[Non-typhoidal Salmonellainfections: not always innocent]. / Non-typhoidale Salmonella-infecties.

Non-typhoidalSalmonellae (NTS) are virulent bacteria that commonly cause gastroenteritis. However, less than 5% of patients infected with NTS develop bacteraemia and metastatic foci of infection. Mortality remains high, despite appropriate use of antibiotic therapy. We present three cases to demonstrate that immunodeficiency - and T-cell dysfunction in particular - is a major risk factor for NTS bacteraemia. All three patients presented with fever and general malaise, while none of them had symptoms of gastroenteritis. Blood cultures revealed the presence of Salmonella enteritidis, but stool cultures were negative. All three patients were diagnosed with vascular infection, for which they were treated with a combination of surgery and antibiotics. The efficiency of NTS clearance depends greatly on successful antigen presentation to T-cells. T-cell dysfunction contributes to the development of bacteraemia. These cases emphasise the importance of recognising extraintestinal complications of NTS infection in immunocompromised patients, particularly those associated with T-cell dysfunction.

Phlegmasia Alba Dolens Caused by a Distended Bladder.

We describe the case of a 64-year-old patient with a deep venous thrombosis unusually caused by the obstruction of a severely distended atonic bladder as a result of an iatrogenic injury. Distention of the urinary bladder has previously been described to elevate pressure in the iliac veins, but has seldom been linked to the development of deep venous thrombosis. Through this case, we want to attract attention to this major complication of bladder distention, and we emphasize the importance of proper physical examination.

[A man with a painful sternum]. / Een man met een pijnlijk sternum na een auto-ongeluk.

We present a case of a 81-year-old man with blunt chest trauma after a car accident. Trauma screening at the emergency department showed multiple rib fractures and a fractured sternum. We made the diagnosis floating sternum. Cardiac contusion may occur after chest-wall trauma, but was not present in this case.

The effects of stimulation of the autonomic nervous system via perioperative nutrition on postoperative ileus and anastomotic leakage following colorectal surgery (SANICS II trial): a study protocol for a double-blind randomized controlled trial.

BACKGROUND: Postoperative ileus and anastomotic leakage are important complications following colorectal surgery associated with short-term morbidity and mortality. Previous experimental and preclinical studies have shown that a short intervention with enriched enteral nutrition dampens inflammation via stimulation of the autonomic nervous system and thereby reduces postoperative ileus. Furthermore, early administration of enteral nutrition reduced anastomotic leakage. This study will investigate the effect of nutritional stimulation of the autonomic nervous system just before, during and early after colorectal surgery on inflammation, postoperative ileus and anastomotic leakage. METHODS/DESIGN: This multicenter, prospective, double-blind, randomized controlled trial will include 280 patients undergoing colorectal surgery. All patients will receive a selfmigrating nasojejunal tube that will be connected to a specially designed blinded tubing system. Patients will be allocated either to the intervention group, receiving perioperative nutrition, or to the control group, receiving no nutrition. The primary endpoint is postoperative ileus. Secondary endpoints include anastomotic leakage, local and systemic inflammation, (aspiration) pneumonia, surgical complications classified according to Clavien-Dindo, quality of life, gut barrier integrity and time until functional recovery. Furthermore, a cost-effectiveness analysis will be performed. DISCUSSION: Activation of the autonomic nervous system via perioperative enteral feeding is expected to dampen the local and systemic inflammatory response. Consequently, postoperative ileus will be reduced as well as anastomotic leakage. The present study is the first to investigate the effects of enriched nutrition given shortly before, during and after surgery in a clinical setting. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02175979 - date of registration: 25 June 2014. Dutch Trial Registry: NTR4670 - date of registration: 1 August 2014.