Short-term chemoprophylaxis with ceftizoximevs. Five-day aminoglycoside with metronidazole in ‘contaminated’ lower gastrointestinal surgery

In a prospective, open, randomized controlled trial, 173 patients requiring surgery for potentially contaminated lower gastrointestinal surgery were allocated to receive either two doses of ceftizoxime (2 gm) with one dose of metronidazole (1.5 gm) or gentamicin 3 mg/kg/day for five days with one dose of metronidazole (1.5 gm). Eighty-nine patients received ceftizoxime and 84 patients received gentamicin. The groups were comparable with respect to diagnosis, procedure, type of anastomosis, and wound closure. The incidence of withdrawal due to failure to respond to the study drug (11.5 percent) was equivalent in the two groups. There was no difference in the overall incidence of postsurgical infection between the ceftizoxime and metronidazole group (22.2 percent) and the gentamicin and metronidazole group (25.7 percent). The incidence of wound infection (ceftizoxime and metronidazole, 6.9 percent; gentamicin and metronidazole, 10 percent) and deep sepsis (ceftizoxime and metronidazole, 15.3 percent; gentamicin and metronidazole, 15.7 percent) was similar.     

A rapid method for detecting barbiturates in serum using EI-SIM

A simple and rapid method for analysis of barbiturates in serum has been developed. In order to extract and clean barbiturates in serum, a separation column packed with Extrelut and Florisil was used, and the eluate was directly analyzed by means of electron impact selected ion monitoring (EI-SIM). Selected ions used were base peak ions of 10 barbituartes, and the internal standard used was allobarbital or secobarbital. The calibration curves were linear over the range 0.5–5 ng. Extraction of replicate serum samples containing 20 g/1.5 ml and 5 g/1.5 ml resulted in a recovery of 87.2–105.2% and 81.6–104.6%, respectively, with the exception of phenobarbital, which was 151.9% and 172.1%, respectively. Secobarbital was also analyzed in the serum of 13 patients who had been given secobarbital intravenously. In 3 out of 10 cases, Secobarbital levels greater than 1 g/ml were detected more than 72 h after administration. This method seems to have possibilities for clinical use.Paper presented at the 2nd International Symposium ADVANCES IN LEGAL MEDICINE, Berlin, Germany, August 30–September 1, 1993     

The Massachusetts Behavioral Health Program Year 5: Transition to a New Managed Care Organization

Year 5 of the Massachusetts Behavioral Health Program was a transition to management by a new private managed care organization. Fifty-eight providers interviewed for an ongoing panel survey reported slightly lower levels of quality, access, utilization, and length of stay than a year earlier. Relationships with providers and advocates improved after an initial difficult period, while consumer and family involvement at all levels remained low. The greatest changes in managed care appeared to take place during the initial transition from fee-for-service care, but intractable problems continue, and full participation of stakeholders seems difficult to achieve.     

Neurons in the temporal cortex changed their preferred direction of motion dependent on shape

To investigate neuronal mechanisms that integrate different visual modalities such as motion and shape, neuronal activities in the superior temporal polysensory area (STP) were recorded from monkeys that were watching rotating images. In total, 194 neurons were identified as visually responsive. Of these, 73 neurons (38%) showed differential response depending on both shape and direction of motion (MS neurons). Of these 73 neurons, 21 (29%) were identified as reversal type MS neurons (MSr neurons), that is, they responded to an opposite preferred direction when the shape was different. The results confirm that neurons in the STP can be simultaneously activated by different attributes of visual stimuli. The data also suggest that individual STP neurons can process more than one type of visual stimulus.     

New monitoring strategies during shock

Disturbances in tissue perfusion and oxygenation are known to occur during shock. To treat shock properly, it is necessary to have a good understanding of its pathophysiological characteristics. By monitoring cardiac output and oxygen delivery, we can assess the systemic oxygen transport to the tissues, while mixed venous oxygen saturation provides an index of the systemic oxygen balance between oxygen delivery and consumption. However, because a redistribution of blood volume and flow occurs in shock, the use of systemic monitoring alone does not allow an assessment of regional oxygenation in the various organs. Monitoring of hepatic and jugular venous oxygen saturation enables us to assess the adequacy of regional tissue oxygenation in the liver and brain, respectively, while monitoring intramucosal pH (pHi) is useful not only to assess regional oxygenation in the splanchnic organs, but also to predict complications and to evaluate the clinical outcome. The use of near-infrared spectroscopy may allow simultaneous, noninvasive monitoring of regional tissue oxygenation and energy levels. There exists a wide variety of viable options for the monitoring of shock, both systemically and regionally. This increases the chances of successful treatment.     

