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A a sixteen year-old girl, presented to our Outpatient department with the complaints of discomfort in the neck and lower back as well as restriction of body movements. She was not able to maintain an erect posture and would tend to fall on either side while standing up from a sitting position. She would keep her head turned to the right and upwards due to the sustained contraction of the neck muscles. There was a sideways bending of the back in the lumbar region. To counter the abnormal positioning of the back and neck, she would keep her limbs in a specific position to allow her body weight to be supported. Due to the restrictions with the body movements at the neck and in the lumbar region, she would require assistance in standing and walking. She would require her parents to help her with daily chores, including all activities of self-care.\nShe had been experiencing these difficulties for the past four months since when she was introduced to olanzapine tablets for the control of her exacerbated mental illness. This was not her first experience with this drug over the past seven years since she had been diagnosed with bipolar affective disorder. Her first episode of the affective disorder was that of mania at the age of eleven which was managed with the use of olanzapine tablets in 2.5–10 mg doses per day at different times. The patient developed pain and discomfort in her neck within the second week of being put on tablet olanzapine at a dose of 5 mg per day. This was associated with a sustained and abnormal contraction of the neck muscles that would pull her head to the right in an upward direction. These features had persisted for the first three years of her illness with a varying intensity, distress, and dysfunction which would tend to correlate with the dose of olanzapine. Apart from a brief period of around three weeks when she was given tablet trihexyphenidyl 4 mg per day for rigidity in her upper limbs, she was not prescribed any other psychotropic medication. The rigidity showed good response to this medication which was subsequently stopped. The introduction and subsequent withdrawal of this medication did not bring about any change in the sustained abnormal contraction of her neck muscles.\nImprovement and subsequent remission of the mood symptoms of the patient provided the treatment team with an opportunity to stop olanzapine. The discomfort in the neck and the abnormal movement of the neck muscles persisted over the next three months’ period when she was off olanzapine without any significant change, even with a trial of propranolol, trihexyphenidyl, and phenargan injection. Reintroduction of olanzapine (at a dose of 2.5 mg per day) after a gap of three months for the reemergence of some behavioral features led to a slight aggravation of the already existing abnormal movement and posturing of the neck.\nWith improvement in the clinical picture, olanzapine was reduced and stopped. She was put on tablet sodium valproate, 1000 mg per day during this period for the stabilization of her mood when she was also given escitalopram for a period of three months for her depressive features. The patient responded well to this change in medication, but she developed amenorrhea for which no cause was established after a detailed gynecological evaluation. Keeping in mind the possibility of valproate-induced menstrual disturbance, she was shifted to tablet lithium 450 mg per day. The patient was well maintained on this medication for a period of around two years. However, she developed hypothyroidism for which eltroxin was introduced at a dose of 50 micrograms per day.\nDuring this period of two years and seven months, the abnormal contraction of the neck muscles and the abnormal positioning of the head improved slightly, and with the improvement, it would cause less discomfort and interference in her activities. However, these movements failed to disappear completely. Another exacerbation of the mood symptoms in the form of mania warranted a need for the introduction of olanzapine (by a different treatment team) and the patient was reintroduced to 10 mg olanzapine on a daily basis, which led to the current presentation as described earlier.\nAfter the case was seen at our institute, the psychotropic medications were stopped as her mood symptoms had remitted and she was put on tablet tetrabenazine (built up to 75 mg per day in divided doses) with which the patient had started showing some response with an improvement in abnormal movements of the muscles of the neck as well as the back. She is now able to stand with support and can do some daily chores on her own. The pain and discomfort in the back and neck have also reduced.\nDuring the course of the illness, the patient has been investigated for the presence of any neurological illness as the cause of her abnormal movements. Her MRI scan of the brain, serum and urine copper levels, slit lamp microscopy for the KF ring, complete blood count, TLC, DLC, and USG of the abdomen did not reveal any abnormalities. Her thyroid function tests were deranged subsequent to the introduction of tablet lithium carbonate which was restored to normal after the introduction of tablet eltroxin.\nDystonia is a syndrome of sustained muscle contractions that produce twisting and repetitive movements or abnormal postures. The descriptions of the extent and severity of muscle involvement are variable, ranging from intermittent contraction limited to a single body region, to generalized dystonia involving the limbs and axial muscles.\nEver since the introduction of the term, “dystonia” by Oppenhiem in the early part of the twentieth century, it has been an area of focused attention of the neurologists. In 1973, Keegan and Rajput introduced the term, “” to describe drug-induced, sustained muscle spasm causing repetitive movements or abnormal postures. “” was a term introduced by Burke in 1982, the description of which required the presence of chronic dystonia, a history of antipsychotic drug treatment preceding or concurrent with the onset of dystonia, the exclusion of known causes of secondary dystonia by appropriate clinical and laboratory evaluation, and a negative family history of dystonia for definitive diagnosis.\nThe dystonia could be classified based on the region(s) of the body involved. Involvement of isolated regions like the face, neck, and arms would be labeled as focal dystonia, whereas simultaneous involvement of two or more contiguous areas would be called segmental dystonia. When the clinical picture is that of involvement of two or more noncontiguous regions, the label used is, “multifocal” and the involvement of one leg and one other body region makes it the generalized type.\nThe symptoms of tardive dystonia could begin even after a few days or weeks of exposure to the offending agent. Tardive dystonia is prevalent in 0.5–21.6% of the patients who are treated with neuroleptics.\nThe syndrome of tardive dystonia has been reported with most of the typical antipsychotics.[] It has been associated with the atypical antipsychotics, namely risperidone, olanzapine, quetiapine, and aripiprazole. Reports of tardive dystonia developing with the use of atypical antipsychotics have been predominantly in the cases of nonaffective psychosis and in the adult population in the age ranges of the midthirties and forties. Our case is the first case of an affective illness in an adolescent girl developing tardive dystonia on olanzapine. The aggravation of the clinical features with the inadvertent reintroduction of the medication suggests olanzapine is the offending agent. With the growing acceptance of olanzapine as the first-line therapy for the manic phase of bipolar illness and as a mood stabilizer for the maintenance therapy, one needs to be cautious about the emergence of this troublesome adverse effect of this therapy. The patient has shown some response to the introduction of tetrabenazine.

This is the case of a 56-year-old man that was complaining of a dump pain on the right back and a swelling right in this place for several weeks. The patient was in good state and very active. There was not any health problem in the past except a thoracic trauma at work one year ago. In that time the patient was diagnosed with a simple fracture of the 9th right rib without any other consequences.\nOn the X-ray was seen a shadow in the lower part of the right hemithorax. After that, it was decided to perform a CT-scan of the thorax that revealed a tumor of the thoracic wall in the right hemithorax that measured 8 × 4 cm and had a heterogeneous density inside of it. The tumor had involved and destructed the 9th rib and was lying even in two adjacent intercostal spaces, but without involving the lung and muscular layers. On lung window of the CT-scan were seen micronodular infiltrations of both lungs with diameters up to 5 mm and only one nodule in lower lobe of the right lung with diameter almost 1 cm (). The mediastinum was without enlarged lymph nodes and no other lesion was seen in adjacent organs. The conclusion of the radiologist was that probably this was the case of a malignant tumor of the thoracic wall with secondary lesions in both lungs and a biopsy of the tumor was recommended.\nBecause there was not a correlation between the clinical picture of the patient and the conclusion of the radiology it was decided to perform frozen biopsy of the lesions of the right lung and an excision biopsy of the tumor of the thoracic wall. So, through a small posterior thoracotomy at 7th intercostal space were sampled five nodular lesions from the right lung and a sample from the tumor. None of these samples resulted positive (no malignant cells found) after frozen biopsy. In such conditions was considered as more realistic the option of performing an oncologic resection of the tumor of the thoracic wall. (We resected three ribs where the 8th and 10th ribs were macroscopically free of the tumor. The resection was extended 10 cm anteriorly from the tumor and posteriorly it was accompanied by disarticulation of the ribs and partial resection of transversal processes of 8th, 9th, and 10th vertebras.) After that, we have performed a plastic procedure with polypropylene mesh in double layers to correct the defect. The clinical course of the patient was very good and five days later he was discharged from the hospital in very good condition. The conclusion of biopsy for both the tumor of thoracic wall and the lung nodules was sclerosing xanthofibroma which is considered by most people to be a tumor with different clinical and radiological features. Lesions were characterized by a network of anastomosing bone trabeculae without osteoblast lining within a fibrous stroma ().\nReferring to the follow-up, the patient was in a great state of health and from the first month after the surgery he turned back at his work place. Two years after the surgery the thoracic CT-scan showed neither recurrences of the lesions of the thoracic wall nor new developments on the lungs.

A 36-year old female patient visited our hospital with a chief complaint of pain and restricted range of motion (ROM) in the left hip joint persisting for two months. Physical examination of the patient revealed severe gait disturbance secondary to hip pain aggravated by hip joint flexion or rotation. The patient had no lifestyle habits or specific comorbidities thought to cause femoral head AVN. An anteroposterior view of the left hip revealed sclerosis and collapse of the femoral head and dysplasia of the hip (). The magnetic resonance imaging (MRI) scan revealed an increased amount of joint fluid and bone marrow edema in the left hip, and femoral head necrosis was detected on the contralateral side; however, the patient did not complain of any pain (). The patient underwent THA after being diagnosed with idiopathic osteonecrosis of the femoral head, was discharged in good condition three weeks after the surgery without specific complications, and followed up via regular outpatient visits. The patient complained of pain and limited ROM in the contralateral hip joint and gait disturbance one year after the initial surgery. Her symptoms continued for two months and increased over the following three weeks. Repeat MRI revealed similar findings to those noted previously in the left hip (). A second THA was performed (one year after the first THA of the left hip); the patient was discharged in good condition after the surgery without specific complications and followed up via regular outpatient visits (). At the time of the second surgery, the patient was 7 kg heavier than she was at the time of the first procedure and developed a moderate moon face, signs that were initially overlooked as weight gain. Subsequently, the patient complained of intensifying feelings of helplessness and central obesity and muscle mass reduction in both the upper and lower limbs aggravated over a three-month period of outpatient follow-up after the second surgery. However, these signs were not significant enough to warrant further investigation. One year after the second surgery, the patient was referred to the Department of Cardiology in our hospital due to a progressive worsening of central obesity and muscle mass reduction of the limbs and hot flushes. She was diagnosed with hypertension due to high blood pressure and electrolyte inbalance and prescribed medication. She was suspected of having secondary hypertension, and abdominal computed tomography (CT) and echocardiography were conducted. Although echocardiography yielded no specific findings, abdominal CT detected a 2.5 cm benign adrenal adenoma (). The patient was immediately referred to the Department of Endocrinology to be screened for Cushing's syndrome. During screening, a 24-hour urine free cortisol revealed an elevation to 394.3 µg/day (normal, >50 µg/day) and a plasma cortisol level of 29.0 µg/dL (normal, <5.0 µg/dL) was noted based on the results of a 48-hour low-dose dexamethasone suppression test. A plasma adrenocorticotropic hormone (ACTH) of 21.5 pg/mL (normal range, 6–76 pg/mL) and cortisol levels between 17.3 and 19.9 µg/day in a high-dose dexamethasone test confirmed Cushing's syndrome. A suspected cause was ectopic ACTH-producing tumors due to an adrenocortical adenoma. An in-depth history was then undertaken. The patient disregarded advice to undergo regular monitoring of a small abdominal mass found in a regular check-up done several years before her first visit to our hospital. At the time, she had menstrual irregularity, mild weight gain, depression and intermittent facial skin problems–clinical signs associated with Cushing's syndrome. We determined that asymptomatic AI developed into symptomatic Cushing's syndrome, and the patient underwent laparoscopic partial adrenalectomy after referral to our urology department (). Histopathological examination confirmed cortical adenoma. Six months after the procedure, Cushing's syndrome-related symptoms completely disappeared, including feelings of helplessness and central obesity. The patient is currently under outpatient observation without any specific symptoms.\nThe patient's informed consent and institutional review board's clearance were obtained for the purpose of publication of a case report. This article was approved by Gwangju Veterans Hospital at July 2, 2018 (project number, GVHIRB 18-0023).

A 49-year-old male presented with a complaint of pain in the left proximal forearm after a fall. The patient had a history of left elbow arthrodesis performed for posttraumatic arthritis at the age of 18. On physical examination he was tender at the proximal ulna. He had no active flexion or extension at his elbow, which was fused at 90 degrees but achieved 40 degrees of pronation and 60 degrees of supination. His motor and sensory exam was normal at the hand. Radiographs of the forearm and the elbow revealed an elbow arthrodesis at 90 degrees with retained hardware and a minimally displaced proximal ulnar shaft fracture (). A decision was made to treat his ulnar shaft fracture closed in a cast, and he subsequently developed a hypertrophic nonunion. At his clinic visit three months after the fall, surgical options for the ulna nonunion were discussed with the patient. We proceeded with conservative treatment for an additional three months, with worsening motion through the nonunion site. He revealed that he was unhappy with the functional limitations of his elbow arthrodesis and inquired about the possibility of converting it to an arthroplasty. The risks of elbow arthroplasty were discussed with the patient at length. Increasing the functional capacity of his arm was his ultimate goal, and understanding that he faced a likely operation for the ulna nonunion, the patient wished to proceed. Due to the patient's prior surgery and history of trauma, as well as risk of infection, we chose to avoid multiple surgeries and combine the repair of nonunion and the conversion of elbow arthrodesis to arthroplasty into one procedure. The stem of the ulnar component would thus act as an intramedullary device.\nIn the operating room the patient was placed in a supine position and a posterior incision centered over the elbow was performed. A prior muscle flap that was used for soft tissue coverage at his index procedure had to be elevated. The ulnar nerve was encased in scar tissue and required a meticulous neuroplasty. A triceps splitting approach to the elbow joint was then performed and multiple buried pins were removed from the humerus []. A wedge osteotomy of the arthrodesis site was then performed and the fusion taken down (). This was performed at the apex of the arthrodesis site with the humeral cut at 90 degrees to the long axis of the humerus and the ulnar cut at 45 degrees to the long axis of the ulna. The cuts were done in this manner to better accommodate the stems of the prosthesis. Resection of the humerus was greater than normal to allow for appropriate range of motion (ROM) of the elbow without undue tension on the neurovascular structures, which had been in this position for over 30 years. Resection of the radial head was performed as it was markedly arthritic. After preparation of the canals, a Stryker distal humeral replacement system was used to perform the total elbow arthroplasty (MRS (Stryker, Kalamazoo, MI)). Intraoperatively, the patient had full flexion and extension of the elbow and full pronation and supination. His muscles were properly tensioned without undue strain on the neurovascular structures. The patient's ulnar nonunion was also addressed with bone graft taken from the resected radial head. He had an uncomplicated hospital course and was allowed full ROM on postoperative day #2. At his 4.5-month appointment, the patient was achieving 0–110° elbow active elbow flexion/extension, as well as nearly full forearm rotation. He was experiencing minimal pain and was happy with the function of his prosthesis. The patient was able to return to work with an elbow brace that he locked at work. Radiographs showed a healed ulna nonunion and a stable total elbow prosthesis without signs of loosening (). Multiple attempts to contact the patient for further follow-up have been unsuccessful.

A 47-year-old male patient was referred to the rheumatology clinic because of recurrent attacks of pain in both knees over 1 year.\nIn September 2016, the patient presented with severe pain over the medial aspect of the left knee for a two-week duration which prevented him from ambulation. The pain increased with weight-bearing physical activity. The patient reported no history of trauma before the onset of the knee pain. Examination showed severe tenderness over the medial side of the knee with mild effusion and moderate limitation of range of motion. There was no erythema or increased warmth of the knee. MRI of the left knee showed a moderate-sized focal area of marrow edema/contusion involving the medial femoral condyle in mid and anterior parts predominantly along the articular surface. The patient was prescribed diclofenac sodium 50 mg twice daily and was advised to avoid prolonged weight-bearing activities. Over the next few weeks, the pain subsided and resolved. Three months later, the patient developed spontaneous new onset of pain involving the lateral aspect of the same knee. MRI showed bone marrow edema involving the lateral femoral condyle with complete resolution of the bone marrow edema of the medial femoral condyle. He was treated conservatively with NSAIDs and physiotherapy and advised to use cane to minimize weight bearing on the diseased knee. demonstrates MRI of the left knee in September 2016 and three months later.\nIn April 2017, the patient developed gradual pain over the medial side of the right knee with no obvious swelling. MRI of the right knee showed a moderate-sized focal area of marrow edema involving the medial tibial plateau medially and anteriorly. The patient was treated conservatively in a similar fashion to the previous episode. Four months later, the pain got more severe for which he underwent another MRI of the right knee which showed extensive marrow edema involving the medial femoral condyle with complete recovery of the medial tibial plateau bone marrow edema noted in the previous MRI (). The patient also recalled a similar pain happened in 2011 to the left knee but did not do MRI at that time.\nIn all previous presentations, the patient did not report any history of trauma, fall, twist, constitutional symptoms, or using corticosteroids. He also had no history of other joint involvement apart from knees and denied any history of low back pain. He did not have any features suggestive of spondyloarthropathy or connective tissue disease.\nPast history is significant for fracture of the greater tuberosity of the left humerus and undisplaced fracture of the left cuboid bone. Fractures happened after he fell off a ladder. Also, he is known to have mild asthma which is controlled with as-needed bronchodilator and hypertension maintained on amlodipine 5 mg daily. The patient had never been a smoker or an alcohol consumer.\nLab investigations revealed vitamin D 8 ng/mL (normal: >30 ng/mL), corrected calcium 2.16 mmol/L (normal: 2.10–2.60 mmol/L), parathyroid hormone 91 pg/ml (normal: 15–65 pg/ml), and alkaline phosphatase 49 U/L (normal: 40–150 U/L). Complete blood count, kidney and liver function, CRP, and ESR were within normal limit. Immunology profile including rheumatoid factor, ACPA, ANA, anticardiolipin, and B2-glycoprotein were all negative.\nDXA scan showed a T score of −1.0 at the lumbar spine and −1.6 at the left femoral neck suggestive of osteopenia. shows further details of the DXA scan.\nThe patient was treated conservatively with oral vitamin D2 50,000 IU/week supplement and NSAIDs. Gradually, the symptoms subsided over the next few weeks, and vitamin D level became normal after 12 weeks.

A 24-year-old Yemeni female presented to the endocrinology clinic in April 2017 because of inability to walk and a long history of osteomalacia. She was unable to walk for the last 4 years with severe weakness and bone pain. She reported that for the last 2 years she was so weak that she could not turn over in bed and this was associated with pain all over her body. Her condition started as a baby as she did not walk till she was 2.5 years old. Then when she started school she stated she could walk but could never run, the family was poor and never sought medical help for her condition. She got married at a young age of 15 and became pregnant soon after that. During her pregnancy she had difficulty in walking and had pain in her legs, she needed assistance to rise from the sitting position and she was told she would need a cesarean section because she had a contracted pelvis, but she went into labor before she was able to have a cesarean section and she delivered vaginally and developed a fracture of the pubic rami during delivery.\nHer condition over the following years worsened and she was having more difficulty in walking and needed assistance in climbing stairs. She went to several orthopedic surgeons and she was diagnosed as osteomalacia and given calcium and vitamin D without any improvement, till she became totally bedridden. At one time she was also given calcitriol in small doses and for short periods of time 0.25 mg daily. She eventually stopped all treatments when she did not see any improvement in her condition. She was also seen by a neurologist and was found to have a normal nerve conduction study and was told there was no evidence of neurological disease.\nShe has no family history of a similar condition in her parents or siblings or other relatives.\nAt her initial presentation, physical examination of the patient showed that she was 144 cm tall and weighed 49 kg, she was much shorter than the rest of her family. She had normal teeth and hair development. Examination was within normal limits except that she had generalized weakness and tenderness in her extremities with bowing of the legs and genu valgus. All the blood work that the patient had from 2012 to 2019 can be seen in Table .

We report a 24-day-old female baby who presented with dyspnea and fever. Examination showed decreased air entry on the left side and a subsequent chest radiograph showed what looked like a consolidation of that lung and air-filled bowel loops inside the chest and a further ultrasound examination also identified intrathoracic ipsilateral kidney. A computed tomography (CT) of her thorax was performed, which confirmed left-sided diaphragmatic defect with large and small bowel and a normal looking, completely intrathoracic, ipsilateral left kidney and adrenal gland. The baby was delivered by spontaneous vaginal delivery with no antenatal diagnosis; she had normal Apgar score and did not require any resuscitation.\nThe procedure was performed in left lateral decubitus position. A 5 mm camera port was inserted by open technique in anterior axillary and two 3 mm working ports were inserted under vision on either side of camera port. The examination confirmed the CT findings (\n). The herniated large and small bowel was pushed and reduced into the abdominal cavity through the diaphragmatic defect which then revealed a completely intrathoracic kidney encased in Gerota's fascia (\n).\nThe kidney was then reduced into the abdominal cavity retroperitoneally by pushing it down through the diaphragmatic defect (\n). A primary repair using interrupted nonabsorbable sutures was achieved without tension (\n). Initially the gas pressure during the reduction in hernia contents was kept at 6 mm Hg but was then reduced to 4 mm Hg during closure of the defect. A chest drain was left in situ through the 5 mm port site at the end of procedure as there was violation of the pleura.\nThe baby had uneventful recovery and was extubated within 24 hours and chest drain was removed after 48 hours. Renal ultrasound scan showed a correctly positioned kidney with good perfusion and no signs of obstruction. She was discharged on day 5 postoperatively and is being followed up as an outpatient; her most recent renal ultrasound scan done 3 years postoperatively showed well and equally perfused kidneys with comparable renal volumes bilaterally without any evidence of hydronephrosis or hydroureter, or recurrence of the diaphragmatic hernia.\nDuring admission, the patient's mother gave a similar family history—her sister had had a similar condition at birth more than three decades ago. She had open repair of her diaphragmatic hernia at which an intrathoracic kidney was also found and reduced into the abdominal cavity. In the previous months, she had been diagnosed with renal cell carcinoma in that kidney and she had just undergone a left radical nephrectomy for her condition. The child's parent asked whether she might have an increased risk of having similarly effected children and whether her daughter now had a higher risk of developing renal cell carcinoma in this kidney.

A 16 years old female patient presented to us with inability to walk on both lower limbs since last 3 months. Earlier the patient was able to walk with a limp and would sway to either side while walking. Three months back patient experienced sudden onset pain in her right groin region while walking and the patient was not able to bear weight on her right lower limb. Then patient was walking with support, bearing weight on her left lower limb. In about a week, patient experienced similar pain in her left groin and was not able to bear weight on either lower limb since then and was left bed ridden. Clinical findings were consistent with coxa vara deformity of bilateral hips with a possibility of bilateral non-union of pathological fracture of femur neck. There was no evidence of any endocrine disturbance, or altered pigmentation or precocious puberty.\nOn imaging it was concluded that the patient suffered from polyostotic fibrous dysplasia with bilateral Shepherd’s crook deformity of the proximal femur with bilateral non – union of pathological fracture of neck femur (). Imaging of the other bones showed evidence of the fibrous dysplastic lesions in the shaft of left tibia ( and ). Magnetic resonance scanning of the bilateral hip region showed the features consistent with fibrous dysplasia of the proximal femur shaft along with sub - capital fracture of femur neck without evidence of avascular necrosis of the femur head (). All the blood and serum biochemical investigations of the patient like the hemoglobin, total and differential white cell counts, erythrocyte sedimentation rate, C – reactive protein, calcium, phosphorus, alkaline phosphatase levels and all the hormonal studies were within normal limits. It was decided to do both correction of the deformity to realign the head, neck and shaft; and to achieve valgus at the neck - shaft region and a horizontal configuration neck fracture increasing the chances of union of pathological fracture of neck femur, in one stage, each side at a time.\nOn the right side, first oblique osteotomy was done from just distal to the greater trochanter up to the level of the neck to separate the greater trochanter and the second, lateral closing wedge abduction osteotomy was done at the subtrochanteric level to achieve alignment of the shaft with the proximal femur. With traction neck was aligned to the head and fixed with a 135° Dynamic Richard’s screw with a long side plate. The high riding greater trochanter was aligned with the neck and held with a tension band wire from above and medial to the abductors to hold the greater trochanter aligned.\n2 months later on the left side double lateral closing wedge abduction osteotomies were performed both at the subtrochanteric level to achieve the valgus at the neck – proximal femur shaft junction and to align the distal shaft with the proximal femur. After full correction the head and neck were aligned and the vertical geometry of pathological fracture neck femur was converted into a more horizontal one increasing the chances of union of the fracture. Fixation was done using a 135° Dynamic Richard’s screw with a long side plate to span both the osteotomy sites.\nPost – operatively we achieved a neck shaft angle of 135° on right side and 133° on the left side (). Patient was started on active and passive quadriceps strengthening exercises and after 6 weeks of immobilization toe touch weight bearing was started followed gradually by partial and complete weight bearing mobilization. Follow up imaging showed union at both the osteotomy sites bilaterally and also at the site of the pathological fracture of neck femur. Presently, at 18 months post – operatively (), patient is walking full weight bearing without support and there are no signs of recurrence of lesions of fibrous dysplasia or the deformity.

We present a case of a seventy-three-year-old Saudi man who has started visiting the primary health care center in our institution twenty-five years ago. He has been concerned with having a cancer that would give him only few days to live. At the beginning, the patient was evaluated medically through detailed history and documentation of his symptoms and then a management plan was created accordingly to exclude cancer. Full history, physical examinations, and radiological and pathological investigations were ordered and the results were all negative for cancer. The physician explained the results of the investigations to the patient but he refused them and continued to insist that he had cancer regardless of the results. The patient was then referred to Psychiatry Department to be evaluated but he could not realize that his symptoms might be of a nonorganic cause, either psychological or mental.\nThe patient continued to visit the general hospital, emergency department, and the primary health care in the institution and was still occupied with the idea of cancer presence. Although the patient was seen by many physicians, the patient was always not satisfied with their conclusions. Eventually a physician reported the case to the department of medical eligibility addressing the issue of continuous primary health care center visits with very variable symptoms, nonconclusive diagnosis, and an unconvinced patient. The department of medical eligibility in the hospital administration took a decision to temporarily limit the patient's file to the psychiatry department to drive the patient to visit the psychiatrist to be evaluated psychologically in order to make his file eligible again. The patient was unhappy at the beginning but he had to visit the psychiatrist. So, an appointment with the psychiatrist was booked and a full psychological and social evaluation was performed by taking a thorough history from the patient. This revealed that the patient fit the criteria of the illness anxiety disorder in which he had a minimum of six months of a persistent belief of having a serious disease which he specifically named. Moreover, this persistent occupation with this belief was disabling and limiting him from having a normal life and thought that his days were counted in this life. Also, a persistent refusal of any medical advice or explanation for his symptoms and fears was neither related to schizophrenia nor related to mood disorders.\nA diagnosis of illness anxiety disorder was made despite the patient's strong refusal. The family and social history evaluation also revealed a very low socioeconomic status and similar conditions in the family. Interestingly, two of the patient's daughters had similar reported conditions which could raise the suspicion of the possible genetic predisposition that could be triggered by shared environmental factors between him and his daughters. Following this extensive detailed history and evaluation, the treating psychiatrist contacted the department of medical eligibility to make the patient's file eligible again as promised by them with an unlimited eligibility to all specialties and primary care center. For the past twenty-five years of continuous hospital visiting, he has had almost weekly and even daily visits to the primary care. The patient kept complaining of variable symptoms every week and specifically asking for certain lab tests and radiological studies. Also, he successfully convinced some physicians to order a biopsy for him.\nIt is reported that physicians in the primary health care center used different techniques of counseling and they applied the biopsychosocial model to overcome the patient's fears but often failed to reach an achievement as the patient continued to complain of different symptoms and became a burden on the physician's clinic time and the hospital resources. It is also reported that the patient was extremely difficult to handle and convince. In the absence of institution guidelines to deal with such cases, all physicians tended to yield to the patient's persistent complaints and accepted his demands and fulfilled his desires by requesting whatever investigations the patient asked for. Over the years, the patient's investigations have cost approximately $178200 due to the system negligence to such cases. The patient's most requested investigations were mainly invasive radiological studies specifically abdomen and pelvis CT (18 times) and wide range of other invasive and noninvasive studies like chest CT (11 times), brain CT (7 times), chest MRI (4 times), lumbar spine MRI (6 times), and other studies. It is important here to put emphasis on the potential harms of radiation from radiological studies that are frequently requested by the patient in the absence of clear guidelines to be followed by practitioners for that group of patients. In addition, the patient asked for a variety of lab tests including renal profile, parathyroid hormone, complete blood count, estimated glomerular filtration rate, coronary risk profile, 25-hydroxy vitamin D, thyroid stimulating hormone, prostate specific antigen, free T4 level, and other very wide range of lab tests. Moreover, the patient underwent several biopsies like renal biopsy, prostate biopsy, gastric biopsy, and other different types of biopsies.\nThe patient was abusing the system in which resources and time were wasted. The patient kept overstepping each barrier by the hospital's staff to minimize his burden on the hospital by manipulating staff and deceiving and misleading them by giving incorrect information. Also, he was targeting junior practitioners and disturbing them and even threatened to sue the administration if restricted from health care. Five years ago, an experienced board-certified family physician was shocked when he looked at the patient's file and decided to put an effort to solve this problem by taking some actions. First action considered, after getting the approval from the family medicine department, was to limit the patient's primary care visits to only one clinic and to refer him to the supervising physician himself. Then, building strong and effective patient rapport based on trust and honesty was initiated. After negotiations, the patient agreed to enroll in cognitive behavioral therapy (CBT) for six sessions ninety minutes each. The patient was advised to have a scheduled sleeping time, ensure healthy eating habits with regular physical exercise, be involved in social activities, stay away from stressors like searching web for symptoms, and avoid TV health shows and health magazines during active cycles of disorder. After that, there was an agreement with the patient not to disturb the clinic and he would get to see the physician regularly for checkups every three months.\nAfter five years of implementing the new rules, the patient is still visiting the clinic for regular follow-up and sometimes he breaks the rules and comes regularly to the clinic especially in active cycles of the disorder. On following the patient's condition in the last five years, it is noticed that there is a dramatic decrease in the total financial cost due to the relative decreasing number of visits, less time spent on arguing with the patient, and the filtration of his requests. Moreover, there is a remarkable improvement in the patient's condition because of CBT and relative compliance to health advice. We think that this rare case of extremely persisting illness anxiety is worth reporting because the patient managed somehow to escape attention and made a huge financial burden on hospital resources in the absence of clear guidelines in such conditions. Also, this case provides useful insight for future guidelines development.

A 23-year-old female patient was admitted to a plastic surgery clinic because of an esthetic problem caused by swelling on the scalp, which started 1 year previously and gradually worsened in the most recent 6 months. She underwent surgery under local anesthesia without guidance using an imaging method. Bleeding started at the beginning of the operation, and the procedure was terminated. Five months after the first operation, she suffered from increased swelling of the lesion. She was seen by another physician, and cerebral magnetic resonance imaging (MRI) was performed []. The physician felt that it was a simple skin lesion that could be completely removed under local anesthesia. She underwent a second surgery and experienced severe hemorrhaging. Later, she was referred to our clinic. Her physical examination revealed a painful mass lesion measuring 5 cm × 4 cm × 4 cm in the left parietal region at the vertex level. She did not have any complaints except for her esthetic problem. The results of her neurological examination were normal. A vascular malformation at the scalp was considered, and a cerebral MR angiography was performed and revealed a vascular mass lesion, which was located in the left parietal region and supplied by the branches of the left external carotid artery for which venous drainage could not be clearly identified []. Therefore, we performed a conventional cerebral angiography and detected AVM in the left parietal region that was supplied via the branches of the left temporalis superficial artery, left meningeal media artery, and right temporalis superficialis artery []. The lesion did not have an intracranial component and had no direct drainage vein into the dural sinuses. The patient was surgically treated under general anesthesia in the supine position, and her head was elevated at a 30° angle. The skin flap was removed with a horseshoe incision considering the vascularization of the scalp. The vascular lesion in the soft tissue was dissected, and the malformation was revealed. Initially, the supplying arteries of the lesion were closed. Later, the lesion was completely removed along with its nidus. The bone underlying the lesion had become thin; hence, the periosteum was cauterized with bipolar coagulation. Hemorrhaging from the bone was controlled with monopolar coagulation and bone wax. The skin flap was closed without the need for an additional plastic intervention. The histopathological diagnosis was as AVM [Figure –].

