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PubMed2002

Bone density and metabolism in children and adolescents with moderate to severe cerebral palsy.

OBJECTIVES: Diminished bone density and a propensity to fracture with minimal trauma are common in children and adolescents with moderate to severe cerebral palsy (CP). The purpose of this study was to provide a detailed evaluation of bone mineral density (BMD) and metabolism in this population and to assess the relationship of these measures to multiple other clinical, growth, and nutrition variables. METHODS: The study group consisted of 117 subjects ages 2 to 19 years (mean: 9.7 years) with moderate to severe CP as defined by the Gross Motor Functional Classification scale. Population-based sampling was used to recruit 62 of the participants, which allows for estimations of prevalence. The remaining 55 subjects were a convenience sampling from both hospital- and school-based sources. The evaluation included measures of BMD, a detailed anthropometric assessment of growth and nutritional status, medical and surgical history, the Child Health Status Questionnaire, and multiple serum analyses. BMD was measured in the distal femur, a site specifically developed for use in this contracted population, and the lumbar spine. BMD measures were converted to age and gender normalized z scores based on our own previously published control series (n > 250). RESULTS: Osteopenia (BMD z score <-2.0) was found in the femur of 77% of the population-based cohort and in 97% of all study participants who were unable to stand and were older than 9 years. BMD was not as low in the lumbar spine (population-based cohort mean +/- standard error z score: -1.8 +/- 0.1) as in the distal femur (mean z score: -3.1 +/- 0.2). Fractures had occurred in 26% of the children who were older than 10 years. Multiple clinical and nutritional variables correlated with BMD z scores, but interpretation of these findings is complicated by covariance among variables. In stepwise regression analyses, it was found that severity of neurologic impairment as graded by Gross Motor Functional Classification level, increasing difficulty feeding the child, use of anticonvulsants, and lower triceps skinfold z scores (in decreasing order of importance) all independently contribute to lower BMD z scores in the femur. CONCLUSIONS: Low BMD is prevalent in children with moderate to severe CP and is associated with significant fracture risk. The underlying pathophysiology is complex, with multiple factors contributing to the problem and significant variation between different regions of the skeleton.

Adolescent↗

PubMed1976

Massive hemorrhage from ileostomy and colostomy stomas due to mucocutaneous varices in patients with coexisting cirrhosis.

Enterostomal varices have been recognized as a cause of serious recurrent hemorrhage in patients with portal hypertension secondary to cirrhosis. Most often the varices at the mucocutaneous junction are the source of the hemorrhage. Three patients--two with hemorrhages from ileostomies and one with hemorrhages from a colostomy--are presented. Local measures have proved successful in controlling hemorrhages. Occasionally direct pressure alone will prove sufficient; more often the bleeding varix will need ligation. Complete revision of the enterostomy under local anesthesia can effect total disruption of the protal-systemic shunt and temporarily can eliminate local hemorrhage. Surgically created portasystemic shunts may be considered in good risk patients in order to eliminate hemorrhage from the stomal varices. Palliative local measures, however, remain the treatment of choice in the high-risk, cirrhotic patient who is unlikely to survive a major operation.

Colostomy↗

PubMed1962

The engima of circulating malignant cells.

There is no doubt that cancer cells do enter the circulating blood of persons with malignant lesions. Differentiation of them from other atypical cells found normally in the bloodstream is at present being studied. Investigators have expressed belief that most of the circulating malignant cells in the early stages of the disease are destroyed by host resistance. Surviving cells, however, develop into occult metastatic emboli which may remain quiescent until host defenses collapse. Clinical measures for the active control of these dormant implants have not been evolved as yet. Inasmuch as the mechanism of host resistance is still beyond clinical comprehension, the only known way to improve survival rates is the universal application of practical clinical methods for preventing iatrogenic disseminations, for devitalizing malignant cells and for apprehending emboli that may have left the main lesion just before surgical operation. Since it adequately eradicates primary sources of cell dissemination, conventional radical resection is still the treatment of choice for dealing with early solid neoplasms.

Humans↗

PubMed1991

[Epidemic outbreak of methicillin-resistant Staphylococcus aureus in a general hospital. Preliminary report].

