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A 23-year-old female was admitted with computed tomography (CT) and magnetic resonance image (MRI) findings of intracranial tumor bleeding, after presenting with clinical symptom of dysarthria a week before admission. The patient had a past medical history of seizure due to diffuse astrocytoma, diagnosed 7 years previously. Initially she had undergone craniotomy and total tumor removal at another institution. The pathologic result from the first operation was diffuse astrocytoma, World Health Organization (WHO) grade II and afterwards the patient had not undergone chemotherapy or radiation therapy. Her annual follow-up MRI showed slow changes in most medial corner of the tumor margin in MR fluid attenuation inversion recovery (FLAIR) image which was not recognized until they were review retrospectively (). She was free of symptom for 7 years until she developed seizure with dysarthria and mild headache. The patient immediately underwent CT scanning which revealed hemorrhage at the right temporal lobe correlating with her tumor site. She was admitted to our hospital a week after the initial onset of the symptoms and brain MRI scan with enhancement, diffusion, spectroscopy, and perfusion were performed to confirm the tumor site and any other changes, such as evidence of malignant transformation. On MRI imaging there was evidence of acute hemorrhage at the previous tumor site with thin rim enhancement of the mass-like lesion with surrounding edema, suggesting possible malignant change to higher grade glioma. Increased regional cerebral blood volume (about >2-2.5) from the peripheral enhancing thin rim of the Lt. perisylvian superior temporal hemorrhagic lesion was also another evidence which suggests recurred tumor with probability of malignant transformation with intratumoral recent hemorrhage ().\nSuspecting the transformation of the hemorrhagic lesion to higher grade glioma, we performed frontotemporal craniotomy and total removal of the tumor. The tumor tissue was dissected and it was soft tissue with an irregular margin from normal brain tissue. The gross total resection of tumor was performed under navigation system.\nAfter tumor removal, the patient recovered without any neurological deficit and is not being treated with chemotherapy or radiation therapy. We plan to withhold chemotherapy or radiation therapy for use in the event of possible later malignant recurrence. Her 4 and 16 months postoperative follow-up MRI after the second operation showed no significant differences other than post-operation changes and there was no sign or symptom of seizure or dysarthria.\nThe frozen biopsy showed vascular proliferation with necrosis, which was highly suspicious of high grade giloma, with the final histopathology results revealing WHO grade II diffuse astrocytoma with red blood cells and no evidence of malignant tumor cells. The pathologist remarked that the pleomorphism of the tumor was rare and the necrotic portions were mostly hemorrhagic necrosis rather than tumor necrosis. Ki-67 showed 1-2% staining with well-differentiated astrocytoma and minimal nuclear atypia. There was no definite hypercellularity (). In addition, because this was her second operation, neovascularization with granular tissues along the tumor margin can be considered as postoperative changes from initial operation.

The patient was a 61-year-old female who had recurrent lower gingival squamous cell carcinoma in the right side of the mandible (Fig. ). Segmental resection of the mandible including the surrounding soft tissue with a 10-mm safety margin was scheduled.\nSurgical simulation and preparation of the surgical device were performed using a 3D model. First, the right and left mandibular rami of the 3D model were connected by the autopolymer resin to keep the preoperative position between the proximal and distal segments (Fig. a). Based on the findings in a CT image, segmental resection was performed on the 3D model with a safety margin of at least 10 mm from the tumor (Fig. b). Since it was necessary to extensively resect not only the mandibular bone but also the soft tissue surrounding the mandible, it was impossible to provisionally fix the reconstruction plate on the mandible before mandibular resection. Therefore, a surgical device that not only guides the direction of bone cutting but also restores the preoperative condylar head positioning in the temporomandibular fossa was needed. The device was made to fit the lower border of the anterior mandible and the posterior border of the mandibular ramus. The surgical device to guide the direction of mandibular resection had a U-shaped handle so that adaptation of the device would not interfere with the soft tissue to be removed and had holes to be fixed on the mandible with screws (Fig. c). A titanium reconstruction plate was bent so as to be inside at the area of resection in the 3D model.\nSegmental mandibular resection was performed via a submandibular approach. The surgical device was fixed on the mandible with two screws each at the proximal segment and distal segment (Fig. a). The mandibular resection was performed along the proximal and distal edges of the device fixed to the mandible (Fig. b). After the pre-bent titanium reconstruction plate had been fixed on the proximal and distal segments with screws, the screws used to fix the surgical device were removed (Fig. c). A panoramic radiograph showed that the mandible had been successfully reconstructed with the reconstruction plate since the preoperative relation between the proximal and distal segments and the position of the condylar heads in the temporomandibular fossae were maintained (Fig. ).

A seven-year old boy was seen in the emergency department with a temperature and a painful right hip. This was thought to be a result of viral arthritis or an irritable hip. The patient was discharged home and his symptoms resolved. The patient was referred to the orthopaedic team after his symptoms returned, causing him significant pain to his right hip and preventing him from attending school. Apart from eczema, he had no other medical issues. On examination he had a very slight restriction of internal rotation in the right hip when compared to the left. However, this was completely pain free. A plain radiograph of the pelvis was performed, which was normal with no evidence of bony injury or Perthes disease (Figure ).\nAn MRI was requested but before this was performed the patient had another episode of right hip pain and a temperature of 38.2. He was, therefore, referred again to the orthopaedic team. On this occasion he walked into clinic with an antalgic gait. On examination he had some limitation of internal rotation compared to the left side. He had pain and tenderness around the right hip joint. He had normal neurovascular status distally. He had his MRI scan, which showed extensive myositis of the right obturator externus muscle and pectineus muscle with a small pocket of high signal collection (Figure ). It also demonstrated osteomyelitis in the right pubic bone. He was seen in clinic and scan results explained to the patient and his family. At this time he was relatively comfortable. He had a full range of motion to the hip and there was no tenderness around the hip joint. He could straight leg raise without any problems. There were no reported spikes in temperature. He was eating, drinking and playing as normal. His white cell count and C-reactive protein were normal but erythrocyte sedimentation rate was raised slightly at 16.\nA second MRI scan was performed in December, which showed significant reduction in the degree of oedema at the right ischiopubic synchondrosis and in the surrounding soft tissue, particularly abductor and lateral rotators (Figure ). There was still marked oedema in the right parasymphyseal region likely in keeping with a further area of stress reaction or stress fracture. A further MRI was performed six weeks later (Figure ), which showed almost complete resolution of the abnormal high signal in the right obturator internus and pectineus and interval improvements in the inferior aspect of left sacral ala. There was, however, little interval change in the oedema/inflammation in the right superior and inferior pubis rami including the synchondrosis. The patient was referred to the paediatric orthopaedic consultant. At this point, clinically he was apyrexial and clinically well. He had a normal stance and a normal gait. He had normal power in both lower limbs and a full range of movement. He had no back or hip pain. Whilst it appears that this condition has improved and may resolve, we are unable to confirm the exact aetiology and the pathophysiology.

A 30-years-old female Turkish patient referred to our clinic with compliant of unpleasant appearance of her anterior teeth. Patient has a history of a dentoalveolar trauma and a surgical operation before being referred to a dentist. She indicated that her smile has changed following the surgical operation which applied after the traffic accident in the year 2004. After the healing period she directed her complaints to the plastic surgeon but the doctor persuade her that the problem was related with her teeth only. Therefore the patient appealed to our clinic. The clinical and radiographic examinations revealed that all of the maxillary incisors were vestibulary positioned. The maxillary right canine along the maxillary incisors had oblique fractures involving enamel. The maxillary left lateral incisor had not fractured and was intact. The position of maxillary segment between the right premolar and left canine was approximately 3 mm lower than its ideal position (). Observing that the inferiority of right canine and lateral incisor is higher than the others, there is a probability that the segment not only placed 3 mm below its ideal position but also placed a few degrees deviation off the vertical axis (). The misplacement of the segment is explained to the patient and segmental osteotomy is suggested. The patient rejected the suggestion indicating that she is tired of serial surgical operations, thus the malpractice played a negative effect on her psychology as well.\nA conservative treatment was taken into consideration. The indication was porcelain laminate veneers for the maxillary incisors and right canine, all ceramic crown for maxillary right first premolar because of excessive hard tissue loss and a metal-ceramic fixed partial denture for the anterior mandible due to economic reasons.\nBefore the prosthetic treatment the maxillary right central incisor and first premolar was endodontically treated as they were found to be non vital during the vitality test. During preparation for ceramic veneers, the facial surfaces were reduced by 1.5-2 mm which resulted finishing the preparation on dentin and the incisal edges were reduced by 3-4 mm. All the incisors and canine were prepared with a chamfered finishing line with rounded internal line angles. Smooth margins were created to prevent stress concentration zones. Once the preparation was completed, impressions were made using polyvinylsiloxane impression material (Elite H-D, Zhermack, Germany), and cast in vacuum-mixed Type IV dental die stone (Fujirock, GC Corp, Tokya, Japan) according to the manufacturer recommendations. Stone dies were carefully separated from the impressions and two coats of die spacer (Spacer-Tray, Kerr) were applied 0.5 mm short of the finish line of the preparations. The veneers were waxed up to dies and they were fabricated from lithium disilicate-reinforced glass ceramic material, IPS Empress 2, using the heat press technique according to the manufacturer recommendations. After divestment the veneers were finished and glazed.\nThe inner surface of indirect veneers were treated with air-particle abrasion using 50 μm Al2O (Korox, Bego, Germany) with a chairside air-abrasion device (CoJet, 3M-ESPE, Germany) from a distance of 10 mm at a pressure of 250 kPa bar for 10 s. Then each surface treatment was followed by acid etching with 9% hydrofluoric acid (Pulpdent Corporation, USA) prior to silanization (). A silane coupling agent (Pulpdent Corporation, USA) was applied to the internal veneer surface for 60 s and air-dried.\nDuring the cementation process each tooth was etched for 15 s using a 37% phosphoric acid etch-gel (Alpha-Etch 37, Dental Technologies, USA). Subsequently, the tooth surface was rinsed thoroughly and air-dried gently. Dentin primer and adhesive were applied as the preparation reached dentin structure, according to the manufacturer instructions (Clearfil, Kuraray). Following the bonding application a thin layer of light polymerizing composite resin luting cement was applied at the intaglio surface of the veneers, placed onto the prepared teeth and light-polymerized for 40 s (Elipar Free Light, 3M ESPE) from palatal, buccal and incisal sides.\nExcess luting cement was removed and the marginal area was finished and polished with abrasive discs. The metal-ceramic fixed partial denture on the anterior mandibula and the full coverage all ceramic crown for maxillary right first premolar are constructed with conventional procedures and cemented (,). Restorations were checked to avoid any occlusal interference.\nThe patient was satisfied with her new smile line and excellent view of the anterior teeth (,). She was recalled in 2 days and encouraged for better dental flossing and also recalled every 6 months for periodical controls. No complication was observed during 3 years clinic service.

A 41-year-old female reported to us with the chief complaint of swelling on the left side of her face since 1 month, which gradually increased in size and was observed by her and her relatives. She also complained of facial discomfort. Her motivation to seek treatment was due to the increase in the size of the swelling as observed by her relatives. During history taking, she revealed undergoing extraction of the second premolar in the second quadrant 2 months prior to the present swelling in her face. The tooth was extracted as it was grossly decayed, for which she had experienced pain and discomfort for a long time. The patient had ignored the initial tooth decay and had not sought any treatment till she developed pain and discomfort.\nOn physical examination, a swelling was noticed on the left side of the face []. This extended superiorly from the ala region of the nose to the malar prominence and inferiorly from the infra-orbital region to the upper part of the angle of the mouth approximately measuring 3 × 2 cm. The swelling was diffuse, but gave a firm feel on palpation. Intraoral examination showed a swelling corresponding to the second premolar region obliterating the upper buccal vestibule. It was firm on palpation and smooth in consistency. Dental and medical examination was not contributory. Lymph nodes could not be appreciated on palpation.\nNasal endoscopic examination revealed a congested maxillary sinus with a suspected nasal polyp.\nComputer tomography was subsequently performed with axial and coronal sections. This showed an abnormal mucosal thickening of the left maxillary sinus along with a breach in the anterior wall of the maxilla [Figures and ]. A soft tissue mass was seen to breach the sinus cavity and spilling over to the soft tissues of the facial region.\nAn incisional biopsy [] was performed and the tissue was subjected to histopathological examination. The histopathology [] showed epithelium and connective tissue. The epithelium showed pseudostratified ciliated columnar cells and connective tissue component with dense chronic inflammatory cells like plasma cells, Russel bodies and lymphocytes. The specimen also showed bony trabacule, blood vessels with extravasated RBCs. This gave an impression of chronic nonspecific inflammatory tissue. A functional endoscopic sinus surgery would be an ideal choice to approach a chronic sinus, but choice of surgical approach should be tailor made for each patient depending on the type of lesion encountered. Hence, observing the extent of the lesion, we decided to go for a conventional approach to this patient. The patient was then taken up under general anesthesia for a total excision of the lesion. The patient was intubated, painted and draped under standard aseptic conditions. A vestibular incision was placed and, on raising a sub-periosteal flap, we observed that the anterior wall of the maxillary sinus had been eroded and breached by the thick mucosal tissue of the maxillary sinus. The lesion was approached through this existing bony window. The entire mucosal lining was removed. A certain amount of lesional tissue was seen between the fibers of the levator labii superioris and the fibers of the zygomaticus minor muscle []. A blunt dissection was performed and the lesion was removed. The specimen was sent for histopathological diagnosis []. After achieving hemostasis, a bismuth iodine paraffin pack was placed and wound closure was done in with 4-0 monocryl. The patient was extubated uneventfully. She was prescribed an antibiotic, analgesic and nasal de-congesting medication.\nThe histopathology diagnosis was given as chronic inflammatory tissue of the left maxillary sinus [Figures and ]. Gomori-methenamine silver staining and Periodic acid Schiff staining were been performed for fungal hyphae, which turned out to be negative.\nThe patient was recalled after 1 week for suture removal and follow-up. The defect, which was created by the excision of the lesion, was rectified with acrylic prosthesis []. The patient has been on regular follow-up without any complications [].

This 30 years old lady from a remote village of Assam, India had a mild pain at the right forearm for last 2 years. She developed a small swelling in that region which gradually increased in size. She took treatment from local doctors, but not getting relieved of her pain and swelling. She then came to Guwahati city for better treatment and visited one of the private hospitals. Biopsy was done there along with CT scan. Biopsy came out to be a soft tissue sarcoma. She was operated in that hospital and discharged 5 days after surgery. Immediate post-operative period was uneventful. She again developed pain at the surgical site one month after the surgery.\nShe was prescribed pain killers, but not getting relieved of her pain. After 6 months of this on and off pains, she was fade up and came to our institute. She was worked up extensively at our institute by the surgical oncology team. MRI of the arm showed residual disease and haziness around the neuromuscular bundle at the right arm. All pre-anesthetic work ups were done and the patient was put for surgery. Consent was taken regarding the consequences following brachial artery resection including amputation and requirement of great saphenous vein graft.\nThe patient was intubated and operated under general anesthesia in supine position. Scar of previous surgery was excised. On exploration, it was found that tumor was in close proximity to the neurovascular bundle. On tedious dissection, we were able to separate the tumor from the median nerve, but it was not possible to separate the tumor from the brachial artery. We had to excise 14 cm of the brachial artery. There was tumor thrombus inside the lumen of the brachial artery. After that, we had marked the course of great saphenous vein on the left leg. With careful dissection, we had isolated approximately 16 cm of the great saphenous vein. That segment was cut and placed on a saline filled tray after marking the proximal and distal end ().\nThat isolated vein segment was transferred to the right arm after reversing its ends. First, we had done anastomosis of the proximal end near the shoulder joint and next at distal end near the elbow. Anastomosis was done with 9-0 ethilon round body under microscope (). Both ulnar and radial artery pulsations were good at the end of the surgery. The glove drain was put around the anastomosis. Posterior arm slab was applied to restrict any movement of elbow and shoulder joint (). In post-operative period, we kept the slab for two weeks and after that arm pouch was advised. Limb elevation was continued for one month. She received chemoradiation following surgery.\nWe had discharged the patient on 7th post-operative day. For follow up, we advised the patient to come to surgical oncology/plastic surgery OPD at 2nd and 4th week and subsequently at 3rd, 6th and 12th month. We carried out a Doppler USG of the right upper limb at 6th and 12th months, which showed good flow at the great saphenous graft with minimal narrowing of anastomosis sites. Patient had no active complaint at the end of 12 months follow up.

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 3-week-old male was referred to pediatric surgery for evaluation of a congenital lung lesion. He was born at 37 weeks via cesarean section for breech presentation with a birthweight of 2.78 kg. After birth, he developed respiratory distress and was admitted to the neonatal intensive care unit where a chest X-ray demonstrated multiple cystic lucencies in the right lung field initially concerning for a CPAM. Prenatal care was limited and it was unknown if the lesion had been previously diagnosed on ultrasound. He required CPAP for respiratory support which was weaned off on day 1 of life. He was discharged home on day 7 of life to follow up with pediatric surgery.\nHe presented for surgical consultation at 3 weeks of life. Examination revealed a well-appearing 3.75 kg infant, with clear breath sounds bilaterally and no evidence of heart failure. His parents reported no further respiratory symptoms. The computed tomography (CT) angiogram was obtained which revealed a cystic lung lesion in the right lower lobe with a large systemic artery originating from the distal thoracic aorta proximal to the origin of the celiac artery (\n). These findings confirmed the diagnosis of a PS. The need for surgery to avoid complications related to the sequestration was discussed with the infant's parents. Due to the large size of the systemic feeding vessel, we elected to perform angiographic embolization preoperatively to reduce the risk of intraoperative bleeding. Ideally, we would have performed resection at 3 months of age, but the procedure was delayed until 7 months due to social circumstances beyond our control. During that time, the infant remained asymptomatic.\nHe was admitted and underwent angiography via right femoral arterial access with interventional radiology. This demonstrated rapid flow through the feeding artery into the sequestration with brisk drainage into the right inferior pulmonary vein. Onyx 18 (ethylene vinyl alcohol, dimethyl sulfoxide) was chosen for embolization because it is a pliable copolymer that would not interfere with the function of a LigaSure device or endothoracic stapler during surgery. We used an occlusion balloon to arrest flow within the feeding vessel so that the brisk arterial flow would not flush the copolymer through the lesion into the pulmonary vein while it hardened. Following embolization, there was no further flow through the sequestration; however, there was some flow noted proximally within the feeding vessel itself (\n). We were unable to embolize the entire length of the feeding artery because the occlusion balloon could not be placed more proximally in the vessel without risking inadvertent embolization into the aorta. Following this procedure, he was monitored in the PICU overnight before proceeding with surgery the following day.\nThoracoscopy was performed via a standard three-port approach with the infant in the left lateral decubitus position. Upon entry, the large systemic feeding artery itself was not thrombosed. However, the embolized portion of sequestered lung was clearly demarcated and appeared dark purple compared with the surrounding, well-perfused pink lung parenchyma. The inferior pulmonary ligament was mobilized allowing complete visualization of the embolized tissue within the right lower lobe. We had initially planned to perform lobectomy, but after this mobilization, it was clear that the lesion was peripheral and could be fully excised with a nonanatomical segmentectomy. The feeding vessel was mobilized circumferentially and divided using a LigaSure device. The lung parenchyma was similarly divided taking care to include a margin of well-perfused lung around the sequestration. A 16 Fr chest tube was placed and the lung re-expanded with no air leak noted. He was extubated and transferred to the surgical ward without complication. His chest tube was removed on postoperative day 1, and he was discharged on postoperative day 2.\nThe infant was seen in follow-up 2 weeks after surgery. His parents reported that his activity level was back to normal and denied pain or respiratory symptoms. Final pathology of the specimen confirmed an intralobar PS.

We experienced a 55-year-old man who developed tetraplegia after neck spinal manipulation for stiff neck pain. The patient was healthy with no significant medical history and no previous history of taking medication (the patient denied taking aspirin or any other anticoagulant medications). But he had several previous mild neck pains and was relieved after manipulation treatment. The patient was treated with cervical manipulation and he felt pain and numbness in his lower limbs about 2 h after the end of the manipulation. The symptoms of his sensory abnormalities gradually worsened and spread upwards. The patient felt seriously ill and was immediately sent by his relatives to the emergency room of our hospital to visit a doctor. After being admitted to the emergency room, the patient was mentally alert during a physical examination. There was tenderness in the neck and increased muscle tension in both upper limbs. The superficial sensation of the upper limb had disappeared, but the deep sensation still remained. The lower extremity had 0/5 power on both sides. There were findings of sensory deprivation at the T2 dermatome and below, and anal tone was absent with the bulbocavernosus reflex. An imaging examination was performed after an indwelling catheter was inserted. There were no abnormal findings on a cervical vertebral X-ray and brain computed tomographic (CT) scans. A cervical magnetic resonance imaging (MRI) scan showed an acute posterior epidural hematoma from the C3 to T3 vertebrae (Figs. and ). MRI also showed a large heterogeneous collection within the right lateral epidural space of C4 until T1, which was consistent with the hyperacute epidural hematoma, with cord edema at the same level (Fig. ). The hematoma resulted in spinal stenosis, the narrowest of which was located at the C5 and C6 levels. There was no evidence of vertebral body fracture or subluxation. Clinical laboratory results at admission were normal and blood investigations showed that platelet counts were within the normal range with a normal coagulation profile (Table ). Subsequently, to exclude vascular malformations, the patient was scheduled to undergo CT angiography. CT angiography showed no malformation of the neck vessels (Fig. ).\nWe started intravenous prednisolone infusion to the patient to alleviate spinal edema and to prepare for spinal canal decompression and evacuation of the hematoma. During the operation, we saw a C4–T1 epidural hematoma and compression of the spinal cord at the corresponding level, especially at the C5–C6 levels. The hematoma was located in the right posterior part of the spinal cord, which is consistent with the results of MRI. The hematoma began to thin below the T1 level, and spinal cord compression was reduced accordingly. Therefore, we only removed the hematoma at the C4–T1 levels.\nAfter surgery, the patient was sent to the intensive care unit for further treatment. On postoperative day 1, there was some improvement in neurology, with a returning of upper extremity strength from 0/5 to 2/5. Superficial sensation and deep sensation between the T2–T8 levels changed from deprivation to hypoesthesia. On the 7th day after the operation, the patient’s symptoms improved further. His upper limb muscle strength increased to 4/5, but sensation below the T10 level was still absent. This condition remained until he was discharged from hospital. During a follow-up of 3 months after discharge, neurological function of the patient did not greatly recover.

A 2-day-old male child was referred to orthopedic department with decreased movements of his right lower limb and both arms and being irritable. A 20-year-old primigravida with twin pregnancy had delivered the baby by cesarean section at 37 weeks of gestation. The first of the twin was a female cephalic presentation and was delivered by normal vaginal delivery who did not have any complications. Non progress of labor and fetal distress with breech presentation compelled the surgeons to perform a cesarean section for the 2nd baby. A history of energetic traction and rotation was elicited from the operating surgeon since it was a difficult delivery as liquor had drained out in the 30 mins after delivery of 1st twin with the 2nd twin in distress. The operating surgeon applied a groin traction with a pull on the right leg and both arms to deliver the baby quickly no obvious sounds were heard during the extraction. A 2490 g female neonate was delivered who cried immediately after birth with Apgar scores of 7 and 9 at 1 and 5 min, respectively.\nOn examination, the baby started crying on moving the right limb and the arms. Radiographs (infantogram) were obtained of both femur and humerus which revealed bilateral undisplaced humerus shaft fracture and a right femur fracture with displacement ( and ). The bone structure and mineralization was visibly normal and there were no other findings like blue sclera or other deformities, hypotonia on physical examination. Ophthalmic consultation was taken who performed an eye fundoscopy and reported as normal. Biochemical analysis such as serum calcium, phosphorus, and alkaline phosphatase was normal. There was no positive family history or similar complaint in the other infant. We considered a working diagnosis of fracture of both humerus and right femur secondary to a birth injury.\nChild was treated by splinting the hip in flexion for the right femur and simple chest strapping for the humerus fracture for 3 weeks. The immobilization was removed, and the child was able to move both his arms and right lower limb actively. Follow-up radiograph showed both the humerus fracture had united and the right femur fracture showed good callus formation with no significant deformity (). Follow-up after 2 months showed complete union of the femur fracture both clinically and radiologically.

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.

We encountered a 43-year-old female patient who presented in shock with cool clammy extremities, tachycardia with a rate of 135 and blood pressure of 80/50 mm Hg. This was preceded by a history of 12h of abdominal pain and progressive distention without a history of trauma. The patient was alert oriented to time place and person with a oxygen saturation of 94% and respiratory rate of 24. Her medical history was positive for a stroke 1 year ago for which she was on warfarin and clopidogrel. We could not find out whether she was allergic to aspirin. We started the primary treatment of shock and bolused her with intravenous fluids, started nasal oxygen, put her on a monitor and collected cultures and blood for complete blood count, differential, electrolytes, type and cross, renal and liver profile. An International Normalize Ratio (INR) test and Prothrombin time were also ordered. Suspecting the worse case scenario of internal hemorrhage secondary to warfarin toxicity we performed a bedside ultrasound which was positive for free fluid in the abdomen. Her laboratory values came back with hemoglobin of 4 gm%, a normal white count, platelet count and an INR of 8 which was way beyond the normal range. After stabilizing her with intravenous normal saline boluses of 2 L, we did a computerized tomography (CT) scan of the abdomen and pelvis to identify a visceral source of bleeding. CT abdomen showed free fluid in the sub diaphragmatic spaces with CT attenuation value of 30 suggesting hemoperitoneum []. CT also showed a segment of grossly thickened bowel loop []. The patient was taken to the operating room for an exploratory laparotomy. More than 2 L of blood was suctioned from the abdomen. There were 2 ft of small bowel and its mesentery which were found to be hemorrhagic and severely congested []. No active sites of bleeding could be identified. The source of bleeding was probably mesenteric vessels. Since the segment of bowel did not appear healthy it was resected and end-to-end anastomosis was performed. Patient had an uneventful postoperative recovery. Anticoagulants were withdrawn.

A 65 year-old male was suffering from chronic abdominal pain and foreign body sensation following incisional hernia repair with mesh in 2010. In March 2010, the patient underwent an open right hemicolectomy for benign multiple colonic polyps and subsequently developed an incisional hernia. In November 2010, he underwent open incisional hernia repair with an onlay Prolene mesh. Subsequent to the mesh repair, he had sharp pain in the epigastric area particularly when bending forward and fullness in his upper abdominal region. He was referred to the outpatient general surgery clinic at a tertiary level hospital for an assessment. On focused abdominal exam, he had a midline laparotomy incision with no acute signs of infection. There was fullness superior to his umbilicus with a palpable subcutaneous mass measuring approximately 6 cm in diameter. Cross sectional imaging revealed an ovoid collection in the anterior abdominal wall, measuring 4.4 × 8 cm on magnetic resonance imaging (MRI) and 3.3 × 5.4 cm on computed tomography (CT). In addition, an abnormal calcification superior to the collection could be appreciated on CT (). These findings were suggestive of a chronic hematoma and scar tissue. The patient agreed to undergo debridement of chronic hematoma and partial mesh excision. Intraoperatively, the ovoid collection was approached via a midline incision and was encountered after dissection through the subcutaneous tissue. It was comprised of a thick rind of scar and fibrous tissue, measuring approximately 8 × 8 cm. It was unroofed, with immediate expression of old hematoma as well as fibrous tissue. Part of the overlying Prolene mesh and thick scar tissue were excised. The remainder of the Prolene mesh was well incorporated to his fascia and left in place. As the superior aspect of the collection was dissected out by entering deep to the fascia, a piece of calcified tissue was dissected out from the preperitoneal space superior to the mesh. It was suspected to be heterotopic ossification, and it was removed (). The fascia was then primarily repaired, and then the incision was closed in layers after thorough irrigation. On postoperative follow-ups in the clinic at 2 and 6 weeks, the patient was doing well, and his pain had improved significantly.\nSymptoms of epigastric pain and fullness in the upper abdomen were gone. There was no recurrence of an incisional hernia on clinical examination.\nSpecimen sent for microbiology was negative for fungal and bacterial growth. Histopathological examination of the specimen revealed soft tissue with osseous metaplasia which is consistent with heterotopic ossification. The cause of this patient pain was likely secondary to a chronic hematoma and scarring, and surprisingly, an abnormal calcified mass consistent with heterotopic ossification.

A 14-year-old healthy male child presented to accident & emergency department with complaints of inability to walk or bear weight on his left lower limb after he spontaneously dislocated his patella while running on uneven ground. Upon further inquiry, the patient gave a history of similar episode 10 months back following a fall. At that time, his mother pushed the patella back after which he was taken to the hospital where radiographic images showed that patella was reduced with no associated fracture of patella, tibial tuberosity or femoral condyles. He was given a full length leg cast for 1 month after which he was able to resume his daily activities without any difficulty. There was a family history of recurrent patellar dislocation (father). Previous hospital records revealed that he had history of anterior knee pain with a positive apprehension sign indicating lateral patellar instability.\nOn examination, the knee was markedly swollen with obvious deformity in the lateral aspect in the form of tenting of the skin and soft tissue by underlying patella without any contusion or bruise. The knee was locked in 15 degrees of flexion and patient was unable to perform any movements at the knee joint. A provisional diagnosis of lateral dislocation of patella was made. Standard anteroposterior and lateral plain radiographs were taken which showed a laterally displaced and vertically rotated patella along its long axis with the medial patellar edge locked and dipping into the lateral gutter (). There was no evidence of associated fracture or signs of osteochondral damage. General examination showed no hyperlaxity of the joints. Clinical signs of genu valgum, patella alta, tibial torsion or trochlear dysplasia were absent and the Quadriceps (Q) angle on the normal limb was within normal range (11 degrees).\nAn attempt to closed reduction was made under conscious sedation but was not successful. A decision for open reduction was made and patient was shifted to operating room. A midline vertical incision was given along the knee joint. The patella was found to be locked with its articular surface facing laterally and the medial edge of patella locked past the lateral femoral condyle and wedged into the lateral gutter. The medial patellar retinaculum was found stretched and attenuated but no tear or defect was noticed.\nA small incision was given along the lateral retinaculum, the index finger inserted was through it and the wedged medial patellar edge was freed from the lateral femoral condyle; and at the same time lifting the patella out of the lateral gutter, it was relocated to its anatomical position.\nThe stability and tracking of the patella was checked and it showed a tight lateral retinaculum along with a lax medial retinaculum. Release of the lateral retinaculum was done along with medial patellar retinaculum plication using multiple interrupted prolene sutures (). Patellar stability and tracking was rechecked and found to be good. Standard skin closure was done and a long leg hinged knee immobiliser was applied. Post operative radiograph showed patella relocated in the trochlear groove ().\nPatient was allowed full weight bearing on day one. Quadriceps setting exercises and active straight leg raising were started in the second post operative week. Progressive active and passive range of motion exercises were started after 3 weeks and full range of motion was achieved by 7 weeks. Patient resumed his sporting activities by 6 months post operative with no recurrence or any symptoms at the time of final follow up of 18 months.

A 22-year-old female patient visited the outpatient department with a complaint of pain in the left jaw joint region since 1½ months. On eliciting the history, patient had pain on mastication and difficulty in opening the mouth due to which she was on the soft diet. Medical history revealed that she was diagnosed with RA 6 months back. The patient took homeopathy medicines for 1 month. But presently was not on any medication. On clinical examination of TMJ, the following signs and symptoms were assessed: Left side TMJ was associated with pain, TMJ range of motion was limited, associated with pain while maximum unassisted mouth opening (18 mm) and while lateral excursion [], deviation of mandible toward left side while opening mouth was noticed. No clicking sounds on opening, closing and lateral movements. Muscles of mastication were tender on palpation. Intra orally, no teeth were carious, no occlusal prematurity was noticed. On radiological examination, panoramic radiograph depicted irregular erosions in the left condyle and decreased joint space both on right and left side. The findings were of degenerative joint disease but nonspecific due to the overlapping of structures []. TMJ tomography both open and closed mouth revealed slight erosion in the anterior surface of the left condyle but was not clearly appreciated []. Further evaluation was carried out by CBCT.\nCone beam computed tomography images revealed sclerosis of the outer surface of the condylar head, narrowing of the articular space bilaterally (more on the left). Coronal left closed mouth view revealed loss of joint space, loss of cortical bone on the superior surface and condylar head erosions compared to right side, which shows normal joint space and condylar structure [Figure and ]. Coronal left open mouth view revealed narrowing of the articular space and erosions on superior head of condyle and right side depicting no changes in the joint space [Figure and ]. Sagittal view open and closed mouth revealed decrease in joint space with erosions of the superior surface of the condyle on the left side [Figures and , and ]. Hand wrist radiograph revealed the joint space narrowing of the distal phalange of the right thumb, narrowing of 3rd and 4th proximal phalanges and erosion of the middle phalange seen of index finger []. Knee and shoulder joint radiographs revealed no changes. Serum investigations were advised and it revealed rheumatoid factor (RF)-340 IU/ml (normally <40 IU/mL), C-reactive protein (CRP)-368 mg/dl (normally <0.8 mg/dL), erythrocyte sedimentation rate (ESR)-40 mm/h (normally <20 mm/h in females). All serum markers for RA were elevated. Final diagnosis of RA affecting TMJ was arrived at.\nPatient was referred to rheumatologist for the further treatment, and she was prescribed Tab Methotrexate 75 mg once a week for 2 months and anti-inflammatory drug twice a day for 15 days and patient responded well to the treatment. Liver function test was also monitored with periodic follow-up. After 2 months of the follow-up, patient reported relief of pain and improvement in mouth opening.