A 32-year-old healthy female presented to a clinic (LS). The main complaint was severe pain in right temporomandibular joint (TMJ) region, right ear, mouth opening limitation, and asymmetrical of the face. The patient reported that she was born at full term by spontaneous vaginal delivery and no perinatal problems and no notable postnatal illness were reported. However, in the months following birth, the parents observed progressive enlargement of her right cheek and a differing eyelid width. According to the patient, the facial asymmetry had become more marked over the following years but had not increased in the past few years. No other family members were affected. Patient's mother reported a normal pregnancy. The enlargement extended from the midline to the preauricular region and inferiorly to the lower border of mandible []. The skin of the involved right side of the face was normal in appearance with no alteration in thickness. The extraoral examination revealed that the right side of the mandible was larger than the left side. The outer contour of the right ear was slightly larger and had a different shape compared to that of the left side []. The nose was normal with no deviation although the chin was deviated toward the side of her face. The lower lip on the right side was appeared thicker with drooping of the corner of the mouth on this side. The lips on the right side seemed very dry. The patient complained clicking in the left TMJ and disability in chewing and headache in the right side. Physical examination revealed normal symmetric body. The patient was mentally healthy. The mouth opening was 12 mm. On intraoral examination, asymmetry of the tongue was evident []. The right part of the tongue shows unilateral enlargement of fungiform papillae. The teeth size on the affected side appeared normal except the dimensions of maxillary right first molar, which was considerably greater than maxillary left first molar. The size of the lower right first molar was slightly greater than lower left first molar. The lower dental centerline was deviated to the right in relation to the midline and a downward canting of the occlusal plane was observed []. On occlusal examination, the central relation was unattainable. Furthermore, there was early contact in both central occlusion and right lateral movement. A discrepancy in range of mandibular motion was observed. The patient was referred for radiography. The radiographs confirmed the clinical findings. The panoramic radiograph [] showed that the right condyle, ramus, condylar neck, and the body of the mandible were enlarged. There was significant deposition of bone growth on the right mandible, and the bony trabeculation alteration was observed. The size of the right inferior dental canal was normal compared to the left mandibular canal and was displaced. Crowns and roots of the right mandibular molars were larger than the contralateral mandibular molars. The roots of the lower right first and second molars were remarkably divergent. Cone-beam computed tomography (CBCT) images of the face and skull revealed that the zygomatic and frontal bones, right mastoid process, right half of the mandible and maxilla, maxillary sinus, and associated soft tissues were enlarged [Figure and ]. CBCT also demonstrated thickening the mucosal membrane of the right maxillary sinus [Figure and ]. There was no obstruction in the sinus meatus. Brain computed tomography (CT) showed no abnormalities [Figure and ]. 3D skull reconstruction CT image revealed hypertrophy of the right mandible, condyle, TMJ, zygomatic bone, petrous bone, and mastoid process []. The posteroanterior radiograph [] revealed enlargement of right half of the mandible, maxilla, and zygoma. The patient was referred to physician. Physician consultation reported systemic abnormality. Blood investigations were within normal limits. Depending on the clinical and radiographic abnormalities were thus consistent with the diagnosis of a hemifacial hypertrophy and fibrous hyperplasia. The patient was referred to oral surgeon. Surgical recontouring of right maxillary and mandibular bone was performed. After 6 months, condylectomy was performed for the right condyle; the size of the condyle was 5 cm × 3 cm []. The mouth opening was significantly increased to 4 cm.

A 64-year-old Caucasian man from Austria was referred to the urological department because of episodes of intermittent gross hematuria. The patient had a colorectal carcinoma treated by rectum and ileum segment resection, chemotherapy and radiotherapy four years before. After radiotherapy ureteric strictures developed on both sides and ureteric stents were placed. At the time of admission the urine specimen showed few white and red blood cells and the urine culture was sterile. During the change of the ureteric stents a retrograde pyelography and cystoscopy were performed, showing a mild gross hematuria coming out of the right ureteric orifice but no further pathological findings. After the stent change, first the hematuria cleared but one day later again an episode of gross hematuria with blood clots in the bladder occurred. A transurethral catheter was placed and a multiphase CT of abdomen and pelvis was performed. CT detected no source of bleeding. The gross hematuria cleared again and an ureteroscopy on both ureteric sides were performed with special emphasis on the right ureter. Once again nothing suspicious could be found. Thereafter gross hematuria appeared again with massive hemorrhage and an arteriography was performed (). But once again no underlying reason for the bleeding could be found. Two days later a gross hematuria with massive hemorrhage occurred. The patient became hemodynamically unstable and needed blood transfusion of 6 U. Therefore, the indication for nephrectomy of the suspicious right side was set and performed. During the operation the ureteric stent was removed and at the end of the operation the hematuria stopped. When the patient left the operation room again a massive hemorrhage was identified within the bladder catheter. Again an arteriography was performed. Finally, the region of the fistula was identified at the distal common iliac artery and a stent graft was deployed across the fistula (). A postoperative angiogram showed complete closure of the fistula (). After adequate blood transfusion and fluid replacement the patient made a rapid and unremarkable recovery. Twelve months later the patient is still well and the stent graft remains patent. However, the patient lost his right kidney.

The patient was a healthy 13-year-old female, who suddenly felt abdominal pain. She was taken to another hospital by ambulance, and the enhanced abdominal computed tomography (CT) revealed a 5 cm diameter cystic tumor in the pancreatic tail with fluid collection around it (). The CT results indicated her acute abdominal pain was due to the hemoperitoneum caused by rupture of the pancreatic tumor. Because she had no history of blunt abdominal trauma, the tumor was considered to have ruptured spontaneously. The pancreatic tumor was diagnosed as a SPT of the pancreas from the finding on the CT combined with her age and gender. Since the bleeding stopped by conservative therapy, she was referred to our hospital for surgical treatment at three months after the rupture of the tumor. At that time, she had no abdominal symptoms and the tumor was not palpable. The CT at our hospital showed the cystic tumor was 4 cm in diameter, which protruded from pancreatic tail and was distant from the main pancreatic duct, and the fluid around the tumor had disappeared (). From these findings, an elective laparoscopic enucleation of the tumor was proposed. Since there seemed to be no peritoneal dissemination from the result of laparoscopic exploration, laparoscopic enucleation was performed by using five trocars under pneumoperitoneum. The pancreatic parenchyma was divided with the laparoscopic coagulating shears (). Duration of operation was 126 minutes and with little blood loss. Because the content of amylase in the fluid from the drain placed at the cut surface of the pancreas was 9710 IU/L on postoperative day 3, the postoperative pancreatic fistula was confirmed according to the international definition []. However, because the volume of the fluid from drain was very small, the drain was removed on postoperative day 4. Except for the pancreatic fistula of grade A [], the postoperative course was uneventful and the patient was discharged on postoperative day 7. Pathologically, the tumor was diagnosed as SPT of the pancreas. The negative surgical margin and the rupture of the capsule of tumor were verified by microscopic examination (). She survived without recurrence of disease for two years after the operation.

A 60-year-old Kashmiri female presented to our department after having sustained a fracture of femur in the supracondylar region. After initial management, the fracture was fixed with a dynamic condylar screw assembly. After an uneventful postoperative period, the patient was discharged with advice to undergo supervised physiotherapy. 3 months into the postoperative period, the patient reported to our emergency department with pain in the thigh. X rays revealed a fracture above the dynamic condylar screw at the plate bone interface. The patient was admitted and revision surgery with a longer barrel plate performed. The patient followed up for a period of 4 months and was bearing weight when she again had pain in the peri implant area. Radiographs revealed a fracture of the femur at the new peri implant region. The patient's femoral neck radiograph revealed an osteoporosis grading of 3 according to Singh's classification []. Keeping in view the potential morbidity associated with the repeat plating we planned a method that would be less invasive and less destructive to the local fracture environment. The proposed surgery was explained to the patient and her attendants. The ethical board permission was sought and obtained. The patient was taken to the operating room and placed on a fracture table. The screws in the plate were removed percutaneously under image intensifier control to ensure the patency of intramedullary canal leaving the plate insitu to avoid reexposure of the bone surface. The fracture was reduced and fixed with a reamed antegrade intramedullary nail. Anticipating the difficulties in distal locking with an insitu plate an external locking device comprising of a distal full ring and a proximal Italian arch connected by two threaded rods were used. No blood transfusion, bone grafting were used and the mean operating time was 40 minutes. The patient was ambulated on the first post operative day and discharged from the hospital on the same day after advising range of motion exercises of the knee. The patient was advised to compress the fracture at a rate of 1 mm per day in divided increments. The follow up was done at two week intervals. At a mean follow up of 8 weeks when the signs of healing were seen on the radiographs the external ilizarov fixator was removed. The fracture united at 14 weeks with a mean range of motion of the ipsilateral Knee being 0 to 120 degrees. There were no complications associated with the procedure.

A 47 year old gentleman presented to his general practitioner with acute onset lower back pain. The pain had commenced during coitus and radiated down the right leg. The initial diagnosis was of acute disc prolapse and he was referred for an urgent neurosurgical opinion. The neurosurgeon concurred that the pain may well have been of neurological origin and arranged an MRI scan. This was reported as showing no evidence of spinal cord pathology. The patient was reassured with the results of the MRI findings and was advised the pain was probably musculoskeletal in origin and should settle. Over the subsequent 6 weeks, the pain persisted and indeed increased in severity. The patient noted claudication-type pain in his right leg after approximately 100 metres. As the pain had not resolved after 6 weeks he revisited his general practitioner. During the subsequent examination the pulses in his right leg were noted to be absent and he was referred for an urgent vascular surgical opinion.\nThe patient was seen the following day in the vascular clinic where a history of severe acute claudication-type pain was noted in the right leg. There was a past medical history of marked hypertension and hyperlipidaemia, for which he took relevant medications, but none of angina, myocardial infarct or valvular heart disease. On clinical examination the heart rate was 68 beats per minute regular. The blood pressure in the right arm 130/70 mmHg was lower than that of the left arm 160/80. Cardiac examination was normal. There was no clinical evidence of an abdominal aortic aneurysm. Examination of the limbs revealed that the right lower limb pulses were all absent whilst those of the left leg were present and of good volume. An urgent abdominal ultrasound scan was arranged which demonstrated dissection of the intra-abdominal aorta and a subsequent CT scan (Figures , , ) confirmed that the dissection was a Type A dissection extending from the aortic valve down to the aortic bifurcation. A dissection flap was identified in the ascending aorta and also in the postero-inferior aspect of the descending aorta. Both lumens were noted to have flow within them with the true lumen supplying the celiac axis, superior mesenteric artery and right renal artery and the false lumen supplying the left renal artery and inferior mesenteric artery. Immediately below the inferior mesenteric artery the false lumen obliterated.\nAn immediate opinion was sought at the regional cardiothoracic unit and the patient was transferred urgently under their care. A transthoracic echocardiogram was performed which confirmed the CT findings demonstrating turbulent flow in the ascending aorta suggestive of an intimal tear in the region although the lesion itself was not seen. The arch was mildly dilated but with no visible flap. Flow in the descending aorta was turbulent in the initial 2–3 cm suggesting intimal disruption.\nHe underwent operative repair of the thoracic dissection on the next available theatre list. The aortic valve was resuspended and the ascending aorta were replaced using an elephant trunk graft with reimplantation of the brachiocephalic artery on 1 patch and the left common carotid and subclavian arteries on a second patch.\nAfter 48 hours in the intensive care unit the patient was transferred to the ward where he made an uneventful recovery. Cardiac and cerebral functions were not impaired by the procedure as evidenced by return to preoperative state and no requirements for chronotropic medications.\nA routine postoperative CT scan demonstrated that the repair was satisfactory. There was thrombosis within the false lumen of the descending aorta but persistence of flow within both lumens of the abdominal aorta.

A 68 year old male patient was admitted 48 hours after he suffered a severe hip injury when falling from a bridge. The initial Rx-ray at admission displayed a femoral neck fracture with dislocation of the femoral head into the pelvis (). The patient also presented macroscopic and laboratory confirmed hematuria. A CT scan was not available at that time, but because of the hematuria we suspected an anterior dislocation of the femoral head. A Foley catheter was introduced into the urinary balder and antibiotics were administrated. Surgery was performed next day in lateral approach of the hip with anterior capsulotomy. The femoral head was not found into the hip but in the pelvis and could not be extracted but only touched by finger through a laceration between the anterior acetabular rim and the decollated labrum, creating a dislocation space similar to the anterior dislocation or the shoulder. However a 50 mm Austin Moore prosthesis was implanted and after the surgery the patient had the femoral head replaced and the fractured femoral head retained as o loose fragment into the pelvis (). The patient was prepared for the next surgery and two days later the urologist extracted the femoral head by a new abdominal approach Gibson with retroperitoneal dissection of the common iliac vessels. The head was placed on the iliopsoas muscle and under the iliac common vessels, and during the procedure no visible injury of the ureter, balder or iliac vessels was found. Soon after removing the abdominal wound drainage the patient experienced pain in the hip, lost mobility and swelling occurred at the hip wound. Several punctures of the hip extracted a large amount of clear liquid which was investigated and was found to have density and elements like urine. A drainage tube was reinserted into the hip wound and the patient underwent repeated urological evaluation by urography and endoscopic techniques. A fistula injury of the ipsilateral ureter was found and an internal drainage of the ureter was introduced and left in situ for three months. The Moore prosthesis was extracted, the hip was debrided and irrigated with saline solution and gentamicin. The hip wound healed and the patient had a Girdlestone hip for about 5 months. The hip was revised with a total cemented Muller prosthesis, which resulted in a normal evolution of the wound and rehabilitation.

A 49 years old female presented with history of recurrent palpitations for last 10 years. During last year, she had 5 episodes of palpitations which required hospitalizations. The tachyardia was repeatedly terminated by intravenous adenosine and verapamil. She was nondiabetic and nonhypertensive. General physical and cardiovascular examination were normal. Her baseline electrocardiogram (ECG) showed left bundle branch block with normal PR interval. The electrocardiogram of tachycardia revealed similar morphology, with the heart rate of 210 beats/min. (). Her transthoracic echocardiogram (TTE) did not show any evidence of structural heart disease. An electrophysiological study was planned with a presumptive diagnosis of AVNRT. Catheter manipulation to obtain His bundle electrogram led to complete heart block because of trauma to right bundle that required temporary right ventricular pacing. No tachycardia could be induced during complete heart block and there was no evidence of accessory pathway. Complete heart block persisted for 3 hours during which she required temporary ventricular pacing support. Patient was discharged after 48 hours with a plan to restudy on recurrence. Within 15 days, she had 3 episode of tachycardia all terminated with intravenous adenosine. After the recurrence of episodes, she was taken up for a restudy with a plan of avoiding His bundle / Right bundle injury and as a part of the same plan to avoid His recording coronary sinus catheter was put from the right internal jugular vein. Three 7 F sheaths were put into right femoral vein and one 6F sheath was put into right internal jugular vein. One catheter was put into high right atrium and another into right ventricular apex carefully avoiding trauma to His bundle. From the internal jugular vein, since the catheter did not follow a normal course, angiogram was done that showed absent right superior vena cava and whole of the jugular system draining into hugely dilated coronary sinus which was missed on transthoracic echocardiogram (). At that point of time, when we found this venous anomaly the risk of ablation was again discussed with the family and the patient, explaining them the risk of development of complete heart block and need of permanent pacemaker which would be difficult in this patient. Deflectable catheter was then used to clearly define the upper and lower lip of coronary sinus to guide the ablation (). A 7F 4 mm tip steerable ablation catheter was positioned in right and left anterior oblique views. Tachycardia was induced and diagnosis of AVNRT was confirmed by standard protocol. The ablation was performed starting from the inferior lip of coronary sinus and gradually moving anteriorly towards the upper limb of coronary sinus. Intracardiac bipolar electrogram did not show any slow pathway potential near the coronary sinus ostium and at the site of successful ablation (). Just at the upper limb of coronary sinus good junctional rhythm was noted (). A complete lesion at 25-30 watts, temperature of 50ºC for 60 seconds was given. No VA or AV block was observed. Post ablation testing revealed absence of dual physiology and noninducable AVNRT. The patient was discharged on next day and till last follow up after 6 months she was asymptomatic.

An 82-year-old female with 60 kg body weight and 156 cm height who was otherwise healthy underwent a right total knee arthroplasty for osteoarthrosis under epidural anesthesia at a hospital nearby. The insertion of the epidural catheter and operation were finished without any problems and the removal of the epidural catheter was attempted as usual two days after the operation. The epidural catheter broke during its removal. The physician felt resistance when he tried to pull out the catheter and then the catheter was broken 13 cm from the tip. X-rays and a computed tomography scan were subsequently taken (). Although the catheter fragment retaining within the patient was long, a wait-and-see approach was initially employed because there was no neurological deficit. The effusion from the drain hole stopped two days later. No neurological deficit or fever developed after the first evaluation of the images. However, the migration of the catheter was found by imaging studies four weeks after the occurrence of the catheter breakage (). After detailed discussions with the patient and her family it was decided that a surgical removal of the retained catheter should be performed. Then, the patient was referred to our hospital.\nThere was no neurological deficit at the time of admission. A laminectomy was performed at L2-3 seven weeks after the catheter had broken. The patient was placed in the prone position under general anesthesia and then the spinal level that needed to be treated and the retained catheter were identified by using an image intensifier. We exposed the spinal process at L2-3 and the L2 spinal process was split by an air drill. The catheter was confirmed to be present between the L2 and L3 spinous processes and the edge of the catheter was found to be broken (). The catheter went entered the epidural space through the flavum.\nAfter removal of the bilateral flavum in an usual manner the catheter was found to be coiled up at the surface of the dura mater and was covered by a thin reactive film (). The catheter was heading to the nerve root. No evidence of dural puncture by the catheter was found. The removal of the catheter was first attempted by simple traction, however, was found to be impossible because of the adhesion (). The adhesion of the dura mater surface was carefully exfoliated and then the removal of the catheter was accomplished (). No cerebral spinal fluid leakage was found after removal of the catheter.

A 78 year old Caucasian male presented to our casualty 6 weeks following admission elsewhere with a history of swelling of the right leg and a pulmonary embolus. He had undergone VQ scanning with a proven diagnosis of pulmonary embolus and was therefore anticoagulated with heparin and warfarin.\nOn admission he had swelling of the right knee and lower thigh with loss of sensation on the dorsolateral aspect of the right foot. Clinical examination revealed a large mass in the right popliteal fossa. The initial diagnosis was that of deep venous thrombosis and imaging was undertaken and the patient referred for a vascular opinion.\nOn vascular review, the patient had a pulsatile mass comparable with a popliteal artery aneurysm of 12 cms diameter on the right and 6 cms on the left. His foot was warm and well perfused and his INR was 2.6. He underwent a duplex scan of the lower limb arteries which revealed ectatic iliacs and an abdominal aorta of 3.4 cms in diameter. A further CT arteriogram (fig , ) confirmed that in fact the swelling on the right side was indeed a pseudo aneurysm following rupture with peripheral calcification.\nThe dilemma was therefore a patient with an established pulmonary embolus and a friable clot in the iliac veins, anticoagulation and the treatment of the ruptured aneurysm. Due to lack of expertise we elected to continue with full anticoagulation rather than place an inferior vena caval filter. Operative exploration was performed through a medial approach under full anticoagulation and the right popliteal artery was found to contain a large volume of blood pointing laterally. The popliteal aneurysm was excluded. Duplex examination of the upper and lower limb veins revealed that the veins were of small diameter therefore revascularization of the leg was established by an inlay 8 mm PTFE graft. Due to continuous oozing, the aneurysm sac was packed and the end of the pack brought out laterally. The pack was removed at 48 hours under sedation. The patient made an uneventful recovery. Six weeks later he underwent repair of the left popliteal aneurysm.

On the 24th April 2006 a 9 month old girl was brought to the Emergency Department of a hospital which routinely refers patients to us. She had sustained a dog bite to her face 30 minutes previously. She was seen by the emergency physicians and was found to have received multiple lacerations to her face over the right zygoma, right paranasal area, right cheek, left eye lid, left paranasal area, left lower cheek and over her left body of her mandible. She was fully examined and found to have no wounds elsewhere however due to the circumstances of patient and parental distress, intra-oral examination was not possible. The initial work up did not include radiographic investigations as it was felt by the emergency physicians that only a soft tissue injury was sustained. On the advice of the on-call maxillofacial team she had her facial wounds cleaned with aqueous iodine solution and she was started on an oral course of Co-Amoxiclav and paracetamol. An examination by the ophthalmologist revealed no ocular injury.\nShe was transferred to our unit the following day, fasted in preparation for an examination under general anaesthesia and primary closure of her facial lacerations. During the procedure it was found that she had sustained an open fracture of her left mandible consistent with a dog bite. (fig ). This was treated via a trans-oral approach with a five hole 1.2 mm titanium plate and four 3 mm screws. (fig ). She had her facial laceration copiously irrigated with normal saline and chlorhexidine and primarily closed in with a fine nylon suture. She was discharged home the next day. Seven days later she attended for removal of sutures under a general anaesthetic and examination of her jaw. The facial wounds were healing well and there was no movement at the fracture site. Ten weeks after the first operation she was admitted for removal of her mandibular plate under general anaesthetic. There was good bony union and the plate was removed with no complications (fig ). She will continue to be reviewed in clinic to monitor dentoalveolar development and mandibular growth.

We present a 58 year old male with an unusual posterior thigh mass for more than a year. Patient had a past medical history significant for RCC, initially diagnosed at stage II, 11 years ago followed by left nephrectomy. Patient also had metastasis to tail of the pancreas and tip of spleen 6 years ago which was followed by total resection of pancreas and spleen. Patient was followed up for RCC and was last seen 2 years ago when his PET/CT showed slightly increased hypermetabolic area in the biceps femoris muscle which was interpreted as a muscle injury secondary to the rarity of the metastasis to the skeletal muscle from RCC. Patient during the current follow up visit developed a large mass in the posterior side of the thigh which was present for more than a year. As per patient, the mass initially was diagnosed as a blood clot on venous doppler, for which he was treated by his primary care physician with warfarin for more than 6 months. However, the mass progressively increased in size. Patient did not mention of any other constitutional symptoms. On physical examination, a painless, tense mass along the length of biceps femoris muscle measuring more than 25 cm was found in the posterior aspect of the left thigh. The mass was hypervascular and numerous varicosities of different sizes were noticeable on the surface. Patient was imaged using FDG-PET/CT which showed hypermetabolic activity with an uptake value of 3.8 to 4.1 in biceps femoris muscle with multiple serpiginous vessels throughout the tumor, in accordance with a large cavernous hemangioma or an angiosarcoma. This was followed by MRI to better understand the morphology of the tumor, demonstrating a mesenchymal component in an encapsulated mass, raising the possibility of a liposarcoma or an angiosarcoma. A core tissue biopsy was done which demonstrated well defined adipose tissue but because of high suspicion for malignancy, patient underwent preembolization followed by surgical resection. A 28 x 17 x 7 cm resected mass was determined to be metastasis from his primary RCC (Figures , , , , and ).\nPatient on his follow up with a whole body FDG-PET/CT was also found to have metastasis to his lateral ventricle in the brain from the RCC.

Our patient is a 73-year-old Caucasian female with medical history of hypertension and type 2 diabetes. She had been treated for invasive ductal breast cancer 7 years ago with lumpectomy of the left breast and axillary lymph node dissection. Radiation therapy and seven cycles of adjuvant chemotherapy were administered to her postoperatively, and Anastrozole was prescribed to her for 5 years. She underwent regular annual follow-up for 5 years with chest and abdominal computed tomography (CT) scanning with no signs of recurrence or metastatic disease. Seven years after the initial treatment for breast cancer, abdominal CT revealed a solid hepatic lesion at segments VI and VII measuring 7 cm in diameter as well as a 1 cm calcified lesion at the tail of the pancreas (, left). Tumor markers AFP, CA 15–3, CA 19–9, and CEA were all within normal limits and the patient did not have any symptoms or signs of abdominal mass apart from mild tenderness on palpation of the right subcostal region. Moreover, biochemical markers of liver and pancreatic function were normal.\nSubsequently the patient went through oncologic consultation, and both lesions were considered to be resectable, although controversy arose whether they were metastatic or second primary malignancies. CT-guided percutaneous biopsies or laparoscopic biopsies were proposed as minimal invasive methods of diagnosis. The patient rejected both of them due to the risk for possible complications and cancer spillage and decided to undergo laparotomy, open rapid biopsy, and excision of the lesions in one procedure. After accessing the peritoneal cavity through an extended right subcostal incision, we performed hepatic mobilization and exposure of the right hepatic lobe. A solid mass was recognized at hepatic segments VI and VII and rapid biopsy was taken which showed primary HCC. Moreover, after entering the lesser sac, a second rapid biopsy was taken from the lesion at the pancreatic tail which showed chronic fibrosis without elements of malignancy (). We decided to perform resection of hepatic segments VI and VII since intraoperative hepatic ultrasound also confirmed that the mass was resectable with safe oncologic margins. Hepatic segmentectomy was achieved using a microwave tissue coagulator to mark and coagulate the margins of hepatectomy and ultrasound harmonic scalpel to transect the hepatic parenchyma with a minimal blood loss of 40 cc (). Moreover, argon beam coagulator and fibrin glue were used to seal the raw liver surface and prophylactic cholecystectomy was also performed. Finally, the pancreatic lesion was left intact since malignancy was not confirmed with rapid biopsy.\nPathology report described a hepatic mass with maximum diameter of 6.5 cm which consisted of malignant cells with mild to severe atypia and low to medium mitotic rate. Immunohistochemistry showed that cancer cells highly expressed keratins 8/18, Hep-Par 1 and AFP and did not express keratin 7 and GATA-3 (). Endothelial cells within the mass were positive for CD 34. The gallbladder along with the cystic lymph node was normal. The final diagnosis was low-grade HCC with liver margins widely free from malignant infiltration.–\nThe postoperative course of the patient was uneventful. The subdiaphragmatic and subhepatic drains were removed on the third postoperative day without signs of hemorrhage or bile leakage and the patient was discharged on the fifth postoperative day. Follow-up abdominal CT scanning on the first and sixth month after the operation showed subcapsular hepatic fluid collection without recurrence of the HCC (, right). The patient remains disease free 2 years after the hepatic segmentectomy without any adjuvant therapy.\nWritten informed consent obtained from the patient is for publication of the case details and any accompanying images.

A 50-year-old right-handed Latino man presented with worsening of previously stable chronic motor symptoms. He had initially developed sudden weakness and difficulty using his right upper extremity at the age of 16 years. He eventually had to learn to write using his left hand because of the severity of his weakness. His symptoms progressed over several years, eventually developing into severe symmetrical upper extremity weakness and atrophy in his distal muscles. His lower extremities were spared. Our patient stated he was diagnosed with a type of muscular dystrophy in the US when he was 25 years old. After receiving this diagnosis, he subsequently had a muscle biopsy in Mexico that reportedly confirmed his diagnosis. He had no family members with muscular dystrophy or any other neuromuscular conditions. His symptoms reached their plateau at this time. Because of the stability of his symptoms and his understanding of the disease course, our patient did not seek any further medical care for over 20 years. Upon returning to the US, he was seen by a primary care physician and referred for neurological examination to establish care as well as evaluate the worsening of previously stable chronic symptoms.\nOn presentation, our patient reported a few months of clinical deterioration, particularly recent left upper arm intermittent mild pressure pain. Our patient grew concerned when he noticed increased difficulty performing fine motor tasks with his left hand. In addition, he was experiencing recurrent intermittent episodes of dysphagia while eating solid foods. Our patient denied ever having any previous bulbar symptoms prior to his recent clinical deterioration.\nA clinical examination demonstrated that our patient was thin with significant bilateral upper extremity muscle atrophy and associated weakness. He had severe asymmetric focal segmental atrophy of his bilateral forearm flexor and extensor muscle groups, with preserved and prominent bilateral brachioradialis muscles (Figure ). He had corresponding severe weakness in his upper extremities as measured using the Medical Research Council Scale, with 4-/5 to 5/5 proximal strength and as low as 1/5 strength in his distal muscles. He had bilateral radial deviation during wrist extension. Although his lower extremities demonstrated normal bulk, he had mild weakness on manual muscle testing as well. Our patient had 4/5 strength in his left hip extensors and flexors as well as 4/5 strength in bilateral knee extensors. He had no face weakness, no sensory deficits, no abnormal reflexes, no muscle fasciculations, and no upper motor neuron signs on examination.\nCompound muscle action potentials (CMAP) of his left median, ulnar and radial nerves were absent. His upper extremity sensory nerve action potential (SNAP) responses were normal except for a slightly low amplitude of his ulnar and radial nerves. His lower extremity peroneal and tibial CMAPs and sural SNAPs were normal. Electromyography (EMG) of his upper extremities demonstrated evidence of diffuse chronic neurogenic changes in C5 to T1 innervated muscles as well as evidence of active denervation in his right triceps brachii. In his left lower extremity, chronic neurogenic changes were noted in the gastrocnemius medial head. His left cervical paraspinal muscles were normal on EMG.\nMagnetic resonance imaging (MRI) without contrast of his cervical, thoracic and lumbar spinal cord demonstrated Chiari malformation type I with associated syringohydromyelia extending from C1 (Figure ) to T11 (Figure ). The maximal anterior-posterior diameter was 4mm and maximal lateral diameter 10mm. There was cord atrophy and mild atrophy of his paraspinal musculature (Figure ). Once the syrinx was identified on MRI, our patient was referred to our neurosurgery team for evaluation. An MRI of his brain with and without contrast provided additional views of the Chiari malformation type I (Figure ).

A 74 year-old Caucasian woman with complete heart block had dual chamber pacemaker implanted in 1990. Her initial system included a Medtronic 4504 passive fixation atrial lead and a Medtronic 4004 passive fixation ventricular lead. She subsequently underwent replacement of her pulse generator in 1998 and insertion of a new Medtronic 5568 active fixation atrial lead and a Medtronic 4068 ventricular leads in August 2003 due to lead failure. She underwent a subsequent generator change in June 2011. The original atrial and ventricular leads were abandoned when the new leads were added in 2003. All procedures had been undertaken at a referring institution and she had not had any prior open-heart surgical procedures. The patient presented at her home hospital with a swollen and erythematous pacemaker pocket in February 2014. Blood cultures did not grow any bacterial or fungal organisms. A trans-esophageal echocardiogram was performed to assess for vegetations on the leads. No vegetations were identified, but there was suspicion that one her atrial lead was extravascular. She underwent chest computerized tomographic imaging and this study revealed that one of her right atrial lead tips was approximately 2 cm within the pericardial space (Figure ). The patient was treated with vancomycin and ceftriaxone based on a diagnosis of suspected pacemaker pocket infection. She underwent pacemaker pocket exploration and debridement, but extraction was not undertaken due to the increased risks involved with the lead being extra-vascular. No organism was identified from samples of fluid cultured during that initial debridement procedure. Despite that debridement procedure and prolonged antibiotics there was clinical recurrence of the infection and the patient was subsequently transferred to our center for complex lead extraction.\nTo minimize the risk of vascular disruption and tamponade given the chronic right atrial lead perforation, a combined transvenous and open surgical extraction approach was undertaken. Using a dedicated hybrid operating theatre with cardiopulmonary bypass support if necessary, midline sternotomy was performed. Dense adhesions were found within the pericardial space consistent with likely prior pericarditis. Given the location of the RA lead, care was taken to leave the right atrial dissection until all other vascular structures were exposed. With uneventful dissection of the right atrium, direct visualization of the protruding passive fixation lead was obtained (Figure ). To avoid the risks associated with cardiopulmonary bypass and given the good visualization of the perforating atria lead, an off-pump technique was considered using a “lead-inverting stitch”. To achieve hemostatic control over the region of the atrial wall where the lead exited, a purse-string stitch was placed circumferentially around the lead tip using 3–0 prolene with multiple pledgets (Figure A). The externalized tip of the perforating atrial lead was then mobilized by cutting a rim of surrounding atrial tissue. This allowed the end of the lead to be dunked within the right atrial chamber while the purse-string suture was tightened for hemostasis (Figure B and C). With this “lead inverting stitch”, the lead was free within the right atrium and could now be safely extracted using transvenous laser extraction techniques.\nWith the heart partially verticalized, the lateral wall of the left ventricle was exposed and an epicardial lead (Medtronic 4968) was placed. It was then tunnelled through the subcutaneous tissue above the rectus sheath, secured and connected to the new pacemaker. The new pacemaker was then placed in a newly created pocket, below the left costal margin. The sternotomy wound was covered with sterile surgical towels.\nThe infected pacemaker pocket was then opened and direct visualization confirmed the presence of a small amount of murky fluid. This fluid was sent for culture. The pocket was then extensively debrided and the four transvenous pacemaker leads were prepared for complex extraction in a standard manner beginning with retraction of the distal screw to facilitate separation of the active fixation lead tip from the myocardium interface during laser extraction. A purse string suture was subsequently positioned along the pectoral muscle around each lead at its insertion site to avoid any significant bleeding when the leads are completely removed. The lumen of each lead was then probed for patency with a standard stylet to ensure that a lead-locking-stylet can be utilized and advanced deep into the lead lumen for adequate gripping during the extraction process. Appropriate sizing of each lumen and distal delivery of the locking stylets was subsequently performed. A long silk suture thread was then tied to the outside of the lead near its insertion site, extended along the length of the lead, and tied to its end to provide further support along with the lead-locking-stylet when applying traction on the lead during laser extraction. Now that the leads have been prepared, transvenous lead extraction with a #14 French laser sheath was attempted. Due to the presence of multiple biding sites, up-sizing to a #16 laser sheath was required along with the use of a less compliant outer sheath (Visi-sheath). All the leads were removed entirely, with the perforating atrial lead removed last. There was no hemodynamic compromise throughout the procedure and no mechanical complications related to the procedure. The “lead inverting stitch” retained its integrity and hemostasis was preserved throughout the transvenous lead extraction.\nFollowing successful lead extraction, the median sternotomy and old pacemaker pocket incisions were closed in a standard fashion and the patient was transferred to the intensive care unit for post-operative monitoring. The total procedure time from incision to wound closure was 5 hours and 24 minutes. Post-operative course was complicated with hypoxia secondary to atelectasis and aspiration pneumonia that resolved after 5 days. The patient was discharged back to her home hospital for ongoing rehabilitation.

