Gas-forming urinary tract infection

Emphysematous or gas-forming infections, a very small percentage of bacterial infections of the urinary tract, attract importance because of their life threatening potential. Herein, we report a 60-year-old Saudi female patient who was a known case of Diabetes mellitus for 15 years. She was admitted with left flank pain of 5 days duration, abdominal distension, nausea, vomiting and chills associated with increased frequency of urine, urgency, and dysuria. She had leukocytosis, high blood sugar, elevated urea and creatinine and pyuria. Urine culture grew Escherichia coli. Ultrasound and CT scan showed left pelvicalyceal dilatation and air in the left kidney and urinary bladder. She was treated with a prolonged parenteral antibiotic course, and insulin, with complete recovery.     

Diffuse alopecia in a child due to dietary zinc deficiency

A 4-year-old girl was evaluated for hair loss of a few weeks' duration. History of the present illness, medical history, and review of systems were obtained from the parents, who described progressive diffuse hair loss with hair dryness and brittleness, with no change in the child's eating habits or any other unusual symptoms. No fever, weight loss, diarrhea, vomiting, abdominal pain, chronic cough, dyspnea, change in appetite, change in bowel habit, or urinary symptoms were noted. On further questioning, her nutritional history revealed that she always favored cow's milk in her diet. The patient has been healthy with no significant medical history, surgical history, psychiatric history, or history of hospitalization. She was taking no medications. Her mother's pregnancy and the child's birth history were uneventful. The child was up-to-date on her vaccinations. Her physical examination showed a healthy-appearing child who was at 50% on the height chart and 70% on the weight growth chart. She was afebrile with a respiratory rate of 24 breaths per minute, pulse rate of 110 beats per minute, and pulse oximetry of 99% on room air. Skin examination revealed interstitial diffuse patchy alopecia with very dry hair and nonscarred, normal-appearing scalp. The hair pull test was normal, with 4 hairs extracted. Results of examination of her eyes (including visual acuity) and lungs were normal, and no abnormalities were found on heart, abdominal, musculoskeletal, and neurologic examinations. Laboratory workup showed normal electrolytes, blood urea nitrogen, creatinine, and blood sugar levels. Her complete blood cell count with differential was normal, ferritin concentration level was 110 ng/mL (reference, 40-200 ng/mL), iron level was 75 microg/dL (reference, 35-175 microg/dL), and total iron-binding capacity was 310 microg/dL (reference, 245-400 microg/dL). Levels of liver enzymes, total bilirubin, serum protein, and albumin were normal, as were the results of urinalysis. Thyroid function test results were normal and levels of vitamins A and D were also normal. Low levels of serum zinc were measured repeatedly at 48 and 61 microg/dL (reference, 66-144 microg/dL) at 2 different laboratories. She was started on zinc supplement (50 mg daily) for 6 months and her diet was modified. The hair loss stopped in 3 weeks. Follow-up in 4 months showed no evidence of alopecia, with normal-looking hair.     

A new web-based operative skills assessment tool effectively tracks progression in surgical resident performance

PURPOSE: The study aim was to demonstrate that a new database tool for assessment of surgical resident operative skills discerns predictable progression in those skills over successive residency years for specific index case types. METHODS: A Web-based interactive database (OpRate) was used to assess selected aspects of resident operative performance as determined by supervising attending surgeons in a medium-sized residency (5-6 residents per postgraduate year [PGY]). This assessment consisted of (1) 3 questions pertaining to patient information, technical, and disease-specific preparedness; (2) 4 laparoscopic technical skills questions pertaining to tissue handling, dexterity, planning, and ability to function independently; and (3) similar open technical skills questions, with the addition of 2 questions defining knot tying ability. Two years of assessment data were examined for cholecystectomy (CH), appendectomy (AP), colon resection (CR), ventral hernia repair (VH), and inguinal hernia repair (IH). Mean scores for total, technical, and preparedness responses, as well as each response area were compared for successive training years for each case type. Mean performance data between postgraduate years were compared by ANOVA, and interitem reliability was assessed by Cronbach's alpha determinations. RESULTS: OpRate data for 579 cases (142 CH, 67 AP, 73 CR, 202 IH, and 95 VH) were examined. Significant incremental increases in open and laparoscopic technical skills scores by training year were observed for all case types (ANOVA, p < 0.0001). Individual technical skills as well as technical and disease-specific preparedness response areas also demonstrated significant improvement by successive training year. Cronbach's alpha determinations were 0.80-0.94 for the preparedness test items and the skills performance scores for all assessed procedures. CONCLUSIONS: Our early results show that the OpRate assessment tool is effective in identifying expected changes in operative performance across successive training years, with a satisfactory level of internal consistency for the test items. As such, the use of this database tool may offer the opportunity to (1) define performance benchmarks for specific levels of training and (2) identify areas where focused training may be required for specific residents.     

