The obturator hernia: difficult to diagnose, easy to repair.

BACKGROUND: The aim of this paper is to present a simple method for obturator hernia repair in two cases with strangulated obturator hernia. METHODS: The authors report on two cases of mechanical bowel obstruction due to incarcerated obturator hernia in elderly, thin women. Both patients presented with clinical and radiological signs of small bowel obstruction. Neither of them had the Howship-Romberg or Hannington-Kiff sign. RESULTS: At laparotomy, incarcerated small bowel in a right-sided obturator hernia was observed in both patients. The small bowel was not necrotic, and no bowel resection was performed. The hernial defect was closed in two layers with interrupted and purse-string nonabsorbable sutures. CONCLUSIONS: Obturator hernia is rare and difficult to diagnose. Often the diagnosis is reached only at laparotomy for small bowel obstruction. The double-layer repair with interrupted and purse-string nonabsorbable sutures could be useful, especially in emergency laparotomies for incarcerated obturator hernia.

Skeletal muscle infarction in diabetes mellitus.

OBJECTIVE: To analyze the risk factors, clinical features, and methods of diagnosis of diabetic muscle infarction (DMI). METHODS: Three patients with diabetes mellitus (DM) and skeletal muscle infarction were studied, and 49 additional cases reported in the English literature (Medline database search) were reviewed. RESULTS: Review of all 52 patients with DMI revealed a number of typical features: equal sex distribution; mean age 41.5 years (range 19-81 yrs); a number of risk factors [long duration of DM (mean 15.2 yrs), poor control and microvascular diabetic complications (neuropathy, retinopathy, nephropathy) (94%), and insulin dependent type I DM (77%)]; a characteristic clinical presentation with painful diffuse muscle swelling (100%); and sometimes a muscle mass (44%), predilection for quadriceps (62%), hip adductors (13%) and leg muscles (13%), elevated serum creatine phosphokinase (47%), abnormal sonograms (81%), abnormal magnetic resonance image (MRI) findings (100%), typical histopathologic findings of a muscle infarct (100%) (ultrastructural evidence of microangiography in one patient); and a tendency toward spontaneous resolution although recurrences are common (51%). CONCLUSION: Skeletal muscle infarction is a rare complication of long standing, poorly controlled DM associated with multiple end organ microvascular sequelae. Increased clinical awareness is important for early recognition, particularly in a diabetic patient presenting with a painful thigh or leg swelling. MR imaging is the diagnostic study of choice, and in the appropriate clinical setting, may obviate the need for a muscle biopsy.

Cyclicity in variations of incidence rates for breast cancer in different countries.

The aim was to analyze breast cancer (ICD9; Dx:174) in the view of studying and forecasting registration and incidence dynamics. Cycles in incidence rates for breast cancer in Bulgaria (1952-1985, period T = 17.63 and TH = 73.50 years) were restated. Patterns of annual incidence rates for different time stretches over the years 1964-1993 in the North West Region (NWR, UK), Ontario (Canada), USA and Bulgaria were compared. Monthly registration of new cases in NWR (1972-1993) and Bulgaria (1991-1994) was also analysed. Analysis of seasonality, non-linear regression, Fourier spectra, ARIMA and periodogram regression analysis with basic, detrended or decycled trigonometric approximations were applied. Cyclic variations in incidence for NWR (T = 10.25 years, p < 0.05), Ontario (T = 17.75 years, p < 0.05) and USA (TH = 20.50 years, p < 0.05) were revealed and previous findings confirmed. The cycle of 20.50 years for USA was considered a single "first-degree hypercycle" (n = 17 years). A stable "hypercycle" was found only for NWR (TH = 44 years, p < 0.01) describing a long-term cyclic trend. Short-term cyclicity for registrations in NWR (T = 4, 7.5 and 10.5 months, p < 0.05) and Bulgaria (T = 3, 6 and 11.5 months, p < 0.05), with peaks in March and June-July for both countries and a peak in October for NWR (all at p < 0.05), was also revealed. Cyclicity in occurrence might contribute to better understanding of breast cancer epidemiology and promote creation of more accurate predictive models. The lack of stable "hypercycles" in variations of incidence rates for USA and Ontario, for example, might be seen as an indicator of effectiveness of screening and/or influence of risk factors.

Pyogenic brain abscess caused by Streptococcus pneumoniae: case report and review.

While Streptococcus pneumoniae is the most common cause of bacterial meningitis in adults, cases of pneumococcal brain abscess have rarely been reported. We describe a case of otogenic brain abscess caused by S. pneumoniae that developed in a patient who was receiving ciprofloxacin for the empirical treatment of otitis media. We also review 23 additional cases of pyogenic brain abscess caused by S. pneumoniae that have previously been reported. The development of a pneumococcal brain abscess was associated with a contiguous intracranial focus of infection in 50% of cases. The majority of patients presented with headache (81%) and focal neurological deficits (86%). However, the classic triad of headache, fever, and focal neurological deficits was present in only 24% of patients. The mortality rate for patients with brain abscess caused by S. pneumoniae was 35%; persistent neurological deficits were documented in 40% of patients who survived.

Risk and predictors for pregnancy-related complications in women with heart disease.

BACKGROUND: The physiological changes of pregnancy can result in cardiovascular complications in the mother, which in turn may have fetal implications. Prior studies have focused on specific cardiac lesions or identified univariate predictors. There is a need to refine the risk stratification of women with heart disease so they can receive appropriate obstetrical counseling and care. METHODS AND RESULTS: We examined the outcomes of 221 women with heart disease who underwent 276 pregnancies and received their obstetrical care at three Toronto hospitals from 1986 through 1994. Those who underwent therapeutic abortions were excluded. Among the study participants, there were 24 miscarriages and 252 completed pregnancies (pregnancies not ending in miscarriage). Maternal heart failure, arrhythmia, or stroke occurred in 45 completed pregnancies (18%). There were no maternal deaths. Poor maternal functional class or cyanosis, myocardial dysfunction, left heart obstruction, prior arrhythmia, and prior cardiac events were predictive of maternal cardiac complications. These predictors were incorporated into a point score that can be used to estimate the probability of a cardiac complication in the mother. The rate of cardiac complications for a patient with 0, 1, and >1 of the above factors was 3%, 30%, and 66%, respectively. Neonatal complications occurred in 42 completed pregnancies (17%). Neonatal events included death (2), respiratory distress syndrome (16), intraventricular hemorrhage (2), premature birth (35), and small-for-gestational-age birth weight (14). Poor maternal functional class or cyanosis was predictive of neonatal events. CONCLUSIONS: Despite low maternal and neonatal mortality, pregnancy in women with heart disease is associated with significant cardiac and neonatal morbidity. The probability of maternal cardiac or neonatal events can be predicted from baseline characteristics of the mother.