A Uniquely Abnormal Stool Specimen: A Case Report.

BACKGROUND: Autoamputation of the appendix is a condition associated with the Ladd's procedure, a pediatric surgical technique for correction of intestinal malrotation. A 4-year-old male patient with a history of a Ladd's procedure performed as a newborn was brought in by his mother for "passing intestine" just prior to arrival. She reported that for several weeks her son had intermittent, crampy abdominal pain that resolved after the unusual-appearing bowel movement. After reviewing an image of the bowel movement, and in consultation with pediatric surgery, it was concluded that the patient had passed a devascularized appendix in his stool immediately prior to arrival. CASE REPORT: A 4-year-old boy with a past medical history of heterotaxy syndrome (inversion of the thoraco-abdominal organs), a double outlet right ventricle, and Ladd's procedure presented to the Emergency Department (ED) after "passing intestine" in his stool. Close examination of the photo demonstrated a tubular structure with taenia, consistent with an appendix. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Autoamputation of the appendix is an uncommon presentation in the ED. Passing a devascularized appendix is a benign condition and can present with weeks of intermittent abdominal pain that resolves with passage of appendix in the stool. Remnants of the appendix can remain within the intestinal lumen years after the Ladd's procedure. Emergency physicians with a general awareness of this rare phenomenon can confidently make the diagnosis and reassure worried parents.

Exertional Heat Illness Resulting in Acute Liver Failure and Liver Transplantation.

Heat illness remains a large medical burden for militaries around the world. Mitigating the incidence as well as the complications of heat illness must remain on the forefront of operational planning when operating in hot environments. We report the case of a 27-year-old male U.S. Marine who sustained a heat-related illness resulting in fulminant liver failure and permanent disability. The patient was transferred from the field to a civilian hospital. On hospital day 5, liver failure was identified. The patient was transferred to a transplant center, where he successfully received a liver transplant.

Valentino's Syndrome: A Life-Threatening Mimic of Acute Appendicitis.

Perforated ulcers are a rare cause of abdominal pain, and may not be considered when pain is localized to the right lower quadrant (RLQ). This case highlights an unusual presentation of a perforated duodenal ulcer that presented with RLQ pain, which has been described as Valentino's syndrome. Valentino's syndrome occurs when gastric or duodenal fluids collect in the right paracolic gutter causing focal peritonitis and RLQ pain. This case highlights that perforated ulcers, while an uncommon cause of RLQ pain, must remain on the differential of any patient that has an abdominal examination consistent with peritonitis.

Outcomes after anterior cervical discectomy and fusion in professional athletes.

BACKGROUND: Significant controversy exists regarding when an athlete may return to contact sports after anterior cervical discectomy and fusion (ACDF). Return-to-play (RTP) recommendations are complicated due to a mix of medical factors, social pressures, and limited outcome data. OBJECTIVE: The aim of this study was to characterize our diagnostic and surgical criteria, intervention, postoperative imaging results, and rehabilitation and report RTP decisions and outcomes for professional athletes with cervical spine injuries. METHODS: Fifteen professional athletes who had undergone a 1-level ACDF by a single neurosurgeon were identified after a retrospective chart and radiographic review from 2003 to 2012. Patient records and imaging studies were recorded. RESULTS: Seven of the 15 athletes presented with neurapraxia, 8 with cervical radiculopathy, and 2 with hyperintensity of the spinal cord. Cervical stenosis with effacement of the cerebrospinal fluid signal was noted in 14 subjects. The operative level included C3-4 (4 patients), C4-5 (1 patient), C5-6 (8 patients), and C6-7 (2 patients). All athletes were cleared for RTP after a neurological examination with normal findings, and radiographic criteria for early fusion were confirmed. Thirteen of the 15 players returned to their sport between 2 and 12 months postoperatively (mean, 6 months), with 8 still participating. The RTP duration of the 5 who retired after full participation ranged from 1 to 3 years. All athletes remain asymptomatic for radicular or myelopathic symptoms or signs. CONCLUSION: After a single-level ACDF, an athlete may return to contact sports if there are normal findings on a neurological examination, full range of neck movement, and solid arthrodesis. There may be an increased risk of the development of adjacent segment disease above or below the level of fusion. Cord hyperintensity may not necessarily preclude RTP.

Photochemical repair of vocal fold microflap defects.