We report the case of a 59-year-old man with hypertension and dyslipidemia, both of which were being treated by his primary physician. The patient suffered a traumatic lumbar fracture in 2013 owing to a fall and underwent surgery. Computed tomography (CT) scans performed at the time were focused on the lumbar spine, so other organs were barely included in the image range and no contrast medium was used. However, when carefully observed retrospectively, the CT scan showed a partial inward deviation of the intimal calcification of the abdominal aorta, suggesting a localized dissection of the abdominal aorta (). However, there was no mention of localized aortic dissection, because the dissection was fairly localized and did not show any abnormal findings, such as aneurysm formation. In addition, the adventitia causing the aortic dissection was also calcified. The findings suggested a chronic aortic dissection that occurred even before the trauma, rather than an acute aortic dissection that occurred at the time of the trauma.\nIn March 2020, the patient was admitted to the emergency department of a nearby general hospital for vomiting. He had no abdominal pain and was subsequently diagnosed with acute gastroenteritis and prescribed oral medication. On physical examination, palpation of the abdomen revealed a pulsating mass, and the patient subsequently consulted his family doctor. After abdominal ultrasound examination, the patient's doctor diagnosed him with an AAA. He subsequently referred the patient to another hospital for a contrast CT scan and a full workup of the AAA. After the enhanced CT scan, the patient was referred to our hospital, where we determined that urgent treatment was necessary owing to the irregular nature of the aneurysm.\nAlthough he did not have any findings suggestive of an infectious disease such as fever or pain, we first considered the possibility of an infectious aortic aneurysm because it was an irregular aneurysm. Upon examination, a pulsating abdominal mass was found, but without tenderness at the site. We conducted a screening test to locate the source of infection. Furthermore, a blood culture was performed, and the results were negative. An oral examination was performed considering the possibility that the oral infection had spread to the aorta and become an infectious aortic aneurysm. Multiple cavities and loose teeth were noted. Although not deemed to be a source of infection, the teeth were extracted, and the patient was prescribed an antibacterial to prevent future exacerbation. To rule out other infections, further laboratory work included a complete blood count, renal function, liver function, erythrocyte sedimentation rate, C-reactive protein, and IgG-4, all of which were found to be within normal limits.\nA CT scan revealed an irregular AAA with a maximum short diameter of 36 mm within the infrarenal aorta (). Furthermore, part of the abdominal aortic intima calcifications were displaced inward, suggesting aortic dissection.\nA laparotomy was performed by midline abdominal incision. There was no thickening of the arterial wall or retroperitoneal adhesions, as found in inflammatory aneurysms; however, part of the abdominal aneurysm wall was firmly adhered to the surrounding tissue. When the aorta was cross-clamped below the renal artery and the aneurysm was cut open, a partial defect in the intima was observed at the point where CT findings had suggested an aortic dissection. The inside of the false lumen was filled with a dark red thrombus, and a partly organized thrombus was also observed. The aorta was trimmed below the renal artery, and a Y graft replacement (J graft 16 × 8 mm) was performed. The distal side was anastomosed to the common iliac artery on both sides.\nPathologic examination revealed that the medial elastic fibers of the aorta were thin. A vascular lumen was formed by fibrous tissue outside the medial elastic fiber of the aorta. Infiltrating inflammatory cells and macrophages that phagocytosed hemosiderin were found in the surrounding area and wall structure. No elastic fibers were found on the wall of the vessel lumen (). From these observations, it was judged that the vascular cavity was formed owing to the collapse of the wall structure of the aortic aneurysm.\nNo bacteria were detected in the thrombus culture obtained during surgery. One week after surgery, a CT scan confirmed that there were no further complications, and the patient was discharged 8 days postoperatively.

A 5-year-old female patient visited the Department of Oral Medicine and Radiology with a complaint of pain in the region of the right posterior teeth of the lower jaw. Her mother also reported that her daughter had shown an asymptomatic swelling on the right side of her face since birth. The patient had undergone examination of this condition at 8 months of age. There was history of a gradual increase in the extent of the swelling with age, and the asymmetry of the face persisted. The child was born at full term with normal delivery and there was no history of consanguineous marriage in the family. The child was of normal build and intelligence. There was no familial history of such complaints in the family and serum chemistry revealed no abnormalities.\nThe swelling over the face extended from the zygomatic arch up to the lower border of the mandible on the right side. It was diffuse and had a sponge-like consistency. It was large enough to cause obliteration of the nasolabial fold and the right corner of the mouth seemed to be drooping. No other physical abnormality was noted ().\nIntraoral examination revealed that the cause of pain was the carious right mandibular deciduous second molar. It was also noticed that premature eruption of the permanent mandibular incisors and first molar, and of the maxillary molar was found on the right side. The tongue was also hypertrophic on the right side with noticeably enlarged papillae. The buccal mucosa and gingiva appeared normal ().\nPanoramic radiograph showed that the right mandibular body and ramus were asymmetrically large in size. There was accelerated development of the maxilla and mandible on the right with advanced eruption of the teeth as compared to the left. Radiographic analysis also revealed that all of the teeth on the right side had accelerated root formation relative to their counterparts on the left side. The condyle and the coronoid process on the right side were large with a prominent sigmoid notch. Multiple carious teeth were also noted ().\nMRI examination revealed the presence of a diffuse lipomatous tissue (which appeared bright or hyperintense on T1 weighted images) in the right cheek region and the region of the pterygomandibular space. There was fatty infiltration in the tissues anterior to the wall of the maxillary sinus and adjacent to the mandible on the right side. Other features of asymmetric enlargement of the right side of the face were also noted ().\nAxial and coronal CT scan sections showed a large markedly hypodense well defined mass causing severe swelling of the right cheek. The lesion extended from the infratemporal fossa superiorly to the lower border of the mandible inferiorly. The interior of the lesion had multiple enhancing hyperdense septae; however, the lesion itself did not appear to be enhanced after contrast administration. The right side of the mandible, coronoid process and condyle, maxillary sinus, and pterygoid plates including the masseter and the base of the skull were larger than the left side structures ( and ).\nThe CT and MRI findings were suggestive of a benign soft tissue mass of fat like density with enlargement of the mandible and base of the skull on the right side suggestive of a developmental anomaly. The infiltration of diffuse fatty tissue around the mandible is suggestive of lipomatosis like lesion in association with hemifacial hyperplasia.

The 30-year-old, gravidity 3, parity 2 patient had no medical problems during her pregnancy follow-up visits, such as gestational diabetes, preeclampsia, intrauterine growth retardation, and premature delivery. The patient had given birth to a baby weighing 3500 grams via spontaneous vaginal delivery at 39 weeks of gestation and she experienced heavy bleeding at day 6 after birth. The patient did not respond to medical therapies and conventional methods and underwent hysterectomy due to impaired hemodynamics caused by uncontrolled bleeding. The patient was discharged on postoperative day 3 with full recovery. The patient experienced active vaginal bleeding on postoperative day 10 and underwent cuff repair through the vaginal route after exploration. Possible bleeding foci that were inspected during exploration were sutured and then the patient was discharged with full recovery. However, the patient experienced recurrent abundant bleeding on postoperative day 20 for which she was hospitalized and underwent bilateral hypogastric artery ligation. The patient experienced another episode of abundant bleeding on day 7 after the hypogastric artery ligation and she was then referred to our clinic. The patient’s hemodynamics was stable on initial examination. Laboratory parameters were normal. Abdominal ultrasonography revealed normal ovaries and no fluid in the abdominal cavity. A vaginal examination revealed no bleeding. The patient experienced heavy bleeding on day 3 after admission to our clinic and she also had impairment in her hemodynamics. Her hemoglobin was 4.8 g/dL and the patient was administered 4 units of erythrocyte suspension. The patient underwent emergency surgery, but no active bleeding focus was detected. A consultation with a radiologist was performed because no bleeding focus was detected intraoperatively, and the patient underwent computed tomography (CT) with contrast enhancement. The CT scans showed findings suggestive of aneurysmal filling in the pelvic area (). The patient had ongoing bleeding and she underwent angiography in the interventional radiology clinic. Initial angiography revealed an arteriovenous fistula and aneurysm filling from the right internal iliac artery (). The artery fistula was closed with a coil. The right internal iliac artery was totally obstructed by the coil, causing intermittent bleeding after partial intraoperative ligation. On the second day after the intervention, the patient still had bleeding, although the amount had decreased. The patient was re-evaluated by interventional radiologists; the branches of the left uterine artery were angiographically obstructed with microparticles and the partially-ligated left internal iliac artery was totally closed by coils (). The patient received 15 units of erythrocyte suspension until the completion of the second procedure. The patient became hemodynamically stable following the procedure and had no recurrent bleeding during the follow-up period; she was discharged with full recovery on postoperative day 15.\nInformed consent was obtained from the patient.

Our patient, an eight-year-old girl, presented to our clinic, with severe swelling and facial asymmetry on the right mandibular molar region. We were informed that the patient developed the swelling as a result of an infection three months previously. The patient had been treated with antibiotics, but as that treatment had not proved successful, she was referred to our clinic. In addition, a passed or congenital disease was not specified in the patient's medical history. Clinical examination revealed severe swelling without fluctuation upon palpation and submandibular lymphadenopathy in the right mandibular region. The patient's skin was of normal color and appearance. In the oral examination, the right mandibular first molar tooth was found to have a deep caries cavity and to not be mobile. The other parts of the oral mucosa were normal. The radiographic examination revealed a deep caries cavity and a radiolucent area in the apical region of the right mandibular first molar tooth. There was also a lamellar appearance on the external cortical surface of the mandible as well as at the lower edge of the mandibular corpus, showing focal new bone formation (). When the axial and cross sections were evaluated during the examination with cone-beam computed tomography (CBCT), a tunnel-like defect was identified in the cortical bone in the vestibule surface of the inflamed bone, starting from the apical region of the right mandibular first molar tooth. Bone deposition at the radiolucent area in the center was observed at the lower edge of the mandible as well as the vestibule surface in this region (). When all these findings were evaluated, it was concluded that the pathologic lesion was Garre's osteomyelitis due to the periapical infection of the right mandibular first molar tooth. In this case, endodontic treatment was considered primarily to retain the infected tooth in the mouth. However, as the patient had come from a remote rural area and could not accept such a treatment due to the prohibitive cost, she was transferred to the surgical clinic, where the most appropriate treatment method was considered to be dental extraction.\nThe postoperative examination four months later revealed that the bone contours had returned to normal, the asymmetry of the face had disappeared, and the cortical bone thickness had decreased and been remodeled to the previous normal appearance (Figures and ).

This 56 years old lady who has been known to the local mental health services for the past 20 years with symptoms of depression and anxiety was attending follow up appointments on and off. For her current episode she was in contact with the local team for the last few years and had presented with moderate to severe depression that needed regular follow up and review of her medication. She also had two inpatient hospital admissions to the psychiatric unit after attempting suicide on two occasions during this episode. During her latest admission, she was treated with different antidepressants and anxiolytics but without any major benefit. Because of the poor control of symptoms of depression, Lamotrigine was added to her other medications (Sertaline and Buspirone which she had been taking for many months). She was started on lamotrigine 25 mg daily which was gradually increased to 50 mg twice daily over the next 2 weeks. Her anxiety and depressive symptoms showed significant improvement on this combination and she started feeling almost back to her normal self. She was continued on this treatment & was discharged from the psychiatric inpatient unit on a combination of Lamotrigine 50mg twice a day, Sertaline 150 mg daily and Buspirone 5mg twice daily. At her weekly follow up, she continued showing improvement in her mental state and the treating team was very satisfied with her response to treatment.\nAbout 16 days following hospital discharge she developed conjunctivitis and over the next 3-4 days, developed swelling of the face and lips. She also developed erosion of the mucous membrane inside her mouth & erythematous papules and bullous eruptions over her body that were particularly bad on the palms of her hands and soles of her feet where she developed detachment of the epidermis. In view of her increasing symptoms, she had to be referred to the general hospital on the 4th day after developing these side effects. She was admitted for further treatment. She had to be treated in the Intensive Care Unit as her physical symptoms deteriorated over the next few days. All her routine blood tests were normal except C-Reactive Protein which was high. She was kept under the care of a medical specialist, ophthalmologist and dermatologist who agreed with the clinical diagnosis of Stevens - Johnson Syndrome. Lamotrigine, along with her other antidepressant medications was stopped. After a few days she started feeling better, made a full recovery in 2 weeks time and was discharged home. Her ophthalmic symptoms needed a few more weeks for full recovery.

A 42-year-old woman applied to the ophthalmology department with a complaint and history of a half-hour-long visual loss of her left eye one day ago. At clinical examination, both of her eyes were found to have full vision, and also microscopic fundus examinations revealed no pathological conditions. The patient gave a history of a prior application to an outer medical center with the same complaint, and there she had been diagnosed with a left ICA occlusion, following Doppler US and angiographic examinations. The patient applied to our department with the demand of an extracranial carotid Doppler US examination. At Doppler US, the right CCA diameter was found to be 8 mm, whereas the left one came out to be 4 mm (Figures and ). The right CCA bifurcation and the ICA and ECA were found to be normal. At the left side, spectral data for the ECA () and the particular branching which demonstrates that the vessel is ECA indeed were present, whereas there was no Doppler signal and gray-scale findings for the ICA (). Because the left CCA was hypoplastic and there were no findings of atherosclerotic plaques in other arterial segments; it was thought that the left ICA might not be suffering an occlusion at all, but instead it might well be agenetic. Based on the presumption of an ICA agenesis, a computed tomographic (CT) examination of the skull base was performed. CT images revealed a normally appearing right carotid canal but no clear image of the left one (). Then, the previous angiographic images of the patient were reevaluated, and it was then recognized that the left ECA and its branches were well visible, while the left ICA and its branches did not show any filling with contrast (). It was also noted that the filling of the left anterior and medial cerebral arteries was sustained by the patent anterior communicating artery following the injection of contrast into the right carotid artery () and also via the posterior communicating artery following the injection of the vertebrobasilary system (). In addition to the ICA agenesis, another surprising finding was that the right vertebral artery was not stemming from the right subclavian artery but instead was originating from the aortic arch, as its first branch (). It was finally understood that the patient did not have an occlusion of the left ICA, but instead her left ICA was agenetic. She also had an additional aortic arch anomaly. At the end, it was concluded that an ipsilateral CCA hypoplasia might be taken as a valuable clue in the differential diagnosis of ICA agenesis and occlusion.

A 39 year-old white female presented to The Arthur G. James Cancer Hospital with worsening pain of the left breast and left chest wall region and a recurrent palpable mass within the inferior aspect of her left breast. She reports having had three separate left breast biopsies in the past (seven years, four years, and one year prior to her current presentation) for a recurring left breast palpable mass in this same location.\nSeven years prior to her current presentation, she presented to an outside community hospital with a palpable left breast mass in the inferior lateral aspect of her left breast. She underwent a left breast biopsy at that time that was reported as showing dense fibrous stroma with fibrocystic changes.\nThree years later (four years prior to her current presentation), she noticed a recurrent enlarging palpable left breast mass. She underwent a repeat left breast biopsy by the same surgeon and this showed hyperplastic fibrosis, consistent with fibromatosis of the breast. The pathology report clearly stated that the tumor involved the surgical margins. The patient reports that the surgeon told her that this was a benign tumor and that nothing further needed to be done.\nThree additional years later (one year prior to her current presentation), she again noticed a recurrent enlarging palpable left breast mass. She again underwent a repeat left breast biopsy by the same surgeon and this again showed findings consistent with fibromatosis of the breast. Again, the pathology report clearly stated that the tumor involved the surgical margins. The patient reports that the surgeon again told her that this was a benign tumor and that nothing further needed to be done.\nSince the time of her last left breast biopsy (one year prior to her current presentation), the patient reports persistent and worsening pain and palpable tenderness within the inferior aspect of her left breast and left chest wall region, with an associated increasing sized palpable mass within the same region.\nUpon presentation to The Arthur G. James Cancer Hospital, she was found on clinical examination to have volume loss along the entire inferior aspect of her left breast and slight downward tilting of her left nipple and areolar complex. She had three separate well-healed surgical scars along the inferior-lateral aspect of her left inframammary fold (Figure ). Underneath these scars, she had a firm palpable mass, clinically measuring 6.5 × 3.0 × 2.5 cm in size and which clinically appeared to be adherent to the underlying left chest wall structures. She had no clinically apparent adenopathy in her left axilla.\nA mammogram showed scarring and tissue disorganization in the inferior left breast from prior multiple biopsies, but appeared unchanged since a prior mammogram done 13 months previously at an outside community hospital. Magnetic resonance imaging of the left breast showed an intensely enhancing lesion in the inferior-lateral aspect of the left breast, measuring 5.0 × 1.7 cm in size (Figure and ). This lesion appeared to abut the underlying chest wall musculature and appeared to efface the underlying fat plane. Computed tomography scan of the chest showed a 5.2 × 1.6 cm mass within the inferior-lateral aspect of the left chest wall that appeared to be in continuity with the left pectoralis major muscle and left serratus anterior muscle (Figure ). A core biopsy was performed to the palpable left breast mass that confirmed the diagnosis of fibromatosis.\nThe patient was taken to the operating room at to The Arthur G. James Cancer Hospital and underwent a left total mastectomy, with en bloc resection of the underlying musculature (inferior lateral portion of the left pectoralis major muscle, superior portion of the left abdominal oblique musculature, and anterior portion of the left serratus anterior muscle) and en bloc resection of the underlying chest wall structures (fourth, fifth, and six ribs, intercostals muscles, and parietal pleura). The left chest wall defect (Figure ) was then closed with a 2-mm DualMesh Gore-Tex patch (W. L. Gore & Associates, Inc., Flagstaff, Arizona). The remaining portions of the left pectoralis major muscle was dissected off the underlying left chest wall and its lateral most attachments to the left humerus and superior attachments to the clavicle were divided, allowing it to rotate inferiorly to completely cover the Gore-Tex patch. The left mastectomy site was then closed in the standard fashion. No attempts at cosmetic breast reconstruction with autologous tissue transfer or expander/implant placement were considered at that time. The patient's post-operative course was uneventful and she was discharged to home on post-operative day eight.\nGross pathologic evaluation of the specimen, which overall measured 14.5 × 13.3 × 6.4 cm in size, revealed a 5.2 cm tumor that was grossly invading the underlying attached skeletal muscle to a depth of about 1.2 cm (Figure ). It could not be definitively determined whether the invasion of the underlying skeletal muscle involved only the superficial muscles resected (consisting of the inferior lateral portion of the left pectoralis major muscle, superior portion of the left abdominal oblique musculature, and anterior portion of the left serratus anterior muscle) or whether skeletal muscle invasion was to the level of the underlying intercostal muscles resected. However, both grossly and microscopically, there was no evidence of invasion into the bony ribs or underlying parietal pleura. Microscopic evaluation revealed a proliferation of relatively evenly spaced plump spindle cells arranged in intersecting fascicles and associated with mild to moderate amounts of collagen and occasional mitotic figures (Figure ) and demonstrated that the spindle cell proliferations invaded into the adjacent skeletal muscle (Figure ). All surgical margins were negative. On immunohistochemical staining, the spindle cells were negative for S-100 protein, muscle actin (HHF-35), and cytokeratin AE1/AE3. On immunohistochemical staining, less than 5% of the spindle cells were positive for Mib1 (Ki-67). The histology and immunohistochemical staining supported a diagnosis of fibromatosis (desmoid tumor).\nThe patient is now 22 months out from her previous aggressive operative management of her previous multiple recurrences of her fibromatosis of her left breast and she remains disease free.

A 66-year-old man presented to emergency department with an anterior shoulder dislocation () after a ski fall without loss of consciousness. At the initial management, the patient did not show any neurological dysfunction or pulse deficit. The first reduction attempts were unsuccessful and the patient was put under general anesthesia before trying again. During the new attempt to reduce the shoulder dislocation, we observed the occurrence of a hematoma in the deltopectoral region (). At the same time, loss of palpable peripheral pulse and upper limb ischemia appeared. A CT scan was performed and showed a compressive hematoma in the axillary region, a disruption of the axillary artery flow, and a bilateral pulmonary embolism (previously unknown). The patient was transferred to a university hospital to be supported by vascular and trauma surgeons. The patient was still under general anesthesia. The dislocation was successfully reduced in the operating room. Upper limb ischemia with persistent pulseless and cold arm led to an emergency vascular management. The humeral artery was dissected through the brachial tunnel and a thromboembolectomy was done. An arteriography was performed due to the persistence of pulsatile hematoma, which revealed a disruption of the axillary artery with extravasation of contrast near the humeral head (). An angioplasty balloon was introduced to control the proximal bleeding. After the introduction of the occlusion balloon, an incision was performed at the pectoralis major muscle and the hematoma was decompressed. The artery was deteriorated over about 1 cm and an end-to-end anastomosis was performed. The bilateral pulmonary embolism was probably due to the compression of the axillary vein during the shoulder dislocation. Nevertheless, no examination has confirmed this hypothesis. The patient received an intravenous anticoagulant therapy by heparin and then by an oral anticoagulant. Postoperatively, Doppler ultrasound showed a good morphologic and hemodynamic result. Concerning the functional outcome, the patient did not have neurological or vascular complications in the postoperative period. Then he presented with a partial functional disability probably due to a distal brachial plexus stunning according to results of electromyogram. The CT scan showed the absence of significant lesion of the rotator cuff.

A 26 year old male presented with increasing right knee pain and functional debility with a history of osteochondritis dissecans and having had multiple past surgical interventions. He was otherwise well, though was currently unable to perform any activities that involved prolonged weight bearing and found it increasingly difficult to continue his occupation within allied health care.\nThe patient noted an initial diagnosis of OCD at age 13. This was appropriately treated conservatively with a period of reduced load and protected weight bearing. He was later able to return to sport - which included Australian Rules football.\nDue to recurrence of pain he underwent arthroscopic examination at age 14. Arthroscopic probing of the OCD lesion indicated that it was stable and conservative management and further unloading was pursued. The patient failed conservative management and 1 year later underwent a repeat arthroscopy at which time an unstable 3 cm × 3 cm lesion involving his medial femoral condyle was removed. It was felt that as the fragment had little subchondral bone that direct repair was not achievable. A further arthroscopy was performed 8 months later and a chondral biopsy was taken for later autologous chondrocyte transplantation. At the time it was noted that no healing had occurred at the site of the defect.\nTwo months later, the treating surgeon, using a lateral arthrotomy approach, patched the defect using a matrix induced autologous chondrocyte implant (MACI). The patch was fixed in place using fibrin glue. One year later, and due to persistent discomfort and swelling of the knee, the patient underwent a further arthroscopy. It was noted that the outer rim of the MACI patch had incorporated well, yet an inner area of 1.5 cm × 1.5 cm had failed to fill completely.\nAt age 23 and due to troubling discomfort and mechanical features of instability the patient underwent another arthroscopy. Numerous loose bodies within both the medial and lateral compartments were washed out. The area of the past OCD and MACI graft had failed with exposure of underlying subchondral bone and formation of a large subchondral cyst. Unstable edges of the area of MACI graft were debrided but as the entrance to the subchondral cyst was small a surgical decision was made not to further expose nor debride the cavity.\nFailing to symptomatically improve, the patient underwent a further arthrotomy with debridement of the subchondral cyst, after which it was filled with bone graft substitute cortico-cancellous crunch granules. A periosteal flap taken from the medial border of the tibia was then applied over the lesion. The patient underwent a final arthroscopy at age 25 for debridement of an unstable fibro-cartilaginous cap at the site of the past periosteal flap.\nIn total the patient underwent seven separate operations.\nInitial examination upon presentation showed evidence of a moderate right knee effusion. The patient had full range of motion and the knee was stable.\nRadiological examination included both X-Ray and MRI. X-Ray confirmed early degenerative change with intercondylar notch osteophytes consistent with Kellgren-Lawrence Grade II. There was noted concavity to the lateral aspect of the medial femoral condyle consistent with the previous area of OCD (Fig. ). MRI showed marked abnormality over the weight bearing portion of the medial femoral condyle measuring 2.3 cm × 1.5 cm. The subchondral cyst had successfully been debrided and grafted and was no longer present on MRI. A thin layer of hyper-intense tissue incompletely covered the area of abnormal cortex (at site of past bone substitute grafting) (Fig. ). The area of pathology had a modified International Cartilage Repair Society (ICRS) score of 4. In addition to routine MRI protocols, the method of T2-relaxation time cartilage mapping was used. T2 mapping indicated significantly elevated values within the thin layer overlying the osteochondral defect but also elevated values within the surrounding cartilage (Fig. ).\nThe patient sought advice regarding further interventions that may improve both his current symptoms but also his long-term prognosis as he wished to avoid progressive degeneration and early joint arthroplasty. After careful consideration and as he now had features of early degenerative change he was assessed as suitable for inclusion in an ethics approved, registered case series on the use of adipose derived MSC therapy in the treatment of osteoarthritis.\nThe patient was given written information regarding the use of MSC therapy, including relative risks of MSC therapy and also relevant treatment alternatives that could otherwise be explored. Formal written informed consent was obtained prior to commencing therapy.\nAdipose tissue was chosen as a source of MSCs due to ease of harvest, abundance of MSCs and the observed chondrogenic potential of adipose derived MSCs. Bone marrow aspirate was considered an alternative source or MSCs but surprisingly has a relative paucity of MSCs – comprising .001–.02% of the mono-nucleated cell population in comparison to ~1–7% found within adipose tissue [–]. Many studies have indicated similar chondrogenic potential between bone marrow derived and adipose derived MSCs [].\nThe patient underwent an abdominal liposuction harvest procedure. Using a lateral abdominal approach, the subcutaneous fat was infiltrated with an anaesthetic tumescent fluid preparation comprising of 30 mls of 2% lignocaine, 1 ml of 1:1000 adrenaline, 1 ml of 8.4% bicarbonate suspended in a normal saline solution (total 1000 ml). Using a 4 mm lipo-aspirate cannula, 60 mls of adipose tissue and tumescent fluid was successfully harvested and collected within a sterile medical grade single use Shippert Tissu-Trans Collection filter (Shippert Medical, Colorado, USA). The sample was then transferred directly from the theatre via an air lock system to a laboratory clean room facility operated by Magellan Stem Cells (Magellan Stem Cells, Melbourne, Australia).\nAutologous MSCs were isolated and expanded from the harvested adipose tissue using previously published protocols []. The processing of the lipo-aspirate was performed within the environment of a Biological Safety Cabinet (BSC) Class II using strict sterile techniques.\nStromal Vascular Fraction (SVF) obtained from the lipo-aspirate was culture purified using standard growth media containing Minimum Essential Media Eagle (MEM) supplemented with 2 mM glutamate and 10% Fetal Bovine Serum (FBS) (HyClone – GE Healthcare, USA). The cells were cultured under hypoxic conditions with 5% CO2 at 37 °C. Non-adherent cells were removed by washing with sterile phosphate buffered saline (PBS). The adherent cells were cultured until 80% confluency in freshly added growth media. The cultured purified cells were then harvested at passage 0 (P0). These cells were further plated to tissue culture flasks and expanded up to passage 2 (P2). The cells were harvested and analyzed for cell count and viability using a Muse Cell Analyzer (Merck Millipore, USA). The harvested cells were washed three times to remove FBS and cryopreserved in cryovials using clinical grade qualified MSC cryoprotectant media and following a previously validated control rate freezing technique of 1 °C/min [, ]. The cryovials were transferred to liquid nitrogen storage until use.\nAt completion of isolation and expansion, the cells underwent independent phenotypic analysis at Monash University and were characterised by flow cytometry using Florescent Activated Cell Sorting (FACS). Using standards established by the Internal Society of Cellular Therapy, the cells were assessed for the presence of positive surface markers CD 90, CD 73 and CD 105 and absence of hematopoetic surface markers CD14, CD19, CD34 and CD45 [] (Tables - and Fig. ). A further sample was sent for independent sterility testing for microbial growth.\nPrior to the intra-articular injection the cryopreserved cells were retrieved from the liquid nitrogen Dewar and thawed quickly within a sterile 37 °C water bath. The thawed cells were then washed in chilled PBS to remove cryoprotectant media, centrifuged and the resultant cell pellet re-suspended in clinical grade 0.9% normal saline. The cells were again analyzed for cell count and viability post thaw using the Muse Cell Analyzer. The cells were injected within 30 min of thawing.\nThe patient received a total of 118 million MSCs (viability 98%) suspended in 3mls of normal saline at commencement of therapy. A second injection of 50 million MSCs (viability 95%) at 6 months was also given.\nAt both injection time points the patient’s right knee was prepped using a chlorhexidine solution and draped. 2 mls of 1% lignocaine was infiltrated subcutaneously at the site of injection. Using a supero-lateral approach to the patella, and under sterile conditions and ultrasound guidance, the MSCs suspended in 3 mls of normal saline were injected into the intra-articular space.\nAfter the initial injection the patient was fitted with a medial compartment customised unloading knee brace to allow protected but full weight-bearing. This was achieved using an Ossur OA Unloader One brace (Ossur, Reykjavic, Iceland).\nThe patient was given post injection instructions, which included range of motion exercises and lower limb muscle activation exercises, and encouraged to perform repetitive low impact and low load exercises against minimal resistance on a stationary bike (continuous active motion versus continuous passive motion). This protocol was developed due to previously published evidence which has indicated the benefit of controlled load on cartilage health [].\nImportantly, recent systematic review and meta-analysis of previous clinical papers investigating the use of mesenchymal stem cell therapy – both intravascular and intra-articular applications – and including autologous, allogeneic and expanded MSC preparations has indicated that MSC therapy is safe. No adverse events including infection, death or malignancy have been recorded.\nSaw and colleagues have documented a self-limited flare up with discomfort and swelling following intra-articular MSC therapy []. This was not considered a serious adverse event.\nRelative risks of the liposuction harvest procedure include infection, bruising and post operative discomfort. Whilst the risk of infection is low, the patient received a single dose of prophylactic antibiotics prior to the procedure as part of accepted routine clinical practice [].\nProspective analysis of patient outcome to intra-articular MSC therapy included the following measures:The Knee Injury and Osteoarthritis Outcome Score (KOOS). This is a validated scoring system intended for the assessment of knee injury that may result in post-traumatic knee osteoarthritis. The score consists of 5 subscales - pain, other symptoms, function in daily living, function in sport and recreation and knee related quality of life. Standardised answers to questions are given (5 Likert scale) and each question is assigned a score of 0–4. A normalized score is calculated for each subscale (100 indicates no symptoms and 0 indicates maximum symptoms) []. The Western Ontario and McMaster Universities Arthritis Index (WOMAC Index 3.0). This score is a validated quality of life score and quantitatively assesses the pain, stiffness and physical function in patients with symptomatic osteoarthritis []. The Numeric Pain Rating Scale (NPRS). The patient rates their knee pain intensity over the previous week on a scale of 0–10. The NPRS has been validated for use in people with knee osteoarthritis [].\nOutcome scores were completed at baseline, 1, 3, 6, 12 and 18 months post commencement of MSC therapy and recorded using the software program Clinical Intelligence (Clinical Intelligence, Melbourne, Australia).\nStructural outcome was assessed using MRI imaging performed prior to commencement of therapy and again at 6 and 18 months post-treatment. Semi quantitative measures of the cartilage defect were obtained using a modified ICRS score []:Grade 0: normal cartilage Grade 1: focal blistering and intra-cartilaginous low-signal intensity area with an intact surface and bottom Grade 2: irregularities on the surface or bottom and loss of thickness of less than 50% Grade 3: deep ulceration with loss of thickness of more than 50% Grade 4: full-thickness cartilage wear with exposure of subchondral bone.\nIn addition to routine MRI protocols, the method of T2-relaxation time cartilage mapping was used. T2 mapping assesses the water content of cartilage by giving a quantifiable value to the ability of free water protons to exchange energy and move through a cartilage matrix []. Observed increased water content resulting in an increased T2 relaxation time is an indication of chondral pathology. T2 mapping has been well studied and is an accepted and validated non invasive measure of cartilage quality [].\nThe numeric pain rating score increased at 1 month from 4 to 5 reflecting an initial self-limiting flare up (see Adverse Events). Follow-up at 6 months however showed a 50% improvement in NPRS from baseline and this had further improved by 75% with a pain score of 1 at completion of follow-up at 18 months (Fig. ).\nKnee Injury and Osteoarthritis Outcome Scores consistently improved across the period of follow-up (Fig. ). At 6 months the patient’s Symptoms Score had improved by 44% and similarly his Sport and Recreational Score had improved by over 100%. These values showed continued improvement at 18 months. The measure of Quality of Life had improved at 18 months by greater than 400% above baseline.\nReflecting the observed improvement in KOOS, the WOMAC Knee Score showed similar consistent improvement from baseline till completion of data collection. At 18 months, the Global WOMAC Score had improved by over 20% (Fig. ).\nStructural follow-up using MRI at both 6 months and 18 months showed significant increase in tissue covering the extensive OCD of the medial femoral condyle. Observed development of a subchondral plate suggested a layering effect from subchondral bone through to the chondral surface. There was smooth integration with the surrounding native cartilage at the periphery of the OCD (Figs. and ). Using the modified ICRS scoring system as described above, ICRS grade improved from 4 to 1.\nT2 mapping at 6 months returned elevated values at the site of regenerative cartilage, consistent with high water content and immature cartilage (Fig. ). Further analysis at 18 months, however, indicated improved T2 values suggestive of progressive maturation of the regenerative tissue (Fig. ).\nFollowing initial MSC therapy the patient reported swelling and increased discomfort of the treated knee. The knee effusion persisted for 6 weeks. This was managed conservatively with application of ice, a compression bandage and simple analgesia. Due to this observed reaction the second injection at 6 months was reduced to 50 million MSCs (viability of 95%). The patient reported minor swelling and discomfort for 2 weeks, with no additional management required.

