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The bacteriology of primary wound sepsis in potentially contaminated abdominal operations: the effect of irrigation, povidone-iodine and cephaloridine on the sepsis rate assessed in a clinical trial.

Two hundred and nine potentially contaminated abdominal operations were randomly allocated to prophylaxis with a single dose of 1 g cephaloridine intraincisionally, irrigation of the wound at the end of the operation with saline or spraying of the wound with povidone-iodine. In high risk operations (ileocolorectal or those in obese patients) the rate of major wound sepsis in those protected by cephaloridine was 3.8% compared with 13.2% in the irrigation and 16.7% in the povidone-iodine groups. In low risk operations no significant differences in sepsis rates were found. Bacteriological studies of incised organs, subcutaneous fat and pus showed that the majority of wound infections arose from endogenous sources. The outstanding problem remains that of prevention of contamination of the abdominal wall during surgery.

Abdomen↗

[Carriers of Staphylococcus aureus as a source of nosocomial infections. Epidemiological and prophylactic aspects].

20% of the normal population are nasal carriers of Staphylococcus aureus (Sa), and the carrier rate is even higher in insulin dependent diabetics, intravenous drug addicts, patients on haemo- and peritoneal dialysis, and HIV infected patients. Nasal Sa carriers have an increased risk of Sa infections following invasive therapy. Mupirocin, a novel topical antibiotic, is highly effective against nasal Sa. A number of studies indicate that it may reduce the incidence of Sa infections in dialysis patients, however experience with other categories of patients is sparse. Surgical wound infection with Sa is a particularly serious complication after implantation of foreign body material, e.g. artificial joints. There is a need for controlled clinical trials to test the efficacy of mupirocin in eradicating Sa in these types of patients. Uncritical use of mupirocin for topical treatment of wounds should be avoided in order to prevent development of resistance.

AIDS-Related Opportunistic Infections↗

Neoadjuvant hormonal therapy in carcinoma of the prostate.

The rising incidence of and mortality from prostate cancer has generated great interest in improving the results of current methods of treatment. It is well-established that large tumour volumes and positive surgical margins are correlated with higher rates of local failure and distant metastasis. Significant decreases in both tumour volume and the rates of positive surgical margins are seen with NHT. Follow-up data from one randomized trial of hormonal therapy before RT have shown significantly improved disease-free survival, but so far there has been no benefit in overall survival. However, the addition of adjuvant hormonal therapy has been reported to improve survival. The results suggest that neoadjuvant and adjuvant hormonal therapy may be a viable option in men with locally advanced prostate cancer in whom cure is probably impossible, but disease progression can potentially be slowed. What remains to be determined is whether hormonal therapy alone can produce the same results. For younger men with clinically localized prostate cancer, radical prostatectomy is increasingly the treatment of choice. Prospective randomized trials of NHT have produced impressive statistics for decreasing the incidence of positive surgical margins, but the potential to down-stage tumours remains controversial. Follow-up serum PSA measurements have thus far shown no benefit from neoadjuvant therapy. The possibility that patients who fail biochemically, whether they are from the pretreated or control group, may simply represent a subgroup with aggressive tumours that may not respond to androgen withdrawal, has yet to be proved. As more follow-up data are analysed within the next several years, there must be a clear survival advantage if NHT is to be offered as a treatment option. Despite the potential of neoadjuvant therapy, the use of androgen withdrawal before definitive surgical treatment should be limited to clinical trials until a clearer picture emerges. Some may argue that although there is no evidence of a true advantage for NHT, neither is there evidence of harm. However, it must be recognized that androgen withdrawal therapy has side-effects and adds significantly to the overall cost of treatment. Furthermore, NHT delays definitive treatment; clearly, this can be a source of anxiety for the patient and the impact on survival is unknown. Currently, the rates of pathologically organ-confined disease are high in some subsets of patients (e.g. low-stage, low-grade and low PSA) so that NHT is unlikely to have great additional benefit. Although the influence of hormones on prostate growth has been known for many decades, we are only now elucidating the biological mechanisms of hormonal therapy. Although androgen ablation therapy has been used in men with metastatic prostate cancer for more than 50 years, further research at the cellular and molecular level is essential if we are to refine treatment modalities for both localized and advanced disease. Furthermore, until we have more follow-up data from randomized clinical trials of NHT, it cannot be considered part of the standard treatment for carcinoma of the prostate. There are still too many unknown factors; only time will tell if the initial promise of NHT will be fulfilled.

