Repeat Aspiration Research Articles

Trans-Disc Aspiration of Anterior Cervical Cysts

Abstract Background Spinal arachnoid cysts are rare entities occurring mainly in the cervical and thoracic spine. The majority of these lesions are treated through posterior approaches with laminectomy or laminotomy. We present trans-disc and trans-vertebral aspiration of anterior cervical arachnoid cysts as an alternative therapeutic approach. Methods We present three cases and four procedures where anterior cervical arachnoid cysts were treated through an anterior trans-discal or trans-vertebral approach. A standard Smith–Robertson approach was used to expose the appropriate level in the cervical spine. A 22-gauge spinal needle is passed through the intervertebral disc or a 3-mm channel created in the midline of the vertebral body. This is performed under fluoroscopic guidance. Results Three out of the four procedures resulted in complete clinical resolution at a 6-month follow-up. One patient required a repeat aspiration for a recurrent cyst at a level lower than the previous procedure. One patient had an initial improvement post-procedure followed by a functional decline within the first 5 postoperative days. Our assessment was that the cyst was re-filled and this was confirmed on magnetic resonance imaging (MRI). A standard posterior approach was used to excise the cyst with a good clinical result. Overall, no morbidity was suffered from the anterior approach. Conclusion We believe this approach is a safe alternative to posterior intradural approaches. MRI scanning is advised at 6 months or earlier if clinical improvement is not demonstrated.

Transient Abnormal Myelopoiesis in Down Syndrome Patients

Neonates with Down Syndrome (DS) have a propensity to develop the unique myeloproliferative disorder, Transient Abnormal Myelopoiesis (TAM). Transient abnormal myelopoiesis usually resolves spontaneously in < 3 months, but approximately 10% of patients with TAM die from hepatic or multi-organ failure. After remission, 20% of patients with TAM progress into acute myeloid leukemia associated with down syndrome (ML-DS). The patient was a full-term 2-day-old baby girl with a birth weight of 3300 gr. Physical examination revealed dysmorphic facial features, hypertelorism, macroglossia, and low set ears, which is a characteristic sign of DS face, skin rash, and there was no anus. On examination of peripheral blood smears and bone marrow aspiration, hematological abnormalities, and circulating blast cells were found. Early diagnosis of low-lying anorectal malformation (MAR) without fistula and down syndrome. In treating patients with TAM, it is first necessary to know whether they have trisomy 21 syndrome, then trace the existing hematological disorders to find the GATA 1 genetic mutation. The most crucial hematological problem in patients with DS is leukemia. Mutations in the GATA 1 gene and the presence of DS can result in abnormal proliferation of megakaryocytes and erythroid progenitors in the fetus and hematological abnormalities in TAM. Transient abnormal myelopoiesis can be fatal in up to 10% of patients and resolves spontaneously. Therefore, laboratory examinations are very significant, including blood tests, peripheral blood smears, supporting examinations such as bone marrow aspiration, monitoring of clinical symptoms, and close monitoring of comorbidities. Examination repeat or follow-up bone marrow aspiration is required within six months of patient follow-up to reduce the risk of further complications. In this case, a follow-up examination is highly recommended because if there are no changes, the further examination must be carried out.

Intrabursal Doxycycline Sclerotherapy for Recurrent Olecranon Bursitis of the Elbow: A Case Control Study

