Abdominal wall reconstruction after open management of the septic abdomen

The increasing popularity of open management of the septic abdomen has generated a challenge that the surgeon is forced to face more frequently. The typical presentation is that of a patient with a full-thickness abdominal wall defect occurring after a protracted, severe illness. The various methods of reconstruction of the abdominal wall are reviewed and evaluated. The reconstruction should only be attempted once intra-abdominal sepsis is controlled, re-exploration of the peritoneal cavity is no longer necessary and organ support is discontinued. Although various methods of reconstruction are described, the recommended technique consists of either medial advancement of the rectus abdominis muscle or direct application of split-thickness skin grafts. Mid-line abdominal defects may also be repaired with tensor fasciae latae or rectus femoris flaps.     

Sino-bronchial syndrome in children with asthma

Thirty children in the age group of 2 to 12 years were brought with a history of recurrent non-seasonal moderate to severe wheezy episodes associated with symptoms of nasal congestion, sneezing and occasional headache. All of them had maxillary or pan sinusitis with 26 having associated right, left or bilateral lower lobe pneumonitis or bronchiectasis. Serum immunoglobulins were normal in 22 and was not done in eight. There was positive (2 to 4+ above negative control) skin test response to dust and dust mite in 15 of the 22 children tested. Throat swabs/sputum or nasal secretions grew B-hemolytic streptococcus or streptococcus pneumoniae in twenty-seven. All the children were put on bactericidal drugs for 6 to 8 weeks and bronchodilators were used when needed. At the end of 6 to 8 weeks follow-up X-ray of sinuses and chest showed significant clearing of the lesions which coincided with marked clinical improvement. Sinus X-ray should be considered in bronchial asthma resistant to medical management since untreated bacterial sinusitis can be an underlying cause of chronic poorly controlled asthma.     

Antitumor efficacy and acute toxicity of the novel dipeptide melphalanyl-p-L-fluorophenylalanine ethyl ester (J1) in vivo

The novel alkylating dipeptide melphalanyl-p-L-fluorophenylalanine ethyl ester (J1) was evaluated for acute toxicity and antitumor activity in mice, with melphalan as a reference. To determine a safe and tolerable dose for efficacy studies the acute toxicity following intravenous injection in the tail vein was monitored using a 14-day schedule with up to four doses. The highest tested dose, 25 micromoles/kg, was considered close to this level, with minor effects on body weight gain but significant effects on hematological parameters. Melphalan and J1 appeared equitoxic with no statistically significant differences. Subsequently a mouse hollow fiber model was employed with subcutaneous implantation of fibers containing human tumor cells. Three different human tumor cell lines as well as two samples of primary human tumor cells (ovarian carcinoma and chronic lymphatic leukemia) were used as tumor models. At the dose level tested there was a marked and statistically significant decrease in both T-cell leukemia CCRF-CEM and small cell lung cancer NCI-H69 tumor cell growth and viability in response to J1 as compared with both placebo and melphalan treated groups. In primary ovarian carcinoma cells only J1 treatment resulted in significant tumor regression (net cell kill). In summary the results indicate that, despite an expected short half time in the blood circulation, the promising in vitro data from the previous studies of J1 seems translatable into the in vivo situation. At equal doses of alkylating units J1, compared to melphalan, was more active in the mouse hollow-fiber model, but showed similar general toxicity.     

Prevention of acute exacerbation of chronic obstructive pulmonary disease after bronchoscopic lung volume reduction with endobronchial valves

IntroductionBronchoscopic lung volume reduction (BLVR) with endobronchial valves (EBVs) has emerged as an important treatment method for patients with severe chronic obstructive pulmonary disease (COPD). Acute exacerbations of COPD (AECOPD) are a frequent complication following BLVR with EBV. However, there is no consensus on the prevention of AECOPD.ObjectivesOur study aims to compare the outcomes of different prophylactic measures on the occurrence of AECOPD after BLVR with EBV.MethodsWe conducted a multicenter, retrospective study of patients who underwent BLVR with EBV at six different institutions. Emphasis was directed towards the specific practices aimed at preventing AECOPD: antibiotics, steroids, antibiotics plus steroids, or no prophylaxis. Subgroups were compared, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated.ResultsA total of 170 patients were reviewed. The rate of AECOPD was 21.2% for the full cohort. Patients who received prophylaxis had a significantly lower rate of AECOPD compared with those who did not (16.7% vs. 46.2%; p = 0.001). The rate was lowest in patients who received antibiotics alone (9.2%). There was no significant difference in the rate of AECOPD between patients who received steroids alone or antibiotics plus steroids, compared with the other subgroups. The OR for AECOPD was 4.3 (95% CI: 1.8–10.4; p = 0.001) for patients not receiving prophylaxis and 3.9 (95% CI: 1.5–10.1; p = 0.004) for prophylaxis other than antibiotics alone.ConclusionsAdministration of antibiotics after BLVR with EBV was associated with a lower rate of AECOPD. This was not observed with the use of steroids or in combination with antibiotics.     

Efficacy of a Prophylactic Epidural Blood Patch in Preventing Post Dural Puncture Headache in Parturients after Inadvertent Dural Puncture

Background: Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch.

Methods: Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch.

Results: Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group.     

