Fat Embolism Syndrome: A Case Report and Review Literature

Fat embolism syndrome (FES) is a life-threatening complication in patients with orthopedic trauma, especially long bone fractures. The diagnosis of fat embolism is made by clinical features alone with no specific laboratory findings. FES has no specific treatment and requires supportive care, although it can be prevented by early fixation of bone fractures. Here, we report a case of FES in a patient with right femoral neck fracture, which was diagnosed initially by Gurd's criteria and subsequently confirmed by typical appearances on magnetic resonance imaging (MRI) of the brain. The patient received supportive management and a short course of intravenous methylprednisolone.

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The impact of complete embedding of remaining tissue in gynecological lymph node dissection specimen in surgical pathology on lymph node yield: is it clinically relevant?

Abstract

The assessment of nodal metastases in gynecological surgical specimen is an important staging parameter, directing further therapeutic procedures. Since the number of lymph nodes (LNs) removed is seen as an indicator of surgical and pathological quality, the demand for higher lymph node (LN) counts is raising. The goal of this prospective study was the comparison between lymph node counts of macroscopically detectable LNs and the LN yield by complete embedding and proceeding of all submitted LN-containing tissue in the pathology laboratory. One hundred six cases of cervical, uterine, or ovarian cancer, treated in three different hospitals within 3 years, were analyzed. All tissue submitted to the pathology from the surgically performed LN dissections was completely dissected and embedded in the institute of pathology. Subsequently, the amount of LN of all macroscopically detectable nodes was compared to the final histologically reached numbers of LN. Furthermore the histologically visible area of the LNs and their metastases was analyzed to assess the relation of LN numbers to the whole examined LN area. Complete embedding raises the average number of LN counted by 3 to 7 but did only minimally increase the LN area for microscopical examination by about 5% due to the small area of the additional LNs in the remaining fat tissue. The staging was in no case altered by complete embedding, even when additional nodal metastases were detected in the remaining fat tissue, since this was only seen in cases which had already metastatic nodes. Complete embedding of LN-containing tissue did not provide relevant additional staging information and seems therefore unnecessarily laborious, careful pathological work-up assumed.

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“Flipped classrooms” in training in maxillofacial surgery: preparation before the traditional didactic lecture?

While virtual learning environments (VLE) can be used in medical education as stand-alone educational interventions, they can also be used in preparation for traditional "face-to-face" training sessions as part of a "flipped classroom" model. We sought to evaluate the introduction of this model in a single module on maxillofacial radiology from a course on trauma skills. Course delegates were randomised into two groups: one was given access to an e-learning resource (test group) and the other attended a traditional didactic lecture (control group).

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Re: Gillies temporal incision: an alternative approach to biopsy of the superficial temporal artery

We appreciate Shastri et al's interest in our paper.1

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Current thinking in medical education research: an overview

Medical education is fast becoming a separate focus, and together with their clinical commitments, many clinicians now seek higher qualifications and professional accreditation in the field. Research is also developing, and there is a need for evidence-based practice in education, just as in clinical work. This review gives an overview of research into medical education, and explains the fundamentals of educational theory and the specific considerations for the quantitative and qualitative research methods that pertain to it.

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Re: Gillies temporal incision: an alternative approach to biopsy of the superficial temporal artery

We read with interest the paper by Markose and Graham in which they proposed a modified Gillies approach for biopsy of the superficial temporal artery.1 They argued that a conventional preauricular approach creates an unsightly scar, decreases the yield of the biopsy to a shorter segment of the artery (with the risk of sampling an unaffected portion), and increases the risk of iatrogenic injury to the facial nerve.

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New technique for endoscopically-assisted particulate graft reconstruction of the mandible

The reconstruction of mandibular defects using particulate grafts is a proven technique that restores the osseous anatomy effectively. Secondary osseous reconstruction can be accomplished with endoscopic assistance and reduced-access incisions if an intermediate spacer is placed during resection. Two patients required reconstruction after resection of mandibular ameloblastomas. We used a modified protocol that involved the implantation of a graft of particulate corticocancellous bone after removal of the spacer, and prepared the recipient site under endoscopic guidance with small extraoral incisions.