This study aimed to determine the efficacy and safety of intrabursal injection of doxycycline sclerotherapy to treat olecranon bursitis (OB) refractory to conservative management. We retrospectively reviewed 27 patients with recurrent OB who were treated over 11 years with intrabursal injections of doxycycline. They were compared with a control group of 18 patients with recurrent OB who underwent surgical bursectomy. Patients were re-evaluated by the treating physician for recurrence of bursitis and treatment complications and completed a questionnaire to assess satisfaction, pain, and other patient-reported outcomes. Eight patients (29.6%) undergoing doxycycline sclerotherapy had recurrence, requiring one more doxycycline lavage within the first 4 weeks of initial doxycycline treatment. Three patients (16.7%) undergoing surgery had recurrence after surgery, requiring repeat aspiration. There were no patients in either doxycycline or surgical groups with recurrence of bursitis at the final follow-up (median= 195 and 1,055 days, respectively). No patients in the doxycycline group ultimately required surgical bursectomy, and no patients undergoing surgery required repeat surgeries. A regression model controlling for covariates did not find a significant difference between groups in the likelihood of physician-identified complication or repeat aspiration after doxycycline lavage or surgical bursectomy. Of patients undergoing doxycycline sclerotherapy, 85.7% of patients reported high satisfaction (Likert score: 8-10), and 95.2% reported that they would pursue this treatment again. Use of intrabursal doxycycline as a sclerosing agent for recurrent OB was safe and effective, with high patient satisfaction and no ultimate recurrence of bursitis at the final follow-up. This may be an effective alternative to surgical bursectomy for patients with recurrent OB refractory to conservative management. Therapeutic IV.

An audit of “Repeat” fine needle aspiration cytology procedures in a cytopathology laboratory—An important quality indicator

Abstract Background: The cytopathology department mainly conducts audits to evaluate the diagnostic efficiency of procedures across different organs. However, the common occurrence of repeat aspirations, typical in many cytology laboratories, has largely been overlooked. This study sought to examine the frequency of repeat Fine Needle Aspiration Cytology (FNAC) procedures within a cytopathology laboratory and to explore the root causes for such repetition. Materials and Methods: A retrospective descriptive analysis was conducted at the cytopathology laboratory affiliated with a tertiary care facility. This study included all FNAC cases reported over six months. Data were extracted from cytology records, and multiple factors leading to repeat aspirations were examined. The rate of repeat FNAC procedures was calculated by dividing the number of “repeat” FNAC procedures in a specific month by the total number of FNACs performed. A quality manager set a benchmark of 15% for the repeat FNAC rate. Results: About 39 out of 303 FNACs (12.8%) were repeated for 6 months. Soft tissue lesions, predominantly lipomas, accounted for most (35.9%) of these repeated aspirations. The principal reason for the need for repeat aspirations was insufficient material obtained during the initial aspiration. Conclusion: In many laboratories, the frequency of repeat FNAC procedures and their root causes often need to be checked. Evaluating the quantity of repeat aspirations in a laboratory indicates its performance and is a vital quality measure, especially when accreditation is required. This research proved beneficial by providing valuable insights into the prevalence of repeat aspirations within a cytology laboratory.

A “Dry Tap” in Prosthetic Joint Infection Workup of Total Hip Arthroplasty Is Not Reassuring

BackgroundSynovial fluid analysis is important in diagnosing prosthetic joint infection (PJI). The rate of culture-positive PJI in patients who have a dry tap of a total hip arthroplasty (THA) is not well described. MethodsWe reviewed all image-guided THA aspirations, performed from 2014 to 2021 at a single academic institution. Aspirations were categorized as successful (≥ 0.5 mL) or unsuccessful (< 0.5 mL, “dry tap”). We analyzed culture data on all repeat aspirations and revision surgeries performed within 90 days of the initial dry tap. ResultsWe reviewed 275 consecutive attempted THA aspirations of which 100 (36.4%) resulted in a dry tap. The dry tap cohort had a significantly higher percentage of fluoroscopic-guided aspirations (64%) and fewer ultrasound-guided aspirations (36%) compared to the successful aspiration cohort (48.9% fluoroscopic, 53.1% ultrasound, P = .0061). Of the 100 patients who have dry taps, 48 underwent revision surgery within 90 days of the initial dry tap, and 15 resulted in 2 or more positive cultures. The rate of PJI defined by MusculoSkeletal Infection Society major criteria in the dry tap cohort was 16.0%. ConclusionsAttempted aspiration of a THA resulted in a dry tap 36.4% of the time. Of those patients who had a dry tap, 16.0% were subsequently found to have PJI based on MusculoSkeletal Infection Society major criteria. Therefore, a “dry tap” does not exclude the diagnosis of infection and should not be considered reassuring for the absence of PJI.

