Acute Calculous Cholecystitis With Sinus Bradycardia: Cope's Sign Encountered.

Acute cholecystitis and cardiac ischemia can have a similar clinical presentation in some patients. Nonspecific electrocardiographic changes and arrhythmias can occur in acute cholecystitis and gallbladder disease that can confuse the treating physician leading to extensive cardiac workup. Emergency physicians and cardiologists should be aware of these changes so they can expedite the management of acute cholecystitis, which can lead to the resolution of these changes. We report a case of a 53-year-old male who presented with diffuse abdominal pain, nausea, and vomiting. His ECG showed sinus bradycardia. Imaging confirmed the diagnosis of acute calculous cholecystitis. His cardiac workup was unremarkable. His sinus bradycardia was resolved with the management of acute cholecystitis. This case highlights the possibility of a "cardio-biliary reflex" that is initiated by gallbladder pain via autonomic vagal innervation.

Impact of centralization of pancreaticoduodenectomy coupled with fast track recovery protocol: a comparative study from India.

BACKGROUND: Fast track strategy in the management of patients undergoing intra-abdominal surgery of various types has emerged as a landmark approach to reduce surgical stress and accelerate recovery. This study was to evaluate the effect of fast track strategy on patients subjected to pancreaticoduodenectomy (PD) from an individual unit during transit from low to a high volume center. METHODS: A total of 142 PD patients who had been subjected to fast track strategy between June 2008 and September 2012 were compared with 46 patients who had received conventional surgery between January 2006 and May 2008. Comparative analysis was made of postoperative complications, postoperative recovery, length of hospital stay and patient readmission requirement. RESULTS: The patients subjected to fast track strategy had a faster recovery and a shorter hospital stay than those who were treated conventionally (7.8 vs 12.1 days). The intraoperative events like operative blood loss (417.9+/-83.8 vs 997.4+/-151.8 mL, P<0.001), blood transfused (a median of 0 vs 1 unit, P<0.001) and operative time taken (125 vs 245 minutes, P<0.001) were significantly lower in the fast track group. The frequency of pancreatic fistula (4.9% vs 13.0%) and delayed gastric emptying (7.0% vs 17.4%) was also significantly reduced with fast track treatment. Nevertheless, the readmission rate (11.3% vs 6.5%) was found relatively higher within the fast track group. However, increased readmission rates in this study seem to be independent of fast track protocol. CONCLUSIONS: This preliminary analysis suggests that the fast track approach might be beneficial to the well-being of the patients after PD, for it accelerates the immediate clinical recovery of patients and significantly shortens their length of hospital stay.

Normative data for vestibular evoked myogenic potential in different age groups among a heterogeneous Indian population.

To establish normative data of vestibular evoked myogenic potential in different age groups among a heterogeneous Indian population. Prospective study design using a sample of convenience. Eighty five normal controls ranging between the ages 7 and 71 years were asked to provide a written signed consent for the study. Demographic characteristics of the patients were summarized using descriptive statistical methods using SPSS-17 analysing software. The outcome variable (VEMP recording) was expressed in percentiles as function of age. In all patients the stimulus which gave the best response was 95 dB (97.7 %) and 100 dB (95 %). The mean of wave latencies (p1 & n1) for 95-VEMP were, 11.2 ± 3.2 and 17.3 ± 4.7 ms on the right and 11.0 ± 2.8 and 17.0 ± 4.2 ms on the left respectively. The amplitude was 45.1 ± 54 mV on right and 46.9 ± 61.6 mV on the left. The mean of latency difference was 0.87 ms. The VEMP is a relatively simple test. The VEMP response rate was maximum in the younger age group; the optimum intensity was 95 dB. The asymmetry ratio interpretation should be done according to the age specific values.

Pericecal hernia: a rare form of internal hernias.

We report a rare and interesting case of a pericecal hernia. A 34-year-old male presented to the emergency department with severe periumbilical pain, emesis and a prior syncopal episode. He noted a 3-month history of intermittent, colicky periumbilical pain. His abdominal examination demonstrated a palpable mass in the right lower quadrant, involuntary guarding and rebound tenderness. CT demonstrated dilated small-bowel loops and findings suggestive of ischemia. The patient was immediately taken to the operating room where a diagnosis of pericecal hernia was made. The patient underwent a reduction of the hernia and a repair of the mesenteric defect.

Ileal diverticulitis: an uncommon diagnosis for right lower quadrant pain.

We report an interesting case of ileal diverticulitis which posed a diagnostic challenge. A 75-year-old female presented to the emergency department with severe right lower quadrant pain for 3 days. The clinical history, examination and imaging suggested a diagnosis of acute appendicitis. The patient was taken to the operating room for an open appendectomy. The intra-operative findings demonstrated a large mass at the ileocecal junction involving the appendix as well as multiple nodular masses in the ileum and cecum. The patient underwent a right hemicolectomy with ileocecal anastomosis. The pathology result revealed Ileal diverticulitis. Ileal diverticulitis is a rare form of diverticulitis. It can often mimic other processes such as acute appendicitis. Once ileal diverticulitis is diagnosed, it should be treated with the same principles as for sigmoid diverticulitis. Though rare, ileal diverticulitis should be considered in the differential diagnosis of a patient who presents with right lower quadrant pain, and a computed tomography scan that shows an inflammatory process in the right lower quadrant, in the setting of a normal appendix.

Rural drinking water at supply and household levels: quality and management.

Access to safe drinking water has been an important national goal in Bangladesh and other developing countries. While Bangladesh has almost achieved accepted bacteriological drinking water standards for water supply, high rates of diarrheal disease morbidity indicate that pathogen transmission continues through water supply chain (and other modes). This paper investigates the association between water quality and selected management practices by users at both the supply and household levels in rural Bangladesh. Two hundred and seventy tube-well water samples and 300 water samples from household storage containers were tested for fecal coliform (FC) concentrations over three surveys (during different seasons). The tube-well water samples were tested for arsenic concentration during the first survey. Overall, the FC was low (the median value ranged from 0 to 4 cfu/100ml) in water at the supply point (tube-well water samples) but significantly higher in water samples stored in households. At the supply point, 61% of tube-well water samples met the Bangladesh and WHO standards of FC; however, only 37% of stored water samples met the standards during the first survey. When arsenic contamination was also taken into account, only 52% of the samples met both the minimum microbiological and arsenic content standards of safety. The contamination rate for water samples from covered household storage containers was significantly lower than that of uncovered containers. The rate of water contamination in storage containers was highest during the February-May period. It is shown that safe drinking water was achieved by a combination of a protected and high quality source at the initial point and maintaining quality from the initial supply (source) point through to final consumption. It is recommended that the government and other relevant actors in Bangladesh establish a comprehensive drinking water system that integrates water supply, quality, handling and related educational programs in order to ensure the safety of drinking water supplies.