Modified Vertical Rectus Abdominis Musculocutaneous Flap for Limb Salvage Procedures in Proximal Lower Limb Musculoskeletal Sarcomas

Introduction and aim. Management of complicated wounds after tumor extipiration of pelvic and proximal lower limb musculoskeletal sarcoma represents an essential component in the outcome of these patients. The authors present modified vertical rectus abdominis musculocutaneous (VRAM) flap techniques to reconstruct extensive defects after debridment of these complicated wounds. Material and Methods. Over a period of 4 years (2002–2005), 5 men and 2 women were managed. Median age was 21 years (range 15–49). The patients were managed for complicated lower trunk, groin, and upper thigh wounds after resection of three pelvic chondrosarcomas as well as two pelvic and two proximal femur osteosarcomas. The modifications included a VRAM flap with lateral and tongue-like extension design of the skin paddle (5 cases) or a delayed extended VRAM flap (2 cases). Results. All flaps showed complete survival and healing with no ischemic events providing stable coverage. All patients were ambulant with good limb functions in terms of walking and gait after adequate rehabilitation, 2 needed support with crutches. Conclusion. The modified VRAM flaps offer reliable reconstructive tools for coverage of complex groin and thigh defects by providing larger well-vascularized soft tissue with acceptable donor site

Spontaneous Chylothorax Secondary to Kyphoscoliosis: A Case Report

chylothorax refers to the accumulation of fluid in the pleural cavity containing chylomicrons due to disruption of the thoracic duct. Currently, the most common causes of chylothorax are surgery and tumors; however, spontaneous chylothorax is still rare. Here we report an unusual presentation of spontaneous chylothorax secondary to severe kyphoscoliosis in a 9-year-old girl who presented with a symptomatic left chylothorax

Defining criteria for disease activity states in systemic juvenile idiopathic arthritis based on the systemic Juvenile Arthritis Disease Activity Score

Objective To develop and validate cutoff values in the systemic Juvenile Arthritis Disease Activity Score 10 (sJADAS10) that distinguish the states of inactive disease (ID), minimal disease activity (MiDA), moderate disease activity (MoDA), and high disease activity (HDA) in children with systemic juvenile idiopathic arthritis (sJIA), based on subjective disease state assessment by the treating pediatric rheumatologist. Methods The cutoffs definition cohort was composed of 400 patients enrolled at 30 pediatric rheumatology centers in 11 countries. Using the subjective physician rating as an external criterion, 6 methods were applied to identify the cutoffs: mapping, calculation of percentiles of cumulative score distribution, Youden index, 90% specificity, maximum agreement, and ROC curve analysis. Sixty percent of the patients were assigned to the definition cohort and 40% to the validation cohort. Cutoff validation was conducted by assessing discriminative ability. Results The sJADAS10 cutoffs that separated ID from MiDA, MiDA from MoDA, and MoDA from HDA were ≤ 2.9, ≤ 10, and > 20.6. The cutoffs discriminated strongly among different levels of pain, between patients with or without morning stiffness, and between patients whose parents judged their disease status as remission or persistent activity/flare or were satisfied or not satisfied with current illness outcome. Conclusion The sJADAS cutoffs revealed good metrologic properties in both definition and validation cohorts, and are therefore suitable for use in clinical trials and routine practice

Bilateral blunt diaphragmatic rupture

Blunt diaphragmatic rupture is an uncommon injury and even less common is the bilateral form. This entity poses diagnostic and therapeutic challenges to the treating team. Despite the advances in diagnostic modalities, it remains a difficult diagnosis leading to missed or late presentations with increased risk of morbidity and mortality. We report a case of a 12-year-old girl who sustained a blunt abdominal trauma and found to have left hemidiaphragmatic rupture for which she underwent laparotomy and repair. Postoperatively, persistent elevation of the right hemidaiphragm was noticed, and right-side rupture was suspected and confirmed by collar sign on repeated computed tomography scan. The second repair was done successfully through a right posteriolateral thoracotomy. She improved dramatically and was discharged in an optimal state to be followed in the surgical outpatient department

Infective Endocarditis Caused by Pseudomonas stutzeri: A Case Report and Literature Review

Pseudomonas bacteria are widespread pathogens that account for considerable infections with significant morbidity and mortality, especially in hospitalized patients. The Pseudomonas genus contains a large number of species; however, the majority of infections are caused by Pseudomonas aeruginosa, infections by other Pseudomonas species are less reported. Pseudomonas stutzeri is a ubiquitous Gram-negative bacterium that has been reported as a causative agent of some infections, particularly in immunocompromised patients but has rarely been reported as a cause of infective endocarditis. Here, we report a case of a 55-year-old female with no significant medical history who presented with exertional dyspnea, productive cough, and fever. She was diagnosed as a case of acute anterior ST myocardial infarction, underwent double valve replacement surgery, and was found to have infective endocarditis caused by Pseudomonas stutzeri