Diagnosis of early intramural ectopic pregnancy

Intramural ectopic pregnancy is a very rare diagnosis. Establishing a diagnosis is difficult and is often made intraoperatively. Demonstration of a live extrauterine gestation is the only specific sign of such a pregnancy. A small number of ectopic pregnancies are interstitial or cornual pregnancies. Rupture of an intramural ectopic pregnancy is a serious clinical complication. Diagnosis of this ectopic pregnancy can sometimes be made using 2-dimensional transvaginal ultrasound (TVS), but it may also require 3-dimensional TVS. We present the case of a 25-year-old gravida 0, para 0 woman with amenorrhea lasting 6(+5) weeks. Previous surgery included a right adnexectomy for torsion of a right dermoid cyst. The patient's serum hCG was elevated. TVS provided a detailed view of the endometrial cavity. The results of 2-dimensional TVS suggested the presence of an ectopic pregnancy. The sonogram showed a gestational sac with an embryonic pole and a yolk sac, which was separated from the endometrium. Use of 3-dimensional TVS demonstrated a live embryo in a gestational sac surrounded by myometrium below the right cornu lying outside the endometrium. This finding was confirmed by laparotomy and the conceptus was excised. The patient had an uneventful postoperative course and was discharged 7 days after surgery. In our case, the previous adnexectomy was an identifiable risk factor. Nonetheless, making a diagnosis of an intramural pregnancy was challenging. Suspicion may arise when sonography has revealed an intramural gestational sac.     

Arteriovenous fistula between the left vertebral artery and the inferior thyroid vein: a case report

Arteriovenous fistula between the left vertebral artery and the inferior thyroid vein is a rare entity. This condition can change the blood supply of the basilar artery system, and then lead to an abnormal blood supply of the vertebral body. Therefore, this rare condition may be misdiagnosed in the clinic. We report an arteriovenous fistula between the left vertebral artery, which was found during an interventional operation of a 49-year-old Asian man. He was non-diabetic and an ex-smoker, and presented with a 1-month history of pain in the neck, shoulder, waist, back, and right lower limb. Vascular angiography showed an arteriovenous fistula, and coils were placed in the fistula. In this setting, coil embolization was effective, and a 1-year follow-up suggested that a good long-term result was likely.     

Incarcerated obturator hernia treated using a hybrid laparoscopic and anterior preperitoneal approach: A case report

Obturator hernia (OH) is a rare cause of bowel obstruction. Although several surgical approaches, including the laparoscopic approach, have been reported to date, a standard approach for treating OH has not been established. A 101‐year‐old woman who presented with constipation and vomiting was admitted to our hospital. CT revealed an incarcerated small bowel within the left obturator foramen, and a diagnosis of left‐sided incarcerated OH with small bowel ileus was made. With the patient under general anesthesia, exploratory laparoscopy was performed; we identified an OH with an incarcerated small bowel, which was judged viable after hernia reduction. We repaired the hernia using an anterior preperitoneal approach under laparoscopic assistance and placed a prosthetic mesh over the obturator foramen. The patient recovered with no postoperative complications and was discharged on postoperative day 4. A hybrid laparoscopic and anterior preperitoneal approach is safe and effective for treating an incarcerated OH in an elderly patient.     

Perineal sonography in diagnosis of an ectopic ureteric opening into the urethra.

OBJECTIVE: To study the role of perineal sonography in the diagnosis of an ectopic ureteric opening into the urethra. METHODS: In this study, carried out over about 4 years, perineal sonography was done to look for a ureter opening ectopically into the urethra in patients for whom abdominal sonography showed the ureter descending below and beyond the urinary bladder. RESULTS:Perineal sonography was done on 11 patients because there was a suggestion of an ectopic ureteric opening shown on abdominal sonography. In all of them, an ectopic ureteric opening into the urethra was shown on perineal sonography. The collecting system was seen to be nonduplicated in 6 patients and duplicated in 4 patients, and a triple ureter was present in 1 patient. CONCLUSIONS: Perineal sonography is a simple, quick, beneficial, and noninvasive technique that can be used as an extension of abdominal sonography to diagnose an ectopic ureteric opening into the urethra.     