The incidence of MRSA infections in Spain had remained in a low level through the years, being MRSA usually less than 1.5% of all S. aureus isolates. Since October 1988, we have detected in our hospital a MRSA outbreak. The epidemic started in the surgical wards, and spread through the rest of the institution. The incidence of cases was higher in the ICU's, areas that act as "multipliers" of the outbreak. In spite of standard control measures, the total number of patients with MRSA was 245 in April 1990. We studied prospectively a sample of 100 MRSA patients: thirty-six percent were colonized and 46% infected. The more common source of infection was the lower respiratory tract and primary bacteremia. The infection-related mortality was 30%. Our MRSA strain belong to phage type III, and shows a characteristic multiple antibiotic resistant pattern, the MRSA strain is sensitive to vancomycin, fusidic acid, phosphomycin and cotrimoxazole. Over the entire outbreak period, the MRSA strain developed resistance to rifampin, imipenem-cilastatin and ciprofloxacin. In spite of all control measures implemented, the outbreak can not have been totally controlled, and MRSA is now an endemic pathogen in our institution. Therefore, major changes in therapeutic approach to nosocomial infections have been since then introduced.

Adult↗

PubMed2004

Environmental investigations and molecular typing of Aspergillus flavus during an outbreak of postoperative infections.

After an outbreak of sternal surgical-site infections (SSSI) with Aspergillus flavus following cardiac surgery, a mycological survey of air and surfaces (41 and 149 samples, respectively) was performed throughout the surgical ward (SW) and in other areas of the hospital. Results showed massive contamination by A. flavus: more than 100 cfu per contact plate were frequently observed in some areas of the SW. The distribution of the A. flavus spores in the building, and especially in the SW, enabled the location of a possible source within the non-medical part of the SW, but the true source could not be identified. Four other surveys were made to follow up the decontamination process; the contamination level did not fall rapidly, needing repetitive cleaning operations. Strains from patients and from the hospital environment selected all over the SW were typed by random amplification of polymorphic DNA (RAPD), using two different primers (ERIC-1, BG-2). All these strains showed the same genotype, proving the clonal single-source of the environmental contamination and the intra-operative acquisition of A. flavus in the SSSI outbreak.

Air Microbiology↗

PubMed1989

Vascular complications of pancreatitis.

Hemorrhage is one of the most life-threatening complications of pancreatitis. It is usually due to erosion of a major pancreatic or peripancreatic vessel with massive bleeding into the gastrointestinal tract or abdominal cavity, or to formation and subsequent rupture of an arterial pseudoaneurysm. In addition, the inflammatory process of pancreatitis may cause thrombosis of the portal vein or its main tributaries, the splenic and superior mesenteric veins, resulting in compartmental portal hypertension with gastric, mesenteric, or colonic varices. Variceal hemorrhage is not an uncommon vascular complication of pancreatitis. The use of the newer, noninvasive imaging modalities of US, duplex Doppler US, and bolus-dynamic CT; earlier use of diagnostic and therapeutic angiography; and a more aggressive surgical approach have led to significant reductions in morbidity and mortality rates for patients with vascular complications secondary to pancreatitis. The radiologic diagnosis of vascular complications can be accomplished with US, CT, and angiography. US and CT may show formation of arterial pseudoaneurysms, evidence of hemorrhage into a pancreatic pseudocyst or fluid collection, or portal venous thrombosis with development of varices. The presence of flow in a pseudoaneurysm, or absence of flow due to portal venous thrombosis, can be confirmed by contrast-enhanced dynamic CT or duplex Doppler US. Angiography should be utilized in all patients, if possible, to show the precise site and source of bleeding. Although active bleeding can be diagnosed only by detection of contrast extravasation, the source of bleeding often can be identified by demonstration of an underlying vascular abnormality, such as a pseudoaneurysm or varices. Patients who are hemodynamically stable and who have angiographic evidence of bleeding can be treated with transcatheter embolization. This may result in permanent control of the bleeding, providing definitive treatment, or temporary control, thus allowing surgery to be performed on an elective or semi-emergent basis. Patients who are unstable or who have vascular involvement that is not amenable to transcatheter embolization should have emergency surgery. Preoperative angiography should be performed prior to surgery, if possible. Angiography can show the surgeon the exact vessel involved, as well as the surrounding vascular anatomy, thus facilitating the surgical approach. In selected patients, occlusion balloon catheters can be employed to obtain hemostasis during or after pancreatic surgery.

