[Post-menopausal osteoporosis. Epidemiologic aspects]. The purpose of this study is to point out the epidemiological features concerning the frequency and seriousness of post-menopausal osteoporosis, and concerning screening and prevention of osteoporotic fractures. Osteoporosis is a condition very widespread, characterised by fragility fractures. It has been estimated that in France one million of women suffer from vertebral fractures. Osteoporosis can alter the quality of life in various ways. Its cost is high, representing 4 billions francs a year in France only for hip fractures. The only preventive treatment that has been agreed on universally is oestrogen therapy. The fact that this treatment is not systematically recommended does not explain that only 8% among french menopausal women take oestrogen. The factors available at present to identify women at high risk of osteoporotic fractures are risk factors evaluated by clinical history, biological markers of bone formation and measurements of bone mass. None of these risk factors have enough sensibility and specificity to define accurately risks groups. Furthermore it is necessary to specify the effects of treatments associating oestrogens and progestogens prescribed in France, in particular effects on the risks of cardio-vascular diseases and breast cancer.


[Breast cancer associated with pregnancy. Nine case reports. Review of the literature and current update]. The authors report nine personal cases in a review of the literature concerning cancers of the breast associated with pregnancy and lactation (until a year post-partum). The diagnosis of the illness is reported to be difficult in pregnant women and it is necessary to use fully all the diagnostic procedures available and in particular cytology and histology. Surgery is urgent. It is classical practice to carry out a mastectomy with axillary clearance. Nevertheless more conservative treatments are now being suggested. The principal problem of therapy is linked to the effects of adjuvant therapy on the fetus be they radiotherapy or chemotherapy, particularly because it is very important that treatments should be thorough and start early in the pregnancy. The overall prognosis is bad because pregnancy seems above all to aggravate serious forms of the disease.


[An original model of experimental endometriosis in the rabbit]. An attempt to create experimental endometriosis in the rabbit by the usual technique was tried on eight animals. It was disappointing. A new technique which is easier to carry out implanting endometrium was suggested. The results were evaluated in 57 animals. The technique proved to be easier and more reliable. The technique cannot be used unless the animal has been through puberty.


[Prognostic value of preovulatory elevations of plasma progesterone during in vitro fertilization using LHRH agonists in a long protocol]. We retrospectively analyzed the prevalence and prognostic significance of plasma progesterone rises during in vitro fertilization (IVF) protocols including pituitary down-regulation by LHRH agonists in a long protocol and stimulation by hMG (n = 1,116: Group A) or pure FSH (n = 178: Group B). On the day of hCG injection, plasma progesterone level was in the 0.60-0.99 ng/ml range in 7.1% of group A patients and 6.2% of group B patients (NS) and above 1 ng/ml in respectively 4.0% and 3.4% of the cases (NS). On the same day, plasma progesterone was strongly correlated with plasma estradiol (r = 0.26 - p < 0.001 in group A; r = 0.21 - p < 0.01 in group B). However, increased progesterone levels were not associated with changes in plasma LH levels, falls in plasma estradiol levels after hCG injection, or significant modifications in biological and clinical results of IVF. The cause of this pattern of progesterone rise remains to be elucidated.


[Turner's syndrome and pregnancy in donor oocytes and in vitro fertilization. Three case reports]. It is extremely rare for pregnancy to occur spontaneously in a woman with a mosaic or non-mosaic karyotype 45 x 0. (Till now only 13 patients with a homogeneous x 0 karyotype have been reported out of 62 patients who between them have had 138 pregnancies). Furthermore these pregnancies have been plagued by a number of important complications or fetal malformations (21% have had chromosome anomalies). It is therefore clear that in vitro fertilization with donor oocytes is a tempting solution for these women. The authors having three personal cases try and point out the conditions under which this technique can be used. It is important to realise that from the age of 10 or 12 years these patients have to have hormone treatment in order to avoid hypoplasia and hypovascularization of the uterus. Those conditions explain why so many these women had premature labours and also suffer from pre-eclampsia. Caesarean section was often found to be necessary because of feto-pelvic disproportion.


[Intramural pregnancy: a case report].

[Intramural pregnancy: a case report]. Implantation into the muscle wall is one of the rarer forms of ectopic pregnancy. We report an uncomplicated case which was discovered during therapeutic termination of pregnancy at 10 weeks. We point out how valuable the use of ultrasound during the operation is for making the diagnosis when suction does not provide adequate quantities of products.


[Role of vaginal echography in the investigation of menorrhagia and metrorrhagia in the reproductive years]. Eighty non-menopausal patients who had troubles of menorrhagia or metrorrhagia who were neither pregnant nor had cervical pathology, were investigated first by vaginal ultrasound and then by hysteroscopy. In 43 of the cases a hysterosalpingogram had been carried out before hand. All patients had histological examination of tissues. The main pathological ultrasound features were clearly made out. Vaginal ultrasound, and the conditions under which the study was undertaken, gives much more information than hysterosalpingography and will be able in future to a greater extent, to replace conventional radiography. Vaginal ultrasound manages to achieve information about the endometrium and the uterine cavity almost equal to that obtained by hysteroscopy and furthermore it gives more precise information about the state of the myometrium. Vaginal ultrasound therefore seems to be an excellent first stage examination to investigate menstrual disturbances in reproductive life, and so long as it is carried out under good conditions will limit the indications for hysteroscopy and will be able to indicate when it is necessary to carry out simple exploratory hysteroscopy or operative hysteroscopy.


[Technique and preliminary results in second-look laparoscopy in epithelial malignant ovarian tumors]. Second-look laparotomy is the usual mean of intraperitoneal evaluation in patients treated for ovarian carcinoma. We present a preliminary study of 33 second-look. Thirteen of these procedures were performed by laparoscopy. Because of previous surgical history a specific technique is necessary including safety tests, cytologic evaluation after peritoneal washing, and biopsies of any abnormal peritoneal areas, original tumors sites and normal appearing peritoneum. In order to achieve the evaluation of the entire peritoneal cavity a complete bowel adhesiolysis is required. For trained laparoscopists the surgical complication rate is low. In this preliminary study we found that prognosis following negative second-look laparoscopy and second-look laparotomy are similar, suggesting that laparoscopy is a valuable alternative to laparotomy for second-look evaluation in ovarian cancer.


[Prenatal screening for cysts of choroid plexus. Evolution and interpretation of 30 cases]. The authors report thirty cases in which they diagnosed a cyst of the choroid plexus antenatally between the 18th and the 36th week of amenorrhoea (mean 21 weeks). Choroid plexus cysts show up in some pictures as round or oval cysts clearly visible in the region of the choroid plexus. They appear in the lateral cerebral ventricles. They frequently occur between the 15th and 25th week of amenorrhoea (0.6 to 2.5% of pregnancies), unilaterally or bilaterally (46%) either on the right of left side and varying in size (3 to 20 mm). These characteristics do not influence the way they evolve. If a single choroid plexus cyst is found a control ultrasound should be carried out four weeks later. 96% of them have disappeared by the end of the second trimester; but if they do persist in the third trimester (4%) they are not necessarily pathological. On the other hand if a choroid plexus cyst is associated with some other morphological biometric abnormality antenatal chromosome testing should be carried out because trisomy 18 is more common in this situation (4.8%) than in the general population.


[Cerebral hemorrhage in utero. Diagnosis and management. A case report]. The authors report a case of massive intracerebral haemorrhage which was diagnosed in utero by ultrasound. The ultrasound of the brain showed a total disorganisation of all known structures with the appearance of unhomogeneous zones spread across both hemispheres and including a large dilatation of the ventricles. Transcervical puncture of the fontanelle allowed the delivery of a stillborn child without other congenital abnormalities. CMV infection was thought to be the cause. A review of the literature shows that there are different ways of treating this conditions depending on the ultrasound appearances. The prognosis must be very guarded and depends on the aetiology.


[Preliminary study on the variability of the fetal cerebral velocimetry in various vessels of the Circle of Willis]. The authors have tried to analyse in a small series, the possibility as well as the variability of blood flow velocity waveforms in the different vessels of the circle of willis using colour Doppler. Fourteen patients were assessed. The 14 fetuses were of normal growth and/or had normal umbilical arterial blood flow velocity waveforms as well as normal uterine blood flow. The mean term at the time of examination was 23.8 +/- 2.9 standard deviation with the extremes going from 28.5 standard deviation to 40.5. The examinations were carried out using colour Doppler (Acuson) machine by the abdominal route with a 3.5-5 MHz bi-frequency sound. The vessels that were explored were the middle cerebral artery (CM), posterior cerebral artery (CP), the internal carotid artery (CI), the anterior cerebral artery (CA) in the region of the circle of Willis. CM and CA were able to be recorded in 100% of the cases, CP and CI in 93% of cases (13 out of 14 cases). The difference between he mean index (D/S, D = residual velocity in the diastole, S = maximum velocity in the systole) in each of these vessels was not statistically significant. In 3 out of 16 measurements (19%) the CP index was considered to be pathological while the index in the other vessels was normal, or when a different form of measurement was carried out in the region of CP, it was normal. This was also the case once for CA, but never for CM or CI.(ABSTRACT TRUNCATED AT 250 WORDS)


[Pregnancy after renal transplantation. 27 patients and review of the literature]. We report the course and outcome of 30 pregnancies in 27 renal transplant patients between 1970 and 1988. Delay between transplantation and pregnancy was 7.3 +/- 4.8 years. There were 1 twin pregnancy and 3 successive pregnancies. Immunosuppressive regime was prednisone and azathioprine in 28 cases and cyclosporine in 2. Hypertension (33%), preterm delivery (74%) and premature rupture of the membranes (33%) were the main complication encountered. The cesarean section rate was 73%, mainly because of these complications. Twenty-seven patients delivered of 31 healthy children. There was no congenital anomaly. Mean birth weight was 2.640 +/- 645 g. In utero growth retardation occurred in 7 cases (23%). Pregnancy after renal transplantation is of good prognosis for both the mother and child but the course of pregnancy can be complicated by hypertension, preterm birth and growth retardation.