Our patient, an eight-year-old girl, presented to our clinic, with severe swelling and facial asymmetry on the right mandibular molar region. We were informed that the patient developed the swelling as a result of an infection three months previously. The patient had been treated with antibiotics, but as that treatment had not proved successful, she was referred to our clinic. In addition, a passed or congenital disease was not specified in the patient's medical history. Clinical examination revealed severe swelling without fluctuation upon palpation and submandibular lymphadenopathy in the right mandibular region. The patient's skin was of normal color and appearance. In the oral examination, the right mandibular first molar tooth was found to have a deep caries cavity and to not be mobile. The other parts of the oral mucosa were normal. The radiographic examination revealed a deep caries cavity and a radiolucent area in the apical region of the right mandibular first molar tooth. There was also a lamellar appearance on the external cortical surface of the mandible as well as at the lower edge of the mandibular corpus, showing focal new bone formation (). When the axial and cross sections were evaluated during the examination with cone-beam computed tomography (CBCT), a tunnel-like defect was identified in the cortical bone in the vestibule surface of the inflamed bone, starting from the apical region of the right mandibular first molar tooth. Bone deposition at the radiolucent area in the center was observed at the lower edge of the mandible as well as the vestibule surface in this region (). When all these findings were evaluated, it was concluded that the pathologic lesion was Garre's osteomyelitis due to the periapical infection of the right mandibular first molar tooth. In this case, endodontic treatment was considered primarily to retain the infected tooth in the mouth. However, as the patient had come from a remote rural area and could not accept such a treatment due to the prohibitive cost, she was transferred to the surgical clinic, where the most appropriate treatment method was considered to be dental extraction.\nThe postoperative examination four months later revealed that the bone contours had returned to normal, the asymmetry of the face had disappeared, and the cortical bone thickness had decreased and been remodeled to the previous normal appearance (Figures and ).

Our patient, an eight-year-old girl, presented to our clinic, with severe swelling and facial asymmetry on the right mandibular molar region. We were informed that the patient developed the swelling as a result of an infection three months previously. The patient had been treated with antibiotics, but as that treatment had not proved successful, she was referred to our clinic. In addition, a passed or congenital disease was not specified in the patient's medical history. Clinical examination revealed severe swelling without fluctuation upon palpation and submandibular lymphadenopathy in the right mandibular region. The patient's skin was of normal color and appearance. In the oral examination, the right mandibular first molar tooth was found to have a deep caries cavity and to not be mobile. The other parts of the oral mucosa were normal. The radiographic examination revealed a deep caries cavity and a radiolucent area in the apical region of the right mandibular first molar tooth. There was also a lamellar appearance on the external cortical surface of the mandible as well as at the lower edge of the mandibular corpus, showing focal new bone formation (). When the axial and cross sections were evaluated during the examination with cone-beam computed tomography (CBCT), a tunnel-like defect was identified in the cortical bone in the vestibule surface of the inflamed bone, starting from the apical region of the right mandibular first molar tooth. Bone deposition at the radiolucent area in the center was observed at the lower edge of the mandible as well as the vestibule surface in this region (). When all these findings were evaluated, it was concluded that the pathologic lesion was Garre's osteomyelitis due to the periapical infection of the right mandibular first molar tooth. In this case, endodontic treatment was considered primarily to retain the infected tooth in the mouth. However, as the patient had come from a remote rural area and could not accept such a treatment due to the prohibitive cost, she was transferred to the surgical clinic, where the most appropriate treatment method was considered to be dental extraction.\nThe postoperative examination four months later revealed that the bone contours had returned to normal, the asymmetry of the face had disappeared, and the cortical bone thickness had decreased and been remodeled to the previous normal appearance (Figures and ).

A 56-year-old female was initially admitted to the neurosurgical department because of retroorbital pain and mild visual deterioration in both eyes. The ophthalmologic examination showed a bilateral constriction of the visual field and a slight reduction in the visual acuity on the right side. A magnetic resonance of the brain and a digital subtraction angiography (DSA) disclosed a giant partially thrombosed aneurysm of the ICA on the right side (). Although there is no randomized evidence showing that the FDs are superior to the conventional treatment options, the FD option was considered for the following reasons: the paraclinoid ICA represents one of the best targets for such devices [], there were no anatomical limitations to a correct deployment, and, by inducing aneurysm shrinkage, it might have been possible to relieve the mass effect on the optic pathways []. The ophthalmic aneurysm was initially loosely coiled and then a Pipeline FD was placed in the parent artery across the aneurysm neck (). The FD was well deployed and the landing zone extended from the supraclinoid ICA to the cavernous ICA (). There was only a mild focal narrowing at the level of the distal ring where the ICA was compressed by the bulk of the aneurysms against the clinoid process (). The visual acuity deteriorated acutely on both sides despite corticosteroids. The patient was discharged home after 7 days with double antiplatelet medication (75 mg of clopidogrel and 100 mg of aspirin per day). Three months after the procedure, in concomitance with the cessation of the clopidogrel, she acutely developed a hemiparesis on the left side that lasted 48 hours. Then, she began suffering from transient ischemic attacks (TIAs). A DSA disclosed the thrombosis of the FD with occlusion of the ICA (). The patient continued suffering from multiple TIAs despite the resumption of antiplatelet medications, adequate hydration, and a thorough blood pressure monitoring to prevent hypotension. A perfusion-weighted CT scan demonstrated a significant increase in the mean transit time and a reduction in the cerebral blood flow on the right side (). The patient underwent a double-barrel extraintracranial (EC-IC) bypass with the occipital artery and the parietal branch of the superficial temporal artery as donors. Her postoperative course was uneventful and she has experienced no further TIAs. The follow-up DSA 3 months later confirmed the patency of the bypasses (Figures -).

A 63-year-old German man with a long past history of tumours was admitted to hospital. 20 years ago a malignant melanoma had been diagnosed on his right loin and radical excision performed. Due to lymph node metastasis in the left groin the patient had chemotherapy. After some time the patient developed haematuria whereupon renal cell carcinoma was diagnosed in the right kidney and a metastasis of the melanoma was found in the left kidney. Partial nephrectomy on the right and complete nephrectomy on the left were performed. The patient had since been free of tumour recurrence until presentation.\nA recent chest X-ray showed a suspicious shadow in the right lower lobe of the lung . Two computer tomography examinations of the chest (fig ) were performed but could not conclusively rule out the possibility of metastasis. It was diagnosed initially as an inflammatory process of the lung. When the shadow failed to change with time further investigations were ordered. This was when a tumour in the right atrium was discovered which was neither haemodynamically nor clinically relevant. Magnetic resonance imaging of the chest showed a spherical tumour (28 × 27 × 20 mm) attached to the wall of the right atrium. The T1 weighted image revealed homogenous signal intensity as well as a loss of signal due to fat tissue. The tumour didn't show any signs of contrast medium uptake so that the diagnosis of a benign lipoma was made preoperatively. Transthoracic echocardiography excluded heart valve dysfunction and confirmed the presence of a mass in the right atrium.\nOn account of the above-mentioned criteria and of the absence of metastasis of the melanoma excision of the lipoma as well as a biopsy of the mass in the right lower lobe was planned. The patient was clinically stable. Heart rate, blood pressure, ECG and lab results were normal with the exception of urea & electrolytes. After careful preparations the lipoma excision was carried out through incision of the right atrium while the patient was supported by cardiopulmonary bypass. The tumour was walnut-sized, yellow, had a smooth surface and was attached to the lateral wall of the right atrium. The excision was performed at the base of the lipoma in the atrial wall. The atrium was then sutured. Afterwards, with the patient now being supported by partial cardiopulmonary bypass, the right lung was inspected. A hard resistance could be palpated in the right lower lobe. Considering the uncertainty of its nature and the use of extracorporeal circulation lobectomy was not performed. A biopsy was performed instead. The pleura was closed and the operation successfully completed.\nThe patient recovered well on the ward and was discharged 9 days after the operation with an appointment for a partial lobectomy at a different hospital. Macroscopical and histological examination of the cardiac tumour showed a tumour measuring 40 × 25 × 20 mm, grey-yellowish coloured on cross section with adequate excisional margin. It was attached to the atrial myocardium which showed signs of interstitial fibrosis. The mesenchymal tumour was capsulated and found to be of variable width and made up of unilocular uniform adipocytes with small nuclei and focal regressive changes as well as focal giant cell granulomas. Thus, the diagnosis lipoma was correct and a good prognosis can be expected. As for the lung tumour a moderately differentiated adenocarcinoma was diagnosed.

Our patient, an eight-year-old girl, presented to our clinic, with severe swelling and facial asymmetry on the right mandibular molar region. We were informed that the patient developed the swelling as a result of an infection three months previously. The patient had been treated with antibiotics, but as that treatment had not proved successful, she was referred to our clinic. In addition, a passed or congenital disease was not specified in the patient's medical history. Clinical examination revealed severe swelling without fluctuation upon palpation and submandibular lymphadenopathy in the right mandibular region. The patient's skin was of normal color and appearance. In the oral examination, the right mandibular first molar tooth was found to have a deep caries cavity and to not be mobile. The other parts of the oral mucosa were normal. The radiographic examination revealed a deep caries cavity and a radiolucent area in the apical region of the right mandibular first molar tooth. There was also a lamellar appearance on the external cortical surface of the mandible as well as at the lower edge of the mandibular corpus, showing focal new bone formation (). When the axial and cross sections were evaluated during the examination with cone-beam computed tomography (CBCT), a tunnel-like defect was identified in the cortical bone in the vestibule surface of the inflamed bone, starting from the apical region of the right mandibular first molar tooth. Bone deposition at the radiolucent area in the center was observed at the lower edge of the mandible as well as the vestibule surface in this region (). When all these findings were evaluated, it was concluded that the pathologic lesion was Garre's osteomyelitis due to the periapical infection of the right mandibular first molar tooth. In this case, endodontic treatment was considered primarily to retain the infected tooth in the mouth. However, as the patient had come from a remote rural area and could not accept such a treatment due to the prohibitive cost, she was transferred to the surgical clinic, where the most appropriate treatment method was considered to be dental extraction.\nThe postoperative examination four months later revealed that the bone contours had returned to normal, the asymmetry of the face had disappeared, and the cortical bone thickness had decreased and been remodeled to the previous normal appearance (Figures and ).

Our patient, an eight-year-old girl, presented to our clinic, with severe swelling and facial asymmetry on the right mandibular molar region. We were informed that the patient developed the swelling as a result of an infection three months previously. The patient had been treated with antibiotics, but as that treatment had not proved successful, she was referred to our clinic. In addition, a passed or congenital disease was not specified in the patient's medical history. Clinical examination revealed severe swelling without fluctuation upon palpation and submandibular lymphadenopathy in the right mandibular region. The patient's skin was of normal color and appearance. In the oral examination, the right mandibular first molar tooth was found to have a deep caries cavity and to not be mobile. The other parts of the oral mucosa were normal. The radiographic examination revealed a deep caries cavity and a radiolucent area in the apical region of the right mandibular first molar tooth. There was also a lamellar appearance on the external cortical surface of the mandible as well as at the lower edge of the mandibular corpus, showing focal new bone formation (). When the axial and cross sections were evaluated during the examination with cone-beam computed tomography (CBCT), a tunnel-like defect was identified in the cortical bone in the vestibule surface of the inflamed bone, starting from the apical region of the right mandibular first molar tooth. Bone deposition at the radiolucent area in the center was observed at the lower edge of the mandible as well as the vestibule surface in this region (). When all these findings were evaluated, it was concluded that the pathologic lesion was Garre's osteomyelitis due to the periapical infection of the right mandibular first molar tooth. In this case, endodontic treatment was considered primarily to retain the infected tooth in the mouth. However, as the patient had come from a remote rural area and could not accept such a treatment due to the prohibitive cost, she was transferred to the surgical clinic, where the most appropriate treatment method was considered to be dental extraction.\nThe postoperative examination four months later revealed that the bone contours had returned to normal, the asymmetry of the face had disappeared, and the cortical bone thickness had decreased and been remodeled to the previous normal appearance (Figures and ).

A male patient aged 60 years reported to the department with the complaint of a hole in upper jaw for 2 years. History revealed that he got his denture constructed 10 years back and wearing the suction cup denture [] entire day and night and removed them only for cleaning. On examination of the palate, there was a perforation in the palate measuring approximately 2.5 cm × 2 cm in size []. The condition has started as an erythematous patch and has developed over a period of 2 years as a fistula to the current size. On palpation, margins were non tender. All surrounding tissues appeared normal in color and texture. When the patient was asked to gargle water, it escaped through his nose. The maxillary occlusal radiograph showed the loss of bone from mid palate region []. Patient's medical history was uneventful, and blood investigations were within normal limits. Serological investigations also showed a negative report for venereal diseases. The patient was advised to discontinue the denture immediately, and the surgery was planned by preferring the palatal rotational flap.\nThe surgical closure of palatal fistula planned under general anesthesia. It was induced by nasotracheal intubation. Patient placed in the supine position and neck extension achieved by keeping a pillow under the shoulder. Local anesthesia with adrenaline was injected around the lesion for hemostasis. The margins of the fistula were excised to remove the epithelial lining. A palatal flap design was planned based upon the course of the greater palatine artery and marked according to the site and size of the defect []. A partial thickness flap was raised and rotated laterally to cover the defect []. The flap was then secured in its new place using 3–0 black silk sutures []. The donor area which was covered by the periosteum of the palatal bone was the left open for a secondary epithelization. Beta dine dressing was given over the entire area []. One week postoperative review showed that the defect area healed without infection, dehiscence, and the donor site was covered with normal fibrin []. Fifteen days after surgery, the wound in the defect area healed well and the donor site was fully covered with granulation tissue []. Clinical review 2 months later showed healthy pink epithelium covering the donor site on the hard palate []. The bulky palatal flap had shrunk considerably so that the hard palate had retained its normal shape. The patient was referred to prosthodontics for new denture construction.

A six year-old boy presented with a congenital anomaly of two upper limbs on the right side [Figures –]. Clinical examination revealed that the superior limb was articulating with the shoulder joint, and the inferior limb laterally attached to the chest wall. Both these limbs on the right side were hypoplastic compared to the left upper limb. The superior limb was approximately 7 cm shorter than the opposite limb (normal side), the superior limb being 33 cm in length from the shoulder joint while the inferior limb was 18 cm from the attachment with the chest wall. The skin over the forearm on the superior limb was shiny and atrophic with very little soft tissue mass compared with the inferior limb which was bulkier with normal-appearing skin. The superior limb was articulating with the torso via a normal shoulder joint. The scapula was small compared to that on the opposite side. The inferior limb was attached to the lateral thoracic wall by soft tissue at the level of the 4th intercostal space. The superior limb had a humerus, a single bone at the forearm level, and a duplicated thumb with an index finger. There was synostosis at the elbow joint and the wrist joint was stable. All fingers showed symphalyngism; the middle ray including the 3rd metacarpal was absent. The inferior limb had two fingers and a single bone with which it was attached to the chest wall. Clinically, the superior limb presented a picture of an ulnar hypoplastic hand where there was a stable wrist joint and a fused elbow joint. The inferior limb presented like a radial club hand with instability of the wrist joint. All movements were possible at the shoulder joint level but none were possible at the elbow joint and the wrist joint in the superior limb. Hand function was better in the inferior limb. The hand flexors were stronger in the inferior limb while the extensors were stronger in the superior limb. The clavicular head of the pectoralis was attached to the superior limb while the sternal head was attached to the inferior limb; the latissmus dorsi was inserted into the inferior limb.\nAn X-ray was taken of the right upper limb [], and color Doppler, and MR Angiography were done.\nThe X-ray [] revealed that the scapula on the right side was hypoplastic and the superior limb had a shoulder joint with elbow joint synostosis.\nColor Doppler study [] showed duplication of the right subclavian artery with separate origin of the inferior accessory subclavian artery. There was a patent radial artery with a inner diameter of 1.7 mm in the superior limb (radial) whereas there was a patent ulnar artery with a inner diameter of 2.0 mm in the inferior limb.\nMagnetic Resonance Angiography [] confirmed the findings of the color Doppler and the duplication of the subclavian vessels was found to arise from the infraclavicular level. The duplicated vessels running to the inferior limb were running along the lateral chest wall into the limb; the nerves also coursed along with the vessels.\nOur goal was to transfer the inferior limb to the superior forearm as a neurovascular island, and to recreate the hand without compromising the existing function and vascularity.\nAn encircling incision was made around the inferior limb, the pectoralis major and the latissmus dorsi muscle attachments were divided, and the neurovascular pedicle was dissected and mobilised up to its anomalous origin in the infraclavicular region from the subclavian vessels. The inferior limb was then transferred to the superior forearm.\nZigzag incisions were made on corresponding sides of the skin on the forearm and hand. The transverse metacarpal ligament was created and carpal bones were approximated with nonabsorbable sutures. [Figures –]\nThe postoperative period was uneventful and the existing hand functions [Figures –] were preserved. However, the abduction and external rotation at the shoulder joint was reduced because of the tautness of the transferred neurovascular pedicle and the bulk added at the forearm level.\nPhysiotherapy and re-education in terms of holding objects has been started early. The patient has been kept on regular follow-up and further staged procedures like distraction and synostosis of the elbow joint and debulking have been planned to provide a better functional and aesthetic limb. (See video on .)

This case study is a product of serendipity. A 27 year old female runner was initially part of an experimental study documenting the muscle onset timing of the posterior leg and trunk muscles during the prone leg extension. At the time of the study the participant had no leg or spine injuries. The participant was part of the asymptomatic control group. Five months after the completion of the study this participant suffered an inversion right ankle sprain during a rainstorm while leaping into a camping tent filled with children. At 2 and 8 weeks post ankle sprain the PLE extension test was performed while recording the posterior muscle activation EMG to determine if an ankle injury influences the timing of muscle activation during the PLE as compared with an injury-free PLE onset timing pattern.\nTwenty seven year old female distance runner (height – 167 cm, weight -58 kg) suffered a right ankle inversion sprain. X rays revealed no fractures. Informed consent to participate in this study was received from the subject. In the initial study the participant read and signed an information and consent form that was approved by the Research Ethics Board of CMCC. For the second half of the study the subject was notified of the risks and benefits of the study which complied with the World Medical Association declaration of Helsinki on the ethical conduct of research using human participants within a private practice and agreed to have her results published.\nNo passive therapy was received by the participant. The participant was encouraged to perform daily weight bearing exercise and range of motion exercises. The participant was running within two weeks of the injury with pain and not at her pre injury level. At two weeks post injury the participant reported that she felt she was functioning at 60% of her optimum. At 8 weeks post injury the participant reported that she was running 95% pain free with little loss of function.\nAn identical testing protocol was used across the 3 experimental days (pre injury, 2 weeks post injury and 8 weeks post injury). The muscle activity of the right gluteus maximus, bilateral lower erector spinae, and right hamstring muscle groups was recorded during right prone leg extension while lying prone on a manual therapy table. The position of the leg was controlled in all planes (no hip adduction/abduction or internal/external rotation) visually by the experimenter. A rig restricting movement or a kinematic analysis system to ensure an identical movement across trials was not used as this is not similar to what occurs during practice. The control of proper form was limited to a visual assessment as this most resembles clinical practice.\nDisposable bipolar Ag-AgCl disc surface electrodes with a diameter of one cm were adhered bilaterally over the five muscle groups with a centre to centre spacing of 1 cm. Raw EMG was amplified 5000 times. The amplifier has a CMRR of 10,000:1 (Bortec EMG, Calgary AB, Canada). Raw EMG was band pass filtered (10 and 1000 Hz) and A/D converted at 2000 Hz using a National Instruments data acquisition system.\nThe prone leg extension exercise was performed five times during each experimental session. The task required the subject to lie prone at complete rest with no movement while the EMG from each muscle was collected for 5 seconds. The subject then extended their straight right leg approximately six inches off the table. The leg was held isometrically for 3 seconds then lowered to the table.\nThe data from each PLE trial was processed in the same manner. The aim of the processing for this study was to determine the order and timing of muscle activation. To determine muscle timing, it is necessary to determine when a muscle is considered active or "on". A muscle was considered "on" when the level of muscle activity was greater than 10% of the peak muscle activity during the prone leg extension. This method of determining muscle onset was used in the previous study by Bullock-Saxton et al []. The order of activation can then be determined by classifying each muscle as "on" when its level of activity exceeds that of its predetermined threshold. Muscle activation time (milliseconds-ms) was referenced to the time of activation of the hamstring muscle. For example, positive values (ms) occurred when a muscle's onset occurred before activation of the hamstring muscle group, and negative values indicated that muscle activation occurred after the onset of the hamstring muscle. The onset of muscle activity was determined for each muscle during each repetition of the prone leg lift. Please note that the EMG activity was not normalized to a maximum voluntary contraction (MVC). While MVCs are important in the collection of EMG when there is a need for determining muscle amplitude, this was not necessary in the current study because muscle timing rather than amplitude was measured. Normalization would not influence the muscle onset results.\nThe data was processed in the following manner: The raw EMG signal was first full wave rectified, then smoothed using a moving average technique which averaged every 100 points of data with an overlap 98 points. The bias was removed from the signal to allow resting activity to be at 0. The peak muscle activity was found and each data point was divided by this peak muscle activity. In this way, muscle onset could be determined by determining the time when the myoelectric signal exceeded 10% of the maximum. The signal was visually inspected to ensure that no artefact occurred or that the results were biologically feasible.

A 11 years old male was referred to the emergency department of Virgen de las Nieves University Hospital due to a slight periodontal bleeding of 5 days of evolution. An orthopantomography was performed to focus the diagnosis. The OPG evidenced a dubious periapical image compatible with a small cyst of dental origin. Hence, the doctors of the emergency service decided to contact with the maxillofacial surgery department. A new clinical examination evidenced a spontaneous alveolar bleeding and high mobility of the first and second molars of the fourth mandibular quadrant. The patient denied cervicofacial trauma or pathologies of the coagulation system. Thus, a CT scan of the cervicofacial area was performed to reach a diagnosis. Surprisingly, this test evidenced a large high-flow intraosseous arteriovenous malformation extending from the right mandibular body to the homolateral pterygoid region and the infratemporal fossa (Fig. ). Moreover, a selective arteriography and a MRI of head and neck were also carried out to identify the limits of the malformation and the key vessel (Fig. ). Considering these findings, we contacted with the interventional radiology unit of the Hospital in order to plan a combined approach. However, after a careful analysis we decided to treat the patient only with an endovascular approach. Specifically, a very large drainage vein was identified with the radiological tests. Hence, we hypothesized that the embolization of this vein and the selective embolization of the main arterial vessels might be enough to treat the pathology. Thus, under general anesthesia and femoral approach, the embolization of the main drainage vein and of the most accessible arteries was carried out. The patient was maintained intubated and sedated for 24 hours and he was extubated when the bleeding had completely stopped. He was discharged from the hospital 7 days after the procedure. In fact, a control arteriography performed 5 day after embolization showed a significant reduction of the size of the lesion. A MRI performed three months after the procedure evidenced the complete regression of the lesion. Furthermore, in a new control 18 month after the patient has no clinical signs of recurrence (Fig. ). Hence, this approach could avoid an extremely mutilating surgery and severe psychological sequels.

A 64-year-old gentleman with a post radiation recurrent squamous carcinoma of the left lower alveolus was posted for composite resection and reconstruction with fibula free flap by simultaneous two team approach. The left fibula was selected and after flap harvest, the left neck vessels (superior thyroid and facial) were assessed for the volume and character of the flow and were found to be good. The bone defect was extending from midline anteriorly to proximal ramus posteriorly and the soft-tissue defect was confined to the oral cavity []. The flap was designed in a manner so that the superior thyroid vessels were to be used as donor vessels as they were away from the previous zone of irradiation and the blood flow was also good after dissecting them and dividing to look for the volume and adequacy of blood flow. After osteotomy and preliminary intra oral in setting of the skin paddle, and during the time of anastomosis, it was found that the flow in the superior thyroid artery was inadequate after initial good flow. Routine measures such as application of warm saline, xylocaine solution and later papaverine did not improve the flow and in such a situation, the options available were\nTo open the right neck and use vessels from that side either directly or with a vein graft To use a vein graft and anastomose with the facial artery on the same (left) side as the flow in this vessel was good To use the distal end of the flap pedicle vessels for anastomosis with left facial artery, so as to establish the vascular flow in a retrograde manner. This was because the clipped distal ends of the peroneal pedicle vessels were near to the left facial artery.\nBefore exploring the opposite neck or harvesting a vein graft, a decision was made to attempt retrograde vascularisation of the flap via the distal end of the peroneal vessels. First, the arterial anastomosis was completed between the distal end of the peroneal artery and left facial artery (end-to-end) and the flow was checked. The arterial flow was good as evidenced by the pulsations of the donor and recipient vessels and with the venous outflow from the distal end of the peroneal venae commitantes. This was followed by venous anastomosis between the distal end of the peroneal venae commitantes and a tributary of the left internal jugular vein (end to end). The skin paddle bleeding was also good with a sterile needle prick. Thus, the vascularity was restored with retrograde flow and was well established by the time the intra oral inset was completed []. The neck was then closed and post-op period was uneventful. After 6 weeks, a computed tomography (CT) angiogram revealed good establishment of blood flow to the neo mandible [Figures and ].

A 32-yr-old woman with no relevant or significant medical history presented with severe left calf pain that had persisted for the past 10 yr. The symptom was constant and worsened with menstruation, standing or walking for more than 30 min. The pain was relieved by elevating the leg in the sitting position or massaging the calf muscles. The pain was not associated with any progressive neurologic symptoms or signs. She reported that none of the medications she had tried provided any significant pain relief. Intramuscular electrical stimulation for 4 months and repeated muscle injections with lidocaine were also ineffective. Alternative treatments including acupuncture and Korean herbal medications had been tried many times without much success.\nThe patient's pain drawing showed a pain pattern limited to the left calf, especially in the medial side, which indicated a referred pain pattern of medial gastrocnemius or soleus muscle (). Physical examination revealed severe tenderness on the medial side of the left calf muscles. Signs of calf swelling were equivocal. Deep tendon reflexes were normal in both sides. Muscle strength of both lower extremities was normal. Sensation in both lower extremities was intact. The straight leg raising test was normal. Conventional radiography of the left leg showed several mottled calcifications within the muscles but did not reveal erosions of tibia or fibula (). To rule out a possible vascular deformity, femoral angiography was performed and a hemangioma was suggested in the left calf (). Magnetic resonance imaging (MRI) of the left lower extremity was performed for further evaluation of these abnormalities and showed an enhancing soft-tissue mass in the medial aspect of the soleus muscle ().\nThe patient was referred to an orthopedic surgeon and underwent excisional biopsy. Operative findings revealed a mass consisting of several irregular fragments of muscular soft tissue, measuring 6×6×4 cm. The final pathologic diagnosis was intramuscular hemangioma with fatty overgrowth isolated to the soleus muscle, which was in concordance with the MRI findings (). Within 1 month, the patient reported 90% pain relief and had discontinued all pain medications. Even with prolonged walking of more than 30 min, calf pain did not occur and the subject was able to resume mountain hiking 3 months following the operation.

As home care doctors and general practitioners, we encountered a 37-year-old woman with ASD who lived with her parents in Japan. Her mother had end-stage breast cancer. We visited her house regularly to care for her mother. The woman with ASD was the main caregiver and a key person for her mother because her father was visually impaired. There were some obstacles we need to overcome together, but in the end, she was able to fulfill the role of the main caregiver for her mother.\nWhen we started home care for the mother, we did not have any knowledge that the daughter was a person with ASD. However, we occasionally heard about her from home visit nurses and home care staff because they worried about whether the mother could continue to stay at home due to the lack of care provided by family members. According to home care staff members, the woman with ASD was usually not present when the home care staff visited the home for her mother's care. They could not contact her or talk with her about her mother's condition. She focused on dishwashing and did not appear concerned about how her mother's medications or clothes were organized or whether the room was clean or not. She could not communicate well with home care staff even when she talked with them. Thus, we did not initially recognize that she was a person with ASD or another developmental disorder. We were wondering why she was having trouble managing the home care schedule and chores even though she worked as an engineer. The home care staff's distrust of the daughter caused irritation and stress in the daughter and the home care staff.\nAfter a few home care visits, with the daughter's consent, the mother's care manager informed us that she had been diagnosed with ASD in adulthood. Her parents had not been informed of the diagnosis. The daughter did not want to let her parents know about the diagnosis. The home care staff started to feel strongly that it was too difficult for the daughter to continue home care for the mother. The woman with ASD also felt difficulties in communicating with staff and understanding how her mother felt or how it feels to be severely ill. Therefore, we initiated consultation and social skill training in our outpatient clinic for the daughter. We discussed the traits of ASD as well as solutions or strategies to manage ASD traits in the home care setting. When we gave her instructions, we tried to make them more specific and provided examples so that she could understand them easily. For example, we suggested that she needed to come into her mother's room to share her mother's condition when the home care staff made a visit.\nAfter several consultations, she gradually obtained life skills in communication, scheduling, and managing things related to home care, such as expectations during home care staff visits or what she should do for her mother. Her psychological stress and caregiving burden decreased day by day. We also shared the fact that she was diagnosed with ASD with home care staff as well as appropriate attitudes, support, and communication styles. We shared her behavioral characteristics with staff, such as lower interest in sharing emotions with others or having difficulties in understanding social cues such as eye contact, facial expressions, and metaphors.\nFive months after the start of home-based care, her mother's condition worsened temporarily. The woman with ASD could not understand her mother's discomfort or pain and her father's sadness and serious feelings about the poor prognosis of his wife. She could not understand why her father was at a loss for words upon hearing the doctor's explanation of her mother's severe condition. Therefore, she asked him “Didn't you hear, Dad?” in a loud voice. These types of reactions by the daughter interfered with her father's acceptance of her mother's condition and he was unable to continue to listen the explanation. After this event, we explained why her father become silent while during the explanation of her mother's condition. We made a rule that we will tell her beforehand what we would say and how she should act when we share bad news. For example, we told her beforehand that we were going to tell her father about her mother's poor condition and prognosis and asked her to listen until we finished. We also told her how her father would react and our guess of the reasons for his reaction. Inappropriate behavior that is not suitable for the situation decreased afterward. She also felt relieved that she knew what she should do and could support her father as much as possible.\nSeven months after the start of home-based care, the mother passed away at home as her mother and she herself hoped. When her mother needed to use oral opioids and subcutaneous injection of opioids, the woman with ASD was able to communicate with homecare staff and ask for help to offer better care for her mother. Her mother died peacefully without any severe pain or discomfort. The woman with ASD did not become confused and was able to accept her mother's death peacefully with her father.

An 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. , , and ). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.\nThe patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transverse fashion in the right lower quadrant through the rectus sheath, and the peritoneum entered. The appendix was clearly visualized exiting the abdominal cavity into the inguinal defect. The appendix and its adhered omentum were then carefully reduced back into the abdominal cavity using intraperitoneal countertension without any rupture or spillage. Due to its densely adherent chronic inflammatory tissue, an incidental appendectomy was performed as there was significant tension on the cecum after placing the appendix back in its anatomical location. There was concern for the development of appendicitis post operatively due to the manipulation performed during the procedure. The appendix was then stapled at its base using a standard gastrointestinal anastomosis stapler and passed off the field. The indirect hernia defect was very small and closed with a medium size lightweight mesh plug. The patient was discharged from the post-anesthesia care unit the same day as surgery and had no complications from his recovery course. No additional antibiotics were given other than a single prophylactic dose during the surgical case. At his 2-week follow-up, he had no recurrence of his hernia and was doing well. On pathologic examination, there was no evidence of appendiceal inflammation or appendicitis. The periappendiceal fat did exhibit some fat necrosis, however, supporting the chronic periappendiceal adhesive changes.

A 50-year-old woman with left breast cancer was referred to the Plastic Surgery Department for immediate breast reconstruction. She had a history of subarachnoid hemorrhage and a lumbar peritoneal shunt tube had been implanted in her abdomen to treat hydrocephalus. She had no other obvious sequelae from the subarachnoid hemorrhage and her medical condition was quite stable with the shunt. Her breasts were large and drooping (), and left nipple areola sparing mastectomy was scheduled. A preoperative computed tomography scan showed the shunt tube, which pierced the intervertebral lumbar and traveled through the subcutaneous layer of the left trunk () and entered into the abdominal cavity from the outer edge of the left rectus abdominal muscle ().\nIn the selection of the reconstruction method, we thought that abdominal flap would be suitable because implant reconstruction would not achieve morphologically favorable results and because a latissimus dorsi musculocutaneous flap would not have sufficient volume. However, it was considered that the shunt tube might cause difficulty in the elevation of the flaps.\nWe consulted brain surgeons on the feasibility of the abdominal flap operation and decided to withdraw the tube from the abdominal cavity once, when the flap was elevated, and to reinsert it upon the closure of the donor site. The patient consented to our preoperative explanation of the procedure and indicated that she desired to undergo DIEP flap reconstruction.\nShe underwent nipple areola sparing mastectomy of the left breast and immediate DIEP flap reconstruction. In the elevation of the flap, a skin incision was first made around the whole circumference of the flap and dissection was carried down to the muscle fascia. The shunt tube was confirmed above the fascia on the left side of the abdomen. The perforator vessel passing through the right rectus sheath, which had been confirmed by color Doppler ultrasound on the day before surgery, was secured and dissected to the right deep inferior epigastric vessels. As the shunt tube was placed on the left side, we prepared the pedicle of the DIEP flap on the right side. Although we could have used the penetrating branch on the left side containing the shunt tube, we considered that using the penetrating branch on the right side that had not previously undergone surgical operation would be safer. The shunt tube, which was located on the fascia, was covered with fibrous tissue and was not directly exposed (). However, on the closure of the donor site, the shunt tube was obstructed as it was excessively bent. We, therefore, dissected the tube from the surrounding tissue and temporally withdrew it from the abdominal cavity and re-inserted it 5-cm caudal from its original position by a brain surgeon (). After surgery, the patient had a smooth recovery and we found no signs of increased intracranial pressure or complications of abdominal wall. Partial necrosis of the spared skin of the breast occurred but was successfully treated following a conservative approach.\nSince her breast cancer was less than 1 cm in diameter and classified as clinical stage 1 (T1N0M0), adjuvant therapy after surgery was expected to be unnecessary. Thus, immediate reconstruction was performed. However, a sentinel lymph node biopsy was positive, and broad invasion of the primary tumor was observed in the pathological examination. Therefore, she received postoperative chemotherapy and radiotherapy, and there was no recurrence of the breast cancer and her reconstructed left breast showed good shape and symmetry in comparison with the right breast at one 1 year after surgery ().

