Post-partum sacral fracture associated with heparin treatment

We report the case of a 19-year-old woman who consulted for low-back pain 3 weeks after her first delivery. This young woman had a personal history of protein C deficiency and was treated daily during her pregnancy with low-molecular-weight heparin. Her body mass index was 34 and she only gained 10 kg during her pregnancy. Since the delivery – which occurred without any complication – she had suffered from a gradually increasing right-buttock pain and limp. Magnetic resonance imaging (MRI) revealed a fracture of the right sacral ala. After analgesia and 1 month of home relative bed rest, the patient recovered her functional capacities. Regarding our patient, who had no potential clinical risk factors for osteoporosis, the causal effect of heparin is thus possible but not certain. This case report illustrates the fact that clinicians should have a high suspicion of pelvic fracture in post-partum women, even in very young ones, presenting sudden onset of low back and pelvic pain, especially when they have received heparin during pregnancy. MRI seems to be the key exam because it is able to detect and stage fractures or microfractures.     

Insufficiency fractures of the calcaneus: a diagnostic pitfall for ankle arthritis

OBJECTIVE: To highlight the differential diagnosis between insufficiency fractures (IF) of the calcaneus and arthritis of the ankle. METHODS: We retrospectively reviewed clinical charts and imaging findings for 6 patients with 7 IF of the calcaneus who were referred with the diagnosis of ankle arthritis. The main predisposing factors, clinical features, therapy, and outcome were recorded. IF was considered when occurring spontaneously or with minimal trauma. RESULTS: All patients were women, with a mean age of 73.8 +/- 6.3 years. The median delay to diagnosis was 6 weeks (25th, 75th percentiles: 1, 12). Two had previous IF at other locations. Three patients had a history of chronic inflammatory conditions while receiving longterm steroid therapy. All complained of moderate to severe pain that interfered with daily activities and was relieved with rest. Physical examination revealed ankle inflammation in all cases. Radiographs were normal in 5 patients. Magnetic resonance imaging (MRI) was diagnostic. All received conservative treatment with complete resolution of symptoms without sequelae. CONCLUSION: IF of the calcaneus are relatively rare but can be mistaken for ankle arthritis. MRI is recommended because this type of fracture is difficult to detect on plain films. Although IF have a good prognosis with conservative treatment, increased awareness is of importance for prompt diagnosis and proper management.     

Acute dissecting aneurysm of the ascending thoracic aorta causing obstruction and thrombosis of the right pulmonary artery.

We present the case of a 69-year-old man with a history of hypertension and a recent pelvic fracture who presented with acute chest pain, shortness of breath, and severe hypotension. The history of recent pelvic fracture and the clinical manifestations, including the sudden onset of acute respiratory distress, hypotension, and hypoxemia, indicated pulmonary embolism; however, at surgery the patient was found to have an acute dissection of the ascending aorta with obstruction and thrombosis of the right pulmonary artery. This case emphasizes the need to consider such a diagnosis in patients who have unilateral absence of perfusion to the right lung.     

Does ethanol affect the reliability of pelvic bone examination in blunt trauma?

STUDY OBJECTIVE: We sought to determine whether the reliability of clinical evaluation for pelvic bone fracture after trauma is compromised by a serum ethanol level of 100 mg/dL or greater. METHODS: This is a retrospective case control study of trauma registry patients presenting from October 1, 1995, to March 31, 1997, to an urban level I trauma center. Inclusion criteria were as follows: blunt trauma, age 13 years or older, and Glasgow Coma Scale score of 13 or greater. Exclusion criteria were as follows: isolated penetrating injury and suspected spinal injury. Patients were separated into 2 groups: those with an ethanol level of 100 mg/dL or greater, and those with an ethanol level of less than 100 mg/dL. Physician performance in clinical identification of pelvic bone fracture by using a complaint of pain, pelvic tenderness, with or without deformity, was compared between the 2 groups. RESULTS: Seven hundred sixty-three patients met inclusion criteria. Fifty-five (7. 2%) patients had a pelvic fracture, 75% of which were isolated acetabulum or pubic ramus fractures. Two hundred six control patients without pelvic fractures were randomly selected. The sensitivity and specificity of the complaint of pain and tenderness, deformity, or both for identification of a pelvic fracture was not significantly different between the ethanol groups. Five (9%) of 55 patients with pelvic fractures had neither a complaint of pain nor bony tenderness or deformity on examination. This was not statistically associated with an ethanol level of 100 mg/dL or greater (P =1.000). CONCLUSION: In our study, clinical evaluation for pelvic fracture in trauma patients with a Glasgow Coma Scale score of 13 or greater was not compromised by an ethanol level of 100 mg/dL or greater. The most common reason for clinically missed pelvic fractures was the presence of additional painful distracting injuries.     

