An observer blind trial of co-amoxiclav versus cefuroxime plus metronidazole in the prevention of postoperative wound infection after general surgery.

A consecutive series of 509 patients undergoing abdominal surgery were entered into a randomized, observer and patient blind, controlled, prospective, study to evaluate the efficiency of co-amoxiclav ('Augmentin', SmithKline Beecham, UK) compared with cefuroxime ('Zinacef', Glaxo, UK) plus metronidazole (Flagyl, M&B, UK) for the prevention of postoperative wound infections. One or three doses of antibiotics were given depending on the type of surgery and operative factors. Co-amoxiclav was given to 230 patients with a total wound infection rate of 5.6% and cefuroxime plus metronidazole were given to 225 patients with a total wound infection rate of 3%. The difference between infection rates was not significant. Both groups were comparable in terms of demographic details, type and duration of surgery, risk factors associated with surgical procedures and postoperative management. Although not statistically significant, a difference in the wound infection rate for those patients undergoing colorectal surgery was seen: 8/69 for the co-amoxiclav group and 2/79 for the cefuroxime/metronidazole group. The estimated cost to our hospital (October, 1993) of one dose of co-amoxiclav was less that half the cost of cefuroxime and metronidazole. This study demonstrates that co-amoxiclav is an effective prophylactic antibiotic for abdominal surgery.

Subcutaneous mastectomy with immediate reconstruction as treatment for early breast cancer.

Subcutaneous mastectomy and axillary dissection combined with immediate reconstruction was used to treat primary breast cancer in a consecutive series of 111 patients. Local recurrence occurred in 19 patients (17 per cent) during a mean follow-up of 30 (range 6-60) months. Complete control of local disease was achieved in all patients except one, who had terminal disease. Prophylactic radiotherapy was avoided for 83 per cent of patients, and good cosmetic results were obtained in 89 per cent. These results support the use of this technique in the treatment of early breast cancer.

Calcitonin and carcino-embryonic antigen in the follow-up of patients with medullary carcinoma of the thyroid.

Nineteen patients who have had medullary carcinomas of the thyroid have been followed up at the Royal Marsden Hospital. All had nodal involvement. Postoperative unprovoked serum calcitonin assays have been performed. Four patients had incomplete excisions of their tumours and these had the highest postoperative levels. Two died within 3 years, one has stable disease 8 years later and one remains well 13 years later. Four patients had postoperative calcitonin assays of over 100 ng/ml but had no clinical evidence of remaining disease. Only one has died (7 years later), the others remaining well 10, 10 and 3 years later. Four patients died of their disease and all had assays of over 200 ng/ml, before death. Slightly raised postoperative assays were found in all the other patients, but these have not significantly altered. These patients had good prognoses. Three patients also had regular carcino-embryonic antigen (CEA) assays and the value of this is discussed.

Synovial sarcoma of the pharynx and oesophagus.

Two patients with synovial sarcomas of the pharynx and oesophagus respectively are reported and their clinical features are described. These tumours in the head and neck rarely metastasize to lymph nodes and their management is discussed.

Rehabilitation after major head and neck surgery--the patients' view.

Forty-nine patients who were free of tumour 5 months to 14 years (mean 30 months) after total laryngectomy or a commando procedure were given questionnaires designed to obtain the patient's assessment of their resulting disability. Sixteen areas of disability were studied grouped under five main headings: speech, eating, cosmetic, employment and social. Following laryngectomy more than half of the patients achieved successful communication by oesophageal speech. Success in this was usually associated with minimal problems in other areas. The disabilities after commando procedures were more varied and complex. More patients reported severe disability in more than one area. Difficulties with chewing and swallowing were prominent. The results are illustrated with patients' comments. Ways in which rehabilitation might be improved are considered.

Results and prognostic factors in salvage surgery for squamous carcinomas of the tongue.

