IVC syndrome in a patient with Factor V Leiden mutation.

Hip flexor injuries account for one-third of acute groin injuries; however, little is known about specific injury characteristics. The aims of this study were to describe acute hip flexor injuries using magnetic resonance imaging (MRI) in athletes with acute groin pain and to compare specific muscle injuries with reported injury situations. Male athletes with acute groin pain were prospectively and consecutively included during three sports seasons. MRI was performed within 7days of injury using a standardized protocol and a reliable assessment approach. All athletes with an MRI confirmed acute hip flexor muscle injury were included. A total of 156 athletes presented with acute groin pain of which 33 athletes were included, median age 26years (range 18-35). There were 16 rectus femoris, 12 iliacus, 7 psoas major, 4 sartorius, and 1 tensor fascia latae injury. Rectus femoris injuries primarily occurred during kicking (10) and sprinting (4), whereas iliacus injuries most frequently occurred during change of direction (5). In 10 (63%) rectus femoris injuries, tendinous injury was observed. The iliacus and psoas major injuries were mainly observed at the musculotendinous junction (MTJ), and two included tendinous injury. We have illustrated specific injury locations within these muscles, which may be relevant for the clinical diagnosis and prognosis of these injuries. Most proximal rectus femoris injuries included tendinous injury. In contrast, distinct acute iliacus and psoas injuries predominantly occurred at the MTJ. Only the iliacus or psoas major were injured during change of direction, whereas rectus femoris injuries occurred primarily during kicking and sprinting.

54-Year-Old Man With Dyspnea and Abdominal Wall Bruising

Acute adductor injuries account for the majority of acute groin injuries; however, little is known about specific injury characteristics, which could be important for the understanding of etiology and management of these injuries. The study aim was to describe acute adductor injuries in athletes using magnetic resonance imaging (MRI). Male athletes with acute groin pain and an MRI confirmed acute adductor muscle injury were prospectively included. MRI was performed within 7days of injury using a standardized protocol and a reliable assessment approach. 156 athletes presented with acute groin pain of which 71 athletes were included, median age 27years (range 18-37). There were 46 isolated muscle injuries and 25 athletes with multiple adductor injuries. In total, 111 acute adductor muscle injuries were recorded; 62 adductor longus, 18 adductor brevis, 17 pectineus, 9 obturator externus, 4 gracilis, and 1 adductor magnus injury. Adductor longus injuries occurred at three main injury locations; proximal insertion (26%), intramuscular musculo-tendinous junction (MTJ) of the proximal tendon (26%) and the MTJ of the distal tendon (37%). Intramuscular tendon injury was seen in one case. At the proximal insertion, 12 of 16 injuries were complete avulsions. This study shows that acute adductor injuries generally occur in isolation from other muscle groups. Adductor longus is the most frequently injured muscle in isolation and in combination with other adductor muscle injuries. Three characteristic adductor longus injury locations were observed on MRI, with avulsion injuries accounting for three-quarters of injuries at the proximal insertion, and intramuscular tendon injury was uncommon.

A large number of individuals develop venous thromboembolism (VTE) every year.1 Each patient’s episode of DVT or PE is, naturally, unique. To highlight a variety of aspects about VTE a compilation case is presented that is composed of clinical data and images from several real patients. ### History of Present Illness A 36-year-old woman presents to the Emergency Department with severe shortness of breath and moderately intense anterior chest pain, worse on deep inspiration, which had started suddenly that morning. She also reports a 6-wk history of mild shortness of breath, for which she had been seen 4 wk earlier by her primary care physician who diagnosed her with “asthma.” Bronchodilators and steroids were prescribed but led to no significant improvement in her symptoms. She also gives a history of mild left calf pain that had started about 2 months earlier without preceding trauma, immobilization, or surgery. Her primary care physician had seen her and prescribed Ibuprofen for a “pulled muscle.” However, in the 1 week before her present presentation her leg symptoms worsened, and she had increased diffuse leg pain and swelling and slightly bluish discoloration of the whole leg. Her past medical history is only significant for an appendectomy at age 16. She has never been pregnant. She is on no medications, except for an estrogen and progestin-containing oral contraceptive, started 10 months earlier. She does not smoke. There is no family history of venous thromboembolism, although the patient reports that her paternal grandmother had a “swollen leg for many years” until she died in her 70’s, but no further details are known of the patient. ### Physical Examination The patient’s weight is 86 kg and her height 165 cm, calculating to a body mass index (weight divided by [height in meters]2) of 31.6 kg/m2, ie, she has grade 1 obesity. Her …