A 26-year-old Asian woman currently residing in the UK presented to the ENT outpatients department with a lump on the right side of her lower neck. She noticed the swelling six weeks prior to presentation and it had been gradually increasing in size. She had no systemic symptoms and had a good apetite and her weight had been stable. Her past medical history was insignificant apart from a diagnosis of polycystic ovaries.\nOn examination there was a nontender firm to hard lump in the right thyroid lobe, measuring 4 × 4 cms. The rest of the ENT examination including flexible nasolaryngoscopy was normal. There was no other lymphadenopathy and the respiratory, cardiovascular, and abdominal examination was unremarkable.\nThe routine laboratory test results and thyroid function tests were normal except for a raised ESR of 40 mm/hr. Ultrasound examination of the neck revealed a 35 × 18 mm cystic mass in the lower pole of the right thyroid lobe with internal echoes (Figures and ). An ultrasound guided FNA of the above mass revealed 10 cc of frank pus which raised the clinical suspicion of TB, and subsequent culture was positive for mycobacterium tuberculosis. Ultrasonogram also revealed some abnormal lymph nodes in the right level 2 area of neck (). Her mantoux test was 34 mm. Chest X-ray was normal. This patient was referred to the chest physicians and was started on standard quadruple therapy.\nShe was seen recently approximately 12 months post treatment and has responded well to treatment and her neck swelling has disappeared. She is euthyroid. A repeat ultrasound showed complete resolution of the neck mass and lymph nodes.\nAlthough tuberculosis has been reported in many parts of the human body, thyroid involvement is extremely rare and its true incidence is unknown. The rarity of this disease is attributed to various factors including bactericidal property of colloid material and high thyroid blood flow [].\nTuberculosis of the thyroid gland may be primary or occur in association with tuberculous infection of other organs []. It can present as multiple thyroid lesions associated with military tuberculosis, solitary caseating thyroid nodule, cold abscess, chronic fibrosing type, and acute abscess [].\nThe clinical presentation of thyroid tuberculosis can range from being totally asymptomatic to solitary, multinodular goitre with concomitant pulmonary tuberculosis, meningitis, dysphagia, or pyrexia of unknown origin. It can sometimes mimic thyroiditis and cancer. Most of the patients are euthyroid. A high ESR and a positive mantoux test may suggest tuberculosis [].\nUltrasound guided fine needle aspiration cytology (FNAC) is a useful diagnostic method in thyroid tuberculosis. It is our practice to perform FNA on almost all neck lumps and it is the aspirate of frank pus in a high-risk patient that raised the suspicion of tuberculosis in our patient.\nThe diagnosis has to be substantiated by histopathologic findings of caseating granuloma and/or identification of AFB on culture. Other investigation modalities include chest X-ray, sputum analysis, PCR, and cultures with 14C-labelled compounds.\nTreatment of thyroid tuberculosis does not differ from other forms of this disease.\nAntitubercular drugs remain the main stay of treatment. The concomitant use of two or three effective drugs has to be prolonged for at least six months with appropriate followup. Surgery may be indicated in acute abscesses to avoid total destruction of the thyroid gland.\nIf left untreated, it can cause complete destruction of the thyroid gland and result in hypothyroidism. The thyroid hormone levels should be monitored before, during, and after treatment.

He was 16-year old school going boy who lived at home with his family was diagnosed with locally advanced head and neck cancer with no known distant metastasis []. The extent of the cancer involved entire left side of the face, left ear, and scalp. He had visual loss in his left eye and facial disfigurement. He was cared for at home by his mother and grandmother. His father lived and worked in a different city and he had one teenage sibling who was his younger sister. After the initial diagnosis, he underwent radical facial surgery including maxillectomy and postoperative chemo radiotherapy. He was Ryle's tube fed after the surgery due to dysphagia. One year later, he had recurrence of the cancer at the operative site. He had an ulceroproliferative wound involving the left side of the face, eroding the left ear canal. The wound was infected and was covered with slough and maggots. He was referred to the community PC by his primary treating doctors for symptom control and specialist PC. At this point of time, he had disease progression on the treatment and options of disease modifying treatment were very limited.\nHe was seen regularly in the community by a multidisciplinary PC team. During the initial visit the patient had uncontrolled pain and purulent discharge from the left side of the face. He was studying in class 9 and had discontinued his schooling. He was fairly independent with activities of daily living and use to watch television and occasionally, turn pages of a magazine, and see pictures. His mood was depressed and often had crying spells. His grandmother was very loving and supportive and her presence was very comforting to him. He always perceived that his mother did not love him, as she was more devoted to the care of his younger teenage sister and household work. His father was away most of the time and had little involvement in boy's care. His sister had a blunted affect and had little involvement in his brother's life or his care.\nHis pain was optimally controlled at home with oral analgesics administered through Ryle's tube. After initial wound debridement, daily dressings were done at home. The team advised patient's father to take time off work and spend time with his son. Along with the patient, all the members of the family received one to one counseling. During the interview, these were the remarks made by the patient. “My mother does not love me and she is not interested in my care.” “I am all alone here and I miss my friends and school.” “I look very bad.” “I do not like what's happening.” These were few remarks made by his parents. “He is our only male child.” “We have struggled to raise him up.” “He was very smart and good looking, look at him now.” We spent all our money on his treatment. His grandmother was caring, optimistic and was always hoping for a miracle cure. His sister had little knowledge about her brother's prognosis, and when confronted with a question about she losing her only brother she was quiet and expressed no emotions. Members of the team had regular debrief sessions among themselves and also externally. Over the period of next 2 weeks, he had involvement of his right eye and had total loss of vision. His general condition gradually worsened and he needed maximal support with activities of daily living. His hearing was still present and he still used to recognize the presence of the health personnel. On further interviewing the patient's mother, her avoidance behavior was due to the fear of losing her only son. She was further counseled, and later on she was more involved in her son's care and was able to spend quality time with her son. He died 2 weeks later at home in the presence of his family with his mother holding his hand.\nThe PC team made two bereavement visits and following were the few remarks made by the patient's family. “Before death he coughed out all the secretions, we thought he will recover fast.” “We were able to spend a lot of time with our son during his last days.” “We thank you for being honest and letting us know he will die, your sincere guidance helped us to support our son throughout the period of illness, dying, and death. Though it was a difficult experience for the team throughout it was also a very rewarding experience. It was an excellent experience for the team members. During the four weeks time, the team was confident enough to face the similar challenges in providing palliative care to the needy clients.\nSome of the issues identified in this situation are as follows.\nCaring for adolescent - difficulties faced compared to caring for adults: level of the stress; poor self-esteem of the child; increased anxiety among parents, grandparents, child, and care providers; impact on the development of siblings; job/home interaction of parents; family coping. The body image: weight loss; muscle weakness; skin changes; disfigurement of face; growth on face; loss of vision; incontinence and catheter. Psychosocial issues: no friends and separation from peers: anger; discontinuation of education; diminished interaction with the family members; financial burden; anxiety; depression. Family members’ feelings/emotions: (some of the points parents expressed during grief and bereavement period.) he is the only male child; brought up to the age of 16 years and he was studying in class 9; he was very smart, good looking and helpful boy; spent money for his treatment instead of his study; crying all the time; before death he coughed out all the secretions, mother thought he will recover fast; while dying he held his mother's hands that provided lot of emotional satisfaction to the mother. Team experiences: Such clients should get good and effective care that gives quality of life to the terminally ill patients.We satisfied with the care provided to the child as the family members expressed their gratitude about our service. Learning experiences: managing complex symptoms issues; prioritization of care; building a therapeutic relationship; communicating prognosis; open and truthful communication; breaking the bad news; giving psychosocial support; building up team spirit.

In July 2008, a 50 year-old white male was referred to us for evaluation of the decision by his primary care physician to maintain him on life-long anticoagulation, a decision based on the findings of deficiencies of both protein C and protein S. He is in good health and has no known family history of DVT or coagulation abnormalities. In June 2006, he fell from a tree at work, and a fracture of his right femur was redressed by insertion of a titanium rod. One week after surgery, he complained of pain in his right calf. DVT was confirmed by Doppler ultrasonography and he was anticoagulated with heparin and Coumadin and maintained on 9 mg Coumadin and 325 mg aspirin until June 2007 when he began noticing spontaneous bruising and large hematoma appearing without provocation. He requested that his primary care physician re-evaluate the basis for his anticoagulation. Blood drawn while he was taking a therapeutic Coumadin dose was sent to a regional laboratory for a thrombophilia work up. Results of laboratory tests were significant for protein S activity levels 36% [normal range 54-130%] and protein C activity levels 10% [normal range 70-130%]. Protein C and protein S antigen levels were not performed, and the test results were interpreted as a protein C and protein S deficiency. In our laboratory we drew a blood sample while the patient was taking Coumadin and we prepared citrate platelet poor plasma from blood with the results shown in . We report a normal coagulation profile and normal response to the prescribed Coumadin dose, with no evidence of thrombophilia. There was no evidence of elevated fibrinogen levels or abnormal fibrinogen variants. Antithrombin levels were 100% as would be anticipated in a patient on Coumadin for such a long period of time. Protein C and protein S were within range expected for the degree of anticoagulation. He was returned to his primary care physician with recommendation that, although he did not have a protein C or protein S deficiency he should remain on Coumadin until resolution of the venous obstruction that occurred consequent to the surgery is confirmed by Doppler ultrasonography. In a healthy male with a first DVT occurring after surgery or trauma, the calculated risk of DVT recurrence is 0.27 very low []. It is estimated that 10% of recurrences occur at 2 years and 23% at 5 years post anticoagulation therapy []. Unresolved DVT may lead to post-phlebitic syndrome and to a 2.6% annual, 12.4% at 5 years and 16.5% at 7 years increased risk of recurrent DVT [].\nOral anticoagulation was discontinued based on a clotting profile negative for thrombophilia and Doppler ultrasonography pattern consistent with normal blood flow in the deep veins of the right calf and thigh predicting a minimal calculated risk for DVT recurrence.

A 23-year-old male patient was referred to our tertiary academic centre because of a defect affecting one side of his face. The patient underwent adenotonsillectomy at 6 years of age, and numbness started to affect the left side of his face 3 months after surgery. At that time, he was informed by his physician, who performed the operation, that there were no problems. However, the numbness affecting the left side of his face increased, and shrinkage and weakness of the left side of the face occurred over the next 2 years. In ten years after surgery, his complaints and symptoms increased (Figures and ) but he could not see the doctor for socioeconomic reasons.\nA physical examination at the time of referral to our centre revealed atrophy of cutaneous and subcutaneous fat tissue on the left side of the patient's face, phthisis of the left ocular bulb and corneal atrophy, left zygomatic atrophy, and asymmetry (Figures , , and ). Hemiglossal atrophy and an increased size of fissures of the left side of the tongue were also seen (). Maxillary atrophy displaced the left upper teeth in an upward and backward direction ().\nThe patient had no dermal lesions or involvement of the extremities. There was no family history of PHA. The patient underwent autologous fat injection at 14 and 16 years of age, but the desired result was not sustained and the atrophy continued (). No antibodies were detected in serological tests. Sedimentation and core reactive protein levels were within normal limits, suggesting that the facial disorders were not caused by inflammatory diseases. Computed tomography revealed no apparent neurodegeneration (), eliminating Rasmussen encephalitis (RE) from the differential diagnosis. The computed tomographic images revealed a decrease in left retroorbital fat tissue and atrophy of the ocular bulb (). The left temporal muscle was atrophic compared with the right temporal muscle (). Magnetic resonance angiography was performed to detect possible vascular causes but revealed no vascular abnormalities of the internal and external carotid arteries or of their branches ().\nThe patient was informed that surgical reconstruction of his facial asymmetry would not stop the progression of the disorder and that the cosmetic results would probably be temporary. The patient did not wish to undergo any surgical interventions.

A 25-year-old male patient re-presented to our department for the first time in 7 years with otorrhea in the right ear and recurrent meningitis. He had been treated for meningitis in another hospital and had experienced fever and seizures two weeks before visiting our hospital. The patient had a history of multiple surgeries for cholesteatoma and had been treated for severe otitis media at the age of 2 years, at which point right temporal bone osteolysis was identified. He subsequently suffered from recurrent meningitis and underwent several brain abscess drainage procedures. At ten years of age right temporal bone surgery was performed to rebuild the separation between the middle ear and lateral temporal lobe. At 16 years, he was diagnosed with cholesteatoma, and radical mastoidectomy was performed. Further details of these operations, performed at other hospitals, were not available. We were unable to obtain detailed past medical records regarding treatment (including surgical procedures) of his cholesteatoma, and we could not estimate whether the past intervention of the cholesteatoma was appropriate. When the patient was 17 years old, he visited our department for the first time to undergo assessment for controlling cholesteatoma, recurrent meningitis, and otalgia. First, tympanoplasty was performed to assess the disease and remove residual cholesteatoma from the middle ear; cholesteatoma was diagnosed by histopathological analysis. It was not possible to determine whether the cholesteatoma was a residual congenital cholesteatoma or a secondary cholesteatoma formed as a result of osteolysis of the external auditory canal or middle ear. At that time, we hesitated a more extensive procedure because of his age and limited information about his past surgical interventions. Meningitis and otalgia were subsequently controlled. However, after six months, when he was 18 years old, the patient experienced another episode of meningitis. At that time, he was also suffering from an epidural abscess, which was drained during hospitalization. He attended our department until he was 19 years old, at which point he chose to discontinue the hospital visits.\nWhen the patient presented at our department again at the age of 25 years, computed tomography (CT) imaging revealed massive osteolysis of the temporal bone (Fig. a−c). Notably, while most of the temporal bone had disappeared, the cochlear bony lateral wall was relatively well preserved, and his hearing by bone conduction had not been completely lost. Magnetic resonance imaging (MRI) revealed that the temporal lobe of the brain had herniated into the mastoid (Fig. d). Compared with a previous CT scan image (Fig. e), there is clear progression of boney destruction during a time when the patient did not undergo any surgery to the temporal bone. At this point, we chose an observational approach as otorrhea had spontaneously resolved. However, during the patient’s follow-up, otorrhea recurred, and cerebrospinal otorrhea was suspected. The patient was hospitalized and treated conservatively with antibiotics. Once again, the otorrhea resolved spontaneously with 2 weeks of bed rest, and skull base reconstruction was planned to prevent recurrence.\n?A3B2 twb=.27w?>Pre-operative CT imaging with three-dimensional reconstruction clearly revealed not only temporal bone osteolysis but also spotted osteolysis of other bones of the skull, including the mandibular bone, zygomatic bone, and contralateral temporal bone (Fig. f). At this point, Gorham-Stout disease was suspected for the first time. To support the diagnosis of Gorham-Stout disease (by ruling out other possible differential diagnoses), we performed temporal bone biopsy under general anesthesia. An incision was made on the post-auricular scar from previous surgery. When the periosteum flap was created, an unexpected massive serous leakage was encountered, spouting from abnormal pores or lytic lesions in the temporal bone (Fig. ), which were similar to those described in previous reports []. Part of the temporal bone appeared blue in color, suggesting resorption. Samples were quickly collected from the bone surrounding the pores, and serous leakage (which appeared to be CSF) was stopped using fibrin glue and absorbable hemostat. There are no signs of recurrence of cholesteatoma at that time. Histopathological analysis revealed abnormal bony structures and accompanying small slits lined by epithelial cells (Fig. ). The findings ruled out other diagnoses, and were supportive of a diagnosis of Gorham Stout Disease in conjunction with the clinical and radiographic information. We concluded that the progressive osteolysis was far more likely to have been caused by Gorham-Stout disease rather than cholesteatoma. Skull base reconstruction was abandoned as osteolysis was considered to be progressive. Conservative treatment with infectious control was implemented as an alternative.\nDuring the first year of follow-up, he suffered a mild headache on one occasion, leading to an unscheduled visit. He was treated with intravenous antibiotics at an outpatient clinic to prevent the development of severe meningitis. At this point, no apparent CSF leakage was observed, no hospitalization was required and his headache had resolved within a few days. After that, there was no need to visit the hospital, except for follow-up once every few months. He was followed every two or 3 months for the next 1 year, during which time there were no signs of CSF or cholesteatoma recurrence.\nWe think that he has little risk of recurrence of the cholesteatoma because there has been no clear evidence of recurrence of cholesteatoma since the age of 18. However, this is an extremely rare case. CT imaging with three-dimensional reconstruction has been taken in every six months to assess the progression of osteolysis of the temporal or other bones of the skull and to watch out recurrent cholesteatoma. He remained well at the time of his last follow up. His quality of life has been maintained.

A 73-year-old lady presented with a fall down of 13 stairs at her home while intoxicated. Her past medical history was significant for chronic obstructive pulmonary disease and degenerative lumbar spinal disease. She was a lifelong smoker who was independent in her daily activities. She presented to her local hospital with symptoms of neck pain and stiffness but denied any chest pain. She was hemodynamically stable and underwent a computed tomography (CT) scan. The scan revealed no obvious vertebral fractures but did reveal a focal pseudoaneurysm along the left lateral wall of the aortic arch between the origins of the left common carotid and subclavian arteries (\n). This measured 19 mm in maximum anteroposterior dimension. She was subsequently referred to the vascular surgical team, who agreed to manage her conservatively with yearly CT scans.\nEleven months later, the patient represented to her local hospital with sudden onset of chest pain radiating to her back. Initial observations were unremarkable. A repeat CT of the aorta demonstrated the aneurysm with no significant size increase compared with the previous CT scan. The vascular surgical team felt that an endovascular approach would not be suitable owing to the proximity of the lesion to the head and neck vessels. Transthoracic echocardiogram and coronary angiography were normal.\nThe patient underwent surgery via a median sternotomy. The aortic arch and the head and neck vessels were dissected. The pseudoaneurysm was identified and appeared isolated to the greater curve on the left lateral aspect of the arch (\n). Following full heparinization, cardiopulmonary bypass was established by cannulation of the ascending aorta and the right atrium at a temperature of 35°C. The base of the aneurysm was approximated using several 3/0 prolene pledgeted mattress sutures from the outside, with reduced flow facilitating the closure (\n). A needle was inserted into the excluded part of the aneurysm to ensure there was no persistent flow. The bypass time was 27 minutes. The patient's postoperative course was unremarkable. She was extubated on the same day and discharged home on the 5th postoperative day. She was reviewed in the outpatient follow-up clinic for 6 months and then at 1 year postoperatively. She was doing very well with no chest or back pain. A repeat CT scan at 6 months revealed an isolated saccular aneurysm which no longer filled with contrast (\n). The ascending aorta and descending thoracic aorta were normal. A follow-up transthoracic echocardiogram revealed normal biventricular function and a normal sized aortic root.

A male patient aged 37 years visited the local hospital and planned to undergo botulinum toxin injection to relieve spasticity and dystonia of his left upper limb 3 years after subarachnoid hemorrhage. His past medical history revealed the fact that he had been affected by dystonia and spasticity in his left upper limb, especially the hand, secondary to tuberculous meningitis at the age of 3. The patient reported that for decades his left upper limb muscle strength was normal, however, it decreased to fair grade after the subarachnoid hemorrhage with worsening of dystonic and spastic symptom.\nThe degree of spasticity before the treatment was Modified Ashworth Scale (MAS) 2 in upper arm flexor muscles. The patient received a total of 200 U of onabotulinum toxin A (Botox): 100 U each into the left biceps brachii muscle and the brachialis muscle to relieve spasticity. Guiding techniques such as the ultrasound or electromyography were not used, but no complications were noted during injection. Electrical stimulation therapy was applied to the treated muscle, and the patient stretched his arm repeatedly to improve the range of motion. He performed exercises of the arm and shoulders at least 3 hours daily at a higher intensity than usual. During the exercise, there was no discomfort, and later, he increased exercise intensity. However, 3 days later, progressive edema and pain occurred in the left upper limb and he was transferred to our hospital the next day. He had no history of trauma except the stretching exercise, with no history of previous cardiovascular or other hemorrhagic diseases. He did not take drugs that affecting blood coagulation tendency. There were no known drug allergies. The thrombophilia profile was negative except for the mildly elevated D-dimer concentration (2.2 μg/mL) ().\nThe strength of the left shoulder flexor and extensor muscle at the time of visiting our clinic was fair grade (manual muscle test, 3/5). The spasticity of the upper arm flexor muscle was identified as MAS 1+. Physical examination revealed edema, heat and tenderness of the left upper extremity (). No sign of a local infection or tenderness was observed in the area of BoNT-A injection conducted 4 days back. The circumferences measured bilaterally at 5 cm above medial epicondyle were 33.5 cm on right and 37.6 cm on left, respectively. Given the patient’s symptoms, DVT was suspected, and thus, Doppler ultrasonography was performed. The results revealed the presence of DVT at the lower region of the left brachial and axillary veins (). In addition, venous computed tomography (CT) angiography was conducted to identify the distribution of thrombosis. Thus, the thrombus was observed from the lower region of internal jugular vein including the brachiocephalic and the axillary veins ().\nThe patient was placed in a sling to immobilize the arm and anticoagulation therapy was initiated with rivaroxaban (Xarelto; 15 mg twice daily per oral). After 1 week, compressive therapy was combined using compression bandage with icepack to reduce febrile sensation and edema. The edema in the upper extremity improved with time and the pain with febrile sensation disappeared.\nAt the 2-week follow-up, the patient had no pain or swelling. CT performed one month later revealed the resolution of filling defect with only small residual thrombosis in the brachiocephalic vein (). To reduce the risk of recurrence of DVT, rivaroxaban (Xarelto) was continued at the dosage of 20 mg once daily for 6 months.

A 45-year-old man presented to our clinic with a left knee injury that had occurred a few days before while skiing. He had been immobilized in a brace at the local medical office.\nClinical examination showed marked swelling of the knee joint, with pain at passive mobilization and restricted active motion: 40° of active flexion and an inability to actively extend the knee. Weight-bearing was hardly possible. There was an obvious gap at the level of the insertion of the patellar tendon on the lower pole of the patella. Testing of the MCL compared to the healthy side showed >10 mm widening of the medial joint line with valgus stress in 30° of flexion as well as in full extension. There was no clinical evidence of instability of the other knee ligaments.\nThe X-ray of the injured knee showed a superior migration of the patella compared to its usual position (). An MRI-scan confirmed the clinical suspicion of a complete tear of the MCL next to its proximal insertion on the medial femoral condyle, as well as a complete rupture of the patellar tendon at the level of its insertion on the lower pole of the patella. There were no lesions of the cruciate ligaments and menisci ().\nThe medical history revealed lower back pain due to a herniated disc, which had been treated conservatively. The patient also reported some pain episodes at the level of the left patellar tendon while jogging in the past. No specific treatment was prescribed for these pains.\nOur patient was operated on under epidural anesthesia 5 days after his accident. Clinical examination under anaesthesia confirmed once again the complete instability of the MCL with valgus stress without laxity in the other plains of motion.\nAt first, we approached the patellar tendon through an anterior longitudinal midline incision. After debridement of the tendinous tissue at the level of the tear, a Krackow-stitch was placed in the patellar tendon distally to its tear. The two loops of this stitch were passed through two bony tunnels in the patella and sutured to each other at the proximal pole of the patella. At the level of the tear, the transosseous reinsertion was reinforced by a running suture of a 3/0 wire. As there was a history of pain at the patellar tendon, we decided to reinforce the reinsertion of the tendon with an allograft of fascia lata, which was sutured directly to the tendinous tissue with absorbable stitches.\nThe tear of the MCL was approached via an oblique medial incision. At first we performed a direct suture which was reinforced with an autograft of the homolateral semitendinosus tendon. The semitendinosus was isolated with an open stripper, taking care to preserve its distal insertion on the tibia. After suturing it to the MCL, the autograft was fixed proximally with a staple at the level of the medial femoral condyle and distally with a direct suture to its original insertion in order to obtain a double-loop reinforcement. The staple fixation was done in a position of 30° knee flexion and slight varus.\nPostoperatively the knee was immobilized in 10° of flexion in a synthetic plaster cast with partial weight-bearing allowed. After 3 weeks the knee was placed in a brace with progressive flexion: 30° the first week, 60° the second week, and 90° the last week. After 6 weeks the brace was removed and complete flexion allowed. A rehabilitation programme with progressive mobilization, proprioceptive training, and muscle strengthening exercises was started.\nClinical control 3 months after the operation showed a limitation of flexion of 20° compared to the other side. There was no swelling of the knee but evident atrophy of the quadriceps muscle without limitation of active extension. Mediolateral stability testing showed no residual valgus instability. A bilateral X-ray of the knee showed normal height of the patella.\nAt 6 months, full motion was recovered and the patient had returned to normal daily life and recreational sports activities (cycling, fitness). Due to discomfort at the level of the medial femoral condyle, the staple fixing the semitendinosus autograft was removed at 9 months. After this removal, no medial instability occurred. At final follow-up 18 months after the injury, the patient was symptom-free and he had returned to skiing, protecting his knee with a brace.

A 15-year-old female with a prior history of aborted cardiac death and surgical correction of anomalous origin of the RCA was referred to the cardiology department due to repeated aborted sudden cardiac death after physical exertion with boxing. The initial electrocardiogram (ECG) showed polymorphic ventricular tachycardia (). Biphasic 200 joules defibrillation restored the heart to sinus rhythm and cardiopulmonary function recovered without neurologic sequelae. Two years prior to this event, she experienced chest discomfort followed by aborted sudden cardiac death after heavy exercise for the first time. Initial ECG at the emergency room showed pulseless electrical activity. She was successfully resuscitated after basic life support maneuvers and fully recovered with hypothermic treatment after being admitted to the emergency department. Her family history of structural heart disease, syncope or sudden cardiac death was unremarkable. Several cardiac examinations were performed at that time. Echocardiography demonstrated no structural heart disease with a normal left ventricular ejection fraction. Cardiac computed tomography revealed anomalous origin of the RCA from the left coronary cusp coursing between the pulmonary artery and the aorta (). Her follow-up ECGs after stabilization showed a sinus rhythm with an inverted T wave and a prolonged QT interval which was suggestive of congenital LQTS (). She was not taking any medications which can prolong the QT interval and laboratory findings did not show electrolyte abnormalities. But this finding was overlooked and anomalous origin of the RCA was provisionally considered as the cause of the aborted cardiac arrest. She underwent surgery to re-implant the anomalous RCA from the left to the right sinus of Valsalva. After receiving surgical correction of anomalous origin of the RCA, she had been doing well before the second event of aborted cardiac death developed. Coronary angiogram with a provocation test using ergonovine was done after the second event, and it revealed no significant abnormalities and the re-implantation site of the RCA ostium was intact. An electrophysiologic study was performed to rule out possible causes of other arrhythmias leading to cardiac arrest. However no other arrhythmia was induced and also polylmorphic ventricular tachycardia was not inducible with programmed stimulation. The ECG after restoring the heart to sinus rhythm showed still significant prolongation of the QT interval, resulting in the diagnosis of LQTS, probably type I, regarding her clinical presentation, even though the ECG pattern showed a prolonged QT interval and a notched T wave suggesting LQTS type 2. Gene studies were recommended, but declined by her family. ECGs of her parents showed no significant QT prolongation. Medication with a β-blocker (atenolol) was started and the dose was titrated up to 1.3 mg/kg (50 mg bid, regarding her body weight; 78 kg). A follow-up exercise tolerance test revealed blunting of the heart rate response during maximal exertion and she was instructed to avoid heavy exercise. She remained free from ventricular arrhythmias while she was on a β-blocker medication during the follow-up of more than 6 months. Her serial follow-up ECGs showed significant QTc prolongation of >500 ms consistently.

The patient was a 15-year-old male child belonging to an urban, middle socioeconomic class, who was living with his father; his mother had abandoned him as a child. He presented to the department of psychiatry with his father, who reported that the child had frequently run away from home in the past three to four years; he had started behaving differently and had shown decreased social interest, irritability, and persistent sadness of mood for the past two to three months. The father reported that after the patients' most recent disappearance from home, he had been contacted by police officials of another state one month after the patient had run away; they had informed him that the patient was at a childcare facility and could be picked up from there. The patient described that after he had run away, he would assume the identity of an 18-year-old Mr. S, who was an electrician. During subsequent interviews, patients described an unusual experience where he had found himself to be floating outside his own body while he visualized his own body from a third-person perspective. This incident had occurred during one of his fugue states in another city; he described being inside a hospital room with doctors who were questioning him about his current state. Later, he had felt like someone else had occupied his body and his soul had left his body and floated up to the ceiling and was completely detached from his body; from his visuospatial angle, he had been able to visualize his own body, which had been very clear while the parasomatic body had not been well defined and he could only see its hands, He had tried tirelessly to reach back to his original self but had been unable to do so. He had seen his body being interviewed by the doctors to whom his parasomatic image tried to reach out, but he had little control over its movement and kept on floating. This episode had only lasted for a short period of time, about 10-15 minutes as estimated by the patient, during which he had remained in the air observing his original self and in very little control of the parasomatic body. The original self had been replying briefly to the interviewers as per the patient as he described it was not him who was in control of his original self.\nThe patient’s past history revealed that he had fled from his residence on three occasions previously, but he did not remember the reason for fleeing. His medical history was negative for symptoms of epilepsy, migraine, syncope, cerebrovascular accident, neurological deficit, etc. There was no history of episodes of hyperpyrexia warranting admission. No psychiatric illness or substance dependence was present in the family. His mother had left home when he had been a year old. His upbringing was done by his father. He was living in a joint family and as per the patient, the relations between family members were not congenial. Also, as per the patient, his father was very aggressive and short-tempered, and frequently hit him brutally, and he had sustained multiple injuries as well. This was why he frequently ran away, according to the patient.\nPersonal history revealed that the patient had been a full-term normal delivery with appropriate developmental milestones. The patient had speech disorder in the form of lisping since childhood and had traits conforming to conduct disorder, such as bullying young children and threatening them, behaving deceitfully, lying, and manipulating people to obtain favors, episodes of truancy from school, staying outside beyond home curfew, etc. He had a prior relationship with three girls, of which his father had not approved, and those had been short-lasting. He had fallen foul of the law during his time away from home, and he had spent few months in a correctional facility for juveniles in Gujarat, India. After corroboration from reliable informants and patient interviews, substance use was ruled out; also, the patient did not display any features of substance withdrawal during his inpatient stay. Premorbid personality assessment revealed that he was an introvert, optimistic regarding new situations, short-tempered, and self-dependent.\nVitals including temperature were unremarkable, ruling out hyperpyrexia. No other abnormality was detected during general and systemic examinations; an otorhinolaryngology opinion was also sought to rule out vestibular defects, which could contribute to OBEs. During the serial mental status examination, a rapport was built with the patient and he revealed that the lack of a mother and harsh parenting by his father had led to him to a state of persistent stress and he wished that this fugue-like state would end and described a feeling of helplessness and persistent sadness, which was also evident in his affect. He did not have any delusions or hallucinations and denied any change in sense of agency routinely. His speech was appropriate with a slight lisp, and his psychomotor activity was normal. Cognitive tests were unremarkable and appropriate to age. Baseline investigations including hemogram, liver, and renal function tests were within normal limits. Electroencephalography (EEG) did not reveal any abnormality. CT scan of the brain did not show any pathological findings.\nA diagnosis of dissociative identity disorder and dissociative fugue was formulated along with secondary depression as per the International Classification of Diseases, Tenth Revision (ICD-10). His Adolescent Dissociative Experiences Scale-II (A-DES) score was 118/300 (suggestive of moderate dissociative experience) on initial assessment. Kutcher Adolescent Depression Scale (KADS) was used to assess depressive symptoms; the patient scored 9, which suggested possible depression. The neuropsychological assessment involved IQ assessment, and the Rorschach test was suggestive of depressive and anxiety disorder but no psychotic features. As a therapeutic modality, abreaction was performed using a guided interview along with injecting 1 mg Intravenous lorazepam after obtaining written consent from the patient and his guardian. He had another OBE during his interview, which was similar to the previous one. During the interview, he slipped into a trance-like state and gave brief answers. He stated as follows: “below me, I saw my body, from outside lying on bed and the doctor standing near me was asking some questions.” His voice was changed, his lisping was absent, and his tone was loud, and within few seconds, he started shouting but later calmed down within a few minutes. After the abreaction, his stress symptoms and depression improved. Escitalopram was initiated at a dose of 10 mg, which was titrated up to 15 mg in four weeks along with clonazepam 0.25 twice a day. Abreaction, hypnosis, and relaxation training along with supportive psychotherapy were provided to the patient in a structured format. His father was psycho-educated about his illness and was briefed about interpersonal conflict management. After four weeks of inpatient management, the symptoms of dissociation and the OBE phenomenon resolved. The patient was followed up for the next six months and did not report any further dissociative state or OBE.

