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The patient was a 17-year-old male who was in previously good health with no history of hearing loss or significant medical issues. He was found at home and was unresponsive due to carbon monoxide (CO) poisoning. He was sleeping on the family couch in the living room on the first floor. Due to a hurricane-related power failure, a diesel generator was running in the family's connected garage. The patient was later found unconscious on the couch. Other family members were also found unconscious on the scene; not all of the family members survived the CO poisoning. The patient had been unconscious for an unknown period of time and was taken to a shock trauma center by emergency personnel arriving at the scene. He was intubated due to his level of consciousness.\nUpon arrival at the shock trauma center, a CT scan of the head showed no signs of obvious pathology. A chest X-ray showed evidence of a small focal consolidation on the lower right lobe. There was evidence of mild bilateral calcification suggesting pulmonary edema. On the evening of his admission, he was taken to a hyperbaric oxygen chamber. The day after his admission an MRI was administered which showed some evidence of anoxic brain injury. He was found to have diffuse white matter cytotoxic edema which involved the bilateral frontal, parietal, and temporal lobes. He was later extubated while at the shock trauma center. By the time of his discharge from the shock trauma center he was able to follow some simple commands and was able to pass a PO diet. However, he remained nonverbal. He was discharged when believed to be stable after nine days to an inpatient brain injury rehabilitation facility. Prior to his transfer his auditory status was not formally assessed.\nUpon admission to the rehabilitation facility he was arousable for short periods of time and was able to respond to yes-no questions with a head nod. Initially he was uncooperative with physical examination. He would attempt to verbalize and was able to follow one-step commands. Overall he had generalized weakness and was flaccid on the left with an increase in tone on the right. His sensation was intact on all four extremities as were deep tendon reflexes. He was diagnosed at admission with gait dysfunction, dysphasia, and generalized weakness. He received intensive physical, occupational, and speech language pathology therapies during his admission where he remained for 23 days. Initially, he appeared to be aphasic. Over the course of his admission his alertness level normalized, and he became more oriented. His speech and language skills reemerged, and he was able to tolerate a regular diet. He was discharged to home after 16 days with 24-hour supervision required. His hearing was never formally assessed during the admission.\nHe subsequently received 13 days of intensive physical therapy, occupational therapy, and speech and language therapy at a day program three days a week. He also received an in-depth neuropsychological evaluation prior to returning to school as well as grief counseling. He was diagnosed at this time with mild mixed aphasia and mild-moderate cognitive deficits. While receiving speech and language pathology services at the day rehabilitation facility, the patient complained of difficulty in hearing to the speech and language pathologist and was referred for an audiological evaluation.\nThe patient was seen for an audiological evaluation 54 days after his exposure to CO. He denied tinnitus. The obtained audiogram is shown in . Findings indicated the presence of a bilateral hearing loss of sensorineural origin. For the right ear, findings indicated the presence of normal sensitivity from 250 to 1000 Hz, sloping to a moderate hearing loss at 1500 Hz and a moderate-to-severe hearing loss at 2000 Hz and above. For the left ear, findings indicated the presence of normal sensitivity at 250–1000 Hz, sloping to a mild hearing loss at 1500–2000 Hz and a moderate-to-severe hearing loss at 3000 Hz and above. Bone conduction thresholds interweaved with air conduction thresholds indicating the impairment to be sensorineural in origin bilaterally. Speech reception thresholds were in good agreement with frequency-specific findings bilaterally. Word recognition performance in quiet was fair-poor bilaterally at a level 40 dB above the speech reception threshold but improved to fair-good at 80 dB SL. There was no PB rollover for either ear. Word recognition performance was not disproportionately impaired relative to the degree of pure-tone sensitivity loss []. Tympanometry revealed normal tympanic membrane/middle ear system mobility bilaterally. Acoustic reflexes were absent or present at elevated sensation levels for ipsilateral stimulation of both ears. Measurements of transient evoked otoacoustic emissions were undertaken for stimulation of both ears. TEOAEs were absent for both ears from 1000 to 4000 Hz, indicating the presence of outer hair cell dysfunction bilaterally. Subsequent audiological assessment one month later revealed no significant changes in the patient's pure tone sensitivity as shown in . Hearing aids were recommended, and the patient was provided with an FM system during the duration of his rehabilitation activities at the day program rehabilitation facility. Staff interacting with the patient in his therapies noted some immediate improvement in his performance. He was subsequently issued binaural hearing aids which were to be coupled with an FM system in his school setting.

Case 2: A 23 year old male, presented with symptoms of crawling sensation and foreign body sensation in his right eye, and had observed a worm in this eye. He had no previous symptoms prior to his presentation. He gave a history of having worked in a cocoa farm plantation during his childhood years and had severally suffered from bites from unknown flies. He had no systemic symptoms nor signs and aside from his ocular complains was healthy. There was no swelling anywhere in the body and no itching. Upon ocular examination his visual acuity was 6/6 in both eyes. The only significant finding was the presence of an actively mobile worm in the nasal subconjunctival space of the right eye "". This worm soon migrated upwards towards the superior fornix and away from view during the examination and before removal could be attempted "". The patient was immediately asked to adopt a face down position and within 30minutes of this time; he could feel a crawling sensation again in the same eye indicating that the worm was back. He was quickly taken to the operating room and the worm was extracted successfully using a local infiltration of the conjunctiva with lignocaine anesthesia. Histological examination revealed it to be an adult Loa loa worm.\nCases 3: A 25 year old female who had suffered sensation of movement and foreign body sensation in both eyes for the past 10 years and gave a past history of swimming in rural streams during childhood years. There was no history of swelling on the body and no itching. She had noticed an increasingly frequent occurrence of a worm like movement in both eyes over these years. Following ingestion of diethyl carbamazepine she noticed a sudden appearance of a red patch in the right eye. Upon examination her visual acuity was 6/5 in both eyes. The only significant finding was a localized hyperemic raised lesion on the surface of the right eye. This turned out to be a subconjuctival worm in the inferotemporal subconjunctival space of the right eye. The worm was found to be lifeless and covered by a surrounding cyst wall "". Care was taken to dissect the conjunctival and subtenons tissue away from the encysted worm, which was carefully extracted with a toothless forceps. Conjunctival incision site was closed with interrupted sutures. Histology revealed an adult Loa loa worm.

A 41-year-old white woman with a past medical history of endometriosis presented to our clinic for her annual examination. She wanted to discuss cyclic rectal bleeding after having undergone a total hysterectomy with bilateral salpingectomy and left oophorectomy 1 year prior. She stated that, over the past 6–8 months, she had been experiencing bloody bowel movements for 1 week each month, in the same pattern as her previous menstrual cycles. She also experienced sharp, lower abdominal pain with these bloody bowel movements, similar to the pain from her endometriosis in the past. She described a mild to moderate amount of bleeding and noted that the blood was typically mixed with stool. The blood was dark red, which she believed looked very similar to her menses. She reported normal bowel movements the other 3 weeks of the month. Prior to her hysterectomy, she completed a colonoscopy which showed no transmural implants. Previous treatment for endometriosis included oral contraceptives which gave no significant symptomatic relief. Her other past medical history included hypertension for which she was taking extended-release metoprolol 50 mg in the morning and 25 mg in the evening before bed. She had never smoked tobacco and consumed alcohol occasionally. At that time, she worked as a systems engineer for information technology.\nShe had the onset of menarche at age 10 with heavy periods until age 16, at which time she went on oral contraceptive pills. At age 37, she gave birth to twins at 29 weeks of gestation via cesarean section without complications. Her other surgical history included a tonsillectomy at age 3, cervical conization at age 22, rhinoplasty at age 26, exploratory laparoscopy for excision of stage IV endometriosis with en bloc excision, left ovarian cystectomy, and bilateral ovarian suspension at age 34, as well as total hysterectomy, as mentioned above.\nShe denied any family history of endometriosis, although she noted that her mother had heavy periods prior to giving birth to our patient. Her mother also suffered from asthma. Her father had heart disease and her grandparents had a history of heart disease, diabetes, stroke, high cholesterol, hypertension, osteoporosis, and alcohol abuse.\nOur patient’s examination revealed a temperature of 36.7 ºC, heart rate of 57 beats per minute (bpm), and blood pressure of 129/78 mmHg. She was alert and oriented with no focal neurologic deficits. Cardiac and lung examinations were normal. An abdominal examination revealed normoactive bowel sounds with no tenderness to palpation. No external hemorrhoids were visualized on rectal examination and stool guaiac was negative. An anoscopy was not performed.\nOur differential diagnoses when we first saw her were: invasive endometriosis, internal hemorrhoids, diverticulosis, adenocarcinoma of the colon, inflammatory bowel disease, and angiodysplasia.\nLaboratory tests revealed a largely normal complete blood count (CBC) with a hemoglobin of 12.4, platelet count was 196,000, and white blood cell count was 10,000. Our patient’s electrolytes and kidney function were normal with creatinine of 0.9, blood urea nitrogen (BUN) of 13, and albumin of 4.1. Other examinations such as urine analysis, serology, and microbiology were not drawn. Magnetic resonance imaging (MRI) of her pelvis, with and without contrast, was performed. Findings were consistent with invasive endometriosis in the pelvis, with possible sigmoid colon invasion (Figs. and ). A colonoscopy was performed and revealed a stricture in the recto-sigmoid colon and endometrial implants (Figs. and ). This was thought likely to be extrinsic infiltrating endometriosis affecting the submucosal and mucosal layers with erythematous mucosal changes. These sites were biopsied. The final pathology report revealed fragments of colonic mucosa with marked lamina propria and submucosal congestion (Figs. and ). Immunostaining for estrogen receptor was negative.\nOur patient was referred for follow-up with both Gynecology and Colorectal Surgery. She was advised by the surgical team to undergo exploratory laparotomy with removal of any endometrial implants and resection of the affected colon to avoid worsening stricture and potential obstruction. They recommended sparing of the remaining ovary to avoid surgical castration which, in women under the age of 45, has been shown to correlate with increased all-cause mortality [, ].\nShe opted to not proceed with the surgery due to concern of recurrence by maintaining her right ovary; she decided to manage the bleeding with stool softeners, increasing the dosage during her menstrual periods. After deciding for the non-surgical approach, our patient never complained about the same symptoms again, suggesting that the stool softeners managed her symptoms. Since her diagnosis over 4 years ago, her pain and bleeding have improved and she is starting to feel the first symptoms of menopause including hot flashes, mood swings, and difficulty sleeping. Since her menopausal symptoms have been mild and intermittent, she has decided to hold off from seeking treatment for them at this time.

A 36-year-old man, originally from Latin America, presented at our outpatient department with complaints of abdominal pain that had persisted for 2 months. The patient had first noticed right lateral abdominal pain 2 months prior to the visit, and the pain was gradually worsening. The abdominal pain was localized in an area ranging from the right upper to the right lateral abdomen. The patient had undergone cholecystectomy for acute cholecystitis as a 32-year-old in Latin America and had moved to Japan for work approximately 3 years prior to his initial visit to our hospital. He had returned to Latin America once about 6 to 7 months before presenting at our clinic. When he went back to Japan, his weight had increased from 130 kg to 145 kg. He did not experience abdominal pain immediately after his return to Japan, but, as noted above, he started to gradually feel pain in the right lateral region about 2 months prior to presentation.\nHe first visited another hospital emergency department 1 month after onset of the pain. Initially, gastrointestinal tract spasm was suspected, and he was treated with tiquizium bromide. Though the medication partially relieved his abdominal pain, most of the pain persisted. The result of a workup by a urologist was negative, even though nephrolithiasis was suspected. His abdominal pain was exacerbated upon changing posture, and thus it was suspected to be of somatic rather than visceral origin. Abdominal pain persisted despite treatment with loxoprofen sodium hydrate, and any cause of abdominal pain was not detected on further evaluations, including hematologic laboratory analysis, urine analysis, gastroscopy, or abdominal computed tomography (CT). Finally, he was referred to our hospital for further examination.\nThe results of screening for depression were negative, and the patient did not have symptoms such as loss of interest, depressed feelings, or any specific changes of surrounding conditions, such as family or work environment changes. He had no history of sexually transmitted infection, and his vital signs were within normal limits. His physical examination result was positive for Carnett’s test, and a prior surgical scar of approximately 18 cm was apparent at the right subcostal region. The patient experienced strong pain surrounding the surgical scar that was exacerbated by tapping. There were no skin rashes localized surrounding the pain. His pain exacerbated to 8 on a pain scale when he moved, such as during standing up or rolling over simultaneously. When he stopped moving, pain was partially relieved within 1 minute (3 on a pain scale). When he moved again, abdominal pain was again exacerbated. Hence, he was awakened by the abdominal pain when rolling over. No inflammation was detected (leukocyte count was 8580/mm3 and C-reactive protein was 0.10 mg/dl), and other laboratory findings were nonspecific, including liver/kidney function, blood glucose, and electrolytes. Urinary analysis indicated red blood cell count < 1/high-power field, white blood cell count 1–4/high-power field. Additionally, no abnormality was detected for Chlamydia trachomatis IgG/IgA, and no abnormality was apparent on the electrocardiogram. Enhanced CT revealed bilateral renal stones and fatty liver.\nWe first considered abdominal wall pain due to nerve entrapment because the Carnett’s test result was positive; therefore, we scheduled a trigger point injection at the site of tenderness. About 2 weeks later, the patient visited the emergency department of our hospital, reporting that his prior abdominal pain had decreased but that he was experiencing right inguinal pain. Loxoprofen administration had no effect on the pain. Costovertebral angle pain was apparent on tapping, the result of urine analysis was positive for occult blood, and abdominal CT revealed a urinary stone at the right urinary duct to the bladder. After pentazocine hydrochloride was administered for pain relief, the urinary stone was passed the following day. However, the patient’s right lateral abdominal pain was not relieved.\nHe felt that lying in the lateral position mostly relieved his pain. He had occasional vomiting. The abdominal pain was exacerbated by movements, such as rolling over, standing up, walking, and coughing. Injection of 1% xylocaine 10 ml at a trigger point of the right lateral region led to about 30% relief in pain. The patient was referred to an anesthesiologist for further evaluation and treatment, who performed transverse abdominal plane block and administered multiple analgesic medications (tramadol hydrochloride, pregabalin, celecoxib, and scopolamine butylbromide). These medications decreased the patient’s pain somewhat, and he reported that scopolamine butylbromide was most effective when the pain worsened. Because the patient’s symptoms were not relieved after trigger point treatment to the abdominal wall, we considered potential causes that might be associated with the location between the abdominal wall and visceral wall or related to other sources, including psychosocial, physiological, and other anatomical factors. We rechecked the abdominal CT scan for a suspected adhesion or abdominal hernia at the region of tenderness due to the prior surgical procedure, and we asked a radiologist to reevaluate the right upper abdomen in more detail. The radiologist confirmed a slight abnormality in the right upper abdomen and suggested the possibility of an adhesion around the surgical scar (Fig. ). We referred the patient to a gastrointestinal surgeon for laparoscopic evaluation and adhesiolysis. The patient underwent additional investigations, including cholecystocholangiography and colonoscopy for suspected postcholecystectomy syndrome, biliary dyskinesia, or colon abnormality. However, no cause of the abdominal pain was identified. On laparoscopic evaluation, a broad adhesion was observed. Adhesiolysis was performed 6 months after the patient first visited our hospital. Figure a shows adhesion between the peritoneum and omentum, liver, and ascending colon; Fig. b shows the condition after adhesiolysis. One month after adhesiolysis, the patient’s right abdomen pain level during movement improved from 8 to 2–3 on a pain scale. Therefore, he was able to move with less pain, and he did not feel pain when rolling over. The result of Carnett’s test was negative. After the patient started walking around his house, he felt abdominal pain about 5 minutes after walking. Hence, he was afraid of recurrence of abdominal pain and felt a little depressed and frustrated because he was unable to return to work early. We recommended a gradual increase in activity. He went on a trip 4 months after the operation without problems due to abdominal pain and then resumed his job 6 months after the operation.\nHowever, his abdominal pain deteriorated within 1 month after he resumed working. He presented with bleeding at the umbilicus, which was the laparoscopic port site, and abdominal incisional hernia was confirmed on the basis of CT. Repair of the abdominal incisional hernias and laparoscopic adhesiolysis were performed 8 months after the first operation. After the second operation, although it took time for some symptoms to improve because of surgical site infection, the patient’s symptoms were ultimately relieved, and he resumed his job again 5 months after undergoing the second operation. Although he reported mild abdominal pain and required analgesic medication, his weight decreased to 133 kg, and he was able to walk normally and work full-time, 2 years after he initially visited our hospital. The timeline of interventions and outcomes is shown in Additional file .

A 27-year-old right-hand-dominant and otherwise healthy female student presented with a pain in the right upper scapular region that increased with shoulder motion and resting in the supine position. She reported that a painless snap in her back had occurred during sports activity 11 years previously and had disappeared 2 years later after discontinuing sports activity. The pain in the right upper scapular region had appeared 3 months earlier during continuous inputting to her personal computer and had rapidly worsened. She presented at a nearby hospital because the pain was generated during activities of daily life and prevented her from sleeping in the supine position. A physician suspected a malignant bone tumor based on radiographic and magnetic resonance imaging (MRI) findings and referred the patient to our hospital.\nThe patient had no relevant family or medical history. The right shoulder was slightly lower than the contralateral shoulder. There were no neurological deficits in the right shoulder or arm. There was winging of the right scapula with the arm at the side. An upper interval between the spine and the medial scapular border was widened by 70%, but the lower one was not (). There was no atrophy of the back muscle, and contraction of the trapezius was normal. The muscle bellies of the short rotators and rotator cuff were not tender and were without defects. The limitations of the active ranges of motion were 10° for total elevation, 15° for external rotation, and two vertebrae for internal rotation. Horizontal adduction was not limited with moderate pain beyond 100°. The empty can test generated upper scapular pain. No deformity or osseous tumor was palpable in the large joints, pelvis, or ribcage. Radiographs revealed a bone mass extruding from the ventral side of the superomedial scapular angle; no abnormality was depicted in the large joints. Computed tomography showed a mushroom-shaped osseous tumor composed of a cortex continuous with the scapular cortex, with a broad flat distal end that almost contacted with the third rib, as well as a soft tissue tumor between the serratus anterior and the ribcage (Figures and ). MRI taken at the previous hospital revealed a cystic lesion containing a large amount of fluid that surrounded the osseous tumor and spread over the upper two-thirds of the scapula (Figures and ). Marked rim enhancement was demonstrated on contrast-enhanced T1-weighted imagery with fat suppression. From these imaging findings, our diagnosis was a solitary OC with a large bursa; the possibility of malignant transformation was considered to be low.\nWe performed surgery 3 months after the patient's first visit to our hospital. Under general anesthesia, the patient was placed in the lateral decubitus position with the shoulder flexed and abducted at 110°. The upper extremity was supported on a pillow to avoid excessive horizontal adduction so that the superomedial scapular angle was situated just underneath the middle trapezius. A 10 cm longitudinal incision was made along and 3 cm medial to the medial scapular border, centering at the most proximal end of the scapular spine. The trapezius and rhomboid minor were divided along their fibers. The thick and edematous cyst wall exposed in the bottom of the operative field was cut, and about 100 ml of clear yellow-brown fluid flowed out. The stalk of the OC arose in the superomedial scapular angle 1 cm lateral to the medial scapular border and penetrated the subscapularis and serratus anterior muscles. The base of the lesion was cut with its periosteum along the ventral scapular surface. We cut the attached thick fibrous tissue attached around the distal stalk, which was considered to be a bursal wall. After resection of the osseous lesion, a large cystic space appeared, covered by a white thick membrane considered to be inflamed synovial tissue; at the bottom of this space a 1 × 3 cm section of the rib surface was exposed in the defect of the thick membrane (). There was no free body in the space or palpable indurations on its wall. We irrigated the space, sutured the fascias of the divided muscles, and subsequently closed the skin.\nMacroscopically, the typical thick perichondrium and cartilage cap were not found, although the flat distal end of the lesion was covered by spotty fibrocartilage-like tissue (). Histological examination revealed characteristic findings of OC without any malignant changes. The distal end was covered by synovial tissue and was composed of bony trabeculae in which mostly fatty tissue and bone marrow intervened.\nThe postoperative course was uneventful. The patient returned to normal daily life and full activity 3 weeks postoperatively. At the time of final follow-up 12 years postoperatively, the right scapula was in the normal position, the scapulothoracic rhythm was symmetrical, and there was no limitation of active range of motion or any associated crepitus. The Constant score ratio compared with the contralateral left shoulder was 100% []. MRI showed no abnormality of the soft tissue or bony structures ().

A 52-year-old female patient visited the Outpatient Department of Our Dental College and Hospital with a chief complaint of a nonhealing ulcerated tissue on the left lower back tooth region for the past 6 months, associated with pain and burning sensation during intake of spicy or hot food items occasionally. She developed continuous severe burning sensation accompanied by pain since 1 week in the same region. No relevant past medical, dental, occupational, and habit history was observed in relation with the chief complaint.\nOn soft tissue examination, a solitary, firm, ulcerative tissue measuring 2 × 2 centimetres was found on the alveolar mucosa near premolar region separated from it by clinically healthy mucosa. On stretching the cheek mucosa, a tooth root was found extruding from the socket impinging on the soft tissue counterpart surrounding areas (Figures and ). No other lesions were observed on either side of the oral mucosa. After comprehensive intraoral examination followed by analysis of the past dental and relevant history, an interim diagnosis of traumatic ulcer was given in association with the tooth as the source of origin. Patient consent was obtained before proceeding with the treatment. Extraction of the tooth root was performed under local anaesthesia (). The procedure was uneventful, and postoperative instructions were given for the same. The patient was normal and freed of complaints during postoperative follow-up made after 15days.\nThe patient reported again to the outpatient department with similar complaints of pain and severe burning sensation after 3 months in the same region. On intraoral examination, nodular proliferous ulcerative growth measuring 3 × 2 centimetres was found on the alveolar mucosa near the premolar-molar region with focal areas of white spots (). She was referred immediately to our oral pathology department followed by prescription of topical application of antiviral drugs (2% acyclovir) for a week. As the lesion did not show signs of regression, routine blood investigations were carried out to rule out complications following biopsy and were found to be normal. An incisional biopsy was advised for the same with differential diagnosis of focal epithelial hyperplasia; traumatic fibroma, verruciform leukoplakia, verruca vulgaris, verrucous carcinoma, and ulcerative squamous cell carcinoma were suggested.\nHistopathological analysis showed a broad bulbous rete pegs with pushing margins in many areas along with features of mild dysplasia and few areas of parakeratin plugging. There were also few areas of severe dysplasia without significant break in the basement membrane and malignant cells infiltrating into the subjacent minimal connective tissue stroma with inflammatory cells which led to a provisional diagnosis of verrucous carcinoma of buccal mucosa.\nVerrucous carcinoma has particular clinical and histopathological features that agree its diagnosis to be obtained, which was an uncharacteristic observation in the present case. First, the clinical reasons for rejection were considered followed by the histological ones for each diagnosis, to obtain a final diagnosis thus clearly separating from others. Oral traumatic fibroma was ruled out since it presents as a firm smooth papule in the mouth, usually the same colour as the rest of the mouth lining, but is sometimes paler or, if it has bled, may look a dark colour. The surface may be ulcerated due to trauma or become rough and scaly. It is usually dome-shaped but may be on a short stalk like a polyp or pedunculated []. It should be noted no histological dysplastic features and other observations are not present and fibromas never develop into oral cancer, similarly verrucous hyperplasia (VH) are often associated with papillomas or arise as a de novo lesion. VH (verrucous hyperplasia) and PVL (Proliferative Verrucous Leukoplakia) are irreversible clinicopathologic lesions with considerable potential for evolving into verrucous or squamous cell carcinoma. PVL is a disease of the oral cavity in which VH is a part of its developmental spectrum. Human papillomavirus, as a cofactor, may play an important role in some of these lesions [, ]; however, no signs suggestive of HPV infection were observed in the present histopathology section.\nIn the present case, as no other findings like nodal involvement or metastasis were observed, clinical staging of T2N0M0 was given. A wide local surgical excision was planned and performed under local anaesthesia (). To ensure complete removal of the lesion with clear margins, further examination of the complete surgical specimen was sent for histopathological investigation and also to rule out infiltrating squamous cell carcinoma. The procedure was uneventful, and postoperative instructions were given. A postoperative follow-up was performed at an interval of every 15 days over a period of 3 months. No further complaints were observed.\nIn this instance, though varied clinical course of the disease was noted, the histological result of the complete surgical specimen showed features of verrucous carcinoma similar to the reports obtained during the incisional biopsy thus ruling out squamous cell carcinoma evolved from a verrucous carcinoma (). Thus, on complete evaluation of clinical and histological findings, a conclusive diagnosis of verrucous carcinoma (VC) was given.

A 29-year-old male was transported to the emergency department after a traumatic near total amputation of the right distal tibia due to a motorcycle accident; the patient's leg was run over by a truck. The distal portion of the leg was severely crushed and the only remaining portions were the anterior and posterior tibial nerves, the tibialis anterior tendon, and some soft tissue connections, with no viable blood flow to the distal stump (). The amputation site was critically contaminated, with circumferential degloving tissue loss of approximately 15 cm in length at the distal portion of the lower leg ().\nA comminuted fracture of the tibia and fibula was observed at the distal portions with damage to the ankle joint. Despite the severity of the damage to the amputated region, the general condition of the patient remained fairly stable. The total ischemia time was more than 10 hours of warm ischemia.\nAfter an external fixator was applied to the open tibial fracture and internal fixation was performed for the fibula, wound exploration was performed (). Thrombosis of the anterior tibial artery and a 20-cm-long segment of the artery's crushed intimal structure were observed, along with a similarly damaged vein. The posterior tibial vessels showed an arterial gap of 10 cm, with one accompanying vein ruptured and the other vein crushed with a venous gap of 7 cm (). The posterior tibial vessels appeared more promising for a successful repair. A lesser saphenous vein graft was harvested from the contralateral leg in a 12 cm segment for the arterial reconstruction (). After blood flow resumed, 400 mL of blood was drained before the vein was repaired.\nThe ruptured vein was repaired primarily, and the vein with a 7 cm gap was repaired with an 8 cm strip of arterial graft from a non-thrombosed segment at the middle portion of the thrombosed anterior tibial artery ().\nThe healthy vein graft was considered more reliable for the arterial reconstruction than the arterial graft from the damaged anterior tibial artery. Therefore, the posterior tibial arterial reconstruction was achieved using the 12 cm harvested contralateral lesser saphenous vein graft. The skin and soft tissue defect around the proximal stump underwent minimal debridement and the Vacuum-Assisted Closure System (KCI Medical, San Antonio, TX, USA) was applied for demarcating the necrotizing portions. To protect the anastomosis site, vessel graft site coverage was performed using overlying soft tissue remnants and a bovine dermal substitute (Matriderm, Dr. Suwelak Skin and Health Care, Billerbeck, Germany), while avoiding applied direct negative suction pressure. During the operation, 800 mL of whole blood was transfused. Prostaglandin E1 (Eglandin, Mitsubishi Tanabe Pharma Korea, Seoul, Korea) and heparin were administered for 2 weeks postoperatively. After the replantation, there were no immediate complications such as pulmonary thromboembolism or shock. Two weeks after the replantation, the wound was demarcated and clean. No definite sign of infection was observed.\nInternal fixation of the tibial bone was carried out and coverage of the defect with a 25×15 cm sized latissimus dorsi myocutaneous flap was performed (). The thoracodorsal artery and vein were anastomosed to the middle 1/3 anterior tibial vessels, where undamaged structures in an end-to-end fashion were found. Split-thickness skin grafts were performed simultaneously to cover portions without exposing major structures. The flap healed well, but long-standing use of a splint resulted in a pressure sore at the heel region with exposure of the Achilles tendon.\nWe performed coverage with bovine dermal substitute (Matriderm, Dr. Suwelak Skin and Health Care, Germany) and split-thickness skin graft to the area 3 weeks after the second surgery.\nThe patient was discharged soon afterwards, and was walking with crutches (). Six months after the operation , the patient was ambulatory without aid, and no additional procedures were required (). Twelve months after the operation, sensory recovery of the foot sole was quantitatively measured using two-point discrimination sensation by a esthesiometer. The two-point discrimination sensation on the damaged foot sole was measured at 14 mm and that of the patient's healthy foot sole was measured at 13 mm. The sensation of the damaged foot sole was not significantly different from that of the healthy foot sole. A grade II in the Chen criteria of the replanted lower limb was achieved. The patient and his family were satisfied with the results.

A nineteen-year-old female patient who had severe facial trauma was referred for dental rehabilitation after a series of esthetic surgery operations. The patient's history revealed a blow to her face after falling off a cliff during mountain biking. Her initial evaluation in Emergency Service reported that her general condition was poor, and her hemoglobin value was 6 mg/dL with severe maxillofacial trauma and bleeding. The patient had an emergency consultation at the Department of Plastic and Reconstructive Surgery after a rapid hemodynamic stabilization and CT scans. According to the medical records obtained from her physician, she had a severe soft tissue injury and accompanying comminuted bone fractures on bilateral maxilla, zygoma, periorbital area, mandible, and nasal bones. Bone fragments were fixed with titanium plates and screws without bone grafting. There was also a posterior vertical split fracture on the hard palate extending anteriorly to both sides creating a mobile free bone fragment on the anterior maxilla. Those fractures were also fixed after reconstruction and then soft tissue repair was done. Complications were not seen in the early postoperative period; however, followup of the patient indicated bone necrosis on the anterior maxilla including the alveolar process extending to the palate. After debridement of the necrosis process, the defect was reconstructed with mucosal flaps and bony reconstruction was postponed. The patient refused the bone graft surgery planned for the repair of the defect on the anterior maxilla and had been consulted for prosthetic treatment.\nHer clinical examination showed soft tissue defects on the face particularly eye area and dysmorphic appearance (). The panoramic radiograph demonstrated mini plates and screws used for fixing fractured zygomatic arch, orbital, and maxillary sinus walls. Intraoral examination revealed the absence of the anterior maxillary alveolar ridge and bone until the apex line; both maxillary central and lateral incisors and right canine teeth were lost as a result of traumatic injury ().\nThe patient had an Angle Class I occlusion with an acceptable vertical and horizontal overlap prior to the accident. Because of the loss of premaxillary segment, the patient experienced speech problems and had difficulty in biting and swallowing (). In addition, the maxillary lip had lost support and was depressed into the defect area. The mandible was overclosed, resulting in a decrease of the vertical facial height. The temporomandibular joints were asymptomatic and jaw movement was in normal limits. The patient has complained of her inability to communicate, emotional disturbance of her appearance, and anxiety about the restoration of her teeth. After her extensive surgical procedures, initially temporary acrylic prosthetic rehabilitation was applied approximately one year later after trauma in order to restore her oral and dental function ().\nAs a treatment method, the zirconia-based crown bridge prosthesis had been planned and applied between right first molar teeth through left second premolar teeth for the replacement of the missing teeth (). A new centric relation was made to transfer the articulator and shade was selected. This prosthesis was combined with gingiva-colored porcelain (Noritake Super Porcelain; Noritake, Nagoya, Japan) to compensate for the loss of hard and soft tissue on the anterior maxillary area and lip support. The zirconia framework was veneered by feldspathic porcelain and occlusion balance was checked. Definitive zirconia_crown bridge prosthesis was fabricated using computer aided design/computer-assisted manufacturing (CAD/CAM) system (Procera, Nobel Biocare). The patient was given home oral health care instructions, including use of dental floss, interproximal brushes, and an oral mouth rinse.\nThe advantages of combined prosthesis included esthetic and biocompatible restoration with zirconia prosthesis. A satisfactory esthetic and functional result was achieved after fixed denture adjustments (). After the 1st, 3rd, 6th, and 12th months recall visit, the patient was satisfied with her new appearance and had no functional difficulties during eating, chewing, or swallowing. Speech impairment was eliminated considerably and the patient's profile was improved to a certain degree. In a followup of 5 years period, the prosthesis was stable and there was no evidence for relapse or dysmorphology was found.

This was a 23-year-old man with a history of blunt trauma to his right hand. While working, an electric motor rolled on his right hand and forearm, resulting in swelling and abrasions on the dorsum of his hand and elbow. There were no fractures seen on radiographs. No surgery or sutures were needed. He complained of constant pain for 15 months. He was diagnosed with RSD without objective imaging conformation. He received a cervical epidural block 3 months after the injury, a stellate ganglion block 4 months after the injury, and an intravenous block 5 months after the injury. He stated that none of these treatments helped his pain. Seven months after the injury, a dorsal column stimulator was implanted, which he stated relieved 50% of the pain. The patient presented 15 months after the injury for a medical evaluation as part of workers’ compensation litigation process. He claimed constant pain and the inability to use his right hand and arm. Upon physical examination, the patient held his right hand in a clenched fist posture with his fingers overlapping. He held his elbow and wrist in a fixed flexed posture and adducted against his body, as shown in .\nHe would only abduct his arm minimally at the shoulder. It was noted that the patient was suntanned, including the axillary area on the right side and on his right chest. All finger nails appeared to be chewed short on both hands. He stated that he did not bite his nails on his right hand because he could not get his hand to his mouth. He claimed that he picked the nails of his right hand off with his left hand. He later stated that his right hand was too tender to be touched, yet there was no allodynia on examination. There was no obvious atrophy upon examination of the upper extremities. Mineralization of the bones was symmetrical on bilateral radiographs. The patient initially claimed that his right hand had been in this position for 6 months, while his wife later said he had held his hand in this position for 1 year. His wife stated that his hand did open while sleeping.\nA private investigator was hired by the patient's former employer. The video surveillance showed the patient grasping and casting repeatedly with a fishing rod and reel in the hand that he claimed to be nonfunctional with a full range of motion.

A 23-year-old male patient presented with cubitus varus deformity of the left elbow. The patient developed the deformity following some fracture around elbow in the childhood at the age of 8 years that was managed conservatively in plaster cast after closed reduction. On examination, the boy had 15° of cubitus varus deformity, full range of elbow movements, and no distal neural deficit.\nRadiograph showed an oblique joint line suggestive of varus deformity and evidence of old healed remodeled fracture line. Two foramina of 3-4 mm diameter were seen on anteroposterior view on a vertical plane. The distal hole had a sharp margins while proximal had indistinct margins, similar holes were seen in oblique view [].\nThis child was undertaken for lateral wedge corrective osteotomy at elbow, The lateral approach to the elbow between the flexor and extensor compartments was used to expose the site of osteotomy. When the perisoteum from the anterior surface of the lower humerus was lifted, some anomalous structure entering into the bone was noticed on the medial side of the supracondylar region. On further dissection it looked like neural tissue [], and was thought to be the median nerve. We attempted to make a window into the bone and free the nerve but it was seen that the nerve was severely entrapped in the bone and on our repeated attempts to remove it, it got transected. We planned to explore all the three nerves at the elbow to ascertain the identity of the nerve as its course was very aberrant. We explored both the median and the ulnar nerves and found them intact. We could not find the radial nerve in its normal course. Thus we got ascertained that the involved nerve was the radial nerve. We did the osteotomy as planned and closed the wound. The nerve was not repaired as it was found to be nonrepairable. Post operatively the function of both ulnar and median nerves was normal, but there was radial nerve palsy [Figure and ].\nThe elbow was mobilized after 1 month. At 2 months all implants were removed and tendon transfers for radial nerve palsy, namely, pronator teres to extensor carpi radialis brevis, palmaris longus to extensor pollicis longus, and flexor carpi radialis to extensor digitorum communis was done. With extensive physiotherapy, the patient regained all his functions at about 4 months postoperatively.