Antineoplastic Agents, Hormonal↗

Open mesh versus non-mesh for repair of femoral and inguinal hernia.

BACKGROUND: Inguinal hernia repair is the most frequent operation in general surgery. Until recently the standard procedure has been open musculo-aponeurotic repair using sutures under tension to close the defect but 'tension-free' repair using prosthetic mesh is becoming increasingly common in many countries. OBJECTIVES: The purpose of this review is to evaluate open mesh techniques in comparison with open non-mesh techniques for the surgical repair of groin hernia. SEARCH STRATEGY: Electronic databases were searched and further trials were sought from the reference lists of reports of known trials. Through the EU Hernia Trialists Collaboration authors of identified randomised controlled trials were asked for information on any other trials known to them. There was no language restriction. SELECTION CRITERIA: Studies were eligible for inclusion if they were randomised or quasi-randomised trials comparing either a) open mesh with open non-mesh repair of groin hernia or b) open flat mesh repair with plug and mesh repair of groin hernia. DATA COLLECTION AND ANALYSIS: For each outcome the results were derived using data from the best available source. The majority of data for this review came from individual patient data (IPD) supplied by the trialists. When these were unavailable data came from additional aggregated information or from published trial reports. All trials were analysed using the 'intention to treat' principle. MAIN RESULTS: Twenty trials comparing open mesh with open non-mesh repair were identified. Open mesh methods, on average, took 7-10 minutes less to perform than Shouldice procedures, but took 1-4 minutes longer than other non-mesh methods. There were no clear differences between mesh and non-mesh groups for haematomas, seromas or wound/superficial infections. Three serious operative complications were reported after open mesh repair and three following non-mesh repair. Overall, those in the mesh groups had a shorter length of hospital stay and quicker return to usual activities, but this pattern was not observed for all trials. There was a suggestion that persisting pain was less frequent after mesh repair than after non-mesh repair but this result was dependent on one trial and data were not available for 11 trials. There was no evidence of a difference between the groups with respect to persisting numbness. Fewer hernia recurrences were reported after mesh repair (Peto OR: 0.37, 95% CI: 0.26 to 0.51). There were too few data to reliably address differential effects for patients with recurrent, bilateral or femoral hernias. Two trials comparing flat mesh with plug and mesh were identified. There was no clear evidence of differences between the groups. REVIEWER'S CONCLUSIONS: There is evidence that the use of open mesh repair is associated with a reduction in the risk of recurrence of between 50% and 75%. Although the trials were heterogeneous there is also some evidence of quicker return to work and of lower rates of persisting pain following mesh repair.

Clinical Trials as Topic↗

Cineplasty as a control input for externally powered prosthetic components.

To achieve significant improvement in the function of electric-powered, upper-limb prostheses, we believe it is necessary to develop better control interfaces with inherent sensory feedback. Small cineplasties, or other surgical procedures that also externalize the force and excursion of a muscle, could potentially provide this superior control. Connecting a muscle to a prosthetic component via a controller that embodies the concept of extended physiological proprioception (EPP) would enable the physiological sensory feedback inherent in the skin, muscle, and other tissues of the cineplasty to inform the user of the state of the prosthesis. Multiple miniature forearm tunnel cineplasties, each with an EPP controller, might enable meaningful independent multifinger control of hand prostheses. At higher levels of amputation (e.g., transhumeral), small pectoral or deltoid cineplasties could augment existing control sources to improve control of multifunctional total arm prostheses. To explore the feasibility of these ideas, we quantified the control capabilities of individuals with preexisting biceps muscle tunnel cineplasties with the use of pursuit tracking experiments. A "proof-of-concept" EPP electric hand prosthesis was also successfully developed for a subject with agonist-antagonist, forearm tendon exteriorization cineplasties. The results of the tracking studies demonstrate numerically the efficacy of control by cineplastized muscles relative to other control approaches.

