Surgical Debridement of an Infected Diabetic Foot Wound

Anatomy of sphenoid bone(Pic & vid)

The sphenoid bone carries its share of creating part of the base of the cranium. While it can be seen laterally and inferiorly, the shape of the bone is a bit unusual and is often described as...............

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CT & Sonography of Pancreatic Serous Cystadenoma

Cystic lesions of the pancreas are common, and 80-90% of these lesions are pseudocysts or retention cysts. Cystic neoplasms of the pancreas are less common, accounting for about 10-15% of all cystic pancreatic lesions. True cysts of the pancreas are rare.

The two most common cystic neoplasms of the pancreas are serous cystadenoma (which is benign )and mucinous cystic neoplasms.Serous cystadenoma is more common than mucinous cystic neoplasm, with a ratio of about 2:1. Intraductal papillary mucinous tumor (IPMT) is a more recently discovered cystic neoplasm that may be a variant of the mucinous cystic neoplasm (biologic behavior of mucinous cystic neoplasm and IPMT ranges from benign to malignant).

Radiography:

No radiographic abnormalities are associated with serous cystadenoma except those related to a mass that is large enough to displace or obstruct the bowel or those related to a prominent central calcification.
The main mimics of this tumor are pseudocysts and mucinous cystic tumors.

C.T. : Classically, these lesions have a mean diameter of 5-8 cm (range, 4-20 cm) and a lobulated external contour. They are composed of a grapelike cluster or honeycomb pattern of 6 or more uniformly sized cysts that are 2 cm or smaller. They tend to occur in the head or neck of the gland, although biliary obstruction is present in only about 15% of the cases.

In about 30% of the cases, a central, stellate, late-enhancing scar is present with calcification. Small septa and internal debris may be seen in individual cysts. Because the capsule of these tumors is poorly developed, there is often poor distinction of the tumor from the surrounding pancreatic parenchyma. No communication occurs with the pancreatic duct, except in rare cases.

Serous cystadenoma on a contrast-enhanced CT scan. Note the Swiss cheese–like enhancement and gentle external lobulation.

Serous cystadenoma on a nonenhanced CT scan. Note the central calcification, attenuation similar to that of water, and external lobulation.

Ultrasonography:

The cluster-of-grapes pattern and external lobulation may be seen. However, when the cysts are small, the mass can be echogenic (because of the large number of acoustic interfaces), and they can appear solid (see the image below). This finding can suggest the presence of an adenocarcinoma. The presence of increased through transmission, even if the mass is fairly echogenic, should suggest the diagnosis.

Sonogram of serous cystadenoma. The large mass in the head of the pancreas is externally lobulated, with some cystic-appearing regions, some solid-appearing regions, and increased through transmission. Image courtesy of Arnold C Friedman, MD, FACR.

Lymphatic Drainage in Axillary Lymph Nodes

The lymphatic vessels of the upper limb, most of those from the breast, and the cutaneous vessels of the trunk above the level of the umbilicus drain into the axillary nodes.

Lymphatics from the fingers accompany the cephalic and basilic veins and enter the lateral axillary and deltopectoral (or infraclavicular) nodes .

Axillary Nodes. These important nodes are arbitrarily divided into five groups:
1. The lateral nodes lie behind the axillary vein and drain the upper limb.

2. The pectoral nodes, at the inferior border of the pectoralis minor, drain most of the breast.

3. The posterior, or subscapular, nodes, in the posterior axillary fold, drain the posterior shoulder.

4. The central nodes, near the base of the axilla, receive the lymph from the preceding three groups. They form the group most likely to be palpable (against the lateral thoracic wall).

5. The apical nodes lie medial to the axillary vein and superior to the pectoralis minor. The apical nodes receive the lymph from all the other groups and sometimes directly from the breast. They drain into two or three subclavian trunks, which enter the jugular-subclavian venous confluence, or join a common lymphatic duct, or empty into lower, deep cervical nodes.

Diagram of the lymphatic drainage of the upper limb and breast. The supratrochlear and deltopectoral nodes receive many superficial lymphatic vessels. The axillary nodes are indicated by capital letters. The lateral nodes drain the upper limb. The subareolar plexus drains by collecting trunks into the axillary nodes. The pectoral nodes drain most of the breast. The apical nodes receive the lymph from the other axillary groups. Retropectoral (R) and transpectoral (T) routes are also shown.

Textbook on Public Health and Community Medicine,free download

by: Rajvir Bhalwar
en

Textbook of Public Health and Community Medicine
RajVir Bhalwar
Published by Department of Community Medicine
Armed Forces Medical Collega, Pune with WHO India Office New Delhi
First Edition 2009

Excellent book of public health specially written in Indian context. A must for all who are interested in public health related issues in india.

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Von Hippel-Lindau - USMLE Study Songs

Mucormycosis

A 44-year-old woman with a 20-year history of poorly controlled diabetes mellitus presents with headache and unilateral proptosis. The patient is febrile and appears toxic. Her serum glucose level is 640 mg/dL. An urgent CT scan of the head reveals a retroorbital abscess and severe opacification of the frontal and ethmoid sinuses.
Which of the following organisms is most likely responsible for this infection?

• a. Cryptococcus neoformans
• b. Mucormycosis
• c. Mycobacterium tuberculosis
• d. Toxoplasma gondii
• e. Listeria monocytogenes
• f. Staphylococcus epidermis

The answer is (b).
Mucormycosis is a rare fungal disease (Rhizopus species are the most common causative organisms ) limited to persons with preexisting illness and may be seen in poorly controlled diabetic patients. Severe infection of the facial sinuses, which may extend into the brain, is the most common presentation. Patients present with fever, nasalcongestion, sinus pain, diplopia, and coma.
Physical examination may reveal a necrotic nasal turbinate, reduced ocular motion, proptosis, and blindness. CT scan or MRI will reveal the extent of sinus involvement prior to surgery.

Postmortem photograph of a woman with diabetes and left rhinocerebral mucormycosis complicating ketoacidosis. Rhizopus oryzae was the causative organism. Note the orbital and facial cellulitis and the black nasal discharge. (Courtesy of A. Allworth, MD, Brisbane, Australia)