A Rare Case of Periprosthetic Joint Infection with Streptococcus dysgalactiae subspecies dysgalactiae.

Periprosthetic joint infection (PJI) is a rare but most vital complication after joint arthroplasty and requires a revision surgery. Synovial fluid analysis is essential in diagnosis of the PJI, and conventional and molecular microbiologic investigations may help in determining the cause of the infection. With this unusual case, we aimed to present the second instance in the literature of PJI of the knee caused by Streptococcus dysgalactiae subspecies dysgalactiae (SDSD). S. dysgalactiae PJI in the literature are commonly Streptococcus dysgalactiae subspecies equisimilis (SDSE), and SDSD mostly infects animals. A farmer with comorbid illnesses who works with cattle and sheep experienced periprosthetic knee joint infection caused by SDSD. Surgical excisional debridement with open washing, decompression, and liner exchange were performed. The identification of the bacteria was done with VITEK MS as SDSD. After 1-year follow-up, the patient has fully recovered without recurrence.

Effects of intranasal and intramuscular administration of butorphanol and zolazepam-tiletamine combination on intraocular pressure and tear secretion in New Zealand White rabbits.

This study aimed to compare the effect of intranasal (IN) and intramuscular (IM) administration of butorphanol and zolazepam-tiletamine (ZT) combination on intraocular pressure (IOP) and tear secretion (TS) in rabbits. Fourteen healthy male New Zealand White rabbits weighing 3.05 ± 0.72 kg, aged between 1 and 2 years old, were included in the study. Animals randomly received 0.5 mg/kg butorphanol and 15 mg/kg ZT combination either with IN or IM administration. IOP and TS were measured at baseline (T0), and followed by 5, 15, 30, 45, and 60 min after drug administration. The sedation variables, the time to onset of sedation, duration of sedation, and sedation scores were also recorded. The route of administration for the butorphanol and ZT combination had no significant effect on the mean IOP (p = .301) and TS (p = .445). Furthermore, there were no significant changes observed in the IOP (p = .472) and TS (p = .348) over time. The time to onset of sedation was earlier in the IN group (4.57 ± 0.79 min) than in the IM group (5.86 ± 0.9 min; p = .0004). The duration of sedation was significantly longer for IM (57.43 ± 3.41 min) compared with IN (45.0 ± 1.91 min; p < .0001). No significant difference in the sedation score was observed between groups at all time points. In conclusion, both IN and IM administration of the butorphanol and ZT combination in rabbits had similar effects on IOP and TS.

Quantitative evaluation of Saliency-Based Explainable artificial intelligence (XAI) methods in Deep Learning-Based mammogram analysis.

BACKGROUND: Explainable Artificial Intelligence (XAI) is prominent in the diagnostics of opaque deep learning (DL) models, especially in medical imaging. Saliency methods are commonly used, yet there's a lack of quantitative evidence regarding their performance. OBJECTIVES: To quantitatively evaluate the performance of widely utilized saliency XAI methods in the task of breast cancer detection on mammograms. METHODS: Three radiologists drew ground-truth boxes on a balanced mammogram dataset of women (n = 1496 cancer-positive and negative scans) from three centers. A modified, pre-trained DL model was employed for breast cancer detection, using MLO and CC images. Saliency XAI methods, including Gradient-weighted Class Activation Mapping (Grad-CAM), Grad-CAM++, and Eigen-CAM, were evaluated. We utilized the Pointing Game to assess these methods, determining if the maximum value of a saliency map aligned with the bounding boxes, representing the ratio of correctly identified lesions among all cancer patients, with a value ranging from 0 to 1. RESULTS: The development sample included 2,244 women (75%), with the remaining 748 women (25%) in the testing set for unbiased XAI evaluation. The model's recall, precision, accuracy, and F1-Score in identifying cancer in the testing set were 69%, 88%, 80%, and 0.77, respectively. The Pointing Game Scores for Grad-CAM, Grad-CAM++, and Eigen-CAM were 0.41, 0.30, and 0.35 in women with cancer and marginally increased to 0.41, 0.31, and 0.36 when considering only true-positive samples. CONCLUSIONS: While saliency-based methods provide some degree of explainability, they frequently fall short in delineating how DL models arrive at decisions in a considerable number of instances.

