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A case of extracapsular hemorrhage from spontaneous rupture of a parathyroid adenoma is reported. In the case presented here, adenoma was revealed by a sudden onset of a huge ecchymosis and hematoma of the entire anterior neck and right chest, causing recurrent nerve paresis. These cases of hemorrhage from rupture of silent parathyroid adenoma mimicking a dissecting thoracic aortic aneurysm are discussed.
The authors report a case of associated injuries (thoracoabdominal trauma with multiple rib and sternum fractures, perforation of the small intestine, abdominal cutaneous ecchymosis) caused by a seat belt, and describe the possible seat-belt mechanisms of lesion in road accidents. Some clinical aspects are discussed; in particular the diagnostic problems concerning a seat-belt syndrome as well as the limits of effectiveness in the use of belts.
The efficacy and safety of a new veno-active flavonoid fraction (S 5682) consisting of micronized diosmin (90%) and hesperidin (10%) have been studied in 100 patients with symptomatic capillary fragility in a double-blind, randomized, placebo-controlled trial. Treatment lasted 6 weeks and consisted of 2 daily tablets of either S 5682 or placebo. Patients were examined at weeks 0, 2, 4 and 6. Compared to placebo, capillary resistance, assessed by the negative suction cup method, was significantly higher in the S 5682 group at week 4 (219 +/- 10 mmHg versus 159 +/- 8 mmHg; p < 0.001) and week 6 (261 +/- 12 mmHg versus 163 +/- 9 mmHg; p < 0.001). This resulted in a significant improvement of symptoms of capillary fragility (spontaneous ecchymosis, epistaxis, purpura, petechiae, gingivorrhagia, metrorrhagia and conjunctival haemorrhage) in S 5682 treated patients (p < 0.001). S 5682 was well tolerated. The rate of side-effects spontaneously volunteered by the patients was similar in both groups. We, therefore, conclude that S 5682 increases to a large extent the capillary resistance in patients with abnormal capillary fragility without significant side-effects.
Advances in laparoscopic technique have provided the opportunity to perform preperitoneal herniorrhaphy and potentially avoid the morbidity associated with open techniques. From January 1991 to May 1992, two primary surgeons repaired 63 inguinal hernias (42 indirect, 20 direct, 1 femoral) on 48 patients using a standardized laparoscopic technique. The hernia defect was visualized laparoscopically, and the peritoneum anterior to the defect was incised. The hernia sac was dissected from the inguinal canal. The hernia defect was then loosely packed with rolled 1 x 6-inch polypropylene mesh (average number of rolls used was 3.4). A sheet of polypropylene mesh (average 5 x 8 cm) was then placed over the mesh rolls and the hernia defect and anchored with an endostapler. The peritoneum was closed over the mesh sheet with standard laparoscopic clips. There were 44 males and 4 females in the study group. The mean age was 55 years (range, 17-89 years). The mean follow-up was 5.8 months (range, 1-12 months). Thirty-three patients underwent unilateral hernia repair, and 15 patients underwent bilateral hernia repair. Clinically unsuspected contralateral hernias were identified at the time of laparoscopy in seven patients. The mean duration of surgery was 118 minutes (range, 80-165 minutes) for bilateral hernia repair, and 70 minutes (range, 45-100 minutes) for unilateral hernia repair. All patients with laparoscopic hernia repairs were treated on a same-day or less-than-24-hour in-hospital stay. Complications were designated as minor, moderate, or severe. There were 14 minor complications, which included subcutaneous hematomas at the trocar site, scrotal ecchymosis, groin swelling emphysema, and testicular asymmetry.(ABSTRACT TRUNCATED AT 250 WORDS)
A 74-year-old man was admitted because of swelling, pain and ecchymosis in the night lower extremity. A blood analysis revealed that Hb was 11.8g/dl, WBC 37,600/microliters, and platelet count 137.1 x 10(4)/microliters. The NAP value was high. Bone marrow examination disclosed marked megakaryocytic hyperplasia. Chromosomal analysis revealed 47, XY, +9. Hemostatic data were within normal ranges, but the 2nd aggregation of platelet by ADP was diminished. The serum beta-TG was 159, PF-4 56ng/ml, B12 1,100, UB12 BC 1,800pg/ml. Gastric fiberoscopy revealed gastric cancer and CT scan disclosed marked splenomegaly. Essential thrombocythemia (ET) coexisting with gastric cancer was diagnosed based on these examinations. He was treated with anti-platelet agents, busulfan and tegafur uracil, however thromboembolic symptoms suggesting central nervous system and peripheral vascular ischemia and gastrointestinal bleeding occurred. Among diagnostic criteria for ET established by the polycythemia vera study group, there is a category "No known cause for reactive thrombocytosis." The case reported here had gastric cancer which may have contributed to the elevated platelet count, however this case could be diagnosed as ET coexisting with gastric cancer because of the above various clinical signs and laboratory results. Although then are few reports of the coexistence of other malignancies in ET, there may be many more similar cases because of the age preponderance in ET. In order to diagnose ET more precisely, more strict diagnostic criteria are needed.
