COVID-19 Palliative and End-of-Life Care Plan: Development and Audit of Outcomes.

Objectives: Palliative care (PC) referral in serious and critical COVID-19 improves decision-making, health resource utilisation, end-of-life symptom management and family support. In this study, we explored developing a systematic decision-making matrix for PC referral in COVID-19 and audited its outcomes. Materials and Methods: A team of interdisciplinary experts developed a hospital COVID-19 PC plan. PC referral and outcomes of PC referral in hospitalised COVID-19 patients were audited. Results: Out of 1575 inpatients, 1066 (67.7%) had mild and 509 (32.3%) had serious and critical COVID-19 illness. Among 50 (3.1%) referred to PC, 5 (0.4%) had mild and 45 (8.8%) had serious and critical COVID-19 illness. Out of 45 serious and critical COVID-19 patients referred to PC, 38 (84%) received end-of-life care (EOLC), 4 (9%) self-discharged against medical advice and 3 (7%) recovered. Forty-seven (94%) were referred for goals-of-care discussion. About 78% received opioids, 70% benzodiazepines and 42% haloperidol for symptom management. Among 45 serious and critical COVID-19 patients referred to PC, foregoing life-sustaining treatment was documented in 43 (96%) but implemented only in 23 (53%). Out of 38 who received EOLC, ICU was the place of death in 31 (82%) and ward in 7 (18%). Conclusion: Despite interdisciplinary experts developing a hospital COVID-19 PC, low referral of serious and critical COVID-19 patients to PC was observed. PC referral enabled access to management of end-of-life symptoms and facilitated limitation of life-sustaining treatment in some COVID-19 patients with serious illness. Educating critical care physicians about the scope of PC in the COVID-19 setting might improve PC referral.

Enchondroma in the Diaphysis of Tibia - A Case Report and Review of its Characteristics and Differentials in the Diaphysis.

INTRODUCTION: Enchondroma is a solitary, benign, intramedullary cartilaginous tumor commonly noticed in the phalanges of hands and feet with characteristic radiological features. Its occurrence in aberrant sites with atypical features lead to diagnostic dilemma. Enchondromas which are usually managed non-operatively can mimic other benign and malignant lesions, especially chondrosarcoma. CASE REPORT: We report the case of a 31-year-old farmer who presented with long standing inconspicuous pain in his left leg which turned out to be a diaphyseal enchondroma even though it demonstrated aggressive radiological features mimicking a chondrosarcoma. Incisional biopsy was done from the scalloped areas to obtain the correct histological diagnosis. He underwent thorough curettage of the lesion and remains asymptomatic 2 years after the procedure. We attempt to discuss the differentials which the orthopedic surgeon should keep in mind for diaphyseal lesions mimicking enchondroma. CONCLUSION: Though classically found in metaphysis, Enchondromas are not uncommon in diaphysis of long bones. Enchondromas are generally benign, but can cause diagnostic dilemma when they present with aggressive features at rare locations and surgeons should be wary of the differentials. Despite a size of more than 6 cm and evidence of cortical erosion and intramedullary widening, the lesion could still be benign. Early biopsy will help to differentiate Enchondroma from a malignant transformation or malignant tumor.

Monophasic spindle cell myxoid synovial sarcoma of the hand: promising results with marginal resection.

Synovial sarcomas are deep-seated, genetically distinct, malignant neoplasms seen in young adults, with a male preponderance. They have unusual clinical and pathological presentation and mimic many other sarcomas and carcinomas, making the diagnosis quite challenging. Although four variants are identified, occurrence in the hand is extremely rare and leads to significant morbidity. There is a high incidence of local recurrence and distant metastasis within the first 2 years. We report the case of an elderly woman with monophasic spindle cell synovial sarcoma who presented with painless swelling in her palm and underwent local excision of the neoplasm. At 2-year follow-up, she remains totally asymptomatic with normal function of the hand. We also attempt to give an overview about monophasic spindle cell synovial sarcoma with the differentials, which would help surgeons in prompt diagnosis and appropriate management.

Effectiveness of customized insoles on maximum plantar pressure in diabetic foot syndrome: A systematic review.