Angiography↗

PubMed1982

An enzyme tracer study of the organization of the somatic motor center for the innervation of different muscles of the tongue: evidence for two sources.

The hypoglossal nucleus has been described as the sole ipsilateral source of somatic motor innervation of the lingual and geniohyoideus muscles (Streeter, '40; Barnard, '40; Crosby et al., '62; Watkins, '78; Jenkins, '78). In this study microliter amounts of 30% solution of horseradish peroxidase (HRP) were injected into intact but surgically isolated canine genioglossus, hyoglossus, styloglossus, geniohyoideus, and intrinsic lingual muscles. All injections were confined to the left half of the tongue, and the right half served as control. The HRP injections resulted in ipsilateral labeling of hypoglossal neurons with the exception of the injections into the genioglossus muscle, which labeled this nucleus bilaterally. Surprisingly, a few neurons associated with the ventromedial aspect of the caudal pole of the ipsilateral facial motor nucleus also labeled after injections of lingual muscles. The somatotopic representation of the geniohyoideus and lingual muscles within the hypoglossal nucleus suggested that those muscles known to originate from the same or related primodia labeled in the same or closely related hypoglossal subnuclei. The presence of labeled neurons associated with facial motor nucleus supported the hypothesis (Langman, '75) of a possible dual origin of lingual muscles.

Animals↗

PubMed1994

The effect of topical antimicrobial agents on the production of toxic shock syndrome toxin-1.

Three hundred isolates of Staphylococcus aureus from wound swabs were examined for the production of toxic shock syndrome toxin 1 (TSST-1). The isolates were collected from community patients, surgical inpatients and from patients in the Regional Burns Unit, Booth Hall Children's Hospital, Manchester. The overall incidence of toxin production was 17% and there was no significant variation between the sources of the strains. All 55 TSST-1-producing strains were grown in sublethal concentrations of five topical antimicrobial compounds and the level of toxin produced was determined and compared with the amount produced in a control broth after incubation for 24 h. The effects of sublethal concentrations of the compounds on TSST-1 production were strain dependent; some compounds tended to increase production (at least four-fold) and some tended to decrease production (at least four-fold). Some of the strains showed an increase in toxin production in the presence of chlorhexidine gluconate/cetrimide solution and silver sulphadiazine cream whereas 18%, 42% and 47% of the strains showed a decrease in toxin production in the presence of povidone iodine solution, stabilised hydrogen peroxide cream and mupirocin ointment, respectively. Preliminary results suggest that silver sulphadiazine cream induces toxin formation earlier in the growth cycle.

Anti-Infective Agents, Local↗

PubMed1992

Adenoidectomy and otitis media.

Adenoid enlargement has traditionally been considered a factor in otitis media; adenoid size, however, does not appear to be correlated with otitis media occurrence. Presence of pathogenic bacteria in the adenoids of children with otitis media has been shown, and adenoidectomy appears to affect the middle ear primarily by removal of the source of infection in the nasopharynx. Three recent randomized, controlled studies showed the efficacy of adenoidectomy in the treatment of chronic secretory otitis media. In one study comparing no treatment, adenoidectomy, and adenotonsillectomy, a significant benefit was seen with adenoidectomy that was not enhanced by tonsillectomy. Another study that compared adenoidectomy, tympanostomy tubes, and a combination of the two showed a significant reduction in effusion time and less surgical retreatment over 2 years in the two adenoidectomy groups. The third study demonstrated the effect of adenoidectomy in children with recurrent chronic otitis media with effusion after failure of tympanostomy tube insertion. All three studies showed that the effect of adenoidectomy was independent of adenoid size. This review discusses current concepts of adenoid physiology and pathology, the major adenoidectomy studies, and indications for the procedure.

