Surgical management of haemorrhage from peptic ulceration.
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Hemostasis, Surgical↗
Biomedical subjects
W R Murray
Publications and source records attributed to W R Murray.
The effect of etretinate, a synthetic retinoid, on pancreatic prostaglandin production.
Prostaglandin E2 levels in hamster pancreas were measured by radioimmunoassay. Control animals (N = 22) were compared to etretinate treated animals (N = 33). There was a highly significant reduction in pancreatic prostaglandin E2 production in the treated animals (means 1.842 ng/mg pancreas and 0.486, p less than 0.0005) suggesting that etretinate is a blocker of pancreatic prostaglandin production.
Animals↗
Hyperamylasaemia and acute pancreatitis following endoscopic retrograde cholangiopancreatography.
Hyperamylasaemia and acute pancreatitis are the more common complications of endoscopic retrograde cholangiopancreatography (ERCP). Ninety patients who underwent ERCP +/- endoscopic papillotomy were monitored for rises in the serum amylase and the development of acute pancreatitis. The incidence of hyperamylasaemia (greater than 300 IU/L) was significantly greater (p = 0.01) when the pancreatic duct was imaged (75%) than with bile duct imaging alone (33%). The incidence of acute pancreatitis following imaging of the pancreatic duct +/- bile duct was 11.3% and was found to be significantly increased in those patients (n = 9) who also underwent endoscopic papillotomy. Imaging of the biliary tree only +/- endoscopic papillotomy carried no significant risk of acute pancreatitis. In those patients who developed pancreatitis, the rise in serum amylase occurred early and was significantly higher at 2 h following ERCP. These findings may help to identify patients who are at risk of developing this complication.
Acute Disease↗
Duodenal ulcer healing after presentation with haemorrhage.
Forty patients who were managed conservatively after haemorrhage from an endoscopically verified duodenal ulcer were randomised at discharge from hospital to enter a blind study of ranitidine therapy (150 mg bd) versus a placebo tablet. The patients were re-endoscoped after four weeks, ulcer status defined and the trial code broken revealing that five of 20 placebo patients had healed their duodenal ulcer compared with 16 of 20 ranitidine patients (p = 0.001). Lifestyle parameters of both groups improved during the study period but no directly related benefit in duodenal ulcer healing could be shown. We conclude that effective anti-ulcer therapy, such as ranitidine, is required to heal a duodenal ulcer which presents with haemorrhage.
Clinical Trials as Topic↗
Salvage of acetabular insufficiency with cementless components.
In conclusion, it appears that large outside-diameter bipolar devices or threaded, cement-free acetabular components (with or without porous surfaces) provide excellent hip stability when used to salvage hips with acetabular insufficiency. The bipolar or threaded devices can maintain or restore normal or nearly normal hip mechanics, minimize pain by preventing motion between the cup and the bone, and permit fill-in of bony defects and healing of nonunited fractures. Both grafting should be used whenever possible, since it may prevent medial migration and allow for replacement with a cemented or cementless porous-surfaced cup in the future should pain occur. A cane or crutch should be used to minimize stress across the joint and thereby prolong the life of the reconstruction. All patients must realize that these are salvage procedures.
Acetabulum↗
Variations in the density of bone cement after centrifugation.
Barium sulfate added to bone cement to provide radiopacity has a density about four times greater than that of polymerized radiolucent bone cement. Because centrifugation might make a clinically significant change in the distribution of barium sulfate, this process was studied. Radiolucent and radiopaque Simplex-P bone cement (Howmedica, Inc., Rutherford, New Jersey) were mixed with and without cooling and centrifuged for two or four minutes at 2,000 g or 1,000 g (gravity acceleration). The density of sections of the hardened bone cement was measured using the Archimedes principle. Erythromycin and colistin were added to cement batches to test whether or not centrifugation affected the distribution of antibiotics. Direct and radiographic observation and density measurements (cooled specimens, 2,000 g, p less than 0.01) verified that barium sulfate does accumulate at the bottom of the centrifugation tubes. Thin sections of the bone cement revealed that only larger particles (20-100 micron) of barium sulfate were deposited at the bottom. No evidence of redistribution of antibiotics after centrifugation was seen. It is recommended that Simplex-P bone cement be reformulated to eliminate concern about inhomogeneities that arise from centrifugation. Further, it is recommended that cooled, centrifuged antibiotic cement be used for long-stem revision hip surgery, where longer setting times are necessary, and room temperature cement for "fresh" hip surgery. A total centrifuge time of two minutes with a 2,000 g maximum force is recommended.
