KADAM topical warm oxygen therapy device for diabetic foot ulcer-a novel approach.

Purpose: Diabetic foot ulcer (DFU) is a significant healthcare burden demanding prompt attention. In the past decade, newer technologies such as topical oxygen therapy have grown increasingly popular. The purpose of the study was to determine effect of KADAM-a topical warm oxygen therapy (TWOT) medical device in healing of DFU. Methods: The KADAM medical device developed by Yostra Labs Pvt Ltd, delivered pure oxygen between 93 ± 3% concentration at an optimal temperature range of 39-42º Celsius to DFU wound site. Results: A total of 40 diabetic foot ulcer individuals, aged over 18 years were included in the study. Individuals with the Grade 1 DFU were 34 (85%), grade 2 were 5 (12.5%) and grade 3 were 1 (2.5%). The changes in initial area and final area for the various diabetic foot ulcer grades were as follows: 0.32 [0.12, 0.96] (< 0.001) for grade 1 ulcer, 0.76 [0.54, 1.17] (P = 0.013) for grade 2 ulcer and 1.26 for grade 3 ulcer. The percentage reduction in wound size achieved for the grade 1 & 2 DFU were 100%, and grade 3 was 75%. Conclusion: Topical warm oxygen therapy serves as an adjunctive modality to facilitate diabetic foot ulcer healing in the clinical practice.

Application of Topical Oxygen Therapy in Healing Dynamics of Diabetic Foot Ulcers - A Systematic Review.

BACKGROUND: Individuals with diabetes may develop diabetic foot ulcers due to diabetic peripheral neuropathy. Multiple factors influence the ulcer healing process; oxygen helps in facilitating the different stages of wound healing. OBJECTIVE: The objective of this systematic review was to analyze the different levels of evidence available in the application of topical oxygen therapy, warm oxygen therapy, or other modes of topical oxygen delivery in the healing dynamics of diabetic foot ulcers. METHODS: Databases searched included Pubmed/Medline, Science Direct, Web of Science, Scopus, Cochrane, and CINAHL. The eligibility criteria of studies included participants ≥18 years with chronic non-healing diabetic foot ulcer (duration ≥3 months) receiving warm oxygen or topical oxygen therapy (TOT), and other modes of topical oxygen administration, which were compared with standard care group. Randomized and non-randomized studies were included. The primary outcome measure assessed was the rate of wound healing or wound closure. RESULTS: The review included 5 studies which used different modes of topical oxygen administration. The healing trajectory of the wounds was completely achieved in low-grade ulcers (grade 1), whereas all high-grade ulcers (grades 2, 3, and above) showed either 100% or 50% healing with a reduction in ulcer size and ulcer tissue depth. CONCLUSION: Topical oxygen therapy facilitates wound healing dynamics among individuals with chronic diabetic foot ulcers.

Hard nodular lesions over the chest wall.

Thirteen years after undergoing a mastectomy for breast cancer, this patient developed lesions near the scar.

Adenocarcinoma of the duodenojejunal flexure presenting as a stricturous lesion.

A 50-year-old woman was referred with a colicky upper abdominal pain of 3 months duration. She experienced an increase in pain 2 weeks prior to presentation. This was associated with bilious vomiting about 5-6 times/day with no change in bowel habits. She had no history of any abdominal pathology. A review of systems showed she had a weight loss of 20 kg over a period of 4 months with recent onset of loss of appetite. Physical examination revealed a soft distended upper abdomen with non-radiating pain in the epigastrium. CT of the abdomen showed a heterogeneously enhancing stricturous growth in the proximal part of the jejunum with gross dilation of the stomach and duodenum. She underwent resection and anastomosis of the proximal jejunum. Histopathology revealed the lesion to be an adenocarcinoma.

Be Careful with an IV Line.