Adenoidectomy↗

PubMedDate not supplied

Fetal fibronectin: a new screening-marker for bladder cancer?

Early detection of transitional cell carcinoma (TCC) of the urinary bladder is essential for effective treatment. While several serum markers have been evaluated, none have been widely accepted for practical clinical use. Thus, urinary markers have been introduced and investigated to detect the evidence of bladder cancer. But sensitivity and specificity range around 80% respectively. In a prospective study we evaluated fetal fibronectin in the urine of patients with TCC of the urinary bladder. The positivity of oncofetal fibronectin was measured in morning urine samples by membrane immunoassay. This FFN membrane immunoassay is a qualitative test, a solid-phase immunogold assay. A positive sample will result in a single spot after binding of the oncofetal fibronectin-immunogold complex to the membrane containing a monoclonal antibody specific to oncofetal fibronectin (FDC-6, which specifically recognizes III-CS region). The morning urine samples were collected from patients with TCC before they underwent transurethral resection (n=40, 34 non-invasive and 6 invasive carcinomas) and healthy controls (n=20). Oncofetal fibronectin was investigated in the surgical samples by immunohistochemistry (antibody FDC-6, APAAP technique). We found a positive result for oncofetal fibronectin in 38/40 patients with transitional cell carcinoma of the urinary bladder. Two patients with a small pTaG1-TCC showed negative results. In the urine of healthy controls no positive results were detected. Thus, there is a sensitivity of 95% and a specificity of 100%. The TCC was demonstrated as a source of oncfn. To our knowledge this is the first study showing that patients with an evident TCC have a demonstrable amount of oncofetal fibronectin in the urine. We conclude that a positive result is common in TCC-patients. The sensitivity and specificity of this test seems to be extraordinarily high. Because of the small number of cases further studies are required.

Adult↗

PubMed2004

Infection after cholecystectomy, hysterectomy or appendectomy.

OBJECTIVES: This article uses patient-linked data to focus on hospitalization with post-operative infection following cholecystectomy, hysterectomy or appendectomy. The average number of hospital days and the costs of readmission are also estimated. DATA SOURCE: Data for surgeries in fiscal years 1997/98, 1998/99 and 1999/00 are from the Health Person-Oriented Information Database. ANALYTICAL TECHNIQUES: Bivariate tabulations were used to estimate the percentage of patients hospitalized with post-operative infection after cholecystectomy, hysterectomy or appendectomy between 1997/98 and 1999/00. Logistic regression was used to explore associations between infection and patient characteristics, readmission, and peri-operative mortality, while controlling for surgical characteristics. MAIN RESULTS: Hospitalization with post-operative infection was relatively rare, occurring in 1.4% of cholecystectomy, 2.0% of hysterectomy, and 3.8% of appendectomy patients. The associated costs of readmission for post-operative infection for the three surgeries were estimated at 5.4 to 6.3 million dollars annually. Old age, being male, surgical complexity and approach, and diabetes were associated with hospitalization involving a post-operative infection.

Adult↗

PubMed1989

[Clinical application of high dose rate interstitial radiation therapy].

High dose rate interstitial radiation (HDR-ISRT) with afterloading method is newly introduced radiotherapeutic modality which can be performed in short time and can lower the radiation exposure to the medical personnel. Afterloading Buchler IR was used in this study which obtains dose distribution by continuous oscillation of small high intensity iridium-192 source in 2.2 mm diameter applicator. The dose calculation programme for HDR-ISRT developed by us proved to be satisfactorily reliable except in the close proximity of less than 5 mm from the applicator. By using the developed programme, optimal applicator insertion interval was calculated which attain the dose homogeneity of 11% in a given plane. It was shown that this oscillating iridium source can give satisfactory dose distribution even if the applicators are inserted with interval greater than 1.5 cm. The clinical application of the HDR-ISRT with evaluable lesions has been performed in 23 sites in 21 patients. In 13 sites local control was obtained in spite of the advanced stage of the tumors. Radiation injury was shown in 5 sites, of which 3 needed to be treated surgically. The analysis of 23 sites which underwent HDR-ISRT showed that external radiation less than 50 Gy, HDR-ISRT dose between 15 to 20 Gy and total dose between 60 to 70 Gy in 40 to 100 days seemed necessary to obtain local control without radiation injury.