Case 2: A 23 year old male, presented with symptoms of crawling sensation and foreign body sensation in his right eye, and had observed a worm in this eye. He had no previous symptoms prior to his presentation. He gave a history of having worked in a cocoa farm plantation during his childhood years and had severally suffered from bites from unknown flies. He had no systemic symptoms nor signs and aside from his ocular complains was healthy. There was no swelling anywhere in the body and no itching. Upon ocular examination his visual acuity was 6/6 in both eyes. The only significant finding was the presence of an actively mobile worm in the nasal subconjunctival space of the right eye "". This worm soon migrated upwards towards the superior fornix and away from view during the examination and before removal could be attempted "". The patient was immediately asked to adopt a face down position and within 30minutes of this time; he could feel a crawling sensation again in the same eye indicating that the worm was back. He was quickly taken to the operating room and the worm was extracted successfully using a local infiltration of the conjunctiva with lignocaine anesthesia. Histological examination revealed it to be an adult Loa loa worm.\nCases 3: A 25 year old female who had suffered sensation of movement and foreign body sensation in both eyes for the past 10 years and gave a past history of swimming in rural streams during childhood years. There was no history of swelling on the body and no itching. She had noticed an increasingly frequent occurrence of a worm like movement in both eyes over these years. Following ingestion of diethyl carbamazepine she noticed a sudden appearance of a red patch in the right eye. Upon examination her visual acuity was 6/5 in both eyes. The only significant finding was a localized hyperemic raised lesion on the surface of the right eye. This turned out to be a subconjuctival worm in the inferotemporal subconjunctival space of the right eye. The worm was found to be lifeless and covered by a surrounding cyst wall "". Care was taken to dissect the conjunctival and subtenons tissue away from the encysted worm, which was carefully extracted with a toothless forceps. Conjunctival incision site was closed with interrupted sutures. Histology revealed an adult Loa loa worm.

A 9 year-old girl has been referred to our clinic because of popping in her right hip for 9 months. Her mother stated that the popping sound was so frequent and loud that was disturbing to the sleep of the family during the night for the last couple of months. Her mother had a normal pregnancy with vaginal delivery without any problem. According to the records, postnatal physical examination by pediatrician in hospital was normal. She was the first child of the family. There was no record of any congenital or connective tissue disease in the family. Past medical history of the patient was negative for trauma. Educational and school records were in normal range. According to the family history she did not have any problem until 9 months ago. The popping was started after separation of her parents. The patient was used to live with her mother afterward. Although the patient was able to produce popping voluntarily during the day but the chief complaint was the frequent and loud popping sound at night after falling asleep. The popping was painless. In physical examination there was no ligamentous laxity and the hip joints were painless, normal in range of motion and stable in all directions. We asked the patient to produce the popping. She positioned the right hip up to 90 degrees flexion and 15-20 degrees adduction, after doing a slight internal rotation we heard a sudden loud popping sound and hip was displaced in posterior direction. After dislocation she relocated the hip by external rotation and abduction. The maneuver was painless. Routine lab tests were normal. Pelvic and right hip radiographs were normal (, ). An anteroposterior radiograph after dislocation maneuver revealed hip dislocation with wide space between the femoral head and the acetabulum (). We discussed the problem and its nature with parents and referred the family to the psychological consultation. The family took part in sessions of family therapy. After 3 months the popping disappeared and did not recurred during 15 months of follow up period.

A 92-year-old man was referred to the department of oral and maxillofacial surgery on a two-week wait basis for assessment of an ulcer on the tongue (). History revealed that the ulcer had been present for two months, was painful and causing discomfort while swallowing. The patient had lost seven kilograms of weight in one month, and he attributed this to the inability to eat due to pain. He had no significant relevant medical history. Social history revealed that he had been a pipe smoker for many years and took moderate amounts of alcohol on a regular basis.\nClinical examination of the head and neck region revealed a 3 cm diameter indurated ulcer of the left posterior dorsum of the tongue. This ulcer was highly suspicious of malignancy. Examination of the neck revealed an ipsilateral solitary lymph node of 4 cm diameter in level 3 region. The patient was informed of the possible diagnosis of squamous cell carcinoma. He underwent urgent incisional biopsy under local anaesthesia, and the histopathology report was suggestive of an adenocarcinoma (). Additional immunohistochemistry performed on the specimen demonstrated that the adenocarcinoma expressed cytokeratin 20 but lacked cytokeratin 7. In addition, the large bowel marker CDX2 was positive, whereas the pulmonary marker TTF1, the thyroid marker, thyroglobulin, and the prostate marker, PSA, were all negative. This suggested that the presenting oral lesion was the first sign of a possible distant metastasis of a primary bowel carcinoma.\nThe patient underwent further investigations; chest X-ray, MRI head and neck, and CT chest and abdomen. The CT demonstrated a sigmoid carcinoma with local lymphadenopathy and also evidence of distant metastasis to right axillary, hepatic, intrapulmonary, retroperitoneal, brain, and bony disease to the thoracic vertebra. This patient was discussed in the head and neck multidisciplinary team meeting and subsequently referred to colorectal team for treatment. The colorectal team confirmed the presence of rectosigmoid tumour on colonoscopy that proved histologically to be a poorly differentiated adenocarcinoma. The patient was referred for palliation due to the extensive nature of his disease.

A 21-year-old female, a Saudi student, presented to the Otolaryngology Department as an outpatient complaining of a left upper maxillary alveolar progressive recurrent mass of six months. The mass had started as a small swelling over the left maxillary alveolar ridge where excision had been done accordingly in the dental office. One month later, the mass had reappeared with rapid growth and had never regressed until a facial bulge was visible. On further history, the patient did not mention any problems with swallowing or respiration, and her past medical history was insignificant with no chronic illness and no prior history of exposure to radiation or chemotherapy and no history of benign bone conditions. Regarding her family history, there was no genetic predisposition or other malignancies. Furthermore, surgical and dental history was insignificant with no pharmacological medications and no history of allergies or smoking.\nOn physical examination, an irregular mass on the left anterior maxillary alveolar ridge measuring around 2 x 2 cm (Figure ) with a missed upper lateral incisor was noted. The overlying mucosa was intact and there was no ulceration. There was no pus coming out of the mass and examination of the cervical lymph nodes revealed no abnormalities. Upon radiological workup, there was no evidence of distant metastasis or any signs of other abnormality.\nThe recurrence of the mass warranted further investigation as an initial differential of osteomyelitis or other mixed lesions. After obtaining the patient’s written consent, an incisional biopsy was performed under local anaesthesia where the histopathology showed high-grade (G3), chondroblastic osteosarcoma (Figure ).\nWhen we discussed the surgical options and treatment with the patient, she was reluctant to follow the treatment protocol and chose to seek a second opinion. After a few months, she presented with a slight increase in mass size (3 x 2 cm).\nA CT scan of the neck done on the same day showed a maxillary lesion with small growth (3 mm). The lesion was seen in the alveolar process of the left maxilla and appeared to be mostly lytic with no material or sunburst changes, while the lesion itself was seen between the left incisor and the left canine; meanwhile, the left lateral incisor was not seen (Figure ). Also, there was no extension into the anterior nasal septum or incisive canal, no superior extension to the submucosa of the left nasal cavity, and no invasion into the palate. The lesion was separate from the orbicularis aureus muscle with no infiltration of the skin and subcutaneous tissue. In addition, a diffuse bilateral mildly enlarged lymph node was noted at level 2A with a few subcentimetric occipital lymph nodes. The adenoid was enlarged, causing mild narrowing of the airway with no obstruction whatsoever. Further investigation was requested, and an MRI of the neck showed left maxillary alveolar ridge osteolytic soft tissue mass of around 3.3 x 1.8 cm extending superiorly to the inferior nasal apparatus (Figure ). Meanwhile, CT scans of chest, abdomen, and pelvis were ordered to exclude any other malignancies, and they showed no evidence of metastasis or lesions.\nRegarding the treatment regimen, the case was discussed in the tumor board and four cycles of neoadjuvant chemotherapy were given, which consisted of doxorubicin and cisplatin. The response to the chemotherapy was very good and the tumor size shrank substantially (Figure ). The chemotherapy was followed by left inferior maxillectomy with a 1.5-cm safety margin with tracheostomy and a left-sided supra-omohyoid neck dissection. Intraoperatively, the frozen section was taken post excision, which showed negative safety margins. With regard to reconstruction, it was carried by an obturator prosthesis, which was planned due to the unavailability of the plastic surgeon. Postoperatively, the patient was admitted to the ICU for a few days for close observation of respiration and, one week later, she was discharged home in stable condition and was advised to follow up with the Oncology Centre for adjuvant chemotherapy.\nThe final histopathology showed a tumor that measured 3.5 x 2.5 x 2.0 cm with extensive therapy-related effect (>99% necrosis) (Figure ) and negative margins. There was no lymphovascular invasion and all the resected lymph nodes were negative for malignancy. The final pathological staging post-surgery was T0N0M0. The patient received two further cycles of doxorubicin and cisplatin postoperatively, and she is still following up with the Oncology Center with no signs or symptoms of recurrence for three years.

A 29-year-old, G2P2 mother was diagnosed with blue rubber bleb nevus syndrome more than five years ago and has had two pregnancies while being treated with sirolimus. These children were small for gestational age at birth and are the focus of this case report. Upon diagnosis of this rare disorder, the patient was treated with oral sirolimus 2mg twice daily. Her cutaneous lesions resolved significantly at 6 months follow up. She had a flare up of the lesions when she discontinued treatment before preconception. Her family history is unremarkable. She conceived naturally at one year of sirolimus therapy through a non-consanguineous marriage. Both the partners are of average built and denied tobacco, alcohol or substance use. In view of the previous flare up history following preconception planning, she was advised to continue sirolimus by the treating physician. Prenatal care for the first pregnancy included an ultrasound for determination of gestational age and routine monitoring of possible side effects of sirolimus. Regular blood investigation revealed normal complete blood count, liver and renal functions, sugar and lipid profile. Routine antenatal checkup done at the rural health care center by the Health Assistant were uneventful. Records maintained in the prenatal care book showed normal blood pressure, maternal weight gain, height of fundus corresponding to gestational age and normal hemoglobin level. Fetal ultrasound done at 36 weeks of gestation at the district hospital by a sonographer technician revealed a single live fetus with adequate amniotic fluid and expected fetal weight corresponding to 34 weeks. In view of maternal medical condition, sirolimus therapy and suspected fetal growth restriction, the mother was referred to the tertiary hospital. No gross anomalies were noted on limited anomaly examination and umbilical artery doppler study was within the normal range for the gestational age. At 40 weeks, she delivered a normal live male newborn weighing 2200 grams (<10th percentile on the customized fetal growth chart) with Apgar score of 9 and 10 at 1 and 10 minutes respectively. The baby had poor suckling and presumed physiological jaundice which were managed with intravenous fluid and phototherapy. Neonatal bilirubin and hemoglobin levels were not recorded. At two years of life, the milestones recorded in the child health card were appropriate for the age. The second pregnancy was likewise conceived naturally while the mother was on sirolimus therapy. Early in this pregnancy she was informed of the risks of miscarriage, poor growth and birth defects. Antenatal check up at the rural health center was unremarkable. Although, referred to the maternal fetal medicine specialist at the national referral hospital, the couple could not make it due to Covid movement restrictions. A live, normal male newborn weighing 2400 grams (<10th percentile on the customized fetal growth chart) was delivered at 39 weeks with Apgar score of 9 and 10 respectively at 1 and 10 minutes respectively. The postnatal period was uneventful. The mother was advised to continue sirolimus following the delivery.

The patient is a pleasant 77 year old female who presented to the Neurology clinic to evaluate unexplained events of syncope. Incidentally, she reported cognitive difficulty over the one to two year period prior to first clinic visit; family history was positive for a sister with progressive dementia. Also, she reported an episodic right visual field event, with the first episode occurring 6 months prior that was relatively sudden when there was an alteration in vision that persisted raising concern for possible retinal ischemic event. Formal report by Radiology did not remark on the hemi-atrophy shown below in the occipital cortex and had no acute ischemic changes evident.\nShe had been followed closely by Ophthalmology, and was found to have right sided homonymous hemianopsia on exam which was confirmed by visual field test and had brain MRI which did not show any clear lesion other than small multiple nonspecific white matter lesions but also showed an asymmetrically larger posterior horn of left lateral ventricle with more prominent atrophy of left occipital lobe. She was not aware of her visual symptoms but later did admit that she cannot see well on her right side at times; this still did not compromise her daily activities and did not feel there was a significant visual field deficit. Her husband also confirmed that she had not had demonstrated any clear symptoms of right visual field deficit that was obvious to him. However, concern developed about her cognitive impairment on bedside cognitive function tests as well as clear right visual field symptoms with corresponding left occipital area atrophy, prompting further testing including a nuclear medicine brain SPECT prefusion scan as well as brain PET using the Florbetapir amyloid tracer (performed under informed signed consent as part of a research protocol approved by institutional IRB for the IDEAS trial).\nHumphrey field plots are shown in Figure 1; hemiatrophy of the visual cortex is shown by CT and MRI in Figure 2; reveals the functional defect for the left occipital cortex; shows no differences in the localization of the florbetapir tracer.\nDespite a major significant finding on exam, the patient still personally feels there is nothing obvious to her about a major defect in her vision. Clinical diagnosis remains as Alzheimer’s disease and has been given Donepezil and Memantine; additional new diagnosis established as Posterior Cortical Atrophy (PCA).

A 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. His past history is pediatric asthma. The diameter of his middle esophageal diverticulum was 47 mm, and the accumulation of contrast medium was observed in the diverticulum. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row (Fig. ), and the diverticulum mucous membrane was partially covered by adherent white matter that was unstained with iodine (Fig. ), and narrowband imaging which revealed type A. We performed a biopsy, and the pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient placed in the prone position and four trocars inserted into the right thoracic cavity. A 12-mm trocar was inserted into the fifth intercostal space on the posterior axillary line. Only the left lung was ventilated, and a pneumothorax in the right chest was created using CO2 gas at 6 mm. Twelve-mm trocars were inserted into the seventh and ninth intercostal spaces at the level of the inferior scapular angle. A 5-mm trocar was then inserted into the seventh intercostal space on the posterior axillary line. The thoracoscope was inserted via the 12-mm port in the ninth intercostal space at the level of the inferior scapular angle. The operator used the 12-mm port in the seventh intercostal space on the inferior scapular angle line and the 5 mm port in the seventh intercostal space on the posterior axillary line. The assistant used the 12-mm port in the fifth intercostal space on the posterior axillary line. The endoscope was inserted into the lumen of the upper thoracic esophagus before the patient was placed in the prone position and kept in the esophagus throughout the surgery. Confirmation of the middle esophageal diverticulum was easily achieved, but the area was difficult to exfoliate because the diverticular wall had adhered to the lymph nodes of the trachea bifurcation. To achieve a complete resection of the diverticulum, threads were placed on the oral and anal sides of the diverticulum, the threads were pulled. A thoracoscope was inserted via the 12-mm port in the fifth intercostal space on the posterior axillary line and the surgical stapler was inserted via the 12-mm port placed in the ninth intercostal spaces at the level of the inferior scapular angle, and the diverticulum was resected using two sets of the Tri-Stapler (Fig. ). A postoperative upper gastrointestinal contrast examination revealed no abnormalities (Fig. ). Oral intake was initiated on postoperative day 7, and he was discharged on postoperative day 12. The histopathological findings were a true diverticulum with a muscular layer and a highly inflamed mucosa. No malignant findings were seen (Fig. ). Postoperatively, the patient visited the hospital at 1 month, 3 months, 6 months, and 1 year after the surgery. He underwent gastrointestinal endoscopy and upper gastrointestinal contrast examination 1 year after the surgery. We found no evidence of recurrence of the esophageal diverticulum. We are planning to repeat the upper gastrointestinal endoscopy at 2 years after the surgery.

A 63-year-old man presented to the emergency room of another hospital with muscle weakness of the limbs after a cow struck his neck and chest. Magnetic resonance imaging of the cervical spine performed at that time revealed a dislocation of the 6th and 7th cervical vertebrae. An anterior internal fixation was conducted from the 6th cervical vertebra to the 1st thoracic vertebra on the day of the injury and a conservative treatment that involved maintaining a supine position was recommended. The patient was admitted to our hospital for rehabilitation treatment 99 days after the injury. The neurological level of injury was determined to be C5 according to the American Spinal Injury Association Impairment scale B. At that time, the patient was using an NG tube. A videofluoroscopic swallowing (VFS) test was attempted at 1 week after admission, but the test could not be performed because the patient could not remain in the required position. Hence, the test was performed 128 days after injury, after confirming that the patient could maintain the required position for the procedure. The oropharyngeal examination during the VFS test showed that the swallowing reflex and processes had progressed without any abnormal findings; therefore, the NG tube was removed and the oral feeding of a dysphagia diet was initiated.\nThe patient complained of swallowing during the feeding because of food stuck in the throat ; moreover, he experienced intermittent vomiting after the feeding. The ability to swallow at that time was estimated to be of grade 2 on the Functional Oral Intake Scale (FOIS) []. A laryngoscopy performed 3 days prior to the occurrence of symptoms revealed no abnormal findings like as laryngeal swelling. First, the patient underwent a surgery to treat a concomitant complaint of sore coccyx. Subsequently, an esophagogastroduodenoscopy (EGD) was performed 27 days after the initiation of oral feeding. This EGD indicated a stricture at 35 cm below the inferior pharyngeal constrictor muscle and was unable to reach beyond this point (). The patient had no history of dysphagia prior to his injury, received no medications inducing endoscopy or stenosis before or after the injury and had no history of medical irradiation. Therefore, his stricture was suspected to be related to the NG tube. The patient was kept in a sitting position of 45° and antiulcer medication was added. The following day, a computed tomography of the chest was performed to examine a transverse section of the esophageal stricture. No mediastinal mass was observed, but a diffuse submucosal edema was present at the left, upper lobar bronchus level of the esophagus and the lumen was narrowed. A balloon dilatation was performed to extend the stricture. EGD-guided insertions of balloon catheters were performed; twice at 1 kPa for 1 minute and twice at 2 kPa for 1 minute, thus achieving a dilation of approximately 7 mm. The resulting esophagogram revealed an increase of the stricture lumen diameter by 3 mm. The patient's symptoms improved, but recurred after 1 day; therefore, a follow-up esophagography was performed. The procedure revealed that the diameter of the stricture had increased after the procedure, but the stenosis still remained. Therefore, an esophageal resection and a reconstruction with the left colon were recommended. However, the patient and his family consented to the surgery, especially and particularly because it would be considered as high risk due to his history of flail chest. A high risk of postoperative complications was also expected. Thus, the balloon dilatation was performed for a total of 4 times at our hospital. After the last balloon dilatation procedure, the patient's symptoms improved to grade 4 on the FOIS scale and an extension of 5 mm was observed for the lumen of the esophageal stricture by esophagography (). After discharge from our hospital, the patient regularly received balloon dilatation at another hospital for a total of 5 times. Each of the dilations was done for one minute for two times, similarly to the procedure in our hospital. Currently, his esophageal stricture is extended to 11 mm in diameter and the swallowing symptoms he experiences during meals have improved to grade 6 on the FOIS scale ().

A 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. His past history is pediatric asthma. The diameter of his middle esophageal diverticulum was 47 mm, and the accumulation of contrast medium was observed in the diverticulum. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row (Fig. ), and the diverticulum mucous membrane was partially covered by adherent white matter that was unstained with iodine (Fig. ), and narrowband imaging which revealed type A. We performed a biopsy, and the pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient placed in the prone position and four trocars inserted into the right thoracic cavity. A 12-mm trocar was inserted into the fifth intercostal space on the posterior axillary line. Only the left lung was ventilated, and a pneumothorax in the right chest was created using CO2 gas at 6 mm. Twelve-mm trocars were inserted into the seventh and ninth intercostal spaces at the level of the inferior scapular angle. A 5-mm trocar was then inserted into the seventh intercostal space on the posterior axillary line. The thoracoscope was inserted via the 12-mm port in the ninth intercostal space at the level of the inferior scapular angle. The operator used the 12-mm port in the seventh intercostal space on the inferior scapular angle line and the 5 mm port in the seventh intercostal space on the posterior axillary line. The assistant used the 12-mm port in the fifth intercostal space on the posterior axillary line. The endoscope was inserted into the lumen of the upper thoracic esophagus before the patient was placed in the prone position and kept in the esophagus throughout the surgery. Confirmation of the middle esophageal diverticulum was easily achieved, but the area was difficult to exfoliate because the diverticular wall had adhered to the lymph nodes of the trachea bifurcation. To achieve a complete resection of the diverticulum, threads were placed on the oral and anal sides of the diverticulum, the threads were pulled. A thoracoscope was inserted via the 12-mm port in the fifth intercostal space on the posterior axillary line and the surgical stapler was inserted via the 12-mm port placed in the ninth intercostal spaces at the level of the inferior scapular angle, and the diverticulum was resected using two sets of the Tri-Stapler (Fig. ). A postoperative upper gastrointestinal contrast examination revealed no abnormalities (Fig. ). Oral intake was initiated on postoperative day 7, and he was discharged on postoperative day 12. The histopathological findings were a true diverticulum with a muscular layer and a highly inflamed mucosa. No malignant findings were seen (Fig. ). Postoperatively, the patient visited the hospital at 1 month, 3 months, 6 months, and 1 year after the surgery. He underwent gastrointestinal endoscopy and upper gastrointestinal contrast examination 1 year after the surgery. We found no evidence of recurrence of the esophageal diverticulum. We are planning to repeat the upper gastrointestinal endoscopy at 2 years after the surgery.

Case 2: A 23 year old male, presented with symptoms of crawling sensation and foreign body sensation in his right eye, and had observed a worm in this eye. He had no previous symptoms prior to his presentation. He gave a history of having worked in a cocoa farm plantation during his childhood years and had severally suffered from bites from unknown flies. He had no systemic symptoms nor signs and aside from his ocular complains was healthy. There was no swelling anywhere in the body and no itching. Upon ocular examination his visual acuity was 6/6 in both eyes. The only significant finding was the presence of an actively mobile worm in the nasal subconjunctival space of the right eye "". This worm soon migrated upwards towards the superior fornix and away from view during the examination and before removal could be attempted "". The patient was immediately asked to adopt a face down position and within 30minutes of this time; he could feel a crawling sensation again in the same eye indicating that the worm was back. He was quickly taken to the operating room and the worm was extracted successfully using a local infiltration of the conjunctiva with lignocaine anesthesia. Histological examination revealed it to be an adult Loa loa worm.\nCases 3: A 25 year old female who had suffered sensation of movement and foreign body sensation in both eyes for the past 10 years and gave a past history of swimming in rural streams during childhood years. There was no history of swelling on the body and no itching. She had noticed an increasingly frequent occurrence of a worm like movement in both eyes over these years. Following ingestion of diethyl carbamazepine she noticed a sudden appearance of a red patch in the right eye. Upon examination her visual acuity was 6/5 in both eyes. The only significant finding was a localized hyperemic raised lesion on the surface of the right eye. This turned out to be a subconjuctival worm in the inferotemporal subconjunctival space of the right eye. The worm was found to be lifeless and covered by a surrounding cyst wall "". Care was taken to dissect the conjunctival and subtenons tissue away from the encysted worm, which was carefully extracted with a toothless forceps. Conjunctival incision site was closed with interrupted sutures. Histology revealed an adult Loa loa worm.

A 36-year-old man, originally from Latin America, presented at our outpatient department with complaints of abdominal pain that had persisted for 2 months. The patient had first noticed right lateral abdominal pain 2 months prior to the visit, and the pain was gradually worsening. The abdominal pain was localized in an area ranging from the right upper to the right lateral abdomen. The patient had undergone cholecystectomy for acute cholecystitis as a 32-year-old in Latin America and had moved to Japan for work approximately 3 years prior to his initial visit to our hospital. He had returned to Latin America once about 6 to 7 months before presenting at our clinic. When he went back to Japan, his weight had increased from 130 kg to 145 kg. He did not experience abdominal pain immediately after his return to Japan, but, as noted above, he started to gradually feel pain in the right lateral region about 2 months prior to presentation.\nHe first visited another hospital emergency department 1 month after onset of the pain. Initially, gastrointestinal tract spasm was suspected, and he was treated with tiquizium bromide. Though the medication partially relieved his abdominal pain, most of the pain persisted. The result of a workup by a urologist was negative, even though nephrolithiasis was suspected. His abdominal pain was exacerbated upon changing posture, and thus it was suspected to be of somatic rather than visceral origin. Abdominal pain persisted despite treatment with loxoprofen sodium hydrate, and any cause of abdominal pain was not detected on further evaluations, including hematologic laboratory analysis, urine analysis, gastroscopy, or abdominal computed tomography (CT). Finally, he was referred to our hospital for further examination.\nThe results of screening for depression were negative, and the patient did not have symptoms such as loss of interest, depressed feelings, or any specific changes of surrounding conditions, such as family or work environment changes. He had no history of sexually transmitted infection, and his vital signs were within normal limits. His physical examination result was positive for Carnett’s test, and a prior surgical scar of approximately 18 cm was apparent at the right subcostal region. The patient experienced strong pain surrounding the surgical scar that was exacerbated by tapping. There were no skin rashes localized surrounding the pain. His pain exacerbated to 8 on a pain scale when he moved, such as during standing up or rolling over simultaneously. When he stopped moving, pain was partially relieved within 1 minute (3 on a pain scale). When he moved again, abdominal pain was again exacerbated. Hence, he was awakened by the abdominal pain when rolling over. No inflammation was detected (leukocyte count was 8580/mm3 and C-reactive protein was 0.10 mg/dl), and other laboratory findings were nonspecific, including liver/kidney function, blood glucose, and electrolytes. Urinary analysis indicated red blood cell count < 1/high-power field, white blood cell count 1–4/high-power field. Additionally, no abnormality was detected for Chlamydia trachomatis IgG/IgA, and no abnormality was apparent on the electrocardiogram. Enhanced CT revealed bilateral renal stones and fatty liver.\nWe first considered abdominal wall pain due to nerve entrapment because the Carnett’s test result was positive; therefore, we scheduled a trigger point injection at the site of tenderness. About 2 weeks later, the patient visited the emergency department of our hospital, reporting that his prior abdominal pain had decreased but that he was experiencing right inguinal pain. Loxoprofen administration had no effect on the pain. Costovertebral angle pain was apparent on tapping, the result of urine analysis was positive for occult blood, and abdominal CT revealed a urinary stone at the right urinary duct to the bladder. After pentazocine hydrochloride was administered for pain relief, the urinary stone was passed the following day. However, the patient’s right lateral abdominal pain was not relieved.\nHe felt that lying in the lateral position mostly relieved his pain. He had occasional vomiting. The abdominal pain was exacerbated by movements, such as rolling over, standing up, walking, and coughing. Injection of 1% xylocaine 10 ml at a trigger point of the right lateral region led to about 30% relief in pain. The patient was referred to an anesthesiologist for further evaluation and treatment, who performed transverse abdominal plane block and administered multiple analgesic medications (tramadol hydrochloride, pregabalin, celecoxib, and scopolamine butylbromide). These medications decreased the patient’s pain somewhat, and he reported that scopolamine butylbromide was most effective when the pain worsened. Because the patient’s symptoms were not relieved after trigger point treatment to the abdominal wall, we considered potential causes that might be associated with the location between the abdominal wall and visceral wall or related to other sources, including psychosocial, physiological, and other anatomical factors. We rechecked the abdominal CT scan for a suspected adhesion or abdominal hernia at the region of tenderness due to the prior surgical procedure, and we asked a radiologist to reevaluate the right upper abdomen in more detail. The radiologist confirmed a slight abnormality in the right upper abdomen and suggested the possibility of an adhesion around the surgical scar (Fig. ). We referred the patient to a gastrointestinal surgeon for laparoscopic evaluation and adhesiolysis. The patient underwent additional investigations, including cholecystocholangiography and colonoscopy for suspected postcholecystectomy syndrome, biliary dyskinesia, or colon abnormality. However, no cause of the abdominal pain was identified. On laparoscopic evaluation, a broad adhesion was observed. Adhesiolysis was performed 6 months after the patient first visited our hospital. Figure a shows adhesion between the peritoneum and omentum, liver, and ascending colon; Fig. b shows the condition after adhesiolysis. One month after adhesiolysis, the patient’s right abdomen pain level during movement improved from 8 to 2–3 on a pain scale. Therefore, he was able to move with less pain, and he did not feel pain when rolling over. The result of Carnett’s test was negative. After the patient started walking around his house, he felt abdominal pain about 5 minutes after walking. Hence, he was afraid of recurrence of abdominal pain and felt a little depressed and frustrated because he was unable to return to work early. We recommended a gradual increase in activity. He went on a trip 4 months after the operation without problems due to abdominal pain and then resumed his job 6 months after the operation.\nHowever, his abdominal pain deteriorated within 1 month after he resumed working. He presented with bleeding at the umbilicus, which was the laparoscopic port site, and abdominal incisional hernia was confirmed on the basis of CT. Repair of the abdominal incisional hernias and laparoscopic adhesiolysis were performed 8 months after the first operation. After the second operation, although it took time for some symptoms to improve because of surgical site infection, the patient’s symptoms were ultimately relieved, and he resumed his job again 5 months after undergoing the second operation. Although he reported mild abdominal pain and required analgesic medication, his weight decreased to 133 kg, and he was able to walk normally and work full-time, 2 years after he initially visited our hospital. The timeline of interventions and outcomes is shown in Additional file .

A 54-year-old right hand dominant Caucasian male cabinet maker was referred for evaluation and treatment of a left distal biceps tendon rupture that occurred 22 months before initial orthopedic evaluation. The patient reported that a heavy door to be installed at his job site fell toward him. He reached out with his left arm and tried to catch the door. As he did so, he felt an immediate sharp pain and tearing sensation in his left elbow. Over the next week, he noted the development of significant swelling and ecchymosis in the left forearm and elbow. He reported that injury to his employer, but was not referred for medical attention. He continued working despite the swelling and pain, relying mostly on his dominant arm to perform his job duties. Over the next several months, the patient noted increasing weakness of elbow flexion and supination and increasing deformity of his left biceps relative to the right side. On presentation, he reported he was unable to lift objects weighing more than 1—pounds and he was not able to flex or supinate his forearm without pain and weakness. He also reported muscle spasm in the left bicep muscle and significant atrophy of the left biceps muscle compared to the right. His main complaint was a profound weakness, specifically with supination, and to a lesser degree with elbow flexion, to the point where he was forced to rely on his right arm for both work-related activities and activities of daily living. He denied any prior history of elbow pain or weakness before his injury. Physical examination of the left upper extremity revealed an obvious deformity of the biceps with significant proximal retraction and atrophy of the muscle belly relative to the opposite side (). Maximum biceps circumference was 32.5 cm in the right arm compared to 29.5 cm in the left arm in the resting position. Palpation revealed tenderness over the biceps muscle belly, as well as over the antecubital fossa. There was also tenderness to palpation over the proximal radius and the radial tuberosity. The biceps tendon was not palpable at the musculotendinous junction or in the antecubital fossa. Range of motion (ROM) of the elbow was symmetric from 0 to 135° of flexion bilaterally. The patient reported pain with active but not passive ROM of the left elbow. He did not report pain with active pronation or supination of the forearm. Pronation and supination were90°, respectively, and were symmetric bilaterally. Strength testing revealed 3/5 strength with left elbow flexion and 3/5 strength with left elbow supination. Spasm of the biceps brachii was noted with attempted elbow flexion and supination against resistance. Sensory testing to light touch and pinprick revealed decreased sensation in the medial aspect of the forearm extending from the elbow to the distal 1/3 of the medial aspect of the forearm. Sensation on the lateral side of the forearm was intact. Anteroposterior, oblique, and lateral radiographs of the left elbow were unremarkable. Magnetic resonance imaging (MRI) scan of the left arm showed a chronic left distal biceps tendon rupture with 17 cm of retraction of the biceps tendon proximally. The retracted stump of the tendon was visualized at the junction of the middle and distal one-third of the humerus, surrounded by edema. There was also some evidence of lateral epicondylitis as well as an interstitial tear of the common extensor origin of the forearm involving 50% of the tendon thickness. An MRI of the elbow had not been obtained. Pre-operative assessment of elbow function utilizing Mayo Elbow Performance Index(MEPI) and disability of arm, shoulder, and hand questionnaire (DASH) [, ] was measured and compared with post-operative values used to evaluate clinical outcome. In the context of the patient’s symptoms, and in conjunction with the clinical and radiographic findings, surgical reconstruction utilizing Achilles tendon allograft augmentation through a two-incision anterior approach was recommended.

The case we present here is about a 40-year-old man who was referred to our pain clinic with severe ischemic pain of right lower limb. The pain started gradually 10 months back and became very severe for the last 1 month. The intensity of pain was increasing in both the sitting and lying down positions and decreasing in a standing position. Many non-steroidal anti-inflammatory drugs were tried earlier without much benefit. Over the last 1 month, the severity of the pain was so bad that the patient had to stand all the time and sitting or decubitus position was not tolerable even for 1 min. His sleep was so miserable that he had been taking small naps in that standing position leaning onto some support. He had carcinoma rectum for which he underwent abdominoperineal resection 8 years ago. There was history of smoking prior to that. After the surgery, he had been leading a near normal life driving auto rickshaw for a living until he developed the present problem. There were many gangrenous ulcers over his right thigh and leg. A computed tomography-angiogram was done previously that showed a thrombus in the right common iliac artery measuring about 9.5 cm extending up to the right superficial femoral artery with a near total occlusion of the lumen and poorly developed collaterals. He was scheduled for a conventional peripheral angiogram for deciding on the further plan. However, he could not lie down in the catheterization laboratory due to severe pain and was referred to our Department of Pain Management. We initially tried a conservative approach with a combination of oral pregabalin, diclofenac, paracetamol, and tramadol as per the standard dosage protocol for 2 days. When there was no satisfactory pain relief, we planned epidural analgesia. However, the problem here was the positioning. Patient was not able to tolerate either sitting or lateral decubitus position even for 1 min. He was somewhat comfortable only in the standing position. Considering the special situation, though not conventional, we decided to place the epidural catheter in that standing position. An intravenous line was started using an 18G venous cannula. Electrocardiogram, pulse oximeter, and non-invasive blood pressure monitors were connected. Patient was made to stand besides the operating table holding on to it for support. He was also supported by a technician from the front []. After painting and draping the back, L 4-5 inter-space was identified and local anesthesia was given with 2% lidocaine. Epidural space was engaged with 18G Tuohy needle using loss of resistance to air technique. The epidural catheter was carefully threaded and placed such that the length of the catheter was 5 cm in the epidural space. Catheter was gently aspirated to check for blood and cerebro-spinal fluid and was fixed after subcutaneous tunneling for about 5 cm []. Patient was reassured and gently placed on the operating table in the supine position. A quick test dose was given with 3 ml of 2% lidocaine with 15 mcg adrenaline confirming the epidural placement followed by a bolus of 10 ml of 1% lidocaine along with 1 ml of 7.5% sodium bicarbonate. The pain was relieved within 1 min and the vital signs were stable. Epidural infusion was maintained thereafter with a solution of 0.125% bupivacaine and dexmedetomidine 2 mcg/ml at the rate of 5 ml/h. Patient was very comfortable and slept peacefully. Next day peripheral angiogram was performed, which confirmed the findings of CT-angiogram. Balloon angioplasty was attempted after 2 days, but was not successful and an above knee amputation was performed subsequently. Epidural catheter was removed after 2 days and further pain control was achieved satisfactorily with oral medications.

