Crohn’s Perforation: Not so Uncommon in the Indian Population

Crohn’s Disease is a chronic, idiopathic, transmural inflammatory disease affecting predominantly distal ileum, the common presentation include stricture and fistula formation. Free perforation in the peritoneal cavity is rare. To study the presentation and management of Crohn’s perforation. A retrospective study of 9 cases of perforative peritonitis later diagnosed due to Crohn’s disease on histopathological examination. Among the 9 patients, 8 were males and 1 was female. The ages of the patients ranged from 30 to 58 years, with mean age of 41.8 years. 6 patients were in the age group of 30–45 years. 8 patients were not known to be suffering from Crohn’s. Resection followed by anastomosis was done in 4 cases including the case of known Crohn’s, while resection follwed by end illeostomy with mucous fistula was done in remaining cases. Resected specimens were sent for histopathological examination in all cases. Though Crohn’s perforation is rare it should be kept in mind when dealing with single or multiple perforation of the small intestine even in the developing countries. Though the number of cases in our series are too few to come to a conclusion, we found that illeostomy sems a prudent alternative to traditional resection anastomosis.     

Health related quality of life in patients with Parkinson’s disease two years following posteroventral pallidotomy

Summary. Background. There has been a new emphasis on the use of health related quality of life (HRQOL) measures for translating how a patients response to treatment is experienced by the patient. The purpose of this study was to describe patient reported HRQOL two years after surgery in subjects who underwent posteroventral pallidotomy (PVP) for the treatment of Parkinsons disease (PD) and a subset of these same subjects four years following PVP.Method. A consecutive series of 52 subjects who were evaluated previously, prior to and at 4 months following PVP [3], received long term follow-up using mailed questionnaires. Twenty seven subjects (52% of the original sample) provided 2 year follow-up data and 15 of these subjects (29%) provided 4 year follow-up data. Severity of disease and subject reported HRQOL were evaluated.Findings. Immediately following surgery, there was a sharp decrease in all measures of severity of disease. While there were differing patterns of increasing severity of disease among the measures following the immediate postoperative assessment, all of the measures remained better than the pre-surgery values. The data showed a pattern of marked improvement in HRQOL at 4 months following PVP. Over the 2 years following surgery, there was a gradual deterioration toward preoperative levels that nevertheless remained better than preoperative HRQOL. For the group with data at 4 years following surgery, there was no significant further deterioration in HRQOL between 2 and 4 years, with the 4 year data also remaining better than the preoperative HRQOL reports.Conclusions. In spite of advanced severe PD and advanced age, subjects in this study reported better HRQOL at 2 years following PVP than they reported at entry into the study prior to surgery. Additionally, the 15 patients who were available for follow-up at 4 years also reported better HRQOL than they experienced prior to the surgery.     

Gallstone ileus in patient with Crohn’s disease

Gallstone ileus is an uncommon form of bowel obstruction, related in the majority of cases to a cholecystoenteric fistula. In patients with Crohn’s disease the stone can obstruct the diseased bowel. We report a case of gallstone ileus in a patient with Crohn’s disease. An explorative laparoscopy and a minimally-invasive laparotomy were achieved to resolve the obstruction. Cholecystectomy and closure of the cholecystoduodenal fistula were not performed. The association of gallstone ileus and Crohn’s disease is very rare; only few cases are reported in the literature. Laparoscopic approach could identify the extension of the disease and the site of impaction, allowing the differential diagnosis in particular in patients with Crohn’s disease. In the cases described, cholecystectomy and the closure of the fistula were not performed considering the absence of any residual stone in the gallbladder and the associated risk of treating the cholecysto-duodenal fistula in an emergency settings.     

Bilateral hydrosalpinx in patients with Hirschsprung’s disease

Purpose

Hirschsprung's disease (HD) is uncommon in females. There are very few reports on the patients' obstetric and gynecological outcome. Hydrosalpinx causes pain and infertility. It is rare in nonsexually active teenagers. It may be because of an intrinsic disease of the fallopian tubes or secondary to surgery. Aim: to describe the relationship between hydrosalpinx and HD or its surgical approach; to report the impact of bilateral hydrosalpinx on fertility in HD.

Rhabdomyolysis in association with Duchenne’s muscular dystrophy

PURPOSE: To present a case of rhabdomyolysis which developed in a child with a known history of Duchenne's muscular dystrophy, following an anesthetic which included sevoflurane. CLINICAL FEATURES: An 11 yr old boy with a known history of Duchenne's muscular dystrophy underwent anesthesia for strabismus repair. The anesthetic consisted of sevoflurane and nitrous oxide without the use of a muscle relaxant. His postoperative course was complicated by a complaint of heel pain and the development of myoglobinuria. He was treated with dantrolene sodium and discharged home after two days, without further complication. CONCLUSION: Sevoflurane anesthesia has not been shown previously to be associated with the development of acute rhabdomyolysis in a child with a history of Duchenne's muscular dystrophy. As with halothane and isoflurane, the continued use of sevoflurane in the presence of Duchenne's muscular dystrophy should be questioned.     