A 55-year-old female admitted to us with complaints of 40% acute flame burns to the neck, chest anterior abdominal wall, and upper limbs. The patient had a history of multiple abdominal surgeries secondary to tuberculosis 10 years back. She had an exploratory laparotomy which ended up having a burst abdomen, for which a temporary colostomy was done and closed, due to which she developed a large ventral hernia. Five years later, the patient underwent an open mesh repair, which got infected, and the mesh had to be removed. When she presented to us, the skin over a ventral hernia had second-degree deep dermal burns which were grafted. The patient after rehabilitation from burn wounds came back again for a ventral hernia repair. The patient had Type 2 abdominal wall defect []. The patient deferred the option of the microvascular free flap.\nWe planned a TFL graft harvested from the left thigh for closing the rectus defect and an islanded TFL myocutaneous flap from right thigh for the abdominal defect.\nOn the table, the edge of a hernia was incised. The skin adherent to peritoneum was excised. There was a defect of 20 cm × 12 cm in the lower two-third of the abdomen in the midline. A fascia lata graft was harvested from left thigh measuring 18 cm × 10 cm and sutured to the edge of the abdominal wall []. On the right side, the TFL islanded flap was elevated of about 30 cm × 10 cm in dimension and turned 120° for the distal end of the flap to reach the upper limit of the abdominal defect []. The segment between the proximal end of the flap and the lower end of the abdominal defect in the right iliac region was incised and opened up to the external fascia to accommodate the bridging segment of the flap. The fascia was reinforced to the inside wall edge, and the skin was sutured with a closed suction drain. The donor area was closed primarily [].\nThe postoperative period was uneventful. The closed suction drain removed on the 6th postoperative day, and the sutures were removed on the 14th postoperative day. At 6-month follow-up, no herniation of the abdominal contents was obtained. Thigh donor site healed without any complications [].

As home care doctors and general practitioners, we encountered a 37-year-old woman with ASD who lived with her parents in Japan. Her mother had end-stage breast cancer. We visited her house regularly to care for her mother. The woman with ASD was the main caregiver and a key person for her mother because her father was visually impaired. There were some obstacles we need to overcome together, but in the end, she was able to fulfill the role of the main caregiver for her mother.\nWhen we started home care for the mother, we did not have any knowledge that the daughter was a person with ASD. However, we occasionally heard about her from home visit nurses and home care staff because they worried about whether the mother could continue to stay at home due to the lack of care provided by family members. According to home care staff members, the woman with ASD was usually not present when the home care staff visited the home for her mother's care. They could not contact her or talk with her about her mother's condition. She focused on dishwashing and did not appear concerned about how her mother's medications or clothes were organized or whether the room was clean or not. She could not communicate well with home care staff even when she talked with them. Thus, we did not initially recognize that she was a person with ASD or another developmental disorder. We were wondering why she was having trouble managing the home care schedule and chores even though she worked as an engineer. The home care staff's distrust of the daughter caused irritation and stress in the daughter and the home care staff.\nAfter a few home care visits, with the daughter's consent, the mother's care manager informed us that she had been diagnosed with ASD in adulthood. Her parents had not been informed of the diagnosis. The daughter did not want to let her parents know about the diagnosis. The home care staff started to feel strongly that it was too difficult for the daughter to continue home care for the mother. The woman with ASD also felt difficulties in communicating with staff and understanding how her mother felt or how it feels to be severely ill. Therefore, we initiated consultation and social skill training in our outpatient clinic for the daughter. We discussed the traits of ASD as well as solutions or strategies to manage ASD traits in the home care setting. When we gave her instructions, we tried to make them more specific and provided examples so that she could understand them easily. For example, we suggested that she needed to come into her mother's room to share her mother's condition when the home care staff made a visit.\nAfter several consultations, she gradually obtained life skills in communication, scheduling, and managing things related to home care, such as expectations during home care staff visits or what she should do for her mother. Her psychological stress and caregiving burden decreased day by day. We also shared the fact that she was diagnosed with ASD with home care staff as well as appropriate attitudes, support, and communication styles. We shared her behavioral characteristics with staff, such as lower interest in sharing emotions with others or having difficulties in understanding social cues such as eye contact, facial expressions, and metaphors.\nFive months after the start of home-based care, her mother's condition worsened temporarily. The woman with ASD could not understand her mother's discomfort or pain and her father's sadness and serious feelings about the poor prognosis of his wife. She could not understand why her father was at a loss for words upon hearing the doctor's explanation of her mother's severe condition. Therefore, she asked him “Didn't you hear, Dad?” in a loud voice. These types of reactions by the daughter interfered with her father's acceptance of her mother's condition and he was unable to continue to listen the explanation. After this event, we explained why her father become silent while during the explanation of her mother's condition. We made a rule that we will tell her beforehand what we would say and how she should act when we share bad news. For example, we told her beforehand that we were going to tell her father about her mother's poor condition and prognosis and asked her to listen until we finished. We also told her how her father would react and our guess of the reasons for his reaction. Inappropriate behavior that is not suitable for the situation decreased afterward. She also felt relieved that she knew what she should do and could support her father as much as possible.\nSeven months after the start of home-based care, the mother passed away at home as her mother and she herself hoped. When her mother needed to use oral opioids and subcutaneous injection of opioids, the woman with ASD was able to communicate with homecare staff and ask for help to offer better care for her mother. Her mother died peacefully without any severe pain or discomfort. The woman with ASD did not become confused and was able to accept her mother's death peacefully with her father.

A male patient aged 62 years reported to our center with the chief complaint of dull gnawing pain and a growth in the mouth [] of 5 years duration associated with difficulty in eating and swallowing. The history revealed that the patient had met with a road traffic accident 5 years back which resulted in injuries to his upper front teeth, lower lip, and left side of the face. A few months after the injury, he noticed a small growth on the left side of the upper gums that progressively increased slowly to the present size. There was a sudden surge in growth 20 days before presentation to our department after the patient removed a tooth fragment sticking to the growth. There was a gross asymmetry of face caused by the diffuse swelling involving the lower two-third of the left side of the face. Superoinferiorly, it extended from the infraorbital region to the lower border of the mandible and the anteroposterior extent was from the midline to the left preauricular region. The mass was reddish pale, exophytic with a lobulated surface, measuring approximately 10 cm × 6 cm and was protruding from the oral cavity causing inability to close the mouth. The growth was attached to the left maxillary alveolus and palate and not fixed to the buccal mucosa or vestibular sulcus. It did not show any focus of surface ulceration, but bleeding spots were distributed randomly. The upper posterior teeth were displaced and attached to the mass on the palatal side. On palpation, the growth was firm and tender with an irregular surface and was fixed to the upper left alveolus. A computed tomography angiogram was taken to check the vascularity of the lesion which revealed no irregular feeder vessels. Further imaging showed a soft-tissue shadow with calcifications. The soft-tissue shadow measured approximately 10 cm × 6 cm in size not involving the mandible but causing destruction of maxilla in the premolar region. Routine blood investigations and serology tests were done. Since it was an abnormally extensive lesion, we approached by giving Weber Fergusson with lateral limb modification connected with intraoral vestibular degloving incision to have a complete access of the lesion []. Then, peripheral osteotomy cut was given to facilitate easy release and that the lesion was excised completely out of the maxilla. The raw area was packed with iodoform gauze. Obturator was constructed postoperatively to close the palatal fistula. During follow-up, wound shrunk and obturator was replaced with maxillary prosthesis. The mass was sent for histopathological examination []. The weight of the excised mass was approximately 230 g. The differential diagnosis given for the mass was fibroma, ossifying fibroma, peripheral giant cell granuloma, pyogenic granuloma, fibrosarcoma. The histopathological examination of the soft-tissue specimen revealed fibrous, connective tissue with numerous plump fibroblasts []. Numerous areas showed ossification in the connective tissue. Chronic inflammatory cells and blood vessels were also seen. All of which suggested the mass be a peripheral ossifying fibroma []. Postsurgical recovery was uneventful and the 6 months follow-up revealed no evidence of recurrence.

A 21-year-old female patient presented with throbbing pain in relation to upper left canine tooth. The tooth had a history of occasional pain since 1 year and was related to have started following an orthognathic surgery done on upper maxilla. On examination she had pain on vertical and lateral percussions on that tooth. The radiograph of the area revealed a root injury in the middle third of the root and the possibility of endodontic involvement of the area. The distal area of the tooth had a periodontal pocket of 9mm probing depth as seen in .\nThe patient was unwilling for extraction of the tooth and its prosthetic rehabilitation. She was referred to do root canal treatment for the immediate management of pain. Her tooth was endodontically treated as shown in , and she was relieved of acute symptoms and periodontal pocket became inactive. Although she was supposed to report for the periodontal review, upon relieved from acute symptoms she did not turn up.\nSix months later, the patient reported with a painful periodontal abscess and a draining sinus opening in relation to the periapex of the same tooth. The gingiva in relation to the abscess was edematous and purulent exudation was noticed draining through the periodontal pocket and the sinus opening as well []. The radiograph showed fast resorption of the root area in the border of lesion with an ample alveolar bone loss surrounding it [].\nThe patient still resisted removal of the tooth and insisted on any treatment to restore her natural teeth as long as possible. Modified Widman flap[] surgery along with restoration of the root lesion with glassionomer cement was proposed and the patient was willing for the treatment. The possibility of treatment failure following root fracture and the recurrence of pocket following non-adaptation of the gingival tissue on the restorative surface were explained to the patient.\nIn order to control the inflammatory status of the gingiva and to drain the abscess for a firm and less hemorrhagic area for operation, a closed curettage of the pocket followed by subgingival irrigation with 0.12% Chlorhexidine gluconate were performed. She was prescribed a course of antibiotic (Tab. Doxicycline - 100 mg) for 10 days. She was recalled after 14 days, the gingiva appeared more firm, exudation through gingival sulcus stopped, and the sinus opening had disappeared. But the disto-labial area of the canine and its distal surface had 10 and 9 mm of periodontal pocket, respectively.\nThe objectives of the treatment approach were to establish a proper surgical access to the resorbing root area, freshen the lesion, and restore the root region with Glass ionomer cement and the flap has to be adapted over the restoration and root.\nModified Widman flap surgery with a single vertical incision distal to first premolar was performed exposing the bony defect and injured root area. The area was thoroughly debrided [] the injured root surface was prepared with a micro motor to expose fresh dentin to receive restoration. The prepared root surface was restored with Glass ionomer cement (Fuji II) and after its initial setting, the excess cement were planed and smoothened as seen in []. The flap was adapted back in its previous position and sutured tightly to the teeth. The immediate post-operative clinical and radiographical view of the area is shown in and , respectively. The patient was prescribed amoxicillin 500 mg and paracetamol 500 mg t.i.d. for next 7 days and the sutures were removed after 10 days.\nThe patient was recalled after 6 months for clinical and radiographical evaluation. Clinically, there were no signs of inflammation in the area of surgery and the flap showed a complete adaptation to the root surface []. Radiograph of the area indicated bone deposition in close proximity to the restoration and the root resorption seems to have not progressed since the restoration [].\nThe patient was again reviewed after one more year (18 months post operatively) for clinical and radiographical evaluation of the healing. Clinically, the flap exhibited close adaptation with the restoration surface with probing depth of just 1 mm [], indicating an attachment gain of 8 mm. The radiographic view of the area at this time showed considerable bone apposition around the restoration surface and a clear alveolar crestal bone substantiating the clinical findings []. The aggressive root resorption following the periodontal abscess had completely ceased.

Our case was a 20 year old female with road traffic accident. An informed consent was taken from her for publication purposes. Her left leg was crushed under a truck tyre and she presented with a grade IIIb compound fracture tibia with a 20cm by 8 cms wound over the anteromedial side of lower third of tibia, extending over to the medial side of ankle joint and foot. Periosteum was seen exposed in lower third of tibia and wound was badly contaminated. Radiographs of the leg showed a distal third tibia fracture with a segmental piece of tibia which was further comminuted. The fibula fracture was at the same level as tibia and was short oblique fracture. Patient presented immediately after the injury and debridement was done within 2 hours of injury. A thorough wash was given with debridement of all dead and devitalized tissue. Fracture was fixed using a biplanar external fixator (). Wound dressing was done regularly and intravenous broad spectrum antibiotics were given. Two further debridements were needed and at 4 weeks the wound was healthy enough to perform a cross leg flap. At 3 weeks post flap surgery, the external fixator was removed due to multiple pin track infections and the limb was immobilized in a long leg cast. At 3 and half months post injury the wound was healthy. Radiographs showed that the segmental tibia fragment was showing good union response at the proximal end; however the distal end appeared to be rounded with attempt to callus formation which is non bridging (). Abnormal mobility at the fracture site indicated a need to stabilize the fracture, however soft tissue condition precluded any form of internal fixation. At that time the fibula fracture was completely united. A decision to do a posterior bone grafting along with bridge fibula grafting was taken to provide additional stability at the non union site. Lateral approach was taken and cancellous graft taken from the same side (right) iliac crest was filled in the interosseous membrane between tibia and fibula by at the site of the fracture, just proximal and just distal to it. Two 3.5 mm cortical screws were passed from the fibula to into the tibia at the site where the graft ends proximally and distally. This was done to make a rigid strut with cancellous graft in the middle (). Patient was put in a long knee brace and advised non-weight bearing for a period of 8 weeks. At two months after bridge grafting good callus was seen bridging the fracture and the patient was given a patella tendon bearing cast and was started on partial weight bearing. Complete union was achieved at 7 months post surgery. The ankle movement was 10 degree dorsiflexion from neutral and 20 degree plantar flexion from neutral position at that time. Patient resumed her activities at 8 months post trauma while screw removal was done at 18 months post injury. The patient was last followed up at 5 years post injury. She was walking full weight bearing and was able to carry out all her activities. The medial soft tissue scar was healthy. Ankle dorsiflexion was restricted to 10° but the plantar flexion was around 50° (). There was no history of pain or discharge from the injury site. The radiograph showed the fracture outline to have a silhouetted appearance with good union on posterior and medial side with good consolidation of the entire area of the bridge graft between tibia and fibula ().

As home care doctors and general practitioners, we encountered a 37-year-old woman with ASD who lived with her parents in Japan. Her mother had end-stage breast cancer. We visited her house regularly to care for her mother. The woman with ASD was the main caregiver and a key person for her mother because her father was visually impaired. There were some obstacles we need to overcome together, but in the end, she was able to fulfill the role of the main caregiver for her mother.\nWhen we started home care for the mother, we did not have any knowledge that the daughter was a person with ASD. However, we occasionally heard about her from home visit nurses and home care staff because they worried about whether the mother could continue to stay at home due to the lack of care provided by family members. According to home care staff members, the woman with ASD was usually not present when the home care staff visited the home for her mother's care. They could not contact her or talk with her about her mother's condition. She focused on dishwashing and did not appear concerned about how her mother's medications or clothes were organized or whether the room was clean or not. She could not communicate well with home care staff even when she talked with them. Thus, we did not initially recognize that she was a person with ASD or another developmental disorder. We were wondering why she was having trouble managing the home care schedule and chores even though she worked as an engineer. The home care staff's distrust of the daughter caused irritation and stress in the daughter and the home care staff.\nAfter a few home care visits, with the daughter's consent, the mother's care manager informed us that she had been diagnosed with ASD in adulthood. Her parents had not been informed of the diagnosis. The daughter did not want to let her parents know about the diagnosis. The home care staff started to feel strongly that it was too difficult for the daughter to continue home care for the mother. The woman with ASD also felt difficulties in communicating with staff and understanding how her mother felt or how it feels to be severely ill. Therefore, we initiated consultation and social skill training in our outpatient clinic for the daughter. We discussed the traits of ASD as well as solutions or strategies to manage ASD traits in the home care setting. When we gave her instructions, we tried to make them more specific and provided examples so that she could understand them easily. For example, we suggested that she needed to come into her mother's room to share her mother's condition when the home care staff made a visit.\nAfter several consultations, she gradually obtained life skills in communication, scheduling, and managing things related to home care, such as expectations during home care staff visits or what she should do for her mother. Her psychological stress and caregiving burden decreased day by day. We also shared the fact that she was diagnosed with ASD with home care staff as well as appropriate attitudes, support, and communication styles. We shared her behavioral characteristics with staff, such as lower interest in sharing emotions with others or having difficulties in understanding social cues such as eye contact, facial expressions, and metaphors.\nFive months after the start of home-based care, her mother's condition worsened temporarily. The woman with ASD could not understand her mother's discomfort or pain and her father's sadness and serious feelings about the poor prognosis of his wife. She could not understand why her father was at a loss for words upon hearing the doctor's explanation of her mother's severe condition. Therefore, she asked him “Didn't you hear, Dad?” in a loud voice. These types of reactions by the daughter interfered with her father's acceptance of her mother's condition and he was unable to continue to listen the explanation. After this event, we explained why her father become silent while during the explanation of her mother's condition. We made a rule that we will tell her beforehand what we would say and how she should act when we share bad news. For example, we told her beforehand that we were going to tell her father about her mother's poor condition and prognosis and asked her to listen until we finished. We also told her how her father would react and our guess of the reasons for his reaction. Inappropriate behavior that is not suitable for the situation decreased afterward. She also felt relieved that she knew what she should do and could support her father as much as possible.\nSeven months after the start of home-based care, the mother passed away at home as her mother and she herself hoped. When her mother needed to use oral opioids and subcutaneous injection of opioids, the woman with ASD was able to communicate with homecare staff and ask for help to offer better care for her mother. Her mother died peacefully without any severe pain or discomfort. The woman with ASD did not become confused and was able to accept her mother's death peacefully with her father.

An 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. , , and ). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.\nThe patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transverse fashion in the right lower quadrant through the rectus sheath, and the peritoneum entered. The appendix was clearly visualized exiting the abdominal cavity into the inguinal defect. The appendix and its adhered omentum were then carefully reduced back into the abdominal cavity using intraperitoneal countertension without any rupture or spillage. Due to its densely adherent chronic inflammatory tissue, an incidental appendectomy was performed as there was significant tension on the cecum after placing the appendix back in its anatomical location. There was concern for the development of appendicitis post operatively due to the manipulation performed during the procedure. The appendix was then stapled at its base using a standard gastrointestinal anastomosis stapler and passed off the field. The indirect hernia defect was very small and closed with a medium size lightweight mesh plug. The patient was discharged from the post-anesthesia care unit the same day as surgery and had no complications from his recovery course. No additional antibiotics were given other than a single prophylactic dose during the surgical case. At his 2-week follow-up, he had no recurrence of his hernia and was doing well. On pathologic examination, there was no evidence of appendiceal inflammation or appendicitis. The periappendiceal fat did exhibit some fat necrosis, however, supporting the chronic periappendiceal adhesive changes.

A 71-year old man was referred to our clinic for the sudden onset back pain with weakness in both legs and sensory change. The pain was located at mid thoracic area, and was positively related to motion. It started 5 days prior to the visit and the neurologic changes occurred the following day. Neurologic examination revealed grade IV motor power on both legs and hypoesthesia was present below the level of the xiphoid process. The patient was able to walk with the aid of a cane. He had been taking anti-arrhythmic medications for a year, and had no other past medical history.\nPlain radiographs and magnetic resonance imaging (MRI) taken from the other hospital revealed a T8 acute compression fracture with cord compression (). Under an impression of the T8 pathologic fracture, we ran a series of tests to find the primary origin of the spinal metastasis. All laboratory tests including tumor markers were within normal limits. Chest and abdominal computed tomography scans did not show any mass lesions in solid organs. We discussed the plan for diagnosis with oncologists. Since the patient presented with neurologic symptoms in both lower extremities, we came to an agreement that planning an early spine surgery of T8 decompression and stabilization and making the pathologic diagnosis through tumor tissue removed during the surgery would be reasonable. Further systemic work ups such as whole body positron emission tomography was planned after confirmation of the pathologic diagnosis. No steroid therapy was performed during the preoperative period.\nA spinal embolization was performed prior to the operation. As a small size of the ASA was visualized on the left T8 segmental artery angiography (), only the right T8 segmental artery was embolized. On the following day, we carried out a total laminectomy of T8 and pedicle screw fixation from T6 to T10. Tumors located at the ventral side of the dura sac were partially removed to achieve circumferential decompression of the spinal cord. For this procedure, we resected both T8 roots. The operation was uneventful. No significant changes were observed on neurophysiologic intraoperative monitoring (NIOM) throughout the operation. Immediate postoperative neurologic examination showed no change in neurologic status compared to the preoperative state.\nAround 8 hours after the operation, the patient suddenly became paraplegic. Neurologic examination revealed motor power grade 0 on both lower extremities. Pain sensation was lost below the level of the xiphoid process, but touch sense and proprioception were intact. Under a suspicion of operation site hematoma, follow-up MRI was taken immediately. However, we could not identify any lesions causing the patient's paraplegia. No notable events such as hypotension during intraoperative and postoperative period was identified. Therefore, medical treatments, including hydration and high dose steroid injection, were administered and the patient was put on overnight observation.\nThe patient did not show any neurologic improvements the next morning. We discussed this situation with the neurology and radiology departments and concluded that the neurologic features were similar to ASA syndrome. Follow-up T2-weighted sagittal and axial T-spine MRI revealed a high signal change at the anterior half of the spinal cord around the T8 level which confirmed ischemia or infarction of the anterior spinal cord (). Anticoagulation with low molecular heparin and antiplatelet medication were added. Mean arterial blood pressure was monitored and kept above 70 mmHg to maintain spinal cord perfusion pressure. However, the patient's neurologic status did not recover. One week later, the remaining touch sense and proprioception of both lower extremities had also disappeared. The spinal pathology confirmed the diagnosis of multiple myeloma. Throughout 6 months follow-up, the patient remained paraplegic without any neurologic improvements.

An 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. , , and ). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.\nThe patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transverse fashion in the right lower quadrant through the rectus sheath, and the peritoneum entered. The appendix was clearly visualized exiting the abdominal cavity into the inguinal defect. The appendix and its adhered omentum were then carefully reduced back into the abdominal cavity using intraperitoneal countertension without any rupture or spillage. Due to its densely adherent chronic inflammatory tissue, an incidental appendectomy was performed as there was significant tension on the cecum after placing the appendix back in its anatomical location. There was concern for the development of appendicitis post operatively due to the manipulation performed during the procedure. The appendix was then stapled at its base using a standard gastrointestinal anastomosis stapler and passed off the field. The indirect hernia defect was very small and closed with a medium size lightweight mesh plug. The patient was discharged from the post-anesthesia care unit the same day as surgery and had no complications from his recovery course. No additional antibiotics were given other than a single prophylactic dose during the surgical case. At his 2-week follow-up, he had no recurrence of his hernia and was doing well. On pathologic examination, there was no evidence of appendiceal inflammation or appendicitis. The periappendiceal fat did exhibit some fat necrosis, however, supporting the chronic periappendiceal adhesive changes.

A 46-year-old female patient was admitted to our department due to a cystic tumor in pancreatic body and tail. Routine chemistry and tumor marker levels (CA 19-9, CEA, CA 125) were all within normal limits. Abdominal CT scan and EUS showed about 5×4 cm sized, slightly septated cystic tumor between the body and tail of the pancreas (). There was no mural nodule, no calcification, and no eccentrically located mass within the cystic area. The benign mucinous cystic tumor of the pancreas was the most favorable preoperative diagnosis. The operation sequence was similar to usual laparoscopic distal pancreatectomy except trocar placement (). The robotic camera arm and other three instrument arms were then connected to their respective ports. At this point, the surgeon sat at the surgical console located about 3 m from the operating table. The assistant surgeon was positioned on the patient's left side for temporary use of laparoscopic instruments through Port 4. In spite of our previous experiences of robot surgical system, the cystic tumor and the remaining splenic vessels were so closely adherent that bleeding was frequently encountered, and most operation time was spent for this process. The risk of cyst rupture was also considered when we tried to separate and divide the small splenic vessels from pancreatic cyst (). Therefore, concomitant segmental resection of splenic vessels was thought to be necessary for spleen preservation. Total operation took about 480 minutes, and about 800 mL of blood loss was noted without blood transfusion. The specimen was delivered through the umbilical port site with small vertical incision after putting into the plastic bag. The patient recovered without complication. She returned to an oral diet on the postoperative second day. After the drain was removed, she was discharged on the fifth day post-operation. The final pathologic examination revealed that the tumor was benign mucinous cystic neoplasm without any characteristics of malignant potential (). A color doppler ultrasound scan obtained 14 days after surgery showed no evidence of splenic infarction and well preserved blood flow within the spleen without definitive peripancreatic fluid collection ().

A 35-year-old male farmer came in contact with 11,000 volts high tension electric wire while irrigating his field. This patient was initially admitted to general surgery ward from main casualty for management as he was having open abdominal wound and was managed there for initial 3 days. He had full thickness burn wounds over the right scapula, right upper limb and anterior abdominal wall along with perforation of the intestine. There was prolapse of the intestinal loops through abdominal wound. Patient was referred to our plastic surgery unit after 3 days. He presented to us in septic shock with an abdominal drain in place. Details of the preliminary management were unavailable except mention of putting in catheter drain through the open abdominal wounds. There was necrosis of burned skin and muscles over the right shoulder and abdomen []. Patient was initially managed conservatively with intravenous fluids, parenteral nutrition, barrier dressing of the abdominal wound and culture specific antibiotics. Patient responded well to the conservative management and once he was stable, a thorough debridement of the necrotic skin over the right shoulder and upper arm was performed. The area was then split skin grafted. The patient developed enterocutaneous fistula, which healed over a period of 8 weeks. The wound over the abdomen was also covered with skin graft and patient was discharged after 18 days [].\nAbout 4 months after the discharge, the patient presented with ventral hernia and requested reconstruction of the abdominal wall. Repair of ventral hernia by synthetic mesh application and reconstruction of the abdominal wall with flap cover was planned. Per-operatively the abdominal skin graft was separated from the peritoneum and the underlying omentum and an inlay composite mesh was applied to secure the abdominal wall []. The graft was not de epithelialised. It was carefully separated from the peritoneum over the bowels. No perforation occurred. A free tensor fascia lata flap was applied over the mesh, but the flap failed. Then after debridement two random pattern transposition skin flaps, one from the right upper and another from the left lower abdomen were transposed over the abdominal wound and donor area was skin grafted []. Patient was discharged after 17 days with advice to wear an abdominal binder. He is presently in follow-up, it has been 18 months since surgery and there is no ventral hernia and abdominal wall is flat and intact. Patient is satisfied with the results [Figures and ].

An 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. , , and ). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.\nThe patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transverse fashion in the right lower quadrant through the rectus sheath, and the peritoneum entered. The appendix was clearly visualized exiting the abdominal cavity into the inguinal defect. The appendix and its adhered omentum were then carefully reduced back into the abdominal cavity using intraperitoneal countertension without any rupture or spillage. Due to its densely adherent chronic inflammatory tissue, an incidental appendectomy was performed as there was significant tension on the cecum after placing the appendix back in its anatomical location. There was concern for the development of appendicitis post operatively due to the manipulation performed during the procedure. The appendix was then stapled at its base using a standard gastrointestinal anastomosis stapler and passed off the field. The indirect hernia defect was very small and closed with a medium size lightweight mesh plug. The patient was discharged from the post-anesthesia care unit the same day as surgery and had no complications from his recovery course. No additional antibiotics were given other than a single prophylactic dose during the surgical case. At his 2-week follow-up, he had no recurrence of his hernia and was doing well. On pathologic examination, there was no evidence of appendiceal inflammation or appendicitis. The periappendiceal fat did exhibit some fat necrosis, however, supporting the chronic periappendiceal adhesive changes.

A previously healthy 73-year-old Caucasian female presents to the clinic with a history of progressive fatigue and dyspnea on exertion over the past couple of months. She denied angina, palpitations, syncope or any other associated symptoms and did not have any cardiovascular disease risk factors. On examination, she was stable and in no distress. Her blood pressure was 148/66 mmHg with a regular pulse of 48 beats per minute. She had no clinical evidence of heart failure on cardiovascular examination but was found to have an S4 on auscultation and cannon A waves on assessment of her jugular venous pressure (JVP). Her exam was otherwise unremarkable. Twelve-lead electrocardiogram during the clinic visit revealed complete heart block with a junctional escape rhythm at 49 beats per minute with right bundle branch block morphology; her 12-lead electrocardiogram 3 months earlier also revealed evidence of underlying conduction disease with a prolonged PR interval and right bundle branch block while in sinus rhythm. Trans-thoracic echocardiography displayed normal left ventricular size and function with mild degenerative changes of the mitral and aortic valves consistent with age related changes. There was no laboratory evidence of any metabolic or ischemic etiologies for the conduction disease. Given her age, clinical presentation, underlying conduction disease in the setting of no significant structural abnormalities on echocardiography, and lack of significant comorbidities, the patient likely had age related degenerative conduction disease. Significant coronary artery disease could not be excluded but was very unlikely given the lack of ischemic symptoms and cardiovascular disease risk factors along with normal cardiac size and function. She was arranged to have a permanent pacemaker implant for the symptomatic complete heart block and will have further risk stratification for possible coronary artery disease following the pacemaker implantation.The patient was brought to the operating theater following informed consent. Initial venous access and lead implantation was attempted across the left cephalic vein but aborted due to difficulty in delivering the pacing lead into the right ventricular (RV) cavity; the venous trajectory was that of a persistent left superior vena cava (SVC) draining directly into the coronary sinus. Right cephalic venous access was subsequently obtained and to our surprise there was an anomalous venous trajectory on the right implantation side as well (Figure ); on intra-operative venography is was evident that the right brachiocephalic vein drained directly into the left persistent SVC as the patient had an absent right SVC (Figure ). Steering the right atrial (RA) pacing lead into the RA cavity was not very difficult however positioning it in the right atrial appendage required careful manipulation. Once in the RA cavity, the straight stylet of the RA pacing lead was exchanged for the curved “J” stylet and clock-wise torque was applied during further advancement of the lead to direct it anteriorly in the optimal atrial appendage position (Figure ). Positioning the RV pacing lead was a challenge since the pacing lead was gaining atrial access across the coronary sinus (CS) OS which is located very close to the RV inlet however the CS OS directs the lead away from the RV inlet towards the lateral free wall of the RA. We were able to redirect the RV pacing lead into the RV by reflecting its tip off the RA free wall thus looping the lead around into the RA and back into the RV (Figure ); in order to reflect the tip of the RV pacing lead off the RA free wall it is very important to withdraw the straight lead stylet back a few centimeters to ensure the tip of the lead is no longer stiff and thus reduce the risk of atrial perforation. Once across the tricuspid valve, the straight stylet can be advanced further if necessary to guide the pacing lead to the RV apex. Alternative methods that could be attempted to direct the RV pacing lead into the RV cavity in such complex anomalous venous anatomy includes adding significant distal curve to the lead stylet or using one of the curved long venous access sheaths that are typically used for CS OS canulation during cardiac-resynchronization therapy device implantation.\nFollowing pacemaker implantation, the patient was monitored overnight in the cardiac telemetry unit and discharged home the following day. Her symptoms of fatigue and dyspnea on exertion resolved following device implant.\nIn this case report, we document our pacemaker implantation technique in a patient with a very rare venous anomaly involving an absent right and persistent left superior vena cava.\nVenous anomalies of the thorax can occur in isolation or association with congenital heart disease (CHD). A persistent left SVC (Figure ) can be identified incidentally in 0.5% of the general population and 4% of patients with CHD. Typically when present the left SVC is alongside a smaller caliber right SVC and the left SVC is usually not associated with a brachiocephalic vein. In the incidental and benign setting, the left SVC drains directly into the coronary sinus; when draining directly into the left atrium, the persistent left SVC is usually associated with CHD with the most common being atrial septal defects and coarctation of the aorta [,].\nAnomalies of the right SVC can include drainage to the left atrium, low right atrial insertion, aneurysmal dilatation, and anomalous left brachiocephalic vein drainage to the right SVC []. Persistent left SVC with an absent right SVC is very uncommon in the general population and occurs in 0.07 to 0.13% of patients who have CHD with viscera-atrial situs solitus [].\nLong-term prognosis in abnormal SVC development is good in the absence associated CHD []. Venous anomalies however can make central venous access and in particular pacemaker lead implantation very challenging; this includes single and dual pacemaker implantation along with cardiac resynchronization therapy whereby the insertion of any lead (atrial, ventricular, or coronary sinus leads) would be challenging due to the unfamiliar venous course which does not conform with the pre-formed shapes of the venous access tools utilized during these procedures. These venous anomalies can also cause procedural challenges in any other types of thoracic and cardiac surgeries especially if the physician is not familiar with the course of the venous anomaly at hand along with other associated congenital abnormalities. Pre-operative imaging with venography, magnetic resonance imaging, computed tomography, or agitated-saline contrast echocardiography can help identify cases of challenging venous anatomy allowing appropriate operative planning; careful patient selection is warranted given the risk of contrast nephrotoxicity.\nThe pacemaker lead implantation techniques we described above to overcome the challenges of this particular anomalous venous drainage case may not apply or be effective in all patients with similar or differing anatomy. It is therefore essential to evaluate the underlying venous anatomy at hand objectively using intra-operative venography or pre-operative imaging if possible when an anomalous anatomy is suspected. Once the anatomy is clarified, the technique that is the safest and least invasive for a particular scenario should be attempted first. Failure to implant pacing leads intravenously may warrant consideration for surgical epicardial lead implantation. In the setting of failed endocardial defibrillator lead implantation attempts, subcutaneous defibrillators can also be considered.

