Gastrocolic fistula as a cause of persistent diarrhea in a patient with a gastrostomy tube

Joo YJ, Koo JH, Song SH. Gastrocolic fistula as a cause of persistent diarrhea in a patient with a gastrostomy tube.A 60-year-old man with a history of recurrent strokes secondary to moyamoya disease underwent insertion of a percutaneous radiologic gastrostomy tube because of severe dysphagia. Feeding was continued for 5 months after the procedure without complications. Persistent diarrhea began 2 weeks after admission for comprehensive rehabilitation. Conservative treatment was not effective. Sigmoidoscopy showed a U-shaped tube suggestive of a gastrocolic fistula in the transverse colon. This was confirmed by means of a tubogram obtained through a gastrostomy tube. The diarrhea resolved after changing the gastrostomy tube. This case report highlights the importance of considering other uncommon conditions, such as a gastrocolic fistula, in the differential diagnosis of persistent diarrhea in a patient with a gastrostomy tube.     

Further characterization of the plasma lipoprotein(a) distribution

The plasma lipoprotein(a) [Lp(a)] distribution in caucasians is heavily skewed to the right, with evidence of bimodality. As there is a well-described inverse relationship between apolipoprotein(a) [apo(a)] size and Lp(a) concentration, it is likely that the presence of multiple apo(a) isoforms of differing frequency has a significant impact on the final distribution of Lp(a) concentrations. We have previously described an immunoblot method for examining the relationship between apolipoprotein(a) [apo(a)] size and lipoprotein(a) [Lp(a)] mass among samples heterozygous for apo(a) size, thus eliminating confounding by null or undetected apo(a) isoforms. In the present study, this method has been applied to examine the plasma Lp(a) distribution, independent of the effects of apo(a) isoform size and frequency. Seventy subjects heterozygous for apo(a) size were studied. To take into account the inverse relationship (P <0.001) between apo(a) isoform size and Lp(a) concentration, Lp(a) data associated with each apo(a) isoform were normalized as multiples of the median Lp(a) concentration for that isoform. These apo(a) isoform-independent Lp(a) data demonstrated a strikingly multimodal distribution, with five major peaks. The relative frequencies of Lp(a) peaks 1–5 were 17.1%, 15.0%, 35.7%, 23.6%, and 8.6%, and associated median Lp(a) concentrations were 1.0, 6.2,15.0, 21.8, and 39.6 mg/dL, respectively. Multivariate analysis demonstrated that apo(a) isoform size accounted for 23% and isoform-independent Lp(a) peaks for 59.5% of the variation in Lp(a) concentration. Further investigation of the characteristics of the apo(a) isoform-independent Lp(a) distribution is warranted.     

Functional approach to investigate Lp(a) in ischaemic heart and cerebral diseases

BACKGROUND: Lp(a), a major cardiovascular risk factor, contains a specific apolipoprotein, apo(a), which by virtue of structural homology with plasminogen inhibits the formation of plasmin, the fibrinolytic enzyme. A number of clinical reports support the role of Lp(a) as a cardiovascular or cerebral risk factor, and experimental data suggest that it may contribute to atherothrombosis by inhibiting fibrinolysis. DESIGN: A well-characterized model of a fibrin surface and an apo(a)-specific monoclonal antibody were used to develop a functional approach to detect pathogenic Lp(a). The assay is based on the competitive binding of Lp(a) and plasminogen for fibrin, and quantifies fibrin-bound Lp(a). High Lp(a) binding to fibrin is correlated with decreased plasmin formation. In a transversal case-control study we studied 248 individuals: 105 had a history of ischaemic cardiopathy (IC), 52 had cerebro-vascular disease (CVD) of thrombotic origin, and 91 were controls. RESULTS: The remarkably high apo(a) fibrin-binding in CVD (0.268 +/- 0.15 nmol L-1) compared with IC (0.155 +/- 0.12 nmol L-1) suggests the existence of peculiar and poorly understood differences in pro- or anti-thrombotic mechanisms in either cerebral and/or coronary arteries. CONCLUSIONS: Our results demonstrated that Lp(a) fibrin-binding and small Apo(a) isoforms are associated with athero-thrombotic disease.     

