Case series of retained rectal foreign body. A Malaysian experience

@#Retained rectal foreign body, with its associated social stigma, is a medical condition that is infrequently reported in Malaysia. We report the surgical management of five cases of retained foreign objects in the rectum seen over a one-year period. There were three young and two elderly male patients. One of the elderly patients presented with altered bowel habits and an abdominal mass that mimicked a symptomatic colonic tumor. All patients had an abdominal radiograph which clinched the diagnosis of a retained foreign rectal body. Successfully retrieved objects included two bottles, one bidet device, and two sex toys. Open surgery for retrieval of the impacted rectal foreign body was required in one patient. All underwent successful retrievals without any adverse postoperative complications. In our case series, retained rectal foreign bodies were observed only in the male gender. The age presentation was bimodal, with age groups in the twenties and sixties. The treatment options used for the retrieval of these impacted foreign bodies included transanal extraction or explorative laparotomy. Proximal migration and delayed presentation are possible indications for the latter approach.

Healthcare Utilization and Treatment Patterns in Diabetic Macular Edema in Korea: a Retrospective Chart Review

BACKGROUND: Limited data exist on real-world treatment patterns for diabetic macular edema (DME) in Korea. In this study, we investigated DME treatment patterns from 2009 to 2014 and the impact of baseline treatment on healthcare resource utilization and visual acuity (VA) outcomes. METHODS: A retrospective cohort chart review of DME patients treated at 11 hospital ophthalmology clinics between January 1, 2012 and December 31, 2013 was conducted. We collected data on demographics, healthcare resource utilization (clinic visits, treatment visits, and visits for ocular investigations), distribution of DME treatments, and VA. RESULTS: Overall, 522 DME patients (men, 55.2%; mean age, 59 years; mean HbA1c [n = 209], 8.4%) with 842 DME eyes were evaluated. For all treatments, healthcare resource utilization was significantly higher during the first 6 months versus months 7–12, year 2, or year 3 (P ≤ 0.001), but was highest for patients whose first treatment was an anti-vascular endothelial growth factor (VEGF) treatment (visits/quarter; anti-VEGF, 1.9; corticosteroids, 1.7; laser, 1.4). Use of macular laser therapy decreased (44% to 8%), whereas use of anti-VEGF injections increased (44% to 69%) during the study period. However, VA improvement was not commensurate with healthcare resource utilization of anti-VEGF treatment (mean VA gain, 2.7 letters). CONCLUSION: A trend toward increasing use of intravitreal anti-VEGF injections for DME treatment was observed in Korea. However, the frequency of dosing and monitoring was lower in clinical practice versus major clinical trials, which may have led to the less-than-favorable improvements in visual outcomes.

Early clinical manifestations of vibrio necrotising fasciitis

We present five patients with vibrio necrotising fasciitis, a lethal and disabling disease. Two of these patients had a history of exposure to either warm seawater or raw/live seafood, three had underlying chronic liver disease, and four presented with hypotension and fever. There were three deaths and four patients required intensive care unit stays. Among the two survivors, one had high morbidity. Only one patient met the criteria of Laboratory Risk Indicator for Necrotising Fasciitis score > 6. A clinician should suspect possible vibrio necrotising fasciitis if the following are present: contact with fresh seafood/warm seawater, a known history of chronic liver disease and pain that is out of proportion to cutaneous signs. All patients must be managed via intensive care in high dependency units. We recommend a two-step surgical protocol for patient management involving an initial local debridement, followed by a second-stage radical debridement and skin grafting.

The long and short of cephalomedullary nails in the treatment of osteoporotic pertrochanteric fracture

<p><b>INTRODUCTION</b>Pertrochanteric fractures after low-energy trauma are common among osteoporotic patients. Although the use of intramedullary devices to treat such fractures is becoming increasingly popular, there is a paucity of data comparing the outcomes of the use of short cephalomedullary nails (SCN) with the use of long cephalomedullary nails (LCN). This study aimed to compare the outcomes of treatment using LCN with treatment using SCN for patients with osteoporotic pertrochanteric fractures.</p><p><b>METHODS</b>A retrospective review of 64 patients with osteoporotic pertrochanteric fractures who were treated with either LCN or SCN and had a minimum follow-up of one year was performed. Primary outcome measures include complications, revision surgeries and union rates. Secondary outcome measures include duration of surgery, estimated blood loss, length of hospital stay, and ambulatory and mortality status at one year.</p><p><b>RESULTS</b>There was no significant difference in the clinical and functional outcomes of the patients who were treated with LCN and those who were treated with SCN. However, there was a higher incidence of heterotopic ossification in the latter group, and a slightly greater average estimated blood loss and duration of surgery in the former group. Patients treated with LCN tended to be more osteoporotic.</p><p><b>CONCLUSION</b>Our study found no significant difference in terms of complications, revision surgeries, union rates and ambulatory status between the patients who were treated with LCN and those who were treated with SCN. Both LCN and SCN provided safe and reliable outcomes in the treatment of osteoporotic pertrochanteric fractures.</p>

Intraoperative airway obstruction related to tracheostomy tube malposition in a patient with achondroplasia and Jeune's syndrome

A 14 year-old adolescent with achondroplasia and Jeune's syndrome [asphyxiating thoracic dystrophy] presented for cervical spine surgery in the prone position. Due to the need for home mechanical ventilation at night, the patient had a tracheostomy in place. With the first surgical procedure, the cuffed tracheostomy tube was left in place during prone positioning. Difficulties encountered with ventilation through the cuffed tracheostomy tube in the prone position necessitated aborting the case. During three subsequent surgeries, the tracheostomy tube was removed and an armored endotracheal tube was placed through the tracheostomy stoma prior to prone positioning. No further difficulties with ventilation were noted with the subsequent cases. There are currently no guidelines in the medical literature regarding perioperative management of patients with a tracheostomy requiring prone positioning for surgery. The management of such patients is reviewed and possible problems with tracheostomy positioning during prone positioning are explored. Given such issues, we would suggest removal of the tracheostomy tube and placement of an armored endotracheal tube through the stoma during surgical procedures in the prone position