Hand infections in hospitalized patients

Two hundred hospital admissions for hand infections are reviewed with regard to the causes of infection, modes of effective therapy and causes of residual impairment. Patients with human bite injuries and those who delayed seeking treatment most frequently had severe injuries. Appropriate antibiotics and prompt surgical therapy of hand abscesses are essential.     

Pancreatic pseudocyst

In 74 patients treated for pancreatic pseudocyst, the underlying disease of acute or chronic pancreatitis was found to influence the clinical course. Even in the era of computed tomographic scans and ultrasonography, selective contrast studies of the pancreatic duct and common bile duct can improve results, particularly when the cause is chronic pancreatitis.     

Recovery of function of the reimplanted lung

In association with reimplantation of the lung of the dog by established techniques, serial determinations of oxygen uptake (bronchospirometry), cardiac output and blood flow to each lung (Fick method), and blood pressure were done preoperatively and postoperatively for 10 to 12 weeks. Ultimately pulmonary artery ligation was performed to demonstrate that animals could survive on the reimplanted lung. In animals free of postoperative complications, oxygen uptake and blood flow returned to normal in 5 to 6 weeks in 4 animals; delay of functional return until 10 to 12 weeks postoperatively occurred in 5. In one-third of the reimplanted lungs, stenosis or occlusion of the bronchial anastomosis prevented evaluation of function.     

The island cheek flap: Repair of cervical esophageal stricture and new extended indications

Seven patients had reconstruction with an island cheek flap based on the facial vein and artery. The flap carries a swatch of buccal mucosa that can be rotated inferiorly as far as the superior mediastinum and superiorly to the oral cavity. Five patients had repair of cervical esophageal strictures and fistulas. In four, results were very successful. One patient had diminished but persistent dysphagia which was shown to be secondary to a carcinomatous polyneuropathy; however, he had complete resolution of aspiration after correction of his mechanical obstruction and tracheoesophageal fistula. Morbidity was minimal. Parotiditis developed in one patient who had Stensen's duct ligated. Minor numbness of the lip and a single case of Frey's syndrome were also observed. In another patient, reconstruction of the floor of the mouth preserved normal speech and swallowing. Finally, a permanent speech fistula was also created but was substantially taken down because of functional dissatisfaction. Other potential applications need to be explored.     

Amputations in peripheral vascular occlusive disease

One hundred consecutive patients undergoing major lower extremity amputations were critically analyzed over a five year period. The results of surgical care and the degree of success of rehabilitation were determined. The number of patients with peripheral vascular occlusive disease who require major lower extremity amputations appears to be increasing and they continue to present a challenge to the surgeon.     

Peer and self assessment in undergraduate surgery

The purpose was to determine if students could identify their own strengths and weaknesses as viewed by their peers and whether peer or self ratings of knowledge and interpersonal skills could predict scores on National Board Medical Examinations and final grades in surgery. Ninety-eight juniors rated themselves on a 13-item scale; 830 peer ratings (about eight per student) were also obtained and averaged to provide a peer score for each student. There were low but significant correlations between the two sets of ratings. Peer scores were excellent predictors of both National Boards and final grade. Self scores were only weakly associated with these outcomes. Interpersonal skill ratings were inversely related to grades. Peer ratings seem to be a valuable addition to evaluation of student performance. Self ratings may be more useful as a means of helping students learn to accurately assess their strengths and weaknesses.     

The anterior chamber of the eye: a sensitive site for the detection of cross-reacting alloantigens.

The anterior chamber of the eye appears to be a sensitive site for the detection of cross-reacting alloantigens. Third-party implants were rapidly rejected in recipients that were previously sensitized with non-specific skin allografts. Similar studies using orthotopic skin-grafting techniques as a means of detecting the same cross-reactivity were negative.     

A controlled clinical trial of whole gut lavage as a method of bowel preparation for colonic operations.

In a prospective randomized clinical trial, whole gut lavage was evaluated against conventional mechanical cleansing for colonic operations. The lavage took less time to perform, was better tolerated by patients, and resulted in more satisfactory preparation as judged by frequency of collapsed intestines. There was no difference in the outcome in the two series as measured by wound infection rate and length of hospitalization. It is concluded that whole gut lavage is as good as conventional mechanical cleansing but surpasses the latter in logistic advantages.     

Pulmonary Mucormycosis (Phycomycetes) Successfully Treated by Resection

Pulmonary mucormycosis (Phycomycetes) is an uncommon fungus infection complicating diabetes mellitus, leukemia, lymphoma, and other debilitating diseases. A review of the literature revealed that of 21 diabetic patients in whom Phycomycetes occurred without underlying malignancy, only 7 survived. These 7 underwent operation. This report concerns another patient with pulmonary mucormycosis who was successfully treated by pulmonary resection.     