A 30-year-old female reported to orthopedic outpatient department with pain and swelling just above the right ankle joint and another swelling over the right iliac region for last 6 months. The patient had a surgery for the swelling of distal right leg 18 months ago by general orthopedic surgeon. Review of surgical records revealed that she was operated for a lytic lesion in distal tibia with preliminary diagnosis of benign bone lesion without preoperative biopsy. Curettage of the lesion was performed along with filling of surgical cavity with autologous bone grafts harvested from the right iliac crest. Histopathology revealed benign GCT of distal tibia. Below knee plaster was kept for 4 months postoperatively. Two months after the removal of plaster, she developed pain in the right leg just above the ankle, along with gradually increasing swelling. Two weeks later, she noticed another swelling over the right iliac crest, associated with mild pain and discomfort. The patient was finally referred to our oncologic clinic. The patient was clinically anemic. There was a swelling over the anterolateral aspect of distal part of right leg with painful restricted ankle movements and another swelling over the right iliac region with mild to moderate tenderness on palpation on both sites.\nPlain X-rays showed lytic lesion in distal tibia with ill defined margins without any evidence of pathological fracture. X-ray of right iliac wing showed large soft tissue mass with irregularity of the bone over the outer table of iliac crest []. Magnetic resonance imaging (MRI) of pelvis and distal tibia was done to delineate the extent of tumor and its extension [Figures and ]. Technetium-99 bone scan showed increased uptake around distal tibia and focally in the ipsilateral iliac region only at the graft harvest site and no additional foci in the body (i.e. ruling out metachronous lesions elsewhere). Core needle biopsy was performed at both sites to confirm the microscopic/tissue diagnosis. The histopathology revealed benign GCT at both sites with identical picture. Computed tomography of the lungs was normal.\nThe patient was taken up for planned surgery under spinal anesthesia after taking informed consent. Distal tibial lesion was widely resected and reconstruction was done with medialization of fibula and fixing it on the dome of talus and in the distal medullary canal of the resected tibia with Kirscher's wires. Wide resection of iliac wing along with soft tissue mass was performed. The iliac swelling was confined to soft tissue underneath the scar with irregularity over iliac crest. The histopathology of both sites reconfirmed GCT.\nPostoperative period was uneventful and the patient was discharged with a long leg cast for 4 months. Then, partial weight bearing was started with crutches. Patient achieved restoration of bone continuity with union at both ends. Hypertrophy of the grafted fibula was observed and patient was mobile with full unprotected weight bearing on the operated leg after 1 year. Two years after surgery, the patient was symptom free and walking without any aid and with no evidence of recurrence at both sites and no metachronous lesions or pulmonary metastasis. Fibula showed good hypertrophy and the iliac region healed well [].

A 74-year-old female patient presented with the feeling of an abdominal growing mass and weight loss (approximatively 10 kg within the last 12 months) without rectal bleeding or abdominal pain. After a computed tomography (CT) scan the patient was referred to our hospital with the suspicion of a rectal tumor. Complex medical history included a subtotal colectomy with an end ileostomy and a mucous fistula at the descending colon due to Crohn disease at the age of 16 years. In the following years, the patient suffered from repeated ileus episodes and a laparotomy with adhesiolysis was performed in 2007. She never took any medication for her Crohn disease and no further manifestations of activity were observed. Clinical examination showed the patient in reduced general condition; the abdomen was soft and there was no pain during the palpation of the abdominal wall. Laboratory values were in the standard range.\nThe imaging in the CT scan was not conclusive, and therefore we performed magnetic resonance imaging (MRI) to confirm the suspicion of tumor and to allow staging. The MRI showed a massive dilatation of the remaining colon and the rectum without detection of a tumor at the anal level (Fig. ). Lower endoscopy failed due to complete anal stenosis and obliteration of the descending colon at the stoma site.\nThe possible therapeutic options were discussed with the patient. She refused a restoration of the intestinal continuity so we decided to perform an abdominoperineal rectum resection. After laparotomy and adhesiolysis the whole sigma and rectum appeared massively dilated (Fig. ). The rectosigmoid was resected until reaching the muscular pelvic floor. The ileostomy was newly created after resecting the approximatively last 5 cm of the ileum because of a prolapse. The anus was dissected carefully intersphincterically and the specimen was removed completely (Fig. ). The perineum was closed tension free.\nThe postoperative course was uneventful. The patient was discharged to rehabilitation on the 13th postoperative day. The pathology report showed a dilated rectum and sigma with large amounts of partly calcified mucus. There was no evidence of dysplasia, malignancy, or Crohn manifestation in the completely obliterated proximal colon and the anus.

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 right hand dominant, 28-year-old Caucasian male presented to the orthopedic associates of Southwest Ohio as a referral to a hand specialist due to an abnormal ultrasound finding and left wrist mass. The ultrasound of the suspected left wrist mass was executed 10 days prior, exhibiting increased echogenicity within the musculature of the left distal wrist at the site of the patient’s reported abnormality. This echogenicity was asymmetric when compared to the right wrist. The image of the left anterior distal forearm on ultrasound is displayed in . There was no evidence of a focal mass or fluid collection according to the ultrasound report. The patient presented complaining of left wrist swelling, with no pain. There was an unremarkable past medical, surgical, or family history significant to the chief complaint. As far as a differential, the questionable echogenicity within the musculature of the left distal forearm could have been related to a mild non-specific myositis. Moreover, there was no evidence of focal mass or fluid collection, so an MRI was considered to rule out a neoplasm.\nThe patient completed the MRI in 10 days, and then followed up in a week to the clinic. The current status of the patient remained unchanged. The MRI of the patient demonstrated a palpable abnormality secondary to a congenital variation consisting of a PL muscle variant due to an accessory muscle belly volar to the flexor tendons. The signal intensity of this muscle appears within normal limits. This finding was confirmed on the retrospective review of the prior ultrasound. The abnormal muscle variant is displayed in the sagittal view T1 MRI in (), it is displayed in the coronal view T1 MRI in (), and it is displayed in the coronal view T2 MRI in ().\nAfter consecutive diagnostic imaging techniques ruled out anything pathologic including neoplasm, the patient was counseled on the plan. Since the muscle variant was not painful and it did not limit functional outcomes, a non-operative conservative plan was instituted. The patient was informed to follow-up as needed, and if any concerning symptoms arose to schedule an appointment and new measures would be taken for continued care.\nIn the present case, the PL muscle belly originated at the distal forearm volar to the flexor digitorum profundus and superficialis tendons. The abnormality lied between the soft tissue markers placed at the site of the patient’s complaint of the palpable abnormality.

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 78-year-old Japanese woman, who had undergone several laparotomies in the past, including an open drainage and sigmoidectomy because of peritonitis and colon cancer resection, underwent a curative bladder resection for bladder cancer via an extraperitoneal approach. On the third postoperative day (POD), a dirty brown discharge was noticed in a surgical drainage tube placed in the postbladder space, associated with a high fever and severe abdominal pain. Abdominal computed tomography (CT) showed fluid collection around a small bowel loop in the pelvis and in the upper abdomen (Figure ). Urgent exploration through a midline incision revealed an injury 5 mm long in the small bowel injury at the base of the pelvis. Because of the presence of severe intestinal adhesions from the previous repeated surgeries, it as not possible to perform adequate bowel dissection for enterectomy and anastomosis, thus the intestinal injury was simply closed by a layer to layer suture.\nAfter this second surgery, no fever elevation or discharge was noted, thus oral feeding was started on 11 days after the first surgery (eight days after the second), as abdominal radiography had not shown any evidence of obstruction or ileus. However, during that night, the patient had a sudden elevation in temperature and enteral drainage from the midline incision was seen. Computed tomography (CT) of the pelvis showed fluid collection and our patient was therefore prepared for further surgery. During the operation, adhesive bands between intestinal loops were dissected apart, the perforated bowel was removed, and intestinal continuity was reestablished via an end to end anastomosis. This operation took almost 10 hours, with estimated blood loss of 576 ml leading to marked tissue edema.\nAfter this third operation, our patient's temperature was normal, but her small bowel was seen to be distended on abdominal radiographs. Contrast examination of the bowel performed on day 21 after the first surgery (day nine after the third surgery) revealed that the passage of contrast medium was poor, but it was unclear whether there was a leak (Figure ). After the examination, our patient experienced sudden abdominal pain and nausea. The following day, enteric drainage was again seen from the midline wound. Radiolography revealed that the contrast medium that had been administered orally the previous day was present in the extraperitoneal drain discharge (Figure ). CT also demonstrated the presence of extraluminal contrast medium (Figure ).\nWe considered it necessary to perform another intervention to close the intestinal injury; however, we concluded that a fourth surgery presented a high risk for this patient. Thus, we decided to treat her conservatively. For decompression and drainage of the intestine, a jejunostomy tube was thought to be necessary, and a percutaneous approach considered the best option. After we obtained our patient's informed consent, PEG-j tube (Transgastric Jejunal Catheter Kit with Funada style fixture; Create Medic Co. Ltd, Yokohama, Japan) was placed as described below.\nEndoscopy was performed to identify a site of insertion for the tube by translumination and palpation of the abdominal wall. Under local anesthesia, the fixture was inserted into the stomach percutaneously via the anterior wall of the stomach. Through the first needle, an endoscopic snare was inserted into the gastric lumen. The suture was then fed out of the second needle into the loop (Figure ). The fixture was extracted and the suture ligated on the outside of the abdominal wall (Figure ). After raising the stomach to appose the abdominal wall, four sutures were placed around the site at which the gastrojejunostomy tube would be inserted (Figure ). A 16F enteric tube was inserted into the jejunum percutaneously (Figure ). Finally, the apex of the gastrojejunostomy tube was placed at the upper jejunum 1100 mm from the stomach (Figure ). No complications or delayed wound infections were experienced.\nA somatostatin analog was administered subcutaneously twice daily, and a proton pump inhibitor was administered intravenously once daily. The discharge from the gastrojejunostomy tube decreased dramatically from 500 ml to 120 ml per day (Figure ), and amylase was not found in the abdominal drain. The PEG-j tube did not limit the activity of our patient. Radiological enteroclysis performed 22 days after the PEG-j tube placement showed not only an absence leakage but also recovery of intestinal flow and a normal gas pattern (Figure ). After confirming that no leakage was present, oral feeding was started two days later (24 days after the PEG-j tube placement). After the PEG-j tube was removed, our patient was discharged, tolerating a regular diet and in good condition.

The present case report is about a 25-year-old male, who had suffered a fall from a height in jungle and traumatic amputation of his left hand with remains of forearm amputated stump.\nPatient had no any past medical or surgical history. Patient had no similar family history.\nSuspecting the involvement of wild animals, patient was given anti rabies vaccine and immunoglobulin according to the WHO protocol. He also had suffered a sub arachnoid hemorrhage and was managed conservatively as advised by our neurosurgery department.\nAs for the amputated hand, high end prosthesis was advised for the patient but being from very poor background it was far beyond his budget. A man who depends entirely on daily wages and manual labor to feed himself and his family, losing the functionality of one hand was devastating and depressing for him. The main problem that presented before us was not only to stabilize him, but also allow him to get back into the society with gratitude and without having to depend on others for his daily chores and financial needs. Considering all these factors, Krukenberg operation was planned for him. Although this surgery is seldom done and even not recommended by many surgeons but it was currently the best available option for him. He was explained in detail about the procedure and extent of functionality he could attain. Videos and photographs were shown to further elucidate the whole process. Earlier the patient and relative were reluctant for the procedure but they had given the consent for the same.\nThe classical procedure described by Swanson and Swanson was followed with few modifications. A longitudinal incision was made on the flexor surface of the forearm. A similar incision on the dorsal surface slightly toward the ulnar side was made. The forearm muscles were separated into two groups and were resected in order to reduce the size of the stump.\nPronator teres was conserved as it is the main operating muscle. Hence all precautions were taken to maintain the integrity of the muscle. Hemostasis was secured. Skin edges were opposed and sutured. Post operative period was without complications. Regular dressing was done and physiotherapy was given so that the patient started using the pincers. Patient was regularly motivated. Help from the psychiatry department was taken to help him cope with his depression.

A 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.\nThe patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.\nOn examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular region. We suspected the sinus track may originate from the dislodged appliance embedded in the cheek soft tissue. A periapical view was then taken with gutta-percha inserted into the sinus for foreign body localization purpose. The radiograph revealed the gutta-percha pointed towards the site of titanium plate and screws placed used for rigid fixation, and with the molar orthodontic tube appliance in its vicinity (). A cone beam CT was performed to provide a 3D detailed location of the appliance (Figures and ) and confirmed it to be located outside the maxillary antrum.\nThe presence of the molar orthodontic tube foreign body reaction was suspected as the most probable cause of the recurrent right cheek pain and swelling associated with an intraoral discharging sinus. Exploration of the site was performed through the sulcular incision under general anesthesia. The dislodged molar tube was identified lying on the zygomatic bone just beneath the raised flap. It was removed by dividing some surrounding fibrous tissue strands. Just below it, one titanium straight bone plate with four screws used for fixing the previous Le Fort I osteotomy site was inspected and found to be rigidly embedded in normal bone. However, a decision was made to remove them based on the fact that they are present in an infected area. (). The Le Fort I osteotomy site showed good healing with new bone formation. Patient had an uneventful recovery thereafter, and the orthognathic surgical team who attended him previously was informed of his progress.

A 27-year-old man presented at the emergency department with massive hemorrhage from the tracheostomy tube. His was a case of multiple traumas due to a car accident that happened 8 month ago. He suffered a neck fracture that made him quadriplegic and was operated 8 month ago []. He had a nasogastric tube inserted and had a past history of discharge of food from the foramen of tracheostomy tube after oral feeding. Eight months after the tracheostomy intubation, massive bleeding was noted from the site of tracheostomy stoma and vital signs of the patient became unstable. His blood pressure was below 80/60 and the peripheral pulse was not palpable. As a result, an urgent surgery was performed on the patient under general anesthesia. The anesthetic agents were administered via the tracheostomy tube. We performed rigid bronchoscopy and observed tracheal stenosis from below the vocal cords. Because of the patient's critical health condition and severe tracheal stenosis, we could not have a clear view of the trachea. The tracheoesophageal fistula (TEF) was placed in membranous part of trachea, behind the tracheostomy stoma. During the operation, the bleeding had stopped, which we concluded as the pressure of tracheostomy cuff. The site of tracheostomy stoma was dissected. The operation procedure included division and ligature of the innominate artery and separation of the trachea from the divided artery. The defect of trachea was repaired and reinforced with strap muscle [].\nThen, the tracheostomy tube was reinserted. Due to TEF, a jejunostomy tube was inserted in the patient. After the operation was over, vital signs of the patient were stabilized. The course of neurologic examination was not changed after the operation, but right radial pulse was found to be weaker than left radial pulse. The patient was discharged from hospital after 13 days. Two months later, the patient was again admitted to the hospital for the repair of TEF. Endoscopy was done on the patient. A large foramen in anterior wall of esophagus below the upper esophageal sphincter was shown.\nIn the course of hospital stay, the patient developed deep vein thrombosis in the left leg that progressed into the inferior vena cava. Heparin was administered to the patient with a dose of 1000 U/h through infusion pump. Colored Doppler sonography was performed after 7 days, which revealed that the deep vein thrombosis had resolved. Later, the patient developed severe purulent discharge from the tracheostomy tube. Chest X-ray showed bronchiectasis and pneumonia in both the lower pulmonary lobes of the lung. Appropriate treatment was started depending on the discharge culture result. Despite full antibiotic coverage, the condition of the patient gradually deteriorated. He developed septic shock that was unresponsive to the medical treatment. Unfortunately, our patient expired after 46 days of the first operation.

Initially, in late October 2013, a 93-year-old male presented with a six-month history of pain and swelling of the left ear. Clinical examination demonstrated a lesion along the posterior auricular sulcus with exposed cartilage within the depth of the lesion. Extending beyond this lesion was a region of erythema that suggested early involvement. There was no evidence of regional metastatic spread. A previous biopsy confirmed the lesion to be a poorly differentiated squamous cell carcinoma. The lesion was treated by surgical resection via a partial auriculectomy removing a 3 cm tumour. The deep surgical margin was positive, necessitating adjuvant radiation therapy. This was initially prescribed by the referring radiation oncologist with a hypofractionated regimen of 45 Gy in 15 fractions delivered daily using a single lateral electron field – 15 MeV with bolus. This hypofractionated lower dose regimen was originally pursued due to the advanced age of the patient. After the third fraction, the lesion had regrown to 3 cm, prompting an additional 15 Gy in six fractions as a concomitant boost for a total of 60 Gy in 21 fractions delivered over just 23 days, completed in January 2014. In April 2014, an irregular skin lining was noted within the treatment site, which was confirmed to be disease recurrence after a biopsy. A near-total auriculectomy sparing the lobe was performed, with final pathology showing a moderately differentiated squamous cell carcinoma and negative margins. Six months later in October 2014, a new squamous cell carcinoma was noted on the lobule of the remaining pinna, and a third completion auriculectomy was performed. Pathology revealed a poorly differentiated squamous cell carcinoma with negative margins. Three months later, in January 2015, a recurrent mass developed at the base of the left auricle extending into the previous treatment site and the external ear canal with an invasion of the parotid gland (Figure ). The gross tumour volume was treated with 50 Gy in five fractions twice a week in 2.5 weeks. A high dose clinical target volume was not added and only a 2 mm circumferential expansion to the gross tumour volume was used for the final planning target volume. The suspicious erythematous area surrounding the gross tumor volume (GTV) received 40 Gy in five fractions concurrently as part of the same plan (Figure ). Within one month post-treatment, the tumour had completely regressed with no residual disease. No significant complications, such as bleeding or persistent or high-grade dermatitis, bone, or cartilaginous necrosis were noted.

A 82-year-old woman was admitted to our hospital because of right sciatic nerve palsy and a mass in the right posterior thigh. Symptoms of sciatica had begun 6 months ago and then she visited another hospital and X-ray and MRI of the lumbar spine was performed. These showed slight canal stenosis of the lumbar spine. Although she was treated conservatively with medications, the symptoms worsened and sciatic nerve palsy resulted 3 weeks before visit to our hospital. Physical examination revealed a soft tissue mass of posterior thigh with pain and a drop foot with concomitant sensory loss. The patella tendon reflex was normal but Achilles tendon reflex was negative. The sensory exam and reflexes and manual muscle testing in the left leg were normal. All routine blood tests were normal. She had undergone partial gastrectomy 2 years ago. Resection was complete and TNM stage was T2b, N0, M0. The size of tumor was 8.5 x 8 cm and histological examination revealed the tumor was a poorly differentiated adenocarcinoma with no regional lymph node metastasis. She didn’t receive adjuvant chemotherapy because of her age and her choice. Current Plain radiographs showed a radiolucent area in the posterior thigh without calcification and no changes in the femur. MRI (Figure ) showed the mass with low signal intensity on T1-weighted images and heterogeneous high intensity on T2-weighted images and homogeneous high intensity on T1- weighted images with gadolinium enhancement was originated from sciatic nerve. We planed the surgical resection because her general condition was good and we confirmed local disease only, no evidence of another site of metastasis by CT. Surgical resection of the sciatic nerve mass was based on the assumption that the diagnosis was soft tissue sarcoma. Segmental resection of the sciatic nerve was performed because of complete paralysis and adequate margin. Intraoperative Macroscopic findings (Figure ) revealed the sciatic nerve was tightly surrounded by the mass and the mass strongly compressed the peripheral muscles. Histological examination (Figure ) showed poorly differentiated adenocarcinoma which was the same as her primary site adenocarcinoma and invaded the sciatic nerve. Based on these findings, we diagnosed sciatic nerve palsy due to intraneural metastasis of gastric carcinoma. She can now walk with a short leg brace and cane. She is free of recurrence in the posterior thigh without chemotherapy and radiation and remains metastasis free after 1 year follow-up.

A 53-year-old female patient who had been suffering for ten years from atypical facial pain combined with a partial facial spasm was referred to our outpatient clinic.\nShe presented with continuous distorsions of the mimic musculature in the region of the lower left lip, which had appeared following severe osteomyelitis of the left side of the mandible that had been treated surgically. For several weeks following the operation the patient experienced hypesthesia in the left mandibular region and skin. Thereafter, constant, disturbing spasms of the mimic musculature occurred combined with dyskinesia and deep spasmodic pain attacks located in her lower left lip region. In addition, a distinct cutaneous erythema appeared in the region of the dyskinesia (figure ).\nThe patient reported that pain attacks occurred daily immediately after awakening in the morning, continued during the day without any improvement and subsided only at bedtime.\nThere had been no satisfactory response to various neurological or dental therapy attempts nor to acupuncture. Only therapy with carbamazepine had brought a slight and transient relief of her symptoms.\nThe patient felt herself immensely restricted by her symptoms and was socially and professionally disabled. She had had to retire because of the intolerable pain attacks, and reported having suicidal thoughts from time to time.\nDuring the following years she detected alleviation points in her left hand and behind the left ear with which she was able to stop the convulsions and the pain as long as pressure was applied to the points (figure ).\nThe patient had had no history of movement disorders such as hemifacial spasms nor of allergy, smoking or alcoholism. She had no history of medication except for carbamazepine.\nOn physical examination, no anatomic disorders, infections or tumors were found except for a discrete septum deviation. We observed continuous spasms in the region of her left lower lip, accompanied by an intense eczema in this region. She was able to stop the spasms and the pain by pressing the points on her hand or behind the ear.\nAfter the patient had given informed consent, BTX-A-treatment was begun. She was treated over a period of 67 weeks with seven different injections of BTX-A at different time points.\nThe dose of BTX-A was increased from initially 5 units to 25 units at the seventh treatment. We also augmented the number of injection points from 2 points to 10 points in the affected area. Injections were made with 2.5 units per site (Botox®, Allergan Inc, Irvine, California; 0.1 ml = 2.5 units BTX-A). The time between the treatment sessions varied from 3 weeks to 24 weeks up to the last treatment. For details see table .\nBTX-A was injected into the inferior depressor labii muscle in the left lower lip region. The seventh injection with 25 units injected into 10 points was the most effective with an effect lasting 24 weeks (table ).\nThe patient was immediately pain-free after the injections and experienced other positive effects such as relief of spasms and eczema. The symptoms improved already after the first injection of botulinum toxin type A. At the check-up, three weeks after the first injection, the patient was free of symptoms and was very satisfied.\nAs agreed upon with the patient, she returned to our outpatient clinic for further treatment whenever any symptoms reappeared.\nThe BTX-A injection was repeated after 5 weeks with a total dose of 10 units at 4 injection points (4 injections à 2.5 units) because of mild spasms.\nAfter the second injection, the patient again experienced a reduction in pain, spasms and eczema for a period of 7 weeks, at which time we injected 15 units into 6 injection points.\nIn the further course, the patient returned four more times after 3, 11, 17 and 24 weeks for further injections with 20 to 25 units BTX-A into 8 to 10 injection sites. Fourteen weeks after the last series, she reported in a telephone interview that the excellent positive effects were long lasting and that she was not suffering from pain, spasms or eczema.\nThe patient was able to reduce the dose of carbamazepine considerably.\nIn the course of the treatment period, the duration of the symptom-free period increased from a minimum of 3 weeks to 24 weeks. The longest positive effect was seen after the injection of 25 units BTX-A into 10 injection points in the lower left lip region.\nThe patient did not note any side effects except for a slight leakage at the corner of her mouth lasting a few days, which she did not find very irritating as the positive benefits were much more important for her. A total follow-up period of 62 weeks was observed in this patient.\nIn summary, the patient expressed great satisfaction and stated: "A completely new period in my life began" after the first injection.

Susan is a 51-year-old woman. As an adolescent, she developed scoliosis. Working as a hairstylist when she was 18 or 19, she began to have severe pain in her hands, making her work very difficult. She had carpal tunnel surgery on her right hand which provided temporary relief. Her symptoms slowly returned and she continued to have intense pain and difficulty with her daily activities. Seeking relief from her symptoms, she received treatment from chiropractors and Chinese medicine practitioners with no significant benefit. She also tried yoga and swimming but depending on the yoga movements or swimming strokes, she began to have more pain.\nWhen she was in her early forties, she began to have weakness in the lower half of her body. Her legs would frequently give out on the stairs, causing her to fall. Control of her bladder and bowel function also began to deteriorate. She had an MRI, and based on the results, she was scheduled for emergency surgery to stabilize her cervical spine and relieve spinal cord compression. She was informed that it would be an outpatient surgery and she would be home the same day.\nIn May 2011, Susan had a 6-level cervical spine fusion to stabilize her spine and relieve pressure on her spinal cord. When she woke up, she realized something was wrong. The entire right side of her body was paralyzed. What was supposed to be an outpatient surgery with a return home the same day ended up being an 8-week hospital and rehabilitation stay to learn how to walk again.\nIn August 2012, a second surgery was performed with the goal of pain relief. However, she reported her pain was significantly worse afterwards. She would receive weekly injections for pain relief that she reports would only marginally decrease her pain for about one week. She was also taking high doses of medication for nerve pain relief which she also reports provided marginal benefit. She had areas of heightened sensitivity on her legs where a bed sheet or even a gentle breeze would cause intense pain. Exposure to hot water would feel cold, and cold water would feel hot. She was unable to walk more than one block and remained in bed for over ten hours per day. She suffered extensive personal and professional quality of life losses at this time.\nLooking for relief, she tried medical yoga and received temporary relief. She also practiced traditional Tai Chi which provided minimal to no relief. She continued to have intense pain which had a significant impact on her quality of life and ability to perform daily tasks, including walking. In 2014, she tried a Qigong class and reported feeling that there was something very different about this class. Almost immediately, she felt a strong sense of relaxation that she had reportedly not found in many years. She was unable to attend many classes, so she purchased a video of the movements. Over the next year, she began to practice the exercises consistently until she could attend formal classes.\nSusan credits the practice of qigong with saving her life. She says it gave her a reason to get out of bed and socialize in the very early days of her practice. She is now able to walk with no limitations and her pain has improved by approximately 90%. Within three months of beginning qigong, she was able to stop all medications and injections she was receiving for pain relief. She continues to have some weakness in her arms and her hands, but it does not interfere with her ability to complete her daily activities. Despite her extensive cervical spine surgery, she reports full mobility in her shoulders and has nearly recovered full mobility in her neck. Her energy has also greatly improved and she routinely teaches three Qigong classes per week. In addition to this, she teaches at special events, including a Qigong class at a large yoga festival with over 1000 people in attendance. Recently, she started her first full time job in over six years.\nJames is a 70-year-old male. Over ten years ago, he was diagnosed with multi-level degenerative disc disease (DDD) in his lumbar spine, as well as severe central stenosis or narrowing of his spinal column around his spinal cord at L3-4, L4-5, and L5-S1. In 2011, he had a CT scan and was told by his physician that it would not be long until he must rely on a wheelchair for all mobility. Surgery was presented as an option, but he was informed that the success rate was less than 10%.\nHe decided to forgo surgery and take his chances. Gradually, his legs became weaker and he would fall spontaneously. He worked as a salesman and as he was talking to clients, his legs would give out without warning and he would fall to the ground. To help his situation, he would park as close as he could to the entrance of stores or other destinations and would walk with carts or holding onto shelves or furniture. This would only help for so long before he would fall again.\nHe began looking for other options to help manage his condition. In 2012, he tried yoga. While it helped to temporarily control his pain, it had no effect on the weakness in his legs and he would continue to fall. One year later, at the suggestion of his wife, he tried a Qigong class. Due to his family’s personal schedules, he was unable to attend another class for two months. He decided to purchase a video of the movements he had learned and practiced them each day for 4–5 months until he was able to return to normal classes.\nSince participating in Qigong classes, he has not fallen even once, and has no reports of pain. He stated that “Qigong gave me my life back.” He has no other medical problems to mention and takes no medications. He revealed that the improvements he has experienced have gone far beyond what he expected. Where he used to fall often and without notice, he has not fallen since he began qigong and reports that he now even has a “spring to his step, and a spring in his heart.” Not too long ago, he sustained a left rotator cuff tear. After continuing to practice qigong, he had a full return of strength and movement with no pain or difficulty with his routine daily activities, all within six months.\nIn his professional life, he felt like he was burning out as an IT programmer but practicing qigong has reinvigorated him. He was able to complete many projects (some complex) that he never would have thought possible. He has since become certified to teach Qigong and tells anyone who will listen about his story. He has also witnessed many others gain significant benefit from the practice of Qigong and is thrilled that he gets to share this with others.

A 78-year-old asymptomatic woman was referred to our hospital for further examination of multiple cardiac tumors in the left atrium and left ventricle, which had been detected on echocardiography conducted before chemotherapy for the third recurrence of breast cancer.\nThe patient was initially diagnosed with right breast cancer in 2003. She had undergone total mastectomy and lymph node dissection before adjuvant chemotherapy. Histopathological analysis indicated scirrhous carcinoma. The first recurrence of the breast cancer was diagnosed in 2007 due to right axillary adenopathy. She had again undergone operation before receiving chemoradiation, and hormonal therapy was started. The second recurrence was detected in 2013, when computed tomography (CT) was performed during a routine outpatient visit. The CT scan revealed right-sided pleural effusion and a mass shadow in the sternum. After switching to another hormonal medication, the pleural effusion disappeared. The third recurrence was confirmed by skin biopsy of a rash on the postoperative scar. Therefore, the regimen was changed to treat the third recurrence of breast cancer. Adriamycin was selected for the patient, and echocardiography was performed for cardiac screening. There were no signs or symptoms such as fever, shortness of breath, platypnea, and systemic embolization until cardiac tumors were accidentally detected on echocardiography. She had never undergone echocardiography previously. She had no family history of cardiac myxoma. Physical examination and laboratory tests showed no spotty skin pigmentation or endocrine hyperfunction. Transthoracic and transesophageal echocardiograms showed 4 tumors in the left atrium and left ventricle ( and ). Coronary angiography showed feeding arteries from the left circumflex coronary artery to the tumors and no obstructive coronary lesion. Although we were not confident about the diagnosis, we decided on surgical resection because the mobile tumors located in the left semilunar cusp of the aortic valve and anterior mitral leaflet carried the risk of causing embolism or obstruction. On pathological examination, all 4 tumors were identified as myxomas (), since they showed myxoma cells with a stellate appearance proliferate in a myxoid background in nests and linear syncytia (). The patient's postoperative course was uneventful with no recurrences as determine by echocardiographic examination during the 12-month postoperative follow-up.