[Pregnancy after hepatic transplantation. 17 pregnancies]. The number of orthotopic liver transplantations (OLT) is increasing and longterm survival is improving. More women recipients may choose to become pregnant. We report a one-center experience with the course and outcome of 17 pregnancies in 17 liver transplant out of 675 OLT since 1985. 10 women delivered of 10 healthy infants at 38 +/- 1.5 week's gestation. There was no preterm delivery and the mean birth weight was 2.990 +/- 370 g, birth weight was adequate for gestational age in any case. Four cesarean sections were performed for obstetrical indications. No congenital anomalies occurred in the children. Hypertension occurred in 2 out of twelve patients and appeared as the main complication to deal with. There was one case with graft function impairment at 37 weeks' gestation. One uncomplicated pregnancy is ongoing at 29 weeks' gestation. There were 4 spontaneous and 2 therapeutic abortions for impaired liver function. Pregnancy is successful in a large proportion of these patients but must be planned and managed as high-risk situations by an obstetrician and a specialist of the liver transplant. Pregnancy should be advised against in patients with poor liver function or active viral infection; a 12 months interval from OLT to pregnancy is since to be the minimal requirement. Post-transplant immunosuppressive therapy consisted of azathioprine, corticosteroids and ciclosporin A, and was maintained throughout pregnancy. Genetic counselling should be provided when the primary liver disease is inherited. This being said, as shown by the results of our study and those reported in the literature, pregnancy is not only feasible but also successful in a large proportion of OLT recipients.


[Pregnancy in the diabetic woman. Incidence of malformations, of macrosomia, update on obstetrical management]. Perinatal mortality for infants born to diabetic mothers has dropped in the years from the 1950's when it was 20% to less than 3% by the end of the 1980's. In spite of this considerable reduction which is due to careful observation and multidisciplinary management in this type of pregnancy, the congenital malformation rate is 4 times greater than with the general population (3%) and the rate of spontaneous abortions is double (13%). The caesarean section rate is 5 times higher (18%). In bringing out a retrospective study we have attempted to analyse the endocrinological and obstetrical features of the cases.


[Major sickle cell anemia and pregnancy. Systematic prophylactic transfusions. 13 case reports]. The seriousness of sickle cell disease together with pregnancy has led doctors to look for therapies which have yet scarcely shown their worth. Systematic blood transfusions in pregnancy did seem to improve the prognosis for both mother and fetus. Prophylactic transfusion has made it possible for us to carry thirteen pregnancies to term. There was no mortality either of fetus or mother while the morbidity either of fetus or mother while the morbidity was significantly cut down to new pathologies which were easily treated. The absence of any side effects from the transfusions encourages us to contribute this treatment working together with a highly competent blood transfusion bank.


[Breech extraction of the second twin with or without version by internal maneuvers]. A retrospective study was done to appraise the recent practice of breech extraction of the second twin (with or without internal version) in our unity. From January 1st, 1988 to April 30, 1991 23 patients with a twin gestation were delivered in our unity (0.5% of all deliveries). Nineteen patients (83%) were delivered vaginally. Each procedure was done by a resident under control of a senior obstetrician and in the presence of two midwives, a pediatrician, and an anesthesiologist. Ten patients having had a breech extraction (GE group) were studied, 13 patients were excluded for not having had a breech extraction. In the GE group the presentations were: 7 vertex/breech and 3 breech/breech. Mean Apgar scores of the second twin at 3 minutes were 8 in the GE group. These results suggest that breech extraction of the second twin is not a pernicious technique if done by trained operators with precise limits. These results need to be confirmed through a prospective randomized and comparative study.


Endoscopic carpal tunnel release: a cadaveric study. Five surgeons performed endoscopic (Dyonics) carpal tunnel releases on 24 fresh cadaver wrists. In 50% of the specimens, transection of the transverse carpal ligament was incomplete. The average amount of incomplete release was 31% (range, 0% to 53%). Three types of incomplete release were noted: (1) release of Guyon's canal release--one, (2) incomplete distal ligament release--five, and (3) incomplete central or superficial release--six. Other technical errors were noted in nine of 24 specimens. There were no nerve lacerations. Endoscopic carpal tunnel release is either a technically demanding procedure, commonly results in incompletely released ligaments, or both. Proper training, followed by practice on several cadaver specimens before its clinical use, is recommended.


Endoscopic carpal tunnel release.

Endoscopic carpal tunnel release. We have performed 149 consecutive one-portal and 152 consecutive two-portal endoscopic carpal tunnel release operations. Average time to cessation of preoperative symptoms was 15 days in both the one-portal and two-portal groups. The average time of return to work was 16 days in the one-portal group and 17 days in the two-portal group. The complication rate in the one-portal group was 6%, and in the two-portal group it was 5%. In our opinion, the one-portal release technique is much more difficult and inherently more dangerous than the two-portal technique, and we recommend the latter for endoscopic carpal tunnel release.


Carpal arch alteration and related clinical status after endoscopic carpal tunnel release. One hundred eight endoscopic carpal tunnel releases were performed by a modification of the technique described by Chow. Eighty-seven of the 108 cases were evaluated for quantitative postoperative widening of the transverse carpal arch. The average postoperative widening of the transverse carpal arch was 0.17 cm (7%), with a range of 0 to 0.5 cm. Seventy percent of the patients showed 0% to 10% widening, 26% showed 10% to 20% widening, and 4% showed more than 20% widening of the transverse carpal arch. Preliminary findings show that 3 weeks after endoscopic carpal tunnel release, pinch strength was at 102% and grip strength at 86% of preoperative values. Six weeks after surgery, pinch strength was 106% and grip strength was 121% of preoperative values. The complication rate in this series was 3%. The transverse dimension of the carpal arch generally widens after endoscopic carpal tunnel release but to a lesser degree than has been reported for open carpal tunnel release. The rate of improvement of pinch and grip strength after endoscopic release is faster than that reported in the literature after open release.


Dynamic changes of the transverse carpal arch during flexion-extension of the wrist: effects of sectioning the transverse carpal ligament. The width of the carpal arch, represented in this study by the distance between the tips of two Kirschner wires--one inserted into the trapezium and another into the hook of the hamate--was measured with precision calipers in 21 patients with carpal tunnel syndrome, both before and after sectioning of the transverse carpal ligament and in different wrist positions. With the ligament intact, most of the wrists showed a decrease in the distance in both flexion and extension. The distance increased an average of 11% after sectioning of the transverse carpal ligament. The dynamic behavior of the carpal arch, however, was not substantially modified by this procedure.


Results of treatment of severe carpal tunnel syndrome. A retrospective study was undertaken to determine the efficacy of carpal tunnel decompression in patients with advanced carpal tunnel syndrome. The criteria for inclusion in this study were unobtainable median sensory-evoked response and absent or prolonged median motor distal latency. Fifteen hands in 13 patients met these criteria. All patients had symptoms, including pain, weakness, or decreased sensation. Postoperative follow-up averaged 27 months. Symptomatic improvement was obtained in 14 of the 15 hands, and sensory-evoked response improved in 13 hands. Preoperative thenar atrophy was present in 10 of the 15 hands and was completely resolved in 2 of the 10 patients. These results indicate that carpal tunnel decompression is of benefit to patients with severe carpal tunnel syndrome. Long-standing symptoms, thenar atrophy, virtual anesthesia, and the absence of demonstrable sensory and motor-evoked responses are not contraindications to surgery.


An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: report of 625 cases. This study was undertaken to determine the presence or absence of tenosynovitis in persons with idiopathic carpal tunnel syndrome. Eight hundred thirty-five consecutive operations for carpal tunnel syndrome were retrospectively reviewed, and 625 cases of idiopathic carpal tunnel syndrome were identified. Of these 96% (601) had a synovial tissue histologic diagnosis of benign fibrous tissue without inflammation, 4% (23) showed chronic inflammation, and 0.2% (1) revealed evidence of acute inflammation. We believe that tenosynovitis is not a part of the pathophysiologic process in chronic idiopathic carpal tunnel syndrome. Further histologic analysis of the flexor synovium for pathologic changes other than inflammation is needed.


Acute gout after carpal tunnel release.

Acute gout after carpal tunnel release. A carpal tunnel release was performed on three patients with known gout of the lower extremity but not of the upper extremity. Each patient had a postoperative inflammatory reaction in a treated hand, and there was some suspicion of an infection in two patients. However, the inflammatory reaction resolved only when treated with a combination of anti-inflammatory and anti-gout medication.


Variations in digital nerve anatomy.

Variations in digital nerve anatomy. One hundred digital nerves from 10 cadaver hands were dissected, and branching patterns were analyzed. Contrary to the traditional belief that the digital nerve predictably trifurcates at the distal interphalangeal crease, much variation exists. Terminal branching occurred distal to the crease in 60% of the thumb digital nerves and in 78% of the digital nerves supplying the other four digits. The number of terminal branches also varied from two to seven in the thumb and from two to five in the other four digits. No significant differences were seen in branching patterns between digits or between radial and ulnar sides. These findings are clinically relevant to the surgeon who is contemplating digital nerve repair.


The superficial branch of the radial nerve: an anatomic study with surgical implications. Twenty fresh cadaver extremities were dissected to delineate and quantify the course of the superficial branch of the radial nerve. This branch bifurcated from the radial nerve at the level of the lateral humeral epicondyle in eight specimens, and in all specimens the bifurcation was no more than 2.1 cm from the lateral epicondyle. It continued distally, deep to the brachioradialis and became subcutaneous a mean of 9.0 cm proximal to the radial styloid, traversing between the tendons of the brachioradialis and extensor carpi radialis longus. The superficial branch of the radial nerve branched a mean of 5.1 cm proximal to the radial styloid. Distally, at the level of the extensor retinaculum, the closest branches to the center of the first dorsal compartment and to Lister's tubercle were mean distances of 0.4 and 1.6 cm, respectively. In the hand, the superficial branch of the radial nerve most commonly supplied branches to the thumb, the index finger, and the dorsoradial aspect of the long finger. Knowledge of the course of the superficial branch of the radial nerve will help prevent injury during operative procedures on the radial side of the hand, wrist, and forearm and will aid in its localization in treatment of traumatic injuries or performance of nerve blocks in its distribution.