BACKGROUND AND AIMS: Diabetic foot syndrome is a severe complication of type 2 diabetes mellitus with diabetic peripheral neuropathy. Increased maximum plantar pressure is a strong predictor that may be detrimental and cause a plantar ulcer. This present systematic review aims to evaluate the effectiveness of customized insoles on reducing maximum plantar pressure in diabetic foot syndrome. METHODS: We conducted a systematic review (PubMed, Cochrane Database of Systematic Reviews, CINAHL, Pedro, Scopus) to summarize the evidence on the customized insole on maximum plantar pressure in diabetic foot syndrome. Randomized and non-randomized studies were included in the review. The quality of the included studies was assessed independently by the two review authors with the Modified Downs and Black checklist for the assessment of the methodological quality of both randomized and non-randomized studies. RESULTS: A total of 1512 studies screened. After the exclusion criteria, 5 studies were included in the study. The outcome measure that was considered is maximum plantar pressure and pressure-time integral. CONCLUSIONS: We concluded that the practice of customized insoles could significantly reduce maximum plantar pressure. While developing an insole, parameters like contoured insoles with shape and pressure based, weight-bearing position, and duration with good adherence to footwear application can significantly reduce maximum plantar pressure.

Osteoid osteoma of the calcaneus misdiagnosed as subtalar sprain.

Osteoid osteoma of foot and ankle account for ten percent of benign bone tumors and commonly involve the talus and metatarsals. Its occurrence in calcaneus is extremely rare and can mimic ankle instability, subtalar arthritis, osteochondritis or plantar fasciitis leading to delay in diagnosis. We present the case of a 17 year old boy with periarticular osteoid osteoma in the calcaneum, who presented following an ankle sprain. He was successfully treated with CT guided percutaneous radiofrequency ablation and we feel that it is a safe, precise and effective treatment option for even periarticular osteoid osteoma in the foot and ankle region.

Anterior elbow dislocation without fracture in an adult: a rare injury pattern.

Anterior elbow dislocation without periarticular fracture (simple dislocation) is an extremely rare injury and is usually caused by distraction or torsional forces. It is important to look for associated ligamentous and musculotendinous injuries in this pattern. We report an elderly patient who sustained simple anterior dislocation of the elbow and in whom successful closed reduction could be achieved. Reduction by closed method is possible if we know the exact mechanism of elbow injury. Despite the presence of medial collateral ligament injury, he was managed non-operatively and had full functional recovery. Checking for joint stability and collateral ligaments after reduction and getting additional radiological investigations help in better treatment planning. Early protected active mobilisation should be initiated to achieve better functional results.

Longitudinal Midline Sacral Split Fracture - A Rare Entity.

Fractures involving the central canal of the sacrum are rare injuries and can be transverse or longitudinal. Transverse fractures are by far common and associated with high incidence of neurological injuries. On the contrary, longitudinal midline split fracture is an extremely rare injury with minimal or no neurological injury. They are always associated with anterior pelvic ring fracture and are vertically stable needing only fixation of the anterior pelvic injury. Plating of the anterior pelvic ring in two planes would be beneficial than single plate to prevent gradual loss of reduction.

A rare tumour of hand: angioleiomyoma.

Angioleiomyoma is a benign tumour composed of smooth muscle and vascular tissue. Because of the paucity of smooth muscles in the hand other than tunica media of the blood vessels, its occurrence is quite rare in the hand and only few cases are reported in the English literature. We present the case of a 49-year-old man with benign painless swelling on the dorsum of hand. Differential diagnosis of ganglion cyst and tendon sheath tumour were considered. However, excision biopsy revealed angioleiomyoma. At 2-year follow-up, the patient remained asymptomatic with no evidence of recurrence.

Aggressive angiomyxoma presenting as a vulval polyp.

Aggressive angiomyxoma is a rare, locally invasive mesenchymal tumor, occurring predominantly in the pelvic-perineal region of adults and carries a high risk for local relapse and hence the need to differentiate it from the other mesenchymal tumors occurring in this region. Presentation as a pedunculated polyp, like in our case, is unusual for this rare tumor. Except for positive surgical margins, there are no clinical or histological means for predicting the tumor recurrence. A diligent long-term follow-up is mandatory. Though rare, this tumor needs to be considered in the differential diagnosis of vulval polyps.