Initiatives to reduce postoperative surgical site infections of the head and neck cancer surgery with a special emphasis on developing countries

Introduction: Surgery in patients with head and neck cancers is frequently complicated by multiple stages of procedure that includes significant surgical removal of all or part of an organ with cancer, tissue reconstruction, and extensive neck dissection. Postoperative wound infections, termed ‘surgical site infections’ (SSIs) are a significant impediment to head-and-neck cancer surgery and recovery, and need to be addressed.

Areas covered: Approximately 10–45% of patients undergoing head-and-neck cancers surgery develop SSIs. SSIs can lead to delayed wound healing, increased morbidity and mortality as well as costs. Consequently, SSIs need to be avoided where possible, as even the surgery itself impacts on patients’ subsequent activities and their quality of life, which is exacerbated by SSIs. Several risk factors for SSIs need to be considered to reduce future rates, and care is also needed in the selection and duration of antibiotic prophylaxis.

Expert commentary: Head and neck surgeons should give personalized care especially to patients at high risk of SSIs. Such patients include those who have had chemoradiotherapy and need reconstructive surgery, and patients from lower and middle-income countries and from poorer communities in high income countries, who often have high levels of co-morbidity because of resource constraints.     

Superior QRS axis in ventricular septal defect

The relation between the superior orientation of the QRS axis and the anatomical site of the defect in the ventricular septum in patients with a ventricular septal defect was studied. Of 1031 patients with a ventricular septal defect, 64 (6.2%) had a superior axis on their electrocardiogram. In 59% of these patients the defect was in the inlet portion of the ventricular septum or affected this area. None of the cases was classified as an isolated ventricular septal defect of the persistent atrioventricular canal type. While there is an association between a superior axis and perimembranous inlet ventricular septal defect, a superior QRS axis does not characterise a ventricular septal defect as being of the atrioventricular canal type.     

Ventricular arrhythmias in syndrome of balloon deformity of mitral valve. Definition of possible high risk group.

Twenty patients clinically identified as having balloon deformity of the mitral valve were studied to assess the incidence of ventricular arrhythmias. Echocardiography and phonocardiography were used to confirm the nature of the mitral valve lesion. Continuous 24-hour electrocardiograms were obtained from all patients and analysed by a computer and 2 observers. One patient has ventricular fibrillation and 3 patients had ventricular tachycardia. There was a high incidence of other less severe forms of ventricular arrhythmias. Eight patients had inferolateral ST and T wave abnormality on the resting electrocardiogram, and were described as having the ausculatatory-electrocardiographic variant of the balloon mitral valve syndrome. The occurrence of serious ventricular arrhythmias (ventricular fibrillation and tachycardia) was significantly more frequent in this group. This raises the possibility that the resting electrocardiogram may identify those patients with balloon deformity of the mitral valve who are at risk from sudden death.     

Functional and anatomical correlates in atrial septal defect. An echocardiographic analysis.

The results of cross sectional echocardiography, intracardiac contrast echocardiography, and balloon sizing techniques and conventional haemodynamic assessment were correlated in 40 consecutive patients evaluated for an isolated left to right shunt at atrial level. Echo free areas along the septum were identified in 23 of 25 patients with a secundum defect, but not in two with a fenestrated defect, and in the upper atrial septum in three of four patients with a sinus venosus defect. No false positive results occurred in 11 patients with a probe patent foramen ovale. Saline contrast injection into the left atrium showed significant left to right shunting in all patients with atrial septal defect; inferior vena caval injection produced right to left shunting in 15 of 29 patients and a negative contrast effect in eight of 29 patients with an atrial septal defect, although neither correlated quantitatively with defect diameter or magnitude of the left to right shunt. Echocardiographic assessment of defect size as small, moderate, or large showed a highly significant correlation with balloon measurement of defect diameter, although some overlap between the groups was evident. In contrast, the correlation between defect diameter and pulmonary to systemic blood flow ratio was poor, mainly because of highly variable shunting in patients with an anatomically large defect. Cross sectional echocardiography has high sensitivity and specificity in the diagnosis of the non-fenestrated atrial septal defect and provides quantitative information about defect diameter. Contrast studies do not add to the diagnostic value of imaging from the subcostal position. The poor correlation between defect size and the measured shunt suggests that the latter may not be the best criterion for surgical management and that size could be an important factor likely to influence both the long term prognosis and the decision for closure.     

Five children with purulent pericarditis and review of the literature

Purulent pericarditis in children is a life-threatening disease that requires early diagnosis and immediate intervention. This cardiac emergency is rarely seen in the western world. However, cases of purulent pericarditis are still being reported in developing countries. We describe our experience with five cases of purulent pericarditis in children seen between 1998 and 2002. Haemophilus influenzae bacteria were isolated in all except one case. With active management, all five children survived.     

Forecasting drug utilization and expenditure in a metropolitan health region

Background  

New pharmacological therapies are challenging the healthcare systems, and there is an increasing need to assess their therapeutic value in relation to existing alternatives as well as their potential budget impact. Consequently, new models to introduce drugs in healthcare are urgently needed. In the metropolitan health region of Stockholm, Sweden, a model has been developed including early warning (horizon scanning), forecasting of drug utilization and expenditure, critical drug evaluation as well as structured programs for the introduction and follow-up of new drugs. The aim of this paper is to present the forecasting model and the predicted growth in all therapeutic areas in 2010 and 2011.