Gastric Barotrauma in a Scuba Diver: Report of a Case

Stomach rupture can occur as a consequence of the expansion of compressed air during rapid ascent after diving. We present the case of a middle-aged woman who suffered a gastric tear from surfacing too quickly after diving, and discuss the diagnosis and management of such patients by reviewing previously reported similar events. Gastric barotrauma should be suspected in divers who complain of abdominal pain, even in the absence of frank signs of peritoneal irritation. Although pneumoperitoneum is always present in these patients, it can also occur as a consequence of pulmonary barotrauma, making gastroscopy or radiological contrast studies, or both, essential for a definitive diagnosis. Surgical repair represents the treatment of choice for an active full-thickness tear and, if associated with arterial gas embolism or decompression sickness, should ideally be performed in a center where a category I (intensive care-capable) hyperbaric unit is available. Received: March 18, 2002 / Accepted: September 3, 2002 Reprint requests to: L.V. Titu     

An internet survey of 2,596 people with fibromyalgia

Background  

This study explored the feasibility of using an Internet survey of people with fibromyalgia (FM), with a view to providing information on demographics, sources of information, symptoms, functionality, perceived aggravating factors, perceived triggering events, health care utilization, management strategies, and medication use.     

The Role of Extended Lymphadenectomy for Adenocarcinoma of the Head of the Pancreas: Strength of the Evidence

With improvements in the safety of Whipple resection in recent decades, surgeons have continued to explore the role of more extensive lymphadenectomy in hope of improving long-term survival. A systematic literature search of level I evidence addressing the role of the extent of lymphadenectomy was undertaken. Only reports of prospective, randomized controlled trials comparing pancreaticoduodenectomy with standard lymphadenectomy to pancreaticoduodenectomy with extended lymphadenectomy where information regarding survival, morbidity, mortality, the number of resected lymph nodes in each group and detailed operative technique were included. Four prospective, randomized trials comprising some 424 patients and one meta-analysis were identified. In aggregate, these studies confirmed that the number of resected lymph nodes was significantly higher in the pancreaticoduodenectomy with extended lymphadenectomy group. Morbidity and mortality rates were comparable. Postoperative diarrhea in the early months after operation was problematic in patients undergoing extended lymphadenectomy. In none of the studies was a benefit in long-term survival demonstrated. Standard pancreaticoduodenectomy continues to be the operation of choice for adenocarcinoma of the head of the pancreas. Presented at The Society for Surgery of the Alimentary Tract Postgraduate Course “Systematic Reviews of Pancreaticobiliary Disease Customized for the Gastroenterologist and Gastrointestinal Surgeon” on May 20, 2007, Washington, D.C.     

Balance algorithm for cluster randomized trials

Background  

Within cluster randomized trials no algorithms exist to generate a full enumeration of a block randomization, balancing for covariates across treatment arms. Furthermore, often for practical reasons multiple blocks are required to fully randomize a study, which may not have been well balanced within blocks.     

Safety evaluation of surgical materials by cytotoxicity testing

The cytotoxicity of three kinds of commercially available absorbable hemostats [oxidized cellulose (Surgicel, gauze and cotton types), microfibrillar collagen (Avitene), and cotton-type collagen (Integran)] and one adhesion barrier [sodium hyaluronate and carboxymethyl-cellulose membrane (Seprafilm)] were comparatively assessed by a colony assay using V79 cells and a minimum essential medium (MEM) elution assay in combination with a neutral red assay using L929 cells. Strong cytotoxicity was detected for Surgicel by both the MEM elution assay and the colony assay. For Avitene, both methods revealed weak cytotoxicity. For Seprafilm, no cytotoxicity was detected by the MEM elution assay, while a moderate degree of cytotoxicity was observed in the colony assay. For Integran cytotoxicity was not detected by either the MEM elution or the colony assay. The results of the different methods showed some inconsistency in terms of the degree of cytotoxicity of the materials. It is proposed that the combination of two or more sensitive cytotoxicity testing methods for the evaluation of biomaterials is necessary to avoid false-negative results for biomaterials at the preclinical stage. Furthermore, investigation of the correlation between the cytotoxicity and the extraction period of the surgical materials is helpful for predicting the effect of prolonged in vivo use of biomaterials on surrounding cells, tissues, and organs.     

