The sandwich design: a new method to close a high-output enterocutaneous fistula and an associated abdominal wall defect

Fistulas draining through large abdominal wall defects are exceptionally difficult to treat and are associated with a very high mortality. This case report describes a new method for closure of these fistulas where prior conservative and surgical treatment had failed. Initial use of a vacuum-assisted closure (VAC) system optimized wound care and led to coverage of the exposed intestines with granulation tissue. The serratus muscle of a composite free latissimus dorsi-serratus flap was used to close the fistula, while the large abdominal wall defect was closed with the musculocutaneous latissimus dorsi flap. Temporary placement of a VAC system between the serratus muscle and the latissimus dorsi muscle immobilized the serratus to the fistula and counteracted changes in abdominal pressure. The layering of muscle, VAC system, and muscle resembles a sandwich. The advantage of the sandwich design is an extraperitoneal approach that provides tension-free closure of the fistula and abdominal wall, with well-vascularized tissue.     

The reliability of a 10-test package for patients with prolonged back and neck pain: could an examiner without formal medical education be used without loss of quality? A methodological study

Background

In the rehabilitation of patients with prolonged back and neck pain, the physical impairment should be assessed. Previous research has exclusively engaged medically educated examiners, mostly physiotherapists. However, less biased evaluations of efforts at rehabilitation might be achieved by personnel standing outside the treatment work itself. Therefore, if medically untrained examiners could be used without cost to the quality, this might produce a better evaluation at defensible cost and could also be useful in a research context. The aim of this study was to answer the question: given a 10-test package for patients with prolonged back and neck pain, could an examiner without formal medical education be used without loss of quality? Five of the ten tests required the examiner to keep a firm hold against the foundation of those parts of the participant's body that were not supposed to move during the test.

Methods

Examination by an experienced physiotherapist (A) in performing the package was compared with that by a research assistant (B) without formal medical education. The reliability, including inter- and intra-rater reliability, was assessed. In the inter-rater reliability study, 50 participants (30 patients + 20 healthy subjects) were tested once each by A and B. In the intra-rater reliability study, the 20 healthy subjects were tested twice by A or B. One-way ANOVA intra-class-correlation coefficient (ICC) was calculated and its possible systematic error was determined using a t-test.

Results

All five tests that required no manual fixation had acceptable reliability (ICC > .60 and no indication of systematic error). Only one of the five tests that required fixation had acceptable reliability. The difference (five vs. one) was significant (p = .01).

Conclusion

In a 10-test package for patients with prolonged back and neck pain, an examiner without formal medical education could be used without loss of quality, at least for the five tests requiring no manual fixation. To make our results more generalizable and their implications more searching, a similar study should be conducted with two or more examiners with and without formal medical education, and the intra-rater reliability study should also include patients and involve more participants.

     

Anaerobic blood culture isolates in a Norwegian university hospital: identification by MALDI‐TOF MS vs 16S rRNA sequencing and antimicrobial susceptibility profiles

We investigated 197 anaerobic isolates recovered from blood cultures in the period 2009–2013. The isolates included were Bacteroides spp., Clostridium spp., Prevotella spp., Fusobacterium spp. and Gram‐positive anaerobic cocci (GPAC). Identification results by MALDI‐TOF MS were compared to those obtained by 16S rRNA sequencing, and the MICs of benzylpenicillin, clindamycin, piperacillin‐tazobactam, meropenem and metronidazole were determined by Etests. The MALDI‐TOF MS correctly identified 94.9% of the anaerobes to the genus level, and 86.8% to the species level, with errors mainly among the non‐fragilis Bacteroides spp. and GPAC. About 73.3% of the isolates were non‐susceptible to penicillin, mainly due to high resistance rates in the Bacteroides spp. (99.2%) and Prevotella spp. (69.2%). About 18.5% of the isolates were clindamycin resistant. Piperacillin‐tazobactam had an excellent activity against all anaerobes except the non‐fragilis Bacteroides spp., of which 43.8% were non‐susceptible. The clinical significance of such a high resistance rate is unclear. Meropenem and metronidazole were the most active antibiotics, with 96.9% and 97.9% of the isolates being susceptible.     

Impact of body composition, fat distribution and sustained weight loss on cardiac function in obesity

Background

Older age is an independent predictor of all-cause mortality in patients with mild to moderate heart failure (HF). Whether older age is also an independent predictor of mortality in patients with more advanced HF is unknown.

Methods

Of the 2707 Beta-Blocker Evaluation of Survival Trial (BEST) participants with ambulatory chronic HF (New York Heart Association class III/IV and left ventricular ejection fraction < 35%), 1091 were elderly (≥ 65 years). Propensity scores for older age, estimated for each of the 2707 patients, were used to assemble a cohort of 603 pairs of younger and older patients, balanced on 66 baseline characteristics.

Results

All-cause mortality occurred in 33% and 36% of younger and older matched patients respectively during 4 years of follow-up (hazard ratio {HR} associated with age ≥65 years, 1.05; 95% confidence interval {CI}, 0.87-1.27; P = 0.614). HF hospitalization occurred in 38% and 40% of younger and older matched patients respectively (HR, 1.01; 95% CI, 0.84-1.21; P = 0.951). Among 603 pairs of unmatched and unbalanced patients, all-cause mortality occurred in 28% and 36% of younger and older patients respectively (HR, 1.34; 95% CI, 1.10-1.64; P = 0.004) and HF hospitalization occurred in 34% and 40% of younger and older unmatched patients respectively (HR, 1.24; 95% CI, 1.03-1.50; P = 0.024).

Conclusion

Significant bivariate associations suggest that older age is a useful marker of poor outcomes in patients with advanced chronic systolic HF. However, lack of significant independent associations suggests that older age per se has no intrinsic effect on outcomes in these patients.     

Developmental level and other factors associated with symptoms of mental disorders and problem behaviour in adults with intellectual disabilities living in the community

Background  

Studies of the relationship between the level of intellectual disability and mental and behavioural disorders have reported divergent findings regarding the direction of the relationship and how it is related to different mental disorders.     

Hla class ii alleles and heterogeneity of juvenile rheumatoid arthritis. drb1*0101 may define a novel subset of the disease

Objective. To examine the distribution of HLA class II alleles in clinically distinct juvenile rheumatoid arthritis (JRA) subsets. Methods. We typed 298 patients and 181 controls for HLA–DRB1, DQA1, DQB1, and DPB1 alleles using polymerase chain reaction and oligonucleotide probe techniques. Results. Each JRA subset was characterized by a distinct distribution of HLA class II alleles. For the persistently pauciarticular and rheumatoid factornegative polyarticular JRA subsets, certain combinations of DRB1 and DPB1 alleles were characteristic. In patients without antinuclear antibodies and chronic iridocyclitis, there was an increase of DRB1*0101/02 and DQA1*0101. Conclusion. Findings of HLA typing support clinical subdivisions of the disease and suggest the existence of a novel DRB1*0101/02 and DQA1*0101 associated disease subset.