Prospective comparison of magnetic resonance imaging and computed tomography in diagnosing occult scaphoid fractures.

BACKGROUND: Suspected scaphoid fracture (SF) after a fall on an outstretched hand is a common presentation in the emergency department. Magnetic resonance imaging (MRI) or computed tomography (CT) has been suggested to assist in the diagnosis or exclusion of SF. PURPOSE: To compare MRI and CT at diagnosing occult SFs. MATERIAL AND METHODS: We routinely perform CT scans in patients with clinically suspected occult SF, after 7-10 days of injury following two negative radiographs. All eligible patients with a clinically suspected SF, but negative radiographs and a negative CT, underwent an MRI scan to assess further for evidence of occult fracture. RESULTS: A total of 100 patients were included in our study. MRI showed fractures in 16% of the time (in 15 patients) when plain radiographs and CT did not. Of these fractures, 8% were SFs. In addition to fractures, 10% had bone bruising. A total of 25% of patients with fractures and bone bruising were referred to the hand surgery team for further follow-up. CONCLUSION: The study demonstrated that MRI would identify a radiographically occult SF more often than CT. This supports NICE guidelines which recommend MRI as the best early diagnostic tool for occult SFs.

Ultrasound guided surgery under Dilutional Local Anaesthesia and no sedation in breast cancer patients.

BACKGROUND: Breast cancer surgery under local anaesthesia (LA) can be challenging due to limitation of dose and quantity of anaesthetic agent that can be used safely. Elderly patients with breast cancer and with multiple co-morbidities are often prevented from having a standard treatment as they are considered unfit for general anaesthesia. We describe a technique of surgery under local anaesthesia without sedation that employs dilution to generate large volumes of LA and infiltration under ultrasound guidance. METHODS: We present a case series by a single surgeon of breast cancer patients who underwent surgery under LA. 40 mls of 1% lignocaine with 1:200,000 adrenaline was diluted with 160 mls of normal saline to make a total of 200 mls, resulting in dilution to a concentration of 0.2% lignocaine. Radioactive isotope having been injected before patient's arrival in theatre, 1 ml of diluted anaesthetic solution is used with 2 mls of 2.5% patent blue to inject in the sub-areolar space. Local anaesthetic is infiltrated at operative site under ultrasound guidance using a long echogenic needle. RESULTS: A total of 71 patients with breast cancer underwent surgery under the LA between September 2015 and October 2018. 64 (90%) patients had wide local excisions and 7 (10%) had mastectomies. All had axillary surgery, 65 (91.5%) had dual technique sentinel lymph node biopsy as a day case and 6 (8.5%) patients had axillary clearance. 8 patients had re excision (12.5%). All patients had '0' pain score and no postoperative analgesia was required in recovery. Local anaesthetic used did not exceed the maximum safe dose in any of the cases. One patient returned to theatre for postoperative wound bleeding. No other postoperative complication was observed. CONCLUSION: Ultrasound guided infiltration allows accurate placement of large volume of diluted local anaesthetic solution safely and provides effective anaesthesia.

The impact of the 21-gene assay on adjuvant treatment decisions in oestrogen receptor-positive early breast cancer: a prospective study.

BACKGROUND: International guidelines, including NICE, recommend using the 21-gene Recurrence Score assay for guiding adjuvant treatment decisions in ER+, HER2-negative early breast cancer (BC). We investigated the impact of adding this assay to standard pathological tests on clinicians'/patients' treatment decisions and on patients' decisional conflict in the United Kingdom. METHODS: In this prospective multicentre study, eligibility criteria included: ER+ HER2-negative BC (N0/Nmic for patients ⩽50 years; ⩽3 positive lymph nodes for patients >50 years) and being fit for chemotherapy. Physicians'/patients' treatment choices and patients' decisional conflict were recorded pre- and post testing. RESULTS: The analysis included 137 patients. Overall, adjuvant treatment recommendations changed in 40.7% of patients, with the direction of the change consistent with the Recurrence Score results (net decrease in chemotherapy recommendation rate in low Recurrence Score patients and net increase in high Recurrence Score patients). Patients' choices were generally consistent with physicians' recommendations. Post-testing, patients' decisional conflict decreased significantly (P<0.0001). In the 67 patients meeting the NICE criteria for testing, the recommendation change rate was 49.3%. CONCLUSIONS: Recurrence Score testing significantly influenced treatment recommendations overall and in the subgroup of patients meeting the NICE criteria, suggesting that this test could substantially alter treatment patterns in the United Kingdom.

