Well leg compartment syndrome: The debit side of hemilithotomy position

We describe a case of well leg compartment syndrome following unilateral lithotomy position in a patient undergoing contralateral antegrade intramedullary femoral nailing. Following two-incision four compartment fasciotomy, the patient recovered with no residual defects. We dissuade use of the hemilithotomy position for antegrade femoral nailing procedures in favour of another previously described position, because this predisposes patients to position-associated complications without offering any substantial advantage

Clinical Presentation, Evaluation, And Management of Patients with Myasthenia Gravis at A Tertiary Care Center in Pakistan

Background and objectives: Little is known about the clinical profile and outcome of myasthenia gravis in Pakistan. The objective of this study is to review the clinical characteristics of patients with myasthenia gravis in Pakistan, and the outcome of investigations and treatment. Methods: The study comprised a retrospective review of charts of patients diagnosed with myasthenia gravis at Aga Khan University Hospital in Karachi, Pakistan, over a period of 16 years from 1987 to 2003. The following features were reviewed: (i) clinical presentation, (ii) investigations especially nerve conduction studies, acetylcholine receptor antibodies, and imaging studies of the thorax, (iii) treatments administered (including thymectomy). Data analysis was done using Excel sheets. Results:Of the 83 patients, 51(61.4%) were males, whereas 32 (38.6%) were females. The age range was from 12 to 81 years, mean age of 43.7 years (SD± 18.2). In the 60 years plus group, there were three times as many males as compared to females. Limb weakness was noted in 58 (69.9%), ocular symptoms in 57(68.7%), and oropharyngeal symptoms in 54(65.1%) patients. Three (3.6%) presented in a state of myasthenic crisis. Tensilon test was performed in 34 patients and was positive in 31(91.2%), repetitive nerve conduction studies (RNS) were performed in 37 patients and was positive in 26(70.3%), acetylcholine receptor antibodies were done in 60 patients, and were positive in 55(91.7%). Thymic enlargement was seen in 28 out of 43 patients who underwent CT-Scan/MRI studies of the thorax. Besides pyridostigmine, most patients received immunosuppressive therapy with either steroids or azathioprine or both. The thymectomy was performed in 44 patients. Conclusion:The general disease pattern of MG, as noted in our series, appears to follow a similar pattern as noted worldwide. However, this retrospective and hospital-based study has its limitations, and more prospective and epidemiological studies are needed

Unicameral bone cysts: Current concepts

Unicameral bone cysts (UBC) or simple/solitary bone cysts are benign fluid filled cavities that enlarge over time, resulting in thinning of the bone. Usually these cysts are reported in the metaphyseal areas of long bones with open physes. 85% of UBCs occur almost exclusively in children and adolescents. UBCs are more aggressive in the first decade of life and correspondingly the recurrence rate for these patients is four times that for adolescents. The proximal humerus and femur account for almost 90% of these cases. UBCs are classified as active when they are within 1 cm of the physis and latent as they progress to a diaphyseal location. Differential diagnoses for UBC include aneurysmal bone cyst, fibrous dysplasia, enchondroma, and intraosseous ganglia. By the time of skeletal maturity most UBCs tend to resolve. Nonoperative treatment may be a viable option for many patients with small or symptomatic lesions. Interventions include steroid injection, open curettage and bone grafting, decompression and percutaneous injection of marrow or graft substitutes

Osteoid osteoma: Contemporary management

Osteoid osteoma is a benign bone-forming tumor with hallmark of tumor cells directly forming mature bone. Osteoid osteoma accounts for around 5% of all bone tumors and 11% of benign bone tumors with a male predilection. It occurs predominantly in long bones of the appendicular skeleton. According to Musculoskeletal Tumor Society staging system for benign tumors, osteoid osteoma is a stage-2 lesion. It is classified based on location as cortical, cancellous, or subperiosteal. Nocturnal pain is the most common symptom that usually responds to salicyclates and non-steroidal anti-inflammatory medications. CT is the modality of choice not only for diagnosis but also for specifying location of the lesion, i.e. cortical vs sub periosteal or medullary. Non-operative treatment can be considered as an option since the natural history of osteoid osteoma is that of spontaneous healing. Surgical treatment is an option for patients with severe pain and those not responding to NSAIDs. Available surgical procedures include radiofrequency (RF) ablation, CT-guided percutaneous excision and en bloc resection

Thoracolumbar tuberculosis: Implications for appropriate management based on disease location and proposal of a novel scoring system

Objective: To identify factors indicating disease severity in patients with thoracolumbar tuberculosis requiring surgical intervention.Design: Medical charts of patients who underwent surgery for thoracic and lumbar spinal tuberculosis from 1990-2005 were reviewed. Patients with different levels of disease were compared in terms of neurological deficits, duration of symptoms, previous antituberculous therapy, nutritional status and associated co-morbids.Results: Ninety-three patients aged 7-77 years (mean age 40 years) were included. Thoracic spine was involved in 80% of operated patients, and lumbar spine in 20%. Severe neurological impairment (Frankel A to C) was present in 68% of patients with thoracic disease, as compared to 5% with lumbar disease (p\u3c0.05). Postoperatively, complete neurological recovery occurred in 65% with thoracic versus 100% with lumbar disease (p\u3c0.05). Based on the disease location and pertinent elements in clinical history, physical signs, radiographic and biochemical features, a scoring system was developed.Conclusion: In endemic areas with limited resources, strategies for cost-effective care are needed. By objectively outlining the treatment approach, the judicious use of surgery offers hope for enormous cost savings in countries endemic for tuberculosis, averting complications from disease progression

Spatial patterns of extensively drug-resistant tuberculosis transmission in KwaZulu-Natal, South Africa

