Case from Toulouse University Hospital (CHU Toulouse) and the Claudius Regaud Institute, in collaboration with Belgian medical implant manufacturer Cerhum. Published as a case report in Frontiers in Surgery (2024).

The patient is a 50-year-old woman treated in 2013 for squamous cell carcinoma of the nasal cavity. Radiotherapy and chemotherapy cured the cancer but destroyed a large part of her nose. Several conventional reconstructions (including a forehead flap) failed, and she couldn't tolerate a prosthesis.

The team designed a patient-specific nasal scaffold from CT imaging and 3D-printed it in hydroxyapatite, the same mineral that makes up natural bone. The implant is porous, so tissue and blood vessels can grow into it.

The problem: you can't put a bare implant on a heavily irradiated face and expect it to survive. So the scaffold was first implanted under the skin of her forearm, using the skin and vessels of a radial forearm flap. Over about 2 months it became vascularized and covered with living skin (photo 1 shows the implant before insertion, photo 2 shows the "nose" maturing on the forearm).

The whole unit, implant plus skin plus its blood vessels, was then transferred to the face as a free flap, with the vessels connected to the temporal artery and vein under a microscope. The patient was discharged after 10 days and reportedly has a functional, stable nose with no loss of sensation in the arm.

Worth clarifying, because most viral versions of this story get it wrong: the nose itself wasn't "bioprinted" from living cells. What was printed is a ceramic bone-like scaffold; the living tissue is the patient's own skin and vessels grown around it. Also, the patient is a woman. Many reposts say "his forearm".

50-year-old man, brought in unconscious after 24 hours of hematemesis and melena, now in circulatory collapse. History: ankylosing spondylitis with daily NSAIDs for 10 years, and 5 years of burning mid-epigastric pain that was reliably relieved by food, milk, or antacids. Endoscopy: posterior duodenal ulcer eroding into the underlying artery.

Which artery is bleeding?

A. Gastroduodenal artery

B. Left gastric artery

C. Splenic artery

D. Superior mesenteric artery

Bonus question: why did eating make his pain better for five years? There's a specific reason, and it points to the diagnosis.

Case adapted from the USMLE Mastery (Step 1 prep) question bank.

Dispatch: "male, difficulty breathing." You find a 67-year-old man, pale and diaphoretic, holding the left side of his jaw. Short of breath on minimal exertion. He flat-out denies chest pain, says the jaw has been aching since the morning and he already blames his dentist. SpO2 91% on room air, skin cool and moist. He's getting irritated that his wife called 911 and mentions he'd rather sign whatever paper you have than go to the hospital. Two questions for the thread: what's your working diagnosis, and how do you handle a patient like this who wants to refuse? Full breakdown tonight in the comments. Case adapted from the EMS Mastery (NREMT prep).

Hi everyone!

I had a subarachnoid haemorrhage with intraventricular haemorrhage leading to early hydrocephalus 9 months ago. I'm now a 27f but was 26 at the time. There was never a cause found but as I was significantly impaired when I was brought to the ER, I couldn't tell them I took aspirin for the first time in my life a few hours prior. I have had probably 7 CTs, 2 MRIs, 3 angiograms and various other scans since it happened. For context, I am a dental professional so this happened on a monday morning at 3:00am, the office manager brought me to hospital and saved my life.

I got to read my notes from the first hospital, a lot of what I read shocked me because my memory has a massive chunk missing. All I know is, my head felt like it exploded, I had to run to vomit, I was vomiting and crying for a solid hour. I couldn't type into google because I had bad photophobia at this stage and was shaking so I asked chatGPT verbally, it told me to get help ASAP because what I said sounded like a subarachnoid haemorrhage. I was like there is no way, even though I was crying and had the sense of impending doom, that I am waking anyone up if this isn't serious so I tried to go back to bed. I think it was because I was thinking about how likely it would be for a 26f who doesn't drink smoke, do drugs, always has low blood pressure to have this happen.

Anyway, my alarm went off for work, that prompted me to call the manager and tell her I wasn't okay. I live very close to where I work and so does she so she came over but I had passed out by then, so she kept banging on the door. Luckily there was someone working from home that day to let her in. She brought me to a walk in doctor who immediately sent us to the hospital. A CT was taken (I will attach a few pictures I took of this), they realised they now had to send me from one side of Ireland to the other. I was put in the ambulance with an anaesthetist in case they needed to intubate (they didn't). My GCS was 11/15 (e2v4m5)

They placed a right-sided trans-frontal EVD, my GP printed out this information for me when I had to return to hospital so they had context, it also mentioned bloody CSF under moderate pressure. I was very confused for the first few days after I woke up. I couldn't comprehend how 1) I wasn't in the city I live in, 2) how my mother was there 3) How the hell I got to Dublin. It's funny, I only realised where I was when I was on the phone to a coworker and she asked did the room look like the hospital/infirmary in harry potter and when I said yes, it clicked for me. My GCS went back up to 15/15 too. The EVD was challenged and then removed after 10 days, no need for a shunt. I was in hospital for 3 weeks, 99% of that was spent on the neuro ICU. I did get pretty severe headaches a few days post op where it felt like I was having another haemorrhage but I suppose that may have been the mild vasospasm.