A socioeconomic analysis of digital replantations resulting from home use of power tools. Forty-seven digits in 21 patients who sustained partial or complete amputations from the home use of power tools were replanted or revascularized during a 1-year period. This represented 69% of the microvascular surgery performed for hand injuries during that year. The cost of repairing an average of 2.4 digits was $7000 (surgeon's fee) plus $697 per hour (operating room fee), as per fiscal year 1987. Postoperative hospitalization averaged 15 days at a cost of $15,679. Hand rehabilitation averaged 8 months at a cost of $3348. Fifty-four percent of the patients had no insurance. Fourteen of 21 patients (67%) required at least one additional procedure. Two patients had to make a career change after the injury. The majority of patients with digital replantations were dissatisfied with the emotional costs and the number of subsequent operations. Lack of patient and family awareness of the length of the rehabilitative period was particularly evident.


Maintenance of patency after vascular trauma by topical irrigation with a peptide homologous to the carboxy-terminus of the fibrinogen gamma chain. Synthetic peptides with amino acid sequences homologous to the carboxy-terminal sequence of the gamma chain of human fibrinogen were evaluated for their capacity to inhibit thrombus development. A 21-residue peptide effectively inhibited surface-mediated fibrin clot propagation in vitro. Since this effect was localized to the surface, we proceeded with in vivo evaluation, using site-specific topical application only. In a rat model of arterial trauma and microvascular repair, topical application of the 21-residue peptide significantly reduced the rate of thrombosis to 17%, as compared with a control rate of 83%; in comparison, a 12-residue homologue reduced the thrombosis rate only modestly to 61%, which was not significant compared with the control rate. These results indicate the feasibility of antithrombotic therapy with topically applied agents, an approach that may obviate the use of systemic anticoagulation in extremity-replantation surgery.


Hemangiopericytoma of the hand: a literature review and case study. We present a case of hemangiopericytoma of the hand. We also attempt to differentiate hemangiopericytoma from glomus tumor with a summary of the history and a comprehensive review of the literature demonstrating the malignant character of the neoplasm, and we offer some guidelines for treatment.


Long-term functional results after pollicization for the congenitally deficient thumb. This study objectively investigated the functional results of 28 index finger pollicizations for correction of congenital deficiency of the thumb. The results indicate that the average total active range of motion at the pollicized digit was 98 degrees, or approximately 50% that of a normal thumb. The average grip strength was 21% of standard values; lateral, tripod, and tip pinch strength values ranged from 22% to 26% of standard values. The pollicized digit was used in the manner of a normal thumb or in modified fashion in 84% of 14 defined activities, with increased use for handling large objects (92%) and less use for small objects (77%). The time required to perform activities averaged 22% longer than the standard for a normal hand. Patients with a radial club hand, a five-finger hand, or a mirror hand on the affected extremity had significantly poorer results; however, patients without one of these associated conditions had near normal use of the pollicized digit, except for reduced strength. These results were not influenced by the age of the patient at the time of operation. This information should be helpful in counseling parents with children who are candidates for pollicization as to what functional results they might anticipate.


Melorheostosis of the hand: a report of two cases. Two cases of melorheostosis of the hand are reported. Histopathologic examination confirmed the characteristic x-ray findings and excluded other skeletal dysplasias, such as osteopoikilosis and osteopathia striata.


Bilateral intraosseous ganglia of the lunate: a case report. A rare case of bilateral intraosseous ganglia of the lunate is reported. The patient had had 7 months of pain in both wrists and a cystic lesion in both lunates. Curettage and bone grafting resulted in complete relief of pain.


Avascular necrosis of the hamate: a case report with reference to the hamate blood supply. Avascular necrosis of the hamate bone has not previously been reported. In this case the proximal fragment of the fractured hamate underwent avascular necrosis and prolonged healing. In an attempt to explain this sequela, angiography of the cadaver carpus followed by dissection of intact wrists and a study of enzyme-cleaned hamates showed that their wedge-shaped proximal segments were mostly enveloped by a distal extension of the midcarpal joint cavity and thus totally dependent on intraosseous nutrition. Consequently, the segment is at risk when a fracture line transects the body proximal to the base of the wedge. Clinically, this condition resulted in persistent discomfort and limitations of motion. A postinjury bone scan of the wrist indicated avascular changes in the proximal third of the hamate, and a delayed union was followed by later revascularization and a more normal scan image.


Parosteal lipoma of the proximal radius: a report of five cases. Parosteal lipoma of the proximal radius is a benign, slow-growing tumor. It may cause compression of either the posterior interosseous or the superficial branch of the radial nerve. Surgical excision usually leads to complete recovery. Five cases of parosteal lipoma of the proximal radius are presented. X-ray films demonstrated a radiolucent mass in contact with the radius. Two patients had signs of posterior interosseous nerve compression, and two showed signs of superficial radial nerve compression. In one case the lipoma surrounded an exostosis arising from the proximal radius. The tumors were excised in four patients. The three patients with neurologic involvement recovered fully. One patient refused surgery, and posterior interosseous nerve paralysis developed.


Efficacy of immobilization following aspiration of carpal and digital ganglions. In a prospective study 69 carpal and digital ganglions were aspirated, multiply punctured, and digitally ruptured. Fifty percent of the wrists and digits were immobilized for 3 weeks and 50% were mobilized early. Follow-up was 1 year. Immobilization in our study did not significantly improve the results of treatment. During the course of the study, 51% of all ganglions did not recur. The outcome was successful in 52% of the wrists and digits that were immobilized and in 50% of those that were not. Forty-six percent of the dorsal carpal ganglions did not recur. Treatment was successful in 48% of dorsal carpal ganglions in which the wrists were immobilized and in 45% of those that were not. Similar percentages were found for palmar and digital ganglions. From our results, we conclude that immobilization does not significantly improve the successful treatment of ganglions over perforation and aspiration alone.


The effect of elbow flexion and time of assessment on the measurement of grip strength in rheumatoid arthritis. Grip strength is one of the traditional outcome measures commonly used in rheumatoid arthritis trials. This study evaluated the degree of morning variation and the effect of elbow flexion in the assessment of grip strength in patients with rheumatoid arthritis. Grip strength was measured in 37 patients (1987 American Rheumatism Association criteria) at 8, 10, and 12 AM with a sphygmomanometer cuff folded on itself, taped permanently, and inflated to 20 mm Hg, with the elbow flexed at 90 degrees. At 10 AM grip strength was also measured with the elbow flexed at 30 and 130 degrees. Mean values for grip strength at 8, 10, and 12 AM were, respectively, 69, 79, and 83 mm Hg. Mean grip strength values with the elbow flexed at 30, 90, and 130 degrees were, respectively, 78, 79, and 75 mm Hg. There was a statistically significant correlation between grip strength and morning stiffness, grip strength and hand function, and grip strength and number of active joints. In rheumatoid arthritis trials, grip strength should be assessed at the same time of the day. Elbow flexion does not play a role in grip strength measurement.


Limited arthrodesis for the rheumatoid wrist. Limited arthrodesis of the proximal carpal row to the radius, synovectomy of the extensor tendons and the wrist joint, and a Darrach procedure were carried out in 25 unstable painful rheumatoid wrists that had ulnar shift and/or palmar subluxation of the carpus. The average follow-up period after the operation was 3 years. Satisfactory results were obtained with relief of pain, improved forearm rotation, and increased grip strength. The average degree of extension and flexion was reduced, respectively, 70% and 54% at follow-up compared with the preoperative range. Postoperative x-ray films showed deterioration in the lunocapitate joint in 12 wrists; however, the wrists remained stable and painless.


Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. Forty-three rheumatoid wrists in 43 patients with bilateral wrist involvement were treated with synovectomy of the extensor tendons and wrist joint combined with a Darrach procedure in the period from 1966 to 1986. Clinical and radiologic assessment of the wrists was carried out after an average follow-up period of 11 years, with comparison of the treated and the opposite untreated wrists. The authors confirmed what others have concluded regarding the operation: pain was generally decreased, forearm rotation increased, and wrist extension and palmar flexion changed little. Radiologically, carpal collapse and palmar carpal subluxation progressed nearly parallel to the opposite wrists, but ulnar carpal shift was much greater in the surgically treated wrists. Therefore it is suggested that some measure to prevent ulnar carpal shift, such as Clayton's tendon transfer or radiolunate arthrodesis, should be included in this operation.


Biomechanical characteristics of extensor tendon suture techniques. Despite their ease of exposure, extensor tendons can be difficult to handle and suture well. Compared with flexor repair, little is known about the various factors that affect the suturing of extensor tendons. The present study was designed to investigate several biomechanical parameters involved in extensor repair. All techniques studied shortened the tendon considerably and produced significant losses of flexion at the metacarpophalangeal and proximal interphalangeal joints. In addition, repairs achieved with all suture techniques were considerably weaker than those achieved when comparable techniques were used on flexor tendons. However, the Kleinert modification of the Bunnell technique provided the strongest sutures in extensor tendons, produced no gapping, caused the least worrisome loss of metacarpophalangeal and proximal interphalangeal flexion, and best approximated the results found in an idealized tendon-shortening model.


Tendon graft donor sites.

Tendon graft donor sites. Each of 480 extremities from 120 cadavers was dissected. Particular attention was given to potential donors for tendon grafts. Both the palmaris longus and the extensor digiti minimi had an average length of 16 cm and an average width of 3 mm. The extensor indicis tendon averaged 13 cm in length and 3 mm in width. The plantaris and second toe extensors averaged 35 cm in length and 2 to 2.5 mm in width. None of these measurements correlated well with age, sex, or hand or foot size. There was, however, a high correlation between right- and left-side measurements in each specimen, in spite of some degree of anatomic variation for all the tendons studied. The palmaris longus was missing in 25% of the upper extremities, and the plantaris in 19% of the lower extremities dissected.