Single‐Center Experience With HeartMate II Left Ventricular Assist Device Explantation

In patients with continuous flow left ventricular assist devices (CF‐LVADs) myocardial recovery is uncommon. Given the heterogeneity of the population implanted and low incidence of recovery, the discovery of native left ventricular (LV) recovery and criteria for explantation of CF‐LVAD system is not clearly determined. We sought to analyze the characteristics of the patients who underwent CF‐LVAD explantation at our institution. Prospectively collected data on patients supported with CF‐LVADs were reviewed retrospectively. Patients who underwent CF‐LVAD explants were identified and their characteristics were analyzed with a focus on patient presentation and determinants of explantability. From November 2006 to June 2014, 223 patients (181 male, 42 female) underwent implantation of HeartMate II LVAD. Seven female (16.7%) and one male (0.6%) patients were explanted (P < 0.001). Mean age was 43 ± 9 years and etiology for cardiomyopathy was ischemic in three (37.5%) patients, nonischemic in four (50%) patients, and mixed in the one (12.5%) male patient of the cohort. Five (62.5%) patients presented acutely with significant hemolysis, and were found to have LV improvement as well as reduced, absent, or reversed diastolic flow velocities on echocardiography. Overall, mean lactate dehydrogenase level before explantation was 1709 ± 1168 U/L compared to the mean baseline level of 601 ± 316 U/L (P = 0.048). Mean LV ejection fraction (LVEF) improved from 17 ± 7% preimplant to 56 ± 11% pre‐explantation (P < 0.001). Median number of days on CF‐LVAD support was 870 (interquartile range, 209–975) while mean duration of follow‐up after the CF‐LVAD explantation was 276 ± 240 days. Mean LVEF dropped from 46 ± 19% postexplantation to 34 ± 10% during the most recent follow‐up (P = 0.015). At our institution, patients who underwent LVAD explants were predominantly women with nonischemic cardiomyopathy. Clinical evidence of hemolysis and echocardiographic evidence of reduced or absent diastolic flow velocities were common findings in these patients. Over time, patient's native LV function declined in the absence of LVAD (after LVAD explantation). Significant challenges remain in predicting LV recovery and identifying those individuals who have recovered myocardial function significant enough to be explanted.     

Compound palmar ganglion with carpal tunnel syndrome

Compound palmer ganglion is an uncommon condition characterized by a swelling in the distal part of volar aspect of wrist and communicating with another swelling over palm across the flexor retinaculum. It commonly results from tuberculous tenosynovitis. It may lead to carpal tunnel syndrome and need surgical excision with division of flexor retinaculum.     

Pulmonary Function Testing in Patients with Tracheostomies: Feasibility and Technical Considerations

Purpose

Pulmonary function testing (PFT) in patients with tracheostomies has been perceived as difficult to perform and clinically unreliable. We studied the feasibility, quality, repeatability and clinical significance of PFT.

Methods

Patients with tracheostomies that underwent PFT from January 1, 2010 to February 29, 2012 were identified. Clinical history and PFT data were reviewed retrospectively.

Results

Fifty patients (88% men) were identified. Forty-seven (94%) patients were able to perform PFT. Acceptable repeatability was obtained for FVC in 39 (83%) and for FEV1 in 41 (87%). Patients with tracheostomies showed difficulty in meeting ATS end-of-test criteria; only 9 (19%) met plateau criteria and 25 (53%) had exhalation times of greater than 6 s. Obstructive pattern was observed in 30 (64%) and restrictive pattern in 9 (19%). DLCO measurements were attempted in 43 patients and satisfactorily obtained in 34 (79%).

Conclusions

PFT can be performed with reliability in patients with tracheostomies, and they are useful for detecting and classifying types of lung dysfunction.

     

Leadership Identity Development Through Reflection and Feedback in Team-Based Learning Medical Student Teams

Problem: Studies on leadership identity development through reflection with Team-Based Learning (TBL) in medical student education are rare. We assumed that reflection and feedback on the team leadership process would advance the progression through leadership identity development stages in medical students within the context of classes using TBL. Intervention: This study is a quasi-experimental design with pretest–posttest control group. The pretest and posttest were reflection papers of medical students about their experience of leadership during their TBL sessions. In the intervention group, TBL and a team-based, guided reflection and feedback on the team leadership process were performed at the end of all TBL sessions. In the other group, only TBL was used. The Stata 12 software was used. Leadership Identity was treated both as a categorical and quantitative variable to control for differences in baseline and gender variables. Chi-square, t tests, and linear regression analysis were performed. Context: The population was a cohort of 2015–2016 medical students in a TBL setting at Tehran University of Medical Sciences, School of Medicine. Teams of four to seven students were formed by random sorting at the beginning of the academic year (intervention group n = 20 teams, control group n = 19 teams). Outcome: At baseline, most students in both groups were categorized in the Awareness and Exploration stage of leadership identity: 51 (52%) in the intervention group and 59 (55%) in the control group: uncorrected χ²(3) = 15.6, design-based F(2.83, 108) = 4.87, p = .003. In the posttest intervention group, 36 (36%) were in exploration, 33 (33%) were in L-identified, 20 (20%) were in Leadership Differentiated, and 10 (10%) were in the Generativity. None were in the Awareness or Integration stages. In the control group, 3 (20%) were in Awareness, 56 (53%) were in Exploration, 35 (33%) were in Leader Identified, 13 (12%) were in Leadership Differentiated. None were in the Generativity and Integration stages. Our hypothesis was supported by the data: uncorrected χ²(4) = 18.6, design-based F(3.77, 143) = 4.46, p = .002. The mean of the leadership identity in the pretest, intervention group equaled 1.93 (SD = 0.85) and the pretest, control group mean was 2.36 (SD = 0.86), p = .004. The mean of the posttest, intervention group was 3.04 (SD = 0.98) and posttest, control group mean was 2.54 (SD = 0.74), T = ?4.00, design df = 38, p < .001, and adjusted on baseline and gender T = ?8.97, design df = 38, p < .001. Lessons Learned: Reflection and feedback on the team leadership process in TBL advances the progression in stages of leadership identity development in medical students. Although the TBL strategy itself could have an impact on leadership identity development, this study demonstrates that when a reflection and feedback on leadership intervention are added, there is much greater impact.