Traumatic Humeral Diaphysis Extrusion and Replantation With Periosteal Involvement.

Open fractures that produce an extruded long bone diaphysis, such as this case, are an exceedingly rare incident, with even fewer cases documented, leading to difficult medical decision-making for the operative management of such situations. Options for operative management include replantation following sterilization of the extruded fragment, bone transport, a vascularized fibular graft, and even allograft reconstruction. Each option is associated with high and variable levels of risk. The authors report a case study of a 35-year-old female, status post motor vehicle collision (MVC), who sustained a fracture and expulsion of her humeral diaphysis during the incident. She presented to the emergency department by ambulance after colliding into a light post at 50 miles per hour. Upon presentation and examination, the patient scored 14 on the Glascow Coma Scale (GCS) with a positive Focused Assessment with Sonography in Trauma (FAST) exam, consistent with splenic and hepatic injuries. In addition to this, the patient exhibited a flaccid left upper extremity combined with an absent left radial pulse and a small puncture wound on the left anterolateral antecubital area. Radiographic imaging revealed a 6-inch fragment of mid to distal humeral diaphysis missing. Moments later the initial Emergency Medical Services (EMS) crew returned from the scene of the accident with the missing 6-inch fragment of humerus contained in an emesis bag, which was found on the floorboard of the patient's vehicle. This fragment was preserved at -20 °C for 2 days and later used as an autograft in an open reduction internal fixation surgery. This case highlights and details the techniques for proper storage, treatment, and sterilization of the bone fragment during the period of patient stabilization following trauma, to optimize the replantation and union of the fragment. This includes contrasting the different techniques that could be utilized to preserve and sterilize bony fragments, such as autoclaving, gamma radiation, chemical sterilization with iodine, or deciding whether the fragment needs to be discarded altogether with the utilization of allograft.

Gastric Pneumatosis After Accidental Ingestion of Concentrated Hydrogen Peroxide: A Case Report.

INTRODUCTION: Hydrogen peroxide is a common oxidizing agent that if ingested may cause injury to the gastrointestinal tract or embolic events. Although therapy is primarily supportive, gastric perforation is a rare but serious complication of corrosive ingestion that may require surgical treatment. CASE REPORT: We report the case of a 77-year-old male who presented for nausea and vomiting after accidentally ingesting approximately 150 milliliters of 35% hydrogen peroxide. Computed tomography revealed gastric pneumatosis and extensive portal venous air. The patient was admitted for observation with plans for endoscopy; however, due to the limitations of our small community hospital, he was transferred to a tertiary care center due to concern for a potential gastric perforation. CONCLUSION: The presence of portal venous air as a result of peroxide ingestion may be treated conservatively depending on presenting symptoms; however, severe injury such as gastrointestinal perforation may necessitate surgical intervention.

Prolonged Positive COVID-19 Test in Recovered Patient.

Coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global pandemic that has affected millions worldwide since its initial outbreak in Wuhan, China in December 2019. Discussion of atypical cases of COVID-19 is essential to gaining insight into the clinical presentations of this infection. The authors report a case in which a 74-year-old female who sought medical evaluation via telemedicine for chief complaints of recurrent low-grade fever, dyspnea, dry cough, and myalgias and subsequently tested positive for the SARS-CoV-2 multiple times in over 7 weeks despite prior resolution of symptoms. The patient's 78-year-old husband who resides in the same household also contracted the SARS-CoV-2.

Self Manipulated Cervical Spine Leads to Posterior Disc Herniation and Spinal Stenosis.