Expected outcomes for a correctly fitted ostomy prosthetic device include sustained, predictable wearing time, protection of the stoma from injury, and maintenance of peristomal skin integrity. To accomplish this, the pouching system must be properly sized and maintain continuous contact with the peristomal skin. Continuous contact is achieved when the faceplate provides a mirror image of the topography of the peristomal plane. Varying degrees of support and convexity of the faceplate are used to fit the unique characteristics of the patient's peristomal plane and stoma. Support can be absent, soft or firm. Convexity is some degree of outward curving of the faceplate. Characteristics of the stoma (i.e., flush, retracted, loop), peristomal plane (i.e., creases, hernia, scarring) and abdomen (i.e., flaccid, soft, or firm) may indicate the need for convexity. Potential problems include mucocutaneous separation, ischemia, laceration, erythema, ecchymosis, and pain if convexity is used inappropriately. Alternatives to convexity include the use of an ostomy belt or surgery. Ongoing, intermittent assessment of the prosthetic is essential to evaluate that the convexity and support have achieved the expected outcomes.
OBJECTIVE: To compare the advantages and disadvantages of the New Bird metal cups and silicone cups in terms of maternal and foetal outcome. To study the adverse effects and factors associated with failed vacuum deliveries. DESIGN: A prospective randomised study of all vacuum deliveries from 1 December 1991 to 31 April 1992. The Hanshin electrical vacuum pump was used. SETTING: A large obstetric unit-The Maternity Hospital Kuala Lumpur (MHKL). SUBJECTS: Seventy-two consecutive patients where vacuum deliveries were indicated. Forty had metal and 32 had silicone cups. Another 7 vacuum deliveries using the manual vacuum pump were excluded. MAIN OUTCOME MEASURES: Success rate of vaginal delivery, birth canal injuries, post-partum haemorrhage, duration of hospital stay, Apgar score, foetal injuries (scalp-ecchymosis, haematomas) neonatal jaundice, the rate of special care nursery (SCN) admission and neonatal mortality rate. RESULTS: Failure to deliver with silicone cups alone was 21.9% compared to 10% for metal cups alone. Material morbidities and serious foetal scalp injuries were almost the same in both cups. However, minor foetal scalp injuries were significantly lower with silicone cups. Maternal height and baby's weight had no independent predictive values for successful vacuum delivery. When the foetal head was palpable per abdomen, the failure rate was 54.5% compared to 8.2% when it was not. Failed vacuum deliveries were associated with increased maternal and foetal morbidities. CONCLUSION: Silicone cups and metal cups can be equally dangerous to the baby. Although our sample size was small, we recommend that vacuum delivery be avoided if the foetal head is palpable per abdomen.
Beagle dogs inoculated with the agent of Rocky Mountain spotted fever, Rickettsia rickettsii, developed a clinical syndrome that extended from febrile exanthema to death and appeared to be dose related. Infected dogs were anorectic and lethargic and developed cutaneous lesions characteristic of Rocky Mountain spotted fever, including petechia, ecchymosis, edema, and necrosis. Hematologic changes after inoculation included anemia, leukopenia proceeding to leukocytosis, and thrombocytopenia. Changes in blood chemistry values included increases in serum alkaline phosphatase and cholesterol, and hyponatremia and hypochloremia. The prominent histopathologic change was necrotizing vasculitis. The canine disease is comparable with human Rocky Mountain spotted fever on a clinical, hematologic, biochemical, and pathologic basis, and may provide a model system for this disease in man. The results suggest the dog may be involved in the epidemiology of R rickettsii infections.