Giant renal angiomyolipoma with fatal hemorrhage due to a large pseudoaneurysm

We report a case of giant renal angiomyolipoma (AML) with a large pseudoaneurysm causing fatal hemorrhage. A 60-year-old woman presented with right-sided abdominal pain. Sonographic examination revealed a large hyperechoic renal mass. CT examination of the abdomen revealed a 15-cm AML of the right kidney with a large hemorrhagic area within it. Subsequent color Doppler examination revealed a 2.9-cm pseudoaneurysm arising from the upper segmental branch of the right renal artery. The patient, who was about to undergo transcatheter embolization of the pseudoaneurysm, died from cardio-respiratory arrest. The autopsy findings confirmed a large right renal AML containing a thrombosed pseudoaneurysm and a large perinephric hematoma.     

Reconstruction of maxillary palatal defects after partial maxillectomy using a pedicled buccal fat pad and a nasolabial flap

The novelty of this procedure is the reconstruction of a maxillary palatal defect with two pedicled flaps: a pedicled buccal fat pad and a nasolabial flap. This use of combination flaps makes the surgery simple, short, and useful for a wide defect.The novelty of this procedure is the reconstruction of a maxillary palatal defect with two pedicled flaps: a pedicled buccal fat pad and a nasolabial flap. This use of combination flaps makes the surgery simple, short, and useful for a wide defect.     

Multidisciplinary integrated headache care: a prospective 12-month follow-up observational study

This prospective study investigated the effectiveness of a three-tier modularized out- and inpatient multidisciplinary integrated headache care program. N = 204 patients with frequent headaches (63 migraine, 11 tension-type headache, 59 migraine + tension-type headache, 68 medication-overuse headache and 3 with other primary headaches) were enrolled. Outcome measures at baseline, 6- and 12-month follow-ups included headache frequency, Migraine Disability Assessment (MIDAS), Hospital Anxiety and Depression Scale (HADS), standardized headache diary and a medication survey. Mean reduction in headache frequency was 5.5 ± 8.5 days/month, p < 0.001 at 6 months’ follow-up and 6.9 ± 8.3 days/month, p < 0.001 after 1 year. MIDAS decreased from 53.0 ± 60.8 to 37.0 ± 52.4 points, p < 0.001 after 6 months and 34.4 ± 53.2 points, p < 0.001 at 1 year. 44.0 % patients demonstrated at baseline an increased HAD-score for anxiety and 16.7 % of patients revealed a HAD-score indicating a depression. At the end of treatment statistically significant changes could be observed for anxiety (p < 0.001) and depression (p < 0.006). The intake frequency of attack-aborting medication decreased from 10.3 ± 7.3 days/month at admission to 4.7 ± 4.1 days/month, p < 0.001 after 6 months and reached 3.8 ± 3.5 days/month, p < 0.001 after 1 year. At baseline 37.9 % of patients had experience with non-pharmacological treatments and 87.0 % at 12-month follow-up. In conclusion, an integrated headache care program was successfully established. Positive health-related outcomes could be obtained with a multidisciplinary out- and inpatient headache treatment program.     

Achieving a sustained reduction in benzodiazepine use through implementation of an area-wide multi-strategic approach