An 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. , , and ). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.\nThe patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transverse fashion in the right lower quadrant through the rectus sheath, and the peritoneum entered. The appendix was clearly visualized exiting the abdominal cavity into the inguinal defect. The appendix and its adhered omentum were then carefully reduced back into the abdominal cavity using intraperitoneal countertension without any rupture or spillage. Due to its densely adherent chronic inflammatory tissue, an incidental appendectomy was performed as there was significant tension on the cecum after placing the appendix back in its anatomical location. There was concern for the development of appendicitis post operatively due to the manipulation performed during the procedure. The appendix was then stapled at its base using a standard gastrointestinal anastomosis stapler and passed off the field. The indirect hernia defect was very small and closed with a medium size lightweight mesh plug. The patient was discharged from the post-anesthesia care unit the same day as surgery and had no complications from his recovery course. No additional antibiotics were given other than a single prophylactic dose during the surgical case. At his 2-week follow-up, he had no recurrence of his hernia and was doing well. On pathologic examination, there was no evidence of appendiceal inflammation or appendicitis. The periappendiceal fat did exhibit some fat necrosis, however, supporting the chronic periappendiceal adhesive changes.

A 43-year-old man presented with a progressive deterioration of visual function for the previous seven years. The patient had no other ocular symptoms such as nystagmus or photophobia. His past history showed stable vision of 20 / 40 since trauma to his right eye when he was approximately 14 years of age. No other systemic abnormalities or malformations were recorded. His best-corrected vision was 20 / 400 in the right eye and 20 / 20 in the left, and his intraocular pressures were 25 mmHg in the right eye and 23 mmHg in the left eye at the time of his initial visit. Under slit lamp examination, a diffuse haze composed of a flaky pattern of stroma was noted throughout the entire cornea. The right eye had decreased vision and exhibited relatively denser homogenous opacities than the left ().\nThe family members stated that corneal changes had been detected only in the patient's mother at 69 years of age, and no specific issues had arisen in any other family member or relative. The patient's father had reported no ophthalmic abnormalities before his death, and his mother had been diagnosed with diffuse corneal opacities of unknown etiology in both eyes three years previously (). She explained that she had experienced decreased vision since childhood, but these deficiencies produced no difficulties in her daily life. The patient's brother and sister had no symptoms at all and no ophthalmic or systemic abnormalities. As far as the family knew, no one in the paternal or maternal lineage or offspring of the patient had experienced any eye problems except for the patient's mother ().\nThe endothelium and Descemet's membrane of the right eye were identified as normal following slit lamp examination. No gross abnormalities, such as Haab's striae or features of posterior polymorphous corneal dystrophy, were detected in the right eye. The patient's past medical records from another hospital demonstrated that his endothelial cells of both eyes presented with a normal shape and numbers under a specular microscope about six years ago. However, endothelial cells were found as indeterminate forms using specular microscopy due to the barrier of stromal opacity at the time of our study. The endothelial cells of the left eye were counted using a Konan Noncon Robo-8400 noncontact specular microscope (Konan Medical Inc., Hyogo, Japan) as 2564 cells/m2. We assumed that the right eye would have a similar amount of endothelial cells and a relatively uniform morphologic pattern as those of the left.\nUltrasound corneal pachymetry (Humphrey Instruments Inc., San Leandro, CA, USA) revealed a central corneal thickness of 658 µm in the right eye and 632 µm in the left. The patient was suspicious for CHSD based upon clinical evidence, and he was scheduled for penetrating keratoplasty of the right eye. A corneal button was sent for light and electron microscopic analysis. There was no problem with corneal wound healing after keratoplasty, and the grafted cornea restored its transparency within two weeks. After 12 months, the corneal graft remained clear, and the patient's best-corrected visual acuity was 20 / 50 in the right eye.\nLight microscopy with hemotoxylin and eosin staining revealed a normal epithelium and uninterrupted Bowman's membrane. The stromal lamellae were separated slightly from one another, forming a relatively compact space in between the anterior and the posterior stroma (). No Descemet's membrane or endothelium was detected in the original corneal button, apparently as the result of inappropriate specimen handling. Any infiltration, vessels, inflammatory, or storage material could not be detected.\nElectron microscopy revealed a criss-crossing pattern of corneal collagen fibers with a relatively electron dense and lucent structure and collagen fibers irregular in shape and size (). Keratocytes extended widely through the zone of low filaments ().\nBlood was sampled from the patient and family members for DNA collection and analysis []. DNA sequencing analysis of the decorin gene in chromosome 12q22 was positive in both the patient and his mother. The novel mutation of a heterozygous, nucleoside substitution (c.1036T>G) point mutation in the decorin gene was detected in both patients (). Lumican and keratocan sequence variants, which are closely located within the decorin gene, did not reveal any mutations. The c.1036T>G mutation resulted in a change of amino acid sequence (p.Cys346Gly). However, no genetic mutations were detected in other family members.

As home care doctors and general practitioners, we encountered a 37-year-old woman with ASD who lived with her parents in Japan. Her mother had end-stage breast cancer. We visited her house regularly to care for her mother. The woman with ASD was the main caregiver and a key person for her mother because her father was visually impaired. There were some obstacles we need to overcome together, but in the end, she was able to fulfill the role of the main caregiver for her mother.\nWhen we started home care for the mother, we did not have any knowledge that the daughter was a person with ASD. However, we occasionally heard about her from home visit nurses and home care staff because they worried about whether the mother could continue to stay at home due to the lack of care provided by family members. According to home care staff members, the woman with ASD was usually not present when the home care staff visited the home for her mother's care. They could not contact her or talk with her about her mother's condition. She focused on dishwashing and did not appear concerned about how her mother's medications or clothes were organized or whether the room was clean or not. She could not communicate well with home care staff even when she talked with them. Thus, we did not initially recognize that she was a person with ASD or another developmental disorder. We were wondering why she was having trouble managing the home care schedule and chores even though she worked as an engineer. The home care staff's distrust of the daughter caused irritation and stress in the daughter and the home care staff.\nAfter a few home care visits, with the daughter's consent, the mother's care manager informed us that she had been diagnosed with ASD in adulthood. Her parents had not been informed of the diagnosis. The daughter did not want to let her parents know about the diagnosis. The home care staff started to feel strongly that it was too difficult for the daughter to continue home care for the mother. The woman with ASD also felt difficulties in communicating with staff and understanding how her mother felt or how it feels to be severely ill. Therefore, we initiated consultation and social skill training in our outpatient clinic for the daughter. We discussed the traits of ASD as well as solutions or strategies to manage ASD traits in the home care setting. When we gave her instructions, we tried to make them more specific and provided examples so that she could understand them easily. For example, we suggested that she needed to come into her mother's room to share her mother's condition when the home care staff made a visit.\nAfter several consultations, she gradually obtained life skills in communication, scheduling, and managing things related to home care, such as expectations during home care staff visits or what she should do for her mother. Her psychological stress and caregiving burden decreased day by day. We also shared the fact that she was diagnosed with ASD with home care staff as well as appropriate attitudes, support, and communication styles. We shared her behavioral characteristics with staff, such as lower interest in sharing emotions with others or having difficulties in understanding social cues such as eye contact, facial expressions, and metaphors.\nFive months after the start of home-based care, her mother's condition worsened temporarily. The woman with ASD could not understand her mother's discomfort or pain and her father's sadness and serious feelings about the poor prognosis of his wife. She could not understand why her father was at a loss for words upon hearing the doctor's explanation of her mother's severe condition. Therefore, she asked him “Didn't you hear, Dad?” in a loud voice. These types of reactions by the daughter interfered with her father's acceptance of her mother's condition and he was unable to continue to listen the explanation. After this event, we explained why her father become silent while during the explanation of her mother's condition. We made a rule that we will tell her beforehand what we would say and how she should act when we share bad news. For example, we told her beforehand that we were going to tell her father about her mother's poor condition and prognosis and asked her to listen until we finished. We also told her how her father would react and our guess of the reasons for his reaction. Inappropriate behavior that is not suitable for the situation decreased afterward. She also felt relieved that she knew what she should do and could support her father as much as possible.\nSeven months after the start of home-based care, the mother passed away at home as her mother and she herself hoped. When her mother needed to use oral opioids and subcutaneous injection of opioids, the woman with ASD was able to communicate with homecare staff and ask for help to offer better care for her mother. Her mother died peacefully without any severe pain or discomfort. The woman with ASD did not become confused and was able to accept her mother's death peacefully with her father.

As home care doctors and general practitioners, we encountered a 37-year-old woman with ASD who lived with her parents in Japan. Her mother had end-stage breast cancer. We visited her house regularly to care for her mother. The woman with ASD was the main caregiver and a key person for her mother because her father was visually impaired. There were some obstacles we need to overcome together, but in the end, she was able to fulfill the role of the main caregiver for her mother.\nWhen we started home care for the mother, we did not have any knowledge that the daughter was a person with ASD. However, we occasionally heard about her from home visit nurses and home care staff because they worried about whether the mother could continue to stay at home due to the lack of care provided by family members. According to home care staff members, the woman with ASD was usually not present when the home care staff visited the home for her mother's care. They could not contact her or talk with her about her mother's condition. She focused on dishwashing and did not appear concerned about how her mother's medications or clothes were organized or whether the room was clean or not. She could not communicate well with home care staff even when she talked with them. Thus, we did not initially recognize that she was a person with ASD or another developmental disorder. We were wondering why she was having trouble managing the home care schedule and chores even though she worked as an engineer. The home care staff's distrust of the daughter caused irritation and stress in the daughter and the home care staff.\nAfter a few home care visits, with the daughter's consent, the mother's care manager informed us that she had been diagnosed with ASD in adulthood. Her parents had not been informed of the diagnosis. The daughter did not want to let her parents know about the diagnosis. The home care staff started to feel strongly that it was too difficult for the daughter to continue home care for the mother. The woman with ASD also felt difficulties in communicating with staff and understanding how her mother felt or how it feels to be severely ill. Therefore, we initiated consultation and social skill training in our outpatient clinic for the daughter. We discussed the traits of ASD as well as solutions or strategies to manage ASD traits in the home care setting. When we gave her instructions, we tried to make them more specific and provided examples so that she could understand them easily. For example, we suggested that she needed to come into her mother's room to share her mother's condition when the home care staff made a visit.\nAfter several consultations, she gradually obtained life skills in communication, scheduling, and managing things related to home care, such as expectations during home care staff visits or what she should do for her mother. Her psychological stress and caregiving burden decreased day by day. We also shared the fact that she was diagnosed with ASD with home care staff as well as appropriate attitudes, support, and communication styles. We shared her behavioral characteristics with staff, such as lower interest in sharing emotions with others or having difficulties in understanding social cues such as eye contact, facial expressions, and metaphors.\nFive months after the start of home-based care, her mother's condition worsened temporarily. The woman with ASD could not understand her mother's discomfort or pain and her father's sadness and serious feelings about the poor prognosis of his wife. She could not understand why her father was at a loss for words upon hearing the doctor's explanation of her mother's severe condition. Therefore, she asked him “Didn't you hear, Dad?” in a loud voice. These types of reactions by the daughter interfered with her father's acceptance of her mother's condition and he was unable to continue to listen the explanation. After this event, we explained why her father become silent while during the explanation of her mother's condition. We made a rule that we will tell her beforehand what we would say and how she should act when we share bad news. For example, we told her beforehand that we were going to tell her father about her mother's poor condition and prognosis and asked her to listen until we finished. We also told her how her father would react and our guess of the reasons for his reaction. Inappropriate behavior that is not suitable for the situation decreased afterward. She also felt relieved that she knew what she should do and could support her father as much as possible.\nSeven months after the start of home-based care, the mother passed away at home as her mother and she herself hoped. When her mother needed to use oral opioids and subcutaneous injection of opioids, the woman with ASD was able to communicate with homecare staff and ask for help to offer better care for her mother. Her mother died peacefully without any severe pain or discomfort. The woman with ASD did not become confused and was able to accept her mother's death peacefully with her father.

A 81-year old woman was referred to our department to evaluate a wound dehiscence on her left knee with hardware exposure. The patient did not have any relevant comorbidities and her general status was good. The patient underwent a total left hip arthroplasty at the age of seventy four due to severe osteoarthritis pain that hindered baseline activities. Eight years later, the patient presented to the orthopedics department with a progressive pain in the affected hip, particularly when walking, causing difficulties in deambulation.\nAn X ray examination revealed an extensive femoral bone loss with displacement of the femoral component, and an MRI showed a femoral pseudo-tumor (bone proliferation). With this finding, a revision total hip arthroplasty was performed with the insertion of a reconstruction ring with cemented dual mobility cups. Three weeks after this last surgery, the patient started with early symptoms of infection (high fever, suppuration, no wound healing and laboratory abnormalities); an attempt at conservative management with intravenous antibiotic, irrigation and suction drainages was unsuccessful and a replacement of the endoprosthesis femur in two stages was planned.\nIn the first stage, the previous prosthesis was removed with enlarged osteotomy of the anterior tuberosity and a cement spacer with antibiotic was placed. Two months later, the spacer was removed and a new coated silver total femoral prosthesis was placed. The patient was referred to our unit four weeks after the last surgery for the assessment of wound dehiscence to the lateral knee with hardware exposure. The patient was taken to the operating room for retention debridement and wound coverage with a flap. Our first decision was to cover the defect with a lateral gastrocnemius flap, however, the surrounding area was highly scarred, and the gastrocnemius muscle was found to be very atrophic and no suitable to fit the large defect. shows no other local flaps to be large enough to cover the whole defect, so we opted for a free flap.\nA lack of receptor vessels was evidenced, descending genicular artery was dissected, but small caliber and calcified plaques in the lumen discarded this option. With the need of a suitable and large vessel close to the defect, we opted for an AV loop that was constructed with ipsilateral greater saphenous vein. The femoral artery was found to be very atherosclerotic, but a healthy segment free of calcific plaque on the middle third of the vessel was used to perform the anastomosis of the vein graft in end-to-side fashion ().\nA latissimus dorsi musculocutaneous flap with a large skin paddle was transferred to the lateral knee defect, and the thoracodorsal artery and vein were anastomosed in an end to end fashion to the limbs of the loop. The flap was properly inset to provide adequate bulk and to avoid dead spaces (). Donor site was closed primarily. Intraoperatively, no incidences occurred and the flap appeared well perfused. The patient was extubated and transferred to the recovery room in stable condition with standard clinical monitoring. Tissue oximetry system (INVOS CO.) was used 72 hours after the surgery. Three drainages were left, two of them in lower limb placed in lateral knee and lateral hip and one in donor area of the flap. Drainages were retained until output was less than 30 ml per day.\nWound healing properly evolved as well as the patient started rehabilitation during admission. The patient received Daptomycin (700 mg/d iv) and fosfomycin (2 g/6h iv) during 6 weeks, according to the infectious medicine protocol. The patient started walking uneventfully with a walking frame one month after surgery. The patient was enrolled in an outpatient rehabilitation program with close monitoring. At present time, the patient is able to ambulance without the need of assistant devices and there are no signsor symptoms of infection recurrence.

This is a 39-year-old male with a past medical history of coronary artery disease requiring coronary artery bypass graft in 2009 and percutaneous coronary intervention and stenting in 2008 to the left anterior descending artery and right coronary artery. Patient also has hypercholesterolemia and hypothyroidism. He presented to the emergency department complaining of substernal chest pain associated with dizziness and shortness of breath. This occurred once to two times a week. His last stress test was in 2013 which was insignificant. One month ago he saw his cardiologist who recommended using nitroglycerin more frequently. His chest pain initially improved but for the past week his pain was increasing in severity and radiating to the left shoulder. Patient denied any nausea, vomiting, sweating, or loss of consciousness. The chest pain was not aggravated or alleviated by position or medication. Vital signs were within normal limits. Physical examination was normal including cardiac and neurological exam. The patient was seen by the cardiac team and was scheduled for a cardiac catheterization.\nA cardiac catheterization was performed which did not show any narrowing or disease of vessels. His ejection fraction was 65% and the previous grafts and stent were patent. The cardiac team cleared the patient for discharge. The patient was scheduled for discharge, however he suddenly developed left-sided weakness and facial droop. NIH stroke scale was 9. The rapid response team was called and the patient underwent a CT scan with no contrast which showed no evidence of any acute or significant intracranial abnormality and no bleeding. Patient was transferred to the ICU and the neurology team was consulted. Neurology recommended the use of tPA as the patient was within the window period for use. While reviewing the guidelines and contraindications, it was discovered that the patient's aPTT was higher than the upper normal limit due to the recent use of unfractionated heparin for cardiac catheterization. At this time, the primary team made the decision to recheck the aPTT after one hour since the patient was still within the therapeutic window for tPA. The repeat aPTT was reported in the normal range, making the patient eligible for thrombolysis. The patient tolerated this intervention well and hemoglobin remained stable throughout hospital course. MRI was done 24 hours after the intervention showed evidence of acute ischemic changes involving the right anterior parietal lobe in the region of the right postcentral gyrus. On discharge, the patient's left-sided weakness and facial droop improved significantly. His NIH stroke scale was only 1 on discharge. The patient was discharged home in stable condition on aspirin and statin, as per neurology recommendations with close follow-up as an outpatient.

A 40-year-old dominant right-handed male working in private insurance company with no significant medical history suffered a distal radius fracture of the left hand due to road traffic accident (). On clinical examination, he could move the fingers of the hand and there was no evidence of any neurovascular deficit distal to the injury. Crepitus could be felt in the distal part of the radius just proximal to wrist joint and movements around the wrist were painful and limited. There were no other associated injuries, and medical history was not significant for any medical illness. A clinical diagnosis of the fracture of lower end radius was made and radiographs were consistent with the clinical diagnosis. Radiographs showed a comminuted fracture of the distal third radius with intra-articular extension for which open reduction and internal fixation through a volar FCR approach was planned. He underwent the definitive treatment of open reduction and internal fixation of the fractures distal radius under regional anesthesia. We had planned to fix the distal radius fracture using the usual FCR approach using 3.5 mm distal end radius locking plate. We could not identify the absence of the FCR tendon preoperatively because of severe swelling of the distal forearm. The incision was made at its usual location and we identified one tendon in the superficial plane which we thought was FCR, but when we traced the tendon proximally it started thinning without any muscle belly and when traced distally to its attachment, it was confirmed to be tendon of palmaris longus (PL). We could not find any tendon between PL and the traced radial artery. At that stage, we realized that FCRL was absent in that patient. We wrongly identified the PL tendon as the FCR because it was the tendinous structure at the most radial location of the volar distal forearm. When we found the median nerve just radial to the PL tendon, we were then able to identify the anatomical abnormality described in this case and immediate post-operative X-ray (-). Therefore, we changed the approach to the classic Henry’s approach after we had identified and gently protected the PCB. When we exposed and protected the radial artery through the same incision, we exposed the flexor pollicis longus (FPL), this must be retracted ulnarly, after the FPL is bluntly retracted, the pronator quadratus (PQ) is seen and incise the radial and distal borders of the PQ, elevating the muscle off the volar radius and fixed the fracture rigidly using a 3.5 mm distal end radius locking plate Nebula (stainless steel), Amritsar, Punjab, India.\nFour months after the operation, the patient had no pain or neurologic problems and complete bone union of the distal radius fracture. The patient returned to his work without any disability. We checked for the existence of an FCR tendon in the opposite forearm and could identify the thick FCR tendon by palpation.

A fourty-year-old man with DEB diagnosed at the age of eight was admitted to the department of gastroenterology because of the dysphagia for two previous months. The diagnosis of DEB was established due to the presence of single blisters on the whole body since the sixth month of life. His sister was also diagnosed with DEB and had similar symptoms of the disease. To our knowledge, the presented patient and his sister are the oldest diagnosed with EB living in Poland. At the age of four the patient started experiencing heartburn occasionally. Five years later dysphagia appeared for the first time. It was an episodal and periodical ailment. He reported a deterioration of dysphagia at the age of nineteen; he mostly consumed liquids and soft consistency meals during that time. Nonetheless, the patient admitted that this esophageal discomfort still was not a constant one and there were time intervals without this ailment. In the past there were also episodes of mild esophageal bleeding. The only one endoscopic esophageal dilatation in this patient took place in 1997; a stenosis was located then approximately 18 cm from incisors. The performed procedure ameliorated swallowing difficulty. A barium swallow test obtained one year after the endoscopic dilatation of the esophagus also revealed esophageal constriction on the same level. In 2014 the patient was diagnosed because of hematochezia and pain in hypogastrium. Tissue samples obtained in colonoscopy revealed the presence of nonspecific inflammatory infiltration in the ascending colon and terminal part of the ileum. Interestingly, 3 years ago he complained of hemoptysis and there was a suspicion of bleeding to pulmonary alveoli in the course of DEB. However, a CT scan did not confirm bleeding. On admission to our department the patient was complaining of painful swallowing of solids. Two months earlier he was diagnosed in the cardiology unit because of the chest pain and elevated level of troponin I. An electrocardiogram did not show any abnormalities. The patient refused to undergo coronarography and no more cardiological diagnostic procedures were performed Additional file . On admission to our unit he did not complain of the chest pain. On physical examination he appeared comfortable, afebrile with pulse 90 beats per minute, blood pressure 125/90 mmHg, respiratory rate 19 per minute and the body mass index (BMI) was 24.7 kg/m2. The patient presented blisters, skin reddening and crust formation on the upper and lower limbs. There were also contractures and disabled movement in his hand joints together with a loss of a finger and toenails (Fig. ). The apex of the tongue and left palatine arch were covered by superficial ulcerations. During his hospital stay, performed laboratory tests did not reveal any abnormalities. A CT scan of the chest and abdomen showed a thickening of the esophageal wall at maximum to 7 mm on the level from the fourth cervical vertebra to the fourth thoracic vertebra (Fig. ). A probe of gastroscopy under sedation with benzodiazepine failed due to an esophageal stenosis. An attempt of examination with paediatric endoscope was also unsuccessful. A barium swallow test revealed a narrowing of upper esophageal lumen to 7 mm along the length of 4 cm together with two diverticula on the right side not emptying of contrast. During swallowing other two diverticula appeared which were emptying of contrast (Fig. ). A barium swallow test also showed a noticeable weakening of the esophageal mucous membrane. After the performed investigation the patient was qualified to endoscopic dilatation of esophageal stenosis and endoscopic management of diverticula. However, he did not agree to undergo this procedure during current hospital stay. In our unit the patient was treated with proton pump inhibitor (PPI) and prokinetic drugs administered intravenously, which caused an amelioration of esophageal discomfort. He was discharged in a good general condition with a recommendation of a diet based on soft consistency meals, oral PPI and prokinetic drugs administration and the next follow-up in a month.

An 88-year-old man was transferred from a referring hospital for descending thoracic aortic injury after attempted pacemaker placement; 3 days prior he was admitted with a transient ischemic attack. He had new onset atrial fibrillation and sinus bradycardia that prompted pacemaker placement. Left subclavian access was attempted after a pocket was created. After placement of a five French sheath, arterial blood return was noted. The sheath was left in place and the procedure was aborted. The patient was hemodynamically stable and taken to computed tomography (CT) scanner for evaluation of arterial injury. The CT scan revealed direct cannulation of the aortic knob with the sheath. The patient was directly transferred by helicopter to our institution for higher level of vascular surgery care. The patient arrived intubated and sedated with the sheath in place in the left chest covered with a dressing and a left chest tube in place with 100cc of sanguinous output.\nThe patient was taken to the hybrid operating room in our facility. Bilateral percutaneous femoral access was obtained and a five French sheath was placed in the right common femoral artery, and initially, a seven French sheath was placed in the left common femoral artery. We placed two proglide devices in the left access in standard preclose technique as this was our anticipated side of device deployment. At this point, a pigtail catheter was advanced into the ascending aorta and an arch aortogram was performed which demonstrated a direct cannulation of the aortic knob (). We elected to proceed to with stent graft placement to manage this injury as the patient’s comorbidities and advanced age were prohibitive risks for open repair. Prior to the placement of an endoprosthesis, a cerebral angiogram was performed to identify cerebrovascular dominance. This demonstrated a dominant right vertebral artery and left vertebral atresia. There was adequate distance from the site of sheath insertion to the left subclavian artery, such that we felt we could achieve a seal without covering the left subclavian artery. Based on our preoperative measurement of our anticipated proximal and distal seal zones, the aortic diameter was 32 mm. Therefore, we selected a 36 mm × 160 mm Valiant thoracic aortic stent graft (Medtronic, Santa Rosa, CA) and advanced and deployed the device distal to the origin of the left subclavian artery. The sheath was removed from the aorta and the device was deployed simultaneously. Angioplasty was then performed with a Coda compliant balloon. Repeat arch and thoracic angiography revealed successful sealing of the injury site and no evidence of extravasation. Additionally, the left subclavian remained patent (). We removed the 24 French sheath from the left femoral access and successfully closed the arteriotomy with the proglide devices. The right groin access was managed with direct pressure. The patient had an uneventful post-operative course. The chest tube output was minimal and serous the remainder of his hospitalization and was removed on post-operative day 4. He was discharged to home on post-operative day 5 ().

A 40-year-old Asian woman who had been in her usual state of good health was incidentally found to have a small nodule in the lower lobe of her right lung during a regular medical checkup. The patient was seen in the department of medicine of our hospital for further evaluation. The patient’s family history was noncontributory, and a physical examination revealed no abnormalities. The results of laboratory studies were either within normal limits or negative. A computed tomographic (CT) scan revealed a lytic lesion of the fifth lumbar vertebral bone, as well as a small nodule (1.2 cm in diameter) in the lower lobe of the right lung (Fig. ). The vertebral lesion was situated on the left transverse process and was separated from the spinal canal (Fig. ). Biopsy specimens of both lesions were histologically similar and showed spindle cell neoplasms with a bland appearance; however, we could not make a definitive diagnosis, owing to the small size of the samples. The patient was placed under close observation with suspicion of multiple metastases from an unknown primary tumor.\nFive years later, a CT scan indicated that the pulmonary nodule had slightly increased in size. Magnetic resonance (MR) imaging also revealed an increase in the size of the lytic lesion in the left transverse process of the fifth lumbar vertebra. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery for the pulmonary lesion and curettage of the lytic bone lesion were performed. The orthopedic surgeons found that the tumor of the fifth left transverse process was exposed on the posterior surface but not on the anterior surface. They also found that the vertebral lesion was completely confined within the vertebral bone and was not connected to the spinal canal. During the clinical course (105 months), no significant findings other than the pulmonary and vertebral lesions were found, even with imaging examinations, including CT and MR imaging. The patient made good postoperative progress and remained free of disease at 41 months after the operation.\nThe resected specimen of the lung contained a well-circumscribed solid lesion 13 mm in diameter. It was composed of fascicular architecture of bland spindle or polygonal cells (Fig. ). Neither necrotic foci nor mitotic figures were observed. The tumor was immunopositive for epithelial membrane antigen (Fig. ), D2-40, progesterone receptor, vimentin, and S100 but negative for alpha-smooth muscle actin. Although curettage specimens from the vertebral bone were fragmented, the morphological and immunohistochemical findings were identical to those of the pulmonary lesion (Fig. ). The tumor was shown to be a transitional meningioma on histological examination, including immunohistochemical analyses (Table ).

A 81-year old woman was referred to our department to evaluate a wound dehiscence on her left knee with hardware exposure. The patient did not have any relevant comorbidities and her general status was good. The patient underwent a total left hip arthroplasty at the age of seventy four due to severe osteoarthritis pain that hindered baseline activities. Eight years later, the patient presented to the orthopedics department with a progressive pain in the affected hip, particularly when walking, causing difficulties in deambulation.\nAn X ray examination revealed an extensive femoral bone loss with displacement of the femoral component, and an MRI showed a femoral pseudo-tumor (bone proliferation). With this finding, a revision total hip arthroplasty was performed with the insertion of a reconstruction ring with cemented dual mobility cups. Three weeks after this last surgery, the patient started with early symptoms of infection (high fever, suppuration, no wound healing and laboratory abnormalities); an attempt at conservative management with intravenous antibiotic, irrigation and suction drainages was unsuccessful and a replacement of the endoprosthesis femur in two stages was planned.\nIn the first stage, the previous prosthesis was removed with enlarged osteotomy of the anterior tuberosity and a cement spacer with antibiotic was placed. Two months later, the spacer was removed and a new coated silver total femoral prosthesis was placed. The patient was referred to our unit four weeks after the last surgery for the assessment of wound dehiscence to the lateral knee with hardware exposure. The patient was taken to the operating room for retention debridement and wound coverage with a flap. Our first decision was to cover the defect with a lateral gastrocnemius flap, however, the surrounding area was highly scarred, and the gastrocnemius muscle was found to be very atrophic and no suitable to fit the large defect. shows no other local flaps to be large enough to cover the whole defect, so we opted for a free flap.\nA lack of receptor vessels was evidenced, descending genicular artery was dissected, but small caliber and calcified plaques in the lumen discarded this option. With the need of a suitable and large vessel close to the defect, we opted for an AV loop that was constructed with ipsilateral greater saphenous vein. The femoral artery was found to be very atherosclerotic, but a healthy segment free of calcific plaque on the middle third of the vessel was used to perform the anastomosis of the vein graft in end-to-side fashion ().\nA latissimus dorsi musculocutaneous flap with a large skin paddle was transferred to the lateral knee defect, and the thoracodorsal artery and vein were anastomosed in an end to end fashion to the limbs of the loop. The flap was properly inset to provide adequate bulk and to avoid dead spaces (). Donor site was closed primarily. Intraoperatively, no incidences occurred and the flap appeared well perfused. The patient was extubated and transferred to the recovery room in stable condition with standard clinical monitoring. Tissue oximetry system (INVOS CO.) was used 72 hours after the surgery. Three drainages were left, two of them in lower limb placed in lateral knee and lateral hip and one in donor area of the flap. Drainages were retained until output was less than 30 ml per day.\nWound healing properly evolved as well as the patient started rehabilitation during admission. The patient received Daptomycin (700 mg/d iv) and fosfomycin (2 g/6h iv) during 6 weeks, according to the infectious medicine protocol. The patient started walking uneventfully with a walking frame one month after surgery. The patient was enrolled in an outpatient rehabilitation program with close monitoring. At present time, the patient is able to ambulance without the need of assistant devices and there are no signsor symptoms of infection recurrence.

A 81-year old woman was referred to our department to evaluate a wound dehiscence on her left knee with hardware exposure. The patient did not have any relevant comorbidities and her general status was good. The patient underwent a total left hip arthroplasty at the age of seventy four due to severe osteoarthritis pain that hindered baseline activities. Eight years later, the patient presented to the orthopedics department with a progressive pain in the affected hip, particularly when walking, causing difficulties in deambulation.\nAn X ray examination revealed an extensive femoral bone loss with displacement of the femoral component, and an MRI showed a femoral pseudo-tumor (bone proliferation). With this finding, a revision total hip arthroplasty was performed with the insertion of a reconstruction ring with cemented dual mobility cups. Three weeks after this last surgery, the patient started with early symptoms of infection (high fever, suppuration, no wound healing and laboratory abnormalities); an attempt at conservative management with intravenous antibiotic, irrigation and suction drainages was unsuccessful and a replacement of the endoprosthesis femur in two stages was planned.\nIn the first stage, the previous prosthesis was removed with enlarged osteotomy of the anterior tuberosity and a cement spacer with antibiotic was placed. Two months later, the spacer was removed and a new coated silver total femoral prosthesis was placed. The patient was referred to our unit four weeks after the last surgery for the assessment of wound dehiscence to the lateral knee with hardware exposure. The patient was taken to the operating room for retention debridement and wound coverage with a flap. Our first decision was to cover the defect with a lateral gastrocnemius flap, however, the surrounding area was highly scarred, and the gastrocnemius muscle was found to be very atrophic and no suitable to fit the large defect. shows no other local flaps to be large enough to cover the whole defect, so we opted for a free flap.\nA lack of receptor vessels was evidenced, descending genicular artery was dissected, but small caliber and calcified plaques in the lumen discarded this option. With the need of a suitable and large vessel close to the defect, we opted for an AV loop that was constructed with ipsilateral greater saphenous vein. The femoral artery was found to be very atherosclerotic, but a healthy segment free of calcific plaque on the middle third of the vessel was used to perform the anastomosis of the vein graft in end-to-side fashion ().\nA latissimus dorsi musculocutaneous flap with a large skin paddle was transferred to the lateral knee defect, and the thoracodorsal artery and vein were anastomosed in an end to end fashion to the limbs of the loop. The flap was properly inset to provide adequate bulk and to avoid dead spaces (). Donor site was closed primarily. Intraoperatively, no incidences occurred and the flap appeared well perfused. The patient was extubated and transferred to the recovery room in stable condition with standard clinical monitoring. Tissue oximetry system (INVOS CO.) was used 72 hours after the surgery. Three drainages were left, two of them in lower limb placed in lateral knee and lateral hip and one in donor area of the flap. Drainages were retained until output was less than 30 ml per day.\nWound healing properly evolved as well as the patient started rehabilitation during admission. The patient received Daptomycin (700 mg/d iv) and fosfomycin (2 g/6h iv) during 6 weeks, according to the infectious medicine protocol. The patient started walking uneventfully with a walking frame one month after surgery. The patient was enrolled in an outpatient rehabilitation program with close monitoring. At present time, the patient is able to ambulance without the need of assistant devices and there are no signsor symptoms of infection recurrence.