Allergic Contact Dermatitis in the Right Forearm Following Splint Application for Distal Radius Fracture: A Rare Case of Plaster Cotton Allergy.

Allergic contact dermatitis (ACD) after splint or cast application (plaster of Paris) is infrequently encountered in orthopedic and traumatology clinical practice. This case study aims to elucidate the identification of ACD after splint application, highlight the conditions that warrant vigilance, and outline the precautions and optional treatment methods available in such instances. A 56-year-old right-hand dominant female presented to the emergency department after a fall on her right hand, manifesting pain, swelling, and tenderness without neurovascular injury. Radiographs revealed a distal radius fracture, leading to the application of a plaster of Paris splint. Within one day, she returned to the emergency department with severe itching and burning in the right arm. The splint was removed, and a dermatology consultation confirmed ACD due to undercast cotton padding. After splint removal, the patient's fracture treatment continued using a shoulder-arm sling until the lesion healed. Topical antihistamine ointment and oral corticosteroids were prescribed. Regular follow-up revealed the healing and union of the fracture by the fifth week, with minimal residual skin color changes. This case underscores the importance of prompt diagnosis and appropriate treatment in managing such occurrences. A key takeaway is the crucial need to schedule a follow-up appointment with the patient within one day of applying the cast or splint. Skin problems can emerge rather than neurovascular issues following casts or splints. Educating patients on warning signs, including skin irritation, neurovascular deficits, and symptoms of compartment syndrome, ensures the timely identification of significant issues. Healthcare practitioners should inquire about patients' histories of allergic skin reactions, taking a proactive approach to prevent ACD through early intervention and preventive measures.

Scanning ion conductance microscopy revealed cisplatin-induced morphological changes related to apoptosis in single adenocarcinoma cells.

The studies of drug-induced apoptosis play a vital role in the identification of potential drugs that could treat diseases such as cancer. Alterations in the native morphology of cancer cells following treatment with anticancer drugs serve as one of the indicators that reveal drug efficacy. Various techniques such as optical microscopy, electron microscopy (EM), and atomic force microscopy (AFM) have been used to map the three dimensional (3D) morphological changes in cells induced with drugs. However, caution should be exercised when interpreting morphological data from techniques that might alter the native morphology of cells, caused by phototoxicity, electron beam invasiveness, intrusive sample preparation, and cell membrane deformation. Herein, we have used scanning ion conductance microscopy (SICM) to study the 3D morphology and roughness of A549 adenocarcinoma cells under physiological conditions before and after cisplatin induced apoptosis, where we observed an increase in height, overall shrinkage of the cells, and irregular features form on the cell membrane. Tracking the morphology of the same single A549 cells exposed to cisplatin unveiled heterogeneity in response to the drug, formation of membrane blebs, and an increase in membrane roughness. We have also demonstrated the use of SICM for studying the effect of cisplatin on the dynamic changes in the volume of A549 cells over days. SICM is demonstrated as a technique for studying the effect of drug induced apoptosis in the same cells over time, and for multiple different single cells.

Comparison of the ABCD Score's Accuracy in Predicting Remission of Type 2 Diabetes Mellitus One Year After Sleeve Gastrectomy, One Anastomosis Gastric Bypass, and Sleeve Gastrectomy with Transit Bipartition.

