Osteomalacia in Hazara District, Pakistan

Osteomalacia is most commonly seen in the remoter northern regions (Kohistan District) of Hazara District, Pakistan. Low serum calcium is common, as is tetany, but not universal. A 2% prevalence was found retrospectively in all obstetric patients from 1978--1985. Overall, there was a 12% caesarean section rate (61/annum), of which 37% (22) exhibited cranio-pelvic disproportion, nearly half of which (n=83, 46%) were thought clinically to be due to osteomalacia. Osteomalacia was found prospectively in 3.6% of all female outpatients (3600/100,000). Purdah did not appear to influence the incidence of osteomalacia, although sunlight exposure varied significantly due to place of abode (0.05 > P> 0.025); those living in the deeper, darker valleys suffered more from osteomalacia and its side effects, such as cranio-pelvic disproportion and the resulting need for caesarean sections. Diet is an important factor, showing little variety in the affected region; it lacks animal protein and is low in calories.The estimated intake of vitamin D is approximately 1 microg per day, seriously short of the daily requirement of 2.5 microg. The other main factor is higher parity in the women with osteomalacia (15/18 affected women had more than three pregnancies compared with 9/18 controls; odds ratio 13, 0.05 > P> 0.025).These all indicate that in a marginal situation added metabolic stress can precipitate the condition. While supplementation of the diet is essential in such communities it will be difficult to initiate and maintain. We therefore also recommend that strategies for prevention be focused on the men to encourage them to help improve the diet and lifestyle of their womenfolk.     

Pulse generator failure due to blunt trauma

This case describes a 69-year-old male who had a permanent pacemaker implanted for sick sinus syndrome. He was struck by a car with a resultant failure of the pulse generator. Trauma-related failure of a pulse generator is a rare event. Its recognition is imperative in the overall management of the trauma patient.     

Aortic valve rupture due to blunt chest trauma

We report a patient admitted to our hospital with aortic valve rupture due to blunt chest trauma. The aortic rupture was accurately identified by the transesophageal echocardiogram, allowing a better surgical approach.     

Acute myocardial infarction due to blunt chest trauma

We report a case of blunt chest injury following a road accident leading to damage of the left main and left anterior descending coronary arteries causing acute myocardial infarction in a young person.     

Contrast-enhanced ultrasound versus MS-CT in blunt abdominal trauma

To evaluate the effectiveness of contrast-enhanced ultrasound (CEUS) in the diagnosis and characterization of hepatic, renal and splenic traumatic injuries versus conventional ultrasound (US) and multislice computed tomography (MS-CT).Between January 2005 and January 2007, 78 patients (48 males, 30 females, mean age 56 years) with blunt abdominal trauma were examined by conventional US, CEUS and MS-CT. CEUS employed a low-MI technique using 1.2 to 2.4 ml of SonoVue (Bracco, Italy) i.v. and a multifrequency transducer (2-4 MHz, Siemens, Sequoia, Acuson). CT examinations were performed on a 64 detector CT scanner (Somatom Sensation 16 or 64, Siemens Medical Systems, Forchheim, Germany) before and after administration of 120 ml intravenous contrast agent (Solutrast, Bracco, Milan, Italy) followed by 50 ml saline. The presence of hepatic, renal and splenic injuries was analyzed and the conspicuousness of findings was assessed.In 15 of the 78 patients conventional US identified solid organ injuries: 8 hepatic, 2 renal and 5 splenic injuries. CEUS identified 3 more injuries (2 hepatic and 1 splenic) that had been missed by conventional US. CEUS identified traumatic lesions in 18/78 patients. In one of the 18 patients even active bleeding could be identified by CEUS. In CEUS solid organ injuries appeared hypoechoic. MS-CT identified 18 solid organ injuries in 78 patients, corroborating the CEUS results.CEUS greatly improves the visualization and characterization of hepatic, renal and splenic injuries compared to conventional ultrasound and correlates well with MS-CT. The imaging technique detects even minor blood flow and is able to depict vascular structures in detail. At our institution it is used as an additional examination technique which supplements MS-CT in unclear cases. Owing to its bedside availability, CEUS provides a good alternative to MS-CT, especially in patients with contraindications to CT contrast agents (e.g. due to renal failure or severe allergy) and in hemodynamically compromised patients.     

Obstruction of aortocoronary bypass due to blunt chest trauma

We report the first case in the literature of acute myocardial infarction due to blunt chest trauma in a patient with saphenous vein aortocoronary bypass to the anterior descending coronary artery. Angiograms demonstrated two stumps - aortic and coronary - suggesting that the primary obstruction was at the graft level with subsequent anterior descending occlusion. A large left ventricular aneurysm developed. As his clinical situation was stable, early aneurysmectomy was not done, and the patient is asymptomatic 15 months after the trauma.     

Junctional ectopic tachycardia in association with blunt abdominal trauma

Junctional ectopic tachycardia is recognized predominantly as a postoperative arrhythmia after surgery for congenital heart disease. Diagnosis and treatment distinguish it from more commonly observed mechanisms of supraventricular tachycardia. We present a case of junctional ectopic tachycardia that occurred in the setting of abdominal trauma caused by child abuse and then explore the significance of this arrhythmia in a patient with trauma.     

Extrahepatic bile duct injury due to abdominal trauma

The diagnosis of bile duct injury due to abdominal trauma is usually not feasible preoperatively, but it must be suspected interoperatively with the presence of bile staining fluid in the subhepatic area. Four patients with bile duct injuries were encountered; these were the results of blunt injury in three and penetrating injury in one. The injury sites were in the common bile duct in two patients, and in the right hepatic duct just proximate to the bifurcation in two patients. One patient was diagnosed on the finding of bile stain discharged from the drainage tube after the first abdominal exploration. The other three patients were diagnosed by the amount of bile stained fluid collected in the subhepatic area during the primary laparotomy. The injuries of the common bile duct were treated by primary repairs and T-tube choledochostomy in two patients. The other two patients with right hepatic duct injuries were treated by right lobectomy because of extensive liver parenchyma injury. The postoperative courses were smooth and there were no deaths. We reviewed 27 reports (1984–1994) from around the world. The total operative mortality of the 75 patients in these reports was 18.67% (14/75) for the primary operation, and 7.14% (1/14) for re-operation in patients in whom reoperation was performed due to overlooked injuries or biliary complications.     

Focal nodular hyperplasia occurring after blunt abdominal trauma

Focal nodular hyperplasia of the liver is a benign neoplasm. The pathogenesis is unknown, but it was hypothesized that focal nodular hyperplasia may be a response to a vascular abnormality. We report on a case of focal nodular hyperplasia that developed in a young patient 1 year after a blunt hepatic injury.     

Chronic tricuspid regurgitation and bifascicular block due to blunt chest trauma

Closed-chest trauma in a young man was followed by rupture of a right ventricular papillary muscle and bifascicular block. This produced signs and symptoms of tricuspid regurgitation and recurrent syncope. Treatment by valve replacement and pacemaker implantation was successful. Review of 30 cases of traumatic tricuspid regurgitation reveals that this patient had characteristic findings: adult onset of isolated tricuspid regurgitation, a history of trauma, right bundle branch block, and cardiomegaly without signs of left ventricular failure. In addition, right atrial hypertension of longstanding may produce cyanosis because of right-left shunting through a patent foramen ovale.