Small bowel obstruction from hollow foreign body ingestion: A case report and brief review of literature

While ingestion of a foreign body by children is common, diagnosis is often challenging, especially when the consumption by a young child is unwitnessed and presenting symptoms mimic other medical conditions. If the foreign body does not pass spontaneously, radiological imaging studies are typically performed, but visualization and identification of the ingested foreign object can be inconclusive, especially when an unidentified mass is radio translucent. Under this circumstance, physicians often have to go on a "fishing expedition", using exploratory endoscopy and/or surgery to identify and extract the object that became lodged. In this report we discuss a case of a 3 year-old boy who presented with abdominal pain and signs of bowel obstruction. Imaging revealed an ingested "radiolucent" foreign body, masqueraded as soft-tissue mass and enteric duplication cyst, delaying the diagnosis. Systematic shape and density reanalysis of CT and US imaging suggested a hollow object lodged at the terminal ileum. The patient underwent exploratory laparotomy with extraction of a hollow toy "fish". There is a dearth of literature regarding hollow ingested objects. This case report highlights the importance of systematic density and shape imaging analyses in order to identify and locate hollow ingested objects.

Incidence, Prevalence, and Outcomes of Pediatric Trauma in Rural Appalachia (West Virginia) From 2017 to 2019

Background Appalachian rural pediatric trauma has its unique incidence, presentation, and distribution due to the mechanisms of injury, geographic location, access to care, and social issues.  Purpose To review, analyze, and understand pediatric trauma in West Virginia during the period 2017-2019. Materials and methods After institutional review board approval, the statewide trauma database was queried and analyzed in a retrospective cohort study for all pediatric trauma ages zero to 18 from 2017-2019 in the Appalachian regions one through four in West Virginia. The following were analyzed: gender, injury mechanism, Glasgow Coma Scale Score (GCS) at admission, injury severity score (ISS), toxicology screen results, hospital length of stay, duration of ventilatory support, number of procedures performed during admission, presence of non-accidental trauma, cardiac arrest, patient discharge disposition, and mortality. Results One-thousand eighty-two (1182) patients between the ages of zero to 18 were admitted to the trauma center. An average of 37% was female and 63% male. In the 11-18 age group, 24% were female and 76% were male. Most injuries were due to blunt force (89%), followed by penetrating injuries (7.2%) and burns (1.4%). The majority had minor or moderate injuries with 95% receiving a Glasgow Coma Scale (GCS) >13 and 72% listed as minor on the injury severity score (ISS). Children in ages 0-2 years had the highest proportion of poor (0-8) GCS scores, high ISS (>14) scores, most hospital admission days, most days on a ventilator, highest mortality, most pre-hospital cardiac arrests, child abuse, burns, and placement with child protective services. An average of 31% of children tested, and 17% in the age group of 0-2 had a positive toxicology screen. There were 3670 procedures done in total and the most common procedure performed was an ultrasound of the abdomen. Procedures were performed in 90% of the patients. Conclusions and relevance Based on our study, the zero to two-year-old pediatric trauma patients are most vulnerable to poor outcomes and may need targeted preventative interventions. Toxicology screens may need to be more widely implemented in pediatric trauma in the Appalachian region. Rural trauma in Appalachia has endemic issues related to substance abuse, poverty, and a lower degree of social support as compared to urban areas. Although the distribution of injury may follow a national distribution, mechanism, management, and outcomes can vary.

Cell Impermeant-based Low-volume Resuscitation in Hemorrhagic Shock: A Biological Basis for Injury Involving Cell Swelling

OBJECTIVE

To determine the role of cell swelling in severe hemorrhagic shock and resuscitation injury.

BACKGROUND

Circulatory shock induces the loss of energy-dependent volume control mechanisms. As water enters ischemic cells, they swell, die, and compress nearby vascular structures, which further aggravates ischemia by reducing local microcirculatory flow and oxygenation. Loading the interstitial space with cell impermeant molecules prevents water movement into the cell by passive biophysical osmotic effects, which prevents swelling injury and no-reflow.

METHODS

Adult rats were hemorrhaged to a pressure of 30 to 35  mm Hg, held there until the plasma lactate reached 10  mM, and given a low-volume resuscitation (LVR) (10%-20% blood volume) with saline or various cell impermeants (sorbitol, raffinose, trehalose, gluconate, and polyethylene glycol-20k (PEG-20k). When lactate again reached 10  mM after LVR, full resuscitation was started with crystalloid and red cells. One hour after full resuscitation, the rats were euthanized. Capillary blood flow was measured by the colored microsphere technique.

RESULTS

Impermeants prevented ischemia-induced cell swelling in liver tissue and dramatically improved LVR outcomes in shocked rats. Small cell impermeants and PEG-20k in LVR solutions increased tolerance to the low flow state by two and fivefold, respectively, normalized arterial pressure during LVR, and lowered plasma lactate after full resuscitation, relative to saline. This was accompanied by higher capillary blood flow with cell impermeants.

