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Parathyroid carcinoma (PC) is a rare malignancy. In January 2022, a 41-year-old woman presented with weight loss, proximal muscle weakness, and bone pain. She was diagnosed with severe hypercalcemia with serum calcium of 15.5 mg/dL (8.8-10.6 mg/dL). A biopsy of cervical lymphadenopathy revealed non-caseating granulomatous lymphadenitis. Primary hyperparathyroidism was subsequently confirmed with parathormone (PTH) exceeding 2,500 pg/mL (12-88 pg/mL), leading to left-superior parathyroidectomy and hemithyroidectomy. Histopathology suggested PC versus adenoma, with oxyphilic cells. Postoperatively, she manifested severe hypocalcemia and vitamin D deficiency alongside elevated PTH levels. In January 2023, she experienced a hypercalcemic crisis and developed a new right-sided neck mass. Wide excision revealed PC with parathyromatosis. By September 2023, another hypercalcemic crisis and new left cervical nodules necessitated further surgery, confirming PC deposits in the neck, though without lymph node metastases. Despite treatment with cinacalcet and zoledronic acid, her hypercalcemia persisted until denosumab produced a dramatic response (serum calcium dropping from 16.7 to 7.9 mg/dL; PTH 1,168 pg/mL). However, she remains at risk for progressive local disease and potential distant metastases.

Gallstone-related diseases, particularly common bile duct (CBD) stones, pose a significant global health challenge. The emergence of laparoscopic common bile duct exploration (LCBDE) has transformed the management of these conditions by offering a less invasive alternative to traditional open surgery. This literature review aims to analyze published literature to identify and understand the risk factors associated with LCBDE. The study aims to offer valuable insights that could potentially enhance patient care and outcomes in managing CBD stones. A comprehensive search of English-language studies from the past 20 years was conducted using PubMed, focusing on peer-reviewed primary research, systematic reviews, and meta-analyses. From 830 initial articles, 25 were selected based on relevance and availability. The review identified several key risk factors influencing LCBDE outcomes, including patient-related factors such as advanced age, high comorbidity scores, narrow bile ducts, and complex stones, which increase the likelihood of complications. Surgeon experience also plays a crucial role, with lower complication rates observed among surgeons who have performed at least 70 LCBDE procedures over a 10-year period. Additionally, procedure-related factors such as the transcystic (TC) approach, primary suture (PS) closure, and intraoperative imaging were found to reduce complication rates. LCBDE remains a promising approach for managing bile duct stones, particularly when patient, surgeon, and procedural factors are optimized.

Renal cell carcinoma (RCC) is a common renal malignancy that frequently metastasizes, though cutaneous metastasis, particularly to the scalp, is rare and generally indicates a poor prognosis. We report a case of scalp metastasis from RCC in a 69-year-old man who presented with unexplained weight loss and painless hematuria. Imaging revealed a 12-cm renal mass with adrenal, pulmonary, and scalp metastases. The patient's condition rapidly deteriorated, and he died one month after the presentation. Hematogenous spread through Batson's plexus might be the primary mechanism of RCC dissemination to the scalp. While targeted therapies have improved the management of metastatic RCC, the prognosis for patients with skin metastases remains poor.

Fracture-dislocations of the proximal humerus with brachial plexus injury are exceedingly rare, and although infrequently encountered, it is important to recognize this complication due to its potentially devastating impact. We present the case of a 75-year-old female who sustained the described injury following a fall onto their left arm, demonstrating combined sensory and motor deficits in the radial, median, and ulnar distribution of the left forearm and hand shortly afterward. Immediate management involved closed reduction under anesthesia, resulting in the improvement of neurological symptoms. For definitive management, surgical fixation of the fracture-dislocation is normally recommended in cases with an associated brachial plexus injury. However, due to a range of personal factors, the patient decided against this. Physiotherapy plays an important role in the management of these injuries, aiding mobility and recovery, with another key part of the follow-up being electrodiagnostic studies. These allow the physician to assess the extent of injury, monitor recovery for prognostication, and aid decisions regarding further surgical management. The importance of these studies is highlighted by the finding of severe brachial plexus injury, despite minimal pathological changes on MRI. Rare but significant, it is important to maintain a high index of suspicion for these injuries and consider underlying risk factors, with prompt surgical input required to optimize outcomes. Alongside surgical management, a considered approach must be taken by the anesthetic team, as regional anesthesia can confound post-procedure neurological assessment.

