Primary Hyperparathyroidism Mimicking Skeletal Metastasis - A Diagnostic Dilemma.

Introduction: Primary hyperparathyroidism (PHPT) is an intrinsic abnormality of the parathyroid glands in which there is an inappropriate secretion of parathormone (PTH), resulting in skeletal resorption and bone loss. The characteristic bony changes of fibrotic cystic lesions are called Brown's tumors. Clinical dilemmas exist due to the varied clinical presentation of hypercalcemia with multiple lytic lesions mimicking metastatic bone disease. The 99 mTc sestamibi scanning is the imaging modality of choice used for the preoperative localization of parathyroid adenomas. Surgery provides a definitive treatment, and the bony lesions resolve completely over a period of time. Case Report: We present four cases of PHPT where they presented with multiple lytic lesions and were evaluated for metastatic deposits. The diagnosis was confirmed with a biopsy. They were successfully treated by excision of the parathyroid gland. A high index of suspicion will avoid misdiagnosis and inappropriate treatment. Conclusion: PHPT must be considered as a differential diagnosis for multiple osteolytic bone lesions. Diagnosis can be aided by a thorough clinical examination, including an assessment for neck swelling, and laboratory testing of serum calcium levels and PTH levels. Surgical excision of the hyperactive gland serves as the definitive treatment for this condition, with bony lesions regressing gradually over time.

Vaginal Drain to Prevent Ascending Infection in Preterm Premature Rupture of Membranes: A Novel Method.

BACKGROUND: Not to delay delivery for more than 24 hours after rupture of the membrane is the thumb rule in obstetrics. Ascending infection from the vagina results in dangerous chorioamnionitis, which threatens the lives of the baby and mother. We developed a novel method to prevent ascending infection by using a vaginal drain, which helps to continue pregnancies if the leak stops and buys some time for antenatal steroids to act if the leak doesn't stop. METHOD: In this study, 20 uncomplicated singleton pregnant women with spontaneous preterm premature rupture of membranes at gestational ages <35 weeks were recruited. Under the speculum, vaginal epithelial debris and secretions were cleared by a saline wash. The tip of the Nelaton Catheter was kept in the posterior fornix and then strapped to the thigh. The outer end was connected to the collection bag system and allowed to hang down to the ground. The foot end of the cot was raised. Leaked amniotic fluid and amniotic fluid index (AFI) were measured daily. A daily AFOD estimation was done for leaked AF. Uterine activity was controlled with low-dose Isoxsuprine Hydrochloride rapid infusion tocolysis. Antenatal steroids (ANS) were given. The spread of infection was monitored by maternal pulse rate, fetal heart rate, TC, and CRP. Pregnancies were terminated when leaks didn't stop, AFI didn't raise, or mature AFOD was observed. The number of women in whom leaks stopped, the number of days pregnancies continued, neonatal respiratory distress (NRD), birth weights, and perinatal deaths were recorded.  Results: Leaks stopped in eight (40%) women. Pregnancy continuation ranged from 7 to 74 days. In 12 women, the leak did not stop, but we could buy 2-5 days' time for ANS to act. All parameters of the infection were within normal limits. Thirteen babies developed mild NRD, and we lost one baby. CONCLUSION: By using a vaginal drain for P(P)ROM, ascending infection can be prevented, leaks can be stopped in 40% of women, and can buy time for ANS to act.

Management of Anterior Cruciate Ligament Aplasia for the Arthroscopy Surgeons: A Systematic Review.

Background: Anterior Cruciate Ligament Aplasia (ACLA) is a rare condition which can sometimes remain asymptomatic into adult life. Although the quoted incidence is 1.7 per 100,000 live births, it is higher due to these silent cases and can be encountered by the arthroscopy surgeon doing reconstructive procedure for the ACL. The aim of this study is to get information on clinical presentation, imaging, arthroscopy findings and management of the knee in patients with ACL aplasia through a systematic review relevant to the arthroscopy surgeon in making a decision when they encounter such a case. Methods: We performed a systematic review of the literature to get information on this condition that may be relevant to the arthroscopy surgeon from PubMed, Ovid full text, Embase and Ovid Medline databases. After exclusions and inclusions, we found 31 articles relevant to the search which included 101 knees. Results: Most of the publications were case reports due to the rarity of this condition. ACLA is commonly associated with Fibular Hemimelia, Congenital Dislocation of the Knee and Proximal Focal Femoral Deficiency (PFFD). Clinical findings, imaging appearances, other associated findings with ACLA have been listed and management options listed and discussed. Conclusions: Patients with ACLA are often asymptomatic and arthroscopic reconstruction of the ACL appears to be a viable option in selected symptomatic cases only. The arthroscopic surgeon should be aware of the clinical picture and intraarticular findings of ACLA to recognize the condition and make a decision on the optimal management. Further studies are required to report on long-term outcomes of the condition in terms of secondary osteoarthritis development as well as the procedures performed. We recommend forming a global registry to study and further understand the aspects of this condition. Level of Evidence: 4. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-022-00651-2.