A male patient, 62 years old, visited Good Samsun Hospital with a chief complaint of a right inguinal region mass accompanied by pain for the previous 3 months. He had no special history of disease; however, the year before his visit to our hospital, he had undergone hernia surgery due to an indolent fixed mass in the right inguinal region. On physical examination, his vital signs were stable, and a hard, fixed mass, accompanied by oppressive pain, with a size of 1 cm × 1 cm was felt in the right inguinal region. The patient's progress was observed for a month during which time an anti-inflammatory analgesic drug was administered to distinguish the oppressive pain from that which might have been generated by the previous hernia surgery. The biopsy of the spermatic cord showed a metastatic mucinous adenocarcinoma (). The image showed a thickening of the right spermatic cord, and infiltration around soft tissues was confirmed by using the scrotal sonography (). In addition, abdominal computed tomography indicated infiltration of the proximal sigmoid colon and rectum, as well as a diffuse peritoneal seeding metastasis (). A tumor accompanied by redness was observed in the rectum during the colonoscopy, and a core needle biopsy was conducted on that tumor. A mucinous adenocarcinoma that was identical to tissue previously taken from the spermatic cord was diagnosed based on the biopsy result (). Positron emission tomography (PET) () confirmed infiltration of the sigmoid colon, rectum, and cecum.\nThis patient received four rounds of FOLFOX (oxaliplatin with fluorouracil and folinic acid) anticancer chemotherapy, and the right spermatic cord mass was smaller on the abdominal computed tomography that that was done 10 weeks after the diagnosis of a spermatic cord tumor. However, the tumor sizes in the sigmoid colon and the rectum had not changed, and the possibility of a new seroperitoneum was checked. An exploratory laparotomy was conducted to confirm the possibility of salvage surgery to remove the primary lesion from the large intestine, but only an orchiectomy on the right side was completed because its metastasis in the peritoneum, omentum, and small bowel mesentery was extensive. Upon surgery, a broad metastasis in the peritoneum, omentum, and small bowel mesentery was confirmed (Peritoneal Cancer Index score, 22), and the biopsy of the peritoneum, omentum, and small bowel mesentery showed a metastatic mucinous adenocarcinoma. As a result of this diagnosis, the therapy was changed to include palliative FOLFIRI (irinotecan with fluorouracil and folinic acid) chemotherapy. The patient came down with pneumonia after the 3rd FOLFIRI treatment. Antibiotic treatment was started, but the pneumonia proceeded to sepsis within a week. The patient finally passed away three months after the initial diagnosis.

A 75-year-old Caucasian man presented to the emergency room of our hospital for dyspnea and new onset generalized oedema rapidly progressing over one week. The patient was known for stable coronary artery disease, paroxysmal atrial fibrillation with oral anticoagulation, chronic obstructive bronchitis, hypertension, and dyslipidemia. He had stopped smoking 3 years before, had no history of alcoholism, and had never taken illegal drugs.\nVital signs at presentation were stable. The patient was afebrile and not in respiratory distress. Physical examination revealed generalized oedema associated with ascites and hepatomegaly. The jugular veins were not distended, but there was a strong clinical suspicion of a right-sided pleural effusion. An initial chest X-ray confirmed an important right pleural effusion and a 1 cm sized nodule in the right lower lobe (not shown). Results of laboratory tests are shown in . Most strikingly, there was a new onset perturbation of liver markers.\nA contrast enhanced CT scan of the chest, abdomen, and the pelvis was performed. The abdominal CT scan showed a very heterogeneous liver. Except for segments 2 and 3, the whole liver contained multiple ill-defined and partially confluent hypodensities of different size suggesting an advanced neoplastic process (). There was also a doubt of a hypodense lesion inside the inferior vena cava (). The hepatic lesions were associated with a moderate quantity of ascites but no splenomegaly (. The chest study confirmed the presence of a large right-sided pleural effusion and a 1 cm sized nodule in the anterior part of the right lower lung lobe (not shown). On transthoracic echocardiography, a well-defined, immobile oval mass with a smooth surface and a size of 23 mm × 30 mm was noted in the right atrium (). The mass was not adherent to the interatrial septum (). The mass extended to the inferior vena cava where it reached a size of 34 mm × 25 mm, creating a subtotal occlusion with a pressure gradient of 13 mmHg between the inferior vena cava and the right atrium (). The occluded inferior vena cava showed no respiratory compliance and had a diameter of 21 mm.\nA complete colonoscopy was negative for a neoplastic lesion, so liver biopsy under CT guidance was performed to establish a histological diagnosis. To complete the tumor staging and further characterize the endovascular lesion of the inferior vena cava and right atrium, a positron emission tomography-CT (PET-CT) was performed. On the PET imagery, there was a strong hypermetabolic zone in the right liver lobe covering an area of 13 cm × 14 cm × 13 cm (maximal normalized capture index 8.9) (). This hypermetabolic zone corresponded to the hepatic lesions seen on the CT scan and extended inside the inferior vena cava over a distance of 3.5 cm (). The hypermetabolic zone stopped at the junction of the inferior vena cava with the right atrium. No abnormal hypermetabolism was noted inside the heart (). The lung nodule seen on the CT scan was also hypermetabolic with a capture index of 2.3 suggesting a metastasis (not shown).\nThe histological examination of the liver biopsy demonstrated a hepatocellular carcinoma with a well- and a poorly-differentiated component (). There were no microscopical signs of liver cirrhosis on the specimen. The serum level of alpha-fetoprotein was 270 000 ng/mL. Taken together, these results established the final diagnosis of a stage IV locally advanced hepatocellular carcinoma with endovascular extension and a single pulmonary metastasis. It remains unclear if the metabolic inactive part of the endocaval and intra-atrial mass represented a superimposed thrombosis or necrotic tumor tissue.\nLaboratory tests to screen underlying risk factors of HCC were performed. Virus serology for hepatitis B, hepatitis C, and human immunodeficiency virus was negative. The serum ferritin level was 398 μg/L, and the serum iron saturation was at 12%. The electrophoresis of serum proteins was normal eliminating alpha1-antitrypsin deficiency.\nConfronted with the diagnosis, the patient did not desire further treatment and was orientated to palliative care.

A 20-year-old Myanmarese woman who was aware of a declining vision in her left eye for three years was diagnosed with a mature cataract in her left eye. She was referred to Chiba University Hospital for further examination and treatment for the cataract. She had no medical history of the left eye, although detailed medical records were not available because she had grown up in Myanmar and had recently moved to Japan to receive occupational training. She did not have any systemic disease and abnormalities. The laboratory tests for infectious diseases were negative. She stated that she was born at full-term and had no family history of retinal detachment. Her left vision was light perception at our first examination. She had a mature cataract with a slightly shallow anterior chamber and the absence of inflammation and iris neovascularization. The dense cataract prevented a detailed examination of the fundus, but B-mode echogram showed some strands of high signals extending anteriorly from the optic nerve head (). Her right eye was normal with a vision of 20/20. The intraocular pressure was 18 mmHg OD and 18 mmHg OS. The axial length was 23.78 mm in the right eye and 23.46 mm in the left eye.\nShe underwent phacoemulsification and implantation of an intraocular lens in her left eye. The surgery was completed without any complications, and the postoperative course was uneventful with a recovery of the left vision to 20/200. A stalk was observed between the optic nerve and posterior capsule, but the retinal detachment was limited to the retina around the optic nerve. One and a half years after the initial surgery, she noticed a decline of the vision in her left eye, and her visual acuity was 20/400. The area of retinal detachment extended over two quadrants of the inferior retina (). There were no retinal breaks. A macula involved detachment was confirmed by optical coherence tomography. PPV with a 27-gauge system was performed, and the stalk was incised with a vitrectomy cutter. Some parts of the stalk were left attached to the optic nerve not to damage the anteriorly stretched retina. No additional procedures such as membrane peeling, drainage of subretinal fluid, and the fluid-air exchange were performed. The posterior vitreous was not separated because the hyaloid was degenerated and attached firmly to the retina. The retinal detachment gradually resolved, and the macula reattachment was confirmed by optical coherence tomography (). The vision in her left eye improved to 20/60 and was stable for 19 months after the second surgery without showing any worsening of the retinal proliferation or detachment.

A 46-year-old asymptomatic man presented to our hospital for follow-up of an abnormal cardiac shadow found on chest X-ray during a medical check-up. He was found to have a benign tumor in the parapharyngeal space 6 years ago. The tumor had gradually grown in size and he felt pain around the back of his teeth and had difficulty in swallowing associated with mass pressing symptom; he had the tumor resected 4 months ago. On histopathology exam, the tumor was identified as a schwannoma. The patient had no medical or family history of cancer, including intradermal carcinomas. There were no abnormal findings in his eyegrounds, such as juvenile cataract, and his audiometry results were normal. Computed tomography (CT) showed three masses measuring 16 × 14 mm in the posterior mediastinum, 15 × 13 mm in the left pulmonary hilar area, and 12 × 10 mm in the right pulmonary apex area (Fig. ). The patient had undergone CT exam at another institute 6 years ago prior to the CT scan performed at our institute. Retrospective evaluation of the previous CT scan revealed that the posterior mediastinum tumor was 13 mm in size at that time. Chest magnetic resonance imaging (MRI) revealed that these masses had low intensity on T1-weighted sequences and high intensity on T2-weighted sequences. Cranial high-quality MRI showed no evidence of bilateral vestibular schwannoma. The thoracic surgeons at our institute initially diagnosed multiple mediastinal tumors.\nResection of the right apex area lesion had the associated risk of causing recurrent nerve deficit symptom; hence, removal of the two other tumors was planned initially; the posterior mediastinum tumor by right thoracotomy and the left pulmonary hilar area tumor by left thoracotomy in a single operation. During right thoracotomy, a small pericardial incision was made and they noticed the posterior mediastinal tumor to be at the cardiac chamber; surgery was suspended immediately. Following surgery, the patient underwent transesophageal echocardiography (TEE), which revealed that the mass was a cardiac tumor originating from the posterior wall of the left atrium (LA) without a stalk (Fig. ). Moreover, an atrial septal defect (ASD) was discovered, which seemed to be an ostium secundum defect with left to right shunt.\nFollowing discharge, the patient was immediately brought to our clinic. Although the patient was asymptomatic, we decided to resect the mass and obtain a confirmed histopathological diagnosis. Cardiac tumor resection was performed 5 months following the explorative thoracotomy. In a median sternotomy approach, the LA was incised through Waterston’s groove after a cardiopulmonary bypass. Even though the tumor was located under the endocardium, we resected it completely as it surrounded the LA wall. The defect in the LA posterior wall was 40 × 30 mm in size. In a right atriotomy, the ASD was identified as three small holes in the thin wall of the fossa ovalis; these were resected, resulting in a defect measuring 30 × 15 mm. The defects caused by excisions were repaired using bovine pericardium (Fig. ). The cut surface of the tumor was hard and yellowish in color. Pathology evaluation showed it had negative tissue margins. Spindle-shaped cells with eosinophilic cytoplasm and nuclei different in size showed a palisading arrangement, and immunohistochemical stain was positive for S-100 protein (Fig. ). These findings were consistent with benign schwannoma [, ].\nThe postoperative course was uneventful, and the patient is scheduled for regular follow-up. One year after the cardiac tumor resection, no findings suggestive of recurrence of cardiac tumor were noted and follow-up tests, such that TEE and CT showed no significant growth of the two remnant mediastinal tumors or residual shunt.

The index patient was a 34-year old female referred to the bariatric clinic by the general practitioner on her own request to treat her morbid obesity. She was born with a normal birth weight but large head circumference for which she never had a diagnostic analysis. At the age of five, her body weight was already significantly higher compared to her peers. No specific life events could explain her obesity. Cognitive development was normal and she followed normal education. She underwent treatment for recurrent nasal polyps. Her mother also had a large head size and suffered from morbid obesity as well. She was diagnosed with thyroid cancer and died from a pulmonary embolism after placement of an Adjustable Gastric Band. A maternal aunt was diagnosed with breast cancer before the age of 50 and the maternal grandmother died from breast cancer at young age. The younger sister of the index patient was overweight and was reported to also have a large head size (Figure ).\nSince childhood, the index patient followed several different coaching programs to change her eating behavior and exercise pattern to induce weight loss. She lost weight several times but was never able to maintain her weight loss. At the time of the intake procedure at the bariatric clinic, her height was 1.69 m (SD −0.2) and weight 164 kg (SD +6.8), resulting in a Body Mass Index (BMI) of 57.6 kg/m2 and a predominant abdominal obesity. Head size was not measured at that time since this is not part of bariatric screening procedures. Biochemical analysis of the blood revealed no abnormalities, and excluded endocrine hormonal disorders such as hypothyroidism. The fasting glucose level was 5.9 mM.\nThe combination of early onset morbid obesity resulted in suspicion of a genetic cause of her obesity. She was offered diagnostic genetic analysis of 52 obesity–associated genes to identify a possible underlying genetic obesity cause.\nThe patient was eligible for bariatric surgery and underwent a sleeve gastrectomy without complications (performed in 2014 using a standardized fashion). At 1, 2 and 3 years after surgery, she achieved a percentage Total Body Weight Loss of 39.4, 48.8 and 44.9, respectively. This resulted in a current BMI of 30.1 kg/m2. This was within the range of the results which were observed in a control group of 18 female patients, with a negative obesity genetic test result. These female patients were matched for age and BMI and achieved a percentage Total Body Weight Loss (TBWL) of 30.3 after 1 year, 31 after 2 years and 30 after 3 years of follow-up.\nA few months after surgery, the result of the obesity gene panel analysis was returned and showed heterozygosity for a known pathogenic mutation in the PTEN gene (): c.202T>C p.(Tyr68His). This mutation has been described previously in patients with PTEN Hamartoma Tumor Syndrome (PTEN HTS) (Marsh et al., ). No other pathogenic mutations were shown in the remaining 50 obesity–associated genes (Table ). At the genetic clinic, a head circumference of 63 cm (+5SD) and pedigree analysis (family history of multiple tumors) further supported the molecular diagnosis of PTEN HTS.\nAccording to the PTEN HTS guidelines, patients with pathogenic PTEN mutations are advised to visit the outpatient clinic for familial tumors, for lifelong surveillance of tumors that are associated with the PTEN mutations (Dutch Guidelines, ; Eng, ). Our patient underwent additional biochemical laboratory- and ultrasound screening to exclude thyroid gland carcinoma. Besides a few benign nodules on the ultrasound, no abnormalities could be determined. A yearly follow-up ultrasound of her thyroid gland and yearly serum thyroid stimulating hormone analysis was advised. Screening for breast, endometrium and colorectal cancer, also revealed no anomalies.

A 63-year-old Caucasian male with two weeks of lightheadedness, diaphoresis, and two episodes of loss of consciousness presented to an outside emergency room due to an abrupt onset of unilateral paresis of the right side of the body as well as speech deficits. The patient was evaluated for stroke and deferred administration of tissue plasminogen activator (tPA) due to the length of time between onset of symptoms and presentation to the emergency department. A computed tomography angiogram (CTA) of the head and neck was ordered and demonstrated occlusion of the intradural right vertebral artery with a severe stenosis of the intradural left vertebral artery. There was a partially occlusive thrombus extending out of the occluded right vertebral artery into the proximal basilar artery (Figure ). It was decided that the patient be transported to our high volume certified Comprehensive Stroke Center where he could receive more specialized treatment. Before transport, he regained full strength and speech which seemed to be largely dependent on blood pressure.\nUpon arrival to our facility, his only complaint was paresthesia of the right foot and blurred vision as well as exacerbation of symptomology with changes in body position. A cerebral digital subtraction angiogram (DSA) revealed that the intracranial segment of the right vertebral artery was recently occluded and likely related to an underlying severe atherosclerotic stenosis near the dural ring. There was also a markedly severe stenosis of the contralateral intradural left vertebral artery (Figure ). DSA also demonstrated the presence of an unstable, partially occlusive clot at the vertebrobasilar junction and a congenital corkscrew configuration of the mid-basilar artery distal to the clot. Due to the precarious nature of the clot in both stability and location as well as the aberrant configuration of the basilar artery prohibiting thrombectomy options, the decision was made to provide dual antiplatelet therapy and heparin for several days in an effort to resolve the unstable clot and allow for development of more favorable conditions in which stenting of the left vertebral artery lesion could occur. Care was taken to maintain the patient at a slightly elevated blood pressure in order to maintain flow through the collateral circulation and not exacerbate any further ischemic damage.\nThe care team developed an emergency plan for potential neurological decompensation requiring emergent transport to the interventional neuroradiology suite. Fortunately, the patient remained stable and without additional neurological deficits. Approximately five days after transfer to our facility, the patient underwent repeat CTA which revealed resolution of unstable thrombus at the vertebrobasilar junction (Figure ). The distal intradural right vertebral artery remained occluded. The following day, the patient was brought to the interventional neuroradiology department and placed under general anesthesia with careful attention given to adequate blood pressure during induction. DSA confirmed the absence of unstable clot in the proximal basilar artery and redemonstrated the severe left vertebral artery stenosis (Figure ). Placement of a balloon-mounted coronary stent across the severe stenosis eliminated any narrowing of the left vertebral artery (Figure ). There was a return of normal posterior fossa flow dynamics, and the patient made a full clinical recovery.

A 60-year-old male presented to the emergency department with urinary retention. After a catheter was placed in the patient's bladder gross hematuria was observed. The patient's medical history is significant for a dual pancreas and kidney transplant 16 years before this emergency department presentation. He received these transplants due to end-stage renal disease caused by type 1 diabetes mellitus. His graft function has been stable since transplant and he no longer requires insulin. He does, however, have retinopathy, nephropathy, and neuropathy complications associated with his Type 1 diabetes diagnosis. The patient has had a colonoscopy for unintended weight loss performed a year before this emergency department visit that revealed no visual abnormalities. Upon physical examination, his vital signs were found to be stable and there were no signs of infection. He did have suprapubic tenderness.\nThe serum creatinine was 114 μmol/L with an estimated glomerular filtration rate (GFR) of 60 when this patient presented to the emergency department. No abnormalities were noted in the rest of the patient's blood work. The patient proceeded to undergo flexible cystoscopy to identify the source of the hematuria. A lesion that was highly suspicious for urothelial carcinoma was identified at the ureteral orifice (). It did appear that the lesion was coming from either the transplant ureter or transplant junction. The rest of the procedure was unremarkable apart from a false passage in the urethra likely from a past catheter insertion. A follow-up CT scan showed no hydronephrosis or urothelial thickening in the transplanted kidney. No mass lesion in the bladder could be identified, however, there was some mild thickening in the dome of the bladder, which was suspected to be inflammatory changes due to pancreatic duct dilatation.\nGiven the findings on cystoscopy, a transurethral resection of the bladder tumor was recommended for the patient. The patient was counseled regarding treatment options and informed consent was obtained for the procedure. The patient's antirejection medications were modified in anticipation of the upcoming surgery. After the patient had received appropriate antibiotics and a general anesthetic, a 26F resectoscope was introduced into the patient's urethra. The tumor was identified after entering the bladder. It had a relatively small stalk adjacent to bowel mucosa that was protruding into the bladder from the graft. The tumor was resected and sent to pathology for analysis. In addition, multiple cold-cup biopsies were taken from the resection site and around the bladder. The conduit was gently inspected to ensure that no perforation had occurred during the procedure. A 20F two-way Foley catheter was placed at the end of the procedure, and the patient was sent to recovery in good condition.\nAnalysis of the pathological specimens following the procedure revealed that the resected lesion at the conduit site was not a urothelial carcinoma, but instead a tubulovillous adenoma (). This tumor is typical for an enteric-type adenoma likely arising from the duodenal graft from the donor instead of the bladder. There was no indication of high-grade dysplasia or invasive carcinoma in the polyps. The rest of the biopsies of the bladder did not reveal any malignant changes. Following the procedure, the patient's renal function remained stable with a creatinine of 105 μmol/L and an estimated GFR of 67 mL/minute.\nThe patient was followed up with cystoscopy 3 months after the operation to reevaluate the site for any signs of recurrence. At this time a small tumor was noted near the previous site of resection but farther up the conduit (). It is unknown whether this represents a new tumor or a recurrence of the previously resected tumor. The pathology for this resection revealed a tubular adenoma. Imaging with a CT scan and a chest X-ray did not reveal any disease outside of the conduit and bladder. A 7 mm tumor was noted in the conduit in keeping with the cystoscopy imaging.\nAfter considering these findings and discussing them with the patient as well as a transplant surgeon colleague, it was determined that the recommended treatment was a laparotomy and excision of this tumor in an open manner. An incision was made inferior to the urachus with cautery down through the fascia. The space of Retzius was developed and a catheter was placed in the surgical field allowing for the insufflation of the bladder. A cystoscope was then introduced allowing the visualization of the dome of the bladder. The bladder was then spatulated with care being given to preserve the pancreas conduit and the transplant ureter. The conduit junction was identified and inverted bluntly to allow direct visualization of the tumor. The tumor was then excised and the excision site was oversewn. Direct visualization did not reveal any other tumor tissue within the conduit. A frozen section of the tumor base revealed negative surgical margins during the surgery. These frozen pathology sections revealed a tubulovillous adenoma with low grade dysplasia. The incisions made were closed and the patient was sent to the recovery room in good condition with minimal blood loss. His postoperative stay in hospital was uneventful apart from some nausea and vomiting. The patient's most recent follow-up cystoscopy, however, shows no signs of regrowth (). No further biopsies were taken on this cystoscopy.\nThe patient is to be followed with serial cystoscopies every 6 months for the next 3 years to reevaluate the site for any signs of recurrence. If recurrence should occur, further surgical management options will be decided upon at that time. It is not believed that the rest of this patient's gastrointestinal tract is at significantly increased risk of tumor formation due to this finding as this tumor arose either donor and/or bladder tissue. Follow-up will be continued with the patient's transplant surgeon and nephrologist at his regularly scheduled appointments at the transplant clinic.

A 48-year-old male presented with his RUQ abdominal pain that is relieved by lying on the right side and sleeping. The patient had no past history of any disease, nor diagnosed of any chronic illnesses. The computed tomography (CT) scan for abdomen was done and showed large retroperitoneal mass of heterogeneous density, with heterogeneous contrast enhancement posterior to the liver (Fig. ). The mass measured 11 × 11 × 12 cm displacing the right kidney, and the right lobe of the liver and IVC anteriorly. There was focal invasion of the liver measuring 3.6 × 6.4 cm at Segment 7. The right adrenal gland was not clearly visible. The patient underwent an US-guided core biopsy of the mass that showed malignant cells consistent with both adrenocortical carcinoma and hepatocellular carcinoma; however, the former diagnosis was favored based on the clinical picture. The patient went for a right hepatectomy with right adrenalectomy, cholecystectomy and excision of associated lymph nodes. The lesion and the excised structures were sent for histopathology that showed a right liver lobe mass attached to it measuring 17 × 10 × 7 cm, and the cut section of the mass showed nodular surface with multiple areas of necrosis. Slicing of the liver showed a gray white mass measuring 5 × 5 × 3 cm, which is adherent to the mass and the remaining liver parenchyma appear unremarkable. The microscopic examination of the mass revealed a moderately differentiated HCC measuring 5 cm in diameter, confined to the liver, <5 cm from resection margins and no lymph-vascular invasion (Fig. ), and a separate adrenocortical neoplasm measuring 17 cm in diameter, multiple foci of necrosis, no capsular or lymph-vascular invasion and resection margins were not involved by the tumor (Fig. ). Excised lymph nodes included a single right portal vein lymph node, a gallbladder lymph node and seven para aortic lymph nodes. All lymph nodes were negative for metastasis. Gallbladder examination showed no significant pathology. Postoperative assessment of the patient revealed that he recovered gradually and was discharged.

The patient is a 46-year-old female with SCC of the breast. She initially had silicone gel breast implantation for breast augmentation in 1995. The implantation was surgically revised in 2002 and 2006. In 2014 she noticed hardening and swelling of her right breast. Because of the death of her husband, she did not seek immediate medical attention. She continued to have swelling and increased pain in the right breast. Magnetic resonance imaging (MRI) performed in January 2016 showed a large fluid collection surrounding the intact right silicone implant as shown in Figure . The case was managed by surgical drainage of fluid collection and capsulectomy. In February 2016, she underwent bilateral prosthesis explantation and bilateral capsulectomy. The pathology demonstrated a 4-cm moderately differentiated invasive SCC. It extended into the muscle, and in situ tumor was noted to extend to the peripheral margin. There was no perineural or lymphovascular invasion. Pathology of the left breast capsule showed chronic inflammation. Computed tomography (CT) of chest, abdomen and pelvis on February 2016 revealed absence of metastatic disease. The patient underwent re-excision of the remaining chest wall mass in March 2016. Pathology showed well differentiated SCC with negative margins. Chest wall fluid was negative for malignant cells. On slide review, it was noted that there was squamous epithelialization of the implant capsule with benign squamous epithelium on both sides. This indicated that the tumor is likely SCC of the implant capsule rather than primary SCC of the breast. Estrogen and progesterone receptor markers were negative as well. Afterwards, she received external beam radiation. She was treated with radiation while supine with free breathing. Four tangent beams were used to target the right breast with 50 Gray in 25 fractions, followed by a 10 Gray boost to the tumor bed delivered in five fractions. Radiation was delivered using opposed tangents completed in May 2016. No adjuvant chemotherapy was offered due to the rare histology and paucity of data. She followed up in clinic in June 2016 without complications or clinical recurrence.\nFollow-up CT scan performed in August 2016 displayed a right upper lobe lung nodule and findings were suspicious for local recurrence (Figure ). She underwent right video thoracoscopy and right upper lobe wedge resection. The pathology was consistent with metastatic moderately differentiated SCC. The patient declined chemotherapy at this time. CT chest and abdomen at another hospital showed new cavitary lung nodules and right renal and psoas abscess. In February 2017, retroperitoneal fine needle aspiration of the right renal collection was positive for SCC. In June 2017, she was admitted to the hospital for abdominal pain and was found to have progressive disease. CT abdomen and pelvis with intravenous and oral contrast on 6/16/17 demonstrated a 6.1 cm x 5.7 cm heterogeneous lesion in the right kidney lower pole with invasion into the adjacent right psoas muscle (Figure ). Progressive metastases to the liver, lungs and retroperitoneum were noted as well. Ultrasound-guided fine-needle aspiration and core biopsy of the liver was positive for metastatic SCC with keratinization and necrosis.\nHer hospital course was complicated by non-ST elevation myocardial infarction, recurrent anemia requiring transfusions, atrial fibrillation with rapid ventricular rate and hypotension. She was noted to have leptomeningeal spread. She was ultimately transferred from the medical intensive care unit to the palliative care unit for comfort care. She expired of her disease in July 2017, one year after her initial diagnosis of cancer.

The patient is a 46-year-old female with SCC of the breast. She initially had silicone gel breast implantation for breast augmentation in 1995. The implantation was surgically revised in 2002 and 2006. In 2014 she noticed hardening and swelling of her right breast. Because of the death of her husband, she did not seek immediate medical attention. She continued to have swelling and increased pain in the right breast. Magnetic resonance imaging (MRI) performed in January 2016 showed a large fluid collection surrounding the intact right silicone implant as shown in Figure . The case was managed by surgical drainage of fluid collection and capsulectomy. In February 2016, she underwent bilateral prosthesis explantation and bilateral capsulectomy. The pathology demonstrated a 4-cm moderately differentiated invasive SCC. It extended into the muscle, and in situ tumor was noted to extend to the peripheral margin. There was no perineural or lymphovascular invasion. Pathology of the left breast capsule showed chronic inflammation. Computed tomography (CT) of chest, abdomen and pelvis on February 2016 revealed absence of metastatic disease. The patient underwent re-excision of the remaining chest wall mass in March 2016. Pathology showed well differentiated SCC with negative margins. Chest wall fluid was negative for malignant cells. On slide review, it was noted that there was squamous epithelialization of the implant capsule with benign squamous epithelium on both sides. This indicated that the tumor is likely SCC of the implant capsule rather than primary SCC of the breast. Estrogen and progesterone receptor markers were negative as well. Afterwards, she received external beam radiation. She was treated with radiation while supine with free breathing. Four tangent beams were used to target the right breast with 50 Gray in 25 fractions, followed by a 10 Gray boost to the tumor bed delivered in five fractions. Radiation was delivered using opposed tangents completed in May 2016. No adjuvant chemotherapy was offered due to the rare histology and paucity of data. She followed up in clinic in June 2016 without complications or clinical recurrence.\nFollow-up CT scan performed in August 2016 displayed a right upper lobe lung nodule and findings were suspicious for local recurrence (Figure ). She underwent right video thoracoscopy and right upper lobe wedge resection. The pathology was consistent with metastatic moderately differentiated SCC. The patient declined chemotherapy at this time. CT chest and abdomen at another hospital showed new cavitary lung nodules and right renal and psoas abscess. In February 2017, retroperitoneal fine needle aspiration of the right renal collection was positive for SCC. In June 2017, she was admitted to the hospital for abdominal pain and was found to have progressive disease. CT abdomen and pelvis with intravenous and oral contrast on 6/16/17 demonstrated a 6.1 cm x 5.7 cm heterogeneous lesion in the right kidney lower pole with invasion into the adjacent right psoas muscle (Figure ). Progressive metastases to the liver, lungs and retroperitoneum were noted as well. Ultrasound-guided fine-needle aspiration and core biopsy of the liver was positive for metastatic SCC with keratinization and necrosis.\nHer hospital course was complicated by non-ST elevation myocardial infarction, recurrent anemia requiring transfusions, atrial fibrillation with rapid ventricular rate and hypotension. She was noted to have leptomeningeal spread. She was ultimately transferred from the medical intensive care unit to the palliative care unit for comfort care. She expired of her disease in July 2017, one year after her initial diagnosis of cancer.

A 53-year-old healthy female with known hypothyroidism being treated with thyroid hormone replacement presented to the emergency department with sudden-onset chest pain and palpitations. Her electrocardiogram revealed atrial fibrillation with a ventricular rate of 140 beats per minute. Cardiac auscultation revealed a continuous murmur at the left sternal border. She spontaneously converted to normal sinus rhythm with complete resolution of her chest pain. Her troponin I level was 17 ng/ml. EKG-gated multidetector cardiac computed tomographic angiography revealed the presence of a large anomalous left main coronary arising from the main pulmonary artery (). The left anterior descending artery, diagonal branch, and left circumflex arteries arising from the left main were ectatic vessels with extensive collateralization with a large ectatic right coronary artery arising from the right aortic coronary sinus (). She remained asymptomatic, and her troponins normalized. Her atrial fibrillation was attributed to iatrogenic hyperthyroidism resulting from an excess in recommended doses for thyroid replacement therapy. The thyroid stimulating hormone level was noted to be low and reported at 0.05 mU/L.\nA 2D echocardiogram revealed normal biventricular size and function with a left ventricular ejection fraction of 55%. Ventricular wall thickness was calculated to be normal in addition to normal left ventricular diastolic function and filling pressures. There were no advanced valvular abnormalities, and a mild degree of mitral and tricuspid regurgitation was present. There was evidence of markedly increased color Doppler signaling within the interventricular septum suggestive of high blood flow through septal collaterals (Figures and ). Coronary angiography showed evidence of retrograde blood flow in the left coronary system into the pulmonary trunk through collateral supply from the systemic side, secondary to relatively low right-sided pressures, and vascular resistance causing coronary steal (). Our patient was offered surgery for reimplantation of her left main into the aorta but she refused. Considering that her presentation of myocardial damage was secondary to a lack of oxygenated blood during increased demand at the time of tachycardia, a rhythm control strategy for the atrial fibrillation was adopted and the patient was discharged from the hospital on a reduced dose of thyroid replacement therapy with close follow-up.

A 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.\nThe patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.\nOn examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular region. We suspected the sinus track may originate from the dislodged appliance embedded in the cheek soft tissue. A periapical view was then taken with gutta-percha inserted into the sinus for foreign body localization purpose. The radiograph revealed the gutta-percha pointed towards the site of titanium plate and screws placed used for rigid fixation, and with the molar orthodontic tube appliance in its vicinity (). A cone beam CT was performed to provide a 3D detailed location of the appliance (Figures and ) and confirmed it to be located outside the maxillary antrum.\nThe presence of the molar orthodontic tube foreign body reaction was suspected as the most probable cause of the recurrent right cheek pain and swelling associated with an intraoral discharging sinus. Exploration of the site was performed through the sulcular incision under general anesthesia. The dislodged molar tube was identified lying on the zygomatic bone just beneath the raised flap. It was removed by dividing some surrounding fibrous tissue strands. Just below it, one titanium straight bone plate with four screws used for fixing the previous Le Fort I osteotomy site was inspected and found to be rigidly embedded in normal bone. However, a decision was made to remove them based on the fact that they are present in an infected area. (). The Le Fort I osteotomy site showed good healing with new bone formation. Patient had an uneventful recovery thereafter, and the orthognathic surgical team who attended him previously was informed of his progress.