BACKGROUND: Bruising and induration associated with subcutaneous heparin injection often result in sustained tenderness and severe ecchymosis at the injection site. Research-based practice guidelines for subcutaneous heparin administration are needed to reduce these adverse effects. OBJECTIVES: The purpose of this study was to investigate the effect of syringe size (1-mL vs 3-mL) on postinjection-site bruising and induration following the administration of subcutaneous heparin. METHODS: A convenience sample of 29 subjects receiving 5000 units of subcutaneous heparin at least twice a day was recruited from a large urban hospital. Subjects received their regularly scheduled subcutaneous heparin injections with a 3-mL or a 1-mL syringe in a randomized sequence using a standardized procedure. Injection sites were assessed for bruises and induration at 24, 48, and 72 hours after injection. RESULTS: The incidence of injection site bruising with 1- and 3-mL syringes was 79% and 69%, respectively. The use of a 3-mL vs 1-mL syringe resulted in significantly smaller bruises at 48 and 72 hours after injection. Induration at the injection site occurred in three patients. CONCLUSIONS: Findings suggest that 3-mL syringes are preferable to 1-mL syringes for heparin administration. The effect of other injection-related variables should be studied with the use of the 3-mL syringe, and tested on various populations.
Child abuse and neglect is a problem that has existed for many years. Federal guidelines and state laws make it necessary for the optometrist to be aware of the definitions that describe abuse and neglect. In addition, it is necessary to review the characteristics of the child and caregiver to ascertain who may be at risk. Physical signs, such as specific types of fractures, burns, scalds, and bruises, should act as a key to suspected abuse. The most frequent ocular sign of abuse is intraocular hemorrhage. Other ocular manifestations include periorbital edema, ecchymosis, and retinal detachment, to name a few. Sexual abuse is also of concern. If a sexually transmitted disease is present in a young child, abuse should not be ruled out. It is the responsibility of the health care provider to report any suspected episodes of child abuse and neglect.
The evaluation of ankle injuries is a common challenge for family physicians. Diagnosis is made by using knowledge of the anatomy and function of the ankle joint to aid in taking an adequate history and performing an appropriate physical examination. The patient should be questioned about the mechanism of injury, previous injury, disability, treatment and pain. The ankle should be evaluated for ecchymosis, swelling, areas of tenderness and laxity. These measures help to determine what, if any, additional diagnostic procedures may be needed. Most ankle sprains are lateral, affecting the anterior talofibular, calcaneofibular and posterior talofibular ligaments. Other injuries include medial ankle sprains affecting the deltoid ligament, trauma to the Achilles and peroneal tendons, tarsal tunnel syndrome, fractures, syndesmotic sprains, synovial impingement and chronic instability. Criteria for radiographic evaluation include inability to bear weight initially or when examined, and tenderness over the medial or lateral malleolus. Accurate diagnosis is critical for appropriate treatment and minimizing functional disability.
Fifty-one patients underwent a study approved by the Food and Drug Administration for laser-assisted liposuction in five plastic surgery centers. The YAG laser fiber is contained within the cannula, shears off the fat cleanly, and coagulates blood vessels as the fat is drawn into the cannula. Hemoglobin decrease was relatively modest after surgery, and patients were able to return to work at 6 days and light exercise at 7 days. Contralateral studies showed a slight benefit for the laser side at both 1 and 8 weeks for ecchymosis, pain and discomfort, and edema. Lipocrit studies were inconsistent. The investigators concluded that no clear benefit was demonstrated with the laser. The Food and Drug Administration did not approve the technique, and the sponsoring laser company has not pursued the study.
Neonatal liver laceration is a relatively rare but probably fatal condition without prompt diagnosis and treatment. It should be considered in newborn infants who are presented with sudden onset of symptoms and signs of hemoperitoneum such as shock, pallor, abdominal distension, abdominal bruising, or scrotal ecchymosis. Roentgenogram may show free peritoneal fluid. Abdominal sonography is helpful in the detection of intraabdominal bleeding. Paracentesis is the most effective diagnostic procedure for the confirmation of hemoperitoneum. The rupture of the liver is the first priority to be considered, though other abdominal organs including adrenals, kidneys, and spleen are also prone to injury. Once liver laceration is highly suspected, resuscitation with blood transfusion, correction of coagulopathy, and then emergency surgical intervention must be performed if conservative treatment fails. Here we present a 1,662 gm premature male neonate who underwent successful surgical repair of the liver laceration.
Eighty-three patients (108 repairs) with inguinal hernias underwent laparoscopic transabdominal preperitoneal repair in the community hospital setting. The patients included 82 men and one woman, ranging in age from 15 to 82 years. Concomitant procedures included umbilical hernia repairs, lysis of adhesions, and varicocoelectomy. Ninety-four percent of these patients were discharged the same day, with only one patient requiring more than an overnight stay. Postoperative complications included five cases of urinary retention requiring overnight catherization (4.6%) and one case each of labile hypertension (0.9%), vasovagal reaction (0.9%), dizziness (0.9%), and ileus (0.9%); there were 12 cases of groin swelling with ecchymosis (11%). With follow-up of almost 2 years, there has been one known recurrence (0.9%). This study demonstrates that laparoscopic hernia repair can be performed safely and successfully in the community hospital setting and can be a sound alternative to the standard open hernia repair.