Heterotopic Ossification in the Posterior Septum of the Knee Excised by an Arthroscopic Dual Portal Technique: A Case Report.

CASE: We present a 15-year-old adolescent girl with acute onset knee pain and a lesion in the posterior septum (PS) believed to be an infectious process on initial investigations. This was excised successfully using a combination of transseptal and transnotch portals and proven to be a case of heterotopic ossification (HO) within the PS with an excellent outcome within 4 weeks. Our case is unique for the pathology that occurred and the technique of excision. CONCLUSION: HO in the PS is a rare pathology that can be treated arthroscopically using a combination of portals. Removal causes complete resolution of symptoms.

Top 50 cited articles on Covid-19 after the first year of the pandemic: A bibliometric analysis.

BACKGROUND & AIMS: It has been just over a year since the Covid-19 pandemic started. The top 50 cited articles on this subject would help identify trends and focus on the research efforts. METHODS: We utilised e-utilities in PubMed to find publications on Covid-19 until the date of search on 7/2/21. The iCite website was used to find the top 50 citations of the output from the search strategy. We looked into their full text for the editorial dates, type of study, level of evidence, focus of the article and country of origin. We also counted the errata and comments on each of them. RESULTS: The total number of citations of all 50 articles was 123,960, the highest being 10, 754 for a single article. Huang C was the most cited first author. They were published from week 4-17, with February being the month with most citations. Lancet was the most cited journal, having published 9 of the 50 articles. Majority belonged to level 3 of the evidence ladder and were retrospective studies. Thirty percent of them had an errata published and an average of 7 comments per article. CONCLUSION: The top 50 most cited articles identify the most impactful studies on Covid-19, providing a resource to educators while identifying trends to guide research and publishing efforts. There has been an explosion of publications and an unprecedented rate and number of citations within the first year for any single condition in the literature.

The Role of Humidity in the Management of Premature Neonates in a Rural Incubator.

Background While growing inside the uterus, the human fetus floats in amniotic fluid, and the mother maintains a stable temperature of 37 °C and a humidity of 100%. In most neonatal incubators, a stable temperature is maintained but not the humidity. We hypothesised that maintaining a humidity of 70% and a temperature of 32 °C in incubator rooms might improve the outcomes related to low birth weight (LBW) neonates. Methods In this interventional study, 30 preterm LBW neonates delivered at different gestational ages were studied. Instead of an incubator box, we converted one entire room (14'/9'/10') into an incubator. Three 200-watt bulbs were fixed to the wall at a height of 1 meter from babies. The room thermometer was mounted on the wall close to babies. The room temperature was maintained at 32 °C by turning the lights on or off as required. Wet cotton sheets (4' × 6') were spread on the opposite wall with the support of a stand. A hygrometer was fixed to the wall near to babies, and the humidity of the room was maintained at 70-80%. The hydration and nutrition needs of the babies were met with IV fluids/nasogastric (NG) tube feeding. Antenatal steroids were given to all mothers before the completion of 38 weeks. Babies were discharged when they were stable, and further care was given at home with similar arrangements of maintaining temperature and humidity. Birth weights, the number of babies that developed neonatal respiratory distress syndrome (NRDS), hypothermia, septicaemia, neonatal intensive care unit (NICU) admission days, home incubator days, and neonatal deaths were recorded and compared with the findings in the existing literature. Results Among the 30 neonates studied, birth weights ranged from 1.00 to 1.95 kg. Twenty-three babies developed NRDS, and four babies developed septicaemia; NICU days ranged from five to 28 days, and at-home incubator days ranged from 15 to 60 days. One baby succumbed to the illness. Conclusion Open nursing care of functionally premature neonates at room temperature of 32 °C and humidity of 70% is a cost-effective method that can lead to excellent outcomes.

