Oesophagomediastinal fistula: a rare complication of tuberculosis

We report a case of a woman from Thailand, living in Malta, who was diagnosed with concomitant tuberculosis (TB) and HIV with depleted CD4 count. Her case was further complicated by the formation of a fistula between the mediastinal lymph nodes and the oesophagus, an unusual finding but for which she had many risk factors. The diagnosis was suspected on CT scan of the thorax and confirmed via upper gastrointestinal endoscopy. Following the commencement of both anti-TB and antiretroviral therapy, she suffered a lapse of immune reconstitution inflammatory syndrome but with aggressive medical management eventually made a full recovery without the need for surgical intervention.

455 A Case of An Unusual Penetrating Brain Injury

Introduction Penetrating brain injuries (PBI) are less common than closed head traumas. Interest in frontal lobe injuries dates back to 1848’s famous Phineas Gage incident. Here, we report a case of a construction worker, who showed a remarkable neuropsychiatric outcome following a workplace accident. Case Presentation 45year old gentleman came with complaint of a foreign body accidentally lodged in his forehead. He had no neurological deficits or CSF leak. X-ray revealed that a 5.5cm metallic screw was penetrating his skull, headfirst; CT revealed that approximately 3cm of the screw was in the frontal sinus. He was given antiepileptics and antibiotics prophylactically. Surgically the screw was removed by raising a bone flap and mobilizing the screw carefully by cutting the dura and adequate irrigation, causing minimal damage to the brain parenchyma. The dural deficits were repaired and the frontal sinus was canalized, then a drain was placed, and the patient was shifted to ICU for postoperative monitoring. Discussion It is important to prognosticate PBI as they can have neurological deficits that may be lifelong. Understanding the mechanism of injury, aggressive medical management and immediate surgical intervention may lead to improved outcomes. A foreign object of the size of 5.5cm, completely penetrating the skull would have otherwise resulted in extensive parenchymal damage. Literature suggests that no two people have an identical frontal sinus. In our patient the size the frontal sinus has served the purpose of protection against PBI and has resulted in minimal parenchymal injury (of only about 1cm).

Intracranial Angioplasty with Enterprise Stent for Intracranial Atherosclerotic Stenosis: A Single-Center Experience and a Systematic Review

Background. The high rate of periprocedural complications for the endovascular stent procedure in the Stenting Versus Aggressive Medical Management Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial resulted in it being less recommended than medical therapy to treat intracranial atherosclerotic stenosis (ICAS). Because Enterprise stent use might reduce the incidence of complications in ICAS treatment compared to other frequently used stents, this paper evaluated the safety and effectiveness of the Enterprise stent for the treatment of ICAS. Methods. We performed a comprehensive literature search for reports on intracranial angioplasty using the Enterprise stent for ICAS treatment from the earliest date available from each database to May 2020 for PubMed, EMBASE, Web of Science, Cochrane, and Clinical Trials databases. We also reviewed the single-center experience of the First Affiliated Hospital of Harbin Medical University. We extracted information regarding periprocedural complications, procedure-related morbidity, mortality, immediate angiographic outcome, and long-term clinical and angiographic outcomes, among others. Event rates were pooled across studies using random-effects or fixed-effects models depending on the heterogeneity. Results. Five hundred fifty-seven patients with 588 lesions from seven studies, including the institutional series, were included in the analysis. The incidence of stroke or death within 30 days was 7.4% (95% confidence interval (CI), 5.5%–10.1%). The incidence of ischemic stroke or TIA in the territory of the qualifying artery beyond 30 days and during follow-up was 3.2% (95% CI, 1.1%–9.5%). The incidence of in-stent restenosis was 10.1% (95% CI, 4.6%–22.2%), and the incidence of symptomatic restenosis was 4.1% (95% CI, 1.7%–9.9%). Conclusions. Intracranial angioplasty utilizing the Enterprise stent for ICAS treatment was relatively safe and effective but required further verification using additional sources for evidence.

Frostbite: A Conundrum in High Altitudes

Cold injuries and its sequelae has for decades, been a relevant problem and an occupational hazard in the army, and continue to be so. These sequelae may hamper future operational capability of the soldier. Frostbite is also becoming more prevalent among the general population due to the increase in numbers of homeless people, along with an increasing participation in outdoor activities such as mountain hiking and skiing. Despite the advances in the field of medical sciences, frostbite management has remained constant and unchanged until recent years, when newer modalities of management have led to favourable, tissue-saving, outcomes. This chapter gives a background understanding of risk factors of frostbite and its pathophysiology and reviews the current evidence and latest frostbite management strategies. In addition, several adjunctive therapies and recent improvements in radiologic assessment of tissue viability provide new avenues of aggressive medical management and earlier surgical interventions.

Cardiac amyloid – a hidden contributor to cardiac dysfunction following cardiac surgery: Case report and literature review

: We present two patients who underwent cardiac surgery followed by post-operative low cardiac output, diastolic dysfunction and resistance to inotropic support. Despite aggressive medical management, both patients died. At autopsy the hearts were enlarged and showed previously undiagnosed myocardial and vascular amyloidosis. Occult cardiac amyloidosis is an uncommon, often occult, contributor to post-operative complications post cardiac surgery. Pre-operative or intra-operative myocardial biopsy may be useful in patients with unexplained diastolic dysfunction.

