Isolated complete avulsion of the gallbladder (near traumatic cholecystectomy): a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>Injury of the gallbladder after blunt abdominal trauma is an unusual finding; the reported incidence is less than 2%. Three groups of injuries are described: simple contusion, laceration, and avulsion, the last of which can be partial, complete, or total traumatic cholecystectomy.</p> <p>Case presentation</p> <p>A case of isolated complete avulsion of the gallbladder (near traumatic cholecystectomy) from its hepatic bed in a 46-year-old Caucasian man without any other sign of injury is presented. The avulsion was due to blunt abdominal trauma after a car accident. The rarity of this injury and the stable condition of our patient at the initial presentation warrant a description. The diagnosis was made incidentally after a computed tomography scan, and our patient was treated successfully with ligation of the cystic duct and artery, removal of the gallbladder, coagulation of the bleeding points, and placement of a drain.</p> <p>Conclusions</p> <p>Early diagnosis of such injuries is quite difficult because abdominal signs are poor, non-specific, or even absent. Therefore, a computed tomography scan should be performed when the mechanism of injury is indicated.</p

Evaluation of compliance and outcomes of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in Pakistan

<p>Abstract</p> <p>Background</p> <p>Massive postpartum hemorrhage is a life threatening obstetric emergency. In order to prevent the complications associated with this condition, an organized and step-wise management protocol should be immediately initiated.</p> <p>Methods</p> <p>An evidence based management protocol for massive postpartum hemorrhage was implemented at Aga Khan University Hospital, Karachi, Pakistan after an audit in 2005. We sought to evaluate the compliance and outcomes associated with this management protocol 3 years after its implementation. A review of all deliveries with massive primary postpartum hemorrhage (blood loss ≥ 1500 ml) between January, 2008 to December, 2008 was carried out. Information regarding mortality, mode of delivery, possible cause of postpartum hemorrhage and medical or surgical intervention was collected. The estimation of blood loss was made via subjective and objective assessment.</p> <p>Results</p> <p>During 2008, massive postpartum hemorrhage occurred in 0.64% cases (26/4,052). No deaths were reported. The mean blood loss was 2431 ± 1817 ml (range: 1500 - 9000 ml). Emergency cesarean section was the most common mode of delivery (13/26; 50%) while uterine atony was the most common cause of massive postpartum hemorrhage (14/26; 54%). B-lynch suture (24%) and balloon tamponade (60%) were used more commonly as compared to our previously reported experience. Cesarean hysterectomy was performed in 3 cases (12%) for control of massive postpartum hemorrhage. More than 80% compliance was observed in 8 out of 10 steps of the management protocol. Initiation of blood transfusion at 1500 ml blood loss (89%) and overall documentation of management (92%) were favorably observed in most cases.</p> <p>Conclusion</p> <p>This report details our experience with the practical implementation of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in a developing country. With the exception of arterial embolization, relatively newer, simpler and potentially safer techniques are now being employed for the management of massive postpartum hemorrhage at our institution. Particular attention should be paid to the documentation of the management steps while ensuring a stricter adherence to the formulated protocols and guidelines in order to further ameliorate patient outcomes in emergency obstetrical practice. More audits like the one we performed are important to recognize and rectify any deficiencies in obstetrical practice in developing countries. Dissemination of the same is pivotal to enable an open discourse on the improvement of existing obstetrical strategies.</p

GMFCS Level-Specific Differences in Kinematics and Joint Moments of the Involved Side in Unilateral Cerebral Palsy

A variety of gait pathologies is seen in cerebral palsy. Movement patterns between different levels of functional impairment may differ. The objective of this work was the evaluation of Gross Motor Function Classification System (GMFCS) level-specific movement disorders. A total of 89 individuals with unilateral cerebral palsy and no history of prior treatment were included and classified according to their functional impairment. GMFCS level-specific differences, kinematics and joint moments, exclusively of the involved side, were analyzed for all planes for all lower limb joints, including pelvic and trunk movements. GMFCS level I and level II individuals most relevantly showed equinus/reduced dorsiflexion moments, knee flexion/reduced knee extension moments, reduced hip extension moments with pronounced flexion, internal hip rotation and reduced hip abduction. Anterior pelvic tilt, obliquity and retraction were found. Individuals with GMFCS level II were characterized by an additional pronounced reduction in all extensor moments, pronounced rotational malalignment and reduced hip abduction. The most striking characteristics of GMFCS level II were excessive anterior pelvic/trunk tilt and excessive trunk obliquity. Pronounced reduction in extensor moments and excessive trunk lean are distinguishing features of GMFCS level II. These patients would benefit particularly from surgical treatment restoring pelvic symmetry and improving hip abductor leverage. Future studies exploring GMFCS level-specific compensation of the sound limb and GMFCS level-specific malalignment are of interest

Transversal Malalignment and Proximal Involvement Play a Relevant Role in Unilateral Cerebral Palsy Regardless the Subtype

Classification of gait disorders in cerebral palsy (CP) remains challenging. The Winters, Gage, and Hicks (WGH) is a commonly used classification system for unilateral CP regarding the gait patterns (lower limb kinematics) solely in the sagittal plane. Due to the high number of unclassified patients, this classification system might fail to depict all gait disorders accurately. As the information on trunk/pelvic movements, frontal and transverse planes, and kinetics are disregarded in WGH, 3D instrumented gait analysis (IGA) for further characterization is necessary. The objective of this study was a detailed analysis of patients with unilateral CP using IGA taking all planes/degrees of freedom into account including pelvic and trunk movements. A total of 89 individuals with unilateral CP matched the inclusion criteria and were classified by WGH. Subtype-specific differences were analyzed. The most remarkable findings, in addition to the established WGH subtype-specific deviations, were pelvic obliquity and pelvic retraction in all WGH types. Furthermore, the unclassified individuals showed altered hip rotation moments and pelvic retraction almost throughout the whole gait cycle. Transversal malalignment and proximal involvement are relevant in all individuals with unilateral CP. Further studies should focus on WGH type-specific rotational malalignment assessment (static vs. dynamic, femoral vs. tibial) including therapeutic effects and potential subtype-specific compensation mechanisms and/or tertiary deviations of the sound limb