Push enteroscopy in the investigation of small-intestinal disease

We report our experience with small-bowel push enteroscopy in 50 patients. The indications for push enteroscopy were: anaemia/occult gastrointestinal bleeding (22 patients); overt gastrointestinal bleeding (17 patients); abnormal small-bowel radiology (8 patients) and miscellaneous (3 patients). In those with undiagnosed gastrointestinal bleeding/anaemia, abnormalities were detected in 24/39 patients (62%): small bowel arteriovenous malformations (AVMs) were detected in 19 (49%), and five (13%) had lesions in the upper gastrointestinal tract. Seventeen patients had heater-probe ablation therapy of vascular lesions: nine patients had small-intestinal lesions, four patients gastric lesions, and four patients combined gastric and small- intestinal lesions. In those with abnormal small-bowel radiology, abnormalities were detected in 6/8 patients. We conclude that (i) push enteroscopy can establish a diagnosis in a high proportion of patients with gastrointestinal bleeding; (ii) heater-probe ablation therapy of vascular lesions can be performed routinely at the time of enteroscopy; (iii) a significant proportion of patients (9/50) referred for enteroscopy with undiagnosed gastrointestinal bleeding have lesions in the stomach/proximal duodenum missed at diagnostic endoscopy. Push enteroscopy is a valuable diagnostic and therapeutic endoscopic procedure.      

Rate of isometric knee extension strength development and walking speed after stroke

The relationship between lower-limb weakness and walking speed after stroke is not clear. This may be related to the measurement used to quantify weakness, typically peak strength. This study examined the relationship between two measures of isometric knee extension strength, i.e., peak torque and the rate of torque development and walking speed in adults with stroke. This study had 83 stroke survivors who participated. For the affected lower limb, rate and peak torque explained 12% of the variance in gait speed. Removing rate from the model significantly reduced the explained variance; in contrast, removing peak torque did not reduce the variance. For the less affected lower limb, rate tended to be more predictive of gait speed than peak torque. Diminished ability to rapidly generate knee extension torque contributes more to decreased walking speed after stroke than does maximal strength. Of note, 88% of the variance in gait speed is not explained by rate and peak isometric knee extension strength. Further studies are needed to determine if rehabilitation poststroke can increase the rate of knee strength development and if it results in faster walking speeds.     

Deleterious effects of chronic clenbuterol treatment on endurance and sprint exercise performance in rats

The beta(2)-adrenergic agonist, clenbuterol, has powerful muscle anabolic and lipolytic effects and is used by athletes to improve exercise performance; however, its use in conjunction with different forms of exercise training has received limited attention. Since previous studies have reported that chronic use of other beta(2)-adrenergic agonists has deleterious effects on cardiac muscle structure and function, the aim of the present study was to determine whether chronic clenbuterol administration would reduce the exercise capabilities of rats subjected to long-term treadmill sprint running, endurance swimming or voluntary wheel running training. The effect of clenbuterol treatment on exercise performance in rats was evaluated in three separate studies. Different groups of male rats were assigned to an endurance swimming (2 h/day, 5/7 days, 18 weeks) group, a treadmill sprint running (8x1 min bouts, 1.05 m/s, 20 weeks) group, or a voluntary wheel running (16 weeks) group. In each study, rats were allocated into either a treated group that received clenbuterol (2 mg.kg(-1).day(-1)) in their drinking water or an untreated control group. In each of the three studies, treated rats exhibited a reduction in exercise performance compared with untreated rats. Treated rats ran approximately 57% less total distance than untreated rats in the voluntary running programme and were unable to complete the swimming and sprinting protocols performed by the untreated rats. In each of the studies, the treated rats exhibited cardiac hypertrophy, with absolute heart mass increased by approximately 19% and heart mass relative to body mass increased by approximately 20%. The hearts of sedentary rats treated with clenbuterol exhibited extensive collagen infiltration surrounding blood vessels and in the wall of the left ventricle. The results indicate strongly that chronic clenbuterol administration deleteriously affects exercise performance in rats, potentially due to alterations in cardiac muscle structure and function.     