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Lemierres syndrome: a rare cause of sepsis presenting with an absence of throat symptoms

A 16-year-old boy presented to hospital with a 6-day history of diarrhoea, vomiting and abdominal pain. During his admission he was found to be hypotensive, tachycardic and persistently feverish. Blood cultures taken on admission isolated Fusobacterium necrophorum. CT scanning of his neck showed a non-occlusive thrombus of the right internal jugular vein and a small right parapharyngeal abscess. CT scans of the chest and abdomen revealed multiple pulmonary abscesses, bilateral pleural effusions and splenomegaly. Treatment consisted of an unfractionated heparin infusion and intravenous antibiotics. A right-sided intercostal drain was inserted for a complex right-sided empyema. He subsequently developed a left-sided pleural effusion which was treated with a video-assisted thoracoscopic surgery (VATS) pleurodesis procedure. His fever resolved after his VATS pleurodesis procedure 3 weeks after initial presentation. Clinically he made a slow recovery but now is improved after 6 weeks of intravenous antibiotics and was discharged home.

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Novel management of vaginal chronic graft-versus-host disease causing haematometra and haematocolpos

Genital chronic graft-versus-host disease (GVHD) in women posthaematopoietic cell transplantation may cause vaginal mucosal sclerosis. Human papillomavirus (HPV) reactivation, also common post-transplantation, limits local immunosuppressive, but not oestrogen treatment. A 36-year-old nulliparous woman developed coincidental genital chronic GVHD and HPV 22 months after transplant for aplastic anaemia. Topical immunosuppression for GVHD led to an eruption of warts successfully treated with laser surgery and cone biopsy. She maintained normal ovarian function and used extended cycle combined hormonal contraception. A vaginal oestrogen ring used continuously limited most scarring for 8 years. Progressive apical vaginal scarring obstructed menstrual flow leading to haematocolpos and haematometra. Normal anatomy was restored with a cruciate incision in the cervicovaginal scar performed during menses. When HPV disease limits use of topical immunosuppression in women with vaginal GVHD, the local scar-reducing effect of a vaginal oestrogen ring is limited, and surgery may be needed and can be successful in treating haematocolpos.This study was registered in ClinicalTrials.gov with trial registration number of NCT00003838.

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Treatment of end-stage renal disease with continuous ambulatory peritoneal dialysis in rural Guatemala

A 42-year-old indigenous Maya man presented to a non-profit clinic in rural Guatemala with signs, symptoms and laboratory values consistent with uncontrolled diabetes. Despite appropriate treatment, approximately 18 months after presentation, he was found to have irreversible end-stage renal disease (ESRD) of uncertain aetiology. He was referred to the national public nephrology clinic and subsequently initiated home-based continuous ambulatory peritoneal dialysis. With primary care provided by the non-profit clinic, his clinical status improved on dialysis, but socioeconomic and psychological challenges persisted for the patient and his family. This case shows how care for people with ESRD in low- and middle-income countries requires scaling up renal replacement therapy and ensuring access to primary care, mental healthcare and social work services.

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Correction: Unilateral retinitis pigmentosa occurring in an individual with a mutation in the CLRN1 gene

Sim PY, Jeganathan VSE, Wright AF et al. Unilateral retinitis pigmentosa occurring in an individual with a mutation in the CLRN1 gene. BMJ Case Rep 2018; doi: 10.1136/bcr-2017-222045.

The following text should have been included in the 'Presented at' section:

Dr V. Swetha E. Jeganathan was finalist for the Novartis Retina Case Awards, held on 27^th February 2013 at the City Hospital, Birmingham. Her case presentation was subsequently published in the Eye News supplement in March 2013.

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Treatment and reconstruction of a complicated infected scalp squamous cell carcinoma with CNS invasion

A 60-year-old male patient with a large infected cranial apex lesion was admitted with lethargy and mental status changes. The patient underwent evaluation with imaging studies, a skin biopsy, cultures with microscopy and a diagnostic burr hole. MRI and positron emission tomography/CT scan revealed a squamous cell carcinoma with ingrowth in the midline of the brain and subdural empyema infected with Streptococcus anginosus and Staphylococcus aureus.