OBJECTIVE: This study aimed to evaluate the impact, in a regional setting, of a multi-strategic partnership approach for reducing benzodiazepine use in the management of insomnia, as recommended in Australia's National Policy on Quality Use of Medicines. METHOD: The setting was a rural region of South Australia, covering approximately 2000 km2, with a population of over 20 000. The study involved participatory action research, with qualitative and quantitative evaluations. The intervention involved a multi-strategic approach, including provision of treatment guidelines, provision of consumer information, a local media campaign and education and training of health professionals. The quantitative evaluation involved a single region before/after study with 2 years of follow-up using pharmacy-based dispensing data for benzodiazepines and antidepressants, gathered for the months of November to April in 1998/99 ('before' period) through to 2000/01 ('after' period). The data were analysed using non-parametric statistics. RESULTS: There was a 19% reduction in benzodiazepine dispensing 2 years after the intervention compared with a 6% reduction nationally. Dispensing of antidepressants increased by 33%, compared with a 28% increase nationally. CONCLUSION: It was concluded that the multi-strategic approach to the management of sleep disorders proved successful in promoting the use of non-drug alternatives, achieving sustained reduction in benzodiazepine consumption in a rural community, without therapeutic substitution of antidepressants. IMPLICATIONS: The study demonstrated that a sustainable reduction in prescribing of benzodiazepines can be achieved through the implementation of a multi-strategic approach involving local consumers, health professionals, a Division of General Practice, a government department, aged-care facilities and the local media.     

Pleomorphic adenoma of the trachea: A case report and review of the literature

BACKGROUNDPleomorphic adenoma (PA) is the most common benign tumor that occurs in the salivary glands; however, tracheobronchial PA is rarely observed. To the best of our knowledge, fewer than 50 cases have been reported in the literature. We report a 49-year-old woman who had been treated for asthma for 2 years before being diagnosed with PA of the trachea.CASE SUMMARYA 49-year-old woman was referred to our hospital due to dyspnea upon exertion and chronic cough with wheezing for 2 years. Laboratory tests showed an elevated white blood cell count, absolute neutrophil count, and percentage of neutrophils. A chest computerized tomography scan showed a well-defined, soft-tissue density lesion measuring 2.4 cm × 2.1 cm in the lower trachea. Flexible bronchoscopy revealed that nearly 90% of the tracheal lumen was obstructed. The histopathological and immunohistochemistry features suggested PA of the trachea. Furthermore, we review the characteristics of 29 patients with tracheobronchial PA over the last 30 years.CONCLUSIONTracheobronchial PA occurs without gender predominance, mostly in the lower or upper trachea, and has a low recurrence rate. The median age at diagnosis is 48 years. The most common symptoms are cough, stridor, dyspnea, and wheezing.     

Likelihood ratios increase diagnostic certainty in pulmonary embolism

Pulmonary embolism (PE) is a difficult diagnosis to confirm. The choice of tests has led to a myriad of algorithms. Diagnostic uncertainty can be quantified by the application of the tests' likelihood ratios (LR). Positive and negative LR enable the conversion of a pretest to a post-test probability, given a positive and negative test result, respectively. Thus, a pretest probability of <17% and a negative D-dimer with a negative LR of 0.05 (sensitivity 98%, specificity 40%) lead to a post-test probability of PE of <1%. Ventilation perfusion (V/Q) scans with a normal, very low, low, intermediate and high probability result have an LR of 0, 0.125, 0.25, 1 and 17, respectively. Also, patients with a V/Q scan result other than normal or high probability still have a post-test probability of PE from 3 to 65%. Positive and negative computed tomography pulmonary angiograms (CTPA) have an LR of 8.6 and 0.06, respectively (sensitivity 95%, specificity 89%). Patients with a high pretest probability and negative CTPA again still have a post-test probability of more than 10%. However, as the post-test probability after one test becomes the pretest probability for the next, test results used cumulatively progressively narrow the gap to a final diagnosis. The post-test probability after a D-dimer, V/Q scan, CTPA, leg ultrasound or pulmonary angiography, alone or in any combination or in any order, can be calculated using their LR. Use of LR thus assists in the precise interpretation of test results, such as in complex algorithms for PE.     

Towards a more place-sensitive nursing research: an invitation to medical and health geography

During recent years, nursing research has adopted and integrated perspectives and theoretical frameworks from a range of social science disciplines. I argue however, that a lack of attention has been paid in past research to the subdiscipline of medical geography. Although this may, in part, be attributed to a divergence between research priorities and foci, traditional 'scientific' geographical approaches may still be relevant to a wide range of nursing research. Furthermore, a recasting, redirecting and broadening of medical geography in the 1990s, towards what is termed health geography, has enhanced the discipline and provided a more cultural and expansive recognition of health, and a more comprehensive understanding of the dynamic relationship between people, health and place. Given the increasing range of places where health-care is provided and received, and some recent linkages made between nursing and place by nurse-theorists, these newer perspectives and concepts may be particularly useful for interpreting nurses' and patients' relationships both within and with a variety of healthcare settings and living spaces. Indeed, although a more place-sensitive nursing research is potentially a trans-disciplinary academic endeavor, a range of geographical approaches would be central to such a project.     

