The effect of six months intensive physical training on the circulation in the legs of patients with intermittend claudication

Out of 94 patients with intermittent claudication 65 completed a program of 6 months intensive physical training. Every 2 months the blood pressure indices at the thigh and at the ankle and the blood flow in the calf were measured at rest, after 5 min arterial occlusion and after exercise of the calf muscles until claudication. First the reproducibility of the blood pressure indices and the blood flow values was established. An increase of 15 in the pressure indices was considered to be substantial. An increase of 6.0 ml/100 ml/min in flow values was considered a substantial change. The blood pressure indices did not increase significantly during the training period, the blood flow values increased significantly. On the basis of the non-invasive tests no reliable statement can be made as to the expected result of the training.     

Neurodevelopmental outcome in full-term newborns with refractory neonatal seizures

Aim: This retrospective study describes the prognosis of full‐term newborns with refractory neonatal seizures, comparing the need for treatment with two versus three or more antiepileptic drugs. Methods: We reviewed our database (January 2002–December 2007) to include newborns with refractory neonatal seizures and abnormal electroencephalogram. Group A consisted of 17 newborns with two antiepileptic drugs. Group B consisted of 29 newborns with three or more antiepileptic drugs. Outcome was determined at 2 years of age using the Dutch Bayley Scales of Infant Development or a neurodevelopmental classification scheme. Results: Group A and group B were comparable regarding to a variety of demographic and aetiologic factors. Thirteen newborns died before 2 years of age and one was lost to follow‐up. Normal development at 2 years of age was found in 50% and 5% for group A and B, respectively. Severe neurodevelopmental delay at 2 years of age was found in 30% and 68% for group A and B, respectively. Conclusion: The number of antiepileptic drugs probably reflects increased seizure burden and is – in that way – related to poor outcome. This may be useful information for early prediction of adverse neurological outcome in the first days of life.     

Cognitive performance after mild traumatic brain injury: the impact of poor effort on test results and its relation to distress, personality and litigation

PRIMARY OBJECTIVE: To compare consecutive Mild Traumatic Brain Injury (MTBI) patients with and without adequate effort on cognitive performance, litigation status, fatigue, distress and personality. RESEARCH DESIGN: (Neuro)psychological assessment was done 6 months post-injury in 110 patients from a cohort of 618 consecutive MTBI patients aged 18-60, who attended the emergency department of our level I trauma centre. Effort was tested with the Amsterdam Short Term Memory test. MAIN OUTCOME AND RESULTS: Thirty patients (27%) failed the effort test. Poor effort was associated with significantly poorer scores on seven out of eleven measures, covering all tested domains. Poor effort was associated with lower educational level and changes in work status, but not litigation. Furthermore, poor effort was related to high levels of distress, Type-D personality and fatigue. CONCLUSIONS: Even in a sample of non-referred MTBI patients, poor effort was common and was strongly associated with inferior test performance. These findings imply that effort testing should be part of all cognitive assessments, also outside mediolegal settings. Behavioural factors like distress and personality should be considered as potential threats to the validity of neuropsychological testing after MTBI.     

Evaluation of the DiversiLab System for Detection of Hospital Outbreaks of Infections by Different Bacterial Species

