Antimicrobials as an adjunct to pilonidal disease surgery: a systematic review of the literature.

Surgical site infection (SSI) after pilonidal disease surgery can lead to serious complications. We systematically searched the PubMed, Scopus, and ClinicalTrials.gov databases for studies evaluating the use of antimicrobials as an adjunct to pilonidal disease surgery. We identified 12 eligible studies [nine randomized controlled trials (RCTs), three retrospective cohort studies], enrolling a total of 1,172 patients. No difference was observed when single-dose prophylaxis was compared to no prophylaxis or to a long course of antibiotics (seven studies, 690 patients). Similarly, gentamicin collagen sponges (GCS) did not appear to be beneficial when compared with no GCS (with primary or secondary closure; four studies, 402 patients). One study (80 patients) reported faster healing and lower SSI and recurrence rates with GCS than a 7-day course of antibiotics. The clinical heterogeneity precluded a formal meta-analysis. Although the generalization of our findings may be limited by the relative paucity and clinical heterogeneity of the existing studies, prophylactic antibiotics or GCS did not appear to be beneficial in promoting healing or reducing SSI or recurrence rates. Large, double-blind, placebo-controlled RCTs are warranted in order to further elucidate this issue.

Morbidity of foreign travelers in Attica, Greece: a retrospective study.

Over the last decade, travel medicine was mainly focused on the epidemiology of diseases among travelers to developing countries. However, less is known about travel-related morbidity in Europe. We evaluated the demographic and clinical characteristics of foreign travelers to Greece during a 5-year period (01/01/2005 - 31/12/2009) who sought medical services from a network of physicians performing house-call visits (SOS Doctors) in the area of Attica, Greece. Overall, 3,414 foreign travelers [children (≤18 years of age): 27%] were identified; 151 (4.4%) required transfer to a hospital. The most common clinical entities were: respiratory disorders (34%), diarrheal disease (19%), musculoskeletal (12%), dermatologic (7%), non-diarrheal gastrointestinal (6%), and genitourinary (5%) disorders. Respiratory disorders were the most frequent diagnosis during all seasons, followed by diarrheal gastrointestinal and musculoskeletal disorders. Respiratory and dental conditions were observed significantly more frequently in children. Respiratory disorders were observed significantly more frequently during winter (47%) compared to spring (36.7%), summer (30.9%), and autumn (30.5%), (p < 0.01). Despite the limitations of the retrospective methodology, our findings suggest that mild, self-limited respiratory events may be the prevalent cause for seeking primary health care during travel to Greece. Our findings may be extrapolated to other countries with similar climatic and socioeconomic status.

Comparison of morbidity of elderly patients in August and November in Attica, Greece: a prospective study.

BACKGROUND: In our clinical practice, we have experienced a consistent increase in the morbidity of elderly in Greece during August. METHODS: We prospectively analysed and compared the morbidity of elderly patients (≥ 75 years old) between August and November of the same year (2010), using data from the SOS Doctors (a network of physicians performing house call visits). RESULTS: We analysed data on 739 and 738 elderly patient house-calls in August and November, respectively. Overall, the most common diagnoses were cardiovascular (17.6%), musculoskeletal (10.7%), gastrointestinal (9.5%), respiratory (8.5%), renal/genitourinary (8.1%), and neurologic/psychiatric (7.9%). In August, patients were older (p < 0.01), carried a heavier burden of disease (as inferred by specific types of comorbidity and associated medical conditions), were more frequently recommended emergency hospitalization (p < 0.01) and had a worse outcome of primary illness (p < 0.05). Mortality of elderly visited in August was significantly higher compared to November (5% vs. 2%, p < 0.01). The sole independent predictor of mortality was patient's bedridden status [adjusted odds ratio (OR) = 5.59, 95% confidence intervals (CI) 2.83-11.06, p < 0.001]. The identified independent predictors of recommendation for emergency hospitalization were patient's lethargic status [OR = 2.88 (1.80, 4.59), p < 0.001], fever [OR = 2.55 (1.84, 3.54), p < 0.001], heat stroke [OR = 2.08 (1.19, 3.64), p = 0.01], Alzheimer's disease [OR = 1.77 (1.15, 2.72), p = 0.01] and bedridden status [OR = 1.45 (1.07, 1.97), p < 0.05]. CONCLUSION: Morbidity and mortality of elderly patients was significantly higher in August compared with November, substantiating the informal term 'Augustitis' for the Greek elderly. Large, prospective population-based studies are warranted to further enlighten this field.