Ischemic stroke (IS) is a common cause of morbidity and mortality with significant socioeconomic impact especially when it affects young patients. Compared to the older adults, the incidence, risk factors, and etiology are distinctly different in younger IS. Hypercoagulable states are relatively more commonly detected in younger IS patients.Thrombophilic states are disorders of hemostatic mechanisms that result in a predisposition to thrombosis .Thrombophilia is an established cause of venous thrombosis. Therefore, it is tempting to assume that these disorders might have a similar relationship with arterial thrombosis. Despite this fact that 1-4 % of ischemic strokes are attributed to Thrombophillia, this alone rarely causes arterial occlusions .Even in individuals with a positive thrombophilia screen and arterial thrombosis, the former might not be the primary etiological factor.Thrombophilic disorders can be broadly divided into inherited or acquired conditions. Inherited thrombophilic states include deficiencies of natural anticoagulants such as protein C, protein S, and antithrombin III (AT III) deficiency, polymorphisms causing resistance to activated protein C(Factor V Leiden mutation), and disturbance in the clotting balance (prothrombin gene 20210G/A variant). Of all the inherited thrombophilic disorders, Factor V Leiden mutation is perhaps the commonest cause. On the contrary, acquired thrombophilic disorders are more common and include conditions such as the antiphospholipid syndrome, associated with lupus anticoagulant and anticardiolipin antibodies.The more useful and practical approach of ordering various diagnostic tests for the uncommon thrombophilic states tests should be determined by a detailed clinical history, physical examination, imaging studies and evaluating whether an underlying hypercoagulable state appears more likely.The laboratory thrombophilia screening should be comprehensive and avoid missing the coexisting defect and It is important that a diagnostic search protocol includes tests for both inherited and acquired thrombophilic disorders.Since the therapeutic approach (anticoagulation and thrombolytic therapy) determines the clinical outcomes, early diagnosis of the thrombophilic disorders plays an important role. Furthermore, the timing of test performance of some of the thrombophilic defects (like protein C, protein S, antithrombin III and fibrinogen levels) is often critical since these proteins can behave as acute phase reactants and erroneously elevated levels of these factors may be observed in patients with acute thrombotic events. On the other hand, the plasma levels of vitamin K-dependent proteins (protein C, protein S and APC resistance) may not be reliable in patients taking vitamin K antagonists. Therefore, it is suggested that plasma-based assays for these disorders should be repeated3 to 6 months after the initial thrombotic episode to avoid false-positive results and avoid unnecessary prolonged anticoagulation therapy. The assays for these disorders are recommended after discontinuation of oral anticoagulant treatment or heparin for at least 2 weeks.

Renal or ureteric colic is often the presumed diagnosis given to many patients presenting with acute loin and/or groin pain. Patients frequently undergo a multitude of investigations before a diagnosis is established. This often leads to a delay in appropriate management. We assessed the emergency management of patients with suspected renal and/or ureteric colic referred to our department. All referrals over a three-month period were included in the study. We found the majority of referrals with suspected urinary tract stones do in fact have an alternative diagnosis. CT was the most sensitive method for establishing diagnosis in patients with acute loin and/or groin pain. We recommend that patients with suspected renal or ureteric colic should undergo CT on admission to confirm the diagnosis and ensure suitable management.