Obtaining an intravenous (IV) access is a simple procedure which can be done in almost any hospital setting. One of the most dreaded complications of this procedure is an inadvertent intra-arterial cannulation. This can result in an accidental injection of medications intra-arterially, which can potentially lead to life altering consequences. In the hope that these types of events can be prevented, we are presenting a case of a 57-year-old male who underwent bougie dilatation for an oesophageal stricture and was accidentally given medication for pain management intra-arterially through an improperly placed IV line, which resulted in ischaemia, gangrene and subsequent loss of the hand. Those who try to obtain an IV access should always be on the lookout for possible clues that can prevent an inadvertent IA injection, especially if cannulation is in an area where an artery is in close proximity to a vein; these clues include but are not limited to the following: a bright-red flash of blood in the cannula, pulsatile movement of blood in the IV line, and intense pain or burning at the site of injection. These signs, as well as educating the patient on early symptoms of ischaemia, may allow early action to be taken, to prevent irreparable damage. We always have to be careful when we insert an I.V line.

Primary colonic signet ring cell carcinoma in a young patient.

A 28-year-old woman presented with colicky abdominal pain for 3 months. Pain was associated with episodes of vomiting, abdominal distension and constipation. She also had loss of weight for this duration. General physical examination was unremarkable and the abdomen was soft, with no palpable organomegaly. A CT of the abdomen showed small bowel and ascending colon dilation with multiple air fluid levels. There was also a short segment of circumferential bowel wall thickening and luminal narrowing in the hepatic flexure with sudden transition of bowel diameter. She underwent a right hemicolectomy after necessary preoperative investigations. Histopathology revealed signet ring cell carcinoma (SRCC). This case highlights the importance of detecting such a lesion in a young, otherwise fit woman. The challenge lies in early diagnosis and awareness of general practitioners about this aggressive form of colonic tumours.

Pancreatic cancer presenting as a Sister Mary Joseph's nodule.

A 69-year-old man presented with a painful umbilical nodule of 1 month duration. On examination the nodule was blackish in colour with a serous discharging fluid and was 2×2 cm in size, tender and fixed to the skin. There were no scars or sinuses at the umbilicus and no palpable mass or organomegaly on systemic examination. The patient underwent wide local excision of the skin nodule and on histopathology was reported as metastatic adenocarcinoma of the skin. A CT of the abdomen was performed to look for the primary site, which showed a 5×4 cm lesion in the tail of the pancreas. A biopsy from the pancreatic lesion was taken which was reported as an adenocarcinoma. CA19-9 was more than 1000 U/mL. The patient was advised palliative chemotherapy with gemcitabine. He was unwilling to take any further treatment in view of the advanced nature of the disease.

Mucinous cystadenoma of the appendix in a 35 year old woman: a case report

Mucoceles of the appendix are rare occurrences and primary appendiceal adenocarcinomas occur in the form of appendiceal mucoceles. A mucocele is a collection of mucoid substances in the appendiceal lumen. Presentation of this neoplasm can be vague and hence the diagnosis is challenging. Optimal surgical therapy is necessary in all cases as dissemination of neoplastic cells into the peritoneal cavity can lead to pseudomyxoma peritonei, a potentially life threatening complication. We present the case of a 35 year old woman who presented with an acute abdomen and subsequently underwent a laparoscopic appendectomy. Following biopsy, a diagnosis of mucinous cystadenoma was made. The patient recovered fully after resection and was subsequently discharged (AU)

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Endometriosis of extra-pelvic round ligament, a diagnostic dilemma for physicians.

A 49-year-old multiparous woman presented with a swelling in the left groin of 6 months duration. The swelling was associated with a dull aching pain. The patient reported increase in size of the swelling during lifting of heavy weights. Menstrual history was normal and there was no increase in pain over the swelling during menstruation. She underwent a caesarean section 20 years ago and the scar had healed by primary intention. She was provisionally diagnosed to have a left-sided inguinal hernia. Ultrasonography showed a multiloculated cyst measuring 5.3×1.5×5.2 cm within the inguinal canal. The patient had excision of the cyst under spinal anaesthesia. Intraoperatively the cyst was found to arise from the left round ligament. It measured 7×6 cm extending to the left lateral vaginal wall. Histopathology revealed endometriosis of the round ligament. Her gynaecological assessment was normal and they recommended no further treatment. On follow-up the patient was asymptomatic and wound had healed well.