Fifty-six patients who had undergone salvage surgery for residual or recurrent squamous carcinomas of the tongue between 1967 and 1977 were reviewed. Failure to obtain operative clearance led to certain local recurrence. The tongue or cervical lymph nodes were involved in 27 of the 28 patients who died with recurrent tumour. The overall age-corrected actuarial postoperative survival was 45.1 per cent at 2 years and 35.3 per cent at 5 years. Survival was reduced in women and patients aged over 60 years at operation, and in patients whose tumors were at first biopsy moderately or poorly differentiated, classified as stage III or IV at initial presentation or preoperatively, or recurred within 6 months of completing primary treatment.

Thyroid function after radiotherapy and laryngectomy for carcinoma of the larynx.

Total levels of thyroxine (T4) and thyroid-stimulating hormone (TSH) were measured in 37 patients who had previously had carcinoma of the larynx treated by radiotherapy and total laryngectomy with thyroid lobectomy. Ten percent of the patients had clinical features of hypothyroidism and 30% had total T4 levels below the lower limit of normal. A further 40% had results in the low normal range. Forty-four percent of patients had raised TSH levels, 90% of these having low or low normal T4 levels. The histology of the thyroid gland was normal in all 37 patients. Attention should be given to preserving intact the vasculature of the contralateral thyroid lobe whenever it is necessary to remove the ipsilateral thyroid lobe during a laryngectomy. Proper postoperative assessment of thyroid gland function is desirable in all these patients to identify those at risk of hypothyroidism and to avoid unnecessary morbidity.

Adjuvant chemotherapy for breast cancer: side effects and quality of life.

In a trial of postoperative adjuvant chemotherapy women with primary breast cancer and spread to one or more axillary nodes were randomised to receive a six-month course of either the single agent chlorambucil or the five-drug combination of chlorambucil, methotrexate, fluorouracil, vincristine, and adriamycin. On completing the treatment 47 patients were asked to fill in questionnaires at home on the side effects of treatment and its influence on the quality of their life. Side effects including nausea, vomiting, malaise, and alopecia had been severe enough to interfere with their lifestyle in 9 (42%) of the patients who had received the single agent and 19 (79%) of those who had received multiple-drug treatment. Various other side effects were reported by a few patients. Seven (29%) of the patients who had received the multiple-drug schedule voluntarily added that the treatment had been "unbearable" or "could never be gone though again." The proportion of patients who had experienced severe side effects while receiving the treatment was considerable; hence such adjuvant chemotherapy is justifiable only if it will substantially improve a patient's prognosis.

Ingrowing toenails: the results of treatment.

Completed questionnaires were received from 208 patients on whom 245 operations for ingrowing toenails had been performed at King's College Hospital. Avulsion of a strip of nail had an 83 per cent recurrence rate, total nail avulsion 70 per cent, Zadik operations 28 per cent and wedge resections 29 per cent. It is recommended that immediate avulsion of ingrown toenails should not be a routine practice.

Incarcerated inguinal hernia in children.

A survey has been made of 110 children under 4 years of age who developed inguinal hernias. Of these, 61 became incarcerated at some time, the highest incidence being in the youngest infants; the bowel was not strangulated in any of these hernias. No untoward effects were seen to result from a short trial of conservative treatment in incarcerated hernia.

Monitoring of a multi-modal schedule for the treatment of disseminated breast cancer.

39 women and 1 man have been monitored by sequential CEA, immunoglobulin, lymphocyte and monocyte readings, hydroxyproline excretion, scans and x-rays. CEA is shown to be a useful monitor of disease. The significance of the lymphocyte counts is discussed.

A survey of patients' reactions to intravenous Corynebacterium parvum therapy.

A survey was made of patients' reactions to high dose (21 mg) Corynebacterium parvum therapy given intravenously over four hours. The patients completed a pro forma. Rigors were the commonest side effect complained of being present in nearly all patients (24/25) and being very severe in one-third (10/25). Other problems were nausea (15/25), vomiting (17/25), bone pain (12/25) and headaches (12/25). One-third also usffered with other less common side effects. Overall, patients felt the side effects were as disagreeable as those experienced with outpatient chemotherapy.