Our patient is a 38-year-old male who presented with right chest wall and shoulder pain after a weight lifting injury. The patient was performing a one-rep max bench press when he felt a pop in his right upper arm, accompanied by severe pain. There was no history of anabolic steroid use. He was initially treated with ice and a sling by a trainer and presented to the emergency department for further evaluation. Plain films were negative for fracture or dislocation and the patient was neurovascularly intact, so he was discharged home by ER staff in the sling. He presented to the orthopedic clinic the following day with moderate pain in the chest and arm. He denied numbness and paresthesia. On physical examination, there was a large amount of swelling and ecchymoses throughout the right upper arm extending into the pectoralis major muscle belly. Additionally, there was a large bulge in the anterior chest with loss of contour of the axillary fold (). The patient had full active range of motion of the elbow, wrist, and digits. He was sensory intact throughout the right upper extremity with a 2+ radial pulse. An MRI was scheduled to determine the extent of the injury and to aid in surgical planning. The patient was given oxycodone and valium to alleviate the pain and muscle spasms until surgery, which was scheduled after his MRI. The MRI demonstrated avulsion of the pectoralis major tendon from its insertion on the humerus with retraction as well as strain of the anterior deltoid (Figures and ). He was scheduled for surgery in five days. Two days later, the patient returned to our facility with severe worsening pain in the right upper arm. Intracompartmental pressure readings in the anterior compartment of the arm taken about the midpoint of the biceps at the point of maximal swelling were 37, 39, and 42 mmHg with a diastolic blood pressure of 71 mmHg (). Thus, with a diagnosis of compartment syndrome confirmed, we proceeded to the operating room for an emergency fasciotomy with repair of the pectoralis major tendon rupture.\nAn extended deltopectoral approach was used, and the deltopectoral and biceps fascia were released. Immediately, a large amount of hematoma was expelled and the muscle bellies visibly bulged from the incision sites (Figures and ). All muscles still appeared viable. No apparent vascular damage was noted. Upon further dissection, both heads of the pectoralis major were found to be avulsed from the proximal humerus (). After preparation of the footprint with curette and rongeur, three double-loaded 4.5 mm Mitek suture anchors (DePuy Synthes, Raynham, MA) were placed lateral to the bicipital groove for the repair of the tendon. The proximal and distal suture anchors were used such that one suture of each was run in a Krakow fashion along the superior and inferior aspects of the tendon, respectively. The remaining suture from each of those anchors was passed in a horizontal mattress fashion medial to the Krakow stitches. The middle suture anchor was used to place a horizontal mattress stitch with a medial ripstop stitch (). The wound was irrigated, and a negative pressure dressing was applied. The patient was made nonweightbearing and placed in a sling with a circumferential strap to ensure adduction of the arm. The patient returned to the operating room four days later to undergo irrigation and debridement with a tension-free primary wound closure. He was again placed into his sling and given strict instructions to avoid abduction and external rotation of the arm. The patient did well postoperatively and was discharged home in a stable condition that same day with a one-week follow-up appointment. He continued to do well and was instructed to remain nonweightbearing in his sling for a total of 6 weeks before beginning formal therapy. Gentle stretching and passive range of motion were then begun, followed by strengthening exercises at the 12th week mark. At his four-month follow-up, the patient had active forward flexion of the shoulder to 150°, abduction to 150°, and external rotation of 50°. His rotator cuff, biceps, triceps, wrist extensors, wrist flexors, and interossei all demonstrated 5/5 strength. There were no sensory deficits on examination. He continues to attend therapy for motion and strengthening and has a lifting restriction of <5 pounds at work.

A 31-year-old man presented with severe episodic, lancinating right-sided facial pain in the distribution of the mandibular nerve and with less severity in the distribution of the maxillary nerve of 6-month duration. The pain was associated with numbness of the right side of his face, especially in the vicinity of the mandibular nerve which could be triggered with drinking cold water. Considering his poor orodental hygiene, decayed teeth had been diagnosed to be the cause of pain and lead to the extraction of several of the right upper and lower teeth while he was also treated with antibiotics for gingivitis for a long period of time.\nTwo days before admission, he developed generalized tonic colonic seizure. Neurological examination revealed bilateral papilledema and mild paresthesia detectable along the distribution area of the mandibular nerve especially over the labial commissure. MRI revealed a large right temporal mass with nonhomogenous postcontrast enhancement, invading the wall of the right cavernous sinus, and spreading down to the right CPA. The enhancing bundle in the right CPA was compatible with the thickened course of the fifth nerve extending to the surface of the pons [Figures and ].\nA right temporal craniotomy was performed and a solid fleshy tumor infiltrating the dura of the floor of the right temporal fossa and lateral wall of the cavernous sinus could be resected as much as possible. The deepest part of the tumor could be excised as a layer of the tumor infiltrating the surface of the cavernous sinus. We stopped just over the tentorium and no dissection was done beyond this point. The contrast-enhanced CT scan and MRI performed in the postoperative period revealed a minimal residual tumor in the right CPA, located along the course of the right trigeminal nerve [].\nThe postoperative course was uneventful and a histopathological examination revealed the tumor to be GBM. The patient received postoperative whole brain radiotherapy. Five weeks after surgery, the patient was pain free but numbness of the face persisted for another 6 months. The patient died 17 months after surgery with tumor recurrence.

The patient was a 61-day-old girl. She was born at a gestational age of 37 weeks and had a birth weight of 2.41 kg. She had a slightly high galactose concentration on mass screening for congenital metabolic abnormalities at 4 days of age. She was examined at another hospital at 13 days of age, when she exhibited white feces and a high circulating direct bilirubin concentration. Her gallbladder could not be identified by abdominal ultrasonography; therefore, biliary atresia was suspected. At the age of 39 days, bile excretion was not observed on hepatobiliary scintigraphy, and hepatobiliary scintigraphy at the previous hospital had not confirmed excretion into the intestinal tract. Due to the novel coronavirus pandemic and the circumstances of the family, her referral to our hospital was slightly delayed. The patient was admitted to our department at the age of 57 days and underwent exploratory laparotomy at the age of 61 days, when she was diagnosed with type III biliary atresia (the type of extrahepatic biliary obstruction was determined using the Japanese Society of Pediatric Surgeons Classification\n) using intraoperative cholangiography (\n) and underwent open KPE using the 8K UHD television system.\nA right subcostal laparotomy was performed and intraoperative cholangiography was performed via the atrophied gallbladder. Only the gallbladder could be detected, and the contrast agent leaked from the lateral aspect under compression. A diagnosis of type III biliary atresia was made on the basis of the cholangiographic and gross findings, and open KPE was performed.\nThe connective tissue in the portal region was dissected using Metzenbaum scissors at the level of the hepatic capsule, from the medial side of the left portal vein toward the medial side of the right portal vein, while applying gauze saturated with warm physiological saline to aid hemostasis.\nAt that time, the site of dissection was confirmed by examining the portal region using the camera of the 8K UHD laparoscopic system, and the biliary outflow site was examined after dissection. Bile outflow near the right hepatic artery was observed in 8K UHD mode (\n,\nand\n), but was not visible in high-definition mode (\n).\nThe jejunum was separated at a point 30 cm from the ligament of Treitz, an ascending limb of 40 cm in length was elevated in front of the colon, and portoenterostomy was performed. The jejunum was anastomosed to the\nporta hepatis\nusing 5–0 PDS II, which sufficiently covered the biliary outflow site (\n).\nThe biliary tract was reconstructed using the Roux-en-Y procedure, with the creation of a Nakajo-type enteric antireflux valve at a point 10 cm toward the liver from the Roux-en-Y limb and the Roux-en-Y limb was secured at an acute angle by suturing the seromuscular layer, to prevent food reflux. We performed an antireflux plasty using the intussuscepted valve Roux-en-Y procedure, according to the technique performed at Tohoku University Hospital.\nThe postoperative course was uneventful. Oral feeding was initiated on postoperative day (POD) 3, and the drain was removed on POD 6. Steroid administration was started, according to the protocol of the Japanese Biliary Atresia Society, on POD 7, and the patient was discharged on POD 17 with a total bilirubin concentration of 2.4 mg/dL. Thereafter, the patient was followed up on an outpatient basis, involving weekly attendance at the clinic during the immediate period following discharge, and once monthly visits when her blood parameters had normalized. She was initially followed up by both a pediatric surgeon and a pediatrician, but in the longer term she is being monitored principally by a pediatric surgeon. At the time of writing (POD 115), no cholangitis has been noted and her total bilirubin concentration is 0.5 mg/dL (\n).

This case features a 73-year-old male patient from the department of neurosurgery who experienced vomiting after taking medication on March 9, 2015. A physician could use the proposed system for this patient following the four steps outlined in . The six drugs amongst the list of drugs that the patient was taking on the symptom start date, were found to be related to vomiting according to the database. Among the six drugs, Tramadol HCI was the most highly ranked according to the decision tree model, and thus would have been recommended as the main culprit drug. In addition to the name of candidate drugs/substances, the system displayed more information on the drug such as the frequency and severity of the symptom. The physician could have chosen any drug from the list of recommendations based on past treatments and medications on the particular patient. In this case, the physician would have accepted the recommendation, and hence entered a prescription change for the selected drug in step 3. Finally, the physician would have reported the outcome of the prescription change a few days later, i.e., assessment of the causality between vomiting and Tramadol HCI as probable/likely (50%). This result would have been stored and used later for patients with symptoms and demographics similar to the ones of this patient.\npresents the decision tree and the rules that were used to provide the recommendations. This shows how the six drugs were ranked as listed in step 2 (), more specifically why Tramadol HCI was recommended as the most likely cause of an adverse event. According to the decision tree, medical department was the most important factor to identify ADE causative drugs. If we consider the case of the patients from the department of neurosurgery, there were only two patients in the same group as the patient of case 1 (i.e., age between 71 and 80 and gender=male) due to a limited dataset. While not enough data are available, the highlighted rule clearly shows that a patient similar to both of them may also have had vomiting after taking Tramadol HCI with 100% confidence.

A 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. His past history is pediatric asthma. The diameter of his middle esophageal diverticulum was 47 mm, and the accumulation of contrast medium was observed in the diverticulum. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row (Fig. ), and the diverticulum mucous membrane was partially covered by adherent white matter that was unstained with iodine (Fig. ), and narrowband imaging which revealed type A. We performed a biopsy, and the pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient placed in the prone position and four trocars inserted into the right thoracic cavity. A 12-mm trocar was inserted into the fifth intercostal space on the posterior axillary line. Only the left lung was ventilated, and a pneumothorax in the right chest was created using CO2 gas at 6 mm. Twelve-mm trocars were inserted into the seventh and ninth intercostal spaces at the level of the inferior scapular angle. A 5-mm trocar was then inserted into the seventh intercostal space on the posterior axillary line. The thoracoscope was inserted via the 12-mm port in the ninth intercostal space at the level of the inferior scapular angle. The operator used the 12-mm port in the seventh intercostal space on the inferior scapular angle line and the 5 mm port in the seventh intercostal space on the posterior axillary line. The assistant used the 12-mm port in the fifth intercostal space on the posterior axillary line. The endoscope was inserted into the lumen of the upper thoracic esophagus before the patient was placed in the prone position and kept in the esophagus throughout the surgery. Confirmation of the middle esophageal diverticulum was easily achieved, but the area was difficult to exfoliate because the diverticular wall had adhered to the lymph nodes of the trachea bifurcation. To achieve a complete resection of the diverticulum, threads were placed on the oral and anal sides of the diverticulum, the threads were pulled. A thoracoscope was inserted via the 12-mm port in the fifth intercostal space on the posterior axillary line and the surgical stapler was inserted via the 12-mm port placed in the ninth intercostal spaces at the level of the inferior scapular angle, and the diverticulum was resected using two sets of the Tri-Stapler (Fig. ). A postoperative upper gastrointestinal contrast examination revealed no abnormalities (Fig. ). Oral intake was initiated on postoperative day 7, and he was discharged on postoperative day 12. The histopathological findings were a true diverticulum with a muscular layer and a highly inflamed mucosa. No malignant findings were seen (Fig. ). Postoperatively, the patient visited the hospital at 1 month, 3 months, 6 months, and 1 year after the surgery. He underwent gastrointestinal endoscopy and upper gastrointestinal contrast examination 1 year after the surgery. We found no evidence of recurrence of the esophageal diverticulum. We are planning to repeat the upper gastrointestinal endoscopy at 2 years after the surgery.

A 75 year old lady was referred to the Orthopaedic Outpatients Department with a painless, slowly growing mass on the dorsum of the right wrist. She first noticed the swelling a year previously and attended her local doctor who felt it was a ganglion. Past medical history included hypertension, osteoarthritis, polymyalgia rheumatica and malunion of a right distal radius following a distal radius fracture sustained 5 months prior for which she declined surgical intervention (,). Clinical examination revealed a radially deviated wrist with a classic dinner fork deformity. There was a 6 X 9 cm round painless mass on the dorsum of the distal radius adherent to both the underlying structures and skin which did not transilluminate and with necrotic area of overlying skin (,). General physical e x a m i n a t i o n w a s u n r e m a r k a b l e w i t h n o o b v i o u s lymphadenopathy, no breast masses, no organomegaly and clear lung fields. Her right hand had capillary refill of under 2 seconds, palpable radial and ulnar pulses and normal sensory and motor exams. Mantoux test was negative making TB an unlikely cause. Blood count, renal and liver function were within normal range, ESR 74 (elevated), haemoglobin 11 g/dl. On ultrasound scan there was a large vascularised soft tissue mass infiltrating the tendinous structures on the dorsum of the right wrist. MRI of the wrist showed a large mass causing extensive osteolysis of the distal radius and extending proximally with abnormal replacement of the marrow in the distal one third of the radius. The soft tissue component of the mass involved the entire extensor tendon groups and infiltrated through the subcutaneous tissues to the dermis (,,). CT thorax abdomen and pelvis and whole body bone scan confirmed that this was an isolated lesion with no evidence of dissemination. The patient was brought to theatre for biopsy following consultation from the National Musculoskeletal Tumour Centre. Subsequent histopathological examination confirmed a B-cell non-Hodgkin lymphoma (diffuse large B-cell lymphoma -DLBCL- right wrist-stage 1EA). The patient was referred to the Haematology Service for further treatment and follow-up. She received chemotherapy (R-C H O P C6 plus Rituximab and R-CHOP C4) and radiotherapy (IFRT) with satisfactory results that caused the mass to shrink considerably (more than 50% after the first cycle of radiotherapy) and subsequent CT scans didn’t show any evidence of metastases. Despite her good response to the therapy, this lady died from causes not related to her primary diagnosis (pulmonary embolism).

A 68-year-old man with no significant medical problems was referred by his primary care physician with a 6-month history of a painful right hip. The pain was localized above the right hip joint and a mass with bony consistency was palpable just above the anterior superior iliac spine. On pelvic x-ray (Fig. ) an exostosis overlying the lateral superior border of the right iliac bone was seen and radiological features on magnetic resonance imaging scan (Fig. ) were in keeping with an osteosarcoma. Biochemical markers including a serum prostate specific antigen concentration was within normal limits. Subsequent biopsy and histopathological analysis of this lesion performed at the regional sarcoma centre showed this to be an adenocarcinoma of metastatic origin. On further staining there were features to suggest mucin production and it was positive for cytokeratin 20 (CK20) and caudal type homeobox transcription factor 2 (CDX2) suggesting a colorectal origin (Figs and ) thereby ruling out a sarcoma. CK20 is a marker of intestinal differentiation, and its expression is highly characteristic of colorectal primary. CDX2 protein is a member of the homeobox genes that encodes an intestine-specific transcription factor and it is an excellent marker for adenocarcinomas arising from the colon.\nStaging computerized tomography scanning of the chest, abdomen and pelvis (Fig. ) did not reveal a primary source but identified thickening of the ascending colon. A subsequent colonoscopy (Figs and ) identified this thickened area as a hepatic flexure adenocarcinoma with mucin production confirmed on histopathological analysis ( and ). Comparison with the histopathology from the bone biopsy confirmed that the bone lesion was a secondary deposit from the colonic adenocarcinoma. Our patient did not have any other clinical or radiological evidence of metastatic spread to other organs like liver, lung or indeed other bones. On further analysis of the colonic tumour it was found that there was no pathogenic mutation in the K-RAS and N-RAS gene.\nThis is a report of an unusual presentation of metastatic colonic cancer as a solitary bony lesion mimicking a sarcoma. The patient was subsequently referred to the local oncological services and has since been commenced on palliative chemotherapy. He has remained well, tolerated chemotherapy without undue side effects and is due a computed tomography scan to assess response to chemotherapy. Radiotherapy to the bony metastasis has been planned at a later stage.

We report the case of a 13-year-old boy who fell down during a skiing trip. He developed left hip pain that prevented him from weight bearing on the affected limb. The patient was Caucasian, had a body mass index (BMI)<20 and no history of endocrinopathy. The patient was evaluated by an orthopaedic surgeon who diagnosed him with an acute unstable SCFE and took the patient to surgery for a percutaneous in-situ fixation. The procedure was uncomplicated with appropriate center-center positioning of the screw within the head and epiphysis [ and ]. The patient returned home with his family at the conclusion of their vacation and followed up with a local orthopaedic surgeon (senior author).\nAt 3 weeks he was ambulating without difficulty when he developed recurrent pain and inability to weight-bear. New X-rays were obtained that demonstrated failure of the hardware with progression of the SCFE displacement, with a Grade 3 slip angle measured at 60 degrees [ and ]. The patient was taken back to surgery for hardware removal and revision closed reduction and percutaneous pinning of the SCFE. Surgical dislocation of the hip with hardware removal, open reduction and pinning was the also listed on the consent if the closed procedure failed. Insitu pinning and remodeling was deemed unlikely to have a successful outcome due to less then 3 years remaining until the patient turned 16 and the patient already achieving nearly the same height as his father and skeletally mature older brother.\nThe patient was brought to the operating room and placed on a fracture table in the supine position. Under fluoroscopic guidance minimal traction was applied to the left leg through the boot harness and the leg was internally rotated so that on both AP and lateral images the long axis of the screw shaft and the distal screw fragment within the epiphysis were co-axial. A guide wire was then threaded back through the screw allowing the cannulated screw driver to be easily seated within the screw head and the proximal screw fragment was removed.\nA cannulated Conical Extraction Screw (Synthes (r) Screw Extraction Set) commonly referred to as an “Easy Out” device () was then inserted over the guide-wire into the fractured distal screw fragment within the epiphysis through tract left after the removal of the proximal screw fragment. The sharp reversed threads of the of the Conical Extraction Screw / Easy Out allows this device to gain purchase in the fractured screw fragment and then back the screw fragment out. Once the screw fragment was removed from the epiphysis three trans physeal 7.0mm screws were placed for improved fixation strength of the SCFE.\nAt 2 weeks post-op the patient had all restrictions lifted and returned to normal activities without pain. Follow-up at 9 months demonstrated a fused physis and no signs of avascular necrosis of the femoral head.

A 73-year old female patient 150 cm tall and weighing 50 kg visited our hospital presenting with the complaints of lower back pain and radiating pain to right lower extremity. The lower back pain started when the patient fell down nine years ago. At first, mild lower back pain had occurred from time to time, but severe pain with a visual analogue score (VAS) of 8 or higher started to occur three months prior to her visit. The patient did not have any particular medical history except osteoporosis diagnosed in her late fifties. She felt pain as if her body was collapsing or sinking, accompanied by pulling pain at the hip and groin. The pain became more severe when standing up and moving, and relieved when lying down at rest. The physical examination showed tenderness at the first lumbar (L1) spinous process region. There were no abnormal findings in any other neurological examinations. The plain radiograph showed severe osteoporosis over the vertebral bodies, a severe compression fracture of the L1 vertebral body in which the anterior compression rate was 70% or higher, and an intravertebral vacuum cleft in the vertebral body (). Magnetic resonance imaging showed a low signal area of L1 in the T1 weighted image and a high signal in the T2 weighted image ().\nDespite conservative treatment for more than four weeks including continuous epidural pain control, the patient's pain did not decrease and she was rejecting surgical procedures such as a spinal fusion. Although the case was not a general indication of percutaneous vertebroplasty and kyphoplasty due to the severe collapse of the vertebral body, we decided to do transpedicular kyphoplasty using this method to block the cement outflow by slowly injecting highly viscous bone cement.\nBefore the procedure, cefazolin 1 g was intravenously injected to the patient as a preventive antibiotic. We had the patient take the prone position, supporting her abdomen with a pillow, in order to reduce abdominal lordosis. To check the patient's state during the procedure, we monitored the blood pressure, heart rate, and oxygen saturation, with supplement of oxygen through a nasal cannula. The skin on the area to be operated on was aseptically prepared and draped. For the sake of sedation and analgesia during the procedure, when needed, we injected fentanyl intravenously with a total of 100 µg. Using the C-arm image, we verified the pedicle of L1 and determined a working cannula implantation position and angle. Local infiltration anesthesia was performed with 1% lidocaine on the expected cannula implantation pathway. Under fluoroscopic C-arm guidance, we implanted the cannula into the fractured vertebral body through the vertebral pedicle. At the moment when the left cannula was inserted into the vertebral body, air flowed into the vertebral body with a popping sound, and the level of the vertebral body recovered spontaneously (). The cannula was also inserted into the right side, and balloons were inflated with a pressure of 50-100 psi to recover the level of vertebral body. Then, 4.5 ml of bone cement was slowly injected through each side of cannulas through the L1 vertebral body (). While injecting the bone cement, cement leakage out of the vertebral body was meticulously examined in both posteroanterior and lateral fluoroscopic views. The kyphoplasty was successfully implemented without cement leakage or clinical problems. The patient was discharged after the procedure without any particular abnormal findings. After the procedure, the VAS of the patient was 2, indicating that the preoperative pain almost disappeared. Currently, the patient during follow-up visits has not received any particular treatments except for the medication for osteoporosis.

A British Caucasian female patient aged 10 years and 11 months presented to our institution with a thoracic and lumbar scoliosis. She was noted to have the phenotypic features indicative of Smith-Magenis syndrome at the age of three years and the diagnosis was confirmed with chromosomal studies. There was no family history of syndromic conditions or scoliosis.\nThe development of a scoliosis was first noted at the age of 4 years and the patient was treated with an underarm spinal brace in another spinal centre. The deformity remained stable up to the age of 10 years when the curvature progressed rapidly as the patient started going through her pubertal growth spurt. During that stage, the brace was discontinued as the patient's compliance was very poor and any brace effectiveness was limited due to the fact that the patient was significantly overweight. At presentation to our clinic, she remained premenarchal with a body weight of 63 kg which was above the 95th percentile for sex- and age-matched normal population. Her arm span was 142 cm which was between the 25th and 50th percentiles for stature and her BMI was calculated to be 31.2.\nOn clinical examination, the patient was found to be very hyperactive. Overall, she had a balanced spine with level shoulders and pelvis despite a mild thoracic translocation to the right and no leg length discrepancy. However, she had a severe thoracic and lumbar deformity with a significant rib hump adjacent to the convexity of the thoracic scoliosis, as well as a marked waist line asymmetry with prominence of the pelvis on the concavity of the lumbar curve. There were no skin or soft tissue abnormalities overlying the spine. The patient was a community ambulator and had no neurological abnormality. Neurological examination showed normal tone, muscle power, sensation and tendon reflexes in the upper and lower limbs, as well as symmetrically elicited abdominal reflexes. There were no upper motor neurone signs.\nRadiographs of the spine during the initial assessment in our clinic revealed a right thoracic scoliosis extending from T4 to T10 and measuring 75° and a left lumbar scoliosis extending from T11 to L4 and measuring 65°. Both curvatures were rigid on supine maximum side-bending and traction radiographs. The radiological evaluation excluded the presence of congenital abnormalities in the development of the vertebral column and the chest wall. There were no features suggestive of congenital spinal stenosis and the interpedicular distance was within normal limits. The Risser grade was 0, indicating that the patient had a significant amount of remaining growth and this could result into further deterioration of her scoliosis.\nAn MRI of the spine demonstrated no intraspinal anomalies, normal appearance of the pedicles, no evidence of spinal stenosis, and normal kidneys. An ultrasound of the kidneys and the bladder did not elicit pathological findings. A cardiological examination showed normal cardiac function. A respiratory assessment did not identify any abnormality. An anaesthetic evaluation confirmed the fitness of the patient to undergo scoliosis surgery and excluded laryngeal anomalies that could complicate intubation. Blood tests demonstrated lower than normal immunoglobulin levels.\nOur patient underwent a posterior spinal arthrodesis extending from T3 to L4 with a double pedicle hook/screw and rod construct six months following initial clinical assessment and while the scoliosis had further progressed (Figure ). An interfacetal and intertransverse arthrodesis was performed bilaterally at every level across the instrumentation using iliac crest graft supplemented by allograft bone. Spinal cord monitoring was performed during the surgery recording somatosensory (SSEP) and motor (MEP) evoked potentials and there were no problems.\nContinuous arterial line blood pressure, as well as ECG monitoring was performed throughout the procedure. Central venous access was also placed to allow for rapid administration of fluids and blood products. Intraoperative blood conservation techniques were applied with the use of a cell saver. Three doses of a first generation cephalosporin were administered immediate preoperatively, at completion of surgery and eight hours later as per routine protocol in our institution.\nIn order to avoid problems related to patient's hyperactivity, as well as her tendency towards a self-injurious behaviour, the period of sedation and assistive ventilation after scoliosis surgery was electively prolonged. The patient was extubated three days following the procedure. During this initial postoperative period nutrition was maintained with nasogastric feeding. She was fitted with a plastazote spinal brace in order to provide additional support to the spine and limit spinal mobility. Six days following surgery, our patient developed a superficial dehiscence of the distal third of the spinal wound; this was treated with resuturing and healed without further problems. There was no sign of a wound infection and both the blood and wound cultures were negative.\nPostoperative radiographs showed correction of the thoracic scoliosis from 85° to 45° and the lumbar scoliosis from 80° to 40° with a balanced spine in the coronal and sagittal planes (Figure ). The patient was discharged 10 days after the initial procedure. At the latest follow-up four years following surgery, the patient had no complaints of her back and had a good level of activities within the limitations of her condition. She was skeletally mature as determined by the Risser grade which was 5. There was no loss of scoliosis correction across the instrumented levels and no detected pseudarthrosis. There was also no evidence of add-on deformity either above or below the levels of the spinal fusion.

A 32-year-old premenopausal female presented to the outpatient department in our hospital with a 1-year history of a mass in her right breast and eruption of the mass through the skin for last 3 months. She reported acceleration in the growth of the mass in the recent months. She also complained of pain and occasional bleeding from the mass. There was no personal or family history of breast cancer. The patient had noticed the mass more than one year before presenting but had sought help of alternative medicine (homeopathy) in her village and was on homeopathic medication for almost a year. The size of the lump did reduce initially, but she did not notice any improvement after a year of therapy; instead the mass grew more rapidly and erupted through the skin. She delayed medical attention because she was not comfortable discussing her condition. She sought help when the mass erupted through the skin and caused pain.\nPhysical examination presented a hanging mass which was ulcerated, having irregular surface and nodular appearance, occupying the lower and outer quadrant of the right breast (). The right breast was asymmetrically drawn down by the mass, which was firm in consistency and was found attached to the underlying structures by a stalk-like process. The mass bled on touch. There was no discharge from the nipple and retraction of nipple was also absent. There were no signs of skin involvement or axillary lymphadenomegaly. The left breast was normal.\nThe patient was subjected to diagnostic investigations which included routine as well as imaging and cytological modalities. Blood examination revealed no abnormality except mildly elevated ESR and all other parameters were within normal limits. Ultrasonography reported the mass as an exophytic growth with heterogeneous echotexture and vascularity. Chest X-rays and abdominal ultrasound were performed which showed no abnormality. Fine-needle aspiration cytology was inconclusive. We suspected a case of Phyllodes tumor owing to the nature and rapid growth of the breast mass and planned an excisional biopsy. The patient underwent wide excision of the mass under general anesthesia; we took a one-centimeter margin from the clinically palpable periphery of the tumour (Figures and ). The resected specimen was 9.5 × 8.5 × 4.5 cm in size and the tumor was not invasive to the surrounding tissues. The specimen was sent for histopathology macroscopic examination evidenced a nodular mass with irregular and ulcerated surface. The anatomopathologic analysis of the surgical specimen revealed epithelial-lined cystic spaces into which the hypercellular stroma was projected, the stroma cellularity was low with mild pleomorphism and low mitotic activity, features compatible with benign Phyllodes tumor (), confirming the initial diagnosis.\nThe post-operative course of our patient was uneventful, and she was discharged on 10th post-operative day in a fairly good condition. Regular follow-up was advised and subsequently the patient was seen every three months and a clinical examination was carried out. Nine months after surgery, no recurrence was reported.

Our patient is a 38-year-old male who presented with right chest wall and shoulder pain after a weight lifting injury. The patient was performing a one-rep max bench press when he felt a pop in his right upper arm, accompanied by severe pain. There was no history of anabolic steroid use. He was initially treated with ice and a sling by a trainer and presented to the emergency department for further evaluation. Plain films were negative for fracture or dislocation and the patient was neurovascularly intact, so he was discharged home by ER staff in the sling. He presented to the orthopedic clinic the following day with moderate pain in the chest and arm. He denied numbness and paresthesia. On physical examination, there was a large amount of swelling and ecchymoses throughout the right upper arm extending into the pectoralis major muscle belly. Additionally, there was a large bulge in the anterior chest with loss of contour of the axillary fold (). The patient had full active range of motion of the elbow, wrist, and digits. He was sensory intact throughout the right upper extremity with a 2+ radial pulse. An MRI was scheduled to determine the extent of the injury and to aid in surgical planning. The patient was given oxycodone and valium to alleviate the pain and muscle spasms until surgery, which was scheduled after his MRI. The MRI demonstrated avulsion of the pectoralis major tendon from its insertion on the humerus with retraction as well as strain of the anterior deltoid (Figures and ). He was scheduled for surgery in five days. Two days later, the patient returned to our facility with severe worsening pain in the right upper arm. Intracompartmental pressure readings in the anterior compartment of the arm taken about the midpoint of the biceps at the point of maximal swelling were 37, 39, and 42 mmHg with a diastolic blood pressure of 71 mmHg (). Thus, with a diagnosis of compartment syndrome confirmed, we proceeded to the operating room for an emergency fasciotomy with repair of the pectoralis major tendon rupture.\nAn extended deltopectoral approach was used, and the deltopectoral and biceps fascia were released. Immediately, a large amount of hematoma was expelled and the muscle bellies visibly bulged from the incision sites (Figures and ). All muscles still appeared viable. No apparent vascular damage was noted. Upon further dissection, both heads of the pectoralis major were found to be avulsed from the proximal humerus (). After preparation of the footprint with curette and rongeur, three double-loaded 4.5 mm Mitek suture anchors (DePuy Synthes, Raynham, MA) were placed lateral to the bicipital groove for the repair of the tendon. The proximal and distal suture anchors were used such that one suture of each was run in a Krakow fashion along the superior and inferior aspects of the tendon, respectively. The remaining suture from each of those anchors was passed in a horizontal mattress fashion medial to the Krakow stitches. The middle suture anchor was used to place a horizontal mattress stitch with a medial ripstop stitch (). The wound was irrigated, and a negative pressure dressing was applied. The patient was made nonweightbearing and placed in a sling with a circumferential strap to ensure adduction of the arm. The patient returned to the operating room four days later to undergo irrigation and debridement with a tension-free primary wound closure. He was again placed into his sling and given strict instructions to avoid abduction and external rotation of the arm. The patient did well postoperatively and was discharged home in a stable condition that same day with a one-week follow-up appointment. He continued to do well and was instructed to remain nonweightbearing in his sling for a total of 6 weeks before beginning formal therapy. Gentle stretching and passive range of motion were then begun, followed by strengthening exercises at the 12th week mark. At his four-month follow-up, the patient had active forward flexion of the shoulder to 150°, abduction to 150°, and external rotation of 50°. His rotator cuff, biceps, triceps, wrist extensors, wrist flexors, and interossei all demonstrated 5/5 strength. There were no sensory deficits on examination. He continues to attend therapy for motion and strengthening and has a lifting restriction of <5 pounds at work.

We report the case of a 42-year-old woman who underwent orthotopic renal transplantation for the first time, using a kidney from her sister. The patient had developed end-stage renal disease secondary to lupus nephritis. She had a medical history of bilateral thrombosis of both common and external iliac arteries due to lupus anticoagulant and antiphospholipid antibodies that had required bilateral percutaneous angioplasty with wall stenting. The medical workup had documented thrombosis of both iliac veins and of the lower portion of the lower part of the inferior vena cava as well as extensive atherosclerotic lesions of the abdominal aorta. In addition, she had a history of mitral valve replacement with a St. Jude prosthetic valve and received anticoagulation therapy with acenocoumarol.\nThe patient had an HLA semi-identical sister who was willing to donate a kidney. The donor workup had documented a slightly lower tubular mass of the right kidney which was chosen for procurement. The “classic” extraperitoneal pelvic transplantation of a kidney graft was contraindicated because of stented iliac arteries and extended atheromatosis of the aorta (). An alternative surgical technique with the transplantation of the graft into the location of a native kidney was proposed to the recipient and her sister who both consented to the procedure. Mapping CT-angiography of the recipient showed that the left renal artery was appropriated for anastomosis with the graft artery. At the same time the anatomical variant of the left recipient renal vein was found with low implantation to vein cava inferior (VCI; ).\nThe graft was procured by laparoscopic right donor transperitoneal nephrectomy with utilization of linear stapler Endo-GIA as previously described []. The warm ischemic time was 3 minutes measured from the first clip applied to the renal artery until the kidney was perfused with preservation solution. The graft was cold flushed with HTK solution and preserved on ice during the left nephrectomy of the recipient. The total duration of the donor nephrectomy was 95 minutes and total blood loss due to the procedure was 25 mL. The donor was discharged at day 4 after the nephrectomy.\nThe recipient was placed in a modified lateral decubitus position and flexed for hyperextension of the left flank. Pneumoperitoneum was established via a Veress needle placed two fingerbreaths below the left costal margin, at the level of the lateral border of the rectus muscle, which was replaced by a 10 mm port for a 0-degree lens optic. Under direct vision the 10 mm trocar for a bipolar grasper, two 5 mm trocar for the monopolar scissors and for a suction device were inserted. The descending colon and the spleen were dissected from the underlying Gerota's fascia. Following the medial mobilization of the colon and the mesocolon, the gonadal vessels were visualized and preserved during operation. The fatty tissue at the level of the lower pole of the kidney was incised and lifted to locate the psoas muscle. By tracking the cephalic course of the ureter, the plane was followed up to the renal pedicle. The left renal vein is dissected and gently displaced till its low implantation in VCI to expose the required length and visualize lumbar and adrenal branches. At this level, the left renal artery was dissected and exposed from its origin to the first bifurcation. The adrenal gland was preserved and separated from the kidney. The posterior and lateral attachments of the kidney to the abdominal wall are released by blunt and sharp dissection. Then two trocar ports under the left costal margin were joined by a 2.5 inch (6 cm) incision to access the left recipient kidney. The kidney was attached only to the hilum. The artery and the vein were clamped using bulldog clamps and the pedicle was divided close to the hilum. The ureter was sectioned at the level of the pyeloureteral junction and the kidney was removed.\nThe native renal vessels were found to be sufficient and were used for the end-to-end anastomoses with prolene 6/00 for the artery and prolene 5/00 for the vein.\nThe left native ureter was then spatulated and anastomosed in an end-to-end fashion to the transplant ureter with vicryl 3–0, over double J stent. A lombonephropexy of the graft was performed and a silicone Jackson-Pratt drain was inserted. The abdominal wall was closed using running vicryl 2–0 suture for the peritoneum, interrupted vicryl 0 suture for the muscle, and running vicryl 1 for the aponeurosis, and the skin incisions were closed with intradermal suture. The second warm ischemia time was 17 minutes and blood loss in the recipient was 15 mL.\nAt the moment of transplantation, the patient had maintenance immunosuppression with azathioprine and steroids for her systemic lupus erythematosus. Basiliximab and tacrolimus were added for prevention of acute graft rejection. The patient had delayed graft function up to day 4 but did not require renal replacement therapy because of the residual function of her native kidney. Anticoagulation consisted first of low molecular weight heparine (enoxaparin 20 mg per day) with resumption of acenocoumarol on postoperative day 6. The only medical complication was a urinary infection with Pseudomonas Aeruginosa treated with ciprofloxacine. The patient left the department two weeks after transplantation with a serum creatinine of 1.2 mg/dL. The double-J stent was removed 4 weeks after transplantation. Three months after transplantation a control angio-MRI showed normal a normal kidney and graft vessels (). At this moment the serum creatinine level and glomerular filtration rate were 1.0 mg/dL and 58 mL/min/1.732, respectively.

A 1-month-old female infant attended a private dental office accompanied by her mother for the presence of two teeth since the child's birth. The mother complained that the teeth were making breastfeeding difficult, irritating the infant who could not manage to suck and then cries continuously. The medical history did not reveal any abnormalities and the patient did not use any medication at presentation.\nIntraoral examination revealed two natal teeth in the mandibular anterior region and an ulcerated lesion on the ventral surface of the tongue (). The lesion had a diameter of 8 mm and was located at the midline anterior portion of the ventral surface of the tongue and seemed to have the impression of the teeth on its center due to repetitive trauma resulting from raking movements of the tongue against the anterior natal teeth leading to the clinical diagnosis of Riga-Fede Disease.\nThe mother refused permission to perform radiographic examination and tongue biopsy of the child; thus it was not possible at the time to identify if the teeth were supernumerary or regular primary teeth and the histopathological diagnosis of the lesion was not executed.\nThe tooth located on the left side presented grade II mobility, with risk of displacement and consequent swallowing or aspiration, leading to the option of surgical removal (). The tooth on the right side with regular mobility was preserved. To prevent the repetition of the trauma on the tongue and to allow wound healing, a small increment of glass ionomer cement was added, covering the cutting edge of that tooth. After carrying out the procedures, the baby was put to breastfeed and the mother reported she was able to suck for a longer period, calming them both. The mother was also instructed to carry out hygiene of the child's tongue wound with saline solution.\nThe patient returned after five days showing a good healing of the lesion. After fifteen days, it was completely healed (). After one year of follow-up, clinical and radiographic control were performed (Figures and ). At the time it was confirmed that the natal teeth were regular primary teeth and there were no signs of recurrence of the lesion.\nThe patient's mother consented to the publication of the child's information along with her photographs and radiographs.