The authors report a case in which a 38-year-old male who presented himself to the emergency department with a chief complaint of cervical neck pain and paresthesia radiating from the right pectoral region down his distal right arm following self-manipulation of the patient's own cervical vertebrae. Initial emergency department imaging via cervical x-ray and magnetic resonance imaging (MRI) without contrast revealed no cervical fractures; however, there was evidence of an acute cervical disc herniation (C3-C7) with severe herniation and spinal stenosis located at C5-C6. Immediate discectomy at C5-C6 and anterior arthrodesis was conducted in order to decompress the cervical spinal cord. Acute traumatic cervical disc herniation is rare in comparison to disc herniation due to the chronic degradation of the posterior annulus fibrosus and nucleus pulposus. Traumatic cervical hernias usually arise due to a very large external force causing hyperflexion or hyperextension of the cervical vertebrae. However, there have been reports of cervical injury arising from cervical spinal manipulation therapy (SMT) where a licensed professional applies a rotary force component. This can be concerning, considering that 12 million Americans receive SMT annually (Powell, F.C.; Hanigan, W.C.; Olivero, W.C. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery 1993, 33, 73-79.). This case study involved an individual who was able to apply enough rotary force to his own cervical vertebrae, causing severe neurological damage requiring surgical intervention. Individuals with neck pain should be advised of the complications of SMT, and provided with alternative treatment methods, especially if one is willing to self manipulate.

Management Considerations for a Retained Plantar Knife Injury.

A 13-year-old girl presented to the emergency department in stable condition with a retained penetrating knife wound injury in her right foot. Routine radiographs taken of the foot revealed deep tissue penetration by the knife without frank bony involvement. It was decided to remove the object in the operating room. Simple removal was performed, followed by wound exploration. The patient was admitted to the hospital for one night of observation and then was discharged without further complications.

Costs of and reasons for obesity.

The purpose of this literature review was to identify and describe the cost of obesity, the contributing factors, and the use of taxation as a possible method of control of this epidemic in a Canadian setting. A review of the current literature found on the PubMed/MEDLINE services of the National Institutes of Health as well as an analysis of Web content was conducted. The PubMed/MEDLINE search identified 677 articles pertaining to Canada and obesity, 323 articles relating to price policy, 26 articles concerning obesity and taxes, and 29 articles about obesity, Canada, and cost (1964-March 2007). The cost of obesity in Canada has been estimated at $4.3 billion per year, although no yearly figures are available. The contributing factors of obesity in Canada are multivariate, ranging from dietary patterns and physical inactivity to the availability of high-calorie foods at a low cost and greater accessibility. No Canadian studies have been conducted on the use of taxes to curb obesity or evaluating food price elasticity. The available literature suggests that the use of taxes is a viable option to address the issue of obesity in Canada.

Prostate cancers scored as Gleason 6 on prostate biopsy are frequently Gleason 7 tumors at radical prostatectomy: implication on outcome.

PURPOSE: Differentiation between Gleason score 6 and 7 in prostate biopsy is important for treatment decision making. Nevertheless, under grading errors compared with the actual pathological grade at radical prostatectomy are common. We compared the characteristics and outcomes of tumors that were scored 6 on prostate biopsy but were 7 on subsequent radical prostatectomy pathological evaluation to those in tumors with a consistent rating of Gleason score 6 or 7 at biopsy and surgery. MATERIALS AND METHODS: We performed a retrospective database analysis from our referral center (1989 to 2004). We compared pre-prostatectomy characteristics, radical prostatectomy pathological features and the post-radical prostatectomy prostate specific antigen failure rate, defined as any 2 consecutive detectable prostate specific antigen measurements, in 3 subgroups of patients, including 156 with matched Gleason score 6 in the prostate biopsy and radical prostatectomy, 205 with upgraded Gleason score 6/7, that is prostate biopsy Gleason score 6 and radical prostatectomy Gleason score 7, and 412 with matched Gleason score 7 in the prostate biopsy and radical prostatectomy. RESULTS: Radical prostatectomy Gleason score matched the prostate biopsy score in 38.2% of biopsy Gleason score 6 and 81.4% of biopsy Gleason score 7 cases. Higher prostate specific antigen was associated and an increased percent of cancer in the prostate biopsy was predictive of discordance between the prostate biopsy and radical prostatectomy Gleason scores (p <0.001). Margin (p = 0.0075) or seminal vesicle involvement (p = 0.0002), cancer volume (p <0.001) and the prostate specific antigen failures rate (p = 0.014) were significantly higher in under graded Gleason score 7 cancer compared to those in matched Gleason score 6 cases. However, they were comparable to those with a matched Gleason score 7 tumor grade (p = 0.66). CONCLUSIONS: Almost half of tumors graded Gleason score 6 at biopsy are Gleason score 7 at surgery. Upgraded Gleason score 6 to 7 tumors have outcomes similar to those of genuine Gleason score 7 cancer. For prostate biopsy Gleason score 6 tumors clinicians should consider the overall likelihood of tumor upgrading as well as specific patient characteristics, such as prostate specific antigen and the percent of tumor in the prostate biopsy, when contemplating treatments that are optimized for low grade tumors, including watchful waiting or brachytherapy.