CONCLUSIONS

Ischemia-induced lethal cell swelling during hemorrhagic shock is a key mediator of resuscitation injury, which can be prevented by cell impermeants in low-volume resuscitation solutions.

Donor gluconate rescues livers from uncontrolled donation after cardiac death

BACKGROUND

Ischemia from organ preservation or donation causes cells and tissues to swell owing to loss of energy-dependent mechanisms of control of cell volume. These volume changes cause substantial preservation injury, because preventing these changes by adding cell impermeants to preservation solutions decreases preservation injury. The objective of this study was to assess if this effect could be realized early in uncontrolled donation after cardiac death (DCD) livers by systemically loading donors with gluconate immediately after death to prevent accelerated swelling injury during the warm ischemia period before liver retrieval.

METHODS

Uncontrolled DCD rat livers were cold-stored in University of Wisconsin solution for 24 hours and reperfused on an isolated perfused liver (IPL) device for 2 hours or transplanted into a rat as an allograft for 7 days. Donors were pretreated with a solution of the impermeant gluconate or a saline control immediately after cardiac death. Livers were retrieved after 30 minutes.

RESULTS

In vivo, gluconate infusion in donors immediately before or after cardiac death prevented DCD-induced increases in total tissue water, decreased vascular resistance, increased oxygen consumption and synthesis of adenosine triphosphate, increased bile production, decreased lactate dehydrogenase release, and decreased histology injury scores after reperfusion on the IPL relative to saline-treated DCD controls. In the transplant model, donor gluconate pretreatment significantly decreased both alanine aminotransferase the first day after transplantation and total bilirubin the seventh day after transplantation.

CONCLUSION

Cell and tissue swelling plays a key role in preservation injury of uncontrolled DCD livers, which can be mitigated by early administration of gluconate solutions to the donor immediately after death.

Histrelin for central precocious puberty-a single surgeon experience

BACKGROUND

The most common cause of precocious puberty is idiopathic central precocious puberty (CPP), which is usually treated with monthly injections. An alternative treatment of precious puberty is a subcutaneous implant that contains histrelin acetate, which is continuously released for more than 1 y and then removed or replaced with a new implant.

METHODS

The aim of this study was to conduct a retrospective review of one surgeon's experience with the histrelin implant and to examine patient satisfaction. After obtaining institutional review board approval, the charts of all children who had undergone at least one implant were reviewed.

RESULTS

Fifty-eight children, average age 8.4 y old (range 7-14), underwent at least one histrelin implant insertion for treatment of CPP. Parents of 44 patients were able to be reached by telephone for this study and rated the histrelin implant treatment highly. All implants were placed, replaced, or removed without significant difficulty, and there were no complications.

CONCLUSIONS

This study suggests that the use of a histrelin subcutaneous implant for control of CPP is a safe and effective method for the treatment of this condition.

Isolation of fecal coliform bacteria from the diamondback terrapin (Malaclemys terrapin centrata)

Total and fecal coliform bacteria were isolated from the cloaca and feces of the estuarine diamondback terrapin. The majority of samples contained fecal coliforms. Escherichia coli was the predominant fecal coliform species isolated, and members of the genus Salmonella were isolated from 2 of 39 terrapins. Fecal coliform numbers are used to regulate shellfish harvests, and diamondback terrapins inhabit the brackish-water habitats where oyster beds are found; therefore, these findings have implications for the efficacy of current regulatory parameters in shellfishing waters.

Addition of a bone marrow "facilitating cell" population increases stem cell-derived cobblestone area formation in impaired long-term bone marrow culture stroma

Treatment of mouse bone marrow (BM) with rabbit anti-mouse brain serum (RAMBS) plus complement (C') depletes several cell types, including T cells and facilitating cells (FCs), that is, cells that facilitate engraftment of sorted allogeneic stem cells (SCs) in vivo. In the present study, treatment of BM with RAMBS+C' resulted in the depletion of approximately half of the late cobblestone area (CA)-forming stem cells as assayed on irradiated long-term bone marrow culture (LTBMC) stroma. In addition, LTBMC of RAMBS+C'-treated BM produced functionally impaired stroma with reduced ability to support CA formation by nontreated exogenous SCs. This stromal impairment was not due to depletion of TCRalphabeta T cells in the BM, because BM cultures from TCR alpha-chain knockout mice supported normal numbers of exogenous CAs. Because CD8+/TCR- cells are enriched for FCs, we tested the effect of adding these cells back to the treated BM prior to culture. The sorted FCs alone did not produce CAs, but did improve the ability of the impaired stroma to support late CA formation by sorted SCs. These studies provide a new model for dissecting the roles of different cellular components of BM in producing functional stroma that supports CA formation by SCs, and show that the number of CAs formed depends on the "quality" of the stroma as well as the number of SCs seeded. These findings further suggest that CD8+/TCR- BM cells may be important for the establishment of functional stroma.

