Sonographic diagnosis of splenogonadal fusion in a 2‐year‐old boy

Splenogonadal fusion (SGF) is a rare congenital abnormality. It is typically identified during orchiectomy for a suspected testicular tumor or during orchiopexy. We describe the sonographic findings in a case of SGF that could help with correct diagnosis preoperatively. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45 :179–182, 2017     

Aggressive Use of Diagnostic Services is Counterproductive

Background

Medical fraternity requisitions diagnostic tests for multiple reasons. More often than not, the tests lead to more tests either to exclude or to confirm doubts raised by the test results. These tests have an inherent morbidity, discomfort and cost. Growing expenditure on diagnostic tests without matching improvement in the health status warrants an internal audit of the laboratory utilization.

Methods

A retrospective utility audit was done for certain routinely advised laboratory tests at a hospital. Blood urea estimation in annual / periodic medical examination (AME/ PME), bleeding and clotting time in pre-anaesthetic check-up and aspartate aminotransferase (AST) and antibodies to hepatitis C virus (anti-HCV) in diagnostic work-up of acute onset jaundice were included in the audit.

Results

During the study period, 793 individuals underwent AME / PME and urea estimation did not provide any additional information in these cases which was not inferred by serum creatinine. Similarly, in diagnostic workup of acute onset jaundice, 6049 aspartate aminotransferase (AST) estimations in 1024 patients did not contribute anything more than what was inferred by alanine aminotransferase (ALT). Prevalence of anti HCV antibodies in acute onset jaundice in serving soldiers (11 out of 1225; 0.89%) though more than that in the blood donors from the same population (17 out of 4105; 0.41%) was less than anticipated false positives (18 out of 1225; 1.5%) as per the claimed specificity (98.5%) of the test kit. None of the 2766 bleeding and clotting time tests detected a bleeding or coagulation disorder.

Conclusion

The study reveals significant overuse of the laboratory that may not be good for the patient and the organization in terms of direct and indirect costs due to false positive results. This laboratory overload adversely affects the quality and availability of laboratory results. Therefore, a test should only be advised, if positive or negative result would dictate a change in patient management.Key Words: Laboratory overuse, Aspartate aminotransferase, Anti HCV, Bleeding time, Clotting time, Blood urea     

Management of Combat Related Vascular Injuries in a Zonal Hospital

Background

The extremity gunshot wound (GSW) and penetrating splinter injuries from mine blast present a surgical challenge in the treatment of arterial trauma especially at non-vascular surgery centre. Adherence to specific principles of management is required for optimal limb salvage.

Methods

Fourteen vascular injuries in patients of GSW and mine explosions were managed at a zonal military hospital with successful outcome in two years. The diagnosis of arterial injury was done clinically.

Results

The commonest site of vascular injury was femoral. The methods of choice for repair were autogenous vein interposition or end-to-end anastomosis. All except for two patients retained a functional limb.

Conclusion

All surgeons in peripheral hospitals should be trained in vascular injury repair to save life and limb. Our series shows that right timing and prompt treatment of vascular injuries in a peripheral hospital, can give satisfactory results.Key Words: Gunshot wounds, Mine blast injuries, Vascular trauma, Autogenous vein interposition, Fasciotomy     

Aberrant DNA methylation profile of hepatitis B virus infection

We aimed to study the aberrant DNA methylation profile associated with hepatitis B virus (HBV) infection and, to identify key genes and pathways associated with the HBV infection stage. A total of 54 antiviral treatment-naïve HBV-infected patients and six healthy controls were included. Genome-wide methylated DNA immunoprecipitation analysis was performed, as previously described, after which the chip data were preprocessed. Subsequently, Cytoscape software was used for the construction of a protein-protein interaction network, and a database for annotation, visualization, and integrated discovery software was used to conduct functional enrichment analysis. A total of 711 794 CpGs were obtained after data quality control, among which 152 780, 113 814, 90 747, and 175 868 CpGs showed differential methylation in acute hepatitis B (AHB) vs control, total-C vs control, CH1 vs CA1, and AHB vs total-C, respectively. Furthermore, RIPK3, PRDM10, JUN, and SNAI1 were at the center of the four associated networks, respectively. Differential methylated genes differentially methylated in these four comparisons were significantly enriched with olfactory transduction; positive regulation of transport; negative regulation of protein amino acid phosphorylation (eg, JUN), phosphorylation, phosphorus metabolic process, and phosphate metabolic process; and programmed cell death, respectively. RIPK3, PRDM10, JUN, and SNAI1 as well as olfactory transduction, positive regulation of transport, negative regulation of phosphorylation, and programmed cell death are important for the transformation associated with HBV infection stage. Moreover, JUN may be involved in HBV infection, mainly via the negative regulation of amino acid phosphorylation.     