Arthroscopic tarsometatarsal (Lisfranc) arthrodesis

We describe an arthroscopic approach of tarsometatarsal arthrodesis for post-traumatic arthritis. Five tarsometatarsal portals (medial, P1–2, P2–3, P3–4, P4–5) are identified at the junctional points between the metatarsals by means of image intensifier. The first metatarsocuneiform joint is approached through the medial and P1–2 portal. Articular cartilage is denuded and micro-fracture of subchondral bone is performed with an arthroscopic awl. The second metatarsocuneiform joint is approached through the P1–2 and P2–3 portals and the third metatarsocuneiform joint is approached through the P2–3 and P3–4 portals. The articular surfaces are prepared for arthrodesis. The articulations are kept in desired position and transfixed with 4.0 mm cannulated screws. The fourth and fifth metatarsocuboid articulations are rarely included in the procedure. Arthroscopic arthrodesis or tendon arthroplasty of the lateral column can be performed through the P3–4 and P4–5 portals.     

Pullout reattachment of tibial avulsion fractures of the anterior cruciate ligament: a firm,effective suture-tying method using a tensioner

We describe a firm, effective suture-tying method using a tensioner for reattaching tibial avulsion fractures of the anterior cruciate ligament. Our simple method achieves strong, firm reattachment of the fracture. In addition, it prevents fixation loosening during suture tying effectively. Since pullout repair using nonabsorbable sutures is commonly used to fix various avulsion fractures, the tensioner helps attain strong, firm reattachment of avulsion fractures simply and effectively.     

Biochemical Abnormality Associated with Smith-Lemli-Opitz Syndrome in an Infant with Features of Rutledge Multiple Congenital Anomaly Syndrome Confirms that the Latter Is a Variant of the Former

We describe a female infant with morphologic features of Rutledge multiple-congenital-anomaly syndrome (RMCAS) and biochemical features of Smith-Lemli-Opitz syndrome (SLOS). She had microcephaly with hypoplastic cerebral frontal lobes and cerebellum, agenesis of the splenium of corpus callosum, abnormal facies including hypertelorism with bilateral inner epicanthal folds, a broad nasal bridge with slightly anteverted nares and patent choanae, low set ears and complex conchal formation, high-arched palate and thick maxillary alveolar ridges, and micrognathia. Her chest was broad, genitalia were ambiguous, and uterus was bicornuate. Skeletal abnormalities included a hypoplastic appendicular skeleton, post-axial hexadactyly of the right hand and the left foot, syndactyly of bilateral 2nd-3rd toes and left 5th-6th toes, right talipes varus and left talipes valgus, and fused L5-S1 vertebrae. Congenital heart disease consisted of hypoplastic left heart, coronary sinus agenesis, ostium secundum and ostium primum defects, and a thickened septum primum. The lungs were hypolobated and the kidneys manifested oligopapillary hypoplasia. Total colonic Hirschsprung disease was noted microscopically. Analysis of liver tissue taken at postmortem examination revealed the ratio of 7-dehydrocholesterol and cholesterol to be 143 (expected, 0.28 +/- 0.28). Although initially described as a distinct syndrome, RMCAS was merged with the severe form of SLOS, because of significantly overlapping features [Online Mendelian Inheritance in Man (OMIM) #268670]. The biochemical data showing an excess of 7-dehydrocholesterol and low cholesterol in the liver tissue of our case supports this viewpoint.     

Diagnostic value of anti-cyclic citrullinated peptide antibodies in Greek patients with rheumatoid arthritis

Background  

Anti-cyclic citrullinated peptide (anti-CCP) antibodies have been of diagnostic value in Northern European Caucasian patients with rheumatoid arthritis (RA). In these populations, anti-CCP antibodies are associated with the HLA-DRB1 shared epitope. We assessed the diagnostic value of anti-CCP antibodies in Greek patients with RA where the HLA shared epitope was reported in a minority of patients.