A randomized study of the effects of perioperative i.v. lidocaine on hemodynamic and hormonal responses for cesarean section

Purpose  Intravenous infusion of lidocaine attenuates the stress response to surgery. We aimed to evaluate the effects of perioperative lidocaine on the hemodynamic and hormonal responses for cesarean delivery. Methods  After the gaining of ethical approval, 90 patients scheduled for elective cesarean delivery were randomly allocated to receive either lidocaine 1.5 mg·kg⁻¹ i.v. bolus 30 min before induction, followed by an infusion of 1.5 mg·kg⁻¹·h⁻¹ until 1 h after surgery (n = 45), or saline placebo (n = 45). Anesthesia was maintained with 50% nitrous oxide in oxygen with 0.7% isoflurane. Hemodynamic variables, plasma cortisol, maternal and neonatal lidocaine concentrations, Apgar scores at 1 and 5 min, neonatal acid-base status, and the neurologic and adaptive capacity score (NACS) were recorded. Results  After induction, patients receiving lidocaine had a smaller increase in heart rate and mean arterial blood pressure (P < 0.02) and lower plasma cortisol concentrations (31.1 ± 9.91 vs 45.6 ± 8.43 μg·dL⁻¹; P < 0.001). There were no differences between the two groups in Apgar scores, NACS, or neonatal acid-base status. After delivery, maternal and umbilical venous concentrations and umbilical vein-to-maternal vein ratios of lidocaine were 2.05 ± 0.42 μg·mL⁻ and 1.06 ± 0.31 μg·mL⁻¹, and 0.52 ± 0.07, respectively. Conclusion  Perioperative lidocaine is safe and effective in attenuating the maternal stress response to surgery for cesarean delivery.     

Implementation of a multidisciplinary team approach and fish oil emulsion administration in the management of infants with short bowel syndrome and parenteral nutrition-associated liver disease

OBJECTIVE:

To describe the authors’ experience with the implementation of a multidisciplinary approach and use of fish oil emulsion (FOE) in the management of infants with short bowel syndrome (SBS) and parenteral nutrition-associated liver disease (PNALD).

METHODS:

Between August 2006 and June 2009, four cases of SBS and severe PNALD were managed by the team using specifically developed protocols. The FOE was initiated if serum direct bilirubin levels were ≥100 μmol/L. To quantify the degree of exposure to high serum direct bilirubin levels over time, the area under the curve (AUC) for each patient was calculated before and after initiation of FOE. Linear regression analyses were performed to evaluate correlations between the AUC, duration of cholestasis and initiation of FOE.

RESULTS:

All patients survived and no complications were observed during the study period. After the first patient, FOE was initiated progressively earlier, but poor correlation between the AUC before and after its introduction was observed (r²=0.41924). However, there was strong correlation between the duration of PNALD before FOE initiation and time to resolution (r²=0.72133): the earlier the FOE was initiated, the shorter the time to resolution.

CONCLUSION:

The authors report a positive experience with the implementation of a multidisciplinary approach and the use of FOE in infants with SBS and severe PNALD. The earlier the FOE was initiated during the cholestatic process, the shorter the time to resolution. The present study is a hypothesis generator, raising the question of whether an earlier introduction of this particular therapy can effectively shorten the cholestasis process in these patients.     

Political Imprisonment and Adult Functioning: A Life Event History Analysis of Palestinians

Political imprisonment is a traumatic event, often accompanied by torture and deprivation. This study explores the association of political imprisonment between 1987 and 2011 with political, economic, community, psychological, physical, and family functioning in a population‐based sample of Palestinian men ages 32–43 years (N = 884) derived from a dataset collected in 2011. Twenty‐six percent (n = 233) had been politically imprisoned. Men imprisoned between 1987 and 2005 reported functioning as well as never‐imprisoned men in most domains, suggesting that men imprisoned as youth have moved forward with their lives in ways similar to their nonimprisoned counterparts. In an exception to this pattern, men imprisoned during the Oslo Accords period (1994–1999) reported higher levels of trauma‐related stress (B = 0.24, p = .027) compared to never‐imprisoned men. Men imprisoned since 2006 reported lower functioning in multiple domains: human insecurity (B = 0.33, p = .023), freedom of public expression (B = ?0.48, p = .017), perceived government stability (B = ?0.38, p = .009), feeling broken or destroyed (B = 0.59, p = .001), physical limitations (B = 0.55, p = .002), and community belonging (B = ?0.33, p = .048). Findings pointed to the value of examining the effects of imprisonment on functioning in multiple domains.