BACKGROUND : Transmission is driving the global drug-resistant tuberculosis (TB) epidemic; nearly three-quarters of drug-resistant TB cases are attributable to transmission. Geographic patterns of disease incidence, combined with information on probable transmission links, can define the spatial scale of transmission and generate hypotheses about factors driving transmission patterns. METHODS : We combined whole-genome sequencing data with home Global Positioning System coordinates from 344 participants with extensively drug-resistant (XDR) TB in KwaZulu-Natal, South Africa, diagnosed from 2011 to 2014. We aimed to determine if genomically linked (difference of ≤5 single-nucleotide polymorphisms) cases lived close to one another, which would suggest a role for local community settings in transmission. RESULTS : One hundred eighty-two study participants were genomically linked, comprising 1084 case-pairs. The median distance between case-pairs’ homes was 108 km (interquartile range, 64–162 km). Between-district, as compared to within-district, links accounted for the majority (912/1084 [84%]) of genomic links. Half (526 [49%]) of genomic links involved a case from Durban, the urban center of KwaZulu-Natal. CONCLUSIONS : The high proportions of between-district links with Durban provide insight into possible drivers of province-wide XDR-TB transmission, including urban–rural migration. Further research should focus on characterizing the contribution of these drivers to overall XDR-TB transmission in KwaZulu-Natal to inform design of targeted strategies to curb the drug-resistant TB epidemic.Grants from the US National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH): R01AI089349 (PI Gandhi and R01AI087465 (PI Gandhi). It was also supported in part by NIH/NIAID grants: K23AI083088 (PI Brust), K24AI114444 (PI Gandhi), K23AI134182 (PI Auld), Emory CFAR P30AI050409 (PI Curran), Einstein CFAR P30AI051519 (PI Goldstein), by Einstein/Montefiore ICTR UL1 TR001073 (PI Shamoon).https://academic.oup.com/jid2019-12-15hj2019Medical Microbiolog

Modeling missing cases and transmission links in networks of extensively drug-resistant tuberculosis in KwaZulu-Natal, South Africa

Patterns of transmission of drug-resistant tuberculosis (TB) remain poorly understood, despite over half a million incident cases worldwide in 2017. Modeling TB transmission networks can provide insight into drivers of transmission, but incomplete sampling of TB cases can pose challenges for inference from individual epidemiologic and molecular data. We assessed the effect of missing cases on a transmission network inferred from Mycobacterium tuberculosis sequencing data on extensively drug-resistant TB cases in KwaZulu-Natal, South Africa, diagnosed in 2011–2014. We tested scenarios in which cases were missing at random, missing differentially by clinical characteristics, or missing differentially by transmission (i.e., cases with many links were under- or oversampled). Under the assumption that cases were missing randomly, the mean number of transmissions per case in the complete network needed to be larger than 20, far higher than expected, to reproduce the observed network. Instead, the most likely scenario involved undersampling of high-transmitting cases, and models provided evidence for super-spreading. To our knowledge, this is the first analysis to have assessed support for different mechanisms of missingness in a TB transmission study, but our results are subject to the distributional assumptions of the network models we used. Transmission studies should consider the potential biases introduced by incomplete sampling and identify host, pathogen, or environmental factors driving super-spreading.This work was presented at the Seventh International Conference on Infectious Disease Dynamics (Epidemics7), Charleston, South Carolina, December 3–6, 2019.The National Institute of Allergy and Infectious Diseases, US National Institutes of Health, the National Institute of Allergy and Infectious Diseases, the Emory Center for AIDS Research, the Einstein Center for AIDS Research and the Einstein/Montefiore Institute for Clinical and Translational Research.https://academic.oup.com/ajehj2021Medical Microbiolog

Surgical management of neglected bilateral obligatory patella dislocation

Congenital dislocation of the patella may present as an isolated anomaly or may be associated with other lower limb deformities as part of a more complex malformative or dystrophic syndrome. One type is the congenitally dislocated patella fixed irreducibly from birth in a lateral position, and second is the obligatory patella dislocation that is hypoplastic to start with and gradually gets fixed into the lateral position as the child grows. We report the surgical management of a 16-year-old boy with neglected obligatory dislocation of bilateral patellae with 2-year follow-up results

Establishing a hospital based fracture liaison service to prevent secondary insufficiency fractures

In the aging population worldwide, osteoporosis is a relatively common condition and a major cause of long-term morbidity. Initial fragility fractures can lead to subsequent fractures. After a vertebral fracture, the risk of any another fracture increases 200% and that of a subsequent hip fracture increases 300%. For starting a hospital based Fracture Liaison Service (FLS) program, the nucleus is based on a physician champion, a FLS coordinator, and a nurse manager. A Fracture Liaison Service (FLS) is a multidisciplinary system approach to reducing subsequent fracture risk in patients with a recent fragility fracture due to compromised bone health by identifying them at or close to the time when they are treated at the hospital for fracture and providing them with easy access to osteoporosis care. It has been shown that when compared to other models such as referral letters to primary care physicians or endocrinologists, the FLS model results in a higher rate of diagnosis and treatment with less attrition in the posffracture phase. Insufficiency fracture care requires more than surgery to stabilize a fractured bone. The FLS program provides an opportunity to treat osteoporosis from a public health perspective rather than leaving this to the whims of individual physicians. This is achieved by providing a seamless integration of care by health care providers, nursing staff and administration. The FLS can be adapted to any model of care including academic health systems. FLS provides a holistic approach to identify patients as well as to provide evidence-based interventions to prevent subsequent fractures. The long term goal is that internationally FLS will result in in decreased fracture-related morbidity, mortality and overall health care expenditure