Small bowel obstruction in pregnancy is a complex surgical problem with a high risk of fetal loss.

INTRODUCTION: Small bowel obstruction (SBO) in pregnancy is rare and is most commonly caused by adhesions from previous abdominal surgery. Previous literature reviews have emphasised the need for prompt laparotomy in all cases of SBO because of the significant risks of fetal loss and maternal mortality. We undertook a review of the contemporary literature to determine the optimum management strategy for SBO in pregnancy. METHODS: The MEDLINE® and PubMed databases were searched for cases of SBO in pregnancy between 1992 and 2014. Two cases from our own institution were also reviewed. RESULTS: Forty-six cases of SBO in pregnancy were identified, with adhesions being the most common aetiology (50%). The overall risk of fetal loss was 17% and the maternal mortality rate was 2%. In cases of adhesional SBO, 91% of cases were managed surgically, with 14% fetal loss. Two cases (9%) were managed conservatively with no complications. Magnetic resonance imaging (MRI) was used to diagnose SBO in 11% of cases. CONCLUSIONS: Based on our experience and the contemporary literature, we recommend that urgent MRI of the abdomen should be undertaken to diagnose the aetiology of SBO in pregnancy. In cases of adhesional SBO, conservative treatment may be safely commenced, with a low threshold for laparotomy. In other causes, such as volvulus or internal hernia, laparotomy remains the treatment of choice.

A cystic biliary tumour responding to regional fluorinated pyrimidine infusion.

We describe a patient with an intrahepatic biliary hamartoma associated with transformation to undifferentiated carcinoma which responded to intrahepatic arterial floxuridine chemotherapy.

Attitudes towards and experience of general practice among HIV-positive patients in the Republic of Ireland.

In order to study their attitudes to and experience of general practitioner care, 150 attenders at the only HIV specialist clinic in the Republic of Ireland were asked to complete an anonymous, self administered questionnaire. (81%) of respondents reported having a regular GP and 94% of those indicated that the GP was aware of their HIV diagnosis. The majority (64%) of patients with a regular GP reported seeing their doctor on more than 5 occasions during the previous year. Most patients were satisfied with the support which they received from their GPs. Even so, the majority of patients (72%) would go directly to the hospital clinic for any problem which they perceive to be HIV related.

Prevention of deep venous thrombosis: overview of available therapy options for rehabilitation patients.

The assessment, diagnosis, and treatment of deep venous thrombosis remain a significant problem facing hospitalized patients. The threat of thromboembolism is no less significant, perhaps more so, when patients are discharged from the hospital for subsequent care in rehabilitation units. These patients can have multiple risk factors that predispose them to a high risk of a thromboembolic event. It is clearly evident that thromboembolic prophylaxis is warranted, as it provides both positive clinical and economic outcomes. A variety of nonpharmacologic and pharmacologic strategies can be used to decrease the risk of developing deep venous thrombosis. The method of thromboembolic prophylaxis used should be based on individual patient characteristics and documented clinical and economic advantages. The purpose of this article is to review currently available thromboembolic prophylaxis measures and the implications of their use by rehabilitation physicians.

Models of brain injury rehabilitation.

Rehabilitation services for patients with brain injury have been slower to develop than those with other disabilities, but have rapidly improved over the past 10-15 years. A range of different, specialized brain injury programmes has evolved. The literature is reviewed and the author describes and discusses the relative merits of these models from personal experience and observation in Australia and other countries. The importance of an integrated network of specialized brain injury rehabilitation services is emphasized.

Does the need to self-digitate or the presence of a large or nonemptying rectocoele on proctography influence the outcome of transanal rectocoele repair?