Laparoscopy-assisted spleen-preserving pancreatic resection for epidermoid cyst in an intrapancreatic accessory spleen

A rare case of an epidermoid cyst originating in an intrapancreatic accessory spleen in a 50-year-old Japanese female is reported. A hypoechoic cystic tumor was detected incidentally by abdominal ultrasonography. It appeared to be a single cyst in the pancreatic tail with a contrasted mass lesion beside it. Laparoscopy-assisted spleen-preserving pancreatic tail resection was performed. Microscopic examination revealed that the cyst was surrounded by fibrous tissue and a thin layer of splenic tissue, adjacent to normal pancreatic parenchyma. The inner surface of the cyst was lined with non-keratinizing squamous epithelium. The diagnosis of an epidermoid cyst occurring in an intrapancreatic accessory spleen was confirmed. Laparoscopy-assisted spleen-preserving pancreatic resection is a safe and effective procedure for benign or low-grade malignant cystic diseases in the pancreas.     

Ruptured Ectopic Pregnancy after Elective Termination of Intrauterine Pregnancy Discovered by Use of Ultrasonography in the Emergency Department

The authors report a case of a 27-year-old female who was diagnosed as having a ruptured ectopic pregnancy approximately 12 hours after an elective termination of an intrauterine pregnancy (IUP) was performed. Multiple previous evaluations by an obstetrician for a chief complaint of abdominal pain revealed an IUP but did not disclose the underlying pathology. The ectopic pregnancy was identified by the emergency physician's use of ultrasound in the emergency department.     

Extraction and replantation of a periapically infected tooth

At times, an infected tooth that may be deemed unrestorable may be salvaged by atraumatic removal, an in‐hand apicoectomy and retrograde seal, then replantation. This patient was referred to this author for an extraction and implant treatment of the maxillary left second premolar. After a discussion, the patient preferred to salvage the tooth if possible. The tooth was successfully atraumatically removed, and an in‐hand apicoectomy and retrograde amalgam seal was placed. The tooth was immediately replaced into its socket and was stable. The occlusal surface was flattened to prevent and off axial loading. A bis‐acryl brace was applied to the facial and lingual aspect to prevent an overload while the tooth was healing. The patient was admonished to maintain a soft diet. After 3 weeks, the braces were removed, and the tooth was found to be stable. After 8 weeks, the tooth was asymptomatic, and the patient was able to revert to her normal diet without pain. While extraction, placing an apical seal and replantation of teeth is not a new modality; nonetheless, clinicians may need to be reminded of this procedure to increase the number of options presented to patients.     

Electrophysiologic Demonstration of an Atriofascicular Accessory Pathway

Evidence of an atriofascicular accessory pathway has not been reported previously. In the patient presented in this case report, an electrophysiology study demonstrated a constant left bundle branch block QRS configuration despite varying degrees of ventricular preexcitation, in association with a constant artrioventricular interval during incremental atrial pacing and programmed atrial stimulation. The presence of an atrioventricular, nodoventricular, nodofascicular, and atrial-His accessory pathway was ruled out. The findings are best explained by the presence of an underlying left bundle branch block and an atriofascicular accessory pathway connecting the atrium and right bundle. The atriofascicular accessory pathway was a passive bystander during an atrial tachycardia and was not directly involved in the generation of the tachycardia. To our knowledge, this is the first report of an atriofascicular accessory pathway.     

The increase in energy cost of walking with an immobilized knee or an unstable ankle

The effect of an immobilized knee joint or of an unstable ankle joint on the walking capacity has been assessed with 50 walking tests in ten healthy subjects. The knee joint was immobilized in extension with a standard splint and an unstable ankle joint was simulated by a modified shoe. A significant decrease in convenient walking speed was found. The energy cost of walking as assessed by oxygen cost at a convenient speed was significantly increased both with an immobilized knee (23%) and with an unstable ankle (10%), compared to normal condition of the subjects. Implications for the management of patients with similar joint disorders are discussed.     

