Iatrogenic Cushing's syndrome in a case of allergic bronchopulmonary aspergillosis treated with oral itraconazole and inhaled budesonide.

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus that occurs in patients with asthma or cystic fibrosis. Here, we report a case of a young female with bronchial asthma who presented to our hospital with worsening breathlessness on exertion. She was diagnosed to have ABPA and was initiated on oral itraconazole while continuing inhaled long acting beta-2 adrenergic agonist and medium dose inhaled corticosteroid (ICS) for her asthma. Three months after initiation of therapy, the patient had significant improvement in breathlessness. However, she had weight gain, facial puffiness, increased facial hair and development of striae on her inner thighs, calf and lower abdomen. Her serum cortisol levels were found to be suppressed and hence a diagnosis of iatrogenic Cushing's syndrome was made. Our case describes the potentially serious interaction between ICS and oral itraconazole, a treatment very commonly prescribed in patients with ABPA.

Resection of Bar in the Management of Calcaneonavicular Coalition: A Systematic Review.

The most commonly encountered type of tarsal coalition in symptomatic patients is the calcaneonavicular coalition. Non-surgical treatments are effective for most patients. However, if surgery is required, excision of the calcaneonavicular bar can be a successful option that preserves hindfoot mobility and function. We conducted a systematic review of calcaneonavicular bar excision in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. To conduct the review, we conducted a thorough search of several databases, including PubMed, Cochrane, Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, and bibliographies. We analyzed the chosen studies to collect information on patient demographics, clinical outcomes, surgical techniques, and potential complications. We identified 11 studies that included 274 patients for a total of 394 feet. The average age of patients in these studies was 12.5 years, ranging from 8.2 to 19.4 years. Follow-up periods varied from 2.3 to 23 years, with an average duration of 5.9 years. Excision of the calcaneonavicular bar was performed at 380 feet, while fusion was performed at 14 feet. In 50.5% of the feet, the extensor digitorum brevis was used as an interposition material. Successful outcomes after bar excision were observed in 82.9% of cases (304 feet) and were described as satisfactory, improved, good, or excellent outcomes. In one study, the American Orthopaedic Foot and Ankle Society (AOFAS) score improved from 47.89 to 90.22 in 12 feet after bar excision. Recurrence was reported in 52 feet out of the 380 feet that underwent bar excision. Progression of arthritis in the ankle and subtalar joint was reported in 25 feet. Various complications were reported, including paraesthesia in the hindfoot (three feet), midfoot pain (three feet), hindfoot pain (two feet), mild wound infection (one foot), and swelling and stiffness (one foot). Surgical excision of the calcaneonavicular bar has shown successful outcomes in most patients, regardless of the use of interposition material. These outcomes are associated with minimal and acceptable complications. However, since the studies conducted in the literature were single-center retrospective and prospective trials, a multicenter prospective study with patient-centered, validated outcomes would provide a better opportunity to support the evidence in favor of surgical excision of the calcaneonavicular bar. Overall, the use of various interposition materials is associated with reduced chances of recurrence compared to cases where no interposition material was used.

Effect of Peri-Operative Blood Transfusion on Short and Long-Term Mortality Rates in Elderly Patients With Neck of Femur Fractures: A Retrospective Study.

Introduction  The current reported mortality rate for elderly neck of femur fractures (eNOFF) is relatively high in the UK. eNOFF patients commonly suffer from associated cardiovascular co-morbidities and tend to have fragile physiological states and poor physiological reserves. Although some studies have shown a potential link between blood transfusion and mortality in eNOFF patients, there is no general consensus on this matter. Therefore, our study aims to explore the possible association between blood transfusion and length of hospital stay (LOHS) as well as short- and long-term mortality rates in eNOFF patients by reviewing the practice of blood transfusion. Methods  This retrospective study was conducted at Wrexham Maelor Hospital, which is part of the Betsi Cadwaladr University Health Board (BCUHB), Wales. The study included patients who were 65 years of age or older and presented with neck of femur fractures. Only patients who required surgical intervention were included, and those managed non-operatively were excluded from the study. The statistical analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, New York, United States). Furthermore, unpaired t-tests and log-rank (Mantel-Cox) tests were performed to compare the groups that received blood transfusions.  Results  During the study period, a total of 501 eNOFF patients were included in the primary cohort of the study, with a mean age of 81 years (ranging from 65 to 102). The majority of the patients were female (n=340). Of the 501 patients, 79 (15.8%) received a blood transfusion during their treatment. Around 52.9% of the eNOFF patients were categorized as American Society of Anesthesiologists (ASA) III, but there was no statistically significant difference in the requirement of blood transfusion between patients in ASA III, II, and IV categories, as compared to ASA I. Additionally, the mean time to surgery was higher in patients who received a blood transfusion (35.8 hours), and this difference was statistically significant (p=0.035). Moreover, the average LOHS after surgery for eNOFF was longer in patients who needed peri-operative blood transfusion (22 days), and this difference in the means was statistically significant (p=0.022). At the one-year post-surgery mark, mortality was higher in the transfused group (33%), and long-term five-year mortality rates were also higher in this group (63.2%).  Conclusion  Peri-operative blood transfusion may confer certain benefits in the management of eNOFF ptients. However, it should not be regarded as a panacea for improving long-term outcomes. The decision to administer blood transfusion must be made on a case-by-case basis, with careful assessment of individual clinical indications, and the potential risks and benefits taken into consideration. To achieve optimal clinical outcomes, close monitoring and follow-up of eNOFF patients, both in the short-term and long-term, are essential.

