Small bowel obstruction caused by intramural hemorrhage secondary to anticoagulant therapy.

Intramural hemorrhage as a cause for small bowel obstruction is extremely rare. We presented an unusual case report of small bowel obstruction caused by intramural jejunal hemorrhage secondary to anticoagulant therapy. An 85-year-old male patient with atrial fibrillation on long-term warfarin presented with nausea and vomiting for 2 days, accompanied with no bowel movement since the onset. Physical exam was unremarkable except soft abdomen with distension but no tenderness, hyperactive bowel sounds and positive fecal occult blood test. Investigations showed anemia with hemoglobin/ hematocrit of 10 (g/dl) / 30%, prothrombin time with an International Normalized Ratio (INR) of 9.58. Abdominal x-ray showed air fluid levels suggestive of small bowel obstruction. Contrast-enhanced abdominal computerized tomography showed circumferential wall thickening, luminal narrowing and partial small bowel obstruction secondary to intramural jejunal hemorrhage. Patient recovered completely 48 hours after medical treatment (nothing per oral, intravenous fluids, nasal gastric tube, Vitamin K, frozen fresh plasma and packed red blood cell transfusion). Spontaneous intramural small-bowel hematoma is rare and occurs in patients who receive excessive anticoagulation with warfarin or who have some other risk factors for bleeding. Intramural hematoma most commonly involves the jejunum, followed by the ileum and the duodenum. The spectrum of presentation is wide, from abdominal pain, emesis to gastrointestinal tract hemorrhage. Abdominal CT is the key for diagnosis, with characteristics including circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction. Early diagnosis is crucial because most patients are treated nonoperatively with a good outcome.

Some effects of deafness on the generation of voice.

Glottal volume-velocity waveform data were collected from twenty male and female hearing-impaired adolescents by means of a reflectionless tube. The subjects each provided samples of phonation in normal- and soft-voice modes and in a three-syllable word with primary stress on the medial syllable. Analysis of the data, in comparison with characteristics of phonation produced by normally hearing subjects, indicates that deafness affects primarily the time-varying characteristics of the glottal source. Among the hearing-impaired subjects, the following abnormalities were noted; diplophonia and creaky-voice episodes at the onset or middle of phonation, and irregular patterns of change in the frequency and intensity of the glottal waveform. For some subjects, the period-to-period changes of frequency and intensity may be greater than normal. For the hearing-impaired subjects, the shape of the isolated glottal pulse and its spectrum are similar or identical to normal, while striking abnormalities may be seen in the way the glottal pulse changes over time. The effect of deafness is thus that it may prevent a speaker from learning the phonatory consequences of the muscular gestures which maintain and alter vocal-fold tension and subglottal air pressure dynamically in the production of voice.

Indirect assessment of the contribution of subglottal air pressure and vocal-fold tension to changes of fundamental frequency in English.

The contributions of vocal-fold tension and of subglottal air pressure to changing fundamental frequency F0 are indirectly assessed by comparing human glottal-source data with synthetic glottal waveforms generated by the Ishizaka-Flanagan two-mass model of vocal-fold vibration. In this model, synthetic male and female glottal waves may be generated with known values of subglottal air pressure and vocal-fold tension. Human glottal waves were recorded with a reflectionless tube into which ten male and female adults phonated. The subjects produced interrogative (rising F0) and declarative (falling F0) glides and trisyllabic words with primary stress on the initial, medial, or final syllable. Two types of change in the glottal wave over time are possible, depending on whether F0 is changed primarily by vocal-fold tension or by subglottal air pressure. Comparison of the natural and synthetic glottal waves indicates that (1) the rise of frequency in interrogative words is due principally to increasing vocal-fold tension, while (2) the fall of frequency in declarative words is due principally to decreasing subglottal air pressure; (3) in the polysyllabic words, the change of frequency within syllables resembles that of the declarative monosyllables and appears due primarily to changes of subglottal air pressure; and (4) the heightened f0 of the stressed syllable is due to an increase in the vocal-fold tension, typically accompanied by increased subglottal air pressure.