Multi-drug-resistant gram-negative bacterial infection in surgical patients hospitalized in the ICU: a cohort study.

We sought to identify risk factors for postoperative infections, caused by multi-drug-resistant gram-negative bacteria (MDR-GNB) in surgical patients. This was a retrospective cohort study among patients hospitalized in the intensive care unit (ICU) for more than 5 days, following general surgical operations. Comparison of patients who developed infection caused by MDR-GNB with the remainder of the cohort showed that every minute of operative time, use of special treatments during hospitalization (antineoplastic, immunosuppressive or immunomodulating therapies), every day of metronidazole, and every day of carbapenems use, increased patients' odds to acquire an infection caused by MDR-GNB by 0.7%, 8.9 times, 9%, and 9%, respectively [OR (95% CI): 1.007 (1.003-1.011), p = 0.001; 8.9 (1.8-17.3), p = 0.004; 1.09 (1.04-1.18), p = 0.039; 1.09 (1.01-1.18), p = 0.023, respectively]. The above were adjusted in the multivariable analysis for the confounder of time distribution of infections caused by MDR-GNB. Finally, the secondary comparison, with patients that did not develop any infection, showed that patients who had received antibiotics, within 3 months prior to admission, had 3.8 times higher odds to acquire an infection caused by MDR-GNB [OR (95% CI): 3.8 (1.07-13.2), p = 0.002]. This study depicts certain, potentially modifiable, risk factors for postoperative infections in patients hospitalized in the ICU for more than 5 days.

Inaccuracies in dosing drugs with teaspoons and tablespoons.

BACKGROUND: We aimed to evaluate the potential inaccuracies in administering the desired dose of drugs with teaspoons and tablespoons. METHODS: We collected all the different teaspoons/tablespoons that were available in 25 households in the area of Attica, Greece and measured their volume capacity (ml). RESULTS: A total of 71 teaspoons and 49 tablespoons were provided by the 25 women (mean age 48.0 years) study participants. When these utensils were filled with water, the volume capacity of the 71 teaspoons and 49 tablespoons ranged from 2.5 to 7.3 ml (the mean and the median volume was 4.4 ml). When the standardised teaspoon was used, the volume ranged from 3.9 to 4.9 ml among the total of the 25 study participants. When a subset of five study participants filled this teaspoon with paracetamol syrup, mean volume was 4.8 ml. CONCLUSIONS: Teaspoons and tablespoons are unreliable dosing devices, and thus their use should no longer be recommended.

Effect of body mass index on the outcome of infections: a systematic review.

It has not been adequately evaluated whether the outcome of infections differs by body-weight category. We performed a systematic review of relevant studies. Eleven studies (one retrospective and 10 prospective cohort studies) were included in this review, involving a total of 3159 hospitalized patients or nursing home residents. Most studies (6/11) referred to lower respiratory tract infections. Seven studies showed an association of patient outcome (mortality in 6/7 studies) with body-weight category. This was shown in multivariate analysis in 4/5 studies that reported relevant data. Obese or morbidly obese patients with infections had worse outcome compared with the rest of the patients or with normal-weight patients, in 4/7 studies that reported relevant data; findings were not significant in the remaining three studies. Patients in the lowest body mass index (BMI) group had worse outcome compared with all other groups combined, in 3/5 studies that reported relevant data; findings were not significant in the remaining two studies. Low BMI was associated with worse outcome in patients with lower respiratory tract infections in 3/4 relevant studies. Although not consistently reported, an association of both ends of the BMI distribution with worse outcome of infections is plausible and merits further investigation.

Effect of meteorological variables on the incidence of lower urinary tract infections.