High dose intravenous antibiotic treatment was initiated and the patient subsequently underwent a surgical resection of the carcinoma with a 1 cm margin of surrounding skin and skull. The defect was reconstructed using a titanium plate and a free microvascular lattisimus dorsi muscle flap then covered with a split skin graft.

The patient received 37 radiation therapy sessions (66 GY) as adjuvant therapy.

Intensive neurorehabilitation slowly improved an initial paraparesis. The 7-month follow-up revealed a satisfactory cosmetic result and residual gait impairment secondary to central nervous system invasion.

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Clostridium difficile cure with fecal microbiota transplantation in a child with Pompe disease: a case report

Recurrent Clostridium difficile infection is a growing problem among children due to both the increasing survival of medically fragile children with complicated chronic medical conditions resulting in prolonged a...

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Performance validation of an amplicon-based targeted next-generation sequencing assay and mutation profiling of 648 Chinese colorectal cancer patients

Abstract

Next-generation sequencing (NGS) has become a promising approach for tumor somatic mutation detection. However, stringent validation is required for its application on clinical specimens, especially for low-quality formalin-fixed paraffin-embedded (FFPE) tissues. Here, we validated the performance of an amplicon-based targeted NGS assay, OncoAim™ DNA panel, on both commercial reference FFPE samples and clinical FFPE samples of Chinese colorectal cancer (CRC) patients. Then we profiled the mutation spectrum of 648 Chinese CRC patients in a multicenter study to explore its clinical utility. This NGS assay achieved 100% test specificity and 95–100% test sensitivity for variants with mutant allele frequency (MAF) ≥ 5% when median read depth ≥ 500×. The orthogonal methods including amplification refractory mutation system (ARMS)-PCR and Sanger sequencing validated that NGS generated three false negatives (FNs) but no false positives (FPs) among 516 clinical samples for KRAS aberration detection. Genomic profiling of Chinese CRC patients with this assay revealed that 63.3% of the tumors harbored clinically actionable alterations. Besides the commonly mutated genes including TP53 (52.82%), KRAS (46.68%), APC (24.09%), PIK3CA (18.94%), SMAD4 (9.47%), BRAF (6.15%), FBXW7 (5.32%), and NRAS (4.15%), other less frequently mutated genes were also identified. Statistically significant association of specific mutated genes with certain clinicopathological features was detected, e.g., both BRAF and PIK3CA were more prevalent in right-side CRC (p < 0.001 and p = 0.002, respectively). We concluded this targeted NGS assay is qualified for clinical practice, and our findings could help the diagnosis and prognosis of Chinese CRC patients.

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Detection of abnormally shaped ears by a trained non-specialist allows for early non-surgical intervention

Publication date: July 2018
Source:International Journal of Pediatric Otorhinolaryngology, Volume 110
Author(s): Daphne Y.D. Lu, Julie Pauwels, Lisa Jin, Frederick K. Kozak, Neil K. Chadha
IntroductionMany children are born with abnormally-shaped ears, including protruding ears or unusually-shaped outer ears. While the majority are benign, these may cause significant issues with self-esteem and bullying in childhood. Early molding can resolve some of these abnormalities, avoiding the need for future corrective surgery. However, newborns with these abnormalities are rarely identified early, within the first few days of life, when molding is most effective. In this study, we investigate whether a trained non-specialist can correctly identify ear shape abnormalities in newborns.MethodsA non-specialist (medical student) was trained on normal and abnormal ear anatomy using photographs and descriptions. Newborns <72 h of age were recruited from maternity wards. Newborns' ears were photographed and these images were assessed independently by two specialists and the non-specialist. External ear shape was classified as either normal or abnormal based on pre-determined criteria.ResultsA total of 661 ears of 334 newborns were photographed and assessed. High inter-rater agreement was achieved with a kappa statistic of 0.863 (SE 0.078). The non-specialist detected abnormally-shaped ears with a sensitivity and specificity of 90.9% and 91.1% respectively.ConclusionsOur study illustrates that non-specialist can be trained to accurately detect newborn ear abnormalities, providing a cost-effective means of ensuring that these children's health care needs are met in a timely fashion. Specifically, we recommend the integration of ear shape assessment into currently established programs such as the newborn hearing screening program.



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