Risk factors for surgical wound infection in digestive surgery. Retrospective study of 3,000 surgical wounds

A retrospective consecutive study was made of 3000 surgical wounds. All wounds were examined for ten days after operation. The overall infection rate of surgical wound infection (SWI) was 3.53%. SWI lengthened significantly duration of hospital stay (12 days vs 4 days, p < 10-6). Monovariate analysis had shown as significantly risk factors: diabetes (12.26% vs 5.49%, p < 10-6), emergency operation (5.64% vs 2.43%, p < 10-3), acute appendicitis (24.53% vs 13.06%, p < 10-3), biliary emergencies (10.37% vs 4.73%, p < 10-3), operations achieved by young surgeons (5.55% vs 2.83%, p < 10-3), choledochotomy (10.38% vs 5.46%, p < 0.05), colorectal resection (8.50% vs 4.14%, p < 0.05), open laparotomy versus laparoscopy (19.81% vs 1.89%, p < 0.05) and operating time (148 mn vs 104 mn, p < 0.05). Logistic regression showed that diabetes (p = 0.00488), biliary emergencies (p = 0.0016), seniority of surgeon (p = 0.0023), type of skin incision (p = 0.0196) and operating time (p = 0.0005) were the independent risk factors for surgical wound infection.     

Predictors of prostate cancer on extended biopsy in patients with high-grade prostatic intraepithelial neoplasia: a multivariate analysis model

OBJECTIVE: To define the importance of extended biopsy in patients with high-grade prostatic intraepithelial neoplasia (HGPIN) and to define predictors of cancer in extended biopsy in patients with HGPIN, using multivariate analysis. PATIENTS AND METHODS: In all, 83 patients with previous sextant biopsy of HGPIN had an extended 11-core biopsy taken. Patients with a negative biopsy for cancer were followed by serum prostate-specific antigen (PSA) and digital rectal examination (DRE) every 6 months. The extended biopsy was repeated in 21 patients. The criteria for second biopsy were an increase in PSA and/or abnormal changes on DRE. Overall, 49 patients had a transurethral resection of the prostate (TURP). The cancer-detection rate on extended biopsy was correlated with risk factors using the chi-square test and multivariate analysis. RESULTS: Extended biopsy detected prostate cancer in 30 of the 83 men (36%), with positive cores in only 20 sextant biopsy sites (67%), in only seven in additional sites (23%), and both in three (10%). Of the 21 patients who had repeat extended biopsy, four (19%) had cancers. There were two carcinomas in the 49 TURP specimens (4%). The PSA level, DRE and transrectal ultrasonography findings were not predictive of cancer in extended biopsies (chi-square test). Patient age, PSA density and the number of cores with HGPIN (all P < 0.001) had a significant effect on the cancer-detection rate, and multivariate analysis showed that all three were independent predictors of cancer. A logistic regression model was designed to predict the probability of cancer in extended biopsy, with an overall accuracy of 78%. CONCLUSION: Extended biopsy improved the cancer detection rate by 23% in patients with HGPIN. Patient age, PSA density and the number of cores with HGPIN were the only independent predictors of cancer.     

Superficial bladder tumours: analysis of prognostic factors and construction of a predictive index

OBJECTIVES: To assess the prognostic factors that could be used to predict tumour recurrence and progression, and to construct and validate a predictive index. PATIENTS AND METHODS: Between June 1991 and December 2000, 533 patients (418 men and 115 women; mean age 55.4 years) underwent complete transurethral resection of histologically confirmed pTa and pT1 transitional cell carcinoma of the bladder, after which 377 (test series) were randomized into two subsequent studies, of six groups, to receive adjuvant intravesical sequential bacillus Calmette-Guérin (BCG) and epirubicin, BCG alone, epirubicin (50 or 80 mg), adriamycin 50 mg or no adjuvant therapy. Factors potentially affecting tumour recurrence or progression were assessed using univariate and multivariate analysis, i.e. tumour stage, histological grade, DNA ploidy, history of recurrence, multiplicity, size, tumour configuration, associated carcinoma in situ, recurrence at the first 3-month check cystoscopy and the use of adjuvant therapy. The regression coefficients determined by Cox regression analysis were used to construct a predictive index (PI). The algebraic sum of the regression coefficients of the factors with independent and significant association with disease-free survival for each case represented a proportional hazard score (PHS). The PI was validated in another series of 156 patients (validation series) in whom the same regression coefficients for the same significant factors as the test series were used to categorize it into three risk groups. Kaplan-Meier survival curves were plotted to compare the different risk categories in both test and validation series. RESULTS: The mean (sd, range) follow-up in the test and validation series were 58 (19, 5-96) and 28.3 (14.9, 2-94) months, respectively. In the test series, tumour stage, DNA ploidy, multiplicity, history of recurrence, tumour configuration, cystoscopy result and the type of adjuvant therapy had independent significance for recurrence on multivariate analysis. For progression, the cystoscopy result, DNA ploidy and grade were the only independent and significant predictors. The ranges of PHS for the factors affecting recurrence-free and progression-free survival were 0.0-7.14 and 0.0-5.84, respectively, which were divided equally into three risk categories with significant differences on Kaplan-Meier curves and a log-rank test (P < 0.001). The three categories in the validation series were significantly different from each other and each was comparable with that in the test series. CONCLUSIONS: Tumour stage, DNA ploidy, multiplicity, history of recurrence, tumour configuration and type of adjuvant therapy affected independently the rate of recurrence after resecting superficial bladder tumour. Recurrence at the 3-month cystoscopy, histological grade and DNA ploidy were the only predictors of progression to muscle-invasion. The PI dividing the patients into three risk groups with different treatment and follow-up strategies for recurrence and progression was reproducible in a validation series.     