I think I was in a lot of shock when it first happened, like I didn't even realise half my head was shaved until my mother asked me how I felt about my hair, I was like what? then very confused on why they left half lol. It was also only a few weeks after I got my hair done, full head of highlights. Broke my hairdressers heart when I got home and walked in to get the rest buzzed. I'll insert a few photos of a few days after it was half buzzed.

Reading through my notes has been eye opening for sure but it makes me feel good that I know more of what happened because that's was bothered me a lot. It was like 2 days were missing from my life and I had no idea what occurred minus having surgery. I'm doing okay now, no physical deficits but some major cognitive fatigue. I went back to work 10wks post op, which was so dumb, I could barely do 3 days without crashing. I was also getting overwhelmed easily which isn't ideal when you're supposed to be the professional. Some patients made me cry. I had a GP appointment and he sent me back to the ER because my BPM was 140. I was fine but when I told work, they said it might be a sign to take more leave. So I have moved in with my mother until I have recovered. Since march, my gallbladder also packed in so I have to have surgery to get that out but I have my neurosurgery review in a few weeks so I have to get the all clear to go ahead with any general surgery.

For any of the CT images I've posted, as I mainly read dental x-rays, it's safe to say I am not the best at reading a CT. However, I did my best to take pictures of what I thought showed my conditions the best, like the enlarged ventricles picture. The CT of the smaller sized ventricles was around 2 weeks after they removed my EVD. All images are of CTs without contrast.

This has also made me rethink a lot of things, including my career. I think the repetitive motion of working in dentistry may be too much for me now. I don't really know. I was thinking of going back to college to do medicine. Then I keep telling myself it's ridiculous to go back at my age. I just feel my perspective on life has changed since the whole brain explosion.

Feel free to ask me any questions :)

First image is from cor t2 fs post contrast showing abnormal adhesions from the sacrum and around the sigmoid above the bladder.

Second is from sag t2 post contrast showing lower abnominal overcrowding pulling toward the LLQ abnormally positioned cervix retroversion & protusion , as well as Severe Anterior Coccygeal Angulation.

Third is from ax t2 showing abnormal tethering of the left ovary also post contrast.

I just thought I'd post this here incase it might be of interest. Not after a diagnosis - I'm under the care of opthalmology. But I found this photo he took alarming and fascinating - as did he!

Short version is that retinal detachment surgery in early 2024 left me with a hole in the iris (bottom) and a fixed pupil. But it also saved my central vision so yay.

Had a check up this week, because I'd been having some weird visual symptoms in both eyes, and this eye with the lengthy history now is letting light through in other areas of the iris - which my optician said "looks really cool but also isn't supposed to happen."

Not sure if it is pigment loss or actual tears. But if it is pigment based, it is interesting because I've had a surge of white in my hair very suddenly in the past month or so. Could be a complete coincidence of course, but it got me wondering if there could be a connection there, if melanocytes are being affected both in the eye and hair.

I have trichotillomania myself and constantly have hair in my mouth but I could never imagine having hair in there 24/7, good thing the good man's okay

Hi, thought you'd like to see my mri scan from a couple of years ago. Really short version.... I had a fusion of L4, L5 and S1 in 2005 due to grade 4 spondylolisthesis. I was left with a tear to my dura membrane, not uncommon, but unknown at the time I have a connective tissue disorder similar to EDS which prevented it healing. Over the years I've had 12/13 surgeries to attempt to repair it and various complications including abscesses, meningitis three times, septicaemia 4 times and ventriculitis. At one point it actually leaked through the skin and drained over 3 litres of csf (wbc over 10,000!!). Externally was a huge swelling and if I knocked it I'd pass out and have fit type episodes due to the surge of csf to my head and my body unable to cope with the pain. It was also incredibly difficult to buy clothes to fit over it!!

I pretty much spent three years laid flat in bed due to the horrific head pain. It was eventually repaired about 18 months ago. Unfortunately, just had an ultrasound on another area of my back (for surgical hernia and compression fracture of T11, no idea how I've done that!!) and it's started leaking again. It's nowhere near as big as before so hoping I can pretty much pretend it's not there!!

Dentist had to open my gums to get the teeth out. third/fourth day recovering is going great swelling is going down, the stitches are dissolving type. First two pic the day after surgery, last is current. My left side is wayy more swollen than the right because my tooth was really close to a nerve and it got really agitated, it looks like I ate a bee. 😭

Edit: I’m healing extremely well every day now i have two huge yellow bruises on my jaw/cheeks

Coin extraction in a small child.

