus tract opening over the anterior aspect of his proximal left thigh, no tenderness to palpation over his hips, and no fluctuance or erythema. He had 10° of internal rotation, 15° of external rotation, and 40–50° of hip flexion bilaterally with no pain with log roll. Plain radiographs showed well-fixed bilateral total hip replacements. On the contralateral right side, there was evidence of some eccentric wear of the polyethylene liner and only minimal wear on the left side. There was no evidence of periosteal reaction, osteolysis, or cloacal openings seen anywhere along the left proximal femur. There was continued presence of Brooker III/IV heterotopic ossification around both hips without subsidence of his left hip compared to his X-rays in 2014 (). Now, twelve years after stopping AST therapy, the patient continues to have no signs of infection or loosening or wear in his hip and reports a good Harris Hip Score of 84.

We report the case of a 41-year-old woman with a history of presumed spinocerebellar ataxia who presented with right heart failure from an invasive mediastinal mass with near complete occlusion of her pulmonary arteries.\nShe was in her usual state of health until first presenting to the emergency department in February 2017 with bilateral lower extremity edema and progressive dyspnea on exertion. She was found to have an amorphous, invasive superior left mediastinal mass involving the main and left pulmonary arteries with occlusion of the left pulmonary arterial tree and severe narrowing of the right pulmonary artery (). At that time, she was noted to have moderate cardiomegaly with right heart enlargement and findings of elevated right heart pressures as well as several scattered, small nonspecific pulmonary nodules. Subsequent PET scan showed marked fluorodeoxyglucose (FDG) avidity of the anterior mediastinal mass. She underwent intravascular biopsy with interventional radiology during that first admission, and an arteriogram revealed a severely stenosed but still-patent right main pulmonary artery with no filling of the left main pulmonary artery. She was discharged with subspecialist follow-up pending biopsy results. However, initial pathology revealed only thrombus material and a minute fragment of unremarkable intima. The patient was unable to tolerate the scheduled cardiac MRI for repeat biopsy planning and was lost to follow-up until representing to thoracic surgery clinic in May 2017 after a progressive decline. At that visit, she was directly admitted for immediate further evaluation given the extent of her mass.\nOn admission in May 2017, her right heart function had declined considerably with echocardiogram notable for a severely dilated right atrium and severely dilated right ventricle with the interatrial septum bowing to the left, suggestive of right heart failure. She underwent a second biopsy via bronchoscopy; however, pathology was again nondiagnostic and notable only for fragments of fibrous tissue with a mixed inflammatory infiltrate. She then underwent a third biopsy via repeat intravascular approach that was also nondiagnostic despite seemingly adequate yield and notable only for vessel wall fragments with myxoid degeneration and few small crushed cells, favoring an inflammatory infiltrate. Although there was suspicion for sarcoma or lymphoma, the radiation oncology and medical oncology teams opted to defer empiric treatment until a definitive diagnosis was made. The cardiac surgery team felt that a biopsy via anterior chest wall window was too high risk due to the orientation of the mass. Due to the significant risk of impending hemodynamic instability from her mass, she underwent pulmonary artery stenting with the interventional radiology team, who felt that they would be able to safely stent the right pulmonary artery but could not intervene on the totally occluded left pulmonary artery. Her gradients improved immediately after stenting, and she tolerated the procedure without complication (Figures and ).\nA fourth biopsy taken at the time of stenting ultimately revealed fibrous tissue with lymphohistiocytic and plasma cell infiltrate with positive staining for S100, CD68, and CD163, negative staining for CD1a and Factor XIIIa, and emperipolesis, consistent with extranodal Rosai–Dorfman disease (). In order to rule out other disease processes, pathologic analysis revealed no significant increase in IgG4+ plasma cells and no evidence of bacteria, acid fast, or fungal organisms on Gram, Fite, AFB, Grocott, and PAS stains. Importantly, she was evaluated by the genetics team, who determined it was unlikely that her development of RDD was at all related to her presumed diagnosis of spinocerebellar atrophy.

A 64-year-old female presented to the office with the complaint of a back mass. When asked to identify the location of the mass, she pointed to her right scapular line just below the costal margin. The patient reported that she first noticed this mass approximately one year prior to that visit. While it had not noticeably increased in size over the last year, the mass had recently started to produce dull pain.\nThe patient's past medical history was notable only for gastroesophageal reflux disease, hypercholesterolemia, and an overweight BMI of 29.1. When prompted, she denied any history of back trauma or back surgery. During the patient's physical examination, it was difficult to identify the mass at the location she indicated. After palpation in various positions, the mass was finally identified when she was instructed to stand and flex her back forward. In this position, a mass approximately 5 cm in diameter was palpable several centimeters inferior to the point the patient had indicated. The mass was soft and mobile with a smooth border. It was not found to be reducible. Palpation did not produce any pain during this examination.\nAt the time of this office visit, it was decided that the diagnosis of lipoma was appropriate for the patient's back mass. This decision was based on her physical findings as well as an understanding of the relatively high incidence of lipoma for individuals with this patient's chief complaint. Excision of the suspected lipoma was felt to be indicated as the mass was producing discomfort and was believed to be located such that it could be accessed by a minimally invasive approach. During preoperative examination on the day of the surgery, the patient's lumbar mass was once again challenging to identify. Palpation and marking of the mass prior to the procedure could eventually be achieved by placing the patient on her left side with her legs flexed up toward her chest. Palpation of the lumbar mass did not reveal tenderness and the exam was otherwise normal with no identified contraindications to surgery.\nFollowing induction of anesthesia and draping of the patient, an incision was made at the marked location below the 12th rib. After dissection through the skin and subcutaneous tissue to the muscle, the mass could neither be visualized nor palpated. At this point, it was decided that it may be harmful to the patient to continue exploration without confidence in the location of the mass. Accordingly, the procedure was promptly terminated and the incision was closed and dressed appropriately.\nThe patient was then sent for a CT scan of her abdomen which identified a 5-6 cm right upper lumbar hernia sac containing retroperitoneal fat (). The fascial defect appeared to be 1.6 cm in diameter. There was no kidney or bowel herniating into the sac. Our diagnosis after this imaging study was that of a Grynfeltt-Lesshaft lumbar hernia.\nA new surgery was scheduled for the repair of the patient's hernia. At the start of the procedure, the horizontal skin incision present below the 12th rib from the attempted lipoma resection was opened and dissection was carried out to expose the latissimus dorsi. A plane was then created under this muscle by blunt dissection and the muscle was retracted anterolaterally to reveal herniated retroperitoneal fat protruding through a 1.5 cm diameter defect in the upper lumbar triangle (). After the hernia was detached from the deep side of the transversalis fascia, a 4.3 cm diameter circular polypropylene mesh patch designed for umbilical hernia repairs was placed under the fascia. This was anchored to the deep side of the fascia with interrupted sutures circumferentially placed 2 cm from the edges of the defect. The edges were then approximated and the defect was directly sutured closed over the mesh. At this point, a 4 cm strip of polypropylene mesh was placed over the closed defect and secured to the fascia with interrupted sutures. The latissimus dorsi was then restored to its normal position and closure of the overlying tissues was performed. The patient was discharged the same day. No recurrences of the hernia or complications have been noted on six-month follow-up.

A 48-year-old African male was referred to our imaging department for a coronary computed tomography angiography (CCTA) due to a recent history of left side chest pain. Further evaluation of the patient revealed complaints of recurrent loss of consciousness for six years, convulsions for four years, a single episode of temporary loss of vision three years ago, and recent skin nodules. He is a known hypertensive patient diagnosed four years ago and is on regular medication with a fair response. He denied any known allergy or surgical history. There is no known history of tuberculosis contact or a known family history of epileptic disorders. He admitted to eating pork meat up to four times a week. He was a truck driver and is married with seven living children. This illness led him to stop driving. His wife and children are all doing well.\nThe first episode of loss of consciousness occurred suddenly and lasted for a few minutes. He denied having a prior illness. He was taken to a nearby hospital where he was treated for malaria and soon resumed normal activities.\nHe was doing well thereafter until the following year when he developed a second episode of a sudden loss of consciousness and woke up in a hospital two days later. During hospitalization, he was put on IV fluids and antimalarial drugs. This episode was followed by a severe headache that lasted for two days, temporarily relieved by acetaminophen tablets. Just like in the first episode, he had no prior illness.\nIn the third year from the onset of the first symptom, he developed an episode of generalized tonic-clonic convulsions associated with tongue biting, frothing from the mouth, and neck stiffness. This was followed by loss of consciousness. During hospitalization, he was once more treated for malaria.\nThese episodes of convulsions and loss of consciousness kept recurring yearly with increasing frequency and the duration of loss of consciousness in each episode until when he reported at our facility. In the past few months prior to presentation, he discovered having small skin nodules distributed on the neck, chest, and back. They were immobile, painless, and had no associated skin color changes (Figure ).\nPhysical examination revealed a stable adult patient, alert, afebrile, not pale or jaundiced, and with no lower limb edema. His pulse rate was 80 beats/min. Blood pressure was 141/90 mmHg. The respiratory exam revealed 28 breaths per minute, oxygen saturation on room air was 99%, and bronchovesicular breath sounds were heard. Normal S1 and S2 sounds were heard on the cardiac exam. There was no murmur or thrill. Skin exam revealed few visible scattered palpable skin nodules at the neck, chest, and back. The rest of the systemic exam was unremarkable. A provisional diagnosis of disseminated cysticercosis and hypertensive heart disease was made.\nHematological tests revealed a normal range of hemoglobin, leukocytes, and platelets. His blood lipid panel, blood renal, and liver profiles were unremarkable. Sickling test, rapid plasma reagin test for syphilis, and ELISA for the human immunodeficiency virus were all negative. Electrocardiography (ECG) exam revealed a normal sinus rhythm.\nCT scan of head and neck, chest, abdomen, and pelvis revealed multiple cystic lesions with dot sign diffusely distributed in the brain, neck, chest, including the heart, abdomen, and pelvis (Figure ).\nCardiac CT images showed multiple hypodense cystic lesions at the interventricular septum and papillary muscles (Figure ). CT chest, abdomen, and pelvis showed cystic lesions (Figures , ). Excision biopsy of two subcutaneous nodules was performed and confirmed cutaneous cysticercosis on the pathological exam. A final diagnosis of disseminated cysticercosis with cardiopulmonary involvement was made based on imaging and histology.\nThe patient was treated with albendazole 400mg twice a day for two weeks, followed by 400mg once a day for two weeks, prednisone 40mg, which was tapered down, and carbamazepine 200mg twice a day for two weeks. During treatment, the patient did not complain of seizures or loss of consciousness or headache. A follow-up CT scan confirmed that the cysts had markedly reduced in number and size, and many had become non-viable (Figures , , , , ). The patient is still on albendazole 400mg once a day and is regularly seen in the outpatient clinic with no further seizures with the plan to continue the albendazole for another four weeks.

The 28-year-old male patient had trained for about 2 weeks after entering a marine training center. It was said that 2-week training at the Marine training center consisted of 2–3 h of swimming training a day and 2 h of basic physical strength reinforcement training. The swimming training consisted of repetitions 50 min of swimming and 10 min of rest. The swimming portion consisted of swimming 25 m back and forth four times at full strength followed by swimming the same distance four times at low speeds. The trainees would then rest and begin again. The basic physical strength reinforcement training consisted of repeating walking and running for around 1 h followed by weight training to reinforce upper and lower extremity muscular strength. The degree of difficulty was no different for him than for his colleagues.\nDue to pain in the both hip joints and the left ankle he visited a private clinic, but although a simple radiological examination was performed no abnormal finding was found (Fig. a); anti-inflammatory analgesics were prescribed and immobilization was recommended. At 4 weeks after enrollment, he presented at our hospital due to the aggravation of his right hip joint symptoms, a simple radiological examination was performed on the hip areas reported to be painful, and the radiographs obtained revealed a displaced femoral neck fracture (Fig. b). A bone scan showed hot uptakes at both hips and at the left ankle joint, MRI revealed fractures of both femoral necks (the right side was displaced and complete fracture) (Fig. c). He underwent open reduction and internal fixation at right hip using cannulated screws. The region of ankle joint hot uptake by bone scan was also investigated and found to be due to a slight fatigue fracture and articular depression of the subtalar joint and diffuse edematous change around the calcaneus on MRI. However, the patient has never made any specific complaint regarding the ankle joint. The left hip and ankle joint were treated conservatively by stabilization and long leg casting.\nHowever, reduction loss was noted 2 weeks after surgery due to non-union (Fig. a) on right hip. The displaced femur neck fracture due to fracture non union was treated by total hip arthroplasty (Depuy pinnacle cup 54 mm, ceramic liner 54–36 mm, Corail stem 314, ceramic head 12/14 medium 36 mm) and operative findings were non-specific (Fig. b).\nSuspecting multiple stress fractures, we scrutinized his history and performed a hematological examination.\nThe patient advised that he had grown in height until he was 21 years old. His body weight was 53 kg and height 170 cm, and there was no particular history of surgery or hospitalization. Seemingly, there was no finding to indicate a hormonal disorder, i.e., abnormal findings regarding early morning erection, sexual hair, etc., and dual energy X-ray absorptiometry (DEXA) returned a lumbar spine T score of 2.8. Findings from the hematological examination were a serum CTx (C-terminal telopeptide) 0.38 ng/ml, NTx (cross-linked N-telopeptides of type1 collagen in urine) 111 BCE/mM, 25(OH) Vitamin D3 22.3 ng/ml, PTH (intact) 27 pg/ml, LH 4.1 mIU/ml, FSH 3.7 mIU/ml, testosterone 2.79 ng/ml, osteocalcin 25.2 ng/ml, T3 (total) 121 ng/ml, free T4 1.35 ng/ml, TSH 1.42 uIU/ml, prolactin 3.5 ng/ml, alk phos 93 U/L, calcium 9.2 mg/dl, and phosphorus 4.4 mg/dl.\nAt 17 months postoperatively, the patient had a normal gait without any supportive equipment, and was pain free without functional restriction with stable fixated implants.

A 43 year old female district nurse presented to the accident and emergency department with a 6 hour history of initially generalized abdominal pain which was localizing to the right. This was associated with nausea and loss of appetite, made worse by movement and not relieved with intramuscular morphine injection. There was no history of recent or past trauma to the chest or abdomen. On examination, she was tender in the right upper quadrant and right iliac fossa with rebound and guarding, with a Rovsing positive sign and normal bowel sounds. She was incidentally found to have some marfanoid features including the long span of upper limbs, a high arched palate and the very soft early diastolic murmur of aortic regurgitation. The patient had a positive family history of Marfan's syndrome but had never undergone genetic testing to confirm the diagnosis.\nA likely diagnosis of appendicitis was made on the clinical picture associated with a pyrexia and raised white cell count and C – reactive protein. Her abdominal X-ray at that time showed absence of gas in the right side of her bowel. Her chest X-ray did not show any obvious abnormality (Figure )\nShe was taken to theatre the same day for appendicectomy through a standard right iliac fossa incision. There was a small amount of free fluid but the right iliac fossa was filled with a normal looking gall bladder and small bowel only with no sign of the caecum, appendix, ascending or proximal transverse colon. The terminal ileum was found to run up under the right lobe of the liver towards the hilum. The right iliac fossa wound was closed and we proceeded to an exploratory laparoscopy.\nAt laparoscopy, the liver was retracted to see under the right liver lobe. The proximal transverse colon was found to be running up towards the liver hilum were it felt to be tethered. This suggested a possible herniation of the right colon into the chest. The procedure was abandoned and a CT thorax and abdomen were performed to define the anatomy involved.\nThis (Figure , ) demonstrated bilateral pleural effusions of moderate size with underlying unexpanded lungs. The liver had what appeared to be a large Reidl's lobe. Behind the right liver lobe, the right kidney was markedly elevated and the ileo-caecal junction appeared to lie between the liver and the kidney. The right side of the colon appeared to lie above the liver. Three dimensional reconstruction of the scans demonstrated absence of the right hemidiaphragm. (Figure , )\nThe symptoms and signs persisted and a laparotomy was performed. At laparotomy, there was some free fluid. There was definitely a large defect in the right hemidiaphragm. The right liver lobe had grown right up into the right intrathoracic space. There was a large hernial sac beneath the right lobe of the liver between the common bile duct, duodenum and liver, displacing the right kidney medially and containing transverse colon, terminal ileum, caecum, appendix and free fluid. The contents of this sac were successfully reduced and a perforated gangrenous appendix with pus was found within the intrathoracic hernial sac. A standard appendicectomy was performed. The right colon was formally mobilized, fully reduced and the caecum was fixed within the right iliac fossa.\nThe patient was admitted to the intensive care unit postoperatively where she made a good recovery. She had instant relief of her abdominal symptoms and post-operative contrast study demonstrated the presence of the right colon within the abdomen (Figure ). She was discharged a week post-operatively.

A 60-year-old male who had a history of liver cirrhosis was referred for evaluation of a pain, swelling, and erythematous changes of the anterolateral aspect of his left leg. His symptoms started a month ago without any specific trauma. He had a history of open reduction and internal fixation performed for a tibial plateau fracture that occurred when his left knee was pinned under a tree 18 years ago. He had sciatic nerve injury at the time of the fracture. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery 8 years after the initial trauma due to a distal femur fracture and femoral artery rupture. At that time, a widespread radiopaque mass was observed on plain radiographs of left leg, and obstruction of popliteal artery with abundant collateral circulation was observed on angiography. The patient had no difficulty with his daily life functions until the aforementioned symptoms appeared, except for limited motion in the ankle and toes and sensory reduction in his foot owing to the sciatic nerve injury.\nAfter admission, the patient maintained with a long leg splint. Two weeks after the admission, the erythematous changes in the left leg localized to the anterior aspect in the middle of the leg and formed a fluid-filled, erythematous mass. A draining sinus had developed on the erythematous mass spontaneously and a thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The range of motion of the knee was 0 degrees to 100 degrees of flexion; ankle dorsiflexion was 0 degrees, ankle plantar flexion was 5 degrees, and all of the toes had clawing deformity. As for the motor strength of the ankle, the dorsiflexion was grade 0 and plantar flexion was grade 3. He had no sensation in the first web space and on the medial aspect of the foot, and had sensory reduction in the lateral, dorsal, and plantar aspects of the foot, in order of decreasing sensation.\nThe radiographs of the left leg taken 10 years ago (8 years after the initial trauma) showed a large, fusiform-shaped, radiopaque soft tissue mass in the space between the tibia and fibula that spanned from 5 cm below the proximal tibio-fibular articulation to just above the distal tibio-fibular articulation. The medial cortex of the middle third of the fibula and the posterior cortex of the distal third were sclerotic. Ten years later (18 years after the initial trauma), the patient's radiographs showed a large, fusiform-shaped soft tissue mass with extensive plaque-like and amorphous calcifications, similar to those seen in the radiographs taken 10 years earlier (Fig. ). Furthermore, we observed that calcification within the fusiform mass and in the distal part of the deep posterior compartment had increased in comparison to that seen in the radiographs taken 10 years earlier. The erosion of the medial and posterior parts of the distal two-thirds of the fibula had also increased, and a sclerotic change in the lateral cortex of the middle third of the tibia was newly observed. We performed a computed tomography (CT) scan to examine the pattern and distribution of the calcifications more closely; peripherally distributed calcification was found in the anterior compartment and in the distal part of the deep posterior compartment, and sclerotic changes were found in the tibial and fibular cortex (Fig. ). There was evidence of increased uptake between the tibia and fibula in the delayed bone phase on 3 phases of bone scan, which was determined to be caused by calcification.\nLaboratory investigations revealed that the erythrocyte sedimentation rate (ESR) was 69 mm/h and the C-reactive protein (CRP) level was 5.80 mg/dL with no fever. Serum calcium, phosphorous, and alkaline phosphatase levels were all within the normal limits.\nWe performed an incisional biopsy to differentiated soft tissue sarcoma and no viable, malignant cells were found. A thick fluid with a chalk-like material continued to be discharged through the sinus opening. We performed an extensive debridement of the anterior and deep posterior compartments to ensure definitive treatment. Intraoperative findings showed that the deep fascia was thickened, and that the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles had become necrotic and changed into a whitish, toothpaste-like material (Fig. ). Hard calcific materials resembling rice grains were spread within the necrotic muscle. Furthermore, we observed an erosion of the cortex without intramedullary involvement on the lateral tibial surface and medial fibular surface. After an en-block resection of the anterior compartment, we approached the posterior compartment through the interosseous membrane. When we opened the interosseous membrane, the turbid fluid was drained, and we found that the flexor hallucis, flexor digitorum, and tibialis posterior muscles formed a twig-shaped, hard calcification in the direction of the muscle fibers, unlike in the anterior compartment (Fig. ). Upon performing extensive debridement, we inserted a drain tube and performed primary closure. As Pseudomonas aeruginosa was identified in the intraoperative culture, we used antibiotic treatment (piperacillin-tazobactam, intravenously for 6 weeks and then ciprofloxacin, orally for 4 weeks). The fluid continued to be discharged through the drain even after the surgery; delayed wound healing occurred four weeks following the surgery, and there was no recurrence and the patients were satisfied with the result of the operation at follow-up conducted 2 years later (Fig. ).\nPathologic evaluation revealed that the anterior compartment specimen had acute and chronic inflammation with dystrophic calcification, and the posterior compartment specimen had fibrosis with dystrophic calcification; the tibial periosteum had acute and chronic inflammation with dystrophic calcification, and the tibial bone was fibrotic. These findings led to the diagnosis of calcific myonecrosis.

