Penetrating carotid artery injuries are rare but life-threatening, particularly in resource-limited and conflict settings. We report a case of a 23-year-old male presenting with hypovolemic shock, respiratory arrest, and active neck hemorrhage secondary to a shrapnel injury. Emergency open exploration and primary repair of the carotid artery were performed in a field hospital without access to anesthesiology support, advanced imaging, or intensive care facilities. The patient survived without neurological deficit and was discharged on postoperative day 14. This case highlights the feasibility of life-saving vascular repair in austere environments using fundamental surgical principles.

Rifampicin-induced purpura is a rare hypersensitivity reaction encountered during anti tubercular therapy (ATT). We report a 43-year-old male with cervical tubercular lymphadenitis who developed purpuric lesions with distinctive orange-colored serous discharge over the left lower limb after initiation of ATT. Investigations excluded thrombocytopenia and systemic vasculitis. A temporal relationship between drug intake and symptom onset confirmed rifampicin as the causative agent. Prompt withdrawal of rifampicin and initiation of systemic corticosteroids led to complete resolution of the lesions. This case highlights the need for vigilance regarding rare dermatological adverse effects in patients on ATT and the importance of prompt clinical recognition to prevent serious complications.

Enhanced Recovery After Surgery (ERAS) pathways safely reduce length of stay (LOS) and resource use in many surgical fields, but their economic impact in thyroidectomy within the Italian National Health Service (SSN) is unclear, particularly under Diagnosis-Related Group (DRG) rules that penalize early discharge. A decision-analytic model compared an ERAS-inspired thyroidectomy pathway-same-day discharge after hemithyroidectomy and 24-hour discharge after total thyroidectomy-with a conventional DRG-driven pathway based on ≥2 postoperative inpatient days. The analysis adopted a hospital/provider perspective over 30 days, using data from a high-volume endocrine surgery unit and contemporary ERAS literature. Outcomes included LOS, postoperative complications, 30-day readmissions, direct hospital costs, and contribution margin under current SSN tariffs (including early-discharge penalties) and under a neutral reimbursement scenario. In hemithyroidectomy (400 cases/year), ERAS reduced mean LOS from 2.6 to 0.33 days (-2.27 days; p<0.001), freeing 908 bed-days annually and lowering variable costs by €1,332 per patient, without increasing complications or readmissions. Despite a 30% DRG penalty for LOS <2 days, the contribution margin increased by €147 per case. In total thyroidectomy (600 cases/year), ERAS reduced LOS from 3.1 to 1.16 days (-1.94 days; p<0.001) and variable costs by €1,079 per patient, again without compromising safety. However, DRG penalties reduced the margin by €481 per case, resulting in an annual loss of approximately €289,000 despite substantial real-resource savings. Overall, ERAS reduced mean LOS by 2.1 days and variable costs by €1,190 per patient across 1,000 procedures. ERAS thyroidectomy is clinically safe and markedly reduces LOS and hospital costs, but current SSN DRG rules penalizing early discharge blunt or reverse its financial benefits for public hospitals, particularly for total thyroidectomy. These findings highlight a structural mismatch between surgical efficiency and reimbursement incentives and support revising thyroidectomy tariffs to reward evidence-based early discharge. Because this is a model-based economic evaluation, these results should be interpreted as scenario-based evidence rather than as definitive real-world cost-accounting estimates.

Pediatric cervical lymphadenitis is usually caused by Staphylococcus aureus and Streptococcus pyogenes. Cases resulting from Gram-negative bacteria are rare. Herein, we report the case of an 11-year-old boy who developed cervical lymphadenitis. He was diagnosed with a Pseudomonas aeruginosa infection through metagenomics next-generation sequencing of blood and biopsy. After treatment with meropenem, the patient's condition improved and he was discharged. Lymphadenitis may be caused by Gram-negative opportunistic pathogens. Metagenomic next-generation sequencing can help identify the underlying cause.

BackgroundPublicly funded health services face persistent challenges in meeting demand for specialty care, particularly in rhinology. Task shifting-the redistribution of clinical tasks from specialists to trained non-specialists-may offer a strategy to optimize health-care delivery. This study evaluates the outcomes of a nurse-led assessment pathway within an outpatient rhinology service in New Zealand.MethodsTo address increased demand for rhinology services, a registered nurse (RN) at Waikato Hospital was trained to perform initial assessments for patients referred for undifferentiated chronic nasal symptoms. We describe outcomes of this approach over the initial 18-month period.ResultsA total of 309 patients were assessed through the nurse-led pathway. The average wait time from referral to assessment decreased when compared to the specialist-led clinic. Most patients were discharged with a treatment plan that did not require specialist care. Patient feedback indicated high satisfaction with the nurse-led consultation.ConclusionTask shifting offers a promising solution to address resource constraints in publicly funded health-care systems. Nurse-led assessments can enhance efficiency and optimize care delivery without compromising quality. These findings suggest that task-shifting may be broadly applied to improve outcomes in other resource-constrained health-care settings.

Patients undergoing radiation therapy (RT) for head and neck cancer frequently require escalation of care, leading to emergency department (ED) visits and hospital admissions. An outpatient urgent care clinic (OncoSTAT) may reduce ED visits.

A 57-year-old man with metastatic colorectal cancer, a left internal jugular port, and reported apixaban use presented to the emergency department with worsening unilateral left upper-extremity swelling. Overnight point-of-care ultrasound did not identify a definite deep venous thrombosis (DVT), and he was discharged with next-morning formal imaging because formal vascular ultrasound was unavailable overnight. Formal imaging later that same day showed axillary thrombosis, and contrast CT of the neck and chest revealed bilateral internal jugular thrombosis, chronic left brachiocephalic thrombosis, suspected acute-on-chronic central venous thrombosis of the left upper extremity, and possible extension into the right transverse sinus. Venography and intravascular ultrasound later demonstrated near-occlusive thrombus involving the left axillary, subclavian, and brachiocephalic veins with severe underlying brachiocephalic stenosis. Aspiration thrombectomy and venoplasty improved central venous outflow. This case illustrates that persistent unilateral arm swelling in a high-risk oncology patient may reflect central venous thrombosis rather than isolated peripheral upper-extremity DVT. A negative peripheral or bedside ultrasound should not close the workup when symptoms and risk factors remain concerning for central disease.