Purchase considerations for a radiology information system

Since choosing a radiology information system can be a trying endeavor, this "nuts and bolts" article offers some practical advice. The authors first emphasize that a strong partnership between the institution and vendor must exist for successful implementation to happen. Ms. Rowe and Ms. Parrish then proceed to outline the commitment, tasks and training necessary to ensure that your organization undertakes this project with favorable results!

Driving in Parkinson's disease

Altered motor or mental skills in Parkinson's disease (PD) could adversely affect driving ability. We interviewed 150 patients regarding their driving habits and compared them with 100 controls. Thirty patients had stopped driving because of PD. PD patients had no more lifetime accidents than controls. With increased disability, however, there was a smaller percentage of patients still driving with fewer miles traveled and with proportionately more accidents occurring. Though disability scores did not correlate well with driving ability, there were significantly more accidents in subjects with more severe PD. The presence of cognitive impairment was associated with an increased accident rate. We conclude that driving in PD may be a public health problem and that some PD patients should not drive.

Sexual dysfunction in Parkinson's disease

Sexual functioning was investigated in 50 parkinsonian male and female patients using a questionnaire. A loss of sexual interest and functioning was reported in a high percentage of patients. Depression was not prevalent but 70% had some evidence of autonomic nervous system dysfunction that may be related to sexual dysfunction. It is concluded that the sexual function is frequently impaired in Parkinson's disease.

A cost analysis of film image management and four PACS based on different network protocols

Picture Archive and Communication Systems (PACS), which allow the electronic acquisition, storage, transportation, and viewing of medical images, hold the eventual promise of reduced costs, improved image-management logistics, and ultimately, improved patient care. But at what point in the future will PACS really cost less than film-based image management for a given hospital size; and how are these costs affected by the choice of the digital communication network? To address these questions, a static differential cost model has been constructed. PAC systems based on two high-speed networks (less than 150 megabytes per second Mbps) and two low-speed networks, as well as film, were considered for five different sized hospitals (ranging from 15,000 to 125,000 procedures per year) and two time periods (1995 and 2000). PACS equipment was assumed to have a payoff of five years. The model considered all capital and supply costs and personnel costs for the PACS and for film storage and retrieval. It did not consider any possible cost savings from logistics improvement likely to result from the adoption of a PACS. Based on the assumptions outlined, high-speed-network PACS are less costly than those based on low-speed networks for all scenarios considered. Further, even though all possible PACS cost savings were not considered, high-speed network PACS appear to be less costly than film for hospitals larger than 60,000 procedures in 1995 and larger than 15,000 in 2000, while low-speed-network PACS should cost less than film for 60,000 and 30,000 procedure hospitals in 1995 and 2000 respectively.

Macroamylasemia: a simple stepwise approach to diagnosis

Typically, macroamylasemia is a condition of elevated serum amylase in the absence of symptomatic disease. However, in the presence of symptoms, especially of abdominal origin, it is important that this condition be identified accurately in order to avoid unnecessary treatment for pancreatitis or other related diseases. This report offers a review of the literature, a case example, and an algorithm for systematically considering the diagnosis of macroamylasemia.

The hemodynamic and clinical responses to terazosin, a new alpha blocking agent, in congestive heart failure

To determine the hemodynamic effects of a new alpha 1 blocker, terazosin, in congestive heart failure, six patients with this condition underwent hemodynamic testing (at rest and during exercise) before and after dosing. Doses of 2, 5, and 10 mg were examined in sequence over 3 days to define dose-response characteristics. Terazosin, in these doses, decreased pulmonary and systemic vascular resistances and right atrial and pulmonary capillary wedge pressures. Terazosin increased stroke volume and cardiac output, presumably through afterload-reduction, without altering heart rate. These aforementioned responses were apparent both at rest and during exercise. While a direct relationship existed between dose and plasma concentration, a similar relationship was not observed for dose (or plasma concentration) and hemodynamic response; no differences were noted between the hemodynamic responses to the three doses. Improvement in hemodynamics persisted and the clinical status and exercise capacity improved in the four patients chronically treated (over 2 months) with terazosin. Treating the heightened tone of the sympathetic nervous system in congestive heart failure with the alpha 1 blocker, terazosin, may be of benefit to some patients afflicted with this disorder.