Management of folliculitis decalvans with ayurveda- A case report.

INTRODUCTION: The superficial infection that involves the hair follicle with bogginess or induration of involved parts of the scalp along with pustules, erosions, crusts, ulcers, and scales resulting in hair fall is known as folliculitis decalvans (FD). This condition accounts for approximately 11% of all cases with primary cicatricial alopecia. Based on clinical features like Keshadhwansha (hair fall) with Harsha (hypersensitivity), Kandu (itching), Toda (pain), FD can be correlated with Raktaja Krimi Vikara (RKV). OBSERVATION AND RESULTS: A 24 years' male patient with the chief complaint of patchy hair loss in the scalp region associated with scale formation, itching, and pain for 2 months. He had a history of pustules-like eruption over the frontal and parietal regions. He tried various topical and oral medications for 8 days but didn't get any sign of improvement and came to NIA hospital for Ayurveda treatment. Due to the signs like pustules over the scalp, hair loss with honey-colored crusting, scarring, mild itching, and pain; he was diagnosed with RKV âˆ¼ FD. After treatment with Ayurveda medicine and leech therapy, complete remission of the scar, lesions, itching, pain, and hair loss was obtained, and there was new hair growth over the scalp with normal distribution. The patient was on follow-up for 33 months with no signs of itching, pain, and hair fall. CONCLUSION: Complete remission of FD was achieved by Ayurveda medicine along with Jalaukavacharana and it seems highly effective on the basis of remission period compared to contemporary treatment modalities. It is suggested to have further clinical studies with large samples to analyze its effectiveness.

Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre.

INTRODUCTION: Team work, communication, and efficiency in the operating theatre are widely recognised to be suboptimal. Poor communication is the single biggest cause of medical error. The surgical operating theatre is a potentially highly stressed environment where poor communication can lead to fatal errors. The objectives of this study were to assess the effects briefings and debriefings had on theatre start time, list lengths, and the staff's impression of these meetings. MATERIALS AND METHODS: Briefings and debriefings were conducted before the start of theatre lists over a 6 month period in 2007 in a district general hospital in north Bristol, UK. Both quantitative and qualitative data were collected. Using the hospital theatre database, theatre start and finish time was found and list length calculated. A questionnaire was devised and used to assess staff attitude to the briefings and debriefings. RESULTS: Staff felt that the briefings highlighted potential problems, improved the team culture, and led to organisational change. Theatre start times tended to be earlier and lists lengths were shorter when briefings were conducted, although this only reached statistical significance on one type of list. DISCUSSION: Briefings and debriefings had a positive impact on teamwork and communication. The lists ran more efficiently and briefings did not delay the theatre start times-in fact, the lists tended to start earlier.

Image-guided intervention in the management of chronic patellar tendinopathy with calcification: a three-pronged approach.

Patellar tendinopathy is a common cause of knee pain and functional impairment in athletes. It is commonly managed using conservative measures such as physiotherapy, but cases that are refractory to such treatment may require a more invasive approach. Various forms of image-guided injection therapy have been described in the literature. We present a case of successful treatment of chronic patellar tendinopathy with calcification with the first reported use of a three-pronged image-guided approach, consisting of dry needling, high volume image-guided injection (but at a reduced dose) and barbotage applied in a single sitting. The patient reported resolution of symptoms persisting to 1 year postprocedure. We suggest that this management option, if supported by further positive research findings, could be used in the future in the management of certain cases of patellar tendinopathy with calcification where conservative measures have failed.

Symptomatic nodular myopathy: an atypical presentation of sarcoidosis.

Symptomatic myopathy is a very rare extrapulmonary manifestation of sarcoidosis that may not be readily recognised in the absence of a known history of sarcoid. Nodular myopathy is the most uncommon subtype of musclar sarcoidosis and, when encountered, establishing the diagnosis can be challenging. We present a case of symptomatic nodular myopathy as a first presentation of sarcoidosis in a young man who required a multidisciplinary approach to diagnose. The patient presented to our radiology department following a short period of flu-like illness and multiple soft tissue lesions. Biopsy of the lesions demonstrated noncaseating granulomata, and a diagnosis of sarcoidosis was established after important differential diagnoses were excluded. We present a literature review of sarcoid-related myopathy and the multimodality imaging characteristics of the different subtypes.

Unusual multiloculated serpiginous ganglion of the foot.