The correlation between controlled range of motion with dynamic traction and results after flexor tendon repair in zone II. This prospective study investigated the extent to which the range of interphalangeal joint motion during early mobilization with dynamic traction influences the results after flexor tendon repair in zone II. The controlled interphalangeal joint range of motion within the splint was measured 3 weeks postoperatively in 51 digits (48 patients). The active range of motion was measured 4 weeks, 6 weeks, and 1 year postoperatively. Linear regression analysis showed that controlled interphalangeal range of motion had a significant effect on both early and late results. The results provide, for the first time, firm clinical evidence to support the rationale for early mobilization programs designed to maximize controlled interphalangeal joint range of motion.


Distal interphalangeal joint arthrodesis: an analysis of complications. One hundred thirty-nine patients underwent 181 arthrodeses of finger distal interphalangeal joints (144) and/or thumb interphalangeal joints (37). Techniques included (1) crossed Kirschner pins (111 joints), (2) interfragmentary wire and longitudinal Kirschner pin (43 joints), and (3) Herbert screw (27 joints). Each technique had a similar nonunion rate. There were 21 nonunions: 13 were pain free, 6 were successfully fused on the second attempt, 1 was painful (but the patient refused further surgery), and 1 was amputated. Inadequate bone stock, inadequate bone resection, premature pin removal, and infection appear to complicate the attainment of bony union. Twenty percent of the fusions had major complications (nonunion, malunion, deep infection, and osteomyelitis). Minor complications (dorsal skin necrosis, cold intolerance, proximal interphalangeal joint stiffness, paresthesias, superficial wound infection, and prominent hardware) occurred in 16% of the joints fused.


Intra-articular corticosteroid reduces joint stiffness after an experimental periarticular fracture. Early care after surgery or trauma to the extremities often includes a period of immobilization. The resultant joint stiffness may require extensive rehabilitation and may permanently limit function of the limb. Posttraumatic joint stiffness is particularly vexing in the small joints. In an experimental model, we tested the effects of intra-articular corticosteroid injections on stiffness in a joint at risk of posttraumatic joint stiffness. Triamcinolone was injected into ankle joints of rabbits after distal tibial fractures. Three weeks after injury, joint stiffness increased 34% in ankles injected with the steroid. Stiffness in ankles injected with saline solution and in ankles treated with no injection increased 133% and 224%, respectively. Limb swelling and tibial torsional strength to failure were not significantly affected by either of the treatments.


Severe contractures of the proximal interphalangeal joint in Dupuytren's disease: results of a prospective trial of operative correction and dynamic extension splinting. In a prospective study, 23 proximal interphalangeal joints that were severely contracted (> or = 45 degrees) as a result of Dupuytren's disease underwent operative correction and 6 months of dynamic extension splinting. Proximal interphalangeal joint extension was measured preoperatively and postoperatively at 3-month intervals for 1 year and at 6-month intervals thereafter. Mean follow-up was 2 years (minimum, 1 year). Overall, at 2 years, 44% improvement in proximal interphalangeal joint extension was noted. Mean improvement of 59% in proximal interphalangeal joint extension was noted in patients who complied with the postoperative dynamic extension splinting program. Patients who were noncomplaint demonstrated a 25% improvement in proximal interphalangeal joint extension. The difference in values between patients who were compliant and those who were not was statistically significant. Other factors--severity of contracture, digit involved, and the necessity for capsular release--were not significantly related to outcome. This study suggests that soft tissue responds to continuous dynamic extension stresses and can be remodeled over time.


A safe, reliable method of carpal tunnel injection. The injection of steroid preparations into the carpal canal is a recognized practice in the management of carpal tunnel syndrome. This procedure is associated with a risk of temporary or permanent damage to the median nerve. We present a new method of carpal tunnel injection based on anatomic dissections. We have used this technique successfully for more than 10 years, and there have been no cases of median nerve injury.


Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. A 10-center randomized prospective multicenter study of endoscopic release of the carpal tunnel was carried out. Surgery was performed with a new device for transecting the transverse carpal ligament while control hands were treated with conventional open surgery. There were 122 patients in the study; 25 had carpal tunnel surgery on both hands and 97 had surgery on one hand. Of the surgical procedures, 65 were in the control group and 82 were in the device group. The endoscopic device was coupled to a fiberoptic light and a video camera. A trigger-activated blade was used to incise the transverse carpal ligament. After surgery, the best predictors of return to work and to activities of daily living were strength and tenderness variables. For patients in the device group with one affected hand, the median time for return to work was 21 1/2 days less than that for the control group. Two patients treated with the endoscopic device required reoperation by open surgical decompression; only one of these had incomplete release with the device. Two patients in the device group experienced transient ulnar neurapraxia.


Endoscopic carpal tunnel release: an anatomic study of the two-incision method in human cadavers. To determine the relationship of neurovascular structures to the sites of portal placement and transverse carpal ligament division during two-portal endoscopic carpal tunnel release, a study of 20 fresh cadaver specimens was carried out. Open dissection of the carpal tunnel after endoscopic surgery showed complete ligamentous release in 18 hands (90%). In 10 specimens, the procedure was performed as described by Chow. There was one partial transection of the superficial palmar arch (5%), and five specimens (50%) had complete divisions of the superficial palmar fascia with considerable pressure placed on the ulnar nerve at the wrist. A modified technique was used in 10 specimens in which the proximal incision was made in a more distal location and a distally based ligamentous flap was created. The superficial palmar arch and the distal edge of the transverse carpal ligament were visualized directly before passage of the trocar. No complications were noted with this method.


Perfusion studies in cholera: methods and procedures. This paper reviews the characteristics of perfusion techniques in the study of intestinal functions by specifically examining the methods and procedures of perfusion in patients with diarrhoea due to infection with V. cholerae 01. Because of abundant jejunal secretion of water and electrolytes in cholera, perfusion studies require special approaches with regard to patient preparation, use of tubing material, selection of markers, and rate of perfusion. A discussion on specific problems involved in marker perfusion techniques in cholera and on the interpretation of the results is followed by practical recommendations.


Regulation of the SLT-1A toxin operon by a ferric uptake regulatory protein in toxinogenic strains of Shigella dysenteriae type 1. The regulation of Shiga toxin expression in a clinical isolate of S. dysenteriae 1 by the Fe-Fur (Iron-ferric uptake regulatory protein) repressor complex was investigated. The presence of an endogenous Fur repressor protein capable of binding to either a Fur binding consensus sequence or the regulatory region of SLT-1A was determined in toxinogenic strains of S. dysenteriae. Plasmid constructs bearing Fur binding sites fused to readily assayable reporter genes were used. Plasmid pSC27.1 contains a 21 bp synthetic oligonucleotide Fur protein binding consensus sequence located upstream to the gene for beta-galactosidase. Plasmid pSC105 contains the regulatory sequences of Shiga-like toxin-1A located upstream to the gene for alkaline phosphatase. In an analogous fashion to Shiga toxin regulation in S. dysenteriae 1, transformants bearing either pSC27.1 or pSC105 plasmid DNA were repressed in gene product expression when grown in minimal medium supplemented with iron. Conversely, transformants were de-repressed when grown under iron limiting conditions. These data suggest the presence of Fe-Fur mediated regulation of toxinogenesis in clinical isolates of S. dysenteriae.


Efficacy of norfloxacin for shigellosis: a double-blind randomised clinical trial. In a double-blind, randomised, clinical trial on 122 adults with acute Shigella dysentery, 60 patients were treated with norfloxacin and 62 with nalidixic acid. Of these, 32 patients in the norfloxacin group and 28 patients in the nalidixic acid group had Shigella in their stool. Patients of the two treatment groups were clinically comparable on admission. No significant differences in clinical responses were observed in the two groups among the Shigella-positive cases, Shigella-negative cases and among the total cases. All isolates of Shigella were susceptible to norfloxacin, whereas 13.8% of the strains were resistant to nalidixic acid.


Detection of specific anti-Giardia antibodies in the serodiagnosis of symptomatic giardiasis. The roles of circulating anti-Giardia IgM and IgG antibodies were assayed by the Enzyme linked immunosorbent assay (ELISA) using axenic Giardia lamblia whole trophozoites as antigen for routine serodiagnosis of Giardia infection. Detection of anti-Giardia IgM antibody was found to be useful in the early detection of symptomatic giardiasis, whereas IgG detection was not, since the latter could not discriminate between present infection and previous exposure. A mean optical density (OD) +/- 2 standard deviation (SD) value of 0.088 at 1:100 serum dilution was found optimal for the detection of anti-Giardia IgM antibodies as it completely separated out the acute Giardia cases from the Giardia-free controls. The same sera did not reveal any marked differences when tested for anti-Giardia IgG antibodies. Detection of IgM antibodies correlated with high sensitivity and specificity (96%) in an evaluation of a large number of sera collected from Giardia cases and controls.


Antimicrobial susceptibility of Clostridium difficile strains isolated from hospitalised patients with acute diarrhoea. The susceptibility of 43 Clostridium difficile strains to twelve antimicrobials was tested in vitro by agar dilution. All of the 43 strains were inhibited by low concentrations of metronidazole, penicillin G, tetracycline and ampicillin. The strains were highly resistant to gentamycin, trimethoprim, sulphamethoxazole, nalidixic acid, cycloserine, cefotaxime and uniformly sensitive to metronidazole and penicillin G whereas the activity of other antimicrobials are variable.


Failure to isolate Yersinia enterocolitica from patients with diarrhoea in Singapore. To determine the presence of Yersinia enterocolitica in Singapore, an attempt was made to isolate this organism from the stool samples of 6,619 patients with diarrhoea. No Y. enterocolitica was detected. The results suggest that Y. enterocolitica is not an important bacterial pathogen causing diarrhoeal disease in this region.


Acute secretory travellers' diarrhoea caused by Vibrio cholerae non-01 which does not produce cholera-like or heat-stable enterotoxins. An Australian tourist suffering from severe acute watery diarrhoea and dehydration due to Vibrio cholerae non-01 was studied. The V. cholerae strain isolated from the patient belonged to serovar 05. The organism did not produce any of the conventional enterotoxins including cholera-toxin (CT) or heat-stable toxins (NAG-ST) that are known to be associated with intestinal secretion. This report suggests that toxin(s) other than CT-like or NAG-ST may be involved in the pathogenesis of diarrhoea by some V. cholerae non-01 strains.


