Gastric Pneumatosis and Its Gastrofibroscopic Findings in Life-Threatening Superior Mesenteric Artery Syndrome Complicated by Anorexia Nervosa in a Child.

A 14-year-old girl was admitted to the emergency department for excessive bile-containing vomiting and severe abdominal pain. She had been healthy until she intentionally lost 25 kg over a 6-month period. Thick, bloody bile-mixed food particles were drained from the stomach through a nasogastric tube. Abdominal computed tomography revealed huge stomach dilatation with extensive gastric pneumatosis, possible near rupture, acute pancreatitis, and a very narrow third of the duodenum, indicating superior mesenteric syndrome. Gastrofibroscopy revealed multiple hemorrhagic ulcers and numerous bead-like cystic lesions in the stomach. Laboratory examination results were notable for severe deficiencies in critical nutrients, including iron, zinc, proteins, and prealbumin, as well as undernutrition-associated endocrine complications such as hypothyroidism and hypogonadotropic hypogonadism. Excessive vomiting ceased after the endoscopic removal of stagnant gastric contents. Gastric pneumatosis improved after 3 days of supportive care.

Molecular diagnosis of hereditary spherocytosis by multi-gene target sequencing in Korea: matching with osmotic fragility test and presence of spherocyte.

BACKGROUND: Current diagnostic tests for hereditary spherocytosis (HS) focus on the detection of hemolysis or indirectly assessing defects of membrane protein, whereas direct methods to detect protein defects are complicated and difficult to implement. In the present study, we investigated the patterns of genetic variation associated with HS among patients clinically diagnosed with HS. METHODS: Multi-gene targeted sequencing of 43 genes (17 RBC membrane protein-encoding genes, 20 RBC enzyme-encoding genes, and six additional genes for the differential diagnosis) was performed using the Illumina HiSeq platform. RESULTS: Among 59 patients with HS, 50 (84.7%) had one or more significant variants in a RBC membrane protein-encoding genes. A total of 54 significant variants including 46 novel mutations were detected in six RBC membrane protein-encoding genes, with the highest number of variants found in SPTB (n = 28), and followed by ANK1 (n = 19), SLC4A1 (n = 3), SPTA1 (n = 2), EPB41 (n = 1), and EPB42 (n = 1). Concurrent mutations of genes encoding RBC enzymes (ALDOB, GAPDH, and GSR) were detected in three patients. UGT1A1 mutations were present in 24 patients (40.7%). Positive rate of osmotic fragility test was 86.8% among patients harboring HS-related gene mutations. CONCLUSIONS: This constitutes the first large-scaled genetic study of Korean patients with HS. We demonstrated that multi-gene target sequencing is sensitive and feasible that can be used as a powerful tool for diagnosing HS. Considering the discrepancies of clinical and molecular diagnoses of HS, our findings suggest that molecular genetic analysis is required for accurate diagnosis of HS.

Treatment of complex regional pain syndrome using free-flap surgery: a case report.

Complex regional pain syndrome is a chronic progressive illness with sensory, autonomic, trophic, and motor abnormalities. Treatment is difficult and controversial. We report the results of free-flap and vein wrapping of the superficial peroneal nerve surgery to treat complex regional pain syndrome.

Point-Connecting Measurements of the Hallux Valgus Deformity: A New Measurement and Its Clinical Application.

PURPOSE: The aim of this study was to investigate new point-connecting measurements for the hallux valgus angle (HVA) and the first intermetatarsal angle (IMA), which can reflect the degree of subluxation of the first metatarsophalangeal joint (MTPJ). Also, this study attempted to compare the validity of midline measurements and the new point-connecting measurements for the determination of HVA and IMA values. MATERIALS AND METHODS: Sixty feet of hallux valgus patients who underwent surgery between 2007 and 2011 were classified in terms of the severity of HVA, congruency of the first MTPJ, and type of chevron metatarsal osteotomy. On weight-bearing dorsal-plantar radiographs, HVA and IMA values were measured and compared preoperatively and postoperatively using both the conventional and new methods. RESULTS: Compared with midline measurements, point-connecting measurements showed higher inter- and intra-observer reliability for preoperative HVA/IMA and similar or higher inter- and intra-observer reliability for postoperative HVA/IMA. Patients who underwent distal chevron metatarsal osteotomy (DCMO) had higher intraclass correlation coefficient for inter- and intra-observer reliability for pre- and post-operative HVA and IMA measured by the point-connecting method compared with the midline method. All differences in the preoperative HVAs and IMAs determined by both the midline method and point-connecting methods were significant between the deviated group and subluxated groups (p=0.001). CONCLUSION: The point-connecting method for measuring HVA and IMA in the subluxated first MTPJ may better reflect the severity of a HV deformity with higher reliability than the midline method, and is more useful in patients with DCMO than in patients with proximal chevron metatarsal osteotomy.