A 60-year-old male who had a history of liver cirrhosis was referred for evaluation of a pain, swelling, and erythematous changes of the anterolateral aspect of his left leg. His symptoms started a month ago without any specific trauma. He had a history of open reduction and internal fixation performed for a tibial plateau fracture that occurred when his left knee was pinned under a tree 18 years ago. He had sciatic nerve injury at the time of the fracture. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery 8 years after the initial trauma due to a distal femur fracture and femoral artery rupture. At that time, a widespread radiopaque mass was observed on plain radiographs of left leg, and obstruction of popliteal artery with abundant collateral circulation was observed on angiography. The patient had no difficulty with his daily life functions until the aforementioned symptoms appeared, except for limited motion in the ankle and toes and sensory reduction in his foot owing to the sciatic nerve injury.\nAfter admission, the patient maintained with a long leg splint. Two weeks after the admission, the erythematous changes in the left leg localized to the anterior aspect in the middle of the leg and formed a fluid-filled, erythematous mass. A draining sinus had developed on the erythematous mass spontaneously and a thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The range of motion of the knee was 0 degrees to 100 degrees of flexion; ankle dorsiflexion was 0 degrees, ankle plantar flexion was 5 degrees, and all of the toes had clawing deformity. As for the motor strength of the ankle, the dorsiflexion was grade 0 and plantar flexion was grade 3. He had no sensation in the first web space and on the medial aspect of the foot, and had sensory reduction in the lateral, dorsal, and plantar aspects of the foot, in order of decreasing sensation.\nThe radiographs of the left leg taken 10 years ago (8 years after the initial trauma) showed a large, fusiform-shaped, radiopaque soft tissue mass in the space between the tibia and fibula that spanned from 5 cm below the proximal tibio-fibular articulation to just above the distal tibio-fibular articulation. The medial cortex of the middle third of the fibula and the posterior cortex of the distal third were sclerotic. Ten years later (18 years after the initial trauma), the patient's radiographs showed a large, fusiform-shaped soft tissue mass with extensive plaque-like and amorphous calcifications, similar to those seen in the radiographs taken 10 years earlier (Fig. ). Furthermore, we observed that calcification within the fusiform mass and in the distal part of the deep posterior compartment had increased in comparison to that seen in the radiographs taken 10 years earlier. The erosion of the medial and posterior parts of the distal two-thirds of the fibula had also increased, and a sclerotic change in the lateral cortex of the middle third of the tibia was newly observed. We performed a computed tomography (CT) scan to examine the pattern and distribution of the calcifications more closely; peripherally distributed calcification was found in the anterior compartment and in the distal part of the deep posterior compartment, and sclerotic changes were found in the tibial and fibular cortex (Fig. ). There was evidence of increased uptake between the tibia and fibula in the delayed bone phase on 3 phases of bone scan, which was determined to be caused by calcification.\nLaboratory investigations revealed that the erythrocyte sedimentation rate (ESR) was 69 mm/h and the C-reactive protein (CRP) level was 5.80 mg/dL with no fever. Serum calcium, phosphorous, and alkaline phosphatase levels were all within the normal limits.\nWe performed an incisional biopsy to differentiated soft tissue sarcoma and no viable, malignant cells were found. A thick fluid with a chalk-like material continued to be discharged through the sinus opening. We performed an extensive debridement of the anterior and deep posterior compartments to ensure definitive treatment. Intraoperative findings showed that the deep fascia was thickened, and that the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles had become necrotic and changed into a whitish, toothpaste-like material (Fig. ). Hard calcific materials resembling rice grains were spread within the necrotic muscle. Furthermore, we observed an erosion of the cortex without intramedullary involvement on the lateral tibial surface and medial fibular surface. After an en-block resection of the anterior compartment, we approached the posterior compartment through the interosseous membrane. When we opened the interosseous membrane, the turbid fluid was drained, and we found that the flexor hallucis, flexor digitorum, and tibialis posterior muscles formed a twig-shaped, hard calcification in the direction of the muscle fibers, unlike in the anterior compartment (Fig. ). Upon performing extensive debridement, we inserted a drain tube and performed primary closure. As Pseudomonas aeruginosa was identified in the intraoperative culture, we used antibiotic treatment (piperacillin-tazobactam, intravenously for 6 weeks and then ciprofloxacin, orally for 4 weeks). The fluid continued to be discharged through the drain even after the surgery; delayed wound healing occurred four weeks following the surgery, and there was no recurrence and the patients were satisfied with the result of the operation at follow-up conducted 2 years later (Fig. ).\nPathologic evaluation revealed that the anterior compartment specimen had acute and chronic inflammation with dystrophic calcification, and the posterior compartment specimen had fibrosis with dystrophic calcification; the tibial periosteum had acute and chronic inflammation with dystrophic calcification, and the tibial bone was fibrotic. These findings led to the diagnosis of calcific myonecrosis.

RH, a 21 year old female presented to a chiropractic teaching clinic with a chief complaint of neck and thoracic spinal pain which had been present for approximately 4 years since commencing her university studies and was aggravated by studying. RH experienced this pain about once per week and it lasted for 'a couple of days'. RH had a secondary complaint of headache, which began about the same time as her primary complaint. The headaches were described as a band of pain across her forehead along with an ache at the base of her skull and in her temples. Past medical history was unremarkable save for shingles in 2004. Routine physical examination was unremarkable. Following history and examination a working diagnosis of mid-back pain of mechanical origin with associated muscle hypertonicity was established and a course of chiropractic treatments proposed. Treatment included SMT to the spinal levels thought to have restricted motion, soft-tissue treatment to the musculature of the upper back and a recommendation for core stability exercises. On a subsequent visit RH reported that she could neither lie prone on the treatment table nor could she perform even the most basic core stability exercises because to do so would result in severe abdominal pain, throat tightness and headache. Following further questioning it was determined that RH had been experiencing this triad of symptoms since she was eight years old and had subsequently avoided any activity that placed pressure on her abdomen, such as sitting close to a table when studying or performing abdominal exercises. Medical investigation for her symptoms had yielded neither a diagnosis nor a treatment. RH traced her symptoms back to a ballet class when she was age eight years during which she was required to lie prone on a wooden floor and, while holding onto her ankle, attempt to touch her toes to her head. Palpation of the area surrounding RH's xiphoid reproduced her abdominal pain and throat tightness immediately with the headache beginning a few minutes later. These symptoms persisted for several hours. A diagnosis of xiphodynia was established and a course of LLLT suggested. Four treatments of 2 minutes each were administered. RH reported a lessening of her symptoms but not cessation. It was noted that, in order to reproduce the symptoms pressure had to be applied to the xiphoid for up to 20 seconds and that RH's symptoms would not begin for until two minutes after pressure was removed. A switch of modality to Ultrasound was commenced. Ultrasound was chosen because of its known effects on tissue repair [,]\nIn addition, RH was advised to use a topical anti-inflammatory gel over the xiphoid. Following four ultrasound treatments RH's symptoms persisted however they have subsided from 8/10 to 2–3/10 and she is content to continue with conservative care because she does not wish to receive an injection of corticosteroid to the area. RH was reviewed in April 2007 and related that she went overseas during the University summer break during which time her symptoms continued to subside. RH stated that her symptoms were mild and intermittent. At this point in time RH elected to have no examination or treatment of the xiphoid, instead opting to return for assessment and treatment if she experienced an exacerbation of symptoms.

A 60-year-old male who had a history of liver cirrhosis was referred for evaluation of a pain, swelling, and erythematous changes of the anterolateral aspect of his left leg. His symptoms started a month ago without any specific trauma. He had a history of open reduction and internal fixation performed for a tibial plateau fracture that occurred when his left knee was pinned under a tree 18 years ago. He had sciatic nerve injury at the time of the fracture. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery 8 years after the initial trauma due to a distal femur fracture and femoral artery rupture. At that time, a widespread radiopaque mass was observed on plain radiographs of left leg, and obstruction of popliteal artery with abundant collateral circulation was observed on angiography. The patient had no difficulty with his daily life functions until the aforementioned symptoms appeared, except for limited motion in the ankle and toes and sensory reduction in his foot owing to the sciatic nerve injury.\nAfter admission, the patient maintained with a long leg splint. Two weeks after the admission, the erythematous changes in the left leg localized to the anterior aspect in the middle of the leg and formed a fluid-filled, erythematous mass. A draining sinus had developed on the erythematous mass spontaneously and a thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The range of motion of the knee was 0 degrees to 100 degrees of flexion; ankle dorsiflexion was 0 degrees, ankle plantar flexion was 5 degrees, and all of the toes had clawing deformity. As for the motor strength of the ankle, the dorsiflexion was grade 0 and plantar flexion was grade 3. He had no sensation in the first web space and on the medial aspect of the foot, and had sensory reduction in the lateral, dorsal, and plantar aspects of the foot, in order of decreasing sensation.\nThe radiographs of the left leg taken 10 years ago (8 years after the initial trauma) showed a large, fusiform-shaped, radiopaque soft tissue mass in the space between the tibia and fibula that spanned from 5 cm below the proximal tibio-fibular articulation to just above the distal tibio-fibular articulation. The medial cortex of the middle third of the fibula and the posterior cortex of the distal third were sclerotic. Ten years later (18 years after the initial trauma), the patient's radiographs showed a large, fusiform-shaped soft tissue mass with extensive plaque-like and amorphous calcifications, similar to those seen in the radiographs taken 10 years earlier (Fig. ). Furthermore, we observed that calcification within the fusiform mass and in the distal part of the deep posterior compartment had increased in comparison to that seen in the radiographs taken 10 years earlier. The erosion of the medial and posterior parts of the distal two-thirds of the fibula had also increased, and a sclerotic change in the lateral cortex of the middle third of the tibia was newly observed. We performed a computed tomography (CT) scan to examine the pattern and distribution of the calcifications more closely; peripherally distributed calcification was found in the anterior compartment and in the distal part of the deep posterior compartment, and sclerotic changes were found in the tibial and fibular cortex (Fig. ). There was evidence of increased uptake between the tibia and fibula in the delayed bone phase on 3 phases of bone scan, which was determined to be caused by calcification.\nLaboratory investigations revealed that the erythrocyte sedimentation rate (ESR) was 69 mm/h and the C-reactive protein (CRP) level was 5.80 mg/dL with no fever. Serum calcium, phosphorous, and alkaline phosphatase levels were all within the normal limits.\nWe performed an incisional biopsy to differentiated soft tissue sarcoma and no viable, malignant cells were found. A thick fluid with a chalk-like material continued to be discharged through the sinus opening. We performed an extensive debridement of the anterior and deep posterior compartments to ensure definitive treatment. Intraoperative findings showed that the deep fascia was thickened, and that the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles had become necrotic and changed into a whitish, toothpaste-like material (Fig. ). Hard calcific materials resembling rice grains were spread within the necrotic muscle. Furthermore, we observed an erosion of the cortex without intramedullary involvement on the lateral tibial surface and medial fibular surface. After an en-block resection of the anterior compartment, we approached the posterior compartment through the interosseous membrane. When we opened the interosseous membrane, the turbid fluid was drained, and we found that the flexor hallucis, flexor digitorum, and tibialis posterior muscles formed a twig-shaped, hard calcification in the direction of the muscle fibers, unlike in the anterior compartment (Fig. ). Upon performing extensive debridement, we inserted a drain tube and performed primary closure. As Pseudomonas aeruginosa was identified in the intraoperative culture, we used antibiotic treatment (piperacillin-tazobactam, intravenously for 6 weeks and then ciprofloxacin, orally for 4 weeks). The fluid continued to be discharged through the drain even after the surgery; delayed wound healing occurred four weeks following the surgery, and there was no recurrence and the patients were satisfied with the result of the operation at follow-up conducted 2 years later (Fig. ).\nPathologic evaluation revealed that the anterior compartment specimen had acute and chronic inflammation with dystrophic calcification, and the posterior compartment specimen had fibrosis with dystrophic calcification; the tibial periosteum had acute and chronic inflammation with dystrophic calcification, and the tibial bone was fibrotic. These findings led to the diagnosis of calcific myonecrosis.

An 87-year-old woman presented to the accident and emergency department after sustaining a fall while on holiday. She complained of pain and reduced range of movement in her left shoulder. Her past medical history included hypertension atrial fibrillation, for which she took aspirin 75 mg once a day. She had previously undergone a thyroidectomy in 2000 for hyperthyroidism. She was otherwise fit and well with no known drug allergies.\nOn examination her left arm was bruised and painful when movements were attempted. Her distal neurovascular status of the affected limb was normal with no deficit detected. Plain film radiographs of her left shoulder demonstrated a minimally displaced and impacted fracture of her proximal humerus (as shown in ). After discussion with the orthopaedic registrar on call she was placed in a collar and cuff and sent home to attend the next available fracture clinic.\nWhen she was reviewed in the following fracture clinic it was noted that she had developed a swelling and erythema on the left side of her neck in the distribution of her external jugular vein (as shown in ). It was also found that the collar and cuff had been applied rather tightly. She was referred to the on call ENT registrar who made a diagnosis of thrombophlebitis of her external jugular vein. Further questioning did not reveal a history of further thrombotic events. The ENT registrar felt the erythema may be developing cellulitis and so started the patient on antibiotics (flucloxacillin 500 mg four times a day for 5 days) and placed her in a better fitting sling. The fracture was deemed suitable for nonsurgical management with regular clinical and radiological follow-up. As she was only on holiday in the region, further follow-up was arranged for two weeks in her local hospital.\nTwo days later, she represented to the accident and emergency department with pain and gross pitting oedema in her left arm. A Doppler scan demonstrated near complete occlusion of the left subclavian and axillary veins consistent with a deep vein thrombosis. She was started on warfarin covered with treatment dose enoxaparin (1 mg/kg once a day) until her INR was therapeutic. As the external jugular vein thrombosis was thought to be triggered by her collar and cuff, the decision was made to anticoagulate the patient for 3 months.\nThe patient made a full recovery and so far has had no further episodes of thrombosis. While this episode of thrombosis did not significantly impede her rehabilitation, it was a potentially life-threatening complication that perhaps could have been diagnosed earlier in her care.

A 35-year old adult, high school educated, married male, tailor by occupation, of lower socio economic status presented to the psychiatry outpatient department of University College of Medical Sciences and Guru Teg Bahadur Hospital, a tertiary care center in the capital city of Delhi. He was referred from the medical department for complaints of increased water intake with two episodes of abnormal movements. Abnormal movements were characterized by sudden tightening of limbs and jaws with jerky movements with urinary incontinence and loss of consciousness one month prior to the visit. Patient was evaluated and found to have low serum sodium levels. The jerky movements were attributed to hyponatremia induced seizure due to increased water intake. On elicitation of history from patient, his wife and his brother who accompanied him, reported that patient was apparently functioning well until 2 to 3 years ago when he had an episode of fever following which he started reporting complaints of weakness and anxiety. He reported that he was advised by the doctor to drink fluids, following which he initially started taking increased amounts of water per day and gradually the intake was raised to about 10 liters / day. He started feeling thirsty while talking or after micturition and there was a need to drink water after every five to ten minutes and also, after whenever he passed urine. He reported that he would feel anxious and irritable if he was unable to get water or if family would stop him from taking water. His appetite had decreased and he had suffered loss of weight over the period of 2 years and had thoughts preoccupied with water intake. He would always keep a 2 liter bottle of water with him. He also lost interest in work and stopped going to work, citing weakness and fatigability all through the day as the reason for absenteeism from work. There was no history of sadness of mood or any other depressive symptoms. No psychotic symptoms could be elicited and no other obsessive thoughts, images or impulses or any other compulsive behavior was present. No history of any organic cause was found. History of smoking was present but he was abstinent for the past 2 years. Past and family history was insignificant. No significant medical history was obtained. Premorbid personality was of an extrovert, cheerful, conscientious, religious adult. He was treated with paroxetine 12.5 mg which he had taken for a few days but had reported no improvement in water drinking and had probably increased the risk of low sodium levels leading to seizure. On Mental Status Examination, patient was conscious, oriented, asthenic built, cooperative, had a 2 liter bottle of water which was half filled (he reported to have finished about 3 liters before the visit in about 4 to 5 hours), and he was taking regular sips from the bottle after almost every few sentences, reporting inability to stop drinking water even when asked to, complaining of feeling thirsty as he spoke, psychomotor activity and speech was normal, preoccupations with drinking water, he appeared anxious with no perceptual abnormality. Differential diagnoses included Syndrome of Inappropriate Anti Diuretic Hormone (SIADH), diabetes insipidus, hyperthyroidism, and excess cortisol and psychogenic polydipsia were considered.\nPatient’s complete hemogram, thyroid function tests, liver function and renal function tests (except serum sodium), blood sugar, urine routine, CT scan brain were found to be normal. Values of serum sodium were low when he was evaluated at the time of seizure. Mild hepatomegaly and bilaterally mildly enlarged kidney were seen on ultrasound of abdomen. Sodium osmolarity was 145 mosm/kg, urine osmolarity was 285mosm/kg. Cortisol levels were normal. No diurnal body weight gain was noted. These findings rule out the possibility of organic causes and the patient was managed on the lines of psychogenic polydipsia (R63.1 according to ICD-10).\nPatient was on treatment initially with vasopressin receptor antagonist (tolvaptan) 30 mg in divided doses which was tapered off after sodium levels were stabilized by the physician. He was started on olanzapine 2.5 mg and clonazepam 0.5 mg for antianxiety effects. Behavior therapy for compulsive water drinking was planned with the patient and brother as co therapist. He was advised to keep a log diary of intake and output for fluids. He was advised to reduce his water intake by keeping a watch on his input/output chart. Family as well as the patient was psycho-educated regarding effects of increased water intake and the need to restrict water intake. This helped family members to stop him from drinking excess fluids even when he would become irritable if restricted. In a span of 6 weeks follow up, he showed remarkable improvement in his water drinking, reduced from 10 liters approx. to 5 liters / day as seen by input/output charting made by the patient and supervised by his family members. His anxiety levels were also reduced and he was motivated and started to go to work. He reported feeling better and motivated for treatment with further reduction in water intake. Patient was advised to gradually stop olanzapine and clonazepam and to continue with behavior therapy (Fig).

A 54-year-old male presented with masses on his left arm and axilla. The axillar mass was 12 × 7 cm and the mass in the proximal lateral humerus was 6 × 5 cm. His symptoms had started a number of years prior. Before the initiation of these symptoms, he denied having any significant medical problems. He had a history of smoking for 20 years. In his family history, no relevant medical condition and/or history of cancer was identified. He had been referred to a surgerical clinic three years prior in which he had a biopsy of the tumor reported as mucinous adenocarcinoma. It appears that he had been evaluated only for possible intestinal primaries at that time and having failed to identify the primary, had been sent to receive radiotherapy of unclear dosage. After the recurrence of his tumor, he was referred to the medical oncology department at our hospital with a mass in the left thoracic region and another in the left humerus, visible on X-rays (). His examination revealed a mass in his left breast besides the aforementioned ones. His biopsy materials were reevaluated in our pathology department and confirmed to be metastatic adenocarcinoma. The report also indicated that the mass might be breast originated, raising the suspicion towards a possible breast primary. He was then given neoadjuvant chemotherapy consisting of docetaxel and capecitabine for six cycles following the decision of our tumor council.\nAn magnetic resonance imaging (MRI) scan was obtained following the cessation of his chemotherapy revealing a 140 × 100 × 90 mm lobulated mass in the proximal epiphyses, metaphysis and diaphysis of the left humerus, which was destructing the cortices on multiple sides with a large soft tissue component, and invading and protruding out of the skin ().\nAnother mass, 123 × 54 × 74 mm in size, was located in the axillary region adjacent to the thoracic wall infiltrating the skin, surrounded by multiple nodular masses of different sizes. These masses also invaded the brachial plexus and the vessels. There were other masses also in his pectoral muscle, as well as in his scapular muscles. Medullar intensity of the scapula appeared to be normal. Computed tomography scans of the chest, abdomen and pelvis and an MRI of the brain failed to demonstrate any other metastasic lesions.\nAt the end of the neoadjuvant chemotherapy protocol, the patient was in intractable pain. He was under a combination analgesic treatment that consisted of ibuprofen (3 × 400 mg), tramadol (4 × 50 mg) and pethidine (1 × 75 mg). His pain scales (out of 10) were 8 to 9 in the mornings and 9 to 10 at night, severe enough to awaken him from his sleep. The status of the patient was discussed amongst the tumor council of our hospital consisting of orthopedic surgeons, radiologists, medical oncologists and radiation oncologists, who decided that amputation would be the best option for the management of the patient's pain and impaired function.\nThe radical nature of the procedure as well as the risks and benefits were discussed with the patient and his family and the patient consented to undergo the operation. The operation was performed by a team of orthopedic, general and plastic-reconstructive surgeons.\nHe was intubated and placed in a right lateral decubitus position. The skin incision was marked in close consultation with the general and plastic surgeons ().\nSkins flap were elevated superiorly to the clavicle, inferiorly to the costal arch, and medially to anterior midline. The lateral border of the skin flaps was latissimus dorsi muscle, inferiorly; and the supero-medial border of the mass, superiorly. Dissection of the pectoralis major muscle was started from the medial side at the origin from the sternum as the insertion was also invaded by the mass. Dissection was then directed to the thoracic wall to excise all the breast tissue, pectoral muscles and the soft tissues, including the periosteum of the ribs without exposing the tumor. The subclavian vessels were ligated and divided. The exposure was continued laterally and posteriorly up to the insertions of rhomboid muscles. Finally, the upper extremity, all together with the mastectomy material, was removed including the scapula, inevitably creating a big tissue defect (). The defect was closed with full thickness skin graft and application of vacuum assisted closure (V.A.C. Therapy, KCI Inc., San Antonio, TX, USA) ().\nThe histopathological observation of the amputation material was then carried out. His biopsy from the excised mass revealed infiltrative ductal carcinoma with negative surgical margins. The specimen consisted of 70 cm of upper extremity and scapula and breast tissue attached to it. Multiple nodules were detected and the biggest nodule was 13 cm in diameter. The axillar region was completely infiltrated with tumor and ulcerated. There was another ulcerated region of 6 × 5 cm in the lateral proximal humeral region. There was another nodule of 0.5 cm in the medial side of the elbow. The tumor was negative for estrogen receptor, c-erbB2 and GCDFP-15, and 1% positive for progesterone receptor. In Fluorescence in situ Hybridization (FISH) studies conducted with DNA probes (REPEAT-FREE POSEIDON FISH DNA Probes, Kreatech Diagnostics, Amsterdam, Netherland) HER-2 gene amplification was not manifested.\nThe patient was monitored in the post anesthesia care unit for a few days until he was stabilized and then transferred to our clinic. In the early post-operative period his pain medication was ibuprofen (3 × 400 mg) and tramadol (2 × 50 mg), with the addition of morphine patient controlled analgesia for the first two days. His pain scales, out of 10, were between 4 to 6 both during the day and at night. He was discharged from the hospital when the wound healed after two weeks (). His outpatient progress was monitored during the first, third, sixth and twelfth weeks post-operatively. In the third and the sixth week controls, the patient reported that he was experiencing reduced levels of pain and had therefore lessened his intake of pain medication; he was only taking ibuprofen (3 × 400 mg). In the control during the twelfth week the patient reported that he was almost entirely pain-free. Unfortunately, a lung metastasis was then discovered at six months. The patient, refusing to receive any further chemotherapy, passed away eleven months after surgery.