Amputation Stumps↗

Control of acute gastroduodenal hemorrhage with cimetidine.

Thirty-four patients with acute gastroduodenal hemorrhage were treated with intravenous Cimetidine. Preliminary endoscopy was done at the onset of bleeding to determine the source of bleeding and to rule out the presence of a brisk arterial bleeding site that would require immediate operation for control. Sixteen of the patients had primary peptic ulcer disease and 18 patients had "stress ulcer" syndrome. The bleeding stopped following Cimetidine administration in 14 of the 16 peptic ulcer patients (88%) and in 13 of 18 stress ulcer patients (72%). There was no subsequent rebleeding. The data suggest that Cimetidine is of value in the immediate nonoperative management of acute gastroduodenal hemorrhage. Further, the availability of Cimetidine for postoperative use may modify the surgical approach to stress ulcer bleeding.

Adult↗

Deep neck infections in diabetic patients.

PURPOSE: Deep neck infections may be lethal if life-threatening complications occur, especially in immunocompromised hosts such as diabetic patients. This study was undertaken to better define the clinical features and prognosis of deep neck infections in the diabetic patients with special emphasis on the use of empirical antibiotics and the role and timing of surgical management. PATIENTS AND METHODS: A retrospective analysis of 105 consecutive patients treated at a single institution during a 9-year period was conducted. Of these, 30 patients also presented with diabetes mellitus. RESULTS: Compared with the nondiabetic patients, the unique features of deep neck infections in diabetic patients were as follows: (1) older age, (2) tendency of unclear infection source, (3) tendency to involve multiple spaces, (4) required more aggressive surgical intervention, (5) prolonged hospitalization, and (6) higher complication rate. The differences were statistically significant (P< .05). There were no significant differences in the complete blood count/ differential count positive findings and fever between the 2 groups (P> .05). Bacterial cultures showed that Klebsilla pneumoniae was the most common causative pathogen in diabetic patients. CONCLUSIONS: In deep neck infection patients with diabetes mellitus, the clinical course is more severe and there is a poorer prognosis. Thus, in treating them, we should keep close observation, appropriately control the diabetes, detect the life-threatening complications early, perform aggressive surgical treatment if fluctuation or complication occurs, and take into account the preponderance of K pneumoniae when administering the empirical antibiotics.

Adolescent↗

[La Peyronie disease. Historical, epidemiological, physiopathological data. Diagnostic and therapeutic approaches].

The origin of Peyronie's disease remains obscure although the first description dates back to 1743. The prevalence of the disease is 388.6 per 100,000 population. Little physiopathologic data is available. Repeated microtrauma to the tunica albuginea appears to favor the onset of inflammatory phenomena, in turn the source of fibrosis. Clinical examination remains the ideal method for diagnosis and follow-up: it can be completed by ultrasonography of the corpora cavernosa. Magnetic resonance imaging does not appear to provide any significant benefits. The inflammation and pain encountered in early stages of the disease can be managed medically. Numerous treatments have been tested (oral route or local injections); results are in the course of evaluation. In the absence of well-controlled clinical trials, there is no standard medical therapy. Radiotherapy today appears inadvisable. The sequels of Peyronie's disease can be treated surgically, especially in patients who can maintain and adequate erection but suffer from a deformation incompatible with sexual activity. Numerous technical artifices have been proposed; correction of deformations is generally satisfactory but perfections need to be made concerning the quality of erection. Patients with advanced disease and severe erectile insufficiency can be offered reconstructive surgery using penile implants: results of the various procedures are analyzed.

Humans↗

[Disorders of the rhythm and conduction in patients operated on for a total correction of tetralogy of Fallot].

