We present four cases of concomitant early (modified Ficat-Arlet stage I) avascular necrosis of the femoral head and acute bacterial arthritis of the hip joint by Gram-negative enteric bacilli. This was found in immunosuppressed oncologic patients whose clinical presentations and radiological findings were not entirely specific for joint sepsis. It is important to recognise the coexistence of these two pathologies, so as to avoid a delay in diagnosis and prevent significant morbidity and mortality.
Acute Disease ; Adenocarcinoma ; complications ; microbiology ; Adult ; Arthritis, Infectious ; complications ; diagnosis ; Bacillus ; isolation & purification ; Contrast Media ; Female ; Femur Head Necrosis ; complications ; diagnosis ; Gram-Negative Bacteria ; isolation & purification ; Hodgkin Disease ; complications ; microbiology ; Humans ; Leukemia, Myeloid, Acute ; complications ; microbiology ; Lung Neoplasms ; complications ; microbiology ; Male ; Middle Aged ; Multiple Myeloma ; complications ; microbiology ; Neoplasms ; complications ; microbiology ; Risk Factors ; Young Adult

Abdominal Pain ; etiology ; Adult ; Appendectomy ; Appendicitis ; complications ; diagnostic imaging ; pathology ; surgery ; Female ; Humans ; Schistosomiasis mansoni ; complications ; diagnostic imaging ; pathology ; surgery ; Tomography, X-Ray Computed

Abdominal Pain ; etiology ; Gastrointestinal Stromal Tumors ; complications ; diagnostic imaging ; Humans ; Jejunal Neoplasms ; complications ; diagnostic imaging ; Male ; Middle Aged ; Neurofibromatosis 1 ; complications ; Radiography ; Tomography, X-Ray Computed

Humans ; Male ; Pleural Effusion ; diagnosis ; physiopathology ; Tomography, X-Ray Computed ; Young Adult

Purpose: We aimed to identify the anterolateral ligament (ALL) tears in anterior cruciate ligament (ACL)-deficient knees using standard 1.5-Tesla magnetic resonance imaging (MRI). Methods: We included all patients who underwent primary ACL reconstruction at our center between 2012 and 2015. Exclusion criteria included patients with multiple ligament injuries, lateral collateral ligament, posterolateral corner, and infections, and patients who underwent MRI more than 2 months after their injury. All patients (n = 148) had ACL tears that were subsequently arthroscopically reconstructed. The magnetic resonance (MR) images of the injured knees performed within 2 months of injury were reviewed by a musculoskeletal radiologist and an orthopedic surgeon. The patients were divided into two groups. The first group of patients had MRI performed within 1 month of injury. The second group of patients had MRI performed 1–2 months after the index injury. Both assessors were blinded and the MR mages were read separately to assess the presence of ALL, presence of a tear and the location of the tear. Based on their readings, interobserver agreement (kappa statistic (K)), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were compared. Results: The ALL was identified in 100% of the patients. However, there was a discrepancy of up to 15% in the identification of tear of the ALL. In the first group in which MRI scans were performed within 1 month of injury, the ALL tear was identified by the radiologist in 92% of patients and by the surgeon in 90% of patients (Κ = 0.86). In the second group in which MRI scans were performed within 1–2 months of the injury, the ALL tear was identified by the radiologist in 78% of patients and by the surgeon in 93% of patients (K = 0.62). Conclusion The ALL can be accurately identified on MRI, but the presence and location of ALL tear and its location cannot be reliably identified on MRI. The accuracy in identification and characterization of a tear was affected by the interval between the time of injury and the time when the MRI was performed.Level of evidence: Diagnostic, level IIIb, retrospective.

Purpose: We aimed to identify the anterolateral ligament (ALL) tears in anterior cruciate ligament (ACL)-deficient knees using standard 1.5-Tesla magnetic resonance imaging (MRI). Methods: We included all patients who underwent primary ACL reconstruction at our center between 2012 and 2015. Exclusion criteria included patients with multiple ligament injuries, lateral collateral ligament, posterolateral corner, and infections, and patients who underwent MRI more than 2 months after their injury. All patients (n = 148) had ACL tears that were subsequently arthroscopically reconstructed. The magnetic resonance (MR) images of the injured knees performed within 2 months of injury were reviewed by a musculoskeletal radiologist and an orthopedic surgeon. The patients were divided into two groups. The first group of patients had MRI performed within 1 month of injury. The second group of patients had MRI performed 1–2 months after the index injury. Both assessors were blinded and the MR mages were read separately to assess the presence of ALL, presence of a tear and the location of the tear. Based on their readings, interobserver agreement (kappa statistic (K)), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were compared. Results: The ALL was identified in 100% of the patients. However, there was a discrepancy of up to 15% in the identification of tear of the ALL. In the first group in which MRI scans were performed within 1 month of injury, the ALL tear was identified by the radiologist in 92% of patients and by the surgeon in 90% of patients (Κ = 0.86). In the second group in which MRI scans were performed within 1–2 months of the injury, the ALL tear was identified by the radiologist in 78% of patients and by the surgeon in 93% of patients (K = 0.62). Conclusion The ALL can be accurately identified on MRI, but the presence and location of ALL tear and its location cannot be reliably identified on MRI. The accuracy in identification and characterization of a tear was affected by the interval between the time of injury and the time when the MRI was performed.Level of evidence: Diagnostic, level IIIb, retrospective.