Our patient is a 38-year-old male who presented with right chest wall and shoulder pain after a weight lifting injury. The patient was performing a one-rep max bench press when he felt a pop in his right upper arm, accompanied by severe pain. There was no history of anabolic steroid use. He was initially treated with ice and a sling by a trainer and presented to the emergency department for further evaluation. Plain films were negative for fracture or dislocation and the patient was neurovascularly intact, so he was discharged home by ER staff in the sling. He presented to the orthopedic clinic the following day with moderate pain in the chest and arm. He denied numbness and paresthesia. On physical examination, there was a large amount of swelling and ecchymoses throughout the right upper arm extending into the pectoralis major muscle belly. Additionally, there was a large bulge in the anterior chest with loss of contour of the axillary fold (). The patient had full active range of motion of the elbow, wrist, and digits. He was sensory intact throughout the right upper extremity with a 2+ radial pulse. An MRI was scheduled to determine the extent of the injury and to aid in surgical planning. The patient was given oxycodone and valium to alleviate the pain and muscle spasms until surgery, which was scheduled after his MRI. The MRI demonstrated avulsion of the pectoralis major tendon from its insertion on the humerus with retraction as well as strain of the anterior deltoid (Figures and ). He was scheduled for surgery in five days. Two days later, the patient returned to our facility with severe worsening pain in the right upper arm. Intracompartmental pressure readings in the anterior compartment of the arm taken about the midpoint of the biceps at the point of maximal swelling were 37, 39, and 42 mmHg with a diastolic blood pressure of 71 mmHg (). Thus, with a diagnosis of compartment syndrome confirmed, we proceeded to the operating room for an emergency fasciotomy with repair of the pectoralis major tendon rupture.\nAn extended deltopectoral approach was used, and the deltopectoral and biceps fascia were released. Immediately, a large amount of hematoma was expelled and the muscle bellies visibly bulged from the incision sites (Figures and ). All muscles still appeared viable. No apparent vascular damage was noted. Upon further dissection, both heads of the pectoralis major were found to be avulsed from the proximal humerus (). After preparation of the footprint with curette and rongeur, three double-loaded 4.5 mm Mitek suture anchors (DePuy Synthes, Raynham, MA) were placed lateral to the bicipital groove for the repair of the tendon. The proximal and distal suture anchors were used such that one suture of each was run in a Krakow fashion along the superior and inferior aspects of the tendon, respectively. The remaining suture from each of those anchors was passed in a horizontal mattress fashion medial to the Krakow stitches. The middle suture anchor was used to place a horizontal mattress stitch with a medial ripstop stitch (). The wound was irrigated, and a negative pressure dressing was applied. The patient was made nonweightbearing and placed in a sling with a circumferential strap to ensure adduction of the arm. The patient returned to the operating room four days later to undergo irrigation and debridement with a tension-free primary wound closure. He was again placed into his sling and given strict instructions to avoid abduction and external rotation of the arm. The patient did well postoperatively and was discharged home in a stable condition that same day with a one-week follow-up appointment. He continued to do well and was instructed to remain nonweightbearing in his sling for a total of 6 weeks before beginning formal therapy. Gentle stretching and passive range of motion were then begun, followed by strengthening exercises at the 12th week mark. At his four-month follow-up, the patient had active forward flexion of the shoulder to 150°, abduction to 150°, and external rotation of 50°. His rotator cuff, biceps, triceps, wrist extensors, wrist flexors, and interossei all demonstrated 5/5 strength. There were no sensory deficits on examination. He continues to attend therapy for motion and strengthening and has a lifting restriction of <5 pounds at work.

This is unique case of a young 23 years old middle Eastern female who developed an acute unilateral eye pain and generalized headache with visual disturbances associated with fatigue and weakness in lower extremities for two days. She presented to a local community hospital and was examined by a neurologist. Physical examination revealed an exaggerated deep tendon reflexes and sustained clonus of extensor plantar responses. Ophthalmologic examination was normal. A spinal tap was performed in the neurologist office with a 22 gauge Quincke spinal needle between the third and fourth lumbar spaces after the first attempt with free flow of clear cerebral spinal fluid (CSF). This fluid was analyzed for IgG, albumin, and oligoclonal banding to confirm the diagnosis of multiple sclerosis (MS), and a magnetic resonance imaging (MRI) of the brain was also obtained. All laboratory tests confirmed the diagnosis of MS. Patient returned home with follow-up appointment in 2 days. She later developed severe headache 10 hours after returning home. Headache was more localized to the back of the head and worsened with ambulation. Patient returned to the neurologist office the next day and was prescribed acetaminophen with bed rest. Nevertheless, she continued with severe headache on ambulation. In addition, she experienced dizziness and neck stiffness for the next 7 days. Follow-up evolutions and repeat physical examination revealed similar findings. Patient family remained concerned and decided to travel to the USA for additional treatment and consultation. She completed an 18 hours flight from her home town to the USA in a sitting position. At the completion of her journey, she experienced severe occipital and frontal headache associated with nausea/vomiting with neck stiffness and back pain. The pain intensity increased particularly during aircraft takeoff. Upon landing at airport, she had to be transported by a wheel chair to her car. She was seen the next day by another neurologist in the USA and after a complete examination was diagnosed with PDPH and repeated MRI of brain was completed at the same day (). She was prescribed complete bed rest, oral analgesics, caffeine 300 mg orally. She was seen again in 72 hours with similar complain of occipital headache worse on ambulation and was referred to a pain clinic for epidural blood patch. An appointment was scheduled for her with an anesthesiologist 4 weeks later after obtaining insurance coverage. An epidural blood patch was performed by withdrawing 20 mL of blood from the right antecubital vein under aseptic condition. At the same, the epidural space was identified between the third and fourth lumbar vertebrate space using the loss of resistance technique. Subsequently, 20 mL of blood was injected into the epidural space. She had an immediate relief of her headache and was able to ambulate to her car without difficulty.

The patient was a 10 year-old boy with a height of 128 cm and a weight of 36 kg who complained of pain in the right lower abdomen. He was diagnosed with appendicitis, and it was decided to do an appendectomy. He had been diagnosed with grade 3 mental retardation at age 4 although an exact diagnosis was not possible because a DNA test was not done. However, the parents were planning for a second child and had a DNA test done in England when the patient was 10 and confirmed an 8p23 deletion. According to the past history, there were no abnormalities that accompanied the genetic disorder such as asthma, and DNA tests were done on the parents for a family history but all were normal. Based on the physical exam, the patient exhibited the characteristic facial features of microcephaly with a broad nasal bridge, short neck, and high arched palate. According to the airway examination, the interincisional distance was approximately 3 cm and the thyromental distance was approximately 5 cm when the mouth was opened at its widest maximum. The Mallampati airway classification was grade 3 and difficulty in intubation was predicted; there were no limitations in neck movement and there were no loose teeth but they were irregular. In an echocardiography conducted at another hospital, the patient had no heart problems that can accompany 50% of the people with deletion 8p23 syndrome, and there were no indication of Ebstein's malformation and TOF. No abnormalities were found in the blood tests or computed tomography (CT) done before surgery. The patient exhibited severe mental retardation and although simple communication was possible, he was not able to use language properly. The patient responded impulsively and showed destructive and aggressive behavior characteristic to this syndrome when moving to the operating bed such as pulling hair and kicking with his feet.\nBlood pressure before anesthesia was 125/70 mmHg; heart rate was 115 beats/min; oxygen saturation was at 100%, and the ECG was normal. In the emergency room before coming up to the operating room, a 22 G intravenous access was prepared on the right upper extremity but no medication before anesthesia was administered. As intubation was predicted to be difficult, a video glidescope was additionally prepared as well as a McCoy laryngoscope. Before proceeding with anesthesia, preoxygenation was done with 100% oxygen for several minutes. 50 µg of fentanyl and 150 mg of pentothal sodium was IV injected and mask ventilation was started with 4.0 vol% sevoflurane and 100% oxygen. After checking that the mask ventilation was operating properly, 30 mg rocuronium bromide was administered for rapid sequence intubation while Sellick's maneuver was done due to the risk of respiratory aspiration. After a minute, proper muscle relaxation was verified and the glottis were exposed using a Macintosh laryngoscope. Grade 3 in Cormack and Lehane airway classification was confirmed, and although intubation of an endotracheal tube with 6.5 mm envelope was attempted, it was unsuccessful so the video glidescope was used to carefully intubate an endotracheal tube with inserted stylet. Directly after intubation, blood pressure was 130/88 mmHg; heart rate was 100 beats/min, and oxygen saturation was at 100%. Mechanical ventilation was started with volume controlled ventilation with a 400 ml tidal volume and a respiratory rate of 15/min, while maintaining anesthesia with 50% oxygen/N2O and 1.0-2.0 vol% of sevoflurane. The operation lasted a total of 1 hour and 35 minutes and 200 ml of Ringer's lactate solution was supplied. There were no abnormalities during surgery and after the surgery had finished, 7.5 mg of pyridostigmine and 0.3 mg of glycopyrrolate was IV injected to contend with muscle relaxation. Spontaneous respiration was induced to confirm stable respiration. After confirming that the tidal volume was more than 5 ml/kg, the patient responded to the command to open his eyes, which indicated that he was awake. Then, extubation was done, followed by 100% oxygen through a mask while checking the recovery of consciousness and muscle motility. Afterwards, the patient was transferred to the recovery room. Respiration was regular in the recovery room but the patient displayed excessive behavior and impulsive responses shown before the anesthesia so 4 mg of nalbupine was IV injected and he was stabilized. Oxygen saturation and blood pressure were all normal.

This is regarding a 54-year-old Hispanic male with no significant past medical or surgical history other than left-sided TN. He first developed this disease in 2019, and at that point was started on carbamazepine 400 mg twice daily. This worked reasonably well to control his neuralgic pain and he was able to continue doing his job until later part of 2020, when he started seeing his primary care physician more frequently. His symptoms gradually became more pronounced and frequent. He was now no longer able to work his usual job and had severe frequent intermittent episodes of left-sided facial pain. He subsequently had minimal oral intake and was barely able to sleep enough. By this time, his PCP had maximized his dose of carbamazepine but it failed to achieve any improvement. An outpatient trial of gabapentin, phenytoin, opioids, and NSAIDs had also been unsuccessful. In a span of 10 days, he had three ER visits before he was finally hospitalized with intractable pain and subsequent suicidal ideations. Family history of chiari malformation was reported in one of the siblings. His physical exam on initial presentation included normal vital signs. Neurological examination was pertinent with hyperalgesia reported along with the left lower V1 and throughout the entire left V2 cranial nerve distribution.\nMany therapeutic interventions were tried, including escalating doses of intravenous opioids, fosphenytoin loads and subcutaneous triptans but with minimal relief. He eventually required sedation with benzodiazepines to control pain and severe suicidal thoughts. After five days of different therapeutic interventions with no significant benefit, patient was transferred to a tertiary level care facility under the care of neurology and internal medicine. Upon arrival to the facility, a trial of ketamine infusion was attempted immediately but had to be stopped due to development of hallucinations. A trigeminal nerve block was attempted but gave minimal and transient relief only.\nIn the interim patient had multiple imaging studies conducted, including Brain MRI and CT angiogram none of which truly identified an etiology. Given refractoriness to medical interventions, neurosurgical team was approached. Patient eventually underwent left retro mastoid suboccipital craniectomy and intraoperatively the left superior cerebellar artery was found to adhere to the inferior ventral aspect of the left trigeminal root entry zone. Lysis of arachnoid adhesions was performed to separate this vessel and relocation to a more ventral lateral position, thereby achieving microvascular decompression. Postoperatively, patient was noted to have a dramatic improvement in his left-sided neuralgic pain and had discomfort over the surgical site only. He was monitored in the intensive care unit for about 24 hours and was discharged to home. A brief follow-up was done over the phone with the patient into four months following surgery. To this point, his symptoms have not recurred.

A 21-month-old boy visited the hospital with a complaint of pain and redness at the right helix with an enlarged mass. A mass on the ear had existed from birth, and the size of the mass had recently shown a slight increase. The patient had no history of trauma, family history, or other associated abnormalities. On the physical examination, an obviously raised lump measuring approximately 2×2 cm in size was found at the upper part and back of the helix. The surface of skin on the mass appeared to be normal, except for a slight redness and skin findings of fistula or skin adhesions were not observed. Because this patient is a child, surgery was performed under general anesthesia with an incision parallel to the auricle and parallel to the longitudinal axis of the mass at the back of helix. Because adhesion of helix cartilage to surrounding tissues was minimal, the skin covering the mass was raised easily. Helix cartilage on the mass was removed easily, however, an unusual depression was found on the helix cartilage. The mass was encapsulated; it was a cystic mass and cheese-like sebum was observed during dissection.\nHistological examination showed that the encapsulated film was composed of stratified squamous epithelium, and the inside of the cyst was composed of a keratinous cyst with laminated keratin material, however, adnexal structures of skin, such as hair and sweat glands, were not observed. Thus, it was diagnosed as an epidermoid cyst and invasion of acute and chronic inflammatory cells was observed around the mass. Skin suture was performed after excision of the mass, and no other procedure was required for treatment of depressed cartilage. Until three months after surgery, no complication such as inflammation was observed, however, at approximately one-year follow-up after surgery, two masses were observed at the top of the ipsilateral helix. The masses were removed and histologic examination showed the same result as that of the last year. Thus, the first mass was diagnosed as a congenital epidermoid cyst and the second was diagnosed as an acquired epidermoid cyst ().

A 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. His past history is pediatric asthma. The diameter of his middle esophageal diverticulum was 47 mm, and the accumulation of contrast medium was observed in the diverticulum. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row (Fig. ), and the diverticulum mucous membrane was partially covered by adherent white matter that was unstained with iodine (Fig. ), and narrowband imaging which revealed type A. We performed a biopsy, and the pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient placed in the prone position and four trocars inserted into the right thoracic cavity. A 12-mm trocar was inserted into the fifth intercostal space on the posterior axillary line. Only the left lung was ventilated, and a pneumothorax in the right chest was created using CO2 gas at 6 mm. Twelve-mm trocars were inserted into the seventh and ninth intercostal spaces at the level of the inferior scapular angle. A 5-mm trocar was then inserted into the seventh intercostal space on the posterior axillary line. The thoracoscope was inserted via the 12-mm port in the ninth intercostal space at the level of the inferior scapular angle. The operator used the 12-mm port in the seventh intercostal space on the inferior scapular angle line and the 5 mm port in the seventh intercostal space on the posterior axillary line. The assistant used the 12-mm port in the fifth intercostal space on the posterior axillary line. The endoscope was inserted into the lumen of the upper thoracic esophagus before the patient was placed in the prone position and kept in the esophagus throughout the surgery. Confirmation of the middle esophageal diverticulum was easily achieved, but the area was difficult to exfoliate because the diverticular wall had adhered to the lymph nodes of the trachea bifurcation. To achieve a complete resection of the diverticulum, threads were placed on the oral and anal sides of the diverticulum, the threads were pulled. A thoracoscope was inserted via the 12-mm port in the fifth intercostal space on the posterior axillary line and the surgical stapler was inserted via the 12-mm port placed in the ninth intercostal spaces at the level of the inferior scapular angle, and the diverticulum was resected using two sets of the Tri-Stapler (Fig. ). A postoperative upper gastrointestinal contrast examination revealed no abnormalities (Fig. ). Oral intake was initiated on postoperative day 7, and he was discharged on postoperative day 12. The histopathological findings were a true diverticulum with a muscular layer and a highly inflamed mucosa. No malignant findings were seen (Fig. ). Postoperatively, the patient visited the hospital at 1 month, 3 months, 6 months, and 1 year after the surgery. He underwent gastrointestinal endoscopy and upper gastrointestinal contrast examination 1 year after the surgery. We found no evidence of recurrence of the esophageal diverticulum. We are planning to repeat the upper gastrointestinal endoscopy at 2 years after the surgery.

A 62-year-old man attended his routine 1 year follow-up consultation following an uncomplicated UKR with a mobile bearing. During this appointment, the patient reported an uneventful initial recovery followed by an on-going pain and swelling in the posterior aspect of his knee, which started around 9 months after his surgery. He noted that the symptoms had evolved to a more constant background ache with consistent activity related pain alongside more stiffness over the last month.\nThe pain triggered his attendance to a community hospital on multiple occasions. The patient reported no specific history of trauma, but he remembers tripping while walking around the time of onset of recurrent symptoms. He complained of variable pain at the back of his knee which would ease, but never fully resolved. The main area of discomfort was around the medial hamstring tendons. At every attendance to the community hospital, he was assessed and reassured that this was most likely to be a hamstring strain and consequently, discharged with analgesia without any requirement of further investigation or discussion with our arthroplasty department.\nAt the 1 year follow-up appointment, radiographs (Fig. 4) were obtained which indicated that the polyethylene inserted was in fact dislocated posteriorly toward the popliteal fossa, into soft tissues adjacent to the neurovascular bundle, with consequent direct contact of metal components.\nClinical examination revealed a moderately swollen knee with a minimal effusion, with the affected limb noted to be in a greater varus alignment at the knee compared to the other leg. The range of motion was 10–125° with no noted major instability, and the varus was not fully correctable. There was moderate tenderness in the medial proximal tibia and distal femur as well as tenderness and focal swelling in the medial aspect of his popliteal fossa and medial hamstring tendon area.\nThe patient underwent a surgical exploration which revealed that both the femoral and tibial components were severely abraded, with consequent severe metallosis within the synovium. The polyethylene insert was encapsulated in thick fibrous tissue in the posterior soft tissues at the back of the knee which caused a difficult dissection close to the popliteal neurovascular structures. The initial incision had to be extended and UKR implants were removed, due to the degree of abrasive damage, to allow for a radical synovectomy and limited bone resection to remove the metallosis and for safe removal of the mobile bearing and its pseudocapsule. A total knee replacement (TKR) was undertaken with the patient mobilizing in a standard fashion, after which, they were discharged a 3 days later, without noted perioperative problem or complication. The patient went on to make a smooth recovery and was reviewed again at 1 and 5 years post-revision surgery.

A 19-year-old male was referred to the Endodontic Department of Babol Dental College with the chief complaint of dental pain and sensitivity to cold in the anterior maxillary region. The patient appeared physically healthy, but mild mental retardation was obvious. In the medical history, he had childhood asthma which ameliorated by the age of seven. No history of trauma or hereditary involvement was reported. The patient showed a straight profile and a symmetric face without abnormal findings in extraoral examinations. Clinical intraoral examinations revealed permanent dentition with poor oral hygiene and multiple caries. The molar relationship was Angle class I in both sides. Maxillary and mandibular arcs were U-shaped with both midlines on (). In the anterior maxillary region, we came to the rare finding of twinning in both central incisors. Both centrals showed an abnormally large mesiodistal width. No lateral incisor existed in the right maxillary region. Instead, a mesiodistally large central existed with a dental projection on its palatal side extending from the cingulum and ending at a small groove in the incisor edge (Figures and ). At the left side of the anterior maxilla, both central and lateral incisors existed. The left maxillary incisor also showed a large mesiodistal width with a large groove on the palatal surface that extended up to the incisal edge (Figures and ). There was no tooth mobility and no tenderness to percussion and palpation tests. A severe response to cold and electric tests was observed in the anterior maxillary incisor teeth. History taking revealed that he has had a previous endodontic treatment of a maxillary premolar in the same department. Reference to his file showed that his mother had been advised to refer to restoring caries in other teeth. She had also been suggested to seal the palatal grooves of the left incisor and esthetic treatment in maxillary anterior region. Because of poor socioeconomic status, further treatment was delayed until pain occurred. A panoramic radiograph was prescribed to detect possible further anomalies and define the condition in the anterior maxillary region (). In the right maxillary, there were two crowns fused by dentin with one root and two canals. One tooth was missing in the right maxillary quadrant. In the left maxillary region, there was one bifid crown with one root and one root canal. No further anomaly was observed. No tooth was missing in the left maxillary quadrant. According to clinical and radiographic findings and tooth count in maxillary quadrants, dental fusion between right maxillary central and lateral incisor with a talon cusp and gemination in left maxillary central incisor were diagnosed.\nAccording to clinical and radiographic findings, caries initiating from the grooves around the talon cusp reached the pulp chamber, and irreversible pulpitis was diagnosed in the right maxillary fused incisors. Endodontic treatment of right incisors accompanied by composite esthetic restoration in both maxillary sides was suggested to the patient and his mother to alleviate pain and make a better appearance. As the patient preferred, our treatment was limited to endodontic treatment and restoration of painful teeth, right maxillary fused central and lateral incisors.\nLocal anesthesia containing 1.8 mL lidocaine and 1/80000 epinephrine (Daroo-Pakhsh Co., Iran) was injected in the labial sulcus and a rubber dam (Hu-friedy, USA) was inserted. Two Access cavities were prepared by a fissure bur number 0.8 (Tees-Karvan, Iran). Pulp tissue was extirpated by a barbed broach (Dentsply Maillefer, Ballaigues, Switzerland). Working lengths of both canals were determined by K-File number 35 (Mani Inc., Japan) and a periapical radiograph. Canals were irrigated by 0.9% normal saline and sodium hypochlorite 2.5%. Cleaning and shaping was completed using a step back technique up to K-file number 80 and number 70 for the central and lateral incisor, respectively. As the patient was beginning to be uncomfortable and uncooperative, the canals were dried by sterile papers, calcium hydroxide was placed in root canals, the access cavities were temporized with cavit (Golchay Co., Iran), and the patient was dismissed. After one week, the patient returned for obturation. No pain or sensitivity during the week was reported. The canals were obturated by thermoplastic vertical condensation technique using gutta percha cones (Meta Biomed Co., Korea) and AH26 (Dentsply, USA) as a sealer (). Access cavities were restored by universal light cure composite resin (3 M, ESPE) (). The patient was asymptomatic in the six-month followup.

A three year old boy with two weeks history of right facial nerve paralysis, gait disturbance and difficulty swallowing, presented in an unconscious condition. CT scan revealed a well defined lesion with area of calcification in the right cerebellum []. There was a right to left shift of the fourth ventricle and severe obstructive hydrocephalus. After a shunting procedure the patient regained full consciousness. Further neurological examination revealed paralysis of right facial nerve, right sided dysmetria and dysdiadokokinesia neck stiffness and nystagmus. Deep reflexes were increased bilaterally. There was no papilledema. There were no cutaneous lesions or significant family history suggesting the diagnosis. A diagnosis of right cerebellar tumor was made and surgical removal was performed three days following shunting procedure.\nRight sub occipital craniotomy was performed. After retracting normal cerebellar tissue, we observed widened and well preserved cerebellar folia with a consistency comparable to a glioma. The tumor tissue was pale gray and poorly vascularized. As we went deeper, the border between tumor and normal cerebellar tissue was clearly distinguished. Further surgical exploration revealed that the lesion involved only the cerebellar folia; there was no infiltration of the medulla, pons and cranial nerves. Gross total tumor removal was achieved in this case.\nThe patient made uneventful recovery. Facial nerve paralysis remained but swallowing difficulties were reduced. On discharge, the patient was able to walk although a little unstable and had no difficulty swallowing. Over the following six month period there was complete resolution of all neurological deficits except for very mild paralysis of the right facial nerve. Control MRI three months after surgery at a private hospital revealed total tumor removal and the brain stem has resumed almost normal size and position [Figure and ].\nSection of the tumor mass revealed relatively well preservation of the cerebellar architecture with widened and distorted folia []. There was diffuse enlargement of the molecular and internal granular layers, which were filled with dispersed of ganglionic cells of varying sizes []. Purkinje cells were absent throughout the entire specimen. On the basis of this pathological report, the patient was diagnosed as LDD. We did not do immunohistochemistry study in this case.

This patient was a male in his early sixties. He was admitted to an integrative ward of a University Hospital, with a progressing two-vessel coronary heart disease. The patient was scheduled for bypass surgery. The medical history of the patient comprised a Non-ST-elevation myocardial infarction. A percutaneous transluminal coronary angioplasty and a stent implantation had been conducted in the past.\nIn a short interview preceding the LAVA assessment the patient reported that he had noticed a worsening of his coronary disease under physical exertion in his daily life before hospitalization. Nevertheless, the extent of deterioration that was diagnosed during his hospitalization, surprised him and he described an uncertainty because he did not know what might have caused the worsening of his disease nor how to positively influence the progression of the disease (e.g., life style modifications).\nFigure shows the LAVA self-assessment of the patient.\nWhen using the LAVA-Tool the patient rated eight terms as very important for his life. The three topics the patient was most dissatisfied with were mobility, contact to nature, and the ability to make decisions independently. The negative rating of mobility and contact with nature were probably influenced by the patient’s current situation in the hospital and by his disease. However, his dissatisfaction with his ability to make decisions independently could be attributed to his lack of knowledge concerning his disease and the expected improvement of his condition and mobility after the bypass surgery. A patient consultation that focused on a shared decision and understanding of the link between the treatment aims and his current negative experiences in life could therefore be helpful.\nFor this patient, the application of the LAVA tool led to the conclusion that the patient had a need for information. In this case, more information about the disease and the planned surgical intervention could probably help the patient to reduce his uncertainty and to feel more empowered to actively participate in his treatment. In the preceding interview the importance of the information need was not fully captured by the interviewer. The LAVA tool – forcing the patient to weigh his satisfaction with important aspects in his life – made it easier to capture his priorities, thereby showing a potential to improve his situation with a simple measure (i.e. patient information). One could argue that more information and a better understanding of the planned intervention would not have changed the somatic state of the patient. However, and most importantly, for patients with multiple conditions an improvement in well-being and a reduction of fear and uncertainty could make an important difference to their quality of life.

A 60-year-old man presented with a 16×6 cm2 open wound with an accompanying tibiofibular fracture due to a traffic accident. Free flap coverage was planned, with a necessary pedicle length of 14 cm from the middle of the flap to the recipient vessel and 9 cm from the flap margin. A 20×6 cm2 ALT flap from the patient’s ipsilateral thigh was planned. The perforator that branched at the proximal descending branch of the lateral circumflex femoral artery was found intraoperatively (). The length of the branched perforator was 7 cm, and the available length of the descending branch on the proximal side was 2 cm, so the estimated pedicle length was 9 cm (). For pedicle length extension, dissection was performed on the distal aspect, which resulted in obtaining 7 cm of the distal descending branch. Thus, we were able to obtain a reverse ALT free flap with a total pedicle length of 14 cm in the distal direction. Before elevating the reverse ALT free flap, we clamped the proximal descending branch to check for flap circulation. We confirmed that flap congestion was present due to impaired retrograde flow through the valves of the vena comitans in the distal direction. To resolve flap congestion, one of the venae comitantes of the distal descending branch was isolated and connected to the proximal venous stump in an antegrade manner (). When connecting a 1.5-mm vena comitans of the distal descending branch with the 2-mm proximal venous stump, the diameter discrepancy of the venous anastomosis was not significant (). A modified ALT flap pedicle 15 cm in length was formed to prevent venous congestion and to ensure adequate length to reach the recipient vessel. As a result, the direction of the arterial flow to the flap was retrograde, and the venous flow was antegrade. To evaluate the flap condition after surgery, the flap color was checked and the pin-prick test and Doppler ultrasonography were performed. For 2 days after surgery, the flap status was maintained, with no findings of congestion or insufficiency. Examinations during the 3-month follow-up revealed that the flap was maintained without complications.

A 30-year-old Indian man was brought to our Emergency Room after a road traffic accident, in which he was riding a motorcycle and was hit by a truck at a speed of approximately 50 miles per hour. Our patient complained of pain in his right arm and the inability to move it. An examination of his extremities revealed contusions over his right upper arm without any evidence of penetrating injury. There was marked swelling and tenderness in the middle part of his right arm associated with a closed injury. His cranial nerves were intact and no neurological deficits were present. No injures were found in his other limbs. In view of the above clinical findings, a radiograph of his right upper limb and a computed tomography (CT) scan of his head were suggested. While the CT scan did not reveal any abnormality, the radiograph of his right arm showed a unilateral displaced comminuted fracture of the mid shaft of his humerus (Figure ). Our patient was then given first aid in the form of a U-slab and immediately transferred to our orthopedic ward for further evaluation. His laboratory results were normal. Liver and kidney function test values were within their normal range. An electrocardiogram did not show any abnormal features.\nOur patient complained of tingling and numbness in his right little and ring fingers the following morning. On examination, there was hyperextension at the metacarpophalangeal joints and flexion at the proximal and distal interphalangeal joints with an inability to move his little and ring finger (Figure ). With the suspicion of an ulnar nerve injury due to the accident, a series of nerve conduction studies of his right upper arm nerves were suggested. The electrodiagnostic evaluation demonstrated a severe ulnar nerve conduction block along his arm with normal amplitudes of conduction along the median and the radial nerves.\nCorrelating the clinical findings with the above radiological and nerve conduction findings, a diagnosis of ulnar nerve injury after the fracture of the shaft of the humerus was made. Our patient was taken to the Operating Room for surgery, during which a fragment of bone was found abutting the ulnar nerve after penetrating the triceps muscle (Figure A,B). This fragment of bone was replaced and the fracture was reduced by open reduction and internal fixation using a dynamic compression plate and screws.\nPostoperatively, the tingling and numbness of the little and ring finger gradually subsided and our patient received regular physiotherapy and was discharged two weeks after surgery. Our patient was advised to come regularly for follow-up every three months for a period of one year. Our patient first came for a follow-up appointment four months after discharge and told the attending surgeon about the recovery of the normal functioning of his right hand 14 weeks after surgery; confirming it to have been ulnar neuropraxia.

An 11-year-old boy visited our outpatient clinic with complaints of persistent right cheek pain. His family history revealed that his father had severe hearing impairment. His medical history showed that he had allergic rhinitis and chronic sinusitis that had been treated until 3 months previously by an otolaryngologist.\nThe patient initially visited our outpatient clinic with complaints of high fever, sore throat, and comorbid right cheek pain and mild swelling 6 weeks previously. A checkup at a dental clinic performed on the day before this initial visit revealed no abnormal findings. He showed clinical symptoms of streptococcal pharyngitis. A rapid antigen test for group A streptococcal infection showed positive results. The patient was diagnosed with streptococcal infection. Facial cellulitis was also suspected and treatment with amoxicillin helped improve symptoms. However, facial pain recurred within 4 weeks of the initial visit. The patient had mild tenderness and swelling of the right cheek. Head computed tomography revealed mild mucous membrane swelling and effusion in both sinuses ( left). Because recurrence of cellulitis with sinusitis was suspected, cefditoren pivoxil treatment was initiated. However, because the pain persisted, he visited our department.\nPhysical examination revealed no abnormal findings except right cheek tenderness in the area that corresponded with the region supplied by the second branch of the trigeminal nerve (the maximally nerve). Although marked tenderness was evident, no point with hyperalgesia, where a light touch elicited severe pain, was observed. No facial paralysis or oral disorders were observed. Blood examination revealed no abnormal findings. Recurrence of sinusitis was suspected. Based on the physical examination and laboratory tests, the patient was clinically diagnosed with TN. Subsequently, oral clarithromycin administration was initiated for sinusitis that might have caused or exacerbated TN. However, administration of clarithromycin for 1 week was not effective for his facial pain. Brain magnetic resonance imaging (MRI) revealed no neurovascular compression ( right), which ruled out idiopathic, classical TN. During this time, we interviewed the patient on the nature of the right cheek pain. The patient described the pain as persistent, nagging, and dull in nature, which was completely different from the characteristics of pain associated with TN. Furthermore, trigger maneuvers failed to evoke pain. These evaluations excluded TN, and, thus, PIFP was diagnosed in week 2. Low dose of oral anticonvulsant carbamazepine (50 mg, twice a day) was initiated but was ceased due to general fatigue after the first administration.\nAlthough the patient had been previously cheerful and greeted us when entering the examination room, he became gradually emotionless with headache and nausea in week 5. In addition, feeding difficulties and numbness in the arms occurred. An orthostatic tolerance test revealed no positive findings for orthostatic dysregulation. It became difficult for the patient to attend school in week 6. Because various somatic symptoms developed in addition to PIFP, psychological factors were suspected to be pertinent in the etiology of PIFP. During a detailed medical interview with the patient and his mother, several problems were revealed: the patient loved swimming but his swimming record had plateaued after fixing his swimming form even though he practiced vigorously at a top-class swimming club team. Moreover, because of a recent finger injury, he could not practice as intensely as he wanted; therefore, his competitive ability as a swimmer deteriorated. Furthermore, in early adolescence, the patient had difficulties in communication and his relationship with his father was strained due to the father's hearing impairment. Because these suggested that the circumstances surrounding him might have led to somatoform disorders, psychological counseling was ordered in week 6.\nAs the patient faced, understood, and tolerated his psychological stress through counseling and psychotherapy twice a week, he gradually became expressive, worked up his appetite, and could attend school in week 10. Although sinusitis recurred at week 29, no facial pain developed. The patient received psychological counseling twice or thrice a month by this time. After 8 months, the frequency of counseling was reduced to once in 2 months. During this period, the patient's voice changed and became deeper at puberty. After confirming that facial pain as well as general malaise did not occur, even when the patient experienced distressing events, such as terminal examinations, counseling was ceased after 1 year and 8 months. After 3 years, the patient went on to high school and currently attends school cheerfully without any complaints and has resumed swimming.

A 55-year-old woman was seen at the outpatient clinic in 2007 because of progressive complaints of angina. Her medical history included hypertension and a cardiac murmur, which had already been diagnosed during a medical examination when she was 18 years old. In 1991, she was evaluated because of symptoms of dizziness and near collapse during exertion. Besides systolic hypertension, no structural heart disease was found except for a mild aortic regurgitation and a peak systolic pressure gradient of 17 mmHg (heart rate 68 beats/min) over the aortic valve. She was treated with antihypertensive drugs and visited her cardiologist on a regular, yearly basis. Because of therapy refractory hypertension she was also referred to the internist to exclude underlying causes of her hypertension, but no underlying cause was diagnosed. When she was 50 years old, she stopped smoking because mild chronic obstructive pulmonary disease was diagnosed. At that time echocardiography showed left ventricular hypertrophy (septum en posterior wall diameter both 12 mm) with normal systolic function, still a mild aortic regurgitation and a peak systolic pressure gradient across the aortic valve of 28 mmHg (heart rate 64 beats/min). In the meantime, she was treated with four different antihypertensive drugs, but she remained hypertensive. To evaluate her complaints of angina in 2007 a nuclear exercise stress test was performed, which showed signs of reversible perfusion defects in the inferior, posterior and lateral walls suggestive of myocardial ischaemia. During following cardiac catheterisation, via the right femoral artery, the catheter could not be advanced up the ascending aorta because of a discrete narrowing of the aorta (Fig. ). Catheterisation performed via the radial artery showed a significant stenosis in the circumflex artery which was subsequently dilated and stented. The calculated peak pressure gradient across the narrowed thoracic aorta was 30 mmHg. Additional computed tomography (CT) scan of the aorta confirmed the diagnosis of coarctation with a pinpoint stenosis in the aorta just distal to the left subclavian artery. Moreover, an extensive collateral network, mainly consisting of bronchial and lumbar arteries, was seen (Fig. ). Atherosclerotic changes in the cerebral vasculature were excluded by a digital subtraction angiography. It was decided by our congenital team to accomplish an extra-anatomical bypass 1 year after coronary stenting (Fig. ). Via a posterolateral thoracotomy an extra-anatomical bypass was constructed between the aortic isthmus and descending aorta by the use of a 16-mm prosthetic graft. No perioperative complications occurred and postoperatively, for the first time in her life, her blood pressure was better under control with antihypertensive drugs even with dose reduction of the medication. After more than 2 years of follow-up she was still free of angina, experienced a better exercise tolerance and her blood pressure levels were under control.

