Outbreak of Arcanobacterium haemolyticum in chronic wounds in The Netherlands.

INTRODUCTION: Aging and comorbidities such as diabetes and vascular problems contribute to the increasing occurrence of chronic wounds. From the beginning of 2016, a marked increase in Arcanobacterium haemolyticum (ARH) in chronic wound cultures was noted among patients visiting a wound expertise centre in The Netherlands. AIM: To report the outbreak investigation of ARH cultured from chronic wounds and describe the implemented infection prevention measures. METHODS: In total, 50 ARH isolates were sent to a reference laboratory for molecular typing. Samples for bacterial culture and ARH polymerase chain reaction were taken from care workers, the environment and items used for wound care. Infection prevention measures were implemented in a bundled approach, involving education, better aseptic wound care conditions and hygienic precautions. Before and after the implementation of infection prevention measures, two screening rounds of ARH testing were performed among all patients receiving home care. RESULTS: ARH isolates from wound care patients were found to be identical by core genome multi-locus sequence typing. No definite outbreak source could be determined by culture. However, three pairs of forceps, used by two nurses on multiple patients, were found to be ARH positive by polymerase chain reaction. In the two screening rounds before and after the implementation of infection prevention measures, the proportion of ARH-positive patients decreased significantly from 20% (20/99) to 3% (3/104). Subsequently, no new cases occurred. CONCLUSION: This first ARH outbreak was likely caused by re-using contaminated instruments. Through the implementation of improved infection prevention measures and re-education of all employees involved, the outbreak was controlled. With the current trend of care transition, infection control must be a major concern.

Use of autologous platelet-rich fibrin on hard-to-heal wounds.

This retrospective study found that use of autologous platelet-rich fibrin on a range of hard-to-heal wounds achieved full healing or a significant reduction in wound diameter with no adverse effects. Prospective studies are now needed

Extracellular matrix prevents split-skin grafting in selected cases.

Surgeons at a Dutch wound clinic close open wounds with split-skin grafts. Concerns about the risk of postoperative complications in some patients led them to find an alternative option. Use of an extracellular matrix dressing was effective.

Use of larval therapy to combat infection after breast-conserving surgery.

Wound infection after breast surgery is not uncommon and is not always simple to treat. This paper presents the case of a patient in whom the wound was successfully treated with larval debridement therapy after other methods failed.

Determining pain levels in patients treated with maggot debridement therapy.

OBJECTIVE: Pain as a complication of maggot debridement therapy (MDT) has been a topic of some controversy. This study set out to determine pain levels in patients treated with MDT. METHOD: A retrospective analysis using a visual analogue scale (VAS) was performed: 41 patients were treated with MDT for non-healing wounds (22 men and 19 women; average age: 67 years). Average wound duration was 14 months (range: two weeks to 132 months). Maggots were applied using the contained or the free-range techniques. Paracetamol (1 g three times daily) and Durogesic plaster (25 microg every three days and 50 microg the day before the maggot change) were given for pain relief in the outpatient clinic. RESULTS: Diabetic patients experienced the same amount of pain before and during MDT. Eight out of 20 non-diabetic patients experienced more pain during MDT than before; the remaining non-diabetic patients had the same amount of pain before and during the therapy. The difference between diabetic and non-diabetic patients was statistically significant (p<0.05) for all applications combined. CONCLUSION: In 78% of patients (29/37) pain can be adequately treated with analgesic therapy. However, if pain is unmanageable in the outpatient department, we believe that options include hospital admission, using the contained method of application or, in the worst case scenario, cessation of treatment. A standardised but individually tailored pain management protocol is mandatory.

Results of radiotherapy in patients with stage I orbital non-Hodgkin's lymphoma.

