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Biomedical subjects

D H Wittmann

Publications and source records attributed to D H Wittmann.

At least 37 records · Page 2Linked to original sources
PubMed1995

Soft tissue abscesses associated with parenteral drug abuse: presentation, microbiology, and treatment.

Abscess formation at the site of drug injection is the commonest infectious complication in drug addicts. This study characterizes the clinical presentation of the condition, its current microbiology, and treatment outcome. All patients presenting for treatment of soft tissue abscesses associated with parenteral drug abuse over a 21-month period were studied. Sixty-six patients with 70 subcutaneous abscesses after injection of cocaine (85%), heroin (5%), or unreported drugs (10%) were identified. Only 42% were febrile (T > 37.5 degrees C), 54 percent had leukocytosis, and 47 percent had wound fluctuance. Wound cultures (243 isolates in 57 patients) grew predominately anaerobes (143 isolates) and facultative gram-positive cocci (88 isolates). Twenty-six blood cultures were obtained, and five (19%) were positive, two with the same bacteria isolated from the wound. Of the patients tested, 29 percent were positive for hepatitis B surface antigen and 9 percent for HIV. Simple incision and drainage was effective in all cases. Classical signs and symptoms of infection and abscess formation may be absent in this patient population. Many of these patients carry other blood-borne infections which the health professional must guard against. Cocaine injection, and "mixed" aerobic-anaerobic infections predominated, in contrast to earlier reports, when narcotics and aerobes predominated. Simple incision and drainage is adequate treatment; antibiotics, when given, should cover gram-positive and anaerobic bacteria; gram-negative coverage is unnecessary.

Abscess↗
PubMed1995

Postoperative complications predict recurrence of Crohn's disease.

OBJECTIVE: To find out if any of six variables influenced the incidence and timing of recurrence after a first resection for Crohn's disease. DESIGN: Open study. SETTING: University hospital, Germany. SUBJECTS: 104 surviving patients of 106 who underwent a first resection for Crohn's disease between January 1976 and December 1990. MAIN OUTCOME MEASURES: Association between 6 variables (age, sex, site of diseased bowel, histological evidence of Crohn's disease, indication for operation, and incidence of postoperative complications) and incidence and time of recurrence after the first operation. RESULTS: Patients were followed up for a mean of 4.5 years (range 1-16). Presentation with acute perforation was associated with a higher incidence of recurrence (10/14 compared with 26/90), chi square 7.90, p = 0.005) and more than doubled the risk of that recurrence developing with six years (log rank chi square 11.7, p = 0.02); the same was true for development of a postoperative complication for which the corresponding figures were 14/26 compared with 22/78, chi square 4.59, p = 0.03, and log rank chi square 6.1, p = 0.01. CONCLUSION: These data support the hypothesis that there may be two types of Crohn's disease: an aggressive type that perforates and is prone to early relapse, and one that develops more slowly with an obstructive pattern, and which relapses less often and after a longer disease free interval. The development of postoperative complications is a previously unrecognised risk factor for early recurrence in Crohn's disease.

Adult↗
PubMed1993

Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care.

Prophylactic administration of antibiotics can decrease postoperative morbidity, shorten hospitalization, and reduce the overall costs attributable to infections. Principles of prophylaxis include providing effective levels of antibiotics in the decisive interval, and, in most instances, limiting the course to intraoperative coverage only. Use in The National Research Council clean contaminated operations is appropriate and, in many instances, has been proven beneficial. Antibiotic prophylaxis is also indicated for clean operations, such as those involved with insertion of prosthetic devices, that are associated with low infection risk and high morbidity. Extension of antibiotic prophylaxis to other categories of clean wounds should be limited to patients with two or more risk factors established by criteria in the study of the efficacy of nosocomial infection control (SENIC) because the baseline infection rate in these patients is high enough to justify their use. Cefazolin (or cefoxitin when anaerobic coverage is necessary) remains the mainstay of prophylactic therapy. Selection of an alternate agent should be based on specific contraindications, local infection control surveillance data, and the results of clinical trials. Newer criteria for determining the risk of "site infection" (wound and intracavitary) are in evolution and may lead to modification of these recommendations over the next several years.

Anti-Bacterial Agents↗
PubMed1993

A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies.

OBJECTIVE: To describe and test a method for temporary closure of the abdomen. DESIGN: Open laboratory and clinical studies. SETTING: Department of Surgery, Medical College of Wisconsin, USA. SUBJECTS: 11 patients who underwent planned relaparotomy. MATERIAL: The burr consists of two adherent sheets of polyamide and polypropylene, which may be trimmed to accommodate any wound. One sheet consists of micro-mushrooms, the second of multiple slings. The two sheets stick to each other upon pressure and can easily be separated to open the wound. INTERVENTION: Planned relaparotomy or staged abdominal repair. OUTCOME MEASURES: Measurements of tensile strength and microbiological cultures. RESULTS: The shearing force required to separate the burr is 150 +/- 27 N/5 cm2 when gas sterilized and 77 +/- 11 N/5 cm2 when used in five subsequent laparotomies. No adverse microbiological effects were seen. CONCLUSION: The artificial burr can be used for temporary closure of the abdomen. It circumvents the problems that occur with zip fasteners, Marlex mesh, slide fasteners, and towel clips.