Predictors of an informative or actionable cytological diagnosis on repeat breast aspiration after an insufficient aspirate: a multicentre retrospective review

An insufficient/inadequate diagnosis on fine-needle aspiration cytology (FNAC) of the breast is not an uncommon diagnostic dilemma. This study aims to review the rate and clinical features predicting an informative...

No Difference in Reintervention at 1-Year Between Ultrasound-Guided versus Blind Dorsal Carpal Ganglion Aspiration

The purpose of this retrospective comparative study was to compare the efficacy of dorsal carpal ganglion aspiration in patients who underwent either "blind" (using surface anatomy alone) or ultrasound-guided (US-guided) aspiration. Outcome measures were conducted during the coronavirus disease 2019 pandemic via telephone for a minimum of 12 months after aspiration, with efficacy defined by reintervention with either repeat aspiration or surgical excision. Data are reported for 141 patients (46 blind; 95 US-guided) at an average of 28 months (range, 12-55 months) from aspiration. Reintervention was not significantly different based on the mode of aspiration-26% and 24% for blind aspiration and US-guided, respectively. Patient-perceived recurrence was higher at 65% for the entire cohort. Patients who received steroid injection at the time of aspiration perceived lower rates of recurrence-44% versus 77% for patients who received a steroid injection and patients who did not, respectively. This study found no significant difference between blind or US-guided aspiration in reintervention at a minimum of 1-year follow-up. Patients who received steroids at the time of aspiration perceived lower rates of recurrence. Therapeutic III.

Abstract #1388241: A Rare Case of an Intrathyroidal Bronchogenic Cyst

Bronchogenic cysts are uncommon congenital cystic malformations that arise due to dysplasia during ventral foregut development of the respiratory tract. They are mostly asymptomatic but can grow in size, causing compressive symptoms secondary to infection or malignancy. Bronchogenic cysts are usually located in the mediastinum or intrapulmonary regions, although they can rarely present in ectopic extrathoracic locations such as the thyroid. Here we report a rare case of an intrathyroidal bronchogenic cyst. A 48-year-old woman was incidentally found to have a thyroid mass on magnetic resonance imaging (MRI) neck by her neurologist during workup for migraines. An initial thyroid ultrasound showed a 4.7 cm left thyroid cyst with no concerning features, and a repeat follow up ultrasound 6 months later reported no change in its size. TSH, free T3, and free T4 were unremarkable. However, the patient began to endorse fullness in her neck that progressed to compressive symptoms, including dysphagia with solids and liquids, shortness of breath, and mild dysphonia. Endocrinology and otolaryngology (ENT) were consulted. ENT performed a nasopharyngolaryngoscopy, which was unremarkable for masses. A fine-needle aspiration (FNA) drained 25 mL of cystic fluid with non-diagnostic pathology with a virtually acellular specimen. FNA for parathyroid hormone level was low at 6 pg/mL (10 to 55 pg/mL), not suggesting parathyroid tissue. Compressive symptoms initially improved after FNA, but within 1 month her symptoms returned. Repeat thyroid ultrasound after FNA showed a 2.6 x 2.0 x 3.8 cm cystic nodule with regular margins. The patient opted for thyroid lobectomy as opposed to repeat aspirations. Her thyroid lobectomy was uncomplicated. The surgical biopsy was consistent with an intrathyroidal bronchogenic cyst. Her symptoms resolved after surgery and at her 3-month follow appointment, she continued to do well with resolution of symptoms. Bronchogenic cysts are quite rare in the thyroid. To our knowledge, there have only been 6 cases of intrathyroidal bronchogenic cysts previously reported. Bronchogenic cysts can grow in size causing compressive symptoms, with simple aspiration having a high rate of recurrence. Infection or, less commonly, transformation into malignant tumors are possible complications. Treatment for asymptomatic bronchogenic cysts remains controversial. However, once symptomatic, surgical resection is recommended over observation. Prognosis is generally excellent without recurrence for full resections.

