Elderly Gentleman Research Articles

A Novel Combined Microsurgical and Endovascular Approach for Type II Endoleak Embolization Through Direct Puncture of a Lumbar Segmental Artery: A Technical Case Instruction

BACKGROUND AND IMPORTANCE: Despite the advances in endovascular aortic repair techniques, type II endoleaks with aneurysm sac expansion remain frequent and challenging problems. CLINICAL PRESENTATION: An elderly gentleman underwent a combined microsurgical and endovascular procedure to address a type 2 endoleak and the growth of a recurrent abdominal aortic aneurysm caused by direct puncture of a lumbar segmental artery. The patient tolerated the procedure well and was discharged without complications. Follow-up imaging revealed no further endoleak and a smaller aneurysm size. CONCLUSION: This unique case presents a novel multidisciplinary surgical strategy for treating complex, recurrent aortic aneurysms with type II endoleaks. The approach is tailored to the individual patient and has shown effectiveness. Long-term follow-up data will be crucial for assessing the efficacy and durability of this approach.

BN SO46 - PANDORA's BOX- When anatomy trumps the pathology

Abstract Background Obturator hernias are usually attributed to elderly females presenting with small bowel obstruction. We present a case of an elderly gentleman with severe Kyphoscoliosis presenting with small bowel obstruction. His past medical history included Ischaemic Heart Disease with stents in the coronary arteries and on dual antiplatelets. His Kyphoscoliosis precluded him from being able to lie flat on his back. The spinal deformity as revealed in the CT scans proved challenging to position him dsafely for surgery. The lack of access between costal margins and the pelvis meant that surgical access with Laparoscopy was going to be impossible. Method After initial resuscitation, he underwent CT scan of his Chest, abdomen and pelvis which revealed an obstructed Obturator Hernia on the left side with small bowel obstruction. The CT was also concerning for the Anaesthetists due to the challenge posed by the severe Kyphoscoliosis. After fibreoptic intubation, abdomen was accessed through a transverse muscle cutting incision, at the level of the umbilicus. The Obturator membrane was approached from above and the hernia was reduced. The obstructed small bowel was viable and the defect in the obturator membrane was closed with No1 Ethibond sutures. The abdomen was closed with mass closure. Results Patient had a smooth post operative period and was discharged home after 2 weeks. Obturator hernias are notorious for their occult presentation. Unless the patient is scanned with CT imaging, it is impossible to make the diagnosis although clinical signs like Howship- Romberg sign may be present with pain on internal rotation of the hip, as a result of irritation of the Obturator nerve. Obturator Neuralgia may be elicited with positive Hannington- Kiff sign, which is an absence of absent adductor reflux in the thigh. Conclusion Obturator hernias are typically seen in skinny old females. When presenting with small bowel obstruction, Obturator herniae are challenging both in terms of diagnosis as well as in management. In our case, the challenging anatomy posed greater risk to safe airway control. From surgical view, laparoscopy as a less invasive option was ruled out because of the restricted access. When anatomy is challenging, the Surgeon will be forced to think outside the box and consider access to the abdomen through incisions which are not routinely used. The preoperative imaging shows the challenge posed by the extreme spinal deformity.

A Real Person

Abstract: A story about an Australian woman who begins having dinner with an elderly gentleman several times a week. They connect through their conversations about food and the Zagat guide and bond in their discussions about their past lives and jobs. As they walk around New York, the young woman learns the impact the older gentleman had on his community through the conversations he has with previous acquaintances and friends. Additionally, we watch the woman as she works through her own literary career, most specifically, with a literary workshop involving Joyce Carol Oates for aspiring writers. We experience the writer’s fear and trepidation to show her work to peers with differing perspectives and writing styles.

Case Report ‘Layer of Hope’: Managing Large Surface Wounds on Frontal Bare Bone in a Challenging Patient

This was a case of an elderly gentleman with large bleeding basal cell carcinoma occupying almost three quarter of the forehead managed with adjunct usage of integra acellular dermal regeneration template after lesion’s wide local excision despite challenged with patient’s newly diagnosed bicytopenia to rule out haematological malignancy. Standard management of tissue reconstruction with purely living tissue (split skin grafting) has higher risk of graft rejection due to bare bone as wound bed. This limits the neo-graft ability to achieve optimal potential of imbibition and inosculation. Thus, dermal matrix usage makes split skin grafting difficult wound bed has higher chance of surviving and hence shortens healing time and reduces hospital stay.