This paper describes the results of radiotherapy in early stage orbital non-Hodgkin's lymphoma. From 1970 to 1985, 33 orbital localizations in 30 patients were treated. The total dose applied ranged from 21 to 57 Gy (2 Gy per fraction), two-thirds of all patients received a dose of 40 Gy. The complete-response rate was 94% and the 10 years actuarial survival was 90%; no significant difference in survival was observed between patients with low grade or intermediate grade lymphoma. No local recurrence was detected during follow up and 20% of the patients developed generalized disease. Two optic nerve neuropathies and three retinopathies were observed in five patients, four of these occurred at a dose level of less than 43 Gy. Keratitis occurred in 58% of the patients treated, a sicca syndrome in 30% and cataract of different grades in 58% of the patients treated. Although local control was excellent, severe complications were observed in 13% of the patients who received a dose of less than 43 Gy.

Arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 55 years.

PURPOSE: To evaluate the end results of arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 55 years of age. TYPE OF STUDY: Case series. METHODS: Over a 5-year period, 201 consecutive patients presented with tibial plateau fracture; 131 of these patients were treated with arthroscopically assisted osteosynthesis of the tibial plateau. Inclusion in the retrospective analysis was limited to those patients older than 55 years at the time of injury and those who were available for follow-up at the time of the study. Thirty patients met these criteria. RESULTS: Secondary displacement occurred in 9 patients (30%) within 12 weeks after surgery. After a median follow-up of 3 years, 24 of 30 patients (80%) had an excellent or good clinical result according to the modified Rasmussen criteria. There was no difference in clinical outcome between the patients with or without secondary displacement of the fracture. CONCLUSIONS: Given the good clinical results, arthroscopically assisted osteosynthesis has been shown to be highly efficient in the treatment of tibial plateau fractures in the elderly.

The Groningen Trauma Study. Injury patterns in a Dutch trauma centre.

During the period 1970-1993, 245,251 visits were recorded in the trauma registry of the University Hospital Groningen, The Netherlands. An analysis of injury antecedents revealed five principal causes (ICD-CM): accidental falls (28%), sports and unspecified accident (26%), traffic (19%), cutting and piercing instruments (10%) and violence (4%). The trend analysis across the 24 year period showed that the incidence of injuries due to traffic and accidental falls decreased, while the rate of injuries due to assault increased 2-fold. Within the subgroup of traffic accidents, injuries caused by cars and motorcycles declined, while bicycle accidents increased dramatically. With respect to sex and age, the highest incidence rate occurred in men of 20-29 years. The overall male to female ration was 1.8. A predominance of male patients was observed in all cause categories, except in accidental falls. In this category, a relatively higher incidence of women was observed. The overall mortality rate was 0.5%, with the highest mortality rate being in women over 70 years. The main three causes of fatal injury concerned traffic (66%), falls (16%) and violence (3%). The injury patterns in the present study are in close agreement with patterns of other large trauma populations. Some discrepancies could be discerned. For example, in traffic injury, most of the victims (66%) concerned were pedestrians and bicyclists and firearms comprised only 1.2% of injuries due to assault. The usefulness of the registry in current community trauma care programmes and the broader perspective of trauma registration in The Netherlands is discussed.

Fractures of the distal radius and scaphoid.

Simultaneous fractures of the distal radius and scaphoid is an uncommon wrist injury. During the period 1980 to 1993, 23 patients with a median age of 39 years were treated for this injury. The median follow-up period was 7 years. All scaphoid fractures were undisplaced and located in the waist or distal third. An extraarticular distal radial fracture was observed in 15 wrists. A below elbow cast including the thumb was applied in 18 wrists for a mean duration of 9 weeks, and operative treatment was used in only 5 patients. All scaphoid fractures healed without complications. During conservative treatment there were three redisplacements of distal radial fractures. The final functional results were good in 18, fair in four, and poor in one patient. Because complications occurred at the distal radius we have changed our conservative treatment policy from a below elbow cast including the thumb to a dorsal splint for 6 weeks.

The distal radial fracture in elderly women and the bone mineral density of the lumbar spine and hip.

