A complication of intramedullary nailing

A case is described of intramedullary nailing of the femur, complicated by non-union, fracture of the nail, pseudarthrosis, malunion and subsequent distal migration of the proximal nail fragment over a period of 8 years.     

Development of a bariatric surgery specific risk assessment tool for perioperative myocardial infarction

BackgroundPerioperative myocardial infarction (PMI) is a feared complication after surgery. Bariatric surgery, due to its intraabdominal nature, is traditionally considered an intermediate risk procedure. However, there are limited data on MI rates and its predictors in patients undergoing bariatric surgery.ObjectivesTo enumerate the prevalence of PMI after bariatric surgery and develop a risk assessment tool.SettingBariatric surgery centers, United States.MethodsPatients undergoing bariatric surgery were identified from the MBSAQIP participant use file (PUF) 2016. Preoperative characteristics, which correlated with PMI were identified by multivariable regression analysis. PUF 2015 was used to validate the scoring tool developed from PUF 2016.ResultsWe identified 172,017 patients from PUF 2016. Event rate for MI within 30 days of the operation was .03%; with a mortality rate of 17.3% in patients with a PMI. Four variables correlated with PMI on regression, including history of a previous MI (odds ratio [OR] = 8.57, confidence interval [CI] = 3.4–21.0), preoperative renal insufficiency (OR = 3.83, CI = 1.2–11.4), hyperlipidemia (OR = 2.60, CI = 1.3–5.1), and age >50 (OR = 2.15, CI = 1.1–4.2). Each predicting variable was assigned a score and event rate for MI was assessed with increasing risk score in PUF 2015; the rate increased from 9.5 per 100,000 operations with a score of 0 to 3.2 per 100 with a score of 5.ConclusionThe prevalence of MI after bariatric surgery is lower than other intraabdominal surgeries. However, mortality with PMI is high. This scoring tool can be used by bariatric surgeons to identify patients who will benefit from focused perioperative cardiac workup.     

Multiple atresias and a new syndrome of hereditary multiple atresias involving the gastrointestinal tract from stomach to rectum

Ten patients with multiple intestinal atresias were seen at Ste Justine Hospital from 1962–1971. Two of the seven patients with multiple atresia were unusual, presenting a rarely reported association of atresia of the duodenum, jejunum, and ileum.In addition, we recently treated three of five children with a special type of multiple atresia who came from the same area and born to three related French-Canadian families. These five cases of hereditary atresia involved the stomach, duodenum, jejunum, colon and rectum. Genetic investigation revealed common ancestors in these three families going back to the original settlers in 1654–1663. In addition, consanguinity was present in some of the more recent generations.It is proposed that when extensive multiple atresias occur a rare autosomal recessive gene is the responsible agent for this congenital birth defect. The etiology of such multiple septal atresia is difficult to place into any present theory of pathogenesis.     

Life-threatening anoxic spells caused by tracheal compression after repair of esophageal atresia: Correction by surgery

Three infants who developed anoxic spells 2, 5, and 20 mo following repair of esophageal atresia developed apneic spells during or within a few minutes of feeding. These episodes began with stridor and cyanosis; when severe, they progressed to apnea and loss of consciousness. Mouth-to-mouth resuscitation was often necessary. Investigations failed to detect esophageal obstruction and/or a recurrent tracheoesophageal fistula. No neurologic or cardiac abnormalities were found. The cause was compression of a 1- to 3-cm segment of trachea anteriorly by a vascular structure and posteriorly by a dilated esophagus that emptied slowly because of poor motility. Endoscopy confirmed the x-ray findings. The aortic arch and innominate artery were suspended to the sternum anteriorly, which relieved the apneic spells in all patients.     

Continuous monitoring of muscle gas tensions and pH during tissue acid-base disturbances

To evaluate the applicability of continuous muscle P_O2 and P_CO2 monitoring as indicators of physiologic abnormalities, muscle (m) P_O2 and P_CO2 was measured by mass spectrometry and pH by muscle surface probe in the limb muscle of 16 dogs subjected to hemorrhage, acid infusion, hypoxia, or hypocarbia and hypercarbia. These values were compared to arterial (a) pH, P_O2, and P_CO2.During hemorrhage, mP_O2 fell sharply; mP_CO2 rose and mpH decreased linearly in proportion to the rate and the magnitude of the bleed. mP_O2 fell with the onset of blood loss, whereas significant mP_CO2 and mpH changes resulting from tissue acidosis were evident only after a large volume loss.Metabolic acidosis produced by acid infusion caused a parallel drop in arterial and mpH, a rise in mP_CO2, and no change in mP_O2.During progressive hypoxia, aP_O2 and mP_O2 reflected the changes in inspired O₂. MpH and apH fell only when mP_O2 fell to low levels. Hypercarbia and hypocarbia caused parallel changes in mP_CO2 which were also reflected in apH and mpH.Continuous muscle gas measurements appear feasible and combined with muscle pH monitoring should help the clinician pinpoint the cause of physiologic derangements in the critically ill.     