Pars plana vitrectomy combined with irido-zonulo-hyaloidectomy for aqueous misdirection

Introduction: To review the indications and necessary steps for successful irido-zonulo-hyaloidectomy in persistent aqueous misdirection. Study design/materials and methods: A 60-year-old woman was referred for persistent aqueous misdirection despite aggressive medical management. Her intraocular pressure would elevate with discontinuation of cycloplegics and her lens shifted anteriorly. She underwent standard 25g pars plana vitrectomy with irido-zonulo-hyaloidectomy. Results: The aqueous misdirection resolved with successful creation of the irido-zonulo-hyaloidectomy with noticeable deepening of the anterior chamber immediately. Vision improved to 20/30 and intraocular pressure was controlled without cycloplegics or ocular hypotensives. Conclusion: In persistent cases of aqueous misdirection unresponsive to medical management, irido-zonulo-hyaloidectomy is a useful adjunct to pars plana vitrectomy in ensuring resolution of the misdirection.

Varied orbital manifestations of paranasal sinus disease

<p class="abstract"><strong>Background:</strong> Even though sinusitis is a common clinical entity, its complications are seen rarely after the advent of antibiotics. Hence we aimed to analyse varied clinical presentations and manifestations of orbital involvement in paranasal sinus diseases and their outcome.</p><p class="abstract"><strong>Methods:</strong> Hospital based prospective study done from January 2007 to December 2017. We selected 65 patients in our study based on our inclusion and exclusion criteria. Type of orbital involvement was analysed by computed tomography scan. Immediate aggressive medical management was started and surgery was undertaken if there is no clinical improvement in 48 hours. Endoscopic sinus surgery done along with orbital decompression and drained pus was sent for culture sensitivity. Patients were followed up regularly and suction clearance was done. </p><p class="abstract"><strong>Results:</strong> Out of 65 patients, 50 were male and 15 were female. 24 patients had bacterial pathology, 40 had fungal pathology and 1 patient had non specific inflammatory disease consistent with mucocoele. Out of 24 bacterial sinusitis, 2 had bilateral disease and 1 patient had scalp and neck extension. Out of 40 fungal sinusitis, 2 patients had 6th cranial nerve palsy with sphenoid disease, 5 patients had palatal extension and 8 patients had intracranial involvement.</p><p class="abstract"><strong>Conclusions:</strong> All cases of orbital oedema and proptosis should be thoroughly evaluated for sinus disease. Computed tomography aids to know the extent of disease, deciding about the type and mode of intervention. Early diagnosis and immediate intervention reduces significant mortality and morbidity. However regular follow up, counselling the patients and relatives helps in achieving appropriate outcome.</p>

Impact of Baseline Features and Risk Factor Control on Cognitive Function in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial

Background: Cerebrovascular disease is an important cause of cognitive impairment. The aim of this study is to report the relationship between cognitive function and risk factors at baseline and during follow-up in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial. Methods: Subjects in the SAMMPRIS trial were included in this study. In order to have an assessment of cognitive function independent of stroke, patients with a stroke as a qualifying event whose deficits included aphasia or neglect were excluded from these analyses as were those with a cerebrovascular event during follow-up. The Montreal Cognitive Assessment (MoCA) score was used to assess cognitive impairment at baseline, 4 months, 12 months and closeout. Cognitive impairment was defined as MoCA < 26. A multivariate analysis was performed to determine what risk factors were independent predictors of cognitive function at baseline, 12 months and closeout. Among patients randomized to aggressive medical management only, the percentage of patients with cognitive impairment was compared between patients in versus out of target for each risk factor at 12 months and closeout. Results: Of the 451 patients in SAMMPRIS, 371 patients met the inclusion criteria. MoCA < 26 was present in 55% at baseline. Older age and physical inactivity were associated with cognitive impairment at baseline. Older age, non-white race, lower baseline body mass index, and baseline cognitive impairment were associated with cognitive impairment at 12 months. In the aggressive medical management group, at 12 months, physical inactivity during follow-up was the strongest risk factor associated with cognitive impairment. Conclusion: Cognitive impairment is common in patients with severe symptomatic intracranial atherosclerosis. Physical inactivity at baseline and during follow-up is a strong predictor of cognitive impairment.

Combination of oral vancomycin and intra-colonic vancomycin: Successful treatment of complicated pseudomembranous colitis in a child patient

The Clostridium difficile infection–related disease varies from mild diarrhoea to pseudomembranouscolitis. Although C. difficile infection is commonly considered to be a hospital-acquired infection, a significant number of cases are community acquired. Community-acquired C. difficile infection can exhibit itself as ileus or toxic megacolon. Severe C. difficile infection that is unresponsive to intravenous metronidazole therapy requires more aggressive medical management and even surgical intervention. We present our case results for which vancomycin was administered both orally and intra-colonically. With this method, we treated the community acquired C. difficile infection patient who was presented as ileus.