PURPOSE: ABCD score is one of the scoring systems that predicts the probability of T2DM remission after bariatric surgery. Its success in determining T2DM remission after sleeve gastrectomy with transit bipartition (TB) has not yet been validated. The aim of this study was to evaluate the predictive value of ABCD score in TB. MATERIALS AND METHODS: Of 438 patients with T2DM, 191 underwent sleeve gastrectomy (SG), 136 underwent one anastomosis gastric bypass (OAGB), and 111 underwent TB. Retrospective analysis of ABCD scores, 1-year postoperative remission rates, and the predictive accuracy of ABCD scores for these were conducted. RESULTS: In the SG, OAGB, and TB groups, respectively, median ABCD scores were 7, 6, and 4, while complete remission rates were 95.3%, 84.6%, and 76.6% (p < 0.001). The area under curves (AUCs) for SG, OAGB, and TB were 0.829 (95% CI = 0.768 to 0.879, p < 0.0001), 0.801 (95% CI = 0.724 to 0.865, p < 0.0001), and 0.840 (95% CI = 0.758 to 0.902, p < 0.0001), respectively. There was no statistically significant difference between AUCs. CONCLUSION: ABCD score predicts the probability of remission at 1-year follow-up in T2DM patients undergoing TB as accurately as in patients receiving SG or OAGB.

Distal Humerus Metaphyseal-Diaphyseal Junctional Fracture of a Four-Year-Old Child Treated With Intramedullary Steinmann Wire Fixation: A Case Report.

Distal humeral metaphyseal-diaphyseal fractures are rare and inherently unstable injuries. Non-operative treatments can make it hard to maintain reduction. Open or closed reduction with percutaneous K-wire fixation may be the preferred treatment option for these fracture types. This case report describes successfully managing a rare distal humerus metaphyseal-diaphyseal junctional (MDJ) fracture in a four-year-old child using intramedullary Steinmann wire fixation. A four-year-old male child applied to the emergency service with a swollen elbow. He had a history of trauma 10 days ago. There was a long arm splint on his arm. A displaced distal MDJ fracture of the left humerus was detected on the radiograph. Due to its instability, we preferred surgical management. With a lateral incision, we obtained a successful reduction after manipulation. Subsequently, we achieved the anatomical reduction with three Steinmann pins. We applied two Steinmann pins intramedullary, and the other one crosses from the medial epicondyle and exits the lateral cortex, forming a crossed-pin configuration at the fracture site. We immobilized the extremity for four weeks with a long arm splint. At the end of the fourth week, we removed the Steinmann pins. After removing the wires, we began an active range of motion exercises. The plain X-ray at the two-month follow-up revealed good fracture healing with no residual elbow deformity. The patient could perform a complete elbow range of motion. The case highlights the challenges in treating pediatric distal metaphyseal-diaphyseal humerus fractures, and it demonstrates the effectiveness of this intramedullary Steinmann wire fixation technique in achieving stable fracture reduction and promoting rapid healing in a small child.

Simultaneous Talocalcaneal and Talonavicular Joint Dislocation With Navicular Bone Fracture of a Teenager While Playing Football: A Report of a Rare Case.

Simultaneous talocalcaneal and talonavicular joint dislocation, in other words, subtalar joint dislocation, and navicular bone lateral process fracture are rare orthopedic injuries. In this case, we aimed to discuss the effectiveness and ergonomics of non-surgical follow-up with a short leg splint after reduction of talonavicular, talocalcaneal joint dislocation, and lateral process fracture of the navicular bone. A 17-year-old male patient was admitted to the emergency department with swelling and pain in his left foot after spraining his left foot while playing football. Pain, swelling, and deformity in the left foot were evident without a neurovascular deficit. Radiographs showed simultaneous left foot talonavicular joint dislocation, talocalcaneal joint dislocation, and navicular lateral process fracture. The patient underwent closed reduction and a short leg splint. We followed the patient regularly, removed the leg splint in the fourth week, and started various movement exercises. We started muscle strengthening exercises in the sixth week and reached full range of motion with full muscle strength without any deformity in the eighth week. In this case, closed reduction and short leg splint with traction along the axis of the left foot and manipulation of the talus laterally by everting the ankle were sufficient. We restricted the movement of the ankle and tarsometatarsal joint with a short leg splint and reached full range of motion with follow-ups and exercises.

Simultaneous Fifth Carpometacarpal Joint Dislocation and Fourth Metacarpal Neck Fracture: A Conservative Treated Case With a Functional Metacarpal Splint.