Second Metatarsal Transfer Lesions Due to First Metatarsal Shortening After Distal Chevron Metatarsal Osteotomy for Hallux Valgus.

BACKGROUND: The first metatarsal bone can shorten after a distal chevron metatarsal osteotomy (DCMO). This shortening can result in a postoperative second metatarsal transfer lesion. The aim of the present study was to investigate the occurrence of second metatarsal transfer lesions after DCMO. METHODS: This study involved 185 feet (138 patients), with hallux valgus (HV) deformity, treated with DCMO with Akin osteotomy. The mean patient age was 51.7 years (range, 21 to 74). Patients were followed for an average of 28 months, between June 2004 and June 2010. We measured the length of first metatarsal relative to second metatarsal preoperatively and postoperatively, using Morton's and Hardy-Clapham's methods. A second metatarsal transfer lesion was defined as a newly developed lesion, including metatarsalgia, a painful callosity, or a painless callosity, which was not present prior to the DCMO. The relation of the shortened first metatarsal after DCMO with the occurrence of second metatarsal transfer lesion was evaluated. RESULTS: Second metatarsal transfer lesions (painless callosity) developed in 5 feet (2.7%) of 185 feet. Twenty-four preoperative second metatarsal lesions were improved postoperatively. The median shortening of the first metatarsal bone after DCMO was 0.6 mm according to Morton's method (range, -6.4 to 6.4), and 1.9 according to Hardy-Clapham's method (range, -5.8 to 5.8). According to the extent of first metatarsal shortening after DCMO by Hardy-Clapham's method and Morton's method, there was no significant difference of the occurrence of second transfer metatarsal lesions (P = .259 and P = .176, respectively). CONCLUSIONS: In our study, second metatarsal transfer lesions developed in 2.7% of feet after DCMO. The occurrence of second metatarsal transfer lesions did not appear to be correlated with the degree of first metatarsal shortening in cases with less than 5.8 mm shortening. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Subungual glomus cell proliferation in the toe: a case report.

Glomus tumors are rare benign neoplasms. They typically present with a triad of severe pain, point tenderness, and cold sensitivity. Most glomus tumors will form well-circumscribed nodules, and excisional biopsy of masses detected by ultrasonography or magnetic resonance imaging of the lesion can relieve the symptoms. We describe a 30-year-old female patient with nontumorous glomus cell proliferation with clinical symptoms similar to those of glomus tumors. The lesion was treated by exploration and excision, with a satisfactory clinical outcome.

Treatment of naviculo-first cuneiform coalition of the foot.

BACKGROUND: Naviculo-first cuneiform coalition is a rare form of tarsal coalition with few reports. We therefore have analyzed its clinical features and the results of treatment. METHODS: We analyzed 36 feet in 28 patients diagnosed with naviculo-first cuneiform coalition from January 2003 to December 2010. The 28 patients were 10 males and 18 females, with 18 right and 18 left feet, including 8 patients with bilateral coalition. The location and morphological pattern of naviculo-first cuneiform coalition were analyzed radiologically. Symptomatic patients initially received conservative management for 6 months. Six feet of 5 patients were treated operatively, 3 feet by curettage and 3 by fusion. RESULTS: Eighteen feet had symptoms, while 18 feet without symptoms were diagnosed incidentally. Mean patient age at diagnosis was 34.6 years (range, 10-68 years). The mean age at diagnosis of symptomatic patients was 29.6 years (range, 10-50 years). Coalitions were located mainly in the medioplantar area. There was no bony coalition. Computed tomography or magnetic resonance imaging showed a cystic pattern in 7 patients, an irregular pattern in 4, a combined pattern in 5, and a spur-forming pattern in 1. The mean American Orthopaedic Foot & Ankle Society scores at the last follow-up in patients treated conservatively and operatively were 95.3 (range, 87-100) and 83.5 (range, 70-95), respectively. Among the 5 operated patients, 3 patients (60%) complained of pain, including 2 who received curettage and 1 who developed a nonunion after attempted fusion. CONCLUSION: Conservative treatment should be considered over surgery in treating naviculo-first cuneiform coalition. LEVEL OF EVIDENCE: Level III, comparative case series.