Laser-induced shock waves enhance sterilization of infected vascular prosthetic grafts

BACKGROUND AND OBJECTIVE: Bacteria that cause infection of vascular prosthetic grafts produce an exopolysaccharide matrix known as biofilm. Growth in biofilms protects the bacteria from leukocytes, antibodies and antimicrobial drugs. Laser-generated shock waves (SW) can disrupt biofilms and increase drug penetration. This study investigates the possibility of increasing antibiotic delivery and sterilization of vascular prosthetic graft. STUDY DESIGN/MATERIALS AND METHODS: Strains of Staphylococcus epidermidis and S. aureus were isolated from infected prosthetic grafts obtained directly from patients. Dacron grafts were inoculated with the isolated bacteria, which were allowed to form adherent bacterial colonies. The colonized grafts underwent the following treatments: (a) antibiotic (vancomycin) alone; (b) antibiotic and SW (c) saline only; and (d) saline and SW. Six hours after treatment, the grafts were sonicated, the effluent was cultured and the colony forming units (CFU) were counted. RESULTS: CFU recovered from control grafts colonized by S. epidermidis were comparable: saline, 3.05 x 10(8) and saline+SW 3.31 x 10(8). The number of S. epidermidis CFU diminished to 7.61 x 10(6) after antibiotic treatment but the combined antibiotic+SW treatment synergistically decreased CFU number to 1.27 x 10(4) (P<0.001). S. aureus showed a higher susceptibility to the antibiotic: 2.26 x 10(6) CFU; antibiotic +SW treatment also had an incremental effect: 8.27 x 10(4) CFU (P<0.001). CONCLUSIONS: This study demonstrates that laser-generated shock waves have no effects alone, but can enhance the effectiveness of antibiotics against bacteria associated with prosthetic vascular graft biofilms, suggesting that this treatment may be of value as adjunctive therapy for prosthetic graft infections.     

Effects of lumbar sympathectomy on skin capillary blood flow in arterial occlusive disease

Thirteen patients undergoing lumbar sympathectomy had skin blood flow measured preoperatively and postoperatively in the lower extremity by ¹³³xenon clearance. Eleven of 15 sympathectomized extremities showed an increase in nutritional blood flow when compared to preoperative measurement. The unsympathectomized extremity was used for control measurements. The clinical symptom that was most improved was rest pain.This measured increase in skin capillary blood flow after sympathectomy supports the continued use of this operative technique for ischemic skin conditions of the lower extremity.     

Systemic emboli due to cloth wear in a Starr-Edwards Model 2320 aortic prosthesis

The evolution of the different cloth coverings of Starr-Edwards prostheses is reviewed along with previously reported cases of wear of the cloth coverings. The first case of wear in the Model 2320 valve, which is covered with a combination of polypropylene over Teflon, is reported. Questions related to the problem are discussed.     

Effect of 16, 16 dimethyl prostaglandin E2 on aspirin-induced permeability changes in the pancreatic duct

Perfusion of the pancreatic duct with acidified aspirin in cats increased the permeability of the duct to HCO₃^?. Intravenous administration of the synthetic prostaglandin analog 16,16 dimethyl prostaglandin E₂ (PGE₂) prevented this permeability change. The effect was dose-related and at the highest dose (50 μg/kg/hour) was essentially complete. The beneficial effect of the PGE₂ was apparent even when it was given after the duct had been exposed to aspirin. PGE₂ had no effect on pancreatic water or electrolyte secretion in the unstimulated nonsecreting gland. No histologic changes in the pancreatic ducts were seen after exposure to aspirin, PGE₂ or both. The effectiveness of PGE₂ in restoring membrane permeability towards normal suggests the possibility of its therapeutic role in pancreatitis.     

Dissecting Aortic Aneurysms

Anatomically, dissecting aneurysms may be classified into four types: Type I, the most common, originates in the ascending aorta or aortic arch and extends into the descending thoracic aorta and beyond. Type II, the rarest, is confined to the ascending aorta and proximal aortic arch. Type III begins in the proximal descending aorta and extends distally; this type has the best prognosis. Type IV, a newly proposed addition to these three, is an iatrogenic retrograde dissection of the aorta which originates in the iliac or femoral arteries during extracorporeal circulation by the transfemoral route.Drug therapy currently is the treatment of choice for all types of acute dissections except those of type IV. Immediate operation is reserved for good-risk patients with type I lesions, all patients with type IV dissections, complicated cases, or patients in whom drug therapy is contraindicated. In the chronic stage, operation is indicated when the patient develops a saccular aneurysm, marked aortic insufficiency, recurrent symptoms of pain, or enlargement of the aneurysm.     

Opportunistic Endocarditis Following Open-Heart Surgery

The incidence of endocarditis following open-heart operations is declining, but the relative incidence of endocarditis by the opportunistic organisms, both bacterial and fungal, has increased. These “opportunists” require careful identification and sensitivity testing so that appropriate therapy can be planned. In cases of candida endocarditis, a positive precipitin test and elevated candida antibody titer may provide an earlier means of diagnosis than blood cultures. These patients should be treated promptly with adequate dosages of specific antimicrobial or antifungal agents. Reoperation should be considered early if there is evidence of valve dehiscence or embolic phenomena or if drug therapy fails to control the infection.