Indeterminate pulmonary nodules are not associated with worse overall survival in Ewing Sarcoma

AimLung metastases are a negative prognostic factor in Ewing sarcoma, however, the incidence and significance of sub-centimetre pulmonary nodules at diagnosis is unclear. The aims of this study were to (1): determine the incidence of indeterminate pulmonary nodules (IPNs) in patients diagnosed with Ewing sarcoma (2); establish the impact of IPNs on overall and metastasis-free survival and (3) identify patient, oncological and radiological factors that correlate with poorer prognosis in patients that present with IPNs on their staging chest CT.Materials & methodsBetween 2008 and 2016, 173 patients with a first presentation of Ewing sarcoma of bone were retrospectively identified from an institutional database. Staging and follow-up chest CTs for all patients with IPN were reviewed by a senior radiologist. Clinical and radiologic course were examined to determine overall- and metastasis-free survival for IPN patients and to identify demographic, oncological or nodule-specific features that predict which IPN represent true lung metastases.ResultsFollowing radiologic re-review, IPN were found in 8.7% of patients. Overall survival for IPN patients was comparable to those with a normal staging chest CT (2-year overall survival of 73.3% [95% CI 43.6–89] and 89.4% [95% CI 81.6–94], respectively; p = 0.34) and was significantly better than for patients with clear metastases (46.0% [95% CI 31.9–59]; p < 0.0001). Similarly, there was no difference in metastasis-free survival between ‘No Metastases’ and ‘IPN’ patients (p = 0.16). Lung metastases developed in 40% of IPN patients at a median 9.6 months. Reduction of nodule size on neoadjuvant chemotherapy was associated with worse overall survival in IPN patients (p = 0.0084).ConclusionIPN are not uncommon in patients diagnosed with Ewing sarcoma. In this study, we were unable to detect a difference in overall- or metastasis-free survival between patients with IPN at diagnosis and patients with normal staging chest CTs.     

Retrospective review of complications following long tourniquet time in foot and ankle surgery

BackgroundTourniquet use is ubiquitous in orthopaedic surgery to create a bloodless field and to facilitate safe surgery, however, we know of the potential complications that can occur as a result of prolonged tourniquet time. Experimental and clinical research has helped define the safe time limits but there is not much literature specific to foot and ankle surgery.MethodsA retrospective review of the postoperative course of patients with prolonged tourniquet time (longer than 180 min) for foot and ankle procedures was done. Data related to the patient factors and the surgical procedure was collected. The length of stay, re-admissions and complications were the important indicators of the individual patient’s recovery.ResultsTwenty patients were identified with longer than 180-min tourniquet times for complex foot and ankle procedures. The average uninterrupted tourniquet time was 191 min. Eight of the twenty procedures were revision surgeries. The average length of stay was 3 days and there were no re-admissions within 30 days. Eight patients (40%) had at least one recorded complication. The complications seen in this group were transient sensory loss, wound issues, superficial infection, ongoing pain and non-union.ConclusionsThis case series has not revealed any major systemic complications resulting from the prolonged tourniquet such as pulmonary embolism or renal dysfunction. Unlike past literature on knee procedures with extended tourniquet times, no major nerve palsies were seen in our patient group. Our understanding of the local and systemic effects of tourniquet is not complete and this study demonstrates that the complications do not necessarily increase in a linear fashion in relation to the tourniquet time.     

Macroglossia due to venous malformation

Massive vascular malformation involving tongue can cause significant functional impairment. In this report we describe a rare case of extensive venous malformation involving tongue leading to obstructive sleep apnoea, inability to speak, eat, severe discomfort due to exposure induced dryness and ulceration. Multimodality treatment approach comprising of sclerotherapy, electrocautery and radiation therapy was used in this case.     

Combat surgery: Status of tactical abbreviated surgical control

Traditionally injury care meant definitive repair following surgical exploration. However the outcome is poor because of deranged physiology in severely injured. Damage control surgery (DCS) is abbreviated initial procedure with subsequent correction of physiological imbalance, followed by definite repair.Tactical abbreviated surgical control (TASC) is application of principles of DCS techniques in the tactical environment. TASC is applied because of patient related factors (classic damage control) and limitations due to tactical reasons. Non-patient related factors only seen in tactical setting are, large numbers of patients arriving in short span, mobility of forward medical units, limitation of resources, and hostile environment. TASC involves only phase one of classical DCS. Complete correction of physiological imbalances and definitive surgery is carried out at a better equipped static hospital. TASC has shown to improve survival, extends benefit to greater number and helps to conserve precious resources. However TASC has its own limitations.     

Use of immunoadsorption columns in ABO-incompatible renal transplantation: A prospective study at a tertiary care center in India

BackgroundWe present our experience of ABO-incompatible renal transplant using immunoadsorption (IA) columns. We have compared efficacy of two commercially available columns.MethodsThis single-center prospective study was conducted at Army Hospital Research and Referral, Delhi. All consecutive ABO-incompatible renal transplants from January 2014 to February 2018 were analyzed. Of 30 patients who underwent transplantations, 28 underwent antibody depletion with immunoadsorption columns. Of them, 14 cases were in the “Glycosorb group,” while 14 in the “Adsopak group.”ResultsThe donors in the Adsopak group were older than those in the Glycosorb group (p < 0.05). Both groups had spousal donors in majority. The cutoff for the antibody titer was 1:8. The median titer in the Adsopak group was 128 (range, 1:4 to 1:2048), while that in the Glycosorb group was 24 (range, 1:8 to 1:128). All patients in the Glycosorb group had baseline titers ≤1:128, while 13 patients in the Adsopak group had baseline titers ≤1:512. Nil titer was achievable with Glycosorb® (50%,7/14) but not with Adsopak® (P < 0.01). Around 4 sessions were required for the Glycosorb group, while around 8 sessions were required for the Adsopak group before transplantation (p < 0.001). The Glycosorb group was advantageous in terms of graft failure because no rejection was noticed in these patients in their follow-up period. Three patients in the Adsopak group developed rejection (two had mixed rejection, and one had antibody-mediated rejection). Four patients died of sepsis (three in the Glycosorb and one in the Adsopak group). Lower baseline serum creatinine level was achieved in the Glycosorb group.ConclusionsResults of ABO-incompatible renal transplantation were satisfactory, and the use of immunoadsorption columns could effectively deplete antibody titers. Glycosorb columns were more efficient than Adsopak columns. Graft survival was better with Glycosorb. Posttransplant infections were a major cause of mortality.