Abdomen↗
PubMed1993

Prospective evaluation of prognostic scoring systems in peritonitis. Peritonitis Study Group.

OBJECTIVE: To assess the accuracy of the APACHE II score, the Mannheim Peritonitis Index (MPI), and the Peritonitis Index Altona (PIA) II in the prediction of outcome of patients with peritonitis. DESIGN: Prospective, multicentre study. SETTING: 12 Departments of Surgery in Europe. SUBJECTS: 271 Patients with peritonitis confirmed at laparatomy. INTERVENTIONS: Computation of the three scores on one set of data for each patient. MAIN OUTCOME MEASURES: The ability to predict death or survival within 30 days of operation with each of the three scores. The prediction were evaluated according to the following criteria: discriminatory ability (areas under the receiver-operator characteristic (ROC) curves relating sensitivity to specificity); sharpness (level of confidence that was associated with a prediction); and reliability (agreement between predicted and observed mortality within equidistant intervals on the scale). RESULTS: APACHE II was superior to both the MPI and PIA II in its discriminatory ability and reliability, but the MPI and PIA II made more "sharp" predictions. CONCLUSIONS: None of the three scores is of any use for predicting the outcome for individual patients. APACHE II is the current standard for assessing the severity of peritonitis.

Adult↗
PubMed1992

Pitfalls in the use of color-flow duplex ultrasound for screening of suspected arterial injuries in penetrated extremities.

We compared color-flow duplex ultrasonographic scanning (CFD) to arteriography in 67 patients who sustained 75 penetrating injuries to the extremities without obvious arterial injury. There were 72 negative and three (4.0%) positive CFD studies and no failed attempts. With arteriography as the "gold standard," CFD had a specificity of 99% and a sensitivity of 50%, positive and negative predictive values of 66% and 97%, and an accuracy of 96%. Small pseudoaneurysms were missed in an axillary and an aberrant radial artery, and a genicular artery pseudoaneurysm was misread as originating from the popliteal artery. Cautious interpretation of negative studies appears warranted, particularly in the axilla and in bifurcated arteries. Extremity arteries should be completely imaged to rule out aberrant anatomy. Questionable studies should be confirmed arteriographically. With these caveats, color-flow duplex scanning may be useful for screening extremities with penetrating injuries thought to harbor occult arterial injuries.

Angiography↗
PubMed1991

Prophylaxis of postoperative infections.

The antibiotic most appropriate for prophylaxis of postoperative infections depends on the nature of the operation. In aseptic (clean) operations, gram-positive postoperative infections are the primary concern, and cefazolin is recommended because of its excellent pharmacokinetics and good activity against gram-positive pathogens, including staphylococci. In those operations where violation of the digestive tract creates a contaminated field, a cefotaxime-generation cephalosporin is the agent of choice because of the excellent safety profiles and the capability of agents of this class to kill essentially all pathogenic gram-negative aerobes as well as a substantial portion of anaerobes. Selection of resistant bacteria has not been significant and is unlikely to become so with single-dose prophylaxis. Occasionally, if there is a high probability that the operative field may be heavily contaminated by anaerobes, metronidazole should be added. Dosing should be sufficient to cover the operative period. Only a single prophylactic dose is necessary, given at the time of induction of anesthesia. For particularly long operations, a second dose of those antibiotics with half-lives shorter than 60 min is required two hours after the first. Single-injection prophylaxis is effective, inexpensive, has no side effects and does not induce bacterial resistance.

Aminoglycosides↗
PubMed1991

Calculated empiric antimicrobial therapy for mixed surgical infections.

In acute life-threatening surgical infections requiring immediate institution of antimicrobial therapy before bacteriological results are available, antibiotic treatment must be empiric. For best efficacy a more sophisticated form of empiric therapy is offered, termed calculated antibiotic therapy (CAT). Calculated antibiotic therapy requires consideration of a) typical bacterial spectrum; b) bacterial pathogenicity and synergism; c) antibacterial concentrations at the site of infection; d) toxicity and adverse effects; e) interaction with immune response; and f) results of properly conducted trials. Intraabdominal infections are used as an example here to assess the efficacy of clinically used cephalosporins and penicillins for determination of calculated antibiotic therapy. CAT identifies Escherichia coli and Bacteroides fragilis as the most important pathogens for intraabdominal infections and determines the most effective antibiotics at the tissue breakpoint, which is defined as the minimal concentration maintained for more than 90% of the dosage interval period at the infected tissues. At the tissue breakpoint calculated antibiotic therapy identifies cefotaxime-generation cephalosporins to be fully (100%) active against the most important aerobic pathogen E. coli and metronidazole as fully active against the important obligate anaerobe B. fragilis. Calculated antibiotic therapy becomes relatively important, since impeccably controlled clinical therapeutic trials as a foundation for therapy are rarely published.