Leadership behaviours that foster nursing group power

Today's health care environment presents many challenges to nursing groups as they seek to achieve their goals. All resources must be recognized and effectively utilized. Power, defined as the capacity to achieve goals (Sieloff 1995), is a valuable resource that can assist nursing groups in the achievement of their goals. The leader of a nursing group can make a significant difference in a group's ability to actualize their power capacity. The purpose of this article is to identify and discuss the use of a tool (Sieloff-King Assessment of Group Power within Organizations) to identify the nurse leader/group power variables that can be used to improve a nursing group's power as a resource in the achievement of its goals. Using behaviours related to a Nurse Leader's Power Competency and Power Perspective variables, identified in the Theory of Group Power within Organizations (Sieloff 1999), a nurse leader can foster a nursing group's power.     

Modes of relating in a caring conversation: a research synthesis on presence, touch and listening

The purpose of this qualitative research synthesis was to develop an ontological and theoretical understanding of presence, touch and listening in a caring conversation. The material consisted of 28 articles published between 1989 and 1997 in caring and nursing journals. The examination was based on a qualitative research synthesis approach applied to each concept separately. The synthesis was summed up in a model encompassing two modes of relating in a caring conversation: a connection with high intersubjectivity and a contact with limited intersubjectivity. In a connection the nurse is listening, using caring and connective touch and is present as 'being with' the patient. In a contact, the nurse is hearing, using task orientated touch and is present as 'being there' for the patient. A connection is grounded in a mutual receiving which allows a high degree of intersubjectivity. The nurse and the patient are not only present to each other as roles but also as unique persons. Contact is grounded in the attentive attitude of the nurse and in the fact that the nurse and the patient are relying on roles which allow a limited intersubjectivity. The model provides a point of departure for clinical discussions among nurses as well as areas for further research in the field of nurse-patient communication.     

A study protocol for enriching the interprofessional collaborative competency attainment survey insights

The following short report outlines a proposed study designed to evaluate the Interprofessional Collaborative Competency Attainment Survey and its recommended method of administration. This exploratory study seeks to determine if there is a significant difference between two methods of administration, the recommended and validated retrospective pre-test and post-test, and a traditional pre-test and post-test. If a significant difference does exist, this data will provide a means to determine the effect size of that difference. The comparison will be done using repeated measure ANOVA and the subsequent effect size will be evaluated using Cohen’s d. As the retrospective design is utilised to evaluate a change in perceived competency, comparison of data from a traditional pre-test with a retrospective pre-test may provide a means for evaluation of the participants’ change in understanding of the construct, and thus a more thorough picture of the forces driving changes to scores.     

Winged scapula caused by a dorsal scapular nerve lesion: a case report

Akgun K, Aktas I, Terzi Y. Winged scapula caused by a dorsal scapular nerve lesion: a case report.Dorsal scapular nerve lesions are quite rare. A case of a 51-year-old man who had right shoulder pain, weakness of right arm elevation, and prominence of right scapula for 6 months is presented. The condition had been abruptly developed after lifting a heavy box overhead on which he felt a sharp pain in the right shoulder. On clinical examination, there was a prominence of the lower medial border and inferior angle of the right scapula compared with the left. In addition, the right scapula was located more lateral. Magnetic resonance imaging of the thorax revealed the presence of a thinner rhomboid major muscle with a pathologic signal compared with the other side. Needle electromyography of the right rhomboid muscle revealed a long duration, polyphasic motor unit potential with reinnervation potentials, and spontaneous activity. According to these findings, the patient was diagnosed as having a winged scapula because of dorsal scapular nerve lesion.     