Ganglions are cystic lesion more commonly seen around the wrist joint. Gangliomas of plantar aspect of the foot are rare. We have presented a case of an unusual serpiginous ganglioma of the plantar aspect of the foot. Less literature is available regarding plantar foot gangliomas. The treatment is challenging because of occurrence of the lesion at weight bearing zone. Available options for treatment includes conservative with splint, intralesional injection,arthroscopic excision and open excision.

Bilateral gluteus medius and minimus calcific tendonitis in a patient with previous bilateral calcific tendonitis of the shoulder: A case report.

Calcific tendonitis of the gluteus medius and minimus tendons is a rare complication of hydroxyapatite deposition disease, with bilateral involvement even more so. Although patients can be asymptomatic, there is often an acute-on-chronic presentation of pain. We present a case of bilateral calcific tendonitis of the gluteus medius and minimus tendons on a background of previous bilateral rotator cuff calcific tendonitis in a middle-aged woman. This patient's long-standing history of multi-focal involvement required a multidisciplinary approach between orthopedics, rheumatology, and musculoskeletal radiology for optimal management, requiring different treatment options for different affected sites.

Rare case of adult-onset phalangeal microgeodic syndrome of the feet.

Phalangeal microgeodic syndrome (PMS) is a rare condition typically affecting children and is characterised by painful digits precipitated by cold temperatures. In medical literature, cases appear to be clustered in Japan. Adult-onset PMS is particularly rare and although imaging features are characteristic, it may go undiagnosed, as it is not commonly encountered. We present, to our knowledge, the fifth reported case in the literature of adult PMS, the second to affect the feet rather than hands, and the first in a Caucasian adult patient. This case report aims to raise awareness of this likely underdiagnosed condition to allow optimal management and avoidance of unnecessary diagnostic procedures.

Arterial injury in total knee arthroplasty.

Arterial complications associated with knee arthroplasty are relatively rare, although probably underreported, complications of knee arthroplasty that carry a risk of significant morbidity. Thorough preoperative assessment and close liaison with a vascular surgeon, combined with an appreciation of common anatomical variants or distorted anatomy, may help prevent both thromboembolic and direct injuries from occurring. Clinical features of arterial complications following knee arthroplasty may vary significantly from acute hemorrhage or ischemia in the immediate postoperative period to chronic pain and swelling presenting even months following the procedure. There is potential for diagnostic confusion and delay that may adversely affect outcome. Early diagnosis along with vascular surgical review and intervention is key to successful management.

Dilutional local anaesthetic techniques in oncoplastic breast surgery and potential benefits during the COVID-19 pandemic and beyond.

INTRODUCTION: COVID-19 has changed the approach to operating on breast cancer for the benefit of patients, staff and the general population. One approach involves the switch from operating under general to local anaesthetic. We assess whether diluational local anaesthetic is as effective as the current standard approach. METHODS: Postoperative pain was recorded in prospective, consecutive patients undergoing wide local excision under dilutional local anaesthetic (concentration < 1mg/ml). Pain scores were documented at 0, 30 and 60 minutes and compared to a control group consisting of combined general with local anaesthetic. RESULTS: Pain significantly increased in the control group during the postoperative recovery. This was not seen in the dilutional local anaesthetic group that was non-inferior to the standard approach at 0, 30 and 60 minutes. CONCLUSION: Dilutional local anaesthetic provides a safe and effective alternative approach to operating on breast cancer patients whilst avoiding risky general anaesthetic in a COVID-19 pandemic environment.

Development of bullous lung disease in a patient with severe COVID-19 pneumonitis.

A 60-year-old man presented with sudden onset right-sided chest pain and gradually worsening shortness of breath on exertion. Eleven days earlier, he had an admission with COVID-19 pneumonitis requiring 8 days of continuous positive airway pressure. He was tachypnoeic with a respiratory rate of 24 breaths/min, oxygen saturations on room air of 91%. Examination revealed reduced air entry and a resonant percussion note over the right hemithorax. Chest radiograph suggested a complex right pneumothorax; however, a CT chest was notable for widespread right-sided bullous lung disease. After a day of observation on a COVID-19 ward (and a repeat radiograph with a stable appearance), he was discharged with a 2-week follow-up with the respiratory team, safety netting advice and ambulatory oxygen. This case suggests that bullous lung disease may be a complication of severe COVID-19 pneumonitis.

Spontaneous pneumomediastinum as a complication of a COVID-19 related pneumonia: case report and review of literature.