Surgical scar revision using silicone gel sheet as an adjunct.

INTRODUCTION: Scar is often referred to as an unattractive mark after healing of a wound. An undesirable scar may have negative social, emotional, and functional impact on the patient. It is our job as surgeons to adequately understand the expectations of the patient and counsel them for a successful procedure. MATERIALS AND METHODS: Twelve patients were randomly chosen for the study, of which five were males and seven were females. The scar tissue was removed surgically, and silicone gel sheets (SGSs) were applied on the 14th postoperative day, and the dimensions of the new scar was measured periodically up to 12 months. RESULTS: The study comprised of 12 patients- 5 males and 7 females. The descriptive statistics were calculated as median and interquartile range and comparison between time intervals was done using Wilcoxon signed rank test. Out of the 12 patients, 10 showing complete resolution of the scar and 2 patients had partial relapse of scar. However, they were satisfied with the final outcome. CONCLUSION: Our study found that SGSs applied to surgically revised scars significantly improves their appearance. The ease of use of the SGSs also makes it patient friendly. We observed almost complete resolution of the scar in ten patients and two patients exhibited partial relapse of the scar. However, there was a significant improvement in the overall appearance of the scar, and the patients were satisfied with the results of the procedure.

Comparative outcome of anaesthetic for elderly hip fracture.

PURPOSE: Current guidelines recommend offering patients both options of a spinal or general anaesthetic. At local level we attempt to ensure whether similar outcome is reflected in our practice regarding difference between General anaesthesia(GA) and Spinal Anaesthesia(SA) in morbidity and mortality. METHODS: Data from spreadsheet maintained for NHFD was used to identify patients with Neck of Femur Fracture in 2018.Mortality data was retrieved from the Welsh Clinical Portal. Data was organised according to the type of anaesthetic received. Outcome measures for Morbidity (length of stay in hospital) and Mortality (at both 30 days and 120 days) following surgery, were then inputted for these patients. Statistical analysis was performed using SPSS software. A Mann Whitney U Test was performed for length of stay and Kaplan-Meier Estimates for survival at 30 and 120 days. Log Rank (Mantel Cox) Hypothesis Test is used to compare mortality between two Anaesthetic groups. RESULTS: We reviewed 203 patients elderly hip fracture with mean age of 83 (range 60-99), there were 142 Female and 61 males.4 patients were treated non operatively, and 2 patients had no data available 0.146 patient received GA and 46 received spinal anaesthesia. Hemiarthroplasty and DHS are commonest procedure in both groups. On applying Mann Whitney U test There is no statistical difference between the length of stay There is no statistical difference between the length of stay for SA and GA Patients. (p = 0.483). for SA and GA Patients (p = 0.483). On APPLYING Log Rank (Mantel-Cox) Analysis there is no statically difference in mortality at 30 days and 120 days with p value 0.087 and 0.397 respectively. CONCLUSION: In summary, this audit remains in line with current literature, that there is not a significant difference between the length of stay, survival at 30 days and at 120 days between the two different groups.

Routine postoperative blood tests in all patients undergoing Total Hip Arthroplasty as part of an enhanced recovery pathway: Are they necessary?

