Important Safety Information –
Revised Directions for Using Rabies Immune Globulin (Human), HyperRAB™ S/D in Fixed Needle 2 mL Pre-filled Syringe

The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) have been notified by Talecris Biotherapeutics, Inc. that its Rabies Immune Globulin (Human), HyperRAB™ S/D in fixed needle 2 mL pre-filled syringe does not address all dosing situations.  Specifically, the fixed needle (22 gauge, 1.25 inch) and the absence of graduations on the 2 mL pre-filled syringe do not permit administration of the recommended dose of Rabies Immune Globulin (Human), HyperRAB™ S/D in one or more of the following situations:

Healthcare providers may continue to administer HyperRAB™ S/D supplied in the 2 mL pre-filled syringe by following the “Revised Directions for Use” that are packaged with these lots.  The full “Revised Directions for Use” of these lots is available on-line: http://www.talecris.com/us/documents/FINAL_FDA_Approved_Revised_Directions_for_Syringe_Use__21-FEB-08.pdf. Talecris has discontinued manufacturing the HyperRAB™ S/D fixed needle, 2 mL pre-filled syringe.  For additional information regarding this product, please contact Talecris on-line at www.talecris.com, or call 919-412-1030, or toll free at 1-800-520-2807.Human rabies PEP (post-exposure prophylaxis) is recommended when potentially infectious material (e.g. saliva) from a rabid animal is introduced via a bite, or comes into direct contact with broken skin or mucous membranes.  More detailed information regarding evaluation for and administration of PEP is available at

http://www.cdc.gov/mmwr/preview/mmwrhtml/00056176.htm.For more information about rabies and its prevention, contact your state or local public health official or CDC at 1-800-CDC-INFO or visit www.cdc.gov/rabies.

Intro:  According to Biogen Idec and Elan, “TYSABRI^® is indicated as monotherapy for the treatment of patients with relapsing forms of multiple sclerosis to delay the accumulation of physical disability and reduce the frequency of clinical exacerbations.”  Unfortunately, FDA has announced that it may cause severe liver damage.  So, if you have a patient with MS and who is turning the color of a banana, check out what meds he/she is on. 

FDA Drug Alert, 2/27/08:  Biogen Idec, Elan and FDA notified healthcare professionals of reports of clinically significant liver injury, including markedly elevated serum hepatic enzymes and elevated total bilirubin, occurred as early as six days after the first dose of Tysabri. The combination of transaminase elevations and elevated bilirubin without evidence of obstruction is recognized as an important predictor of severe liver injury that may lead to death or the need for a liver transplant in some patients. Tysabri should be discontinued in patients with jaundice or other evidence of significant liver injury. Physicians should inform patients that Tysabri may cause liver injury.

NY Times, 2/28/08:  With reports of more than 400 patients in the United States suffering serious complications after receiving the blood-thinner heparin, American investigators are trying to determine whether the raw material for the drug, made from pig intestines, became contaminated on the journey that begins in the slaughterhouses of China.The investigators are examining the records of a factory an hour from here that supplies much of the active ingredient in heparin for Baxter International, which earlier this month halted sales of multidose vials of heparin after reports of injuries and four deaths.

The owner of the factory, which is known as Changzhou SPL, says its supply chain is safe. It buys raw material from only two reputable wholesalers, it says, and audits their 10 to 12 suppliers.

“We have a collection chain in place, and we stick with that,” said David Strunce, the president of Scientific Protein Laboratories, an American company that owns a majority of Changzhou SPL. He declined repeated requests from The New York Times to identify those smaller suppliers, saying it was proprietary information.

But interviews with dozens of heparin producers and traders in several Chinese provinces, as well as a visit to a village near here dominated by tiny family workshops that process crude heparin from pig intestines, show the difficulties confronting investigators as they seek to trace the supply chain. The picture that emerges is of a chain more complex, and less orderly, than the one Mr. Strunce laid out.

The Chinese heparin market has become increasingly unsettled over the last year, as pig disease has swept through the country, depleting stocks, leading some farmers to sell sick pigs into the market and forcing heparin producers to scramble for new sources of raw material. Traders and industry experts say even big companies have been turning more often to the small village workshops, which are unregulated and often unsanitary.

One of the wholesalers named by Scientific Protein Laboratories, Ruihua Biochemical in Hangzhou, said it provided a mix of crude heparin that it manufactured and some that it bought “from small factories nearby in several villages.” The owner, Hua Ruihua, said he never inspected the small factories. “We are not the government,” he said in a telephone interview. “We have no right to inspect their pigs or intestines or facilities.”