Accumulate experience, from 1955 to 1995, in an outpatient university parasitology clinic in Santiago, with 1,384 patients referred from diverse public and private medical institutions because of a probable spider bite or insect stings, is presented. It is noteworthy that only 618 (44.7%) of consultations corresponded to clinical conditions originated by arthropods, whereas from the remaining 766, 612 (44.2%) were due to a bacterial, viral or parasitic etiology and 154 (11.1%) were caused by physical or chemical agents. Frequency of diagnosis was: loxoscelism 16.6%, spider bites (excluded Loxosceles laeta) 1.3%, scorpion sting 0.9%, tick stings 2.2%, insect bites 23.7%, impetigo 6.6%, folliculitis 11.3%, boil 22.7%, erysipelas 0.1%, pustula maligna 0.3%, herpes simplex 2.5, palpebral herpes zoster 0.3%, acute Chagas' disease 0.4%, angioneurotic edema 0.1%, ecchymosis 3.0, contact dermitis 7.8% and chemical dermitis 0.2%. These frequencies do not indicate the real occurrence of the diagnosed nosologies, but what happened in a specialized outpatient clinic dealing cheaply with parasitic diseases and arthropod envenomations. Description of relevant clinical features and epidemiological considerations of pathology observed, conjointly with differential diagnosis are presented.
PURPOSE: In a previous study, 83% of 14 patients noted that their symptoms of Peyronie's disease had arrested or improved after intralesional injection of verapamil. This nonrandomized, prospective study further investigates the use of verapamil in a larger, thoroughly characterized patient population. MATERIALS AND METHODS: Forty-six men began treatment; 38 completed the study. Using a multiple puncture technique, 10 mg. of verapamil diluted to 10 cc were distributed throughout the plaque every 2 weeks for a total of 12 injections. Response to treatment was evaluated through subjective and objective measurements of pain, plaque size, deformity, duration of disease and sexual function, and with the Kelami classification system based on plaque size and curvature. RESULTS: Pain resolved in 97% of the patients who presented with pain after a mean of 2.5 injections. After therapy, 76% reported a subjective decrease in curvature, 9.5% noted an increase and 14.5% remained unchanged. Of the treated patients 72% reported an improvement in the ability to engage in coitus. Objective measurements demonstrated that curvature was decreased in 54% of the patients, increased in 11% and remained unchanged in 34%. There were no substantial differences in response to treatment based on duration of disease or within the 3 Kelami classification groups. Other than transient post-injection ecchymosis, there were no significant acute or chronic side effects. CONCLUSIONS: Verapamil injection therapy resulted in a reduction of pain in 97% of the patients, an improvement in sexual function in 72%, a reduction of deformity in 86%, an improvement in distal rigidity in 93% and an objective reduction of curvature in 54%. Further studies are required to determine the effectiveness of this nontoxic, inexpensive, nonsurgical approach to Peyronie's disease.
Ehlers-Danlos syndrome comprises a very heterogeneous group of collagen diseases characterised in clinical terms by fragility and cutaneous hyperextensability, ligamentous hyperlaxity, ecchymosis, scarring, visceral and neurological manifestations. Having been described in detail by Ehlers in 1899 and Danlos in 1908, it was subsequently classified into various clinical types. At present at least 11 forms are recognised on the basis of their clinical characteristics, methods of transmission and biochemical defect; the first four types of the syndrome account for approximately 95% of cases. Almost all forms are transmitted with a dominant autosomic character. Specific genetic mutations have been ascertained whereas the biochemical defect has been identified in numerous types. Ehlers-Danlos type 1 syndrome is the most frequent and most severe form. The biochemical anomaly underlying the altered deposition of collagen fibre is still unknown and this is responsible for the "storiform" appearance of collagen fibre on ultrastructural examination. The authors have described a typical case of "Ehlers-Danlos type 1 syndrome" in which the diagnosis was confirmed by comparing clinical data and the results of ultrastructural tests which revealed the characteristic "pattern" of collagen fibres.
Cutaneous manifestations of petechiae, purpura, and ecchymosis can lead the physician to discover an underlying platelet abnormality. Autoimmune idiopathic thrombocytopenic purpura (AITP) is a diagnosis of exclusion, mediated by a destructive IgG antibody response to the platelets' membrane components. In addition to showing evidence of cutaneous and mucosal bleeding (ie, epistaxis, hematuria), patients with AITP are at an increased risk for systemic lupus erythematosus (SLE). Therefore, it is suggested that patients with AITP be closely monitored for SLE.