A 77-year-old female presented to the orthopedic hand clinic with a three-year history of an extremely sensitive small mass on her right wrist. The mass had subjectively grown over this period of time. The pain had progressively worsened over time, and she had developed significant hypersensitivity to light contact. There was no complaint of cold sensitivity to the mass. The pain occasionally radiated down the ulnar aspect of her wrist. She had no known history of previous trauma to this area; however, she did have a history of squamous cell carcinoma to the dorsal-radial aspect of that hand. This had been treated previously for which she subsequently developed a reflex sympathetic dystrophy (RSD), resulting in a delayed recovery in the range of motion. A previous stellate ganglion block did not provide relief for her RSD, and her range of motion had been slowly progressing with home exercises.\nOn physical exam, a small round nodule approximately 5 mm x 5 mm was palpable dorsal to the extensor carpi ulnaris and 1 cm proximal to the ulnar styloid. There was significant point tenderness that did not radiate or display a Tinel’s sign. Her imaging included plain films of the affected extremity that showed no abnormality outside of diffuse osteopenia.\nThe location and exam were consistent with a neuroma that had evolved from a cutaneous nerve or possibly from the dorsal sensory branch of the ulnar nerve. The patient was taken to the operative theatre and deep dissection revealed a maroon-colored mass approximately 5 mm x 5 mm, connected to a cutaneous nerve branch. The nerve and mass were excised and sent for histopathological review. The ulnar nerve and dorsal sensory branch were visualized and confirmed to have no involvement with the mass. At her first postoperative visit, she reported no pain and that she was very satisfied with the results of her surgery. Diagnostic pathological stains were consistent with a glomus tumor. This was confirmed with strong reactivity to immunostaining of type IV collagen and smooth muscle actin (Figures , ).

43year old male presented to the Emergency Department with a day old history of acute left upper abdominal pain; nausea and vomiting for 2 days with some associated dizziness and anorexia. The patient underwent an emergency contrast enhanced CT scan of the abdomen/pelvis which showed an markedly abnormal spleen, inhomogeneous and enlarged, approximately 20 × 11 cm with fluid in the inferior aspect of the mesenteric fat, with free fluid in the abdomen and enlarged retroperitoneal lymph nodes.\nThe patient was volume resuscitated following admission to the hospital, and his Hct was serially followed. Since there was no history of trauma and the CT did not look like a traumatic splenic laceration the oncology service was contacted who felt that the findings were most compatible with lymphoma and because there was some bleeding going on did not recommend trying to treat it without a tissue diagnosis.\nThe patient underwent a splenectomy. He was found to have a massively enlarged spleen with areas where it appeared to be tumor extruding through the splenic capsule. There was a lot of ecchymotic tissue inferior to where the spleen had been and there was slight oozing which was controlled as much as possible as the area was quite friable. The tail of the pancreas was identified and left alone as there was no bleeding. The estimated blood loss was approx 2 L.\nFollowing extubation the patient had some issues with agitation which was attributable to ETOH withdrawal. The patient had a history of 6pack qd ETOH abuse. He was placed on CIWA protocol. His mental status remained at the level of agitation and confusion for the next 4 days not helped by serax or ativan or haldol. Psychiatry consult was given and they felt the agitation was secondary to post op delirium vs. paradoxical ativan reaction. At that point it was thought that the agitation and delirium was secondary to possible 'pain vs. sepsis.' He was started on cefazolin 1 gm q8 hrs post op which was changed to meropenem 1 gm q 12 hr on POD#4.\nIn the post operative period the patient's Hct remained stable on serial examination. however his Bilirubin continually rose and peaked at 10.5 on post op day # 3. Other LFT s were mildly elevated. Gastroenterology team was consulted who felt that the increase bilirubin was secondary to sepsis. Differential diagnosis of hemolysis was considered but was thought unlikely as the Hct remained stable. Biliary obstruction was unlikely given his LFT s were only mildly elevated. A hepatitis panel was run and the patient was found to be positive for Hepatitis C. Anesthesia related rise in bilirubin was also considered but again AST and ALT were mildly elevated.\nThe patient was discharged home on post op day #9 on PO Moxifloxacin 400 mg q d for 5 days to complete a 14 day course of antibiotics. His liver function test lab values were almost near normal on discharge.

A 51-year-old man reported with complaints of recent onset of left knee pain. He had sustained a displaced comminuted fracture of his left patella following a fall 15 months ago. Modified tension band wiring with cerclage wiring was successfully performed, and the patient was recovering well. He was well for the last 14 months and returned to his job without any pain or functional disability. However, he started experiencing deep-seated pain within the left knee with restriction of movements for the last 4 weeks. There was no recent history of any fall or trauma to the left knee. Clinical examination of the left knee revealed no patella or joint line tenderness but pieces of wires were palpable percutaneously. There was no effusion and the cruciate and collateral ligaments were intact; there was no neurovascular deficit. There was no extensor lag and knee extension power was normal. The range of motion of the knee was painfully restricted.\nRadiographs of the left knee revealed a united fracture patella with broken cerclage wire (). The inferio-medial segment of the broken cerclage wire was found to have migrated into the posterior compartment of the knee joint and hooked anteriorly at the base of anterior cruciate ligament.\nThe patient underwent surgery for removal of the patella wires. Fluoroscopic examination before surgery revealed the posterior part of wire had shifted its position with anterior part of it still hooked with anterior cruciate ligament. An arthroscopic examination of the knee was done through the standard anteromedial and anterolateral portal. Any structural damage including chondral lesion due to wire migration was not found, a migrated piece of wire was found embedded at the base of anterior cruciate ligament, going toward posterior compartment of knee through medial side of notch, which was removed (). We used intraoperative fluoroscopy (), before finishing the arthroscopic examination of knee, which demonstrated that, there was no remaining piece of wire in posterior compartment of knee. The rest of the broken wires were removed via a midline anterior knee incision along the old scar. The patella was stable after complete removal of the wires, indicating union of the rest of the fragments.\nThe patient was discharged the next morning and his wounds healed at 2 weeks. Complaints of knee pain resolved completely following the surgery, and the patient was able to resume work at 2 weeks.

A 77-year-old female presented to the orthopedic hand clinic with a three-year history of an extremely sensitive small mass on her right wrist. The mass had subjectively grown over this period of time. The pain had progressively worsened over time, and she had developed significant hypersensitivity to light contact. There was no complaint of cold sensitivity to the mass. The pain occasionally radiated down the ulnar aspect of her wrist. She had no known history of previous trauma to this area; however, she did have a history of squamous cell carcinoma to the dorsal-radial aspect of that hand. This had been treated previously for which she subsequently developed a reflex sympathetic dystrophy (RSD), resulting in a delayed recovery in the range of motion. A previous stellate ganglion block did not provide relief for her RSD, and her range of motion had been slowly progressing with home exercises.\nOn physical exam, a small round nodule approximately 5 mm x 5 mm was palpable dorsal to the extensor carpi ulnaris and 1 cm proximal to the ulnar styloid. There was significant point tenderness that did not radiate or display a Tinel’s sign. Her imaging included plain films of the affected extremity that showed no abnormality outside of diffuse osteopenia.\nThe location and exam were consistent with a neuroma that had evolved from a cutaneous nerve or possibly from the dorsal sensory branch of the ulnar nerve. The patient was taken to the operative theatre and deep dissection revealed a maroon-colored mass approximately 5 mm x 5 mm, connected to a cutaneous nerve branch. The nerve and mass were excised and sent for histopathological review. The ulnar nerve and dorsal sensory branch were visualized and confirmed to have no involvement with the mass. At her first postoperative visit, she reported no pain and that she was very satisfied with the results of her surgery. Diagnostic pathological stains were consistent with a glomus tumor. This was confirmed with strong reactivity to immunostaining of type IV collagen and smooth muscle actin (Figures , ).

A 32-year-old white man presented to a local emergency department with a noticeable puncture wound, progressive swelling, and erythema to the right leg. The injury was sustained when he fell against the metal pedal of his bicycle. After 3 days of hospitalization and multiple courses of antibiotic, a surgical team was consulted for operative debridement of the wound. Diagnosis and confirmation of necrotizing fasciitis by polymicrobial group A streptococcal organisms was made. The resultant surgical debridement of the right posterior leg over the span of 1 week resulted in an open wound extending from the right popliteal fossa to about 8 cm from his right ankle (). After a period of negative pressure wound therapy, the patient was referred to University of California Davis Medical Center for definitive reconstruction of his posterior right leg wound with exposed Achilles tendon. The patient had a history of Hodgkin's lymphoma, currently in remission, and ureteral stone causing hydronephrosis. He had no history of diabetes, alcoholism, or other general medical condition. The patient was a habitual smoker with history of drug abuse. Upon transfer to University of California Davis medical center, he was immediately prepared for free-tissue transfer.\nA line was drawn from anterior superior iliac spine to the lateral border of the patella (). This line roughly corresponds to the intermuscular septum between the rectus femoris and the vastus lateralis muscles. Skin vessels supplying the ALT flap are centered along this line or slightly lateral of it. The midpoint of this line, an area where skin perforators are generally located, was marked. Additional perforators were located within 10 cm proximal and distal to the midpoint perforator. At each location, this conventional naming system of skin perforator clusters provides a guideline for vascular localization. A handheld Doppler was used to localize the skin perforators in the anterolateral aspect of the thigh. The required size of the ALT flap was then measured and marked incorporating these perforators.\nExamination of the foot revealed palpable dorsalis pedis and posterior tibial vessels and a normal modified lower-extremity Allen's test. After debridement of the open wound, the right posterior tibial vessels were exposed for use as recipient vessels. A large free ALT flap with a 15 × 20 cm2 skin paddle based on 2 perforators was harvested from the right thigh for coverage of the right Achilles tendon. No thinning of the flap was performed. Of note, the flap pedicle was medial and pierced through the medial aspect of the rectus muscle, slightly increasing dissection time. Once the flap was raised, the pedicle was divided at the bifurcation from the profunda femoral artery and was anastomosed to the posterior tibial vessels using a surgical microscope without complication. Vein couplers were used for venous anastomosis. Arterial anastomosis was performed with interrupted 9.0 Nylon suture in an end-to-end fashion. The flap was inset to completely cover the Achilles tendon. The remaining exposed gastrocnemius muscle was covered with STSG from the right thigh and vacuum-assisted closure therapy (KCI, San Antonio, Texas) was initiated (). The foot perfusion was examined by normal capillary refill in all toes and palpable dorsalis pedis artery.\nThe patient was placed in an intensive care unit for Cook Doppler monitoring for 4 days postoperatively and on a splint to keep his foot at 90 degrees. The Cook Dopplers and vacuum-assisted closure device were removed on postoperative day (POD) 5, and the patient was discharged home on POD 7 (). Although the patient was scheduled for immediate physical therapy to improve foot function, he did not begin therapy until 4 to 5 weeks after discharge due to financial difficulties. Despite the late start, the patient was able to gain independent ambulation by 8 weeks postoperatively ().

A 19-year-old male patient reported to the department of conservative dentistry and endodontics following trauma to the maxillary anterior region due to a road accident around 20 days back. He complained of fractured maxillary incisors and presented a desire to get them restored in order to have an aesthetic smile. Clinical examination of the patient revealed complicated crown fracture of the upper incisors. An intraoral swelling with a sinus tract was present on the labial gingiva between upper right central and lateral incisor (Figures and ). A radiograph of the maxillary anterior region illustrated horizontal root fracture at the middle third of the upper right central and lateral incisors () but clinically no mobility of the coronal fragment was evident. On the other hand the roots of the upper left central and lateral incisors were intact and endodontic treatment had been done for the upper left central and lateral incisors ().\nAfter explaining the treatment plan to the patient and obtaining his consent, endodontic treatment with the upper right central and lateral incisors was initiated. The working length was correctly determined and canals were cleaned, shaped using K files in a step-back manner to an apical file size #60. The remainder of the canals were shaped to obtain a uniform taper from apex towards coronal. An interappointment calcium hydroxide dressing was given and the patient was recalled after 7 days.\nOn the second visit, when the swelling had resolved, root canals were sectionally obturated with gutta percha cone and AH plus sealer. A gutta percha cone of the same size of the prepared root canal (size #60, with a taper of 2%) was selected and tried into the canal to obtain a snug fit. It was then cut to obtain a section which would be 2-3 mm short of the apical fragment of the root. A suitable plugger which loosely fits 2-3 mm short of the apical root fragment was selected and a stopper was set at this length. The sectioned gutta percha was then coated with AH plus sealer. One end of gutta percha was mounted to a heated plugger and then carried into the canal to the desired length. After this, gutta percha was disengaged from the plugger by slightly rotating the plugger in anticlockwise direction ().\nAfter 5 days of recall, the tooth was asymptomatic and the sinus tract healed. Next, glass fiber posts were used to retain the fractured root fragments. Appropriate glass fiber posts were tried into the canals, adjusted to the desired length until they just passively touched the apical gutta percha. Root canals were etched with 37% phosphoric acid gel and dried with paper points. The fiber posts were luted with dual cure resin cement, inserted into the canal without applying any pressure, and then light cured for 40 seconds. The benefit of higher viscosity of the cement in absence of pressure is that it reduces the flow of the resin. Also, the resin was used cautiously only in the amount necessary to achieve a desirable bond between the post and the dentin. Only the post was luted with the cement. Coating the root canal walls with resin cement was precluded to prevent the flow of excess cement laterally between the root fragments.\nThese fiber posts served as an intraradicular splint, stabilizing the fractured fragments in position. Glass fiber-reinforced posts were used as they exhibit high fatigue strength and high tensile strength and have a modulus of elasticity closer to dentin. Composite cores were built over the posts (). The other two incisors (maxillary left central and lateral incisors) received a similar post and core treatment (Figures –). The teeth were then restored with full-coverage porcelain fused to metal crowns (Figures –).\nThe patient was reevaluated on a regular basis. After 12 months of recall, the patient presented with aesthetically pleasing results and sound periodontium and the fractured root fragments were well retained with the aid of a post (Figures and ).

Case 2: A 23 year old male, presented with symptoms of crawling sensation and foreign body sensation in his right eye, and had observed a worm in this eye. He had no previous symptoms prior to his presentation. He gave a history of having worked in a cocoa farm plantation during his childhood years and had severally suffered from bites from unknown flies. He had no systemic symptoms nor signs and aside from his ocular complains was healthy. There was no swelling anywhere in the body and no itching. Upon ocular examination his visual acuity was 6/6 in both eyes. The only significant finding was the presence of an actively mobile worm in the nasal subconjunctival space of the right eye "". This worm soon migrated upwards towards the superior fornix and away from view during the examination and before removal could be attempted "". The patient was immediately asked to adopt a face down position and within 30minutes of this time; he could feel a crawling sensation again in the same eye indicating that the worm was back. He was quickly taken to the operating room and the worm was extracted successfully using a local infiltration of the conjunctiva with lignocaine anesthesia. Histological examination revealed it to be an adult Loa loa worm.\nCases 3: A 25 year old female who had suffered sensation of movement and foreign body sensation in both eyes for the past 10 years and gave a past history of swimming in rural streams during childhood years. There was no history of swelling on the body and no itching. She had noticed an increasingly frequent occurrence of a worm like movement in both eyes over these years. Following ingestion of diethyl carbamazepine she noticed a sudden appearance of a red patch in the right eye. Upon examination her visual acuity was 6/5 in both eyes. The only significant finding was a localized hyperemic raised lesion on the surface of the right eye. This turned out to be a subconjuctival worm in the inferotemporal subconjunctival space of the right eye. The worm was found to be lifeless and covered by a surrounding cyst wall "". Care was taken to dissect the conjunctival and subtenons tissue away from the encysted worm, which was carefully extracted with a toothless forceps. Conjunctival incision site was closed with interrupted sutures. Histology revealed an adult Loa loa worm.

A 6-year-old male child presented to the emergency department with a history of orchiopexy done elsewhere for a right undescended testis palpable in the superficial inguinal pouch. While performing the orchiopexy, the surgeon had inadvertently injured the right femoral artery by electrocautery. The artery was repaired, but as he failed to palpate a good distal pulse, the patient was referred to us at a tertiary hospital which is about 300 km away. The patient was transported by road and reported to us about 12 h after the injury. On examination of the referral notes, it was found that a peripheral computed tomography angiography of the lower extremity with aortography was performed immediately after the repair of the femoral artery at the primary institute, which suggested abrupt cutoff of the right femoral artery near the origin of the profunda femoris artery. At presentation, the distal pulses were absent in the right lower limb, and the limb was pale and cold. The patient had a sutured wound over the right upper thigh starting from the pubic bone medially and extending laterally along the skin crease between the thigh and abdomen up to a point lying about 5 cm below the anterior superior iliac spine []. After clinical examination at our institute, Doppler study of the lower limbs was performed to know the extent of the thrombosis, which showed a thrombus extending from the femoral up to the external iliac artery above the inguinal ligament proximally. Immediate reexploration was planned in view of pale and cold peripheries of the affected leg and no distal flow on Doppler. On exploration of the wound, it was found that orchiopexy was not completed by the previous surgeon and the testis was seen lying in the superficial inguinal pouch at the superior flap of the wound. At the middle of the wound, the sutured, contracted femoral artery was seen []. A longitudinal extension of the incision was made along the long axis of the limb for better exposure of the femoral artery. Systemic heparinization was performed, the artery was isolated, and control was taken with vascular loops, both proximally and distally. The arterial sutures were removed and an intraluminal clot was removed. The lumen was thoroughly irrigated with heparinized saline. A Fogarty balloon thrombectomy was performed proximally and distally. A polytetrafluoroethylene (PTFE) on lay graft was applied over the defect []. The wounds were closed after completing orchiopexy. The patient had a good distal flow on the table. Postoperatively, the patient was continued with low–molecular-weight heparin for 5 days and antiplatelet therapy for 3 months. Doppler study at 3 months showed good caliber and flow in the femoral artery. He is asymptomatic at 6-month follow-up.

A 77-year-old female presented to the orthopedic hand clinic with a three-year history of an extremely sensitive small mass on her right wrist. The mass had subjectively grown over this period of time. The pain had progressively worsened over time, and she had developed significant hypersensitivity to light contact. There was no complaint of cold sensitivity to the mass. The pain occasionally radiated down the ulnar aspect of her wrist. She had no known history of previous trauma to this area; however, she did have a history of squamous cell carcinoma to the dorsal-radial aspect of that hand. This had been treated previously for which she subsequently developed a reflex sympathetic dystrophy (RSD), resulting in a delayed recovery in the range of motion. A previous stellate ganglion block did not provide relief for her RSD, and her range of motion had been slowly progressing with home exercises.\nOn physical exam, a small round nodule approximately 5 mm x 5 mm was palpable dorsal to the extensor carpi ulnaris and 1 cm proximal to the ulnar styloid. There was significant point tenderness that did not radiate or display a Tinel’s sign. Her imaging included plain films of the affected extremity that showed no abnormality outside of diffuse osteopenia.\nThe location and exam were consistent with a neuroma that had evolved from a cutaneous nerve or possibly from the dorsal sensory branch of the ulnar nerve. The patient was taken to the operative theatre and deep dissection revealed a maroon-colored mass approximately 5 mm x 5 mm, connected to a cutaneous nerve branch. The nerve and mass were excised and sent for histopathological review. The ulnar nerve and dorsal sensory branch were visualized and confirmed to have no involvement with the mass. At her first postoperative visit, she reported no pain and that she was very satisfied with the results of her surgery. Diagnostic pathological stains were consistent with a glomus tumor. This was confirmed with strong reactivity to immunostaining of type IV collagen and smooth muscle actin (Figures , ).

A 59-year-old female initially presented to the emergency department 10 months prior with right arm pain and swelling. A computed tomography of the neck with contrast at the time showed two confluent masses in the right axillary and right supraclavicular regions encasing the right subclavian and axillary vein, the internal mammary artery, and narrowing of the lower internal jugular vein. Patient was subsequently diagnosed with primary mammary carcinoma of the axilla with metastasis. The patient was evaluated by the oncology and radiation oncology services and underwent multiple rounds of chemotherapy and radiation therapy. Her course of chemotherapy was complicated by thrombocytopenia and metastatic disease progression. The patient was determined to be a nonsurgical candidate. Gradually, her pain of the right upper extremity worsened, and the patient was started on opioid therapy. Despite titration of her oral medications to extended release morphine 90 mg two times a day, immediate release morphine 30 mg every 2 to 3 hours, methadone 5 mg daily, and gabapentin 800 mg three times daily, her pain control remained suboptimal. She was referred to our pain clinic for further management of her intractable pain.\nOn presentation, the patient reported a constant 10/10 pain on the numeric pain rating scale (NRS) of the right proximal humerus, right anterior and posterior shoulder, and right supraclavicular region. The pain was reported as dull, aching, burning, and electric in nature. Her pain was worsened by passive and active range of motion, and the pain at its best was a 7/10 with oral medications. Patient also reported progressive weakness of the entire right upper extremity. Magnetic resonance imaging of the brachial plexus was obtained, and the study revealed a mass encasing the right brachial plexus at the level of the divisions and cords as well as the right brachial artery ().\nDiagnostic brachial plexus block was performed in the hospital due to functional decline and acute worsening of pain. The brachial plexus was unable to be visualized using ultrasonography in the classic supraclavicular area due to the tumor effect, thus the block was performed at the level of the trunks using a lower interscalene approach. 18 mL of 0.5% ropivacaine was injected under direct ultrasound guidance. The patient reported complete pain relief lasting approximately 12 hours after the nerve block. Given the success of the diagnostic nerve block, the patient was offered the option of chemical neurolytic brachial plexus block with an extensive discussion of the unique risks, benefits, and alternatives. The patient elected to proceed to a right brachial plexus nerve block with dehydrated ethanol.

A 46 years old housewife presented with left knee pain of ten months’ duration without significant trauma. She had been treated elsewhere as septic arthritis of the left knee based on the radiological features of severe bone defect of the medical condyle of the left tibia. There was neither history nor clinical appearance suggestive of septic arthritis of the left knee. Results of investigations did not support the diagnosis of infection of her left knee. There was genu varus deformity of her left knee, and she walked with an antalgic gait, occasionally requiring a walking frame for long-distance walking. She had never been hospitalised before. She was given two trials of oral antibiotics empirically but to no avail. Due to the persistent pain that had not resolved with nonsteroidal anti-inflammatory therapy and antibiotics, she was referred to our orthopaedic department.\nAt our centre, we found there was muscular weakness in the lower extremities. Movement of the left knee was painful with limited range of movement of 0° to 90°. The skin in the affected knee was normal without signs of infection, vascular abnormalities or oedema. Peripheral pulses in the left lower limb were normal. The varus deformity of left knee was passively correctable. Radiograph of her left knee showed no progressive changes of the bone defect compared to the bone defect ten months previously. () Laboratory studies including haematological tests revealed no evidence of metabolic, neoplastic, immunological or infectious aetiology. She was then scheduled for total knee replacement for her left knee, six months later.\nHowever, while awaiting elective surgery, three months after presenting to our centre, she returned with complaint of right hip pain of three weeks duration. The right lower limb was shorter by two centimetres compared to the left lower limb. There was no history of trauma or infection. Radiograph of the right hip revealed complete osteolysis of the femoral head, though a radiograph three months earlier had shown a normal hip joint. () Laboratory studies again failed to disclose any significant findings for this occurrence as all the haematological tests were within normal limits. Sputum cultures for tuberculosis and Mantoux test were negative. Dual-energy x ray absorptiometry of the spine showed osteopenia. Her family history was non-contributory and no family members had an illness resembling hers.\nA CT-guided biopsy of the femoral head was performed. The histopathological results showed few bone trabeculae with many fragments of fibrovascular tissue. A few fragments showed entrapped skeletal muscle and trabeculae of osteoid with osteoblastic rimming. In addition, necrotic cartilage and isolated irregular clusters of amorphous hyaline material were present which stained equivocally with Congo red. There was no cellular evidence of atypia or malignancy. The findings were interpreted as osteocartilaginous necrosis, in keeping with disappearing bone disease.\nWe discussed the diagnosis, prognosis and treatment with the patient. After numerous consultations with the patient and her family members, consent was obtained for total knee replacement of her left knee and conservative management of her right hip. We performed arthroplasty for her knee. Histopathological findings from the tissues revealed findings consistent with disappearing bone disease. The patient’s left knee pain was markedly reduced post arthroplasty and she was able to resume her normal activities. There was no radiological evidence of periprosthetic loosening of the tibia implant three months post operation. Due to the good outcome of her left knee, the patient wished to have right hip arthroplasty. A year later, after confirming that the osteolysis had stopped through serial hip radiographs, total hip replacement was performed. At five years post-arthroplasties, she remains pain free and the fixations are stable without any evidence of subsidence. ()

Our patient is a 38-year-old male who presented with right chest wall and shoulder pain after a weight lifting injury. The patient was performing a one-rep max bench press when he felt a pop in his right upper arm, accompanied by severe pain. There was no history of anabolic steroid use. He was initially treated with ice and a sling by a trainer and presented to the emergency department for further evaluation. Plain films were negative for fracture or dislocation and the patient was neurovascularly intact, so he was discharged home by ER staff in the sling. He presented to the orthopedic clinic the following day with moderate pain in the chest and arm. He denied numbness and paresthesia. On physical examination, there was a large amount of swelling and ecchymoses throughout the right upper arm extending into the pectoralis major muscle belly. Additionally, there was a large bulge in the anterior chest with loss of contour of the axillary fold (). The patient had full active range of motion of the elbow, wrist, and digits. He was sensory intact throughout the right upper extremity with a 2+ radial pulse. An MRI was scheduled to determine the extent of the injury and to aid in surgical planning. The patient was given oxycodone and valium to alleviate the pain and muscle spasms until surgery, which was scheduled after his MRI. The MRI demonstrated avulsion of the pectoralis major tendon from its insertion on the humerus with retraction as well as strain of the anterior deltoid (Figures and ). He was scheduled for surgery in five days. Two days later, the patient returned to our facility with severe worsening pain in the right upper arm. Intracompartmental pressure readings in the anterior compartment of the arm taken about the midpoint of the biceps at the point of maximal swelling were 37, 39, and 42 mmHg with a diastolic blood pressure of 71 mmHg (). Thus, with a diagnosis of compartment syndrome confirmed, we proceeded to the operating room for an emergency fasciotomy with repair of the pectoralis major tendon rupture.\nAn extended deltopectoral approach was used, and the deltopectoral and biceps fascia were released. Immediately, a large amount of hematoma was expelled and the muscle bellies visibly bulged from the incision sites (Figures and ). All muscles still appeared viable. No apparent vascular damage was noted. Upon further dissection, both heads of the pectoralis major were found to be avulsed from the proximal humerus (). After preparation of the footprint with curette and rongeur, three double-loaded 4.5 mm Mitek suture anchors (DePuy Synthes, Raynham, MA) were placed lateral to the bicipital groove for the repair of the tendon. The proximal and distal suture anchors were used such that one suture of each was run in a Krakow fashion along the superior and inferior aspects of the tendon, respectively. The remaining suture from each of those anchors was passed in a horizontal mattress fashion medial to the Krakow stitches. The middle suture anchor was used to place a horizontal mattress stitch with a medial ripstop stitch (). The wound was irrigated, and a negative pressure dressing was applied. The patient was made nonweightbearing and placed in a sling with a circumferential strap to ensure adduction of the arm. The patient returned to the operating room four days later to undergo irrigation and debridement with a tension-free primary wound closure. He was again placed into his sling and given strict instructions to avoid abduction and external rotation of the arm. The patient did well postoperatively and was discharged home in a stable condition that same day with a one-week follow-up appointment. He continued to do well and was instructed to remain nonweightbearing in his sling for a total of 6 weeks before beginning formal therapy. Gentle stretching and passive range of motion were then begun, followed by strengthening exercises at the 12th week mark. At his four-month follow-up, the patient had active forward flexion of the shoulder to 150°, abduction to 150°, and external rotation of 50°. His rotator cuff, biceps, triceps, wrist extensors, wrist flexors, and interossei all demonstrated 5/5 strength. There were no sensory deficits on examination. He continues to attend therapy for motion and strengthening and has a lifting restriction of <5 pounds at work.

A 59-year-old female initially presented to the emergency department 10 months prior with right arm pain and swelling. A computed tomography of the neck with contrast at the time showed two confluent masses in the right axillary and right supraclavicular regions encasing the right subclavian and axillary vein, the internal mammary artery, and narrowing of the lower internal jugular vein. Patient was subsequently diagnosed with primary mammary carcinoma of the axilla with metastasis. The patient was evaluated by the oncology and radiation oncology services and underwent multiple rounds of chemotherapy and radiation therapy. Her course of chemotherapy was complicated by thrombocytopenia and metastatic disease progression. The patient was determined to be a nonsurgical candidate. Gradually, her pain of the right upper extremity worsened, and the patient was started on opioid therapy. Despite titration of her oral medications to extended release morphine 90 mg two times a day, immediate release morphine 30 mg every 2 to 3 hours, methadone 5 mg daily, and gabapentin 800 mg three times daily, her pain control remained suboptimal. She was referred to our pain clinic for further management of her intractable pain.\nOn presentation, the patient reported a constant 10/10 pain on the numeric pain rating scale (NRS) of the right proximal humerus, right anterior and posterior shoulder, and right supraclavicular region. The pain was reported as dull, aching, burning, and electric in nature. Her pain was worsened by passive and active range of motion, and the pain at its best was a 7/10 with oral medications. Patient also reported progressive weakness of the entire right upper extremity. Magnetic resonance imaging of the brachial plexus was obtained, and the study revealed a mass encasing the right brachial plexus at the level of the divisions and cords as well as the right brachial artery ().\nDiagnostic brachial plexus block was performed in the hospital due to functional decline and acute worsening of pain. The brachial plexus was unable to be visualized using ultrasonography in the classic supraclavicular area due to the tumor effect, thus the block was performed at the level of the trunks using a lower interscalene approach. 18 mL of 0.5% ropivacaine was injected under direct ultrasound guidance. The patient reported complete pain relief lasting approximately 12 hours after the nerve block. Given the success of the diagnostic nerve block, the patient was offered the option of chemical neurolytic brachial plexus block with an extensive discussion of the unique risks, benefits, and alternatives. The patient elected to proceed to a right brachial plexus nerve block with dehydrated ethanol.

A 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. His past history is pediatric asthma. The diameter of his middle esophageal diverticulum was 47 mm, and the accumulation of contrast medium was observed in the diverticulum. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row (Fig. ), and the diverticulum mucous membrane was partially covered by adherent white matter that was unstained with iodine (Fig. ), and narrowband imaging which revealed type A. We performed a biopsy, and the pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient placed in the prone position and four trocars inserted into the right thoracic cavity. A 12-mm trocar was inserted into the fifth intercostal space on the posterior axillary line. Only the left lung was ventilated, and a pneumothorax in the right chest was created using CO2 gas at 6 mm. Twelve-mm trocars were inserted into the seventh and ninth intercostal spaces at the level of the inferior scapular angle. A 5-mm trocar was then inserted into the seventh intercostal space on the posterior axillary line. The thoracoscope was inserted via the 12-mm port in the ninth intercostal space at the level of the inferior scapular angle. The operator used the 12-mm port in the seventh intercostal space on the inferior scapular angle line and the 5 mm port in the seventh intercostal space on the posterior axillary line. The assistant used the 12-mm port in the fifth intercostal space on the posterior axillary line. The endoscope was inserted into the lumen of the upper thoracic esophagus before the patient was placed in the prone position and kept in the esophagus throughout the surgery. Confirmation of the middle esophageal diverticulum was easily achieved, but the area was difficult to exfoliate because the diverticular wall had adhered to the lymph nodes of the trachea bifurcation. To achieve a complete resection of the diverticulum, threads were placed on the oral and anal sides of the diverticulum, the threads were pulled. A thoracoscope was inserted via the 12-mm port in the fifth intercostal space on the posterior axillary line and the surgical stapler was inserted via the 12-mm port placed in the ninth intercostal spaces at the level of the inferior scapular angle, and the diverticulum was resected using two sets of the Tri-Stapler (Fig. ). A postoperative upper gastrointestinal contrast examination revealed no abnormalities (Fig. ). Oral intake was initiated on postoperative day 7, and he was discharged on postoperative day 12. The histopathological findings were a true diverticulum with a muscular layer and a highly inflamed mucosa. No malignant findings were seen (Fig. ). Postoperatively, the patient visited the hospital at 1 month, 3 months, 6 months, and 1 year after the surgery. He underwent gastrointestinal endoscopy and upper gastrointestinal contrast examination 1 year after the surgery. We found no evidence of recurrence of the esophageal diverticulum. We are planning to repeat the upper gastrointestinal endoscopy at 2 years after the surgery.

A 64-year-old man with possible fracture of the shoulder was referred to an X-ray examination of his left shoulder. The X-ray visualized an osteolytic tumor in the proximal part of the left humerus and destruction of the cortex at the greater tuberosity (). Supplemental MRI showed a heterogeneous tumor of 4 × 6 cm, which was enhancing on the T1 sequences after contrast administration, and a periosteal reaction at the distal part of the tumor (). The cortical destruction and the contrast enhancing areas in the bone by MRI may suggest malignancy. The patient was referred to a national sarcoma center where a thorough medical history revealed that the patient had undergone left sided hemi-thyroidectomy 2 years previously due to a 5 cm follicular adenoma. He also had a malignant melanoma excised 8 years earlier from his left upper arm.\nA whole-body PET-CT confirmed the suspicion of malignant tumor in the proximal part of the left humerus and cortical destruction at the greater tuberosity (). A fat layer separated the tumor from the surrounding soft tissue, indicating that the tumor was only located to the bone. The PET-CT also revealed a small lymph node at the angle of the left mandible, suspected of being malignant. It was impossible to perform a biopsy of the lymph node due to its small size and location. Instead an ultrasound-guided histological biopsy was performed from the tumor in the left humerus, where cortical destruction enabled the needle to pass (). Histology revealed a carcinoma with morphology and immunohistochemical profile indicative of metastasis from the thyroid gland. The cells where characterized by abundant granular cytoplasm due to aberrant accumulation of mitochondria, which is a characteristic of oncocytes () ().\nDue to this, the patient underwent thyroidectomy of the right side and isthmus of the gland, excision of the lymph nodes on the right side of the neck, and excision of the PET-positive lymph node on the left side of the neck. None of the excised tissue did contain malignancy.\nBecause the primary cancer originating from thyroid tissue had not been located, the 2-year-old resected left lobe of the thyroid gland was re-evaluated. It had identical cytomorphology and the same immunohistochemical profile as the specimen from the tumor in the left humerus. There was no histological evidence of malignancy in any of the samples of the 5 cm tumor of the left thyroid lobe (). The patient was referred to the department of oncology in order to start medical therapy.