The owner of one of those workshops, Fan Yinan, said, “I sold to Ruihua several times before, but since last September I have had no intestines.” He confirmed that “no one from Ruihua inspected my pigs or intestines.”

Asked about Ruihua Biochemical, the S.P.L. chief, Mr. Strunce, said, “We have no information to suggest that your information is true.”

This week, a spokeswoman for Baxter said the number of reports of adverse reactions to heparin had surpassed 400. A spokeswoman for the Food and Drug Administration in the United States said the agency was reviewing the new reports and did not yet have a revised count.

The authorities have not determined that problems with the heparin supply chain led to the deaths and adverse reactions, first reported last month in Missouri. Nor have investigators determined that heparin from China was the culprit. Baxter also gets some of its ingredients from a plant in Wisconsin. Neither S.P.L. nor Baxter has been accused of doing anything wrong.

Even so, the problems involving heparin have again focused attention on the quality of products from China and the gaps in regulation by both the Chinese and United States governments. S.P.L.’s plant in Changzhou was certified by American officials to export to the United States even though neither government had inspected it. The plant has been exporting heparin to Baxter since 2004.

Like many chemical companies in China that make pharmaceutical ingredients for export, S.P.L. fell into a regulatory void. A spokesman for China’s State Food and Drug Administration, Shen Chen, said his agency had not inspected the S.P.L. factory because “as far as we know, it is not a drug manufacturer; it is a producer of chemical ingredients.” Mr. Shen said his agency was helping American investigators as part of a recent agreement with American regulators.

The process of making heparin begins with the intestines of slaughtered pigs, from which mucous membrane is collected and cooked, eventually producing a dry substance known as crude heparin. Major heparin producers like S.P.L. take that substance, refine it and sell it to companies like Baxter that make the final product, which is widely used in cardiovascular surgery and dialysis.

Some experts say as much as 70 percent of China’s crude heparin — for domestic use and for export — comes from small factories in poor villages. One of the biggest areas for these workshops is here in coastal Jiangsu Province, north of Shanghai, where entire villages have become heparin production centers.

In a village called Xinwangzhuang, nearly every house along a narrow street doubles as a tiny heparin operation, where teams of four to eight women wearing aprons and white boots wash, splice, separate and process pig intestines into sausage casings and crude heparin.

The floors had large puddles and drainage channels; the workshops were dilapidated and unheated; and steam from the production process fogged up the windows and soaked the walls. There were large ovens to cook ingredients and halls lined with barrels to store enzymes, resins, intestines and wastewater.

“This is our family-style workshop,” said Zhu Jinlan, the owner of one heparin operation, who stopped sorting pig intestines and invited visitors to a back room, where she lives with her husband and child. “We’ve been doing this about 10 years.”

Experts say the small, unregulated factories could pose dangers because they do not have the same controls and rules as large slaughterhouses, which also produce crude heparin.

“If you don’t control the incoming source, it’s very hard to get rid of the contaminants,” says Liu Jian, a heparin expert at the University of North Carolina.

Mr. Strunce of S.P.L. says his company never buys directly from the crude-heparin producers, only through its wholesalers, which he called “consolidators” — Changzhou Techpool, its Chinese joint venture partner, and Ruihua. His company, he said, has records documenting all the transactions.

But here in Rugao, producers of crude heparin tell a somewhat different story. A sales manager for a major supplier, Nantong Koulong, said he sells directly to S.P.L. without going through either of the two wholesalers. “We provided crude heparin to Changzhou SPL,” said the sales manager, Chen Jianjun. Some of Koulong’s stock comes from the unregulated workshops, he said.

The owner of one such workshop, Ms. Zhu in Xinwangzhuang, said she sold to S.P.L. two years ago. She also sells to Koulong. “We are really a traditional family-style plant,” she said. “We have no certificate.”

S.P.L. said it never bought directly or indirectly from Koulong.

To the south, in Zhejiang Province, two officials of Zhejiang Willing Animal Byproducts Processing said they, too, sold to S.P.L. “We supply heparin to Changzhou SPL,” said Fang Weicai, the general manager, although he said later that he sold it privately and not under the auspices of his company.