Radical Radiotherapy in Primary Extra Nodal Lymphoma of Tonsil: A Rare Case Report

Primary non-Hodgkin’s lymphoma (NHL) usually arises within the lymphnodes, but 20-30% account for extranodal sites. Non-Hodgkin’s lymphoma (NHL) of the Waldeyer’s ring is a clinical rarity. Among these tumors, palatine tonsils are most frequently involved. Most common high-grade rapidly growing NHL is diffuse large B-cell lymphoma (DLBCL), reaching about 80% in some of the studies. For aggressive localized Extranodal Lymphoma, systemic therapy is the primary treatment modality unless patients are unfit for, or refuse, such therapy. Here, we report a 71 years old elderly gentleman who presented with complaints of left tonsillar swelling, difficulty in swallowing and change in voice since 10 days. He was diagnosed as localised Primary Extra nodal NHL - DLBCL of left tonsil. But he was unfit for chemotherapy in view of elderly age and multiple comorbidities, hence he received radical radiotherapy. During the treatment, he had symptomatic relief. He responded to radical radiotherapy well & is on regular follow up.

A diagnosis of syphilis following a radical circumcision for suspected penile cancer.

We present a case of a 70-year-old gentleman who was referred to our tertiary 2-week-wait penile cancer clinic with a penile mass that was ulcerated, painful and discharging. This was suspicious for penile cancer and a radical circumcision was performed to remove the diseased foreskin en bloc with the lesion that was arising from the inner foreskin. Histopathology did not reveal cancer; however, we identified spirochaetes in keeping with syphilis. This was confirmed on serology. The patient was referred to the genitourinary medicine team and treated with antibiotics. This case demonstrates a rare presentation of genital syphilis in an elderly gentleman initially referred with concerns of penile cancer. Although, rare, especially in this age group, syphilis should be considered as a differential diagnosis in a patient presenting with an ulcerated, discharging, firm penile mass, especially given that the incidence of syphilis has been rising in recent years.

Hyperkalemia in the tropics: multiple causes and a not so common presentation—a case report

BackgroundHyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. But all cases of hyperkalemia need not be symptomatic either. The feared consequence of hyperkalemia is that on the heart, it can induce fatal arrhythmias; rarely, it can present with neuromuscular signs. Most cases of hyperkalemia can be attributed to a single cause. Rarely, it can be multifactorial.Case presentationFrom the province of Kerala in India, we describe an elderly gentleman with severe hyperkalemia, who presented with quadriparesis. He had ECG changes consistent with hyperkalemia. Diverse causes were involved at the same time for the hyperkalemia. An uncommon cause observed was a diet rich in tropical fruits. As he did not respond to conservative (medications) measures, he had to be dialyzed. With dialysis, there was a rapid neurological recovery, and the potassium levels had improved.ConclusionsIn patients presenting with ascending paralysis, especially old people with morbidities, one differential diagnosis to be considered is hyperkalemia. Once hyperkalemia is confirmed, in addition to medications and illnesses, the preceding diet should also be enquired, especially the intake of fruits. In all, a good history in such a case is without a doubt imperative.

An unusual cecal submucosal mass in an elderly gentleman.

A 60-years-old man with previous hypertension was hospitalized because of colonoscopy revealed a cecal submucosal mass for community health examination 1 month ago. The patient has no symptoms such as poor appetite, fatigue, abdominal pain, diarrhea, nausea and vomiting. Laboratory tests and physical examination was unremarkable. A protrusion with multiple superficial small ulcers on the smooth surface measuring 1.5 × 2.0-cm was found beside the appendiceal orifice by colonoscopy. Abdominal computed tomography demonstrated a high-density mass without enhancement protruding towards the ileocecal cavity at the appendiceal orifice measured 1.5 × 1.8 cm. Laparoscopic ileocecal resection was performed because of appendiceal tumor couldn't be excluded and the patient's strong request. Pathology examination of the postoperative specimen revealed dilated appendix cavity with fecalith inside in the submucosal layer of the ileocecal region. The patient was diagnosed as appendiceal orifice submucosal fecalith. He was discharged home uneventfully and no symptoms was observed in 3 months follow-up.