Respiratory rates in pediatric emergency patients. Respiratory rates are routinely measured in pediatric emergency patients. The normal range has not been established, and commonly reported ranges seem lower than those encountered in clinical practice. This prospective study selected subjects from pediatric patients presenting for care to a suburban emergency department. All respiratory rates were measured for one full minute. Patients with complaints related to the cardiopulmonary system or with an elevated temperature were excluded. A total of 434 patients were entered into the study over a 3-month period of time. Ages ranged from 2 weeks to 18 years. Respiratory rates ranged from a high of 65 breaths/min in a 4-month-old to a low of 12 breaths/min in a 14-year-old. Respiratory rate was inversely related to age, and there was a broad range in every age group. Our study shows that a normal respiratory rate is inversely related to age and is higher than noted in previously published studies. The wide range of "normal" pediatric respiratory rates makes identification of "abnormal" more difficult.


Peer review organization payment denials: comparative analysis of emergency department and non-emergency-department admissions. The Health Care Financing Administration has contracted with regional peer review organizations to review Medicare admissions and to deny payment for hospital admissions that fail to meet peer review organization criteria. The purpose of this study was to compare emergency department admissions with non-emergency-department admissions with respect to rates of peer review organization denial and the reasons for those denials. All hospital Medicare admissions between January 1984 and April 1987 were retrospectively reviewed. Patients were excluded if they received peer review organization pre-authorization prior to admission. The rest were classified by 1) source of admission (emergency department or non-emergency department), 2) peer review organization decision, 3) reason for peer review organization denial, 4) whether the denial was appealed, 5) the results of appeal. Chi-square or Fisher's Exact Test analysis was performed, and P less than 0.05 was considered to be significant. During the 40-month study period, there were 19,847 emergency department Medicare admissions and 19,752 non-emergency-department Medicare admissions. Of the non-emergency-department admissions, 7887 received pre-authorization. None of the emergency department admissions received pre-authorization. Of the 19,847 emergency department admissions, 433 (2.23%) were denied. Of these denials, 269 (60.7%) were appealed by the hospital; 136 (50.5%) successfully. Of the 11,865 non-emergency department, non-pre-authorized admissions, 333 (2.81%) were denied. Of these denials, 174 (52.2%) were appealed, 76 (43.6%) successfully. Overall, emergency department admissions were significantly less likely to receive peer review organization denial than non-emergency-department, non-pre-authorized admissions (P less than 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)


Pain comparison of unbuffered versus buffered lidocaine in local wound infiltration. The purpose of this study was to compare the pain of infiltration between unbuffered lidocaine and buffered lidocaine in a traumatic laceration. Solutions of unbuffered 1% lidocaine and buffered 1% lidocaine were randomly assigned to Site I or Site II of a single laceration for each subject, with the patient serving as self-control. Pain scores were recorded for each site, and an anesthetic preference was determined for each patient. It was found that buffered lidocaine had a preference ratio of 3.0 over unbuffered lidocaine (95% confidence interval, 1.86 to 4.84; P less than 0.0001). It was also found that Site I was preferred more often than Site II regardless of which medication was used. The conclusion is that buffered lidocaine is preferred over unbuffered lidocaine and that the order of injection is an important factor in trials that involve multiple sequential injections in the same patient.


Insertion forces and risk of complications during cricothyroid cannulation. Our purpose was to determine the forces required to insert several different styles of cricothyroid cannulas and to relate the magnitude of these forces and cannula design features to the incidence of complications during insertion. Tests were done on unembalmed cadavers and anesthetized dogs. Samples of 4 different commercial cricothyroid cannulas were tested. Each cannula type was tested in 5 different cadavers and 10 different dogs. A lubricant was applied to the cannulas in half of the dogs tested. Major findings are 1) there is a linear correlation between insertion force and device diameter, 2) higher puncture force is associated with a greater incidence of complications, 3) posterior wall penetration occurs more frequently with a curved penetrating device, 4) using small pilot needles to guide insertion of large cannulas minimizes complications, and 5) lubricant is less effective for cannulas having abrupt diameter changes. These findings provide guidelines for design of safer cricothyroid cannulas.


Accidental hypothermia with cardiac arrest: recovery following rewarming by cardiopulmonary bypass. A 22-year-old man eventually had a good neurologic recovery following prolonged coma after extracorporeal rewarming from profound hypothermia (24 degrees C) due to exposure. The patient was in full arrest for 60 minutes prior to institution of cardiopulmonary bypass (CPB). Total bypass time was 50 minutes. Cardiopulmonary bypass is the current rewarming method of choice for severe hypothermia associated with a persistent nonperfusing cardiac rhythm. CPB provides the most rapid core rewarming with the additional benefit of circulatory support during the period of cardiac instability.


Xiphodynia: a report of three cases.

Xiphodynia: a report of three cases. Xiphodynia is an uncommon musculoskeletal disorder that mimics a number of common abdominal and thoracic diseases. We report three cases of xiphodynia. The diagnosis is suggested when a given patient's chest or abdominal discomfort is completely or almost completely reproduced with light pressure on the xiphoid process. Local injection with an anesthetic-steroid combination is frequently curative. No more than 5 to 7 mL of solution should be injected, and results are variable when several trigger points are found on the anterior chest wall. Tack hammer deformity of the xiphoid, another cause of xiphoid pain, has been successfully treated with surgical excision.


Wooden transnasal intracranial penetration: an unusual presentation. A 2 1/2-year-old child presented to the emergency department with a wooden stick lodged firmly in her right nares. No nasal discharge or neurological abnormalities were noted at presentation. After plain radiographs failed to demonstrate any evidence of a foreign body, computed tomography (CT scan) was obtained that revealed a hypodense region in the right frontal lobe corresponding to the projected tract of the branch. The patient underwent a right frontal craniotomy with debridement of her contused right frontal lobe. She was discharged 8 days postoperatively without evidence of neurologic sequelae. This case illustrates an unusual presentation of intracranial penetration, with only six similar cases found in the literature. It also highlights the need for the emergency physician to be concerned about intracranial penetration when treating intranasal foreign bodies, particularly those of the nonmetallic type. The literature is reviewed regarding transnasal intracranial penetration by wooden foreign bodies.


The sepsis workup for the febrile child. The sick infant or toddler who presents with a high fever or suspected sepsis must have all possible sources for bacterial infection excluded by clinical evaluation or laboratory studies as quickly and safely as possible. The process is frightening and often painful for the child. The process can be difficult for the physician because of the smallness of anatomic structures in children and the infrequent performance of pediatric procedures by many emergency physicians. This article uses a case report to illustrate features of the sepsis workup. Methods and sites that have been used with the most frequent success are described and alternatives and pitfalls are listed.


A disposable emergency wound treatment kit. Biomechanical studies in our laboratory have provided a scientific basis for selecting surgical gloves and instruments, drugs, and dressings for traumatic wound treatment. This armamentarium has been incorporated into a disposable emergency wound treatment kit for use in the emergency department. Its upper tray is for wound cleansing, while its lower tray is used for wound closure. A clinical evaluation of the kit by emergency physicians was very favorable because it saved time, eliminating the need to search for and assemble the gloves, instruments, drugs, and dressings for wound treatment.


Technical considerations in manual and instrument tying techniques. The purpose of this study was to relate the two-hand (manual) and instrument tie techniques with the ultimate security of granny and square knots constructed in multifilament and monofilament nylon sutures. Instrument-tie technique constructed secure granny and square knots, which failed by breakage rather than slippage. Similarly, two-hand (manual) tie techniques constructed square knots, which achieved knot security, failing only by breakage. In contrast, knot security was not reliably achieved with granny knots constructed by the two-hand (manual) tie techniques, with the knots frequently failing by slippage.


A perspective on emergency medicine in the developing world. The author spent 6 months as director of a major university hospital accident and emergency department in Kuala Lumpur, Malaysia. A brief summary of this experience is provided, followed by a series of recommendations based on the experience that may provide some guidance in future efforts to establish emergency medicine in developing areas of the world.


The diagnosis of acute myocardial infarction in the emergency department; Part 1. Despite major advances in treatment, the accurate diagnosis of acute myocardial infarction (AMI) in the emergency department (ED) remains a difficult clinical problem and is still mainly based on the history and interpretation of the electrocardiogram. Although the physician's clinical impression is a highly sensitive indicator for AMI, at least 4% of patients presenting to the ED with AMI may be mistakenly sent home. Although chest pain is the most common chief complaint, the clinical presentation can be extremely variable, particularly in the elderly. Complaints of sharp chest pain or chest wall tenderness should not be relied upon to exclude AMI. Radiation of chest pain is an important symptom. With careful analysis, the electrocardiogram may yield a higher diagnostic sensitivity than is commonly accepted.


Review of medical negligence cases: an essential part of residency programs. Residency programs routinely review cases involving "morbidity and mortality." It would be a valuable experience to similarly review medical malpractice cases and the associated testimony by medical experts. When available, the cases reviewed in residency programs would be those in which faculty members at the same institution had testified. The faculty member in such cases would be intimately familiar with the case and able to share the knowledge necessary to take part in the legal process. This case review process would expose residents to the legal realities of medical practice, provide a forum for peer review of legal testimony by experts, and show residents how to participate in the legal system should the need arise.


Objectives to direct the training of emergency medicine residents on off-service rotations; radiologic imaging 1: Plain films. Interpretation of radiologic images is an essential skill for the emergency physician. This is the first of two sets of objectives for an off-service rotation in radiology. It covers the interpretation of plain films. The second series will address commonly used, but more sophisticated, imaging modalities including the use of contrast materials, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. This set of objectives may be used to guide a one-month radiology rotation or serve as part of a teaching program integrated with didactic training and emergency department experience.