After an outbreak of blue ear pig disease swept through 25 of China’s 31 provinces and regions last year, prices soared, and many drug suppliers had to look to the small workshops. The epidemic, said Cui Huifei, a heparin expert at the Shandong University School of Medicine, “made those biotech companies inevitably purchase from the family-style plants, for cheaper prices.”

A sales manager for another large slaughterhouse in Shandong Province, north of Jiangsu, said he was approached late last year by a buyer for S.P.L. offering what he described as rock-bottom prices for crude heparin.

“It was impossible,” said the sales manager, Wang Shengfu, who works for Shandong Jinluo Group, a major producer of crude heparin. “Only small factory-style farms could accept that low price.”

The deal was never consummated.

Mr. Strunce said S.P.L. responded to the disease outbreak by buying less raw material in China. “We were not out looking for additional heparin because we made do with what we already have,” he said, adding that the company “pays more than many people for heparin over there because we require a higher standard of heparin.”

ABSTRACT

Background Vasopressin is commonly used as an adjunct to catecholamines to support blood pressure in refractory septic shock, but its effect on mortality is unknown. We hypothesized that low-dose vasopressin as compared with norepinephrine would decrease mortality among patients with septic shock who were being treated with conventional (catecholamine) vasopressors. Methods In this multicenter, randomized, double-blind trial, we assigned patients who had septic shock and were receiving a minimum of 5 µg of norepinephrine per minute to receive either low-dose vasopressin (0.01 to 0.03 U per minute) or norepinephrine (5 to 15 µg per minute) in addition to open-label vasopressors. All vasopressor infusions were titrated and tapered according to protocols to maintain a target blood pressure. The primary end point was the mortality rate 28 days after the start of infusions.

AP (2/28, Stobbe) reports that according to data presented before the meeting of the Advisory Committee on Immunization Practices, “[c]hildren suffered higher rates of fever-related convulsions when they got a Merck & Co. combination vaccine instead of two separate shots.”

Specifically, the Centers for Disease Control and Prevention-funded study found that for “children ages 12 months through 23 months, the rate of seizures was twice as high in toddlers who got ProQuad, compared with those who got one shot for chickenpox, and one for the three other diseases:” measles, mumps, and rubella. Merck officials said that “there was five times more chickenpox antigen, the key ingredient, in the” vaccine “than in the stand-alone chickenpox shot.” But, it remains to be seen if that explains the seizure phenomenon. Although the federal panel “had previously taken a position that they preferred doctors give children as few needle sticks as possible,” this finding has prompted them “to water down their preference for the combo vaccine.”

NY Times, 2/28/08: 

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NY Times, 2/27/08:  On a winter night in 2006, a disabled and brain damaged man named Ruben Navarro was wheeled into an operating room at a hospital here. By most accounts, Mr. Navarro, 25, was near death, and doctors hoped that he might sustain other lives by donating his kidneys and liver.But what happened to Mr. Navarro quickly went from the potentially life-saving to what law enforcement officials say was criminal. In what transplant experts believe is the first such case in the country, prosecutors have charged the surgeon, Dr. Hootan C. Roozrokh, with prescribing excessive and improper doses of drugs, apparently in an attempt to hasten Mr. Navarro’s death to retrieve his organs sooner.

A preliminary hearing begins here on Wednesday, with Dr. Roozrokh facing three felony counts relating to Mr. Navarro’s treatment as a donor. At the heart of the case is whether Dr. Roozrokh, who studied at a transplant fellowship program at the Stanford University School of Medicine, was pursuing organs at any cost or had become entangled in a web of misunderstanding about a lesser-used harvesting technique known as “donation after cardiac death.”

Dr. Roozrokh has pleaded not guilty, and his lawyer said the charges were the result of overzealous prosecutors. But the case has sent a shudder through the tight-knit field of transplant surgeons — if convicted on all counts, Dr. Roozrokh could face eight years in prison — while also worrying donation advocacy groups that organ donors could be frightened away.

“If you think a malpractice lawsuit is scaring surgeons off, wait to see what happens when people see a surgeon being charged criminally and going to jail,” said Dr. Goran B. Klintmalm, president of the American Society of Transplant Surgeons, who added that he considered the case unprecedented.

David Fleming, the executive director of Donate Life America, a nonprofit group that promotes donations, said the case had “given some support to the myths and misperceptions we spend an inordinate amount of time telling people won’t happen.”

Mr. Fleming said about 18 people a day die in the United States waiting for transplants. That has created a tremendous demand for donor organs, and over the years the medical community has established strict protocols to govern organ harvesting.