Early short segment left colon interposition for esophageal atresia

Colon Interposition is frequently used for correction of esophageal atresia. The use of both retrosternal right colon^1–5 and transthoracic left or transverse colon^2,6–10 has been recommended. Retrosternal right colon interposition may be complicated by break downs and/or stricture of the anastomosis between cervical pharyngo-esophagus and the proximal interposed colon;^3–5,9 by vascular compromise and ischemia of the colon segment;^2,5 and by peptic ulceration of the distal interposed colon where it is anastomosed to the stomach.¹¹ Long-segment transthoracic left colon interposition may be attended by the first two complications as well;¹⁰ utilization of the esophageal stump for the distal colo-esophageal anastomosis in this technique may prevent gastroesophgeal reflux.^8–10,12Because of these problems, other methods of treatment have been suggested. The use of a gastric tube as esophageal replacement has been recommended;^13–15 however, peptic ulceration of the gastric esophagus may result.¹⁶ Elongation of the upper and, sometimes, the lower esophageal pouch with delayed primary anastomosis has been advocated.^17–19 Anastomotic leaks and/or stricture frequently accompany this procedure.Short-segment transthoracic left colon interpositions for esophageal stricture or varices have been attended by relatively fewer complications.^6–8 Therefore, a modified procedure was adopted for wide-gap esophageal atresia in 1968. A short segment of left colon was interposed transthoracically between the distal esophageal stump and proximal esophageal pouch in two infants after several weeks of bougienage had stretched the proximal pouch well below the aortic arch, so that a colo-esophageal anastomosis could be accomplished within the thorax without difficulty.     

The occult neuropathic bladder

A condition of occult neuropathic bladder can be defined by clinical and radiologic investigations in which the course of the disease closely simulated that observed in the well-defined congenital neuropathies but in which ordinary neurological signs are lacking. The bethanechol stimulation test has some place in confirming this diagnosis, and bethanechol may be of value in this and other forms of neuropathic bladder.     

Chronic exertional compartment syndrome of the forearm: a case report

A 40-year-old man sustained a circumferential crush injury to his right forearm. Four months after injury, he experienced the onset of numbness and tingling in the distribution of the median nerve after exercise. Elevated compartment pressures of the palmar forearm and slowing of median nerve conduction after exercise suggested chronic exertional compartment syndrome. A flexor fasciotomy led to complete relief of symptoms, which allowed the patient unrestricted activity.     

Hepatic “intravenous fat pigment” in infants and children receiving lipid emulsion

In 23 patients who received fat emulsion (Intralipid) intravenously and had subsequent necropsy, the deposition of pigment in the liver was evaluated quantitatively. Pigment was found in hepatic cells (HC) in 14 of 23 patients as well as reticuloendothelial cells (REC) in 22 of 23 patients. There was more pigment deposition in HC in younger children. HC pigment deposition occurred most frequently in patients with acute inflammatory processes within the abdomen. Patients infused with emulsion at rates less than 0.5 g/kg body wt/hr had less pigment deposition than patients infused at faster rates. Neonates infused at rates less than 0.2 g/kg body wt/hr for 24 hr had less HC pigment than neonates infused at higher rates. The quantity of REC pigment bore no apparent relationship to age, clinical diagnosis, rate or total dose of fat emulsion, but was increased in groups infused more than 14 days.     

Research Pearls: How Do We Establish the Level of Evidence?

Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used. Unfortunately, study quality is not assessed by the assigned hierarchy level. LOE and EBM have increased the number of investigations published with better levels of evidence. As authors, reviewers, editors, and publishers, we desire a system that is consistent, effective, and reliable. Fortunately, the system has proven to have all of those attributes with good interobserver and intra-observer values. The increase in investigations with higher LOEs allows for more frequent use of EBM.     

Surgical management of hiatal hernia in children.

Hiatal hernia should be included in the differential diagnosis of all children with emesis and failure to thrive, since early diagnosis is imperative to prevent the irreversible esophageal damage from long-standing peptic esophagitis. The Nissen fundoplication as described in this paper appears to be far superior to gastropexy in preventing recurrence of gastroesophageal reflux. Colon interposition should be reserved for those cases in which hiatal herniorrhaphy is technically impossible. Successful repair of the hiatal hernia results in rapid improvement in the nutritional status of these children.     

Fracture due to shock from domestic electricity supply

This report describes a fracture-dislocation of the shoulder joint due to electric shock. This is the first case reported in an English language journal of fracture due to shock from the domestic electricity supply. Other cases have been reported but not caused by such a low voltage current.     

Research Pearls: Expert Consensus Based Evidence Using the Delphi Method

The evolution of a systematic approach to assessing pertinent investigations is known as evidence-based medicine (EBM). EBM is defined as the conscientious and judicious use of current best evidence from clinical care research and integration of clinical expertise in the management of individual patients. There is no doubt that EBM is important but may not give clinically meaningful guidance on topics with clinical equipoise for individual patient care. When EBM has been insufficiently developed for a specific topic, a consensus opinion of experts can be valuable. In principle, there are 2 consensus methods for expert opinion available: the nominal group technique and the Delphi method. The nominal group technique is a structured face-to-face meeting facilitating discussion and allows participants to voice their opinions. The key characteristics of the Delphi method are the use of panel experts to obtain data, no face-to-face discussions, the use of sequential questionnaires, the systematic emergence of a concurrent opinion, use of frequency distributions to identify patterns, and the use of at least 2 rounds with feedback between rounds. We should not dismiss the collective experience of our leading experts, and expert consensus-based evidence should be explored as another tool to improve the quality of treatment for our patients.     

Radiocarpal septum after trauma

A case is presented in which trauma, followed by open reduction and pinning, resulted in the formation of a radiocarpal septum that divided the joint into two distinct compartments. A simple resection of the septum was not sufficient, since it uncovered underlying carpal instability that required ligamentous reconstruction.     

Flexor tendon gliding in the hand. Part II. Differential gliding

Flexor tendon gliding was studied in vivo in 48 hands. Three finger motions--straight-fist, hook, and fist--were found to provide maximum differential gliding for superficialis and profundus tendons in respect to each other, as well as in respect to the flexor sheath and bone.