A male patient aged 19 years visited the Outpatient Department of Periodontics with a complaint of a defect in his gums and bad appearance of front teeth.\nThe patient was young, healthy with no significant medical history. His previous dental history revealed that he had a history of trauma 2 years back, in which his anterior teeth and right upper and lower central incisors were fractured. He underwent dental treatment for the same that included root canal therapy followed by crown placement on both the teeth. The patient remained asymptomatic for a year when he started noticing a defect in his gum related to his lower front teeth. He again visited the dentist where his scaling was done and was advised to massage his gums with a chlorhexidine gel. The patient had been regularly massaging his gum ever since and did not report back to his previous dentist to seek further treatment.\nHis intraoral examination revealed fair oral hygiene. Upper and lower right central incisors had a porcelain-fused-to-metal crown of which the lower was dislodged from the tooth. A mucosal with alveolar bone fenestration on the labial surface was apparent in relation to lower right mandibular central incisor, and a portion of the root which appeared apex of the root of mandibular right central incisor was visible through the defect []. The fenestration was slightly elongated in shape, measuring approximately 5 mm × 3 mm in diameter. The area was free of pus and calculus, and the surrounding gingiva appeared healthy. There were no periodontal pocket, no mobility, and no communication of fenestration with the gingival sulcus on periodontal probing. A transgingival probing or bone sounding under local anesthetic infiltration gave the impression of probable loss of alveolar bone along the length of the root facially. An intraoral periapical radiograph showed the concerned tooth slightly under obturated with diffuse radiolucency around its root []. The treatment was planned with repeat endodontic therapy in the affected tooth followed by periodontal surgical correction by raising a full-thickness flap.\nOn first sitting, the root exposed through the defect was scaled and planed and full-mouth scaling was also done. The internal surface of the gingiva and margin of the fenestration were gently curetted. The old obturated material was removed from the canal and was meticulously cleaned and reshaped using ProTaper files under copious irrigation with 2.5% sodium hypochlorite. The canal was medicated with calcium hydroxide paste, and the access cavity sealed for 1 week with a temporary restorative material. On the subsequent visit, the paste was flushed out of the canal using thorough irrigation with normal saline and dried and obturated with gutta-percha.\nAfter 1 week of endodontic treatment, periodontal surgery was carried out under local anesthesia. The thin epithelial lining of the mucosal defect was removed first with 11 No. blade [], followed by elevation of a full-thickness mucoperiosteal flap []. There was a complete loss of alveolar cortical plate on the labial side up to the root apex, and the lower portion of the root showed a significant amount of calculus deposits []. Calculus from root was scaled, root planing was done, and the pathology was completely debrided from the surgical area []. Around 1 mm of the root apex was resected. Synthetic bone graft material β-tricalcium phosphate (TCP) (resorbable tissue replacement [RTR] syringe–Septodont: RTR bone substitute of TCP) [] was packed into the defect, around the root apex and over the denuded root surface []. A bioresorbable collagen barrier membrane (PerioCol-GTR-Eucare Pharmaceuticals Private Limited, India: collagen membrane) [] was placed over the bone graft and sutured with resorbable sutures to the adjacent periosteum and connective tissue []. The elevated flap was replaced and sutured using interrupted sutures with 4–0 vicryl. The de-epithelized mucosal defect was also approximated and sutured []. Coe-Pak was placed over the surgical site, and the patient was given postoperative instructions. The patient had been prophylactically prescribed antibiotic, amoxicillin 500 mg, from the day before surgery and anti-inflammatory from the day of surgery for 5 days and was put on 0.2% chlorhexidine mouthwash. The patient was recalled for review after 7 days. Healing was uneventful and the follow-up visits showed complete healing and correction of mucosal defect [].

A 54-year-old Caucasian female with a history of lupus presented for elective left total knee arthroplasty following the development of osteoarthritis that had failed conservative measures. The patient had a history of previous left knee ACL reconstruction approximately 25 years ago using the Arthrotek bone mulch screw and WasherLoc system []. She underwent removal of the tibial WasherLoc approximately 10 years later, in the early 2000's ().\nThe patient was positioned supine; standard incision with a medial parapatellar arthrotomy was performed. A measured resection technique was then performed with an intramedullary guide placed in the femur. The femur was cut in 6 degrees of valgus and 3 degrees of external rotation. A size 4 femoral prosthesis was placed and noted to overhang both medially and laterally on the condyles. At this time, it was decided to downsize the femoral component. The 4 in 1 femoral cutting block was then placed back on the femur and was noted to be in contact with the bone mulch ACL screw. The bone mulch screw was located and identified in the lateral femoral condyle; a curette was used to clear the head of the screw, and it was removed. The proximal tibia was then prepared using an intramedullary guide with 3 degrees of posterior slope. A size 3 tibial component and a 9 mm poly were placed; the knee was noted to be tight in both flexion and extension. An additional 2 mm resection was performed on the proximal tibia. It was noted at this time while trying to trial the prostheses that the lateral femoral condyle was fractured. Conversion to a stemmed femoral component with a cruciate stabilizing prosthesis was attempted. The femoral canal was reamed, and the femoral box cut was made. However, during trialing, the medial femoral condyle was now noted to have a fracture as well. An intraoperative consultation with an adult reconstruction trained orthopaedic surgeon was performed. Immediate surgical correction was not possible due to improper implants being presented. The femoral and tibial canals were then reamed to accept a 200 mm × 9 mm intramedullary nail to act as a temporary internal stabilization device (). The knee was irrigated and closed, and the patient was admitted to the floor. The patient was then brought back to the OR on postoperative day 3 following the index procedure. The prior incision was utilized; the wound was copiously irrigated. It was noted that due to the patient's poor bone quality and comminution of the fractures that the only viable option was a distal femoral replacement. The distal femur was resected, the femoral canal was reamed, and a planar was used on the distal femur. A skim cut and reaming of the tibia were performed. The components were trialed. Final implants included a 13 × 127 mm hinged femoral prosthesis and small 1-stemmed tibial tray; a 32 mm patellar component was used, and a size 10 polyethylene was then inserted; all components were cemented. The knee was noted to be stable throughout range of motion with good patellofemoral tracking. The surgical wound was copiously irrigated and closed (). Estimated blood loss was 100 mL; no postoperative transfusion was necessary. She was able to bear weight as tolerated immediately postoperatively. The patient's pain was controlled postoperatively, and she worked well with physical therapy and was discharged home with home health care on postoperative day two with 3 weeks of Coumadin for venous thromboembolism prophylaxis.\nThe first postoperative visit was at two weeks; the patient had some swelling and quadriceps weakness, and the incision was healing well. Range of motion (ROM) was from 0-100°. At 6 weeks, she was still requiring narcotic medication; quadriceps strength was improving, ROM from 0-105°.\nAt 12 weeks, X-rays remained unchanged; the patient continued to have mild quadriceps weakness and was no longer requiring narcotic medications. ROM was not documented at this visit. At 6 months, ROM was 0-120°. The incision was well healed; X-rays were unchanged. The patient was doing well; however, she continued to have some residual quadriceps weakness and difficulty ambulating long distances. The patient was lost to follow-up after 6 months.

A 26-year-old Indian woman was admitted to our gastroenterology unit with extrahepatic portal vein obstruction with features of massive malena at 29 weeks of gestation. She had a previous pregnancy that resulted in a single offspring. She was referred for an antenatal check-up to our obstetric unit, where after clinical examination, an ultrasonography was performed which revealed gross fetal hydrops. She was transferred to our obstetric unit for further evaluation and management.\nHer prenatal course was complicated by recurrent episodes of hematemesis and malena for 10 years prior to admission and she was previously diagnosed with esophageal varices. She had a history of multiple blood transfusions and sclerotherapy sessions. Her first pregnancy was 2 years prior to admission, in which she had regular supervised antenatal checkups on her first and second trimesters with a normal anomaly scan. Her pregnancy was complicated by gestational diabetes mellitus that was controlled through diet. She had episodes of recurrent malena in this pregnancy. Her third trimester was unsupervised at home and she was admitted to a local private practitioner at the onset of her labour. She underwent caesarean section for meconium-stained liquor. She delivered a grossly normal male baby with jaundice at birth. Details pertaining to the baby are not available, but the baby had received a blood transfusion on the third day of life and died on the seventh day.\nHer present pregnancy was a spontaneous conception. Her first and second trimester antenatal checkups were with a private practitioner in her hometown. She presented in the gastroenterology department of our institute at 29 weeks of gestation with massive malena and anemia. Upper gastrointestinal (GI) endoscopy revealed the presence of grade II esophageal varices for which sclerotherapy was done. She was given three units of packed red blood cells to raise her haemoglobin from 6 gm% to 10 gm%. Upon obstetric referral, ultrasonography at 30 weeks and 5 days revealed severe fetal hydrops. Doppler studies were suggestive of fetal anemia. She was given corticosteroids for fetal lung maturity. At 31 weeks, cordocentesis was done and intravascular intrauterine fetal transfusion with O-negative cross-matched blood was given. Since she was Rhesus (D) O type positive, non-immune hydrops was suspected. Fetal blood was thus sent for blood grouping, haemoglobin, haematocrit, TORCH serology, parvovirus B19 serology, haemoglobin electrophoresis, G6PD enzyme assay and karyotype.\nThe results of fetal echocardiography were normal. Fetal blood group was A-positive and was negative in workup for non-immune hydrops. Maternal serum indirect Coomb's test was positive, thus leading to a suspicion of the presence of non-anti-D antibodies. A special request was sent to the blood bank to screen for uncommon rare blood groups and non-D antibodies. Anti-c was detected in maternal serum in 1:4 dilutions.\nMaternal blood was resent to the blood bank to establish exact Rhesus haplotype, which was determined to be R1R1 (CDe/CDe). The fetus was monitored with bi-weekly biophysical profiling and a second intrauterine transfusion was given one week later with compatible O-negative and c-negative cross-matched blood. At 32 weeks and 5 days, an emergency caesarean section was done due to poor biophysical profile.\nA grossly hydropic female baby with a birth weight of 1.6 kg was born with massive ascites, hepatosplenomegaly, pallor and hypotonia. At birth, 150 ml of ascitic tap was done and the baby was transferred to the nursery on bag and tube ventilation. Her cord blood hematocrit was 15 and total serum bilirubin was 6.5 mg/dl. A partial exchange transfusion followed by double volume exchange transfusion with O-positive, c-negative blood was performed. Intravenous immunoglobulin in doses of 1 gram/kg was administered after the exchange. The baby required intense phototherapy for 4 days. By the second week, she developed conjugated hyperbilirubinemia due to inspissated bile syndrome, which resolved on its own. The baby was then managed conservatively and was discharged in stable condition on the 30th day of her life.\nThe fetal rhesus haplotype was established finally as cDe/cDe. The source of maternal isoimmunisation may be either fetomaternal haemorrhage in the mother s current or previous pregnancy or from multiple blood transfusions.

A 64-year-old female, with multiple previous hospitalizations for acute heart failure, was admitted for shortness of breath, peripheral edema, and increasing abdominal size in her local hospital emergency department with subsequent hospitalization. She had a history of idiopathic dilated cardiomyopathy with severe biventricular systolic dysfunction, secondary severe mitral and tricuspid regurgitation, and permanent atrial fibrillation. As part of the sequence of heart failure therapies, the patient also had a previous implant of an ICD for primary prevention 5 years before.\nDuring hospitalization, the patient developed diverse infectious complications which contributed to a slow resolution of acute heart failure, with the need of many days of inotropic and vasopressor support and subsequent suboptimization of heart failure therapy. As the patient was recognized as having criteria for advanced heart failure, she was referred and transferred to our advanced heart failure center.\nFollowing admission to our hospital, an ECG was performed, showing ventricular paced rhythm with RBBB pattern in V1 through V5 leads and extreme right axis displacement of the mean QRS in the frontal plane clearly indicating an electrical activation from the left ventricle [], which raised suspicion of ICD lead malposition. Chest radiography was performed also showing an abnormal lead path, suggestive of implantation of the lead in the left ventricle []. To confirm our suspicion, our patient then performed a transthoracic echocardiogram, which showed biventricular dilatation with moderate systolic dysfunction, severe mitral and tricuspid regurgitation, and signs of right ventricular pressure overload with plethoric inferior vena cava and abnormal septal motion with systolic “flattening” toward the left ventricle. Peak systolic gradient between the right ventricle and the right atrium was normal, probably underestimated because of right ventricular dysfunction and severe enlargement of the right atrium. However, the implanted ICD appeared to pass through the interatrial septum, with its lead tip in contact with the midsegment of the left ventricular anterolateral wall [-]. Our patient also underwent a transesophageal echocardiogram to better clarify valvular regurgitations and the behavior of the ICD lead at the level of the interatrial septum [-].\nInitially, our patient registered an important decrease in body weight and improvement in symptoms; however, after many days of stay, her hospitalization was complicated with refractory ascites and cardiogenic shock, with fast progression in INTERMACS classification. As our patient reached INTERMACS Level 2, we launched a desperate appeal for cardiac transplantation, as neither extracorporeal membrane oxygenation nor left ventricular assist devices were available at our center at the time. After a couple of days, we got contacted as there was an available heart, and our patient was promptly transferred to our cardiac surgery unit where she underwent successful orthotopic heart transplantation. Analysis of the explanted heart confirmed the presence in the left ventricle of the ICD catheter. Immediate postoperative course was favorable with extubation after 24 h, requiring inotropic support with dobutamine for 2 days with no need for mechanical support. The patient was discharged after 72 days after transplantation, and to this day remains symptom-free with no further hospitalizations.

A 46-year-old premenopausal woman underwent mastectomy and axillary clearance in 1993 for multifocal right breast malignancy. Histology demonstrated an 8 mm grade 1 carcinoma and 10 and 25 mm grade 3 carcinomas. There was no nodal involvement. Hormone receptor status was not assessed but she was prescribed adjuvant tamoxifen for 5 years.\nAlmost 10 years later, in December 2002, our patient underwent a left mastectomy and axillary clearance for a 23 mm grade 3 invasive ductal carcinoma showing vascular invasion and involving 2 axillary lymph nodes. The carcinoma was only focally ER positive and PR negative, but c-erbB2 strongly positive. She received adjuvant chemotherapy [6 cycles FEC] and chest wall radiotherapy, and in view of the albeit weak ER positivity, she was started again on tamoxifen.\nIn August 2004 she complained of back pain. An MRI scan demonstrated multiple bone metastases in the cervical and thoracic spine, and there was some spinal cord compression at T3. A good symptomatic response followed palliative radiotherapy to the upper thoracic spine, and this was followed by 6 cycles of docetaxel chemotherapy in combination with trastuzumab, a change in her hormonal treatment from tamoxifen to letrozole, and a 2-year course of bisphosphonate therapy with zoledronic acid infusions. She continued indefinitely on the three weekly infusions of trastuzumab.\nThe response was maintained for 2 years, but slight nausea and newly abnormal liver function biochemistry led to a CT scan in August 2006. This showed a 9 cm, apparently solitary, lower right liver lobe metastasis in addition to the numerous sclerotic bone metastases. There was no clinical or investigative evidence of disease progression at any site other than in the liver. The liver metastasis was involving both the left and right portal inflows and was considered inoperable. It was decided to continue with trastuzumab but to treat again with docetaxel chemotherapy. She received another 6 cycles and the diameter of the metastasis reduced by more than 50%. It was then considered operable and following an extended right hepatectomy in March 2007, she made an uneventful swift recovery.\nOur patient remained symptomatically well until November 2007, when her upper thoracic spine again became painful. An MRI scan showed some improvement in the degree of bone involvement compared with the MRI scan in 2004, but in view of the pain she was retreated with palliative radiotherapy, to good effect. She continued on trastuzumab and letrozole, and remained symptomatically well until June 2008 when she developed headache, dizziness and vomiting, and a CT scan showed an apparently solitary 33 mm left cerebellar metastasis. She underwent craniotomy and gross total resection. This was followed by whole brain radiotherapy, 40 Gy in 20 fractions, and she made a good recovery.\nA now ‘routine’ 6-monthly whole body CT scan in May 2010, showed a new 2.3 cm lesion in the right adrenal gland. PET CT demonstrated that this was the only significant source of uptake. There was only mild residual activity in the bone metastases and the brain and liver were clear. Adrenalectomy was undertaken in June 2010, histology confirming a 30 × 20 mm metastasis of poorly differentiated ductal carcinoma with moderate ER and weak PR positivity.\nOur patient continues on the trastuzumab and letrozole combination she has now taken for over six years and is currently [April 2011] symptomatically very well and continuing to enjoy a good quality of life, her metastatic bone disease remaining quiescent. She will shortly be receiving her 110th trastuzumab infusion.

A 35-year-old man has been referred to our Dermatology Clinic with the complaint of painful firm immobile nodules along with a surgical scar on the dorsum of his hand. There were also pus drainage and ulceration in some part of the scar. He claimed that there was a tumoral swelling at the dorsum of his left hand in the second metacarpal area for 12 months. It had been gradually increased in size and led to the restriction of the movement of the index finger. Therefore, he came to an orthopedic surgeon and underwent a tumor excision operation about six months ago. He completely improved after this surgery and did not follow up any further treatment. Four months after the surgery, some painful immobile ulcerated nodules with low discharge appeared on the way of the surgical scar. He works as an electrical technician but there was no obvious history of trauma or significant medical problem. Physical examination showed swollen areas at the dorsum of the left hand and palpable tender immobile nodules on the surgical scar with low discharge. Some nodules showed ulcerated crusted surface ().\nThe hematological and biochemical laboratory tests were normal. The hand radiography was done and reported as normal. Therefore, he underwent an incisional biopsy of the nodules. Microscopic examination reveals an ulcerated epidermis with underlying neutrophilic microabscesses surrounded by granulation tissues consisting of plasma cell, macrophage, and fibroblast infiltration. Sulfur granules were found at the center of these inflammatory reactions as filamentous basophilic radiating fungal-like structures in the dermis (Figures and ).\nRegarding these clinical and histopathological data, the diagnosis of actinomycosis was made. Moreover, we asked the patient to bring us any histopathology report of the tumor excised on his hand about one year before his admission. Surprisingly, the diagnosis of actinomycosis had also been mentioned in that report. But he had not come to his surgeon for any further treatment and the recurrence of the lesions occurred on the surgical scar. The patient was treated with intravenous penicillin G for four weeks and then oral penicillin. Resolution of symptoms and sings occurred but the patient did not come back for further follow-up.

The case involved is a 53 year-old female who experienced a loss of right visual acuity after endoscopic sinus surgery under local anesthesia at a local clinic one day prior to being admitted to our department. Her past surgical history included both endoscopic sinus surgery, which had been performed 15 years previously at another local ENT clinic. Immediately after recent right endoscopic sinus surgery, the right eye had no light perception. The orbital CT from the local radiology center showed a small right medial wall fracture. () A thick bony septa observed in the right ethmoid area. () On the first day of admission in our hospital (2 days after surgery), steroid therapy was started for traumatic optic neuropathy. Steroid pulse therapy was treated for 4 days, and then prednisolone orally for 10 days. On the second day of admission, a visual evoked potential (VEP) test revealed the absence of right optic nerve activity (P100: not detected, flat wave). After steroid treatment for 2 weeks, light perception was absent. Orbital MRI was performed on the second day of admission and showed a mild enhancement of the posterior half of the right optic nerve sheath, and a dark signal focus of medial rectus muscle near the right orbit apex (). Two months after ESS, her visual acuity remained zero.\nOptic nerve injury that occurs during ESS usually happens when the operation is performed under general anesthesia. Under local anesthesia, optic nerve injury can be prevented because the patient complains of pain the moment that the lamina papyracea is broken. Optic nerve injury under general anesthesia may occur under the following circumstances; 1) When the surgeon relies on his own experience rather than precise anatomical knowledge; 2) When preoperative CT has not been fully reviewed, or 3) When the operation is conducted without frequently checking the position and direction of the endoscope. Blindness is a rare complication, and can result from; direct damage to the optic nerve by surgical instruments, loss of blood supply to the optic nerve, or indirect damage to the optic nerve due to optic nerve compression by a retrobulbar hematoma. However, in many cases, it is not easy to determine whether blindness has been caused by direct or indirect damage.\nThe reason why direct damage to the optic nerve occurs especially around the posterior ethmoid sinus, may be explained by the proximity of the lamina papyracea and the optic nerve, and the fact that it is difficult for the surgeon to be aware of the break through the lamina papyracea because of the thin fat layer at this site. Morever, aerated posterior ethmoid air cells alongside the optic canal (Onodi cells) occur in a few people and these may place the optic nerve at greater risk of injury during ethmoidectomy.-\nThe mechanisms of blindness caused by indirect injury are a loss of blood supply to the retina or optic nerve compression. Retinal blood supply is sustained by branches of the internal ophthalmic artery, namely the posterior ciliary artery and central retinal artery. Since the central retinal artery and medial posterior ciliary artery run along the inferolateral and medial portions of the optic nerve respectively, they can be easily injured during ESS.-\nTotal blindness, that is irreversible damage, may result from central retinal artery injury due to a loss of blood to the retina; however, ischemic optic neuropathy is more likely to occur when the medial posterior ciliary artery is injured, because it is not a major feeding vessel. Retrobulbar hematoma due to optic nerve compression can be easily diagnosed by proptosis and a stony hard orbit. Measures undertaken to release the pressure, such as orbital massage, lateral canthotomy, and steroid administration can prevent blindness to some degree.,\nIn this study, all three cases presented with optic nerve damage at the posterior ethmoid sinus, and cases 2 and 3 were revision cases. Case 2 was under general anesthesia and case 1 and 3 were under local anesthesia. In cases 1, and 3, direct damage to the optic nerve was presumed since the patient suddenly felt a sharp pain during the operation. In case 3, the surgeon mistook the thick ethmoid bony septum as the middle turbinate during operation. Retrobulbar hematoma was accompanied in case 2 only. In that case, early orbital apex decompression or optic nerve decompression would be helpful because lateral canthotomy and steroids did not bring the vision back. Since no improvement of blindness was observed despite steroid administration in all 3 cases and after the management of retrobulbar hematoma in case 2, we suggest that in the majority of cases blindness may be irreversible and that the prevention of optic nerve damage by a thorough preoperative review of the patient is most important.\nEspecially in revision cases, thickening of the ethmoid septa and displacement of the ethmoid septa can cause the incorrect recognition of structures in the operative field and therefore careful attention is needed. Also, in case of a lateralized middle turbinate, severe septal mucosal hypertrophy, and high septal deviation, care must be taken because the endoscope can easily head laterally.\nIt is important to frequently check the location and direction of the endoscope during surgery, to avoid optic nerve injury. In addition, surgeons must have precise knowledge of the detailed anatomy through cadaver dissections, the ability to interpret the PNS CT scan and experienced procedural surgical skills.

A 28-year-old female had experienced intermittent abdominal pain for 3 months and visited the Asan Medical Center, Seoul, South Korea, for further evaluation and treatment. An abdominal-pelvic computed tomography scan taken in January 2010 at the Asan Medical Center revealed a huge mass involving most of the lower abdomen and pelvic cavity with multiple septations and areas of enhancement (). The provisional diagnosis on the basis of the image findings was either borderline or malignant ovarian neoplasm. Neither ascites nor metastatic lymphadenopathy was found.\nThe patient had a history of radical nephrectomy for Wilms' tumor of the right kidney 25 years previously, at the age of 3 years, in April 1985 at an outside hospital. After surgery, she had been treated with intravenous injection of dactinomycin 25 mcg for 5 days and vincristine 1 mg on the 7th day after the operation. Since then, she had been healthy with no evidence of recurrence or metastasis until she noticed abdominal pain in September 2009.\nUnder the clinical diagnosis of an ovarian tumor, the pelvic mass was resected in February 2010. During surgery, the mass was noted to occupy the entire lower abdominal cavity without involving both adnexa. Intraoperative consultation was made and the frozen section diagnosis was malignant gastrointestinal stromal tumor or other malignant mesenchymal tumor such as leiomyosarcoma with pending evaluation of permanent sections.\nThe original slides of the Wilms' tumor, resected 25 years ago, could not be reviewed because the slides were not available in the file of the outside hospital. However, the outside pathology report stated that the size of the tumor was 12 cm and it was located at the right kidney. The tumor was abutting the head of the pancreas, and in the operation record it was written that the tumor was not completely excised. Microscopically, the tumor was shown to be a classic Wilms' tumor with predominant epithelial tubular elements and minor blastemal and mesenchymal components. No anaplasia or lymphovascular invasion was recorded, and the mitotic count was stated as scant. The final diagnosis of the nephrectomy specimen was Wilms' tumor, stage III.\nGrossly, the resected tumor in February 2010 was a 30-cm, previously ruptured, solid and cystic mass. On the cut surface, the tumor was heterogeneous, pinkish tan to yellow, and had both solid and friable areas. Multifocal hemorrhagic, cystic, and necrotic changes were also noted (). Microscopically, the tumor was composed of three different cell types, epithelial, mesenchymal, and blastemal components (). Areas of tumor necrosis were seen (). The mesenchymal tumor cells were short, spindle-shaped to round cells with scanty cytoplasm in a myxoid background (). The epithelial cell component formed tumor cell nests with glandular architecture (). The majority of the tumor compartment was an undifferentiated blastemal cell component. Mitoses were frequently observed up to 30/10 HPFs, particularly in the blastemal component. Hyperchromatism was also observed, but significant pleomorphism was not obvious (). Immunohistochemical staining was done and the results were as follows: focal positive for cytokeratin in the epithelial component but negative in the blastemal and mesenchymal components (). The Ki-67 labeling index was positive in about 50% of the tumor cells (), and p53 staining was positive in about one third of the tumor cells in all three elements. The immunohistochemical staining for WT-1, S-100 protein, SMA, desmin, myogenin, myoglobin, CD117, and CD34 was negative in all three components.\nOn the basis of the histologic findings in conjunction with the immunohistochemical findings, the tumor was diagnosed as a recurrent classic Wilms' tumor without anaplastic changes.

We present a 10 year old male, who presented with a history of recurrent seizures and impaired speech development from the age of 6 months, hyperactivity, aggressive behavior and poor academic performance of 5 years duration. Informant was the mother. The seizures were described as afebrile and generalized tonic-clonic in nature. The child received several medications, from the hospital of his birth and other secondary health care facilities, for the seizures. Parents introduced traditional herbal oral medication at 2 years when seizures remained intractable, and which he continued till presentation at the CAMH unit. Speech has remained audible but incomprehensible since the 6th month of life till date and has not received any specific therapy for this. Though described as socially interactive with people he was observed to be hyperactive and aggressive in the past 5 years. These features, in addition to the recurrent seizures even in school had resulted in poor academic performance. Persistent complaints and rejection by schools culminated in complete withdrawal from school. Pregnancy and delivery were uneventful. Developmental motor milestones were described as normal until the 9th month of life when parents observed comparative weakness in the left upper and lower limbs. He started walking with a limp at 2 years. He developed a facial rash at 5 years which has increased in spread and defied repeated administration of a variety of topical skin creams. He was first diagnosed as having cerebral palsy at 2 years. It was at 5 years of age that a diagnosis of Tuberous Sclerosis was made in a tertiary health facility. After 2 years of several visits to this facility, the parents stopped attending due to lack of significant improvement in the child's condition and non availability of the special health services such as speech therapy. Currently he is at home and away from school. He is being tendered to by his mother, who had to relinquish her career pursuit, and two hired house helps. There was no family history of seizures. Father is a 37 year old salesman. The child has two younger siblings who have no growth or developmental challenges. Expenses incurred in the care of child were described as prohibitive and have been borne exclusively by the parents. On a monthly basis, his care is said to consume over a third of the family resources. Parents are not aware of any support group or supportive governmental program they can access. Increasing inappropriate hostility towards parents, relatives and other caregivers in addition to the associated difficulty in restraining him and the embarrassment the parents feel from his untoward activities informed his presentation to the CAMH Unit. On examination at presentation he was hyperactive but well kempt. He had Adenoma Sebaceum []. Weight, height and occipito- frontal circumference were appropriate for age. Other significant findings were expressive language disorder and left hemiplegia. Chest x-ray, abdominal ultra sonography and audiogram were normal. Electroencephalogram (EEG) indicated generalized tonic clonic-seizures. A CT-Scan showed intra-ventricular subependymal calcifications []. He had features of Attention Deficit Hyperactivity Disorder (ADHD). Outcome of draw-a-person test was very poor. Overall, a diagnosis of Tuberous Sclerosis with mental retardation, left hemiplegia and ADHD was made. Outlined management included parental counseling, physiotherapy for the hemiplegia, sodium valproate and methyl phenidate were prescribed for seizures and ADHD respectively. The frequency of the seizures and the degree of hyperactivity reduced with commencement of the drugs. The child and parents were subsequently introduced to a special education and rehabilitation facility in the community.

A 54-year-old Caucasian female with a history of lupus presented for elective left total knee arthroplasty following the development of osteoarthritis that had failed conservative measures. The patient had a history of previous left knee ACL reconstruction approximately 25 years ago using the Arthrotek bone mulch screw and WasherLoc system []. She underwent removal of the tibial WasherLoc approximately 10 years later, in the early 2000's ().\nThe patient was positioned supine; standard incision with a medial parapatellar arthrotomy was performed. A measured resection technique was then performed with an intramedullary guide placed in the femur. The femur was cut in 6 degrees of valgus and 3 degrees of external rotation. A size 4 femoral prosthesis was placed and noted to overhang both medially and laterally on the condyles. At this time, it was decided to downsize the femoral component. The 4 in 1 femoral cutting block was then placed back on the femur and was noted to be in contact with the bone mulch ACL screw. The bone mulch screw was located and identified in the lateral femoral condyle; a curette was used to clear the head of the screw, and it was removed. The proximal tibia was then prepared using an intramedullary guide with 3 degrees of posterior slope. A size 3 tibial component and a 9 mm poly were placed; the knee was noted to be tight in both flexion and extension. An additional 2 mm resection was performed on the proximal tibia. It was noted at this time while trying to trial the prostheses that the lateral femoral condyle was fractured. Conversion to a stemmed femoral component with a cruciate stabilizing prosthesis was attempted. The femoral canal was reamed, and the femoral box cut was made. However, during trialing, the medial femoral condyle was now noted to have a fracture as well. An intraoperative consultation with an adult reconstruction trained orthopaedic surgeon was performed. Immediate surgical correction was not possible due to improper implants being presented. The femoral and tibial canals were then reamed to accept a 200 mm × 9 mm intramedullary nail to act as a temporary internal stabilization device (). The knee was irrigated and closed, and the patient was admitted to the floor. The patient was then brought back to the OR on postoperative day 3 following the index procedure. The prior incision was utilized; the wound was copiously irrigated. It was noted that due to the patient's poor bone quality and comminution of the fractures that the only viable option was a distal femoral replacement. The distal femur was resected, the femoral canal was reamed, and a planar was used on the distal femur. A skim cut and reaming of the tibia were performed. The components were trialed. Final implants included a 13 × 127 mm hinged femoral prosthesis and small 1-stemmed tibial tray; a 32 mm patellar component was used, and a size 10 polyethylene was then inserted; all components were cemented. The knee was noted to be stable throughout range of motion with good patellofemoral tracking. The surgical wound was copiously irrigated and closed (). Estimated blood loss was 100 mL; no postoperative transfusion was necessary. She was able to bear weight as tolerated immediately postoperatively. The patient's pain was controlled postoperatively, and she worked well with physical therapy and was discharged home with home health care on postoperative day two with 3 weeks of Coumadin for venous thromboembolism prophylaxis.\nThe first postoperative visit was at two weeks; the patient had some swelling and quadriceps weakness, and the incision was healing well. Range of motion (ROM) was from 0-100°. At 6 weeks, she was still requiring narcotic medication; quadriceps strength was improving, ROM from 0-105°.\nAt 12 weeks, X-rays remained unchanged; the patient continued to have mild quadriceps weakness and was no longer requiring narcotic medications. ROM was not documented at this visit. At 6 months, ROM was 0-120°. The incision was well healed; X-rays were unchanged. The patient was doing well; however, she continued to have some residual quadriceps weakness and difficulty ambulating long distances. The patient was lost to follow-up after 6 months.

A 43-year-old man had no notable findings on a past history, and he worked in a moving company. Due to the pain in the neck and shoulder, the patient received a cervical massage from a massage therapist with a private certificate at a massage center in Kyounggi province, in March of 2008. The massage was performed in such a manner that the massage therapist pressed the patient's back with the palm and then pushed it in an upward direction from the thoracic to the cervical in a prone position. During the massage, the patient had a sensation of paralysis in the right upper and lower extremities. Because the weakness was not severely notable, however, the patient returned home with no other specific treatments. On the evening of that day, the patient felt a weakness in all the extremities, and then visited an emergency care center of another hospital. An OPLL was revealed in the fifth cervical spine on a cervical computed tomography, which was performed at an emergency care center (). On a cervical magnetic resonance imaging, there was an acute herniated nucleus pulposus (HNP) between the C5 and C6. Further, T2-weighted images showed a high signal intensity, which is indicative of myeolopathy around the sixth cervical spine (). The patient had undergone a sixth cervical corpectomy, the anterior cervical fusion and the device fixation for the fifth to seventh cervical spine, the posterior cervical fusion and the device fixation for the third to seventh cervical spine and the posterior laminectomy for the fourth to the sixth cervical spine ().\nFour months following the onset of the trauma, the patient was referred to the department of rehabilitation medicine in our hospital to receive a comprehensive rehabilitative treatment. The results of a manual muscle test and sensation test are shown in . Based on a neurologic level of injury of C4 and an ASIA Impairment Scale of D according to the criteria of the American Spinal Injury Association (ASIA), the patient was diagnosed with incomplete spinal cord injury (). In addition, an electrophysiologic test was also performed at four months following the onset of the trauma. The sensory and motor nerve conduction studies were normal and no significant difference was noted between both sides. On a needle electromyography, abnormal spontaneous activities were found in the right C5-C7, the left C4-C5, C6-C7 paraspinal muscles, the both triceps brachii, the flexor carpi radialis, the extensor digitorum communis and the first dorsal interosseous muscles. Besides, the recruitment patterns of the motor unit action potentials were decreased in both triceps brachii, the flexor carpi radialis and the extensor digitorum communis muscles. These led to the diagnosis of bilateral lower cervical radiculopathy. The muscle stretch reflexes were increased in the upper and lower extremities on both sides. Hoffmann's sign and ankle clonus were observed on both sides. The patient was able to walk using a walker at indoors, and he needed a minimal assist to perform activities of daily living, such as grooming, feeding, dressing, transfer from a bed to a wheelchair and a gait. But, the patient needed a moderate assist to perform such activities as toileting and bathing. Therefore, the Korea spinal cord independence measure (KSCIM) was 67/100. Following a 3-week of comprehensive rehabilitative therapy, the patient was discharged in such a condition that the patient walked independently indoors with a right ankle foot orthosis.\nThe patient received a physical and occupational therapy, and was monitored of the clinical course at an outpatient clinic of the rehabilitation medicine in our institution. Three years after the trauma, a manual muscle test showed that the muscle strength was increased in the left elbow extensor, both finger abductor, the right hip flexor, the right ankle dorsiflexor, the right ankle plantar flexor, and the right great toe extensor muscles. The pain and temperature sensation were normal up to the level of T8/T4 (right/left), and the proprioception was improved to the normal range at all the spinal levels. This led to changes in a neurologic level of an injury to C6 (). Furthermore, the patient was able to perform most of the activities of daily living, including outdoor walking and driving, without an orthosis. Therefore, the score of KSCIM was 97/100. But the patient needed to hold a balustrade, while going up and down the stairs, used a fork because of the difficulty in using a chopstick when having a meal, and usually wore clothes without buttons because of the difficulty in manipulating the buttons. That is, the patient had a restriction in going up and down the stairs and performing a fine motor coordination.

A 32-year-old woman who had been attempting to achieve pregnancy for 6 years was referred to our reproductive medicine centre with a request for intracytoplasmic sperm injection in October 2016. The indication was primary infertility, and her husband had asthenozoospermia and teratospermia. At 3 days after oocyte retrieval, the patient presented to our hospital complaining of 7 hours of right lower quadrant and right flank pain with nausea and vomiting for no known cause. Her temperature and blood pressure were normal. An abdominal examination showed normal bowel sounds, moderate right lower quadrant tenderness, and voluntary guarding. A vaginal examination showed a tender mass of 10 cm at the right iliac fossa with rebound tenderness. An ultrasound scan indicated hyperstimulation with enlarged ovaries that measured 97 × 68 mm (right ovary) and 71 × 50 mm (left ovary), and excessive fluid in the pelvic area. Doppler imaging showed diminished right ovarian vascular flow compared with the left ovary. A diagnosis of OHSS with right ovarian torsion was made and an emergency operation was immediately performed. At laparoscopy, there was approximately 500 ml of clear ascitic fluid. The right ovary was 9 × 6 × 5 cm in size, dark blue, and the pedicle was twisted 360 degrees (). The left ovary appeared healthy, was 5 × 4 × 4 cm in size, and had multiple follicles on the surface. At 5 minutes after untwisting the right pedicle, there was an improvement of colour. We continued observation until the right ovary, as well as the fallopian tube, turned a similar colour to the left ovary 30 minutes later (). At 9 days after operation, an ultrasound scan indicated that the right ovary was 63 × 48 mm in size with good blood flow signals. The patient was then discharged. On 3 April 2017, frozen-thawed embryo transfer was performed, and her pregnancy test 12 days later was positive. Currently, the patients is asymptomatic and in her 7th month of pregnancy.\nThe patient provided verbal informed consent for publication of this report.

