Vitamin D Deficiency in Patients With Low-Energy Hip Fractures in Accordance With the Mediterranean Paradox.

Introduction Vitamin D deficiency (VDD) is considered one of the leading causes of poor bone quality. It may also be related to severe muscular weakness, especially in the elderly, which leads to frequent falls. Thus, VDD might be associated with fragility fractures of the hip, wrist, and spine in this age category. In this cross-sectional study, our goal was to present vitamin D levels in an elderly Mediterranean population with hip fractures and to assess whether its levels are related to the incidence or prevention of such injuries. Methods Between January and December 2021, 140 patients aged 65 years or older were hospitalized in our department with a fracture involving the hip joint. Serum calcium and vitamin D level control was performed upon admission, as well as recording whether anti-osteoporosis medication had been prescribed. Only patients with low-energy fractures were included, whereas oncologic patients and those with high-energy trauma were excluded. Results Thirty-eight men and 102 women, with a mean age of 83.12 and 84.88 years, respectively, participated in our study. Intertrochanteric fractures were the most common injuries (50.72%). Low vitamin D levels (<30 ng/mL) were observed in 132 patients (94.28%). A bone density scan during the last year had been conducted by only seven patients (5%), whereas in 136 patients (97.14%), no anti-osteoporotic medication was given. Conclusion There is an excessive percentage of aged patients with hip fractures in Greece, demonstrating a significant vitamin D insufficiency despite the high annual frequency of sunny days in this Mediterranean region. Presumably, most of these patients neither perform the routine bone density scan nor do they take any kind of preventive pharmaceutical treatment, which might reveal devaluation of osteoporosis from this age group due to contingent comorbidities.

Pyoderma Gangrenosum - a Challenging Diagnostic Approach.

Pyoderma gangrenosum (PG) is an infrequent, aseptic neutrophilic dermatosis that can be observed in patients with systemic diseases such as inflammatory bowel disease or rheumatic disorders. Due to its rare entity, PG often constitutes a diagnostic enigma, as it simulates other skin disorders. Typically, it is displayed as painful, ulcerative lesions localized to the lower extremities. In our study, we present a case of a 67-year-old woman with recently diagnosed ulcerative colitis who presented with two painful ulcers, one on the left anterior tibia and the other one on the left subclavian area. Initially, their clinical image overlapped with skin abscess. However, taking into account patient's medical history, skin examination, sterile wound cultures and skin biopsy, the diagnosis of PG was established. The patient was completely recovered with high doses of corticosteroids, daily wound changes and surgical intervention involving loose wound edge approximation. In this study, we highlight that clinicians should always be aware of patient's medical history in such cases, in order to early diagnose PG and avoid inaccurate medical approaches which might have an impact on patients' quality of life.

Peer review practices in academic medicine: how the example of orthopaedic surgery may help shift the paradigm?

PURPOSE: To establish the current peer-reviewed practices in the discipline of orthopaedic surgery and correlate these to the journal's impact factor. Unfortunately, this is not receiving much attention and a critical literature gap in various disciplines; thus, determining the current practices in the discipline of orthopaedic surgery could provide valid insight that may be potentially applicable to other academic medicine disciplines as well. METHODS: Orthopaedic surgery journals belonging to the Journal Citation Reports were queried, and the following was extracted: impact factor (IF) and blinding practices: single (SBPR), double (DBPR), triple (TBPR), quadruple (QBPR), and open (OPR) blinding review process and possibility of author-suggested reviewer (ASR) and non-preferred reviewer (NPR) options. RESULTS: Of the 82 journals, four were excluded as they allowed submission by invitation only. In the remaining, blinding was as follows: SBPR nine (11.5%), DBPR 52 (66.7%), TBPR two (2.6%), QBPR zero (0%), and OPR three (3.8%), and in 12 (15.4%), this was unclear. ASR and NPR options were offered by 34 (43.6%) and 27 (34.6%) journals respectively, whereas ASR was mandatory in eight (10.2%). No correlation between IF and any other parameter was found. CONCLUSION: The rules of the "game" are unclear/not disclosed in a significant number of cases, and the SBPR system, along with the ASR (mandatory sometimes) and NPR, is still extensively used with questionable integrity and fairness. Several recommendations are provided to mitigate potentially compromising practices, along with future directions to address the scarcity of research in this critical aspect of science.