Emergency department knowledge management in the age of Web 2.0: Evaluation of a new concept

Objective: The objective of the present study was to describe the implementation of an organizational learning model and evaluate the effectiveness and usability of an application used to facilitate it in an ED setting. Methods: This was an implementation case study and technology evaluation. The organizational learning model was implemented using an online Web 2.0 collaborative learning application developed by the investigating team. Online use was tracked over a 9‐month period. At the end of the study period, a usability assessment was conducted as well as a semistructured interview of participants to assess perceptions of usefulness and effect on learning capacity in the ED. Results: Over a period of 9 months, a total of 54 individual sites from 74 eligible staff members were created within a specific web domain. There were 251 registered users including users outside the ED, who accessed learning materials within these sites 7494 times. The majority of staff members interviewed agreed or strongly agreed that the collaborative learning application had improved learning capacity within this ED (88%, 95% CI 74–94%). Conclusion: We demonstrate the implementation of an organizational learning model based on independent online sites networking together within an organization. This appears to be both usable and acceptable to staff members working in a large ED as a means of knowledge management.     

Guiding the transition of nursing practise from an inpatient to a community-care setting: a Saudi Arabian experience

The purpose of this paper is to provide an overview of the Transitional Practise Model, which was used as the educational learning program to guide the transition of two Saudi nurses from an acute inpatient environment into a community setting. This model was informed by Benner's "novice to expert" concept and is grounded in experiential learning and critical thinking. The aim was to enhance knowledge and skills by providing opportunities for learning in order to make an effective transition from an acute inpatient environment into community nursing. The model was effective in guiding and bridging the gap for nurses to undertake a transition from a hospital inpatient environment into a community setting. The use of preceptors was invaluable in providing an understanding of the nature of professional practise through learning opportunities, mentoring, and support.     

Transesophageal echocardiographic diagnosis of left atrial mass as thrombus by demonstrating its attachment to the patch closing atrial septal defect: a case report.

A 65-year-old-man was referred for echocardiographic examination because of palpitations. He had a history of an atrial septal defect surgically treated with an artificial synthetic polyester textile fiber patch. TTE showed a large, mobile mass in a dilated left atrium. The attachment site of the mass was not clear by transthoracic approach, and it was difficult to diagnose the mass as a thrombus or a myxoma from the nature of the echocardiographic findings. Transesophageal echocardiography clearly demonstrated that the mass was attached to the patch closing the atrial septal defect and the mass was confirmed as thrombus at surgery. A patient with left atrial thrombus in whom transesophageal echocardiographic demonstration of the attachment of the left atrial mass to a patch closing an atrial septal defect served as an essential clue leading to accurate diagnosis is reported. Transesophageal echocardiography is feasible to evaluate the attachment site of a left atrial mass and to lead to an accurate diagnosis.     

Using e-learning for maintenance of ALS competence

ContextA well-suited e-learning program might be a feasible strategy to maintain competence following a resuscitation course.AimThis study had 2 aims: (1) to examine the effect of an e-learning program as a booster of competence acquired from an Advanced Life Support (ALS) course. (2) To identify factors related to the use of the e-learning program.Materials and methodsThe study contained two parts pertaining to the two aims. The first part was a prospective single blinded randomised controlled study on junior doctors. The intervention was the monthly use of an e-learning program during one year and effect was measured as ALS-competence, a composite of a knowledge and skills test.The second part was a telephone interview of the intervention group. An interview guide was constructed based on existing knowledge of e-learning. In order to identify factors explaining the use of e-learning a univariate correlation was used to select significant variables to be included in a multiple regression analysis.ResultsOf the 134 invited to participate, 103 accepted the invitation. There were 79/103 (77%) participants, 40/51 in the intervention group and 39/52 in the control group. There was no difference between the groups with regards to ALS competence. Only ‘social interaction’ was an individually significant factor influencing the use of the e-learning program.ConclusionsThis study did not demonstrate an effect of an e-learning program as a booster of competence acquired from an ALS course. The primary factor influencing the use of e-learning was the lack of social interaction.     

