Rejected

Ovarian cyst is a fluid-filled sac in the ovary, common among reproductive women. Mucinous cystadenoma is a common variety of non-functional benign lesions that presents vague symptoms and can mislead the diagnosis. A 26-year-old female presented to the clinic with weakness and lethargy, which lasted for 3 months, along with other symptoms like headache, abdominal pain, bloating, nausea, and constipation. She was managed with iron deficiency anaemia, however, her symptoms did not improve. Later, an ultrasound revealed an ovarian cyst. Laparoscopic left-sided ovarian cystectomy was performed and a biopsy was sent for histopathological examination. The case highlights the various nonspecific symptoms in a case of an ovarian cyst. Gynaecological causes for systemic symptoms should always be considered, along with proper gynaecological history and examination. This helps with the accuracy of diagnosis and treatment options, with minimal costs.

 The complicated anatomy in the parasellar region of the middle cranial fossa renders a surgical challenge in the management of cavernous malformation in this region. We demonstrate the resection of a cavernous malformation in this operative video.  The procedure is presented via a surgical instructional video.  The operation was performed by a skull base team in a tertiary neurosurgical center.  A 49-year-old female presented with intermittent headache and right facial numbness for 6 months. Physical examination suggested a decreased sensation of pain, temperature, and light-touch on the right side of the face. Magnetic resonance imaging indicated that a space-occupying lesion located in the middle cranial fossa.  Gross total resection was achieved, and the cranial nerve function was preserved.  The lesion involving middle cranial fossa should be managed meticulously. Transnasal endoscopic approach is a good option for the resection of the lesion. Simultaneously, the cavernous sinus should be protected to a great extent in case of bleeding and cranial nerve injury. The link to the video can be found at https://youtu.be/tbN8tuEb6nM ( Figs. 1 and 2 ).

Thoracic epidural and paravertebral blocks are gold standard analgesic techniques but they are associated with complications. Erector spinae plane (ESP) block is safer with comparable pain relief. ESP block is an established technique for postoperative pain relief. Its intraoperative use as an adjuvant to general anaesthesia (GA) is not yet known. The aim of this study was to assess the efficacy of ESP as an adjuvant to GA during laparoscopic surgery.

This case study aims to demonstrate the use of cannabidiol (CBD) with low-dose tetrahydrocannabinol (THC) in managing symptoms associated with autism spectrum disorder (ASD) to increase the overall quality of life for these individuals and their families. ASD is a neurodevelopmental disorder affecting cognitive development, behavior, social communication, and motor skills. Despite the increasing awareness of ASD, there is still a lack of safe and effective treatment options. The study includes a nine-year-old male patient who was diagnosed with nonverbal ASD. He exhibited emotional outbursts, inappropriate behaviors, and social deficits including challenges in communicating his needs with others. Since the patient was unable to attain independence at school and at home, his condition was a significant burden to his caregivers. The patient was treated with full-spectrum high CBD and low THC oil formulation, with each milliliter containing 20 mg of CBD and <1 mg of THC. CBD oil starting dose was 0.1ml twice daily, increased every three to four days to 0.5ml twice daily. Overall, the patient experienced a reduction in negative behaviors, including violent outbursts, self-injurious behaviors, and sleep disruptions. There was an improvement in social interactions, concentration, and emotional stability. A combination of high CBD and low-dose THC oil was demonstrated to be an effective treatment option for managing symptoms associated with autism, leading to a better quality of life for both the patient and the caregivers.

Lathyriasis or lathyrism is a form of upper motor neuron disease caused by the dietary intake of grass pea (). It is an irreversible crippling disease with poor outcomes. The possible pathogenesis is attributed to a toxin present in the legume, i.e., BOAA (beta-n-oxalyl amino L-alanine). Lathyrism can also be associated with vascular involvement resulting in angiolathyrism, which is mediated by a toxin β-aminopropionitrile, and bony involvement resulting in osteolathyrism characterized by bone growth impairment. A 12-year-old male child presented to us with chronic myalgia and a gradual decline in the power in the bilateral lower limbs, both in extension and flexion, followed by an inability to walk. On examination, he had spastic paraparesis with brisk deep tendon reflexes and positive Babinski sign with sustained bilateral ankle clonus suggestive of upper motor neuron lesion. Doppler studies of the bilateral lower limb suggested deep vein thrombosis of the right posterior tibial vein. His electrophysiological studies and neuroimaging were otherwise normal. We found deep vein thrombosis and bony exostosis, which have never been reported in the existing literature. This could be a new form of angiolathyrism and osteolathyrism we are reporting here. A review of dietary history revealed consumption of grass pea over the past few years daily, following which diagnosis of neurolathyrism was considered. A review of the literature does not suggest any specific treatment for this crippling disease and the treatment largely remains supportive. The child was provided vitamin C, gabapentin, and perampanel for neuromuscular pain, and low molecular weight heparin for deep vein thrombosis. Physiotherapy was initiated and surgical excision was planned by the orthopedic team for the exostotic lesion. The diagnosis of lathyrism should strongly be suspected if there is a history of consumption of grass pea. Public health education, improvement in the socio-economic condition, and strict prohibition of the sale and consumption of grass pea can root out the problem of lathyrism.