This systematic review and meta-analysis aimed to compare the outcomes of intramedullary nailing (IMN) and open reduction with internal fixation (ORIF) in treating traumatic humeral shaft fractures in adults (18 years and above). A comprehensive literature search was conducted in databases including PubMed, Google Scholar, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome was time to union, while secondary outcomes included non-union rates, incidences of iatrogenic radial nerve palsy, surgical site infections, and intra-operative comminution. Twenty-six studies, encompassing 1,674 patients (867 IMN, 807 ORIF), were included. IMN demonstrated a shorter time to union compared to ORIF (mean difference -1.06 (95% CI, -1.88 to -0.23)), with significant statistical heterogeneity (I² = 70%), and a mean difference of -2.14 (95% CI, -3.16 to -1.12) in the randomized controlled trial (RCT) subgroup analysis, which had no significant statistical heterogeneity. Both techniques had comparable non-union rates (risk ratio 0.34 (95% CI, 0.94 to 1.93)). IMN was associated with lower incidences of iatrogenic radial nerve palsy (risk ratio 0.48 (95% CI, 0.27 to 0.87)) and surgical site infections (risk ratio 0.44 (95% CI, 0.25 to 0.76)), but had a higher risk of intra-operative comminution (risk ratio 3.04 (95% CI, 1.24 to 7.44)). The studies exhibited significant heterogeneity and varying outcome measures, highlighting the need for cautious interpretation. IMN offers rapid fracture stabilization and minimal additional physiological insult, while ORIF remains preferable for achieving precise anatomical reduction. These findings highlight the importance of considering patient-specific factors and surgical expertise in selecting the appropriate fixation technique.

Background Myelodysplastic syndromes (MDS) are clonal myeloid disorders characterised by ineffective haematopoiesis, leading to anaemia that often requires dependence on red blood cell (RBC) transfusions. Epoetin alfa (Eprex®) is now a mainstay in the management of symptomatic anaemia in low-risk MDS patients, reducing transfusion dependence and improving the quality of life in this patient group. Objective This retrospective study aimed to assess the efficacy of epoetin alfa in treating symptomatic anaemia in low-risk MDS patients, focusing on transfusion independence and its relationship with baseline erythropoietin (EPO) levels and haemoglobin (Hb) response. Methods Data from 56 patients with low-risk MDS treated with epoetin alfa at Norfolk and Norwich University Hospital, Norwich, United Kingdom, between 2018 and 2023 were retrospectively analysed. Baseline EPO levels, transfusion history, Hb response, and the duration of transfusion independence were assessed. Statistical analyses were performed to evaluate the correlation between baseline characteristics and treatment outcomes. Results Among the patients, 98.2% had baseline EPO levels below the 500 IU/L threshold, with a median EPO level of 74.3 IU/L. Following an eight-week trial of 30,000 units of epoetin-alfa, 41.1% of patients showed improved Hb levels, 41.1% maintained stable Hb levels, and 17.9% experienced a decline. A significant correlation was found between lower baseline EPO levels (<250 IU/L) and a positive treatment response (p = 0.0065). Additionally, patients who required fewer transfusions before treatment had longer durations of transfusion independence (correlation coefficient = -0.40, p = 0.015). Dose escalation to 60,000 units provided a benefit to 53.3% of patients with initially stable Hb levels. The average duration of transfusion independence was 8.1 months, and patients with improved Hb levels had the longest periods of transfusion independence (p = 0.005). Conclusion Epoetin alfa is an effective therapy for managing symptomatic anaemia in low-risk MDS patients. This study highlights its efficacy and provides valuable predictive information, particularly showing that patients with lower baseline EPO levels are more likely to respond to treatment. While prior transfusion dependence did not significantly predict response to therapy in this cohort, it was associated with the duration of transfusion independence.