Simultaneous carpometacarpal joint dislocation and fractures of adjacent carpal bones are rare orthopedic injuries. With this case, we aimed to discuss the effectiveness and ergonomics of the functional metacarpal splint in carpometacarpal joint dislocations and metacarpal neck fractures without surgery. A 27-year-old right-hand dominant male applied to the emergency department after a punch on a wall with his right fist. Pain, swelling, and deformity were evident without neurovascular injury. The radiographs showed simultaneous fifth carpometacarpal joint dislocation and fracture of the neck of the fourth metacarpal bone. We performed closed reduction with longitudinal traction and applied a functional metacarpal splint. We followed up with the patient regularly, and on the fourth week, we removed the splint and began a range of motion exercises. On the sixth week, we began muscle strengthening exercises, and we reached full range of motion with fair muscle strength on the eighth week of the follow-up without any deformity. In this case, prompt diagnosis, longitudinal traction, closed reduction with manual dorsal manipulation, and functional metacarpal splinting were adequate. We achieved a full range of motion without the need to immobilize the wrist or metacarpophalangeal joints or undergo surgery after proper immobilization with a functional metacarpal splint.

Ulnar Nerve Management in Distal Humerus Fracture Surgery: A Case of Developing Ulnar Neuropathy After Open Reduction and Internal Fixation.

In this case report, we want to show how a patient who underwent surgery for a distal humerus fracture developed postoperative ulnar neuropathy symptoms, how nonunion persisted even at the ninth month of follow-up, and whether the nonunion was connected to the ulnar neuropathy that developed. Due to this, we used this case to explore ulnar nerve care and whether ulnar nerve transposition, manipulation, or decompression should be carried out during surgery on patients with distal humerus fractures. A 52-year-old man with a bi-columnar distal humerus fracture from a fall on his right elbow underwent open reduction and internal fixation at an external center one year before. Elbow restriction, discomfort, numbness, and weakness in the fourth and fifth digits of the right hand were all symptoms the patient experienced eight months following the surgery. We discovered the distal right humerus' nonunion during the radiological exams. It became apparent that the patient had no signs of ulnar neuropathy before the injury. In the eighth month following the injury, the patient had implant removal, open reduction internal fixation with autograft, and ulnar nerve transposition. We discovered during follow-up that the patient's ulnar neuropathy symptoms had subsided. The surgeon's familiarity with the procedure and command of the anatomy of the elbow has a role in managing the ulnar nerve in distal humerus fractures. We concluded that more study is required to determine the connection between the onset of ulnar neuropathy and nonunion while treating distal humerus fractures.

Evaluation of patients' post-operative results operated for hip fracture with computerized dynamic posturography: Proximal femoral nailing versus hip arthroplasty.

BACKGROUND: Proximal femoral nailing (PFN) and hip arthroplasty (HA) are the two most often utilized surgical procedures for treating hip fractures in older patients. The post-operative postural balance and functional outcomes of patients may be significantly influenced by the technical distinctions between PFN and HA. This will influence the surgeon's preferred course of therapy. To examine the functional outcomes of patients treated with PFN and HA following a hip fracture, this study used computerized dynamic posturography (CDP). The aim of that study was to evaluate how the two treatment modalities affected patients' post-operative balance, postural stability, and functional rehabilitation. METHODS: A total of 26 patients who underwent proximal femoral surgery (15 patients PFN [58%] and 11 patients HA [42%]) due to hip fractures were evaluated at least 12 months postoperatively. They were tested by direct radiographs, hip joint examinations, Harris hip score (HHS), and CDP. RESULTS: Twelve (46%) of 26 patients were male and 14 (54%) were female. The mean age of the participants in the study was 67.9±14.2 years. The mean follow-up period was 24 (12-44) months. The average Harris score of PFN group was 79.3 (46.8-100) points and HA group was 83.7 (61.9-99.9) points. There was no significant difference between the groups in terms of Harris Score (P=0.54). The average of the mixed value of the balance results obtained with CDP (the Composite score) for PFN group was 70.5 (56-79) points, and for HA group was 71.9 (56-83) points. There was no significant difference between the groups in terms of the Composite Score (P=0.47). Accordingly, 12 (80%) of the patients who underwent PFN had good results and 3 (20%) of them had bad results. Eight (72.7%) of those who underwent HA had good results and 3 (27.3%) had bad results. There was no statistically significant difference (P=0.66). CONCLUSION: Comparing the composite score for balance results and HHS results for rehabilitation with the data of the patients who underwent PFN and HA, there was no statistically significant difference between these two techniques in terms of postural stabil-ity and balance as a result of CDP examination.