Anti-Bacterial Agents↗
Treatment of the infected total hip arthroplasty.
Based on our present experience, excisional arthroplasty is the most reliable option. Infections caused by organisms of significant virulence are best treated with excisional arthroplasty or Girdlestone resection followed by delayed reinsertion after adequate antibiotic treatment has controlled the sepsis, as determined by clinical and laboratory criteria. In patients with infections caused by organisms of relatively low virulence, for example, Staphylococcus epidermidis or anaerobic diphtheroids, the surgeon should seriously consider either incision and drainage, debridement, and local and systemic antibiotics if there is no component loosening, or direct exchange (removing both components and reinserting them with antibiotic cement) if there is loosening of one or both components. However, if incision and debridement or direct exchange fails, then excisional arthroplasty as a definitive procedure or as a first stage of a removal and reinsertion should be carried out. While we have not been successful in treating even early infections caused by Staphylococcus aureus with incision, drainage, and antibiotics, the morbidity associated with this procedure is extremely low compared with that of the other procedures; therefore it seems reasonable to use this modality as an emergency treatment for acute infections, with the full realization that it probably will not succeed as the definitive procedure, and the surgeon should prepare for early, more definitive surgical intervention.
Anti-Bacterial Agents↗
Peri-incisional mezlocillin versus rectal-metronidazole for wound infection prophylaxis.
One hundred and forty patients who underwent appendicectomy were included in a prospective randomized trial to compare the ability of preoperative rectal metronidazole and peri-incisional mezlocillin to prevent wound infection following appendicectomy. The results show that bactericidal local tissue levels of mezlocillin were uniformly achieved using the peri-incisional technique. The wound infection rate for the metronidazole group was found to be 15.9% and did not significantly differ from the wound infection rate when mezlocillin was used (10.4%). Peri-incisional mezlocillin therefore appears to be a viable prophylactic technique against wound infection following appendicectomy and may offer a cheaper alternative to intravenous intra-operative metronidazole administration in cases when pre-operative metronidazole suppositories have been omitted. The peri-incisional mezlocillin technique is also suitable for routine prophylaxis against wound infection following appendicectomy.
Adolescent↗
Multinuclide digital subtraction imaging in symptomatic prosthetic joints.
One hundred eleven patients with symptomatic prosthetic joints (86 hips, 23 knees, and two shoulders) were evaluated for prosthetic loosening and infection by combined technetium-99m-MDP/gallium-67 digital subtraction imaging. Clinical correlation was based on the assessment of loosening and bacterial cultures obtained at the time of surgery in 54 patients, joint aspiration cultures obtained in 37 patients, and long-term clinical follow-up for greater than 1.5 years in an additional 15 patients. Results revealed an 80%-90% predictive value of a positive test for loosening, and a 95% predictive value of a negative test for infection. However, because of the low sensitivities and specificities observed, this approach to the evaluation of symptomatic prosthetic joints does not seem cost effective.
Adult↗
Magnetic resonance imaging of the hip.
Magnetic resonance imaging of the musculoskeletal system in general and the hip in particular offers many exciting opportunities for innovative and revolutionary diagnostic avenues, the full potential of which awaits further investigative and clinical experience.
Bone Marrow Diseases↗
Subsidence of the femoral prosthesis. A stereophotogrammetric evaluation.