Ethanol Sclerotherapy for Postoperative Seroma of the Breast and Axilla.

Evaluate the effectiveness of alcohol sclerotherapy in postoperative breast and axillary seromas. This was an IRB-approved retrospective review of consecutive patients from 2017 to 2021. The procedure involves aspiration of seroma fluid, injection of ethanol for 15 to 30 minutes, and then aspiration of the injected ethanol. Following review of the medical record, patient and procedure data were recorded. Success was defined as no recurrence of seroma. Statistical analysis was performed using a chi-square or t-test, as appropriate. Twenty seromas were treated in 19 patients (mean age, 63 years; range, 49-79) following mastectomy (9/20, 45%), lumpectomy (25%, 5/20), axillary nodal dissection (5/20, 25%), or chest wall surgery (1/20, 5%). The mean seroma volume was 146 ± 165 mL. There was a mean of 1.4 prior aspiration attempts (range, 0-3). Mean injected ethanol volume was 39 mL (range, 8-60 mL) for a mean of 26 ± 5 minutes. Seromas recurred in 85% (17/20) of cases, and repeat aspiration was performed in 35% (6/17). The mean recurrence time was 34 ± 29 days. The recurrent seromas were 31% smaller (mean, 80 ± 48 mL). Only a smaller pre-ablation seroma was associated with successful ablation (P < 0.01), as the mean pre-ablation volume was 36 ± 24 mL for successful ablations and 119 ± 56 mL for unsuccessful ablations. There were no post-procedural complications. Single-treatment ethanol sclerotherapy is typically unsuccessful in ablating breast and axillary seromas. Only a smaller pre-ablation seroma size was associated with successful ablation.

Reduced percentage of inconclusive reports and need for repeated fine needle aspirations in ultrasound versus free-hand parotid cytology

BackgroundFine needle aspiration cytology has been established as a minimally invasive, non-tumour seeding investigation of choice in the initial diagnostic pathway of parotid lesions. The purpose of this study was to compare the accuracy of fine needle aspiration cytology performed with and without ultrasound to determine whether one method should be preferred to the other. A retrospective review of all patients undergoing fine needle aspiration cytology with and without ultrasound for parotid masses in a large district general hospital between 2012 and 2016 was performed. Specificity, sensitivity, accuracy, positive and negative predictive value, percentage of inconclusive fine needle aspiration cytology and percentage of second fine needle aspiration cytology were determined for each group.ResultsA total of 397 fine needle aspiration cytology results were available for analysis. The numbers performed with ultrasound guidance and free-hand were roughly equal (208 (52.3%) versus 189 (47.7%)). The number of inconclusive fine needle aspiration cytology reports was significantly higher in the free-hand group (65/189 (34.4%)) than the ultrasound group (25/208 (12%)) (p < 0.0001). A significantly higher number of repeated fine needle aspiration cytology were undertaken in the free-hand group vs ultrasound group (43 vs 15, p < 0.0001); overall 7.2% of ultrasound-guided fine needle aspiration cytology required a second fine needle aspiration cytology, compared to 22.8% in the free-hand group. The sensitivity, specificity, positive and negative predictive values were all higher in the ultrasound group versus the free-hand group.ConclusionsUltrasound-guided fine needle aspiration cytology is superior to free-hand fine needle aspiration cytology in the investigation of parotid tumours. There is a significant benefit in reducing the number of inconclusive results and repeat fine needle aspiration cytology, and a potential benefit in improving the sensitivity and positive predictive value, when immediate cytology assessment of the sample quality is not performed.