A study of the etiologies and treatment of nosocomial pneumonia in a community-based teaching hospital. To compare the frequency of the pathogens of nosocomial pneumonia in a community-based teaching hospital to the frequencies previously published, and to evaluate recommendations for the therapy of nosocomial pneumonia in this setting. Retrospective review of prospectively acquired data accrued during 9 randomized single-blinded and 4 single-agent investigational antibiotic studies for the therapy of pneumonia in hospitalized patients between 1981 and 1989. The study was performed at a university affiliated, community-based teaching Department of Veterans Affairs Medical Center. Patients were hospitalized on the acute medical/surgical and intermediate medicine wards. Informed consent was obtained prior to enrolling patients into the respective antimicrobial studies. Pneumonia was documented radiographically and clinically for each patient. Two hundred thirty-one episodes of nosocomial pneumonia were treated. Overall, 51% of pneumonias were caused by Streptococcus pneumoniae or Hemophilus influenzae with or without other organisms that were not gram-negative bacilli. Gram-negative bacilli, with or without other organisms, accounted for only 26% of all nosocomial pneumonias. Overall, monotherapy with a cephalosporin (usually a broad-spectrum agent) was equally efficacious compared with combination therapy (87% versus 81%, respectively). Cure rates for nosocomial pneumonias from gram-negative bacilli treated with these 2 therapies also were similar (70% versus 60%, respectively). In nontertiary care settings, gram-negative bacilli may cause fewer episodes of nosocomial pneumonia (26% in this study) than noted by previously published reports, which indicated that these organisms account for 50% of nosocomial pneumonias. Further, S pneumoniae and H influenzae may account etiologically for many of these nosocomial pneumonias. Monotherapy with an extended-spectrum cephalosporin may be more appropriate than combined treatment with a beta-lactam and an aminoglycoside in a nontertiary care setting, thereby reducing potential toxicity in an older, hospitalized patient population.


Outbreak of surgical wound infections associated with total hip arthroplasty. Describe an outbreak of surgical wound infections associated with total hip arthroplasty; identify risk factors for surgical wound infection during the pre-outbreak and outbreak periods. A 100-bed hospital. From May 1 to September 30, 1988, 7 of 15 patients who underwent total hip arthroplasty developed surgical wound infections from Staphylococcus aureus (5), Enterobacter cloacae (1), beta-hemolytic streptococci (1), enterococci (1), coagulase-negative staphylococci (1), and Escherichia coli (1) (attack rate = 46.7%). Retrospective cohort studies comparing surgical wound infection rates by patient- and procedure-related risk factors during the pre-outbreak and outbreak periods were conducted. Drop plate quantitative air culturing was conducted in 10 consecutive total hip arthroplasties in the subsequent 6 months. Rates of surgical wound infection were surgically higher for arthroplasties in which no intraoperative prophylactic antimicrobials were given (44% versus 8%, relative risk [RR] = 5.4, p = .01), or in which the posterior approach (20% versus 3%, RR = 6.7, p = .04) or a specific prosthesis (39% versus 5%, RR = 6.3, p = 0.01) was used. The surgical wound infection rate was highest when one circulating nurse, Nurse A, assisted (47% versus 4%, RR = 12.8, p less than .001). Logistic regression analysis identified use of the posterior approach (RR = 1.8, p = .04) and Nurse A's participation (RR = 5.0, p less than .001) as independent risk factors for surgical wound infection. Interviews of the nursing supervisor indicated that Nurse A had recurrent dermatitis on her hands. During 6 months following Nurse A's reassignment, the rate declined significantly (from 7/15 to 0/10, p = .01). Drop plate culturing yielded 2 to 10 colonies per plate of organisms that did not match outbreak organisms. Outbreaks associated with personnel generally involve only 1 species. In this outbreak, Nurse A (possibly because of her dermatitis), technique, the posterior approach, and/or other undetermined factors were the primary predictors of surgical wound infection.


Infections and infection risks in home care settings. To describe the characteristics of home healthcare clients with respect to infection risks and the presence of infections. Descriptive survey of client charts using a point prevalence design. A private San Francisco, California, Bay area home care agency. A random sample of 175 clients (28%) was taken from the active client list for a single day; demographic data and clinical data from the last visit prior to the selection day were collected from each chart. The clients were predominantly elderly (mean = 68.6) with an average of 3.6 co-morbid conditions; 12% had an invasive device. Over 20% had an infection on the day surveyed. Five percent had an infection that occurred during home care delivery. A substantial proportion of home health clients have infections, and they represent persons with a number of the risks associated with infections. Guidelines for defining and monitoring infections in home care need to be developed. Hospital-based surveillance methods are not altogether appropriate in this setting; redesigning methods such as targeted surveillance, monitoring rehospitalization, or immunization practices are discussed as potential ways to measure quality of care in the home setting.


Needlestick injury in hospital personnel: a multicenter survey from central Italy. The Latium Hepatitis B Prevention Group. To assess the rate of needlestick injury in hospital personnel in an Italian region. To identify risk factors potentially amendable to correction. Hospital workers undergoing hepatitis B prevaccination testing in 1985 through 1986 were interviewed regarding needlestick injury in the previous year, job category, area of work, years of employment, and other pertinent information. Of the 98 public hospitals of the Latium region, 68 participated in the survey: 32 of 55 with less than 200 beds, 20 of 25 with 200 to 300 beds, 11 of 13 with 400 to 900 beds, and all of the 5 with more than 1,000 beds. All healthcare workers providing direct patient care or environmental services as well as student nurses were invited by the hospital directors to undergo hepatitis B prevaccination testing and vaccination, if eligible. Of 30,226 hospital workers of the 68 participating hospitals, 20,055 were interviewed (66.3%): 47.7% of the 7,172 doctors, 71% of the 14,157 nurses, 55.9% of the 2,513 technicians, and 71.9% of the 6,384 ancillary workers. Needlestick injury was recalled by 29.3%; the rates were 54.9%, 35.3%, 33.8%, 26.5%, 18.7%, and 14.7% in surgeons, registered and unskilled nurses, physicians, ancillary workers, and technicians, respectively. The recalled injury rate was 39.7% and 34.0% in surgical and intensive care areas; in infectious diseases, it was 16.7%. Rates were lower in hospitals with 200 to 300 beds (25.6%). The needlestick injury rate declined from 32% in those with less than 5 years of employment to 28% in those with more than 20 years (p less than .01). Prevalence of HBV infection was higher in student nurses and young workers recalling a needlestick exposure (14.3% and 15.8%, respectively), versus 10.1% and 12.8% in those not exposed (p less than .01 and less than .05, respectively). Parenteral exposure to blood-borne infectious agents is a relevant risk among healthcare workers in our region, particularly in defined job categories and hospital areas (surgeons, nurses, surgical, and intensive care areas). Immunization and educational efforts should be made along with better designs of devices to reduce the risk of infection.


Emergency department discharges against medical advice. A retrospective chart review was performed on 52 consecutive discharges against medical advice (AMA) from an emergency department. The study's objective was to assess documentation of the medical record as well as the patients' perceptions of their experience. Sixty-seven percent of the charts reflected the competence of the patient. The physicians documented that the patients understood their diagnosis (36%), proposed treatment (44%), alternative therapy (2%), and the clinical consequences of refusal (57%). The discharge instructions included a referral to a physician 62% of the time. A post-visit survey contacting 46% of the group revealed that 82% of these respondents left because they didn't agree with the physician's management plan, although 70% of the patients were either "very satisfied" or "satisfied" with their interaction with the physician. These results suggest that more attention and better documentation needs to be directed to the patient who is leaving the emergency department against medical advice.


Introductory comments: a brief history of the development of paroxetine. In the late 1960s research was begun to develop antidepressant agents that would be selective inhibitors of serotonin reuptake. The antidepressants then available, the tricyclic antidepressants, inhibited the reuptake not only of serotonin but also of other monoamines such as noradrenaline--and it is this activity, together with anticholinergic actions, that is responsible for many of the adverse effects such as cardiac toxicity. After much chemical research a family of antidepressants with similar pharmacological activity but disparate chemical structure was developed by several medicinal research laboratories. Because the selective serotonin reuptake inhibitors are chemically different they do not possess the common structural side-effect profile of the tricyclic antidepressants.


A double-blind comparison of paroxetine and placebo in the treatment of depressed outpatients. A double-blind, placebo-controlled, randomized trial was carried out to compare the efficacy and tolerability of paroxetine in outpatients with moderate to moderately severe depression without mania. Paroxetine was found to be an effective antidepressant drug when compared to placebo. For most of the measures of efficacy the benefit appeared after two weeks of therapy, but sleep was improved after one week. Patients taking paroxetine complained of more adverse effects than those on placebo; they were mainly gastrointestinal with nausea the most commonly reported.


A double-blind comparison of paroxetine, imipramine and placebo in depressed outpatients. Diagnostic criteria, random parallel placebo-controlled study design, and appropriate clinical assessment for both safety and efficacy are all among the essential requirements for the evaluation of a new antidepressant agent. Paroxetine and imipramine were compared for efficacy and safety in a large multicentre, randomized, placebo-controlled, double-blind, parallel design study in the USA. The study involved 717 outpatients with major depressive disorder; after a one-week washout period they were treated for 6 weeks, being assessed at weekly intervals. The results from all six participant centres combined showed that both active drugs were statistically superior to placebo by week 2 and that the antidepressant response was significant for both. Paroxetine was better tolerated than imipramine with fewer dropouts from side effects. This combined study clearly indicated that paroxetine was an effective and well-tolerated antidepressant.


A double-blind multicentre study of paroxetine and amitriptyline in depressed outpatients. Italian Paroxetine Study Group. A comparative double-blind study of paroxetine and amitriptyline in the treatment of depressed hospital outpatients was undertaken at 15 centres in Italy. Three hundred and nine patients of either sex were admitted to the study. The starting dose of paroxetine was 20 mg daily and of amitriptyline 75 mg daily in divided doses; at week 3 these doses could be increased at the investigators' discretion. Efficacy was measured on the Hamilton Depression Rating Scale and on Clinical Global Impression. Both treatment groups showed significant improvement at week 6 with no significant between-group differences. Significantly fewer patients receiving paroxetine reported adverse events compared with those on amitriptyline (44% vs 62%; p < 0.01 in favour of paroxetine).