Role of arterial smooth muscle tone and geometry in the regulation of peripheral conduit artery mechanics by shear stress

1. Although arterial blood flow is recognized as an important modulator of vascular tone and geometry, the effect of acute changes in shear-stress on conduit artery mechanics has not been fully investigated in humans because of technical limitations. 2. To assess, respectively, the effects of decreases and increases in flow and shear stress on radial artery tone and mechanics, arterial pressure (photoplethysmography), total blood viscosity, radial artery internal diameter, wall thickness (echotracking) and blood flow (Doppler) were measured in healthy volunteers (mean (+/-SEM) age 25 +/- 1 years) during a distal flow arrest (n=12) and hand skin heating (n=18). 3. Radial artery flow decreased from 31 +/- 4 to 7 +/- 1 10(-3) L/min during distal flow arrest (P < 0.001) and increased from 10 +/- 2 to 22 +/- 4 and 69 +/- 6 10(-3) L/min during heating (P < 0.001). At mean arterial pressure, these changes in flow were respectively associated with a parallel flow-dependent reduction and increase in diameter and midwall stress. There was no significant modification in mean elastic modulus. Compliance did not change when flow decreased and only increased at the highest level of flow. Finally, the cross-sectional compliance and incremental modulus were fitted as functions of midwall stress. The decrease in flow was associated with an upward shift of the modulus-midwall stress curve and a downward shift of the compliance-midwall stress curve. The increase in flow was associated with a downward shift of the modulus-midwall stress curve and an upward shift of the compliance-midwall stress curve at each level of wall shear stress. 4. By using two different procedures, we obtained similar results concerning the direct effects of increases and decreases in flow on stiffness of the arterial wall and on arterial compliance and demonstrated the presence of a flow-dependent regulation of arterial smooth muscle tone of peripheral conduit arteries in humans.     

A blinded, controlled trial of an ultrasound device as mosquito repellent

Ultrasound emitting devices are used to repel mosquitoes. We tested the repelling properties of a commercially available ultrasound device in a domestic setting in Gabon. Devices emitting three different block frequencies ranging from 3 to 11 kHz were tested in a paired, cross-over blinded and placebo controlled trial during eighteen nights in nine pairs of houses. A total of 7485 mosquitoes (10% Anopheles, 62% Culex, 27% Mansonia and 1% Aedes) were caught, 23 per house per night. There was no significant difference in landing rate between the houses with ultrasound device and the houses with placebo for any species of mosquito. Thus the ultrasound device used was not effective against mosquitoes in this strictly controlled trial.     

Tubeless percutaneous neprolithotomy: the new gold standard

PURPOSE: We present our experience with tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Between July 2004 and December 2006, 121 patients (82 males and 39 females) with 18-70 mm (mean 31.19 mm) renal stones underwent tubeless PCNL leaving only a 6 Fr externalized ureteric catheter. Their ages ranged between 4 and 80 years (mean 37.27). Two patients had bilateral disease, so a total of 123 renal units are included. The procedure was performed under general anesthesia in the prone (110 units) or supine position (13 units). A total of 133 punctures were performed. The punctures were single (114 units), double (8 units), or triple (1 unit). The approach was subcostal through the lower calyx (n = 110) or middle calyx (n = 10), or supracostal through the middle calyx (n = 8) or upper calyx (n = 5). RESULTS: Mean operative time was 46.30 min (range 15-100). Mean reduction in hemoglobin level was 1.57 g (range 0.3-4) with blood transfusion rate 4.13%. Complication rate was 9.9% in the form of perirenal collection (five patients), urinary leakage (two patients), fever (four patients), and hydrothorax (one patient). The ureteric catheter was left for 7-72 h (mean 45.67). Postoperative analgesia was required in 22 patients (18.2%) with mean 22.9 mg diclofenac sodium per patient. Mean hospital stay was 50.69 h (range 12-96) with 106 units (86.18%) rendered stone free, 13 (10.57%) with insignificant residuals, and four units (3.25%) were left with significant residual stones. CONCLUSIONS: Tubeless PCNL is a good option in non-complicated PCNL with the advantages of reduced hospital stay, low postoperative pain, and little need for postoperative analgesia.     

