Background: According to the classical concept the capillary closing pressure is 30-32?mmHg and the calf interface pressure is 10-20 mmHg. So, pressure ulcers cannot occur on the calf. Observations from the bedside oppose the concept. Aim: To examine the features and clinical context of what appear to be calf pressure ulcers. Design: Prospective observational study in a long-term geriatric and palliative care unit. Methods Guideline directed diagnosis and treatment of skin ulcers. Results: Six out of 1631 patients newly admitted to our institution during a 15 month period had skin ulcers on their calves, resembling typical pressure ulcers. In four patients the calf ulcers evolved concurrently with pressure ulcers at other sites. Two patients had a single calf ulcer and no other pressure ulcer. By the ulcers location, the clinical context and the normal appearance of the adjacent skin, the calf ulcers differed from venous, ischemic, neuropathic and vasculitic ulcers. Except for their elongated shape, contrasting to the round shape of pressure ulcers at other sites, the calf ulcers were similar to typical pressure ulcers. Calf pressure ulcers have been ignored in the literature, maybe as a consequence of the longtime dominant theory concerning pathophysiology of pressure injury. Recent studies have revised the classical concept, showing that tissue pressures can become critical at levels inferior to conventional capillary closure pressure, depending on systemic influences. Conclusions: Six case histories provide evidence that calf ulcers may be genuine pressure ulcers and lend support to the contemporary, comprehensive theory of pressure injury.

Diabetes mellitus is a serious disease with a high incidence of occurrence all over the world. The number of diabetic patient will jump to 439 million by 2030. Diabetes cause a lot of complication as it can affect the entire organ in the body as liver, kidney, retina and heart. Apigenin is a potent antioxidant, it can stimulate the metabolism of glucose and transportation of it in the peripheral tissues; also enhance secretion of insulin from pancreas. It has the ability to overcome dyslipidemia which result as a non-control of diabetes. Apigenin can enhance the metabolism of glucose via suppression the activities of gluconeogenic enzymes and aldose reductase enzyme and so prevent diabetic complication as cataracts, retinopathy, and neuropathy that may result if sorbitol diffuses out cell membrane.

Macrophage activation syndrome (MAS) is a rare but serious and potentially life-threatening complication of several chronic rheumatic diseases and can also occur in people with autoimmune or immunodeficiency conditions. It occurs most commonly with systemic-onset juvenile idiopathic arthritis, which is also known as Stills disease. MAS is thought to be closely related to and pathophysiologically very similar to hemophagocytic lymphohistiocytosis. A high index of suspicion should be maintained during diagnosis as correct early diagnosis is paramount to avoid serious complications. Here we present the case of a 23-year-old woman with a history of juvenile rheumatoid arthritis (JRA) who presented with a progressively worsening erythematous rash, cervical lymphadenopathy, splenomegaly, and pancytopenia. She was initially thought to be having a JRA flare, but she did not improve with steroids. She was then found to have MAS, which improved after treatment with cyclosporine. Although the duration of treatment of MAS with cyclosporine is not clear in the literature, we found that 3 months of therapy was sufficient.

Stiff-person syndrome (SPS) is a rare disorder of the nervous system, characterized by muscle stiffness, rigidity, and painful spasms involving truncal and limb musculature that may severely limit mobility. Our case documents a 53-year-old patient with SPS and endometrial cancer who was positive for anti-GAD and paraneoplastic antibodies, who presented to our institution for robotic surgery. These patients are at high risk for prolonged hypotonia and mechanical ventilation. Our patient underwent general anesthesia without complications despite multiple comorbidities.

Due to the worldwide obesity epidemic, bariatric operations are gaining more and more popularity due to their effectiveness in battling this disease . One such operation, the biliopancreatic diversion with duodenal switch (BPD-DS), is being used more frequently on the super morbidly obese population. This operation is a combination of the sleeve gastrectomy and intestinal bypass that results in the most significant long-term weight loss and the least weight recidivism . This procedure can be performed in both single and staged operations depending on surgeon preference and patient factors. The risks associated with this particular operation are well documented and include but are not limited to anastomotic leak, bleeding, bowel obstruction, wound infection and deep vein thrombosis. Late complications such as vitamin and protein deficiency are not uncommon with this procedure. We are presenting a case of a patient with cecal volvulus 13 months after a BPD-DS who presented to an outside hospital with acute abdominal pain and was transferred to our facility for management.