Corynebacterium kroppenstedtii breast abscesses in context, a retrospective cohort study.

Corynebacterium kroppenstedtii breast abscesses and granulomatous mastitis have gained increased recognition in the 20 years since their association was first described. No studies to date have described this organism in the context of all breast abscess pathogens. We retrospectively reviewed 160 community-acquired breast abscess samples from 135 patients in a 3 year period, describing the organisms isolated along with risk factors, site of infection and outcomes. We compared patient subgroups with acute and chronic abscesses, the latter defined as having a requirement for repeat aspiration more than 1 month apart. The prevalence of C. kroppenstedtii breast abscesses was 8 % in all patients (11/135), rising to 32 % in chronic abscesses (10/31), but only 1 % in acute abscesses (1/104; P<0.01). Only 10 % (1/10) of patients with C. kroppenstedtii chronic abscesses were smokers, whereas 75 % of patients (15/20) with non-C. kroppenstedtii chronic abscesses were smokers (P=0.01). C. kroppenstedtii should be considered in recurrent and prolonged infections, especially in non-smokers, and diagnostic methods altered accordingly. Identifying C. kroppenstedtii provides diagnostic clarity and alters management with recommendations for longer courses of treatment using non-beta-lactam antibiotics.

Point-of-Care Ultrasound-Guided Aspiration of the Hip Joint by an Emergency Medicine Physician: A Pediatric Retrospective Case Series.

Early administration of antibiotics is crucial to treating septic hip. This study aimed to describe the clinical course and outcomes of children with septic hip diagnosed using point-of-care ultrasound (POCUS)-guided hip aspirations performed by an emergency medicine physician. A retrospective case series analysis. Between January 1, 2014, and December 31, 2019, 10 children with septic hip were diagnosed by emergency physicians using POCUS-guided hip aspirations. Six of them were female; the mean age was 4.2 ± 4.5 years, and the mean time from onset of symptoms to diagnosis was 2.9 ± 1.7 days. Seven patients (70%) had a history of fever. All the patients had elevated inflammatory blood markers (white blood cell count >12 K/μL, erythrocyte sedimentation rate >40 mm/h, or a C-reactive protein >2 mg/dL). The mean time from hospital arrival to the first antibiotic dose was 5.2 + 4.0 hours. All the children were discharged fully ambulatory and did not require rehospitalization or repeat aspiration after discharge. This case series shows that POCUS-guided hip aspiration is both safe and feasible in diagnosing septic hip in the pediatric emergency department. The procedure enables rapid diagnosis and early initiation of antibiotic treatment, thus reducing the risk for complications related to delayed initiation of therapy.

172 Septic Arthritis of the Wrist: Audit of Management and Awareness of National Guidelines Amongst Orthopaedic Surgeons in a District General Hospital

Abstract Aim Septic arthritis (SA) of the wrist is relatively uncommon and, in contrast to SA of large joints, can safely be managed with serial aspiration to dryness rather than traditional open surgical drainage. This is supported by BSR &amp; BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. We conducted an audit of management of suspected wrist SA patients and surveyed awareness of relevant guidelines amongst orthopaedic surgeons. Method Electronic records of patients referred as suspected wrist SA to the orthopaedic department over a six-month period (August 2020 to February 2021) were retrospectively reviewed. Data analysis included demographics, diagnosis, management, and treatment outcome. In addition, knowledge of wrist SA management amongst orthopaedic medical staff was determined via a multiple-choice questionnaire. Results 11 patients were identified (5M:6F, age range 62–91). 6/11 patients underwent wrist aspiration though only one patient had a positive gram stain. No patients underwent serial aspiration as advocated by national guidelines. 2/11 patients underwent formal surgical washout in theatre. 15 orthopaedic doctors were surveyed (8 Junior Doctors, 4 Registrars, 3 Consultants). 2/15 were aware of national guidelines. 11/15 chose joint aspiration as an initial investigation. 2/15 considered repeated joint aspiration to dryness as definitive management. Conclusions This audit highlighted low compliance with national guidelines when managing wrist SA, although this did not adversely affect patient outcomes. We demonstrated lack of awareness of relevant guidelines amongst orthopaedic surgeons. We propose relevant teaching and incorporation of national guidelines into Trust policy.

