Rejected

Shoulder arthroplasty is associated with significant postoperative pain. Interscalene plexus block is the gold standard for pain management in patients undergoing this surgery, however, alternatives are currently being developed. We hypothesized that a combination of anterior suprascapular nerve block and lateral sagittal infraclavicular block would provide effective postoperative analgesia. Primary aims for this study were to document numeric rating scale (NRS) pain score and use of oral morphine equivalents (OMEq) during the first 24 hours after surgery. Secondary aim was to determine the incidence of hemidiaphragmatic paralysis.

EUS-directed transgastric ERCP (EDGE) has emerged as a viable, completely endoscopic method for performing pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy. The aims of this systematic review are: 1) to describe indications, outcomes and complications of EDGE; and 2) to identify deficiencies in our knowledge of important technical approaches and clinical outcomes.

A 47-year-old woman with history of seizure disorder (semiology of seizure unknown), not well controlled with antiepileptic drugs since last 30 years presented with 1-year history of intermittent throbbing headache. On the day prior to admission, she experienced worst headache, followed by loss of consciousness. On regaining consciousness, she had neck pain without any focal neurological deficit, but examination was marked by positive meningeal signs. She had history of oral ulceration, photosensitivity and small joints pain for which no medical consultancy was sought until. Following relevant investigations, this case came out to be moyamoya angiopathy secondary to underlying systemic lupus erythematosus. She was put on immunosuppressive and immunomodulator as per recommendations. Among neurological symptoms, headache improved dramatically without any further seizure recurrence till the 6 months of follow-up.

Fungal infections involving the pituitary gland are rare and can be life threatening. A 75-year-old man with hypertension and diabetes mellitus presented with headache and hyponatraemia. Imaging study showed right upper lung mass, and mass resection showed aspergilloma without tissue invasion on histology. The patient developed visual impairment a few weeks later, and MRI of the brain revealed bilateral sphenoid sinusitis and pituitary invasion. The trans-sphenoidal biopsy confirmed invasive infection. His sphenoidal sinuses were endoscopically debrided, and he was treated with oral voriconazole. Pituitary aspergillosis should be considered in the differential diagnosis in patients with lung aspergilloma with headache and sinusitis. Prompt biopsy and antifungal treatment are important due to the high mortality rate of the infection.

Actinomycotic mycetoma is a disease of the tropical region and usually presents as a chronic, suppurative and deforming granulomatous infection. We present an unusual case of actinomycotic mycetoma of the abdominal wall that was found to infiltrate into the bowel. A 51 year-old man presented with pain and swelling in the left flank of 2-year duration. Even after comprehensive preoperative evaluation with advanced radiological imaging, biochemistry and pathology, the diagnosis could not be arrived at. Histopathological examination of the excised specimen after the surgery guided to the diagnosis of actinomycotic mycetoma, which entirely changed the management in the postoperative period. We propose that mycetoma should be kept as a possible differential diagnosis for anterior abdominal wall swelling in the indicated clinical setting and the investigations be done keeping the same in mind. Otherwise, a lot of valuable time may be lost allowing the disease to progress further.

A 39-year-old multiparous Afro-Caribbean woman attended the emergency department with sudden-onset severe right iliac fossa pain. Her inflammatory markers were mildly elevated. Computerised tomography of the abdomen demonstrated features of fat stranding in the right iliac fossa suspicious of acute appendicitis. The scan also noted uterine leiomyomas. The patient was taken to theatre for an emergency diagnostic laparoscopy where her appendix was found to be macroscopically normal. A necrotic heavily calcified parasitic leiomyoma was seen in the right adnexa, free of the uterus and adherent to the greater omentum on a long torted pedicle. The parasitic leiomyoma was successfully removed piecemeal laparoscopically. Complications of leiomyomas, namely, torsion and necrosis, are important differentials in women presenting with sudden-onset lower abdominal pain. A history of sudden-onset severe lower abdominal pain with a background of known leiomyoma should prompt the clerking surgeon to consider a complication of leiomyoma as part of the differential diagnoses.

We designed a device to close accidental dural puncture via the offending puncturing epidural needle directly after diagnosis of the puncture and before removing the needle. The aim of this study was to quantify this device's ability to seal cerebrospinal fluid leakage.

To use continuous real-time monitoring of maternal core body temperature during labor and investigate the association between epidural analgesia, intrapartum maternal fever, and maternal and neonatal outcomes.

Placental transmogrification is a peculiar clinical entity of the lung of uncertain etiology. We report 2 cases of pulmonary placental transmogrification in 2 patients of different nationalities. Both of them had no history of smoking or chronic lung disease. The main presentations were dyspnea and chest pain. Radiologic studies showed a unilateral giant bulla in both patients; additional pneumothorax was present in only 1patient. They underwent surgical bullectomy. Histopathologic studies revealed the presence of intracystic placenta-like villous structures and a diagnosis of placental transmogrification was made. Placental transmogrification should be considered in cases of unilateral bullae.

This case report describes a patient who developed allergic contact dermatitis to a chlorhexidine skin preparation applied for a transversus abdominis plane block, but not to a different chlorhexidine solution applied to the surgical field. The patient had presented for an elective inguinal hernia repair. He had a known history of anaphylaxis to non-steroidal anti-inflammatory medication but was otherwise well. The surgery was completed uneventfully. Three or four days postoperatively, the patient developed a rash at the site where chlorhexidine skin preparation had been used to prepare the skin for the transversus abdominis plane block. The rash had well-demarcated edges and exactly matched the distribution of the previously applied skin preparation. No rash was present at the surgical site, which had been prepared with a different chlorhexidine-containing solution. The rash gradually resolved over several weeks with the application of topical corticosteroids. The patient was otherwise completely well with no evidence of infection or any other systemic illness. The skin preparations differed in the dyes and alcohols that they contained. The dyes or alcohol in the preparation for the transversus abdominis plane block were therefore considered the likely cause of this patient's allergic reaction. Dyes and alcohols should be considered as a cause of skin allergy in the perioperative setting.