A 60-year-old male who had a history of liver cirrhosis was referred for evaluation of a pain, swelling, and erythematous changes of the anterolateral aspect of his left leg. His symptoms started a month ago without any specific trauma. He had a history of open reduction and internal fixation performed for a tibial plateau fracture that occurred when his left knee was pinned under a tree 18 years ago. He had sciatic nerve injury at the time of the fracture. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery 8 years after the initial trauma due to a distal femur fracture and femoral artery rupture. At that time, a widespread radiopaque mass was observed on plain radiographs of left leg, and obstruction of popliteal artery with abundant collateral circulation was observed on angiography. The patient had no difficulty with his daily life functions until the aforementioned symptoms appeared, except for limited motion in the ankle and toes and sensory reduction in his foot owing to the sciatic nerve injury.\nAfter admission, the patient maintained with a long leg splint. Two weeks after the admission, the erythematous changes in the left leg localized to the anterior aspect in the middle of the leg and formed a fluid-filled, erythematous mass. A draining sinus had developed on the erythematous mass spontaneously and a thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The range of motion of the knee was 0 degrees to 100 degrees of flexion; ankle dorsiflexion was 0 degrees, ankle plantar flexion was 5 degrees, and all of the toes had clawing deformity. As for the motor strength of the ankle, the dorsiflexion was grade 0 and plantar flexion was grade 3. He had no sensation in the first web space and on the medial aspect of the foot, and had sensory reduction in the lateral, dorsal, and plantar aspects of the foot, in order of decreasing sensation.\nThe radiographs of the left leg taken 10 years ago (8 years after the initial trauma) showed a large, fusiform-shaped, radiopaque soft tissue mass in the space between the tibia and fibula that spanned from 5 cm below the proximal tibio-fibular articulation to just above the distal tibio-fibular articulation. The medial cortex of the middle third of the fibula and the posterior cortex of the distal third were sclerotic. Ten years later (18 years after the initial trauma), the patient's radiographs showed a large, fusiform-shaped soft tissue mass with extensive plaque-like and amorphous calcifications, similar to those seen in the radiographs taken 10 years earlier (Fig. ). Furthermore, we observed that calcification within the fusiform mass and in the distal part of the deep posterior compartment had increased in comparison to that seen in the radiographs taken 10 years earlier. The erosion of the medial and posterior parts of the distal two-thirds of the fibula had also increased, and a sclerotic change in the lateral cortex of the middle third of the tibia was newly observed. We performed a computed tomography (CT) scan to examine the pattern and distribution of the calcifications more closely; peripherally distributed calcification was found in the anterior compartment and in the distal part of the deep posterior compartment, and sclerotic changes were found in the tibial and fibular cortex (Fig. ). There was evidence of increased uptake between the tibia and fibula in the delayed bone phase on 3 phases of bone scan, which was determined to be caused by calcification.\nLaboratory investigations revealed that the erythrocyte sedimentation rate (ESR) was 69 mm/h and the C-reactive protein (CRP) level was 5.80 mg/dL with no fever. Serum calcium, phosphorous, and alkaline phosphatase levels were all within the normal limits.\nWe performed an incisional biopsy to differentiated soft tissue sarcoma and no viable, malignant cells were found. A thick fluid with a chalk-like material continued to be discharged through the sinus opening. We performed an extensive debridement of the anterior and deep posterior compartments to ensure definitive treatment. Intraoperative findings showed that the deep fascia was thickened, and that the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles had become necrotic and changed into a whitish, toothpaste-like material (Fig. ). Hard calcific materials resembling rice grains were spread within the necrotic muscle. Furthermore, we observed an erosion of the cortex without intramedullary involvement on the lateral tibial surface and medial fibular surface. After an en-block resection of the anterior compartment, we approached the posterior compartment through the interosseous membrane. When we opened the interosseous membrane, the turbid fluid was drained, and we found that the flexor hallucis, flexor digitorum, and tibialis posterior muscles formed a twig-shaped, hard calcification in the direction of the muscle fibers, unlike in the anterior compartment (Fig. ). Upon performing extensive debridement, we inserted a drain tube and performed primary closure. As Pseudomonas aeruginosa was identified in the intraoperative culture, we used antibiotic treatment (piperacillin-tazobactam, intravenously for 6 weeks and then ciprofloxacin, orally for 4 weeks). The fluid continued to be discharged through the drain even after the surgery; delayed wound healing occurred four weeks following the surgery, and there was no recurrence and the patients were satisfied with the result of the operation at follow-up conducted 2 years later (Fig. ).\nPathologic evaluation revealed that the anterior compartment specimen had acute and chronic inflammation with dystrophic calcification, and the posterior compartment specimen had fibrosis with dystrophic calcification; the tibial periosteum had acute and chronic inflammation with dystrophic calcification, and the tibial bone was fibrotic. These findings led to the diagnosis of calcific myonecrosis.

A 39-year-old female presented to the outpatient clinic with the complaints of recurrent painless swelling in the left thigh and had a history of surgery twice for its removal. She was apparently well until 2001 when she noticed a painless swelling over left mid-thigh. The swelling progressively increased in size and she underwent surgical excision in 2005. She remained asymptomatic for the next 2 years when she again noticed a new swelling over the left distal thigh which was excised surgically in 2009. She remained asymptomatic for the next 3 years when she had a recurrent swelling over the left distal thigh. The swelling was progressively increasing in size and was associated with some discomfort. At the time of presentation to us, she had a large, oval, around 8 cm × 4 cm size, painless swelling over the medial aspect of the left distal thigh. There was a healed scar over the left medial thigh with quadriceps wasting. The swelling was intramuscular on clinical examination. Systemic examination was unremarkable. She was further evaluated with radiographs of the thigh which was suggestive of fibrous dysplasia. This led us to go for a thorough skeletal survey, which showed the involvement of the left femur and tibia (). She was also evaluated with magnetic resonance imaging (MRI) of whole of the thigh which showed two additional soft tissue masses; one in left mid-thigh and the other in the left inguinal region (). As the previous biopsy report was suggestive of myxoma, clinical diagnosis of Mazabraud’s syndrome was made. The patient decided for operative management of the large distal thigh symptomatic swelling and conservative management for the remaining two small, asymptomatic swelling. After informed consent, she underwent wide excision of the distal thigh swelling through the previous skin incision. The mass was intramuscular, located within vastus medialis. A single, globular, pale white, encapsulated nodular mass measuring 8 cm × 4 cm × 3 cm was excised (). The mass weighed around 88 g. Histopathological examination was suggestive of intramuscular myxoma (). No necrotic areas or atypical mitotic figures were identified, ruling out any malignancy. The patient was managed with weekly oral bisphosphonates for fibrous dysplasia, which was stopped after 1.5 years. A regular MRI every 6 months was advised to assess the recurrence and interval enlargement of the remaining two lesions. On follow-up, MRI was done 6 months postoperatively, and these two masses seemed to have slightly increased in size; however, the patient remained asymptomatic (). At latest follow-up after 2 years, the patient was pain free with no recurrence and the MRI showed decrease in the size of the mid-thigh lesion and minimal increase in the size of the left inguinal lesion ().

An 80-year-old woman was referred to our clinic with a history of chronic abdominal pain and weight loss of 10 kilograms in the past six months. The patient was postmenopausal for 30 years and had a free medical history. Physical examination revealed no tenderness, but a hard and mobile mass palpable in the right iliac fossa. Further investigation by means of transvaginal ultrasound revealed a cystic formation, sized 83 × 65 × 64 mm in the right adnexal area. The mass was of mixed structure, comprising of solid and cystic areas. The wall was smooth and anechoic on ultrasound imaging. No papillary projections or septations were identified and there were no signs of blood flow during the color Doppler evaluation. The left ovary was illustrated measuring 25 × 13 × 11 mm, but the right ovary could not be visualized (Figures and ). A polyp of the endometrium was also recorded, with total endometrial thickness of 8 mm. No free fluid was seen in the Douglas pouch. However, it was inconclusive whether the mass originated from the right adnexa or it concerned a uterine necrotic leiomyoma that protruded towards the adnexa. Because of the indeterminate ultrasound findings, an abdominal CT scan was carried out which identified a cyst sized 100 × 80 mm with signs of peripheral calcification attributed to a lesion of the right ovary (Figures and ). As a routine investigation, when an ovarian tumor is suspected, our patient underwent colonoscopy, during which a benign polyp of the sigmoid colon was excised; also a submucosal round smooth cystic formation of one cm in diameter at the site of the appendix was identified. Tumor markers were within normal limits, with the exception of carcinoembryonic antigen (CEA: 54, 2 ng/mL).\nThe patient underwent laparotomy with the diagnosis of a pelvic mass, in which a cystic tumor originating from the appendix, sized 80 × 90 mm, was identified, whereas the uterus and ovaries were atrophic. The abdominal viscera were covered with surgical pad gauzes to protect from spillage of the cyst contents. However, several intestinal loops adhered to the cyst, and despite meticulous dissection, the cystic mass ruptured intraoperatively. Frozen section was performed, which revealed malignant mucinous neoplasm. Appendectomy, omentectomy, total abdominal hysterectomy, and bilateral salpingooophorectomy were performed, in collaboration with the General Surgery Team of the hospital. The histopathologic examination of the surgical specimen revealed a low-grade appendiceal mucinous neoplasm with focal invasion of the muscle layer (Stage I-T2N0M0, WHO Classification 2010), without desmoplastic reaction. The patient had an uneventful recovery and was discharged from the hospital one week later. Soon afterwards she underwent six cycles of chemotherapy and up to present, 12 months after surgery, she remains in good health.

An 18-year-old female patient reported to our department with the complaint of poor esthetic appearance due to missing upper and lower front teeth since 4 years and seeking prosthetic treatment. Patient gave no history of trauma and extractions in relation with the missing teeth. The patient reported that the teeth exfoliated due to loosening. The patient's medical history was not contributory. Family history revealed no such abnormality among other family members.\nOn intraoral examination [] the morphologic appearance and color of the permanent teeth were normal. In maxillary arch, the missing teeth were from right canine region to left canine region and in mandibular arch, all the incisors were missing. There was generalized grade II and grade III mobility. Oral hygiene was poor and there were plaque and calculus deposits in all the quadrants. Restorations were present in left maxillary first molar and mandibular second molar.\nPanoramic radiograph [] revealed adequate enamel thickness on the cuspal tips of all the teeth. There was no root formation in most of the teeth while some of the teeth exhibited short, blunted and malformed roots of only a few millimeters with obliterated pulp chambers. The mandibular first left molar tooth had taurodontism like appearance. Well-defined periapical radiolucencies were present in association with the apex of the mandibular left first molar and right first and second molar.\nAlthough the patient had attained her physical maturity and was ready for definitive dental treatment but her physical, financial and psychological situations were important to be considered in selecting the final treatment plan. The following treatment plan was formulated for the patient. Dietary and oral hygiene instructions were given to the patient and extraction of the teeth that were mobile was advised along with the rehabilitation of the missing teeth with prosthesis.\nThe right maxillary first molar tooth was extracted and sent to Department of Oral Pathology and Microbiology. Clinical examination of the gross specimen [] revealed an intact tooth. The tooth crown was of normal dimensions measuring around 7.5 mm but the roots were short and measured about 6 mm. The specimen was sectioned mesiodistally into halves. The mesiodistally cut tooth surface showed total obliteration of pulp chambers with dentin. One half of the cut tooth specimen was decalcified in 10% nitric acid and processed for hematoxylin-eosin (H and E) staining. Other half of the cut tooth specimen was used for preparing ground section.\nThe ground section [Figure and ] showed normal crown outline with normal enamel covering. A thin layer of superficial mantle dentin appeared but the pulp chamber was totally obliterated by an unusual calcified material consisting of atypical tubular dentin and osteodentin covered by thin discontinuous layer of cementum. Normal dentinal tubule formation appeared to have been blocked and the new dentin so formed around obstacle, gave rise to the characteristic appearance of “lava flow around the boulder” [].\nHistopathologic examination of the decalcified hematoxylin-eosin section [] showed total obliteration of pulp that was filled with tubular dentin, osteodentin and irregular, globular masses of dentin [Figure and ]. A cluster of odontoblasts was seen within the globular masses of dentin.\nBased on the clinical, radiographic, gross features and histological examination of the ground section and decalcified section, diagnosis of dentin dysplasia type I was made.

A 39-year-old female patient was referred to our Nephrology Department during late 2009. She was newly diagnosed with SLE after a spontaneous miscarriage during the second trimester of pregnancy. Due to significant proteinuria and microscopic hematuria a kidney biopsy was performed which revealed crescentic focal segmental glomerulonephritis [class III lupus nephritis with crescents according to WHO classification ()]. She was initially managed with a combined therapeutic regimen of cyclophosphamide, corticosteroids and azathioprine which was modified due to poor response, to mycophenolic acid with the addition of rituximab. However, despite the absence of extra-renal manifestations of lupus, kidney function gradually deteriorated and patient reached ESKD about 4 years after the initiation of immunosuppression. Peritoneal dialysis was the type of renal replacement therapy that was initiated with the concomitant administration of hydroxychloroquine and low dose methylprednisolone.\nShortly after the induction of peritoneal dialysis, the patient presented with fever for the first time. All possible infectious causes were investigated including peritonitis, catheter related infection and a lupus flair, nevertheless no definite diagnosis was reached, and she was managed with empiric antibiotic treatment that led to full recovery. During the next 12 months she had 3 more hospitalizations with fever as main cause of admission and all workups were inconclusive except her last admission when high CMV viral load with 157.000 copies/mL was found. Further investigation revealed remarkably low serum immunoglobulin levels and five pulses of intravenous immunoglobulin were administered. In this direction, supplementary investigation for hypoglobulinemia was performed with repetitive measurement of immunoglobulin levels after a symptom free period which confirmed earlier findings with low IgA, IgG and IgE levels but slightly elevated IgM levels (). Then on, patient had no major complications apart from two to three episodes of upper respiratory infections and acute tonsilitis each year. Evaluating both clinical course and laboratory findings the monthly administration of intravenous immunoglobulin was initiated as acquired immunodeficiency was the most likely cause. The regimen was well tolerated.\nIn June 2020, the patient received a cadaveric kidney transplant. The compatibility analysis revealed two shared HLA class I antigens and the donor was CMV IgG positive. Immunosuppression regimen included basiliximab 25 mg on day 0 and 4, mycophenolic acid 540 mg twice daily, tacrolimus with trough levels of 8 ng/ml directly post-operatively and methylprednisolone as well as prophylactic treatment with trimethoprim-sulfamethoxazole and valganciclovir. There was direct allograft function postoperatively and no need for renal replacement therapy. The only remarkable manifestation post-transplant was a lymphocele that was surgically managed with a peritoneal window drainage.\nTreatment with IVIG was continued seamlessly and a change in immunoglobulin profile was noticed (). In more detail, IgG CMV antibodies that were absent even after the resolution of her former CMV infection were detected. Of note, our patient had also failed to acquire immunity for hepatitis B after vaccination, but HBV surface antibodies were now present. Peripheral blood immunophenotyping with flow cytometry appointed an almost absent CD20+ lymphocytes count (0.11%, 2 cells/μl).

A 60-year-old male patient reported to the clinics with a chief complaint of vesicular eruptions on the left side of the face since 5 days. Past medical history was not contributing and the patient reported burning sensation in the affected area. The localization and distribution of the skin findings were distinctive and presented as ulcers ranging from 4 mm to 0.5 cm interspersed with crustaceans, extending on the left half of the face, characteristically not crossing the midline []. Intraoral examination revealed similar vesicular eruptions on the left side of the mid-palatine suture involving the hard and soft palate, not crossing the midline. Based on the clinical findings, the patient was diagnosed as herpes zoster involving the ophthalmic and maxillary division of the trigeminal nerve. After a thorough medical evaluation and required investigations, the patient was put on antiviral therapy, Acyclovir 800 mg orally 5 times daily for 7 days. To combat pain, tramadol 50 mg twice daily was given. At 4 weeks follow-up revealed good improvement in lesions, the lesions of the face and palate showed remission []. Patient reported of reduction in burning sensation, but persistent pain. Patient gave a history of continuous stabbing and burning type of pain with periods of exacerbations and remissions. Patient reported of exacerbation of pain with even a light touch of clothing in the left middle half of the face, a stimulus that does not usually evoke pain (allodynia). The region from the ala of the nose to the lower canthus of the eye and laterally up to the malar region evoked pain on touch indicative of trigger zones. A new treatment approach was tried in this patient. All the other medications were stopped and the patient was given Streptomycin sulfate injections 1 g mixed with 2% lidocaine deposited in the peripheral region of posterior superior alveolar nerve and the infra orbital area []. The injections were given bi-weekly for the first 6 weeks and followed once every alternate week for the next 4 weeks. Patient showed marked improvement in symptoms after 6 weeks and complete remission of pain in the following 4 weeks. Patient was followed-up for the next 1 year and remained pain free.

A 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.\nThe examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation (). A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.\nThe blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous surgery site an upper GI endoscopy was performed. A small benign looking ulcer was seen at the pylorus of the stomach.\nWith a strong suspicion of gastrocutaneous fistula, a CT fistulogram was performed. An enterocutaneous fistula between the pylorus of the stomach and the anterior abdominal wall was seen. A long side branch of the fistula tract was seen communicating to a moderate sized left subphrenic collection ().\nWith confirmed diagnosis of complex gastrocutaneous fistula a repeat surgery was planned. The abdomen was entered after incising the previous scar on left lateral side and extending the incision downwards and upwards. Dense interbowel adhesions were encountered. Meticulous adhesiolysis and dissection was performed. The abscess cavity was drained and the perforation on the pylorus of the stomach was identified. It was around 1 cm × 1 cm size. Repeat omental patch repair was performed. In view of difficult dissection, feeding jejunostomy and retrograde tube duodenostomy were also made.\nAn uneventful recovery happened. He attended follow up clinic till 4 months following the discharge. There was an incisional hernia but otherwise he was doing fine. After this he was lost to follow up.\nTimeline

A 76 years-old woman with history of controlled hypertension (with losartan and amlodipine) presented to our hospital referring weight loss of 4 kg in two months, edema that progressed to anasarca and back lumbar pain. Besides the edema her physical examination was completely normal with no clinical signs suggestive of hypercortisolism. Among the studies requested, an abdominal tomography showed a right adrenal gland nodule of 14x9 mm and another one in the left adrenal gland of 23x18 mm (), additionally multiple vertebral fractures were reported. As part of the study of adrenal adenomas the patient had an abnormal value of cortisol after a low dose suppression test with dexamethasone (13.3 µg/dL (normal value: <1.8 µg/dL), with a normal value of free urinary cortisol and her potassium was low (she was not on diuretics). The results of the patient laboratory test are shown on .\nWith these results an ACTH (adrenocorticotropic hormone) independent form of hypercortisolism was diagnosed and because the scan of the abdomen had documented the presence of two adenomas, one in each adrenal gland larger than 10 mm, we found ourselves with a therapeutic challenge since the resection of one of the glands may not cure the hypercortisolism in case that the hormonal production came from both glands and the resection of both glands with leave the patient with a permanent hypoadrenalism. It was decided then to perform an adrenal venous sampling to try to determine the origin of the of cortisol production.\nA previously described protocol was used with some changes. The authors of the original protocol propose the measurement of epinephrine as a method to determine the proper location of the catheters when performing the sampling. Because we do not have readily available the measurement of plasma catecholamines the test was performed using radiographic documentation of the tip of the catheter and aldosterone levels were used to make the corrections in the dilution between both sides . Samples of both adrenal veins and inferior cava vein were taken (the procedure is shown in and the results are shown in ). Based on the model of interpretation of adrenal venous sampling proposed by Young the test suggest that the patient has an adrenal hyperplasia with predominance in the production of cortisol from the right side, the results were discussed with the patient and the surgical team and it was then decided to perform a bilateral adrenalectomy. The result of the histological study of the glands was consistent with a bilateral adrenal macronodular hyperplasia.\nThe patient did not have any postoperative complication and received replacement therapy with hydrocortisone 50 mg every 8 h during the first 48 h and subsequently received prednisolone 10 mg and 0.1 mg of fludrocortisone replacement with resolution of the hypokalemia.

