Laparoscopic Major Vascular Injuries Report of Two Cases and Review.

Laparoscopic surgery is the standard of care for various abdominal pathologies due to its apparent advantages. Unintentional and accidental injuries of the intraabdominal organs and vessels caused by trocars and Veress needles are rare, but potentially fatal complications of laparoscopic surgery. Veress needle and trocar can cause major vascular, bowel, or urinary tract injuries. We report two cases of vascular laparoscopic entry injuries. Laparoscopic entry injuries are rare but life-threatening and can cause multiple organ dysfunctions. Therefore, early recognition, aggressive resuscitation, and appropriate management of laparoscopic entry injuries are vital for better outcomes.

Nebulized fentanyl for respiratory symptoms in patients with COVID-19 (ventanyl trial).

ABSTRACT: Patients with coronavirus disease (COVID-19) commonly experience distressing and challenging respiratory symptoms. Interventions such as oxygen therapy, oral opiates, and traditional nebulizers like ipratropium bromide and salbutamol are variable in their efficacy, and therapy responses in patients are difficult to predict. The purpose of this study is to investigate the efficacy of nebulized fentanyl citrate on dyspnea, cough, and throat pain in patients with COVID-19 and evaluate the safety with any potential adverse events.In COVID-19, about 59% of patients will exhibit cough, 35% generalized body ache and sore throat, and 31% dyspnea. Some methods such as nebulized lidocaine, magnesium sulfate, and systemic opioids have been used to manage the respiratory symptoms. It has been previously shown that fentanyl nebulizer has beneficial effect in improving shortness of breath in patients with chronic obstructive pulmonary disease. The proposed theory behind that was that fentanyl decreased the rate of spontaneous respiratory rate, diminished the brain stem chemoreceptor response to hypoxia and hypercarbia, in addition to exhibiting a modulating effect on the brain stem. Therefore, we hypothesize that nebulized fentanyl has superior effect in improving shortness of breath and relieving cough compared to normal saline, in addition to its advantageous throat pain relief, while exhibiting fewer side effects in patients with COVID 19 infection. Therefore, this phase-III, randomized, comparative, parallel assignment, single-blinded clinical trial aims at assessing the efficacy and safety of nebulized fentanyl to suppress cough, improve breathlessness, and relieve throat pain in patients with COVID-19.

Recording 'sublingual crescents' in lower complete dentures: a technique so effective but still esoteric and arcane.

AIM: To achieve retention in severely resorbed mandibular ridges during impression making and to maintain the retention and stability of these dentures during function. BACKGROUND: No good method with adequate clinical photographs that will empower the dentist with the necessary skill has been reported in the literature. TECHNIQUE: The technique involves making a preliminary impression in alginate to record the denture bearing area clearly, doing a border moulding procedure with excess width to fill the wide sulcus present; except in the area of anterior lingual flange from second premolar to second premolar area. The anterior lingual border of the impression is then extended sublingually without interfering with the tongue function or blocking the opening of the ducts of the sublingual gland; to maintain contact with the surrounding sublingual tissue in both protruded and retruded positions of the tongue, thereby creating good peripheral seal in the most vulnerable area in the lower denture, where the seal is easily broken during tongue movements. CONCLUSION: This impression technique, combined with arrangement of teeth on the center of the ridge in the posterior part, use of flattened cusp posterior teeth and contoured polish surface of denture base (Fisch concept) provide sufficient retention and stability to the dentures made on these severely resorbed ridges. CLINICAL SIGNIFICANCE: Patients with severely resorbed ridges cannot be rehabilitated with implants also and so normally suffer with loose lower denture fabricated with normal border moulding procedures. These patients can be rehabilitated to a great extent properly.

The management of nephroblastoma with cavo-atrial disease at presentation: experience from a developing country.