The patient is a 46-year-old female with SCC of the breast. She initially had silicone gel breast implantation for breast augmentation in 1995. The implantation was surgically revised in 2002 and 2006. In 2014 she noticed hardening and swelling of her right breast. Because of the death of her husband, she did not seek immediate medical attention. She continued to have swelling and increased pain in the right breast. Magnetic resonance imaging (MRI) performed in January 2016 showed a large fluid collection surrounding the intact right silicone implant as shown in Figure . The case was managed by surgical drainage of fluid collection and capsulectomy. In February 2016, she underwent bilateral prosthesis explantation and bilateral capsulectomy. The pathology demonstrated a 4-cm moderately differentiated invasive SCC. It extended into the muscle, and in situ tumor was noted to extend to the peripheral margin. There was no perineural or lymphovascular invasion. Pathology of the left breast capsule showed chronic inflammation. Computed tomography (CT) of chest, abdomen and pelvis on February 2016 revealed absence of metastatic disease. The patient underwent re-excision of the remaining chest wall mass in March 2016. Pathology showed well differentiated SCC with negative margins. Chest wall fluid was negative for malignant cells. On slide review, it was noted that there was squamous epithelialization of the implant capsule with benign squamous epithelium on both sides. This indicated that the tumor is likely SCC of the implant capsule rather than primary SCC of the breast. Estrogen and progesterone receptor markers were negative as well. Afterwards, she received external beam radiation. She was treated with radiation while supine with free breathing. Four tangent beams were used to target the right breast with 50 Gray in 25 fractions, followed by a 10 Gray boost to the tumor bed delivered in five fractions. Radiation was delivered using opposed tangents completed in May 2016. No adjuvant chemotherapy was offered due to the rare histology and paucity of data. She followed up in clinic in June 2016 without complications or clinical recurrence.\nFollow-up CT scan performed in August 2016 displayed a right upper lobe lung nodule and findings were suspicious for local recurrence (Figure ). She underwent right video thoracoscopy and right upper lobe wedge resection. The pathology was consistent with metastatic moderately differentiated SCC. The patient declined chemotherapy at this time. CT chest and abdomen at another hospital showed new cavitary lung nodules and right renal and psoas abscess. In February 2017, retroperitoneal fine needle aspiration of the right renal collection was positive for SCC. In June 2017, she was admitted to the hospital for abdominal pain and was found to have progressive disease. CT abdomen and pelvis with intravenous and oral contrast on 6/16/17 demonstrated a 6.1 cm x 5.7 cm heterogeneous lesion in the right kidney lower pole with invasion into the adjacent right psoas muscle (Figure ). Progressive metastases to the liver, lungs and retroperitoneum were noted as well. Ultrasound-guided fine-needle aspiration and core biopsy of the liver was positive for metastatic SCC with keratinization and necrosis.\nHer hospital course was complicated by non-ST elevation myocardial infarction, recurrent anemia requiring transfusions, atrial fibrillation with rapid ventricular rate and hypotension. She was noted to have leptomeningeal spread. She was ultimately transferred from the medical intensive care unit to the palliative care unit for comfort care. She expired of her disease in July 2017, one year after her initial diagnosis of cancer.

Patient No. 4 was a 69 year old male with a history of laryngeal cancer treated with radiation therapy several years prior to presentation. He required a tracheostomy at the time of his cancer diagnosis but was subsequently decannulated after therapy. His past medical was significant for coronary artery disease requiring stenting, hypertension and uncontrolled insulin dependent diabetes mellitus. He developed right angle torsion and subluxation of trachea at the site of his tracheostomy site that was not amenable to endoscopic resection. He underwent cervicothoracic tracheal resection involving the cricoid and 3 tracheal rings, with primary anastomosis. On POD#3 he developed an anastomotic leak. He was taken to the operating room with the intent to place a tracheostomy through the dehiscent trachea but the anastomosis was noted to abut the innominate artery. Therefore, the tracheal dehiscence was primarily repaired and covered with sternohyoid muscle advancement and he was left intubated with the cuff past the anastomosis. A repeat bronchoscopy on POD#6 revealed intact anastomotic site but he failed extubation trial due to development of supraglottic edema from prolonged intubation and inability to clear secretions and a tracheostomy was performed. The tracheostomy incision was made vertically and encompassed the airway anastomotic site and a stomaplasty was performed to protect the innominate artery and to support the tracheal anastomosis. He subsequently underwent one endoscopic treatment 4 months after airway resection and was decannulated successfully. The patient continues to do well with mild grade 1 stenosis 5.5 years later.\nThere were two patients who could not be decannulated (). Patient 5 had somewhat poorly controlled COPD and a history of tracheal stenting, a procedure that predisposes patients to re-stenosis at the level of the stent []. He was noted to aspirate after resection. Therefore, a tracheostomy was placed for pulmonary toilet, and the anastomosis eventually restenosed completely. He prioritized eating over speaking and no further intervention was performed. Patient 7 was a 72 years old male who developed airway stenosis after an emergent slash tracheostomy using a vertical incision. Advanced age is identified by several studies as a risk factor for poor surgical outcome after tracheal resection. At the time of resection, the condition of the tracheal wall was very poor and the cricoid plus 6 tracheal rings were resected. Postoperatively, he developed an infection resulting in anastomotic dehiscence. He was taken back to the operating room for debridement of the necrotic anterior tracheal wall and for tracheostomy placement. The tracheostomy was eventually replaced with a T-tube. After 5 years with the T-tube the patient was lost to follow up.

Case 1: a 54-year-old male patient was admitted with complaints of shortness of breath simultaneous abdominal pain, stiffness, and swelling. The patient was referred to specialist pulmonologist. Thorax CT scan revealed the presence of common pleural effusion on the right side of the patient and changes in the lung fields adjacent to the effusion revealed the presence of passive atelectasis. The presence of collapse and consolidation was revealed in the right lateral segment lung. Thoracic surgery consultation was requested for the patient because of the right pleural effusion. Thoracentesis was performed to the patient by the thoracic surgeon. Cytological examination of the material was reported to be compatible with malignant epithelial tumor. However, distinction of mesothelioma and carcinomatous adenocarcinoma could not be made as a result of cytopathology. He had no known previous exposure to asbestos. In abdominal examination, an abdominal mass was palpated in the right upper quadrant. Abdominal CT was also performed to the patient because of prolonged abdominal pain. In abdominal CT imaging, suspected invasion of omentum has been found in hepatic flexure and right transvers colon (). In addition, suspected infiltration and signs of compression of these colonic segments were determined. Laparotomy was scheduled for the intraabdominal mass. Mass of the omentum adherent to the hepatic flexure was found in the operation. After dissection of adhesions, the patient underwent total omentectomy. There was no other pathology in the abdomen. After recovery, the patient was discharged. Histopathology revealed malignant mesothelioma (). Patient was referred to medical oncology after the period of recovery. Chemotherapy was administered to the patient by the medical oncology specialist. Control abdominal CT was performed after six cycles of chemotherapy. Two cystic lesions were detected in CT. One of them was in size of 18 × 12 cm and located inferior of the right lobe of the liver and the other one was in size of 10 × 8 cm and located in right inferior quadrant. Percutaneous drainage was performed for both cysts. The patient was hospitalized until the cysts completely collapsed. The patient was discharged after recovery. Patient is in follow-up period.\nIn the second case, a 40-year-old male patient was admitted with abdominal pain that has continued for 2 months and abdominal swelling in the right upper quadrant. There was a palpable mass in the right hypochondrium in the physical examination. In the size of 7 × 5 cm, mass originating from the gallbladder was detected in the abdominal CT (). The decision of the operation was given for the patient. The gallbladder was greater than normal size and in size of 7 × 5 cm, and tumoral mass was found originating from the inferior wall of the gallbladder. The patient had undergone cholecystectomy and resection of liver segment adjacent to gallbladder. The histopathology revealed epithelioid malignant mesothelioma (). The patient was discharged and referred to medical oncology after the recovery.

An 80-year-old woman with a history of collapse at home was admitted to Emergency when she had a cardiac arrest and was successfully resuscitated and intubated. She also had diabetes mellitus, hypertension, and atrial fibrillation. She had a past history of total thyroidectomy.\nWhile she was ventilated in the ICU she developed pneumonia, was treated and extubated. She had another episode of respiratory distress and needed re-intubation, was ventilated and shifted to our hospital.\nOn admission she had an episode of upper gastrointestinal bleeding which was treated endoscopically. She got infected with acinotobacter in the sputum, had bilateral pleural effusion and was unweanable from the ventilator. Considering the status of the patient a decision was taken to do the PDT electively. This was expected to facilitate the weaning from the ventilator or as a therapeutic measure considering the uncertainty of duration of the ventilator support.\nHer past history of thyroidectomy was considered in expecting an altered anatomy and difficulty in identifying the landmarks during PDT. The patient was positioned for PDT and prepared and draped. On identification of landmarks with palpation, a pulse was felt which is unusual at the midline of the trachea at the level of the third and fourth tracheal rings. The pulse was rhythmic with the monitor which confirmed the presence of an artery. The artery was traced superiorly and inferiorly and it was seen that it became lateral to the trachea on the right side.\nThe confirmation of this distortion was done by ultrasound guidance (sonosite M turbo - USA) with a high-frequency linear probe. The sonoanotomy revealed that the right common carotid artery after emerging in the neck ascended in the neck very close to the trachea and formed a loop anterior to the trachea at the level of the third and fourth rings and ascended laterally further before dividing into the external and internal carotid arteries []. There were no other abnormalities seen in the vasculature either on the right side or left side. The procedure was abandoned citing the abnormal anatomy and expected difficulties in the PDT. The case was referred to thoracic surgery for surgical tracheostomy and the findings on ultrasound were confirmed during surgical tracheostomy []. There was presence of fibrous tissue lateral to the trachea on both sides, on the right the common carotid artery was found adherent to the tracheal wall and forming a loop anterior to the trachea. The surgical tracheostomy was done successfully.

A 21-year-old male was involved in a high-speed motor vehicle collision and sustained multiple injuries, including a right closed subtrochanteric femur fracture, bilateral pulmonary contusions, as well as a splenic injury requiring an exploratory laparotomy with splenectomy upon arrival to the hospital. Due to hemodynamic instability, a distal femoral traction pin with 25 pounds of weight was placed in his right femur on the date of admission as a temporary stabilization of his fracture. This smooth traction pin was placed without difficulty using sterile technique and was placed from medial to lateral at the level of the adductor tubercle. The pin sites were then covered with a sterile dressing. Radiographs of his fracture are shown in .\nThe patient's overall condition worsened over the ensuing three days, with development of high fevers, increasing leukocytosis, and continued cardiopulmonary lability. He remained intubated throughout his hospitalization. Due to significantly increased swelling and erythema about the right thigh and hip region, a plain radiograph as well as computed tomography scan was ordered to evaluate for abscess or hematoma formation. Representative images from the scan are shown in . Mild serous drainage was seen about the traction pin sites, but no purulence was noted. The edema and erythema in the region of the knee was significant as well and was slightly more than the proximal thigh.\nDue to the findings of a significant amount of soft tissue gas in his thigh extending to the groin and caudal abdominal wall, the patient was taken emergently to the operating room for evaluation and debridement. Upon incision into the thigh, malodorous gas was released, and it was discovered that all of the distal muscle and fascia were necrotic; due to these findings, the decision was made to undergo a proximal open guillotine transfemoral amputation through his fracture site. He also underwent debridement of his lower abdominal wall at this time, with removal of all necrotic tissues. Intraoperative deep tissue specimens were obtained at this time and identified Clostridium perfringens as the culprit. Unfortunately, the infection continued to spread, and he underwent a hip disarticulation with further abdominal and groin debridement the following day. A final debridement of his hip musculature, including removal of his ipsilateral testicle, was performed two days after his initial amputation. Unfortunately, due to further development of intra-abdominal infection in the face of continued cardiopulmonary instability, the decision was made by family to withdraw support; he ultimately passed away eight days after his injury.

A 49-year old female patient was admitted to the department of neurosurgery at another hospital under the diagnosis of a subarachnoid hemorrhage. She underwent a decompressive craniectomy, surgical neck clipping of ruptured aneurysm and hematoma removal. The patient was treated in the intensive care unit for three weeks. The patient had no prior operative history of tracheostomy, and a cranioplasty was performed. Following the completion of intensive care, the patient was moved to a general ward, and transferred to the department of rehabilitation medicine. At the time of the transfer, the patient was alert and conscious with motor power in the right upper and lower extremities that presented at a grade one on examination. To independently turn-over in bed was possible, but sitting-up required moderate assistance. The patient showed difficulty in maintaining balance while seated and generally required moderate assistance in daily activities. The patient was on Levin tube feeding, and treatment for dysphagia was carried out. The patient was transferred to our department of rehabilitation medicine at ten weeks after the onset of a hemorrhagic stroke. On admission to our hospital, the patient presented with persistent dysphagia, and was still receiving Levin tube feeding. Cervical pain with severity of grade four to five according to visual analogue scale was rated by the patient. The exact onset of diabetes mellitus was uncertain but HbA1c was 5.5% on laboratory examination, and the patient had no family history of diabetes mellitus. The patient was on insulin therapy, but the medication regimen was modified to the administration of Metformin Hydrochloride 500 mg two times a day owing to adequate control of blood glucose level, and afterward, the patient had a favorable blood glucose level. The vital signs were stable on admission with a blood pressure at 106/73 mmHg, heart rate 98/minute, respiratory rate 19/minute and body temperature of 36.3℃, and the patient did not present with respiratory distress. Motor power examination showed normal findings on the left side, but the right upper extremity presented with a grade one and the right lower extremity presented with grade two. Her cognitive function was rated with score of 22 according to Korean Mini-Mental State Examination (K-MMSE). Blood test results showed no remarkable abnormal findings other than a mildly elevated ESR level of ESR 36 mm/hr. Other results revealed WBC 8,410/µl and CRP 0.04 mg/dl. On a video fluoroscopy swallowing test for the evaluation of dysphagia, retropharyngeal edema was identified, which lead to impairment of a migration of bolus into the esophagus, and the aspiration occurred due to residual contents (). With a consultation to the department of otolaryngology, a laryngoscopy was performed and retropharyngeal edema and profuse discharge were identified (). A cervical computed tomography examination showed generalized retropharyngeal edema and cortical contrast enhancement of the fourth cervical spine along with partial osteoclastic findings (). An additional differential diagnosis of retropharyngeal abscess, malignant tumor and tuberculous spondylitis, cervical magnetic resonance imaging (MRI) was carried out, and revealed a signal change at the medulla from the second to the fourth cervical spine along with generalized retropharyngeal edema. At the anterior portion of the second to fourth cervical spine, a soft tissue lesion of low signal intensity on T1, high signal intensity on T2, and contrast enhancement was identified (). The marginal portion of the abscess did not show contrast enhancement, and the posterior portion of the vertebral body adjacent to the retropharyngeal space showed contrast enhancement. This lead to difficulty in excluding the malignant tumor, and a biopsy was planned. The location of the lesion was difficult to access for complete resection or incision and drainage. Since the trial of the incision and drainage does not affect the period of antibiotics administration, an excisional biopsy under local anesthesia was performed, and an acid-fast bacillus stain along with a culture study was carried out. Biopsy results revealed findings consistent with inflammatory granulation tissue and acid-fast bacillus staining which showed no specific findings. A culture study showed positive results for Staphylococcus aureus susceptible to methicillin. The lesion was concluded as a retropharyngeal abscess, and treatment with antibiotics was initiated with the administration of intravenous Cefazolin 2 g every 8 hours. The total treatment period with antibiotics was eight weeks. The follow-up evaluation with blood tests showed no abnormal findings regarding the WBC, ESR and CRP. Re-evaluation with cervical MRI after treatment with antibiotics showed improvement of a retropharyngeal abscess (). On video fluoroscopic swallowing study, aspiration was not observed, and the residual contents were remarkably decreased leading to initiation of feeding with a regular diet (). The cervical pain was managed with the administration of Tramadol HCL 18.75 mg/Acetaminophen 162.5 mg three times a day since admission but did not show improvement. However, the cervical pain started improving after the initiation of treatment with intravenous antibiotics. Medication with Tramadol HCL 18.75 mg/Acetaminophen 162.5 mg was administrated for a total period of four weeks, and the patient no longer complained of cervical pain.

A 59-year-old female patient presented with fracture neck humerus along with absent pulsations in the left upper limb due to blunt trauma. Patient also had history of diabetes mellitus and hypertension. Colour Doppler study revealed monophasic flow in the upper limb arteries suggestive of proximal occlusion. Computed tomographic (CT) angiogram showed complete occlusion of the left axillary artery (Figures and ) by sharp edge of the fractured humerus and distal filling of brachial artery through collaterals. Although patient had absent pulsations in the upper limb, capillary refilling was there. Urgent surgical intervention was done in the form of fixation of fracture followed by repair of the axillary artery. Patient was operated under supraclavicular block; orthopedic team first did the open reduction and fixation of the neck of the humerus through a longitudinal incision over the anterolateral aspect of left shoulder. After fixation of fracture, vascular surgery team did the exploration of axillary artery. Axillary artery was explored in the left axilla through a separate incision other than that used for fixation of fracture. Longitudinal incision midway between anterior and posterior axillary folds was given and extended on to the medial aspect of the proximal arm. The axillary artery was found contused for a segment of approximately 8 cm; fortunately, there was no associated nerve injury and the basilic vein was also intact allowing us to use the basilic vein for repair of the axillary artery. Contused segment of the axillary artery was excised after taking proximal and distal control and after heparinization (1 mg/kg). Basilic vein of appropriate length was harvested through the same incision and axillary artery was repaired using reversed basilic vein graft in an end to end fashion using 6-0 polypropylene sutures (). Postprocedure pulsations were present in the left upper limb. Fasciotomy was not done as there was no evidence of compartment syndrome and the limb was not edematous. Total duration of procedure including both fixation of fracture and repair of the axillary artery was approximately three hours. Patient recovered well and came for follow-up three months after the procedure with palpable pulsations.

A 74-year-old female with a history of severe aortic stenosis and interventricular septal hypertrophy underwent bioprosthetic aortic valve replacement with concomitant septal myectomy. Two months after the surgical intervention she presented to another hospital with syncope. On presentation, it was described that this obese patient was bradycardic with a heart rate of 40 beats per minute with stable blood pressure readings. No jugular venous distention was noted and occasional cannon A waves were noted. Examination of the lungs revealed adequate aeration in all fields with no crackles or wheezing. Point of maximum impulse was not displaced. Regular heart sounds with variable intensity were noted with no atrial or ventricular gallops but an early systolic murmur grade II/VI was described noted at the left sternal border. Due to the symptomatic bradycardia a dual chamber pacemaker was recommended and placed without complications. The patient was subsequently discharged home 24 hours after the pacemaker implantation. Four months post pacemaker implantation she was seen in follow-up and she doing fine and reported no complaints. An echocardiogram was obtained and it was reported that normal left ventricular systolic function as well as prosthetic aortic valve function were noted, with no other abnormalities.\nThe patient then relocated and was seen a year later for the first time at our institution. An echocardiogram obtained at the time of her initial visit, while still asymptomatic, showed normal left ventricular chamber dimensions, systolic function, and bioprosthetic valve function. In addition, a pacer wire that was correctly positioned in the right ventricular apex was also seen. However, an abnormal color flow signal arising from the interventricular septum with a predominant flow away from the transducer into the left ventricular cavity was noted. Continuous and pulse wave Doppler interrogation demonstrated a continuous flow with a predominant diastolic component, as shown in Figures , and , all these findings consistent with coronary arterial flow. This abnormal color flow signal, traversing the interventricular septum, was never identified in previous studies.\nThe patient presented in this case was asymptomatic at the time of diagnosis and consequently no intervention was recommended. The patient was seen in follow-up and was doing fine, reporting no complaints.

A 43-year-old incarcerated woman with borderline personality disorder and a long history of swallowing various foreign objects in periods of stress presented to the emergency department after swallowing a cup of bleach. Her surgical history was significant for multiple celiotomies for retrievals of purposefully ingested foreign bodies. During evaluation, she also admitted to swallowing an ink pen 3 weeks prior to swallowing the bleach for which she did not seek medical evaluation. She reported no food intolerance or changes in bowel function secondary to swallowing these objects. She presented with mild abdominal pain and cramping, and her vital signs and laboratory investigations were all within normal limits. Her abdominal exam was notable for mild tenderness to palpation diffusely. Computed tomography (CT) of the abdomen () showed a linear foreign body in the distal gastric antrum penetrating the inferior wall and extending into the adjacent peritoneal fat. No free air or free fluid was appreciated. Initial esophagogastroduodenoscopy (EGD) was significant for mild erythema and edema to the esophageal and duodenal mucosa as a result of the caustic ingestion, and the pen was found to be deeply perforating the stomach antral wall with no associated ulcer or edema (). The depth at which the foreign body was lodged was uncertain, so there was concern for organ involvement outside of the gastric wall. Repeat EGD was done to assess for manifestations of esophageal, gastric or duodenal injuries from her caustic ingestion, and it revealed normal gastric mucosa (). A joint case was planned with the gastroenterology service for endoscopic foreign body retrieval, possible laparoscopic retrieval and gastric repair and possible open retrieval and gastric repair. The patient was taken to the operating room for the third EGD, which revealed spontaneous migration of the foreign body from the perforation site into the lumen of the gastric body (). Additionally, there was spontaneous closure of the site of previous perforation (). The ink pen was easily removed transorally using an endoscopic snare, and no further surgical intervention was required. After the procedure, the patient reported complete resolution of her abdominal pain and was able to tolerate a regular diet without problems.

A 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.\nThe patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.\nOn examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular region. We suspected the sinus track may originate from the dislodged appliance embedded in the cheek soft tissue. A periapical view was then taken with gutta-percha inserted into the sinus for foreign body localization purpose. The radiograph revealed the gutta-percha pointed towards the site of titanium plate and screws placed used for rigid fixation, and with the molar orthodontic tube appliance in its vicinity (). A cone beam CT was performed to provide a 3D detailed location of the appliance (Figures and ) and confirmed it to be located outside the maxillary antrum.\nThe presence of the molar orthodontic tube foreign body reaction was suspected as the most probable cause of the recurrent right cheek pain and swelling associated with an intraoral discharging sinus. Exploration of the site was performed through the sulcular incision under general anesthesia. The dislodged molar tube was identified lying on the zygomatic bone just beneath the raised flap. It was removed by dividing some surrounding fibrous tissue strands. Just below it, one titanium straight bone plate with four screws used for fixing the previous Le Fort I osteotomy site was inspected and found to be rigidly embedded in normal bone. However, a decision was made to remove them based on the fact that they are present in an infected area. (). The Le Fort I osteotomy site showed good healing with new bone formation. Patient had an uneventful recovery thereafter, and the orthognathic surgical team who attended him previously was informed of his progress.

A 27-year-old man with a 2-year history of recurrent hospitalizations for various neurologic and cardiologic emergencies was admitted to our hospital presenting with left hemiparesis, which gradually progressed to quadriparesis, bilateral hemianopsia, intracranial hypertension syndrome, and seizures. A diagnosis of echinococcosis was made, based on the radiologic findings of multiple cerebral hydatid cysts and a sizable cyst of the heart (\n). The hydatid cyst of the heart was treated first with a thoracotomy, and after a month, he underwent three consecutive surgical operations for the removal of the six cerebral cysts. The patient was on albendazole treatment throughout his hospitalization, and this led to the shrinkage and finally to the disappearance of two other cerebral cysts.\nDuring the first surgical procedure, two frontal hydatid cysts were completely removed via a right frontal craniotomy and another cyst of the occipital lobe was removed via a separate right occipital craniotomy (\n). The patient initially had an uneventful postoperative recovery but 2 weeks later, while the second operation was being planned, he presented with generalized seizures (with loss of consciousness and urinary incontinence). Emergent cerebral CT scan revealed a marked expansion of the left occipital lobe cyst, cerebral edema, and midline shift (\n). A possible explanation of this event is that the removal of the contralateral (right occipital) cyst disturbed the pressure balance between these two lesions and allowed the expansion of the left occipital cyst toward the right side. The patient was emergently operated on and a left occipital craniotomy was performed for the complete removal of the left occipital cyst. There were no postoperative events, and 10 days later the third procedure was performed. A right cerebellar hemisphere cyst was removed via a right suboccipital craniectomy, and a left frontal lobe cyst was removed via a left frontal craniotomy (\n).\nThe patient's focal neurologic signs eventually disappeared, with the exception of a slight unilateral hemianopsia. Ten years after his discharge, he remains in a good condition, with no signs of clinical or radiologic relapse.

A 52-year-old female patient presented with pain in both the hip joints since 3 months. She was unable to walk, stand, climb, or do any activities with her lower limbs.\nShe had undergone bilateral TKR in July 2012 for severe OA of both the knees. She was assured that she would be able to walk freely after the surgery. No mention was made about the existing disease in the hip joints and about the need to operate both the hips. One month into the post-operative period after TKR the patient was totally unable to walk and was reduced to a wheel chair existence. Prior to surgery she was able to walk and do her day to day activities with pain. Even this was not possible after the surgery. When the patient went back to the surgeon seeking remedy, she was told that she needs to undergo bilateral hip replacement in order to walk again. When asked why this was not told to her earlier there was no response. When patient expressed her unwillingness for the surgery due to the previous bad experience and also due to extreme financial crunch to muster money for another twin replacement surgery. She was told to return back once she would not arrange money and until such time continue taking the pain killer. On request for any alternative method of treatment, the surgeon categorically said nothing could be done. It is then the patient approached me for treatment.\nOn enquiry, she told me that she was an old patient of RA and was on treatment since 2009. She did not have typical RA presentation and her problems started as pain in both the knees unlike a typical RA small joint presentation. Subsequently she did develop pain in the hands, feet, shoulder, hip, and wrist but hip the presentation was unlike a typical RA. Her RA test was 26 u/ml and the normal reading was up to 15 u/ml. Her other blood parameters and X-rays did not support the diagnosis of RA [].\nIn 2009, she underwent a diagnostic arthroscopy for pain in both the knees since 3 months. During the diagnostic arthroscopy she was diagnosed left medial meniscus tear with synovitis and partial medial meniscectomy, synovectomy and chondroplasty was done on 19/1/09. She had no fall or trauma to the left knee. She had no history of swelling etc., of the knee. Clinically, she was not diagnosed to have medial meniscus torn and no magnetic resonance imaging was done prior to arthroscopy. She always complained of bilateral knee pain and not a single joint pain. After the surgery, there was no relief in her pain in the knees and she was put on anti RA treatment by another orthopedic surgeon. She was also diagnosed to have diabetes and hypertension and was taking of treatment for these ailments also.\nHer pain in both the knees steadily increased until 2012 despite taking regular treatment for RA such as methotrexate, folic acid. By then she had developed pain in the hands, hips, wrist, and shoulders. On July 2012 she was advised to undergo bilateral TKR and the diagnosis mentioned was severe bilateral OA! The X-ray reports have also suggested that the patient had OA knees and hips and lumbar spondylosis but her RA factor had shot up to 90 IU/ml (normal 0-30) on 4/7/12 and by 17/11/12 it had dropped to <10.4 IU/ml. Radiologists did not diagnose RA of the hips and knees, but a vague juxta-articular rarefaction in the hands was mentioned. Her erythrocyte sedimentation rate was 98, 103, 75 mm/h in 2011, July 2012, November 12 respectively. The radiology report on 23/8/12 had severe OA changes in both knees and hips.\nPatient was wheel chair bounded []. Her pain in both the hips as per the Numerical Pain Analog scale was nine. She had 86% disability in the hip as per the Western Ontario and McMaster Universities Osteoarthritis Index Score for the Knee Joint WOMAC score. She had Grade 3 tenderness in both the hips and the movements of the hip were severely restricted. Flexion - 50°, abduction - 10°, adduction - 50°. Flexion - 10°, external rotation - nil, internal rotation - nil, extension - 5°. Her walking time was 2 minutes 20 seconds for 50 meters [].\nShe was put on 30 days integrated physiotherapy consisting of ultrasound, interferential therapy and moist heat and IAYT practices and data's were collected, after 10th day, 20th days and 30th day []. She improved steadily in all the clinical parameters and she was off the wheel chair by the 3rd day and graduated to walking with the support on both sides [], one side support [] by 7th day as by 10th day she was walking without support []. Her pain also steadily decreased from 9 to 2 by the end of 3 weeks. She expressed satisfaction at the outcome of the treatment as she had progressed from wheel chair to independent walking and that too after being told she had no other alternative!

Our patient is a 16-year-old otherwise healthy male who sustained an injury to the left leg while playing football, 2 years before presentation. He was found to have a left distal third oblique tibia fracture () and was splinted in an outside emergency department that evening. Soon after, he was transitioned to a cast which remained in place for 6 weeks, and then to a boot for an additional 4 weeks. The patient then returned to playing football and did well, with mild occasional symptoms of aching pain for approximately 2 years.\nTwo years after the initial injury, the patient was tackled from the side while playing football. He had immediate pain in the left tibia in the same location of the previous fracture. The pain persisted for approximately 6 months. It was localized to the site of the prior tibia fracture and extended to the anterior aspect of the foot. The patient also noted occasional numbness and tingling in the tips of his toes.\nInitial assessment at the time of presentation to our institution showed the left lower extremity to be grossly normal in appearance, with no swelling or deformity. The patient had tenderness to palpation along the left distal tibia. He had no neurologic deficit, with normal motor and sensory function throughout the lower extremities. Vascular exam was also normal.\nRadiographs showed an apparent channel in the lateral aspect of the distal tibia, consistent with a partial nonunion; however, the remainder of the fracture appeared well-healed ().\nA CT scan was obtained for further evaluation and showed a tubular channel running through the lateral cortex of the distal third of the tibia, at the previous fracture site (). The appearance was consistent with entrapment of the neurovascular bundle, warranting further imaging with an magnetic resonance imaging (MRI) ().\nMRI demonstrated the anterior tibial artery and deep peroneal nerve embedded within the lateral distal tibial cortex ().\nGiven the patient’s persistent pain at the fracture site and concern for entrapment of the neurovascular bundle in the setting of partial nonunion, surgical intervention was offered. The decision was made to proceed with exploration and removal of the neurovascular bundle from within the cortical bone. We discussed that if the artery appeared to be coursing through the bone, it would likely not be functional. Given his foot remained well perfused, bypass was not planned (even if the anterior tibial artery was nonfunctional).\nA longitudinal incision was made along the distal third of the anterior tibial crest of the left leg. Sharp dissection was carried down through the floor of the anterior tibialis tendon sheath. The periosteum was elevated using a Cobb elevator, to expose the anterior tibial artery and deep peroneal nerve. Exploration of the deep peroneal nerve showed it to be adherent to the periosteum, but not encased within the bone. The nerve was mobilized and neurolyzed throughout the entire zone of injury. The nerve was protected for the remainder of the procedure. The anterior tibial artery was encased in bone, entering the tibial cortex approximately 9 cm above the tibiotalar joint and exiting approximately 4 cm above the tibiotalar joint ().\nAn osteotome was used to create a trough in the tibia, extending from the entrance and exit points of the anterior tibial artery. The artery was easily removed from the bone after creation of the trough and was left in continuity. The artery was found to be non-pulsatile when the tourniquet was released. The patient was placed in a soft dressing and allowed to weight bear as tolerated in a walking boot.\nThe post-operative course was uncomplicated. The patient was seen at 6 weeks postoperatively. He reported significant improvement in his pain compared to preoperatively. He had been wearing the boot while out of the house. He had not yet returned to sporting activities. Examination at that time showed no motor or sensory deficits and a normal vascular exam. Radiographs showed the cortical defect along the lateral distal tibia with signs of ongoing healing at the fracture site ().\nThe patient was allowed to gradually return to his activities. He will be seen again at 6 months postoperatively.