Spontaneous intracranial hypotension (SIH) is a neurologic condition where the intracranial pressure is reduced due to a loss of cerebrospinal fluid from its reservoir, the intrathecal space, to surrounding tissues. It is commonly characterized by an incapacitating headache, phono-photophobia, nausea, and vomiting, commonly refractory to medical treatment and requires further investigation. We describe the case of a healthy young man who presented to the emergency room with a postural headache, accompanied by nausea, vomiting, and phono-photophobia. Brain computed tomography (CT) imaging study was unremarkable and he was initially treated symptomatically. Because of persisting pain even on medical treatment, additional imaging studies, including a myelo-CT scan, were performed and a diagnosis of multi-level cerebrospinal fluid fistulas was made. To treat the underlying cause, a first epidural blood patch (EBP) was initially performed at C7-T1 with 20 mL of autologous blood, but failed to provide complete symptomatic relief. Months later, a second EBP was conducted at C6-C7 with higher volume (30 mL) but as in the first EBP this procedure too did not result in total resolution of the headache and accompanying symptoms. Since there was no surgical indication from Orthopedics and Neurosurgery and the symptoms persisted, a third EBP was carried out, this time at a lumbar level (L2-L3) with infusion of 60 mL of blood so the upper dorsal and cervical epidural space was reached. This resulted in a better symptom relief, allowing the patient to now carry out his normal activities with only residual pain. The need for repeat procedures is one of the pitfalls of the blood patching technique. If possible, it should be performed at the level of the documented fistula, but always with safety in mind and by experienced hands, especially when cervical levels are concerned. A consensus has not been reached regarding the blood volume to be administered; however, any discomfort or pain reported by the patient should be seen as warning sign and the procedure should be interrupted. Although not being a perfect solution, EBP can completely or partially resolve SIH symptoms, without the need for surgical intervention.

Trigger fingers is a condition that causes locking/stiffness due to inflammation and hypertrophy of the tendon sheaths. This inflammatory process occurs due to degenerative conditions, such as aging, chronic daily overuse, and other factors such as metabolic disorders.

Enterobius vermicularis is the most common parasitic infection in developed countries of temperate and cool climates.The feco-oral route is the most common route of human infection. Due to obstruction of appendiceal lumen, the presence of parasites in the appendix may cause appendiceal colic or cause inflammation of the appendix.

To document the clinical presentation, complications, management strategy and post-operative outcomes of extensive cholesteatomas. Cholesteatoma is a well demarcated cystic lesion derived from an abnormal growth of keratinizing squamous epithelium in the temporal bone. Cholesteatomas commonly involve the middle ear, epitympanum, mastoid antrum and air cells and can remain within these confines for a considerable period. Bony erosion is present confined to ossicular chain and scutum initially, but as the cholesteatoma expands, erosion of the otic capsule, fallopian canal and tegmen can occur. Erosion of the tegmen tymapani or tegmen mastoideum may lead to development of a brain hernia or cerebrospinal fluid leakage. Invasion of jugular bulb, sigmoid sinus, internal carotid artery are noticed in extensive cholesteatoma and are quite challenging and requires expertise. Neurosurgical intervention should be considered along with the otological management in the same sitting in all possible cases. A retrospective review of 12 patients were carried out to assess the clinical presentation, complications, surgical management and postoperative outcomes of extensive cholesteatomas presenting at our centre between January 2017 and December 2019. CT or MRI findings, extent of cholesteatoma intra-operatively along with the status of major neurovascular structures and disease clearance, and the post-operative outcomes including morbidity and mortality were noted. All patients underwent canal wall down mastoidectomy with or without ossiculoplasty. Post operatively all patients were treated with intravenous antibiotics and if required intravenous steroids. Amongst the 12 patients of extensive cholesteatoma (EC), all of them (100%) presented with foul smelling, purulent ear discharge. 9 (75%) patients presented with otalgia. 4 (33.33%) patients had temporal headache. 10 (83.33%) patients complained of hard of hearing. 7 (58.33%) patients gives history of vertigo at the time of presentation. In 8 (66.66%) patients there was tegmen plate erosion noticed in CT scan. In 3 (25%) patients, the disease was invading the sigmoid sinus and in 1 (8.33%) patient jugular bulb was involved. In 3 (25%) cases of EC, blind sac closure was performed. In two patients who developed cerebellar abscess, drainage procedure was performed. 2 (16.66%) patients developed sigmoid sinus thrombosis, 1 (8.33%) patient had petrositis.

Rib fractures represent a substantial health burden. Chest injuries contribute to 25% of deaths after trauma and survivors can experience long-standing consequences, such as reduced functional capabilities and loss of employment. Over recent years, there has been an increase in the awareness of the importance of early identification, aggressive pain management and adequate safety netting for patients with chest injuries. Substandard management leads to increased rates of morbidity and mortality. The development of protocols in the emergency department (ED) for management of patients with chest wall injuries has demonstrated reduction of complication rates.Our aim was to develop an evidence-based, multidisciplinary chest injury pathway for the management of patients presenting with rib injury to our ED.Prior to implementation of the pathway in our department, only 39% of patients were documented as having received analgesia and only 7% of discharged patients had documented written verbal advice. There was no standardised method to perform regional anaesthetic blocks. Using quality improvement methods, we standardised imaging modality, risk stratification with a scoring system, analgesia with emphasis on regional anaesthesia blocks and disposition with information leaflets for those discharged.Implementation of the pathway increased rates of documented analgesia received from 39% to 70%. The number of regional anaesthetic blocks performed went from 0% to 60% and the number of patients receiving discharge advice went from 7% to 70%. Compliance of doctors and nurses with the pathway was 63%.Our previous audits showed substandard management of patients with chest injuries in our department. Through this quality improvement project, we were able to improve the quality of care provided to patients attending with rib fractures by increasing rate of analgesia received, regional blocks performed and discharge advice given.