Paroxetine in the treatment of elderly depressed patients in general practice: a double-blind comparison with amitriptyline. A total of 101 patients entered a double-blind, parallel-group study in general practice, comparing the efficacy and tolerability of paroxetine and amitriptyline in elderly depressed patients. All patients received placebo for 1 week followed by active therapy for a total of 6 weeks. Medication was randomly allocated, two-thirds of the patients took paroxetine (20 mg daily) and one-third received amitriptyline (50 mg daily); this dose was increased to 30 mg and 100 mg, respectively, after 1 week. Of the patients who entered the placebo run-in, 90 took active treatment and were evaluable on an intention-to-treat basis (56 paroxetine, 32 amitriptyline). The mean age of the patients was 72 years. Significant reductions in Hamilton Depression Rating Scale (HAMD) from baseline to the end of treatment were seen for both groups (p < 0.01), with no difference between treatments. The HAMD score was reduced by half, or more, for 76% of patients taking paroxetine and 86% taking amitriptyline. Significant improvement was observed in the investigators' Clinical Global Impression (CGI) score for 57% of patients taking paroxetine and 52% on amitriptyline. Improvements after treatment were also observed in the Leeds Sleep Evaluation Questionnaire (LSEQ) scores. Significantly fewer patients taking paroxetine reported adverse events (34% vs 63% taking amitriptyline, p = 0.02). Those taking paroxetine experienced significantly fewer anticholinergic side effects (7% vs 25% taking amitriptyline, p = 0.04). Overall, this study confirmed the effectiveness of paroxetine as an antidepressant drug.(ABSTRACT TRUNCATED AT 250 WORDS)


Serotonin in affective disorders.

Serotonin in affective disorders. Serotonin (5-hydroxytryptamine; 5-HT) is a signalling molecule within the central nervous system. Overall, the impression gained from biochemical, pharmacological, and neuroendocrine studies is that 5-HT synthesis or function is reduced in the brains of depressed patients. There is more direct evidence from animal studies and indirect evidence in man that drugs (and electroconvulsive therapy--ECT) which are efficacious in various facets of affective disorders have clear effects on 5-HT function. 5-HT function is complex. There are at least seven different 5-HT receptor subtypes, several anatomically different 5-HT neuronal tracts emanating from the raphe nuclei in the pons/medulla and projecting widely throughout the brain and downwards into the spinal cord. There are fine mechanisms controlling almost every aspect of function in the 5-HT neurone and the action of 5-HT released from it. There is ample scope for 5-HT to influence many areas of the brain involved in psychological, cognitive, sensory, autonomic, neuroendocrine, and emotional function. Inhibition of reuptake by drugs selective for 5-HT, such as paroxetine, has important acute and chronic effects on 5-HT systems and function, and upon other neurotransmitter systems with which 5-HT interacts. It is of great interest that selective and non-selective monoamine uptake blocking agents, monoamine oxidase inhibitors, lithium and ECT, all affect 5-HT function, albeit slightly differently, and that they should be efficacious in various aspects of affective illness.


Sleep and paroxetine: a comparison with mianserin in elderly depressed patients. A total of 60 patients aged 65 years and over who were suffering from unipolar depression were entered into a double-blind 6-week comparative study of paroxetine and mianserin. Assessments of efficacy of treatment included the Hamilton Depression Rating Scale, Clinical Global Impression, and the Leeds Sleep Evaluation Questionnaire. The results showed that the two drugs had equal and acceptable clinical efficacy. There was a similar overall incidence of spontaneously reported adverse events, but with clearly different profiles and a suggestion that mianserin was associated with more anticholinergic effects. In terms of sleep, the study provided evidence of a more beneficial effect from paroxetine.


Cardiovascular effects of antidepressants: studies of paroxetine in healthy men and depressed patients. The classical tricyclic antidepressant drugs effectively relieve the symptoms of depression, but they have the potential to be severely toxic to the cardiovascular system--including postural hypotension after therapeutic doses and lethal arrhythmias after overdosage. Paroxetine has been shown to be of similar efficacy to the tricyclic antidepressants but has lower cardiovascular toxicity in animal models and has no effects on heart rate, blood pressure or the electrocardiogram in healthy men receiving single 20-40 mg doses. The results of two contrasting studies in depressive patients and healthy men provide strong evidence that therapeutic doses of paroxetine lack any important haemodynamic or electrophysiological effects.


A review of the psychomotor effects of paroxetine. Studies on the behavioural effects of paroxetine on healthy young volunteers, elderly volunteers, and patients suffering from major depressive illness failed to show any evidence of detrimental effects on a battery of objective and subjective measures even when alcohol was taken. In contrast, the chosen verum, amitriptyline or lorazepam, produced significant impairment. The study on depressed patients showed improvement in cognitive functions among the paroxetine group from the start, whereas these functions were, initially, significantly impaired in the dothiepin group. Moreover, the Leeds Sleep Evaluation Questionnaire indicated that dothiepin produced, with respect to paroxetine, a significantly poorer quality of sleep.


Paroxetine: an overview of dosage, tolerability, and safety. Paroxetine is a new selective serotonin reuptake inhibitor which has been extensively evaluated as an antidepressant in clinical trials and a large computerized safety database has been accumulated. A comprehensive review of data on dosage supports the recommendation that 20 mg paroxetine daily is the optimal therapeutic dose for most patients. When compared to active controls--mainly tricyclic antidepressants--paroxetine was found to have a different adverse-event profile with fewer anticholinergic, cardiovascular and nervous system events but more gastrointestinal events, particularly nausea. However, these events were not severe and did not usually lead to discontinuation of treatment. The adverse events reported with paroxetine were most likely to occur early in the course of treatment and there was no evidence of any increase in events in the elderly or with longer-term treatment. Paroxetine was not associated with excess of death from any cause, suicides, suicide attempts or serious life-threatening events. No clinically significant drug-related abnormalities were reported in laboratory monitoring, including liver function tests, in short- or long-term use. Finally, and importantly for an antidepressant, paroxetine appears relatively safe in overdose.


The anti-anxiety and anti-agitation effects of paroxetine in depressed patients. A worldwide database was employed to assess the effect of paroxetine on symptoms of anxiety and agitation associated with depression. Data derived from the use of paroxetine (n = 2963), placebo (n = 554) and active control (n = 1151) in short-term clinical trials were compared. Paroxetine and active control were significantly better than placebo in reducing psychic anxiety. However, paroxetine was superior to active control from week 2 onwards. Both paroxetine and active control had a beneficial effect on somatic anxiety, but this effect was seen earlier with active control. Neither paroxetine nor active control caused emergent (new) anxiety symptoms. Paroxetine had a more robust effect in reducing baseline symptoms of agitation when compared with active control, while both therapies protected from emergent (new) agitation, when compared with placebo. There was no difference between the three groups in the spontaneously reported adverse events indicative of increased arousal. The use of major and minor tranquillizers in the paroxetine and active control groups was similar.


The advantages of paroxetine in different subgroups of depression. Paroxetine is a selective serotonin reuptake inhibitor that is now licensed in various countries in Europe. It has comparable efficacy with the reference tricyclic antidepressants and is well tolerated with few adverse effects which are usually mild, transient and do not appear to compromise treatment. Paroxetine has a number of advantages as an antidepressant; of particular interest is its ability to improve sleep early in treatment without daytime sedation or interference with psychomotor function. Paroxetine appears effective compared with placebo in different subgroups of depression: it is effective in both endogenous and reactive depression, as well as being effective in moderate and severe depression. Paroxetine appears particularly effective in treating the anxiety associated with depression and has been shown to have greater efficacy than imipramine. There is some evidence that the onset of antidepressant action occurs slightly earlier with paroxetine than with imipramine. As well as being effective in the acute episode, placebo-controlled, long-term data are available indicating paroxetine to be of value in the prevention of depressive relapse.


Clinical pharmacokinetics of citalopram and other selective serotonergic reuptake inhibitors (SSRI). The pharmacokinetics and clinical properties of clomipramine, the classic 5-HT uptake inhibiting antidepressant is well known. Within the last years, several new and more selective serotonin uptake inhibitors have been introduced in clinical practice, including trazodone, citalopram, paroxetine, femoxetine, fluvoxamine and fluoxetine. They differ by their chemical structure, and therefore, important differences can be expected with respect to their metabolism and kinetics in man. In this presentation, the following points will be addressed: Present knowledge about their metabolism and their kinetics, taking into account that most of them are racemates, whose clinical role is only partially understood, including that of the metabolites. It will further be examined whether they are candidates for a genetic polymorphism of metabolism of the debrisoquine-spartein-dextromethorphan type. This may e.g. be suspected for fluoxetine which interferes strongly with the metabolism of tricyclic antidepressants. Finally, data of the literature will be analysed about a possible relationship between the clinical efficacy of these drugs and their plasma levels, including those of their active metabolites.


Serotonin, panic disorder and agoraphobia: short-term and long-term efficacy of citalopram in panic disorders. A serotonin-anxiety connection has been widely recognized. In panic disorder (PD), however, most researchers have emphasized noradrenergic mechanisms. Serotonin related findings in PD, e.g. the documented antipanic potential of selective serotonin reuptake inhibitors (SSRIs), are reviewed, lending support for a serotonergic deficit contributing to the pathophysiology of PD. Since citalopram is the most selective SSRI described, it was chosen as a tool for testing whether the serotonin reuptake inhibition per se is responsible for this antipanic effect. Twenty patients with PD with or without agoraphobia (DSM-III-R criteria) were treated openly with citalopram and assessed with CAS, MADRS, SCL-90 the Agoraphobia Scale, other self-ratings, and a panic diary. Thirteen of the 17 patients completing 8 weeks of treatment were judged as responders. The response seemed similar to or better than that seen with other antidepressants. The response covered broad aspects of morbidity, e.g. anticipatory anxiety, agoraphobia and somatization. In the first week, a transient increase of panic-related symptoms was observed. Sixteen of the patients were enrolled in a 15 months' study of long-term maintenance treatment; 11 patients completed this phase. The gains were maintained during this follow-up, and further improvement was observed. Side-effects were similar to those of other SSRIs and mostly mild. For instance, weight-gain was not associated with citalopram treatment. The results support the hypothesis that serotonin reuptake inhibition is essential for the antipanic effect of antidepressants as well as for the initial paradoxical increase of anxiety often seen with these drugs. Thus, an initial deterioration, possibly due to transient decrease of serotonin transmission, turns to improvement when serotonergic potentiation has occurred.