Many bacterial typing methods are specific for one species only, time-consuming, or poorly reproducible. DiversiLab (DL; bioMérieux) potentially overcomes these limitations. In this study, we evaluated the DL system for the identification of hospital outbreaks of a number bacterial species. Appropriately typed clinical isolates were tested with DL. DL typing agreed with pulsed-field gel electrophoresis (PFGE) for Acinetobacter (n = 26) and Stenotrophomonas maltophilia (n = 13) isolates. With two exceptions, DL typing of Klebsiella isolates (n = 23) also correlated with PFGE, and in addition, PFGE-nontypeable (PFGE-NT) isolates could be typed. Enterobacter (n = 28) results also correlated with PFGE results; also, PFGE-NT isolates could be clustered. In a larger study (n = 270), a cluster of 30 isolates was observed that could be subdivided by PFGE. The results for Escherichia coli (n = 38) correlated less well with an experimental multilocus variable number of tandem repeats analysis (MLVA) scheme. Pseudomonas aeruginosa (n = 52) showed only a limited number of amplification products for most isolates. When multiple Pseudomonas isolates were assigned to a single type in DL, all except one showed multiple multilocus sequence types. Methicillin-resistant Staphylococcus aureus generally also showed a limited number of amplification products. Isolates that belonged to different outbreaks by other typing methods, including PFGE, spa typing, and MLVA, were grouped together in a number of cases. For Enterococcus faecium, the limited variability of the amplification products obtained made interpretation difficult and correlation with MLVA and esp gene typing was poor. All of the results are reflected in Simpson''s index of diversity and adjusted Rand''s and Wallace''s coefficients. DL is a useful tool to help identify hospital outbreaks of Acinetobacter spp., S. maltophilia, the Enterobacter cloacae complex, Klebsiella spp., and, to a somewhat lesser extent, E. coli. In our study, DL was inadequate for P. aeruginosa, E. faecium, and MRSA. However, it should be noted that for the identification of outbreaks, epidemiological data should be combined with typing results.Pulsed-field gel electrophoresis (PFGE) is generally considered the “gold standard” method for the typing of many bacterial species. Other commonly used typing procedures include multilocus sequence typing (MLST), Multiple-locus variable number of tandem repeats analysis (MLVA), and amplified fragment length polymorphism analysis (6, 8, 11, 14, 21). But all of these methods suffer from different drawbacks. They are specific for one species, time-consuming, or poorly reproducible. The recently introduced DiversiLab (DL) system (bioMérieux) potentially overcomes these limitations. This typing technique is based on the repetitive-sequence-based PCR (rep-PCR) for typing (3, 4, 23, 24). This method was developed in the 1990s and, though still used today, suffers from reproducibility problems. The DL system is a semiautomated rep-PCR with a high level of standardization, in particular for the electrophoresis step by using a Bioanalyzer (Agilent Technologies, Inc., Santa Clara, CA). This reduces reproducibility problems due to variation in assay conditions. The analysis software allows the comparison of individual amplification product patterns (peak patterns), which enables easier interpretation of the patterns, but a virtual gel image is also generated. The patterns can be stored in a database and used for comparison. An important advantage of DL is that a result can be obtained in 1 day starting from a pure culture. A number of studies investigating DL have been published (5, 7, 16, 18, 19), but these were limited to one species and sometimes used collections or made comparisons at the level of MLST, a method which is not discriminatory enough for hospital outbreak analysis.In this study, we evaluated the DL system for the identification of established hospital outbreaks of a number of bacterial species, including methicillin-resistant Staphylococcus aureus (MRSA), Enterococcus faecium, Escherichia coli, the Enterobacter cloacae complex, Acinetobacter species, Klebsiella species, Stenotrophomonas maltophilia, and Pseudomonas aeruginosa, using typed collections.     

Hypertrophic scarring is associated with epidermal abnormalities: an immunohistochemical study

The role of epidermal keratinocytes in the early phases of normal unimpaired wound healing has been studied extensively. However, little is known about the cell biological processes in the epidermis and the basal membrane zone during the later phases of dermal matrix formation and remodelling of the scar tissue. This study investigated epidermal growth and differentiation and maturation of the basal membrane zone. Biopsies were taken from (clinically) hypertrophic and non-hypertrophic scars at 3 and 12 months after a breast- reduction operation. Tissues were analysed using immunohistochemical techniques. The data showed that epidermal abnormalities with respect to differentiation persist up to 3 months, as witnessed by the expression of cytokeratin 16. Remarkably, hypertrophic scars that remained hypertrophic throughout the period of analysis (up to 12 months) showed significantly more cytokeratin 16 expression at 3 months, when compared either with normal scars or with hypertrophic scars that became normal after 12 months. Staining for Ki-67 antigen, a marker for cell proliferation, revealed an increase in basal keratinocyte proliferation rate in 3-month-old hypertrophic scars compared with non-hypertrophic scars. After 12 months, this difference had disappeared completely and the number of cycling basal cells had returned to normal values. Three-month-old hypertrophic scars showed more acanthosis than non-hypertrophic scars of the same age, irrespective of whether they remained hypertrophic or became normal scars. After 12 months, this difference was no longer present. Staining for various heparan sulphate proteoglycan epitopes revealed that restoration of the basal membrane was incomplete at 3 months, but was complete at 12 months with respect to this component. No differences in the expression of several components of the basal membrane zone (heparan sulphate proteoglycan, laminin, tenascin) were noted between hypertrophic and non-hypertrophic scars. These data show that in the early phase of hypertrophic scarring, epidermal abnormalities are found compared with normal wound healing. In addition, early (3 months) epidermal abnormalities are associated with the clinical outcome at 12 months. These findings raise the possibility that the epidermal compartment is involved in the pathogenic process. Copyright © 1998 John Wiley & Sons, Ltd.     

Pyloric atresia

We present a case of a female newborn with a single air bubble on abdominal x-ray by pyloric atresia and a short review of the literature.