A 34-year-old woman who was working as an international migrant worker sustained a crush and degloving injury to the right elbow while operating a waste agitator at an industrial waste management site. On initial examination, the patient was found to have massive skin and soft tissue defects on the anterior aspect of the elbow. The median nerve and brachial artery were exposed and contaminated (). In addition, the proximal part of the entire extensor muscle group was lost, along with segmental loss of the radial nerve with a 6-cm gap. The patient could not extend the right wrist or fingers, and severe muscle weakness (0 or 1 on manual muscle testing) was found in the area innervated by the median and ulnar nerves. The distal area of the right arm showed signs of perfusion, albeit weaker than that in the contralateral arm. The wound was irrigated and debrided, but a bacterial infection was detected after a few days and threatened to obstruct the brachial artery further. The patient was returned to the operating room for additional debridement, a saphenous vein bypass graft to reperfuse the occluded artery and placement of a muscle flap to close the open wound using the distal part of the extensor muscles, which were not salvageable due to the proximal muscle injury and the radial nerve defect.\nThe infection resolved following those surgical procedures. Six months later, the ulnar collateral artery was found to perfuse distally due to occlusion of the saphenous vein graft. Muscle strengths in the area innervated by the median and ulnar nerves improved to 2 or 3 on the manual muscle test, but there were no signs of recovery in the extensor muscles (). Protective sensation was confirmed in the area innervated by the median and ulnar nerves. Reconstruction of the finger extension with stabilization of the wrist were planned. The tendons of extensor carpi radialis and the tendon of abductor pollicis longus were secured to the radius under 30° of dorsiflexion at the wrist and 10° of radial abduction of the thumb, respectively. The tendon of extensor pollicis longus was transferred to the palmaris longus. Due to insufficient muscle strength, other flexors of the forearm could not be used for tendon transfer. Latissimus dorsi was generally harvested according to the conventional method. To avoid overstretching of the muscle, its resting length was marked by placing sutures in the muscle belly at 5-cm intervals. The origins from the thoracic spinous processes and the thoracolumbar fascia were divided. Caudally, the dissection was continued down to the gluteal fascia across the iliac crest, producing a latissimus dorsi flap that was 50 cm long (). A 14 × 7-cm skin paddle on the muscle belly was applied to the posterior aspect of the upper arm. The fascial end of the flap was introduced subcutaneously to the dorsal forearm, where it was tightly sutured to the tendinous portion of extensor digitorum, with 15° of flexion at the metacarpophalangeal joints (MPJ) under 90° of flexion at the elbow (). On the day after surgery, the skin paddle was noted to have a congested appearance, which resolved when the stitches around the skin paddle were unfastened. Neither torsion of the pedicle nor vasospasm was confirmed in visual exploration. Otherwise, the post-operative course was uneventful. The arm was immobilized in a long arm splint with mild shoulder abduction and the elbow flexed at 90° for 4 weeks; during this time and following period, the patient performed thumb and finger exercises with wearing an outrigger splint (). The patient needed to return to her country of origin 3 months after the reconstruction surgery. At the last visit to our institute, natural dorsiflexion of the wrist was maintained, and active thumb and finger flexion was workable (>70° of flexion at the MPJ), where muscle strengths were >3 on the manual muscle test and grip strength rose from 0 preoperatively to 1.2 kgf. These could contribute to improve grasp and several activities of daily living (). Although active muscle contraction was detected in the transferred latissimus dorsi muscle on ultrasound, active finger extension had not yet been confirmed. At 1.5 years after the surgery, the patient answered a questionnaire about the current hand function. She was able to grasp things used in daily life and to extend fingers up as far as approximately 30° of flexion at the MPJ.

A 66-year-old male, with a BMI of approximately 28 kg/m2, presented to our surgery clinic for a symptomatic right lower quadrant trocar site hernia, following robotic assisted radical prostatectomy. In December of 2010 he underwent an uncomplicated robotic assisted radical prostatectomy. At the time of the operation a 12 mm trocar was placed in the right lower quadrant, and it is unclear from the operative note whether the fascia was closed at the conclusion of the operation. He recovered from the surgery without issue but unfortunately developed widely metastatic disease over the next 18 months. Upon presentation to our clinic in May of 2012, he was complaining of a two-week history of right lower quadrant pain and a newly discovered mass in the vicinity of a previous trocar site. He initially noted the onset of the pain when performing pull-ups at a local gym, at which time he noted pulling sensation in the right lower quadrant. Following the initial onset of symptoms, he continued to have pain in the area and noted an intermittent bulge as well. He presented for initial evaluation by his primary care provider who obtained a CT scan of the abdomen and pelvis. The scan revealed a 10 mm right lower quadrant hernia with herniated fat and a tubular structure which was read as a possible omental vessel, with concern for incarceration (). Upon reviewing the CT with the patient in clinic it was felt that the tubular structure was actually the vermiform appendix and thus laparoscopic incisional hernia repair was recommended.\nHe presented the following week for an elective hernia repair. Pneumoperitoneum was established through a 12 mm umbilical Hasson port. Two additional 5 mm ports were then placed, one in the left lower quadrant and one in the suprapubic area. On inspection of the abdomen there was no evidence of peritoneal disease. The right lower quadrant was then inspected, and as suspected from preoperative imaging a small hernia was identified which contained an incarcerated appendix (). The appendix was reduced from the hernia and during the reduction the mesoappendix was injured so a standard laparoscopic appendectomy was performed. Due to the concern for mesh infection following the appendectomy, the hernia was then closed primarily using 0-Ethibond sutures passed transfascially using a suture-passing device. The patient was discharged home from the recovery room and had no postoperative complications at his 2-week follow-up visit. He has no evidence of hernia recurrence at 12 months.

A 65-year-old female was initially admitted with typical angina and impression of acute coronary syndrome in another center. She only had a medical history of hypertension. The electrocardiogram (ECG) had shown 2 mm T inversion in V1-V3 leads, biphasic t waves in I, aVL and QT prolongation (QTc: 0.520 seconds). In the hospital coronary angiography was performed which had revealed two vessel disease. Successful percutaneous coronary intervention was done on left anterior descending artery (LAD) and right coronary artery (RCA) in the same session (). The patient was discharged home the next day. She was doing well for about a month till 2 days prior to her second admission when presented with multiple episodes of angina on exertion. She was admitted again. Cardiac enzymes were within normal limits and there were no new ECG changes. Echocardiography showed left ventricular ejection fraction of 55% without any resting wall motion abnormalities. She still complained of occasional angina pain until she developed a severe resting chest pain associated with nausea, vomiting and diaphoresis at the second day of admission. There was dynamic ECG changed associated with a rise in cardiac biomarkers. The patient was transferred to our center for urgent coronary angiography. In our emergency department, her angina had already decreased to 3 out of a 10 scale pain score. Electrocardiography showed ST depression in V2-V5 leads. The patient was sent to catheterization unit and the problem was observed just before contrast injection. There was a foreign body material stuck in the left main coronary artery which was the tip of a guiding catheter. Coronary angiography showed patent RCA and LAD stents, but there was a significant thrombotic narrowing of distal left main artery with extension of thrombus to the proximal parts of both LAD and left circumflex arteries because of the tip of a guiding catheter lodged in the left main coronary artery ( and ). The patient was sent immediately to the operating room and coronary artery bypass grafting was done successfully. Only two saphenous vein grafts on LAD and main obtuse marginal branches were anastomosed without any attempt to remove the foreign body. The patient was discharged from hospital after 3 days without any further complications.

We report the case of a healthy 19-year old male with no significant past medical or surgical history who injured his right foot his right foot in a road traffic accident and reported to our hospital within two hours of the injury. On examination, there was significant swelling of the foot with a 1.5 cm x 1 cm wound on the plantar aspect through which a bony prominence that appeared to be the head of the first metatarsal was visible. Sensation and vascularity of the foot were normal. Radiographs of the injured foot showed dorsal dislocation of the first and second MTP joints with dorsal displacement of the sesamoid complex ().\nAfter thorough irrigation and debridement of the wound under local anesthesia, reduction was attempted within four hours of the injury using longitudinal traction and dorsally directed pressure over head of metatarsal through the wound and simultaneous plantar directed force on base of proximal phalanx in hyperextension as well as neutral position of the MTP joint, but reduction was not achieved. Patient was then investigated further and in the emergency OT under spinal anesthesia around 12 hours after the injury, reduction was again attempted but failed. The plantar wound (approx 2cm x 1.5 cm in size) which was already located in a nearly transverse direction over the 1st and 2nd metatarsal heads was extended 1.5 cm distally and medially for adequate exposure.\nThe head of the first metatarsal was found to be protruding plantarwards through a rent in the plantar fascia with intact collateral ligaments. The lateral collateral ligament was divided, a lever placed dorsal to the proximal phalanx, longitudinal traction and dorsal push was applied to the head of the metatarsal to achieve reduction of the 1st MTP joint. The sesamoid complex followed the proximal phalanx but the 2nd MTP joint remained unreduced after an attempt at closed reduction. A lever was applied dorsal to the head of 2nd metatarsal along with longitudinal traction through the same wound to facilitate its leverage out of deep transverse metatarsal ligament lying dorsal to its neck to achieve reduction. The reduction of both the MTP joints was assessed for stability after repair of the divided collateral ligament and there was no requirement for fixation with K-wires. (, ).\nThe wound was closed in layers after thorough irrigation and debridement and a bulky dressing with a below knee POP splint was applied. Immediate post-operative radiographs showed proper position and alignment of the joints and sessamoid apparatus. The post-operative dressing was clean and dry and there was no neurovascular deficit. Patient was discharged and followed up for dressings. and was kept nonweight bearing. The wound had healed well, with minimal oedema, and sutures were removed on the 14th postoperative day, and the patient was able to actively plantar flex and dorsiflex the MTP joints.\nThe extremity was placed in a walking cast boot with toe-touch weight bearing aided with a stick for two weeks and then the patient was instructed to bear weight as tolerated on the right foot and advised active and passive range of motion exercises. At one month follow up post-operatively, the patient had good active and passive range of motion and had only mild pain on excessive walking. Thereafter, the patient was evaluated monthly for six months, then three monthly and 12 months and 18 months post-operative follow-up. There was no instance of redislocations or signs of avascular necrosis of the heads of the metatarsals. Range of motion was similar to the contralateral foot and walking was pain free.

A 25-year-old Caucasian female presented to our care with a chronic history of regurgitation of previously ingested food. For the past 4 years, she regurgitated immediately in the postprandial period, occurring within 5 - 25 min after per oral (PO) intake and lasting up to 2 h. These acts of regurgitation were frequently observed by friends and family. When she presented to our care, she was very malnourished and had been maintained on nocturnal jejunal tube feedings. She also complained of multiple bouts of watery diarrhea, amounting to as much as ten episodes per day. Due to the repercussions of her illness, she avoided social gatherings and was not able to maintain her job due to these frequent episodes of regurgitation and subsequent vomiting or swallowing of the food.\nHer past medical problems included asthma and anxiety. Since the beginning of her symptoms 4 years ago she was misdiagnosed multiple times with other gastrointestinal disorders. Therefore, she unnecessarily underwent many diagnostic studies and invasive surgical procedures. This downward spiral started when she was being evaluated for right upper quadrant abdominal pain associated with persistent episodes of vomiting. She subsequently had an abdominal ultrasound revealing biliary sludge and HIDA scan with an ejection fraction of < 20%. A laparoscopic cholecystectomy was performed in March 2010 based on the assumption that her condition was of biliary disease etiology. Her symptoms persisted despite this procedure, and idiopathic gastroparesis was the next assumption on their differentials of postprandial nausea and vomiting. The diagnosis of idiopathic gastroparesis was aided by a delayed GES. A unique finding from this evaluation was that some of the isotope was immediately regurgitated after being ingested. A normal upper endoscopy was also noted at this time. After failing medical therapy for gastroparesis, a gastric stimulator was placed in October of 2010 but with only < 10% improvement of symptoms. As a result, the patient underwent a pyloroplasty in January of 2011. Her symptoms improved for 2 - 3 weeks but then recurred and became associated with watery diarrhea. Her nutritional status deteriorated to the point that she eventually had a jejunostomy tube being placed in August of 2011.\nAfter being referred to several gastroenterologists, she was eventually diagnosed to have rumination syndrome. To aid in the diagnosis, an antroduodenal manometry (ADM) was performed that revealed the characteristic R-waves exhibited in patients with rumination syndrome. The treatment of adult rumination syndrome consists of reassurance, behavior therapy, psychotherapy and relaxation therapies. All of these therapies were attempted and failed to provide a sustained relief of symptoms.\nPhysical examination findings revealed a cachectic female with a body mass index (BMI) of 16. Vital signs that were only significant for hypotension (BP: 80/55 mm Hg). She was in no acute distress with a normal mood, affect, attention span and concentration. Abdomen was soft, not distended, and not tender to palpation. A J-tube was located in the left upper quadrant and a gastric pacing device in the right upper quadrant, with no signs of infection. The remainder of the physical examination was unremarkable. There were no significant laboratory findings on admission.\nThe working diagnosis upon admission was rumination syndrome with conditioned vomiting. Our primary goal was to decrease the frequency of vomiting and diarrhea, which was eventually controlled with medical therapies of loperamide, dicycloamine, nortriptyline and scopolamine for nausea and pain control. Once the nausea, vomiting and diarrhea were better controlled, we gradually increased the rate of J-tube feeding to enhance her nutritional status. The general surgery service removed the gastric stimulator and replaced the feeding jejunostomy tube with a Mic-Key button. An upper endoscopy with subsequently done to obtain full thickness gastric biopsies for study of the gastric smooth muscle.\nThe surgical pathology results from the gastric biopsies revealed no evidence of inflammation, necrosis, intestinal metaplasia, dysplasia or malignancy. The nerve bundles and ganglion cells (myenteric plexus) were positive for S100 immunostain and were normal in number. An adequate population of cells of Cajal within the muscularis propria was indicated by positive C-kit staining. Ultimately these findings confirmed that the stomach was functionally normal at the molecular level. The patient was subsequently discharged with outpatient follow-up with a psychologist to put forth a dedicated effort in relaxation and other behavioral techniques.\nAfter 1 year of dedicated attempts of “breathing relaxation techniques”, while being nutritionally maintained by nocturnal jejunostomy feedings, the patient presented again to our care with refractory nausea and vomiting. Her initial vital signs on admission were within normal limits. No significant physical examination findings were noted except she still weighed 90 lbs and had a BMI of 16. No significant abnormalities were noted on the initial laboratory work-up. An upper endoscopy was performed to evaluate the persistent vomiting and hematemesis. But no significant findings were noted except gastric mucosal atrophy. A GES was delayed with > 85% isotope retention. It was apparent that the stomach was anatomically normal but was not functionally normal.\nSurgical intervention was considered as a last resort measure to improve the quality of life of the patient. An extensive psychiatrist evaluation was performed to rule out any psychiatric or eating disorders. The psychiatrist did not establish a diagnosis of anorexia or bulimia nervosa.\nShe underwent a subtotal gastrectomy (80%) with Roux-en-Y reconstruction on the fourth hospital day and the jejunostomy feeding was continued. Pathologic evaluation of the resected stomach revealed chronic gastritis, and the C-kit immunostain showed an average of 11 interstitial cells of Cajal (ICC) in the body of the stomach and 10 ICC in the antrum of the stomach. The jejunostomy tube feeding rate was gradually increased over the hospital course to a goal of 80 cc per hour and she was also tolerating a liquid diet. On subsequent follow-up visits over a 6-month course, the refractory nausea and vomiting had resolved by more than 85% with and improvement in her BMI and quality of life.

The patient was a 47-year-old female with a history of rheumatoid arthritis who presented to our institution with dysphagia and neck pain after multiple previous cervical spine surgeries at an outside hospital. Her history began with an ACDF from C5 to C7 in 2009 for neck and arm pain. Following her index procedure, she experienced nonunion with loosening of screws and thus underwent a revision extension ACDF from C3 to C7 in 2010 which resulted in significant and immediate neck and arm pain relief. Despite her pain relief, her postoperative course was complicated by superficial surgical site infection necessitating irrigation and debridement 3 days later and antibiotics. Despite no apparent intraoperative complications or oropharyngeal perforation, she experienced significant dysphagia following the third surgery, and, despite unremarkable serial esophagrams, required a feeding tube for approximately 1 year. Gradually, after this period of oropharyngeal rest, her dysphagia somewhat improved and she was able to tolerate a mechanical soft diet with some difficulty. The patient had sustained pain relief but persistent dysphagia for approximately 3 years without any additional work-up. The patient initially presented to our institution following a low-energy fall. Her symptomatology had not changed but routine cervical spine imaging was obtained and she was subsequently referred to our spine specialty clinic for continued evaluation.\nAt the time of her presentation, her plain film radiography () and computed tomography (CT) of the cervical spine () revealed nonhealing posterior pseudarthrosis with local kyphosis, screw loosening, plate migration, and air communicating with the plate raising concern for esophageal perforation. In the context of her persistent dysphagia, mild pain, and imaging findings, it was deemed reasonable to proceed with neck exploration in conjunction with our otolaryngology colleagues with plans to remove hardware and then perform staged revision extension of previous fusion from a posterior approach.\nThe patient was brought to the operating room and direct laryngoscopy was performed. A pharyngeal defect with exposure of the spinal hardware was noted in the posterior pharynx in the midline (). Further evaluation beyond the proximal esophagus was not attempted for fear of worsening the defect. A nasogastric tube was inserted and attention was turned to the neck dissection.\nThe previous left vertical incision was incorporated into the planned surgical incision, as is customary with revision cervical procedures to protect the contralateral recurrent laryngeal nerve, and a standard anterior approach to the cervical spine was undertaken. The dissection was maintained above the level of the inferior aspect of the thyroid cartilage therefore minimizing risk to the recurrent laryngeal nerve, which was monitored with electromyography throughout the case. The cervical plate was found to have eroded through a 2.5 cm posterior pharyngeal wall defect that appeared to be chronic. Reconstruction of the pharynx was performed after plate removal by oversewing the defect with imbricating stitches. The decision was then made to prepare for a staged procedure with posterior spinal fusion (PSF) in the immediate future, but, first, a C3-C4 cervical osteotomy was performed to remove any anterior bony elements and allow deformity correction during definitive fusion. A drain was left in place, and the patient was placed in a halo for temporary cervical spine stabilization.\nTwo days following the initial surgery, the patient was again taken to the operating room and underwent posterior cervical osteotomies and facet resections at C2-C3 and C3-C4 and PSF from C1 to T2 with correction of kyphotic deformity. Her postoperative course consisted of no intake by mouth with nutrition through Dobhoff feeding tube. The halo was left on for a total of 1 month postoperatively and then removed. She remained in a skilled nursing facility for 1 month postoperatively. The patient's pain and dysphagia improved, and there was no evidence of frank contrast extravasation on the immediate or 2-month follow-up swallow study. Flexible fiber optic laryngoscopy at those time intervals also demonstrated an upper airway in continuity without evidence of erosion or abnormalities. The patient's diet was advanced to a mechanical soft diet at 2 months postoperatively, which she tolerated well, and the patient self-advanced her diet to a regular diet approximately 6 months postoperatively with some mild episodic dysphagia. Flexible fiber optic laryngoscopy at 8 months postoperatively demonstrated a well-healed posterior pharyngeal wall all the way to the cricopharyngeus without evidence of exposed cervical spine or cervical spine hardware or any other visual abnormality.

A 26-year-old man presented with melena and underwent upper gastrointestinal endoscopy and abdominal CT.\nEndoscopy showed a large submucosal tumor in the gastric body with concomitant bleeding from a large central ulceration containing fluid and residual contrast material from a previous barium study (). Endoscopic ultrasound similarly showed a large submucosal mass (). A first endoscopic biopsy result was non-specific and showed acute and chronic inflammation with ulceration. The second biopsy revealed ulceration and tissue granulation with foreign body giant cells suggestive of a barium granuloma.\nAn abdominal CT scan demonstrated about 5.5 × 3.2 cm sized, well-defined and large exophytically growing mass arising from the posterior aspect of the lesser curvature side in the gastric body. The mass showed a large ulceration at the gastric luminal side and a cavity in the central portion communicating with the gastric lumen. The bulk of the tumor was seen in an extragastric location with extensions into the gastrohepatic ligament and lesser sac. There was no evidence of direct invasion of the adjacent organs or peritoneal spread. No metastatic lesions or lymphadenopathy was seen in the abdomen or pelvis. The mass showed relative hypoattenuation on the precontrast images () and increased heterogeneous enhancement in the portal phase () and prolonged enhancement in the equilibrium phase images (). The radiologic findings were distinct from those of epithelial tumors and the possibility of a malignant gastrointestinal stromal tumor of the stomach was considered on CT. The mass was removed under general anesthesia by laparoscopic wedge resection of the stomach. During laparotomy there was a round and well demarcated mass arising from the lesser curvature side of the gastric body, and there were prominent vessels around the mass with no detected ascites and no adhesion to the adjacent structures. On gross pathology, the specimen consisted of a portion of the stomach measuring 8.5 × 5 cm with an attached ovoid and lobulated rubbery to firm solid mass measuring 5.4 × 5.2 × 4 cm. The mucosa of the stomach was retracted by underlying the attached mass. Sectioning of the specimen revealed a well demarcated and relatively homogeneously yellow colored mass involving the submucosa and muscular layer ().\nMicroscopic examination indicated that the mass was composed of a patternless proliferation of bland spindle cells with abundant perivascular and intercellular mature collagen formation (). There were few mitotic cells and no nuclear atypia observed in 10 high-power fields, nor any tumor necrosis, suggesting high grade malignant degeneration.\nImmunohistochemistry showed that the neoplastic cells were strongly and diffusely positive for CD34 and negative for c-kit (CD117) (), and they were also positive for S-100 and negative for both smooth muscle actin and desmin. Because solitary fibrous tumor rarely develop in the stomach, kit negative GIST was considered as its alternative and PDGFRA gene analysis was performed. However, there was no mutation in the result of PDGFRA gene analysis. Although S-100 positive finding can be seen in neurogenic tumors such as schwannoma, there were no histologic findings suggestive of neurogenic tumor such as nuclear palisading, whorling of the cells and Verocay bodies. Moreover, CD34 test result was positive which are very exceptional in the case of neurogenic tumor, thus greatly diminishing the possibility of neurogenic tumor as its final diagnosis. Conclusively, all these findings are diagnostic for solitary fibrous tumors. The patient's melena resolved following removal of the tumor and the subsequent one year of follow up has revealed no evidence of recurrence or metastasis in this patient.

A 56-year-old male patient, whose plasmacytoma was enucleated 3 years ago from the medial side of the left mandible, was referred to our clinic due to his complaints of persistent orocutaneous fistula (Figures –). Past medical history revealed that the patient was operated three times to close the orocutaneous fistula by local flaps; however, none of these operations were successful. CT images of the patient demonstrated that the medial side of the left mandible was missing and there was a 3 × 2 cm diameter defect located between the left side of the mouth floor and the basis of the left mandible neighboring the left submandibular gland. The main reason of the failed attempts to close the fistula was considered to be the ineffective management of dead space surrounding the fistula. Consequently, it was decided to use the submandibular gland as a pedicled flap to fill the defect and support the oral and the cutaneous flaps.\nUnder general anesthesia, the fistula was excised initially and the oral and the cutaneous healthy soft tissues were prepared. At the extraoral site, the incision was extended to the posterior and anterior directions, following the previous incision lines. In the subplatysmal plane, the superficial layer of the neck fascia was dissected to reach the base of the mandible. After the dissection of the fascia, the submandibular gland and the base of the mandible were exposed, the soft tissues surrounding the submandibular gland were dissected, and the gland was mobilized by protecting the arteriovenous supply and the duct. At the oral site, the margins of the wound were released by blunt dissection and were closed by mattress sutures via 5/0 polypropylene. Following the mobilization of the gland, a soft tissue tunnel was prepared between the submandibular space and the defect area and the submandibular gland was rotated by passing the gland through the soft tissue tunnel by preserving the pedicle (). The rotated gland was sutured to the recipient site with 3/0 reabsorbable polyglaction sutures for the stabilization. At the cutaneous site, the flap was closed layer by layer by using 3/0 resorbable polyglaction for the facia and the subcutaneous layers and 3/0 polypropylene sutures for the skin. After the surgery, pressure bandage was applied for the edema control externally and the patient was ordered soft diet for a week. The postoperative healing was uneventful, and at the sixth month follow-up visit, ideal closure of the fistula was observed (Figures and ).