OBJECTIVES: To bond vocal fold flaps using a sutureless, nonthermal laser-assisted method combining visible light and photosensitizing dyes to produce collagen crosslinks. STUDY DESIGN: In the ex vivo study, epithelial incisions were created in sheep vocal folds. The concentration of the Rose Bengal, and the laser fluence were varied and studied. The in vivo canine study evaluated the thickness of the basement membrane zone, density and distribution of collagen, elastin, and fibroblasts at time zero, 2 weeks, and 8 weeks. METHODS: Ex Vivo: Rose Bengal at concentrations between 0.5% and 1.0% was applied to the free margins of the incision and irradiated with an Nd:YAG laser at fluences varying from 150 to 600 J/cm2 . The bonding was considered positive when the incision could withstand air at 2 pounds per square inch (psi) from a distance of 3 cm. In Vivo: 0.75% Rose Bengal was applied to the microflap edges and irradiated with an Nd:YAG laser for 140 seconds (100 J/cm2). The control side was not irradiated. RESULTS: Ex Vivo: Bonding was achieved with a minimum of 0.75% Rose Bengal and 300 J/cm2 . In Vivo: There was no difference in the amount of subepithelial reaction between the experimental and control sides at 8 weeks. CONCLUSIONS: Photochemical tissue bonding is effective at sealing vocal fold incisions and did not create long-term scarring of the vocal folds. Use of this technique may allow for more predictable healing after microflap resection and may reduce the need for postoperative voice rest.

Photochemical tissue bonding: a promising technique for peripheral nerve repair.

BACKGROUND: Photochemical tissue bonding (PTB) is a novel tissue repair technique that uses visible light and a photosensitizing dye to crosslink proteins on tissue surfaces. This technique has been successfully demonstrated in a number of tissue repair models. An ideal nerve repair technique would be atraumatic and avoid placement of foreign bodies at the repair site. The epineurium is suited to photochemical repair as it is thin, translucent and has a relatively high collagen content. This study was designed to determine if PTB could be successfully applied in a peripheral nerve repair model. MATERIAL AND METHODS: Forty Sprague Dawley rats underwent transection of the sciatic nerve. Animals were then randomized to four treatment groups; epineurial suture repair, epineurial cuff with PTB, epineurial cuff alone, and no repair. Functional recovery was assessed at 10 day intervals using walking track analysis and sciatic function index calculations. At 90 days postoperatively animals were sacrificed and sciatic nerves harvested for histology and histomorphometry. RESULTS: Functional recovery in the suture repair and epineural cuff with PTB groups were not significantly different (-70.6 +/- 17.8 versus -76.9 +/- 10.3, P = 0.64) at 90 days postrepair. Histology showed good axonal regeneration with all repair techniques. Histomorphometric analysis found no significant difference between the repair groups. CONCLUSIONS: This study illustrates that peripheral nerves can be successfully repaired using a photochemical tissue bonding technique with results similar to those achieved with the current gold standard. With further development and refinement PTB may prove a useful tool in peripheral nerve repair.

Photochemical repair of Achilles tendon rupture in a rat model.

BACKGROUND: Photochemical tissue bonding (PTB) is an emerging technique for bonding or sealing tissue surfaces that requires light and a photoactive dye for its effect. The potential of PTB for tendon repair was assessed in a rat model. MATERIALS AND METHODS: The optical properties of bovine tendon were determined ex vivo to gauge the depth of light penetration as a function of wavelength and dosimetry parameters were established for PTB repair of ruptured tendon. PTB was then tested in vivo to repair transected tendons in Sprague-Dawley rats. Repair strengths were measured using a strain gauge up to 14 days post treatment. RESULTS: The effective penetration depth in tendon was estimated to be 0.68 mm at 514 nm. Following PTB treatment of mechanically ruptured tendon, significant bonding was dependent on the presence of both light and dye and attained a plateau strength at a fluence of 125 J/cm2. In a subsequent in vivo study to investigate PTB for repair of transected rat Achilles tendon, the ultimate stress required to break the repaired tendon was measured immediately after irradiation and at 7 and 14 days post-repair. Results showed that the difference in the ultimate stress between control and PTB treatment groups was statistically significant immediately after treatment and at 7 days (p = 0.04) but not 14 days (p = 0.75) post-repair. CONCLUSIONS: PTB provides a benefit to tendon repair at early stages in repair and is worthy of further investigation as a potential surgical adjunct for tendon repair in orthopedic surgeries.