Prospective evaluation of the role of computed tomography in the assessment of abdominal stab wounds.

IMPORTANCE: An important adjunct in the management of abdominal gunshot wounds, the role of computed tomography (CT) in the diagnostic workup of abdominal stab wounds remains controversial. OBJECTIVE: To prospectively compare CT against serial physical examination in the evaluation of patients who have sustained a stab wound to the abdomen. DESIGN, SETTING, AND PATIENTS: Prospective single-center observational study of all patients sustaining abdominal stab wounds from March 1, 2009, through March 31, 2011. Patients who were hemodynamically unstable, unevaluable, peritonitic, or eviscerated proceeded directly to laparotomy (n = 249). The remainder underwent CT evaluation. The impact of CT findings and physical examination on the decision to operate was analyzed. MAIN OUTCOMES AND MEASURES: Diagnostic accuracy of CT vs physical examination in determining the need for therapeutic laparotomy. RESULTS: A total of 249 patients were enrolled (94% male; mean [SD]: age, 30.8 [12.9] years [range, 16-87 years]; systolic blood pressure, 128 [28] mm Hg; Glasgow Coma Scale score, 14 [2]; Injury Severity Score, 6.8 [6.5]). Forty-five patients (18.1%) underwent immediate laparotomy, 27 (10.8%) had superficial injuries allowing immediate discharge, and the remaining 177 (71.1%) underwent CT. Of these, 154 (87.0%) were successfully observed, with 20 (11.3%) requiring laparotomy, 2 (1.1%) thoracotomy, and 1 (0.6%) sternotomy. Of the 20 laparotomies, 16 (80.0%) were therapeutic. All patients who underwent therapeutic laparotomy did so based on their physical examination. The most common finding leading to laparotomy was the development of peritonitis in 70%. The CT scan findings did not alter clinical decision making. The sensitivity and specificity of physical examination were 100.0% and 98.7%, respectively, while those of CT were 31.3% and 84.2%, respectively. CONCLUSIONS AND RELEVANCE: In this prospective evaluation of abdominal stab wound management, serial physical examination was able to discriminate between patients requiring a therapeutic laparotomy and those who could be safely observed. A physical examination-based diagnostic algorithm was effective and decreased radiation burden in the management of abdominal stab wounds.

Novel application of a fecal management system for vaginal use in radiotherapy-associated rectovaginal fistula.

While highly effective for treating certain gynecologic malignancies, radiotherapy carries known risks, including fistula formation. We report a 75-year-old female with advanced cervical carcinoma who was provided a vaginally placed fecal management system after developing a rectovaginal fistula following primary treatment with chemoradiation. This report presents and discusses a novel method to palliate symptomatic RVFs in advanced-stage cancer.

Transient global amnesia: a case report.

INTRODUCTION: Transient global amnesia is a syndrome of temporary and reversible disruption of short-term memory accompanied by repetitive questioning. Although the etiology is unknown, the prognosis usually benign, and no particular treatment is required, it is important for all involved clinicians to recognize the diagnosis and possess knowledge about the evaluation of these affected patients. CASE PRESENTATION: A middle-aged Caucasian woman presented for neurologic evaluation for acute forgetfulness. Neurologic examination disclosed repetitive questioning with preserved orientation and no focal motor, speech, sensory, coordination, or cranial nerve deficits. Neurologic investigations did not reveal any pathologic findings. Her memory improved and reverted to normal baseline over the course of a 24-hour hospital stay. CONCLUSION: Transient global amnesia is an interesting syndrome of reversible anterograde amnesia associated with repetitive questioning that occurs with an unclear etiology in middle-aged and elderly individuals. Due clinical diligence is required in the investigation of these patients. Treatment is generally not required, and the condition usually does not recur. Clinicians, including neurologists, internists, family practice physicians, and psychiatrists, need awareness of this condition.

One-hour post-glucola results and pre-pregnancy body mass index are associated with the need for insulin therapy in women with gestational diabetes.

OBJECTIVE: The purpose of this study was to analyze the relationship of 1-h post-glucola (PG) screening results and the need for insulin therapy in women with gestational diabetes (GDM). METHODS: The study group was comprised of women with GDM treated at a single institution during calendar years 2000-2004. Women with singleton, term (≥ 37 weeks gestation), liveborn fetuses were included. The association of 1-h PG results and other perinatal risk factors to the need for subsequent insulin therapy was analyzed using multivariable logistic regression models. RESULTS: Of the 1451 women were included in the analysis, 18.1% required insulin treatment. The mean 1-h PG result was 170.0 ± 26.1 mg/dl (range 140-414 mg/dl). We determined that a 1-h PG ≥ 190 mg/dl (p < 0.0001), an obese body mass index (BMI) (p < 0.0001), an overweight BMI (p = 0.0019), prior GDM (p = 0.0019), and prior macrosomia (p = 0.0210) were each highly associated with the need for subsequent insulin therapy during the pregnancy. CONCLUSIONS: A 1-h PG ≥ 190 mg/dl was strongly associated with the need for insulin therapy in women with GDM. These data may be helpful in counseling and managing women with GDM.

Treatment-seeking behavior for sexually transmitted infections in a high-risk population.

The World Health Organization estimates that 340 million new cases of curable sexually transmitted infections (STIs) occur every year, while 33 million individuals are estimated to be living with HIV. The AIDS and STI epidemics are not independent with untreated STIs increasing HIV acquisition and transmission. Female sex workers have increased prevalence of untreated STIs and have been hypothesized to affect the health and HIV incidence of the general population. This paper aims to investigate why some female sex workers who experience symptoms of vaginal discharge or genital ulcers seek treatment while others do not. Data were collected from a cohort study conducted between 2002 and 2005 among female bar and hotel workers in Moshi, Tanzania. Study subjects were recruited from 7 out of 15 administrative wards in Moshi as part of the Moshi's Women's Health Project. Data were restricted to women self-reporting symptoms of vaginal discharge or genital ulcers (n=459) within the past year. Logistic regression was performed with SAS 9.1. Qualitative analysis was performed using in-depth interviews and focus group discussions among a convenience sample (n=42) of women already enrolled in the study. All interviews and focus group discussions were tape-recorded and transcribed, and data were analyzed thematically. Sixty-four percent of the sample sought treatment for either ailment. Multivariate analysis identified relationship to man of last sexual intercourse, ever experiencing a pregnancy, and age as significant predictors to seeking treatment. Four salient themes of threats to fertility, stigma correlated with prostitution, discomfort with the physical exam, and perceived views of clients were revealed as predictors to why women seek or intentionally ignore symptoms. Understanding the motivations and barriers for seeking treatment of STIs has far ranging public health implications that could help curtail the unnecessary associated morbidity and mortality and curtail the transmission of HIV.