Gastrocnemius muscle herniation as a rare differential diagnosis of ankle sprain: case report and review of the literature

BACKGROUND: Muscle herniation of the leg is a rare clinical entity. Yet, knowing this condition is necessary to avoid misdiagnosis and delayed treatment. In the extremities, muscle herniation most commonly occurs as a result of an acquired fascial defect, often due to trauma. Different treatment options for symptomatic extremity muscle herniation in the extremities, including conservative treatment, fasciotomy and mesh repair have been described. CASE PRESENTATION: We present the case of a patient who presented with prolonged symptoms after an ankle sprain. The clinical picture showed a fascial insufficiency with muscle bulging under tension. Ultrasound and MRI imaging confirmed the diagnosis of muscle hernia of the medial gastrocnemius on the right leg. Conservative treatment did not lead to success. Therefore, the fascial defect was treated surgically by repairing the muscle herniation using a synthetic vicryl propylene patch. CONCLUSIONS: Muscle hernias should be taken into consideration as a rare differential diagnosis whenever patients present with persisting pain or soft tissue swelling after ankle sprain. Diagnosis is mainly based on clinical aspect and physical examination, but can be confirmed by radiologic imaging techniques, including (dynamic) ultrasound and MRI. If conservative treatment fails, we recommend the closure with mesh patches for large fascial defects

Key Learning Outcomes for Clinical Pharmacology and Therapeutics Education in Europe: A Modified Delphi Study.

Harmonizing clinical pharmacology and therapeutics (CPT) education in Europe is necessary to ensure that the prescribing competency of future doctors is of a uniform high standard. As there are currently no uniform requirements, our aim was to achieve consensus on key learning outcomes for undergraduate CPT education in Europe. We used a modified Delphi method consisting of three questionnaire rounds and a panel meeting. A total of 129 experts from 27 European countries were asked to rate 307 learning outcomes. In all, 92 experts (71%) completed all three questionnaire rounds, and 33 experts (26%) attended the meeting. 232 learning outcomes from the original list, 15 newly suggested and 5 rephrased outcomes were included. These 252 learning outcomes should be included in undergraduate CPT curricula to ensure that European graduates are able to prescribe safely and effectively. We provide a blueprint of a European core curriculum describing when and how the learning outcomes might be acquired

Pre- and postconditioning effect of Sevoflurane on myocardial dysfunction after cardiopulmonary resuscitation in rats

Post-resuscitation myocardial dysfunction is an important cause of death in the intensive care unit after initially successful cardiopulmonary resuscitation (CPR) of pre-hospital cardiac arrest (CA) patients. Volatile anaesthetics reduce ischaemic-reperfusion injury in regional ischaemia in beating hearts. This effect, called anaesthetic-induced pre- or postconditioning, can be shown when the volatile anaesthetic is given either before regional ischaemia or in the reperfusion phase. However, up to now, little data exist for volatile anaesthetics after global ischaemia due to CA. Therefore, the goal of this study was to clarify whether Sevoflurane improves post-resuscitation myocardial dysfunction after CA in rats. Following institutional approval by the Governmental Animal Care Committee, 144 male Wistar rats (341 +/- 19 g) were randomized either to a control group or to one of the 9 interventional groups receiving 0.25 MAC, 0.5 MAC or 1 MAC of Sevoflurane for 5 min either before resuscitation (SBR), during resuscitation (SDR) or after resuscitation (SAR). After 6 min of electrically induced ventricular fibrillation CPR was performed. Before CA (baseline) as well as 1 h and 24h after restoration of spontaneous circulation (ROSC), continuous measurement of ejection fraction (EF), and preload adjusted maximum power (PAMP) as primary outcome parameters and end systolic pressure (ESP), end diastolic volume (EDV) and maximal slope of systolic pressure increment (dP/dt(max)) as secondary outcome parameters was performed using a conductance catheter. EF was improved in all Sevoflurane treated groups 1 h after ROSC in comparison to control, except for the 0.25 MAC SDR and 0.25 MAC SAR group (0.25 MAC SBR: 38 +/- 8,p = 0.02; 0.5 MAC SBR: 39 +/- 7, p = 0.04; 1 MAC SBR: 40 +/- 6, p = 0.007; 0.5 MAC SDR: 38 +/- 7, p = 0.02; 1 MAC SDR: 40 +/- 6, p = 0.006; 0.5 MAC SAR: 39 +/- 6, p = 0.01; 1 MAC SAR: 39 +/- 6, p = 0.002, vs. 30 +/- 7%). Twenty-four hours after ROSC, EF was higher than control in all interventional groups (p<0.05 for all groups). EF recovered to baseline values 24 h after ROSC in all SBR and SAR groups. PAMP was improved in comparison to control (4.6 +/- 3.0 mW/mu l(2)) 24h after ROSC in 0.5 MAC SBR (9.4 +/- 6.9 mW/mu l(2), p = 0.04), 1 MAC SBR (8.9 +/- 4.4 mW/mu l(2), p = 0.04), 1 MAC SDR (8.0 +/- 5.7 mW/mu l(2), p = 0.04), and 1 MAC SAR (7.3 +/- 3.5 mW/mu l(2), p = 0.04). ESP, EDV, and dP/dtmax was not different from control 1 h as well as 24 h after ROSC with the exception of 1 MAC SDR with a reduced ESP 1 h after ROSC (89 +/- 16 vs. 103 +/- 22 mmHg, p =0.04). Sevoflurane treatment did not affect survival rate. This animal study of CA and resuscitation provides the hypothesis that pharmacological pre- or postconditioning with the volatile anaesthetic Sevoflurane - administered before CA, during resuscitation or after ROSC - results in an improved myocardial inotropy 24h after ROSC. Sevoflurane treatment seems to improve EF even in the early phase of reperfusion 1 h after ROSC. Therefore further targeted studies on the optimal dose and time point of administration of Sevoflurane in cardiopulmonary resuscitation seem to be worthwhile (Institutional protocol number: 35-9185.811G-24108). (C) 2013 Elsevier Ireland Ltd. All rights reserved