Incarcerated ventral (epigastric) hernia containing a strangulated Meckel's diverticulum

Summary A Meckel's diverticulum is the result of an incomplete obliteration of the omphalomesenteric, or vitelline, duct. The duct connects the midgut to the yolk sac of the developing intestinal tract and normally atrophies by the eighth to ninth week of gestation. This event fails to occur in approximately two percent of the population, resulting in the congenital anomaly named after Johann Friedrich Meckel, who first characterized this diverticulum in 1809. Our patient presented with signs and symptoms consistent with a small bowel obstruction secondary to an incarcerated hernia, and underwent emergent laparotomy. An ischemie small bowel segment with a Meckel's diverticulum was resected. Pathology revealed ectopic pancreatic tissue within the diverticulum. Meckel's diverticula have been observed among the contents of hernia sacs in various locations including the inguinal, femoral, and umbilical regions. We report a case of a Meckel's diverticulum presenting in a spontaneous ventral (epigastric) hernia.     

The Influence of Vibration on Muscle Activation and Rate of Force Development during Maximal Isometric Contractions

At present there appears to be a need for research conducted on the effects of vibration on the contractile ability of skeletal muscle tissue. The aim of this study was to address this issue by examining the effects of a superimposed muscle/tendon vibration at 50.42±1.16 Hz (acceleration 13.24 ± 0.18ms^-2: displacement ≈5mm) on muscular activation and maximal isometric contraction. Sixteen participants with a mean age, body mass, and height of 22 ± 4.4 years, 73.2 ± 11.7 kg and 173.1 ± 9.7 cms, respectively, were recruited for this study. Electromyography and accelerometry from the rectus femoris, and maximal isometric force data characteristics were collected from the dominant limb under conditions of vibration, and no-vibration. A superimposed 50 Hz vibration was used during the contraction phase for the maximal isometric leg extension for the condition of vibration. A one-way ANOVA revealed no significant (p > 0.05) differences between the vibration and no-vibration conditions for peak normalized EMG_RMS (84.74% Vs 88.1%) values. An ANOVA revealed significant (p > 0.05) differences between the peak fundamental frequencies of the FFT between the conditions vibration (27.1 ± 12.2 Hz) and no-vibration (9.8 ± 3.5 Hz). Peak isometric force, peak rate of force development, rate of force development at times 0.05, 0.01, 0.1, 0.5 seconds, and rate of force development at 50, 75, and 90% of peak force were not significantly different. The results of this study suggest that the application of vibration stimulation at 50 Hz during the contraction does not contribute to muscle activation, or enhance force production for maximal isometric contractions.

Key Points

• The application of a vibratory stimulation to the human body increases the normal acceleration resulting in an increase in force and a change in performance
• This study was to address this issue by examining the effects of a direct superimposed muscle/tendon vibration at 50 Hz on isometric strength characteristics
• No improvement or change in isometric force or rate of force development
• No changes to peak normalized EMG_RMS values

Key words: Strength, oscillations, isometric, peak, muscle activation     

A triple-blinded randomized trial comparing the hemostatic effects of large-dose 10% hydroxyethyl starch 264/0.45 versus 5% albumin during major reconstructive surgery

In Canada, hydroxyethyl starch 264/0.45 (HES 264/0.45; molar weight 264 kDa, molar substitution 0.45) has largely replaced albumin as the colloidal fluid of choice for perioperative intravascular volume expansion. The maximum recommended dose of HES 264/0.45 is 28 mL/kg; however, there are no clinical data supporting this limit. In this study we compared the hemostatic effects of HES 264/0.45 versus 5% albumin in doses up to 45 mL/kg over 24 h during major reconstructive head and neck surgery. Fifty patients were randomized to receive HES 264/0.45 or 5% human albumin from the induction of anesthesia until 24 h thereafter. Both albumin and HES 264/0.45 effectively maintained physiologic variables in the perioperative and postoperative periods. The partial thromboplastin time and international normalized ratio were significantly increased in the HES 264/0.45 group compared with the albumin group after infusion of 30 mL/kg and 45 mL/kg (P < 0.05). Factor VIII activity and von Willebrand factor level were significantly reduced in the HES 264/0.45 group compared with the albumin group after infusion of 15 mL/kg, 30 mL/kg, and 45 mL/kg (P < 0.05). Significantly more subjects in the HES 264/0.45 group received allogeneic red blood cell transfusions (P < 0.02). We conclude that HES 264/0.45 infusions >30 mL/kg over 24 h impair coagulation to a greater extent than albumin, possibly leading to more allogeneic transfusions.     

Renal and vestibular toxicity due to inhaled tobramycin in a lung transplant recipient.

Chronic rejection is the major hurdle to long-term survival after lung transplantation. Endobronchial infection with Pseudomonas aeruginosa is common in patients with chronic rejection and this may further contribute to deterioration of the allograft. Inhaled tobramycin is commonly used to treat P aeruginosa airways infection in patients with cystic fibrosis. The safety of inhaled tobramycin in transplant recipients, however, has not been established. We describe the first report of a lung transplant recipient who developed renal failure and vestibular injury after receiving inhaled tobramycin. We review the literature regarding the safety of inhaled tobramycin and discuss potential mechanisms that may promote systemic toxicity in transplant recipients.     

