Modern theatre design and usage: do joint replacements need laminar flow?

Since the introduction of laminar flow to theatre systems by Charnley, it has become a necessity in arthroplasty surgery. His initial work in the 1960s and 70s created improvements in terms of reducing overall rates of periprosthetic joint replacement, but it has been hard to ascertain if this stems from the laminar flow itself or improvements in asepsis and the utilization of perioperative antibiotics. The aim of this paper is therefore to establish if laminar flow is still a necessary addition to modern theatre design, particularly in joint replacement surgery, irrespective of other surgical factors. A wide variety of studies were utilized to form an objective analysis of whether laminar flow is essential to asepsis in theatre design. It explores a number of smaller earlier studies and ends with two large trials which provide evidence that laminar flow may in fact have a deleterious effect on the potential for peri-prosthetic joint infection (PJI). The article discusses potential reasons for these findings and seeks to explain them in context of overall asepsis during joint replacement surgery.     

Inflammation-induced increase in the density of neuropeptide-immunoreactive nerve endings in rat skeletal muscle

The density of substance P (SP)-, calcitonin gene-related peptide (CGRP)- and vasoactive intestinal polypeptide (VIP)-immunoreactive (ir) nerve endings was quantitatively evaluated in intact and inflamed gastrocnemius-soleus muscle of the rat. In persistently inflamed muscle (12 days after a single injection of Freund’s adjuvant into the muscle), the density of SP-ir fibres was significantly increased. CGRP- and VIP-ir fibres displayed an insignificant increase in density. The density of fibres ir for nerve growth factor (NGF) and for growth-associated protein 43 (GAP-43/B-50), a marker for axonal sprouting, regeneration and synaptic reorganisation, increased significantly in persistently inflamed muscle. The data are consistent with the established contribution of NGF on the expression of SP and GAP-43 in afferent neurones under the influence of a persistent inflammation. Received: 8 September 1997 / Accepted: 12 February 1998     

Mapping the rat somatosensory pathway from the anterior cruciate ligament nerve endings to the cerebrum

The anterior cruciate ligament (ACL) serves as the primary restraint to anterior tibial translation. In addition to this biomechanical function, the ACL appears to have a function in neuromuscular control. This hypothesis was formulated after the discovery of mechanoreceptors within the ACL. The full somatosensory pathway from the ACL to the cerebrum has yet to be elucidated. In order to map this sensory pathway, we conducted a viral trans-synaptic tracing experiment using the neurotropic pseudorabies virus (PRV). The pseudorabies virus was injected into the ACL of rats and allowed to replicate and spread trans-synaptically for 6-7 days. The brain and spinal cord of each sacrificed rat was then removed and processed immunohistochemically to detect the presence of PRV. PRV-immunoreactive neurons were found to be localized in several different regions from the spinal cord to the cerebrum. Four nuclei in the reticular formation of the brain stem demonstrated strong positive labeling: the mesencephalic reticular nucleus, magnocellular reticular nucleus, paragigantocellular reticular nucleus, and gigantocellular reticular nucleus. This finding suggests that the nerve endings of the rat ACL project into the cerebrum and that the reticular formation may play an important role in the afferent pathway of those nerve endings.     

Fine Structure of A: Autonomic Nerve Fibers and Terminals in Human Myocardium; and B: Myocardial Changes in Congenital Heart Disease

In a histological and fine structural study of right atrial biopsy specimens from 31 patients with rheumatic heart disease (RHD), aged 7 to 46 years, and 11 patients with congenital heart disease (CHD), aged 3 to 36 years, nerve fibers or endings were seen by electron microscopy in 11 specimens. There was concurrence of ordinary axons along with terminals bearing pale cholinergic or dark adrenergic synaptic vesicles. Smaller and denser cholinergic vesicles suggested proliferation followed by exhaustion of such nerve endings. The closest proximity of nerve terminal to muscle fiber was about 100 nm. In one RHD specimen a “specific terminal cell” was present between a nerve ending and muscle fiber; in another a possible neuromuscular contact was developing at the surface of a regenerating small muscle fiber with a few myofilaments. Unmyelinated axons amidst increased subendocardial and subepicardial collagen, with prominent fibroblasts and depleted muscle fibers, were seen more frequently in specimens of CHD. Loss of myofibrils and accumulation of mitochondria, with infrequent formation of lipofuscin bodies, characterized degenerating muscle fibers in CHD also, although to a lesser degree than in RHD (reported earlier, 1985). The myocardial blood vessels in CHD tended to have pale swollen endothelial cells and narrowed lumen. The most severely affected cases of CHD were those with (1) a very wide atrial septal defect (ASD), (2) ventricular septal defect (VSD) with vegetations near the defect, (3) 1 infundibular pulmonary stenosis, and (4) Fallot's tetralogy.     

