Safety of incidental appendectomy

Reports in the surgical literature are conflicting as to whether appendectomy "in passing" during laparotomy for trauma or for some other disease state does or does not significantly increase patient morbidity or mortality. A chart survey of all appendectomies (342 for acute appendicitis and 146 as incidental procedures) performed on the trauma service of Grady Memorial Hospital over a 40 month period appeared to indicate that the wound infection rate (6.8 percent) was the same as that for acute simple or suppurative appendicitis (6.7 percent), whereas the intraabdominal sepsis rate (17.5 percent) paralleled that for more advanced gangrenous or perforative appendicitis (18.6 percent). Since the validity of a retrospective review is always open to question, a prospective, randomized trial was carried out only on patients with a negative abdominal exploration for trauma over a 22 month interval at the same trauma service. An odd second from the last digit hospital number dictated appendectomy, provided the appendix was readily accessible; an even digit in the same locus dictated retention of the appendix. In no patient did intraperitoneal sepsis develop, regardless of the procedure chosen. Wound infection rates were 1.8 percent for appendectomy (1 of 56), if local anatomic considerations precluded an easy appendectomy (0 of 45), and 3.6 percent for the control subjects without appendectomy (3 of 83). There were no deaths. These data cast considerable doubt on the reliability of retrospective reviews and support the generally accepted dictum that incidental appendectomy, especially in the trauma patient, can be a relatively innocuous procedure.     

Comparison of basic infection prevention techniques,with standard room reverse isolation or with reverse isolation plus added air filtration

Forty-two uninfected, previously untreated patients with acute nonlymphocytic leukemia were randomly allocated to one of three groups to evaluate whether a basic program of infection prevention plus complete reverse isolation with added air filtration (Group I) or the basic program plus reverse isolation without added air filtration (Group II) would be more efficacious for infection prevention than the basic program alone which included a cooked food diet, patient and staff hygiene education and oral nonabsorbable antibiotics (Group III) in a hospital setting with generally excellent environmental controls including filtration of incoming air. The patient populations in the three groups were comparable. Environmental culture results indicated minimal contamination in each of the three settings. There were no substantial differences in new organism acquisition, infection incidence, infection site or pathogen, infectious deaths, hematologic remission or survival among these three groups. We conclude that, in a setting where aquisition and colonization with potential pathogens was kept at a minimum with basic techniques, the added isolation procedures in regular patient rooms were insufficient to further substantially reduce microbial contamination. This suggests that in the current setting of a modern facility, the isolation procedures must be substantially more intensive to further effect a reduction in organism acquisition.     

Synthesis and tumour-localizing properties of [18F]-5-fluorocytosine-arabinoside and [18F]-5-fluorocyclocytidine

[¹⁸F]-5-fluorocytosine-arabinoside (2) and [¹⁸F]-5-fluorocyclocytidine (4) were prepared by reaction of [¹⁸F]-acetylhypofluorite with cytosine-arabinoside (1) or cyclocytidine (3) in acetic acid and were isolated in an overall radiochemical yield of 20% and 9%, respectively. The biodistribution of both radiopharmaceuticals was determined in melanoma bearing Syrian golden hamsters. It was found that 2 is a good tumour-localizing agent for pigmented and non-pigmented Greene melanoma.     

Patterns of Care and Survival in Stage III NSCLC Among Black and Latino Patients Compared With White Patients

BackgroundRace and socioeconomic status have continued to affect the survival and patterns of care of patients with non–small-cell lung cancer (NSCLC). However, data evaluating these associations in patients with stage III disease remain limited. Therefore, we investigated the patterns of care and overall survival (OS) of black and Latino patients with locally advanced NSCLC compared with white patients, using the National Cancer Database.Materials and MethodsAll patients with stage III NSCLC from 2004 to 2013 who had undergone external beam radiotherapy (RT) alone, RT with chemotherapy (bimodality), or RT with chemotherapy followed by surgery (trimodality) were analyzed within the National Cancer Database according to race (n = 113,945). Univariate associations among the demographic, disease, and treatment characteristics within the 3 cohorts were assessed using χ² tests. The OS between cohorts were analyzed using the log-rank test and multivariate Cox proportional hazards regression.ResultsThe black and Latino patients were younger at diagnosis, had lower median household incomes, and were less likely to be insured than were the white patients. The black patients were more likely to receive RT alone (19.3% vs. 18%; P < .001) and less likely to have undergone concurrent chemo-RT (53.6% vs. 56.1%; P < .001) compared with the white patients. Black patients had improved OS (P < .001). In contrast, the Latino patients had survival equivalent to that of the white patients (P = .920).ConclusionsDespite epidemiologic differences and a propensity for less aggressive treatment, black patients with locally advanced NSCLC had better OS than white patients and Latino patients had equivalent outcomes. Additional research is needed to elucidate this finding, perhaps focusing on biological differences among the cohorts.     

Detection of cardiac dysrhythmias by continuous electrocardiographic recording in children undergoing cardiac surgery

The incidence of dysrhythmias was studied using 24-hour ambulatory electrocardiographic monitoring in 65 consecutive cases of children undergoing cardiac surgery. Recordings were made prior to surgery and in the early (1-10 days) and late (3-12 months) post operative periods. Prior to surgery, 25% of the patients displayed supraventricular dysrhythmias (SVD) and 39% ventricular dysrhythmias (VD). Immediately following surgery a dramatic increase in incidence occurred in both SVD and VD. On late follow-up the frequency of ectopy decreased but not to pre-operative levels. Standard 12-lead ECG was much less sensitive than Holter monitoring, detecting less than 25% of all dysrhythmias. Assessment of preoperative rhythm status is necessary to properly interpret postoperative dysrhythmias. Twenty-four hour ambulatory ECG recording is essential for the detection and evaluation of dysrhythmias in children undergoing cardiac surgery.     

Randomized trial of empiric antibiotic therapy with ticarcillin in combination with gentamicin, amikacin or netilmicin in febrile patients with granulocytopenia and cancer.

A randomized trial of ticarcillin plus gentamicin (group 1), ticarcillin plus amikacin (group 2) and ticarcillin plus netilmicin (group 3) as empiric antibiotic therapy in patients with granulocytopenia and cancer was carried out at the Baltimore Cancer Research Center. The response rate for all infections was 97 per cent in group 1, 91 per cent in group 2 and 95 per cent in group 3. Patients with bacteremias showed improvement in 93 per cent (group 1), 78 per cent (group 2) and 82 per cent (group 3) of cases. All failures were among patients with gram-negative bacteremias. Both antibiotic susceptibility of the bacteremic organism and granulocyte recovery correlated with patient improvement. Nephrotoxicity and ototoxicity were rare and were not significantly different in three groups of patients. Therefore, ticarcillin plus gentamicin, ticarcillin plus amikacin and ticarcillin plus netilmicin appear to be equally efficacious and minimally toxic in this patient population. Excellent over-all results can be expected with these combinations provided the etiologic agent is susceptible.