A Large Mass Displaying a Malignant Character on the Forearm: A Rare Case of Upper Extremity Pilomatrixoma.

In this study, a 50-year-old male patient had a painless swelling on his right forearm. The lump on the forearm started one year ago and increased in size in the last two months. The mass was 3x6 cm and had a malignant appearance on radiological imaging. The case was reported as pilomatrixoma in the histopathological examination after marginal excision. In this case report, we emphasized that pilomatrixoma is one of the diagnoses we considered in mass formations that can be seen in the upper extremity, although rare. The large mass displaying a malignant character in radiological imaging can be pilomatrixoma, and the Tru-cut biopsy before the final surgery may help diagnosis by preventing the surgeons from aggressive surgical treatment. The marginal excision shall be enough in the definitive treatment. With this study, we aimed to discuss the place of pilomatrixoma in the orthopedic literature, which is published chiefly by otolaryngology, pathology, and dermatology clinics and lacks in the orthopedic literature because it rarely involves the extremities.

Aspergillus fumigatus Septic Arthritis of the Wrist: A Report of a Rare Case in an Immunocompromised Patient.

Aspergillus fumigatus is a saprophytic fungus encountered as a pathogen in airborne lung infections. Although it commonly causes pulmonary infectious diseases, when disseminated, it may cause a systemic infection termed invasive aspergillosis, which is associated with high mortality and morbidity. Virtually, all organ systems may be involved. However, the musculoskeletal system is relatively uncommon. Here, we present a case of invasive aspergillosis in an immunocompromised patient involving the wrist joint, an exceedingly rare site. Our treatment choice is serial open debridement, irrigation, and intravenous antibiotics. This case study exemplifies the potential challenges in the identification and treatment of such an uncommon clinical condition. A thorough clinical and microbiological evaluation is essential for accurate diagnosis of fungal septic arthritis of the wrist. Aggressive early surgical treatment combined with appropriate early intravenous antibiotics is crucial for eradicating joint infection.

Match the Metatarsal Heads: A Case of All-Metatarsal Fractures After a Motorcycle Accident.

Metatarsal bone fractures are one of the most frequent foot injuries, especially after motor vehicle accidents in children. This case report briefly demonstrated a rare instance of pediatric all-metatarsal fractures of the left foot in an adolescent patient with polytrauma after a motorcycle accident. This case report illustrated the surgical procedure's potential for healing pediatric foot fractures in teenage patients after polytrauma. In the examination of a 16-year-old male patient brought to the emergency department after a motorcycle accident, we detected a right foot third finger proximal phalanx open fracture, right foot fourth finger proximal phalanx fracture, left foot first metatarsal proximal fracture, left foot second, third, fourth, and fifth metatarsal distal fractures, left foot cuboid, and navicular bone fractures. The patient's left foot's metatarsals were all fractured. The posterolateral wall fracture of the patient's right maxilla was also detected. All metatarsals were displaced, the second metatarsal paired with the third, etc., and because of this displacement, the closed reduction was impossible, and even the open reduction was challenging to reach the correct pairs. We performed closed reduction and fixation with Kirschner wire for the left foot's first metatarsal fracture and open reduction and fixation with Kirschner wire for the left foot's second, third, and fourth metatarsal distal fractures. We also performed closed reduction and fixation with Kirschner wire for the right foot third and fourth proximal phalanx fractures. We observed callus formation in the sixth week and removed the patient's K-wires. At eight weeks, the X-ray demonstrated the correct alignment of all metatarsals. The proper alignment of all metatarsals and the full range of motion of all foot and ankle joints were achieved with early surgical intervention, open reduction, and timely rehabilitation. This case also emphasizes the importance of open reduction in such irreducible and heavily displaced cases of multiple fractures as all-metatarsal fractures and contributes to the literature with a specific treatment modality in the case of all-metatarsal fractures lacking in the literature.