The structure and structural effects of VA rehabilitation bedservice care for stroke

The purpose of this study was to: 1) examine the variation in organizational structure within rehabilitation bed-service units (RBU) in the Veterans Health Administration (VHA), and 2) evaluate the effects of RBU and parent hospital structure on stroke rehabilitation outcomes. Two VHA-wide surveys of acute and rehabilitation services for stroke were linked with 2 y of VHA rehabilitation outcomes for stroke patients. A random effects mixed model was used to adjust for patient level covariates, control for unique site effects, and test for facility level structural effects. After adjusting for patient covariates, four structural variables were associated with length of stay or patient functional gain. These results indicate that rehabilitation structure is important to rehabilitation outcome. The individual variables identified in this study, namely, diverse multidisciplinary staff, expert physician leadership, staff participation in team care, and richer rehabilitation equipment resources, may represent the distinct aspects of a successful, comprehensive rehabilitation unit.     

Identification and characterization of teicoplanin-intermediate Staphylococcus aureus blood culture isolates in NE Scotland

The study objective was to screen both methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) isolates from blood cultures for reduced susceptibility to vancomycin and teicoplanin. A total of 72 MRSA and 143 MSSA isolates were screened on brain-heart infusion agar containing either 4 mg/L vancomycin or 8 mg/L teicoplanin, using an inoculum of approximately 10(6) organisms. MICs were determined by Etest, broth microdilution and agar incorporation. Isolates were characterized by PFGE, mecA and nuc PCR, transmission electron microscopy (TEM) and analysis of cell proteins (proteomics). Based on British Society for Antimicrobial Chemotherapy (BSAC) breakpoints, seven MRSAs and seven MSSAs were teicoplanin resistant, with MICs of up to 16 and 24 mg/L respectively, but were vancomycin sensitive. Based on higher NCCLS breakpoints, five MRSAs and six MSSAs were teicoplanin intermediate, vancomycin sensitive. All the MRSAs belonged to the EMRSA-16 clone and subdivided into two groups. The MSSAs belonged to five different clones. TEM showed the resistant variants to have slightly thicker cell walls than sensitive variants. Most notably, the resistant variants possessed characteristic dark, granular material concentrated in the middle of the cells, believed to be chromosome. Proteomics showed the resistant variants to overexpress phosphoglycerate kinase. Both MRSA and MSSA with reduced teicoplanin susceptibility may remain vancomycin sensitive by NCCLS and BSAC criteria and it is important to screen clinical isolates of MRSA and MSSA for reduced susceptibility to both agents.     

Emergence of Gentamicin-Resistant Klebsiella in a General Hospital

Gentamicin had been in use in a general hospital for over 7 years before any gentamicin-resistant Klebsiella were observed. In 1974 and 1975, nine different gentamicin-resistant serobiotypes of Klebsiella were isolated from 35 patients. The first strain to appear had R-factor-mediated gentamicin resistance, and it infected 19 patients during a period of almost 2 years, spreading largely by case-to-case infection in patients with urinary catheters. It appeared to lose the capacity to transfer its gentamicin resistance after it had infected five of the patients. We had previously isolated on the same ward a gentamicin-susceptible Klebsiella of identical type, and it was found to be capable of acquiring an R-factor for gentamicin resistance. All of the other types of gentamicin-resistant Klebsiella infected few patients and did not persist in the hospital; four of them had R-factor-mediated resistance to gentamicin and all four, as did the original strain, cotransferred kanamycin, neomycin, and tobramycin resistance. Every gentamicin-resistant Klebsiella was susceptible to amikacin and netilmicin.     

Postantibiotic effect of meropenem on members of the family Enterobacteriaceae determined by five methods.