The incidence of distal radial fractures in elderly women is high and is associated with osteoporosis and hip fracture. Osteoporosis can be detected by measuring the bone mineral density (BMD) of the lumbar spine or hip with dual energy X-ray absorptiometry. Low BMD of the lumbar spine or hip is a strong predictor for future vertebral deformities and hip fractures. At present, elderly women with a distal radial fracture are not investigated for osteoporosis on a routine basis. The BMD of the lumbar spine and hip were assessed in 94 women (mean age, 69 years) with a distal radial fracture. A low BMD was found in 85% of the patients, and osteoporosis was diagnosed in 51%. The mean BMD decreased by 0.04 SD per year and there was a significant relationship between post-menopausal status and decreased BMD of the hip. The BMD in patients treated with bisphosphonate medication increased significantly in 1 year. As more than half of the elderly women with a distal radial fracture have osteoporotic BMD values for the lumbar spine or hip, it is our opinion that such patients should be screened for osteoporosis.

Combining topical negative pressure and a Bogota bag for managing a difficult laparostomy.

A patient with a severe intra-abdominal infection required a laparostomy. A Bogota bag was combined with topical negative pressure therapy, saving nursing time and enabling successful management of wound fluid.

An evaluation of immune competence in different swine breeds.

The purpose of this investigation was to establish parameters for the evaluation of immune competence in different swine breeds. Cellular and humoral immune reactivity against keyhole limpet haemocyanin (KLH) was analysed using the lymphocyte stimulation test (LST), a skin allergy test and the IgG response. Various characteristics of the KLH-specific immune response were studied in 988 sows of four breeds. KLH-specific immune responses showed considerable variability. The applied statistical model explained 63 to 73 per cent of this variation. Genetic influences, expressed as the heritability estimate, were rather high for the IgG response (0.33), as well as for the skin reaction (0.26) and the LST (0.41-0.45). A positive correlation between the various immune parameters was found. Selective breeding for immune responsiveness seems to be feasible, but selection for cellular as well as humoral immune reactivity also seems to be possible with KLH as the antigen.

Intermittent gallstone ileus following endoscopic biliary sphincterotomy. A case report.

A 72-year-old woman presented with periods of colicky abdominal pain following endoscopic sphincterotomy and lithotripsy for choledocholithiasis. A diagnosis of intermittent gallstone ileus was made, while it appeared that a large gallstone, that was not removed from the common bile duct, obstructed the small bowel. The intermittent course was elicited by pendulation of a gallstone between two stenoses, which originated from chronic radiation enteritis.

[Diagnostic image (211). A man with a skin wound after a dog bite]. / Diagnose in beeld (211). Een man met een huidwond na een hondenbeet.

A 34-year-old man sought medical advice for a dog bite on his left lower leg. The wound progressed after split skin transplantation. It was proved to be pyoderma gangrenosum associated with colitis ulcerosa and responded well to oral prednisone therapy.

Clinicians' recognition of 10 different types of distal radial fractures.

This study concerned baseline performance in recognition of 10 different types of distal radial fractures. Verbal tasks of admitting knowing about fractures and Visual tasks were designed for each fracture type. The Verbal task of admitting knowing consisted of a description with the relevant distinctive features of the fracture. The surgical resident was asked whether he admitted knowing the particular fracture described. The Visual task consisted of X-rays for which the subject had to label the fracture or identify its distinctive features. The test was presented to 30 surgical trainees working in five teaching hospitals. On the Verbal task of admitting knowing, scores were statistically significantly higher (68% "yes") than on the Visual task (33% correct). Responses met our criterion of 80% correct for the following fracture types: Colles's, distal forearm, and Smith's fracture. For seven other fracture types (combination radius and scaphoid, radial styloid process, dorsal Barton's, volar Barton's, pilon, chauffeur's, and lunate load fracture), the 80% criterion was not met. Analysis of the incorrect answers on the Visual task indicated that the surgical residents tended to label unknown fracture types as Colles's or Smith's fractures. Furthermore, the residents tended to overestimate their own diagnostic competence (overconfidence bias) for several fracture types. It was concluded that to improve diagnosis, the relevant distinctive features of distal radial fractures should be taught.