Post-partum sacral fracture associated with heparin treatment

We report the case of a 19-year-old woman who consulted for low-back pain 3 weeks after her first delivery. This young woman had a personal history of protein C deficiency and was treated daily during her pregnancy with low-molecular-weight heparin. Her body mass index was 34 and she only gained 10 kg during her pregnancy. Since the delivery - which occurred without any complication - she had suffered from a gradually increasing right-buttock pain and limp. Magnetic resonance imaging (MRI) revealed a fracture of the right sacral ala. After analgesia and 1 month of home relative bed rest, the patient recovered her functional capacities. Regarding our patient, who had no potential clinical risk factors for osteoporosis, the causal effect of heparin is thus possible but not certain. This case report illustrates the fact that clinicians should have a high suspicion of pelvic fracture in post-partum women, even in very young ones, presenting sudden onset of low back and pelvic pain, especially when they have received heparin during pregnancy. MRI seems to be the key exam because it is able to detect and stage fractures or microfractures.     

Long-acting octreotide in the treatment of diarrhea after pelvic pouch surgery

After pelvic pouch surgery (restorative proctocolectomy), periodic or continuous diarrhea is common. Distressing diarrhea may be triggered by pouchitis, cuffitis or an anastomotic stricture. Medical therapy with loperamide or diphenoxylate is often unsatisfactory even after the correction of the underlying problem. Seven patients, who earlier had undergone restorative proctocolectomy, were treated with a standard dose of 10 mg of long-acting octreotide (Sandostatin LAR) for prolonged and distressing diarrhea which had not responded to conventional medication. Five of the patients had complete relief of diarrhea. The effect lasted for at least two months after a single dose. Two patients did not respond. No sideeffects were reported. Long-acting octreotide is effective in the treatment of severe diarrhea in patients after pelvic pouch surgery.     

棓丙酯、动静脉泵预防骨盆骨折深静脉血栓的临床应用价值

目的探讨动静脉泵及注射棓丙酯在降低骨盆骨折围手术期深静脉血栓（DVT）中的作用。方法采用完全随机对照的方法将96例骨盆骨折需内固定手术治疗的患者分为A、B、C三组。A组39例术后使用动静脉泵治疗,B组27例给予180 mg棓丙酯注射,C组30例手术后未行任何预防DVT措施。术后第1、3、7、14天分别使用双重超声波测定下肢远、近端的静脉血栓,同时测量大腿、小腿的周长。结果A组静脉血流峰速度、平均速度加快,静脉血栓发生率降低,术后大腿、小腿水肿明显减轻,与B、C组比较差异有统计学意义（P均〈0.01）。B组与C组比较预防DVT形成的效果明显,差异有统计学意义（P〈0.01）。结论骨盆骨折围手术期,动静脉泵及注射棓丙酯治疗均能有效的降低血栓发生率,同时动静脉泵可有效促进局部及远端肢体软组织水肿的消除。     

骨盆骨折合并腹盆脏器损伤的救治体会

目的总结骨盆骨折合并腹盆脏器损伤的救治体会。方法对2000～2012年该院收治的25例严重骨盆骨折合并腹盆脏器损伤患者的临床资料进行回顾性分析。结果 25例患者中,早期手术治疗23例,其中22例获得随访。治疗效果优12例,良10例,死亡3例,优良率为88%。结论早期正确诊断和处理合并伤可提高骨盆骨折合并腹盆脏器损伤患者的生存率。     

