Gallbladder torsion.

ABSTRACT: Gallbladder torsion is a rare cause of acute surgical abdomen. Early recognition and surgical intervention are important for reducing complications and improving postoperative patient outcomes, but standard imaging and laboratory evaluation typically are indistinguishable from those of acute cholecystitis. This article describes a patient with gangrenous cholecystitis secondary to torsion and summarizes recommendations for evaluation and management.

Plasmacytoma of Liver Mimicking Hepatocellular Carcinoma at Multiphasic Computed Tomography Evaluation.

Plasmacytoma of liver is a rare hepatic tumor more often seen at autopsy than described in the literature; it is also more likely diagnosed in the setting of multiple myeloma than as isolated extramedullary plasmacytoma. However, when found in the setting of multiple myeloma, it is associated with worse clinical outcome. The authors describe a case of an elderly man presenting with nonspecific chronic abdominal pain and a new 4-cm hepatic mass. At multiphasic computed tomography, the mass demonstrated an enhancement pattern identical to that expected of hepatocellular carcinoma; however, thorough history failed to uncover necessary risk factors for hepatic cirrhosis. Ultrasound-guided core biopsy of the mass, as well as additional clinical and radiologic assessment, subsequently confirmed a diagnosis of multiple myeloma.

Rhino-orbital-cerebral mucormycosis in times of COVID-19: A neurosurgical experience.

BACKGROUND: The gravity of "second wave" of COVID-19 has effaced many new challenges in India; mucormycosis being a recent one. Diabetes mellitus (DM) is a known significant risk factor for mucormycosis. Here, we present our experience with rhino-orbital-cerebral mucormycosis (ROCM) during the "second wave of COVID-19" at a tertiary health care centre in North India. METHODS: This case series includes four cases of ROCM that were managed by our neurosurgical team in view ofcerebral involvement. RESULTS: All the cases with an exception of one (Case 1), had a history of treatment for COVID-19 pneumonia. Case 2, 3 had undergone functional endoscopic sinus surgery (FESS) and orbital decompression before the onset of cerebral involvement; Case 4 underwent FESS and cranial surgery in the same sitting. All the patients had a history of DM and all the cases treated for COVID-19 pneumonia had a history of treatment with corticosteroids. Two patients underwent surgery with the exception of one patient, who did not provide consent for the same. One patient expired before surgical excision could be attempted. CONCLUSION: Regular and intensive follow-up is the key in swift detection and management of ROCM in post-COVID patients. While surgical excision is advisable in the fungal lesion, it must be borne in mind that radical excision of cerebral lesions is associated with morbidity, delayed recovery, and prolonged ICU stay. Culture and sensitivity-based antibiotics should be used judiciously as fever is a common postoperative complication. Blood sugar monitoring and control of DM are paramount in this condition. Steroids should be avoided in the management of cerebral edema with judicious use of hypertonic saline or mannitol.

Cefoperazone-sulbactam for treatment of intra-abdominal infections: results from a randomized, parallel group study in India.

BACKGROUND: Combinations of a third-generation cephalosporin and metronidazole, with or without an aminoglycoside, often are used for the treatment of intra-abdominal infections in surgical settings. Simpler regimens that preserve an adequate spectrum of coverage, but allow easier administration and have fewer side effects, may be a more desirable option. METHODS: This randomized, open-label, active comparator study evaluated the effectiveness (non-inferiority hypothesis) of the beta-lactam/beta-lactamase inhibitor combination cefoperazone-sulbactam (2-8 g/day), compared with ceftazidime (2-6 g/day)-amikacin (15 mg/kg/day)-metronidazole (500 mg three times daily) in 154 and 152 subjects, respectively, having intra-abdominal infections. The study was conducted at 17 centers in India. RESULTS: Non-inferiority of cefoperazone-sulbactam (91.9%) compared with ceftazidime-amikacin-metronidazole (81.8%) was demonstrated for continued resolution of clinical signs and symptoms at the 30-day follow-up (primary endpoint) with a treatment difference of 10.1% (95% confidence interval 2.1%, 18.1%; pre-defined non-inferiority limit > -12.5%). Superiority of cefoperazone-sulbactam also was demonstrated for this endpoint, with significantly more subjects achieving continued resolution at the 30-day follow-up than in the comparator group (p = 0.015). On microbiologic outcomes, cefoperazone-sulbactam had higher success rates than ceftazidime-amikacin-metronidazole (92.9% vs. 80.0%). The pathogens (202 isolated) isolated most commonly were Escherichia coli (38.6%) and Klebsiella spp. (12.9%). The incidence of treatment-related adverse events was 6.5% and 16.4% in the cefoperazone-sulbactam and ceftazidime-amikacin-metronidazole groups, respectively, with more discontinuations due to treatment-related adverse events in the comparator arm (3.2% vs. 9.9%). CONCLUSION: Empirical cefoperazone-sulbactam monotherapy could be a useful adjunct to surgical intervention for intra-abdominal infections.