A 17-year-old female presented with a history of osteosarcoma that was confirmed after undergoing a surgery to remove an enlarging bone tumor in the left temporal region 2 years ago. She later got pregnant and delivered her child but never got back for a checkup until she was admitted to our hospital with a severe and unresponsive to medication headache that progressed over the course of 6 months and blurred vision that progressed to complete left-sided vision loss. Physical examination revealed a tough and mobile yet fixed at the base 7-cm mass towards the left of the frontal bone. Many more masses were revealed in the left side of the skull including the anterior cranial fossa, orbit, base of the skull and the left part of the occipital region where the previous procedure was performed (). These masses had been increasing in size probably under the influence of pregnancy hormones causing pain that radiated along the orbital and maxillary branches of the left trigeminal nerve. Physical examination and past medical history were otherwise unremarkable. Laboratory tests were all normal, and her family history was negative. Staging studies showed no evidence of distant metastatic disease in the chest, the abdomen and the pelvis. CT scan of the skull revealed a bone-forming non-lytic lesion accompanied by periosteal reaction. This lesion bulges to the outside towards the scalp spreading into both the soft tissues and the inside of the entire left side of the skull with a sunburst-pattern ( and ). Its rims are unsymmetrical and pointy, and it bulges into the left orbit outside the muscles causing exophthalmos with a semi-complete proptosis of the eyeball out of the orbit ( and ). This lesion applies pressure to the left frontal and temporal lobes causing mild edema in both these lobes without invading the brain tissue. This edema in turn applies pressure to the left lateral ventricles (minor shift of the elements of the midline to the right side can be seen on CT) (). Due to the tumor’s wide spread, the surgical procedure was performed in two stages (approximately 6-hour-long each). In the first stage, the bone mass was removed through a procedure of wide skull approach including the frontal, temporal and parietal bones and a removal of the invading part of the temporal muscle. Moreover, the lateral wall and roof of the left orbit were removed, the left optic nerve was dissected free and part of the meninges was removed and replaced with an autogenic patch from the fascia lata. Then, the bone loss was compensated for by using bone cement Synicem VTP (poly methyl methacrylate and Barium sulfate), and the orbit was rebuilt; the eyeball was placed back with noticeable decline of the exophthalmos. In the second stage, a complementary left parietal occipital incision of the previous approach was performed 3 weeks later; the remaining of the frontal and occipital bones was removed, and a partial mastoid surgery was done. Furthermore, the cavernous sinus were revealed and found to be not invaded. Later on, the normal skull shape was restored using the same cement. The histopathology of the lesion revealed proliferation of neoplastic chondroblasts, osteoblasts and spindle-shaped cells. The features are consistent with low-grade chondroblastic osteosarcoma (). The patient did not need ICU admission. She recovered well 3 days after the surgery and was discharged with no deficits. A CT scan that was performed post-operatively revealed that the masses were successfully excised ( and ). At the last follow-up 1 month post-operation, the patient was scheduled to undergo a course of radiotherapy, 60 Gy of radiotherapy in 30 fractions over 4 weeks without chemotherapy, as it is not recommended with low-grade osteosarcoma.

A 39-year-old female was admitted into our clinic with a complaint of a 3-month history of a slowly growing mass along the neck midline. The physical examination revealed a 3 × 1.5 cm immobile mass along the neck midline over the thyrohyoid membrane, accompanied by a 3 × 2 cm palpable nodule in the left thyroid gland. A neck US revealed a calcified heterogenic-hypoechoic solid lesion of 30 × 18 mm at the level of the hyoid bone in the submental area, which was not related to the thyroid gland. A thyroid gland US revealed several hypoechoic nodules, the largest being 38 × 24 mm, with some having micro calcifications in the left lobe of thyroid gland, while the study identified no right lobe lesions. FNAB was performed on both the midline neck mass and the left lobe nodule. The FNAB results were reported as being consistent with papillary thyroidal carcinoma for the mass along the neck midline and as benign cytology for the nodule in the left thyroid lobe. MRI of the neck showed a 30 × 20 mm midline solid soft tissue mass with hyperintense signal after injection with contrast media. The MRI also demonstrated cystic changes in the mass and evidence of invasion into the infrahyoid muscle group (). After considering all of the clinical and radiological data, despite a histopathologic diagnosis of benign cytology for the left lobe nodule, we performed a Sistrunk procedure with total thyroidectomy and central neck exploration due to suspicion of simultaneous de novo development of papillary carcinoma in the TDC and the thyroid gland. Informed consent was obtained prior to the procedure.\nDuring the Sistrunk procedure, a solid mass invading the infrahyoid muscle group was encountered, and gross total resection of the tumor was performed. A total thyroidectomy operation was also conducted (). During central neck exploration, samples of the suspected lymph nodes were sent for frozen section pathology, the results of which confirmed the diagnosis of papillary carcinoma metastasis. After completion of the exploration, the central neck was dissected and additional specimens were sent to pathology. Pathologic examination identified the thyroid specimen as containing papillary carcinoma of the diffuse sclerosing type and papillary carcinoma of the classical type for the TDC specimen.\nHistopathology revealed the nodule which was seen on the cut section of thyroglossal cyst tissue; the tumor was located within cysts, composed of complex branching true papillae that contain fibrovascular stalk (Figures and ). The papillae were lined by neoplastic epithelial cells with enlarged, clear “Orphan Annie eye” nuclei and some of them had nuclear grooves () that were characteristics for papillary thyroid carcinoma, classical variant. The tumor was unencapsulated with 3,5 cm in diameter. The histopathological examination of the nodule that was seen on the cut section of left lobe of thyroid gland was as follows: unencapsulated, with a 2 mm diameter of lesion being determined (). The tumor cells were composed of large, oval shaped and clear nuclei with some having a groove which was also characteristic for papillary carcinoma (). Because of the tumor size that was smaller than 1 cm in diameter and the presence of dense desmoplastic stroma, we described it as diffuse sclerosing variant of papillary microcarcinoma. Immunohistochemistry results showed that the tumor cells were positive for CK 19, Galectin-3, and HBME-1 which was compatible with papillary carcinoma (Figures , , and ).\nAfter the operation, a radioactive iodine (RAI-131) dose of 150 mCi was administered as adjuvant therapy. After RAI treatment, the patient had an undetectable thyroglobulin level at the 6-month follow-up. In addition, an I-131 whole body scan dose of 5 mCi revealed no pathologic involvement. Both a thyroglobulin level and an I-131 whole body scan were planned during follow-up at 1, 2, and 5 years after the initial RAI adjunctive therapy.

A 14 year-old female presented with a year's history of painless enlargement of the right parotid gland and one week's history of facial asymmetry. Physical examination revealed a firm mass 2 × 3 cm in diameter in the region of the parotid gland as well as right facial nerve paralysis. The mass was fixed with palpation as was a palpable right cervical lymph node. She had a normal body temperature and normal complete blood count, erythrocyte sedimentation rate, and blood chemistry.\nWe investigated the possibility of other diseases that could cause a swelling in the parotid gland: granulomatous infections such as mycobacterial diseases and autoimmune disorders. The results were negative.\nMagnetic resonance imaging (MRI) showed an enlargement of the right parotid gland with evidence of multiple cystic masses involving both the superficial and deep portions of the gland.\nFine-needle aspiration (FNA) biopsy was used for diagnosis. Cytopathological examination suggested ACC with the finding of large globules of the extracellular matrix, partially surrounded by basaloid tumour cells but lacking characteristic globules.\nA radical parotidectomy and modified radical neck dissection with spinal accessory nerve preservation was planned under general anesthesia. A preauricular incision that curved under the ear lobule was made in extension with the neck dissection incision. A skin subcutaneous flap was raised over the parotid until the distal branches of the facial nerve were seen to exit the gland. The mandibular, buccal, and zygomatic branches were incised and tagged with fine silk sutures for later grafting []. As the main trunk was considered to be encased by the tumour, a mastoidectomy was performed, to identify the main trunk of the facial nerve, increase the length of the proximal nerve stump for grafting, and also to provide adequate surgical margin.[] Once the main trunk was identified, extensive resection was performed to remove the parotid neoplasm. Frozen sections from the facial nerve confirm uninvolved nerve margins. After resection of the parotid neoplasm, modified neck dissection was subsequently added and the donor nerve graft was prepared from the great auricular nerve []. The greater auricular nerve was traced proximally until additional branches coming off the cervical nerve roots were isolated.[] After freshening the cable nerve graft ends as well as the proximal and distal facial nerve branches with a scalpel, microscopic epineural repair was performed with an interrupted 8-0 monofilament nylon suture, with three to five sutures used at each anastomosis. The distal part of the graft was anastomosed to the main trunk of the facial nerve and the proximal branches coming off the cervical nerve roots were anastomosed to peripheral stumps [].\nThe postoperative period was uneventful without any complications. Topical moisturizing agents were used for postoperative eye management. Gold weight placement was recommended but not accepted by the patient. Adenoid cystic carcinoma and facial nerve invasion was confirmed in the pathological examination of the surgical specimen of the parotid gland. Four weeks after surgery, the patient was irradiated with 2 Gy fractions; the total dose was 60 Gy.\nThe patient was followed every six months for two years. The House-Brackmann facial nerve grading system was utilized to assess postoperative facial nerve function.[] One year after surgery, the patient achieved facial symmetry at rest, but there was still asymmetry during mimetic motion. The patient was judged to have grade IV level of facial function. Two years after operation, the patient presented with a swelling on the left side of her neck. Physical examination revealed several palpable left cervical lymph nodes ranging from 1–2 cm in diameter in the deep jugular chain. The largest one located in the upper cervical region lying in level II was excised in another medical center. The findings of the histopathological examination were consistent with inflammatory changes; no tumour cells were detected. A CT scan of the chest at this time showed a few millimetre sized nodular lesions in the lung but there was no increase in the nodular size over two years. Hence, we did not consider these lesions as evidence of metastasis; however, follow-up was done every year. At the end of four years, the patient had slightly better facial function than at the end of the first year [].

A 48 year old male presented to our emergency department with pain and restriction of movements involving both shoulders following a fall. A thorough history into the mechanism of fall revealed that the patient was a known diabetic on oral hypoglycaemic drugs and following a syncopal attack, he fell on his outstretched right hand with the body weight falling on it, causing it to dislocate posteriorly. And a bystander in trying to prevent the patient from falling held on to his left upper limb, which was pulled into abduction, extension and external rotation producing an anterior dislocation on the left side. A detailed clinical examination showed flattening of deltoid contours on both sides. Humeral head was palpable posteriorly on the right side and anteriorly on the left side. Surprisingly, there were no characteristic deformities with the arms hanging by the side of the body. Attempted range of motion was painful on both sides. Plain radiograph anteroposterior view of both shoulders showed posterior dislocation of right shoulder with a fracture of greater tuberosity and anterior dislocation of left shoulder with a greater tuberosity fracture. Special radiographs including axillary lateral and scapular Y view were taken which confirmed the findings. He was not a known epileptic and did not give any history of a seizure episode in the past. He did not have any history of dislocation in the past. There were no features suggestive of generalized ligamentous laxity.\nA closed reduction was achieved for both shoulders under general anaesthesia, anterior dislocation was reduced easily by Kochers method, and posterior was reduced by giving gentle traction on the arm in flexion and adduction, with a direct pressure to the humeral head from behind, but as the posterior dislocation was unstable, after reduction, it was immobilised by spica in slight flexion and abduction with 20 degrees external rotation, whereas a chest arm bandage was applied for the other side. Post reduction check X-ray showed concentric reduction of both shoulders with minimal displacement of fracture fragments. The spica and bandage were removed after 3 weeks and shoulder pendulum exercises were initiated. After a couple of weeks, complete range of motion exercises were started. X-ray of bilateral shoulders, at 3 months, showed complete union of the fracture. Both the shoulders have satisfactory painless range of motion with no instability.\nWritten informed consent was obtained from the patient for publication of his details in this report.

A 26-year old man accidentally had a cut from a circular saw in the medial, posterior part of the right thigh during work. Due to vascular damage of the femoral vessels he suffered substantial blood loss and when he was brought to the emergency room he was in shock but awake. The damage to the femoral artery and vein was repaired immediately and circulation of the leg and foot was restored within three hours of injury. On examination the day after surgery it was discovered that the patient had loss of sensory and motor function matching the area of the sciatic nerve below the point of injury. On the third postoperative day the area was explored and the sciatic nerve was found to be transected. After trimming of the nerve ends there was a gap of 3–4 cm. The individual tibial and peroneal groups of fascicles could be identified in the wound and by electrical stimulation of the distal nerve end. The sural nerve of the injured leg was harvested and divided into eight segments, which were then used as grafts, 5 segments for the tibial component and 3 segments for the peroneal component (Figure \n). The grafts were applied with extended knee position and fixed with single 9–0 sutures and tissue glue (Tissel®).\nThe leg was immobilized in semi flexion for four weeks. The initial rehabilitation was without complication. Follow-up was conducted at our department, every three months the first year and then every six months. The patient used an orthosis during daytime for support and to hold the foot up and physical therapy to counter contractions. Sensory re-education was performed. He later had some tendency towards plantar flexion contracture, especially in the mornings, which was treated with an orthosis during night.\nThe physical therapy aimed to encourage counter contractions in the leg. Motor function progress was measured according to the British Medical Research Council (MRC) scale showing a continuous improvement of muscle force (Table \n) At final follow up (58 months) he, above the muscle force described in Table \n, also had M4 in toe extensor muscles and even M3+ in toe flexor muscles, although more concentration was required by the patient to activate the latter muscles. Regeneration was followed with Tinel’s sign. Sensory function was examined with Semmes-Weinstein monofilament conducted by an independent occupational therapist. At 24 months follow-up he could feel the 4.56 evaluator filament (indicating diminished protective sensation) on the mid lateral part of the sole of the foot. Apart from that he only had deep pressure sensation in the foot. He had no sensation over the heel. At 40 months follow-up he could feel the 4.31 evaluator filament (diminished light touch) in the mid lateral part of the sole of the foot and under the third and fifth toe. Under the big toe and the heel he could feel the 6.65 evaluator filament (deep pressure sensation) and in the rest of the sole of the foot he could feel the 4.56 evaluator filament (diminished protective sensation). At 58 months he could feel 3.61 evaluator filament in all toes and in most of the sole of the foot, except at the heel (4.31 evaluator filament). At no point did he have problems with cold sensitivity. He had some problems with allodynia, which was treated with tramadol hydrochloride (Tramadol®) for pain relief. An electromyography (EMG) done at 41 months showed decreased nerve conduction over knee level compared to the un-injured leg. In the majority of the muscles of the lower leg denervation activity was seen, most prominent in the distal muscles. However, in the gastronemius, long peroneal and anterior tibial muscles there were good voluntary activations. A low voltage response from the abductor hallucis muscle on stimulation of the tibial nerve at the ankle indicated that there was some reinnervation of the muscles of the foot.

A 40-year old female with history of breast cancer was referred from an out-side clinic. She had received a lumpectomy of her right breast with an axillary lymph node dissection 34 months before she first visited our institute. The pathology report obtained at the time of surgery documented infiltrating ductal carcinoma, and the resection margins were confirmed to be clear of carcinoma invasion. Three regional lymph nodes out of 16 were found to possess adenocarcinoma cells. Lymphovascular invasion was reported negative. Routine staging workup showed no evidence of distant metastasis, staging her as T2N1M0 based on an American Joint Committee on Cancer staging system at the time of surgery. As a surgical procedure, a catheter draining from the lumpectomy site was placed, which was later removed. She had completed 6 cycles of chemotherapy with cyclophosphamide, methotrexate, 5-fluoruracil regimen, and radiotherapy of the whole breast with 50.4 Gray plus a boost of 9 Gray was performed. She denied receiving any other type of surgery. No evidence of recur were observed by thorough imaging studies; regular checkups were done at the out side clinic.\nOn her visit, she complained of a recently noticed palpable lump on her right chest wall. Physical exam revealed an approximately 2 cm sized moveable subcutaneous nodule with rubber consistency located on the middle axillary line at the level of nipple. A small scar was noticed on the skin lying directly superficial to the nodule, which the patient claimed to be the wound site of drain catheter insertion during the lumpectomy she previously received. Ultrasonography of breast and chest wall revealed a well demarcated subcutaneous mass measuring 1.8 cm in length (). No other abnormalities were demonstrated in the remaining breast. A sonographically guided 14-gauge core needle biopsy yielded infiltrating ductal carcinoma.\nA whole body bone scan and whole body positron emission tomography scan failed to demonstrate any suspected metastatic lesion other than the mentioned nodule at the right chest wall. A chest CT was obtained in addition to ultrasonography to evaluate the extent depth of the lesion, and both modalities disclosed the previously mentioned nodule to be confined to the subcutaneous compartment.\nA wide excision of the recurred mass was performed. Gross inspection of the specimen showed a block of tissue containing a subcutaneous ill-defined pinkish nodule with an expanding growth pattern measuring 1.8 cm. Histopathologic evaluation of the specimen showed clear resection margins and the tumor lesion was confined to the subcutaneous compartment. Subsequent irradiation of 50 gray at the region was performed. She is symptom free without evidence of any additional tumor recurrence, while 18 months have passed since the wide excision of the previous drain site mass has been carried out.

A 54-year-old Caucasian female with a history of lupus presented for elective left total knee arthroplasty following the development of osteoarthritis that had failed conservative measures. The patient had a history of previous left knee ACL reconstruction approximately 25 years ago using the Arthrotek bone mulch screw and WasherLoc system []. She underwent removal of the tibial WasherLoc approximately 10 years later, in the early 2000's ().\nThe patient was positioned supine; standard incision with a medial parapatellar arthrotomy was performed. A measured resection technique was then performed with an intramedullary guide placed in the femur. The femur was cut in 6 degrees of valgus and 3 degrees of external rotation. A size 4 femoral prosthesis was placed and noted to overhang both medially and laterally on the condyles. At this time, it was decided to downsize the femoral component. The 4 in 1 femoral cutting block was then placed back on the femur and was noted to be in contact with the bone mulch ACL screw. The bone mulch screw was located and identified in the lateral femoral condyle; a curette was used to clear the head of the screw, and it was removed. The proximal tibia was then prepared using an intramedullary guide with 3 degrees of posterior slope. A size 3 tibial component and a 9 mm poly were placed; the knee was noted to be tight in both flexion and extension. An additional 2 mm resection was performed on the proximal tibia. It was noted at this time while trying to trial the prostheses that the lateral femoral condyle was fractured. Conversion to a stemmed femoral component with a cruciate stabilizing prosthesis was attempted. The femoral canal was reamed, and the femoral box cut was made. However, during trialing, the medial femoral condyle was now noted to have a fracture as well. An intraoperative consultation with an adult reconstruction trained orthopaedic surgeon was performed. Immediate surgical correction was not possible due to improper implants being presented. The femoral and tibial canals were then reamed to accept a 200 mm × 9 mm intramedullary nail to act as a temporary internal stabilization device (). The knee was irrigated and closed, and the patient was admitted to the floor. The patient was then brought back to the OR on postoperative day 3 following the index procedure. The prior incision was utilized; the wound was copiously irrigated. It was noted that due to the patient's poor bone quality and comminution of the fractures that the only viable option was a distal femoral replacement. The distal femur was resected, the femoral canal was reamed, and a planar was used on the distal femur. A skim cut and reaming of the tibia were performed. The components were trialed. Final implants included a 13 × 127 mm hinged femoral prosthesis and small 1-stemmed tibial tray; a 32 mm patellar component was used, and a size 10 polyethylene was then inserted; all components were cemented. The knee was noted to be stable throughout range of motion with good patellofemoral tracking. The surgical wound was copiously irrigated and closed (). Estimated blood loss was 100 mL; no postoperative transfusion was necessary. She was able to bear weight as tolerated immediately postoperatively. The patient's pain was controlled postoperatively, and she worked well with physical therapy and was discharged home with home health care on postoperative day two with 3 weeks of Coumadin for venous thromboembolism prophylaxis.\nThe first postoperative visit was at two weeks; the patient had some swelling and quadriceps weakness, and the incision was healing well. Range of motion (ROM) was from 0-100°. At 6 weeks, she was still requiring narcotic medication; quadriceps strength was improving, ROM from 0-105°.\nAt 12 weeks, X-rays remained unchanged; the patient continued to have mild quadriceps weakness and was no longer requiring narcotic medications. ROM was not documented at this visit. At 6 months, ROM was 0-120°. The incision was well healed; X-rays were unchanged. The patient was doing well; however, she continued to have some residual quadriceps weakness and difficulty ambulating long distances. The patient was lost to follow-up after 6 months.

A 60-year-old female patient was admitted to the inpatient treatment section from the outpatient therapy wing of the physical medicine and rehabilitation department for the evaluation and treatment of impaired walking due to gradual weakening of the bilateral lower extremities that had lasted for three months. The patient seemed to have cognitive impairment, and did not have accurate memory of the trauma. However, according to the report of a family member, the patient had been medicated for cerebral infarction, hypertension, and osteoporosis, with no problems in ambulation and other activities of daily living before slipping down three months ago. After that, she had been in a bed ridden state and showed gait disturbance. Based on neurological examination, her mental status was alert, but her orientation, memory, calculation and other cerebral functions were generally impaired, whereas her speech was intact. In terms of the cerebellar function, there were no specific findings on both of the upper extremities, and the lower extremities could not be checked due to muscle weakness. Although an accurate evaluation of motor function was challenging during the manual muscle test, the upper extremities were found to be in normal range. For the lower extremities, the flexor and extensor of the hip and knee of both sides were in poor grade, and the dorsiflexor and plantarflexor of both ankle joints were degraded to trace grade level. There was no limitation in passive range of motion. In both lower extremities, the spasticity corresponded to the Modified Ashworth Scale I grade. Although accurate evaluation for sensory function was also difficult, the patient showed a relatively intact result in the pinprick test, but the proprioception and vibration sensation were impaired. Deep tendon reflex was normal for both upper extremities but increased in both lower extremities, and Barbinski's signs and ankle clonus were found on both sides. Results of the functional evaluation showed impossibility of independent ambulation. Although the activities of daily living using the upper extremities were possible, the patient needed considerable assistance in other areas. In terms of urinary function, urinary retention was observed, so we inserted a foley catheter since the patient was incapable of self-voiding. In addition, due to severe constipation, medication was provided and we helped defection with the use of glycerine enema, 2-3 per day as needed. The first lumbar vertebral body bursting fracture was found in the simple film taken at admission. From the magnetic resonance imaging (MRI) of the lumbar spine, the spinal dural arteriovenous fistula was found in the first lumbar vertebral body bursting fracture in addition to the shades of dilated vein in the periphery of the spines starting from the fifth thoracic vertebra to the cornus medullaris. As a result, the spinal cord edema was accompanied, and the specific findings of high signal, light shade of the spine were observed from the T2 weighted image (). Although electromyography and somatosensory evoked potential test were considered, we could not conduct them because of the patient's transfer to the neurosurgical department due to urgent need of arterial embolization. For more accurate location mapping of the spinal arteriovenous fistula, we conducted spinal vessel angiography and found that the arteriovenous fistula originated from the twelfth intercostal artery and first lumbar radicular artery. In addition, the spinal vein located on the anterior and posterior spine that continued to the cervical vertebra region was observed (). Since the artery of interest was not that large, we planned the embolization procedure employing glue (n-butyl cyanoacrylate) rather than the operation. After embolization of the number twelve right thoracic vertebrate intercostal artery and first lumber, the embolization of all fistula was followed. As a result, there was no venous plexus observed around the spine (), and the neurologic symptoms of the patient improved. The hip flexor and knee extensor improved to 'fair grade' and the ankle plantar flexor improved to 'poor grade'. Although we were not able to check the sensory function due to the patient's impaired cognition, big changes were not observed after the treatment. As a result of the post therapy follow-up using MRI to see the condition of spinal cord edema, we found that the spinal vein was dilated due to arteriovenous fistula not being found, as well as the spinal cord edema around the artery. Therefore, we were able to observe normal low signal intensity of the spinal cord from the T2 weighted image (). With the help of rehabilitation therapy including strengthening and endurance exercise of the lower extremities, gait training, and functional electrical stimulation to both tibialis anterior, the patient showed gradual improvement and could ambulate about 2-3 m. The urinary symptoms also improved and the patient was able to self-void after removal of the foley catheter following normal functioning results based on the urodynamic study. Bowel function also improved and the patient was capable of daily defecation.

A 59-year-old female patient reported to the hospital for replacement of missing teeth. On examination, the patient had lost all her teeth and her one side of the face was paralyzed. The patient gave a history of trauma before some years and gradually lost all her teeth due to periodontal problems. The patient underwent medical treatment for the same in a general hospital. The paralysis was noted both in upper and lower regions of the face and the patient was unable to smile and close her eyes on her left side. The patient was unable to lift her left eyebrow and complained of reduced taste sensation, but was not insisting on the symptoms. The patient had spasms in her facial muscles with synkinesis, which developed gradually [Figures and ] and was not clear of the time period over which it developed. There was an asymmetry of her face when she tried to smile or close her eyes with a maximal effort. The diagnosis was Bell's palsy Grade IV[] on the left side of the patient's face which involved the ipsilateral part of the facial nerve. The patient was not willing for the invasive treatment for the same. The patient was given an option of complete dentures with cheek plumpers,[] which can somewhat improve her facial appearance. The patient readily accepted the treatment plan and primary impressions were made for the upper and lower edentulous arches.\nThe diagnostic casts showed normal arch form without any pathologic conditions. The labial and buccal flanges of the dentures were planned to be enhanced as the circumoral muscles were weak. A simple way of enhancing the labial flanges with wax and later processing with acrylic resin was planned due to time and economic factors. Proper physiologic impressions were made after explaining the treatment plan to the patient with her consent. The occlusal rims were fabricated from the master casts with additional wax on the labial and buccal flanges. The jaw relations were made and try-in verification was done at a later date. Wax was added more on the right side and less on her left side to reproduce the symmetry of her face [Figures –]. After satisfactory results with the patient's consent, the denture was fabricated with high impact acrylic resin. The upper and lower dentures were inserted in a later appointment [Figures and ]. The patient was taught to use the prosthesis and proper instructions were given to the patient. Oral hygiene was emphasized to avoid food entrapment between the dentures and the cheek. The patient was further referred to an ophthalmologist for corneal protection.

A 78 year-old male was diagnosed with central non-small cell lung cancer 12 months earlier. The primary lung cancer was located in the proximal right upper lobar bronchus associated with postobstuctive atelectasis of the right upper lobe. However, at the time of diagnosis, the patient refused all the curative means. He had exhibited cough and increasing blood tinged sputum in the previous 4 months. We performed CT imaging on outpatient clinics, which showed a completely obstructed right upper lobar bronchus by a tumor with postobstructive pneumonia of the right upper lobe. The wall of the right main bronchus and bronchus intermedius was thickened and the lumen of the right main bronchus was almost narrowed by tumor infiltrations. Metastatic lymphadenopathy was observed in the right lower paratracheal and subcarinal area (). Nine days after the CT scan, the patient was hospitalized and underwent bronchoscopy. A bronchoscopic examination demonstrated that orifice of the right main bronchus was nearly completely obstructed by the endoluminal mass and there was diffuse bleeding from the right main bronchus. The patient received urgent external beam radiotherapy to control bleeding from the friable endobronchial tumor and bleeding gradually decreased for several days. However, eleven days after the radiation therapy, a sudden onset of dyspnea developed. Chest radiography showed that the right lung had totally collapsed and bronchoscopic examination revealed complete obstruction of the right main bronchus with diffuse bleeding.\nBronchial artery embolization could not be considered as a treatment option for hemoptysis because bleeding conditions were not because of active arterial bleeding and there was no prominent contrast enhancement of the mass as seen on the CT scan. We decided that bronchial stent insertion in the right main bronchus was necessary to both, re-open the airway and to control the bleeding of tumor through the tamponade effect. After the bronchogram, which was performed to identify the airway on a fluoroscopic image, we decided to sacrifice superior segment of the right lower bronchus to preserve basal segments of the right lower lobe. The 12 mm - 4.3 cm self-expanding silicone-covered nitinol stent (Hercules airway stent, S & G Biotech, Seongnam, Korea) was deployed in the right lower lobar bronchus to the right main bronchus. However, proximal portion of the right main bronchus was not completely covered due to its insufficient length. For this reason, another 12 mm - 5.3 cm self-expanding silicone-covered nitinol stent was reinserted, overlapping the first stent.\nAt the end of the procedure, an immediate improvement in the aeration of the right basal lung was observed on fluoroscopy and hemoptysis was subsided (). Nevertheless, the patient died two days later due to lack of expectoration that resulted in whole lung aspiration pneumonitis or pneumonia.

A 78-year-old man with a history of severe peripheral arterial disease (PAD) requiring left third toe amputation and percutaneous stenting of the left superficial femoral artery was admitted to the intensive care unit (ICU) due to an acute subarachnoid hemorrhage (SAH) which occurred after a fall. The patient was also found to have an acute fracture in the tenth thoracic vertebra, and he subsequently underwent spinal fusion of the eighth to twelfth thoracic vertebrae. Within three hours postoperation, the patient was still lethargic and did not complain of pain; however, his left lower extremity was noted to be swollen and cool to the touch from the thigh down with a mottled skin appearance (). Pedal pulses were completely absent on palpation, and no signal was detected on a portable Doppler device. The initial suspicion was for an arterial embolic event causing limb ischemia as the patient had a history of atrial fibrillation. As a result, a computed tomography arteriography (CTA) of the abdominal aorta with bilateral runoff was done and showed the previously placed stent extending from the left superficial femoral artery to the proximal popliteal artery with absent filling consistent with vascular occlusion (). Due to significant leg swelling, a venous duplex ultrasound was done and revealed extensive acute deep vein thrombosis (DVT) ranging from the left common femoral vein down to the popliteal vein with completely absent venous blood flow. The clinical and radiographic findings were consistent with a diagnosis of phlegmasia cerulea dolens (PCD).\nAfter clearance from the neurosurgeon, IV heparin was started approximately 7 hours after the development of symptoms. Due to the extensive DVT and the advanced PAD, the vascular surgery team deemed that the chances of limb salvage are very small and that any procedural intervention will pose a great risk to the patient's life. Thrombolysis was contraindicated due to the recent SAH and spinal surgery. After comprehensive multidisciplinary discussions including a second expert opinion which was sought from a peripheral interventional cardiologist, a delayed decision was reached to attempt a minimally invasive percutaneous limb-salvaging approach which occurred 20 hours after the diagnosis was established. In the catheterization lab, venography of the inferior vena cava (IVC) via left popliteal vein access revealed extensive and occlusive thrombosis of the iliac, femoral, and popliteal veins (). The IVC was patent. Doppler ultrasound confirmed the absence of blood flow in the popliteal artery. Under ultrasound guidance, the left popliteal vein was accessed, and the ClotTriever (Inari Medical) sheath was placed. The ClotTriever thrombectomy catheter was then introduced, and six device passes were made extending from the iliac vein back into the popliteal vein with extraction of a significant amount of thrombus (). An intravascular ultrasound detected compression strictures of the common iliac and femoral veins (), and percutaneous transluminal angioplasty was performed (). Immediate postintervention venography revealed restoration of the venous flow (), and ultrasound Doppler detected a strong popliteal arterial flow. Sixteen hours postintervention, the leg swelling and discoloration almost completely resolved (). At 1-month follow-up, the left leg had completely returned to baseline appearance without any evidence of edema or discoloration (). No amputation was needed. The patient reported in this article has provided consent to publish their case details and images.

A 33-year-old man was admitted to our hospital on December 21th, 2009 with recurrent dyskinesia episodes. He had not had any problems during the perinatal period, but after his first birthday, his limbs had twisted intermittently. Symptoms occurred on either the right or left side limbs, starting from the leg to the arm, and occasionally occurred in the arm and leg simultaneously, or were only experienced on the arm or leg. The symptoms lasted from hours to days. He reported having frequent symptoms that were more than four times per week, and for almost every instance he reported crying. He was unable to move during the hemiplegic episodes and also had a history of convulsions that had occurred several times before starting elementary school. Without the episodes, his developmental milestones were normal in the childhood.\nAfter he entered an elementary school, hemiplegic events recurred if he was nervous or encountered a new environment although it was not provoked by his crying anymore. Symptoms occurred on alternating sides and occasionally in all four extremities. However, once the symptoms presented on one side, the symptoms did not progress to the other side. His symptoms still lasted hours to days and recurred several times a week. Because of these frequent episodes, he could not complete the elementary school although he did not have mental retardation. However, he had not had growth or cognitive abnormality until he became an adult.\nBefore visiting our outpatient clinic, he reported that the symptoms manifested once a month, and lasted for three days to two weeks. The characteristics of the episodes were similar to the episodes during his elementary school age. When the attacks were not present, he could live normally and did not have cognitive dysfunction. He did not have any loss of consciousness during the attack. The family history revealed that his cousin was diagnosed with cerebral palsy and died in her twenties.\nAn initial neurological examination revealed motor weakness (motor power on upper and lower extremities: Medical Research Council grade IV- and III, respectively) and dystonia on the right side and peripheral type facial palsy (). There was no hearing loss or ataxic features, and other examination findings were normal. His mini-mental status exam score was 24/30 (−1 point in memory recall, −4 in attention and calculation, and −1 in interlocking pentagon drawing). In addition, the pes planovalgus deformity was identified in his feet ().\nBrain magnetic resonance imaging (MRI) showed cerebellar atrophy () without any vascular lesions. There was no abnormal finding on Tc-99m-hexamethylpropylenamineoxime single photon emission computed tomography () during the hemiplegic attack on the right side. In addition, the result of the 24-hour video electroencephalogram monitoring during the hemiplegic attack was also normal. We tried quetiapine 50 mg per day and methazolamide 50 mg twice per day for symptomatic treatment, but they were not effective.\nWhole exome sequencing was conducted in August 2017, which revealed a heterozygous G947R variant in the ATP1A3 gene (c.2839G > C, read depth = 54; rs398122887), which is a known pathologic variant. The patient was treated with 5 mg of flunarizine three times per day, but this treatment was not effective and the patient discontinued because of dizziness.\nThis study was approved by the Institutional Review Board (IRB) of Seoul National University Hospital (IRB No. 1601-048-733). A waiver of documentation of informed consent for the genetic analysis was granted as the requirements were satisfied. The informed consent for the figures and reports were obtained from the patient.