Postgastrectomy megaloblastic anemia--possible participation of anti-intrinsic factor antibody in its pathogenesis--report of a case

A case of 78-year old man with megaloblastic anemia occurring 20 years after partial gastrectomy is reported. Since about 2 years earlier he had an episode of convulsion, and he had been on anti-convulsants (diphenylhydantion, phenobarbital) until admission. Physical examination revealed a pale lean man with polyneuropathy and mental impairment. Laboratory findings revealed WBC 3100/microliters, RBC 187 X 10(4)/microliters, HB 7.9 g/dl, MCV 124.4 microns3, MCH 42.7 micrograms, platelet counts 15.7 X 10(4)/microliters, serum vitamin B12 (VB12) 380 pg/ml, and serum folic acid 5.1 ng/ml. Serum autoantibodies to intrinsic factor (IF) and parietal cells were positive. Bone marrow examination revealed erythroid hyperplasia and megaloblastic changes. Schilling test revealed impaired absorption of VB12 with or without IF, but X-ray study of the small bowels was unremarkable. Treatment with intramuscular cyanocobalamin resulted in a rapid clinical improvement. A repeat Schilling test after 4 months of therapy showed a normal VB12 absorption in the presence of IF. These findings suggest that VB12 malabsorption of the 1st Schilling test was due to intestinal dysfunction caused by the VB12 deficiency state itself, and the improvement of VB12 absorption with IF after therapy suggests a pathogenesis similar to pernicious anemia in this patient.     

Total Pelvic Exenteration With Distal Sacrectomy for Fixed Recurrent Rectal Cancer in the Pelvis

PURPOSE This study evaluates the effectiveness of total pelvic exenteration with distal sacrectomy for fixed recurrent tumor that developed from primary rectal cancer.METHODS We investigated surgical indications, techniques to minimize blood loss and reduce complications, and oncological outcomes in 57 patients who underwent total pelvic exenteration with distal sacrectomy between 1983 and 2001.RESULTS Forty-eight patients (84 percent) had negative margins. A comparison between two periods (1983–1992 and 1993–2001) showed that mean blood loss decreased from 4,229 to 2,500 ml (P = 0.002), indicating a favorable learning curve in minimizing blood loss. Two hospital deaths were observed in the earlier period and none in the later period. The most common sacral amputation level was the S3 superior margin, followed by the S4 inferior margin and the S2 inferior margin. The most frequent complication was sacral wound dehiscence in 51 percent, followed by pelvic sepsis in 39 percent. The incidence of pelvic sepsis in the later period was significantly decreased to 23 percent, compared with 72 percent in the earlier period (P = 0.046). Multivariate analysis showed that negative margins and negative carcinoembryonic antigen predicted improved survival. In 48 patients with negative margins, three-year and five-year disease-specific survival rates were 62 percent and 42 percent, respectively.CONCLUSION Strict patient selection makes total pelvic exenteration with distal sacrectomy a feasible radical approach for fixed recurrent tumor. Careful performance of this surgical procedure along with the proper steps to decrease blood loss should achieve a favorable learning curve and low rate of surgical complications.This study was supported by the Second Term Comprehensive 10-Year Strategy for Cancer Control, Health and Welfare Ministry of Japan.Presented at the Ninth Congress of the Asian Federation of Coloproctology, Seoul, Korea, November 27 to 28, 2003.     