Several types of infections involving the respiratory tract have a seasonal variation. We further examined whether lower urinary tract infections (UTIs) are associated with meteorological parameters. We retrospectively evaluated the correlation of the weekly percentage of house call visits for lower UTIs (relatively to all house call visits, excluding those for respiratory tract infections), performed by "SOS Doctors" specialized physicians in Attica, Greece (1/11/2000-18/1/2005), with the average weekly temperature and humidity, recorded at the same area, 3 days earlier. Three thousand two hundred and twenty-one visits for lower UTIs were recorded in patients of 62.9 +/- 21.0 years of age. House call visits for lower UTIs, as defined above, correlated with the average weekly temperature (Spearman's rho+0.468) and humidity (Spearman's rho -0.394); similarly, if respiratory tract infections were not excluded from the calculations (Spearman's rho +0.491 and -0.406, respectively); or if a 2-day lag between measurements was used (Spearman's rho +0.468 and -0.386, respectively). All the above findings were significant (p<0.001). In conclusion, in a population that consisted mainly of patients of advanced age, higher temperature and decreased humidity are associated with an increase in house call visits for lower UTIs. The awareness of this association may facilitate preventive public health strategies. [corrected]

Matching criteria in case-control studies on postoperative infections.

Matching is commonly used in case-control studies to control for the effect of major confounding factors. We evaluated the available evidence from case-control studies regarding postoperative infections to identify how frequently matching was performed and with what specific variables. We searched for relevant case-control studies in PubMed until August 2006 and further evaluated those that used individual matching between cases and controls. We identified and evaluated 42 relevant studies. Age was used as a matching criterion in 27 of these 42 (64.3%) case-control studies. The specific type of surgical procedure was the second most commonly used criterion in 17 of 42 studies (40.5%). Gender was used in 14/42 studies (33.3%) as a matching criterion between case and control patients. The period at risk for development of surgical site and/or other postoperative infections, i.e. time from surgery to the diagnosis of infection, was used in nine of 42 studies (21.4%), as was date of operation, and the primary diagnosis that led the case and control patients to surgery. The same surgeon or surgical team was used in seven studies (16.7%); matching according to the National Nosocomial Infection Surveillance system risk score was performed in five studies (11.9%). The findings of our analysis suggest that various characteristics are used for matching in case-control studies of postoperative infections. A more consistent use of matching with the specific type of surgical procedure may help in increasing the internal validity of a case-control study in this field of clinical research.

Meta-analysis: ertapenem for complicated intra-abdominal infections.

BACKGROUND: Ertapenem is a new member of the carbapenem class of antibiotics, with a favourable pharmacokinetic profile, but a narrower spectrum of antimicrobial activity, compared with older representatives of this class. AIM: To evaluate the effectiveness and safety of ertapenem for treatment of complicated intra-abdominal infections. METHODS: We performed a meta-analysis of randomized-controlled trials identified in PubMed, Cochrane and Scopus that compared ertapenem with other antimicrobial regimens, in patients of all ages, with complicated intra-abdominal infections. The primary outcomes evaluated were clinical success (cure or improvement) in the modified intention-to-treat population and clinical adverse events. RESULTS: Six randomized-controlled trials involving patients with complicated intra-abdominal infections, mainly of mild-to-moderate severity (three with a double-blind design; one performed in children) that compared ertapenem treatment (once daily) against piperacillin/tazobactam, ceftriaxone plus metronidazole and ticarcillin/clavulanic acid (in three, two and one randomized-controlled trials respectively) were included. No difference was found between adult patients with complicated intra-abdominal infections treated with ertapenem vs. comparators, regarding clinical success (five randomized-controlled trials, 2002 patients, fixed-effect model, odds ratio: 1.11, 95% confidence interval (CI): 0.89-1.39); clinical adverse events (four randomized-controlled trials, 1530 patients, fixed-effect model, OR: 0.86, 95% CI: 0.61-1.20); microbiological success; mortality and withdrawals because of adverse events. Ertapenem was associated with more laboratory adverse events (four randomized-controlled trials, 1530 patients, fixed-effect model, OR: 1.73, 95% CI: 1.14-2.61), but none was reported as serious. CONCLUSION: This meta-analysis provides additional evidence that ertapenem can be used as effectively and safely, as other recommended antimicrobial regimens, for the treatment of complicated intra-abdominal infections, particularly of mild-to-moderate severity.