An 80-year-old male was referred to us with squamous cell carcinoma of the left pre-auricular area that was confirmed through incisional biopsy (). The patient was suffering from occasional bleeding, discharge, and repeated ulceration of the lesion. We performed computed tomography of the head and neck region before surgery, which showed no evidence of invasion. We performed wide excision of the tumor with a 0.5 cm lateral margin throughout. We obtained a safe margin of depth without parotid gland injury even though the tumor bed was close to the parotid gland fascia (). However, we could not completely rule out micro-injuries to the parotid gland fascia although we reserved parotid gland fascia. After wide excision, the skin defect was covered with a 5×6 cm full thickness skin graft from the left inguinal area. The usual compression dressing with a tie-over suture was applied to maintain the skin graft.\nOn the fifth postoperative day, we discovered exudate from the base of the skin graft through the slit incision site (). The dressing materials were wet and the discharge from the operative site increased during meals. The amount of discharge was approximately 50 mL, and its amylase level was 200,000 unit/L. Accordingly, we confirmed the exudate was salivary discharge and he was diagnosed with a sialo-cutaneous fistula.\nWe decided to use botulinum toxin type A injection because of concern for graft failure due to increased sialorrhea that was not controlled by conventional compression dressings. Using a tuberculin syringe, we administered a transcutaneous injection of 25 IU of the toxin at a point 0.5 cm above the site of the fistula at the surgical incision line and administered another 25 IU injection 0.5 cm anterior from that point. The injections were performed only for the superficial parotid gland in order to avoid post injection facial nerve paralysis. The discharge draining from the sialo-cutaneous fistula was considerably reduced after the second day of injection. The patient fully recovered within a week without any complications such as graft shearing or failure ().

A 55-year-old male who was a known case of cancer of floor of mouth came to the outpatient department with complaints of difficulty in swallowing and burning sensation in the oral cavity for the past 3 months. The pain was insidious in onset, burning, and stinging in nature and radiating to the earlobe. The patient reported that he had not taken his meals properly for the past 10 days and appeared very distressed. He reported restriction in mouth opening and alteration of taste for the past 3 months. He, therefore, was not on any medications as oral intake was very poor. He revealed that he had consumed lice poison (pyrethrins) 5 days back, while feeling hopeless due to his pain.\nThe patient was diagnosed 1 year ago, when he presented in the head and neck clinic with an ulcer in the floor of his mouth for 6 months. He had also noticed swelling in the neck for the same duration. The patient noticed a change in voice for the past 1 month, and he also reported that recently a painful ulcer had developed inside his right cheek. He was evaluated by a biopsy which revealed moderately differentiated squamous cell cancer.\nPatient was planned for palliative radiotherapy and received five fractions recently. His previous radical radiotherapy session was in September 2017.\nThe patient reported that he developed severe ulceration and burning sensation in his mouth after his radiotherapy.\nThe patient had been a follow-up case of pain clinic since 2016 and was started on morphine 4 h along with adjuncts such as paracetamol and gabapentin, and the dose was subsequently increased after the period when he received radiotherapy. He was late to his follow-up this time, admitted that due to some personal issues, he could not come on time.\nOn speaking with him alone, he confessed that he consumed the poison when he was alone and was suffering from intolerable pain. He repeatedly ensured that there was no emotional distress that he suffered other than the pain. He was thankful to God that his family members were very supportive. There were no attempts like this in the past.\nOn discussion with his eldest son who was accompanying him, his statements echoed with what his father had told. He was upset that his father resorted to poisoning himself because of the pain and requested painkillers. He told that he has never left his father's side since then.\nA personal history showed that the patient was a smoker for the past 40 years, 1 pack/day. He was an alcoholic for the past 40 years and had a consumption of about 50 ml every day. The patient also reported disturbed sleep for 6 months.\nA history showed that the patient was a diabetic, diagnosed 6 months ago. He was not on any antidiabetic medication.\nA psychosocial history showed that the patient had four children, of them two were married. Two girls who were married lived with their families in the same town. The patient had a supporting wife; both the husband and the wife lived with their two sons and their families in the same house. The family knew about the diagnosis and were involved actively in the treatment since the diagnosis of the disease.\nOn examination, the patient seemed anxious, avoided eye contact, and was teary during the whole conversation. He was conscious, oriented, and alert. There was mild pallor. There was an ulceroproliferative growth 6 cm × 5 cm in the floor of the mouth on the undersurface of the tongue with restricted mouth opening, admitting only two fingers. There were areas of white patches involving the buccal mucosa and the tongue. There were intermittent areas of erythema over the buccal mucosa as well as the lips. There was no bleeding. There were multiple ulcers present on the floor of the mouth, the buccal mucosa, and the hard palate. Oral mucositis WHO grade IV was present. The oral hygiene was poor. There was halitosis.\nThe patient was admitted in the ward and he was started on morphine infusion. The intravenous infusion was titrated according to the patient's response. He was advised triple gargle (concoction containing syrup Benadryl, lignocaine viscous, and sodium bicarbonate is an indigenous preparation used in low-income countries for oral hygiene) six times a day and was instructed to maintain proper oral hygiene. The patient was counseled on a daily basis and his mental functioning was noted on the basis of being able to perform his daily activities, and his spiritual and psychosocial pain was addressed. A psychology consult in this patient was not deemed necessary as the suicide attempt was due to pain and the patient when admitted in ward was under full supervision, while being titrated with pain medication.\nThe patient was seen on follow-up visit after 2 weeks and was found to be feeling better. He seemed pain free. He reported that he was more functional after the discharge and felt happy about himself and his family.

A 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.\nThe patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.\nOn examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular region. We suspected the sinus track may originate from the dislodged appliance embedded in the cheek soft tissue. A periapical view was then taken with gutta-percha inserted into the sinus for foreign body localization purpose. The radiograph revealed the gutta-percha pointed towards the site of titanium plate and screws placed used for rigid fixation, and with the molar orthodontic tube appliance in its vicinity (). A cone beam CT was performed to provide a 3D detailed location of the appliance (Figures and ) and confirmed it to be located outside the maxillary antrum.\nThe presence of the molar orthodontic tube foreign body reaction was suspected as the most probable cause of the recurrent right cheek pain and swelling associated with an intraoral discharging sinus. Exploration of the site was performed through the sulcular incision under general anesthesia. The dislodged molar tube was identified lying on the zygomatic bone just beneath the raised flap. It was removed by dividing some surrounding fibrous tissue strands. Just below it, one titanium straight bone plate with four screws used for fixing the previous Le Fort I osteotomy site was inspected and found to be rigidly embedded in normal bone. However, a decision was made to remove them based on the fact that they are present in an infected area. (). The Le Fort I osteotomy site showed good healing with new bone formation. Patient had an uneventful recovery thereafter, and the orthognathic surgical team who attended him previously was informed of his progress.

A 52-year-old female achondroplasia patient (body height 130 centimeters) was referred for orthopaedic treatment with a symptomatic leg length difference after bilateral total hip arthroplasty. Her medical history contained psoriasis and atopic dermatitis, as well as several orthopedic operations in the course of her underlying disease. During childhood and adolescence, she had undergone several surgical procedures due to recurrent bilateral dislocation of the patella including bilateral varus osteotomy of the distal femur. Apart from orthopedic issues, no other complications from achondroplasia were apparent.\nDysplastic cox arthrosis affecting both hip joints had been treated with bilateral hip replacement surgery. The first prosthesis was implanted on the right hip without any perioperative complications eight years prior to presentation at our clinic. Hip replacement surgery on the left side was carried out six years after total hip arthroplasty on the right side. A postoperative overlength of five centimeters of the left femur resulted whereas prior to the procedure the leg length had been balanced out.\nAt our clinic, the patient presented with a limping gait pattern and complained about constant pain in the left hip ¡oint as well as intense and motion dependent lower back pain. Activities of daily living were possible only with extreme difficulty. A heel elevation of three centimeters had been tried temporarily on the right side, but did not prove to be sufficient for the patient. Both hip implants were found to be stable with no radiological signs of loosening. A postoperative overlength of the left femur (70 centimeters versus 65 centimeters) was apparent while the tibiae were of approximately equal length with both leg axes in slight (normo)-varus positions.\nThe patient had become well adapted to her short stature during lifetime and did not feel any strain for increasing her body height. Now she was eager to cope with everyday life again - as she had been before her second total hip arthroplasty. The possible therapeutic options were evaluated and discussed with the patient. We advised for right leg lengthening. The patient strongly opposed and refused the operation, mentioning friends with short stature history who underwent lengthening procedures. She did not want to “suffer the same complications” and lengthening treatment schedule.\nInformed consent for a distal femoral shortening osteotomy of the left lower limb was obtained. Shortening of the distal femur by five cm was performed using a Low Compression Plate with angle stability (LCP DF, Synthes, Solothurn, Switzerland) for osteotomy fixation. There were no perioperative complications. In the postoperative course, the patient was instructed in 15 kilograms weight bearing and was mobilized with full range of motion. The patient was discharged in good medical condition with clean wound conditions four days after surgery. At the follow-up six weeks later, the patient presented with a balanced leg length. Three month after surgery the osteotomy was healed and the patient was allowed full weight bearing. Walking without crutches was reached four months after the operation.\nOne year after surgery, the control radiograph showed a fully consolidated osteotomy. In the gait analysis, the gait pattern was normal showing no signs of instability and the patient managed walking on uneven ground without difficulty. The straight leg raise test was performed without any signs of a muscular deficit. During the chair rising test, neither assistance nor support by the upper extremity was needed. Active bending of the knee joint was performed with good muscular strength. The patient was entirely satisfied with the postoperative result.

A 45 year old woman had a bariatric gastric bypass surgical operation. A few years before the operation she had a weight of 192 kg (BMI 65). Over a two years period she was able to reduce her weight to 149 kg. This preoperative weight of 149 kg was stable over the last four months before the gastric bypass operation. She had a medical history of insulin-dependent diabetes mellitus and severe psoriasis. She had also been hospitalised with erysipelas and ulcers on the lower extremities a few years prior to having gastric bypass surgery.\nThough she received postoperative advice from a dietician about the importance of eating a vitamin rich diet, she continued with an insufficient diet in order to obtain further weight loss. Three months postoperatively she had lost further 20 kg in weight. At the same time she began to develop painful swelling, bruising and small ulcers on the lower extremities. She was hospitalised at the local hospital with fever one week after these symptoms appeared. Within the next 24 hours she developed purpura on the lower extremities and a sepsis like condition. Due to this she was transferred to Intensive care unit (ICU) at Odense University hospital. Within days she developed multiple organ dysfunction syndrome with cerebral, respiratory, circulatory and renal failure. It was necessary to intubate and ventilate the patient and renal failure was treated with continuous renal replacement therapy (CRRT). To restore the circulation it was necessary to treat the patient with a large amount of intravenous fluids and vasopressor agents. Infected leg ulcers were suspected to be the focus for sepsis. After appropriate samples of blood and secretion were taken for cultures, broad-spectrum antibiotic was initiated. No bacteria occurred in the cultures and the patient showed no signs of improvement on antibiotic therapy. In contrast the changes in the skin progressed with increasing erythema, and ecchymosis forming a painful, confluent purpuric plaques and bullae. Minimal trauma to the skin resulted in petechiae and confluent purpuric plaques. It was estimated that 30% of the skin was affected by confluent purpuric plaques. As a result of these haemorrhagic bullae the patient was continuously bleeding from the skin. On the worst days the blood loss from the skin was estimated to be 61 per day. In addition to blood loss the patient lost a large amount of fluid from the skin-estimated on the worst days to be 201 per day. The patient’s lips were covered with haemorrhagic crust but no major gingival bleeding was observed. Skin biopsy was performed. This biopsy showed diffuse extravasation of erythrocytes but no hyperkeratosis or “corkscrew hair”. The subdermal tissue was vital. A biopsy from the bone marrow was without any sign of malignancy.\nOver the three weeks in the ICU it became obvious that the skin changes and the massive loss of blood and fluid from the skin were not in accordance with a diagnosis of sepsis. It was proposed that the massive bleeding from the skin might be due to scurvy. A blood sample for the analysis of serum-ascorbic acid levels was taken and the patient was treated with enteral ascorbic acid at a dose of 2 g per day. The blood sample showed a serum-ascorbic acid concentration of 6.6 (normal range 26 - 85 μmol per l). After two days of vitamin-C treatment the patient’s condition began gradually to improve. The skin changes gradually disappeared, haemodynamics improved, the patient regained her renal function and could be weaned from the ventilator. A few weeks after the start of ascorbic acid treatment the patient could be transferred to the medical ward.

An 84-year-old white female underwent surgical repair of a macular hole in her left eye. The surgery consisted of a vitrectomy followed by the instillation of a mixture of C3F8 gas and sterile air into the vitreous cavity. After such a procedure, the patient is asked to maintain a face-down position for several days, which facilitates hole closure and improves vision. The gas bubble is then gradually absorbed over a period of weeks and the eye returns to a fluid-filled state. The patient's past medical history was notable for long-standing coronary artery disease, hypertension, diabetes mellitus, and a past surgical history of right carotid endarterectomy. The surgery was uneventful, but on postoperative day one the pressure in the eye was elevated. The surgeon performed an anterior chamber paracentesis to normalize the pressure. That evening the patient presented to the ED with a headache and symptomatic bradycardia with a heart rate of 25. She was noted to have high-grade AV block with AV dissociation and intermittent idioventricular escape. She underwent implantation of a dual-chamber permanent pacemaker, which corrected her dysrhythmia. During this period of time she was unable to maintain the recommended position for the retinal surgery.\nHer retinal surgeon was not informed of these events and she was ultimately seen again on postoperative day five. On that visit her anterior chamber was flat. (The iris and her intraocular lens had been pushed forward against the back of the cornea. This was an indication that the gas bubble had significantly expanded or she had been positioning improperly, with the bubble pushing up against the front of the eye rather than back toward the macular hole.) The pressure in the eye was markedly elevated to 88 (normal being up to 21). The ophthalmologist lowered the pressure to the normal range by withdrawing gas from the vitreous cavity. Later that day the patient developed acute mental status changes and again presented to the ED. A computed tomography (CT) scan demonstrated intracranial air in addition to the gas bubble in the eye (). She was referred to a tertiary care center where it was opined that the intraocular gas bubble had expanded and tracked along the optic nerve, eventually entering the brain. This was likely due to the use of an expansile gas concentration during the surgery. The intracranial air gradually resolved, as did her mental status changes, but the involved eye lost all vision due to high pressure maintained over an extended period of time.\nA case of pneumocephalus following macula hole repair has previously been published in the ophthalmology literature because it was opined that an incorrect gas concentration was instilled in the eye, resulting in marked expansion of the gas bubble []. Our case is presented here because gas bubbles are frequently used in retinal surgery, and there are specific management issues that apply to such patients in the ED. To our knowledge there is no discussion of such cases in the emergency medicine literature.

A female patient aged 11 years had reported to the hospital with her parents with complaint of presence of extra mouth since birth. They were embarrassed and had been not treated well by others in the village, thought it to be a bad omen, and came to remove it. There were no other specific problems due to the extra mouth. The patient was brushing that accessory mouth.\nOn examination there were two oral cavities, one normal and other accessory.\nOn extra oral examination of the normal oral cavity, the upper and lower lips were normal. The maxilla was normal. The mandible was asymmetrical due to the bony prominence.\nOn intra oral examination the buccal and labial vestibules of the maxilla were normal. In mandible, the buccal vestibule was normal, but the depth of the labial vestibule was obliterated due to the prominent presence of the accessory oral cavity. The maxillary and mandibular posterior teeth were in normal occlusion, but the mandibular anterior teeth were present at the right side were inclined lingually, but in the left side lower anterior teeth were normally placed.\nThe position was elevated at the right side due to the presence of the cystic lesion of the floor of the mouth, which extends from the midline to right retromolar region. But there was no disturbance in normal swallowing. The tongue movement was normal. Speech was normal.\nOn extra oral examination, the accessory oral cavity was situated below the lower lip of the normal oral cavity on the right symphysis region. There were small upper and lower lips fused at the angle. The right angle was situated 1 cm below the right angle of the normal oral cavity and the left angle was crossing the normal midline extending ½ cm on the left symphysis region. There was skin present in between the lower lip of the normal oral cavity and the accessory upper lip.\nOn intra oral examination in the center of the accessory oral cavity there was a bony prominence with the presence of seven lower anterior teeth with gingival attachment. The base of the bony prominence was fused with the labial surface of the mandible of normal oral cavity. There were associated right and left buccal and labial vestibules. Salivary discharge too found.\nThe patient was not able to swallow through that accessory mouth and was able to move both the upper and lower lips of that accessory oral cavity and able to approximate both the lips of the same [Figures –].\nCT Examination shows excessive growth of mandible with presence of cystic swelling and radiolucency on the lingual surface of mandible extending from the midline to right angle of mandible [Figures –].\n3D CT shows excessive bony growth over the labial surface of the mandible [].\nUnder nasoendotracheal intubation first crevicular incision from 32 to 43 was put and labial gingiva with alveolar mucosa was reflected completely and bone exposed to lower border of mandible. During the procedure labial mucosa attached to the bony prominence over accessory mouth was incised and bony prominence was brought to normal oral cavity.\nThere were seven teeth resembling lower permanent anterior teeth. Then excision of accessory lips was done around the vermilion border. Inside the oral cavity 41 was extracted and through that socket osteotomy done. Vertical incisions were put over 41 extracted site and between 43 and 44 and horizontally connected half cm below the lower border of bony prominence of accessory mouth. The lesion was displaced lingually and mylohyoid muscle exposed and able to see dermoid cyst both below and above the mylohyoid muscle. Through the same approach excised the entire dermoid cyst. During the excision could see one small rudimentary tongue approximately 1-1/2 × 1 cm which was attached with the lining mucosa of dermoid cyst. There were multiple calcified granules and hair follicles filled with straw colored fluid. This dermoid cyst was attached on the lingual surface of the excised accessory bony prominence and there was communication from the dermoid cyst to the oral cavity. There was separate blood supply to the mouth. The excised specimen was sent for biopsy. Closure was done intraorally with 3-0 chromic catgut and normal labial lower vestibule was reconstructed. The outer skin layer was approximated with lower portion of the skin of original lower lips with 3-0 black silk. The postoperative course was uneventful and the patient went home happy [Figures –].\nRevealed teratoma with presence of multiple small bony granules and hair follicles and teeth. The rudimentary tongue too was confirmed by the pathologist [Figures –].

A 62-year-old woman was admitted to our hospital complaining of severe right abdominal pain for 4 months. A fixed stony-hard tumor of about 100 mm in diameter was found on palpation, with slight tenderness on the right side of her abdomen. A full blood examination gave values within the normal limit. Abdominal CT showed a large mass with diffuse calcification of size about 130 × 110 mm in the right retroperitoneal space between the right kidney and the inferior vena cava, with slight hydronephrosis (). Lymph node swelling, ascites, liver tumor, and lung tumor were not detected by chest and abdominal CT, and the patient had no history of trauma or radiation therapy at the tumor site. However, the patient had undergone bilateral resection of tumors of the adrenal glands on the left side at the age of 46 years old and on the right side at at the age of 50 years old. Pathological findings revealed that both adrenal gland tumors were pheochromocytoma and no adjuvant therapy was administered. This led to a preoperative diagnosis of recurrent pheochromocytoma or retroperitoneal osteosarcoma or leiomyosarcoma. There were no carcinomas or sarcomas in her history or in her family history.\nComplete surgical resection of the primary tumor was performed. The tumor was situated behind the mesenterium of the ascending colon, compressing the right kidney, but no direct invasion of the surrounding organs was observed: there was no lymph node swelling, ascites or peritoneal dissemination, and the tumor was not present in the parenchyma of the liver and the kidney. The surgical margin was determined based on the rough connective tissue surrounding the tumor. Dissection of lymph nodes was not performed.\nGross examination revealed a rounded, bony, and hard tumor of size about 140 × 110 × 80 mm and weight 1100 g that was yellowish-white in color (). Histologically, the tumor consisted of a mixture of dense fibrous tissue, woven bone, and atypical cartilage. Some osteoclastic giant cells were observed. Woven bone trabeculae were arranged irregularly and were anastomosed to each other. The architecture of the woven bone trabeculae displayed a reverse zoning phenomenon, with mature bony tissue in the center and less mature bony tissue in the periphery. Although the cellularity of spindle cells within the fibrous tissue was not greatly increased, these cells showed mild but definite nuclear atypism with hyperchromasia and scattered mitotic figures. There was no evidence of fatty differentiation of these cells, indicating the absence of a well-differentiated or dedifferentiated liposarcoma. Operative findings showed no continuity with skeletal bones, leading to a final diagnosis of well-differentiated (low-grade) extraskeletal osteosarcoma of the retroperitoneum (Figures and ).\nThe postoperative course was uneventful. We recommended adjuvant therapy because of the probable poor prognosis, but the patient refused radiotherapy and chemotherapy. The patient was followed up by CT every 6 months without receiving adjuvant radiation therapy or chemotherapy.\nThirty-one months after the operation, she was readmitted to our hospital due to severe pain in the lumbar region and the right lower leg. Abdominal CT revealed a large mass in the right retroperitoneal space. No calcification was seen, but recurrence of the primary tumor was strongly suspected. Surgical resection of the recurrent tumor was performed via a transabdominal approach, in which a tumor with adherence to the right kidney was completely removed, a procedure of tumor resection and right nephrectomy. Grossly, the recurrent retroperitoneal tumor adherent to the right kidney was of size 310 × 300 mm, with necrosis and hemorrhage and a yellowish-white color on the cut surface. The recurrent tumor was characterized histologically by proliferation of atypical nonepithelial cells with hyperchromatic nuclei and a high nuclear-cytoplasmic ratio. The mitotic count of the neoplastic cells was about 50 per 10 high-power fields. Anaplastic features predominated, but a few foci of matrix production looked like osteoid or hyalinized collagen within the recurrent neoplastic tissues. These findings led to a diagnosis of high-grade malignant anaplastic spindle cell sarcoma, consistent with the recurrence of extraskeletal osteosarcoma (). There were no malignant findings in the kidney. The abdominal CT scan did not show an apparent recurrent tumor until the 30th month after the initial operation and there were no established tumor markers for extraskeletal osteosarcoma. We thought that the recurrent tumor had increased rapidly in one month and the pathological findings for the tumor were compatible with this conclusion. The patient was discharged on the 18th postoperative day, but 2 months later she was re-admitted due to severe back pain. Oxycodone hydrochloride was administered orally, but gradually she complained of dyspnea and received intravenous morphine hydrochloride for sedation. Chest and abdominal CT showed a lesion corresponding to the location of the primary tumor, together with multiple lung nodules and right pleural effusion. Gradually her general status worsened and the patient died due to widespread metastasis 33 months after the initial operation.

A 33-year-old-male patient presented initially with lower abdominal pain in March 2006. He was diagnosed with appendicitis based upon his exam and history. A CT scan of the abdomen was performed at that time and demonstrated extensive inflammatory changes in the right lower quadrant with possible interloop abscess (). Two nonspecific calcifications were noted radiographically and the differential diagnosis included appendicitis, ileitis, or diverticulitis. He did not have any urinary complaints at that time. He underwent an uneventful open appendectomy and had resolution of his initial symptoms and no further follow up.\nThe patient presented again in August 2011 with right flank pain and urinary symptoms. A noncontrast CT scan of the abdomen was performed and demonstrated a right ureterovesicular junction calculus with mild right ureteral dilation (). Again, calcifications were noted near the anterior fundus of the bladder (). He was managed medically and discharged with instructions to follow up with an urologist as an outpatient.\nHe subsequently presented again 3 weeks later with severe abdominal pain and induration of his lower abdominal wall. CT imaging now demonstrated interval enlargement of a complex cystic mass inseparable from the anterior superior wall of the urinary balder and abutting the posterior margin of the abdominal wall (). The radiographic diagnosis was an urachal remnant abscess versus tumor. He denied any urologic complaints at that time. He was started on antibiotics, and surgical consultation was performed. After an extensive discussion with the patient regarding his radiographic diagnosis and suspicion of complications related to an urachal remnant, he was scheduled for cystoscopy and surgical exploration.\nAt the time of surgery, cystoscopy did not demonstrate any abnormalities of the bladder. Exploratory laparotomy was performed and an indurated mass and abscess were encountered near the area of the anterior abdominal wall and bladder. The abscess was drained and a few small calcifications were encountered and removed for pathologic examination. A complete exploration was performed and the phlegmon appeared to be limited to the dome of the bladder. This area was excised and the dome of the bladder was closed primarily in layers with absorbable suture. Drains were placed and the abdominal wall was debrided and closed. He had an uncomplicated postoperative course. Final pathology demonstrated urachal remnants with no evidence of malignancy.

Susan is a 51-year-old woman. As an adolescent, she developed scoliosis. Working as a hairstylist when she was 18 or 19, she began to have severe pain in her hands, making her work very difficult. She had carpal tunnel surgery on her right hand which provided temporary relief. Her symptoms slowly returned and she continued to have intense pain and difficulty with her daily activities. Seeking relief from her symptoms, she received treatment from chiropractors and Chinese medicine practitioners with no significant benefit. She also tried yoga and swimming but depending on the yoga movements or swimming strokes, she began to have more pain.\nWhen she was in her early forties, she began to have weakness in the lower half of her body. Her legs would frequently give out on the stairs, causing her to fall. Control of her bladder and bowel function also began to deteriorate. She had an MRI, and based on the results, she was scheduled for emergency surgery to stabilize her cervical spine and relieve spinal cord compression. She was informed that it would be an outpatient surgery and she would be home the same day.\nIn May 2011, Susan had a 6-level cervical spine fusion to stabilize her spine and relieve pressure on her spinal cord. When she woke up, she realized something was wrong. The entire right side of her body was paralyzed. What was supposed to be an outpatient surgery with a return home the same day ended up being an 8-week hospital and rehabilitation stay to learn how to walk again.\nIn August 2012, a second surgery was performed with the goal of pain relief. However, she reported her pain was significantly worse afterwards. She would receive weekly injections for pain relief that she reports would only marginally decrease her pain for about one week. She was also taking high doses of medication for nerve pain relief which she also reports provided marginal benefit. She had areas of heightened sensitivity on her legs where a bed sheet or even a gentle breeze would cause intense pain. Exposure to hot water would feel cold, and cold water would feel hot. She was unable to walk more than one block and remained in bed for over ten hours per day. She suffered extensive personal and professional quality of life losses at this time.\nLooking for relief, she tried medical yoga and received temporary relief. She also practiced traditional Tai Chi which provided minimal to no relief. She continued to have intense pain which had a significant impact on her quality of life and ability to perform daily tasks, including walking. In 2014, she tried a Qigong class and reported feeling that there was something very different about this class. Almost immediately, she felt a strong sense of relaxation that she had reportedly not found in many years. She was unable to attend many classes, so she purchased a video of the movements. Over the next year, she began to practice the exercises consistently until she could attend formal classes.\nSusan credits the practice of qigong with saving her life. She says it gave her a reason to get out of bed and socialize in the very early days of her practice. She is now able to walk with no limitations and her pain has improved by approximately 90%. Within three months of beginning qigong, she was able to stop all medications and injections she was receiving for pain relief. She continues to have some weakness in her arms and her hands, but it does not interfere with her ability to complete her daily activities. Despite her extensive cervical spine surgery, she reports full mobility in her shoulders and has nearly recovered full mobility in her neck. Her energy has also greatly improved and she routinely teaches three Qigong classes per week. In addition to this, she teaches at special events, including a Qigong class at a large yoga festival with over 1000 people in attendance. Recently, she started her first full time job in over six years.\nJames is a 70-year-old male. Over ten years ago, he was diagnosed with multi-level degenerative disc disease (DDD) in his lumbar spine, as well as severe central stenosis or narrowing of his spinal column around his spinal cord at L3-4, L4-5, and L5-S1. In 2011, he had a CT scan and was told by his physician that it would not be long until he must rely on a wheelchair for all mobility. Surgery was presented as an option, but he was informed that the success rate was less than 10%.\nHe decided to forgo surgery and take his chances. Gradually, his legs became weaker and he would fall spontaneously. He worked as a salesman and as he was talking to clients, his legs would give out without warning and he would fall to the ground. To help his situation, he would park as close as he could to the entrance of stores or other destinations and would walk with carts or holding onto shelves or furniture. This would only help for so long before he would fall again.\nHe began looking for other options to help manage his condition. In 2012, he tried yoga. While it helped to temporarily control his pain, it had no effect on the weakness in his legs and he would continue to fall. One year later, at the suggestion of his wife, he tried a Qigong class. Due to his family’s personal schedules, he was unable to attend another class for two months. He decided to purchase a video of the movements he had learned and practiced them each day for 4–5 months until he was able to return to normal classes.\nSince participating in Qigong classes, he has not fallen even once, and has no reports of pain. He stated that “Qigong gave me my life back.” He has no other medical problems to mention and takes no medications. He revealed that the improvements he has experienced have gone far beyond what he expected. Where he used to fall often and without notice, he has not fallen since he began qigong and reports that he now even has a “spring to his step, and a spring in his heart.” Not too long ago, he sustained a left rotator cuff tear. After continuing to practice qigong, he had a full return of strength and movement with no pain or difficulty with his routine daily activities, all within six months.\nIn his professional life, he felt like he was burning out as an IT programmer but practicing qigong has reinvigorated him. He was able to complete many projects (some complex) that he never would have thought possible. He has since become certified to teach Qigong and tells anyone who will listen about his story. He has also witnessed many others gain significant benefit from the practice of Qigong and is thrilled that he gets to share this with others.

We report a case of 24-year-old primigravida at 39-week period of gestation with severe kyphosis who was referred to our centre in second stage of labor with features of obstructed labor.\nThis patient was resident of remote hilly district who had history of physical assault at age of five years of life leading to vertebral fractures. She was managed with one month of bed rest and then she was mobilized without any support. She regained functional mobility but developed a hunchback.\nAt ten years of age, she developed fever, hemoptysis, swelling over back with pus like discharge, and weight loss for which she was admitted in another centre for one month and was diagnosed as a case of Pott's spine and treated with antitubercular drugs. She did not receive any formal education and used to do all household chores with no restriction in daily activities. She was married at the age of 20 years and conceived spontaneously. She became aware of pregnancy after she felt quickening at four months of gestation and went to the nearest primary health centre which was at a distance of two hours from her home on foot. She was advised to visit a better centre for risk assessment and safe confinement of pregnancy but due to monetary problem she decided to go only after term. She presented to the primary health centre at 39 weeks after one day of labor pain and leaking per vaginum for 48 hours, at around 12 pm midday where she was found to be fully dilated and was immediately referred. She arrived at our facility at 12 midnight and when examined, she was of short stature with height of 4 feet and thin built weighing 33 kgs. Her back was severely kyphotic with large gibbus in the lumbosacral region and multiple healed sinus in the back (Figures and ). She was exhausted due to prolonged labor and her blood pressure was 150/100 mm of hg. The anterior abdominal wall was markedly protuberant and the axis of the term size uterus showed corresponding anterior angulation. The presentation of the fetus was cephalic with right occiput transverse position and the cardiotocograph was reassuring. Her per vaginum findings were consistent with those of kyphotic pelvis with features of obstructed labor with flat sacrum, narrow outlet, and subpubic angle, the station of the head was −2, there was a large caput succedaneum and moulding, and the liquor was meconium stained. The patient was dyspneic and occasional crepitations could be auscultated in bilateral lung fields and normal cardiac auscultation. Since the patient presented in advanced labor pulmonary function, tests could not be done prior to delivery. As vaginal delivery was not possible, she was immediately taken up for emergency caesarean section. Since the deformity was present in the lumbosacral region with no previous evaluation, spinal anesthesia was not contemplated. General anesthesia was given by using rapid sequence induction with propofol. Caesarean section was done by giving paramedian skin incision. Lower segment uterine incision was used and baby was delivered by reverse breech extraction. It was a 3.7 kg male baby, vigorous at birth, but was admitted in nursery for observation for meconium aspiration syndrome. There was atonic postpartum hemorrhage which was managed with uterine massage, uterotonics, and bilateral uterine artery ligation. Intraoperatively, one pint of blood was transfused. Keeping in view the risk to the health of the patient in subsequent pregnancy, even option of tubal ligation was discussed with the patient and her husband prior to caesarean but they refused to give consent for ligation. Intraoperatively, bladder was found to be edematous and pulled up so catheterization was done for 14 days. Postoperative period was uneventful. Blood pressure normalized after delivery and patient was able to ambulate from second postoperative day. Postoperative hemoglobin was 9.4 mg/dL. Baby was shifted out from nursery on second day and breastfeeding was initiated. Suture was removed on tenth day and wound healing was good. X-ray done after delivery showed reversal of normal curvature of spine with lordosis in thoracic region and kyphosis in lumbar region (). Pulmonary function test showed mild restrictive pattern. Patient was discharged on persistent request on 10th postoperative day with catheter in situ and she was advised to follow up at the primary health centre as she cited inability to commute to our centre.