Predictors of antiviral therapy in a post-transfusion cohort of hepatitis C patients.

INTRODUCTION: In the past, antiviral therapy has been given to 15% to 30% of patients infected with hepatitis C virus (HCV). The efficacy of therapy has recently improved with the addition of ribavirin and pegylated interferon. The aim of the present study was to identify the clinical, socioeconomic and health-system predictors of antiviral treatment for HCV. METHODS: A retrospective analysis of compensation claims data of patients who acquired HCV through blood transfusions between 1986 and 1990 was performed. The patients consisted of 2456 Canadian HCV-positive individuals. The authors reviewed narrative comments from physicians, and constructed univariate and multivariate logistic regression models, using receipt of antiviral therapy with interferon or interferon/ribavirin as the primary outcome. RESULTS: Of the 2456 patients, approximately 30% appeared to be eligible, but only 16% received treatment. Univariate analyses suggested that the disease severity, age, HIV status and province of residence were associated with the likelihood of receiving treatment (P<0.01). The final, multivariable model indicated that in patients with HCV: intermediate disease severity (eg, fibrosis, P<0.0001); middle age (P<0.0001); HIV-negative status (P<0.0001); and province of residence (Quebec, P<0.0001; and Saskatchewan, P<0.0001) were independent predictors of treatment. Narrative comments of physicians emphasized the importance of age, HIV status and patient preferences in clinical decision-making. DISCUSSION: Given the efficacy and cost-effectiveness of current antiviral therapy, treatment rates of HCV patients may be suboptimal. Further work is required to understand barriers to treatment related to geography, organization of medical care, age, medical provider and patient preferences.

Public drug plan coverage for children across Canada: a portrait of too many colours.

BACKGROUND: As debate continues regarding pharmacare in Canada, little discussion has addressed appropriate drug plan coverage for vulnerable populations, such as children. The primary objective of this study was to determine the extent of medication coverage for children in publicly administered programs in each province across Canada. METHODS: Data were collected on provincial, territorial and federal government drug plans, and 2003 formulary updates were obtained. A simulation model was constructed to demonstrate costs to a low-income family with an asthmatic child in each province. Programs were compared descriptively. The extent of interprovincial variation in 2003 formulary approvals was summarized statistically. RESULTS: There was 39% variation between provinces with respect to 2003 formulary approvals (chi-square p < 0.0001) and 48% variation for 2003 paediatric-labelled products (chi-square p < 0.0001). Across Canada, only 8% of 2003 formulary approvals were indicated primarily for paediatric conditions. In the simulation model, costs were less than or equal to 3% of household income in provinces with plans for low-income families, catastrophic costs (Ontario) or for the population. Families who failed to qualify for low income plans or who resided in New Brunswick or Newfoundland faced costs up to 7% of household income. INTERPRETATION: With regard to pharmaceutical benefits for children, provincial drug programs vary considerably in terms of whom they cover, what drugs are covered and how much subscribers must pay out of pocket. Unlike seniors and social assistance recipients, the provinces do not agree on the importance of providing comprehensive coverage for all children. For many Canadian children, significant financial barriers exist to medication access.