A novel coronavirus, SARS-COV-2, related infection is thought to have originated in Wuhan, China, in November 2019 but spread rapidly to be declared a global pandemic by the WHO in March 2020. The patients typically present with fever and shortness of breath. We describe a case of spontaneous pneumomediastinum at presentation as a complication of severe Covid-19 infection. A 54 year old male patient with no history of smoking, asthma or other underlying chronic lung disease, presented to our emergency department with severe Covid-19 symptoms. His chest x-ray and CT scan on arrival at the emergency department, and prior to any intervention, demonstrated severe bilateral Covid-19 pneumonia complicated by a pneumomediastinum. The aetiology of the pneumomediastinum is thought to be a direct complication of severe covid-19 pneumonia in absence of any previous respiratory history or iatrogenic cause.

Unlocking a locked knee by ultrasound guided anesthetic injection.

Twenty-three-year old male patient with a background of mild cerebral palsy (with limited effect on mobility) presented with 36 hours history of pain on the lateral aspect of his left knee. On examination his knee was locked and there was no associated history of trauma. A detailed MRI scan required in extension and unlocked leg to elucidate the cause. This was achieved by administration of local anesthetic under ultrasound guidance to the lateral aspect of the knee with successful results. This case is important as it looks at minimally invasive management of the acutely locked knee prior to more detailed imaging. Pseudolocking of the knee is a well-known cause of knee locking. Performing a magnetic resonance imaging (MRI) scan to diagnose cases of pseudolocking can prevent unnecessary intervention such as arthroscopy. In our case, the orthopedic team was reluctant to take the patient to theatre without more detailed imaging, given his medical history. There are very few case reports in the literature which address this issue and there is no case in the literature using this technique in cerebral palsy with muscle spasm.

Insufficiency fractures: A rare cause of foot and ankle pain in three patients with rheumatoid arthritis.

Insufficiency fractures are recognized but rare complications in patients with longstanding rheumatoid arthritis. Such fractures are typically solitary and are rarely seen to affect the foot and ankle. We describe 3 women with longstanding rheumatoid arthritis, treated with one, or a combination of, corticosteroids, DMARDs and anti-TNF, presenting with foot and ankle pain with no prior history of trauma. MRIs showed rare multiple florid insufficiency fractures of the foot and ankle, in 2 cases bilaterally, which were managed conservatively. These cases highlight the importance of considering insufficiency fractures in similar patients presenting with foot and ankle pain. Radiographs may fail to demonstrate these lesions, delaying diagnosis, and worsening patient outcome, therefore in such cases MRI is a valuable modality.

Scar endometriosis: a mimic of acute abdominal emergencies.

Scar endometriosis can be a great mimic of common surgical and gynaecological conditions in reproductive age females. The correct preoperative diagnosis is only achieved in a relatively low number of patients (20-50%). This uncommon condition presents diagnostic challenges and requires surgical excision in most cases. Ultrasound represents a useful tool to triage and direct management as well as further investigations. We present a case of scar endometriosis in a young female with a previous history of caesarean section.

Muscle mania: the quest for the perfect body.

We describe the case of a young man with repeated hospital presentations for a variety of symptoms related to excessive bodybuilding and associated behaviours. He presented to our department (radiology) with right arm pain and loss of function. Ultrasound showed complete triceps rupture, rare in young patients and multiple cystic areas within the muscles of the arm. MRI revealed these to be multiple proteinaceous lesions within the muscle bellies and the possibility of self-innoculation was raised by the reporting radiologist. The patient subsequently admitted to injecting coconut oil to improve muscle contour lost secondary to injury. A review of his hospital presentations was then made and revealed further concerning practices performed by the patient to enhance his muscular appearance.

Multiple Step-section Frozen Section sentinel lymph node biopsy--a review of 717 patients.

Sentinel Lymph Node Biopsy (SLNB) is the standard of care for axillary staging in breast cancer. Multiple Step-section Frozen Section (MSFS) analysis is used in our institution for SLNB. This is performed intra-operatively by freezing sentinel lymph nodes to obtain multiple step-sections which are examined histologically for evidence of metastases. Patients whose sentinel lymph nodes contained macrometastases proceeded to an axillary node clearance during the same operation. 717 patients over a two and a half year period had MSFS analysis. With regards to macrometastases, MSFS analysis had a sensitivity of 93.8%, a specificity of 99.3%, a positive-predictive value of 97.4% and a negative-predictive value of 98.2%. MSFS analysis of sentinel lymph nodes is a safe and accurate procedure. It is a relatively cost-effective alternative to molecular technologies relying on DNA amplification and more accurate than standard frozen section or touch-prep cytology.