Space, Place and Identity in Bernard Shaw’s The Tragedy of an Elderly Gentleman

The last of Bernard Shaw’s “Irish” plays, The Tragedy of an Elderly Gentleman (1921), raises the same concerns over colonialism, nationalism, and identity explored in John Bull’s Other Island (1904) and O’Flaherty V.C.: A Recruiting Pamphlet (1915) but does so from outside his preferred dramatic style, theatrical Realism. In this proto-Absurdist experiment, Shaw invents an Ireland in which differences of religion, class, and politics are moot; in 3000 A.D., age is the only category of social distinction. Experimenting with dramaturgical form and eschewing mimetic scenic design, Shaw utilizes Ireland’s mythic wildness and the transformational effect of its climate as an affective element of the play’s argument. Through Shaw’s treatment of space, this future Ireland with its inherently Irish inhabitants becomes the utopic home to a superior race that portends a life beyond the oppressive British/Irish and later intra-national binary partisan reality of post-WWI and pre-Free State Ireland.

Ischaemic Stroke After Chronic Subdural Haematoma: An Uncommon Complication in a Common Disease

Background Chronic subdural haematoma (CSDH) is a common neurosurgical disease, particularly among the elderly, especially those on antiplatelet or anticoagulation with trivial trauma. While anticoagulants/antiplatelets increase the chance of rebleeding in cases of CSDH, discontinuation may increase the risk of stroke in these patients. Case Description We report two cases of CSDH in elderly patients with risk factors who suffered from an ischaemic stroke after undergoing surgery. The first case was an elderly gentleman who had a history of percutaneous coronary intervention, presenting with a CSDH. He developed an anterior cerebral artery infarct in the immediate postoperative period. The second was an elderly gentleman with a history of hypertension presenting with a concomitant left thalamic infarct and large left-sided CSDH. He developed a second middle cerebral artery infarct of the opposite side in the immediate postoperative period. Conclusion The medications used for stroke prophylaxis, that is, antiplatelets and anticoagulants are predisposing factors for the development of CSDH. However, the perioperative period of these patients remains vulnerable to the development of new-onset ischaemic stroke.

Unusual presentation of a giant solitary lung cyst in an elderly gentleman.

Unusual presentation of a giant solitary lung cyst in an elderly gentleman.

#2907 ASYMPTOMATIC NEPHROTIC SYNDROME: AN INTERESTING PRESENTATION OF ADULT ONSET MINIMAL CHANGE DISEASE

Abstract Background and Aims Minimal change disease (MCD), a predominantly pediatric disease, is less common in adults. Patients often present with florid hypervolemia, manifested by significant lower extremity edema, anasarca, pericardial effusion or pleural effusion. Herein, we present a case of newly diagnosed MCD in an elderly gentleman with an atypical presentation. Method A 69 year old male with hypertension and benign prostate hypertrophy presented to the emergency department (ED). He was noted to have abnormal labs at an outside clinic on routine testing and was directed to the ED. In the ED, he was found to have a serum creatinine (SCr) of 10.89 mg/dL. Initial urine studies also revealed proteinuria of 11g/g with 6.5 g/g of albuminuria. Other initial labs were significant for a potassium of 4.5 mEq/L, BUN 126 mg/dL and albumin 2.2 g/dL with normal liver enzymes. Renal ultrasound was unremarkable. Upon further discussion with the patient, he endorsed long term daily use of diclofenac for many months. He stated that he stopped diclofenac three weeks prior to presentation. He denied any proton pump inhibitor or recent antibiotic use. He denied any fevers, nights sweats or weight loss to suggest Type B symptoms. There was no personal kidney disease history nor family history of kidney disease. He was a non-alcoholic and non-smoker. We continued to hold further non-steroidal anti-inflammatory medications as well as other nephrotoxic medications. Although patient had elevated SCr and azotemia, he did not meet any acute indications for dialysis and we continued to manage the patient conservatively. Serologies were negative for ANA, ANCA, Anti-GBM, HIV, hepatitis B and C, as well as antiPLA2R. Serum protein electrophoresis, kappa to lambda ratio, complements 3 and 4 were all within normal values. A kidney biopsy was revealing for patchy interstitial inflammatory infiltrate containing mononuclear cells admixed with few eosinophils on light microscopy as well as diffuse foot process effacement on electron microscopy (Figure 2). The patient had a one-week hospital stay with improvement of SCr to 2.29 mg/dL without any prednisone or treatment for MCD. Spot urine protein improved to 7.4 g/g by time of discharge. At clinic follow up 2 weeks later his creatinine had improved to 1.1 mg/dL with UPCR of 0.4 g/g. Results MCD is a podocytopathy that can occur in up to 10% of adults with nephrotic syndrome [1]. Secondary MCD has been reported with NSAIDs. Steroids are the first line therapy for MCD and can lead to remission in the majority of the cases. In patients who do not respond to steroids, calcineurin inhibitors or mycophenolate can be used. Conclusion Our patient presented with biopsy proven-MCD that was presumed to be secondary to diclofenac. His clinical presentation was not characteristic of nephrotic syndrome with no edema. Few reports exist of spontaneous remission in these patients with most of the patient requiring steroids. While it is uncommon for patients with MCD to spontaneously resolve, not all patients with NSAID-induced MCD require treatment and these patients could be monitored conservatively.

