Evaluation of routine proximal bone analysis for microbiology and histopathology in diabetes-related foot infections and osteomyelitis.

PURPOSE: The value of proximal bone analysis for surgical clearance of infection remains debated. Real-world practice traditionally utilized proximal bone microbiology rather than histopathology to diagnose residual diabetes-related osteomyelitis of the foot (DFO) post-amputation. We assessed the concordance between proximal bone microbiology and histopathology in determining residual infection and their predictability for revision operation in DFO and diabetes-related foot infection (DFI). METHODOLOGY: A single-centre retrospective study was conducted between June and December 2020 at a tertiary institution. We recruited patients with diabetes mellitus who had minor amputations for DFO and DFI and analyzed their proximal bone microbiology, histopathology and outcomes at 6 months. RESULTS: Eighty-four patients were recruited; 64 (76.2%) were male. The mean age was 69.3 years. The mean HbA1c was 8.6%. Seventy-seven operations were performed for DFO and 17 for DFI. Negative microbiology showed complete concordance with histopathology; and none had revision operation (P = 0.99). Positive microbiology had 9.8% concordance with histopathology (P = 0.99). Positive histopathology was associated with a higher rate of revision operation (80% vs. 12.5%; P = 0.01). High preoperative C-reactive protein was associated with residual DFO (P = 0.02) and revision operation (P = 0.01). CONCLUSION: Positive histopathology was more reliable for determining significant residual DFO and predicting revision operation. Positive microbiology was valuable for guiding antibiotic selection. We suggest routine proximal bone analysis for both histopathology and microbiology to optimize the treatment of DFO and DFI.

Successful, staged management of an iliac artery to ileal urinary conduit fistula.

Fistula formation between the iliac artery and an ileal conduit is a rare pathology. A 39-year-old female patient presented with intermittent hematuria from her ileal conduit for 4 days, which progressed to massive hemorrhage on the ward. Her background includes stage 4A squamous cell carcinoma of the cervix treated with pelvic chemoradiotherapy and brachytherapy, recurrent obstructive uropathy requiring bilateral nephrostomies and bilateral ureteral stenting. Twelve months before this presentation, she had been treated for an iliac artery-ileal conduit fistula with a covered stent to the left common iliac artery. After initial fluid resuscitation, the bleeding was managed with endovascular placement of a covered stent. She subsequently underwent definitive vascular reconstruction with removal of the common iliac artery stents, an aortoiliac bypass using a vein graft, and repair of the ileal conduit electively. This case demonstrates the management of a rare clinical pathology and highlights the importance of close surveillance after endovascular procedures.

Dissecting a diagnostic enigma: Hypertension in a young patient from an organ of Zuckerkandl paraganglioma.

Hypertension in young patients can mask rare conditions like paragangliomas, especially in the absence of conventional symptoms. A comprehensive diagnostic evaluation and multidisciplinary approach are crucial for optimal management and outcomes.

Acute carpal tunnel syndrome from thrombosed persistent median artery in a patient with congenitally absent radial artery.

OBJECTIVES: Thrombosis of the persistent median artery (PMA) is a rare cause of acute carpal tunnel syndrome (ACTS). Existence of a congenitally absent radial artery in this setting has not been described in the literature. METHODS: Computed Tomography Angiography (CTA) and doppler screening were used in pre surgical planning. Open surgical decompression was achieved through the release of the flexor retinaculum in the left hand. A regimen of 100 mg of Aspirin for 3 months time was initiated to encourage clot resolution and recanalization of the thrombosed artery. RESULTS: The PMA was found to be abnormally large measuring approximately 4 mm in diameter. Visible clotting off of the PMA in keeping with the doppler scans with maintenance of distal flow and was left intact with the hopes that it would recanalize over time. At the 3-month post-op review the antiplatelet therapy was ceased and the patient was symptom free, demonstrated no signs of ischaemia in the hand, and had returned to full functionality and physical activity. CONCLUSIONS: Although infrequently encountered, the knowledge of the anatomical variations of the forearm and hand together with doppler screening and CTA is essential to the surgical management of ACTS.

Acute Mesenteric Ischemia.

The surgical treatment of occlusive acute mesenteric ischemia (AMI) without revascularization is associated with an 80% overall mortality. Early diagnosis is crucial, and revascularization may reduce overall mortality in AMI by up to 50%. A diagnosis of AMI requires a high index of clinical suspicion and the collaborative effort of emergency department physicians, general and vascular surgeons, and radiologists. This article provides an overview of the etiology, physiology, evaluation, and management of acute mesenteric ischemia.

Grade four blunt traumatic aortic injury with massive haemothorax: Resuscitation considerations during the primary survey.

Advanced Trauma Life Support principles prioritise the management of 'breathing' over 'circulation' in an acute trauma primary survey. In a tamponaded thoracic aortic rupture, however, this may lead to fatal haemorrhagic shock. In this case, we discuss the resuscitation and management of a patient with a massive left sided haemothorax secondary to a grade four blunt traumatic aortic injury. A 26-year-old male was involved in a high-speed motor vehicle crash and was hypoxic and hypotensive at the scene. His oxygenation and haemodynamics improved with supplemental oxygen and fluid resuscitation. He had a left intercostal catheter inserted after an urgent thoracic endovascular aortic repair was performed to prevent disruption of the contained haemothorax in the presence of a grade four thoracic aortic injury. It is vital to recognise the potential disruption of a tamponaded blunt traumatic aortic injury during consideration of thoracostomy and chest drain decompression.

Intracardiac migration and knotting of a ventriculoperitoneal shunt.

We report a patient with delayed migration of the distal ventriculoperitoneal shunt catheter from the peritoneum to the right atrium with associated knotting of the catheter complicating removal. We also review the literature on this topic.