The effect of ketone bodies on leucine and alanine metabolism in dogs

1. The effect of an infusion of sodium beta-hydroxybutyrate on leucine and alanine metabolism was investigated in dogs starved for 12 h. To determine whether the metabolic changes produced by this infusion were due to the resultant alkalaemia the effect of an equimolar infusion of sodium bicarbonate was also studied. 2. The sodium beta-hydroxybutyrate infusion reduced alanine concentration as a result of a decrease in alanine production rate and an increase in alanine metabolic clearance rate. The sodium bicarbonate infusion induced a small decrease in alanine concentration which was due to an increased metabolic clearance rate. Alanine production rate showed no change. This demonstrates that the fall in alanine concentration after a sodium beta-hydroxybutyrate infusion is due both to a ketone-specific inhibitory effect on alanine production rate and an increased metabolic clearance rate caused by the alkalaemia. 3. Leucine concentration was increased after the ketone infusion due to a small increase in production rate and there was a small increase in the rate of leucine incorporation into protein. Alkalaemia had no effect on leucine concentration or metabolism.     

A large hypopigmented skin lesion following extravasation of intravenous fluid

This report describes an unusual presentation and complication of extravasation of intravenous fluid in an infant who presented with a large hypopigmented skin lesion distant from the site of intravenous cannulation. The infusion was immediately discontinued and an alternate intravenous site secured. A chest radiograph revealed that the catheter was not in the external jugular vein site, and a large fluid collection was apparent over the right lateral chest wall. The hypopigmented skin lesion disappeared within 48 h, and the infant remained stable. This article serves to alert the physician to consider the extravasation of intravenous fluid as a potential cause of acute development of skin hypopigmentation in an at-risk patient.     

INFECTIOUS CATARRH OF MICE : I. A NATURAL OUTBREAK OF THE DISEASE

A natural outbreak of an infectious catarrh in a colony of Swiss mice is reported. The disease was generally characterized by a peculiar chattering sound during life and by a rhinitis, an otitis media, and a pneumonia at autopsy. The pneumonia was slowly progressive and terminated fatally in a high percentage of cases. The mortality in a group of 75 naturally infected mice was 95 per cent over a period of 11 months. The disease was readily reproducible in susceptible mice by the nasal instillation of exudate from any locus of infection. It was also transmissible by direct contact. In both naturally and experimentally infected animals there was an incubation period of 10 days or more before symptoms were apparent. Recovery from the disease was not observed.     

Integration of nurse practitioners into a family health network

A randomized controlled study called Anticipatory and Preventative Team Care (APTCare) explored a new role for nurse practitioners (NPs) within a multidisciplinary team. The aim of the study was to evaluate whether integrating NPs and a pharmacist was an effective approach for the management of patients living with multiple chronic illnesses. Over an 18-month period, three part-time NPs and a pharmacist became part of a rural Family Health Network (FHN). They established relationships with study patients and collaborated to provide optimum care. Each NP had 40 patients, all of whom received care in the home. Study results showed that an initial home visit was invaluable for establishing a care plan, developing a relationship with the patient and assessing the home environment. Ongoing monitoring at home, however, was found to be an inefficient use of the NP role. By the end of the study, all clinicians agreed that the NP role had been successfully integrated into the multidisciplinary team.     

Long-term mortality among patients discharged alive after out-of-hospital cardiac arrest does not differ markedly compared with that of myocardial infarct patients without out-of-hospital cardiac arrest.