Elvis, "Coolness" and Masculinity in the 50s USA

This article discusses Elvis Presley in relation to the concepts of coolness and masculinity in the 1950's in the USA. One point of departure is that words can be used in a number of different ways; for example, as carrying either a more literal, or more metaphorical or figurative meaning. An example of the way in which words are given figurative meanings, without us even giving it further thought, is the song by the American country singer and songwriter Tom T. Hall. The song "Old Dogs, Children and Watermelon Wine" tells the story of the singer's encounter with, as the song goes, "an old gray black gentleman". The two adjectives signifying colours, that is, grey and black, here very clearly carry different meanings and are formed on different bases. The word "gray" metonymically, primarily based on hair colour, refers to the man's age, that is, how the man is categorised agewise as an elderly gentleman. Also the word "black" is used metaphorically, but in a different way: as signifying that the man in question is ethnically AfroAmerican, thus also referring to the problem of colour, which is still highly topical in present-day USA. The concepts of "cool" and "coolness" are also, in my opinion, directly connected with issues of colour in a metaphorical sense.

Squamous Cell Carcinoma of the Finger Nail Bed: An Onychomycosis Like Lesion

Squamous cell carcinoma is a form of skin malignancy that involves squamous cells lining the epidermis. It is the second most common form of non-melanoma skin malignancy. We describe a case of squamous cell carcinoma involving the nail bed of an elderly gentleman that was initially diagnosed as a case of fungal infection of the nail bed.

Unusual Intracerebral Hemorrhage Secondary to Delayed Posttraumatic Middle Meningeal Artery Pseudoaneurysm, Successfully Treated by Endovascular N-Butyl Cyanoacrylate Embolization

AbstractPseudoaneurysm of the middle meningeal artery, presenting as a delayed sequela of trauma, being a rare entity, may sometimes present as an acute intraparenchymal hemorrhage, with a risk of rerupture and mortality. The optimal management in acute settings remains undetermined. We, hereby, report a case of elderly gentleman with a history of a road traffic accident. Noncontrast computed tomography (NCCT) brain was reported to have left parietal hemorrhagic contusion without any mass effect. The patient was managed conservatively without any major neurological deficits. After 7 months, the patient presented with severe headache, altered sensorium, and right hemiparesis. NCCT brain showed acute left thalamocapsular hemorrhage with minimal subarachnoid hemorrhage with associated mass effect and impending herniation. Considering the fall in patient's baseline Glasgow comma scale response, pupillary asymmetry, and CT findings, immediate decompression and hematoma evacuation were advised. In view of atypical morphology, the patient was planned for urgent digital subtraction angiography prior to the surgery to rule out the ruptured aneurysm or pial arterio-venous fistula. Selective angiography of the left external carotid artery demonstrated a dissecting pseudoaneurysm feeding from the middle meningeal artery (MMA), which was embolized using n-butyl cyanoacrylate (NBCA). Postprocedure DynaCT revealed the left temporal bone fracture, indicating this pseudoaneurysm to be most likely posttraumatic delayed sequelae. Postembolization, the patient underwent surgical decompression and excision of hematoma. Patient's neurological status gradually improved and was discharged with the minimal deficit. Our case highlights the importance of awareness of the posttraumatic MMA pseudoaneurysm as an uncommon but treatable entity, which can be easily diagnosed using cerebral angiography and amenable to safe and effective endovascular embolization using NBCA.