Incidence of Soccer Injuries among 15- to 19-Year-Old Boys in Norwegian National Teams Purpose: The incidence of soccer-related injuries among young players has not yet been registered in Norway. It is important to find out which injuries are most frequent on each level and how we can best prevent these injuries. The purpose of this study was to examine which injuries 15-, 17-, and 19-year-old male soccer players are exposed to. Methods: A descriptive epidemiologic study. Male soccer players aged 15, 17, and 19 years were asked to complete a questionnaire covering their injuries in the last two years. These players were all on the national teams in Norway. Results: Among the 15-year-old boys, 51% reported acute ankle sprains, 50% acute groin pain, 36% acute knee pain, and 29% acute hamstring injuries. Fifty-four percent reported one or more overuse injuries. Among the 17-year-old boys, 55% reported acute ankle sprains, 35% acute groin pain, 30% acute knee pain, and 28% acute hamstring injuries. Sixty percent reported one or more overuse injuries. Among the 19-year-old boys, 52% reported acute ankle sprains, 39% acute knee pain, 29% acute groin pain, and 10% acute hamstring injuries. Sixty-eight percent reported one or more overuse injuries. Conclusion: This study indicates that 15-, 17-, and 19-year-old boys playing for the Norwegian national teams have many overuse injuries. Ankle sprain is the most commonly reported acute injury. The high incidence of injuries in these players highlights the need for education and prevention programs in youth soccer.

Objective We present a case of small intestinal perforation within an inguinal hernia followinglow-energy indirect trauma.Patient A 55-year-old man with a known right inguinal hernia which had no prior indication forsurgery developed acute right groin pain after sudden braking caused his scooterhandlebar to strike his right thigh.Results Physical examination and computed tomography (CT) scan of the abdomen and pelvisrevealed multiple pockets of extraluminal air within the hernia sac, as well as gasbubbles in the surrounding intestinal contents. Based on these findings, we made adiagnosis of small intestinal perforation within the inguinal hernia.Conclusion Small intestinal perforation within an inguinal hernia is an uncommon but potentiallylife-threatening complication requiring emergent surgical intervention. Delays indiagnosis and management can lead to peritonitis, abscess formation, sepsis, andprolonged hospitalization. Therefore, clinicians should maintain a high index ofsuspicion for intestinal perforation in patients with inguinal hernias, even in theabsence of direct trauma or subsequent low-energy injuries.

Case Presentation 1: A 33-year-old previously healthy man presented with sudden-onset dyspnea and sharp right-sided chest pain. He had noted right leg edema and calf discomfort a week earlier. He denied recent trauma, surgery, or immobility. His mother had a history of postpartum deep vein thrombosis (DVT). On physical examination, he was tachycardic with a heart rate of 114 bpm, normotensive with a blood pressure of 102/76 mm Hg, and hypoxemic to 88% on room air. Contrast-enhanced chest computed tomogram demonstrated bilateral segmental pulmonary embolism. Right lower-extremity venous ultrasound documented femoral and popliteal DVT. Case Presentation 2: A 78-year-old woman with hypertension and obesity developed acute left leg edema and pain 2 days after open reduction and internal fixation of a right hip fracture. On physical examination, the patient had severe edema and tenderness of the left lower leg and thigh. Left lower-extremity venous ultrasound documented left common femoral, distal femoral, and popliteal DVT. Thrombophilias describe inherited and acquired hypercoagulable states that increase the risk of venous and, in some cases, arterial thrombosis. The prevalence of thrombophilias varies according to the population studied. In the general population, thrombophilias are less frequent than “traditional” venous thromboembolism (VTE) risk factors such as cancer, immobility, and obesity. However, in patients who have experienced an initial episode of VTE or have a family history of VTE, the prevalence of thrombophilia increases. In a European registry of 21 367 consecutive patients with symptomatic VTE, thrombophilia testing was performed in 21%.1 Thrombophilia was detected in 32% of those in whom testing was performed. The most frequently detected thrombophilias were factor V Leiden (26%), antiphospholipid antibodies (20%), and prothrombin gene mutation (18%). The rate of thrombophilia detection was similar in patients with idiopathic (unprovoked) and provoked VTE. Thrombophilias may be classified according to their diagnostic yield. …

Acute groin injuries in 109 athletes – Clinical and radiological findings

Kinematic and kinetic changes in a single leg drop landing task following athletic groin pain rehabilitation

