Ileal pouch fistulas after restorative proctocolectomy: management and outcomes

Background

Fistula between an ileal pouch and the vagina, anus, or perineum is an uncommon complication of ileal pouch-anal anastomosis and is a cause of considerable morbidity. Its optimal management has not been determined because of its low incidence. The aim of this study was to review the outcomes of patients who presented with symptomatic ileal pouch-associated fistulas after restorative proctocolectomy (RPC) and to present a diagnostic and treatment algorithm.

Methods

Retrospective review of patients treated for symptomatic ileal pouch-associated fistulas after RPC from 1989 to 2011.

Results

Twenty-five patients (14 men, mean age 40 years) were presented with symptomatic ileal pouch-associated fistulas. Median time to pouch fistula following RPC was 6.9 years (range 1 month–20 years). Fistulas were classified as pouch-anal (n = 12, 48 %), pouch-vaginal (n = 7, 28 %), complex (n = 4, 16 %), and pouch-perineal (n = 2, 8 %). Etiology included Crohn’s disease (n = 15, 60 %), cryptoglandular (n = 6, 24 %), and anastomotic failure (n = 4, 16 %). Each patient underwent an average of 2.8 local procedures or repairs. Overall healing rate was 64 % at a median follow-up of 29 (range 2–108) months. None of the complex fistulas were healed. Postoperative pelvic sepsis, fecal diversion, anti-tumor necrosis factor therapy, and fistula etiology did not significantly impact fistula healing. Three patients required pouch excision with end ileostomy.

Conclusions

Operative treatment of pouch fistulas after RPC resulted in complete healing in 64 % of patients following a stepwise diagnostic and therapeutic approach.     

Early oral feeding after pancreatoduodenectomy enhances recovery without increasing morbidity

Objective

The aim of this study was to evaluate whether a change in the routine feeding strategy applied after pancreatoduodenectomy (PD) from nasojejunal tube (NJT) feeding to early oral feeding improved clinical outcomes.

Methods

An observational cohort study was performed in 102 consecutive patients undergoing PD. In period 1 (n = 51, historical controls), the routine postoperative feeding strategy was NJT feeding. This was changed to a protocol of early oral feeding with on-demand NJT feeding in period 2 (n = 51, consecutive prospective cohort). The primary outcome was time to resumption of adequate oral intake.

Results

The baseline characteristics of study subjects in both periods were comparable. In period 1, 98% (n = 50) of patients received NJT feeding, whereas in period 2, 53% (n = 27) of patients did so [for delayed gastric empting (DGE) (n = 20) or preoperative malnutrition (n = 7)]. The time to resumption of adequate oral intake significantly decreased from 12 days in period 1 to 9 days in period 2 (P = 0.015), and the length of hospital stay shortened from 18 days in period 1 to 13 days in period 2 (P = 0.015). Overall, there were no differences in the incidences of complications of Clavien–Dindo Grade III or higher, DGE, pancreatic fistula, postoperative haemorrhage and mortality between the two periods.

Conclusions

The introduction of an early oral feeding strategy after PD reduced the time to resumption of adequate oral intake and length of hospital stay without negatively impacting postoperative morbidity.     

Aktuelle Epidemiologie der Tuberkulose weltweit,in Europa und in Deutschland

Background

Tuberculosis remains one of the most important infectious diseases worldwide. For 2011 the World Health Organization estimated that there were 8.7 million new cases of tuberculosis and 1.4 million deaths from tuberculosis.

Objectives

This article gives an overview on the current tuberculosis (TB) situation worldwide, in Europe as well as in Germany. Special attention is given to drug resistance and the HIV and tuberculosis coepidemic as they strongly impact on the epidemiology of tuberculosis.

Methods

International and national epidemiological reports on tuberculosis as well as selected epidemiological studies were considered. Challenges for tuberculosis control in Germany are discussed.

