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*History* 21 y.o. man presented to the emergency room one day after playing flag football. He remembers hearing a pop and feeling pain in his right small finger during the game. *Exam* Edema and tenderness over right small finger, proximal phalanx. Limited range of motion. No sensory deficits. *Findings* Complete fracture of the right fifth proximal phalanx traversing through a 0.94 x 1.43cm well-defined geographic medullary lesion with lobulated appearance and scalloping of the adjacent cortex. Appearance consistent with a geographic 1B lesion. *Differential Diagnosis* Geographic 1B lesion (well-defined, no sclerosis): -Enchondroma -Chondroblastoma -Chondromyxoid fibroma -Fibrous dysplasia -Bone cyst -Giant cell tumor -Myeloma/Metastasis *Case Diagnosis* Enchondroma with Pathologic Fracture *Diagnosis By* Radiology *Treatment & Follow Up* Observation if the lesion is asymptomatic. If a pathologic fracture is present, the fracture is first allowed to heal. Otherwise once healed, or if the tumor becomes symptomatic, it is resected with subsequent histological tests to rule out malignancy, and the extirpation cavity can be filled with autogenous spongy bone. *Discussion* A chondroma is a benign neoplasm of hyaline cartilage. When it arises within the medullary cavity of bone, it is called an enchondroma. Multiple echondromas, or enchondromatosis, is known as Ollier disease. If the enchondromatosis is associated with soft tissue hemangiomas, this is known as Maffucci syndrome. These lesions typically present between 20 and 50 years of age and are equally frequent in men and women. Enchondromas usually occur as a solitary lesion with approximately 40-65% occurring in the hands, or less frequently, the feet. Solitary enchondromas also occur in the long tubular bones in approximately 25% of cases, more frequently in the upper extremities than in the lower extremities. Rare areas of involvement include the skull, facial bones, patella, clavicle, sternum, scapula, ulna, and vertebrae. A general rule chondroid lesions of the axial skeleton are chondrosarcomas. Solitary lesions are generally asymptomatic or associated with painless swelling. Often these tumors go unnoticed and are found incidentally on x-ray, occasionally associated with a pathologic fracture. Radiographic features of solitary enchondromas in the hand or foot are characteristic. A well-defined, medullary lesion with lobulated contour and endosteal erosion. Cortical expansion or thickening, foci of calcification(but lesions of the hand and foot are frequently not mineralized), and pathologic fracture are also possible characteristics. Magnetic resonance imaging typically show a well-circumscribed, lobulated lesion of low signal intensity (less than or equal to skeletal muscle) on T1-weighted spin echo, and high signal intensity (similar to water) on T2-weighted spin echo. Solitary lesions rarely undergo malignant transformation into chondrosarcomas, however lesions associated with enchondromatosis are more likely to undergo sarcomatous change than monostotic lesions. In addition to sarcomatous transformation, those with Maffucci syndrome are also at risk of developing other malignancies to include ovarian carcinomas and brain gliomas. Lesions larger than 5 cm in diameter are much more likely to be chondrosarcomas and patients are frequently older than those with enchondroma. Other finding in long bone cartilage lesions to suggest chondrosarcoma include greater than 2/3 endosteal scalloping, cortical thickening/remodeling, or soft tissue extension.

58 years old patient came with complain of severe itching with hard scaly patches on the left lower limb since one year. It was on under control with the antifungal cream. But now its becoming worse since 3 days. Please suggest the treatment and proper diagnosis???

Treatment for severe acute respiratory distress syndrome from COVID-19 In The Lancet Respiratory Medicine, Kollengode Ramanathan and colleagues provide excellent recommendations for the use of extracorporeal membrane oxygenation (ECMO) for patients with respiratory failure from acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19). The authors describe pragmatic approaches to the challenges of delivering ECMO to patients with COVID-19, including training health-care personnel, resolving equipment and facilities issues, implementing systems for infection control and personal protection, providing overall support for health-care staff, and mitigating ethical issues. For patients with COVID-19 who require endotracheal intubation, use of low tidal volume (6 mL/kg per predicted bodyweight) with a plateau airway pressure of less than 30 cm H2O, and increasing the respiratory rate to 35 breaths per min as needed, is the mainstay of lung-protective ventilation. If the hypoxaemia progresses to a PaO2:FiO2 ratio of less than 100–150 mm Hg, there are several therapeutic options. The level of positive end-expiratory pressure can be increased by 2–3 cm H2O every 15–30 min to improve oxygen saturation to 88–90%, with the goal of maintaining a plateau airway pressure of less than 30 cm H2O. Lower driving pressures (plateau airway pressure minus positive end-expiratory pressure) with a target of 13–15 cm H2O can also be used. To read more- https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30127-2/fulltext Source- The Lancet Authors- Michael A Matthay, J Matthew Aldrich, Jeffrey E Gotts

Care for Critically Ill Patients With COVID-19 Initial reports suggest that COVID-19 is associated with severe disease that requires intensive care in approximately 5% of proven infections. Given how common the disease is becoming, as in prior major severe acute respiratory infection outbreaks—SARS (severe acute respiratory syndrome), MERS (Middle East respiratory syndrome), avian influenza A(H7N9), and influenza A(H1N1)pdm09—critical care will be an integral component of the global response to this emerging infection. Management of severe COVID-19 is not different from management of most viral pneumonia causing respiratory failure. The principal feature of patients with severe disease is the development of ARDS: a syndrome characterized by acute onset of hypoxemic respiratory failure with bilateral infiltrates. Evidence-based treatment guidelines for ARDS should be followed, including conservative fluid strategies for patients without shock following initial resuscitation, empirical early antibiotics for suspected bacterial co-infection until a specific diagnosis is made, lung-protective ventilation, prone positioning, and consideration of extracorporeal membrane oxygenation for refractory hypoxemia. To read complete article- https://jamanetwork.com/journals/jama/fullarticle/2762996 Source- JAMA Authors- Srinivas Murthy, MD, CM, MHSc; Charles D. Gomersall, MBBS; Robert A. Fowler, MD, CM, MSc

2 yr baby girl have this type of itchy patches diagnosis and treatment plz