Risk factors affecting chronic rupture of the plantar fascia.

BACKGROUND: Prior to 1994, plantar fascia ruptures were considered as an acute injury that occurred primarily in athletes. However, plantar fascia ruptures have recently been reported in the setting of preexisting plantar fasciitis. We analyzed risk factors causing plantar fascia rupture in the presence of preexisting plantar fasciitis. METHODS: We retrospectively reviewed 286 patients with plantar fasciitis who were referred from private clinics between March 2004 and February 2008. Patients were divided into those with or without a plantar fascia rupture. There were 35 patients in the rupture group and 251 in the nonrupture group. The clinical characteristics and risk factors for plantar fascia rupture were compared between the 2 groups. We compared age, gender, the affected site, visual analog scale pain score, previous treatment regimen, body mass index, degree of ankle dorsiflexion, the use of steroid injections, the extent of activity, calcaneal pitch angle, the presence of a calcaneal spur, and heel alignment between the 2 groups. RESULTS: Of the assessed risk factors, only steroid injection was associated with the occurrence of a plantar fascia rupture. Among the 35 patients with a rupture, 33 had received steroid injections. The odds ratio of steroid injection was 33. CONCLUSION: Steroid injections for plantar fasciitis should be cautiously administered because of the higher risk for plantar fascia rupture. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Impact of Physician's Education on Adherence to Tuberculosis Treatment for Patients of Low Socioeconomic Status in Bangladesh.

Successful tuberculosis control depends on good adherence to treatment. Yet, limited data are available on the efficacy of methods for improving the adherence of patients of low socioeconomic status. We evaluated the impact of physician-provided patient education on adherence to anti-tuberculosis medication in a low socioeconomic status and resource-limited setting. A pre-/post-intervention study was conducted at a suburban primary health care clinic in Bangladesh where an intensive education strategy was established in May 2006. Treatment outcomes of tuberculosis patients from March 2005 to April 2006 (pre-intervention) and from May 2006 to December 2007 (post-intervention) were compared. Among 354 patients, 198 (56%) were treated before intervention and 156 (44%) were treated after intervention. Cumulative adherence to anti-tuberculosis medication was significantly greater in the intervention group than in the control group in univariate and multivariate analyses. Physician's education can contribute to increasing the adherence of patients in resource-limited settings.

Surgical treatment of non-diabetic chronic osteomyelitis involving the foot and ankle.

BACKGROUND: We evaluated the clinical characteristics and treatment outcomes of patients with chronic osteomyelitis in the foot and ankle in patients without diabetes. METHODS: We reviewed 15 patients treated for chronic osteomyelitis involving the foot and ankle between September 2004 and March 2007. Patients with diabetes mellitus or who were immunocompromised were excluded. The cause of osteomyelitis, sites of occurrence, causative pathogens, and invasion of the adjacent joint(s) were reviewed, then the clinical characteristics were analyzed. Magnetic resonance imaging was performed to clarify the extent of infection and invasion of the adjacent joint. Surgical management included wide debridement, dead space control, and arthrodesis if there was invasion of the adjacent joint. The mean postoperative followup period was 3.3 years, during which recurrences and complications were evaluated. RESULTS: Extrinsic causes accounted for 86.7% of the chronic osteomyelitis involving the foot and ankle. The most common cause of osteomyelitis was trauma with ten cases due to complications following fractures or dislocation. Methicillin-resistant Staphylococcus aureus and Pseudomonas were the most common causative pathogens. In 46.7% of the patients, the adjacent joint was involved and an arthrodesis was performed. The mean length of the hospital stay was 39.1 days. The average of number of surgeries was two. Fourteen of 15 patients had no recurrence. CONCLUSION: For the successful treatment of chronic osteomyelitis involving the foot and ankle, an arthrodesis based on invasion of the adjacent joint as well as wide debridement and dead space control was successful in this series.