Transplanting organs from patients whose hearts have stopped, or cardiac-death donations, began to go out of vogue in the late 1960s and early ’70s after medical advances like life support and subsequent changes in the legal definition of death made donations from those declared brain dead more efficient. But health officials have encouraged cardiac-death donations in recent years.

There were 670 cardiac-death donations through the first nine months of 2007, the most in any year this decade, according to the United Network for Organ Sharing, which oversees organ allocation. Over the same period, there were 12,553 brain-dead donations, according to the network.

In brain-death donations, the donor is legally dead, but machines keep the organs viable by machines. In cardiac-death donations, after the patient’s ventilator is removed, the heart slows. Once it stops, brain function ceases. Most donor protocols call for a five-minute delay before the patient is declared dead. Transplant teams are not allowed in the room of the potential donor before that.

Cardiac-death donations can make some doctors and nurses skittish if they have not previously witnessed one, said Dr. Robert Sade, the former chairman of the American Medical Association’s Council on Ethical and Judicial Affairs.

“It all works exactly the same, the cuts and the procedure,” Dr. Sade said. “But the circumstances are quite different.”

Several days after Mr. Navarro was hospitalized at the Sierra Vista Regional Medical Center here, a decision was made to remove his ventilator. According to the criminal complaint, Dr. Roozrokh ordered excessive doses of morphine and Ativan, an anti-anxiety medicine, both of which are used to comfort dying patients. In the most shocking accusation, the complaint said Dr. Roozrokh introduced Betadine, a topical antiseptic, into Mr. Navarro’s system; Betadine, the complaint said, is “a harmful substance that may cause death if ingested.”

Mr. Navarro died about eight hours later of what the coroner ruled was natural causes. In the end, however, because his death was not more immediate, his organs had deteriorated too much to be usable for transplant.

Prosecutors have charged Dr. Roozrokh with felony counts of dependent adult abuse, mingling a harmful substance (Betadine) and prescribing a controlled substance (morphine and Ativan) without medical purpose.

The doctor’s lawyer, M. Gerald Schwartzbach, said that Dr. Roozrokh, 34, who moved to Wisconsin from Iran when he was a toddler and excelled as a collegiate swimmer, did “nothing that adversely affected the quality or length” of Mr. Navarro’s life.

“Dr. Roozrokh is a brilliant young surgeon, who has dedicated his life to saving lives,” Mr. Schwartzbach said. Neither the police nor prosecutors would comment on the case.

Mr. Navarro was diagnosed with adrenoleukodystrophy, a neurological disorder, when he was 9. “He would walk like he was drunk,” said his mother, Rosa, a Guatemalan immigrant. “And when he would play, he would fall like Bambi.”

By his early 20s, however, Mr. Navarro’s mental and physical condition had deteriorated to a point where he was placed in an assisted-care facility.

On Jan. 29, 2006, Ms. Navarro received a call from the facility that her son had been found unconscious, in cardiac and respiratory arrest, but that he had been revived and transported to Sierra Vista. His brain had been damaged from lack of oxygen.

Several days later, Ms. Navarro says she was told by a doctor at the hospital, whose name she did not know, that her son would not recover and that he would be disconnected from life support.

Ms. Navarro, a machinist from Oxnard, Calif., who is on disability, said she did not have enough money to stay another night near her son. She said that shortly after leaving the hospital, she received a call from the California Transplant Donor Network, a nonprofit organization. On a tape recording made by the network, Ms. Navarro agreed to donate her son’s organs, saying she did not want him “to suffer too long.”

Late on Feb. 3, a transplant team including Dr. Roozrokh arrived at the hospital.

According to a police interview with Jennifer Endsley, a nurse, the transplant team, including Dr. Roozrokh, stayed in the room during the removal of the ventilator and gave orders for medication, something that would violate donation protocol. Ms. Endsley, who stayed to watch because she had never participated in this type of procedure, also told the police that Dr. Roozrokh asked an intensive care nurse to administer more “candy” — meaning drugs — after Mr. Navarro did not die immediately after his ventilator was removed.

Mr. Schwartzbach said he would address the accusations in court. “I think a great many people, lay and medical, will realize they have been significantly misinformed,” he said.

Several months after the incident, federal health officials cited the hospital for a series of lapses, including failing to grant temporary clinical privileges to Dr. Roozrokh, who was under contract with the donor network. Last February, the United Network for Organ Sharing reprimanded the California Transplant Donor Network for breaking “established protocol” in the case. The donor network declined to comment.