A 32-year-old man presented to the emergency department with severe right lower limb pain and swelling of three days' duration. He had multiple prior admissions for recurrent seizures and suicide attempts. Markedly elevated serum creatine kinase levels and urine myoglobinuria were consistent with a diagnosis of rhabdomyolysis. Initial magnetic resonance imaging of the right lower limb revealed diffuse muscle oedema and features of myositis in the gluteal muscles and the adductor, anterior and posterior compartments of the thigh. Follow-up magnetic resonance imaging performed 11 days later showed interval development of areas of myonecrosis and haemorrhage. The causes, clinical presentation and imaging features of rhabdomyolysis are discussed.

A 74-year-old woman receiving long-term anticoagulation with warfarin for chronic atrial fibrillation presented with severe acute abdominal pain, diarrhoea and vomiting. Initial laboratory workup revealed a deranged coagulation profile. Computed tomography of the abdomen and pelvis demonstrated spontaneous distal jejunal intramural haematoma with associated reactive ileus. No overt pneumatosis intestinalis, intraperitoneal free gas or haemoperitoneum was seen. Based on clinical and imaging findings, a diagnosis of over-anticoagulation complicated by small bowel intramural haematoma was made. The patient was managed non-operatively with analgesia, cessation of warfarin and reversal therapy with vitamin K. Warfarin therapy was recommenced upon resolution of symptoms and optimisation of coagulation status. The clinical presentation, radiological features and overall management of anticoagulation-induced bleeding are further discussed in this article.

BACKGROUNDMedical superstitions remain prevalent in today's stressful and technology driven healthcare environment. These irrational beliefs commonly involve night calls, which are periods of volatile workload. In Singapore and Hong Kong, it is commonly held that consumption of steamed buns ("bao") by on-call physicians is associated with increased patient admissions and mortality, due to a homonymous interpretation of the word "bao" in dialect.

MATERIALS AND METHODSA prospective unblinded randomised controlled trial with a permuted block randomisation design was performed on weekdays over 6 weeks. Steamed buns or control food were offered to the internal medicine night-call team of a tertiary-care hospital on a nightly basis. Information on admissions and mortality was collected from the hospital electronic database. Data on sleep patterns and shift duration were obtained by interview.

RESULTSThere were no significant differences in the median number of hours slept on days on "bao" administration versus "control" intervention (2 +/- median absolute variation of 1.5 h vs 2 +/- 1.5 h, P = 0.30) or in the number of hours spent in the hospital (30.8 +/- 1.9 h vs 30.5 +/- 2.2 h, P = 0.09). There were no significant differences in the median number of general ward admissions per night (n = 73 +/- 6 versus 71 +/- 7 admissions, P = 0.35), monitored care unit admissions (4 +/- 1.5 vs 4 +/- 1.5 admissions, P = 0.65) or inpatient mortality (2 +/- 1.5 vs 2 +/- 1.5 deaths per night, P = 0.47).

CONCLUSIONThe consumption of steamed buns ("bao") has no effect on inpatient admissions, mortality, or sleep duration on call. Regardless, our results indicate that the night call in Singapore remains a challenge in terms of workload and shift duration.

A 51-year-old man with no significant medical history was referred to our institution for further management of a palpable, painless right breast lump that had been gradually increasing in size for a period of six months. Physical examination revealed a firm right breast lump and bloody right nipple discharge, but no skin involvement or axillary lymphadenopathy was observed. Subsequent mammography and breast ultrasonography demonstrated a discrete, heterogeneous and vascular right breast mass with spiculated and angulated margins. The breast mass was found to be an invasive ductal carcinoma on ultrasonography-guided core needle biopsy. This case illustrates that a combination of detailed clinical history, careful physical examination and radiological assessment using mammography and breast ultrasonography may be used to identify cases suspicious for male breast carcinoma that warrant biopsy.
Biopsy, Needle ; Breast Neoplasms, Male ; diagnosis ; diagnostic imaging ; Diagnosis, Differential ; Gynecomastia ; diagnosis ; diagnostic imaging ; Humans ; Male ; Mammography ; methods ; Middle Aged ; Ultrasonography, Doppler ; Ultrasonography, Mammary