Gerard Baltazar

Discovery of a case of Waugh's syndrome during a mission to Haiti

INTRODUCTION A rarely reported entity, Waughs syndrome is the association between intestinal malrotation and intussusception. We present a case of Waughs syndrome encountered during a medical mission to a resource poor country. PRESENTATION OF CASE A 3-month-old female presented with septic shock and acute bowel obstruction secondary to intussusception and malrotation. She required aggressive resuscitation and emergent laparotomy, bowel resection, Ladd procedure and temporary ileostomy. DISCUSSION First described in 1911, Waughs syndrome has been rarely reported in the literature. We summarize a total of 54 cases of Waughs syndrome that are reported in the literature to date. The complicated but successful care of this patient reflects the severe outcome of any inadequate treatment of Waughs syndrome and illustrates the importance of medical volunteers in developing countries. CONCLUSION As the relationship between malrotation and intussusception may be more frequent than recorded, surgeons must be aware that non-operative management of intussusception may be inadequate therapy.

Systemic inflammatory response syndrome and platelet count ≥250×10 9 are associated with venous thromboembolic disease

Introduction Prior research has demonstrated that platelet count and inflammation are dominant contributors to hypercoagulability. Our objective is to determine whether elevated platelet count and systemic inflammatory response syndrome (SIRS) have an association with the development of venous thromboembolism (VTE) in hospitalized patients with a high clinical index of suspicion for thromboembolic disease. Methods We performed a retrospective medical record review of 844 medical and surgical patients with suspected VTE hospitalized from July 2012 to May 2013 who underwent screening by venous duplex and computed tomography pulmonary angiogram. For our purposes, thrombocytosis was arbitrarily defined as platelet count ≥250×109/L. Results Venous thromboembolic disease was detected in 229 patients (25.9%). Thrombocytosis was present in 389 patients (44%) and SIRS was present in 203 patients (23%) around the time of imaging. Thrombocytosis and SIRS were positively correlated with VTE (P<0.001). There was no correlation between thrombocytosis and SIRS. Multivariate analysis revealed that SIRS (odds ratio 1.91, 95% confidence interval 1.36–2.68, P<0.001) and thrombocytosis (odds ration 1.67, 95% confidence interval 1.23–2.26, P=0.001) were independently associated with VTE. Conclusion Patients at high risk for VTE should be routinely assessed for thrombocytosis (≥250×109/L) and SIRS; if either is present, consideration for empiric anticoagulation should be given while diagnostic imaging is undertaken.

Colonic atresia and anorectal malformation in a Haitian patient: a case study of rare diseases

IntroductionColonic atresia and anorectal malformation are rare congenital anomalies individually. Few reports of the conditions combined in a single patient have been published in the literature. Neither colonic atresia, anorectal malformation or a combination of the disorders has previously been reported in the Haitian population.Case presentationA 5-day-old female presented with feculent emesis, failure to pass stool since birth and an imperforate and stenotic anus. Exploratory laparotomy revealed colorectal atresia distal to a malformed cecum and a Wingspread low subtype anorectal malformation without any associated urogenital fistulae. Temporizing percutaneous ileal drainage was followed by second-stage anal perforation and dilation, ileal J-pouch and pull through.DiscussionThis is the first reported case of colonic atresia, anorectal malformation or the combination of the disorders among the Haitian population and one of only a handful of such cases reported worldwide. Although vascular accidents in utero have been implicated as the etiology of colonic atresia, simultaneous presence of anorectal malformation suggests a multifactorial cause. Investigation for multisystem abnormalities is warranted. Two-staged operative correction is considered the best treatment; however, long-term postoperative outcomes are uncertain.ConclusionThe coexistence of colonic atresia and anorectal malformation is a very rare occurrence and presents unique clinical and operative challenges. Investigation for additional congenital abnormalities is appropriate, and although two-stage operative correction is considered the best treatment, long-term outcomes are uncertain.

Spontaneous Common Bile Duct Perforation—a rare clinical entity

Highlights • Spontaneous common bile duct perforation is a rare clinical entity.• Our case is the first case in the literature of a witnessed spontaneous common bile duct perforation.• Our patient was diagnosed prior to surgical intervention, which is unusual with this disease process.

Older patients have increased risk of poor outcomes after low-velocity pedestrian–motor vehicle collisions

Background Motor vehicle collisions (MVCs) are a leading cause of injury in the US. While the probability of collision with a pedestrian (PMVC) has declined in recent years, the probability of a pedestrian fatality has risen. Our objective was to determine whether older age impacts potential outcomes in patients involved in low-velocity PMVCs. Materials and methods We performed a retrospective-cohort study of adult patients aged >14 years involved in low-velocity pedestrian–MVCs (<15 miles per hour [24.14 km/h]), presenting to an urban level I trauma center from January to November 2013. Subjects were identified via trauma registry and stratified: ages 15–49 years and ≥50 years. Electronic medical records were reviewed for demographics, vital signs, and laboratory results on initial presentation, presence or absence of systemic inflammatory response syndrome (SIRS), shock index (SI), injury-severity score (ISS), length of stay (LOS), and survival to discharge. For statistical analysis, χ2 or Student’s t-tests were utilized. Results Our study included 145 patients (77 female) with a mean age of 41.9±3 years; 95 patients were aged 15–49 years (mean 31.9±2.2 years), and 50 patients were aged ≥50 years or older (mean 62.44±2.9 years). Mean ISS was 10.05±1.95, mean SI was 0.68±0.03, and mean LOS was 3.67±0.57 days. A total of 41 patients met SIRS criteria on arrival, and nine patients expired (6.2%). Mean ISS (15.64±4.42 vs 7.1±1.64, P<0.001) and mean SI (0.75±0.07 vs 0.65±0.03, P=0.002) were higher in patients aged ≥50 years. Mean LOS was longer in older patients (5.22±1.14 vs 2.85±0.58 days, P<0.001). Older age was associated with SIRS on arrival (P=0.023) and associated with mortality (P=0.004). Conclusion Age ≥50 years is associated with greater severity of injury and poor outcomes for patients involved in low-velocity PMVCs. Increased clinical attention and resource allocation should be directed toward older patients after low-velocity PMVCs.

Osteopathic Manipulative Treatment for Somatic Dysfunction After Acute Severe Traumatic Brain Injury

Somatic dysfunction caused by traumatic brain injury (TBI) may be managed by osteopathic manipulative treatment (OMT). In this case report, the authors describe 2 patients with severe TBI who were each treated with OMT in a level-1 regional trauma center. Both patients received OMT beginning in the acute care phase of injury. Somatic dysfunction improved during the course of treatment, and no adverse effects of OMT were noted. More comprehensive research may clarify the efficacy and adverse effects of OMT as part of multimodal acute care of patients with severe TBI.