The purpose of this paper is to analyze the incidence of arrhythmias and conduction disturbances in 81 patients after total surgical repair of tetralogy of Fallot. The study was done at the National Institute of Cardiology "Ignacio Chávez" from 1974 to 1989. Sixty five patients (78.9%) developed a pattern of right bundle block and ten patients (12.3%) had additional left anterior hemiblock following surgery. Two patients had complete heart block so pacemaker was implanted. The incidence of serious ventricular arrhythmias was found in 11 patients often polymorphic ventricular premature complexes. One case sustained monomorphic ventricular tachycardia. Electrophysiological study demonstrated that it source was the scar of the right ventricle outflow tract. This tachycardia is now under control with specific antiarrhythmic therapy.

Arrhythmias, Cardiac↗

Fundamental and practical aspects of therapeutic uses of pulsed electromagnetic fields (PEMFs).

The beneficial therapeutic effects of selected low-energy, time-varying magnetic fields, called PEMFs, have been documented with increasing frequency since 1973. Initially, this form of athermal energy was used mainly as a salvage for patients with long-standing juvenile and adult nonunions. Many of these individuals were candidates for amputation. Their clearly documented resistance to the usual forms of surgical treatment, including bone grafting, served as a reasonable control in judging the efficacy of this new therapeutic method, particularly when PEMFs were the sole change in patient management. More recently, the biological effectiveness of this approach in augmenting bone healing has been confirmed by several highly significant double-blind and controlled prospective studies in less challenging clinical circumstances. Furthermore, double-blind evidence of therapeutic effects in other clinical disorders has emerged. These data, coupled with well-controlled laboratory findings on pertinent mechanisms of action, have begun to place PEMFs on a therapeutic par with surgically invasive methods but at considerably less risk and cost. As a result of these clinical observations and concerns about electromagnetic "pollution", interactions of nonionizing electromagnetic fields with biological processes have been the subject of increasing investigational activity. Over the past decade, the number of publications on these topics has risen exponentially. They now include textbooks, speciality journals, regular reviews by government agencies, in addition to individual articles, appearing in the wide spectrum of peer-reviewed, scientific sources. In a recent editorial in Current Contents, the editor reviews the frontiers of biomedical engineering focusing on Science Citation Index methods for identifying core research endeavors. Dr. Garfield chose PEMFs from among other biomedical engineering efforts as an example of a rapidly emerging discipline. Three new societies in the bioelectromagnetics, bioelectrochemistry, and bioelectrical growth and repair have been organized during this time, along with a number of national and international committees and conferences. These activities augment a continuing interest by the IEEE in the U.S. and the IEE in the U.K. This review focuses on the principles and practice behind the therapeutic use of "PEMFs". This term is restricted to time-varying magnetic field characteristics that induce voltage waveform patterns in bone similar to those resulting from mechanical deformation. These asymmetric, broad-band pulses affect a number of biologic processes athermally. Many of these processes appear to have the ability to modify selected pathologic states in the musculoskeletal and other systems.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

Variability in clinical systems: applying modern quality control methods to health care.

BACKGROUND: Quality health care depends on timely completion of sequences of clinical care. This study evaluated the concepts and tools of quality management for measuring system performance in ambulatory care. STUDY DESIGN: Clinical staff in nine centers of a group model health maintenance organization described the procedure for ordering and completing a complete blood count, mammogram, and surgical consultation. Variability was noted among the processes as intended and as actually performed, as well as inconsistencies reported within and among centers. In two centers investigators tracked performance of key sequences of care and the achievement of other key quality characteristics believed desired by physicians and patients. Computerized patient records and departmental files were the only available sources of data for assessing completion and followup of tests and consultations. Even these data were difficult to obtain and, in many instances, incomplete. RESULTS: Although data were often difficult to obtain, the quality management techniques used were helpful in revealing process failures that appeared to be the result of design flaws built into the clinical systems. CONCLUSION: Robust process designs and improved management information systems for monitoring these processes are recommended to reduce variability and improve the quality of clinical care.

