Medical treatment decision making after total avulsion brachial plexus injury: a qualitative study.

OBJECT: Complete avulsion traumatic brachial plexus injuries (BPIs) can be treated using nerve and musculoskeletal reconstruction procedures. However, these interventions are most viable within certain timeframes, and even then they cannot restore all lost function. Little is known about how patients make decisions regarding surgical treatment or what impediments they face during the decision-making process. Using qualitative methodology, the authors aimed to describe how and why patients elect to pursue or forego surgical reconstruction, identify the barriers precluding adequate information transfer, and determine whether these patients are satisfied with their treatment choices over time. METHODS: Twelve patients with total avulsion BPIs were interviewed according to a semi-structured guide. The interview transcripts were qualitatively analyzed using the systematic inductive techniques of grounded theory to identify key themes related to the decision-making process and long-term satisfaction with decisions. RESULTS: Four decision factors emerged from our analysis: desire to restore function, perceived value of functional gains, weighing the risks and costs of surgery, and having concomitant injuries. Lack of insurance coverage (4 patients), delayed diagnosis (3 patients), and insufficient information regarding treatment (4 patients) prevented patients from making informed decisions and accessing care. Three individuals, all of whom had decided against reconstruction, had regrets about their treatment choices. CONCLUSIONS: Patients with panplexus avulsion injuries are missing opportunities for reconstruction and often not considering the long-term outcomes of surgery. As more Americans gain health insurance coverage, it is very likely that the number of patients able to pursue reconstruction will increase. The authors recommend implementing clinical pathways to help patients meet critical points in care within the ideal timeframe and using a patient- and family-centered care approach combined with patient decision aids to foster shared decision making, increase access to information, and improve patient satisfaction with decisions. These measures could greatly benefit patients with BPI while reducing costs, improving efficiency, and generating better outcomes.

Molecular details of a starch utilization pathway in the human gut symbiont Eubacterium rectale.

Eubacterium rectale is a prominent human gut symbiont yet little is known about the molecular strategies this bacterium has developed to acquire nutrients within the competitive gut ecosystem. Starch is one of the most abundant glycans in the human diet, and E. rectale increases in vivo when the host consumes a diet rich in resistant starch, although it is not a primary degrader of this glycan. Here we present the results of a quantitative proteomics study in which we identify two glycoside hydrolase 13 family enzymes, and three ABC transporter solute-binding proteins that are abundant during growth on starch and, we hypothesize, work together at the cell surface to degrade starch and capture the released maltooligosaccharides. EUR_21100 is a multidomain cell wall anchored amylase that preferentially targets starch polysaccharides, liberating maltotetraose, whereas the membrane-associated maltogenic amylase EUR_01860 breaks down maltooligosaccharides longer than maltotriose. The three solute-binding proteins display a range of glycan-binding specificities that ensure the capture of glucose through maltoheptaose and some α1,6-branched glycans. Taken together, we describe a pathway for starch utilization by E. rectale DSM 17629 that may be conserved among other starch-degrading Clostridium cluster XIVa organisms in the human gut.

Monteggia fracture dislocations: a historical review.

The eponym Monteggia fracture dislocation originally referred to a fracture of the shaft of the ulna accompanied by anterior dislocation of the radial head that was described by Giovanni Battista Monteggia of Italy in 1814. Subsequently, a further classification system based on the direction of the radial head dislocation and associated fractures of the radius and ulna was proposed by Jose Luis Bado of Uruguay in 1958. This article investigates the evolution of treatment, classification, and outcomes of the Monteggia injury and sheds light on the lives and contributions of Monteggia and Bado.

Multidomain Carbohydrate-binding Proteins Involved in Bacteroides thetaiotaomicron Starch Metabolism.

Human colonic bacteria are necessary for the digestion of many dietary polysaccharides. The intestinal symbiont Bacteroides thetaiotaomicron uses five outer membrane proteins to bind and degrade starch. Here, we report the x-ray crystallographic structures of SusE and SusF, two outer membrane proteins composed of tandem starch specific carbohydrate-binding modules (CBMs) with no enzymatic activity. Examination of the two CBMs in SusE and three CBMs in SusF reveals subtle differences in the way each binds starch and is reflected in their K(d) values for both high molecular weight starch and small maltooligosaccharides. Thus, each site seems to have a unique starch preference that may enable these proteins to interact with different regions of starch or its breakdown products. Proteins similar to SusE and SusF are encoded in many other polysaccharide utilization loci that are possessed by human gut bacteria in the phylum Bacteroidetes. Thus, these proteins are likely to play an important role in carbohydrate metabolism in these abundant symbiotic species. Understanding structural changes that diversify and adapt related proteins in the human gut microbial community will be critical to understanding the detailed mechanistic roles that they perform in the complex digestive ecosystem.