Neuromodulation for the Treatment of Lower Urinary Tract Symptoms

Neuromodulation therapy incorporates electrical stimulation to target specific nerves that control lower urinary tract symptoms (LUTS). The objectives of this article are to review the mechanism of action, the type of neuromodulation, and the efficacy of neuromodulation mainly according to the results of randomized controlled trials. Neuromodulation includes pelvic floor electrical stimulation (ES) using vaginal, anal and surface electrodes, interferential therapy (IF), magnetic stimulation (MS), percutaneous tibial nerve stimulation, and sacral nerve stimulation (SNS). The former four stimulations are used for external periodic (short‐term) stimulation, and SNS are used for internal, chronic (long‐term) stimulation. All of these therapies have been reported to be effective for overactive bladder or urgency urinary incontinence. Pelvic floor ES, IF, and MS have also been reported to be effective for stress urinary incontinence. The mechanism of neuromodulation for overactive bladder has been reported to be the reflex inhibition of detrusor contraction by the activation of afferent fibers by three actions, i.e., the activation of hypogastric nerve, the direct inhibition of the pelvic nerve within the sacral cord and the supraspinal inhibition of the detrusor reflex. The mechanism of neuromodulation for stress incontinence is contraction of the pelvic floor muscles through an effect on the muscle fibers as well as through the stimulation of pudendal nerves. Overall, cure and improvement rates of these therapies for urinary incontinence are 30–50, and 60–90% respectively. MS has been considered to be a technique for stimulating nervous system noninvasively. SNS is indicated for patients with refractory overactive bladder and urinary retention.     

Reconstruction of the Pelvic Floor Using the Rectus Abdominis Muscles After Radical Pelvic Surgery

PURPOSE: To support the small intestine out of the pelvic cavity, many methods have been described to reconstruct the pelvic floor after radical pelvic surgery. I describe a new technique using the rectus abdominis muscles for pelvic floor reconstruction. METHODS: The posterior rectus sheath and peritoneum are opened. The rectus muscles are exposed at both sides and they are divided between paired clamps at the level of the umbilicus. Then, the rectus muscles are carefully retracted downward, and the edges are sutured posteriorly to the promontorium and laterally around the linea terminalis. RESULTS: This method was used in 11 patients who underwent radical pelvic surgery. Seven of 11 patients had radiation therapy started 4 weeks postoperatively. The patients were followed up for two years. No patient showed any complication such as adhesive obstruction of the bowel or radiation enteritis, even in the patients who underwent radiotherapy. CONCLUSIONS: Reconstruction of the pelvic floor using the rectus abdominis muscles after radical pelvic surgery is an easy and safe technique that avoids complications and serves as a barrier to radiation injury. Therefore, we believe that this method is a promising proposal requiring further investigation in a larger number of patients.     

Assessing and treating pelvic organ prolapse

At least half of all women who have given birth experience pelvic organ prolapse, a condition where pelvic organs protrude through the vagina. Because of the presentation of the different aspects of prolapse, treatment had become compartmentalized in line with pelvic involvement, with urologists, gynecologists, colorectal surgeons, and gastroenterologists each addressing their field of expertise. In addition, urinary or fecal incontinence, urinary retention, and urinary tract infections often are associated with pelvic organ prolapse. Both pelvic organ prolapse and incontinence have a significant impact on the quality of life. New training programs in urogynecology and reconstructive pelvic surgery are producing clinicians who are better equipped to treat pelvic organ prolapse, as well as related urinary and fecal incontinence. This article provides an overview of the various aspects of pelvic organ prolapse for all clinicians involved in assessment, treatment, and potential prevention of this condition.     

Follow-up for osteoporosis in older patients three years after a fracture

BACKGROUND: Recently a Fracture and Osteoporosis outpatient clinic (FO clinic) was set up at the University Medical Centre groningen (UMCG) with the aim to optimise case-finding of osteoporosis in older patients with a low-energy fracture. To provide a diagnostic setting before the start of our fo clinic, case-finding was carried out in patients who suffered an 'osteoporotic' fracture in the year prior to the foundation of the FO clinic. During a three years follow up project, osteoporotic patients who needed therapy were identified. METHODS: Patients aged 50 years or older who were seen in the UMCG for a low-energy fracture (shoulder, wrist or hip) one year before that period were asked to participate. The study was carried out in two parts - a telephone questionnaire and measurement of the bone mineral density (BMD). The data were compared with the results of the FO clinic. RESULTS: Of the 191 patients, 88 could be contacted and were analysed. of these 88 patients only 12 had undergone additional investigations for the presence of osteoporosis in the year of the fracture, and only six patients were on antiosteoporosis medication; 45 patients had already suffered an earlier fracture and ten had a more recent subsequent fracture. Measurements three years after their fracture revealed that 55% of the 88 patients had osteoporosis (T-score less than -2.5 SD). CONCLUSION: After a fracture, case-finding for osteoporosis is good clinical practice. In our study more than half of the patients were lost for follow-up after three years. But it is still worthwhile to check whether patients with fractures in the past had the necessary diagnostics and proper therapy. Comparing these results with those of the FO clinic, it is evident, however, that case-finding of osteoporosis after a fracture can be organised most effectively at the location where the patient first attends for treatment of the fracture, namely in the emergency department of the hospital.     