INTRODUCTION: Transanal repair of anterior rectocoele is a well described technique with variable success rate. In our department we offer repair to patients who fit the following criteria; the need to self digitate (transvaginal or perineal); a large rectocoele; a nonemptying rectocoele. Using these selection criteria previous authors have shown excellent results. The aim of our study was to review our results using this selective approach and also to determine whether the need to self digitate, the presence of a large rectocoele and the degree of emptying could predict which patients would achieve a successful result. METHODS: Fifty-five patients underwent repair over a three-year period. The main presenting symptom was noted for each patient and also whether self-digitation was required in order to achieve successful evacuation. Dynamic evacuation proctography was performed on all patients. Size of rectocoele, percentage of paste expelled and other proctographic abnormalities were noted for each patient. Follow up was at 6 weeks and 6 months at which point patients were asked whether their symptoms had resolved, improved, remained the same or had worsened. RESULTS: Complete data were available for 48 of the patients (median age 52 years, IQR 43-63). The presenting complaint was constipation in 22 patients, obstructive defaecation in 15, incomplete evacuation in 5, postdefaecation soiling in 4 and dyspareunia in 2. Thirty-eight patients noted the need to self-digitate, 10 did not. Proctography revealed a large rectocoele (> 4 cm) in 22 patients and a medium or small rectocoele (< 4 cm) in 26 patients. There was a rectocoele alone in 34 patients, in combination with perineal descent in 11 and with intussusception in 3. Median percentage of paste expelled was 70% (range 20-95). At 6 weeks postoperatively, 43 patients had complete resolution of their symptoms whilst 5 reported only some or no improvement. At 6 months, 37 patients sustained complete resolution of their symptoms and 11 did not. Pre-operative factors were compared for these two groups of patients. There was no difference in age (P > 0.05, Mann-Whitney U-test) between the two groups There was also no difference in size of rectocoele, degree of emptying, the presence of another proctographic abnormality and the need to self-digitate between the two groups (P > 0.05, Fisher's exact test). DISCUSSION: No factors were seen to distinguish between the successful and unsuccessful groups of patients following rectocoele repair, however, an overall success rate of 75% was achieved using our selection criteria. This figure is in keeping with reported success rates in the literature.

Post-stroke violent adventitial movement responsive to levo-dopa/carbi-dopa therapy.

Previous reports in the literature concerning cerebrovascular accident have illustrated cases of post-stroke tremor. Treatments of these studies have varied. Trials of levo-dopa have been reported in two such cases. This case study reports on a case of a patient with a left thalamic, left superior cerebellar artery infarction with a lacunar infarction in the basal ganglia. The patient developed a violent tremor/movement disorder which was unresponsive to haloperidol. With this failure, and with the evidence of a basal ganglion lesion, levo-dopa/carbi-dopa was introduced as an intervention. The amplitude of the tremor was dramatically reduced, with protective devices removed, and with complete cessation of the tremor at rest. The medication was withdrawn and reintroduced with a reduction and subsequent resolution of the symptoms. A discussion of the previous studies of movement disorder with cerebrovascular accident is included.

Effect of aberrant hepatic arterial anatomy on tumour response to hepatic artery infusion of floxuridine for colorectal liver metastases.

Regional hepatic artery infusion of colorectal liver metastases produces the highest reported treatment response. The effect of variation in hepatic artery anatomy on tumour response to regional floxuridine (FUdR) was studied. Aberrant hepatic arterial anatomy occurred in 13 of 74 patients (18 per cent) who underwent cannulation of the hepatic artery and infusion of FUdR for colorectal liver metastases. The non-dominant hepatic artery was ligated and the dominant artery cannulated in those with aberrant anatomy. Despite evidence of a collateral circulation to the non-dominant area of the liver in these patients, there was no significant reduction in median tumour volume with treatment (before treatment 214 ml, after treatment 339 ml). By contrast, there was a significant (P < 0.001) decrease in median tumour volume (before treatment 329 ml, after treatment 148 ml) in those with normal anatomy. Delivery of FUdR to metastases via an intrahepatic collateral circulation was not as effective as through a main hepatic artery.

Naltrexone: effects on motor function, speech, and activities of daily living in a patient with traumatic brain injury.

Evidence from many studies has suggested that endogenous opioid peptides participate in a number of pathophysiological responses to brain injury. This provides the rationale for the use of opioid antagonists for the enhancement of neural recovery after brain injury. A case is presented of an 18-year-old male who had loss of consciousness for 1 month after a severe brain injury. Three months of intensive rehabilitative therapies did not change his functional status. A trial of naltrexone was given while his performance in mobility, speech and overall Functional Independence Measure (FIM) scores were monitored. Results indicate an accelerated improvement in functional status and statistically improved FIM score.