Sternal wound dehiscence after internal mammary artery harvesting. Logical management. Part 2

Wound breakdown is a serious complication of median sternotomy. This is generally met with a further attempt at surgical apposition using sutures of monofilament surgical steel, following wound debridement. This often fails. The aim of this article is to demonstrate one surgeon's experience in his revised management of sternal wound dehiscence, following internal mammary artery (IMA) harvest, over a 7-year period. Treatment consisted of sternal and soft tissue debridement, and closed irrigation. Wound closure was performed using multiple interrupted deep tension sutures (DTS) only. We believe this article demonstrates that the use of DTS is a safe and effective method of closure, for patients suffering from sternal wound dehiscence following IMA harvest.     

Complications Related to Dapsone Use for Pneumocystis Jirovecii Pneumonia Prophylaxis in Solid Organ Transplant Recipients

Dapsone, used for prevention of Pneumocystis jirovecii infections, has been reported to cause hemolytic anemia and methemoglobinemia; its tolerability in solid organ transplant recipients is not well described. We investigated dapsone-related adverse events in patients undergoing solid organ transplantation from 1999 to 2004. Transplant providers identified patients for the investigators who then reviewed the patients' hospital and outpatient records. Sixteen solid organ transplant recipients fit case definitions for dapsone-related hemolytic anemia (n = 11) or methemoglobinemia (n = 5). Median time from event to dapsone discontinuation was 15 days; all patients improved after drug discontinuation. G6PD enzyme activity was normal in all patients whose test results were available. Dapsone may be associated with hemolytic anemia or methemoglobinemia, even with normal G6PD levels. These events are often not promptly recognized, and drug discontinuation is delayed. Dapsone-related hemolytic anemia or methemoglobinemia should be considered in solid organ transplant recipients with unexplained anemia or hypoxia.     

Rate of nitrous oxide exchange across the middle ear mucosa in monkeys before and after blockage of the mastoid antrum.

OBJECTIVES: We tested the hypothesis that mastoid volume buffers the rate of change in middle ear pressure caused by transmucosal, inert gas exchange. STUDY DESIGN: Twelve monkeys were randomly assigned to group 1 or group 2. Right ears of group 1 had sham surgery and of group 2 had obstruction of the mastoid antrum. Before and after surgery, the time constant for transmucosal N(2)O exchange was estimated from N(2)O breathing experiments. The hypothesis predicts that the postoperative time constant measured for right ears of group 2 but not group 1 is greater than that measured before surgery. RESULTS: Mastoid antrum block significantly decreased right middle ear volume but did not affect the time constant for transmucosal N(2)O exchange. CONCLUSION: A mastoid gas-reserve function is not supported by the experimental data. SIGNIFICANCE: These results for monkeys and the theory developed to explain the effect of mastoid volume on transmucosal inert gas exchange suggest that the results for previous experiments in humans interpreted as evidencing a mastoid gas-reserve function are consistent with alternative explanations.     

Clinical evaluation of a novel internal nasal dilation stent for the improvement of nasal breathing.

OBJECTIVE: This study assessed rhinometric improvement in nasal airflow, perceived comfort, and the utility of nasal dilation devices for individuals with nasal obstruction treated with an external nasal dilator (END) or a novel internal nasal dilation stent (INDS). STUDY DESIGN: Prospective, randomized, crossover trial. SUBJECTS: Individuals with symptoms of nasal obstruction. METHODS: Twenty-three participants underwent rhinometry and a trial with a novel INDS and a validated END. Devices were used in a randomized, crossover fashion. Nasal airflow, maximum use, continuous use, comfort, and challenge with these devices were assessed. RESULTS: The END and INDS showed greater nasal airflow from baseline, with the INDS being significantly better than the END. The INDS was used significantly more than the END, and demonstrated significantly greater comfort and less associated challenge. CONCLUSIONS: The novel INDS showed 3.4 times improved nasal airflow from baseline, was used maximally and continuously longer than a validated END, and was judged to be significantly more tolerable.     

A rat model of otitis media with effusion caused by eustachian tube obstruction with and without Streptococcus pneumoniae infection: methods and disease course.

OBJECTIVE: To describe the clinical and histopathologic progression of a rat model of otitis media with effusion caused by eustachian tube obstruction (ETO) with and without Streptococcus pneumoniae infection. METHODS: In 164 rats, the left, bony eustachian tube was approached via a ventral incision and obstructed with dental material. Then 108 rats were infected via an intrabullar injection with S pneumoniae. At 48 hours, the infected rats were treated for 5 days with ampicillin. All ears were evaluated by weekly otomicroscopy. On each of days 1, 2, 7, 21, 35, 56, and 112, four rats were killed for histologic study. All effusions were cultured for bacteria. RESULTS: Fourteen rats died of surgical complications; effusion resolved by 2 weeks in 9 rats. During the first few days, infected ears with ETO had bulging tympanic membranes, followed by tympanic membrane retraction, purulent effusion, and otorrhea (50%) over the next few weeks, whereas uninfected ears with ETO developed retraction and serous effusion during the same time frame. At later times, all ears with ETO presented with retraction and serous or serous-mucoid effusion. S pneumoniae was recovered only from the infected ears with ETO (days 1 and 2), with some colonization by nonpathogenic microorganisms observed equally in both groups of ears. Histology showed a typical acute inflammatory reaction in the challenged ears with ETO through day 14 and then a chronic inflammation for all ears with ETO. CONCLUSION: The experimental methods provoked reproducible pathologic signs similar to those for otitis media with effusion. Given the availability of rat-specific reagents, this model is well suited for studies of cytokine elaboration during disease pathogenesis.