Different impacts of dementia on two-year mortality after osteosynthesis and hemiarthroplasty in treating geriatric hip fractures

BackgroundGeriatric hip fractures are mostly managed by internal fixation (IF) or hemiarthroplasty (HA). Survivorship of dementia patients following these surgeries has not been extensively compared in literature. By analysis of nationwide database, this study aimed to investigate the impact of dementia on two-year mortality after IF and HA in treating geriatric hip fractures.MethodFrom retrospective review of Taiwan's National Health Insurance Research Database, we enrolled 153,623 subjects aged 65 years and older with hospitalization for first hip fracture operated by IF (93,029 cases) or HA (60,594 cases) between 2000 and 2011. Postoperative mortality was compared between subjects with and without dementia after adjustments of age, gender, Charlson comorbidity index and hospital level.ResultsThe prevalence of dementia was 5.24% in the IF and 5.29% in the HA group. In the IF group, dementia increased adjusted hazard ratio of one-year (1.06, 95%CI:1.00–1.13) and two-year mortality (1.10, 95%CI:1.05–1.16). However, short and long-term mortality following HA was not significantly impacted by dementia (in-hospital OR:0.79, 95%CI:0.60–1.03; three-month HR:0.99, 95%CI:0.87–1.12; one-year HR:1.01, 95%CI:0.93–1.10; two-year HR:1.03, 95%CI:0.96–1.09). In a subgroup of dementia patients, mortality following IF was 15% higher than HA in one (p = 0.004) and two years (p < 0.001). The negative prognostic factors included female (HR:1.10; 95%CI:1.03–1.18) and aging 65–84 years (HR:1.15; 95%CI:1.00–1.32).ConclusionDementia increased one and two-year mortality following geriatric hip fracture treated by IF, rather than HA. Dementia patients undergoing HA, especially female or 65–84 years old, sustained better one and two-year survival than those receiving IF.     

Dynamic magnetic resonance imaging evaluation of the structural and functional results of postanal repair for neuropathic fecal incontinence

PURPOSE: The aim of this study was to determine whether dynamic magnetic resonance imaging of the pelvic floor can discriminate between patients who improve after postanal repair for neurogenic fecal incontinence and those who remain symptomatic. METHODS: Pelvic floor measurements obtained during dynamic magnetic resonance imaging in eight females whose anal incontinence had improved after postanal repair were compared with those from nine females who remained symptomatic. All subjects also underwent standard anorectal physiology testing. RESULTS: There was no significant difference between groups with respect to any measurement of anterior or middle pelvic floor compartments. Additionally, there was no difference in posterior pelvic floor configuration when symptomatic patients were compared with those who had improved. However, dynamic magnetic resonance measurements revealed patients who remained symptomatic had significantly greater posterior pelvic floor weakness. Anorectal physiology was unable to differentiate between groups. CONCLUSIONS: There is no difference in static pelvic floor measurements when subjects remaining symptomatic after postanal repair are compared with those who have improved. In contrast, dynamic measurements may be able to predict failure in those who demonstrate excessive posterior pelvic floor mobility.     

Cloning and mapping of a gene for translational initiation factor IF2 in Escherichia coli.