A 58-year-old female patient, known to be hypertensive on medical treatment, was planned for elective laparoscopic cholecystectomy for cholelithiasis. The patient was seen in the anesthesia clinic preoperatively, where her medical history was taken, and physical examination was performed. The patient had a past medical history of essential hypertension on treatment by valsartan 160 milligrams daily and bisoprolol 5 milligrams daily that were prescribed by her treating physician. The patient had a past anesthetic history of spinal anesthesia for a cesarean section twenty years before the time of presentation. The patient history was otherwise unremarkable. Physical examination was only remarkable for uncontrolled blood pressure of 180/90 mmHg which was attributed to poor compliance with antihypertensive therapy. Her abdominal ultrasound was only significant for cholelithiasis. The patient was advised for better compliance to antihypertensive therapy and another anesthesia clinic visit was scheduled. The patient was seen again in the anesthesia clinic three months later. Her blood pressure at that time was found to be 150/80 mmHg, and the remainder of her examination was normal. Screening echocardiography recommended by the treating physician two months before that visit showed normal ejection fraction (66%) and mild tricuspid regurgitation in an otherwise normal study. Electrocardiogram (ECG) was performed before the anesthesia clinic visit and was normal (). The patient was scheduled for surgery and admitted for the operation on the following day. Preoperatively, she was assessed by the anesthesia team in the hospital on the morning of the operation and her blood pressure was found to be 180/110 mmHg, which was again attributed to poor compliance with medication regimen. As the operation was scheduled on elective basis, it was therefore postponed until a tighter control of blood pressure could be achieved and the patient was discharged. She was seen four weeks later in the anesthesia clinic; there were no new complaints and there was no change in her examination except for her blood pressure, which was controlled, being 140/80 mmHg after proper compliance to her medication regimen. She was deemed fit for surgery, readmitted to the hospital, and scheduled for the operation as an American Society of Anesthesiologists physical status classification-2 (ASA-2) on the following day.\nAfter admission, the patient's blood pressure was continuously monitored. Her routine labs, including blood electrolyte, were within normal limits. Premedication with 15 milligrams of oral midazolam was administered in two divided doses, once at bedtime and the second dose one hour before transfer to the operation theatre. On arrival to the theatre, her blood pressure (BP) and heart rate (HR) were 130/80 mmHg and 82 beats per minute (bpm), respectively, and her peripheral oxygen saturation (SpO2) was 100%. The patient had a 20-gauge cannula fixed in the surgical ward; another 18-gauge cannula was fixed in the operation theatre before induction. Intravenous infusion of lactated ringer was started; a total of around 350 ml of lactated ringer was transfused before induction. Standard monitoring of HR, BP, SpO2, and ETCO2 was connected. Invasive blood pressure monitoring and bispectral index monitoring were not connected as they are not part of the routine monitoring in the institution. Induction of general anesthesia was achieved using an intravenous injection of 150 milligrams of propofol and 10 micrograms of sufentanyl. Muscle relaxation was achieved using 8 milligrams of intravenous cisatracurium. The patient was intubated using a size 7 endotracheal tube; she was then connected to mechanical ventilation using volume control mode with a tidal volume of 450 ml, respiratory rate of 12 per minute, and positive end-expiratory pressure (PEEP) of 5 mmHg. End-tidal carbon dioxide (ETCO2) was maintained at about 38 mmHg and peak inspiratory pressure (PIP) was maintained at 15 centimeters of water (cmH2O). Anesthesia was maintained with 45% oxygen mixture with air and inhalation of 6% desflurane. Almost ten to twelve minutes after induction and preparation, the surgical team proceeded with Veress needle insertion and peritoneal insufflation. Insufflation was performed using carbon dioxide (CO2) at a flow rate of 40 liters per minute (L/M) to achieve an intraperitoneal pressure of 20 mmHg. Immediately after starting peritoneal insufflation, the patient developed sinus bradycardia and her heart rate started to drop reaching 35 to 40 bpm within a few seconds; however, there was no change in her ETCO2 or SpO2. The anesthetist immediately instructed the surgeon to stop the insufflation and deflate the abdomen. Intravenous injection of atropine (1 mg), which was prepared preoperatively, was given immediately and flushed with intravenous saline. Blood pressure reading obtained at the time did not show change in blood pressure. While the atropine was being administered, the patient's heart rate continued to drop, reaching 10–15 bpm, while her ETCO2 did not change. It was then decided that the patient would progress into cardiac arrest, so the anesthetist called for help of senior anesthesia staff to be present in the operating room and ordered the assistant staff to prepare intravenous adrenaline. The anesthetist then could not palpate the patient's pulse, so cardiopulmonary resuscitation was started. The anesthetist started chest compressions and an injection of adrenaline (100 micrograms) was given intravenously. The patient's pulse was restored within 30 seconds as sinus tachycardia of 124 bpm. Her blood pressure was 130/90 mmHg, SpO2 was 99%, and ETCO2 was 32 mmHg. An arterial line was then fixed under ultrasound guidance to monitor blood pressure, and blood samples were taken to check for blood electrolytes, gases levels, and cardiac markers, including troponin and creatine kinase-MB (CK-MB). During the following 15 minutes, the patient's vitals were closely monitored as the case was being discussed between the seniors of the surgical and anesthesia teams. During that time, the results of the blood gases and electrolytes came back and were within normal limits; in addition, there were no changes in the patient's ECG, except for sinus tachycardia that gradually returned to normal sinus rhythm. It was noted by the team that the insufflation flow rate had been high, and it was assumed that this was the cause of the event.\nAfter being reassured that the patient was vitally stable and that there were no signs of cardiac or metabolic insult, the case was deemed fit to proceed for surgery. The surgical team started the operation again approximately 30 minutes after the bradycardia event. Another two milligrams of cisatracurium was administered, and a total of around 750 ml of lactated ringer was transfused by that time. The second time, peritoneal insufflation was performed using CO2 at a flow rate of 8 liters per minute (L/M) to achieve intraperitoneal pressure of 12 mmHg; pneumoperitoneum was achieved without complications. The patient was positioned in the reverse Trendelenburg left tilt position and the surgery was completed uneventfully within 20 minutes. The abdomen was deflated with the patient in the supine position. Intravenous injection of 5 milligrams of morphine was given and then the patient was extubated smoothly and shifted to the postanesthesia care unit (PACU). In the PACU, the patient was kept in the semi-sitting position and her vital signs and conscious level were closely observed. She was assessed for any postoperative pain or any new complains, and 1 gram of acetaminophen was given for pain control. The result for the confirmatory cardiac marker levels came back by that time and was within normal limits.\nThe patient was discharged from the PACU to the surgical ward after around 30 minutes with an Aldrete score of 10. Follow-up ECG () was performed and troponin levels were examined postoperatively in the surgical ward, both were within normal limits. The patient was seen in the surgical ward postoperatively by the anesthesia team after being discharged and then in the evening and then again on the next morning; on all occasions, she was vitally stable and fully conscious, with no complains. The patient was assessed by a cardiologist before discharge and was deemed free from cardiovascular problems. The patient was counselled about the intraoperative events by the surgical and anesthesia teams and was discharged on her postoperative day 3. She was scheduled for a routine follow-up visit to the surgical outpatient clinic one week following discharge. She was seen in the outpatient clinic after one week and was stable vitally and had no complains.

This is a case of a 27-year-old Caucasian male with past medical history significant for ALL who was brought into the ED by the EMS after an episode of cardiac arrest.\nThe patient's history starts when he was 5 years of age when he was diagnosed with Acute Lymphoblastic Leukemia. He underwent chemotherapy with vincristine, doxorubicin, and steroids at the time of diagnosis. At the end of two years, it was diagnosed that his ALL has progressed to involve the central nervous system and he was given chemotherapy for an additional two years which also included methotrexate. During this time the patient had complaints of constipation and after two weeks of no bowel movements, the patient was found straining in the toilet when he clenched his chest due to pain and fainted. He was taken to the hospital where he had a blood work and echocardiogram which were unremarkable. The patient recovered completely with no further similar episodes in his childhood. It is unclear whether the patient had an acute coronary syndrome or any arrythmias at that time. The patient eventually lost follow-up with his primary care doctor. There is no other past medical history and no positive family history for cardiac diseases. The patient also denied smoking, drinking of alcohol, and illicit drug use which was confirmed with the patient later.\nOn the day of admission, the patient was performing his usual duties in his workplace which included lifting of heavy objects. When the patient was walking after his work, he suddenly collapsed down on the floor. His friend who was present at the side witnessed this event. There was no breathing or palpable pulse. CPR was started and the paddles of the AED were connected which showed a shockable rhythm. The patient was shocked for four times and chest compression was given in between. When the patient was brought to the emergency department of the hospital he had an EKG () which showed normal sinus rhythm, Q waves in the inferior wall leads concerning old myocardial infarction versus a direct damage to the RCA territory myocardium due to chemotherapy effect. His vitals at the time of admission were blood pressure 86/47, heart rate 88, and respiratory rate 16 and he was afebrile. His labs were unremarkable with negative troponins. He was unresponsive at this time and his lungs and heart were clear to auscultation. He was intubated in the emergency department for airway protection and the patient was immediately admitted to the Intensive Care Unit.\nEventually the patient got stabilized and was extubated. He had an echocardiogram which showed a LVEF of 36.9%, large basal and mid inferior aneurysm, akinesis of the inferior and inferolateral wall, moderate global hypokinesis of the left ventricle, and trace mitral regurgitation. He had a left and right cardiac catheterization along with left ventriculography (Figures , , and ) which showed no evidence of disease in his left main, left anterior descending, and right coronary artery and left circumflex. His left ventriculography showed a normal sized ventricle, LVEF of 35 to 40%, and a large inferior wall aneurysm with the inferior base and midportion being akinetic. After the cardiac catheterization, the patient was transferred to a tertiary medical center for further care and he eventually received an Implantable Cardioverter Defibrillator with no surgical intervention and was managed medically with beta blocker and ACE inhibitor. Six months later after this event, the patient has been doing well with no further episodes of arrhythmias and has improved EF.

A 55-year-old edentulous denture wearer female reported with the chief complaints of burning sensation in the oral cavity especially in anterior portion of mouth, frequent redness of mucosa, inability to sense temperature changes of food, and recurrent allergic and microbial infections with present acrylic dentures. Medical history revealed that the patient was undergoing treatment under a gynecologist for menopausal symptoms. Dental history revealed patient was edentulous since 2 years and had been experiencing above problems since 1 year.\nSo it was decided to fabricate a complete denture with a customized metal palate design that along with the ongoing treatment from gynecologist would relieve the patient from symptoms because contact sensitivity to denture base materials or to allergens and microbial antigens on the acrylic denture plate plays a greater role in burning sensation in edentulous persons.[]\nThe customized metal palate, apart from fulfilling the patient's needs, was designed in an innovative way with metal loops in specific directions and positions that would enhance interlocking with acrylic portion and also not to interfere with the teeth arrangement of artificial teeth.\nThe primary impression was made with irreversible hydrocolloid. Custom tray was fabricated and secondary impression was made with zinc oxide eugenol. The final cast derived from this impression was duplicated and refractory cast was formed. The refractory cast is used for the fabrication of the customized metal palate.\nA sheet of green spacer wax was adapted on the palatal portion of the cast covering the crest of the ridge and extending 2-3 mm beyond it. Loops of 2-3 mm length made of wax were attached to the peripheral border of the previously adapted palatal spacer wax. It was taken care that all these loops were 2-3 mm short of the sulcus as shown by straight arrow []. These loops would enhance the interlocking of acrylic. This was important because no loop should interfere with the acrylic border of the denture extending into the sulcus.\nTiny loops were placed slightly palatal to the crest as shown by the curved arrow []. The height of these loops was such that it would not interfere with the arrangement of artificial teeth but was sufficient enough for inflow of acrylic resin. A butt joint was created palatal to the crest at the junction of acrylic and metal that enhances the strength of the metal acrylic junction creates a smooth joining of acrylic with metal avoiding any step formation, thus making it comfortable for the patient.\nFor making the butt joint, a 2-mm cylindrical blue wax beading was adapted palatal to the crest of the ridge as shown by straight arrow []. A bard parker knife was run 45° to the border of the bead. Once the design of the palate in wax was done, wax sprues were attached and casting was done. The metal palate after finishing was placed now on the master cast [] and maxillary rim was made for jaw relations []. The jaw relations were recorded and teeth arrangement was done. After curing, the maxillary metal denture was finished and polished []. The patient's pre-treatment [] and post-treatment [] photographs showed marked improvement in esthetics. After 3-month follow-up, patient reported drastic improvement in symptoms previously mentioned.

A male patient aged 49 years with no previous medical history presented with neck pain from a foreign object. The patient was accidentally struck by a projectile from a nail gun on a construction site. The patient complained of pain along the left side of the neck and inability to swallow. On initial evaluation, patient was neurologically intact with absent Horner's syndrome. There were no signs of active bleeding or hemodynamic instability. The head of the nail was visible behind and above the angle of the mandible at the level of the skin - neck zone 3 (Figure , Table )\nThe point of the nail was not visible in the oral cavity but was palpable along the oral mucosa along the left side of the oropharynx. The patient was intubated and sedated for airway protection without complications in an outlying emergency room (ER) and triaged to the local Level One trauma center for further management. Upon arrival to our trauma center, a computed tomography (CT) angiography of the neck was obtained which demonstrated the nail traversing in very close proximity to the left internal carotid artery close to the skull base with preserved flow proximal and distal to the nail. There was no active contrast extravasation or definitive presence of a pseudoaneurysm although the evaluation was limited by the beam-hardening artifact from the nail (Figure ).\nThe patient was emergently transported to the interventional radiology suite to determine the status of the left carotid artery and possible endovascular repair. Left common carotid angiography in the neck demonstrated preserved flow through the left internal carotid artery but significant vessel narrowing at the level of the nail (Figure ).\nFurther investigation with three-dimensional (3D) rotational angiography demonstrated small areas of contrast stagnation proximal and distal to the nail with a small dissection flap proximal to the nail, consistent with at least a partial vessel injury (Figure ).\nThe intracranial left anterior circulation imaged normally without abnormal vessel dropout. Upon discussion among trauma surgery, oral and maxillofacial surgery and neurointerventional teams, the decision was made to proceed with endovascular repair in conjunction with nail removal. The patient was given 600 mg of clopidogrel and 325 mg of aspirin via orogastric tube and was heparinized to an activated clotting time (ACT) greater than 250. The short 6F sheath was exchanged for 6F Terumo Destination sheath (Terumo Medical, Somerset, New Jersey, USA) and positioned in the distal left common carotid artery. The injury site was crossed with a Synchro-2 0.014 microwire (Stryker, Fremont, California, USA) under the fluoroscopic roadmap. A 5 x 25 mm Gore Viabahn covered stent (W.L. Gore & Associates, Flagstaff, Arizona, USA) was positioned across the level of injury. The nail was removed by gentle traction by trauma surgery with the simultaneous deployment of the Gore Viabahn covered stent into the left internal carotid artery spanning the injured segment. Follow-up angiography demonstrated excellent flow through the stent but with active extravasation secondary to a proximal endoleak related to incomplete apposition of the proximal stent to the vessel wall (Figure ).\nAt this time, the anaesthesia team noted blood pooling in the oropharynx. We introduced a 5 x 30 mm Aviator Plus balloon (Cordis, Milpitas, California, USA) and performed angioplasty of the proximal end of the stent. Follow-up angiography demonstrated no active extravasation and excellent flow through the stent (Figure ).\nCerebral angiography demonstrated no abnormal vessel dropout in the left anterior circulation. There was no further bleeding in the oropharynx or through the tract. The patient was transferred to intensive care unit (ICU) for further care.\nOn a postoperative day one, the patient was extubated without incident. No neurological deficits were noted. The patient was continued on 325 mg of Aspirin and 75 mg of clopidogrel daily. The patient was cleared for an oral diet. Follow-up CT angiogram demonstrated patency of the left internal carotid stent and no pseudoaneurysm formation (Figure ). The patient did receive tetanus boosters and antibiotics as part of the initial management to prevent secondary infection. The patient was discharged to home on hospital day five. We planned to follow up the patient with CT angiogram at six weeks after the procedure. Unfortunately, we were not able to obtain the imaging as the patient was out of state and was uninsured. Per phone conversation the patient was doing very well and did not report any symptoms consistent with stroke or transient ischemic attack (TIA) at two months after the procedure. The patient stopped his clopidogrel one week after the procedure due to financial reasons but continues on the aspirin regimen.

A 14-year-old girl, accompanied by his father, presented to a university primary care clinic with a complaint of intolerable low back pain after two recent falls. On further history taking, she had been experiencing a chronic back pain for the last 2 years. She described her initial pain to be acute in onset, occurring at the lower back because of prolonged sitting on the floor, after which she had an ongoing chronic low back pain. In her current boarding school training, children were accustomed to be sitting on the floor for many hours to learn the Koran.\nShe could perform her daily activities but distanced herself from any sports. Having developed increasing pain in her back, she requested her father to take her to a general practitioner (GP), which required her to be excused from school activities. Hence, her father became suspicious of her real intention and attributed her complaint of pain to the secondary intention of wanting to be away from school. Her father, who had a strong character, dominated the consultation and tried to convince the physician to the idea that his daughter feigned the back pain as an excuse to be away from school.\nOver the last 24 months, she had visited multiple GP clinics. Her recurrent clinic visits were initially driven by symptoms of low back pain, sciatica, and later, lower limb numbness and weakness. The latter was noticeable 21 months after the first clinic visit. On recalling her history, she revealed four crucial time points at which she sought medical help for symptom progression. Most of the time, she was attended by different physicians during her clinic visits. The GP whom she visited several times gathered information on her history mainly from her father, who downrated and attributed her symptoms to prolonged sitting with lack of stretching.\nHer first clinic visit was at 12 years of age for a complaint of intermittent low back pain without neurological deficit. A diagnosis of nonspecific low back pain was made, and a paracetamol with topical ointments was prescribed.\nApproximately 18 months later, at the age of 13 years, she started to experiencing persistent low back pain, for which she visited the GP’s clinic on a monthly basis. The pain started to radiate to the right lower leg on walking. At that time, she could still maintain her schooling and other activities of daily living. Her symptoms were treated conservatively as muscular pain and sciatica. No radiological imaging was ordered at that time. Continuous analgesia, topical ointment, and multi-vitamins were prescribed by different GPs.\nThree months later, she started to develop persistent weakness and numbness on her right lower limb, especially on sitting. This was worsened by lifting objects and ambulation. A diagnosis of sciatica was consistently made by her physicians. Management of her condition remained conservative with regular analgesia and back care. In addition, multiple medical leave certificates were issued, which her father disliked.\nThree months later, when she was 14 years old, she visited our primary care center with a severe low back pain triggered by two incidents of fall in the bathroom. The pain disturbed her sleep, and her right lower limb weakness and numbness worsened. She was unable to ambulate well. On examination, she walked with antalgic gain due to pain. No spinal tenderness was elicited upon palpation, but paraspinal muscle stiffness was observed. Her lumbar spine range of motion was restricted at 45° on forward flexion. Straight leg raising was up to 45° bilaterally, with evidence of nerve root tension. Sacroiliac and hip joint dysfunction test results were negative. A neurological examination of her lower limbs revealed a depressed deep tendon reflex in both knees. Her muscle strength was graded 4/5 on hip flexion, knee flexion, and extension, but was slightly weaker on the right side. Her tone was normal bilaterally. She felt patchy reduced sensation to light and sharp touches in the right lower limb at L2 to L5 dermatomes. No saddle paresthesia was observed. A lumbosacral radiograph showed loss of normal lumbar lordosis.\nOur primary care center, located within a university-based hospital, provides an added advantage of direct access to advanced radiological services. We liaised with the radiologist who suggested performing magnetic resonance imaging (MRI) of the spine urgently. Upon detection of the spinal lesion, a contrast medium was administered during the MRI. An immediate report revealed an enhancing spinal mass in the region of the conus medullaris, which suggested an ependymoma as shown in and .\nSubsequently, she underwent L1 to L3 laminectomy and gross tumor excision. Histopathological examination (HPE) of the spinal mass showed features consistent with ependymoma WHO grade II as shown in . After the surgery, her right-sided lower limb weakness improved tremendously. However, she developed bladder and bowel dysfunctions, which are possible complications of any spinal cord surgery. Assessment by a rehabilitation specialist revealed a significant neurogenic bladder on the basis of the failed trial without a catheter. Further evaluation using single-channel cystometry revealed detrusor acontractility with high residual volume. The 4-hourly, clean, intermittent, self-catheterization residual volume was >20%. A bowel assessment revealed an upper motor neuron type of neurogenic bowel. Five months after the surgery, her neurogenic bladder and bowel remained. She needed regular rectal enema with manual evacuation to empty her bowel. Moreover, she needed to perform 4-hourly intermittent self-catheterization to empty her urinary bladder. While her right lower limb and saddle paresthesia only gradually improved, her lower limb weakness completely resolved.\nThe patient provided written informed consent for the publication of clinical details and images.

A male patient aged 49 years with no previous medical history presented with neck pain from a foreign object. The patient was accidentally struck by a projectile from a nail gun on a construction site. The patient complained of pain along the left side of the neck and inability to swallow. On initial evaluation, patient was neurologically intact with absent Horner's syndrome. There were no signs of active bleeding or hemodynamic instability. The head of the nail was visible behind and above the angle of the mandible at the level of the skin - neck zone 3 (Figure , Table )\nThe point of the nail was not visible in the oral cavity but was palpable along the oral mucosa along the left side of the oropharynx. The patient was intubated and sedated for airway protection without complications in an outlying emergency room (ER) and triaged to the local Level One trauma center for further management. Upon arrival to our trauma center, a computed tomography (CT) angiography of the neck was obtained which demonstrated the nail traversing in very close proximity to the left internal carotid artery close to the skull base with preserved flow proximal and distal to the nail. There was no active contrast extravasation or definitive presence of a pseudoaneurysm although the evaluation was limited by the beam-hardening artifact from the nail (Figure ).\nThe patient was emergently transported to the interventional radiology suite to determine the status of the left carotid artery and possible endovascular repair. Left common carotid angiography in the neck demonstrated preserved flow through the left internal carotid artery but significant vessel narrowing at the level of the nail (Figure ).\nFurther investigation with three-dimensional (3D) rotational angiography demonstrated small areas of contrast stagnation proximal and distal to the nail with a small dissection flap proximal to the nail, consistent with at least a partial vessel injury (Figure ).\nThe intracranial left anterior circulation imaged normally without abnormal vessel dropout. Upon discussion among trauma surgery, oral and maxillofacial surgery and neurointerventional teams, the decision was made to proceed with endovascular repair in conjunction with nail removal. The patient was given 600 mg of clopidogrel and 325 mg of aspirin via orogastric tube and was heparinized to an activated clotting time (ACT) greater than 250. The short 6F sheath was exchanged for 6F Terumo Destination sheath (Terumo Medical, Somerset, New Jersey, USA) and positioned in the distal left common carotid artery. The injury site was crossed with a Synchro-2 0.014 microwire (Stryker, Fremont, California, USA) under the fluoroscopic roadmap. A 5 x 25 mm Gore Viabahn covered stent (W.L. Gore & Associates, Flagstaff, Arizona, USA) was positioned across the level of injury. The nail was removed by gentle traction by trauma surgery with the simultaneous deployment of the Gore Viabahn covered stent into the left internal carotid artery spanning the injured segment. Follow-up angiography demonstrated excellent flow through the stent but with active extravasation secondary to a proximal endoleak related to incomplete apposition of the proximal stent to the vessel wall (Figure ).\nAt this time, the anaesthesia team noted blood pooling in the oropharynx. We introduced a 5 x 30 mm Aviator Plus balloon (Cordis, Milpitas, California, USA) and performed angioplasty of the proximal end of the stent. Follow-up angiography demonstrated no active extravasation and excellent flow through the stent (Figure ).\nCerebral angiography demonstrated no abnormal vessel dropout in the left anterior circulation. There was no further bleeding in the oropharynx or through the tract. The patient was transferred to intensive care unit (ICU) for further care.\nOn a postoperative day one, the patient was extubated without incident. No neurological deficits were noted. The patient was continued on 325 mg of Aspirin and 75 mg of clopidogrel daily. The patient was cleared for an oral diet. Follow-up CT angiogram demonstrated patency of the left internal carotid stent and no pseudoaneurysm formation (Figure ). The patient did receive tetanus boosters and antibiotics as part of the initial management to prevent secondary infection. The patient was discharged to home on hospital day five. We planned to follow up the patient with CT angiogram at six weeks after the procedure. Unfortunately, we were not able to obtain the imaging as the patient was out of state and was uninsured. Per phone conversation the patient was doing very well and did not report any symptoms consistent with stroke or transient ischemic attack (TIA) at two months after the procedure. The patient stopped his clopidogrel one week after the procedure due to financial reasons but continues on the aspirin regimen.

A 23-year-old, nulliparous, Chinese woman at 35 weeks gestation, was admitted to the hospital complaining of hematuria accompanied by severe pain in the left abdomen and left subcostal area. She had no past history of urological difficulties until week 26 of pregnancy when she was diagnosed with a spontaneous renal rupture resulting in acute left loin pain and hematuria. She denied any accident or renal problems at that time. Magnetic resonance imaging (MRI) confirmed the diagnosis (Fig. a, b), and that the fluid around the ruptured left kidney had spread from the superior margin of the 10th thoracic vertebral body to the inferior margin of the second lumbar vertebral body. The patient was admitted to the hospital for observation. The hematuria resolved the day following admission, and she was discharged 1 week after admission when the loin pain decreased and her hemodynamic status was stabilized.\nAt 34 weeks gestation, she presented at the urology clinic with a growing mass in the left subcostal area. Ultrasound showed right renal hydronephrosis without hydroureter. In addition, a cyst was noted to surround the left kidney, and this was measured as 250 × 170 × 233 mm. The cyst was located under the left renal capsule, and the margins were 100 mm from the upper pole, and 60 mm from the lower pole of the left kidney. The medial margin of the cyst was 70 mm away from the medial edge of the left kidney, and 103 mm away from the lateral edge. It was suspected that she had a subcapsular hematoma following renal rupture. At the time, she was more than 33 weeks pregnant, and her laboratory values were normal for kidney function, hematocrit and hemoglobin. She declined further testing of the mass because she was concerned about the side effects on the fetus.\nThe patient came to the Obstetric Department requesting a cesarean section when she was 35 weeks pregnant because she could not bear the severe pain of the increasingly swollen left subcostal mass. She denied nausea, shortness of breath, fever or chills, and there was no vaginal bleeding or uterine contractions. After she was admitted to the obstetrics ward, the fetal heart non-stress test was determined to be reactive. The fetal bi-parietal diameter (BPD) measured by ultrasound was 86 mm, and femoral length. (FL) was 66 mm, which were both consistent with the gestational age. The amniotic fluid index was 95 mm and umbilical arterial S/D was 2.5. The biophysical profile score was 8. Additionally, ultrasound demonstrated signs of maternal hydronephrosis accompanied by a much larger cyst surrounding the left kidney than that observed in the previous ultrasound. Over the past few weeks, this sub-capsular cyst had increased to a size of 319 × 175 × 250 mm.\nPhysical examination revealed the gravid uterus, and obvious swelling over the left abdominal region. A large firm mass with undefined boundary was palpable over the left lumbar region extending to the side of uterus. The left flank and subcostal area had notable tenderness with significant hyperesthesia of the overlying skin. Laboratory evaluation demonstrated a normal white blood cell count and hemoglobin. The urinalysis and kidney function values showed no abnormalities.\nThe patient was known to have had a spontaneous renal rupture and a growing mass in the left subcostal area at week 26 of gestation. The first diagnosis was hematoma or abscess surrounding the left kidney. Because her hemodynamic status was stable without anemia or fever for more than 2 months after the renal rupture, she had been followed using repeat urine analyses, which showed no hematuria. The urologist diagnosed her current condition as perirenal urine extravasation, and it was decided to place a percutaneous nephrostomy tube (PCN) before delivery or during the surgery.\nThe patient requested Cesarean section because the gestational age was 35 weeks, and due to concerns about the progression of the subcostal mass, the surgery was performed. The patient agreed to receive the PCN placement along with the Cesarean section. A male newborn weighing 2580 g with an Apgar score 10/10 at 1 and 5 min was delivered. Following completion of the Cesarean section, the patient’s upper abdominal cavity was explored, and, on the left side, a large retroperitoneal bulging mass was noted with an estimated size of 300 × 200 × 300 mm. The consulting urologist suctioned 5 ml of light yellow fluid from the mass and the sample was sent for creatinine determination. The creatinine level of the sample was 2100 μmol/L and similar to the level in the patient’s urine. A left urinoma as a result of spontaneous renal rupture was then diagnosed, and a total of 4 L of fluid was drained via the PCN. PCN was left in the urinoma to allow for further drainage of urine. After 3 days, a computer tomography (CT) scan was performed to assess the effect of draining the urinoma. The CT revealed that the PCN was properly placed in the cyst, and that the urinoma had decreased in size. The patient was discharged 1 week after the surgery with the PCN in place. She was closely followed by a urologist, and the nephrostomy tube was to be removed when there was no further drainage. Two months postpartum, the CT scan showed the cyst had diminished in size to 50 mm (Fig. ). Six months later, an ultrasound scan was performed and revealed that no perirenal extravasation was present. The urine analysis and renal function tests at that time were normal.

A 22-year-old nulliparous Chinese woman with no significant family history of cancer presented to a private medical center with a painless 5 cm swelling in the left breast. The swelling, which was first noticed 3 months earlier, increased in size gradually. There was no associated nipple discharge or swelling elsewhere. Core biopsy of the swelling confirmed an infiltrating ductal carcinoma with triple negative receptor status for ER, PR, and HER2 receptors. Computed tomography (CT) of the thorax, abdomen, and pelvis was negative for distant metastasis. By then, 2 weeks had passed since she first presented with her complaints. Following discussion between the attending surgeons, the patient, and her family, the decision to proceed with neoadjuvant chemotherapy immediately, was made. Two weeks into her neoadjuvant chemotherapy, she complained that the left breast mass had significantly increased in size from the initial 5 cm to 10 cm in diameter. She also developed a swelling in the left axilla that was clinically consistent with that of an axillary lymph node. Fine needle aspiration cytology of the left axillary lymph node was reported to be a metastatic carcinoma. A decision was made to proceed with left mastectomy and axillary clearance. Histopathology examination of the 14 cm by 12 cm left breast mass was conclusive for high-grade metaplastic breast carcinoma – spindle cell subtype, triple negative receptor status. All 12 excised axillary lymph nodes were positive for metastases. Six weeks following surgery, she underwent adjuvant chemotherapy. She defaulted follow-up soon after completion of chemotherapy and underwent Traditional Chinese Medication instead, despite advice regarding potential spread of the disease, and grave prognosis should that occur.\nFour months later, she presented to a district hospital with complaints of pain over the left chest wall and inability to move her left upper limb. On examination, a large fungating mass with a necrotic patch was seen at her left chest wall, extending into the axilla. The tumor had infiltrated the anterior chest wall and was even seen over the posterior chest wall. The left upper limb was cold, pale, and mottled with patchy areas of necrosis. The brachial artery, radial artery, and ulnar artery were not palpable. Doppler signals were negative for all three arteries as well. Capillary refill time was significantly prolonged. There was no motor or sensory function in the left upper limb. A right breast lump was also noted during examination, measuring approximately 6 cm by 5 cm with enlarged ipsilateral axillary lymph nodes. Core biopsy of the right breast lump revealed similar histopathology and immunohistochemistry findings as the left breast lump, supporting the suspicion of a metastatic disease, rather than a separate entity.\nCT of the thorax and abdomen was negative for distant metastases. CT angiogram was not performed, as the patient and family did not agree for her to undergo this invasive investigation. The patient was advised to have another round of palliative chemotherapy and debulking surgery, including a left forequarter amputation. She denied all modalities of intervention. She was given regular subcutaneous morphine and fentanyl patches for analgesia, and her wounds were dressed regularly. The left upper limb tissue gradually became waxy and soft. The flesh over the limb also began to spontaneously separate from the underlying bone, exposing parts of the humerus. The patient eventually requested amputation of the left upper limb, as it was becoming increasingly difficult for her family and nurses to take care of the truncal lesions with the rotting flesh and fragile, non-functioning limb getting in the way. The amputation at the site of the exposed left humerus was performed under intravenous sedation by an experienced orthopedic consultant. The patient succumbed 2 weeks later, slightly more than 6 months from the onset of the disease ( and ). The next of kin has provided written consent for publication of this case report and the accompanying images.

An 80 year old female with a history of hypertension, hypothyroidism, hyperlipidemia, and endometrial cancer status post pelvic radiation and hysterectomy, with previous abdominal surgery secondary to iatrogenic colonic perforation during colonoscopy, presented to an outside facility four days prior to arrival at our institution due to severe colicky epigastric, periumbilical, and right upper quadrant pain of one day duration associated with nausea and chills. Patient was made NPO with NG decompression in addition to receiving empiric meropenem at the outside facility where a cholecystoduodenal fistula with large gallstone in the duodenal lumen was identified by abdominal CT. Upper GI was performed on hospital day four at the outside facility, which revealed failure of stone progression prompting transfer to our institution for definitive management. On intake exam her vitals were stable within normal limits and she was found to have no abdominal tenderness and no distention. Her laboratory values were without any significant abnormalities.\nGastroenterology attempted endoscopic retrieval of the duodenal gallstone, at which time the stone was noted to be 3.5 cm in diameter and obstructing the lumen of the bulbar duodenum. Endoscopic retrieval attempts resulted in partial fragmentation of the stone but were ultimately unsuccessful. The following day repeat abdominal CT revealed migration of the stone into the proximal jejunum ().\nThe decision to proceed with surgical removal hinged on the concern that further distal transit of the stone may result in it becoming lodged in a bowel loop contained in the patient's incisional hernia or a pelvic loop due to previous pelvic radiation. The abdomen was entered laparoscopically. Multiple areas of adhesions were encountered requiring adhesiolysis and ultimately the insertion of a hand port. The stone-containing small bowel was located and delivered through the hand port after which two stay sutures were placed on the antimesenteric border. An enterotomy was then made through which the gallstone was subsequently delivered (). Closure of the enterotomy was achieved via two transverse layers of suture and the bowel was returned into the abdomen. The cholecystoduodenal fistula was left intact for closure at a later date. The patient was transferred back to the general medical/surgical floor for post-operative recovery. Her diet was advanced on post-operative day 1 and she experienced return of gastrointestinal function on post operative day 2. The patient was discharged home on post operative day 2. She is now 16 months post-surgery and has had no recurrent symptoms.

A male patient aged 49 years with no previous medical history presented with neck pain from a foreign object. The patient was accidentally struck by a projectile from a nail gun on a construction site. The patient complained of pain along the left side of the neck and inability to swallow. On initial evaluation, patient was neurologically intact with absent Horner's syndrome. There were no signs of active bleeding or hemodynamic instability. The head of the nail was visible behind and above the angle of the mandible at the level of the skin - neck zone 3 (Figure , Table )\nThe point of the nail was not visible in the oral cavity but was palpable along the oral mucosa along the left side of the oropharynx. The patient was intubated and sedated for airway protection without complications in an outlying emergency room (ER) and triaged to the local Level One trauma center for further management. Upon arrival to our trauma center, a computed tomography (CT) angiography of the neck was obtained which demonstrated the nail traversing in very close proximity to the left internal carotid artery close to the skull base with preserved flow proximal and distal to the nail. There was no active contrast extravasation or definitive presence of a pseudoaneurysm although the evaluation was limited by the beam-hardening artifact from the nail (Figure ).\nThe patient was emergently transported to the interventional radiology suite to determine the status of the left carotid artery and possible endovascular repair. Left common carotid angiography in the neck demonstrated preserved flow through the left internal carotid artery but significant vessel narrowing at the level of the nail (Figure ).\nFurther investigation with three-dimensional (3D) rotational angiography demonstrated small areas of contrast stagnation proximal and distal to the nail with a small dissection flap proximal to the nail, consistent with at least a partial vessel injury (Figure ).\nThe intracranial left anterior circulation imaged normally without abnormal vessel dropout. Upon discussion among trauma surgery, oral and maxillofacial surgery and neurointerventional teams, the decision was made to proceed with endovascular repair in conjunction with nail removal. The patient was given 600 mg of clopidogrel and 325 mg of aspirin via orogastric tube and was heparinized to an activated clotting time (ACT) greater than 250. The short 6F sheath was exchanged for 6F Terumo Destination sheath (Terumo Medical, Somerset, New Jersey, USA) and positioned in the distal left common carotid artery. The injury site was crossed with a Synchro-2 0.014 microwire (Stryker, Fremont, California, USA) under the fluoroscopic roadmap. A 5 x 25 mm Gore Viabahn covered stent (W.L. Gore & Associates, Flagstaff, Arizona, USA) was positioned across the level of injury. The nail was removed by gentle traction by trauma surgery with the simultaneous deployment of the Gore Viabahn covered stent into the left internal carotid artery spanning the injured segment. Follow-up angiography demonstrated excellent flow through the stent but with active extravasation secondary to a proximal endoleak related to incomplete apposition of the proximal stent to the vessel wall (Figure ).\nAt this time, the anaesthesia team noted blood pooling in the oropharynx. We introduced a 5 x 30 mm Aviator Plus balloon (Cordis, Milpitas, California, USA) and performed angioplasty of the proximal end of the stent. Follow-up angiography demonstrated no active extravasation and excellent flow through the stent (Figure ).\nCerebral angiography demonstrated no abnormal vessel dropout in the left anterior circulation. There was no further bleeding in the oropharynx or through the tract. The patient was transferred to intensive care unit (ICU) for further care.\nOn a postoperative day one, the patient was extubated without incident. No neurological deficits were noted. The patient was continued on 325 mg of Aspirin and 75 mg of clopidogrel daily. The patient was cleared for an oral diet. Follow-up CT angiogram demonstrated patency of the left internal carotid stent and no pseudoaneurysm formation (Figure ). The patient did receive tetanus boosters and antibiotics as part of the initial management to prevent secondary infection. The patient was discharged to home on hospital day five. We planned to follow up the patient with CT angiogram at six weeks after the procedure. Unfortunately, we were not able to obtain the imaging as the patient was out of state and was uninsured. Per phone conversation the patient was doing very well and did not report any symptoms consistent with stroke or transient ischemic attack (TIA) at two months after the procedure. The patient stopped his clopidogrel one week after the procedure due to financial reasons but continues on the aspirin regimen.