A 24-year-old pregnant woman (gravida 3, para 0) with a 6-year history of septate uterus presented to the emergency room with premature rupture of the membranes and the threat of premature labor for 9 hours. In her personal medical history, she had used misoprostol for medical abortion 6 and 3 years previously. There was no history of smoking, alcoholic beverage consumption, or drug abuse during the pregnancy, and no hereditary anomalies were identified in her family.\nA male neonate who weighed 2400 g was born at 34 weeks and 4 days of gestation by cesarean section. His Apgar scores were 10 at 1 minute and 10 at 5 minutes. At birth, we noticed an amniotic band that consisted of a layer of annular amniotic tissue approximately 1 cm wide, which was tightened around the upper third of the right upper limb. The distal limb displayed cyanoderma, edema of the extremity, and focal peeling, with no autonomous activities or reactions of tenderness (). An X-ray showed a negative result for the humerus, but clear swelling of the soft tissues (). During the operation, the space between the amniotic band and upper limb skin was carefully separated and the band was cut off directly. The neonate was then transferred to the neonatal intensive care unit. Four hours later, swelling of the right limb was further aggravated, the radial artery could not be reached, and the local skin color did not improve. Hypoperfusion of the limb was continued and the limb remained insensate without motor compromise (). We considered the possibility that further necrosis of the limb and local toxin absorption could lead to death of the neonate. We decided to amputate the upper third of the right upper extremity. The patient was relatively stable during anesthesia and successfully underwent surgery (). No severe complications occurred after the operation. The incision was almost healed without infection, dehiscence, or other complications, as observed by postoperative X-ray images (). The neonate recovered rapidly and was discharged 9 days after surgery. The stitches were removed 14 days after surgery. The patient was followed up at 1, 3, and 6 months post-surgery, with no complaints of pain or clinical evidence of infection or further limb necrosis.

The index patient was a 34-year old female referred to the bariatric clinic by the general practitioner on her own request to treat her morbid obesity. She was born with a normal birth weight but large head circumference for which she never had a diagnostic analysis. At the age of five, her body weight was already significantly higher compared to her peers. No specific life events could explain her obesity. Cognitive development was normal and she followed normal education. She underwent treatment for recurrent nasal polyps. Her mother also had a large head size and suffered from morbid obesity as well. She was diagnosed with thyroid cancer and died from a pulmonary embolism after placement of an Adjustable Gastric Band. A maternal aunt was diagnosed with breast cancer before the age of 50 and the maternal grandmother died from breast cancer at young age. The younger sister of the index patient was overweight and was reported to also have a large head size (Figure ).\nSince childhood, the index patient followed several different coaching programs to change her eating behavior and exercise pattern to induce weight loss. She lost weight several times but was never able to maintain her weight loss. At the time of the intake procedure at the bariatric clinic, her height was 1.69 m (SD −0.2) and weight 164 kg (SD +6.8), resulting in a Body Mass Index (BMI) of 57.6 kg/m2 and a predominant abdominal obesity. Head size was not measured at that time since this is not part of bariatric screening procedures. Biochemical analysis of the blood revealed no abnormalities, and excluded endocrine hormonal disorders such as hypothyroidism. The fasting glucose level was 5.9 mM.\nThe combination of early onset morbid obesity resulted in suspicion of a genetic cause of her obesity. She was offered diagnostic genetic analysis of 52 obesity–associated genes to identify a possible underlying genetic obesity cause.\nThe patient was eligible for bariatric surgery and underwent a sleeve gastrectomy without complications (performed in 2014 using a standardized fashion). At 1, 2 and 3 years after surgery, she achieved a percentage Total Body Weight Loss of 39.4, 48.8 and 44.9, respectively. This resulted in a current BMI of 30.1 kg/m2. This was within the range of the results which were observed in a control group of 18 female patients, with a negative obesity genetic test result. These female patients were matched for age and BMI and achieved a percentage Total Body Weight Loss (TBWL) of 30.3 after 1 year, 31 after 2 years and 30 after 3 years of follow-up.\nA few months after surgery, the result of the obesity gene panel analysis was returned and showed heterozygosity for a known pathogenic mutation in the PTEN gene (): c.202T>C p.(Tyr68His). This mutation has been described previously in patients with PTEN Hamartoma Tumor Syndrome (PTEN HTS) (Marsh et al., ). No other pathogenic mutations were shown in the remaining 50 obesity–associated genes (Table ). At the genetic clinic, a head circumference of 63 cm (+5SD) and pedigree analysis (family history of multiple tumors) further supported the molecular diagnosis of PTEN HTS.\nAccording to the PTEN HTS guidelines, patients with pathogenic PTEN mutations are advised to visit the outpatient clinic for familial tumors, for lifelong surveillance of tumors that are associated with the PTEN mutations (Dutch Guidelines, ; Eng, ). Our patient underwent additional biochemical laboratory- and ultrasound screening to exclude thyroid gland carcinoma. Besides a few benign nodules on the ultrasound, no abnormalities could be determined. A yearly follow-up ultrasound of her thyroid gland and yearly serum thyroid stimulating hormone analysis was advised. Screening for breast, endometrium and colorectal cancer, also revealed no anomalies.

A 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.\nThe patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.\nOn examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular region. We suspected the sinus track may originate from the dislodged appliance embedded in the cheek soft tissue. A periapical view was then taken with gutta-percha inserted into the sinus for foreign body localization purpose. The radiograph revealed the gutta-percha pointed towards the site of titanium plate and screws placed used for rigid fixation, and with the molar orthodontic tube appliance in its vicinity (). A cone beam CT was performed to provide a 3D detailed location of the appliance (Figures and ) and confirmed it to be located outside the maxillary antrum.\nThe presence of the molar orthodontic tube foreign body reaction was suspected as the most probable cause of the recurrent right cheek pain and swelling associated with an intraoral discharging sinus. Exploration of the site was performed through the sulcular incision under general anesthesia. The dislodged molar tube was identified lying on the zygomatic bone just beneath the raised flap. It was removed by dividing some surrounding fibrous tissue strands. Just below it, one titanium straight bone plate with four screws used for fixing the previous Le Fort I osteotomy site was inspected and found to be rigidly embedded in normal bone. However, a decision was made to remove them based on the fact that they are present in an infected area. (). The Le Fort I osteotomy site showed good healing with new bone formation. Patient had an uneventful recovery thereafter, and the orthognathic surgical team who attended him previously was informed of his progress.

A 40 year old woman was admitted to the obstetrics ward during the 25th week of gestation to adjust her anticoagulation regimen. She was gravida 2, with one previous miscarriage and had a metallic mitral valve prosthesis as a result of a childhood episode of rheumatic fever. Except for her cardiac disease, which was under control, she led a normal life and was employed as a social worker. This woman discovered that she was pregnant in the first trimester of gestation, and without consulting her physician, stopped using her anticoagulants. She was late in initiating antenatal care and consequently her referral to a specialized antenatal clinic was also delayed. When she was in the 25th week of gestation, she reached the third level of care and was admitted to the obstetrics ward where she was prescribed 10,000 units of unfractionated heparin twice a day. During her third night in the hospital, after receiving subcutaneous heparin for almost 72 hours (at that time the dose had been increased to 12,000 units twice a day), she developed headache, nausea, vomiting and mental confusion. At that time, physical examination revealed a stiff neck, but no focal neurological deficits were noted. The patient's pupils showed isocoria and were reactive to light, and she had a Glasgow coma score of 11. During this initial phase of hospitalization, her blood pressure and pulse remained within the normal range. APTT (Activated Partial Thromboplastin Time) was 57 seconds. A computerized tomography scan displayed an intraparenchymatous haematoma with bloody obliteration of the ventricles. The patient underwent neurosurgical drainage of this lesion and was admitted to the obstetrical intensive care unit, where postoperative care and ventilatory support was continued. During the following hours, her neurological status deteriorated progressively and on the following day, the patient appeared to have gone into a non-reactive coma with no sign of brainstem activity. Maternal brain death was confirmed by a transcranial Doppler scan of the cerebral arteries. At that time, foetal weight was estimated at 660 g according to ultrasound evaluation. After the diagnosis of brain death, the situation was explained to the woman's family, who informed the medical team that the deceased woman had legally registered her desire to posthumously donate her organs. In view of the deceased woman's wishes and the status of the foetus, a conservative approach was adopted by the medical team, and the necessary measures to prolong maternal homeostasis were implemented.\nWe assumed that brain death would have resulted in a condition of panhypopituitarism caused by loss of the hypothalamic-pituitary axis function. Accordingly, enteral replacement of thyroid hormone and cortisol (prednisone) was carried out. The patient also developed a persistent state of hyperglycemia that was treated with continuous intravenous insulin. Diabetes Insipidus was treated with enteric desmopressin (DDAVP), and diuresis and serum sodium were used to titrate the dose of DDAVP.\nThe patient developed mild hypotension, which was initially treated with crystalloid and colloid replacement to maintain central venous pressure between 14 and 18 centimetres of water, plus low doses of norepinephrine. A moderate but persistent bradycardia was initially treated with dopamine and later with low doses of epinephrine. Pressure-limited mechanical ventilation was used to manage mild respiratory alkalosis (CO2 = 32 mmHg) and an arterial oxygen saturation greater than 94%.\nBasal energy expenditure (BEE) was calculated using the Harris-Benedict formula (BEE = 655 + [9.6 × weight(kg)] + [1.8 × height(cm)] - [4.7 × age(yr)]), multiplied by 1.25 (stress factor for pregnancy), adding 300 Kcal for a single foetus and deducting 15% from the BEE to compensate for the reduction in metabolism associated with the state of brain death []. Enteral nutrition was used to provide the total daily calorie requirement.\nHypothermia was a major feature during this period and was treated with passive heating using an air heater and blankets to maintain temperature > 36°C. After ten days of somatic support, the patient developed ventilation-associated pneumonia, which was treated with ceftriaxone, and a tracheotomy was performed to facilitate bronchial hygiene and mechanical ventilation.\nFoetal well-being was thoroughly evaluated by electronic foetal heart rate monitoring, foetal Doppler velocimetry and biophysical profile. Betamethasone was used to accelerate foetal lung maturity. During a total of twenty-five days of prolongation, the maternal organism remained mostly stable. Nevertheless, in the last week of prolongation progressive oligohydramnios was detected in the foetus and a Doppler test revealed centralization (brain sparring). Foetal status helped in reaching the decision to perform a Caesarean section at that moment. It is possible that, even at the low doses used, the vasoconstrictors may have contributed to the functional placental insufficiency by constricting the uterine vessels, resulting in placental hypoperfusion. A male infant was born weighting 815 g, with an Apgar score of 9 and 10 in the first and fifth minutes, respectively. Following delivery, the premature newborn was admitted to the neonatal intensive care unit. He required no mechanical ventilation and had no major complications. Some hours after delivery, the maternal organs were removed for donation. The baby was discharged from hospital weighing 1850 g at 40 days of life. Re-evaluation of the infant during a follow-up visit at 90 days of life revealed normal development and no detectable sequelae.

A 26-year-old healthy woman had developed papules and nodules on the right arm 6 months ago. Despite treatment with short course systemic antibiotics the lesions had enlarged and gradually extended to the forearm and hand and also to her fingers. She was referred to us for the evaluation of the eruption. The patient was not febrile and denied having been scratched by any cat. She had had no previous illness nor received any immunosuppressive drugs. On physical examination, multiple tender erythematous angiomatous papules and nodules in a grouped pattern were seen on the extensor aspect of the right arm that extended to the distal part in varying sizes of 1 to 2 cm in diameter []. The remainder of her skin was essentially normal, with no signs of a blistering or erythematous background. There was revealed painful axillary lymphadenopathy on general examination. There was no sign of a mucous membrane lesion or hepatosplenomegaly. It became evident that she also suffers from severe pruritus and occasionally bleeding in the papules. Routine laboratory blood tests, CD4 count were normal. ELISA tests for HIV were negative. No evidence of other immunosuppressive status was revealed by various systemic examinations. Histopathological examination showed an epidermal collaret with mild hyperkeratosis with focal parakeratosis and crust formation. In the dermis, proliferation of blood vessels and inflammatory cells were seen. The vascular component in the upper dermis was constituted by thin-walled vessels lined by plump, and deeper are small and thick-walled vessels []. The inflammatory cells were composed of lymphocytes and some eosinophils and neutrophils. In some areas eosinophilic granular material was present. The silver stain revealed a small number of bacilli like organisms []; we diagnosed the patient's eruption as BA. A cutaneous lesion did not respond within 4 weeks of adequate oral erythromycin, so the patient was treated with oral clarithromycin 500 mg twice daily (second- line of treatment) and in order to control the sever with pruritus doxepin 25 mg once daily which resulted in significant improvement over a 3 month treatment period []. The patient is now, 3 months after treatment, living her normal life without experiencing any problems or showing any signs of the recurrence of the disease.

A 57-year-old male Han Chinese patient was admitted to our hospital in September 2018 due to neck discomfort. Physical examination on admission showed a local bulge on the right side of the neck, while the trachea was shifted to the left. Clinical examination revealed a large lump on the right lobe of the thyroid gland, which was approximately 5 × 4 cm in size. His previous medical history showed that he was admitted to the hospital in June 2007 due to painless hematuria and was diagnosed with right renal carcinoma. He then underwent radical resection of the right renal carcinoma. Postoperative pathological examination showed a moderately differentiated right ccRCC (stage III), and the patient did not receive further treatment after the operation. The re-examination of kidneys was done every year through ultrasound, which showed no abnormal echo in the right renal fossa. Ultrasound examination in July 2012 in our hospital showed the presence of multiple thyroid nodules, and the size of the largest nodule was about 1.2 × 0.6 cm, which was present in the right lobe with a clear boundary and homogenous echo. The patient refused the treatment because he was asymptomatic. Color ultrasound examination of thyroid in March 2015 revealed that the size of the largest nodule with clear boundary in the right lobe was about 2.5 × 1.3 cm, but the echo was heterogeneous, and small patchy fluid sonolucent area was found in the lesion. Color Doppler flow imaging (CDFI) showed circular blood flow signals around the nodule and poor blood flow signals inside the nodule (Fig. ). So, re-examination by ultrasound was suggested due to his previous medical history. The results of the ultrasound examination conducted in September 2018 showed an evident increase in the volume of the right thyroid lobe, and the shape of the right lobe also remained abnormal. The thickness of the right lobe was 4.6 cm. Multiple hypoechoic nodules were detected in the thyroid gland, and the size of the largest nodule was about 5.6 × 3.7 cm (in the right lobe, and was merged with several nodules), in which the boundary was unclear, and the internal echo remained heterogeneous. In addition, dotty calcification and irregular fluid sonolucent area were also found. The results of CDFI showed relatively rich blood flow signals inside and around the nodule (Fig. ). CT showed an oval lesion with slightly lower density in the right lobe of the thyroid, and the area of the maximum cross-section was about 5.1 cm × 4.3 cm. The density inside the lesion was slightly uneven, with a mean CT value of about 30 Hu, and multiple sand-like calcifications were found (Fig. ). Laboratory examinations revealed serum free tri-iodothyronine (T3) of 5.45 pmol/l, serum-free tetraiodothyronine (T4) of 7.72 pmol/l, serum thyrotropin (TSH) of 1.01 uIU/ml, thyroglobulin antibody (TGA) of 0.00 IU/ml, thyroid peroxidase antibody (TPOA) of 0.70 IU/ml and parathyroid hormone (PTH) of 23.50 pg/ml.\nAs thyroid metastasis from ccRCC is very rare, and the patient had a long history of a thyroid nodule, thyroid metastasis was not considered, and so the patient was initially diagnosed with nodular goiter. The patient chose surgical resection and refused a preoperative fine needle aspiration cytology (FNAC) examination to confirm the pathology. Bilateral partial thyroidectomy under general anesthesia was conducted. Intraoperative frozen pathological examination showed clear cell carcinoma in the right lobe of the thyroid gland, which was surrounded by benign thyroid tumors and accompanied by borderline tumors in the left lobe. Therefore, total thyroidectomy and lymph node dissection in the central neck area was conducted. The postoperative pathological examination showed clear cell carcinoma in the right thyroid tissue (tumor size: 4 × 3. 5 × 3.5 cm), and nodular goiter accompanied with non-typical follicular adenoma around the clear cell carcinoma and no metastasis in one of the lymph nodes in the central neck area of the left lobe. Immunohistochemistry revealed CKAE1/AE3 (+); Vimentin (+); CD10 (+); CK8/18 (partially +); CK7 (-); CK19 (-); Galectin-3 (-); CD117 (-); RCC (-); TG (-); CT (-); PTH (-); P53 (+), and S of 8%; and Ki-67 (+) and S of 15% (Fig. ). According to immunohistochemistry findings and previous medical histories, the patient was confirmed with the diagnosis of thyroid metastasis from ccRCC. The patient recovered well from the operation and was advised to receive targeted therapy in the Oncology Department. However, the patient refused further treatment considering financial issues. The patient was followed up for 2 years and had not developed any additional metastasis. This case report was approved by the Ethics Committee of Zibo Central Hospital and the patients informed written consent.

A 19-year-old female was treated in our clinic in 2012 because of an ACL rupture. She had twisted and injured her knee in the guard position during a judo match. Preoperative physical examination revealed a Lachman test score of 3+ and a KneeLax examination, in which a 132 N force was applied, showed a 10-mm slippage of the affected knee compared with the unaffected one. The diagnosis of ACL tear was confirmed using MRI. The patient underwent arthroscopic anatomic double-bundle reconstruction using hamstring tendons in a surgical procedure that was the same as that described in case 1.\nPostoperative CT revealed that the distance between the TR button and the exit of the tunnel on the lateral femoral cortex was 0 mm for the AM bundle and 0.5 mm for the PL bundle (). She undertook routine rehabilitation. At six months after the operation, she felt a slight lateral knee pain on the TR button of the PL bundle. However, she was able to carry out her routine rehabilitation schedule and return to playing judo. One year after the surgery, she could play judo and participate in competitions, but the lateral pain did not disappear and a slight swelling occurred on the lateral side of the knee. The lateral pain was not dependent on the knee flexion angle. She wanted to remove the TR buttons at the time of the second arthroscopy. TR buttons of both AM and PL bundles were removed; that of the PL bundle was just beneath the ITB. In addition, the adjustable loop in the TR of the PL bundle had partially worn out, and therefore was easily removed. A second arthroscopic evaluation of the graft indicated that the reconstructed ACL had good synovial coverage and rigid tensioning and the graft had been incorporated into the femoral bone tunnel. After removal of the TR button, graft tensioning and incorporation did not change and the lateral knee pain immediately disappeared. Therefore, we considered that the lateral pain was related to irritation between the TR button of the PL bundle and the ITB as in cases 1 and 2. The patient could finally return to performing judo.\nThis study had Institutional Review Board approval and informed consent was obtained from the patients.

A 12-year-old boy presented to the oral and maxillofacial surgery department of our institution with swelling in lower jaw since 6 months, which progressively increased in size and was painful. It was diagnosed to be dentigerous cyst that required excision due to its painful symptomatology. He was an established case of Duchenne muscular dystrophy since childhood and was confined to wheel chair since then. The child had no history of recent upper respiratory tract infection or previous anesthetic exposures. On physical examination, the weight of the child was measured to be 48 kg and he had wasting of muscles in both the lower limbs with motor power of grade II. Airway examination revealed mouth opening of >3 cm with modified Mallampati grade of II, normal thyromental and mento-hyoid distance and normal range of neck movements []. Examination of the back revealed a mild scoliosis involving the thoraco-lumbar region with convexity toward the right side. Cardiovascular and respiratory system examination was unremarkable. The laboratory investigations were all within normal limits except for raised creatine kinase levels of 1823 IU/L (normal 75–230). The electrocardiography showed sinus tachycardia and biventricular hypertrophy and findings of echocardiography revealed an ejection fraction of 32% with moderate depression of the left ventricular systolic function. The child was planned for excision of dentigerous cyst. During the preoperative visit, the child and the parents were highly anxious about the procedure but after careful counseling and discussion of various implications and the risks associated with general anesthesia, the parents and the child agreed to undergo the procedure under procedural sedation. The child was given nil per oral instructions according to the standard protocol and was advised tab. ranitidine 150 mg PO and tab. metoclopramide 10 mg PO in the night and in the morning 2 h before the planned procedure. On the day of procedure, the anesthesia machine was properly checked and flushed to remove any traces of inhalational agents and all vaporizers were removed. The child was shifted to the operating room and an intravenous line was secured and preloading done with 400 mL of the normal saline solution. The monitoring included five lead electrocardiography, noninvasive blood pressure (NIBP) and pulse oximetry. The child was then premedicated with glycopyrrolate 0.2 mg intravenously (IV) and fentanyl 1 μg/kg was given IV to achieve analgesia. Dexmedetomidine was administered slowly with a loading dose of 1 μg/kg over 15 min followed by a continuous infusion at 0.5 μg/kg/h throughout the surgical procedure. Lignocaine with 1 in 2 lakh adrenaline was used for local infiltration and the child was given supplemental oxygen through nasal prongs at 3 L/min. The child remained calm and comfortable throughout the procedure which lasted for 40 min and did not complain of any pain. At the end of procedure, the dexmedetomidine infusion was discontinued and the child remained sedated but arousable to verbal commands. Postoperatively, the child was observed in a high dependency unit for 2 h. The recovery period was uneventful and the child was discharged after 6 h when fully awake and responding.

A 29-year-old male patient came to the Emergency Department complaining of a sudden onset of right upper quadrant pain, which was associated with nausea and vomiting. On history the patient reported some chronic pain in the right upper quadrant, which had been present in the previous days, which suddenly had become worse prior to admission to the hospital. Past medical history was completely unremarkable. On clinical examination the patient appeared pale and in distress. Blood pressure was 80/60 mm Hg, heart rate was 120, and respiratory rate was 40. The abdomen was painful with guarding and rebound in all four quadrants. Laboratory tests showed Hb of 69 g/dL and WBC 15.000 μL. A FAST ultrasound performed in emergency showed an eight by five cm lesion in segments V and VI of the liver, with diffuse hemoperitoneum. An emergency abdominal CT scan was requested, and it showed evidence of an eight by five cm ruptured hepatic lesion with massive hemoperitoneum and leakage of contrast medium. The lesion had a big extrahepatic component with possible invasion of the hepatoduodenal ligament and gallbladder (). While the CT scan was being performed the patient became clinically unstable, and therefore decision was taken to bring the patient to the operating room for an emergency surgery. In the operating room, a Chevron incision was performed to gain access into the abdomen. Packing of the liver together with a Pringle maneuver was performed to achieve hepatic inflow occlusion and slow down the bleeding. After aspiration of three liters of blood that had been accumulating in the abdominal cavity we proceeded to a thorough inspection of the bleeding mass in the liver. The mass was invading the hepatoduodenal ligament, and it was extending into but not penetrating the second part of the duodenum (). No other visible masses were seen in the liver or in the peritoneal cavity. Resection of segments V and VI of the liver en bloc with the gallbladder was performed using LigaSure device (Figures and ). The patient was then transferred to ICU. He made an uneventful recovery and was discharged on POD 10. Pathology confirmed the suspicion that the mass was a ruptured fibrolamellar hepatocellular carcinoma with lymphovascular invasion. Follow-up CT scans after 6 months showed recurrence of the disease in the liver bilaterally and peritoneal metastases, which were treated with chemotherapy. The patient died 26 months after the surgery.

A 49 year old gentleman presented to cardiology with lower limb claudication pain and breathlessness of three years duration. Clinical examination revealed upper limb hypertension, with similar blood pressures in both arms (180/100 mm Hg). His past history included repair of coarctation of aorta about 30 years ago. The medical records and operative details from the previous operation were unavailable. The operation had been performed through a left thoracotomy. An MRI scan revealed a 2 cm long narrowing of the aorta just distal to the origin of an aberrant right subclavian artery, which was the last of four branches from the aortic arch (Fig. ). The origins of the arch vessels did not show any sign of narrowing. The aortic root and ascending aorta were 3.5 cm in diameter, and the arch was of normal calibre. The diameter in the region of the stenosis was 1.4 cm with an additional web-like stenotic lesion at the distal end of the stenotic segment. There was evidence of calcification, possibly of an interposition tube graft which had been used at the time of the first operation. The descending thoracic aorta was of normal calibre.\nIn view of his symptomatic status, a re-intervention was considered appropriate. In view of his previous surgery, and especially the fact that the area of re-coarctation appeared to be calcified, it was decided to approach the aorta via a median sternotomy and construct an extra-anatomic ascending to descending thoracic aorta bypass graft. Cardiopulmonary bypass would be necessary to lift the heart out of the way to gain access to the descending thoracic aorta just above the diaphragm. We planned to use an apical suction device to keep the empty beating heart elevated.\nThe sternotomy was completed uneventfully. The pericardial cavity was obliterated with dense adhesions. This was rather surprising since we had anticipated that the previous procedure would have been extra-pericardial. However, further dissection revealed a large hole in the pericardial sac with the left lung directly adherent to the heart. The adhesions were released, some of them after establishing cardiopulmonary bypass using ascending aortic cannulation for inflow and bicaval cannulation (to maintain adequate venous drainage even after lifting up the heart) for venous outflow. Once the apex and the posterior surface of the heart were free of adhesions, an apical suction device (URCHIN™ Heart Positioner, Medtronic Inc., Minneapolis MN55432-5604 USA) was placed in position and the beating heart was lifted superiorly. This allowed further dissection in the posterior pericardium and allowing freeing up of adhesions between the left lung and the descending thoracic aorta, and allowed visualization of and access to the descending thoracic aorta just above the diaphragm in spite of a deep thoracic cavity (Fig. ). Proximal and distal cross clamps were applied isolating a 4 cm length of aorta. A longitudinal incision was made in this segment and an 18 mm Haemashield Platinum™ Woven Double Velour Vascular tube graft (Boston Scientific Corporation, Natick, MA 01760-1537) was anastomosed in an end to side manner using continuous 3-0 polypropylene sutures. The clamps were released, the distal one first, the aorta was de-aired and the anastomosis was checked. The graft was then routed to the right of the inferior vena cava and brought up alongside the right atrium to the ascending aorta. The apical suction device was released and the heart was replaced in the pericardial sac. The length of the tube graft was estimated after filling up the heart. A side biting clamp was applied to the ascending aorta and the proximal anastomosis of the tube graft was constructed to a longitudinal arteriotomy using 3-0 polypropylene sutures. The clamp was released, the graft was de-aired, and the anastomosis checked. The patient was weaned off cardiopulmonary bypass with no inotropic support. Haemostasis was ensured and the chest was closed in the routine manner leaving two drains in the left pleural space, one drain in the pericardial sac and one in the mediastinum.\nThe patient was extubated eight hours after arrival in the intensive care unit. His drains were removed the next morning. He made an uneventful recovery thereafter except for needing some respiratory support with non-invasive continuous positive airway pressure for treating basal atelectasis. A CT scan was done prior to his discharge from hospital on the tenth postoperative day. Figure shows an oblique 3-D reconstructed view from the CT scan demonstrating the locations of the proximal and distal anastomoses, and the lie of the graft. The patient was reviewed in outpatients six weeks after his discharge. His claudication pain had disappeared completely. His upper limb blood pressure was 120/60 mm Hg on a reduced amount of medication.

A 49-year-old female experiencing untreated hypertension for several years presented with severe chest and back pain. A CT scan was performed and revealed an aortic dissection (Stanford type B) and an intimal flap was noted immediately distal from the origin of the left subclavian artery. After 4 days of medical management, her urine output decreased and both femoral pulses were weakened. Another CT scan was performed, showing that the aortic dissection had worsened and there was nearly total occlusion of the mid-aorta (). We recommended aortic repair operation, which the patient and her family refused. TEVAR was recommended as another treatment option to cover the intimal flap of the dissection. To acquire the proper proximal landing zone, her left subclavian artery and two thirds of the origin of the left common carotid artery would be covered by the stent graft. For the occluded left subclavian artery, revascularization can then be selectively considered in a staged approach if left arm pain, claudication and subclavian steal syndrome develop. The modified chimney technique was planned to preserve the blood flow of the left common carotid artery. The patient was taken to the cardiac catheterization laboratory and a left femoral arteriotomy was performed under general anesthesia. The 035 inch wire was placed in the ascending aorta and the left subclavian artery through the left radial artery approach. This wire is important to rescue the left carotid artery flow. If an aortic stent graft totally covers the left carotid artery or if it is difficult to select the left carotid artery with a catheter, then we can perform emergency balloon dilatation and place a chimney graft stent from the left subclavian artery to the aorta via this wire. The deployment of a 38×150 mm SEAL aortic stent graft (S&G Biotech, Seongnam, Korea) was performed so that the proximal part of the stent graft covered two thirds of the ostium of the left common carotid artery. After selection of the left common carotid artery using a 5 Fr Judkin right catheter (Cordis, Hialeah, FL, USA) through the gap between the stent graft and the left carotid artery, we passed a 035 inch Terumo wire (Terumo, Tokyo, Japan) into the left carotid artery through the right femoral artery and exchanged it with an Amplatz stiff wire. Then, an 8×60 mm SMART nitinol stent (Cordis, Hialeah, FL, USA) was deployed into the left common carotid artery. A final angiogram showed excellent results with good flow to both the thoracic aorta and the left common carotid artery. No endoleak was noted (). The occluded true lumen was re-expanded and the false lumen was not seen. The mean pressure gradient between the thoracic and abdominal aorta was decreased to 20 mm Hg from 90 mm Hg immediately after TEVAR (). After 18 months there has been no endoleak, restenosis of the stent in the left carotid artery or other complications.

A 32-year-old healthy pregnant woman with more than 30 gestational weeks was admitted to the hospital due to the fetal cardiac mass. The fetal echocardiography showed a heterogeneous lesion of 2.85 cm × 2.25 cm on the right side of the heart, which compressed the tricuspid annulus by 50% with pericardial effusion []. It was difficult to distinguish the source of fetal cardiac mass either within the heart or in the pericardial cavity by fetal echocardiography. The fetus was at risk when the fetal heart rate decreased to less than 80 bpm and pericardial effusion continued to increase during the hospitalization. The EXIT procedure was performed to resect fetal cardiac tumor if it was located in the pericardial cavity or to ameliorate cardiac compression and bradycardia by pericardial effusion drainage.\nThe cesarean section was performed, and the uterine relaxation was attained with the inhalation of a high dose of sevoflurane (5–10%). The fetus was released from the uterus, and the placental circulation was kept intact. The fetal heart was exposed through the median sternotomy. The mass was located within the right atrium and hence could not be quickly removed without cardiopulmonary bypass. Therefore, about 30 ml of pericardial effusion was drained, and the skin was just sutured without closing the sternum to release the space for the cardiac mass. The tricuspid annulus compression was ameliorated as demonstrated by fetal echocardiography []. The fetus delivered weighed 2.2 kg and had a sinus rhythm of 130–150 bpm. The cesarean section was completed with the administration of oxytocin and termination of sevoflurane inhalation after fetal delivery. The pregnant woman recovered uneventfully and was discharged on the 5th day postoperatively.\nThe neonate was intubated with mechanical respiratory support, and his heart function was still impaired by the cardiac mass compression. Dopamine was administered at a rate of 10 μg·kg−1·min−1 to maintain the mean blood pressure ranging from 40 to 50 mmHg (1 mmHg = 0.133 kPa). Therefore, cardiac tumor resection was performed under the cardiopulmonary bypass on the 2nd day after birth []. The pathological examination demonstrated the diagnosis of cardiac hemangioma. The neonate recovered well and was discharged after 1 month with 2.75 kg weight. No evidence of cardiac tumor recurrence was reported after a follow-up of 10 months.

