Alexius Ramcharan

Introduction. Duodenal diverticulum is a rare disease that can be easily missed. The incidence of duodenal diverticulum diagnosed by upper GI study is approximately 5%. Autopsy results show that 22% of the population have duodenum diverticulum. Most patients with duodenal diverticulum are asymptomatic. However, complications like inflammation, perforation with retroperitoneal abscess, sepsis, pancreatitis, bile duct obstruction, and bleeding can occur. Approximately 162 cases of perforated duodenal diverticulum have been reported in the literature. Case Presentation. We present a rare case of an 82-year-old female with perforation of a duodenal diverticulum caused by small bowel obstruction; in addition to this, there was a synchronous colonic tumor. Conclusion. Diagnosis and management of this rare disorder are controversial. Nonoperative management is advocated in some cases. Some of the cases require early aggressive surgical intervention. The mortality rate remains approximately 45% in all these patients.

Pediatric burns in the urban environment present special problems. Inner-city communities may be unique with hardships due to various socioeconomic factors. There is lack of literature analyzing pediatric burns in the inner-city, and there has been no report to date reviewing Harlem New York City, one of the most challenged areas in the nation. The aim of this study is to understand the pre-hospital circumstances, socioeconomic factors and management of pediatric burns admitted to our hospital. A retrospective review was performed including all patients aged 0-18 years admitted to the burn care unit from January 2006-May 2017. Data collected includes demographics, burn mechanism, total burn surface area (TBSA), first aid response, socioeconomic factors such as parental supervision, single parenting, caregiver financial and employment status, child protective service reporting. A total of 177 patients were included with majority being toddlers. Most common burn type was scald and average TBSA was 9%. Strikingly, the majority of patients, over 75%, did not receive appropriate first aid measures. Socioeconomic issues were significant with 59.9% single parenting, 36.2% with lack of supervision and CPS reporting rate of 24.9%. Socioeconomic challenges these inner-city children face are significantly different than other communities. It is important to consider community variations with pediatric burns. This analysis is informative, providing professionals and caregivers topics of consideration regarding safe practices at home, appropriate first aid measures, prevalent socioeconomic issues which if addressed may potentially prevent pediatric burn admissions in these inner-city communities.

Introduction: Traumatic brain injury (TBI) is one of the main causes of morbidity and mortality in young trauma patients with resultant multi-organ effects. Hypopituitarism following TBI can be debilitating and life threatening. TBI which causes hypopituitarism may be characterized by a single head injury, such as from a motor vehicle accident, or by chronic repetitive head trauma, as seen in combative supports including boxing, kick-boxing, and football. In the majority of cases, a diagnosis of hypopituitarism can be entirely missed resulting in severe neuro-endocrine dysfunction. We present a case series of two patients diagnosed with hypopituitarism after TBI and treated appropriately with favorable outcome. Case presentations: The first case is a 34 year-old male, who presented to the emergency department with blunt head trauma after a motor vehicle accident while riding his bicycle. He suffered from severe cranio-facial injuries, resulting in multifocal hemorrhagic contusions, epidural hematoma, and extensive cranio-facial fractures involving the sinuses. The patient developed persistent hypotension with a blood pressure as low as 60/40 mmHg on hospital day three. The second case is a 56 year-old male with a history of schizophrenia, who suffered traumatic brain injury after he was hit by a train. The patient sustained multiple facial fractures, pneumocephalus and C2/7 transverse processes fractures. He also had persistent hypotension, unresponsive to standard treatment. Investigation revealed a deficiency of anterior pituitary hormones resulting from pituitary axis disruption. Discussion: Hypopituitarism is becoming an increasingly recognized complication following TBI, ranging from total to isolated deficiencies. Traumatic Brain Injury is a major public health problem and is one of the leading causes of disability. Understanding and recognizing pituitary dysfunction after TBI can lead to better outcomes and improved quality of life. Conclusion: Patients with major head injury and, in particular, those with fractures of the base of the skull, must be closely monitored for signs and symptoms of endocrine dysfunction. Appropriate dynamic pituitary-function screening should be performed. Highlights:

Tracheostomy tube change is a relatively common and simple procedure once a tract is formed between the skin and the trachea. Regular tracheostomy tube changes decrease the risk of postoperative pulmonary infection and granulation tissue formation. However, serious complications, such as loss of airway, subcutaneous emphysema, and mediastinitis, can occur if the tube exchange is performed inappropriately. We present a rare association of subcutaneous emphysema, tension pneumothorax, pneumomediastinum, and pneumoperitoneum following a tracheostomy tube exchange in a 56-year-old patient who had his tracheotomy placed a month ago. The patient was successfully managed conservatively by chest tube and supportive care.

Small bowel obstruction in HIV patients is reportedly caused by inflammatory pseudotumor, Kaposi’s sarcoma, cryptococcal lymphadenopathy and intestinal tuberculosis. The incidence of Mycobacterium avium complex (MAC) infection in HIV patients is 3% for CD4 cell count of 100–199 /mm³. MAC causing small bowel obstruction is rarely reported in the literature. We report a rare case of MAC causing mesenteric abscess with small bowel obstruction in a HIV patient with a CD4 cell count of 144 /mm³. Patient was a 35-year-old HIV-positive male on highly active antiretroviral therapy who presented with partial small bowel obstruction secondary to mesenteric abscess. He underwent operative intervention for drainage with cultures growing MAC.

Granulomatous mastitis is a chronic inflammatory breast disease with an enigmatic clinical presentation that can delay diagnosis and perpetuate ineffective treatments. We report our experience with the diagnosis and management of eighteen cases of gr

Laparoscopic hysterectomy is a commonly performed gynecological procedure. Although the outcomes are favorable, severe life threatening complications such as pneumothorax, pneumomediastinum and subcutaneous emphysema can occur during laparoscopy secondary to carbon dioxide insufflation. We report a 46-year-old female who was scheduled for laparoscopic-assisted supra-cervical hysterectomy for uterine fibroids. Patient tolerated the procedure and there were no intra-operative complications. Post operatively she developed hypercarbia, subcutaneous emphysema and pneumomediastinum. She was managed conservatively. This case demonstrates a rare occurrence of subcutaneous emphysema and pneumomediastinum after supra-cervical hysterectomy.

Listeria monocytogenes (LM) is an aerobic, motile, intracellular gram-positive bacterium. Most invasive systemic infections caused by LM are commonly seen in patients at both extremes of age, during pregnancy or in immunocompromised hosts. Common clinical manifestations of LM infection in immunocompromised adults are bacteremia, infections of central nervous system, such as meningitis, and self-limiting febrile gastroenteritis. Focal infections of listeria are rare, especially cholecystitis, with only few cases reported in the last 33 years. A 62-year-old man presented with multiple myeloma, cholecystitis and LM bacteremia. Due to prompt surgical treatment and antibiotics (amoxicillin plus clavulanic acid and gentamycin), this high-risk patient recovered without any complications.

The incidence of splenic injury may be higher than suggested in the literature. The authors caution against excessive force during colonoscopy and loop formation as splenic injury can occur in a normal spleen without intraperitoneal adhesions.