A Case of Malignant Myxofibrosarcoma With Hypoglycemia Attacks.

Myxofibrosarcoma is a malignant mesenchymal tumor and a fibroblastic sarcoma of the elderly. Myxofibrosarcoma can be low-grade or high-grade depending on the cell characteristics. Wide surgical resection with or without radiotherapy and chemotherapy is the basis of its treatment. Sometimes, tumor cells secrete insulin or insulin-like substances and cause hypoglycemia attacks. Here, we intend to demonstrate the role of early surgery to end hypoglycemia attacks and prevent recurrence and metastases. We also intend to show the insufficiency of tru-cut biopsy to distinguish between low- and high-grade myxofibrosarcoma. An 82-year-old male patient visited our clinic with a rapidly growing giant mass in the left retroscapular area and suffered from hypoglycemic attacks several times a day. After imaging and initial biopsy, the tumor grade was indeterminate on histopathological examination; hence, the mass was removed surgically. The pathological examination resulted in high-grade myxofibrosarcoma whereas the initial biopsy could not elaborate on the grade. The hypoglycemia attacks ceased after the surgery. Adjuvant local radiotherapy at a total dose of 60 Gy was administered in 30 fractions to the surgery area with no complications after the surgery. No new mass, recurrence, or hypoglycemia attack was detected in the three-year follow-up. In conclusion, hypoglycemia attacks may be a marker of malignant tumor presence and may be a clue at the beginning and in the follow-up period both for recurrence and the aggressiveness of the tumoral mass. Because a biopsy may show the diagnosis but not the grade of the tumor, early surgical intervention is needed.

Comparison of Diagnostic Accuracy of Panoramic Radiography to CBCT in Maxillary Sinus Diseases.

We aimed to compare the effectiveness of panoramic radiography (PR) and cone beam computed tomography (CBCT) in radiographic diagnosis of maxillary sinus (MS) diseases. MS diseases (mucosal thickening, mucus retention cyst, polyp sinusitis, mucocele and tumoral formations) was carried out on both PR and CBCT images belonging to 625 patients. Analyzes were performed separately for right and left maxillary sinus, and total of 1250 PR and CBCT images. While a diagnosis of disease was made in 42.96% of a total of 1250 MS according to CBCT. According to PR, diagnosis was made in 58.72%. The 537 diagnoses where lesion presence was determined on CBCT in our study were compared over PR, and it was observed that, there was the right diagnosis (true positive) in 106 (19.73%) of these including respectively mucus retention cyst (n = 88), polyp (n = 16), 1 sinusitis and 1 tumor, and there was an incorrect diagnosis (false positive) in 221 (41.15%). In 42.92% of the MS that were identified as healthy based on CBCT, the correct diagnosis was also made on PR (true negative). The use of CBCT instead of PR in the diagnosis of pathological or inflammatory diseases contributes to a more accurate radiographic differential diagnosis.

Inflammation-associated long non-coding RNA signature in radicular cyst tissues.

Radicular cysts are characterized by significant levels of changes in inflammatory biomarkers. Among them, interleukins and growth factors have been reported to be deregulated in radicular cyst tissues. Moreover, long non-coding RNAs are recently discovered non-coding RNA molecules that regulate various intracellular stimuli to keep homeostasis in balance. A growing body of evidence suggests that lncRNAs are significantly involved in the regulation of inflammation by targeting various inflammatory biomarkers. Accordingly, the present study was aimed to investigate the gene expression levels of inflammation-related lncRNAs in radicular cysts and show their possible roles in the development of radicular cysts. For the study, a total of 25 patients with a radiologically and pathologically confirmed radicular cyst were enrolled. For the determination of non-coding RNA expression levels, real-time qPCR was used. As a result of the current study, expression levels of PACER and THRIL were found to be significantly elevated in radicular cyst tissues compared to control tissue samples. However, MALAT1, ANRIL, and NEAT1 expression levels were not significantly altered in radicular cyst tissues compared to control tissue samples. In conclusion, long non-coding RNAs, PACER and THRIL, seem to have significant pathophysiological roles by acquiring molecular changes during inflammation and might be involved in the development and formation of radicular cysts.