A 60-year-old male patient reported to the Department of Oral and Maxillofacial Surgery with a chief complaint of pain and discharge in the upper left back region of the jaw since one and half years. According to the patient one year prior to our consultation, he got the maxillary molars extracted from a local dentist due to pain and mobility of the teeth in that area. Upon consultation patient revealed that the pain continued to exist even after the extraction.\nThe extra oral examination was within normal limits with no evidence of lymphadenopathy. The patient is a known hypertensive and is on medication since three years for the same. The patient had smoking habit, which he quit only a couple of years ago. Intraoral examination revealed a solitary erythematous swelling with diffuse borders involving the left posterior portion of hard palate and was also seen involving the soft palate on the same side. The swelling was seen extending from mesial aspect of first premolar to 1 cm posterior to tuberosity on left side, involving the palatal area but not crossing the midline []. An oro-antral communication was seen with purulent discharge. The remainder of the intraoral examination was within normal limits.\nThe swelling was nontender. The inspectory findings were confirmed on palpation. CT scan revealed complete obliteration of the left maxillary sinus []. The clinical differential diagnosis included a benign or malignant neoplasm of minor salivary glands, a neoplasm of maxillary sinus.\nAn incisional biopsy of palate and sinus lining was performed. Histopathological examination revealed fibrous stroma with areas of hyalinization. Islands of uniform cells arranged in cord-like pattern with hyperchromatic nuclei were seen enclosing round to oval pseudocystic spaces in the stroma. Few of these spaces showed eosinophilic coagulum []. The tumor cells are also seen arranged in the form of solid islands [] and ductal pattern []. The present case showed all the three histological types. There was no evidence of perineural invasion even on serial sectioning. Focal areas showed small cords and longitudinal tubules of isomorphic cells set in a background of densely hyalinized stroma [].\nA diagnosis of ADCC (cribriform pattern) was established. The patient was treated by wide surgical excision with clear margins and hemi-maxillectomy of left maxillary region with post-radiotherapy. The present case was staged as T4N0M0 based on American Joint Committee on cancer as a guide to prognosis. The patient was under regular follow-up and is free of the disease at one-year follow-up.

A 60-year-old Caucasian female patient presented with a painless swelling in the soft palate, breathing and swallowing difficulties, and suffocation feeling. Clinical examination revealed that the lesion was located mostly in the right side, extending from the limit between the hard and soft palate and continuing to the oropharynx. The lesion had smooth surface, hard consistency, and irregular shape (). Cervical tomography was requested (Figures and ). Based on clinical and imaging aspects, a hypothesis of benign X malignant salivary gland tumor was formulated. An incisional biopsy was performed under local anesthesia to establish the definitive diagnosis. However, the histopathological examination of the fragment revealed normal mucosa (). The professionals decided to perform a second conventional biopsy giving attention to collecting material from a greater depth. Once again, the histopathological analysis revealed normal mucosa ().\nThe otorhinolaryngologist team was consulted and the decision was made to perform a CNB. The localization of the lesion was identified during the intraoral exam with no need of imaging guidance (). In CNB a needle is activated by an automatic spring system equipped with outer cannula and inner stylet. Under local anesthesia using 1% lidocaine the biopsy area was chosen with palpation of the lump and the tip of the needle was positioned adjacently to the lesion. The handpiece was activated, moving quickly 20 mm back and forth, cutting a sample measuring 17 mm in length. Only one core of tissue was obtained and carefully removed from the biopsy needle. The quality of the specimen was assessed by visual inspection and, with care not to damage the thin tissue, it was put into 10% formalin for fixation. The biopsy site was compressed for five minutes to avoid bleeding and the patient was observed for more 30 minutes and later discharged as no signs or symptoms as bleeding or pain were noted. The histopathological analysis of the sample revealed pleomorphic adenoma (Figures and ).\nThe patient was referred to the head and neck service for complete resection of the tumor. The specimen was sent to the pathology service and the histopathological analysis confirmed the diagnosis established with CNB (). No complications occurred in the postoperative period and no signs of recurrence were found at the 12-month follow-up ().

A 67 year old male patient was admitted to the emergency room with dizziness and gait ataxia that had suddenly developed two days previously. The patient was receiving pharmacological treatment for hypertension and diabetes and there was no relevant family history. Other than the dizziness and gait ataxia, the patient complaining of headache, hearing loss and aural pressure in the left ear, and aural discharge but these did not accompany otalgia or tinnitus. The patient displayed a clear state of consciousness in neurological examination, his papillary reflex was normal, and nystagmus was not observed. The patient fell toward left even with his eyes open in the Romberg test and displayed dysmetria on the left side in the cerebellar function finger to nose test. Brain CT taken in the emergency room displayed the formation of a common wall, including the wall that enhanced the contrast in a circle of 5×5 cm toward the left cerebellum and a manifestation in which it pressed the brain stem and the fourth ventricle (). With the suspicion of brain abscess in the left cerebellum, the patient was admitted to the neurosurgical ward and received antibiotic treatment. Two days after he was admitted to hospital, his state of consciousness suddenly altered to drowsy and craniotomy and drainage of abscess was performed in response. As a result of requesting department of otorhinolaryngology for phy-sical examination in order to assess the causative diseases after surgery, it was found that the external auditory canal was narrow and aural discharge and granulation tissue were observed in the left ear. The right ear was normal. Tympanic mem-brane retraction and the aural discharge that accompanies keratin were also observed ().\nOn temporal bone CT taken with the suspicion of left otitis media cholesteatomatica, an overall destruction of the cochlea and vestibular organ in the left ear caused by cholesteatoma was indicated (). Air conduction hearing and bone conduction hearing of 36 dB respectively was presented for the right ear and hearing loss was found in the left ear when performing pure tone audiometry. The degree of paralysis in the left semicircular duct was 100% on the results of a caloric test using air. Under diagnosis of otitis media cholesteatomatica, which causes cerebellar abscess with overall invasion of labyrinth and intracranial expansion, cholesteatoma and granulation tissue were removed through transotic approach (). The surgery was performed a month after performing drainage of the abscess in neurosurgery. As the granulation tissue including keratin had infiltrated the mastoid antrum, auris media, and vestibular labyrinth and had destructed the bone structure, it was difficult to pinpoint the landmark that is seen during tympanomastoidectomy. Although the abscess was discharged within the cochlea, there was invasion into the internal acoustic canal. The junction between the mastoid antrum and posterior fossa was cut after connecting with fibrous tissue and there was no outflow of cerebrospinal fluid. As partial outflow of cerebrospinal fluid was found in the internal acoustic canal, this was stopped with soft tissue and the surgery was finished after filling the deletion by sampling fatty tissue from the stomach. As a result of assessing the bacterial culture from the abscess that was displayed in the mastoid antrum during surgery, group D enterococcus was cultivated and the result for acid-fast bacilli culture was negative. The patient was discharged from the hospital after recovery without neurological sequela and is currently under observation through follow-up CT without relapse ().

A 44-year-old woman was admitted to our outpatient clinic presenting with dysuria and intermittent hematuria for 2 years. She had a medical history of insertion of an IUD inserted 9 years ago. Three months after the insertion of IUD, she fell pregnant unexpectedly. It was her third pregnancy when she was 35 years old and previously she had two children who were 9 and 10 years old at that time. At the visit for pregnancy, the string of the device had not been detected by her gynecologist and it was assumed that IUD had been expelled spontaneously. She had continued her pregnancy and had a normal vaginal delivery without complication. Forty days after delivery, a second IUD had been inserted for contraception. After insertion of the second IUD she had no complaint in the following six years. The second IUD was removed 2 years before her presentation by her gynecologist because of the persistent urinary symptoms which was of newly onset. Physical examination at that time did not show any remarkable finding. Urinalysis was indicative of pyuria and hematuria and urine culture was negative. Abdominal ultrasonography revealed an echogenic intravesical lesion measuring about 27 mm with distal acoustic shadow suggestive of a foreign body or calculus. Plain radiography of the pelvis was not informative enough to show details of a foreign body.\nBecause of a lost IUD history and abnormal localized hyperechogenic lesion which was suggestive of a foreign body, we had planned a medical consultation to obstetric and gynecology department. Gynecologic examination reported that there were no visible strings of an IUD and cervix was closed. Transvaginal ultrasonography had revealed that more than half of the echogenic foreign body seemed to be in the bladder and a small part of it in the uterovesical space (). For confirmation and definitive diagnosis, cystoscopic evaluation was performed under local anesthesia and revealed a partially embedded intravesical IUD on the posterior bladder wall, complicated with a stone formation (Figures and ). So the patient underwent endoscopic surgery and the stone around the IUD was crushed using holmium laser lithotripsy. After complete disintegration and extraction of fragmented stones, the IUD was removed through the cystoscope using mechanical forceps (). The operation time was 50 minutes. The urethral catheter was removed and the patient was discharged on the postoperative day. She was followed up for three months. At the first and third month visit, physical examination and urinalysis were normal.

We present a case of a 42-year-old female who was found to have an incidental renal mass, which, on histological examination of the excised specimen, was revealed to be a clear cell papillary carcinoma, a relatively uncommon variant of renal cell carcinoma. The patient is a 42-year-old female who presented to her local medical officer with a two-week history of neck pain and radicular like pains extending into her right arm. A CT scan of her cervical spine revealed multilevel intervertebral disc and facet joint degenerative change resulting in neural exit foraminal narrowing. She was noted to have raised inflammatory markers (WCC 27.5, neutrophils 24.8, and CRP 319) and S. aureus was isolated on a blood culture. She was commenced on IV antibiotics; however her symptoms failed to improve and she subsequently developed significant lower back pain for which a CT of her lumbar spine was arranged. This revealed no convincing evidence of a lumbar spine infective process; however a 47 × 31 mm solid upper pole mass with an irregular periphery and internal calcification was identified in the left kidney, suspicious for a renal cell carcinoma.\nThe renal mass was further characterized with a triple phase abdominal CT scan and this confirmed a 4 × 4.9 × 4.5 cm heterogenous mass in the upper pole of the left kidney. There was no evidence of left renal vein involvement nor was any radiologically significant lymphadenopathy seen. Her films were reviewed and the decision was made to biopsy the left renal mass to establish whether the lesion was neoplastic or inflammatory. A core biopsy of the left kidney was reported as a Fuhrman grade 1, clear cell renal cell carcinoma (). She was then booked for an elective laparoscopic left radical nephrectomy. She underwent this procedure without complication and had an uneventful postoperative course subsequently being discharged home on day four.\nMacroscopic examination of the surgical specimen revealed a tumor in the mid portion of the kidney located superior to the renal hilum measuring 48 mm × 40 mm × 46 mm. The tumour was well circumscribed and bulged anteriorly into but not through the renal capsule. The cut surface was variegated cream, light brown, yellow, and dark brown with no areas of necrosis. Focal calcification was seen. Microscopic examination revealed the tumour to consist of uniform cells with clear cytoplasm and low nuclear grade arranged in tubules with small cysts and papillary structures. A single cell layer was seen in these formations. The component cells showed prominent subnuclear cytoplasmic clearing. There were areas of stromal sclerosis with fresh and old haemorrhage, cholesterol crystals, and haemosiderin laden macrophages. Dystrophic calcification was seen in the areas of sclerotic stroma. There were no psammoma bodies. Bundles of smooth muscle were present in the tumour capsule and within the tumour, in areas surrounding the tubular and acinar structures. The tumor cells were strongly positive for CK7 and CK19 and negative for CD10 and racemase. This pattern of staining is in keeping with a clear cell papillary carcinoma rather than a conventional clear cell renal cell carcinoma or papillary cell carcinoma.

A 45-year-old male with end stage renal disease due to chronic glomerulonephritis started automated PD in February 2015 and presented 7 months later with nausea and cloudy PD effluent. The peritoneal effluent white cell count was 996 cells/mL, with a polymorphonuclear cell fraction of 56%. The peritoneal fluid was sent for microbiological investigations and he was given IP vancomycin 2 g and ceftazidime 1.5 g as per the hospital empiric protocol. The culture grew coagulase-negative staphylococcus resistant to beta lactams but sensitive to vancomycin. The IP ceftazidime was discontinued after 2 doses and he continued IP vancomycin every 4 days for a total of 3 weeks. The vancomycin dose was adjusted according to serum vancomycin level and the level remained greater than 25 mg/L throughout the treatment with the highest level being 35 mg/L. His levels were kept deliberately high as he was due for a live donor kidney transplant the following month and the treating team wanted to minimize the risk of relapsed peritonitis.\nOne day after completing the course of vancomycin, the patient presented with general malaise and a skin rash which had begun on the abdomen and progressed to involve the entire trunk and proximal limbs. He reported intense pruritus and pain. He was hypotensive with mean arterial blood pressure of 50 mm Hg, heart rate 115, and temperature T 39.1°C. There was a diffuse blanchable papular rash involving the trunk and proximal limbs without blistering or sloughing. There was no mucous membrane involvement and no lymphadenopathy. He was admitted to the intensive care unit for hypotension requiring vasopressors and was initially treated for possible sepsis with intravenous saline and broad spectrum antibiotics including vancomycin. Initial laboratory investigations are shown in . All imaging was normal, and blood and urine cultures revealed no growth. After admission day 2 he had a skin biopsy performed which revealed a moderate mixed perivascular infiltrate, composed mostly of lymphocytes with a few neutrophils and scattered eosinophils (). There was a moderate amount of both vacuolar and a slightly lichenoid interface dermatitis, and a few necrotic keratinocytes were seen within the spongiotic epidermis. A few minute foci of parakeratosis were present (). PAS stain was negative for fungal organisms. Biopsy findings were compatible with a drug reaction, and clinically he was felt to meet criteria for drug reaction with eosinophilia and systemic symptoms (DRESS syndrome). He was given one dose of intravenous solumedrol 80 mg and then switched to oral prednisone 50 g daily for 5 days. He responded well to corticosteroid therapy and was discharged in stable condition after 3 days and received a live donor kidney transplant 7 weeks later.

A 70-year-old female was referred to breast re-implantation of the right side due to iatrogenic rupture and explantation during thoracic surgery. The patient had a medical history of cancer in the right breast in 1984 with subsequent treatment including unilateral mastectomy, radiochemotherapy and secondary reconstruction with a subpectoral silicone implant. In 2015 the patient was diagnosed with leiomyosarcoma in the right thigh and bilateral pulmonary metastases. The patient underwent video-assisted thoracoscopic surgery (VATS) wedge resection of the right lung and during this procedure iatrogenic perforation of the silicone implant and injury to the thoracic wall occurred. The thoracic cavity was closed and the perforated breast implant removed without diagnosis of the defect.\nIn stabile condition, the patient expressed a strong desire for breast re-implantation and during this procedure the defect of the thoracic wall and parietal pleura was observed. As the defect was minor, simple closure of soft tissue over the defect would be appropriate in patients not planned for breast reconstruction, however the patient in this case had expressed an extremely strong desire for breast reconstruction. In case of direct closure communication would persist between the lung and the capsular space and therefore it was necessary to close the defect with a thin layer of material allowing both secure closure of the defect and re-implantation. The highly vascularised capsule is known to be appropriate for creation of flaps and grafts, and has previously been used in management of issues in relation to breast implants []. The capsule tissue was an appropriate choice for creation of a pedicled flap in this case because the tissue presented a minimally invasive treatment option for the patient compared to closure with a muscle flap or addition of non-autologus tissue such ADM, increasing infection risk. The anterior part of the capsule in relation to the pectoral muscle was dissected free from the upper pole to the inframammary fold resulting in a medially and centrally vascularised flap. The flap was rotated with the agglutinating side facing downwards to cover the pleural defect and sutured shut. The flap was not expected to be airtight, however placement of the implant directly over the flap ensured necessary pressure to prevent displacement and air leaks. Pressure ventilation found the new capsular patch airtight. Next pleuracentesis was performed in order to control the pneumothorax and finally the flap was sutured in place to close the defect before placement of the silicone implant. Preventative iv. antibiotics were administered. Postoperatively the patient had discrete air effusion once the chest tube suction was discontinued and after five days chest x-ray showed a 5,2 cm apical lung pneumothorax. The patient had no pulmonary symptoms. At the one-week follow-up a regression of the pneumothorax from 5,2 cm to 3,1 cm was found and at the twelve month follow up the reconstruction was fully functioning and the patient asymptomatic.

This is a healthy appearing 77 year old man with bladder cancer. He presented in April 2016 with an episode of gross hematuria. He lives in Central America and was seen by a urologist there.\nHis past medical history is uneventful. He has adult onset type 2 diabetes and takes metformin. He was never a cigarette smoker. The only surgery he had was a right inguinal hernia repair. He is not overweight.\nIn April 2016 he had two papillary tumors which appeared to be Ta. He underwent a transurethral resection and the pathology was low grade Ta. His first surveillance cystoscopy was negative. In October 2016 he had four LG Ta tumors which were resected. This was followed by 6 weeks of intravesical chemotherapy using mitomycin C.\nThe patient was tumor free until August 2018 at which time he was found to have multifocal bladder cancer. A transurethral resection revealed high grade Ta urothelial cancer. There was also focal carcinoma in situ. Lamina propria and muscularis propria were present and were free of cancer. He received one dose of intravesical MMC postoperatively. He elected to have a consultation here in South Florida.\nHe presented with nocturia×4 and some daytime frequency. Prior to the recent TUR BT he had nocturia×2 and no daytime voiding complaints.\nI saw the patient in September 2018. I reviewed the recent bladder tissue (–) and proceeded with office flexible cystoscopy. The bladder had several areas of necrosis consistent with MMC effect on the previous resected urothelium (). In addition there were areas of persistent or new tumor which appeared to be high grade Ta ().\nThere are two quite different alternatives in my view. One might proceed with a TUR BT and remove all visible tumor. If the pathology is, as expected, high grade Ta with or without CIS one might proceed with a bladder preservation approach which would consist of a course of intravesical BCG. This might be reasonable as he has not had a bladder cancer which invaded the lamina propria or muscularis propria. Given his voiding symptoms there would be some question as to whether he could tolerate BCG.\nAlthough it is unusual to consider a radical cystoprostatectomy for someone who has yet to have an invasive bladder cancer this man has an unusual course. Relatively few patients with initial LG Ta BC progress in grade and even fewer progress in stage, i.e. T1 or T2. Although this man has not progressed in stage the dramatic change in grade and extent of urothelial involvement has been striking. The extensive urothelial alteration by the MMC has led to bothersome voiding complaints and this is unlikely to relent while proceeding with another TUR BT and BCG.\nThis man has a negative CT scan and no evidence of other pathology.\nWhat would you suggest? If you suggest a cystectomy would you favor an ileal conduit given his age or offer him a neobladder if he would prefer to avoid a stoma.\nWe invite our readers to review and comment on the case and management by using the online comment section below the case:

A 38-year-old Indian male was referred to the Oral and Maxillofacial Surgery Clinic, Boston University Goldman School of Dental Medicine for the evaluation and management of progressive trismus. Patient presented with main complaint of inability to chew food and limited mouth opening. He reported that this has been going on with him for the last few years but became more concern for him just recently. His medical history was significant for hypertension, hypercholesterolemia, and benign prostatic hyperplasia which all are controlled by medications. Patient reported that he has been chewing pan of Indian tobacco for the last 15 years. Clinical exam showed no lymphadenopathy, swelling, or asymmetry. Limited mouth opening at 15 mm and cranial nerves exam is unremarkable except for alter sensation in the buccal branch of V 3 bilaterally (). Intraoral exam showed poor oral hygiene, multiple carious teeth. Palpable severe fibrous bands in buccal mucosa from just inside the commeasure of the mouth up to the pterygomandibular raphe were felt bilaterally. Soft palate, tongue and floor of mouth were not involved. The fibrosis has resulted in pale-appearing mucosa. An incisional biopsy was taken for histopathological evaluation which confirmed the diagnosis of submucous fibrosis infiltrating the muscular layer (), after discussion of the clinical findings and treatment options with the patient. The patient was taken to the operating room where he was placed on the surgical table hooked to the anesthesia, cardiac monitors, and pulse oximeter. Next patient was induced via intravenous general anesthesia and intubated with no complications. Local anesthesia was infiltrated in the intended surgical areas. Using a transoral approach a blade number 15 was utilized for the surgical excision of the fibrous bands and protecting underlying vital structures. Surgical dissection was carried out to the level of the buccinator muscle. After controlling bleeding the wound edges were prepared for the graft placement. Next attention was made toward the right thigh from which a 7 × 7 cm full thickness skin graft was harvested (); using sharp dissection, was done to the level of the subcutaneous fat. Electrocautery was use to ensure homeostasis and appropriate pressure was placed on the donor site. After that the graft was cut to custom fit each defect and multiple perforations were done throughout the graft to ensure rapid revascularization and prevent hematomas from developing. Next the grafts were sutured into place using 3′0 Chromic Gut restorable sutures in simple interrupted fashion (). Mouth opening was measured toward the end of the procedure and was recorded at 32 mm. After that the surgical area was irrigated and patient was extubated and transferred to the recovery room in stable condition. Postoperatively the patient was placed on full liquid diet for two weeks and one week supply of Motrin 400 mg, Percocet 5/325 mg, Keflex 250 mg, Medrol dose pack. Patient was followed regularly and on the second week his mouth opening was noted to decrease to 25 mm at which a course of total of 80 mg of Triamcinolone intramuscular injections were done with 40 mg in each side. Patient was placed on vigorous mouth opening exercises using Therabite devise. Patient responded well to the treatment regimen and maintained mouth opening at 30 mm after 12 months of treatment with good ability to have a satisfactory masticatory function ().