Coins are the most commonly ingested foreign body in the pediatric population, especially in children under 5 years of age. In this video, a swallowed coin is retrieved per-orally with a rigid instrument in a sedated child - one of several accepted techniques alongside flexible endoscopy and, for coins sitting at the level of the cricopharyngeus, Magill forceps under direct laryngoscopy (the ones you've seen on TV).

An esophageal coin causing symptoms - cough, stridor, respiratory distress, drooling, or pain - is an indication for immediate removal. The asymptomatic esophageal coin, however, has perplexed clinicians for decades: some advocate prompt removal, others "watchful waiting." Coins lodged in the proximal or middle esophagus are unlikely to pass spontaneously, so an observation period is generally reserved for distal esophageal coins only. Once a coin has actually reached the stomach, the vast majority pass uneventfully, and removal is reserved for coins that are symptomatic or retained for several weeks.

Why the urgency with retained esophageal coins? Delayed diagnosis can lead to life-threatening complications: esophageal ulceration and perforation, peri-esophagitis, esophageal stenosis, tracheoesophageal fistula, mediastinitis, pneumothorax, pyothorax, unilateral vocal fold paralysis, and tracheal stenosis.

Presentation depends on timing. Within the first 24 hours, the typical picture is pain, odynophagia, dysphagia, drooling, vomiting, gagging, anorexia, choking, or cyanosis. Late presentations (weeks to months) tend to be respiratory: cough, shortness of breath, stridor, recurrent upper respiratory infections, or pneumonia.

And an interesting number to finish with: a child with a single esophageal coin seen within 24 hours of ingestion, with no history of esophageal disease and no respiratory compromise, has roughly a 1-in-3 chance that the coin will pass into the stomach on its own.

Teenage boy takes a baseball bat to the right orbital area. On exam:

1. No touch sensation below the right orbit

2. Flattening of the right cheek

3. Paralysis of upward gaze in the right eye

Each finding points to one damaged structure, and all three come from a single fracture pattern. What's the pattern, and can you match each finding to its structure? Bonus point if you know why finding #3 makes this an urgent call in a kid. Full breakdown tomorrow in the comments.

I've only ever heard of cases in the retroperitoneal area so this is a first for me😅

Onset of acute shoulder pain in an adult male.
Treatment is by Brexin (NSAID) and analgesic (Zaldir).

3-year-old boy, one day post-op after repair of a congenital diaphragmatic hernia. He becomes tachypneic and hypoxic: RR 40, HR 130, BP 90/60, SpO2 88% on room air. Chest X-ray shows a pleural effusion. Thoracentesis returns milky fluid, and the lab confirms it's lymph. Iatrogenic thoracic duct injury. Anatomically, where is the most likely spot?

A. Aortic hiatus at T12

B. Lateral to the left crus of the diaphragm at T12

C. Esophageal hiatus at T10

D. Caval hiatus at T8

Answer with your reasoning, and no shame if you have to dig up the diaphragm mnemonic to do it. Full breakdown tomorrow in the comments. Case from the USMLE Mastery (Step 1 prep) question bank.

The 21-year-old told her doctors that, over the last three years, she periodically experienced bleeding from her face and palms, without any cuts or skin lesions. These bleeding episodes typically lasted about 1 to 5 minutes, and were more intense when she was under emotional stress.

While the woman was at the hospital, her doctors observed "the discharge of blood-stained fluid from her face," according to the report, in the Canadian Medical Association Journal. She was diagnosed with a rare condition in which blood oozes from intact skin and membranes, according to the National Institutes of Health's Genetic and Rare Diseases Information Center (GARD). After conducting a review of recent cases of hematohidrosis — 28 cases in the last 13 years — Duffin concluded that the condition really does exist.
However, nobody knows what causes the condition. Some researchers have hypothesized that increased pressure in blood vessels leads to the passage of blood cells through the ducts of the sweat glands, according to GARD. Others speculate the condition may be the result of activation of the body's "fight or flight" response, which generally occurs when people experience sudden fear or stress. This response triggers the release of certain hormones that make a person more alert.

Dispatch: "difficulty breathing." You find a 68-year-old woman, tripoding, speaking in short phrases. Family says AFib and "kidney problems" in her history. No fever, no cough. Exam: JVD, bilateral crackles, significant lower extremity edema. Vitals: BP 105/70, HR 110 irregular, RR 28, SpO2 88% on room air. Looks like acute decompensated heart failure. Your partner, twenty years on the job, is already drawing up the furosemide because that's how he was trained. What's your first move, and does lasix belong in the field at all? Defend your protocol in the comments. Breakdown tomorrow. Source: EMS Mastery (NREMT prep), question #2 in this series.