Global left ventricular contractility in three models of hypertrophy evaluated with Emax

Using the load independent contractility index, end-systolic pressure-volume ratio (Emax), contractility of the hypertrophied left ventricle (LV) from three different models was evaluated in conscious, resting dogs. The experimental animals included 12 dogs with perinephritic hypertension (HYP) (aortic diastolic pressure 130 +/- 5 mm Hg), 12 dogs who underwent aortic banding (AOB) at 6 to 8 weeks of age (resting aortic gradient 110 +/- 15 mm Hg), and 12 dogs with chronic fluid overload from aortocaval fistula (ACF). These were compared with 12 normal dogs (CTL). LV dimension and pressure were measured with ultrasonic tranducers and micromanometers. All three models resulted in hypertrophy with significant (P less than 0.01) increase in LV weight-to-body weight ratio (6.3 +/- 0.4, 8.4 +/- 0.5, 6.3 +/- 0.4, respectively, vs 4.4 +/- 0.1 g/kg). Cardiac output (6908 +/- 740 vs 2424 +/- 276 ml/min) and end-diastolic volume (118 +/- 11 vs 50 +/- 4 ml) were significantly (P less than 0.01) increased in AOB (18 +/- 1 vs 9 +/- 2 mm Hg). dp/dtmax was not significantly different among all groups. Emax (CTL = 5.3 +/- 0.4 mm Hg/ml) was not significantly changed in HYP (9.5 +/- 2.1) but was significantly (P less than 0.01) increased in AOB (14.1 +/- 2.6), and significantly (P less than 0.01) depressed in ACF (2.4 +/- .03). Thus, LV hypertrophy from systemic hypertension (HYP) or proximal aortic hypertension (AOB) is, at least initially, associated with preservation of contractility and normal hemodynamic performance.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of a direct potentiometric method for sodium and potassium used in the Du Pont aca

We evaluated an accessory that enables the Du Pont aca discrete analyzer to measure Na+ and K+ by direct potentiometry (aca/ISE). Na+ and K+ gave linear responses in both the blood and urine modes, with no carryover. No interfering species were identified in the blood mode. Intra-assay and interassay precision for Na+ and K+ were more than adequate and analytical recoveries comparable to those with flame photometry were found for plasma. The Na+ and K+ values for plasma were comparable with those obtained by use of another direct potentiometric analyzer (the Orion SS-30), but slightly higher than flame-photometric values. Samples from patients with hyperlipemia and multiple myeloma gave clinically relevant values with the aca/ISE, but the flame photometric values were artefactually low. Whole blood could not be accurately analyzed. The aca/ISE is a precise, easy-to-use instrument, which gives values for plasma similar to those obtained with direct potentiometric analyzers. For analysis of urine, certain precautions are necessary.

Evaluation of a direct potentiometric method for sodium and potassium used in the Du Pont aca

We evaluated an accessory that enables the Du Pont aca discrete analyzer to measure Na+ and K+ by direct potentiometry (aca/ISE). Na+ and K+ gave linear responses in both the blood and urine modes, with no carryover. No interfering species were identified in the blood mode. Intra-assay and interassay precision for Na+ and K+ were more than adequate and analytical recoveries comparable to those with flame photometry were found for plasma. The Na+ and K+ values for plasma were comparable with those obtained by use of another direct potentiometric analyzer (the Orion SS-30), but slightly higher than flame-photometric values. Samples from patients with hyperlipemia and multiple myeloma gave clinically relevant values with the aca/ISE, but the flame photometric values were artefactually low. Whole blood could not be accurately analyzed. The aca/ISE is a precise, easy-to-use instrument, which gives values for plasma similar to those obtained with direct potentiometric analyzers. For analysis of urine, certain precautions are necessary.

Quantitative evaluation of sympathetic and parasympathetic control of iris function

The use of quantitative measurements of pupil size as an index of autonomic nervous system (ANS) activity in normal and diabetic subjects is described. The dual innervation of the iris by the parasympathetic (PNS) and sympathetic (SNS) nervous system was demonstrated by measurement of steady-state pupil size before and after changes in ANS activity by pharmacologic agents. In the presence of total PNS blockade, dark-adapted pupil size was a reliable index of SNS activity to the iris. Latency time (time from light stimulation to initial pupil response) appeared to be a good index of PNS activity. However, increased SNS activity may also prolong the latency time. Thus, consideration of SNS activity is necessary when evaluating the latency time. In 25 diabetic subjects, there was evidence of impaired SNS activity (smaller dark-adapted pupil size during total PNS blockade) and PNS activity (prolonged latency time). In a subgroup of diabetic subjects without clinical manifestations of autonomic neuropathy and normal subjects, both dark-adapted pupil size during PNS blockade (SNS index) and latency time (PNS index) were abnormal. The coefficient of variation for these two indices was less than 5% in glycemic stable diabetic subjects. Thus, these two indices are reliable and sensitive measures of the SNS and PNS activity to the iris in normal and diabetic subjects.