Results

Globally, a slight decline in tuberculosis incidence is currently being observed. This is partly attributed to improvements in diagnostic and therapeutic care and also for HIV infected patients. However, drug resistance rates are causing concern, especially in several newly independent states of the former Soviet Union. Although tuberculosis case numbers and incidences in the European Union and the European Economic Area (EU/EEA) are comparably low, tuberculosis still represents a considerable burden of disease. In Germany, as in several other western European countries with a low incidence of tuberculosis, case numbers are stagnating and childhood tuberculosis is slightly increasing. Therefore, efforts to ensure an effective tuberculosis control cannot be allowed to wane.     

Utility of snout wipe samples for influenza A virus surveillance in exhibition swine populations

Background

Sporadic influenza A virus (IAV) outbreaks in humans and swine have resulted from commingling of large numbers of people and pigs at agricultural fairs in the United States. Current antemortem IAV surveillance strategies in swine require collecting nasal swabs, which entails restraining pigs with snares. Restraint is labor-intensive for samplers, stressful for pigs, and displeasing to onlookers because pigs often resist and vocalize.

Objective

To evaluate the utility of snout wipes in exhibition swine as a method to make IAV surveillance efforts less intrusive, less labor-intensive, and more widely accepted among pig owners and exhibition officials.

Methods

Three materials (rayon/polyester gauze, cotton gauze, and Swiffer® Sweeper dry cloths) were inoculated with IAV, and viral recoveries from these materials were quantified using qRT-PCR and TCID₅₀ assays. In a field trial, paired cotton gauze snout wipes and gold standard polyester-tipped nasal swabs were collected from 553 pigs representing 29 agricultural fairs and the qualitative results of rRT-PCR and viral isolation were compared.

Results and Conclusions

Viral recoveries from potential snout wipe materials ranged from 0·26 to 1·59 log₁₀ TCID₅₀/ml less than that of the positive control in which no substrate was included; rayon/polyester gauze performed significantly worse than the other materials. In the field, snout wipes and nasal swabs had high levels of agreement for both rRT-PCR detection and virus isolation. Although further investigation and refinement of the sampling method is needed, results indicate that snout wipes will facilitate convenient and undisruptive IAV surveillance in pigs at agricultural fairs.     

In vitro suppression of programmed cell death of B cells by tissue inhibitor of metalloproteinases-1.

Cellular pathways for induction of programmed cell death (PCD) have been identified, but little is known about specific extracellular matrix processes that may affect apoptosis along those pathways. In this study, a series of Burkitt's lymphoma (BL) cell lines were assayed for their expression of tissue inhibitor of metalloproteinases (TIMP)-1. Results indicate that TIMP-1-positive BL lines show resistance to cold-shock-induced apoptosis. Furthermore, recombinant TIMP-1, but not TIMP-2 or a synthetic metalloproteinase inhibitor (BB-94), confers resistance to apoptosis induced by both CD95-dependent and -independent (cold shock, serum deprivation, and gamma-radiation) pathways in TIMP-1-negative BL lines. TIMP-1 suppression of PCD is not due to metalloproteinase inhibition, as reduction and alkylation of the TIMP-1 did not abolish this activity. Retroviral induction of TIMP-1 not only resulted in cell survival but also in continued DNA synthesis for up to 5 d in the absence of serum, while controls underwent apoptosis. This resistance to apoptosis is reversed by anti-TIMP-1 antibodies, demonstrating that secreted TIMP-1 is active in blocking apoptosis. Furthermore, TIMP-1 upregulation induced expression of Bcl-XL but not Bcl-2 as well as decreased NF-kappaB activity as compared with controls. These results demonstrate that TIMP-1 suppresses apoptosis in B cells and suggests a novel activity for TIMP-1 in tissue homeostasis.     

„Oxygen to see“ bei der computertomographiegesteuerten Sympathikolyse

Background

The indications for chemical sympathectomy (CS) for sympathicolytic treatment of peripheral artery occlusive disease (PAOD) are still controversially discussed. This measure is not mentioned in the current guidelines of the transatlantic inter-society consensus document on management of peripheral arterial disease (TASC II). The reason is that CS could cause an increase in arteriovenous shunts and an improvement in oxygen saturation by CS has not yet been confirmed. Additionally, it was difficult to determine ex ante which patients could benefit from CS. “Oxygen to see” (O2C) allows a non-invasive measurement of microvascular perfusion under static conditions and an estimate of endothelial integrity by functional tests. This study tested the utilization of O2C in CS.