The location and distribution of type A and type B atrial endings in cats

Summary In the attempt to explain the difference in discharge pattern of atrial endings, 131 endings were localized by punctate stimulation, 44 were type A, 77 type B and 10 of an intermediate type. All were located on the dorsal wall of the atria with none on the ventral wall or in the appendage. On the right side, 74% of type A were located in the atria and 63% of type B in or near the veins. On the left side, 67% of type A and 94% of type B were located in or near the veins. Thus, there appeared to be some difference in the location of type A and type B endings on the right side, but on the left side both types of endings were for the most part confined to the venous region. Further, on both right and left sides, these endings were present both in the central part of the atria and in or adjacent to veins. This leads to the suggestion that the difference in discharge patterns is not caused by the location but may be due to some other reasons, e. g. difference of arrangement in the atrial wall with respect to the contractile elements.     

The cerebrospinal fluid transferrin/tau proteins. A study by two-dimensional polyacrylamide gel electrophoresis (2D) and agarose isoelectrofocusing (IEF) followed by double-antibody peroxidase labeling and avidin-biotin amplification

The cerebrospinal fluid (CSF) transferrin/Tau proteins were studied by two-dimensional polyacrylamide gel electrophoresis (2D) followed by immunoblotting and by agarose isoelectrofocusing (IEF), and subsequent double immunofixation, peroxidase staining and Avidin-Biotin Complex (ABC) amplification. The pattern of the Tau protein was similar but not equal to that of the transferrin (Tf). When a genetic variant of Tf was present in the serum, the same variant was also observed in the corresponding CSF Tf and in the Tau fraction. After neuraminidase treatment, both serum and CSF Tf moved to the Tau position on IEF and 2D. On 2D, no desialized precursors of the Tau proteins were detected, whereas the Tf precursors were always detected. No synthesis of the Tau globulin in the brain can, therefore, be inferred. In CSF not treated with neuraminidase, Tf is the only sialoglycoprotein clearly desialized, showing that the Tau fraction cannot be generated by neuraminidase action at CSF level. In fact, the treatment of serum and CSF proteins with neuraminidase produced a clear shift in the isoelectric mobility of all sialoglycoproteins. We clearly demonstrate that the Tau globulin is the result of neuraminidase activity not located in the CSF compartment. We suggest that Tf could be desialized by the action of neuraminidase at the brain level and then be "washed" into the CSF. Brain utilization of Tf, meeting the brain iron requirement, seems likely.     

Studies on the possible contribution of a peripheral presynaptic action of clonidine and dopamine to their vascular effects under in vivo conditions

