Spontaneous bacterial peritonitis from Salmonella: an unusual bacterium with unusual presentation

Spontaneous bacterial peritonitis (SBP) is a common cause of morbidity and mortality in patients with advanced cirrhosis and portal hypertension. While gram-negative rods and Enterococcus species are the common offending organisms, Salmonella has also been recognized as a rare and atypical offending organism. Atypical features of Salmonella SBP include both its occurrence in cirrhotic patients with immunosuppressive state and its lack of typical neutroascitic response. Diagnosis is often delayed as it requires confirmation from ascitic fluid culture. We report a case of Salmonella SBP occurring in a patient with decompensated cryptogenic cirrhosis with concurrent low-grade non-Hodgkin lymphoma and prior treatment with rituximab. Physicians should be aware of the atypical presentation, especially in cirrhotic patients who are immunosuppressed.     

Diverticular per oral endoscopic myotomy (DPOEM) for esophageal diverticular disease: a systematic review and meta-analysis

The traditional way to tackle Zenker’s diverticulum (ZD) has been flexible endoscopic septum division (FESD). Recently, the concept of per oral endoscopic myotomy has been found useful for managing diverticular diseases of the esophagus and has been termed DPOEM. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of D-POEM in diverticular disease of the esophagus and to compare it with FESD. We systematically searched PubMed and Embase, for studies reporting clinical success, technical success and adverse events in D-POEM alone or D-POEM comparing with FESD. We computed pooled prevalence for D-POEM alone and risk ratio for D-POEM vs FESD using random effect method with inverse variance approach. Subgroup analysis for ZD, non-ZD and mixed diverticulum was conducted. Totally 19 studies including 341 patients were identified reporting on D-POEM. The pooled clinical, technical success and adverse event rates for D-POEM were 87.07%, 95.19% and 10.22%, respectively. The clinical success was significantly better than FESD while the technical success, adverse event rate, procedure time and length of hospital stay were comparable with FESD. The recurrence rate was negligible for D-POEM compared to FESD. On subgroup analysis by dividing into three groups of ZD, non-ZD and mixed, there was no difference between clinical, technical success and adverse event rate among the three groups. D-POEM is an effective and safe technique among both ZD and non-ZD patients and has better clinical success than FESD.

     

Development of a wheelchair virtual driving environment: trials with subjects with traumatic brain injury

Spaeth DM, Mahajan H, Karmarkar A, Collins D, Cooper RA, Boninger ML. Development of a wheelchair virtual driving environment: trials with subjects with traumatic brain injury.

Objective

To develop and test a wheelchair virtual driving environment that can provide quantifiable measures of driving ability, offer driver training, and measure the performance of alternative controls.

Design

A virtual driving environment was developed. The wheelchair icon is displayed in a 2-dimensional, bird's eye view and has realistic steering and inertial properties. Eight subjects were recruited to test the virtual driving environment. They were clinically evaluated for range of motion, muscle strength, and visual field function. Driving capacity was assessed by a brief trial with an actual wheelchair. During virtual trials, subjects were seated in a stationary wheelchair; a standard motion sensing joystick (MSJ) was compared with an experimental isometric joystick by using a repeated-measures design.

Setting

Subjects made 2 laboratory visits. The first visit included clinical evaluation, tuning the isometric joystick, familiarization with virtual driving environment, and 4 driving tasks. The second visit included 40 trials with each joystick.

Participants

Subjects (n=8; 7 men, 1 woman) with a mean age of 22.65±2y and traumatic brain injury, both ambulatory and nonambulatory, were recruited.

Interventions

The MSJ used factory settings. A tuning program customized the isometric joystick transfer functions during visit 1. During the second visit, subjects performed 40 trials with each joystick.

Main Outcome Measure

The root mean square error (RMSE) was defined as the average deviation from track centerline (in meters) and speed (in m/s).

Results

Data analysis from the first 8 subjects showed no statistically significant differences between joysticks. RMSE averaged .12 to .21m; speed averaged .75m/s. For all tasks and joysticks, driving in reverse resulted in a higher RMSE and more virtual collisions than forward driving. RMSE rates were greater in left and right turns than straight and docking tasks.

Conclusions

Testing with instrumented real wheelchairs can validate the virtual driving environment and assess whether virtual driving skills transfer to actual driving.