A novel method, not relying on genetic complementation of a mutation, was used to clone a gene for translational initiation factor IF2. Two clones from a cosmid library of total Escherichia coli DNA were isolated for their ability to overproduce IF2 in vivo as determined by quantitative immunoblotting. "Maxicell" analysis of cosmid-encoded proteins and specific immune precipitation of the labeled proteins showed that the structural gene for IF2 (inf B) had been cloned. Subcloning fragments from the original cosmids located the inf B gene to a 4.8-kilobase pair HindIII/BamHI fragment. This fragment has been inserted into an integration-deficient recombinant lambda phage that lysogenizes by homology. By mapping the point of lysogenization on the E. coli chromosome, inf B has been located at 68 min, very close to argG, nusA, rpsO, and pnp. Because the gene for initiation factor IF3 is located at 38 min on the chromosome, the genes for translational initiation factors are not grouped together.     

Comparative efficacy and safety of the minimally invasive ilioinguinal approach for anterior pelvic ring fracture: A protocol for systematic review and network meta-analysis

Background:Anterior pelvic ring contributes up to 40% of the stability of the pelvic ring and is located in close proximity to key pelvic organs, blood vessels, and nerves. An anterior pelvic ring fracture causes severe pain and is a potentially life-threatening condition in trauma patients. Currently available surgical repair methods are highly technical and include high risks of complications. The minimally invasive ilioinguinal approach (MIIA) is an emerging technique that reduces the risk of femoral nerve and external iliac vessel injury. However, the safety and efficacy of this technique have yet to be systematically scrutinized. This study outlines a proposed protocol for a network meta-analysis that investigates the efficacy of MIIA for anterior pelvic ring fracture.Methods:This study will utilize both Chinese and English language databases. All randomized controlled trials studying the use of MIIA for anterior pelvic ring fracture from January 2016 to May 2021 will be incorporated. Researchers will screen for literature that fits the inclusion criteria, followed by an assessment of risk bias and, finally, data extraction.Results:The Bayesian network meta-analysis will be used to evaluate all available Stata 14.0 and WinBUGS software.Conclusion:Our research aims to uncover the clinical utility of the MIIA approach for anterior pelvic ring fractures.Ethics and dissemination:Not requiredINPLASY registration number:INPLASY2021110020.     

Liver tumours due to endometriosis and endometrial stromal sarcoma

BACKGROUND: Endometriosis can occur in unusual sites, liver involvement being first described in 1986. Extra-uterine malignant transformation in endometriosis has been reported, occurring mainly in the ovary. Liver involvement with endometrial stromal sarcoma (ESS) has not been previously reported. CASE OUTLINE: Two patients presenting with symptomatic liver masses related to endometriosis, who successfully underwent surgical intervention, are presented. CASE 1: A 31-year-old woman previously had been treated with hysterectomy and bilateral salpingoophorectomy for severe pelvic endometriosis. Six years later, she presented with malaise from bilobar liver involvement with endometrial deposits. She proceeded acutely to hilar obstruction with obstructive jaundice and portal vein thrombosis. CASE 2: A 59-year-old post-menopausal woman had earlier presented acutely from a ruptured mesenteric cyst, which showed features of endometrial stromal sarcoma (ESS). Two years later, she presented with symptoms from a large ESS occupying the right lobe. Discussion: Endometriosis per se, as well as malignant transformation into ESS can involve the liver.These should be considered in women with hepatic space occupying lesions of unknown etiology.     

Efficacy of pelvic packing in maintaining hemostasis after rectal excision for cancer

In a retrospective study, the records of 95 patients who underwent rectal resection for carcinoma were reviowed to assess the efficacy and complications of pelvic packing for hemorrhage. Heavier blood loss was noted with fixed tumors, where preoperative radiation had been given, or there had been previous pelvic surgery, compared with situations where these factors were absent. Three patients died from myocardial infarction, pulmonary embolus, and renal failure, respectively. No patients required further hemostatic measures after pack removal. Perineal wound infection or delayed perineal wound healing occurred in 22 percent and abdominal wound infection in 6 percent of the patients. There were no instances of anastomotic leak, abdominal abscess, or pelvic abscess requiring laparotomy for treatment in this series. Pelvic packing is a safe, simple, and effective procedure for patients with problematic pelvic bleeding after rectal resection. Read at the meeting of The American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987.