Rhabdomyosarcoma of spermatic cord in a 65-year-old man presenting as a groin swelling.

A 65-year-old man presented with a swelling in the right groin of 6 months duration. The swelling was associated with dull aching pain and the patient reported of increase in size of the swelling during lifting of heavy weights. The swelling was 6×5 cm, hard in consistency, mobile and there was no impulse of cough. Ultrasonography showed a solid mass measuring 5.3×1.5×5.2 cm arising from the spermatic cord. High-inguinal orchiectomy was performed. Histopathology revealed rhabdomyosarcoma (RMS) of the spermatic cord. Patient was advised adjuvant chemotherapy but he refused. Spermatic cord RMS is a rare tumour derived from the undifferentiated mesoderm. It is most often observed in children and adolescents. It rarely appears after the second decade of life. It usually manifests as a painless, firm to hard mass in the inguinal canal or scrotum. Radical high-inguinal orchiectomy is the treatment of choice.

Jejuno-jejunal intussusception: an unusual complication of feeding jejunostomy.

The jejuno-jejunal intussusception is a rare complication of jejunostomy tube placement. We are reporting a case of 33-year-old man who was suffering from absolute dysphagia due to carcinoma of cricopharynx with advanced metastatic disease, who underwent Stamms feeding jejunostomy as a part of palliative care. After 1 month he presented with colicky type of pain in the abdomen and vomiting. Sonogram of abdomen revealed a target sign and a feeding tube in a dilated jejunum. Abdominal CT proved the sonographic impression of jejuno-jejunal intussusception. He, therefore, underwent exploratory laparotomy and resection and anastomosis of the intussuscepted bowel. New feeding jejunostomy (FJ) was done distally from the anastomotic site. As per the literature this complication has been reported in Witzels jejunostomy. In our case the patient had undergone Stamms jejunostomy with placement of a Ryle's tube. Intussusception should be considered if a patient comes with abdominal pain and vomiting following FJ.

Aggressive fibromatosis (desmoid tumour) of the head and neck: a benign neoplasm with high recurrence.

A 50-year-old man presented with a 5-month history of swelling over the right side of neck. The swelling was associated with dull aching pain radiating to the forearm without associated weakness of upper extremity or sensory loss. There was no history of trauma. On examination a fixed mass approximately 8×6 cm in size, smooth, firm in consistency, with ill-defined margins was present in the right posterior triangle. MRI scan of the neck revealed well-defined, lobulated, heterogeneously enhancing altered signal intensity mass at the root of neck. Debulking of the tumour was performed in view of its close proximity to the brachial plexus. Histopathology revealed aggressive fibromatosis (AF). AF is a benign fibrous neoplasm arising from fascia, periosteum and musculoaponeurotic structures of the body. AF in the head and neck region tends to be locally aggressive with a nature to invade bone and soft tissue structures.

Extragenital aggressive angiomyxoma of the axilla and the chest wall.

Aggressive angiomyxomas are uncommon mesenchymal tumours which most often arise in the perineal and the pelvic regions in women. Extragenital aggressive angiomyxonas are extremely rare. We are reporting a young male with an aggressive angiomyxoma which involved the axillary region and extended into the anterior chest wall, which demonstrated its characteristic histomorphological features. The diagnosis was confirmed by immunohistochemistry. A careful histological examination, along with immunohistochemistry, aids in diagnosing this lesion and differentiating it from tumours which have similar histologies.

Iliac crest bone graft donor site hernia: not so uncommon.