Long-Term Outcome of Surgical Treatment of Penile Fracture Complicated by Urethral Rupture

IntroductionThe combination of lesions of the penile urethra and the corpus cavernosum is rare and is likely to worsen the immediate and long-term prognosis.AimTo assess the late effects of penile fractures complicated by urethral rupture treated by immediate surgical intervention.MethodsFourteen patients with concomitant urethral rupture were treated surgically at our center. Those patients were seen in the outpatient follow-up clinic and were re-evaluated.Main Outcome MeasuresSexual Health Inventory for Men questionnaire, local examination, uroflowmetry and penile color Doppler ultrasound.ResultsThe most common cause of penile fracture is sexual intercourse (50%). The site of tunical tear was in the proximal shaft of the penis in 3 patients (21%) and in the mid of the shaft in 11 patients (79%). Urethral injury was localized at the same level as the corpus cavernosum tear in all cases; and it was partial in 11 cases and complete in 3. Long-term follow-up (mean = 90 months) was available for 12 patients; among whom there was no complications in 4 (33%), painful erection in 1 (8%), erectile dysfunction in 2 (17%), and palpable fibrous nodule in 5 (47%). All patients had a normal urinary flow except one who developed relative urethral narrowing that required regular dilatation for 1 month.ConclusionsThe urethral injury complicating penile fracture is often partial and localized at the level of the corpora cavenosa tear. Standard treatment consists of immediate surgical repair of both urethral and corporal ruptures with no harmful long-term sequelae on urethral and erectile function in most of patients. El-Assmy A, El-Tholoth HS, Mohsen T, and Ibrahiem EHI. Long-term outcome of surgical treatment of penile fracture complicated by urethral rupture.     

Metformin in Peritoneal Dialysis: A Pilot Experience

♦ Objective: In a number of patients, the antidiabetic drug metformin has been associated with lactic acidosis. Despite the fact that diabetes mellitus is the most common cause of end-stage renal disease (ESRD) and that peritoneal dialysis (PD) is an expanding modality of treatment, little is known about optimal treatment strategies in the large group of PD patients with diabetes. In patients with ESRD, the use of metformin has been limited because of the perceived risk of lactic acidosis or severe hypoglycemia. However, metformin use is likely to be beneficial, and PD might itself be a safeguard against the alleged complications.♦ Methods: Our study involved 35 patients with insulin-dependent type 2 diabetes [median age: 54 years; interquartile range (IQR): 47-59 years] on automated PD (APD) therapy. Patients with additional risk factors for lactic acidosis were excluded. Metformin was introduced at a daily dose in the range 0.5 - 1.0 g. All patients were monitored for glycemic control by blood sugar levels and HbA1c. Plasma lactic acid levels were measured weekly for 4 weeks and then monthly to the end of the study. Plasma and effluent metformin and plasma lactate levels were measured simultaneously.♦ Results: In this cohort, the median duration of diabetes was 18 years (IQR: 14 - 21 years), median time on PD was 31 months (IQR: 27 - 36 months), and median HbA1c was 6.8% (IQR: 5.9% - 6.9%). At metformin introduction and at the end of the study, the median anion gap was 11 mmol/L (IQR: 9 - 16 mmol/L) and 12 mmol/L (IQR: 9 - 16 mmol/L; p > 0.05) respectively, median pH was 7.33 (IQR: 7.32 - 7.36) and 7.34 (IQR: 7.32 - 7.36, p > 0.05) respectively, and mean metformin concentration in plasma and peritoneal fluid was 2.57 ± 1.49 mg/L and 2.83 ± 1.7 mg/L respectively. In the group overall, mean lactate was 1.39 ± 0.61 mmol/L, and hyperlactemia (>2 mmol/L to 5 mmol/L) was found in 4 of 525 plasma samples (0.76%), but the patients presented no symptoms. None of the patients registered a plasma lactate level above 5 mmol/L. We observed no correlation between plasma metformin and plasma lactate (r = 0.27).♦ Conclusions: Metformin may be used with caution in APD patients with insulin-dependent type 2 diabetes. Although our study demonstrated the feasibility of metformin use in APD, it was not large enough to demonstrate safety; a large-scale study is needed.     

The possible effect of human menopausal gonadotropin on the audio-vestibular system

Objective

Human menopausal gonadotropin (HMG) is one of the commonest drugs used for ovarian stimulation with no reports on the audio-vestibular system. This study aims to examine HMG on the hearing profile of patients planning intracytoplasmic sperm injection (ICSI).