Abdomen↗
PubMed1991

Comparison of three methods of rewarming from hypothermia: advantages of extracorporeal blood warming.

We developed a new technique, extracorporeal venovenous rewarming (EVR), to rewarm hypothermic patients in the intensive care unit or operating room. We compared this method with the active external (standard) techniques of warming blankets; heated ventilator circuits, intravenous fluids, and gastric and peritoneal lavage; and cardiopulmonary bypass. The EVR technique warmed patients' blood or additional blood products and crystalloids to 40 degrees C at 150-400 mL/min and allowed survival from a core temperature of 31.1 degrees C after massive injury. The EVR technique rewarming patients more rapidly than standard techniques and may be most appropriate in patients with multisystem trauma when rapid correction of hypothermia-related hypovolemia, coagulopathy, and arrhythmia is necessary. Cardiopulmonary bypass is required in severely hypothermic patients with cardiac arrest. Standard techniques can be used when these immediately life-threatening conditions are not present.

Adult↗
PubMed1990

Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma.

Planned relaparotomy (temporary abdominal closure) was studied prospectively in 20 trauma patients. Four died in the first 24 hours from hypothermia, coagulopathy, shock (three), and septic shock (one). The 16 survivors had a Velcro-like prosthetic placed to facilitate abdominal closure and re-entry. Prosthetic was necessary in eight because bowel edema precluded fascial closure, and useful for removal of packing (three) and for the management of peritonitis (five). The prosthetic did not open spontaneously, nor was it associated with evisceration or bowel fistula. Temporary abdominal closure (TAC) permitted reappraisal and staged repair of intra-abdominal pathology, including bowel resection and anastomosis. TAC identified 14 problems early: bleeding (five), bile leaks (two), GI complications (six), liver necrosis (one). Five patients developed superficial wound infections, and three went on to develop fascial necrosis.

Abdominal Injuries↗
PubMed1986

Scheduled reoperations (etappenlavage) for diffuse peritonitis.

Etappenlavage, a new concept of scheduled multiple laparotomies with abdominal lavage for diffuse peritonitis, has been in use since 1979. The purpose of etappenlavage is to ensure exclusion of the infected source, promote maximal elimination of toxic necrotic material, and allow prompt recognition of complications to effect immediate repair. Patients with diffuse peritonitis at high risk of developing multiple system organ failure (as assessed by high scores in the Peritonitis Index Altona and Acute Physiology and Chronic Health Evaluation classifications) were routinely reexplored on a daily basis until evidence of improvement or healing was noted. From 1980 to 1984, 61 patients with intra-abdominal sepsis were treated. Thirty-four cases were due to spontaneous perforation of an intestinal viscus, and 27 cases were secondary to postoperative infections. In 51 cases the primary process was present for more than 48 hours. A total of 235 etappenlavages were performed (mean, 3.9 per patient). In ten cases, additional bowel lacerations were noted and repaired at the second laparotomy. In the last 31 patients, closure with a zipper has facilitated reoperation. No drains were used. After definitive closure, primary wound healing was seen in 79% of cases. The overall mortality in this high-risk group was 22.9%.

Adolescent↗
PubMed1986

[Bone concentrations of imipenem after a dose of imipenem/cilastatin].

The concentration of imipenem in organic bone, determined in 16 patients by bioassay after short infusion (15 min) of 1 g imipenem/cilastatin was 4.3 +/- 2.06 mg/kg (geometric mean +/- standard deviation, n = 13) after 45 minutes, and 2.8 +/- 1.86 mg/kg (n = 26) after 88 minutes. Imipenem penetrates into inorganic hydroxylapatite (imbution), however, its antimicrobial activity is lost. The mean serum concentration in 12 patients (mean age 77 years) with normal renal and hepatic function 15 minutes after the beginning of the infusion was 93.1 mg/l imipenem. The mean serum half life t (1/2 beta) was 1.32 hours, the total body clearance 108.6 1/h, and the volume of distribution during the beta phase V(beta) 12.4 1.

Aged↗
PubMed1986

Further methodological improvement in antibiotic bone concentration measurements: penetration of ofloxacin into bone and cartilage.

Ten patients (mean age 63 years) undergoing alloarthroplastic hip joint replacement received 400 mg ofloxacin orally before anaesthesia. Venous blood samples were obtained before administration of the drug and then at intervals of up to 24 h. Bone samples were taken from femoral head and femoral shaft. Antibiotic concentrations were assessed by means of HPLC. The maximum serum concentration was 3.45 mg/l on average, after 90 min, and the maximum average bone concentration was 1.22 mg/l after 270 min. The half-life of ofloxacin in bone was shorter than that in serum. The concentrations measured in bone were superior to the minimal inhibitory concentrations reported for most pathogens of bone and joint infections. Therefore ofloxacin appears to be a valuable contribution to the therapeutic options of oral treatment for bone and joint infections.

Aged↗