Outcomes of topical phenytoin in the management of traumatic wounds.

INTRODUCTION: Regular dressing of traumatic wounds is of paramount importance for healing. Phenytoin, an anticonvulsant, is thought to promote wound healing through multiple mechanisms, including fibroblast proliferation, granulation tissue formation, antibacterial activity, and pain alleviation. AIM: To assess the effect of topical phenytoin on traumatic wound healing in terms of granulation tissue formation, pain alleviation, and time taken for wound healing. METHODOLOGY: Fifty patients with traumatic wounds were divided into equal and comparable groups. After cleaning the wound, phenytoin dressing was done in the study group and saline dressing in the control group. Thereafter, regular dressings of the wounds were done, and healing was assessed on day 14 and day 21. RESULTS: On day 14, the wound surface area, percentage of granulation tissue, VAS score amongst cases was 39.4 ± 29.75 cm2, 82.12 ± 9.71%, 4.52 ± 1.08, and that of controls was and 51.28 ± 25.33 cm2, 62.72 ± 9.01%, 6.52 ± 1.22, respectively. On day 21, the wound surface area, percentage of granulation tissue, VAS score amongst cases were 29.4 ± 29.88 cm2, 92 ± 4.46%, 2.8 ± 0.94, and that of controls were 38.92 ± 23.24 cm2, 78.56 ± 8.19%, and 4.88 ± 1.17, respectively. The time taken for wound healing was 21.76 ± 5.28 days amongst cases and 31.64 ± 8.31 days amongst controls. Staphylococcus aureus was the commonest organism isolated in both the groups. On day 14,18(72%), wounds in the study group showed negative culture, whereas, in the control group, it was negative in 12 (48%) patients. The rate of granulation tissue formation was higher in cases when compared to controls amongst smokers and diabetics. The difference in all these parameters between the groups was statistically significant (P-value <0.05). DISCUSSION AND CONCLUSION: We observed a considerable increase in granulation tissue formation, pain alleviation, and reduction in time taken for wound healing. Topical phenytoin is a safe, effective, readily available, and frugal agent that can accelerate wound healing through its multimodal action, thus reducing patient morbidity and economic burden. MESH TERMS: Phenytoin, Wound healing, Topical, Ulcer, Anticonvulsant, Granulation Tissue, Saline dressing.

Chondromyxoid Fibroma of Distal Phalanx of the Great Toe: A Rare Clinical Entity.

Chondromyxoid fibroma is a rare benign tumor of cartilaginous origin with myxoid and fibrous components. It accounts for approximately 1% of bone tumors. Metaphysis of long bones is the most common location of this tumor. However, there a few case reports of this tumor arising from epiphysis of short tubular bones of the hand and feet. An 11-year-old girl presented to our OPD with complaints of pain and a gradually progressive swelling of the right great toe. On examination, the swelling was diffuse with no signs of inflammation. X-ray examination revealed a well-defined, longitudinally oval lytic lesion in the right distal phalanx of great toe, involving the growth plate and, eroding the medial cortex. Computed tomography (CT) scan did not show any evidence of calcification, septations or involvement of soft tissue. Open biopsy and curettage was done and the specimen was sent for histopathological examination. Histopathological examination (HPE) showed a lobular pattern consisting of myxomatous stroma and immature cartilaginous cells in lacunae. The lobules were separated by fibrous septae. It was reported to be Chondromyxoid fibroma. The patient presented six months later with persisting pain and X-ray showed recurrence of the tumor. Hence, complete excision of the tumor was done and the defect was filled using synthetic bone graft. At six months follow up, the patient did not complain of pain and X-rays showed signs of bone formation with incorporation of the graft. Chondromyxoid fibroma is a low grade tumor, which may demonstrate nuclear atypia histologically and mimic chondrosarcoma. Differentiating these two is of paramount importance to avoid over-diagnosis and aggressive treatment. Recurrence is common with marginal excision and especially in younger patients like in our case. Complete resection is the mainstay of management. Long-term follow up of patients is necessary to watch for malignant transformation, a rare complication. Chondromyxoid fibroma is an extremely rare neoplasm of bone. There are no specific radiologic features, and histopathology provides a definitive diagnosis. It should be considered in differential diagnosis of lytic lesion, and differentiated from other tumors, especially from chondrosarcoma to treat the patient appropriately.