Les accidents musculo-squelettiques avec les consoles vidéos de nouvelle génération. À propos d’un cas et revue de la littérature

The rise of next generation consoles game, with their share of sport simulations, has caused appearance of new sport injuries. We present a case of a traumatic rupture of the calcaneal tendon, after a game of virtual sport. It concerned a non-athletic 40-year-old woman. The surgery was performed with a very good long-term result. Literature review demonstrated the extent of these pathologies, with a prevalence of musculoskeletal troubles.     

Fractures simultanées de la base et du col du cinquième métacarpien. À propos d’une association lésionnelle rare

We report the case of a rare combination of a fracture-dislocation of the base and a neck fracture of the 5th metacarpal, the mechanism was direct, result of a punch in a young sportsman. We made a closed reduction of both fractures with a pinning of the neck of the fifth metacarpal in L according to Vives, and intermetacarpal plinning of the base. Evolution over 12 months was satisfactory.     

Dependence of maximum performance time on work intensity in patients with a hereditary myopathy with succinate dehydrogenase deficiency

Summary. Patients with a hereditary mitochondrial myopathy with succinate dehydrogenase (SDH) deficiency and abnormal lactacidosis during physical exercise have a low work capacity when exercising for about 10–15 min. Their maximum voluntary muscular strength is fairly normal. The relationship between the time (t) and a constant workload (N) that a healthy subject can maximally sustain can be expressed as: log t =β+α log N. For normal subjects the constant a is approximately -5 and the constant β has a large interindividual variation. Of four myopathy patients a was determined from two or three maximum bicycle exercise tests of different duration (including ramp- and steady-state tests using a new application of the method of adding submaximal loads to the final maximum workload). The value of a varied between -1.0 and -1.81 and p had low values, both significantly different from those of healthy subjects. The a values explain the divergent results that may be obtained with different types of exercise tests in some of these patients, i.e. a normal or moderately reduced capacity in exercise tests of short duration (for example a short Tornvall or a ramp type of test) and a very low exercise capacity in tests of longer duration (for example a steady state type of test with workloads chosen to allow at least two loads). The low absolute value of α may be related to the abnormally increased anaerobic metabolism of these patients during exercise, caused by the SDH deficiency.     

Primary soft tissue chondroma of the posterior mediastinum: a rare case report and literature review

A chondroma is a common benign cartilaginous tumor. However, a primary soft tissue chondroma of the posterior mediastinum is very rare. We herein report a case involving a 51-year-old man with a posterior mediastinal mass. The mass was dissected by thoracoscopy through the eighth intercostal space. Pathological examination led to a definitive diagnosis of a primary mediastinal chondroma with no criteria of malignancy. Preoperative diagnosis of a posterior mediastinal soft tissue chondroma is not easy because of its rarity and lack of typical features other than calcification. When a posterior mediastinal well-circumscribed soft tissue mass contains calcification and shows no obvious enhancement, the possibility of a soft tissue chondroma should be considered.     

Body mass index and migraine: a survey of the Chinese adult population

The objective of this study is to evaluate the association between body mass index (BMI) and migraine in general population Chinese cohort. This was a cross-sectional secondary analysis from a general population Chinese cohort of men and women of reproductive and post-reproductive age ranging between 18 and 65 years. Migraine was defined utilizing ICHD criteria. Body mass indices were calculated using measured height and weight and categorized based on the World Health Organizations criteria. The 1-year period prevalence of migraine was 9.3 %. No association was identified between migraine and those with a BMI < 30.0. Compared to those with normal BMI (18.5–23.0), those with BMI ≥ 30 (morbid obesity) had a greater prevalence of migraine (8.6 vs. 13.8 %, p = 0.000). Multivariate-adjusted odds ratio demonstrated that those with morbid obesity had a greater than twofold increased odds of migraine [OR 2.10 (1.39–3.12)] as compared to those with a BMI between 18.5 and 23.0. No association was found between obesity and migraine severity, frequency, or disability. Morbid obesity was associated with twofold increased odds of migraine in this Chinese men and women cohort of predominantly reproductive age.