The use of alginate, a derivative of seaweed, has been proposed for multiple orthopedic indications. We aimed to review the current use of alginate in orthopedics and to focus on the future applications of alginate for peripheral nerve repair. A comprehensive literature search was performed to identify biomechanical, laboratory, animal, and human studies where alginate has been utilized for orthopedic or nerve repair indications. A systematic review of orthopedic indications was conducted for safety and efficacy, and a specific focus was placed on alginate for use in peripheral nerve repair and reconstruction. Thirty-two studies were identified. Alginate has a strong history and safety profile for usage in orthopedic surgery. Its primary usage has been for the repair of articular cartilage, although it has also been used for disc regeneration of the lumbar spine and for cushioning joints in osteoarthritis. The primary indication in peripheral nerve repair is to create an environment that encourages Schwann cell migration and repair in nerve injuries while blocking fibrotic scar tissue formation by inhibiting the activity of fibroblasts. Alginate hydrogel may serve as a potential conduit for nerve regeneration in nerve injuries with small to medium-sized gaps.

We report a case of corneal endothelial graft failure that developed after endoscopic cyclophotocoagulation (ECP) for elevated intraocular pressure (IOP) following Descemet's stripping automated endothelial keratoplasty (DSAEK). The patient was a 69-year-old Japanese woman with primary angle-closure glaucoma who had undergone phacoemulsification with intraocular lens implantation and goniosynechialysis for peripheral anterior synechiae (PAS), followed by trabeculectomy, repeat bleb revisions, Baerveldt glaucoma implant surgery, and Ahmed glaucoma valve implantation with tube insertion into the anterior chamber in the past two years. Subsequently, she developed bullous keratopathy, and the first DSAEK was performed in July 2020. Subsequently, iris adhesion and atrophy progressed around the tube, and PAS became severe, resulting in graft failure. A second DSAEK combined with pupilloplasty was performed in November 2021, after which the graft transparency was maintained. Since March 2022, IOP has increased despite treatment with maximum medication; therefore, ECP was performed to reduce IOP in September 2022. IOP decreased after ECP; however, the patient developed graft failure within a few months. A third DSAEK was performed in July 2023. In conclusion, for eyes with borderline corneal endothelial cell decompensation, the indications for ECP should be decided with caution.

We report the case of a 38-year-old woman with a history of extrahepatic portal vein obstruction (EHPVO) who became pregnant and developed portal vein thrombosis. She gave birth after intervention by gastroenterology and cardiology. She was referred to our department due to significant leg edema at eight weeks of gestation, and we noticed EHPVO, portal vein thrombosis, and left pulmonary arteriovenous fistula by contrast-enhanced CT. Therefore, subcutaneous heparin injections of 10,000 units/day were started as a preventive anticoagulant therapy. We performed an emergency cesarean section at 36 weeks of gestation. After surgery, the mother was administered a continuous heparin infusion. On the 11th day after surgery, the postoperative progress was good, so heparin was switched to oral warfarin, and the patient was discharged on the same day. During pregnancy, the risk of varicose vein rupture, hyperammonemia, and pulmonary hypertension increases due to an increase in circulating blood volume. This was a case in which careful perinatal management was performed in collaboration with other departments, resulting in a live birth.

This case report presents the case of a 20-year-old female patient who sought emergency medical attention for severe abdominal pain, nausea and vomiting, tachycardia, hypertension, and discolored urine. Initial diagnostic evaluations yielded no significant abnormalities; however, subsequent analysis revealed elevated urinary porphobilinogen, corroborating a diagnosis of acute intermittent porphyria (AIP). The patient's medical history included recurrent urinary tract infections and a prior episode of syndrome of inappropriate antidiuretic hormone secretion (SIADH), in conjunction with psychiatric comorbidities of anxiety and depression. Management encompassed a multifaceted approach involving supportive therapies, such as hydration and analgesia, alongside the imperative to abstain from using contraindicated pharmacological agents. Following referral to the National Acute Porphyria Service (NAPS), the patient received intravenous Haem arginate, resulting in clinical improvement and subsequent discharge. Nonetheless, she later necessitated further hospitalization due to the recurrence of similar symptoms. This case highlights the exigency of recognizing AIP in young women presenting with nonspecific symptoms, necessitating a high index of clinical suspicion. Furthermore, it accentuates the critical importance of early specialist intervention to avert severe sequelae associated with acute episodes. The integration of targeted educational initiatives within Acute Medicine departments is paramount for fostering awareness and facilitating prompt diagnosis and management of this rare yet significant disorder.