General Competencies Are Intrinsic to Emergency Medicine Training: A Multicenter Study

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has promulgated six areas called General Competencies (GCs) that residency programs are required to evaluate. The authors sought to determine if these domains were an intrinsic part of emergency medicine (EM) residency training by using a global assessment evaluation device. METHODS: This was an observational, multicenter, cross-sectional study that compared GC acquisition between first-, second-, and third-year (EM1, EM2, and EM3) residents. Five postgraduate year (PGY) 1 to PGY 3 allopathic EM programs in Michigan participated. A global assessment form using a 1 through 9 ordinal scale with 86 scoring items was given to program directors for each resident in their programs. Analysis of variance (ANOVA) was used to compare the means between EM1, EM2, and EM3 scores. RESULTS: Five EM programs evaluated 150 residents. The GC scores were as follows: Patient Care: EM1 4.92, EM2 5.79, and EM3 6.40; Medical Knowledge: EM1 4.90, EM2 5.80, and EM3 6.46; Practice-based Learning and Improvement: EM1 4.60, EM2 5.48, and EM3 6.16; Interpersonal and Communication Skills: EM1 4.99, EM2 5.39, and EM3 6.01; Professionalism: EM1 5.43, EM2 5.68, and EM3 6.27; Systems-based Practice: EM1 4.80, EM2 5.48, and EM3 6.21. ANOVA showed statistically significant differences (p < 0.001) for all GCs. CONCLUSIONS: EM residents from several residency programs showed statistically significant progressive acquisition of the ACGME GCs using a global assessment device. This suggests that the GCs may be an intrinsic component in the training of EM residents.     

Lateral Subcutaneous Locking Compression Plate and Small Incision Reduction for Distal‐third Diaphyseal Humerus Fractures

Objective

Iatrogenic radial nerve injury is a great challenge for orthopaedic surgeons who deal with distal‐third diaphyseal humerus fractures. Conventional open reduction and internal fixation (ORIF) remains the gold standard, but complications such as nonunion and iatrogenic radial nerve injury still occur. We fixed the fractures with a lateral locking compression plate (LCP) subcutaneously after small incision reduction to protect the radial nerve. This study reports the clinical and radiographic outcomes of our modified method.

Methods

Thirty‐eight patients with distal‐third diaphyseal humerus fractures were treated with lateral subcutaneous LCP and small incision reduction at our department between September 2013 and August 2016. There were 33 males and 5 females, with an average age of 30.3 years (range, 17 to 49 years). All the cases were types A or B (AO/OTA classification, type A, 24 cases; type B, 14 cases). Among them, 6 cases were combined with preoperative radial nerve palsy. All patients were diagnosed with closed humeral fractures after X‐ray examination, and had typical upper limb pain, swelling, and movement disorders. The operations were performed by a single surgeons’ team. Union time, range of motion (ROM), University of California, Los Angeles (UCLA) shoulder rating scale, and Mayo Elbow Performance Index (MEPI) scores were assessed to evaluate the postoperative results.

Results

All patients were followed up for an average of 11.4 months (range, 3 to 36 months). The average operation time was 75.5 min (range, 60 to 150 min) and average intraoperative radiation exposure was 10.5 s (range, 8 to 18 s). Bony union was achieved in all cases after an average of 16.2 weeks (range, 12 to 25 weeks). No complications such as infection or screw and plate fracture occurred, and no iatrogenic radial nerve injury was observed. According to the UCLA shoulder rating scale, the average score was 33.7 (range, 31 to 35), with 33 excellent (86.8%) and 5 good cases (13.2%). They were all excellent according to their MEPI scores (ranging, 94 to 100, with an average of 97.4). The average operation time for secondary removal of the plate was 15.2 min (range, 10 to 20 min), and no complications such as infection or secondary radial nerve injury occurred.

Conclusions

Lateral subcutaneous LCP and small incision reduction may reduce the risk of iatrogenic radial nerve injury significantly in the treatment of distal‐third diaphyseal humerus fractures. It also leads to solid fixation, good postoperative function, and convenient removal of the plate without injuring the radial nerve.