Ms. Navarro has filed a civil suit against Dr. Roozrokh, the donor network and other doctors in the operating room, and has settled a lawsuit against the hospital. A spokesman for the hospital, Ron Yukelson, said a plan to correct the problems had been accepted by federal health officials.

Ms. Navarro said she remained angry about the way her son’s life ended.

“He didn’t deserve to be like that, to go that way,” she said. “He died without dignity and sympathy and without respect.”

Intro:  Woman With an Acute Onset of Nausea and VomitingCraig Johnson, DO; Rathachai Kaewlai, MD.  A 46-year-old woman presents to the emergency department (ED) with constant right upper quadrant pain that radiates to her back and side. She underwent a laparoscopic cholecystectomy 2 weeks ago, without complications. Imaging shows dilated segments of bowel with a characteristic appearance. What is the diagnosis? 

CASE REPORT:  A 46-year-old woman presents to the emergency department (ED) with a history of worsening, constant right upper quadrant pain that radiates to her back and side. She has had nausea and has vomited twice in the past several hours. She underwent a laparoscopic cholecystectomy 2 weeks ago, without complications, and returned to her normal diet. She has not had any bowel movements or flatulence since the pain began. She denies having any fever, chills, or rigors. Her medical history is significant only for high blood pressure, high cholesterol levels, and gallbladder disease. She takes lisinopril, aspirin, multivitamins, and ginseng. She denies smoking or drinking alcohol.

On physical examination, the patient is awake, alert, and oriented. Her vital signs are within the normal range, with a heart rate of 84 bpm and a blood pressure of 124/76 mm Hg. She appears to be in mild distress. The cardiorespiratory examination yields normal findings, with clear lungs and a regular heart rhythm. Her abdomen is soft, but her bowel sounds are decreased, and she has marked tenderness in the right upper quadrant. The rest of her abdomen is minimally tender, with no evidence of guarding or rebound and no palpable masses. The other physical findings are normal.

The laboratory investigation reveals an elevated WBC count of 14.0 × 10⁹/L (14.0 × 10³/µL), with a left shift of 87% neutrophils. Her liver function tests, lipase level, and basic chemistry panel are unremarkable.

Contrast-enhanced computed tomography (CT) scans of the abdomen and pelvis are ordered. Figure 1A shows an anteroposterior (AP) scout image, and Figure 1B shows a selected axial section.

Discussion

The initial scout image (see Figure 2A) demonstrates a markedly dilated segment of bowel with a “kidney-bean” appearance. The vector of the C-loop points toward the right lower quadrant and suggests a cecal volvulus. The axial CT image (see Figure 2B) demonstrates a colon dilated to 8 cm, with an air-fluid level. The collapsed ascending colon and transverse colon are adjacent to the dilated bowel (arrow).

Cecal volvulus is a condition that is characterized by twisting or folding of the right colon. The term cecal volvulus is actually a misnomer because, in most patients with cecal volvulus, the torsion is located in the ascending colon above the ileocecal valve. In general, a partial malrotation is necessary for cecal volvulus to occur because, besides the cecum, parts of the ascending colon are also involved. Defective peritoneal fixation of the ascending colon and cecum has been described in approximately 10% of the population; because this defective fixation results in abnormal mobility of the ascending colon and cecum, displacement of the right colon into any part of the abdominal cavity is possible. An association with adhesions, membranes, and bands, which may provide a nodal point around which the mobile ascending colon may twist, has been described; although these conditions are frequently present, they are not required for a volvulus to occur. Other predisposing risk factors with clearly defined roles in the development of cecal volvulus have also been described. Associations with colonic atony, partial distal large-bowel obstruction, traction resulting from disease of the appendix, colonoscopy, pregnancy, postoperative abdomen, and colonic ileus (pseudo-obstruction) have all been reported. The most common distal colonic lesions associated with cecal volvulus are colonic carcinoma and diverticulitis. Urticaria, with submucosal edema and cellular infiltrate of the bowel, has also been reported in association with cecal volvulus.