Aged↗

PubMed1980

A case-control study of menopausal estrogen therapy and breast cancer.

The association between estrogen replacement therapy and female breast cancer was studied in two Los Angeles area retirement communities. The 138 study cases of breast cancer occurring in residents younger than 75 years were compared with age- and race-matched community control subjects. The risk ratio for a total cumulative dose in excess of 1,500 mg was estimated to be 2.5 in women with intact ovaries. This increase was present using various independent sources of drug usage information but was inconsistent at low dose and undetectable in oophorectomized women. No important sources of confounding could be identified, and no risk modifiers could be identified except for a history of surgically confirmed benign breast disease. In such women with intact ovaries, the risk ratio for a high cumulative dose rose to 5.7 relative to nonusers with normal breasts.

Age Factors↗

PubMed2005

Thermal ablation and high-temperature thermal therapy: overview of technology and clinical implementation.

High-temperature hyperthermia or thermal therapy is being applied for destruction of cancerous tissue, eradication or reduction of benign tumours and targeted tissue modification and remodelling. Many of these high-temperature technologies provide a minimally-invasive alternative with lower morbidities compared to the traditional surgical procedures. The effects of high-temperature thermal exposure on tissues, examples of heating technology and procedures of clinical practice related to high-temperature thermal therapy are reviewed. This brief review encompasses interstitial, endocavity, intraluminal and external applications of RF, microwave, ultrasound, laser and thermal conduction energy sources. The technology is prevalent and in various levels of advancement, with the move toward more spatially-accurate and controllable heating systems combined with image-guidance and treatment verification warranted, especially for the treatment of cancer.

Hot Temperature↗

PubMedDate not supplied

Management of infectious waste by US hospitals.

In July 1987 and January 1988, forty-six percent (441/955) of randomly selected US hospitals responded to a questionnaire intended to identify their waste disposal practices. Survey responses were received from hospitals in 48 states. United States hospitals generated a median of 6.93 kg of hospital waste per patient per day and infectious waste made up 15% of the total hospital waste. Most hospitals (greater than 90%) considered blood, microbiology, "sharps," communicable disease isolation, pathology, autopsy, and contaminated animal carcass waste as infectious. Other sources of hospital waste that were commonly (greater than 80%) designated infectious were surgical, dialysis, and miscellaneous laboratory waste. The infectious waste was normally (80%) treated via incineration or steam sterilization before disposal, whereas noninfectious waste was discarded directly in a sanitary landfill. Eight-two percent of these US hospitals are discarding blood, microbiology, sharps, pathology, and contaminated animal carcass waste in accordance with the Centers for Disease Control's recommendations, while the compliance rate for the Environmental Protection Agency's recommendations (excluding optional waste) is 75%. No hospital could identify an infection problem (excluding needle-stick injuries) that was attributable to the disposal of infectious waste. While the management of infectious waste by US hospitals is generally consistent with the Centers for Disease Control's guidelines, many hospitals employ overly inclusive definitions of infectious waste.

Centers for Disease Control and Prevention, U.S.↗

PubMed2004

Nosocomial infections in neurosurgery intensive care units.

BACKGROUND: Nosocomial infections can lead to complications in the patients admitted to neurosurgery intensive care units. The most common causes are ventriculitis, shunt infections, meningitis, surgical wound infections, urinary tract infections, pneumonia, intravascular catheter related to infections and gastrointestinal infections. AIM AND OBJECTIVE: This article is written to determine strategies that nurses can apply to minimize nosocomial infections seen in neurosurgery intensive care units. DESIGN: The article is systematic review. METHOD: A MEDLINE and CINAHL search was carried out using descriptor terms. This overview is targeted at neurosurgery intensive care nurses to demonstrate to them that principles of infection control in the neurosurgery intensive care units are based on simple concepts and that basic measures are easy to implement at the bedside. The 20 articles were identified that met the requirements for methodological quality and inclusion criteria. RESULT: In order to reduce infection rates it is useful to inform intensive care nurses about the infection sources and it is useful to change their behaviours. CONCLUSION: Infection control measures are to be viewed as priority and have to be integrated fully into the continuous process of improvement of quality of care. RELEVANCE TO CLINICAL PRACTICE: Little research about the treatment/care and rates of nosocomial infections in the neurosurgery care unit was found. It was found that this subject has not been widely covered in nursing journals. This article can provide knowledge regarding the effective strategies of infection control in the neurosurgery intensive care units. Practicing nurses can use that knowledge to enhance the quality of nursing care.