INTRODUCTION: The increasing demand for Total Hip replacement (THR)/Total Hip Arthroplasty (THA) continues to place significant financial pressure on the National Health Service (NHS). Many institutions undertake post-operative blood tests routinely in this group of patients. The aim of this study was to identify if such routine blood tests (Full Blood Count (FBC) and Urea and Electrolytes(U&Es)) are required in all THR patients post-operatively. METHODS: Single institute, Multi-surgeon, retrospective observational study of consecutive patients who underwent primary elective THR done from Jan 2014 to Dec 2018.Post-operative blood tests and medical records were reviewed to identify derangement in haemoglobin (Hb) level and renal function requiring clinical intervention. RESULTS: Over the period of 4 years, 353 patients underwent elective THR with mean age of 70 years (range: 42-90). There were 203 Males and 150 Females. Mean pre-operative Hb was 134.7 g/l. Mean post-operative drop in Hb was 22.3 g/l. None of the patients in ASA grade 1 and 2 with age ≤70 years required blood transfusion post operatively.6.4% of patients (n = 18/280) with an ASA of 1-2 had postoperative blood results requiring intervention of which only four (1.2%) were ≤70 years of age compared to 17.8% of patients (n = 14/73) with ASA 3-4.Overall none of the patients in ASA grade 1 and 2 with age ≤70 years required blood transfusion post operatively nor had electrolyte disturbance. 1.2% had deranged renal function that needed minor clinical intervention. CONCLUSION: Routine post-operative blood analyses may not required for all patients undergoing THA. Young and healthier patients seldom have significant abnormalities on routine post-operative blood analyses which requires clinical intervention.

Paget-Schroetter syndrome as a result of 1st rib stress fracture due to gym activity presenting with Urschel's sign - A case report and review of literature.

BACKGROUND: Paget-Schrotter Syndrome (PSS) also known as "effort thrombosis" is a form of primary thrombosis in the subclavian vein at the costoclavicular junction is usually seen in younger patients after repeated strenuous activity of the shoulders and arms. When occurring in younger patients, PSS presents itself with predisposing factors such as unilateral dull, aching pain in the shoulder or axilla and swelling of the arm and hand. CASE PRESENTATION: We report a rare case of unusual left axillo-subclavian vein thrombosis following narrowing of thoracic outlet due to stress injury of rib fracture likely during gym activity in absence of other clear risk factors and a negative hypercoagulable workup in a 27-year-old man who was admitted as left deltoid rupture 5 days after his usual gym. Subsequently he was transferred under vascular surgery for thrombectomy. CONCLUSION: In addition to the unusual location in the left upper extremity in our case, the absence of common etiologic factors makes our case of Paget-Schroetter Syndrome a very unique one. This case report aims to discuss the common causes of PSS in order to raise a high index of suspicion in certain groups of patients. This will allow early identification and avoidance of catastrophic outcomes such as pulmonary embolism and stroke.

Wernicke’s encephalopathy associated with liver abscess.

Wernicke's encephalopathy is a rare neurological disorder caused by thiamine deficiency, characterised by ocular motor dysfunction, ataxia and impairment in consciousness. It predominantly affects brain regions with a high metabolic rate such as mammillary bodies, medial thalamic nuclei, the tectal region and the cerebellum. Although chronic alcoholism is the most common cause of Wernicke's encephalopathy, various other conditions not related to alcohol consumption such as bariatric surgery, acute pancreatitis, hyperemesis gravidarum, prolonged fasting and gastrointestinal surgery have been implicated in its aetiology. We report the case of a patient who underwent surgery for liver abscess and subsequently developed Wernicke's encephalopathy; he showed a positive response to thiamine supplementation. This is the first report describing liver abscess as the cause of Wernicke's encephalopathy.

Adenoid Cystic Carcinoma of Buccal Mucosa: A Rare Case Report.

Adenoid cystic carcinoma is a malignant neoplasm most commonly originating in salivary glands of head and neck region. Among intra oral adenoid cystic carcinoma, buccal mucosa is among the rarest sites. We report a case of adenoid cystic of buccal mucosa in a 40-year old female. We have discussed the clinical features, histopathology, diagnosis and treatment along with a brief review of the relevant literature. Although the buccal mucosa is an uncommon site for adenoid cystic carcinoma, the relatively indolent growth pattern of this case and its location which is rather atypical for this type of salivary gland malignancy primarily warrants the necessity behind reporting of this case. Secondly, adenoid cystic carcinoma should be considered in the differential diagnosis of mass of buccal mucosa. It is important to identify such cases rather early and surgical removal with adequate margins is the treatment of choice .

Dislocation Intermediate Cuneiform with Fracture Medial Cuneiform.

