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.     

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.     

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.     

Vertebral anomalies associated with esophageal atresia and tracheoesophageal fistula with reference to the initial operative mortality

In a series of 40 patients with esophageal atresia and tracheoesophageal fistula, the incidence of musculoskeletal anomalies was 45% (18 patients). An extra mesodermal segment was found in 15 patients (13 paired thoracic vertebrae and 13 paired ribs in nine patients; six lumbar vertebrae in 6 patients). The mortality in grade A infants with an extra mesodermal segment was significantly higher than in those infants with a normal spine (p > 0.01). It is suggested that segmentation or abnormal segmentation of the embryo may be important as a cause of esophageal atresia.     

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.     

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.     

Preoperative saline versus gelatin for hip fracture patients; a randomized trial of 396 patients

Background. The aim of this study was to determine if the preoperativeadministration of 500 ml of a gelatin colloid solution intravenouslybefore hip fracture surgery improves outcome, compared witha conventional i.v. fluid regime with a crystalloid solution. Methods. Randomized, double blind, controlled trial of i.v.saline vs colloid for 396 patients having hip fracture surgeryadmitted to a district general hospital. Patients were followedup for 1 yr. Results. There was no statistically significant difference betweengroups for mortality (30-day mortality 9/198 for saline groupvs 19/198 for colloid group, 95% confidence intervals 0.21–1.02),length of hospital stay (22.5 days vs 17.3 days, 95% CI –10.78to 0.38), or occurrence of postoperative complications. Conclusions. The inclusion of 500 ml of colloid solution tothe i.v. fluid regime before hip fracture surgery does not improveoutcome. Br J Anaesth 2004; 92: 67–70     

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.     

Differential effects of propofol, ketamine, and thiopental anaesthesia on the skeletal muscle microcirculation of normotensive and hypertensive rats in vivo

Background. This study utilized the dorsal microcirculatorychamber (DMC) model to determine differential effects of i.v.propofol, ketamine, and thiopental anaesthesia on the skeletalmuscle microcirculation (10–180 µm) of normotensive(Male Wistar Kyoto, WKY) and hypertensive (spontaneously hypertensiveHarlan, SHR) rats, importantly, comparing responses to a consciousbaseline. Methods. Three weeks following implantation of the DMC in WKY(n=8) and SHR (n=6) (130 g) 0.25 ml 100 g^–1 FITC–BSA(i.v.) was administered and the microcirculation viewed usingfluorescent in vivo microscopy for a 30 min baseline (t=0–30min). This was followed by either propofol, thiopental, ketamine,or saline (i.v. bolus induction over 5 min (t=30–35 min)),then maintenance step-up infusion for 60 min (t=45–105min), so that animals received all four agents 1 week apart(56 experiments). Results. Dilation of A3 arterioles (15–30 µm) andV3 venules (20–40 µm) with propofol was greaterin SHR (t=95 min, A3 36.7 (12)%, V3 15.5 (2.3)%) than WKY (t=95min, A3 19.4 (7.4)%, V3 8.0 (2.3)%) (P<0.05). Constrictionof A3 with ketamine was greater in SHR (t=95 min, A3 –29.1(6.4)%) than WKY (A3 –17.5 (8.8)%) (P<0.05). This wasaccompanied by hypotension with propofol in SHR (–32%decrease in systolic arterial pressure), but not WKY (–6%)and hypertension with ketamine in WKY (–15%) and SHR (–24%)(P<0.05). During thiopental anaesthesia there was dilationof A1 (80–180 µm), A3, and V3 in WKY (P<0.05).Conversely, in SHR dilation of venules (29.2 (8.7)%) was accompaniedby constriction of A1 and A3 (t=95 min, A1 –25.1 (5.9)%,A3 –45.2 (3.1)%) (P<0.05). Conclusion. Within the skeletal muscle microcirculation of hypertensiverats there is enhanced dilation with propofol and constrictionwith ketamine, associated with exaggerated changes in arterialpressure. Thus, dysfunctional control mechanisms at the levelof the microcirculation alter responses to anaesthesia duringhypertension.      

Intramedullary nailing for fractures of the femoral shaft

The results of a survey of 136 fractured femoral shafts treated by open reduction and intramedullary nailing between 1963 and 1970 are presented.Complications of the operation such as mechanical failure of fixation, wound infection, delayed union and non-union are discussed.The final results based on the range of knee flexion and freedom from complications are given: 80 per cent of the results were good.     

Aeromedical transportation for infants and children.

Transfer of a critically ill child to a pediatric center is indicated when patient needs have exceeded local expertise or facilities. It is illogical to impose on the referring hospital the added burden of transporting such a patient. The receiving hospital is better equipped to extend its specialized services by assuming responsibility for interim management and transfer of the patient. An aeromedical transport system capable of quick response was built around National Guard helicopters. In 21 cases, doctors, nurses, and equipment were flown to children in community hospitals, and urgent treatment was begun in half the time formerly possible. Only after the patients were stabilized were they returned safely under continuing appropriate management. The helicopter is a versatile and speedy tool to deliver expertise and equipment when and where needed. Timely arrival of specialty services can be expected to improve patient care and salvage.     

Peptic ulcer in children with gastric tube interposition.

An infrequent, but potentially serious, complication of gastric tube interposition is ulceration within the conduit. It is important, therefore, to recognize ulcer formation in its early stages by serial radiographs throughout the childhood years. While redundancy and partial obstruction with impaired drainage of the tube appear to be etiologic factors, distension of the transposed antrum may lead to hyperacidity and may play a role in ulcerogenesis. A course of dietary and antacid therapy may heal the ulcer, but surgical revision of the tube may prove necessary.     

Ongoing cirrhosis after successful porticoenterostomy in infants with biliary atresia.

Thirty-one patients were treated by portoenterostomy procedures for extrahepatic biliary atresia. In 20, there was unequivocal evidence of bile drainage. Eleven of these 20 were restudied from 3 to 23 mo postoperatively by liver biopsy. The clinical condition of most of these infants was satisfactory. Despite absence of clinical jaundice, normal rose bengal scan, and normal liver function studies, eight showed progressive degrees of hepatic fibrosis when compared to the results of the biopsy taken at the time of portoenterostomy. Two patients showed stable histology and one, after progressing on a second biopsy, had normal liver histology on a third study. The implications of progressive hepatic histopathology despite bile drainage are discussed.     

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.