New aspects in the treatment of depression. Because of the limitations in efficacy and safety of the older tricyclic antidepressants (TCA) and monoamine oxidase inhibitors (MAOI) a number of new approaches have been made in recent years to the treatment of depression to obtain more effective, more rapidly acting, better tolerated and safer drugs. One tactic has been to develop compounds with greater neuropharmacological selectivity in inhibiting the neuronal reuptake of 5-HT. Most of these are as effective as TCA but with fewer side-effects and greater safety. Another development has been 'reversible' MAOI which reduce the risk of interaction with tyramine-containing foods. For resistant depression the addition of lithium (and/or tryptophan) may be effective, possibly through promoting 5-HT neurotransmission. Continuous treatment with a selective 5-HT reuptake inhibitor can reduce the relapse rate in patients with recurrent depression. Unfortunately, these new approaches, despite their advantages in terms of side-effects and safety, have thus far not proved to be more effective or faster acting than the standard TCA. That remains a challenge for the future.


Citalopram in depression--meta-analysis of intended and unintended effects. An updated qualitative meta-analysis of controlled clinical trials is presented. When compared to reference drugs, especially tricyclics, citalopram after 6 weeks of treatment showed a similar intended effect on the depression index of the Hamilton scale. However, on the sleep index of the scale citalopram was weaker than tricyclics. When compared to placebo, citalopram after 6 weeks of treatment showed to be significantly superior on the Hamilton scale and on the global assessment scales. Analysis of unintended effects showed that citalopram had fewer side-effects than tricyclics, especially of anticholinergic types. In conclusion, citalopram has been found to be a non-sedating antidepressant which is well accepted by the patients due to its lack of unintended effects.


Potential indications for the selective serotonin reuptake inhibitors. The selective serotonin reuptake inhibitors (SSRIs) include fluoxetine, fluvoxamine, citalopram, paroxetine and sertraline. These medications may be effective for a variety of indications. The literature clearly supports their efficacy in some of these conditions in major depression. Data concerning their use in other areas is clearly preliminary but promising. These include reports of treatment of obsessive-compulsive disorder, atypical depression, panic disorder, premenstrual tension, eating disorders, substance use disorders, chronic pain, dementia, and personality disorders with aggressive or impulsive features. The variety of clinical uses for the SSRIs may compel re-examination of traditional diagnostic categories and theories of how antidepressants work.


Treatment of depression in elderly patients with and without dementia disorders. In two inter-Nordic multicenter controlled studies the effect of Citalopram on elderly patients with depression and emotional disturbances has been studied. One investigation included 98 patients in whom Alzheimer type dementia (AD/SDAT) and vascular dementia (VD) had been diagnosed, many of whom also had emotional disturbances. After four weeks treatment with Citalopram (10-30 mg/daily) there was significant improvement in confusion, irritability, anxiety, depressed mood and restlessness. No effect was seen on the intellectual capacity or motor performance measured. In the other study, which was a six weeks trial comparing Citalopram and placebo, elderly patients with a treatment-requiring depression were treated. Demented as well as non-demented patients were included. The Hamilton Depression Scale, the Montgomery-Asberg Depression Rating Scale and The Clinical Global Impressions all recorded an effect of Citalopram superior to that of placebo. In both studies depressive symptoms as well as symptoms of agitation, anxiety, restlessness and irritability improved. Citalopram is therefore considered not only an antidepressive drug but also an emotional stabilizer. The drug was well tolerated by elderly often somatically ill patients. Side effects were few.


Toxicity of antidepressants: comparisons with fluoxetine. Antidepressant drugs have been available for 30 years. Although effective and useful in restoring quality of life, the older drugs in particular have many unwanted properties. The anticholinergic effects of the tricyclic drugs are a major drawback, and the risk of interactions limits the usefulness of the monoamine oxidase inhibitors (MAOIs). Generally, newer drugs including fluoxetine have a more favourable adverse effect profile. Although a number of drugs produce rare but serious adverse effects, overdose toxicity is a matter of greater importance, especially in patients who are at risk of suicide. Toxicity indices, calculated from the number of deaths per million prescriptions for each drug, enable comparisons between drugs to be made. These show that several of the older tricyclic drugs have relatively high mortality in overdose. Many of the newer drugs including fluoxetine have a good record of safety in overdose, and this forms an important part of their risk-benefit profile.


Operative management of intra-abdominal infections. Operation for intra-abdominal infection aims to prevent further contamination of the abdominal cavity, treat the underlying source of infection, and prevent residual or recurrent sepsis by cleaning the peritoneal cavity. Aggressive attempts at early diagnosis are warranted, even if laparotomy is occasionally required for diagnostic as well as therapeutic purposes. Conversely, the degree to which more aggressive methods of peritoneal debridement are helpful is the subject of great controversy that can be resolved only by prospective, randomized multicenter trials. Current standard treatment consists of closure, drainage, or excision of the source of contamination; intra-operative saline or antibiotic lavage of the peritoneal cavity; fascial closure; and secondary or delayed primary closure of the wound.


Percutaneous versus open operative drainage of intra-abdominal abscesses. This article has tried to provide some perspective on the results of surgical and percutaneous drainage of intra-abdominal abscesses and the impact of CT localization on the successful management of this problem. It is most likely that the recent decrease in mortality for intra-abdominal abscesses over the past decade is due to a variety of factors, including better antibiotics, more aggressive critical care, and earlier diagnosis and treatment of the intraabdominal problem. These factors combined to reduce the incidence of pre-drainage organ failure and the degree of physiologic derangement of these patients at the time of their abscess drainage. Percutaneous drainage and surgical drainage techniques should not be considered competitive but rather complementary. If an abscess is accessible by percutaneous techniques, it is reasonable to consider a nonoperative approach to the problem. It is also clear that patients should respond promptly to whatever technique is employed to drain their intra-abdominal abscess. An improvement should be seen clinically within 24 to 48 hours following drainage. Should improvement not be forthcoming, the patient must be aggressively re-evaluated with repeat CT and decisions made by the responsible surgeon in consultation with the radiologist as to the next appropriate course of action. As our review of the Wayne State University experience suggested, patients are never too sick for an appropriate operation. Although it appears that most abscesses can be successfully treated by percutaneous drainage, pancreatic abscesses with pancreatic necrosis should generally be treated by surgical debridement, usually accompanied by repeated explorations. In addition, splenectomy has not yet been replaced by percutaneous drainage of splenic abscesses.


Antimicrobial therapy of intra-abdominal sepsis. Intra-abdominal sepsis remains a highly morbid and lethal event despite the availability of potent antimicrobial agents and improvements in surgical management and intensive care. Appropriate management consists of source control, antimicrobial agents directed against both facultative gram-negative and anaerobic organisms, and physiologic and metabolic support. A variety of single and dual agent regimens are appropriate for initial therapy, as long as both aerobes and anaerobes are effectively targeted. Culture, Gram stain, and sensitivity testing may provide valuable information, especially when resistant organisms are encountered. Further studies to determine the relative efficacy of various agents need to be carefully designed both to avoid the pitfalls of previous studies and to provide useful and comparable data.


Acute cholangitis.

Acute cholangitis. Acute cholangitis is a clinical syndrome marked by fever, jaundice, and abdominal pain that develops because of stasis and infection in the biliary tract. Patients with cholangitis may present with symptoms ranging from a mild, recurrent illness to overwhelming sepsis. Increased age, malignant obstruction, and a rapidly progressive, systemic illness define a group of patients at increased risk. Patients who are delayed in diagnosis, present with septicemia, or fail to respond to conservative treatment still have substantial morbidity and death from cholangitis. Antibiotic therapy that includes coverage for anaerobes and gram-negative, enteric organisms together with other supportive measures often resolves the acute episode, permitting elective diagnostic procedures prior to definitive treatment of biliary tract obstruction. Advances in endoscopic and transhepatic procedures have reduced the necessity for and risks associated with emergent operative biliary drainage.


Infections complicating severe pancreatitis. Infections accompanying severe pancreatitis are secondary and of three types: infected pancreatic necrosis, infected pseudocyst (including peripancreatic fluid collection), and pancreatic abscess. The first is an earlier, more morbid process, with antibiotics supportive and surgical debridement necessary. The latter two processes occur later in the course of pancreatitis and are less morbid. Antibiotics are supportive and invasive-nonsurgical drainage methods are possible. The decision for intervention is based first on clinical toxicity as determined by an overall assessment by the clinician. The presence of parenchymal necrosis is best determined by the dynamic bolus CT scan. The presence of infection is best determined by percutaneous CT-guided aspiration. Infected necrosis is fatal unless treated with operative intervention. A peripancreatic fluid collection, pseudocyst, or pancreatic abscess needs to be treated if symptomatic. If infected, as determined by CT-guided needle aspiration, then they should be drained. Radiologic or endoscopic invasive-nonsurgical methods are tried initially and then surgery is attempted if they fail. The nonsurgical methods are most successful with pancreatitis of a nonbiliary or a nonalcohol etiology.


Antibiotic prophylaxis for scheduled operative procedures. As a result of numerous trials during the past two decades addressing antibiotic prophylaxis for surgical procedures, it has been established that appropriately administered antibiotic prophylaxis reduces the risk of postoperative infection by about 50% when compared with comparable untreated patients. Antibiotics cannot completely eliminate all risk of infection, however, and will never be a substitute for good surgical practices.


Antibiotic prophylaxis for injured patients. Infection is the major cause of serious complication in injured patients. This article addresses antibiotic use in the injured patient and clarifies the limitations of antimicrobials in the prevention of infection.


Wound infection surveillance.

Wound infection surveillance. Wound infection surveillance is the information-gathering arm of a wound infection control program. Wound infection control concerns prevention--not therapy--of an infrequent but expensive kind of surgical morbidity. Topics discussed in this article include the effectiveness of wound infection surveillance; turf issues; phenomenology; and the gathering, reporting, manipulating, and use of wound infection data.