Blood Cell Count↗

The surgical treatment of adenocarcinoma of the duodenum distal to the ampulla of Vater.

The case analysis of five patients with post-ampullary adenocarcinoma of the duodenum showed this to be a tumor which favors local extension into surrounding organs, instead of lymphatic or hepatic metastasis. This justifies and aggressive resectional approach to treatment, pancreaticoduodenectomy being the basic operation to be applied. Proximity to the superior mesenteric vessels involving them in four out of five of our tumors, is the major anatomic limiting factor. Leaving vascular control for the end of the excision and perfusing them to maintain viability of the gut until a comfortable vascular anastomosis can be constructed, should solve the problem. Misdiagnosis proved to be a prominent source of error, causing delays and inappropriate therapy. The Cancer Registry of Puerto Rico has documented an incidence of carcinoma of the duodenum similar to that of the ampulla of Vater. This fact demands the same care in the conduct of diagnostic procedures of the distal duodenum as is customary in the visualization of the ampulla.

Adenocarcinoma↗

Management of patients with locally advanced breast cancer.

Increased breast health awareness has led to earlier stage distribution among breast cancer patients in the United States; however, locally advanced tumors remain a major source of morbidity and mortality. Early attempts to control this high-risk pattern of disease with surgery or radiation alone were met with disappointingly high rates of treatment failure in locoregional and distant sites. Multimodality strategies represent a major advance in management of these difficult cancers. The current standard of care is neoadjuvant chemotherapy to improve operability, followed by breast and axillary surgery (including lumpectomy for appropriately selected patients). Following surgery, decisions regarding the need for additional chemotherapy with or without locoregional irradiation are made based on stage at presentation, response to systemic therapy, and surgical-pathology findings. Recommendations for adjuvant endocrine therapy are based on hormone receptor status. Studies of these tumors have confirmed that primary response to induction therapy is an excellent surrogate marker of success in eradicating micrometastases, as patients experiencing a complete pathologic response have a statistically significant survival advantage. Ongoing investigations of locally advanced breast cancer include studies of systemic chemotherapy with or without neoadjuvant endocrine regimens that increase the complete pathologic response rate, and correlation with outcome; integration of lymphatic mapping and sentinel lymph node biopsy into clinical trials; and defining the optimal extent of locoregional irradiation in patients who experience a strong response to neoadjuvant treatment.

Breast Neoplasms↗

[Inflammatory response and haematological disorders in cardiac surgery: toward a more physiological cardiopulmonary bypass].

The systemic inflammatory response in cardiac surgery is closely related to the haemostasis disturbances. It is responsible of a significant morbidity and mortality that was previously suspected to be caused by cardiopulmonary bypass alone. However, it is time now to clearly identify the factors that are material-dependent from that material-independent. From this point of view, off-pump surgery allowed for better comprehension of the multiple sources of the inflammatory response. Numerous pathways are activated, involving complement, platelets, neutrophiles and monocytes. The tissue pathway of the coagulation system, through tissue factor, is of major importance and has to be surgically considered in order to reduce the whole body inflammatory response postoperatively. The quality of the extracorporeal perfusion through its consequences on organ perfusion, particularly in the splanchnic area, also participates to this pathophysiological process. Beyond the progress of technology provided by the industry, particularly the minimally extracorporeal circulation derived from off-pump surgery evolution, the surgical approach is of major importance in the control of the systemic inflammatory response and must not be ignored yet.

Anesthetics↗

Nosocomial bacteremia due to Acinetobacter baumannii: epidemiology, clinical features and treatment.