A 84-year-old female was scheduled for bilateral total hip replacement due to osteoarthritis of both hips (). Medical history included chronic Hepatitis C virus infection with no other medical conditions reported. The patient was allowed to decide which hip would be performed first. 5 months after scheduling, the patient was admitted for surgery arriving in a wheelchair, and new pelvis radiographs were taken (). Other causes of the rapid destruction of the hip joint were ruled out, and the patient was diagnosed of bilateral RDO. Keeping in mind a possible septic etiology, despite there was no history of septicemia and inflammatory markers were elevated due to chronic hepatitis, we decided to take samples for microbiology and histology during the procedures. The right hip was performed through an anterior approach by a senior surgeon following standard antibiotic prophylaxis with 2 g of cefazolin 20 min before skin incision. An uncemented prosthesis was implanted with no complications. Femoral head destruction led to an important defect in the posterior and superior wall of the acetabulum. This conditioned high and medial implantation of the cup to achieve stability. 4 days after the first procedure was performed, one out of six cultures was positive for Enterococcus faecium with no local and systemic signs of infection or pain. Synovial biopsy revealed fibrosis, chronic inflammation, calcifications, macrophages, and osteoclast giant cells with no signs of acute inflammation. Urine cultures were negative. The Musculoskeletal Infection Society criteria [] were not met and the patient did not receive antibiotic treatment. 6 days later, after a favorable post-operative evolution, the left hip was performed through a posterior approach by a different senior surgeon with the same hip system but with a cemented stem (). In the left hip, the acetabulum was also affected by the bone destruction, but the cup was able to be placed at a correct height. This ended up with a leg length discrepancy that is well tolerated by the patient taking into account her previous functional status. 5 days after the second procedure and following a post-operative period without complications, the patient was discharged before obtaining definitive microbiological results. Cement was loaded with gentamycin, and the same antibiotic prophylaxis protocol was used. For the second surgery, three out of four samples were positive for the same microorganism. 2 weeks later, the patient was readmitted due to wound drainage of the right hip. Surgical debridement and irrigation with the exchange of the modular components were performed. Empiric antibiotic treatment was started with teicoplanin, amikacin, and rifampicin according to the Infectious Diseases Department’s protocol at our institution. Amikacin was stopped 3 days after surgery because no Gram-negative Bacilli were isolated. All four samples obtained during the debridement were positive for E. faecium 5 days after surgery with identical sensitivity tests as for the first hip. Pathogen-specific antibiotic treatment was then started with amoxicillin and rifampicin. 2 weeks after debridement and 1 month after the first surgery, the patient was again readmitted due to wound drainage of the same right hip. Again, surgical debridement and exchange of modular components were performed continuing with the same antibiotic treatment. For the second debridement, one out of five samples was positive for Propionibacterium acnes. Amoxicilin treatment was followed during 3 months. At 18 months after surgery, the patient had recovered to previous full activity. Blood tests at 18 months showed normal C-reactive protein levels and an erythrocyte sedimentation rate of 40 mm/h. In the last X-ray control, there were no signs of loosening (). Patient regained complete gait independence without pain. No further complications were reported.

A 60 year old male presented with Staphylococcus aureous infection of his endocardial pacing system. His past medical history was remarkable for mild dilated cardiomyopathy, ventricular tachycardia, a biventricular endocardial pacing for cardiac resynchronization therapy, and several previous percutaneous endocardial pacing system implantations via the right and the left subclavian veins. The pacing leads and box were removed and the infection was treated with antibiotics. Due to subclavian vein stenosis and pacing box pocket infection, transvenous approach for implantation of a new pacing system proved not to be feasible. Therefore he was referred for surgical implantation of a new epicardial pacing system.\nA lower half limited median sternotomy was performed starting from the xiphoid process, up to the level of the third intercostal space. A second limited transverse sternotomy was performed starting from the left third intercostal space and joining the midline sternotomy (Figure ). The pericardium was opened in the midline, providing excellent exposure and easy access to both the right atrial appendage and the right ventricle. The right atrial leads were sutured to the surface of the right atrial appendage, while the right ventricular bipolar leads were sutured to the anterior muscular part of the right ventricle. Access to the left ventricle was achieved by gently lifting up the heart, using an epicardial tissue stabilizing system and exposing the lateral wall of the left ventricle with no hemodynamic compromise. The left ventricular lead was screwed into the proximal part of the lateral wall between the obtuse marginal arteries and then the defibrillator patch was sutured to the distal lateral wall. It was made sure that there was a good orientation between the patch and the pacing box which was subsequently inserted in the sheath of the right rectus muscle. The thresholds on the pacing leads were checked and the defibrillating patch was tested. A right subcostal incision was made and a pocket was created in the lateral side of the right rectus muscle. The pacing wires were tunneled between the right hemi-diaphragm and the lateral edge of the right rectus muscle, into the pacing box pouch and connected to the pacing box. Defibrillation threshold testing was performed, and the lowest effective threshold was found to be < 10 Jules. The sternum was approximated using interrupted stainless steel wires. Sternotomy and subcostal incisions were closed in layers. The patient had a good post operative recovery and was discharged home on day 4 after the operation. Follow-up studies showed well functioning biventricular pacing system, stable pacing lead positions (Figure ), good biventricular synchronized function, and no pericardial effusion.

At the time of diagnosis this patient was a 9 year-old female with a one year history of pain and swelling about her left knee. She had experienced a fall and related all symptoms to the fall. She was seen in her local emergency room by her family physician; there was no diagnosis or treatment. Approximately one month prior to her representation, she was struck in the left knee by a basketball and developed worsening pain. She was seen by an orthopedic surgeon (December 1999) and was noted to have a valgus posture of both lower extremities, exaggerated on the left by external rotation and she walked with a mild limp. The left knee had no effusion but was hypersensitive to light touch over the lateral aspect where there was soft tissue swelling just below the knee. There was no obvious mass in the area, although firm palpation was difficult because of patient discomfort. Plain films were normal and an MR was ordered that revealed an apparent meniscal cyst in the lateral aspect of the left knee [Figure ]. Biopsy of the cystic structure was performed (November 1999) that revealed a high-grade synovial cell sarcoma. Metastatic work-up consisting of nuclear bone scan and CT of the chest were negative. Amputation was offered by the local care team that included a radiation oncologist because of their concern about possible contamination of the joint space and uncertain functional outcome. The patient was referred to St. Jude Children's Hospital for further evaluation and treatment.\nAt the time of her evaluation after referral (January 2000), there was a well healed scar with no excessive swelling. There was mild tenderness on the lateral aspect of her left knee. Additional imaging studies showed abnormality at the site of prior surgery equivocal for residual tumor. There was no evidence of abnormality in the joint space. The tumor bed was explored. There was no physical evidence of compromise at the level of the joint space. She underwent wide local excision with placement of afterloading catheters. Six catheters were placed in a parallel array with 1 cm spacing. Radio-opaque clips were placed to delineate the tumor bed and assist in brachytherapy planning [Figure ]. The margins of the resection were involved with tumor, as demonstrated by field biopsies and assessment of the margins of resection. Satellite tumor nodules were present in the resection specimen. Four days after surgery the six afterloading catheters were loaded with 82 seeds representing 302 mCi of I125 (Figure). The dwell time of the implant was 62 hours and the patient received a total implant dose of 2480 cGy delivered at 40 cGy/hr. Two weeks later the patient began external beam irradiation at 180 cGy/day and received a course of treatment and total external beam dose of 5040 cGy using 6 MV photons with treatment delivered with two beams using a CT based treatment plan [Figure ]. Radiation therapy was completed in March 2000.\nThe patient suffered moist desquamation corresponding to the radiation therapy portal that was predicted based on the treatment and the use of a tissue equivalent bolus material which was placed on the wound on alternating days during her course of external beam irradiation. She was able to return home on the last day of treatment. On routine follow-up, only 4 months after treatment, left leg appearing to be slightly longer than her right leg by less than 1 cm. No corresponding gait problems were reported. Nearly one year after treatment (January 2000) physical examination showed good range of motion at the left knee; however, there was significant valgus angulation. An MR study was reviewed by Orthopedic Surgery and was noted to show growth arrest laterally and predominantly involving the distal femoral physis [Figure ]. Based on these findings, the family was informed that an epiphysiodesis of the distal femoral physis would likely be required to prevent additional deformity. Due to the angulatory deformity, an osteotomy of the distal femur would be required. Because of high-dose irradiation and concerns about bone healing, osteotomy and epiphysiodesis were deferred until the three year evaluation was performed. At that time, the patient had a significant valgus deformity. The morbidity of the deformity was such that ambulation was difficult. The patient underwent a closing wedge correcting osteotomy, which was fixed with a contour plate. The patient subsequently fractured the plate secondary to early and unprotected weightbearing (against medical advice). She was placed in a cast and ultimately healed her osteotomy. She continues to have a significant limb length discrepancy and will require future lengthening procedures. She remains without evidence of disease nearly 4 years after treatment.

A 81-year old woman was referred to our department to evaluate a wound dehiscence on her left knee with hardware exposure. The patient did not have any relevant comorbidities and her general status was good. The patient underwent a total left hip arthroplasty at the age of seventy four due to severe osteoarthritis pain that hindered baseline activities. Eight years later, the patient presented to the orthopedics department with a progressive pain in the affected hip, particularly when walking, causing difficulties in deambulation.\nAn X ray examination revealed an extensive femoral bone loss with displacement of the femoral component, and an MRI showed a femoral pseudo-tumor (bone proliferation). With this finding, a revision total hip arthroplasty was performed with the insertion of a reconstruction ring with cemented dual mobility cups. Three weeks after this last surgery, the patient started with early symptoms of infection (high fever, suppuration, no wound healing and laboratory abnormalities); an attempt at conservative management with intravenous antibiotic, irrigation and suction drainages was unsuccessful and a replacement of the endoprosthesis femur in two stages was planned.\nIn the first stage, the previous prosthesis was removed with enlarged osteotomy of the anterior tuberosity and a cement spacer with antibiotic was placed. Two months later, the spacer was removed and a new coated silver total femoral prosthesis was placed. The patient was referred to our unit four weeks after the last surgery for the assessment of wound dehiscence to the lateral knee with hardware exposure. The patient was taken to the operating room for retention debridement and wound coverage with a flap. Our first decision was to cover the defect with a lateral gastrocnemius flap, however, the surrounding area was highly scarred, and the gastrocnemius muscle was found to be very atrophic and no suitable to fit the large defect. shows no other local flaps to be large enough to cover the whole defect, so we opted for a free flap.\nA lack of receptor vessels was evidenced, descending genicular artery was dissected, but small caliber and calcified plaques in the lumen discarded this option. With the need of a suitable and large vessel close to the defect, we opted for an AV loop that was constructed with ipsilateral greater saphenous vein. The femoral artery was found to be very atherosclerotic, but a healthy segment free of calcific plaque on the middle third of the vessel was used to perform the anastomosis of the vein graft in end-to-side fashion ().\nA latissimus dorsi musculocutaneous flap with a large skin paddle was transferred to the lateral knee defect, and the thoracodorsal artery and vein were anastomosed in an end to end fashion to the limbs of the loop. The flap was properly inset to provide adequate bulk and to avoid dead spaces (). Donor site was closed primarily. Intraoperatively, no incidences occurred and the flap appeared well perfused. The patient was extubated and transferred to the recovery room in stable condition with standard clinical monitoring. Tissue oximetry system (INVOS CO.) was used 72 hours after the surgery. Three drainages were left, two of them in lower limb placed in lateral knee and lateral hip and one in donor area of the flap. Drainages were retained until output was less than 30 ml per day.\nWound healing properly evolved as well as the patient started rehabilitation during admission. The patient received Daptomycin (700 mg/d iv) and fosfomycin (2 g/6h iv) during 6 weeks, according to the infectious medicine protocol. The patient started walking uneventfully with a walking frame one month after surgery. The patient was enrolled in an outpatient rehabilitation program with close monitoring. At present time, the patient is able to ambulance without the need of assistant devices and there are no signsor symptoms of infection recurrence.

A 54-year-old woman with a history of large goiter and liver function abnormalities was referred by her physician to the CAMC to address her multiple dietary supplement use. She was noted to have moderate liver function abnormalities (ALT 3 times normal range) during a medical evaluation. After extensive evaluation of her liver dysfunction no apparent causes were found. She did not drink alcohol or take any medications, and was of normal body weight. Infectious, obstructive and autoimmune causes were ruled out. She was noted to consume a number of dietary supplements and referred to our clinic to address dietary supplement polyherbacy and its potential affect on her liver function tests. She brought all her supplements for review. At that evaluation, we addressed the purpose of her use of each supplement ().\nShe reported adding more and more dietary supplements over the years, as she read extensively and frequently researched the internet for information on these products. Ultimately she felt at a loss as to which supplements might be of benefit or which supplements to stop taking. This patient typically would use less than the recommended dose noted on the label, but at times would use a higher than recommended dose. She also would vary which supplement she might use in any given day. She expressed concern that her dietary supplement intake had gotten out of control and felt she may be addicted to using supplements as they gave her a greater sense of control.\nAfter discussing the purpose for using each dietary supplement and concerns with dietary supplement polypharmacy and its potential effect on her liver dysfunction, she agreed to stop all supplements for the time being, with the exception of calcium and vitamin D, and one multivitamin a day. Until her follow-up visit she would increase her dietary intake of antioxidant foods, acidophilus and omega 3 fatty acids in place of her supplements, and practice mind-body techniques and exercise for health and stress reduction. We also offered a referral to counseling for anxiety management. Follow-up liver function tests were normal. We proposed to re-introduce a fewer number of supplements, based on evidence-based indications and safe dose ranges, one at a time, while we followed her liver function tests. She elected however to stay off the supplements over the next two follow-up visits, as she was happy with her dietary modifications. Based on the evidence presented above, we believe that her abnormal liver function tests were a result of excessive supplement use and resolved completely with withdrawal of offending agents.

The 32-year-old female was referred to the center for vascular consultation. The patient was a house wife and a mother of two children. She reported having an episode of sudden onset severe headache associated with generalized tonic and clonic fits and loss of consciousness. She regained consciousness after a period of 24 h without any neurological deficit with a complaint of neck rigidity and headache. The patient had a past history of similar episodes dating back 1 year. Upon interview she recalled a long history of trivial headaches, malaise and low grade fever for the past 6 years, whose severity had never warranted any further investigation. She also had a history of intermittent claudication in her bilateral upper limbs. Physical examination revealed no neurological deficit, however, radial and brachial arteries were impalpable bilaterally. Right to left blood pressure discrepancies were detected, measuring at 140/80 from right arm and 160/80 from the left arm.\nA CT brain was conducted that revealed subarachnoid hemorrhage with intraventricular extension (). Similar findings were evident in previous CT scan brain which was done 1 year ago at the previous presentation of ictus (). Laboratory investigation showed raised ESR upto 40 mm/h and C Reactive Protein was positive. Cerebral angiography and aortogram showed total occlusion of left common carotid artery from its origin and 90% occlusion of right common carotid artery from its origin with slightly dilated segment prior to its tapering (). The sole arteries supplying the intracranial circulation were bilateral vertebral arteries and showed saccular basilar tip aneurysm of size 7.30 x 5.39 mm (). Additional imaging showed bilateral occlusion of subclavian arteries from their initial segments. There were extensive collateral branches to intercostal arteries supplying both upper arms (). The terminal aorta was irregular but bilateral renal arteries and other branches of aorta were normal (). We started the patient on 20 mg prednisone resulting in a reduction of ESR as well as normalization of C Reactive Protein. Further the patient was referred for endovascular coil embolization as vertebral arteries were relatively straight and easy to access.\nCoil embolization procedure was decided as line of approach for therapy. The navigation was straightforward from vertebral artery but unfortunately the patient had complication and third episode of subarachnoid hemorrhage night before the procedure and expired.

A 22 years old female patient reported to our department with a complaint of facial disfigurement on the left side of the face which gradually progressed over the past 14 years. Progressive atrophy on the left half of the face was initially noticed at the age of 8 years as an area of hyper pigmentation on the left malar area which gradually progressed with resultant atrophy of the underlying fat and subcutaneous tissue resulting in the present disfigurement (Fig. ). However it was not associated with any other symptoms except for the limited mouth opening which the patient experienced gradually as the condition progressed. The patient had not sought any consultation earlier, for the facial disfigurement. Her medical and family history was non contributory. On general physical examination patient was conscious, oriented, a febrile, general condition was fair and vital signs were stable. Right side of the face appeared normal with marked facial asymmetry noted on left side. Head and neck examination confirmed the asymmetry with flattening, hyperpigmented, parchment like overlying skin. There was an evident loss of underlying fat, muscle and subcutaneous tissue giving a sunken in appearance. Thinning of the lips on the affected side with exposition of the teeth due to the corner of the mouth pulled to left side. Ocular examination and skin examination showed no abnormality with any evidence of lymphadenopathy. There was no evidence of sensory or motor deficits on both sides. On palpation, the skin on the affected side was rigid with signs of sclerosis. TMJ on the affected side was tender with deviation to the left on mouth opening. Intraoral examination revealed normal moist mucosa but tense oral mucosa on the affected side. Tongue on the affected side showed marked atrophy on the left side with shift in the dorsal median fissure (Fig. ). Hard tissue examination revealed crowding of the teeth with shift in midline to the affected side and obliteration of the buccal and vestibular sulcus due to tense oral tissue. Upper and lower arch showed constriction of the arch with multiple carious teeth on left side. Based on history and clinical examination a preliminary diagnosis of hemifacial atrophy of the left side of the face was made. Routine blood investigation revealed values within normal range, Patient was negative for Anti nuclear Antibodies suggestive of absence of any auto immune disease. Biopsy specimen of the affected skin lesion showed sclerodermoid tissue reaction suggestive of morphic changes. Radiographic investigation of chest, lateral lumbosacral spine, terminal phalanges of long bone showed no abnormality. Orthopantamograph [OPG] revealed significant findings of asymmetry with thinning of the body of mandible with smaller condyle and coronoid process, short roots on affected side when compared to right side. Crowding and carious tooth was also noted (Fig.). Paranasal sinus view showed hypoplasia of the frontal and maxillary sinus. Posterio- anterior view revealed asymmetry of the jaws. Computed tomography [CT] scan revealed generalized atrophy of the soft tissue of the left hemi face resulting in asymmetry on the left side with deviated nasal septum and marked hypoplasia of the frontal and maxillary sinus. Computed Tomographic scan of brain was normal.\nCorrelating all the investigation with the patient’s history and clinical examination a final diagnosis of Parry Romberg Syndrome was established. Dental and reconstructive plastic surgery using autologous fat transplant was considered as part of the treatment.

A 35 year old obese African American male, a mechanic by profession and no significant previous medical problems, came to the emergency room with left sided chest pain that started the night before and slowly got worse. By the time he reached the emergency room, the pain had reached 8 out of a maximum of10 in intensity. The pain was precipitated and aggravated by a stressful situation at home. It radiated to his left shoulder and was not relieved by rest. Patient had a five pack-year history of smoking but quit 10 years ago. He would occasionally drink alcohol. On further questioning, the patient revealed that he had been having mild left sided chest pains, sharp in nature and similar to the current episode, for the last few months. The pain would occur either with stress or exertion. He did not seek medical attention before because the pain would be transient and go away on its own after a few minutes. He was not on any medications and did not use any pain relieving medicines either for his prior symptoms.\nIn the emergency room, patient was in mild distress and had a blood pressure of 165/81, something new for him. All the rest of the vital signs were normal and both the cardiac and pulmonary examination did not reveal any abnormality either. The basic laboratory work up was normal except a lipid profile showing elevated cholesterol of 238 mg/dl. The patient had an electrocardiogram that showed some premature supraventricular complexes without any ischemic changes. Cardiac biomarkers including serial troponin-I were also normal. The chest pain subsided in the emergency room with intravenous morphine. The patient was admitted to the hospital in the telemetry unit. He was found to have some runs of non-sustained ventricular tachycardia while in the hospital. He underwent a cardiac exercise stress test and an echocardiogram which revealed that patient had a normal ejection fraction but a dilated left atrium along with apical wall motion abnormality.\nPatient then underwent a cardiac catheterization. It did not show any obstruction in the coronary arteries, but did reveal a "tumor blush" with neovascularization seen projecting from the left circumflex artery to the "tumor blush". (Figure ) Following the cardiac catheterization, patient had a CT scan of the chest to evaluate for any mass or tumor. The CT scan showed a 6 cm solid and likely necrotic mass beginning slightly anterior to the carina and extending caudally posterior to the left atrium. (Figure ) No prior imaging was available for comparison.\nAs it was still unclear whether the mass was originating intrinsic or extrinsic to the heart, so to define it better anatomically, a transesophageal echocardiogram (TEE) was performed. The TEE also showed the large mass, likely extrinsic to the heart, compressing the left atrium. (Figure ) Finally, the patient underwent an open heart surgery for definitive diagnosis and management. During surgical exploration, an extremely hard mass was found on the dome of the left atrium, and on further exploration, the indurated tissue clearly extended to the left atrial appendage, underneath the superior vena cava and past the origin of the right superior pulmonary vein. Frozen sections of the biopsy from the tumor were suggestive of "Cardiac Paraganglioma", showing tumor cells arranged in a nest-like (Zellballen) pattern-separated by thin vascular network. (Figure ) This was later confirmed further with special staining. The patient's tumor was initially deemed unresectable, because of its location and local invasion, by the operating surgeon and the median sternotomy incision was closed. However, patient then had a second opinion by a different surgeon who successfully resected the tumor and the patient recovered from the operation without any major complications. His normetanephrine levels which were very elevated before the tumor resection (1447 microgram/24 hours), normalized to 312 microgram/24 hours (normal value 110–620 microgram/24 hours) after the tumor was resected. Five years later he is doing well with no recurrence of the tumor, though he has to use a thiazide diuretic for blood pressure control.

A 45-year-old man was presented in our department with a large, painful swelling in the popliteal fossa in his left leg. There has been a puncture wound by a nail 11 years ago and he resorted to another hospital. At that institution, medical treatment was given in accordance with the patient's momentary condition. Nevertheless, a slowly growing mass occurred in his popliteal fossa in a year following being subjected to the puncture wound. He resorted to cardiovascular surgery department in another hospital and Doppler ultrasonography together with arteriography was taken. A popliteal pseudoaneurysm was detected in the distal part of the popliteal artery near the bifurcation to the anterior and posterior tibial arteries and was about 4 cm in diameter (). The patient was taken into operation by cardiovascular surgeons after the angiography. He had an excision of the pseudoaneurysm and primary repair surgery to popliteal artery. After surgery, the popliteal artery was patent according to Doppler USG. He had a foot drop after the operation which resolves spontaneously after a year. At early follow-up, a gradually expanding mass recurred in the popliteal fossa. He went to cardiovascular surgery with this complain, but observation was recommended. Monophasic flow was seen on the popliteal artery according to Doppler ultrasonography which was taken 5 years after the operation. He resorted to some medical centers for his swelling to be treated during 10 years after bypass surgery, but observation without any interference was suggested according to the patient's momentary condition. He applied to our department with a huge popliteal mass associated with obstructed popliteal artery.\nOn the physical examination of the patient, there was a large mass (28 × 10 cm) in the popliteal fossa with old surgical scars. The lesion was soft, fluctuant, and painless in palpation (). The neurological examination of the lower leg was normal. The blood tests were normal. In the arteriography images, the popliteal artery occluded in the proximal section but was filled in the distal section with collateral vessels (). The MRI scan revealed an enormous soft tissue mass of 115 × 107 × 196 cm in size between the medial and lateral heads of the gastrocnemius with the features compatible with hematoma with lobulation ().\nThe mass is excised from the adhered tibia protecting the nerve and the collateral vessels with hockey stick incision on the popliteal fossa on prone position (). There was about 1,5 L of chocolate-brown fluid evacuated from a well-defined wall and a multilocular cyst-like appearance was seen. The findings we gathered from the operation were compatible with a large fibrous cavity with villous formation containing a considerable quantity of altered blood clot (). A complete resection of the pseudocapsule was performed. The underlying fascia was extendedly sutured with the subcutaneous tissue, in order to avoid any dead space where new hematoma can develop. The liquid and soft tissue culture was sterile. The histopathological examination revealed abundant fibrous tissue with the features of hemorrhage. After one year from the surgical treatment, the patient has not shown any sign of recurrence ().

The patient is a 58-year old male who was being evaluated for inguinal hernia repair. His past medical history included CAD with prior stenting of the left circumflex artery, diabetes with a HbA1c of 5.7 and an 80-pack year smoking history. He reported a 37 kg unintentional weight loss over 6 months with postprandial abdominal pain and nausea. In addition, he had exertional angina relieved by rest and sublingual nitrates. He had an abdominal CT scan for evaluation of the hernia, and this demonstrated severe atherosclerotic abdominal aortic disease with occlusion of the origin of the celiac and superior mesenteric arteries and patency of the inferior mesenteric artery. This was confirmed by mesenteric angiography which demonstrated occlusion of the celiac and SMA with a large mesenteric collateral originating from the inferior mesenteric artery (). This artery had a 90% orifice stenosis. With his cardiac history and symptoms, he underwent coronary angiography, which demonstrated significant left main and 3-vessel CAD (). Left ventricular function was preserved with no valvular heart disease by transthoracic echocardiography.\nHe was referred initially for evaluation for coronary artery bypass grafting (CABG) and reported a brief episode of slurred speech in the past 2 months. A carotid duplex was obtained and showed 80–99% left internal carotid artery stenosis and 50–79% right internal carotid artery stenosis. Given his severe symptomatic carotid and mesenteric arterial disease, there would be significantly greater risk of neurological and mesenteric ischemic complications associated with CABG. The decision was made to perform surgical revascularization to address each vascular system in a staged and combined manner.\nThe patient underwent uncomplicated left carotid endarterectomy and was admitted postoperatively. He had no neurologic complications and was taken for combined CABG and mesenteric bypass on the fourth postoperative day. After induction of anesthesia and placement of hemodynamic monitoring lines, the procedure was initiated with a median sternotomy and mobilization of the left internal mammary artery as a pedicled graft. The greater saphenous vein was harvested endoscopically. After this was performed, a midline laparotomy was performed, extending the sternotomy incision. Dissection was carried through the lesser sac until the supra-celiac aorta was identified. The supra-celiac aorta, celiac artery and superior mesenteric artery were dissected from surrounding tissues. The patient was then systemically heparinized to achieve an activated clotting time (ACT) of greater than 450 seconds, and following aortic and right atrial cannulation, the patient was placed on cardiopulmonary bypass. Normothermic conditions were maintained. The mesenteric bypass was then performed from the supra-celiac aorta to the celiac artery and SMA with a bifurcated Vascutek® 12 mm × 6 mm Gelsoft™ graft (Terumo Cardiovascular Group, Ann Arbor, MI) in an end-to-end fashion (). After completion of the mesenteric bypass, the patient was cooled to 34°C, and coronary artery bypass grafting was performed with saphenous vein grafts to the first diagonal, first obtuse marginal, second obtuse marginal and posterior descending coronary arteries followed by the left internal mammary artery graft to mid-left anterior descending artery (). He was weaned from cardiopulmonary bypass without inotropic support. Total cardiopulmonary bypass time was 236 minutes (90 minutes for the mesenteric revascularization), and aortic cross clamp time was 125 minutes, using a single clamp technique. After administration of protamine, drains were placed and the sternum and laparotomy incision were closed. The patient had an uncomplicated course with return of bowel function on post-operative day 3 and was discharged home on day 7 from the combined procedure. The patient was seen in follow-up at 30 and 90 days post-operatively and had no recurrent neurological, cardiac or mesenteric symptoms.

A 40-year-old Asian woman who had been in her usual state of good health was incidentally found to have a small nodule in the lower lobe of her right lung during a regular medical checkup. The patient was seen in the department of medicine of our hospital for further evaluation. The patient’s family history was noncontributory, and a physical examination revealed no abnormalities. The results of laboratory studies were either within normal limits or negative. A computed tomographic (CT) scan revealed a lytic lesion of the fifth lumbar vertebral bone, as well as a small nodule (1.2 cm in diameter) in the lower lobe of the right lung (Fig. ). The vertebral lesion was situated on the left transverse process and was separated from the spinal canal (Fig. ). Biopsy specimens of both lesions were histologically similar and showed spindle cell neoplasms with a bland appearance; however, we could not make a definitive diagnosis, owing to the small size of the samples. The patient was placed under close observation with suspicion of multiple metastases from an unknown primary tumor.\nFive years later, a CT scan indicated that the pulmonary nodule had slightly increased in size. Magnetic resonance (MR) imaging also revealed an increase in the size of the lytic lesion in the left transverse process of the fifth lumbar vertebra. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery for the pulmonary lesion and curettage of the lytic bone lesion were performed. The orthopedic surgeons found that the tumor of the fifth left transverse process was exposed on the posterior surface but not on the anterior surface. They also found that the vertebral lesion was completely confined within the vertebral bone and was not connected to the spinal canal. During the clinical course (105 months), no significant findings other than the pulmonary and vertebral lesions were found, even with imaging examinations, including CT and MR imaging. The patient made good postoperative progress and remained free of disease at 41 months after the operation.\nThe resected specimen of the lung contained a well-circumscribed solid lesion 13 mm in diameter. It was composed of fascicular architecture of bland spindle or polygonal cells (Fig. ). Neither necrotic foci nor mitotic figures were observed. The tumor was immunopositive for epithelial membrane antigen (Fig. ), D2-40, progesterone receptor, vimentin, and S100 but negative for alpha-smooth muscle actin. Although curettage specimens from the vertebral bone were fragmented, the morphological and immunohistochemical findings were identical to those of the pulmonary lesion (Fig. ). The tumor was shown to be a transitional meningioma on histological examination, including immunohistochemical analyses (Table ).

A 40-year-old Asian woman who had been in her usual state of good health was incidentally found to have a small nodule in the lower lobe of her right lung during a regular medical checkup. The patient was seen in the department of medicine of our hospital for further evaluation. The patient’s family history was noncontributory, and a physical examination revealed no abnormalities. The results of laboratory studies were either within normal limits or negative. A computed tomographic (CT) scan revealed a lytic lesion of the fifth lumbar vertebral bone, as well as a small nodule (1.2 cm in diameter) in the lower lobe of the right lung (Fig. ). The vertebral lesion was situated on the left transverse process and was separated from the spinal canal (Fig. ). Biopsy specimens of both lesions were histologically similar and showed spindle cell neoplasms with a bland appearance; however, we could not make a definitive diagnosis, owing to the small size of the samples. The patient was placed under close observation with suspicion of multiple metastases from an unknown primary tumor.\nFive years later, a CT scan indicated that the pulmonary nodule had slightly increased in size. Magnetic resonance (MR) imaging also revealed an increase in the size of the lytic lesion in the left transverse process of the fifth lumbar vertebra. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery for the pulmonary lesion and curettage of the lytic bone lesion were performed. The orthopedic surgeons found that the tumor of the fifth left transverse process was exposed on the posterior surface but not on the anterior surface. They also found that the vertebral lesion was completely confined within the vertebral bone and was not connected to the spinal canal. During the clinical course (105 months), no significant findings other than the pulmonary and vertebral lesions were found, even with imaging examinations, including CT and MR imaging. The patient made good postoperative progress and remained free of disease at 41 months after the operation.\nThe resected specimen of the lung contained a well-circumscribed solid lesion 13 mm in diameter. It was composed of fascicular architecture of bland spindle or polygonal cells (Fig. ). Neither necrotic foci nor mitotic figures were observed. The tumor was immunopositive for epithelial membrane antigen (Fig. ), D2-40, progesterone receptor, vimentin, and S100 but negative for alpha-smooth muscle actin. Although curettage specimens from the vertebral bone were fragmented, the morphological and immunohistochemical findings were identical to those of the pulmonary lesion (Fig. ). The tumor was shown to be a transitional meningioma on histological examination, including immunohistochemical analyses (Table ).

A 75-year-old man was seen in our orthopedic outpatient clinic with osteoarthritis of the right knee. He experienced morning stiffness, pain on the medial side of his right knee after walking and he had difficulties with full flexion of his knee. Conservative treatment was started with steroid infiltration, 4 cc lidocaine mixed with 1 cc depomedrol. Besides these complaints the patient reported a bilateral painless swollen calf muscle. The patient had noticed these swellings of the calf muscle a few years ago without any traumatic history. He had no pain at night and no fever or medical illness. The past medical history of the patient was uneventful.\nOn physical examination the soleus muscle was swollen on both sides. The swelling was localized on the right leg over the whole soleus muscle, 10 by 3 cm. On the left lower leg the swelling was about 3 by 3 cm over the medial part of the soleus muscle. A dimpling in both legs (right more than left) at the medial calf area was seen while standing (Figure ). There was full strength in all lower leg muscles and the reflexes were normal on examination. The rest of the examination was unremarkable, the overlying skin appeared normal without deformities, erythema or warmth and the arterial pulsations were intact. Laboratory test results did not show any abnormalities. An X-ray did not show any bony irregularities in the tibia.\nMagnetic resonance imaging (MRI) of the legs revealed bilateral multiple saccular intramuscular venous malformations involving the soleus muscle (Figure ). There was no nidus seen on MRI so an arteriovenous form of the malformation was not plausible. Due to its asymptomatic presentation no angiogram or ultrasonography was performed to further specify the lesion. After consultation of the vascular surgeon we did not perform surgical resection or focal sclerotherapy because of the asymptomatic nature of the lesions. After explanation of the possible muscle damage from resection and because of the fact that our patient had no disabilities in daily living, we agreed upon conservative management. At three mo follow up the swollen calf muscles were still asymptomatic and examination did not show any change of the venous malformations. We continued the conservative treatment focused on the osteoarthritis of the knee with good result.