The patient was a 45-year-old male having visited our department with a complaint of right facial swelling in 2007. He felt a ‘shock’ at the right cheek as if hit by something hard while operating a construction vehicle. Bleeding from the skin of the right cheek was observed but stopped after a few minutes of applying pressure to the site. In a few days, swelling developed on the right side of his face accompanied by a slight trismus. He visited a dental office and was prescribed antibiotics and referred to our department. The patient was well-built, and the right side of his face was diffusely swollen. The wound at the site of penetration was not remarkable. Panorama and posteroanterior X-ray examination revealed a small radiopaque foreign body at the lateral aspect of the right mandibular ramus. CT examination indicated that the foreign body was located under the masseter muscle. The foreign body was not palpable from the surface of the face or the oral mucosa. With the diagnosis of a foreign body on the right side of his face, the removal was planned after receiving medications for symptom improvement. However, the patient did not return to the hospital or for a follow-up appointment.\nIn 2015, the patient revisited our department for the removal of the foreign body. In 2008, he felt strong traction in the right side of his face when he approached an MRI scanner for a brain image examination. He remembered that a foreign body was impacted in his face. Because it was shown to be ferromagnetic, the MRI examination was cancelled and contraindicated. He was positive for the hepatitis C virus and suffering from liver cirrhosis. Recently, hepatocellular carcinoma had developed and was treated by radiofrequency ablation. His liver function was impaired and had a Child Pugh B score in addition to thrombocytopenia and leukopenia. Although esophageal varices were not observed, he needed to be strictly followed. Because MRI examination was necessary to evaluate this condition, the removal of the foreign body was reconsidered. The patient’s face was symmetric without visible scaring from the wound (Fig. ). The foreign body was not palpable through the skin or the oral mucosa. There had been no episodes of swelling or pain on the right side of his face since the last visit. Panorama and posteroanterior X-ray (Fig. and ) and CT (Fig. and ) examination showed that the foreign body was present at the same site as 8 years prior.\nConsultations with internal medicine and the anesthesiology department were made. The patient’s general condition was strictly controlled before surgery. Removal of the foreign body was performed under general anesthesia. An incision was made along the right anterior mandibular ramus. Soft tissue under the masseter muscle was dissected over the periosteum of the mandibular ramus (Fig. ). The foreign body was not visible from the incision but was palpable by the finger of the surgeon. Care was taken not to cause the migration of the foreign body into the deep space. After blunt dissection of the surrounding tissue by the finger of the surgeon, the object was removed with forceps. The wound was gently irrigated with saline and hemostasis was confirmed. The wound was closed by suturing after the insertion of a silicone drain. The foreign body was 12 × 5 × 1 mm and weighed 0.48 g (Fig. ). It was ferromagnetic and attracted to a magnet (Fig. ).\nThe patient’s postoperative course was uneventful. Swelling around the wound was minimal and no postoperative bleeding or infection was observed. The drain and the threads were removed 2 days and 7 days after surgery, respectively. Postoperative X-ray examination revealed that the foreign body was removed and no residual radiopaque materials were observed. The patient was discharged and received follow-up as an outpatient. Since surgery, he has been in generally stable condition with no complications related to surgery.

A 12-year-old Brazilian female, with no systemic comorbidities, attended the oral and maxillofacial surgery service with a chief complaint of a painless growing facial swelling for 8 months (). On extraoral examination, a unilateral expansive lesion was detected on the lower right aspect of her face. On intraoral examination, the swelling could be seen affecting the body and the angle of the mandible on the right side associated with her lower right third molar. Panoramic radiographic examination revealed a unilocular radiolucent lesion extending from the body of the mandible through to the angle and right ascending ramus, causing displacement of the second molar towards the base of the mandible and the third molar towards the ascending ramus (). A CT scan revealed that the lesion caused expansion of the buccal and lingual aspects of the cortical bone with areas of fenestration. Needle aspiration was performed to evaluate the contents of the swelling, mainly to exclude the possibility of a vascular lesion. An incisional biopsy was then performed, and the specimen was sent for histological evaluation (). The access window left from the biopsy was used to accommodate a flexible tube for decompression and subsequent volume reduction of the lesion in an attempt to minimize the need for mutilating surgery in such a young patient. In view of the clinical and radiographic characteristics, two differential diagnoses were raised, namely, unicystic ameloblastoma or dentigerous cyst (). The histological diagnosis confirmed the suspicion of a unicystic ameloblastoma. A decision was made to continue with the assisted decompression approach using daily irrigations of sterile saline solution intercalated with 0.12% chlorhexidine digluconate to remove debris and decontaminate the site, which was followed up both clinically and radiographically. After 5 months of decompression, a significant reduction of the lesion was observed radiographically, with evidence of bone neoformation in the periphery of the lesion. In view of the favorable progression, complete enucleation of the lesion combined with peripheral osteotomy and cryotherapy was performed under general anesthesia to reduce the risk of recurrence. The excised specimen was sent for histopathological evaluation, which reiterated the previous diagnosis of unicystic ameloblastoma. The patient has been followed up for 6 months, with no clinical or radiographic evidence of recurrence (). A supernumerary tooth in the right maxilla was also observed in the panoramic radiograph. This tooth was not removed since cone beam computed tomography was not available for a better surgical planning due to financial reasons. However, the patient remains in close follow-up.\nThe histological sections showed the presence of a fibrous capsule lined by nonkeratinized stratified pavement epithelium exhibiting spongiosis, reverse polarization of the basal layer, and areas that resembled the stellate reticulum. The fibrous capsule consisted of dense connective tissue, presenting moderate to severe lymphoplasmacytic inflammatory infiltrate and hemorrhagic areas ().

The index patient was a 34-year old female referred to the bariatric clinic by the general practitioner on her own request to treat her morbid obesity. She was born with a normal birth weight but large head circumference for which she never had a diagnostic analysis. At the age of five, her body weight was already significantly higher compared to her peers. No specific life events could explain her obesity. Cognitive development was normal and she followed normal education. She underwent treatment for recurrent nasal polyps. Her mother also had a large head size and suffered from morbid obesity as well. She was diagnosed with thyroid cancer and died from a pulmonary embolism after placement of an Adjustable Gastric Band. A maternal aunt was diagnosed with breast cancer before the age of 50 and the maternal grandmother died from breast cancer at young age. The younger sister of the index patient was overweight and was reported to also have a large head size (Figure ).\nSince childhood, the index patient followed several different coaching programs to change her eating behavior and exercise pattern to induce weight loss. She lost weight several times but was never able to maintain her weight loss. At the time of the intake procedure at the bariatric clinic, her height was 1.69 m (SD −0.2) and weight 164 kg (SD +6.8), resulting in a Body Mass Index (BMI) of 57.6 kg/m2 and a predominant abdominal obesity. Head size was not measured at that time since this is not part of bariatric screening procedures. Biochemical analysis of the blood revealed no abnormalities, and excluded endocrine hormonal disorders such as hypothyroidism. The fasting glucose level was 5.9 mM.\nThe combination of early onset morbid obesity resulted in suspicion of a genetic cause of her obesity. She was offered diagnostic genetic analysis of 52 obesity–associated genes to identify a possible underlying genetic obesity cause.\nThe patient was eligible for bariatric surgery and underwent a sleeve gastrectomy without complications (performed in 2014 using a standardized fashion). At 1, 2 and 3 years after surgery, she achieved a percentage Total Body Weight Loss of 39.4, 48.8 and 44.9, respectively. This resulted in a current BMI of 30.1 kg/m2. This was within the range of the results which were observed in a control group of 18 female patients, with a negative obesity genetic test result. These female patients were matched for age and BMI and achieved a percentage Total Body Weight Loss (TBWL) of 30.3 after 1 year, 31 after 2 years and 30 after 3 years of follow-up.\nA few months after surgery, the result of the obesity gene panel analysis was returned and showed heterozygosity for a known pathogenic mutation in the PTEN gene (): c.202T>C p.(Tyr68His). This mutation has been described previously in patients with PTEN Hamartoma Tumor Syndrome (PTEN HTS) (Marsh et al., ). No other pathogenic mutations were shown in the remaining 50 obesity–associated genes (Table ). At the genetic clinic, a head circumference of 63 cm (+5SD) and pedigree analysis (family history of multiple tumors) further supported the molecular diagnosis of PTEN HTS.\nAccording to the PTEN HTS guidelines, patients with pathogenic PTEN mutations are advised to visit the outpatient clinic for familial tumors, for lifelong surveillance of tumors that are associated with the PTEN mutations (Dutch Guidelines, ; Eng, ). Our patient underwent additional biochemical laboratory- and ultrasound screening to exclude thyroid gland carcinoma. Besides a few benign nodules on the ultrasound, no abnormalities could be determined. A yearly follow-up ultrasound of her thyroid gland and yearly serum thyroid stimulating hormone analysis was advised. Screening for breast, endometrium and colorectal cancer, also revealed no anomalies.

A 55 year old female patient diagnosed with epilepsy and under follow up developed generalized tonic clonic seizure that lasted for 5 minutes. The emergency department team was informed and she was brought to the emergency department. On arriving at the site the emergency team where the patient had the seizure, found her lying in a supin position with a foamy mouth and bitten tongue. A 2 cm cut was seen at the back of the head most probably as a result of falling and hitting it. The patient was found to have difficulty in breathing and after suction of the mouth, oxygen was administered. The general clinical condition being quite poor and having an apneic respiratory pattern, the patient was immediately intubated. The patient was unconscious with a blood pressure level of 80/60 mm Hg and pulse count of 66/min. Light reflexes were normal in the patient, there were no verbal and pain responses and the Babinski sign was bilateraly unresponsive. The patient was brought to the hospital by the emergency team in an intubated state and admitted to the neurology intensive care unit. The patient's hematologic and biochemical tests were unremarkable and the carbamazepine levels were found to be 3.8 µg/mL (4–12). The patient had been diagnosed with epilepsy and under follow up for 40 years, had a moderate level of mental retardation, did not use her medical treatment (carbamazepine 800 mg/day) regularly and failed to go for her routine medical checkups. It was also learned that she develops once or twice a month generalized tonic clonic seizures and that during some of these seizures she has suffered small injuries but had not had any fatal trauma or accident. Antiepileptic treatment was started and on the 6th hour of follow up consciousness was regained and flask quadriplegia was seen on neurologic examination. A cervical MRI was taken and a severe spinal cord compression, widespread spinal cord edema and also subluxation at C3–4 were seen due to fracture of the lower back part of C3 vertebra most probably as a result of trauma (, ). The patient was diagnosed with flask quadriplegia due to cervical fracture. Surgical operation was not recommended by the neurosurgery department because the patient had low arterial blood pressure during her follow-ups, had bradycardia and could not be separated from the mechanical ventilator due to respiratory acidosis. The patient was given pulse steroid therapy. Antiepileptic, inotropic and fluid therapy was administered. The patient died on the 2nd day of treatment.

A 34 year old right hand-dominant male, who works as a chef, presented with a 4 month history of left wrist mass. It had increased rapidly in size during the final month. The patient also began to experience numbness of his left thumb, index and middle fingers. He was normally well and not on regular medications. There was no family history of note.\nAn ultrasound was initially performed which showed a large, complex cystic structure within the carpal tunnel. A subsequent MRI revealed a heterogeneous, well defined mass with fluid and solid components. The mass was located middle and ring fingers. It appeared to arise from the tendon sheath of the middle and ring finger flexors, but was not between the superficial and deep flexor tendon sheaths of the invading the tendons. It extended distally to the carpal tunnel, with overall dimensions of 19 x 24 x 38 mm. It showed peripheral enhancement and areas of necrosis, and there was no flow void (Fig. ). The median nerve had a normal appearance. In light of the clinical history and radiological features, a malignant lesion such a synovial sarcoma, was considered the likely provisional diagnosis.\nThe patient was referred to our unit for urgent review. On examination he had a mobile and palpable mass which moved from the mid palm to the volar wrist region with flexion and extension of his wrist. The mass was not adherent to overlying skin. He had full power in his left hand and there was no thenar muscle wasting. He had decreased sensation in his thumb, index and middle finger, and Tinel’s test was negative.\nHe underwent surgical exploration and removal of tumour within one week of the consultation. An extended carpal tunnel incision was made (Fig. ), from the mid palm to the volar wrist. After the TCL was divided, a large tan coloured soft-tissue tumor was visible on the ulnar aspect of the median nerve. It appeared to arise from the deep flexor tendon sheath of the ring finger, extending distally to the lumbrical muscle of the 4th ray, and it infiltrated these structures only minimally. A persistent median artery was observed overlying the median nerve, which did not appear to be involved by the tumour. The tumour was resected with macroscopic margins. Post-operative recovery was uneventful and the patient reported immediate relief of compressive median nerve symptoms.\nHistological analysis was consistent with a synovial haemangioma, comprising of numerous thin-walled blood vessels with a central cystic cavity filled with blood and fibrin (Fig. ). There was no evidence of malignancy.\nA three month follow-up confirmed complete resolution of his neurosensory symptoms and showed a well healing scar.

The index patient was a 34-year old female referred to the bariatric clinic by the general practitioner on her own request to treat her morbid obesity. She was born with a normal birth weight but large head circumference for which she never had a diagnostic analysis. At the age of five, her body weight was already significantly higher compared to her peers. No specific life events could explain her obesity. Cognitive development was normal and she followed normal education. She underwent treatment for recurrent nasal polyps. Her mother also had a large head size and suffered from morbid obesity as well. She was diagnosed with thyroid cancer and died from a pulmonary embolism after placement of an Adjustable Gastric Band. A maternal aunt was diagnosed with breast cancer before the age of 50 and the maternal grandmother died from breast cancer at young age. The younger sister of the index patient was overweight and was reported to also have a large head size (Figure ).\nSince childhood, the index patient followed several different coaching programs to change her eating behavior and exercise pattern to induce weight loss. She lost weight several times but was never able to maintain her weight loss. At the time of the intake procedure at the bariatric clinic, her height was 1.69 m (SD −0.2) and weight 164 kg (SD +6.8), resulting in a Body Mass Index (BMI) of 57.6 kg/m2 and a predominant abdominal obesity. Head size was not measured at that time since this is not part of bariatric screening procedures. Biochemical analysis of the blood revealed no abnormalities, and excluded endocrine hormonal disorders such as hypothyroidism. The fasting glucose level was 5.9 mM.\nThe combination of early onset morbid obesity resulted in suspicion of a genetic cause of her obesity. She was offered diagnostic genetic analysis of 52 obesity–associated genes to identify a possible underlying genetic obesity cause.\nThe patient was eligible for bariatric surgery and underwent a sleeve gastrectomy without complications (performed in 2014 using a standardized fashion). At 1, 2 and 3 years after surgery, she achieved a percentage Total Body Weight Loss of 39.4, 48.8 and 44.9, respectively. This resulted in a current BMI of 30.1 kg/m2. This was within the range of the results which were observed in a control group of 18 female patients, with a negative obesity genetic test result. These female patients were matched for age and BMI and achieved a percentage Total Body Weight Loss (TBWL) of 30.3 after 1 year, 31 after 2 years and 30 after 3 years of follow-up.\nA few months after surgery, the result of the obesity gene panel analysis was returned and showed heterozygosity for a known pathogenic mutation in the PTEN gene (): c.202T>C p.(Tyr68His). This mutation has been described previously in patients with PTEN Hamartoma Tumor Syndrome (PTEN HTS) (Marsh et al., ). No other pathogenic mutations were shown in the remaining 50 obesity–associated genes (Table ). At the genetic clinic, a head circumference of 63 cm (+5SD) and pedigree analysis (family history of multiple tumors) further supported the molecular diagnosis of PTEN HTS.\nAccording to the PTEN HTS guidelines, patients with pathogenic PTEN mutations are advised to visit the outpatient clinic for familial tumors, for lifelong surveillance of tumors that are associated with the PTEN mutations (Dutch Guidelines, ; Eng, ). Our patient underwent additional biochemical laboratory- and ultrasound screening to exclude thyroid gland carcinoma. Besides a few benign nodules on the ultrasound, no abnormalities could be determined. A yearly follow-up ultrasound of her thyroid gland and yearly serum thyroid stimulating hormone analysis was advised. Screening for breast, endometrium and colorectal cancer, also revealed no anomalies.

The first patient (P1) was a 68-year old female, retired from work, and living with her husband. A few years ago she had had problems with her right jaw when chewing. Ever since then she had felt that her jaw was tense. At some point, she started to have light headaches now and then that accelerated to headaches almost every day. The headache was usually present already when she woke up in the morning. It seemed to get somewhat worse during days when she was stressed. She perceived her jaw muscles as tense and tender. She had low-intensity headaches most of the days ( and ), with no perceived disability but affecting feelings of happiness in activities with family and friends (). Her self-efficacy for managing headache (HMSE) was low (). She used analgesics but not that much that it would be a primary problem behavior ().\nIn the FBA, it was hypothesized that the behavior that would have most effect on her headaches was her continuous contracting of jaws. Therefore, the behavior of contracting the jaw muscles was analyzed in order to understand the function of the behavior. The behavior seemed to be going on almost all the time, even during nights, and in that way it had become more or less automatic. The antecedents and consequences of this behavior were therefore hard to identify. However, it could be concluded that the behavior was intensified in situations with psychological stress, for example, worrying about family members being ill. She was motivated for changing her behavior.\nThe long-term goal was set to no headache more than twice a week. It was concluded that the primary purpose of the treatment would be to find a way for her to increase the control of tension of the jaw during the daytime activities. It was hypothesized that the jaw muscles would continue to be relaxed during the nights if they were relaxed during the days.\nThe treatment consisted of eight visits with home exercises in between, including two follow-up visits.\nBasic skills targeted were to know and feel what is a neutral relaxed position of the jaw, to be able to control the muscular tension, and to do her exercises regularly. Applied skills targeted were to recognize when her jaw gets tense in the activities and to do the exercises when necessary to decrease tension. Generalization of the skills was not needed.\nThe behavior change techniques of self-monitoring, feedback, reevaluation of goals, shaping, and fading were used, and the physical therapist aimed to strengthen the patient’s self-efficacy for behavior change through reinforcement of every progress during all treatment stages.\nAll outcomes were considered as proxy measures for increased control of the tension of jaw muscles.\nThe goal of no headache more than twice a week was met.\nHeadache frequency and headache index are presented in and . During baseline, she had headaches at 6 out of 7 days and during the two follow-up visits these figures were 1 and 2 out of 7 days, respectively.\nThe behavior of consumption of analgesics is presented in and was reduced to zero at the follow-ups.\nDisability and feelings of loss of happiness: she reported no disability in activities during any of the phases. Loss of happiness was reduced to zero after treatment and was stable through follow-up ().\nHMSE score increased considerably from baseline to directly after the treatment and was stable through followup ().

During the dissection of a 91-year-old female cadaver, whose cause of death was reported as Alzheimer's disease, an enlarged gallbladder filled with approximately 350 ml of thin bilious fluid was identified. This gallbladder was normally situated in the fossa for the gallbladder. Upon opening, a prominent transverse partial septation in the body was found. This partial septum was located near the infundibulum (Hartmann's pouch) and this divided the gallbladder into a smaller chamber near the opening of the cystic duct and a larger chamber near the fundus (). There was a one centimeter opening between the two chambers allowing communication of fluid. No stones, mucus, or obstructive masses were found in the gallbladder or along its path of drainage into the duodenum. The diameter of the biliary duct system appeared enlarged; the cystic duct measured 12 mm (normal 2-3 mm), the hepatic duct 18 mm (normal 6 mm) and the common bile duct 21 mm (normal 7 mm), in the collapsed state [,]. The common bile duct, near its termination, measured 7 mm with a patent opening into the pancreaticobiliary antrum (). No anatomical explanation for the enlarged ductal system was found. It is possible that the patient passed a gallstone prior to death, causing a constriction at the pancreaticobiliary antrum and subsequent dilation of the biliary tree, but this is only conjecture. The gallbladder wall was of normal thickness and had no evidence of past inflammation in the form of adhesions or other structural changes. The liver appeared grossly normal. The authors hypothesize this septal abnormality was congenital and during life may have caused symptoms of biliary colic due to the septum intermittently obstructing the cystic duct during contraction of the gallbladder; this may have resulted in incomplete emptying of the gallbladder and subsequent enlargement.\nIn addition to the enlarged gallbladder, an aberrant right hepatic artery and an accessory left hepatic artery were found. The left hepatic artery was normally located but there was also an accessory left hepatic artery originating from the left gastric artery. The right hepatic artery originated from the superior mesenteric artery (, ). To our knowledge, this combination of a transverse septum with such vascular anomalies has not been reported in the literature (). The vascular variations are likely unrelated to the enlargement of the gallbladder, as there has been no record of these variations causing enlargement of the gallbladder nor development of a partial transverse septum.

Susan is a 51-year-old woman. As an adolescent, she developed scoliosis. Working as a hairstylist when she was 18 or 19, she began to have severe pain in her hands, making her work very difficult. She had carpal tunnel surgery on her right hand which provided temporary relief. Her symptoms slowly returned and she continued to have intense pain and difficulty with her daily activities. Seeking relief from her symptoms, she received treatment from chiropractors and Chinese medicine practitioners with no significant benefit. She also tried yoga and swimming but depending on the yoga movements or swimming strokes, she began to have more pain.\nWhen she was in her early forties, she began to have weakness in the lower half of her body. Her legs would frequently give out on the stairs, causing her to fall. Control of her bladder and bowel function also began to deteriorate. She had an MRI, and based on the results, she was scheduled for emergency surgery to stabilize her cervical spine and relieve spinal cord compression. She was informed that it would be an outpatient surgery and she would be home the same day.\nIn May 2011, Susan had a 6-level cervical spine fusion to stabilize her spine and relieve pressure on her spinal cord. When she woke up, she realized something was wrong. The entire right side of her body was paralyzed. What was supposed to be an outpatient surgery with a return home the same day ended up being an 8-week hospital and rehabilitation stay to learn how to walk again.\nIn August 2012, a second surgery was performed with the goal of pain relief. However, she reported her pain was significantly worse afterwards. She would receive weekly injections for pain relief that she reports would only marginally decrease her pain for about one week. She was also taking high doses of medication for nerve pain relief which she also reports provided marginal benefit. She had areas of heightened sensitivity on her legs where a bed sheet or even a gentle breeze would cause intense pain. Exposure to hot water would feel cold, and cold water would feel hot. She was unable to walk more than one block and remained in bed for over ten hours per day. She suffered extensive personal and professional quality of life losses at this time.\nLooking for relief, she tried medical yoga and received temporary relief. She also practiced traditional Tai Chi which provided minimal to no relief. She continued to have intense pain which had a significant impact on her quality of life and ability to perform daily tasks, including walking. In 2014, she tried a Qigong class and reported feeling that there was something very different about this class. Almost immediately, she felt a strong sense of relaxation that she had reportedly not found in many years. She was unable to attend many classes, so she purchased a video of the movements. Over the next year, she began to practice the exercises consistently until she could attend formal classes.\nSusan credits the practice of qigong with saving her life. She says it gave her a reason to get out of bed and socialize in the very early days of her practice. She is now able to walk with no limitations and her pain has improved by approximately 90%. Within three months of beginning qigong, she was able to stop all medications and injections she was receiving for pain relief. She continues to have some weakness in her arms and her hands, but it does not interfere with her ability to complete her daily activities. Despite her extensive cervical spine surgery, she reports full mobility in her shoulders and has nearly recovered full mobility in her neck. Her energy has also greatly improved and she routinely teaches three Qigong classes per week. In addition to this, she teaches at special events, including a Qigong class at a large yoga festival with over 1000 people in attendance. Recently, she started her first full time job in over six years.\nJames is a 70-year-old male. Over ten years ago, he was diagnosed with multi-level degenerative disc disease (DDD) in his lumbar spine, as well as severe central stenosis or narrowing of his spinal column around his spinal cord at L3-4, L4-5, and L5-S1. In 2011, he had a CT scan and was told by his physician that it would not be long until he must rely on a wheelchair for all mobility. Surgery was presented as an option, but he was informed that the success rate was less than 10%.\nHe decided to forgo surgery and take his chances. Gradually, his legs became weaker and he would fall spontaneously. He worked as a salesman and as he was talking to clients, his legs would give out without warning and he would fall to the ground. To help his situation, he would park as close as he could to the entrance of stores or other destinations and would walk with carts or holding onto shelves or furniture. This would only help for so long before he would fall again.\nHe began looking for other options to help manage his condition. In 2012, he tried yoga. While it helped to temporarily control his pain, it had no effect on the weakness in his legs and he would continue to fall. One year later, at the suggestion of his wife, he tried a Qigong class. Due to his family’s personal schedules, he was unable to attend another class for two months. He decided to purchase a video of the movements he had learned and practiced them each day for 4–5 months until he was able to return to normal classes.\nSince participating in Qigong classes, he has not fallen even once, and has no reports of pain. He stated that “Qigong gave me my life back.” He has no other medical problems to mention and takes no medications. He revealed that the improvements he has experienced have gone far beyond what he expected. Where he used to fall often and without notice, he has not fallen since he began qigong and reports that he now even has a “spring to his step, and a spring in his heart.” Not too long ago, he sustained a left rotator cuff tear. After continuing to practice qigong, he had a full return of strength and movement with no pain or difficulty with his routine daily activities, all within six months.\nIn his professional life, he felt like he was burning out as an IT programmer but practicing qigong has reinvigorated him. He was able to complete many projects (some complex) that he never would have thought possible. He has since become certified to teach Qigong and tells anyone who will listen about his story. He has also witnessed many others gain significant benefit from the practice of Qigong and is thrilled that he gets to share this with others.

A 21-year-old woman with SCD presented frequently to the medical casualty department with severe pain due to sickle cell VOC. For the last 2 years, her sickle cell pain included intermittent pain in the left ankle. Her recurrent severe VOCs were treated with opioids, as they are the general treatment in such patients. She had experienced osteomyelitis in the right ulnar bone 12 years previously, which resolved after intravenous broad-spectrum antibiotic treatment. Additionally, she underwent splenectomy 4 years ago to reduce blood transfusion requirements because of her congenital hemolytic anemia. She was referred for a triple-phase bone scan and complementary bone marrow and infection imaging as part of the SCD research project. A plain radiograph of the left foot was normal, but SPECT-CT revealed an increased uptake in the shoulders, knees, and sternum on blood pool and delayed images, consistent with marrow expansion. A similar uptake pattern was seen during bone marrow study, confirming bone marrow expansion around the large joints. There was a mildly increased blood pool and bone uptake in the left ankle involving the proximal talus and the region of the medial malleolus, with focal increased uptake in the left talus. This nidus of activity appeared to correspond to a round lucent area surrounded by a dense sclerotic rim and sinus tract formation together with a fracture line in the proximal talus on CT. The WBC scan showed no evidence of significant uptake, and the bone marrow scan showed asymmetrical uptake between the two ankles without a cold lesion in the left talus, which is consistent with moderate bone marrow expansion. The CT and bone scan findings suggested Brodie’s abscess in the proximal left talus with possible surrounding chronic osteomyelitis. Intravenous antibiotics were administered for 10 days with no response. The abscess was then treated with surgical curettage under general anesthesia and antibiotic administration for 10 days. At 18 months after removal of the abscess, the patient did not have pain or swelling at the site of the abscess even with sickle cell VOC.

A 24-year-old Saudi male was referred to the oral and maxillofacial surgery clinic for consultation and treatment of repeated infection and pain in the right side of the lower jaw of over one-year duration. He also complained of bad odor and difficulty to open his mouth during the same period. On examination intra-orally, a hard bone-like structure with a rough surface exposed to the oral cavity distal to the right lower second molar was seen. Plaque accumulation over the mass with very foul odor and bad oral hygiene was noticed. The hard mass fenestrated the lingual tissues together with the gingival surrounding the lesion appearing very inflamed (Figures ). Ortho-pantomo-graphic x-ray view showed a calcified mass distal to the lower right second molar, with the third molar on that side being displaced distally by the present mass. The calcified mass was encircled inferiorly on its central part by a radiolucent halo with the inferior dental canal being more inferiorly placed to the lesion. The lower right second molar showed advanced periodontal involvement with bone loss but without any resorption of its distal root ().\nHe consented for the potential complications of surgically removing the mass in terms of inferior alveolar and lingual nerves injury, and possible pathologic fracture of the right side of the lower jaw while removing the lesion. The proposed treatment plan also included disimpaction of lower right third molar and extraction of periodontally involved second molar. He accepted the proposed treatment under local anesthesia but refused the extraction of the lower right second molar. Under local anesthesia, the surgical removal of the lower right third molar in addition to the calcified mass together with curettage of the infected soft tissues in the area was carried over. The specimens sent for histopathological examination included the soft tissues around the lesion and the hard, calcified lesion. The healing course postoperatively was uneventful without any neural defect of the related nerves.\nHistopathological report showed that the soft tissue specimen stained with hematoxylin and eosin stain (H&E stain) composed of inflammatory cells, necrotic debris, epithelial proliferation, and mucosal epithelial fragments. While the calcified specimen also stained with H&E stain showed irregular areas of decalcified dentine and enamel with a final diagnosis of complex odontome associated with infected tissues (Figures ).

A 68-year-old woman with a history of previous abdominal surgery presented with abdominal pain and vomiting. One day prior to admission, she noted the gradual onset of abdominal pain. She had one bowel movement but the abdominal pain persisted. The pain was intermittent and gradually worsened. She vomited several times. She underwent a hernia repair 15 years previously and had a lower midline incision, although the details of that procedure were unavailable. On physical examination, her lower abdomen was slightly distended with mild tenderness to palpation. Dilated intestine was palpable, but there were no signs of peritonitis. Nasogastric suction was initiated but inadequate and the abdominal pain persisted. Abdominal CT scan revealed dilated loops of small intestine with a small amount of ascites.\nThe diagnosis of small bowel obstruction was established and exploration undertaken. This was begun laparoscopically which demonstrated multiple areas of adherent loops of small bowel. The adhesions were lysed sharply and further exploration revealed a small bowel perforation, which was repaired in a conventional manner after conversion to open laparotomy.\nOn postoperative day (POD) 1, her temperature increased to 39°C; however, it resolved over five days without specific treatment. The abdominal pain persisted and became more intense on POD 6. Abdominal CT scan was performed on POD 7, which showed a small fluid collection with some air. Due to persistence and increasing severity of the abdominal pain, repeat operative exploration was undertaken on POD 8. Exploration revealed abscesses in the abdominal wall and between loops of small bowel, as well as a site of perforation, which was resected and repaired with a primary anastomosis.\nThe postoperative course was uneventful except for persistent anorexia. Ten days after the second exploration, CT scan was obtained due to the persistent anorexia. The CT scan revealed edematous small intestine and dilatation of the mesenteric veins. The scan also revealed a filling defect in the superior mesenteric vein () suggestive of a thrombus. She had no evidence of intestinal gangrene or peritonitis, and systemic heparin was begun followed by warfarin therapy. Laboratory data were not consistent with protein C, protein S, or antithrombin III deficiencies. She had no past history or family history of deep venous thrombosis or other coagulation disorders. Over the next six days, the thrombus resolved on repeat imaging studies (), and her appetite recovered. She was discharged without further complications, continuing oral anticoagulation with warfarin.

An 82-year-old woman presented to the emergency department with hip pain and an inability to weight bear following a simple mechanical fall at home. She had a past medical history of chronic kidney disease following curative right total nephrectomy for renal cell carcinoma several years before but was otherwise in good health. On examination her leg was shortened and externally rotated. AP and lateral radiographs of her hip confirmed an extracapsular neck of femur fracture, as shown in . After discussion with the patient and her family, consent was taken for internal fixation of the fracture using a dynamic hip screw. Preoperative blood workup revealed a mild anaemia (Hb of 110 g/L) and chronic kidney disease stage 3.\nSurgery was performed on the following day's trauma list by a registrar under image intensifier guidance, as shown in . The procedure was supervised by a consultant surgeon. The procedure appeared to be routine with no intraoperative complications noted. The following day the patient had a persistent tachycardia with low oxygen saturations on arterial blood gas sampling. A NM V/Q SPECT (ventilation/perfusion) scan was arranged which revealed a mismatch in the midzone of the left lung, consistent with a pulmonary embolism. After review by the medical team she was started on treatment dose enoxaparin.\nOver the next week she had episodes of intermittent tachycardia and low blood pressure. Her haemoglobin fell from 110 g/L to 80 g/L despite a 3 unit red blood cell transfusion. There were no signs of external bleeding and the surgical wound was clean and dry. Several days after surgery she developed extensive proximal thigh bruising over a 24-hour period, raising the possibility of bleeding from around the fracture site. CT angiography demonstrated a large left thigh haematoma extending along the femoral sheath and a small area of active extravasation of contrast relating to a branch of the profunda femoris artery. Angiography was performed demonstrating a pseudoaneurysm arising from a branch of the proximal profunda corresponding to the abnormality seen on the preceding CT angiogram, as shown in . The small supplying vessel was catheterised with difficulty using a microcatheter but a stable position could not be achieved here for embolisation. Therefore the main vessel was embolised at this point using 5 mm and 6 mm 0.035 coils, with preservation of large profunda branches above and below. Follow-up angiography revealed no further active haemorrhage of filling of the pseudoaneurysm, as shown in . A Cook Celect retrievable IVC filter was deployed within the infrarenal vena cava. After several days of no further bleeding, warfarin was commenced and the patient was discharged to a community rehabilitation facility. While the pseudoaneurysm did delay her discharge and rehabilitation, she has progressed to make a full recovery.