Ultrasound in patients affected with Peyronie’s disease

Peyronies disease (PD, induratio penis plastica) is uncommon. Its etiology is unknown and the incidence is stated to be 1%, although more recent data suggest that it is higher. The symptoms are penile deviation and painful erection in association with penile plaques. The diagnosis is performed by palpation of the penis. X-ray diagnostics are only used to visualize the calcified plaques in soft tissue imaging, and the survey of plaque size and consistence is done by sonography with high reproduction. This enables the exact evaluation of treatment effects. By application of high frequency scanners (7–12 MHz) the extent and depth of the plaques can be estimated non-invasively in high resolution images. Furthermore, color coded duplex sonography and recording of Doppler spectra are used to assess hemo-perfusion in the penile vessels and the analysis of erectile dysfunction, often seen in combination with PD. Sonographic diagnosis appears as a valuable supplement and requirement for a successful therapy of PD.     

Pregnancy in women with Fowler’s syndrome treated with sacral neuromodulation

Introduction and hypothesis

Our aim was to determine the impact of pregnancy on sacral neuromodulation (SNM) and vice versa in patients with Fowler’s syndrome (FS), which is typified by chronic urinary retention (CUR).

Methods

We performed a retrospective study of pregnancy in patients with FS who underwent a two-stage SNM implantation. Data were obtained using a standard questionnaire and clinical interview.

Results

There were a total of ten patients with 13 pregnancies. The SNM was switched off in ten of the 13 pregnancies, with CUR recurring in nine of the ten pregnancies and recurrent urinary tract infections (UTI) occurring in four of these pregnancies (more than three UTI in the pregnancy). Those in whom the device was left on continued to void normally. One woman had a first trimester miscarriage, eight pregnancies went to term, and four deliveries were premature. Caesarean section was performed in eight pregnancies for obstetric reasons. Four pregnancies resulted in a vaginal delivery. There were no congenital anomalies reported. Following delivery, four of nine women experienced dysfunction of their SNM device when it was switched back on.

Conclusion

Turing off the SNM during pregnancy results in recurrence of CUR, with an increased risk of recurrent UTI associated with preterm delivery. This did not impact foetal well-being. The option of keeping the SNM on during pregnancy should therefore be considered, and as caesarean section affects the SNM device, we advise that caesarean section should only be performed for obstetric reasons.     

China＇s Development Plan for Anesthesiology

I The prospect of anesthesiology a. Leding disciplines for the development of ＂comfort Medicine＂ The development of a discipline depends on its market. In the past, Anesthesiology is not taken seriously because of China＇s underdeveloped economy. At the same time, China does not have sufficient funds to meet the health care needs. It can only provide the people with minimal, or the most basic medical services. Such as Resection of tonsil squeeze of children, surgical abortion of young women,     

Hypokalemic rhabdomyolysis in a child with Gitelman’s syndrome

We report here the first published case of a pediatric patient with Gitelman’s syndrome (GS) in whom hypokalemia-associated rhabdomyolysis developed. A 13-year-old girl was admitted with weakness of the extremities, walking difficulty and calf pain. Laboratory data showed a serum potassium level of 2.1 mmol/l and a serum creatinine phosphokinase level of 1,248 IU/l plus myoglobinemia. The presence of normomagnesemia was the basis for a genetic analysis of the thiazide-sensitive sodium chloride cotransporter gene, which revealed compound heterozygous mutations in this gene. Prompt fluid expansion and potassium supplementation led to regression of the muscle symptoms. Hypokalemia can be a rare cause of rhabdomyolysis in patients with GS, even in childhood. We emphasize that genetic analysis is advisable to determine whether the suspicion of GS is warranted.     

Single ventricle repair in children with Down’s syndrome

Objective There is a paucity of information regarding appropriate management of children with Down’s syndrome and a functional single ventricle. We report the results of bidirectional superior cavopulmonary shunts in six patients with Down’s syndrome with a functional single ventricle. Methods Between January 1991 and December 2004, we identified six patients with Down’s syndrome among 263 who had undergone bidirectional superior cavopulmonary shunts (BCPSs). There were four males and two females. The age at BCPS ranged from 1 to 12 years (mean 4.3 ± 3.9 years), and body weight varied between 8.2 and 29.4 kg (mean 13.8 ± 7.8 kg). All six patients had an unbalanced complete atrioventricular septal defect, with right ventricular hypoplasia present in five and left ventricular hypoplasia in one. Results There were no operative deaths, but one case required takedown of the BCPS. Except for this case, postoperative courses were generally uneventful. The median duration of follow-up was 46 months (range 12–80 months). Only two of five survivors after BCPS underwent a subsequent Fontan procedure, and one of these patients died of pulmonary hypertension post-operatively. The remaining three patients appeared to have significant risk factors for the Fontan procedure due to severe common atrioventricular valve regurgitation or persistent pulmonary vascular obstructive disease, including one who has completely dropped out from the Fontan track. Conclusion Down’s syndrome is a risk factor in patients with functionally single ventricle due to persistent pulmonary hypertension and airway obstruction. These results show that single ventricle repair in patients with Down’s syndrome is accompanied with difficulties, and patient selection for the Fontan procedure should be done carefully.     