Material and methods

Patients with PAOD Fontaine stages III and IV underwent CS using a standard clinical protocol (temporary and definitive CS). Microcirculatory parameters (e.g. tissue oxygen saturation and blood flow) were recorded in a standardized protocol including baseline and functional measurements with O2C before and after CS. A total of eight patients with chronic ischemia of the extremities and no possibility of surgical and interventional revascularization were included in the study.

Aims

This pilot study investigated the effects on microvascular perfusion before and after CS using the O2C procedure to characterize potential pathophysiological mechanisms also in patients with diabetes.

Results

A clinical response to CS was shown by seven out of the eight patients. The O2C procedure was capable of discriminating between the clinically more prominent extremity and the contralateral side (baseline and functional oxygen saturation and flow). Functional measurements with a defined high positioning of the extremity (65 cm equivalent to 50 mmHg) were more qualified than static measurements to show CS-induced changes in tissue microcirculation.

Discussion

As measurable effects of CS on the microcirculation were evident which correlated with the clinical response, this method could be used to characterize microcirculatory changes when performing prospective controlled clinical trials in patients with chronic limb ischemia. This is particularly true for patients who are difficult to assess with clinical parameters (e.g. diabetic neuropathy).     

Risk of fracture in patients with Guillain-Barré syndrome

Summary

The aim of this study was to evaluate fracture risk in patients with Guillain-Barré syndrome (GBS). No association with risk of fracture was observed for GBS patients compared with controls. Only GBS patients using pain treatment had a doubled risk of fracture.

Introduction

Symptoms of Guillain-Barré syndrome (GBS) may vary from mild difficulty in walking to complete paralysis, which may increase the risk of fractures. Therefore, the aim of this study was to evaluate fracture risk in patients with GBS.

Methods

We conducted a retrospective cohort study using the UK Clinical Practice Research Datalink (1987–2012). Each patient with GBS was matched by year of birth, sex, and practice, up to six patients without a history of GBS. Outcome measure was any fracture.

Results

There were no associations between GBS and any fracture, adjusted hazard ratio (AHR) 1.01 (95 % confidence interval [CI] 0.77–1.33), or osteoporotic fracture, AHR 0.76 (95 % CI 0.50–1.17), compared with controls. Stratification to gender, age, and duration since diagnosis did not show an association either. Only for GBS patients using pain treatment, risk of fracture was doubled AHR 1.97 (95 % confidence CI 1.21–3.21) compared with controls. The risk of fracture in GBS patients exposed to pain treatment was equivalent to risk of fracture among controls exposed to pain treatment.

Conclusions

No association with risk of fracture was observed for GBS patients compared with controls. Only GBS patients using pain treatment had a doubled risk of fracture, but their risk was equivalent to fracture risk among controls exposed to pain treatment.     

Die sympathetische Salbe des Wundarztes Matthaeus Gothofrid Purmann anno 1716

The sympathetic salve, also known as weapon salve or unguentum armarium, is one of the magical medical compounds. The composition includes human ingredients, such as mummies and natural products, such as wild pig and bear fat, earthworms, various plants and stones as well as moss from the human skull (usnea cranii humani). In the “magic touch” blood had manifold important functions also for the explanation of the sympathetic salve. It stuck to the weapon or was taken from the wound of an injured person with a wooden spatula then smeared with the wonder salve and stored in a safe place. In this way the spirits in the blood could be set free and have a favorable effect on wound healing even from a large distance away. The word sympathetic means magical and medicine in the sixteenth to the eighteenth centuries was still deeply impregnated by magical influences. Paracelsus and 200 years later the famous and respected wound surgeon Purmann found themselves with their theories on the borderline between the superstitious Middle Ages and the already scientifically influenced modern era. We have been successful in finding the original sentence from the year 1603 in the extensive writings of Paracelsus.