A 75-year-old female patient reported to our maxillofacial surgical services with the chief complaint of intra-oral painless growth since one and half year. She also had a complaint of difficulty in closing the mouth since past 2-3 months.\nThe patient was relatively asymptomatic one and half year back, then the patient started noticing small painless growth inside the oral cavity in the right mandibular alveolar region, and growth gradually started increasing in size. Few months later she also started having fetid odor from the oral cavity. Because of large size of the growth the patient started having difficult in closing the mouth completely and inability to chew the food. The patient had a history of exfoliation of mandibular teeth and few maxillary teeth due to extensive mobility. During the dental education camp held in patient's village, the patient turned up for consultation. The patient was then referred to outpatient department of maxillofacial surgery at Sardar Patel Institute of Dental and Medical Sciences, Lucknow. Past history and medical history did not reveal any relevant information. She was taking no medication and had no history of known drug allergy. Her general physical examination revealed no abnormality other than those related to the chief complaint except for moderate visual and hearing impairment.\nOn examination growth was slightly visible when the patient protruded the tongue. The patient was unable to close the mouth completely due to size of the lesion []. On intra-oral examination smooth surfaced, and lobulated growth of approximately 5 × 4 × 2 cm in size was present covering the alveolar ridge from the midline to molar region on completely edentulous alveolar ridge. Growth was pedunculated and was freely movable over peduncle which was present on the alveolar ridge of the premolar region. Surface of growth was smooth and showing normal color in certain areas whereas superior surface of the growth in certain area was covered by yellowish plaque like material. Growth was partially divided into two large lobules covering both buccal and lingual vestibules []. Mild indentation of maxillary teeth was observed on the superior surface of the growth. On palpation, growth was nontender, nonfluctuant, hard and fibrous in consistency without tendency for excessive bleeding upon probing under topical anesthesia. While the mandibular ridge was completely edentulous, the maxillary arch showed the presence of supra eruption of maxillary teeth from first molar to first molar on both sides. All maxillary teeth were periodontally compromised and showed grade 3 mobility. Tongue movements were unrestricted. There was no evidence of submandibular lymphadenopathy or paresthesia/anesthesia in the region of inferior alveolar nerve.\nProvisional diagnosis of benign irritational hyperplasia/fibroma was made. Supra-eruption and the presence of sharp edges of maxillary teeth were considered responsible for providing low grade chronic irritation required for development o growths.\nOn radiographical examination of the mandibular ridge a moderate resorption of the alveolar ridge was observed which was biconcave in shape, which might be suggestive resorption due to pressure from the growing lesion. The presence of small root piece of about 3–4 mm was seen in the right mandibular posterior region [].\nSince the lesion was though unusual in size but having pedunculated base, treatment plan comprising of excisional biopsy of the growth and total teeth extraction was formulated and explained to the patient and her relatives and written and informed consent was procured. Routine hematological examination was advised and values were found to be within normal limits. An excisional biopsy was performed under local anesthesia [xylocaine 2% with adrenaline 1:200000]. After securing local anesthesia, growth was gently lifted to make the peduncle visible from both buccal and lingual. A sharp bone touching elliptical incision was made around the peduncle and on the alveolar ridge. With the help of periosteal elevator it was lifted along with the underlying periosteum from the bone surface and removed. Hemostasis was achieved and single layer closure was performed with the help of 3–0 silk suture. Excised specimen was preserved and sent to Dept. of oral and maxillofacial pathology for histopathological examination which confirmed it as Pyogenic granuloma [Figures and ]. The patient revisited after 7 days for suture removal []. The patient is currently under follow up without any signs of the recurrence of a lesion. The time of the total follow up till date is 1 year.

A 6-month-old baby boy presented at the Vascular Surgery clinic with a 2-month history of swelling noticed by his parents on the hypothenar eminence of the left hand (). The swelling was gradually increasing in size. The parents gave no history of any unusual crying of the baby, which concludes that it was painless. On our examination, the swelling was around 4×2 cm in size. It was pulsatile on palpation, and there were no motor deficits in the left hand. This swelling was localized in the left hand hypothenar eminence, and both the radial and ulnar pulses were palpable with a good capillary refill. On taking a detailed history, the mother explained that the baby had the habit of hitting his left hand mainly on the table while having food and on other objects. With the clinical history and examination, an aneurysmal swelling was confirmed, most likely arising from the ulnar artery or the palmar arch because of its location. He came in with an arterial duplex, which confirmed only an aneurysmal sac. There was no detailed anatomical description because of the compromised examination due to the age of the child. No other investigations were carried out to confirm the diagnosis because of financial limitations and the very young age of the child, and we opted for surgical excision directly. Intraoperatively, it was an aneurysmal swelling involving the ulnar artery from below the wrist and at the distal forearm involving the superficial palmar arch distally and taking the digital blood supply of the little finger and the ring finger with it (). This aneurysm was excised and repaired with an interposition reverse cephalic vein graft from the forearm of the same side (). A segment of the Y-shaped cephalic vein with a tributary was taken from the distal forearm of the same side. The proximal end of the reverse cephalic vein was anastomosed to the distal end of the ulnar artery, and the two distal ends of the reverse cephalic vein in a Y-shape fashion were anastomosed, one at the superficial palmar arch and one at the common digital artery of the fourth and fifth fingers at the fourth web space. The histopathology of the aneurysmal sac confirmed a dilated vascular channel with fibrin and an attenuated intima, compatible with an aneurysm with no signs of vasculitis. Postoperatively, he had palpable pulses in both the ulnar and radial arteries, and his motor movement was intact. He was not kept on any anticoagulation, and no further follow-up studies were conducted.

A 10 year old male patient presented with a severe head trauma after falling from a roof that required an immediate decompressive craniotomy (Fig. ). The patient was hospitalized in the ICU for 8 days, after which the cerebral oedema resolved, and he was then discharged. Three months later, he was referred to the Plastic Surgery Department by the Department of Neurosurgery to plan the patient’s treatment and his cranial reconstruction. He was assessed by our department and was found to be alert and oriented, calm, and cooperative. A CT revealed a 12 cm by 12 cm defect (Fig. ). The prosthesis was fashioned and the patient was operated 10 days later (Fig. ). The thickness of the implant produced for this case was of 5 mm. The thickness of the prosthesis matches the patient’s cranial vault thickness. The patient was discharged from the hospital 2 days after surgery, he immediately started a physical therapy program and he returned to school after 2 months of therapy without sequelae or neurologic damage. The patient said that his headache subsided, since the prosthesis relieves atmospheric pressure on brain tissue.\nA 17 year old male patient presented after a motorcycle accident where he was not wearing a helmet. Upon his arrival at the hospital with a diagnosis of TBI (traumatic brain injury), he was evaluated by the Department of Neurosurgery who decided to treat the patient with a decompressive craniotomy. A CT was done to complete the diagnosis and plan the surgery. The patient had a bifrontal 20 cm cranial defect from the temporal fossa of one side to the other and 10 cm vertical distance (Fig. ). The thickness of the implant in this case was of 6 mm. It is 1 mm thicker than that of the previous case due to patient anatomic differences in diploe thickness. After surgery, he remained hospitalized for 2 weeks before discharging him. He was referred to us after 3 months of physical therapy once the Neurosurgical Department considered cranial reconstruction feasible. The patient was evaluated and was found to have no neurologic damage and an intact scalp. The patient was deemed an excellent candidate for the placement of a 3D PMMA pre-operative manufactured cranial prosthesis, 2 days after which the patient had a good evolution and was discharged. After 2 months, the patient returned to his normal school activities.\nIn Mexico these procedures have to be payed in full by the patient, limiting their reach and practice in the general population since they are costly. A customized titanium implant costs around US$5000, and those made from PEEK around US$7000 or more depending on their size. The customized prostheses proposed by the authors have a cost of about US$600, including the digital design, printing of a 3D prototype and the PMMA prosthesis itself. Both titanium and PMMA are the most commonly used alloplastic materials [, ].\nThe CT scan data is stored in the standard format DICOM (Digital Images and Communications in Medicine) which allows generating an interface between the medical equipment and any other device to visualize the images. Through the DICOM viewer, Osirix® generated a three-dimensional reconstruction of all the CT cross-sectional images. A bone filter is applied in order to only observe the bone structure, achieved by taking as reference its attenuation degree.\nThe implant is generated using the software of the computer-aided design (CAD) ZBrush 4R5® since Osirix® is only a viewer.\nThe implant piece, Vimplant, is generated from the CT skeletal reconstruction of the patient’s cranium. With volumetric reconstruction, Vtotal, and considering its symmetry; an imaginary division is made on the sagittal plane, obtaining two volumes, Vleft and Vright. A boolean operation is applied to the volumes Vleft and Vright: Vimplant = Vleft - Vright (Fig. ).\nThe implant design must have a precise shape and volume according to each patient’s cranial anatomy. Finally, the data is exported in a stereolithography extension file (STL) and fed to the printer.\nA CUBE 3D (from 3D System) printer is used to print out a PLA prosthesis from the STL file using a fused deposition model by means of a 1,75 mm filament at a 260 °C extruder temperature (Fig. ). Once the printing process is finished, which takes about 20 h, the scaffolds are removed with a low-speed motor and a carbide bur and the adjustment is verified (Fig. ). The prosthesis is then taken to the dental laboratory.\nThe prosthesis is placed in metal containers to obtain two plaster impressions (an internal and an external surface impression). A transparent PMMA OPTI-CRYLR is poured into the space created by the internal plaster impression and pressed with the external mold. The casts are opened and the prosthesis is revealed after a 25-min polymerization time (Fig. ). The prosthesis is then cut, perforated, and polished with a low-speed motor. Precise anatomical compliance to the model is verified and approved by the multi-disciplinary team (including the neurosurgeons), and the prosthesis is then placed on a mannequin for academic and illustrative purposes (Fig. ). After obtaining the prosthesis in the laboratory, it is washed with normal saline solution and then submerged in a chlorine based antiseptic solution (Microdacyn 60 by Oculus lnnovative Sciences in Petaluma, CA.) for 15 min before taking it to the hospital where it is sterilized with ethylene oxide gas before its implantation (Fig. ).\nCranioplasties were carried out 3 months after craniotomy in conjunction with the neurosurgeons. The prostheses were then placed over each of the defects to adjust them in vivo with minimum adjustments with the same low-speed electric motor, and fixed with 3 long titanium bridge plates, each held down with 2 screws (Fig. ). The procedure ended without any unexpected events. The patients were hospitalized for 2 days and discharged after a single drain is removed from each patient to continue their care as outpatients (Fig. ).\nThe patients were evaluated every week for 6 months to register PMMA behaviour, biological sefety and any eventualities (Fig. ).

A 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.\nThe examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation (). A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.\nThe blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous surgery site an upper GI endoscopy was performed. A small benign looking ulcer was seen at the pylorus of the stomach.\nWith a strong suspicion of gastrocutaneous fistula, a CT fistulogram was performed. An enterocutaneous fistula between the pylorus of the stomach and the anterior abdominal wall was seen. A long side branch of the fistula tract was seen communicating to a moderate sized left subphrenic collection ().\nWith confirmed diagnosis of complex gastrocutaneous fistula a repeat surgery was planned. The abdomen was entered after incising the previous scar on left lateral side and extending the incision downwards and upwards. Dense interbowel adhesions were encountered. Meticulous adhesiolysis and dissection was performed. The abscess cavity was drained and the perforation on the pylorus of the stomach was identified. It was around 1 cm × 1 cm size. Repeat omental patch repair was performed. In view of difficult dissection, feeding jejunostomy and retrograde tube duodenostomy were also made.\nAn uneventful recovery happened. He attended follow up clinic till 4 months following the discharge. There was an incisional hernia but otherwise he was doing fine. After this he was lost to follow up.\nTimeline

A 46-year-old man with diabetes mellitus presented to the emergency department at our hospital with symptoms of right foot pain and fever. The patient developed ASO in the right lower extremity as a complication of diabetes. Arterial occlusion started from 10 cm distal to the knee joint and involved the anterior tibial artery, posterior tibial artery, and peroneal artery. The patient had already had right second and third metatarsophalangeal joint disarticulations in the plastic surgery department of our hospital. Nevertheless, infection and necrosis in the right foot progressed rapidly and worsened to a condition requiring additional surgery (). However, because a tibial IM nail had been inserted into the ipsilateral limb, the patient was referred to the orthopedic surgery department.\nAbove-knee and through-knee amputations were also considered surgical options for the patient. However, it was determined that the blood flow to the distal part of the popliteal artery was intact. Also, infection and necrosis had not progressed beyond the foot. The skin color of the right calf seemed healthy on physical examination. Therefore, we decided to remove the tibial IM nail and perform a below-knee amputation. However, performing additional surgery around the knee joint to remove the tibial IM nail was thought to have a high possibility of complications. Thus, surgery was planned to remove the amputated limb and IM nail at the same time by performing an amputation with the nail fixed on the ankle by distal locking screws.\nThe tibial bone cutting level was determined by referring to the lateral view of the tibial plain radiograph. The tibial IM nail is designed to have an anterior angulation in the proximal part. Therefore, if tibial bone cutting is performed distal to the angulation of the nail, the nail may not be removed from the proximal part of the tibia due to the angulation of the nail. Therefore, we decided to perform tibial bone cutting at the point of the anterior angulation in the nail to leave as much of the tibia as possible (). In this patient, the anterior angulation of the tibial nail was about 10 cm away from the tibial plateau on the X-ray, so tibial bone cutting was performed 10 cm away from the tibial plateau.\nThe patient was positioned in a supine position on the operating table. A nonsterile tourniquet was applied to the upper thigh for use in case of major bleeding, and surgery was initiated without inflation of the tourniquet under general anesthesia. Most of the surgery was performed similarly to the typical transtibial amputation procedure, and a long posterior flap was used. The skin incision was designed for a long posterior flap, and an incision was made in the skin and fascia. The anterior and lateral compartment muscles were divided. During dissection, the anterior tibial artery and vein were ligated. The fibula and tibia were exposed, and the proximal interlocking screw of the tibial nail was removed. Among the proximal interlocking screws, the screw located at the distal part was removed from the exposed tibia without an additional incision. The remaining proximal interlocking screw was removed by making a minimal incision of about 7 mm in the previous surgical scar. Next, tibial cutting was performed. Using a ruler, a site about 10 cm away from the tibial plateau was measured and marked on the tibia, and the tibia was cut using an oscillating saw, except the IM nail. A sagittal cutting blade was used for the blade of the oscillating saw. However, the posterior surface of the tibia was cut using a reciprocating blade while protecting the deep posterior compartment with Adson tissue forceps. The fibula was cut 1 cm proximal to the tibia using an oscillating saw and bone cutter. The posterior flap was made by completely separating the posterior musculature from the tibia and fibula. At this point, the amputated limb and lower extremity were connected only by the IM nail inserted into the tibia. Insert an osteotome into the tibial osteotomy gap with a mallet to expand the gap. If the opening of the osteotomy seems insufficient, use 2 or 3 stacked osteotomes or thicker osteotome until the osteotomy is opened to the desired extent. After widening the gap to about 2-3 mm, gentle traction and a twisting force were applied several times on the amputated limb. Then, the amputated limb was separated from the proximal tibia with the IM nail connected (). The anterior lip of the tibia was beveled. The tibial, peroneal, and sural nerves were sharply divided and allowed to retract to prevent neuroma formation. The bulky soft tissue of the posterior flap was trimmed to create a properly shaped posterior flap. After irrigation and drainage insertion, the deep fascia and skin were sutured without tension (). No hardware remained after surgery ().

A 79 year old man presented with a discharging sinus in the epigastrium. He had undergone a mechanical aortic valve replacement for aortic stenosis 14 years ago which was followed 2 years later by repeat mechanical aortic valve replacement for streptococcal prosthetic valve endocarditis. His postoperative recovery following his second valve replacement was uneventful. He continued to be well and asymptomatic with a well healed sternal wound for the next 12 years. However, 12 years following his 2nd operation, he presented with a discharging sinus in epigastrium (fig ) which was initially treated with dressings and antibiotics by his GP. Exploration of the sinus under general anaesthetic was undertaken after the sinus failed to heal. The sinus was in communication with anterior mediastinum by penetrating the rectus sheath and was divided at the point of entry into mediastinum and removed. All sternal wires were removed. Microbiology of the excised tissue revealed staphylococcus aureus infection and this was treated with appropriate antibiotics for 4 weeks. However, the wound failed to heal although he never developed any signs of systemic illness. A CT scan of chest showed an encapsulated mass extending from ascending aorta to the diaphragm and normal sternum. Transthoracic echocardiography ruled out pseudoaneurysm of ascending aorta, prosthetic endocarditis or aortic root abscess. An MR scan confirmed a longitudinal retrosternal mass extending from mid ascending aorta to the diaphragm (figs and ) and cutaneous fistulization to the epigastrium through left rectus sheath.\nAn exploratory secondary median sternotomy was made with cardiopulmonary bypass on standby. Heart and the great vessels were dissected out within the pericardial cavity. A nonpulsatile longitudinal 15 cm mass was found on the anterior surface of ascending aorta and right ventricle along the entire length of anterior mediastinum. At the level of the diaphragm, the mass exited the mediastinum by penetrating the left rectus sheath and communicated with the skin in the epigastrium. At the junction of the superior 1/3 and inferior 2/3, there was a branching tract extending from the main tract to the right and inferiorly over right atrium and the hilum of right lung. The upper part of the mass was aspirated with a wide bore needle when thick cheesy material came out (fig ). The entire mass and the branching tract were laid open (fig ), only the middle 2 inches of the mass over the right ventricle having no lumen. The superior half of the tract that lay open was, interestingly, filled with old suture material and Teflon pledgets in addition to thick cheesy material mentioned before. The inferior part of the tract, that had fistulized through the rectus sheath to the epigastric skin, was filled with yellow fresh pus and a piece of old temporary pacing wire. Both the white cheesy material and the pus were sent separately for bacteriological analysis and both grew staphylococcus aureus. The upper mass was almost completely excised except for a thin rim posteriorly which was densely adherent to aorta and the adjacent right atrium and right ventricle. The lower mass was completely excised along with the contiguous portions of rectus muscle, xiphoid, subcutaneous tissue, the sinus and the core of the epigastric skin. Through the same incision, the diaphragm and peritoneum were opened. The greater omentum, based on the right gastroepiploic pedicle, was freed from the greater curvature of the stomach, divided to the far left of the stomach and transposed into the chest to cover the entire raw area of the excised mass and sinus and secured in place with stitches (fig ). Patient received intravenous antibiotics for 6 weeks and was discharge home thereafter, his sternal wound having healed satisfactorily. At follow up 2 years later, he remains fit and well.

The patient, a 36-year-old woman with a known case of exstrophy of the bladder had undergone repair of the defect 17 years previously. However, dehiscence of the repair had occurred and the patient continued to leak urine from the lower abdominal wall. Six months following this, an ileal conduit urinary diversion was done to prevent the continuous leakage of urine. Six month prior to presentation, the patient had noticed an irregular mass arising from the exposed bladder mucosa that was rapidly increasing in size. On examination, a hemispherical growth with an irregular surface was seen in the region of the exposed bladder mucosa (). The computed tomography scan showed a mildly enhancing nodular lesion on the right side of the lower abdomen superficially. The lesion was confined to the urinary bladder. A wedge biopsy was taken from the growth, and the results were suggestive of squamous cell carcinoma. The results of a routine hematological evaluation, liver function tests, and a chest radiograph were normal. The patient thus underwent removal of the urinary bladder along with a cuff of the surrounding abdominal wall and pelvic lymph node dissection (radical cystectomy). After resection, there was a full thickness defect of the lower abdomen about 8 cm×9 cm in size. To cover this defect, the peritoneum was mobilized on both sides and was sutured in the midline. Both recti were also mobilized and sutured in the midline. The skin defect was resurfaced with an extended groin flap from the left side and the secondary defect thus created was covered by a split thickness skin graft (, ). Histopathological examination of the resected specimen was suggestive of well-differentiated squamous cell carcinoma infiltrating the underlying muscle (stage pT2a) with dense lymphocytic infiltration of the stroma. All the resected margins and deeper plane of resection were free of tumor (). In the postoperative period, the patient developed a small collection beneath the flap that was drained by removal of two stitches, and daily dressings were done. This site granulated well and healed without any significant additional scaring. The patient is on regular follow-up and is doing well without any evidence of recurrence to date (5 months postoperatively) ().

A 35-year-old educated young male is the main caregiver of his mother, who is a cancer survivor. He has two children of 3 years and 6 years old. He is the sole earning member of his family. The journey of his life has been filled with many challenges for the past 10 years.\nHis first complex caregiving episode dates back to the time when he was 25 years old. He had just started a new job after completing his education. However unfortunately, at the same time, his mother was diagnosed with colon carcinoma. He recalled that it seemed to him as the end of the world at that time. It was for the first time in his life that he experienced a sense of great responsibility toward his mother. He assumed the role of a parent for her and followed her up for treatments in the hospital, caring for her at home after surgery and supporting her emotionally as well. As his father was not educated and sister too young to understand, he did not share much of his loneliness and distress with anyone. After the surgery slowly over a period of a year, his mother's health improved, which relieved his distress.\nThe second complex caregiving episode was when his father died due to a sudden cardiac event (massive heart attack) 4 years back. This was a major turning point in his life. He felt all alone. He hardly used to discuss all his fears with his father, but still, he felt that his father was the only source of social and emotional support for him. Furthermore, seeing the mother in grief and fearing the ill effects of stress on her health. He now realized that he has to be the support system for his whole family. With responsibility came more stress, which further strained him emotionally.\nHe describes the present complex caregiving situation due to the pandemic as the worst experience in which it seemed to him that there is only sadness, distress without any hope of something good. He describes the present state of his mind as being filled with hopelessness and fear. He states that to add to his distress was the new symptoms of pain abdomen and bowel disturbances in his mother. The thoughts of having a recurrence terrified him for which he desperately wanted to visit the hospital. However considering his mother at high risk of complications from the COVID-19 infections, he was too perplexed to decide what to do. Another thought of his children being at risk of the infection if he visited a hospital heightened his anxiety. He recalls himself having sleepless nights wondering what is better in the current scenario for the safety of his whole family without adversely affecting his mother's health. He remembered having episodes of anger, frustration on his kids and wife over small immaterial things. However, when the situation continued and had almost felt devastated for >2 months he finally thought to visit the hospital once.\nWhen he presented to the outpatient department to show his mother, it seemed evident that he was in great psychological distress. The mother was evaluated and suspected of an infection for which treatment was prescribed. However, we thought of communicating with him regarding his fears, distress, and anxiety. Once he was comfortable, he expressed his distress which he stated had completely ruined his life. He discussed his worries and slowly and gradually felt much better. We followed them using teleconsultation and found that his negative symptoms such as helplessness, anger, and distress had decreased and he felt good to be with his family.