Lemierre’s Syndrome in a Patient with Antiphospholipid Syndrome

Internal jugular vein thrombosis is usually associated with intravenous drug abuse, long-term venous catheterization, local infection, or spontaneous occlusion. The antiphospholipid syndrome is now recognized as one of the commonest causes of acquired arterial or venous thrombosis. Lemierre’s syndrome is an uncommon but potentially lethal complication of internal jugular vein thrombosis after an oropharyngeal infection. A 34-year-old man presented with fever and progressive, painful right neck swelling 6 days after an episode of pharyngitis. Clinical studies including radiological and laboratory tests confirmed the diagnosis of Lemierre’s syndrome associated with antiphospholipid syndrome. Although Lemierre’s syndrome is a well-known cause of internal jugular vein thrombosis, association with antiphospholipid syndrome is very rare.     

Hypokalemic rhabdomyolysis in a child with Bartter’s syndrome

Hypokalemia represents a rare cause of rhabdomyolysis. Some reports have described a few adult patients affected by Bartters syndrome and Gitelmans syndrome with rhabdomyolysis due to severe hypokalemia. We report the first pediatric patient with Bartters syndrome in whom rhabdomyolysis developed when her plasma potassium level was less than 2 mEq/l. Prompt intravenous fluid and potassium prevented tubular damage and acute renal failure. We recommend determining serum creatine phosphokinase in all patients affected by Bartters syndrome and profound hypokalemia.     

Coagulation Parameters in the Patients with Fournier’s Gangrene

Aim: In this prospective study, we aimed to determine the coagulation parameters in the patients with Fournier’s gangrene. Methods: The study group is consisted of 12 consecutive Fournier’s gangrene patients (11 men and 1 woman) and control group is consisted of patients with Periurethral abscess (n=2), Scrotal abscess (n=4) and Epididimorchitis (n=4). Fibrinogen, protein C, protein S,␣antithrombin III, lupus anticoagulant, cardiolipin IgG and IgM, prothrombin time-international normalized ratio, activated partial thromboplastin time, platelet count, proaccelerin, antihemophilic globulin (FVIII), albumin, and calcium were evaluated in all subjects. Tissue specimens were taken from Fournier’s gangrene patients. These specimens were tested for arterial and venous thrombosis using light microscopy. Results: All of the patients with Fournier’s gangrene had both arterial and venous thrombosis in tissue specimens. The levels of fibrinogen and FVIII were high, the level of protein C was low in 12 patients. Lupus Anticoagulant was positive 11 of 12 patients. Conclusions: According to our findings, we think that some coagulation parameters (FVIII, Lupus anticoagulant, protein C, fibrinogen) may be diagnostic for Fournier’s gangrene.     

Risk of fracture in patients with Parkinson’s disease

Summary

The aim of the study was to determine fracture risk in incident Parkinson’s disease (PD) patients. This study showed that fracture risk assessment may be indicated among patients with PD, in particular when they have recently used selective serotonin re-uptake inhibitors or high-dose antipsychotics, or have a history of fracture, falling, low body mass index (BMI) or renal disease.

Introduction

PD is a movement disorder associated with falling and detrimental effects on bone. Both are recognized risk factors for fracture. Therefore, the aim was to determine fracture risk in incident PD patients stratified by treatment, severity, duration of disease and related comorbidities.

Methods

We conducted a retrospective cohort study using the UK General Practice Research Database (1987–2011). Each PD patient was matched by age, sex, calendar time and practice to a control patient without history of PD.

Results

We identified 4,687 incident PD patients. Compared to controls, a statistically significant increased risk was observed for any fracture (adjusted hazard ratio [AHR], 1.89; 95 % confidence interval [CI], 1.67–2.14), osteoporotic fracture (AHR, 1.99; 95 % CI, 1.72–2.30) and hip fracture (AHR 3.08; 95 % CI, 2.43–3.89). Fracture risk further increased with history of fracture, falling, low BMI, renal disease, antidepressant use and use of high-dose antipsychotics.

Conclusion

This study showed that incident PD patients have a statistically significant increased risk of fracture. Therefore, fracture risk assessment may be indicated among PD patients, who, besides the general risk factors for fracture, like increasing age and female gender, have recently used selective serotonin re-uptake inhibitors or high-dose antipsychotics or have a history of fracture, falling, low BMI or renal disease.