A quantitative three-dimensional measurement method, radiographic stereophotogrammetry (SPG), was employed to assess the relation between early subsidence of the femoral prosthesis after total hip arthroplasty (THA) and subsequent clinical course. The SPG technique and the authors' error control mechanisms are described in 15 patients in the early postoperative period, and the findings are correlated with those of follow-up clinical examinations. Among the 12 patients who remained clinically asymptomatic with respect to pain, only one had an SPG estimate of subsidence in excess of 1 mm at any point in time. Each of the three patients who later became symptomatic had SPG estimates of subsidence in excess of 1.75 mm within six months of the operation. Thus far, the patient with the largest estimate of subsidence is the only one who required surgical revision.
Evaluation Studies as Topic↗
Anaphylactic reaction to aprotinin despite negative ocular sensitivity tests.
A man with a history of pancreatitis was given aprotinin intravenously just before endoscopic retrograde pancreatography. Despite negative sensitivity tests with aprotinin eye drops he developed a profound anaphylactic reaction on intravenous administration of the drug. Ocular sensitivity tests may not predict severe anaphylactic reactions to intravenous aprotinin.
Adult↗
Work disability before and after total hip arthroplasty. Assessment of effectiveness in reducing disability.
We evaluated the impact of total hip arthroplasty (THA) on work disability among working age persons. Just over one-third of those totally work disabled prior to THA were working at 1 or at 4 years after surgery. A significant long-term decrease in work disability after surgery was demonstrated by estimating disability prevented by THA, but the decrease was less than suggested by the literature. Preoperative work status and the number of painful joints were significant predictors of return to work.
Cost-Benefit Analysis↗
Use of antibiotic-containing bone cement.
Erythromycin and colistin (or other thermostable antibiotics) may legally be added to polymethylmethacrylate (PMMA) for use in the fixation of prostheses to bone. The antibiotics are leached or rapidly released from the combination in bactericidal concentrations. They do not reduce the strength characteristics of the cement below acceptable standards, nor do they change its handling characteristics. Erythromycin alone was used in 1112 total hip arthroplasties between 1971 and 1976, with an infection rate of 0.98%. Erythromycin-colistin bone cement was used in 786 total hip arthroplasties from July 1976 to December 1980, with a deep-wound infection rate of 0.4%. Erythromycin-colistin-containing bone cement is safe and effective in treatment of and prophylaxis against deep-wound infection in total joint arthroplasty.
Anti-Bacterial Agents↗
Salvage of acetabular insufficiency with bipolar prostheses.
Salvage of severely compromised, deficient, and insufficient acetabula associated with failed total hip arthroplasty, nonunited or malunited acetabular fractures, and metastatic tumor can be accomplished with the bipolar prosthesis. The procedure must be regarded as a salvage procedure, providing the patient with limited functional capabilities. All patients are prescribed permanent external support, even though some have refused to use it. This procedure is usually done by means of a transtrochanteric approach and frequently requires bone grafting. The acetabular component is fitted as tightly as possible, consistent with complete seating, stability, and rim or equatorial fit, and, in my opinion, holds and molds the bone grafts. The procedure is far more acceptable and gives a much more functional result than a Girdlestone resection. If necessary, a standard total hip arthroplasty acetabular component could be inserted after graft incorporation, fracture healing, or both.
Acetabulum↗
Endotoxaemia and complement activation in acute pancreatitis in man.
Twenty-four patients who experienced 26 attacks of acute pancreatitis were studied. Endotoxaemia, as measured by the limulus lysate assay, was present in 13 of the attacks. Six out of seven patients with systemic complications of the disease had endotoxaemia. C3 catabolism was increased in all 26 attacks of pancreatitis, and a falling level of C3 during attacks of severe pancreatitis was associated with a fatal outcome. There was statistical evidence of more complement activation in serum samples taken when patients had positive limulus lysate tests than when endotoxin was not detected in their blood.
Acute Disease↗
Phenol cauterization in the management of ingrowing toenails.
Phenol cauterization has been carried out on 150 toes in 121 patients with an ingrowing toenail. There was no significant morbidity and the procedure was tolerated well by all patients. Overall recurrence rate was found to be 4 per cent after nine months. This figure compares favourably with surgical ablation techniques and when combined with improved patient tolerance indicates that phenol cauterisation may be the ablation procedure of choice in the treatment of an ingrowing toenail.
Cautery↗