The use of tourniquets in the excision of unexsanguinated extremity burn wounds.

PURPOSE: Tangential excision of burns is complicated by blood loss. Tourniquet use decreases blood loss, but adequacy of excision has been questioned. An attempt was made to assess the value of not exsanguinating the limb prior to tourniquet inflation to improve visualization of bleeding points and subsequent engraftment. METHODS: Eleven excisions of bilateral extremity wounds were performed. One limb was excised without the benefit of a tourniquet, the other with tourniquet but without exsanguination. Tangential excision was performed, hemostasis achieved, and blood loss quantified. Engraftment of skin was assessed at first dressing change and at initial follow-up after discharge. RESULTS: Area of burn was the same, 4.8% with tourniquet, 5.1% without (P=0.38). Overall blood loss was less with tourniquet control, 100-259 cm(3) (P=0.002); as was blood loss per area, 0.19-0.58 cc/cm(2) (P=0.04). Graft take was similar, 98.2% early and 98.1% later with tourniquet, with 98.2 and 96.8% take without (P>0.1). CONCLUSIONS: Tourniquet use in the unexsanquinated extremity reduced blood loss without affecting engraftment.

Contrast flow characteristics in the cervical epidural space: an analysis of cervical epidurograms.

STUDY DESIGN: A single-center prospective analysis of cervical epidurograms, using a crossover design. OBJECTIVES: To delineate the extent and pattern of spread of epidural contrast during cervical epidural steroid injections. To determine the volume of solution needed for effective cervical epidural steroid injections. To determine the most appropriate neck flexion angles for cervical epidural steroid injections. To determine the relationships between epidural spread, degree of neck flexion, and volume of solution used during cervical epidural steroid injections. SUMMARY OF BACKGROUND DATA: The decreased epidural space in the cervical region makes injections here liable to rare, but potentially serious, complications. The lower cervical (C6-C7, C7-T1) levels are thought to be safer because of the increased epidural space here, as compared with higher levels. There is, however, considerable controversy in the scientific literature regarding the levels at which cervical epidural injections should be performed. There is also no consensus regarding the volume of solution needed or the extent of neck flexion required for effective epidural spread. To date, no study has examined these questions. METHODS: Patients with lower cervical spine pathology who were referred for cervical epidural steroid injections were randomly assigned to have the injections performed at the C6-C7 or C7-T1 midline level. Volume of solutions used and degree of neck flexion were measured. Characteristics of epidural spread were recorded. Patients requiring repeat injections had the injections performed at the adjacent level with identical volume and angle of neck flexion using a goniometer. Contrast flow characteristics were again recorded. Extent of spread was correlated with the level of injection, volume of injectant, and degree of neck flexion. RESULTS: No major or permanent complications were noted. The contrast was found to spread evenly throughout the entire dorsal cervical epidural space, on a consistent basis, in all cases. At C6-C7, it was found to spread an average of 3.61 +/- 0.84 levels; and at C7-T1, it spread an average of 3.88 +/- 1.01 levels. Using a three-way analysis of variance, the level at which the epidural was performed, the amount of contrast used, and the neck flexion angle did not affect the number of levels spread. CONCLUSIONS: In cervical epidural steroid injections performed in the midline at C6-C7 and C7-T1, the contrast consistently covers the dorsal cervical epidural space bilaterally, irrespective of the volume used or neck flexion angle used. This suggests that solutions introduced here would cover the dorsal cervical epidural space. This questions the utility of performing potentially more dangerous injections at higher cervical levels or more invasive procedures, such as the use of epidural catheters.