The postantibiotic effect (PAE) of meropenem was determined for 11 strains, both clinical isolates and reference strains of members of the family Enterobacteriaceae. The study compares PAE results obtained by five methods used to monitor bacterial regrowth, including viable counting, alone and in combination with impedance; bioluminescence, alone and in combination with impedance; and a morphological technique. After exposure of the test organisms to meropenem (0.1 x to 100 x MIC) for 2 h, concentration-dependent differences in counts by bioluminescence and viable counts were observed, the latter always being lower. The differences varied with the test organism. For example, after exposure of Providentia stuartii NCTC 10318 to 0.1 x MIC, the counts were 5.5 x 10(5) and 2.0 x 10(5) whereas after exposure of Citrobacter freundii MR76 to 0.1 x MIC of meropenem the counts were 2.3 x 10(6) and 6.8 x 10(3) by bioluminescence and viable counting, respectively. The discrepancies were probably due to the relative inability of the viable counting procedure to detect fragile aberrant morphologies and resulted in differences in the calculated PAE values. With methods which do not detect fragile morphologies, the PAE may be underestimated. A general trend was observed for the order of magnitude of the PAEs by the following methods (in order of decreasing magnitude of PAE): (i) morphological technique, (ii) bioluminescence technique alone, (iii) bioluminescence in combination with impedance, (iv) viable counting in combination with impedance, and (v) viable counting alone. It is our opinion that of the methods examined in this study, bioluminescence in combination with impedance best reflects the true values for PAEs, and these results were examined more closely.     

Translation,cross-cultural adaptation and psychometric properties of the Back Beliefs Questionnaire in Modern Standard Arabic

Purpose To translate and cross-culturally adapt the Back Beliefs Questionnaire (BBQ) into modern standard Arabic and examine its validity, acceptability and reliability in Arabic-speaking patients with low back pain (LBP). Method The BBQ was forward, back-translated and reviewed by an expert committee. Seventeen bilingual patients completed Arabic and English BBQs. LBP patients (n?=?199) completed the Arabic BBQ. Sixty-four repeated it a week later, and 151 completed the Arabic Fear-avoidance Beliefs Questionnaire (FABQ). Results The expert committee followed advice from the developers to maintain Arabic equivalence of “back trouble(s)”. Patients found the questionnaire comprehensible and acceptable. Agreement between the English and Arabic versions of the BBQ was acceptable, ICC?= 0.65 (0.25–0.86). Most item-by-item agreement ranged from fair to moderate (K?=?0.12–0.54). Mean (SD) of BBQ, FABQ total, work and physical activity subscales were 25.31(6.13), 44.76(19.49), 21.17(10.10) and 13.95(6.65). The BBQ correlated with the FABQ at r?=??0.33, work subscale r?=??0.29 and physical activity r?=??0.30 (all p?α?=?0.73 indicated high internal consistency. Test–retest reliability was high, ICC?=?0.80 (0.68–0.87). Item-by-item agreement ranged from fair to acceptable (K?=?0.31–0.66). Conclusions The Arabic BBQ has good comprehensibility and acceptability, acceptable agreement with the English BBQ, high internal consistency and test–retest reliability. We recommend its use with Arabic-speaking LBP patient to determine their beliefs and attitudes about their back pain, as they have been shown to be important predictors of persistent LBP disability.

• Implications for Rehabilitation

• There are limited valid and reliable outcome measures for back pain in Arabic. The Back Beliefs Questionnaire (BBQ) is a tool that measures attitudes and beliefs about back pain.

• We recommend the use of our valid and reliable, translated and cross-culturally adapted tool with Arabic-speaking patients.

• The tool can measure attitudes and beliefs concerning the future consequences of LBP, with regards to recovery and return to work in this sample.

• Findings will improve back pain management options aimed at reducing back pain disability though challenging and modifying beliefs in the Middle East or with migrant populations in the West.