SURG-01. CYSTIC BRAIN METASTASES MANAGED WITH RESERVOIR PLACEMENT AND STEREOTACTIC RADIOSURGERY

Abstract BACKGROUND Stereotactic radiosurgery (SRS) has become a mainstay of treatment for patients with metastatic brain tumors. However, metastatic tumors with a large cystic component often exceed the size limit for safe and effective SRS. In such cases, surgical resection may not be the preferred first method of treatment, due to tumor location, patient co-morbidities, and patient preference. In such cases volume reduction by cyst aspiration followed by SRS may be a preferred option. OBJECTIVE To present the treatment of patients with cystic metastases using reservoir placement followed by SRS. METHODS Seven patients were treated with this method. We performed reservoir insertion for the aspiration of cystic component in each patient and followed that with outpatient SRS. RESULTS Mean overall volume reduction from this treatment method was 80% (range 46.5-94.9). Mean volume reduction from the cyst aspiration alone was 60.7% (range 3.5-90.9), and after SRS a further 71.6% (range 34.6-94.4), accounting for some cyst reaccumulation between the time of surgery and SRS. The interval between those two procedures were 24 days on average (range 11-58 days). Repeat reservoir aspiration was done a total of 10 times in 5 patients. CONCLUSION Cyst aspiration with reservoir placement followed by SRS is a good option for patients with large cystic brain metastases. The reservoir allows for repeat aspiration if needed. Catheter placement at the center of the cyst, and SRS within 2-3 weeks of surgery, can maximize the likelihood of a successful outcome.

Case Series: Cystic Brain Metastases Managed With Reservoir Placement and Stereotactic Radiosurgery

Abstract BACKGROUND Stereotactic radiosurgery (SRS) has become one of the mainstays of treatment for patients with metastatic brain tumors. However, metastatic tumors with a large cystic component often exceed the size limit for safe and effective SRS. In such cases, surgical resection may not be the preferred first method of treatment, due to tumor location, patient co-morbidities, and patient preference. In these patients, volume reduction by cyst aspiration (CA) followed by SRS may be a viable alternative treatment option. OBJECTIVE To present the treatment of patients with cystic metastases using reservoir placement followed by SRS. METHODS Nine patients were treated with this method. We performed reservoir insertion for the aspiration of cystic component in each patient and followed that with outpatient SRS. RESULTS Mean overall volume reduction from this treatment method was 78.5%. Mean volume reduction from the CA alone was 59.8%, and after SRS, a further 66.6%, accounting for some cyst reaccumulation between the time of surgery and SRS. Repeat reservoir aspiration was done a total of 10 times in 5 patients. Our study showed local tumor control in 7 of 9 patients (77.8%), while 2 patients required later surgical resection of their tumors. CONCLUSION CA with reservoir placement followed by SRS is a good option for patients with large cystic brain metastases. The reservoir allows for repeat aspiration if needed. Catheter placement at the center of the cyst, and SRS within 2 to 3 wk of surgery, can maximize the likelihood of a successful outcome.