Acinetobacter baumannii is an important cause of nosocomial infections in many hospitals. It is difficult to control and infection caused is difficult to treat due to its high resistance in the environment and its ability to develop resistance to antimicrobials. Bacteremia, followed by respiratory tract and surgical wound infections, is the most significant infection caused by A. baumannii. The known risk factors for A. baumannii bacteremia are invasive procedures and the use of broad-spectrum antimicrobials. Consequently, episodes of bacteremia due to A. baumannii occur most frequently in critically-ill patients admitted to an intensive care unit. The clinical manifestations of bacteremia by A. baumannii are not specific. The most common sources of bacteremia are intravascular catheters and the respiratory tract. A. baumannii bacteremia is associated with a high crude mortality rate, but it is difficult to distinguish morbidity and mortality attributable to A. baumannii from that attributable to the common and severe co-morbidity in these patients. A. baumannii is a bacterium that appears to have a propensity for developing multiple antimicrobial resistance extremely rapidly. These data are disturbing because the therapeutic possibilities decrease while inappropriate antimicrobial treatment contributes to patient mortality. Generally, imipenem is the most active agent against A. baumannii. However, the description of imipenem-resistant A. baumannii strains is becoming increasingly common. The usual treatment for A. baumannii bacteremia is an active beta-lactam alone, preferably one with a limited spectrum. Before beginning treatment of a bacteremia by A. baumannii, it is very important to carry out a clinical evaluation of the patient to eliminate the possibility of a pseudobacteremia, and thereby avoid unnecessary treatment.

Acinetobacter Infections↗

ON THE USE OF TRITIUM-LABELLED ALBUMIN FOR STUDIES OF INTESTINAL ABSORPTION.

Human serum albumin has been successfully labelled with tritium. It is considerably denatured in the process and has a shorter half life when given intravenously than (131)I-labelled albumin. Nevertheless it is satisfactory for absorption studies, although not for turnover observations. These studies on absorption in control subjects and in patients with intestinal malabsorption indicate that the excreted radioactivity may have been derived from endogenous sources rather than from the results of malabsorption alone.

Biomedical Research↗

Osteoclasts in chronic otitis media, cholesteatoma, and otosclerosis.

Bone resorption and remodeling are characteristic of chronic otitis media with and without cholesteatoma and otosclerosis. The consequences of this remodeling process may be hearing loss, repeated infection, vestibular disturbance, or intracranial complications. Evidence of osteoclastic bone resorption was found in surgical specimens of 11 of 24 cases of cholesteatoma, two of three cases of chronic otitis media, and three of ten cases of otosclerotic stapes; all three spongiotic lesions had osteoclasts. With careful serial sectioning these cells are almost always multinucleate and have the typical appearance of osteoclasts with ruffled borders. Some specimens had evidence of bone erosion in the absence of osteoclasts; this finding represents an inactive phase of the remodeling process. Since the osteoclast plays an important role in the resorption and remodeling of bone in these middle ear diseases, the source, physiology, and local control of these cells are of prime importance in investigating the pathophysiology of these diseases. At the present time, the local control of activation and recruitment of osteoclasts, as well as their chemotactic responses, is poorly understood.

Bone Resorption↗

[Acute hemorrhage of the upper digestive tract with special reference to stress ulcer. Prevention and surgical therapy].

For the surgical therapy of an acute stress-ulcer bleeding there are three methods to someones disposal: 1.) the local care of a bleeding source 2.) the partial gastrectomy and 3.) vagotomy with pyloroplasty and local care of a bleeding source and as prophylaxis of an acute stomach bleeding the highly selective vagotomy with or without pyloroplasty. On judging the success of these methods, some has to consider the basal illness with its letality, because it is to differ, wether a patient died postoperative on his basal disease, or on the effect of the operation, or out of deficient control of the situation. Considering such points it comes out clear, that today the vagotomy with a drainage operation is the method of choice, because: 1.) through this intervention patients are tainted less as for instance through a partial gastrectomy, 2.) through a technical faultless done operation, especially through a vagotomy a success concerning a relapse bleeding is guaranteed. Beside that, the highly selective vagotomy without drainage operation presents itself as prophylactic measure, to prevent an acute stomach bleeding in a number of transplanted patients (kidney transplantation). The first experiences with this method show, that a improvement of the results is to be expected.

Acute Disease↗