PURPOSE: To describe the management of cavoatrial extension of nephroblastoma in a developing country. PATIENTS AND METHODS: Of 406 consecutive children with Wilms tumour, 40 (10%) presented with tumour extension into the inferior vena cava (IVC) (30), right atrium or right ventricle and form the inception cohort. Of this group, 17 (43%) had visceral metastases and two had bilateral synchronous tumours. RESULTS: Neoadjuvant chemotherapy appropriate to the pre-operative stage caused reduction in intravascular tumour in 18 (45%) patients, allowing 3 children who had atrial tumour at presentation to be surgically managed without recourse to cardiopulmonary bypass. Neoadjuvant chemotherapy also provided a window of opportunity to assess and manage co-morbidity especially malnutrition. Of the inception cohort, 31 (78%) underwent surgical resection; 23 had simple cavotomy, one caval resection and seven resection under cardiopulmonary bypass. There was one post-operative death. 77% of resected specimen contained viable malignant cells despite one or more cycles of neoadjuvant chemotherapy. Retrograde extension into caval tributaries threatened the completeness of resection in all patients necessitating the addition of post-operative radiotherapy. Of nine patients who did not undergo resection, five died pre-operatively. Three of these children died of chemotherapy induced neutropaenic sepsis. Four patients refused surgical treatment. Twenty-three patients completed the post-operative treatment protocol (1,203 characters).

Clear cell sarcoma of the kidney in children: experience in a developing country.

INTRODUCTION: Clear cell sarcoma of the kidney (CCSK) is a rare tumour comprising 4% of primary renal tumours in children. It has a unique constellation of chromosomal and molecular features and should no longer be viewed as an unfavourable histological variant of Wilms tumour. Little is known of its clinical presentation and pathological profile in children living in a developing country. AIM: To describe the clinical and pathological features of CCSK in children in our practice and to identify factors contributing to poor patient outcomes. METHOD: A retrospective review of patients with a confirmed diagnosis of CCSK who presented for treatment at a single institution between 1990 and 2008. RESULTS: 14 patients fulfilled the inception criteria. They represented 4% of 356 patients presenting with primary renal tumours during the review period. Clinical and radiological features were indistinguishable from Wilms tumour. Tumours were large (Mean mass 1.4 kg; median 0.9 kg) and metastases were common (42%). Lung and lymph node metastases were more common than skeletal disease. Co-morbidity, particularly hypertension (64%) was common. Initial diagnosis by needle biopsy was correct in only two of seven patients (29%) leading to inappropriate neoadjuvant chemotherapy. Overall survival is poor with 57% of patients alive and disease free from 1 to 7 years off treatment. CONCLUSION: In a developing country, CCSK is rare and clinically and radiologically indistinguishable from Wilms tumour. Associated hypertension is common. Pretreatment diagnosis is difficult and sampling errors using needle biopsies may be unavoidable. Treatment results are poor and, given the propensity for late recurrence in CCSK, may not be sustained.

Traumatic thoracobiliary fistula: report of a case successfully managed conservatively, with an overview of current diagnostic and therapeutic options.

Thoracobiliary fistula is a rare complication of hepatic trauma that may present a diagnostic and therapeutic challenge. We report a case of a thoracobiliary fistula complicating thoracoabdominal trauma. Although numerous imaging modalities are able to detect the condition, optimal imaging is achieved with endoscopic retrograde cholangiography, which provides anatomic delineation and has the therapeutic potential of a sphincterotomy. Conservative therapy consists of a safe temporizing measure during the workup and may, on occasion, be the only therapy that is necessary provided that controlled drainage of the fistula is achieved. The current recommendation would be the exhaustion of nonoperative therapeutic modalities before resorting to surgical intervention.

The co-existence of psychiatric disorders and substance misuse: working with dual diagnosis patients.

The co-existence of substance misuse and psychiatric disorders is often referred to by the term 'dual diagnosis'. The health-related problems associated with dual diagnosis has received growing attention by clinicians and researchers alike. Severely mentally ill patients who misuse drugs (prescribed and illicit) or alcohol have complex health and social needs. Mental health nurses have a key role to play in the early recognition and management of this group of patients. This paper examines the nature and extent of dual diagnosis and its implications for mental health nurses. It also addresses treatment strategies that are required to meet the needs of this cohort of patients.

Recurrent epidermal cyst infection caused by Brucella melitensis in a diabetic patient.

A presternal swelling diagnosed clinically as a sebaceous cyst in a 60-year-old diabetic patient was surgically drained, and the aspirated purulant material yielded growth of Brucella melitensis. The swelling recurred four times and was drained on every occasion. The patient responded to surgical excision and antibrucella treatment. The histologic diagnosis was an epidermal cyst.