A 73-year-old man, who had undergone fracture fixation of humerus with LCP plating and bone grafting, presented again with a peri-implant fracture after 1 year. A repeat surgery was contemplated and replating was performed with tricortical bone graft harvested from the iliac crest. In the postoperative period the patient developed a tender swelling at the graft site with nausea and abdominal discomfort. It was managed conservatively thinking it to be a haematoma at the graft site. In the following 2 days his symptoms worsened. A CT abdomen showed the herniation of caecum from the bone graft donor site with obstruction. The patient was taken up for emergency surgical repair, the caecum was reduced and polypropylene mesh hernioplasty was performed. The patient recovered well without recurrence in the follow-up period. Iliac crest bone graft site hernia is not so uncommon and care has to be taken while harvesting.

Primary mesenteric fibromatosis: a case report with brief review of literature.

Although fibromatosis of the mesentery is a very rare locally aggressive benign condition, the uncertain treatment modalities, the natural history of the disease, and the other common differential diagnosis of the condition along with inexperience of the general clinicians with this disease pose a challenge to the professionals. The prolonged periods of stability and even regression in size of the tumor offer a hope for treatment. Accounting for 0.03 % of all neoplasms, it is also known as deep fibromatosis and desmoid tumor. Here, we discuss one case of primary mesenteric fibromatosis in a young male patient who presented to us with chronic abdominal pain after he was treated for acid peptic disease for the same at a local hospital. This case shows how management of this disease can be delayed due to unfamiliarity among clinicians of this condition. In our patient, a palliative surgical management plan was undertaken due to symptomatic mass in the abdomen, owing to unresectability.

Symmetrical peripheral gangrene-a case report and brief review.

A 30 year-old gentleman presented to casualty with history of pain abdomen for six days, fever and decreased urine output since two days. He was in a state of septic shock and was diagnosed to have intestinal perforation. His peripheral pulses were not palpable except for the femoral and brachial vessels. Despite fluid resuscitation, he needed infusion of high doses of dopamine and noradrenaline to maintain his blood pressure. He was operated for repair of perforation. On the first postoperative day, in the intensive care unit, vasopressin infusion was added in view of persistent hypotension. Appropriate fluid resuscitation and antibiotic therapy helped to wean him off inotropes and vasopressors by the second postoperative day. On the 3rd postoperative day, however, the patient developed discolouration and blebs on the fingers of left hand, followed by the right hand and then both the lower limbs. Subsequently, over a period of 10 days, this progressed to gangrene formation in the hands despite the patient being haemodynamically stable without any inotropes or vasopressors in this period. We conclude that the septic shock is a systemic derangement affecting all organ systems including coagulation and microcirculation. Early recognition and prompt management of sepsis, optimisation of fluid status to wean off the inotropes and vasopressors at the earliest is necessary to avoid catastrophes such as symmetrical peripheral gangrene.

A brief review of common oral premalignant lesions with emphasis on their management and cancer prevention.

UNLABELLED: Long-term outcomes associated with oral cancer and its management over the past several decades has caused concern and the value of mass oral cancer screenings has come under scrutiny. Though not all oral carcinomas are preceded by premalignant lesions as clinically visible morphological alterations occur secondary to the cellular or molecular changes, certain high risk lesions have been identified. Their management remains controversially polarized between surgical excision to prevent malignant change and conservative medical or surveillance techniques. Though oral cancer is one of the "major killers" of modern times, there seem to be no widely accepted criteria for decision making in clinical practice, the evidence base is scanty and uncertainty persists throughout investigation, diagnosis, and treatment. In this article, we have briefly discussed the common premalignant lesions, with an emphasis on their evidence based management and prevention. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12262-011-0286-6) contains supplementary material, which is available to authorized users.

Segmental jejunal lipomatosis--a rare cause of intestinal obstruction.

A rare case of a segmental small intestinal (jejunal) lipomatosis is described. A 33-year-old male was admitted with a clinical diagnosis of an acute intestinal obstruction. A plain erect abdominal x-ray showed multiple air-fluid levels. On an exploratory laparotomy, a jejunojejunal intussusception was found secondary to a segmental submucosal lipomatosis. This was treated by a segmental resection and anastomosis, which resulted in a complete cure. Here we present this case with a review of the relevant literature.