In the last 20 years, less than 20 cases of plantar vein thrombosis were reported in the literature. Current ultrasound investigation protocols for deep venous thrombosis neglect this entity which is also not specifically mentioned in therapeutic guidelines. Case 1: An 82-year-old man presented for a left foot plantar pain. Foot X-rays and duplex sonography of the deep venous system were unremarkable; plantar fasciitis was diagnosed and non-steroidal anti-inflammatory drugs were given. One week later, physical examination revealed swelling and tenderness of the plantar side of the foot with retromalleolar tenderness and slight redness extending below and above the medial malleolus. A new Duplex sonography showed enlarged non-compressible left lateral plantar veins with a 10 cm extension of the thrombus to the posterior tibial veins. The patient was put under low molecular weight heparin and switched later to anti vitamin K for a three-month period. Investigations did not reveal any malignancy however, one year later, colonoscopy was performed in the setting of a rectal bleeding and an adenocarcinomatous lesion was discovered. Case 2: A 57-year-old female who presented with one-week history of spontaneous left foot plantar pain. She had no history of foot trauma, recent surgery and was not under any hormonal treatment. Physical examination revealed tenderness along the lateral course of the plantar side of the left foot with a discrete swelling. A contrast-enhanced magnetic resonance imaging revealed filling defects in one of the left lateral plantar veins, confirmed by a color Doppler ultrasound showing the non-compressible vein. The patient was put under low molecular weight heparin followed by anti-vitamin K therapy for a three-month period. Duplex control showed complete re-permeabilization of the vein. A complete hypercoagulation investigation revealed slightly positive anticardiolipine antibodies and heterozygote mutations of the MTHFR gene and the G20210A mutation of the prothrombin gene. In front of a unilateral plantar pain plantar fasciitis, described as first-step pain, is the most common cause, followed by plantar fibromatosis, Morton’s neuroma, stress fractures of the metatarsal bones, tendon abnormalities and ganglion cysts, while retromalleolar redness and tenderness may suggest erysipelas, arthritis, hyperuricemia and neuroalgodystrophia. In plantar veins thrombosis cases usually predisposing factors are present, as recent surgery, trauma, infection, malignancy, airplane travel, use of contraceptive pills. Thrombophilia should be highly suspected in the absence of other predisposing factors, specially the G20210A prothrombin mutation. In over 50-year-old patients with no evident predisposing factors, undiagnosed malignancy should be ruled out. For treatment, the use on anticoagulation for a three-month period is recommended.

The author of the article investigates the interpretation of the phenomenon of dream as a na-tional myth in Philip Roths trilogy consisting of the novels American Pastoral, I Married a Communist and The Human Stain.

40-Year-Old Woman With Breathlessness and Fatigue

BackgroundIt is important to detect splenomegaly as it can have important diagnostic implications. Previous studies, however, have shown that the traditional physical examination is limited in its ability to rule in or rule out splenomegaly.ObjectiveTo determine if performing point-of-care ultrasonography (POCUS) in addition to the traditional physical examination improves the sensitivity and specificity for diagnosing splenomegaly.MethodsThis was a prospective trial of diagnostic accuracy. Physical and sonographic examinations for splenomegaly were performed by students, residents and attending physicians enrolled in an ultrasound training course. Participants received less than 1 h training for ultrasound diagnosis of splenomegaly. The findings were compared to radiographic interpretation of gold standard studies.Setting/patientsHospitalized adult patients at an academic medical center without severe abdominal pain or recent surgery who had abdominal CT, MRI or ultrasound performed within previous 48 h.ResultsThirty-nine subjects were enrolled. Five patients had splenomegaly (12.5 %). The physical examination for splenomegaly had a sensitivity of 40 % (95 % CI 12–77 %) and specificity of 88 % (95 % CI 74–95 %) while physical examination plus POCUS had a sensitivity of 100 % (95 % CI 57–100 %) and specificity of 74 % (95 % CI 57–85 %). Physical examination alone for splenomegaly had an LR+ of 3.4 (95 % CI 0.83–14) and LR− of 0.68 (95 % CI 0.33–1.41); for physical exam plus POCUS the LR+ was 3.8 (2.16–6.62) and LR− was 0.ConclusionsPoint-of-care ultrasonography significantly improves examiners’ sensitivity in diagnosing splenomegaly.