Studentschool bonding and adolescent problem behavior

Adolescent problem behavior, including substance use, schoolmisconduct and delinquency, is a national concern. Implicitin the concept of middle school is the recognition that studentswho develop positive social bonds with their school are morelikely to perform well academically, and refrain from misconductand other antisocial behavior. However, little scientific attentionhas been given to the complex interactions between middle schoolstudents and the school environment. Prior to implementing amiddle school problem behavior prevention program we conducteda survey in the seven middle schools in one US school district.Out of 4668 grade 6–8 students enrolled, 4263 (91.3%)completed the survey. Student–school bonding was positivelycorrelated with school adjustment (r = 0.49) and perceived schoolclimate (r = 0.77), but inversely correlated with problem behavior(r = –0.39 to –0.43). Problem behavior was significantlyhigher (P < 0.001) among males than females and among studentsin higher grades. Conversely, school bonding, climate and adjustmentwere significantly higher (P < 0.001) among females thanmales, but declined significantly from one grade to the next.The data support the conclusion that school bonding is associatedwith problem behavior. We describe the development of a multiple-componentintervention in middle schools designed to increase student–schoolbonding and prevent problem behavior.     

Phase II trial of circadian infusion floxuridine (FUDR) in hormone refractory metastatic prostate cancer

Circadian administration of chemotherapy has been reported to decrease toxicity and possibly enhance efficacy. Between March 1991 and December 1993, 18 evaluable patients with progressive, hormone-refractory metastatic prostate cancer were treated in this phase II trial of circadian infusion floxuridine (FUDR). The drug was delivered through a central venous catheter using a CADD-Plus computerized pump such that approximately 70% of the drug was administered between 3 and 9 p.m. and the rest (30%) was administered between 9 p.m. and 3 p.m. The dose of FUDR was 0.15 mg/kg/day × 14 days every 4 weeks. A total of 79 complete cycles was administered.Two of 18 evaluable patients (11.1%) had decreases in PSA lasting five and eight months. No objective responses or improvement in bone scans was noted. The major toxicity observed was diarrhea. Although circadian infusion FUDR is feasible and tolerable, it has limited activity in hormone refractory prostate cancer.     

Prognostic Significance of Proliferating Cell Nuclear Antigen (PCNA) in Squamous Cell Carcinoma of the Esophagus

Proliferating cell nuclear antigen (PCNA) has been shown tobe of prognostic significance in some gastrointestinal tumors.Immunohistochemical analysis was performed to determine whetherPCNA is useful for predicting the outcome of patients with squamouscell carcinoma of the esophagus. Using a mouse monoclonal antibody,PC 10, the expression of PCNA was studied in resected squamouscell carcinomas of the esophagus from 59 patients who had undergonecurative esophagectomy. None had received any preceding therapy.The proliferation rate was assessed in terms of the percentageof the PCNA-positive nuclear area relative to the total areaof cancer nuclei using a cell analysis system (CAS). Clinicopathologicalvariables including PCNA staining were assessed in relationto prognosis. Survival rate was obtained by the Kaplan-Meiermethod. The PCNA indices (percentage of the positive nucleararea) of the tumors varied from 4.4% to 96.2%. Among the clinicopathologicalvariables, only tumor size (5 cm) and depth of invasion werecorrelated significantly with PCNA index (P<0.05). Microscopically,PCNA was stained in non-keratinized cells but not in keratinizedcells. However the histological grade was not correlated withPCNA index. The survival rate was significantly worse in patientswith high PCNA indices (40%) than in those with low indices(<40%) (P<0.05). However, multivariate analysis revealedthat PCNA index was not an independent prognostic factor.     

Catecholamine Release caused by Carbon Dioxide Insufflation during Laparoscopic Surgery

Purpose

We evaluated plasma catecholamine levels during pneumoperitoneum in laparoscopic surgery.

Materials and Methods

Plasma epinephrine and norepinephrine were evaluated in 29 patients who underwent laparoscopic retroperitoneal surgery in a half lateral decubitus position (group 1) or laparoscopic varicocelectomy in a Trendelenburg position (group 2).

Results

The levels of epinephrine and norepinephrine increased significantly 5 minutes after carbon dioxide insufflation compared to levels after Veress needle insertion and just before insufflation. The elevation of catecholamine levels during laparoscopic procedures was greater in group 1.

Conclusions

Our results indicate that carbon dioxide insufflation may cause catecholamine release during laparoscopic surgery. Careful monitoring of hemodynamics is mandatory at the beginning of the procedure.     

Esophageal pressure and apnea hypopnea index in sleep-disordered breathing

Severity of negative esophageal pressure (Pes) and apnea hypopnea index (AHI) were investigated in six cases of upper airway resistance syndrome (UARS) and 11 cases of obstructive sleep apnea syndrome (OSAS). The severity of negative Pes was represented by the highest peak (Pes Max) and the number of increased episodes (more than 13.5 cmH2O) per h (NPesI13.5). There was no significant correlation between Pes indices and AHI. Pes Max and NPesI13.5 were not different among severe OSAS (AHI > 30), mild OSAS (AHI < 30) and UARS. Apnea hypopnea index failed to represent the severity of negative Pes, which is an important aspect of the pathophysiology of sleep-disordered breathing.