Interrater reliability for the basic categories of the AO/ASIF's system as a frame of reference for classifying distal radial fractures.

This study is about agreement on the assignment into the three basic classes or categories (A, B, C) of the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation's (AO/ASIF) classification system for distal radial fractures. A random sample of 124 distal radial fractures was classified by two experienced observers. Their agreement was calculated according to Cohen's kappa statistic. To investigate the possible bases for disagreement, all conflicting X-ray assessments were discussed in a consensus meeting. It appeared that the kappa value was .65 (good agreement) before the meeting; kappa rose to .86 (excellent agreement) after the consensus meeting. It appeared that the undisplaced fractures were a major source of disagreement. Further, the presence of articular involvement was an important issue. It was frequently noted that one observer classified the fracture as extraarticular (basic Class A), while the other observer chose classification as an intra-articular fracture (basic Class C) or vice versa. This phenomenon has been called the A/C reversal shift. It is concluded that radiological innovations might enhance agreement on articular involvement, and a separate category for undisplaced fractures should be defined in the Arbeitsgemeinschaft für Osteosynthesefragen (AO) system. However, agreement on relevant distinctive features and discussion of conflicting assessments may also be important in achieving excellent agreement.

[Blood collection in pigs]. / Bloedafname bij het varken.

Reasons for and methods of collection of blood in pigs are reviewed. The best method is punction of the external jugular vein after correct fixation of the animal. A number of instances of materials used in various age groups are presented. Finally, possible complications following collection of blood are summarised.

[The relationship between hereditary characteristics in the blood (Phi-PO2-Pgd) and susceptibility to stress in swine. A pilot study]. / De relatie tussen erfelijke kenmerken in het bloed (Phi-PO2-Pgd) en stressgevoeligheid bij varkens. Een oriënterend onderzoek.

Deaths during transport and the incidence of a poor quality of the meat in pigs were the most important reasons for studying the stress-syndrome (MHS) during the past twenty years. MHS is controlled by an autosomal Hal locus with two alleles N and n. Only pigs of genotype nn are sensitive to halothane and susceptible to stress. As a standard test for use in practice, the halothane test was developed in the Netherlands in 1974 and only this test is used to detect MHS. Heterozygotes can not be detected using this test. Since 1986, additional blood typing was carried out for the systems Phi, Po2 en Pgd in litters including at least one halothane-positive reactor. Blood typing was carried out in 533 pigs of four different lines of breeding company Cofok in Oosterhout and was found to be very successful (using the linkage groups) in identifying the heterozygotes. In 15.5 per cent of the offspring, it could not be stated whether the genotype was HalNN or HalNn. This was due to the fact that in these Nn x Nn matings the two haplotypes of one or both parents were identical. In this population, the haplotype PhiB-Po2S-PgdB was strongly (72-89 per cent) linked to the Haln-allele.

[A case of selenium poisoning in weaned piglets; the persistent one wins]. / Een geval van seleniumintoxicatie bij gespeende biggen; de aanhouder wint.

A case of selenium poisoning involving eighty approximately nine-week-old piglets is reported. Feed and water were supplied with a dry feed hopper with nipple in the through. Clinical symptoms appeared within ten days after the feed-intake. The symptoms consisted in loss of condition (emaciation), drawn-in thin bellies, long hair, loss of appetite, hard, dark faeces, cerebral symptoms and mortality. Autopsy was performed on a total number of four piglets, in which severe hepatic degeneration was detected. When pig prestarter (creep feed) was substituted for piglet-raising feed (weaner-diet), the condition was gradually restored to normal within a few days.