INTRODUCTION: Dislocation of intermediate cuneiform is a rare injury in English language literature. Dislocation of intermediate cuneiform with undisplaced medial cuneiform fracture has been reported only once. We report the first case of dislocation intermediate cuneiform with displaced medial cuneiform fracture. CASE REPORT: A 43-year-old male was diagnosed of dislocation of intermediate cuneiform with fracture medial cuneiform after a road traffic accident. This was treated by a method of distractor application that is only reported in navicular fracture dislocation. This treatment method avoids open reduction with minimal of complications and good outcome. CONCLUSION: Distractor technique was applied for the first time in cuneiform fracture dislocation in this case, and we recommend it to avoid open reduction. The previous reported injuries in this region were mostly treated by open reduction. Due to the rarity of this injury and technique, our case adds to the literature a novel reduction method.

Comparison of efficacy of mandible and iliac bone as autogenous bone graft for orbital floor reconstruction.

OBJECTIVE: This study evaluated and compared the efficacy of mandible and iliac bone as autogenous bone graft for correction of orbital floor fractures. PATIENTS AND METHODS: Twenty patients who suffered orbital floor fractures took part in the study. The subjects enrolled in the study sustained both isolated orbital floor fracture and orbital floor fracture associated with fracture of zygomatico-maxillary complex. Each inferior orbital wall was reconstructed using either a mandible bone graft or an iliac graft. Mandibular symphysis was opted as a donor site for graft harvest from mandible and anterior iliac crest for the iliac group. CT scans were taken before the operation. Inclusion criteria consisted of at least 2 months postsurgical follow-up, pre- and post-surgical photographic documentation, and complete medical records regarding inpatient and outpatient data. To describe the distribution of complications and facilitate statistical analysis, we categorized our findings into diplopia, enophthalmos, and restriction of ocular movements before and after treatment. We also considered the time required for the harvest of the grafts and the donor site complications. A comparative study was carried out using Chi square test and student t test. We considered P value <0.05 to be statistically significant. RESULTS: Ten iliac crest grafts and ten mandible bone grafts were placed. The mean age of the patients was 33.1 years. 80 % of the patients were males. The most common complication of orbital floor fracture was diplopia, followed by enophthalmos and restriction of ocular movements. The post operative results were compared after 2 months of the surgery. In iliac crest group, diplopia got corrected in six out of seven patients (85 %), enophthalmos in four out of five patients (80 %) and restricted ocular movement showed 100 % correction. While in mandible group, diplopia and ocular movement showed 100 % correction and enophthalmos got corrected in five out of six patients (83 %). No statistically significant differences were found between the two groups on comparing these variables. On the other hand the mean time required for the harvest of iliac graft and mandible graft was 30.2 ± 3.52 min and 16.8 ± 1.75 min respectively. The difference was statistically significant. CONCLUSION: There is no difference in the ability of mandible and anterior iliac crest bone grafts to correct post-traumatic diplopia, enophthalmos and restricted ocular movements. But the time and ease of harvest of the graft from mandible was comparatively less and easy especially when the treating doctor was an oral and maxillofacial surgeon. Secondly the post-operative morbidity was low and the quality and contour of the bone graft was very adaptable for the reconstruction of the orbital floor.

Traumatic bilateral posterior hip dislocation in 10 year old male child.

Traumatic bilateral posterior hip dislocation in skeletally immature patient is reported very less in literature. We report a 10 yr old boy presented to us following farmyard injury with bilateral posterior hip dislocation, which was reduced manually under sedation with uneventful follow-up and complete hip range of motion at 2 year.

Evaluation of stromal myofibroblasts expression in keratocystic odontogenic tumor and orthokeratinized odontogenic cysts: A comparative study.

OBJECTIVE: Keratocystic odontogenic tumor (KCOT) has an aggressive clinical course and a high tendency of recurrence, while orthokeratinized odontogenic cyst (OOC) has different characteristics and does not show aggressive behaviour. Even the treatment of these two lesions varies considerably. A large number of epithelial molecules have been studied in order to differentiate odontogenic keratocyst (OKC) from OOC, but stromal factors have not been adequately studied. Recently, tumor stroma has evolved as a particular field of interest. In the present study, we aim to evaluate and compare the expression of stromal myofibroblasts (MFs) in these entities and correlate it to its aggressive behavior. The term 'keratocystic odontogenic tumor' has been introduced by WHO in 2005 for odontogenic keratocyst keeping in mind its aggressive behavior, however still many pathologists and clinicians use the term OKC synonymously. MATERIALS AND METHODS: A total of 10 cases of KCOT and 10 cases of OOC were stained for alpha-smooth muscle actin (αSMA) for demonstration of stromal MFs. MF frequency was assessed as the number of αSMA-positive stromal cells in 10 high power fields, presented as the mean number of positive cells per field. RESULTS: Counts showed that the mean number of positive cells in KCOT (20.6 ± 2.05) was significantly higher than that seen in OOC (10.4 ± 1.06) (P < 0.05). CONCLUSION: The different behaviors of these lesions are compatible with the finding of the present study. The increased number of stromal MFs in KCOT in comparison to OOC correlates with its aggressive behavior and increased tendency towards recurrence.