Efficacy of needle aspiration in patients with oral-maxillofacial abscesses: A retrospective study of 15 consecutive patients

The aim of this study was to determine the adequacy and safety of needle aspiration (NA) as an alternative to open surgical drainage for oral-maxillofacial abscesses. Fifteen consecutive patients who were diagnosed with oral-maxillofacial abscesses via contrast-enhanced CT from January 2020 to December 2020 were included. All patients were on antibiotics and treated with NA under local anaesthesia using a 20 mL syringe. Data collection included patient characteristics, signs and symptoms, physical examinations, laboratory tests, imaging findings, and outcomes. Next-generation sequencing (NGS) was used to identify the infectious microorganisms from the abscess samples. The study included 15 patients with oral-maxillofacial abscesses. None of our 15 patients required surgical incision and drainage, although repeat aspiration was required. However, after the first NA, the pain was reportedly extremely relieved for all patients. The average duration of antibiotic treatment was 9.20 ± 5.15 days (range 4–23 days). The abscess-affected spaces mainly included the masseter space and submandibular space. Odontogenic infection was the most common aetiology in 15 patients (10/15). The average volume of the abscesses on CT was 5866.26 ± 3627.18 mm3. The main pathogens identified in this study were Prevotella oris (5/15), Peptostreptococcus stomatis (4/15) and Porphyromonas endodontalis (2/15). According to the results of our study, the data support the use of NA as an effective, minimally invasive treatment modality for oral-maxillofacial abscesses. Surgeons should familiarise themselves with this technique, as it can easily be performed in the clinic using local anaesthesia, culture samples may be obtained, and airway obstruction and pain may be relieved.

RADI-01. Cystic brain metastases managed with reservoir placement and stereotactic radiosurgery

BackgroundStereotactic radiosurgery (SRS) has become a mainstay of treatment for patients with metastatic brain tumors. However, metastatic tumors with a large cystic component often exceed the size limit for safe and effective SRS. In such cases, surgical resection may not be the preferred first method of treatment, due to tumor location, patient co-morbidities, and patient preference. In such cases volume reduction by cyst aspiration followed by SRS may be a preferred option.MethodsSeven patients were treated with this method. We performed reservoir insertion for the aspiration of cystic component in each patient and followed that with outpatient SRS.ResultsMean overall volume reduction from this treatment method was 80% (range 46.5–94.9). Mean volume reduction from the cyst aspiration alone was 60.7% (range 3.5–90.9), and after SRS a further 71.6% (range 34.6–94.4), accounting for some cyst reaccumulation between the time of surgery and SRS. The interval between those two procedures were 24 days on average (range 11–58 days). Repeat reservoir aspiration was done a total of 10 times in 5 patients.ConclusionCyst aspiration with reservoir placement followed by SRS is a good option for patients with large cystic brain metastases. The reservoir allows for repeat aspiration if needed. Catheter placement at the center of the cyst, and SRS within 2–3 weeks of surgery, can maximize the likelihood of a successful outcome.

A Case Of A Swollen Leg

HISTORY: Patient is an 83 year old female with a history of hypertension and hyperlipidemia that originally presented to vascular clinic with 7 months of left lower extremity swelling and numbness. At that time, she first noticed numbness in her left foot that extended up to mid calf. She also mentioned that in particular, her 3rd, 4th, and 5th toes felt numb and it made it difficult to walk. She denied any injuries to her left lower leg. PHYSICAL EXAMINATION: General: Well appearing in no acute distress, AO x 3. Right knee exam: Normal. Left knee exam: Mild swelling in popliteal fossa. Normal ROM of left knee. No tenderness to palpation along joint lines. Left lower extremity: 1+ edema present to the knee, bluish discoloration of toes on left foot. Unable to fan out 3rd, 4th, and 5th digit. No tenderness to palpation. Right lower extremity: Normal exam DIFFERENTIAL DIAGNOSIS: 1. Popliteal artery/nerve entrapment. 2. Peroneal nerve dysfunction. 3. Baker's cyst causing compression. 4. Cystic adventitial disease. 5. DVT. 6. Arterial thrombosis. 7. Popliteal fossa mass. TEST AND RESULTS: ABI @ DP was 0.37 indicating severe occlusive disease. ABI @ PT was 0.44 indicating severe occlusive disease. MRI revealed extensive cystic structure which occluded a short portion of popliteal artery. FINAL WORKING DIAGNOSIS: Cystic adventitial disease resulting in compression/occlusion of popliteal artery. TREATMENT AND OUTCOMES: We saw this patient in sports clinic to discuss ultrasound guided aspiration of the cyst that was compressing popliteal artery. Initial procedure resulted in removal of 5 cc of thick, gelatinous fluid that was identified as a sparse mucoid matrix. During the procedure, we were able to watch the popliteal artery begin pulsing again. Patient was able to move toes and had improved sensation immediately after procedure. Fatigue in left lower leg has been slowly improving. Plan is to repeat aspiration in an attempt to fully drain entire cystic structure.