Summary The functional consequences of drug-induced stimulation under in vivo conditions of -adrenoceptors and dopamine receptors at vascular adrenergic nerve endings (presynaptic receptors) was studied in the autoperfused hindquarters or hindlegs of cats anaesthetized with urethane. The changes in perfusion pressure in response to electrical stimulation of the lumbar sympathetic chain were taken as a measure of noradrenaline release from the vascular adrenergic nerves. Presynaptic inhibitory -adrenoceptors and dopamine receptors were activated by clonidine and dopamine, respectively. According to in vitro experiments these two drugs are more potent stimulants of peripheral presynaptic than postsynaptic receptors. The lowest frequency of stimulation of the lumbar sympathetic chain which yielded a reproducible pressor response was 4 Hz for the autoperfused hindquarters and 1 Hz for the hindlegs. Clonidine was tested over a wide dose range (1–100 g/kg i.v.). A reduction of the stimulation-induced pressor response in the autoperfused hindquarters or hindlegs was observed only after the rather high dose of 100 g/kg of clonidine. The inhibition was marked at low frequencies of stimulation (1–4 Hz) and weak or absent at high frequencies (16 and 32 Hz). The dose of clonidine (100 g/kg) which proved to be effective at presynaptic receptors produced a transient increase in blood pressure and in perfusion pressure of the hindquarters and hindlegs and virtually abolished spontaneous sympathetic nervous activity. In spinal cats, the clonidine-induced increases in blood pressure and perfusion pressure were very pronounced and of rather long duration. Thus, under in vivo conditions clonidine showed no selectivity for presynaptic -adrenoceptors in a blood-perfused vascular bed, and its presynaptic action was negligible as compared to its powerful central sympatho-inhibitory effect.Dopamine was constantly infused into the autoperfused hindquarters or hindlegs at increasing rates until a vasoconstriction due to stimulation of vascular (postsynaptic) -adrenoceptors occurred. The monoamine did not inhibit the stimulation-induced increases in perfusion pressure of the autoperfused hindquarters or hindlegs and, thus, an effect on presynaptic receptors was not found. The results underscore the importance of in vivo experiments for assessing the therapeutic significance of drug-induced stimulation of presynaptic receptors.Part of the results has been presented at the 16th Spring Meeting of the German Pharmacological Society in Mainz (Haeusler, 1975)     

A ventral approach to stereotaxy of the guinea pig brain

For skeletal muscles, a well-known match exists between the properties of motoneurones and those of their muscle fibres. Hence, the intramuscular distribution of different kinds of motoneuronal nerve endings (e.g. ‘slow’ versus ‘fast’) can be mapped by determining the distribution of the corresponding types of muscle fibre. As a background for further studies of motoneuronal plasticity, we needed precise measures of such distributions. Simple quantitative methods were developed for defining the position and extent of sub-populations of cells within a structure (e.g. the regional distribution of slow versus fast muscle fibres within a muscle cross-section): (a) The ‘mass vector method’ defined the relative position of the target cell cloud. A line was drawn between the calculated centre of mass for the target cells and that for the whole structure. The direction (a1) and length (a2) of this line gave a measure of the direction and degree of target cell eccentricity within the structure. (b) The ‘sector method’ delineated the region containing the target fibres. A circle around the centre of mass for the target fibres was subdivided into a number of equal sectors (standard setting: 20). The most remote point was found within each sector and a line joining these points defined the region of the target fibres. When applied to the ‘slow’ type I fibres of cross-sections from rat hindlimb muscles, the regional area estimates obtained by the sector method were highly correlated with, but 10% lower than those achieved by the well-established ‘convex hull’ method. Highly significant inter-muscular differences were observed for each one of the three new parameters described in this paper (a1, a2, b).     

普通手术室和层流洁净手术室对手术切口感染率的影响

目的了解手术室空气质量与手术切口感染率的关系。方法比较在普通手术室和层流洁净手术室施行的手术切口感染率。结果在普通手术室施行的17 707例手术中发生切口感染232例,切口感染率为1.31%;洁净手术室施行的8 931例手术中发生切口感染65例,切口感染率为0.73%;两者比较,差异有显著性(P<0.005)。在普通手术室施行的Ⅰ、Ⅱ、Ⅲ类手术切口感染率分别为0.59%、1.63%、5.23%,洁净手术室施行的Ⅰ、Ⅱ、Ⅲ类手术切口感染率分别为0.25%、0.77%、6.06%,上述Ⅰ、Ⅱ类手术切口感染率差异均有显著性(分别为P<0.05,P<0.005),Ⅲ类手术切口感染率差异无显著性(P>0.05)。结论手术室采用层流空气净化系统可以明显降低Ⅰ、Ⅱ类手术切口感染率。     

数字化手术室规划和建设

数字化手术室是今后手术室建设的发展方向,也是医院数字化建设的重要组成部分。我们在建设层流洁净手术室的同时,研发了一套与HIS、PACS、LIS、EMR等系统相集成的手术室信息管理系统。该系统满足了手术病人信息自动记录及全院共享、手术示教及远程会诊、科室事务及二级库房智能化管理等方面的需求。实践表明,该系统的使用有助于优化手术工作流程、提高手术工作效率、增强手术安全性和质量。