The aim of our research was to study the long-term prognosis among patients discharged alive after an out-of-hospital cardiac arrest (OHCA) in comparison with patients discharged alive after acute myocardial infarction (AMI) without OHCA, and also to study the long-term influence of AMI in connection with OHCA. Our research was conducted in the municipality of G?teborg. We retrospectively studied patients discharged from hospital 1990-91 after an OHCA of cardiac aetiology and patients discharged after an AMI without prehospital cardiac arrest. During 1980-98, we studied all patients discharged alive after OHCA of cardiac aetiology, divided into groups of precipitating AMI and no AMI. The study includes 48 patients discharged alive after an OHCA 1990-91, 30 (62%) of whom had a simultaneous AMI and 1425 patients with an AMI without OHCA. Compared with AMI survivors, survivors of an OHCA of cardiac origin were younger but had more frequently a history of congestive heart failure. Their mortality rate during the subsequent 5 years was 46%, compared with 40% among survivors of an AMI (NS). The 5-year mortality rate among patients with an OHCA precipitated by an AMI was 40%. When correcting for differences at baseline, the adjusted risk ratio for death among patients with an OHCA of cardiac origin was 1.2 (95% CI 0.8-1.8) compared with patients with an uncomplicated AMI. During 1980-98, 215 patients were judged as having an OHCA precipitated by an AMI and 115 patients had an OHCA of cardiac aetiology but no simultaneous AMI. Five-year mortality was 54% and 50% respectively (NS). It is concluded that survivors of an OHCA of cardiac origin differed from survivors of an uncomplicated AMI in that they were younger and more frequently had a history of cardiovascular disease. Their 5-year mortality after discharge was similar to that of survivors of an AMI without a prehospital cardiac arrest, even after adjusting for differences at baseline.     

Abuse experiences, perceptions, and associated decisions during the childbearing cycle

The study purpose was to generate a theoretical understanding of women's experiences and perceptions of intimate partner abuse during the childbearing cycle. Dimensional analysis, a grounded theory method, was used. Twenty-one interviews were conducted with 12 women who were (a) currently in an abusive relationship with an intimate male partner and pregnant or postpartum (n = 5) or who had (b) experienced abuse by an intimate male partner during a past pregnancy or postpartum (n = 7). Disparities between the two concurrent phenomena of abuse and pregnancy led women to feel as though they were living two separate lives. Pregnancy provided the impetus for reinvesting in the partnered relationship and constructing a family. Leaving an abusive relationship was not considered unless the partner ended the relationship first or the woman perceived an increased risk of danger. Postpartum up to 2 years after birth was a critical transitional time for women.     

Phenolsulphotransferase: enzyme activity and endogenous inhibitors in the human erythrocyte.

PST (E.C. 2.8.2.1) plays an important role in the metabolism of many drugs, catecholamine metabolites, and catecholamines. PST activity was detected in each of 178 human RBC lysates. When MHPG was used as a substrate, the activity ranged from 28 to 1385 U/ml of RBC, with an average value of 217.7 +/- 13.1 (mean +/- S.E.M.). However, there was not a direct relationship between quantity of RBC lysate and enzyme activity, an observation that raised the possibility of endogenous enzyme inhibitors. Therefore human RBC PST was partially purified (415-fold) to use in the study of tissue enzyme inhibitors. The pH optimum of the partially purified enzyme was 7.5, with an apparent Km value for [35S]PAPS of 0.46 microM and an apparent Km value for MHPG of 260 microM. When the partially purified enzyme was added to each of 20 human RBC lysates, its activity was inhibited an average of 91% +/- 0.6 (mean +/- S.E.M.). Endogenous inhibitors were also present in homogenates of human renal cortex and in homogenates of a variety of rat tissues. RBC lysates contained at least two PST inhibitors: a low-molecular-weight inhibitor (less than 2000) that was heat-, acid-, and base-stable, dialyzable, and resistant to digestion by chymotrypsin; and a high-molecular-weight inhibitor (greater than 65,000) that was heat-labile and nondialyzable. Whether the RBC enzyme activity may serve as an indicator of PST activity in less accessible tissues remains to be determined. However, the first step toward testing this hypothesis will require the accurate measurement of PST activity in tissue preparations by a procedure that removes or inactivates enzyme inhibitors.