Bacteremia↗

PubMed1996

Nosocomial infections with vancomycin-resistant Enterococcus faecium in liver transplant recipients: risk factors for acquisition and mortality.

The risk factors for acquisition of and mortality due to nosocomial infection with vancomycin-resistant Enterococcus faecium (VREF) in orthotopic liver transplant (OLT) recipients were studied at a tertiary care hospital; 32 VREF-infected OLT patients (cases) were compared with 33 randomly selected OLT recipients (controls). More antibiotics were administered preoperatively to cases (mean, 4 antibiotics per patient for 474 antibiotic-days) than to controls (mean, 1.8 antibiotics per patient for 131 antibiotic-days). Cases were more likely than controls to have received vancomycin therapy preoperatively and to have been hospitalized in the intensive care unit (ICU) preoperatively. Logistic regression revealed that the risk factors for acquisition of VREF infection were surgical reexploration and a prolonged stay in the surgical ICU postoperatively. In the cases, the risk factors for mortality were admission to the ICU preoperatively and hemodialysis. The mortality rate associated with polymicrobial bloodstream infections was 100% despite appropriate therapy. Sixteen and 18 cases received parenteral chloramphenicol and doxycycline, respectively, for treatment of VREF infection. There were no hematologic adverse effects attributed to chloramphenicol treatment. DNA analysis of selected E. faecium isolates suggested that infections were due to multiple clones. In summary, the source of VREF infection in OLT patients is the gastrointestinal tract. Antibiotic selective pressure may contribute to colonization. Infection with VREF is a predictor of morbidity and mortality in OLT patients.

Anti-Bacterial Agents↗

PubMed2006

A 4-cm thermoactive viscoelastic foam pad on the operating room table to prevent pressure ulcer during cardiac surgery.

AIMS AND OBJECTIVES: In this experimental study, a 4-cm thermoactive viscoelastic foam overlay and a heating source on the operating room table was compared with the standard operating room table with a heating source for the effect on the postoperative pressure ulcer incidence in cardiac surgery patients. BACKGROUND: Pressure ulcer incidence in the cardiac surgery population is reported to be up to 29.5%. The prolonged compressive forces from lying on the operating room table are one source of pressure ulcer development in this population. Pressure-reducing devices on the operating room (OR)-table should reduce the patients' interface pressure and thus the hazard of skin breakdown. METHODS: A randomized controlled trial was performed to test the effect of a 4-cm thermoactive viscoelastic foam overlay with a water-filled warming mattress on the OR-table (test OR-table) compared with the standard OR-table (a water-filled warming mattress, no pressure-reducing device) on the postoperative pressure ulcer incidence in cardiac surgery patients. INSTRUMENTS: The pressure ulcer classification system of the European Pressure Ulcer Advisory Panel (EPUAP) was used for pressure ulcer grading. RESULTS: The results show that patients lying on the 4-cm thermoactive viscoelastic foam overlay suffer slightly more pressure ulcer (17.6%) than patients on the standard OR-table without the foam overlay (11.1%). Because of the clinical relevance of the results, the randomized controlled trial was terminated after 175 patients at the interim analysis although the power calculation stated 350 patients. CONCLUSIONS: The combination of a 4-cm viscoelastic foam overlay and a warming source cannot be recommended for pressure ulcer prevention on the operating room table. RELEVANCE TO CLINICAL PRACTICE: Foam overlays are used to prevent pressure ulcers in patients. It is necessary to use such devices according to patient safety and use of resources.

Adult↗