Cytopathological study of thyroid lesions and its correlation with histopathology in a tertiary care centre of Gujarat – A retrospective study

Thyroid gland is one the important organs, which play a wide and vital physiological role in the body. Thyroid diseases are quite common. The incidence of thyroid diseases depends mainly depending upon iron deficiency status. Fine-needle aspiration cytology (FNAC) plays a vital role in evaluating patients with thyroid nodules. Surgical excision and histopathological evaluation are crucial to establish the diagnosis.This study mainly aims to classify the cytomorphology of palpable thyroid lesions by FNAC and correlate the results with histopathology. This study also aims to determine the spectrum of histopathological diagnosis in thyroid surgeries. The present study was carried out at cytopathology and histopathology section of pathology department of GMERS Medical College, Valsad. In present study, we analysed 276 cases of palpable thyroid nodule underwent FNAC. Out of them 152 cases underwent surgical procedure like lobectomy or partial or total thyroidectomy Out of these 276 patient, females were 218 and males were 58 with F:M ratio of 3.76:1. Out of total 276 patients, 81 (29.3%) were between 31-40 years followed by 75 (27.2%) were between 21-30 years and 237 (85.9%) were fall into category-II. Out of these 152 patients, 88 (57.9%) having colloid goitre and 79 (89.7%) were confirmed histologically. FNAC is an invaluable tool in management of thyroid lesions. It is a safe, simple and cost effective procedure and can be performed on outdoor patients. If the cytology report is malignant, surgery is the recommended procedure; for suspicious lesions, repeat aspiration is required and for benign lesions no further immediate diagnostic studies are required.

Suturing Gone Wrong.

Practice guidelines provide checklists to decrease complications during central venous introducer placement.1 Fixation of introducers should rely on institutional practice, which may include suturing, stapling, or an adhesive method.1,2 Our institutional practice uses a two-point suture securement technique: one at the suture wing and a second wrapped around the introducer’s hub (Panel A).Panel B illustrates a 9Fr ARROW Percutaneous Sheath Introducer (Teleflex, USA) with an inadvertent retention suture through the sheath. The practice guideline checklist recommends securement after aspiration and flushing.1 Before fixation, the sheath was immediately aspirated, revealing venous blood. After fixation, repeat aspiration revealed an air-filled venous blood mixture within the side port tubing and fluid leakage at the insertion site.Introducer damage during fixation may be secondary to various factors: limited visibility, restricted neck rotation, emergent access, etc. Although practice guidelines remain ambiguous regarding fixation techniques, ARROW specifically recommends sutures remain outside the immediate sheath area.3 Considering the manufacturer’s recommendations, placing a skin suture beside the venous introducer (Panel A) followed by circumferentially wrapping around the hub’s ring is preferable to a suture trajectory posterior to the sheath.Prompt identification of a venous introducer integrity breech remains critical in preventing potential air emboli, blood stream infections, insufficient intravascular volume resuscitation, and vasoactive drug administration. The current practice guideline checklist recommends flushing the catheter prior to securement only.1 Considering Panel B, integrity checks involving aspiration and flushing should be considered after sheath fixation and before use.The authors declare no competing interests.