A 81-year old woman was referred to our department to evaluate a wound dehiscence on her left knee with hardware exposure. The patient did not have any relevant comorbidities and her general status was good. The patient underwent a total left hip arthroplasty at the age of seventy four due to severe osteoarthritis pain that hindered baseline activities. Eight years later, the patient presented to the orthopedics department with a progressive pain in the affected hip, particularly when walking, causing difficulties in deambulation.\nAn X ray examination revealed an extensive femoral bone loss with displacement of the femoral component, and an MRI showed a femoral pseudo-tumor (bone proliferation). With this finding, a revision total hip arthroplasty was performed with the insertion of a reconstruction ring with cemented dual mobility cups. Three weeks after this last surgery, the patient started with early symptoms of infection (high fever, suppuration, no wound healing and laboratory abnormalities); an attempt at conservative management with intravenous antibiotic, irrigation and suction drainages was unsuccessful and a replacement of the endoprosthesis femur in two stages was planned.\nIn the first stage, the previous prosthesis was removed with enlarged osteotomy of the anterior tuberosity and a cement spacer with antibiotic was placed. Two months later, the spacer was removed and a new coated silver total femoral prosthesis was placed. The patient was referred to our unit four weeks after the last surgery for the assessment of wound dehiscence to the lateral knee with hardware exposure. The patient was taken to the operating room for retention debridement and wound coverage with a flap. Our first decision was to cover the defect with a lateral gastrocnemius flap, however, the surrounding area was highly scarred, and the gastrocnemius muscle was found to be very atrophic and no suitable to fit the large defect. shows no other local flaps to be large enough to cover the whole defect, so we opted for a free flap.\nA lack of receptor vessels was evidenced, descending genicular artery was dissected, but small caliber and calcified plaques in the lumen discarded this option. With the need of a suitable and large vessel close to the defect, we opted for an AV loop that was constructed with ipsilateral greater saphenous vein. The femoral artery was found to be very atherosclerotic, but a healthy segment free of calcific plaque on the middle third of the vessel was used to perform the anastomosis of the vein graft in end-to-side fashion ().\nA latissimus dorsi musculocutaneous flap with a large skin paddle was transferred to the lateral knee defect, and the thoracodorsal artery and vein were anastomosed in an end to end fashion to the limbs of the loop. The flap was properly inset to provide adequate bulk and to avoid dead spaces (). Donor site was closed primarily. Intraoperatively, no incidences occurred and the flap appeared well perfused. The patient was extubated and transferred to the recovery room in stable condition with standard clinical monitoring. Tissue oximetry system (INVOS CO.) was used 72 hours after the surgery. Three drainages were left, two of them in lower limb placed in lateral knee and lateral hip and one in donor area of the flap. Drainages were retained until output was less than 30 ml per day.\nWound healing properly evolved as well as the patient started rehabilitation during admission. The patient received Daptomycin (700 mg/d iv) and fosfomycin (2 g/6h iv) during 6 weeks, according to the infectious medicine protocol. The patient started walking uneventfully with a walking frame one month after surgery. The patient was enrolled in an outpatient rehabilitation program with close monitoring. At present time, the patient is able to ambulance without the need of assistant devices and there are no signsor symptoms of infection recurrence.

A 40-year-old Asian woman who had been in her usual state of good health was incidentally found to have a small nodule in the lower lobe of her right lung during a regular medical checkup. The patient was seen in the department of medicine of our hospital for further evaluation. The patient’s family history was noncontributory, and a physical examination revealed no abnormalities. The results of laboratory studies were either within normal limits or negative. A computed tomographic (CT) scan revealed a lytic lesion of the fifth lumbar vertebral bone, as well as a small nodule (1.2 cm in diameter) in the lower lobe of the right lung (Fig. ). The vertebral lesion was situated on the left transverse process and was separated from the spinal canal (Fig. ). Biopsy specimens of both lesions were histologically similar and showed spindle cell neoplasms with a bland appearance; however, we could not make a definitive diagnosis, owing to the small size of the samples. The patient was placed under close observation with suspicion of multiple metastases from an unknown primary tumor.\nFive years later, a CT scan indicated that the pulmonary nodule had slightly increased in size. Magnetic resonance (MR) imaging also revealed an increase in the size of the lytic lesion in the left transverse process of the fifth lumbar vertebra. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery for the pulmonary lesion and curettage of the lytic bone lesion were performed. The orthopedic surgeons found that the tumor of the fifth left transverse process was exposed on the posterior surface but not on the anterior surface. They also found that the vertebral lesion was completely confined within the vertebral bone and was not connected to the spinal canal. During the clinical course (105 months), no significant findings other than the pulmonary and vertebral lesions were found, even with imaging examinations, including CT and MR imaging. The patient made good postoperative progress and remained free of disease at 41 months after the operation.\nThe resected specimen of the lung contained a well-circumscribed solid lesion 13 mm in diameter. It was composed of fascicular architecture of bland spindle or polygonal cells (Fig. ). Neither necrotic foci nor mitotic figures were observed. The tumor was immunopositive for epithelial membrane antigen (Fig. ), D2-40, progesterone receptor, vimentin, and S100 but negative for alpha-smooth muscle actin. Although curettage specimens from the vertebral bone were fragmented, the morphological and immunohistochemical findings were identical to those of the pulmonary lesion (Fig. ). The tumor was shown to be a transitional meningioma on histological examination, including immunohistochemical analyses (Table ).

A 40-year-old Asian woman who had been in her usual state of good health was incidentally found to have a small nodule in the lower lobe of her right lung during a regular medical checkup. The patient was seen in the department of medicine of our hospital for further evaluation. The patient’s family history was noncontributory, and a physical examination revealed no abnormalities. The results of laboratory studies were either within normal limits or negative. A computed tomographic (CT) scan revealed a lytic lesion of the fifth lumbar vertebral bone, as well as a small nodule (1.2 cm in diameter) in the lower lobe of the right lung (Fig. ). The vertebral lesion was situated on the left transverse process and was separated from the spinal canal (Fig. ). Biopsy specimens of both lesions were histologically similar and showed spindle cell neoplasms with a bland appearance; however, we could not make a definitive diagnosis, owing to the small size of the samples. The patient was placed under close observation with suspicion of multiple metastases from an unknown primary tumor.\nFive years later, a CT scan indicated that the pulmonary nodule had slightly increased in size. Magnetic resonance (MR) imaging also revealed an increase in the size of the lytic lesion in the left transverse process of the fifth lumbar vertebra. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery for the pulmonary lesion and curettage of the lytic bone lesion were performed. The orthopedic surgeons found that the tumor of the fifth left transverse process was exposed on the posterior surface but not on the anterior surface. They also found that the vertebral lesion was completely confined within the vertebral bone and was not connected to the spinal canal. During the clinical course (105 months), no significant findings other than the pulmonary and vertebral lesions were found, even with imaging examinations, including CT and MR imaging. The patient made good postoperative progress and remained free of disease at 41 months after the operation.\nThe resected specimen of the lung contained a well-circumscribed solid lesion 13 mm in diameter. It was composed of fascicular architecture of bland spindle or polygonal cells (Fig. ). Neither necrotic foci nor mitotic figures were observed. The tumor was immunopositive for epithelial membrane antigen (Fig. ), D2-40, progesterone receptor, vimentin, and S100 but negative for alpha-smooth muscle actin. Although curettage specimens from the vertebral bone were fragmented, the morphological and immunohistochemical findings were identical to those of the pulmonary lesion (Fig. ). The tumor was shown to be a transitional meningioma on histological examination, including immunohistochemical analyses (Table ).

An 18-year-old American college football player presented with a vague headache since he was tackled during exercise several weeks ago. Brain computed tomography (CT) was performed at a local hospital a few days before visiting our hospital because the headache worsened and was not relieved through medication. Initial brain CT revealed a small amount of subdural hematoma on the left cerebral convexity (). Few calcified nodules were noted at the left frontotemporal cortex. However, it was initially considered a simple traumatic hemorrhage and was managed by conservative means. Several days later, the headache aggravated and the patient experienced an episode of generalized partial seizure. On the magnetic resonance imaging (MRI) performed immediately after the seizure, the size of acute hematoma and cerebral edema was markedly increased, and a small enhancing mass was observed at the left cerebral convexity (). Magnetic resonance angiography (MRA) revealed a 4 mm sized aneurysmal dilatation of the cortical branch of the MCA, which supplies the superior temporal region (). Emergency craniotomy was performed to eliminate the aneurysm and lower the elevated intracranial pressure by removing the hematoma. A large craniotomy was done, and the subdural hematoma was removed by repeated gentle irrigation and suction after small dural incision. While further opening of the dura, we were encountered by several irregularly shaped, hard subdural nodules which were tightly adhered to the dura and the underlying brain (). Upon careful dissection, these nodules were noted to be buried in the sulcus while being severely adhered to the brain cortex and the cortical arteries. Between the nodules was an organizing hematoma and upon careful removal, a pseudoaneurysm of the cortical MCA branch was exposed. The involved MCA branch was carefully dissected and was trapped by clips at the proximal and distal portion of the severely injured and adherent segment, along with the pseudoaneurysm. The aneurysm and the calcified nodules were then excised. The ischemic injury was minimized because the collateral flow retrogradely supplied the distal part of the occluded artery. The patient recovered without sequelae and was discharged after a short while.

An 82-year-old male presented with a large right IIA aneurysm diagnosed during routine surveillance on a long background history of complicated aortoiliac endovascular intervention. His comorbidities included chronic renal failure, hypertension, and hyperlipidaemia. He had undergone an endovascular AAA repair 9 years previously for treatment of a 5 cm infrarenal abdominal aortic aneurysm. This treatment was complicated by the subsequent development of bilateral common iliac artery aneurysms. In attempting to endovascularly repair these aneurysms 3 years after the initial surgery, a rupture of the right external iliac artery necessitated placement of a covered stent across the origin of the right internal iliac artery and into the body of the main aortic endograft. Ongoing surveillance of his aortoiliac system with duplex ultrasound demonstrated the gradual development of bilateral IIA aneurysms. A dedicated CT angiogram performed 6 years after the IIA origin was covered showing the sac having expanded to a diameter 6.4 cm. The source of expansion was thought to be a type II endoleak from collaterals originating in left iliac system. Endovascular embolisation of these vessels was attempted via a left sided femoral artery puncture, with angiography demonstrating the origin of the endoleak being the right superior gluteal artery that was being fed through a plexus of collateral channels through the body of the sacrum. It was not possible to cannulate these vessels with a microcatheter, and therefore endovascular treatment of the endoleak was not possible. The patient was offered an open procedure to manage the enlarging IIA aneurysm, which was declined due to the significant risks in light of the patient's previous abdominal interventions and poor overall health ().\nThe decision was made to treat the aneurysm via direct puncture method employing a posterior approach under CT visualisation. Under general anaesthetic and with the patient in a prone position, CT guidance was used to insert a 17-gauge needle into the right superior gluteal artery. The artery was accessed via a transgluteal approach with the catheter passing through the sciatic notch. Contrast injection in the angiography suite confirmed the catheter to be situated in the right superior gluteal artery distal to the site of the endoleak. Angiography demonstrated five branches leading from the sacral body, feeding the gluteal artery, and perfusing the aneurysmal sac. These branches were selectively cannulated with a microcatheter and embolised with a variety of Interlock (Boston Scientific, Marlborough, MA, USA), Nestor (Cook Medical, Bloomington, IN, USA), and Target embolism coils (Stryker Neurovascular, Fremont, CA, USA). Subsequent contrast injection showed only filling of the sac with no further feeding collaterals identified.\nFollowing successful embolisation of all collateral vessels, the main aneurysm sac was then injected with a liquid embolic agent, 1.5 mL of Lipidiol (Guerbet Group, Roissy, France), and 0.5 mL of Histoacryl (Tissue Seal, Ann Arbor, MN, USA). Completion angiography demonstrated no perfusion of the IIA aneurysm sac. Follow-up imaging demonstrated a stable aneurysm excluded from circulation. The patient made an uneventful recovery.

A 44-year-old woman was referred to our hospital from a local clinic for decreased visual acuity in her left eye. Two hours before the manifestation of symptoms, an autologous fat injection was administered in the periocular area under intravenous anesthesia. The autologous fat was obtained from the abdominal area and the procedure was performed by a local plastic surgeon. When the effect of the anesthesia wore off, the patient reported a loss of vision in the left eye. The best corrected visual acuity was 1.0 in the right eye and no light perception on the left side. The left pupil was dilated and a relative afferent pupillary defect was detected. During physical examination, the patient suddenly complained of dysarthria and the skin color of the nose changed to purple (). The patient was immediately transferred to the emergency room and neurological examination, blood tests, and an MRI scan of the brain were performed. Within 30 minutes, the dysarthria improved significantly and the patient was able to speak normally. On examination, the right fundus appeared to be normal but the left showed a cherry red spot with visible emboli in several retinal arteries (). Fluorescein angiography of the left eye revealed markedly prolonged choroidal filling around the optic disc and a delay in retinal arterial filling while that of the right eye revealed no abnormalities (). The results of laboratory examinations were normal, however the MRI scan showed an ill-defined hyperintense lesion at the left insular cortex (). The patient was finally diagnosed with ophthalmic artery obstruction and left middle cerebral artery infarction. The patient was promptly administered ocular massage, intravenous mannitolization, and oxygen and carbon dioxide therapy. Twenty-four hours after autologous fat injection, the left fundus exhibited marked retinal edema and multiple fat emboli and the visual acuity of the left eye was no light perception (). At 2 months after the injection, the patient had no perception of light in the left eye and the left fundus showed optic atrophy, multiple retinal hemorrhages, and a fibrous change on its posterior pole ().

A 55-year-old female presented to the ophthalmology department of the hospital with complaints of a painful swelling in the left eye. The swelling had been gradually increasing in size over the last 8 months with dull continuous pain in the eye and periorbital area. There was progressive diminution of vision for the last 6 months in the affected eye, and at the time of presentation in the hospital, the affected eye was completely blind. The progressive increase in the size of the swelling and pain in and around the eye compelled the patient to avail hospital services. The treatment history was not significant. The patient was being treated by a local doctor with eye drops and certain oral medicines the records of which were not available with her. She did not have any history of significant ocular disease or any ophthalmic surgery. There was no history of similar disease in the family.\nOn examination, an intraorbital mass protruding from the left eye was visible. Axial proptosis with stretched out sclera along with dilated blood vessels covering the entire exposed part of the eye ball was seen. The underlying cornea was barely visible through the widened palpebral aperture with hyperemic keratinized conjunctiva tissue. The swelling was more prominent in the region superior to the upper eye lid. The skin appeared stretched along with dilated vessels in the superior part of the eye ball []. On palpation, the mass was tender and soft in consistency. Fundus examination was not possible because of overlying vascularized keratinized tissue over cornea. The intraocular tension was also not recorded because of these reasons. The status of the pupil of the diseased eye could also not be commented upon, even though it appeared slightly dilated. The patient had no perception of light in the left eye. Ophthalmological examination of the right eye did not show any abnormality both in the anterior as well as in posterior chamber. The fundus examination of the right eye was normal. The intraocular tension of right eye was also normal.\nSystemic examination of the patient was normal. Breast examination and gynecological examination were also normal. Clinically, at that stage, differential diagnoses of metastatic carcinoma, astrocytoma, and adult-onset retinoblastoma were considered by treating ophthalmologist and investigations were planned.\nBlood examination was within normal limits. This included hemoglobin values, total leucocyte count, differential leucocyte count, and erythrocyte sedimentation rate. Peripheral blood smear was normal. The kidney function tests, liver functions tests, serum alkaline phosphatase, serum calcium, and serum phosphorus were normal. Urine examination was also normal. Electrocardiogram was also normal.\nNoncontrast computed tomography (NCCT) scan off the orbit and Para Nasal Sinuses (PNS) revealed marked left proptosis with markedly expanded left ocular globe by a hyperdense mass, few cystic components with extension into left anterior cranial fossa, left anterior ethmoid, left frontal sinus, left frontal fossa soft tissues with destruction of left orbital walls, and great wing of sphenoid bone []. A precise diagnosis was not possible based upon CT findings. The radiologist considered provisional diagnosis of primary intraocular tumor, metastatic carcinoma, malignant melanoma, or lymphoma and advised further investigations. Chest CT and abdomen ultrasonography were carried out and found to be normal. The patient was referred to us for fine needle aspiration cytology (FNAC) at this stage.\nFNAC was done using a 22-gauze needle. Smears were prepared, air dried, and stained with Giemsa stain and Periodic Acid Schiff's stain (PAS stain). The microscopic examination of Giemsa-stained smears showed small, round cells in cluster and rosettes formation, suggestive of retinoblastoma []. PAS positive granules in the cytoplasm of tumor cells were seen in PAS-stained smears, consistent with the diagnosis of retinoblastoma [].

The patient was a 60-year-old man who referred to our emergency department due to worsening dyspnea and hemoptysis since 2-3 days prior to admission. He reported to have dyspnea and hoarseness during the previous year. He had undergone a direct laryngoscopy which had revealed left vocal cord palsy and a chest computed tomography (CT) scan which had shown a mediastinal mass and with possibility of a malignancy process a direct needle biopsy was done which demonstrated inflammatory cells in the background of blood. His past medical history only included a mild stroke 6 years before without any sequel.\nAt the emergency department he had pulse rate of 86 beats/min, respiratory rate of 18/min and blood pressure of 135/80 mm Hg. He had a continuous murmur in left sternal and pulmonic area and decreased breathing sound in left hemithorax.\nA chest x-ray was obtained which showed a large density in mediastinum and left sided pleural effusion. In echocardiography he had normal left ventricle but dilated right sided chambers with supravalvular pulmonic stenosis. Trans-esophageal echocardiography revealed a pseudoaneurysm of distal aortic arch with clot formation and compression of the main and left pulmonary artery. As a result a chest CT scan with contrast and angiographic construction was done which confirmed the previous finding of a 45 mm × 37 mm pseudoaneurysm in lateral side of aortic arch distal to left subclavian origin with associated 9.5 cm × 10 cm hematoma in mediastinum ( and ). At this stage and upon further investigation he remembered to have fallen down from a few stairs 10 years ago which did not result in any injuries and accordingly he did not seek medical advice.\nThe patient initially refused operation but a few days later developed severe chest pain and so finally agreed to a surgical plan.\nThe patient had a preoperative selective coronary angiography via right radial artery which was normal. He underwent left thoracotomy via femorofemoral bypass. A large pseudoaneurysm of distal aortic arch was detected (). Large hematoma was evacuated from the mediastinum and the aortic wall was repaired with a patch.\nHis hospital course in intensive care unit (ICU) was uneventful and was discharged after 1 week.

A 38 year old Vietnamese man was admitted with a 10 month history of epigastric pain, fatigue, 10 kg weight loss and recent onset jaundice. He had no other significant medical history. Clinical examination demonstrated anaemia and a tender mass in the right upper quadrant of the abdomen. A computerised tomography (CT) scan of the abdomen revealed a 7 × 5 cm thick-walled, complex mass adjacent to the second part of the duodenum, which contained fluid and air and abutted the hepatic flexure of the colon. The working diagnosis was a collection secondary to a colonic perforation and he was treated with intravenous antibiotics. He improved with conservative management and was discharged a month later for outpatient colonoscopy. The colonoscopy revealed a lesion in the transverse colon, histology of which showed a mucinous adenocarcinoma.\nHe subsequently returned to the Accident and Emergency Department following an upper gastrointestinal bleed. On his second admission, a repeat CT scan again suggested localised colonic perforation with formation of an abscess adjacent to the duodenum, along with thickening of the ascending colon, predominantly centred around the hepatic flexure. Given the clinical presentation and diagnostic uncertainty a diagnostic laparoscopy was performed which revealed a large perforated tumour at the hepatic flexure with ascites and peritoneal tumour nodules. A laparotomy was performed via a transverse incision and following mobilisation of the hepatic flexure, a colonic tumour was found to have invaded the gallbladder and duodenum with an abscess cavity anterior to the second part of the duodenum. At the base of the abscess cavity a large hole was apparent in the second part of the duodenum with malignant tumour invading the duodenum. Given the size of the defect (5 cm × 2 cm) and the presence of tumour it was not possible to resect and form a primary closure of the duodenum. The presence of metastatic spread precluded a curative resection by pancreatoduodenectomy.\nA right hemicolectomy was performed to debulk the tumour and an ileotransverse anastamosis formed. Due to the extent of the disease and associated abscess the anterior wall of the duodenum came away with the colon during this manoeuvre. A retrograde cholecystectomy was carried out to resect the residual tumour invading the gall bladder. The ampulla was identified with the aid of a transcystic catheter. An 82 mm expandable covered duodenal stent with a diameter of 18 mm (Hanarostent, duodenal/pyloric, M.I. Tech Co. Ltd, Seoul, N. Korea) was manually inserted through the duodenal perforation into the proximal duodenum with the distal end of the stent inserted into D2. A small opening into the side wall of the stent was made prior to the positioning of the stent to accommodate the ampulla and thus facilitate drainage of bile within the stent. A per-operative cholangiogram confirmed free flow of contrast in the duodenum. The residual duodenal wall was closed over the stent and following antrectomy a gastrojejunostomy was formed to bypass the duodenum (Bilroth II reconstruction).\nThe patient was discharged 7 weeks later following a prolonged, but otherwise uncomplicated recovery. He subsequently underwent a palliative course of chemotherapy survived for a further 18 months without gastrointestinal symptoms, before succumbing to his disease.

An African American male in his 50s presented with increased shortness of breath, dyspnea on exertion, and orthopnea. He has a past medical history of coronary artery disease with multiple myocardial infarctions and two coronary stents placed in 2003 and two additional coronary stents placed two months prior to his admission. He had a history of systolic heart failure with a left ventricle ejection fraction of 20%. In the emergency department atrial fibrillation with rapid ventricular rate was noted with a heart rate of 140. A diltiazem infusion was started and he was admitted to the Cardiac Intensive Care Unit. Repeat echocardiogram several days later showed progressive worsening of his ischemic cardiomyopathy with an ejection fraction of 18%. He was started on inotropic support and underwent placement of an intra-aortic balloon pump (IABP) to assist with hemodynamic stability. Approximately 24 hours later the patient had an episode of melena associated with a drop in his hemoglobin from 10.1 to 7.7. He was started on proton pump inhibitor infusion. He underwent emergent esophagogastroduodenoscopy which showed erythema and erosions in the gastric fundus compatible with gastritis as well as grade 1 reflux esophagitis but no evidence of active bleeding. A Helicobacter pylori stool antigen was found to be negative. A colonoscopy was performed after hemodynamic stabilization for further evaluation of melena and pretransplant screen. This was positive for abnormal vascularity, congestion, nodularity, erosions, erythema, and ulceration in the cecum and ascending colon suggestive of ischemic colitis which was later confirmed by biopsy (). Given the unusual involvement of nonwatershed areas such as the cecum and ascending colon, a CT of the abdomen and pelvis with contrast was performed to evaluate the celiac and mesenteric vasculature. There was no significant narrowing of either vessel noted on the CT; however the inferior metallic marker of the IABP was found to be inferior to the origin of the superior mesenteric artery (). Findings were consistent with ischemic colitis of the cecum and ascending colon as visualized on colonoscopy from occlusion caused by the IABP. The IABP was repositioned and the patient's melena resolved.

A 30-year-old woman was admitted to our institution in June 2002 for the treatment of a giant fusiform aneurysm of the basilar trunk. A giant ICA aneurysm had been found during a previous evaluation of abducens nerve palsy on her right side in November 2001 (). At that time, a tortuous basilar artery had been found, but without any aneurysmal dilatation (). She had undergone endovascular trapping of the giant fusiform aneurysm, involving the petrous to cavernous parts of the right ICA, at another hospital (). However, she developed severe headache seven months after the treatment. At the time of admission, she complained of progressive dyspnea, as well as dull headache in the occipital area. Neurologic examination revealed a 6th cranial nerve palsy on the right side and increased deep tendon reflexes in the four extremities. On MR imaging, a giant aneurysm of the basilar artery was found to be compressing the brain stem (). Cerebral angiography showed a fusiform giant aneurysm, with an irregular contour, involving the basilar trunk (). The left anterior inferior cerebellar artery originated just proximal to the basilar trunk aneurysm. In addition, another de novo small paraclinoid aneurysm was found on the left ICA.\nTo relieve the brain stem compression, we decided to obliterate the basilar trunk aneurysm in spite of the risk associated with this intervention. In advance of performing endovascular embolization of the aneurysm, a high-flow bypass from the external carotid artery to the middle cerebral artery was performed using a saphenous vein graft. This is because occlusion of the basilar trunk would have endangered the blood supply to the posterior circulation, leaving the left ICA as the only vessel responsible for the perfusion of the entire brain after the basilar trunk occlusion, since the patient had already undergone occlusion of the right ICA. The bypass supplied the right middle cerebral artery territory (), and an adequate blood supply to the upper portion of the posterior circulation was maintained via the left posterior communicating artery (PCoA). During surgery, part of the occluded right ICA was sectioned and referred for pathologic examination, in an attempt to determine the etiology of the rapid sequential development of the giant fusiform aneurysm.\nFollow-up angiography, performed three days after the bypass surgery, revealed a patent bypass graft. After a test balloon occlusion at the level of the proximal basilar artery, which ensured adequate perfusion to the upper parts of the brain stem and cerebellum through the left PCoA (), coil embolization of the basilar trunk aneurysm was done. Fourteen detachable platinum coils with a total length of 155 cm were deployed in the aneurysm. Upon completion of the embolization procedure, the blood flow to the posterior circulation through the PCoA was maintained well, with near-complete occlusion of the aneurysm (). Postprocedural heparinization was not done. The patient was managed in the neurosurgical intensive care unit and recovered without further neurologic deficit. However, six hours after the end of the embolization procedure, the patient developed dyspnea, dysarthria, and quadriparesis. Intubation and ventilator care was undertaken, and heparinization was started. Enlargement of the aneurysm due to thrombus was revealed by MR imaging, and angiography confirmed complete occlusion of the aneurysm. The patient became stable after two days and, one month after the intervention, independent daily activity became possible and she was discharged from hospital. Pathologic examination of the vessel specimen showed intraluminal projections of fibrous tissue with smooth muscle and capillary proliferation, but failed to reach a definite etiologic diagnosis.\nFollow-up angiography performed three months and one year post-treatment, respectively, revealed complete and stable occlusion of the basilar trunk aneurysm and good perfusion to the entire brain. MR imaging showed marked shrinkage of the aneurysm of the basilar trunk, with no evidence of brain stem compression (). In contrast, the size of the carotid fusiform aneurysm showed no significant change. The patient is currently leading a normal life as a housewife.

A 51-year-old hypertensive Pakistani male patient was admitted in the cardiac intensive care unit in King Fahd University Hospital on 30 July 2017 complaining of chest and back pain for two weeks prior to the presentation; he took nonsteroidal anti-inflammatory drugs but were not effective. Physical examination was done in the emergency department and revealed stable vital signs; the patient was conscious, moving all his limbs; there were warm palpable pulses of the upper arms.\nThe CTA of the aorta revealed a large dissection flap from the origin of the left subclavian artery extending down all the way to the level of renal arteries; there was enlargement of the false lumen at the proximal aorta with large aneurysmal dilatation (mural thrombus) and a compression of the true lumen (ascending aorta). Additionally, there was a large entry point seen 2 cm distal to the right subclavian artery. The aberrant right subclavian artery was noted crossing posterior to the trachea and arising as a last branch of the aortic arch distal to the left subclavian artery; also, the left vertebral artery was arising directly from the aortic arch. There was no other evidence of vascular dissection or occlusion below the level of the renal arteries (Figures and ).\nThe patient underwent general anesthesia for thoracic endovascular repair (TEVAR) two days after his first day of admission; the procedure was done through the right femoral approach; an angiogram was performed intraoperatively (). Stent graft with a size of 34 mm × 15 cm was used and deployed into the descending thoracic aorta; the intimal entry tear was completely covered by the stent, and the false lumen was obliterated. A postdeployment angiogram revealed successful proximal occlusion of the entry point with no perfusion of the false lumen and good flow through both carotid and left vertebral arteries as well as patent right and left subclavian arteries.\nThe patient was postoperatively moving all his limbs, and the peripheral pulses were intact. He got discharged one day after the surgery and was doing well afterward. We evaluated patient's prognosis by following up for 3 to 6 months for a chest X-ray, CTA, and CT aorta 3D reconstruction (Figures and ) which confirmed no endovascular leak as well as no ischemic or stroke signs in the clinical follow-up; we assessed the patency of the subclavian arteries by examining the bilateral upper arms' blood supply in addition to radial arteries by evaluating the pulses with no evidence of morbidity.

An 18-year-old male patient (height 140 cm, weight 20 kg) was referred to our hospital for dental treatment under general anesthesia with a chief complaint of an inability to open his mouth wide for dental treatment. The patient was diagnosed with spinal muscular atrophy (SMA) at one year of age through muscle biopsy. While he has clear consciousness, he has never walked, as he was unable to move his arms or legs. Since the age of 8, when he suffered aspiration pneumonia, he been completely bedridden and has been using continuous positive airway pressure (CPAP) during sleep. The patient usually has his neck turned to the left because he has difficulty breathing and sometimes experiences signs of dyspnea when he turns his neck to the right. He underwent two rounds of general anesthesia for scoliosis surgery in 2008 and 2010, and had a history of tracheostomy for dyspnea that occurred in the intensive care unit (ICU) after undergoing general anesthesia for the second time. In a limited manner, the patient was able to voluntarily open his mouth and was able to eat regular food. The patient has been complaining of pain in his TMJ and temporal area during mouth opening for 10 years, which hindered him from receiving treatment for long-term molar pain.\nTherefore, he was referred to undergo general anesthesia for treatment of the molar area. However, we decided to defer general anesthesia due to a high risk of respiratory complications based on his medical history and physical examination, and instead performed local anesthesia of his TMJ area. We determined that the patient had severe pain in the bilateral temporal and TMJ area due to hyperextension of the mouth closing muscle while opening his mouth, and perform local anesthesia to alleviate tension in the TMJ and mouth closing muscle area during dental treatment. At the dental clinic, 1 mL 0.5% levobupivacaine was injected on each side of the TMJ and temporalis fascia before performing oral and maxillofacial surgery (). In approximately 10 minutes, the patient reported feeling no pain while opening his mouth, and oral examination and the required dental treatments were performed while monitoring his oxygen saturation levels. During the examination, his #36, #45, and #46 teeth were identified as severely carious with exposed pulp in addition to a severely carious #26 tooth, moderately carious #13, #37, and #42 teeth, and mildly carious #43 tooth. Hence, we extracted #36 and #46, and performed restorative treatment and root canal for #37 and #45, respectively. The patient maintained a limited degree of mouth opening ability (20 mm), and remaining treatments were conducted in subsequent visits without additional local anesthesia of the mouth closing muscle and TMJ.

A 12-year-old female child presented to us initially when she was 5 years old with an episode of generalized convulsion, loss of consciousness and left sided hemiplegia. A non-contrast CT scan done at this time showed a right posterior frontal hematoma. CT angiography did not show any evidence of a vascular malformation. Digital substraction angiography did not show any arteriovenous malformation, though an early draining vein was visualized []. The patient was managed conservatively. The patient presented 1 year after the episode. She had improved in power in her left sided limbs which was now Grade 3-4/5. She was able to walk on her own with little support. A MRI was performed that showed resolution of the hematoma and the presence of a gliotic cavity. A contrast image showed the normal vessels in the region, and there was no evidence of any flow voids in the region of the cavity. MR angiogram performed at the same time also did not show any evidence of an arteriovenous malformation or nidus []. The patient was again observed and asked to follow-up. The patient presented after 4 years, at the age of 9 years, with complaints of intermittent episodes of seizures. A MRI was again repeated which showed the gliotic cavity on T1 weighted scan. On T2 weighted image, some abnormal vessels were seen in the region of the gliotic cavity. MR angiography showed the presence of an arteriovenous malformation fed by the branches of the middle cerebral artery []. A four vessel angiogram was performed which showed an arteriovenous malformation fed by multiple anterior branches of the middle cerebral artery and drained via multiple veins in the superior sagittal sinus. The patient was advised surgery at this time, but since she only had intermittent episodes of seizures the parents were not willing for surgery. One year after this the patient again presented with complaints of intractable seizures. Digital substraction angiography showed the arteriovenous malformation, similar in size and configuration as was seen earlier []. The patient was now operated. The arteriovenous malformation was resected with routine surgical steps and considerations. The arteriovenous malformation was of significantly high-flow, but could be safely dissected and resected. Post-operatively the patient did well and she did not have any added neurological deficit. Post-operative angiogram showed excision of the arteriovenous malformation. At a follow-up after 1 year of surgery, she was well and was free from convulsions. Her hemiparesis persisted.