Isolated Intra-Oral Relapsed B-Acute Lymphoblastic Leukemia (B-ALL): A Case Report

B-Lymphoblastic Leukemia (B-ALL) is the second most common acute leukemia in adults. Its clinical manifestations include leukocytosis or leukopenia, anemia, and thrombocytopenia with an overall poor prognosis in elderly patients. If relapse occurs, it commonly involves the bone marrow but can also involve Extramedullary (EM) sites such as the brain, testis, liver, spleen and lymph nodes. Isolated extramedullary involvement of the oral cavity in relapse B-ALL is extremely rare with only a few reposted cases in the literature in pediatrics and Adolescent-and-Young-Adult (AYA) population. Here we describe the case of an elderly gentleman who presented with isolated EM B-ALL relapse involving the oral cavity and gnathic bones which was initially misdiagnosed as an odontogenic infection.

Tenofovir disoproxil fumarate-related toxicity: A case of Fanconi syndrome

Background: Tenofovir-based regimens remain the first choice for the treatment of human immunodeficiency virus infection and hepatitis B infection. Despite its virologic efficacy and ease of administration, it can lead to significant nephrotoxicity which may not be fully reversible. Case Description: An elderly gentleman on Tenofovir disoproxil fumarate (TDF)-based antiretroviral therapy for 10 years presented with vague symptoms of fatigue, poor oral intake and constipation. He was found to have hypokalemia and a volume depleted status. Detailed evaluation revealed hyperchloremic metabolic acidosis, hypophosphatemia, hypouricemia, proteinuria and amino aciduria consistent with a diagnosis of Fanconi syndrome. He was switched to Abacavir-based regimen, and supplements to correct acidosis and electrolytes were given. At the follow-up visit after a month, his proximal renal tubular injury recovered partially and he was symptomatically better. Conclusion: Patients on long-term therapy with tenofovir should be monitored for proximal renal tubular injury besides estimation of the glomerular filtration rate. Fanconi syndrome may present late after several years of being on TDF therapy. Partial or complete recovery of the renal tubular function occurs after stopping tenofovir.

JEJUNAL DIVERTICULAR PERFORATION, RARE BUT A SERIOUS ENTITY IN THE ELDERLY POPULATION

Compared to colonic diverticula, the jejunum has signicantly less of a tendency to develop diverticulitis because to the diverticulum's bigger size, better intraluminal ow, and relatively sterile jejunal content . Acute intestinal obstruction, diverticular bleeding , and most commonly perforation with mesenteric abscess, localized or global peritonitis are complications of jejunal diverticulitis. Multidectector row computed tomography is now the best diagnostic imaging for small bowel diverticulitis as well as its complications [1]. Treatment depends on the symptomatology of patients, can be non surgical or surgical. Advanced age, concomitant comorbidities , delayed diagnosis , and primarily the gap between perforation and surgery are poor prognostic factors[1]. We present an elderly gentleman whose diagnosis was not made till he had his laparotomy

The Scrotal Excision of Paratesticular Mesothelioma of the Tunica Vaginalis: A Case Report

Mesotheliomas are malignancies which involve mesothelial cells, and are commonly found in the pleura, peritoneum, pericardium, and (rarely) the testis. We present a case of paratesticular mesothelioma that was excised without the testis. An elderly gentleman presented with a painless right scrotal mass, which appeared clinically benign and separable from the underlying testis. An ultrasound showed an extratesticular lesion adhered to the scrotal wall with a complex hydrocele. An excisional biopsy was conducted, and the Jaboulay procedure was performed on the right testis. Pathological examination revealed mesothelioma, showing focal invasion into the underlying stroma. A post-operative computed tomography (CT) scan evaluation manifested no local or distant metastasis. No further surgery was performed, and no chemotherapy or radiotherapy was offered to the patient. Subsequent clinical examinations and radiological scans carried out during each clinic follow-up for two years showed no new lesion or recurrence.

Rescue of inadvertent superior sagittal sinus occlusion during middle meningeal artery embolization.

Middle meningeal artery embolization is increasingly becoming popular in the treatment of chronic subdural hematomas. The safety and efficacy of the procedure has previously been demonstrated in the literature; however, complications do arise from time to time. Here we present the case of an elderly gentleman who experienced inadvertent embolization of the superior sagittal sinus through an occult arteriovenous fistula between the middle meningeal artery and the superior sagittal sinus. Multiple rescue techniques including aspiration and stent retriever thrombectomy were performed with restoration of venous flow and an overall optimal result.