A 52-year-old female who recently recovered from a myocardial infarction following a coronary angiography and stenting was not fortunate enough to be in good health thereafter. She developed symptoms such as pain upper abdomen, feeling of fullness even with small meals, and loss of appetite just 1 month after her stenting. Perplexed by her symptoms, she visited the hospital in January 2020. She underwent a battery of investigations including an upper gastrointestinal endoscopy which suggested a growth at the lower end of the stomach compromising the gastric outlet. After having a tissue diagnosis of adenocarcinoma stomach, the patient was devastated and worried about the outcome the disease will have for her. The patient developed a ray of hope when she was planned for surgery considering the localized nature of the disease. She was informed that an early diagnosis and treatment will have favorable outcomes for her. She was scared by the outcomes and extensive nature of the surgery but still hoped to get through it and be better.\nHowever, when her surgery time neared, the country had been hit by the pandemic. Because of the few people being diagnosed of coronavirus, the hospital where her surgery was planned decided to put on hold major elective surgeries to avoid the risk of coronavirus to patients. She was informed that her surgery was canceled to avoid any risk to her health considering her high risk for complications because of the pandemic. She recalled that she felt like the floor slipped off from under her. Her caregiver stated that they understood that the decision of postponing of surgery was in their favor, but they were distressed by the fact that what if it progressed. Their mind kept wondering if there was some way that they could get the surgery done and still did not get the infection. They were advised certain home-based medications for the disease to tide over some time.\nAfter 1½ months of this, the patient presented in the emergency department of our hospital with progressively increasing dysphagia, multiple episodes of vomiting, and significant weight loss. On initial stabilizing, a scan was done which suggested complete gastric outlet obstruction along with metastatic spread to the liver. It was informed that all that could be done for her in the present situation is a feeding jejunostomy to help her intake of food. Because in the present cachexic situation, it will take her some time to build up before she can tolerate a chemotherapy. This left the patient and her relative startled and they could not believe their ears. On explaining about the advanced nature of the disease, they were heart wrenched. The patient was annoyed at the entire situation and said I do not know whom to blame for my current situation. She said that ever since I was diagnosed with this disease, the only good thing I thought was its early stage. But now, because of this pandemic, although I did not get infected, should I be happy or be furious that I am in an even worse situation nearing death. It was a difficult conversation which led us wondering what went wrong that she is in such a situation.

A 48-year old Caucasian man presented to clinic for evaluation of his options for the treatment of brainstem fibrosarcoma. In 1977, 26 years prior to this presentation, the patient was diagnosed with a large pituitary adenoma based on a head computer tomography. Biopsy was not performed at the time. However, he received conformal fractionated radiotherapy of unknown dose. He also had concurrent hydrocephalus and a ventriculo–peritoneal shunt was placed. The patient was asymptomatic until 2003 when he started to develop eye left eyelid drooping and diplopia. A magnetic resonance study performed in February of 2004 showed a right brainstem lesion. Stereotactic needle brain biopsy was performed but the results were inconclusive. The patient was followed with serial neuroimaging until August of 2006 when the tumor experienced significant growth associated with progressive neurologic impairment. At that time a second stereotactic biopsy was performed, which also failed to show the pathology of the tumor. In May of 2007, the patient underwent subtotal resection of his large right pontine enhancing mass. Pathology results revealed that the tissue was most consisted with grade 2 fibrosarcoma. Post operatively the patient suffered a pseudomeningocele at the incision site, which required a VP shunt revision. Subsequently he presented to our clinic for reevaluation of this therapeutic options. After careful consideration of the different options available we decided to use a combination of metronomic cyclophosphamide at 50 mg a day and Imatinib 400 mg a day. The choice of Imatinib was based on the newest published data on the soft-tissue sarcoma and gastrointestinal stromal tumors sensitivity to Imatinib [] and the recent clinical trials showing that this chemotherapy agent is a potential option for primary malignant gliomas []. Cyclophosphamide is very commonly used in the treatment of multiple CNS malignancies such as malignant glioma and meningioma [], and also shows good activity in the treatment of systemic fibrosarcoma [] which motivates our decision to include this drug in this patient’s regimen.\nThe patient tolerated the treatment well, with slow improvement in his neurologic function and with minimal (grade II) chemotherapy-related hematologic toxicities. No treatment discontinuation was needed. Serial magnetic resonance studies of the brain showed that the tumor did not grow over the course of 6 month of chemotherapy, measures being stable at 30.2 mm × 35 mm (November 2007) and 30.4 mm × 35 mm (May 2008) (Fig. c–f). Unfortunately, the patient expired due to bacterial pneumonia with subsequent Gram negative sepsis while continuing to experience neurologic improvement, 6 months after the onset of chemotherapy. At the wish of the family, no autopsy was performed.\nThe pathology report indicated that the subtotal resection specimen was most consistent with brainstem tissue (Fig. c, d). Microscopical analysis if the specimen revealed spindle cell proliferation, with mild to moderate pleomorphism (Fig. a, b). These cells were also negative for EMA, GFAP, Keratin, Melan-A and S 100 (Fig. d). In some areas, ten to fifteen percent of these cells reacted with Ki-67 (Fig. h). These areas were also positive for Vimentin (Fig. f) and showed a delicate reticulin network (Fig. e). Faint to moderate positivity for p53 was demonstrated in some areas. A desmin stain was also positive. Within the brain tissue there were some areas of necrosis in which macrophages could be seen.\nT1 weighted axial and sagittal images delineated a gadolinium enhancing midbrain mass with lesional edema. T2 weighted axial images demonstrated a heterogenous hyperintensity corresponding to the gadolinium-enhancing areas (Fig. ). Compared o the MRI from May 2007 the MRI from November 2007 showed rapidly expanding tumor (Fig. ). The follow-up MRIs obtained at 6 months showed stability of the tumor over a period of 6 month (Fig. ).

A 56-year-old male patient, whose plasmacytoma was enucleated 3 years ago from the medial side of the left mandible, was referred to our clinic due to his complaints of persistent orocutaneous fistula (Figures –). Past medical history revealed that the patient was operated three times to close the orocutaneous fistula by local flaps; however, none of these operations were successful. CT images of the patient demonstrated that the medial side of the left mandible was missing and there was a 3 × 2 cm diameter defect located between the left side of the mouth floor and the basis of the left mandible neighboring the left submandibular gland. The main reason of the failed attempts to close the fistula was considered to be the ineffective management of dead space surrounding the fistula. Consequently, it was decided to use the submandibular gland as a pedicled flap to fill the defect and support the oral and the cutaneous flaps.\nUnder general anesthesia, the fistula was excised initially and the oral and the cutaneous healthy soft tissues were prepared. At the extraoral site, the incision was extended to the posterior and anterior directions, following the previous incision lines. In the subplatysmal plane, the superficial layer of the neck fascia was dissected to reach the base of the mandible. After the dissection of the fascia, the submandibular gland and the base of the mandible were exposed, the soft tissues surrounding the submandibular gland were dissected, and the gland was mobilized by protecting the arteriovenous supply and the duct. At the oral site, the margins of the wound were released by blunt dissection and were closed by mattress sutures via 5/0 polypropylene. Following the mobilization of the gland, a soft tissue tunnel was prepared between the submandibular space and the defect area and the submandibular gland was rotated by passing the gland through the soft tissue tunnel by preserving the pedicle (). The rotated gland was sutured to the recipient site with 3/0 reabsorbable polyglaction sutures for the stabilization. At the cutaneous site, the flap was closed layer by layer by using 3/0 resorbable polyglaction for the facia and the subcutaneous layers and 3/0 polypropylene sutures for the skin. After the surgery, pressure bandage was applied for the edema control externally and the patient was ordered soft diet for a week. The postoperative healing was uneventful, and at the sixth month follow-up visit, ideal closure of the fistula was observed (Figures and ).

Mrs. S, a 36-year-old patient underwent IVF for tubal factor infertility in January 2007, with beta human chorionic gonadotropin (hCG) being positive on 20 Jan 2007. Early ultrasound showed a twin pregnancy, each containing a yolk sac and a live embryo. One sac was placed low towards the cervical canal while the other sac was placed towards the fundus, corresponding to 6 weeks of gestation. Early ultrasound suggested the possibility of a low implantation but did not confirm heterotopic pregnancy. On 4 Feb 2007, the patient was hospitalized in view of one episode of bleeding pervaginum. Keeping in mind the diagnosis of threatened abortion, she was managed conservatively and was discharged after 3 days. A repeat ultrasound at 7 weeks and 5 days of gestation confirmed the diagnosis of intrauterine and cervical heterotropic pregnancy []. The patient was readmitted on 19 Feb 2007. Fetal reduction of cervical pregnancy was performed under general anesthesia by injecting intrathoracic potassium chloride under transvaginal ultrasound guidance. The cardiac activity of the intrauterine fetus was found to be normal after the procedure was completed. The patient was discharged after 2 days. The rest of the pregnancy went uneventfully, except for mild vaginal spotting off and on. At 28 weeks of gestation, the patient was readmitted with asymmetrical intrauterine growth retardation. Fetal Doppler study on ultrasound showed reduced umbilical blood flows with adequate liquor and normal middle cerebral artery blood flows. She was serially monitored with biweekly ultrasound for fetal Doppler blood flow studies. At 31 weeks of gestation, a lower segment cesarean section was performed in view of absent end diastolic umbilical arterial fetal blood flow with reduced amniotic fluid index (amniotic fluid index 5). A male baby weighing 1.16 kg was born on 26 July 2007. Intraoperatively, the lower uterine segment showed presence of trophoblastic tissue and hemostatic sutures had to be taken in view of active bleeding from the anterior wall near the isthmus. The lower segment was ballooned up. Post-operative ultrasonography showed the presence of small amounts of trophoblastic tissue with low vascularity, suggestive of non-active tissue. Beta hCG levels performed immediately pre-operatively fell from 21,250 to 250 mIU/ ml 4 days after lower segment caesarean section. The patient was discharged on the 6th post-operative day in satisfactory condition. The baby was doing fine post-natally.

An 18-year-old male reported to our emergency department with a history of pain in the right shoulder and inability to move it without significant discomfort. He reported that he had been assaulted 4 weeks before the presentation and had sustained head injuries. He had been admitted elsewhere for the management of those injuries and had been managed on an indoor basis for 16 days. His shoulder discomfort had not been thought to be serious during his stay in that hospital. Orthopaedic consultation had been recommended at the time of discharge. Examination revealed a reasonably maintained contour of the shoulder with total restriction of abduction. The patient was able to internally rotate the shoulder up to 20° and external rotation was not possible (Figs. , , ).\nRadiographs of the shoulder showed that the proximal humerus was fractured, and the proximal end of the distal fragment had migrated proximally to lie under the deltoid giving it a near normal contour. The head was dislocated inferiorly. This was confirmed by the axillary view. A significant callus had formed around the head and the shaft at their new position of contact.\nIt was obvious that the proximal pull on the distal fragment had made it migrate proximally.\nAccording to these findings, open reduction and reconstruction of the proximal humerus were considered necessary. Under general anaesthesia, the patient was placed in a supine position and the glenohumeral joint was assessed via a deltopectoral approach. The axillary nerve was palpated to ascertain its position. The long head of the biceps was still intact. The glenoid cavity and the proximal humerus were exposed, and granulation tissue and the callus were cleared from it. After meticulous removal of the scar tissue, the glenoid articular cartilage looked to be in good condition and the humeral head was reduced.\nAs expected, it was not possible to reduce the distal fragment to its normal position beneath the head of the humerus. The end was stripped of soft tissue and shortened by 2 cm. This made the reduction possible beneath the head. The supraspinatus was reattached to the tuberosity area. The other muscles were reefed along with the capsule of the shoulder joint.\nThe wound was covered in layers, and the shoulder immobilised in 45° of internal rotation. After 4 weeks, pendular exercises were started with gradual institution of range of motion exercises. The final range of motion was recorded after 1 year when the patient had a more than normal internal rotation with an external rotation of 15°. However, abduction was only 25° at the joint. The flexion was 70° and the extension 20°. The patient was pain free and was able to perform his routine duties.\nThe X-ray, however, showed a gradual superior subluxation of the shoulder joint which was suggestive of undue tissue tension and rotator cuff insufficiency.

A 60 years old male presented in June 2010, to our department with complaints of severe pain and swelling in left hip and upper thigh region since last 2 days, following a history of trauma. He was unable to walk and bear weight on the left lower limb following the trauma. Pain was present on the anterior and lateral aspect of left hip and upper thigh region. It was constant in nature, was present even at rest, dull aching type, severe in intensity and aggravated by hip movements. It was accompanied with difficulty in walking due to pain and the patient was unable to bear weight on the left lower limb. It was also associated with diffuse swelling over the upper part of thigh.\nThe patient had a history of hip hemireplacement operation on the left side 5 years back. There was no other significant past history. Patient was a sedentary worker with no history of tobacco or drug intake. No sensitivity or allergy to any drug. There was no family history of tuberculosis or malignancy. On examination the left lower limb was externally rotated. There was a diffuse swelling over antero-lateral aspect of upper part of left thigh. The skin overlying the swelling was neither warm nor inflamed. There was deep tenderness over the swelling. Bony crepitus was present and there was loss of transmitted movements. There was no apparent shortening or true shortening. Straight leg raising test was negative. Distal neurovascular status of the limb was intact.\nRoutine blood investigations were under normal limits. Plain radiographs of the left hip and thigh showed a Vancouver type B1 periprosthetic fracture with a broken cemented bipolar prosthesis insitu []. There was sufficient bone stock and there was no osteopenia and osteolysis.\nThe patient was planned for surgery with options for internal fixation of the fracture with revision of the prosthesis, and reconstruction of proximal femur with proximal femoral mega prosthesis.\nThe hip was opened by posterior approach. The head of the broken prosthesis was removed easily but the stem was well fixed in the bone stock and could not be removed despite of all the efforts. So we opted for proximal femoral replacement with customized hip mega prosthesis. An osteotomy of the greater trochanter was performed and it was raised separately along with the attached abductors. The rest of the proximal part of the femur up to the fracture site was resected and removed along with the broken prosthesis. It was replaced by long stem steel cemented proximal femoral mega prosthesis. The remaining portion of the greater trochanter along with the abductors was attached to the ports provided at the lateral side of the prosthesis. Wound was closed over a suction drain. The patient was allowed to bear weight after removal of the stitches on the 12th post operative day with the help of four post walker. He has completed 2 years of follow up and is totally asymptomatic, pain free and walks independently without support.

A 56-year-old male patient, whose plasmacytoma was enucleated 3 years ago from the medial side of the left mandible, was referred to our clinic due to his complaints of persistent orocutaneous fistula (Figures –). Past medical history revealed that the patient was operated three times to close the orocutaneous fistula by local flaps; however, none of these operations were successful. CT images of the patient demonstrated that the medial side of the left mandible was missing and there was a 3 × 2 cm diameter defect located between the left side of the mouth floor and the basis of the left mandible neighboring the left submandibular gland. The main reason of the failed attempts to close the fistula was considered to be the ineffective management of dead space surrounding the fistula. Consequently, it was decided to use the submandibular gland as a pedicled flap to fill the defect and support the oral and the cutaneous flaps.\nUnder general anesthesia, the fistula was excised initially and the oral and the cutaneous healthy soft tissues were prepared. At the extraoral site, the incision was extended to the posterior and anterior directions, following the previous incision lines. In the subplatysmal plane, the superficial layer of the neck fascia was dissected to reach the base of the mandible. After the dissection of the fascia, the submandibular gland and the base of the mandible were exposed, the soft tissues surrounding the submandibular gland were dissected, and the gland was mobilized by protecting the arteriovenous supply and the duct. At the oral site, the margins of the wound were released by blunt dissection and were closed by mattress sutures via 5/0 polypropylene. Following the mobilization of the gland, a soft tissue tunnel was prepared between the submandibular space and the defect area and the submandibular gland was rotated by passing the gland through the soft tissue tunnel by preserving the pedicle (). The rotated gland was sutured to the recipient site with 3/0 reabsorbable polyglaction sutures for the stabilization. At the cutaneous site, the flap was closed layer by layer by using 3/0 resorbable polyglaction for the facia and the subcutaneous layers and 3/0 polypropylene sutures for the skin. After the surgery, pressure bandage was applied for the edema control externally and the patient was ordered soft diet for a week. The postoperative healing was uneventful, and at the sixth month follow-up visit, ideal closure of the fistula was observed (Figures and ).

A 38-year-old Caucasian Greek man presented to our emergency department complaining of a three-month history of intermittent abdominal pain and frequent episodes of diarrhea. He had a history of a previous admission in another surgical department four months earlier for BAT after a road traffic accident. At that time he underwent an abdominal ultrasound, which showed no intraperitoneal fluid or solid organ injury, and he was admitted for observation. We also recovered from his discharge note that, during the first 48 hours of his hospitalization, a progressive decrease in the hematocrit value from 41% to 28% was noted. An abdominal CT scan at that time showed a small amount of fluid in the rectovesical pouch with no solid organ abnormalities and a large hematoma in the subcutaneous fat tissue on both lumbar areas. He was hemodynamically stable and he had a transfusion with one unit of packed red blood cells and three units of fresh frozen plasma. He improved rapidly with conservative treatment and was discharged on the fifth day, asymptomatic. One month later he started to have episodes of vague abdominal pains and frequent episodes of diarrhea after meals. Our patient also mentioned that during that four-month period he had lost 10 kg in weight. Due to his fear of the resulting diarrhea, he had cut down on eating.\nOn our patient's current admission he complained of a colicky pain at the periumbilical region for the last 24 hours and two episodes of vomiting. On physical examination his abdomen was mildly distended with a diffuse tenderness on the hypogastrium. There was no rebound or guarding and palpation did not reveal any abdominal masses. His bowel sounds were increased. His blood tests were unremarkable. Plain abdominal X-rays revealed a dilated small bowel loop consistent with intestinal obstruction. He was initially treated with intravenous fluid replacement and nasogastric tube but his symptoms did not resolved. An enhanced-abdominal CT scan showed a small bowel loop with a thickened wall and narrow lumen with proximal bowel dilation. There was also increased density of the adjacent mesenteric fat (Figure ). Bearing in mind the episodes of diarrhea as well as the loss of weight, we included Crohn's disease in our differential diagnosis. Further investigation with colonoscopy and a barium enema did not reveal any pathology. In view of his continuing symptoms and the radiological evidence of a small bowel obstruction, a laparoscopic exploration was carried out. Due to multiple adhesions though, we had to convert our plan to a laparotomy. During the operation we found a thickened segment of ileum in his pelvis adherent to his bladder and the apex of the sigmoid loop. There was a stricture in his ileum at this point, and an ileosigmoid fistula was present (Figure ). The abnormal ileal loop was mobilized from his bladder and the sigmoid and resected, with restoration of intestinal continuity by primary side-to-side ileoileal anastomosis. The sigmoid fistula point was closed with seromucosal sutures. Histological examination of the resected specimen showed a mixed acute and chronic inflammatory process with hypertrophy of the muscularis externa. There was no evidence of Crohn's disease or malignancy. Our patient had an uneventful recovery and was discharged from hospital nine days later. At follow-up eight months later, he was symptom free and had regained weight.

A 50-year-old female presented with history of sudden onset weakness of right upper and lower limb for 1 day with deviation of angle of mouth to the left side. There was no history of headache, vomiting, seizures, or previous history of stroke or transient ischemic attacks. Also there was no history of chest pain, palpitations, or any cardiac disease. She is not a diabetic or hypertensive and there was no other comorbid illness. Her general examination revealed a pulse rate of 180/ min, regular, low volume, and blood pressure of 130/80 mmHg. The central nervous system examination showed normal higher mental functions, right upper motor neuron facial nerve palsy, and muscle power of 3/5 in upper limbs, 2/5 in lower in lower limbs with right extensor plantar response. The examination of other systems was normal. The laboratory investigations revealed normal liver and renal function tests. The serum calcium, magnesium, and potassium levels were normal. The serum troponin T and creatine phosphokinase levels were normal. The CT brain revealed left middle cerebral artery territory infarct measuring around 2×3 cm.\nOur patient presented to the emergency medical services department within 8 h of acute stroke. Her ECG showed regular narrow QRS complex long RP tachycardia at a rate of 186 beats per minute (bpm) with inverted p waves in lead III []. She had a normal study on echocardiography without structural changes or thrombus. On intravenous injection of 6 mg of adenosine, the patient transiently developed complete atrioventricular block but the atrial rate was persisting at the same 186 bpm with regular p waves separated by isoelectric baseline [] which reverted back to AT within a minute []. A diagnosis of atrial tachycardia was made and she was started on verapamil 40 mg three times daily orally. Following one dose of verapamil she developed sinus bradycardia (50 bpm). So verapamil was withheld and she was monitored in intensive care unit. In the following 1 week, she did not had any other episode of arrhythmia. Considering her elderly age, she was advised to undergo electrophysiological study to know whether she has any substrate for inducible arrhythmia but she did not consent for that. The ECG took before discharge showed normal sinus rhythm (64 bpm), with occasional premature atrial complex. One month later, she came for follow up and she did not report any palpitation and her ECG was in normal sinus rhythm with rate of 68 bpm.