Evaluation of biochemical variables in patients with recurrent aphthous stomatitis.

PURPOSE: We investigated the effects of various biochemical agents on the etiopathogenesis of recurrent aphthous stomatitis (RAS). METHODS: We enrolled 70 RAS patients and 70 healthy volunteers. Peripheral venous blood samples were collected. We performed complete blood counts, then measured the levels of ferritin, vitamin B12, iron, magnesium, phosphorus, calcium, thyroid-stimulating hormone, T3, T4, and 25-hydroxy D3. RESULTS: The groups did not differ in terms of age (p = 0.912) or sex (p = 0.612). The levels of ferritin and 25-hydroxy vitamin D were significantly lower in RAS patients (both p Ë‚ 0.05). CONCLUSION: Vitamin D and/or ferritin deficiency may induce RAS. Measurements of vitamin D and ferritin may assist diagnosis and follow-up.

Bilateral Femur and Humerus Avascular Necrosis Associated With Corticosteroids: A Rare Case Presentation.

Avascular necrosis of the bone is a pathology characterized by compromised blood circulation, leading to necrosis due to insufficient vascular nourishment. Within the realm of orthopedics and traumatology, instances of avascular necrosis are steadily increasing. Notably, the escalating use of corticosteroids in managing inflammatory diseases and acute respiratory distress syndrome associated with the COVID-19 pandemic has resulted in a surge of outpatient referrals concerning cases of glucocorticoid-associated avascular necrosis. This study aims to elucidate the management of avascular necrosis following oral corticosteroid use in a young and otherwise healthy male patient, impacting both humeral and femoral heads bilaterally. A 26-year-old adult male, devoid of chronic health conditions, received a diagnosis of bilateral avascular necrosis in humeral and femoral heads within two years following a one-month course of oral corticosteroids. The patient underwent a comprehensive treatment regimen, encompassing hyperbaric oxygen therapy, oral antiplatelet therapy, a tailored physical therapy and rehabilitation program, and bilateral core decompression surgery for both hip joints. During the three-year follow-up, the patient exhibited a favorable response to treatment, demonstrating a complete and painless range of motion in both shoulder and hip joints. This case serves to underscore a crucial point: femoral head avascular necrosis may not invariably manifest as the initial bone affected, and a substantial time lapse may transpire between corticosteroid use and the onset of clinical symptoms. We emphasize the critical importance of not dismissing complaints pertaining to other bones in patients with a confirmed diagnosis and stress the significance of prompt detection in avascular necrosis. Furthermore, this study highlights the necessity for heightened vigilance in instances of orthopedic grievances among individuals with a history of corticosteroid use, particularly those related to the pandemic and inflammatory diseases, to facilitate early diagnosis and intervention for avascular necrosis.

Controller placement with critical switch aware in software-defined network (CPCSA).

Software-defined networking (SDN) is a networking architecture with improved efficiency achieved by moving networking decisions from the data plane to provide them critically at the control plane. In a traditional SDN, typically, a single controller is used. However, the complexity of modern networks due to their size and high traffic volume with varied quality of service requirements have introduced high control message communications overhead on the controller. Similarly, the solution found using multiple distributed controllers brings forth the 'controller placement problem' (CPP). Incorporating switch roles in the CPP modelling during network partitioning for controller placement has not been adequately considered by any existing CPP techniques. This article proposes the controller placement algorithm with network partition based on critical switch awareness (CPCSA). CPCSA identifies critical switch in the software defined wide area network (SDWAN) and then partition the network based on the criticality. Subsequently, a controller is assigned to each partition to improve control messages communication overhead, loss, throughput, and flow setup delay. The CPSCSA experimented with real network topologies obtained from the Internet Topology Zoo. Results show that CPCSA has achieved an aggregate reduction in the controller's overhead by 73%, loss by 51%, and latency by 16% while improving throughput by 16% compared to the benchmark algorithms.