Septic arthritis caused by Candida albicans: post intra-articular steroid injection in a native joint.

Intra-articular steroid injections are widely prescribed for management of osteoarthritis when oral medication or physiotherapy treatment fails to relieve patient's pain. Septic arthritis is an uncommon side effect of steroid injection. Common causal micro-organisms are bacterial with Staphylococcus aureus being the most frequent. Fungal septic arthritis is rare and does not usually present beyond the neonatal period. We present a rare case of septic arthritis secondary to fungal infection.

Metastatic Melanoma Epidural Tumour Regression Following Percutaneous Radiofrequency Ablation.

Percutaneous radiofrequency ablation of spinal metastases is an emerging treatment for patients with painful metastatic spine disease. It is typically performed for patients who have not responded to conventional treatments or who have contraindications to radiotherapy. Destruction of the posterior wall of the vertebral body and epidural disease may be considered relative contraindications for radiofrequency ablation. This is due to the difficulty in achieving satisfactory ablation balanced against the risk of neural injury. We describe a case of metastatic melanoma with an expansile lytic metastasis and epidural tumour extension at the L4 vertebral body level resulting in severe central canal stenosis. This was successfully treated with percutaneous radiofrequency ablation and vertebral augmentation. The patient reported significant pain relief post-procedure and follow-up MRI at two months demonstrated local tumour regression, epidural disease resolution and improved spinal canal dimensions. To the best of our knowledge, this is the first report of epidural disease resolution from metastatic melanoma following radiofrequency ablation and emphasises the potential benefits of ablation therapy even in the presence of canal stenosis and epidural metastatic disease.

Polyarticular extension of pigmented villonodular synovitis to contiguous joints via pigmented villonodular tenosynovitis.

Pigmented villonodular synovitis is an uncommon benign neoplastic process that affects synovial-lined joints, bursae and tendon sheaths. We describe polyarticular extension of pigmented villonodular synovitis across joints secondary to pigmented villonodular tenosynovitis. Given that treatment is required to prevent progressive destruction of the involved joint, tendon or bursa, radiologists must be vigilant for diffuse polyarticular or extrasynovial involvement to optimize patient care and initiate appropriate therapy.

Does coronary artery bypass grafting improve quality of life in elderly patients?

Traditional outcome measures such as long-term mortality may be of less value than symptomatic improvement in elderly patients undergoing coronary artery bypass grafting (CABG). In this systematic review, we analyse health-related quality of life (HRQOL) as a marker of outcome after CABG. We aimed to assess the role of HRQOL tools in making recommendations for elderly patients undergoing surgery, where symptomatic and quality-of-life improvement may often be the key indications for intervention. Twenty-three studies, encompassing 4793 patients were included. Overall, elderly patients underwent CABG at reasonably low risk. Our findings, therefore, support the conclusion that performing CABG in the elderly may be associated with significant improvements in HRQOL. In order to overcome previous methodological limitations, future work must clearly define and stringently follow-up this elderly population, to develop a more robust, sensitive and specialty-specific HRQOL tool.

Acute ethics: risk assessment and the Doctrine of Double Effect in a referral to on-call urology.

The Doctrine of Double Effect has been described as often used in medicine and surgery but is seldom described outside the palliative medicine context. This paper presents a possible clinically focussed illustration of the doctrine of double effect used in an acute urological setting. The authors describe the case of an elderly patient with significant dementia and haematuria who required anticoagulation. Implicit double effect reasoning may have helped the surgical team reach their initial decision with regard to a treatment plan, reconciling a duty to beneficence with a duty not to cause harm. This short case is offered as a stimulus for further discussion over the role of duty-based ethical reasoning in the acute surgical setting. It also highlights a possible need for more detailed case-analysis in identifying areas of interest in surgical ethics.

The role of oesophageal diversion and exclusion in the management of oesophageal perforations.

AIM: Persistent sepsis from an oesophageal perforation has a near 100% mortality. We describe our experience with early oesophageal diversion and exclusion for patients in-extremis. METHODS: A retrospective review of oesophageal perforations was performed between 2000 and 2007. There were five cases Boerhaaves and one case of iatrogenic perforation that required oesophageal diversion and exclusion. 4 males, 2 females with a mean age of 67.6 (58-72) years. RESULTS: The primary procedure was performed within 24h in four patients; the other two were after 3 and 10 days. The intensive care unit (ITU) stay was a median of 25 days. Mortality rate was 50%. Median length of stay for the survivors was 60 days. Three patients underwent a successful colonic interposition in our unit after 6 months. CONCLUSION: Exclusion and diversion procedures are required in very rare circumstances. In conditions of persistent leak and continuing sepsis or those patients not fit to undergo a major procedure they could be lifesaving if performed early. As it is a relatively easy and quick procedure it should be considered early as a 2nd line management option.

Bilateral retrovascular femoral hernia.

A 34-year-old woman with cystic fibrosis presented with bilateral femoral hernias, which were found to be retrovascular at operation. The hernias were not amenable to conventional open or laparoscopic repair, and were repaired using pre-peritoneal mesh inserted deep to transversalis fascia. The anatomical basis and management of uncommon variants of femoral hernia are discussed.