A 56 year old man had transient loss of consciousness while driving. His wife pulled over and, in A& E, he was found to have a large superior mediastinal shadow, extending into neck, on chest X-ray (Figure ). CT scan revealed a 7 cm × 11 cm saccular aneurysm arising from the distal aortic arch between the origins of the left common carotid and left subclavian arteries, with cephalic ectopy. Transthoracic echocardiogram demonstrated large saccular aneurysm of the distal aortic arch with turbulent flow at the left subclavian artery. MR scan confirmed the presence of a large distal aortic arch aneurysm arising from the aortic arch between the origins of left common carotid and left subclavian arteries with extreme displacement of both vessels, the left common carotid artery being displaced anteriorly and to the right and also stretched and distorted owing to vertical expansion of the aneurysm posterior to it, and the left subclavian artery displaced well down and posteriorly into the left chest with even greater distortion (Figures and ). An aortogram clarified the situation further by showing that the aneurysm involved the arch beyond the origin of the left common carotid artery and that the left subclavian artery had been displaced by the aneurysm posteroinferiorly into the left chest. There was a great tortuosity and redundancy of the aorta between the two vessels and the aorta and aneurysm rose well into the neck. Coronary angiogram was normal.\nAt median sternotomy, the distal arch rose into the neck for a variable distance. There was a 9 cm × 11 cm aortic arch aneurysm arising distal to the left common carotid artery and proximal to the left subclavian artery, extending in both vertical and horizontal directions, with tortuosity and redundancy of the distal arch, causing compression, deviation and distortion of a number of adjacent structures (Figure ). Trachea was severely compressed with deviation to the right and the aneurysm formed a posterior relation of the ascending aorta and displaced it and the left common carotid artery anteriorly. The left pulmonary artery and the main pulmonary trunk were displaced posteriorly and inferiorly and the left vagus and the left phrenic nerves were stretched over the entire length of the aneurysm. Ascending aorta and proximal arch were normal sized. The proximal descending aorta was diffusely atheromatous. In order to get a better access to the descending aorta, a T shaped anterolateral extension was made in the 4th space. Cardiopulmonary bypass was instituted with common femoral arterial and right atrial venous cannulations and patient cooled to 14°C. Left ventricle was vented through right superior pulmonary vein. Under lower body deep hypothermic circulatory arrest (LBDHCA) and selective antegrade cerebral perfusion (SACP), the arch aneurysm was excised and a 30 mm VASCUTEK interposition graft used to establish the continuity between the arch distal to the left common carotid artery and the proximal part of the descending aorta (Figure ). The left subclavian artery was ligated and not reimplanted as it was severely atheromatous along its entire length. Selective antegrade cerebral perfusion was achieved through external cannulation of the left common carotid artery by a 10 F MEDTRONIC perfusion cannula using IL/min flow.\nPatient was extubated on first postoperative day and, except for mild hoarseness of voice which improved, made uncomplicated postoperative recovery. Biopsy of aortic tissue showed a picture consistent with arteriosclerosis and he was discharged home on seventh postoperative day. Follow up MR scan 4 months later showed satisfactory repair (Figure ) although he needed thyroplasty with a titanium clip for left vocal cord palsy. He continues to be fully active and asymptomatic 4 years after surgery and his follow up MR scans are normal.

A 50-year-old woman with an extensive medical history including spina bifida and hydrocephalus with placement of VA shunt and subsequent VP shunt due to VA shunt failure, both in her early 20s, presented with worsening shortness of breath for several years. An echocardiogram revealed normal left and right ventricular size, and systolic function however showed severe pulmonic valve insufficiency secondary to a migrated VA shunt catheter into the pulmonary artery [Figure and ]. Color Doppler and continuous wave Doppler assessment was consistent with severe pulmonic insufficiency with large regurgitant jet size and broadwidth (vena contracta jet width to transpulmonary annulus ratio 64%) as well as a dense jet on continuous wave Doppler with greatly increased pulmonic systolic flow compared to systemic flow by pulsed wave Doppler [Figure and ]. She underwent an exercise stress echocardiogram to assess her functional capacity but was only able to tolerate 3 min of exercise on a standard Bruce protocol, achieving 4.6 METS with a peak heart rate of 210 bpm (124% of the maximum predicted heart rate) limited by exertional dyspnea. The stress echocardiogram was nondiagnostic for the detection of ischemia due to submaximal workload achieved; however, no segmental wall motion abnormalities were seen. Pulmonary artery systolic pressure increased from 27 to 58 mmHg with exercise. She previously presented to the hospital with chest pain after outpatient pharmacologic stress myocardial perfusion imaging test that revealed moderate ischemia and scarring of the apical anterior and apical walls. She had coronary angiography, which did not reveal obstructive coronary artery disease but identified the migrated VA shunt catheter into the pulmonary artery []. Computed tomography scan of the chest with contrast was performed to rule out pulmonary embolism and further evaluate the migrated shunt catheter, which was negative for pulmonary embolism, and the retained catheter was noted to be coiling in the main pulmonary artery []. A multidisciplinary team discussion was held, and removal of this entrenched indwelling catheter through endovascular approach was considered to be too risky. She subsequently underwent open surgical intracardiac catheter removal and repair of the pulmonary artery with a bovine pericardial patch. The majority of the catheter was easily retrieved; however, there were areas that were embedded into the right ventricle myocardial wall as well as the superior vena cava []. The portion of the catheter adherent to the right ventricle wall was carefully excised; however, the adhesion to the superior vena cava was extensive and was therefore that portion was left in place. The pulmonic valve appeared to be well functioning, and it was deemed not necessary to proceed with pulmonic valve replacement. An echocardiogram obtained 2 months after the surgery showed improvement of pulmonic insufficiency, and the shunt catheter was no longer visualized. At 6-month follow-up, the patient reported significant improvement in her symptom.

A 43 year old female with chronic back pain developed depression and attempted suicide with an overdose of diazepam and methadone after an argument with her husband in the evening. She intentionally consumed approximately 40 to 50 tablets of diazepam at 5 mg strength as well as an unknown quantity of methadone tablets was found the following day in an unresponsive state with a respiratory state of only 4 breaths per minute but was revived at a local hospital with the use of naloxone. Although she could awaken and answer questions appropriately, this was only transient and required a naloxone drip infusion over 24 hours; no flumazenil had been used. Her potassium was also elevated initially at 7.6 that later normalized and had a leukocytosis secondary to mild aspiration pneumonia that was successfully treated with antibiotics. She was discharged within one week in a much improved state to a psychiatric facility. After two days as in-patient for psychiatric care, she was discharged to home in a markedly improved state with a mental status that was back to her baseline and fully able to be self-sufficient without any cognitive deficits. Interview with family and friends confirmed that she was cognitively normal and fine up until 3 weeks after the event when she abruptly changed midday and seemed confused and forgetful with a rapid worsening the following day. She was first noted not be able to play cards with her family, had developed social withdrawal with a lack of personal hygiene, and became incontinent as well. She appeared very lethargic and not very interactive. After this continued for approximately 5 days without any improvement, she was evaluated at the Emergency Dept. and admitted after a CT head exam disclosed marked and diffuse hypointensity throughout the subcortical white matter (). This was later evaluated by MRI as being a confluent change throughout the entire white matter, and appeared diffusely hyperintense on both FLAIR and T2 weighted sequences (), with hyper-intensity also noted on diffusion weighted imaging. The unusual feature though was that the cerebellar white mater had been spared, and that the change was a strictly supratentorial effect () without altering signal intensity for the white matter tracts in the internal capsule and brain stem area. Using large voxels placed over the semi-centrum ovale, MR spectroscopic analysis at 1.5 Tesla showed elevated abnormal elevations in the choline and creatinine peaks with a small peak seen for lactic acid as well (). Neurological exam revealed a blunted flat affect with abnormally slow gait and left side neglect, with disorientation and very poor short term recall. As the patient had a detectable benzodiazepine level at approximately 83 ng/mL, 1.0 mg flumazenil was given in 0.2 mg increments every 30 seconds during EEG monitoring. Although background slowing improved slightly, there was a clear and definite transient neurological improvement. Serum benzodiazepine levels continued to decline from 67.9 to 32.8 ng/mL over 4 days, with modest clinical improvement in her mental status also observed. Follow-up evaluation revealed substantial improvement both clinically and radiographically, with a normal mental status and normal MR imaging of the brain within one year of the event, with normal metabolism of both the gray and white matter of the brain, as assessed by 18F-FDG PET imaging ().

A 42-year-old right-handed man was referred to our neurosurgery department for generalized epileptic seizures, muscular weakness of both upper and lower limbs, gait instability and headache. The patient was suffering from recurrent seizures since his childhood and was under anticonvulsant treatment with phenobarbital and valproic acid. He was a heavy smoker and had a history of dyslipidemia and allergy in amoxicillin. Also, in the past, the patient underwent a surgery on his right hip after a traffic accident that he had 2 years before.\nHis clinical examination showed increased reflexes of his left leg without other neurological findings. A brain CT scan without contrast was initially performed and revealed a lesion in his right parietal-occipital lobe. The additional intravenous administration of contrast medium showed that the dimensions of the lesion were 7.5 × 2 × 4.6 cm. The contrast uptake and the density of the tumor were heterogeneous. There was also 1 cm middle line shift to the left as well as elevation of the right occipital horn. The patient had screws in his right hip, which were surgically removed in order to perform an MRI for further investigation of the tumor. MRI examination confirmed the existence of a lesion in the right occipital lobe, nearby the occipital horn compatible with the image of a low grade glioma (). The patient did not have any visual disorders as the opthalmologists reported before surgery. Also, blood exams did not reveal any numerical or functional disorders. The CT of the thorax, pelvis, upper and lower abdomen did not show any other pathological signs. The patient was scheduled for an occipital craniotomy for biopsy and depending on the result, resection or not of the lesion. Due to the inability of the biopsy to clarify the type of the tumor and considering the young age of the patient, we proceeded to surgical excision of the tumor. Intraoperative neuromonitoring (motorsensory and visual evoked potentials) and neuronavigation were used. The tumor was resected with the use of microscope and CUSA. A post-surgical MRI was performed after the operation and confirmed the subtotal excision of lesion (). CSF analysis did not reveal any pathological findings. Histopathological analysis revealed DLBCL () and the patient was referred to hematologists-oncologists of our hospital for further treatment manipulations. The patient was treated with radiotherapy and methotrexate and 16 months after his surgery is still tumor free.

A 56-year-old male patient, whose plasmacytoma was enucleated 3 years ago from the medial side of the left mandible, was referred to our clinic due to his complaints of persistent orocutaneous fistula (Figures –). Past medical history revealed that the patient was operated three times to close the orocutaneous fistula by local flaps; however, none of these operations were successful. CT images of the patient demonstrated that the medial side of the left mandible was missing and there was a 3 × 2 cm diameter defect located between the left side of the mouth floor and the basis of the left mandible neighboring the left submandibular gland. The main reason of the failed attempts to close the fistula was considered to be the ineffective management of dead space surrounding the fistula. Consequently, it was decided to use the submandibular gland as a pedicled flap to fill the defect and support the oral and the cutaneous flaps.\nUnder general anesthesia, the fistula was excised initially and the oral and the cutaneous healthy soft tissues were prepared. At the extraoral site, the incision was extended to the posterior and anterior directions, following the previous incision lines. In the subplatysmal plane, the superficial layer of the neck fascia was dissected to reach the base of the mandible. After the dissection of the fascia, the submandibular gland and the base of the mandible were exposed, the soft tissues surrounding the submandibular gland were dissected, and the gland was mobilized by protecting the arteriovenous supply and the duct. At the oral site, the margins of the wound were released by blunt dissection and were closed by mattress sutures via 5/0 polypropylene. Following the mobilization of the gland, a soft tissue tunnel was prepared between the submandibular space and the defect area and the submandibular gland was rotated by passing the gland through the soft tissue tunnel by preserving the pedicle (). The rotated gland was sutured to the recipient site with 3/0 reabsorbable polyglaction sutures for the stabilization. At the cutaneous site, the flap was closed layer by layer by using 3/0 resorbable polyglaction for the facia and the subcutaneous layers and 3/0 polypropylene sutures for the skin. After the surgery, pressure bandage was applied for the edema control externally and the patient was ordered soft diet for a week. The postoperative healing was uneventful, and at the sixth month follow-up visit, ideal closure of the fistula was observed (Figures and ).

A 22-year-old intoxicated male without any medical comorbidity was involved in a motor vehicle accident when he lost control of his automobile in a residential area and ultimately collided into a house. The patient was unrestrained and did not lose consciousness in the accident. Emergency medical personnel at the scene did report the deployment of the airbags with the patient displaying a Glasgow Coma Scale score of 15. He was emergently brought to the trauma center in stable condition. His primary survey revealed diminished breath sounds over his right hemithorax in conjunction with an increased respiratory rate. On further examination, he did appear to have crepitus over his right clavicle and gross deformity in his right thigh. Neurologic and vascular examinations of his extremities were normal.\nRadiographic analysis of his chest revealed a right proximal third clavicle fracture with inferior displacement complicated by a partial pneumothorax (). He had also sustained a displaced femoral shaft fracture. A chest thoracostomy tube was inserted emergently into the right pleural cavity and placed under suction to inflate the lung. Further radiographic studies including computerized tomography images confirmed that the fractured clavicle had penetrated the pleural cavity and caused a partial lung collapse (). The patient was initially placed in a sling for the clavicle fracture to allow access to the thoracostomy site. The patient underwent intramedullary nailing of his femur with a centromedullary device without complication the day of his injury. Due to the magnitude of displacement of the clavicle fracture, it was thought that achieving union with nonoperative modalities would be problematic. Pulmonary alveolar tissue seemed to be interposed in the fracture site further complicating the probability of union as well pneumothorax resolution with conservative treatment. The patient was counseled regarding both the orthopedic and cardiopulmonary risks of the surgery. If a closed reduction was unsuccessful, he was informed that an open reduction would be indicated. He understood the possible complications and wished to proceed. 2 days after stabilization of his femur fracture, the patient had an open reduction with internal fixation of his right clavicle.\nThe patient was positioned supine on a radiolucent table. After multiple unsuccessful attempts at closed reduction, a traditional anterior approach was employed to gain access to the fracture (). Once the fracture was exposed and the chest tube under suction, a pointed reduction clamp was used to retract the lateral fragment from the pleural cavity (). There was noted to be some comminution at the fracture site. A general trauma surgeon was available in the operating room in case of any cardiopulmonary compromise. The patient’s vital signs and oxygenation remained stable throughout the operative procedure. After debridement of the fracture ends, the fracture was reduced and provisionally fixed with a bone holding reduction clamp. A six-hole locking 3.5 mm dynamic compression plate was affixed to the clavicle with hybrid screw technique to achieve stable fixation ().\nOn the 2nd post-operative day, his chest thoracostomy tube was removed without incident. The patient was discharged from the hospital on the 3rd postoperative day. At 6-month follow-up, the patient did not complain of pulmonary symptoms. His wounds were well healed and he had regained full active range of motion of his shoulder. Repeat radiographs showed no residual pneumothorax and a healed clavicle fracture ().

The 55 years old male patient received a locking distal tibial plate along with distal fibular plate 3years back from UAE. Now patient came with complaint of non healing ulcer over medial aspect of lower 1/3rd of right leg from past 1 year. Patient was also type 2 diabetic diagnosed 5 years back. Non operative management did not improve the symptoms. The patient consented to implant removal, with the express understanding that implant removal might be impossible because already one failed attempt had been performed at some other hospital six months back. One of the 5 proximal locking screws was removed using the standard screwdriver. Rest of the proximal screws were stripped headed. For their extraction we used the AO synthes screw extraction kit along with conical extraction screw (AO Synthes) but the screws did not come out. The carbide drill was not available at that time. We then decided to proceed with the new technique. The rest of the proximal screws were removed using a technique not previously described. We used stainless steel metal cutting blades that are used to cut door locks or pad locks to cut the remaining stripped headed screws. Firstly, after exposing the plate to be removed a space is created between locking plate and bone adjacent to screws to be cut with the help of sharp osteotome. Then an iron cutting blade which was previously autoclaved introduced between plate and bone adjacent to screws to be cut and with to and fro motion all the remaining screws were cut. The remaining threaded parts of screws were left in the bone because there removal may further weaken the bone. Overall 2 blades were used to cut the 4 screws. Screws were cut with care with slow to and fro motion of blades but with firm pressure on blade to avoid any unnecessary soft tissue injury. It only takes 10 minutes to cut all the remaining 4 proximal screws and there was no heating problem during the cutting of screws as there is with other procedures such carbide drills and high speed burrs. At the end of the procedure, the surgical wound was washed thoroughly with normal saline to remove metal debris. We name this technique as Rohit’s technique for removal of stripped headed/jammed interlocking screws.

We report a rare malposition of a PA catheter secondary to kinking in a 63-year-old male who was scheduled for an off-pump coronary artery by-pass graft. The patient had a history of diabetes mellitus with neuropathy, early stage nephropathy and retinopathy. The pre-operative echocardiogram was significant for diffuse left ventricular hypokinesis with a corresponding ejection fraction of 51 %. The right ventricle size was normal and there was no evidence of pulmonary hypertension. After placement of standard monitors and preoxygenation of the patient, midazolam, fentanyl and rocuronium were administered. The patient was then intubated and maintenance of anesthesia was achieved using 1 % sevoflurane along with a continuous infusion of remifentanil. Subsequently, an arterial line was placed and a central venous catheter and a sheath for a PA catheter were inserted in the right internal jugular vein. The patient showed stable hemodynamics throughout the insertion of the catheters.\nDuring insertion of the PA catheter, we monitored the pressure waveform from the distal catheter port. The catheter was advanced to the right ventricle at a depth of 40 cm, then, was further advanced to the pulmonary artery at a depth of 55 cm. However, it was relatively easy to drop back the catheter to the right ventricle. Even after several attempts, no stable pulmonary artery waveform was obtained. We then discovered that the distal and proximal ports presented the same waveform pattern. We made the range of the two pressure lines the same and then realized that the two waveforms were completely identical (Fig. ).\nWe first suspected a mechanical problem with the catheter itself such as communication between lumens, so we flushed saline in each lumen. This changed each waveform independently, thus, communication between lumens seemed to be unlikely. Although we tried to remove the catheter, it was firmly in place at 15 cm depth. Flushing of cold saline through the distal port and placement of a guide wire were not successful in attempts to remove the catheter. We then utilized portable fluoroscopy to visualize the catheter in situ. We were able to determine that the catheter had formed a kink around the apex of the right ventricle (Fig. ). With the use of a guide wire and alternating patient body position, we were able to straighten the catheter, which allowed for its subsequent removal. The removed catheter showed evidence of bend at the distal site of the thermo-dilution lead (Fig. ). While reinsertion of new PA catheter, fluoroscopy showed that a kink started to form around the apex of the right ventricle. However, this time we advanced the PA catheter successfully using fluoroscopy and alternations in patient body position. Thereafter, the surgical procedure and postoperative course were both uneventful.

A 55-year-old male reported with complaints of a gradually enlarging lump in the left side of the abdomen over a period of 5 months associated with dull aching pain and occasional vomiting. On examination there was a huge mass of around 25 × 20 cm spanning the whole abdomen with an irregular surface and variable soft to firm consistency. The ultrasonography of the abdomen suggested a large multiloculated cystic mass occupying the whole abdomen and pelvis, right kidney was normal but the left kidney could not be visualized. Contrast enhanced computer tomography of the abdomen showed a homogenous non enhancing retroperitoneal mass measuring approximately 17 × 21 cm with a mixed echogenic pattern in its anterolateral region (). The cystic mass occupied the whole of the abdomen displacing the pancreas and left ureter anteriorly and across the midline. A focus of calcification was seen at the pheriphery of the lesion. Left kidney and its pelvicalyceal system was not visualized. There was a loss of fat plans with the adjacent gut loops. An exploratory laparotomy was done and a large cystic mass with solid areas weighing around 7 kg was found in the left side of the abdomen adherent to the distal transverse colon, splenic flexure and the descending colon (). There was no identifiable left kidney. The tumor was resected en mass along with the adherent large bowel and a primary colo-colic anastamosis was done. The patient had an uneventful post operative course and was followed up for six months without recurrence.\nThe specimen grossly revealed 29 × 20 × 15 cm mass with marked congestion and a multinodular external surface, while the cut section revealed a multicystic mass with solid areas. Segment of large intestine measuring 5 cm was attached to it with no kidney identified grossly. Microsections showed a biphasic (epithelial and mesenchymal differentiation) malignant tumor with solid and cystic components infiltrating through the wall of the adherent bowel. However, the resection margins were free from the tumor. One of the sections showed a small amount of residual renal tissue at the periphery indicating that by and large the kidney was replaced by the tumor (). The immunohistochemistry panel revealed CD34, CD117, calretinin, desmin, LCA, synaptophysin and chromogranin negativity and, NSE positive (), patchy bcl2 positivity in ganglion cells and patchy EMA positive membrane. Hence the diagnosis of a retroperitoneal MPNST was made based on the clinic pathological co correlation.

A 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.\nThe examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation (). A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.\nThe blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous surgery site an upper GI endoscopy was performed. A small benign looking ulcer was seen at the pylorus of the stomach.\nWith a strong suspicion of gastrocutaneous fistula, a CT fistulogram was performed. An enterocutaneous fistula between the pylorus of the stomach and the anterior abdominal wall was seen. A long side branch of the fistula tract was seen communicating to a moderate sized left subphrenic collection ().\nWith confirmed diagnosis of complex gastrocutaneous fistula a repeat surgery was planned. The abdomen was entered after incising the previous scar on left lateral side and extending the incision downwards and upwards. Dense interbowel adhesions were encountered. Meticulous adhesiolysis and dissection was performed. The abscess cavity was drained and the perforation on the pylorus of the stomach was identified. It was around 1 cm × 1 cm size. Repeat omental patch repair was performed. In view of difficult dissection, feeding jejunostomy and retrograde tube duodenostomy were also made.\nAn uneventful recovery happened. He attended follow up clinic till 4 months following the discharge. There was an incisional hernia but otherwise he was doing fine. After this he was lost to follow up.\nTimeline