Two types of cecal volvulus are described: cecal bascule (type 1; which accounts for approximately 10% of cases) and axial torsion (type 2; which accounts for approximately 90% of cases). Axial torsion, or type 2, occurs when the ascending colon twists 180-360° along its longitudinal axis. Type 2 cecal volvulus is associated with a high mortality rate because of the resultant vascular compromise, which can lead to gangrene and perforation. In the cecal bascule type of volvulus, the cecum folds anteromedially to the ascending colon. A flap-valve occlusion at the site of flexion develops, with marked distention of the cecum and central displacement. Reduction of a cecal bascule after a barium enema has been reported. The ileum may passively twist with the cecum, and usually, a constricting band across the ascending colon is present, which is found at laparotomy.

Volvulus of the large bowel is the cause of approximately 10% of large-bowel obstructions. Cecal volvulus represents approximately 1-2% of intestinal obstructions and about 33% of all cases of colonic volvulus. The majority of volvulus cases are caused by sigmoid volvulus. Cecal volvulus occurs predominantly in patients with poor right colon fixation (found in 10-25% of the general population) and is caused by excessive cecal mobility.

Patients with cecal volvulus usually present with an acute onset of severe, colicky pain with nausea and vomiting, unless partial obstruction is present or the volvulus is intermittent; in the latter cases, the onset may be relatively insidious. Abdominal distention may or may not develop. Proposed etiologies for cecal volvulus include trauma, laxative use, appendicitis, postoperative complications (such as adhesions), constipation, postpartum ligamentous laxity, and distal colonic obstruction from colon cancer or diverticulitis. Cecal volvulus may also occur in other clinical situations, such as after a colonoscopy or a barium enema study, as well as in pregnancy.

An abdominal series alone will help make the diagnosis in approximately 50% of cases of cecal volvulus. The radiographs show a single air-fluid level in a dilated, air-filled cecum in the midabdomen or in the left upper quadrant. The cecal valve may produce a soft-tissue indentation, creating a “kidney-bean” appearance to the air-filled cecum; this is in contrast to a “coffee-bean” sign, caused by grossly dilated and closely apposed loops of bowel, which is more typically noted with sigmoid volvulus. The small bowel should be dilated or fluid-filled, unless the process is early in its course and the bowel has collapsed. In axial torsion, the radiograph may show a markedly distended loop of large bowel with its long axis extending from the right lower quadrant to the epigastrium or the left upper quadrant; this is the most common site to which the cecum is displaced. If the obstruction is complete, the distal colon is usually empty and, frequently, the small bowel is distended. In the cecal bascule form of volvulus, the distended air-filled cecum is more centrally located. With this variant, the ileum can passively twist with the cecum, and the small bowel may not be obstructed. If abdominal radiographs are nondiagnostic, CT scanning or contrast enema studies can help to further define the condition. Barium enema studies can show beaking at the point of the volvulus in the mid-ascending colon. CT scans show the volvulus itself and progressive tapering of the afferent and efferent limbs, which leads to a twist; this is described as the whirl sign. Ultrasonography, if used to investigate the acute abdomen, may demonstrate the small-bowel loops of an associated small-bowel obstruction, or the cecal volvulus may appear as a grossly distended fluid-filled cecum at a lead point of small-bowel obstruction, but generally, the appearances are nonspecific.

Treatment usually consists of surgical reduction with or without a colonic resection and an ileocolostomy. Nonsurgical techniques, such as barium enemas and colonoscopy, are less successful for reducing cecal volvulus than for sigmoid volvulus, and the rate of associated perforation is higher with a cecal volvulus than it is with a sigmoid volvulus. Nonsurgical reduction may be most successful in type 1 volvulus (cecal bascule). Although treatment and management is the same for type 1 and type 2, a type 2 volvulus increases the risk of vascular compromise and perforation. Perforation occurs in 65% of cases involving mechanical distention combined with a vascular compromise. Gangrene is observed in as many as 20% of patients, and mortality is estimated to be as high as 20-40% in the elderly.

The patient underwent an exploratory laparotomy for the bowel obstruction and the suspected cecal volvulus, without a preoperative attempt at reduction. The cecum was edematous and exhibited a dusky appearance (see Figure 3A). A floppy segment of bowel that was not adherent to the lateral wall had folded upward into the upper abdomen and twisted around; these observations were consistent with the final diagnosis of cecal volvulus. The volvulus was reduced, and the color of the involved bowel improved (”pinked up”) nicely (see Figure 3B). A right colonic resection was performed with a stapled ileocolostomy, without complication; this was done because of a risk of recurrence and the possibility of underlying ischemic damage (even though flow may have been restored). The pathology screening revealed ischemic changes, with marked dilatation and serosal adhesions; no perforation was observed. The patient recovered uneventfully.