Alpha smooth muscle actin expression in a case of ameloblastic carcinoma: a case report.

BACKGROUND: The aim of the present article is to report a case of ameloblastic carcinoma and use a marker alpha smooth muscle actin as a tool to differentiate cases of ameloblastic carcinoma from that of ameloblastoma. METHODS: Case study reporting a case of ameloblastic carcinoma (AC) with expression of alpha smooth muscle actin (alpha-SMA) as a marker for emergence of stromal myofibroblasts. The expression of myofibroblasts was also compared with that of ameloblastoma. RESULTS: Difference between the two lesions in the pattern of expression of alpha smooth muscle actin was also observed. There was increase in the number of myofibroblasts in the stroma of AC while in ameloblastoma, it was comparatively less. Secondly, few areas of the carcinomatous ameloblastic island also exhibited a mild positivity towards alpha smooth muscle actin. CONCLUSIONS: Increase in number of stromal myofibroblast may be taken as a predictor for carcinomatous transformation. Further studies with greater sample size can validate the use of alpha-SMA as a marker to differentiate ameloblastic carcinoma from ameloblastoma.

Outcome of surgical treatment of type IV capitellum fractures in adults.

OBJECTIVE: Fractures of the capitellum and trochlea constitute less than 1% of all elbow fractures and a shear fracture involving the capitellum and extending medially into most of the trochlea is rarely reported. Type IV capitellum fracture is still controversial in regard to its radiographic appearance, surgical approach and osteosynthesis. We report 10 cases of type IV capitellum fracture with a view to elucidating its clinical features and treatment outcome. METHODS: We treated 10 patients of type IV capitellum fracture with a mean age of 32 years. A uniform surgical approach and postoperative rehabilitation were followed. RESULTS: Nine patients presented to us after a mean of 4 days of injury and one patient was nonunion after 6 months of injury who had been treated conservatively by a bone setter. Double arc sign was absent in 6 cases. Intraoperatively 6 capitellotrochlear fragments were devoid of soft tissue attachments. By Mayo Elbow Performance Score evaluation, 7 patients got excellent, 2 good and 1 fair results. One patient with associated elbow dislocation developed heterotopic ossification. There was no case of avascular necrosis, osteoarthrosis or fixation failures. CONCLUSIONS: Type IV capitellum fractures are rare and belong to complex articular injuries. A good functional outcome can only be achieved with open reduction and stable internal fixation followed by early mobilization. Preoperative radiographic assessment and computed tomography help surgeons in choosing the right surgical approach and implants. Good surgical technique and stable internal fixation are the keys to early mobilization and good functional outcome.

Aggressive atypical ameloblastic fibrodentinoma: Report of a case.

Ameloblastic fibroma and related lesions constitute a group of lesions, which range in biologic behaviour from true neoplasms to hamartomas. This group of lesions is also sometimes referred to as mixed odontogenic tumors and usually includes ameloblastic fibroma, ameloblastic fibrodentinoma and ameloblastic fibro-odontoma. Despite numerous efforts however, there is still considerable confusion concerning the nature and interrelationship of these mixed odontogenic tumors and related lesions. The malignant counterpart of these lesions namely aameloblastic fibrosarcoma, ameloblastic dentinosarcoma and ameloblastic odontosarcoma respectively are said to arise secondarily in their benign counterpart or de novo. Recurrence of the benign lesion raises the risk towards malignant transformation therefore a radical surgery should be planned inspite of enucleation or curettage. Here we present a case of an aggressive ameloblastic fibrodentinoma which was radically excised in the light of clinical and histological presentation followed by reconstruction of mandible.

An unusual case of jaundice in a 2-month-old boy.

A 2-month-old previously healthy infant presented to the emergency department with a complaint of projectile vomiting for 4 days and jaundice for the last 2 days. An ultrasound of the abdomen showed no sign of pyloric stenosis. All results of laboratory workups related to gastrointestinal cause for vomiting and jaundice were normal. The patient was admitted for further gastrointestinal workup. Finally, a computed tomographic scan of the head showed active and chronic subdural bilateral hematomas with multiple calvarial fractures consistent with nonaccidental trauma.