Diagnostic and Therapeutic Challenges of Intrahepatic Biliary Cystadenoma and Cystadenocarcinoma: A Report of 10 Cases and Review of the Literature.

The objective of this study was to present our experience with intrahepatic biliary cystadenomas and cystadenocarcinomas in 10 patients surgically managed in our department. Intrahepatic biliary cystadenomas and cystadenocarcinomas are rare cystic tumors that are often misdiagnosed preoperatively as simple cysts or hydatid cysts. They recur after incomplete resection and entail a risk of malignant transformation to cystadenocarcinoma. A retrospective review was conducted of patients with histologically confirmed intrahepatic biliary cystadenomas and cystadenocarcinomas between August 2004 and February 2013 who were surgically managed in our department. A total of 10 patients, 9 female and 1 male (mean age, 50 years), with cystic liver were reviewed. The size of the cysts ranged between 3.5 and 16 cm (mean, 10.6). Five patients had undergone previous interventions elsewhere and presented with recurrences. Liver resections included 6 hepatectomies, 2 bisegmentectomies, 1 extended right hepatectomy, and 1 enucleation due to the central position and the large size of the lesion. Pathology reports confirmed R0 resections in all cases. All patients were alive after a median follow-up of 6 years (range, 1-10 years), and no recurrence was detected. Intrahepatic biliary cystadenoma and cystadenocarcinoma should be considered in differential diagnosis in patients with liver cystic tumors. Because of the high recurrence rate and difficult accurate preoperative diagnosis, formal liver resection is mandatory. Enucleation with free margins is an option and is indicated where resection is impossible.

Adenocarcinoma of the third portion of the duodenum in a man with CREST syndrome.

BACKGROUND: CREST (Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly and Telangiectasias) syndrome has been rarely associated with other malignancies (lung, esophagus). This is the first report of a primary adenocarcinoma of the third portion of the duodenum in a patient with CREST syndrome. CASE PRESENTATION: A 54-year-old male patient with CREST syndrome presented with colicky postprandial pain of the upper abdomen, diminished food uptake and a 6-Kg-body weight loss during the previous 2 months. An ulcerative lesion in the third portion of the duodenum was revealed during duodenoscopy, with a diagnosis of adenocarcinoma on biopsy specimen histology. The patient underwent a partial pancreatoduodenectomy. No adjuvant therapy was instituted and follow-up is negative for local recurrence or metastases 21 months postoperatively. CONCLUSION: CREST syndrome has been associated with colon cancer, gastric polyps, familial adenomatous polyposis (FAP) syndrome and Crohn's disease; however, this is the first report of a primary adenocarcinoma of the duodenum in a patient with CREST syndrome. However, any etiologic relationship remains to be further investigated.

Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery: an algorithmic approach.

AIM: To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed. METHODS: During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography (E/MRCP), scintigraphy and fistulography. RESULTS: Thirty (12.8%) patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants (mortality rate 28.5%). CONCLUSION: Management of major biliary fistulae that are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.

Subcutaneous extension of a large diaphragmatic hydatid cyst.

A 53-year-old male patient with a large hydatid cyst of the left hemidiaphragm and smaller secondary cysts located in the left thoracic cavity and upper left abdominal quadrant presented with two progressively enlarging lipoma-like masses in the left hypochondrium and under the left scapulae respectively. Total excision of all the cysts was performed through a bilateral subcostal incision, with the left hemidiaphragm near totally excised and replaced by a synthetic bilayer mesh.