Diagnosis of a Strangulated Laparoscopic Incisional Hernia with Point-of-Care Ultrasonography

The use of point-of-care ultrasound for the diagnosis of bowel obstructions and hernias is becoming increasingly common in the emergency department (ED). Using a relatively rare case of an incisional port hernia, we demonstrate the ultrasound findings of a strangulated hernia causing a partial small bowel obstruction. A 46-year-old female presented four days following a laparoscopic surgery complaining of abdominal pain, nausea and lack of bowel movements. There was a palpable mass in the left lower quadrant under the 12mm trocar port incision. ED point-of-care ultrasound revealed herniated akinetic loops of bowel through her laparoscopy incision. This is the first case report to describe the use of point-of-care ultrasound for the diagnosis of a strangulated incisional port hernia at the bedside.

Respiratory syncytial virus infection-associated hospitalization in adults: a retrospective cohort study

BACKGROUND

Once considered primarily a pediatric concern, respiratory syncytial virus (RSV) infection is gaining recognition as a cause of significant morbidity and mortality in adults. A better understanding of RSV epidemiology and disease in adults is needed to guide patient management and to assess the need for prophylaxis, vaccines, and treatments.

METHODS

We conducted a retrospective cohort study of adults admitted to four hospitals in Toronto, Canada, between September 2012 and June 2013 with RSV identified by a qualitative real-time reverse-transcriptase polymerase chain reaction assay in nasopharyngeal swab or bronchoscopy specimens. Main outcomes were hospital length of stay, need for intensive care unit (ICU) or mechanical ventilation, and all-cause mortality.

RESULTS

Eighty-six patients were identified as requiring hospitalization for RSV infection (56% female). Median age was 74 (range 19-102) years; 29 (34%) were < 65 years. Eighty-three (97%) had underlying chronic medical conditions; 27 (31%) were immunosuppressed, and 10 (12%) known smokers. The most common symptoms and signs were cough in 73 (85%), shortness of breath in 68 (79%), sputum production in 54 (63%), weakness in 43 (50%), fever in 41 (48%), and wheezing in 33 (38%). Lower respiratory tract complications occurred in 45 (52%), cardiovascular complications occurred in 19 (22%), and possible co-pathogens were identified in 11 (13%). Sixty-seven (78%) were treated with antibiotics and 31 (36%) with anti-influenza therapy. Thirteen (15%) required ICU care and 8 (9%) required mechanical ventilation. Five (6%) died during hospitalization. Need for ICU and mechanical ventilation were associated with mortality (P ≤ 0.02). Median hospital length of stay was 6 days (mean 10.8 days).

CONCLUSIONS

RSV infection is associated with the need for extended hospital stay, ICU care and mortality in adults of all ages with chronic underlying conditions. Presenting signs and symptoms are nonspecific, co-infections occur, and patients often receive antibiotics and anti-influenza therapy. There is need for ongoing research and development of RSV prophylaxis, vaccines and treatments for adults.

Rib Fracture Patterns Predict Thoracic Chest Wall and Abdominal Solid Organ Injury

Blunt trauma patients with rib fractures were studied to determine whether the number of rib fractures or their patterns were more predictive of abdominal solid organ injury and/or other thoracic trauma. Rib fractures were characterized as upper zone (ribs 1 to 4), midzone (ribs 5 to 8), and lower zone (ribs 9 to 12). Findings of sternal and scapular fractures, pulmonary contusions, and solid organ injures (liver, spleen, kidney) were characterized by the total number and predominant zone of ribs fractured. There were 296 men and 14 women. There were 38 patients with scapular fracture and 19 patients with sternal fractures. There were 90 patients with 116 solid organ injuries: liver (n = 42), kidney (n = 27), and spleen (n = 47). Lower rib fractures, whether zone-limited or overlapping, were highly predictive of solid organ injury when compared with upper and midzones. Scapular and sternal fractures were more common with upper zone fractures and pulmonary contusions increased with the number of fractured ribs. Multiple rib fractures involving the lower ribs have a high association with solid organ injury, 51 per cent in this series. The increasing number of rib fractures enhanced the likelihood of other chest wall and pulmonary injuries but did not affect the incidence of solid organ injury.

Rib fracture patterns predict thoracic chest wall and abdominal solid organ injury

Blunt trauma patients with rib fractures were studied to determine whether the number of rib fractures or their patterns were more predictive of abdominal solid organ injury and/or other thoracic trauma. Rib fractures were characterized as upper zone (ribs 1 to 4), midzone (ribs 5 to 8), and lower zone (ribs 9 to 12). Findings of sternal and scapular fractures, pulmonary contusions, and solid organ injures (liver, spleen, kidney) were characterized by the total number and predominant zone of ribs fractured. There were 296 men and 14 women. There were 38 patients with scapular fracture and 19 patients with sternal fractures. There were 90 patients with 116 solid organ injuries: liver (n = 42), kidney (n = 27), and spleen (n = 47). Lower rib fractures, whether zone-limited or overlapping, were highly predictive of solid organ injury when compared with upper and midzones. Scapular and sternal fractures were more common with upper zone fractures and pulmonary contusions increased with the number of fractured ribs. Multiple rib fractures involving the lower ribs have a high association with solid organ injury, 51 per cent in this series. The increasing number of rib fractures enhanced the likelihood of other chest wall and pulmonary injuries but did not affect the incidence of solid organ injury.