Vaccination of asplenic or hyposplenic adults.

BACKGROUND: Sepsis is a feared complication in patients with an absent or dysfunctioning spleen. METHODS: A literature search was undertaken to identify recommendations for vaccination in asplenic or hyposplenic adults, and published data regarding the effectiveness of the vaccines in reducing the incidence of infections, and vaccine failures. RESULTS: Various committees and organizations recommend that the pneumococcal, meningococcal and Haemophilus influenza vaccine, plus booster doses, should be administered to patients with an absent or dysfunctional spleen. However, adherence to such recommendations varies. Furthermore, vaccine failures still occur in a subset of properly immunized individuals. Immunocompromised individuals, in particular, have a greater risk of inadequate antibody response. CONCLUSION: Immunization is partially responsible for the observed reduction in sepsis after splenectomy.

Meta-analysis: randomized controlled trials of clindamycin/aminoglycoside vs. beta-lactam monotherapy for the treatment of intra-abdominal infections.

AIM: To compare the effectiveness and safety of clindamycin/aminoglycoside with broad-spectrum beta-lactam monotherapy in patients with intra-abdominal infections by performing a meta-analysis of randomized controlled trials (RCTs). METHODS: The relevant 28 RCTS were retrieved from PubMed searches and reviewed by two reviewers independently. RESULTS: beta-lactam monotherapy was more effective regarding cure of the infection than clindamycin/aminoglycoside (3177 clinically evaluable patients, fixed effects model, OR = 0.67, 95% CI: 0.55-0.81). The same result was found in several subset analyses. There was no difference in all-cause mortality and attributable-to-infection mortality [2382 intention-to-treat (ITT) patients, fixed effects model, OR = 1.25, 95% CI: 0.74-2.11 and 1976 ITT patients, OR = 1.19, 95% CI: 0.59-2.41, respectively]. There was no difference regarding overall adverse events and ototoxicity (1460 ITT patients, OR = 1.05, 95% CI: 0.80-1.37, and 1404 ITT patients, OR = 3.22, 95% CI: 0.72-14.45, respectively). However, treatment with clindamycin/aminoglycoside was more likely to be associated with nephrotoxicity compared to beta-lactam (3065 ITT patients, OR = 3.7, 95% CI: 2.09-6.57). Clindamycin/aminoglycoside was less likely to be associated with antibiotic-associated diarrhoea compared to beta-lactam (3050 ITT patients, OR = 0.68, 95% CI: 0.46-1.00). CONCLUSION: The results of our meta-analysis suggest that beta-lactams are more effective in the treatment of intra-abdominal infections compared with clindamycin/aminoglycoside.

Laparoscopy in the context of lower abdominal pain in young women.

The management of lower abdominal pain in young women carries up to 45% chance of diagnostic error. Laparoscopic management may be particularly beneficial in this subset of patients. This study reviews the authors' experience with laparoscopy as a potential diagnostic and therapeutic tool in young women with lower abdominal pain. The authors analyzed 121 consecutive female patients, with a mean age of 30 years, who were evaluated from June 1995 to October 1997. All patients were managed by early laparoscopy within 24 h from the onset of symptoms. Radiographic imaging, including computed tomography and ultrasound, was performed in 79 patients (65.2%). Laparoscopy was diagnostic in all cases. In 58 patients (48%), multiple pathologic conditions were identified. Acute appendicitis was the most common diagnosis (82.6%), and benign gynecologic disorders was the predominant reason for multiple pathologic conditions (clinical evaluation was erroneous in 15% of patients). In 96% of patients, definite surgical treatment was provided laparoscopically. The mean hospitalization time was 2.0 +/- 1 days, and the mean operative time was 59.8 +/- 21 min. The overall complication rate was 2.5%. In young women, early laparoscopy can offer a safe and effective alternative for the definite diagnosis and treatment of lower abdominal pain.

Ambulatory motility patterns of the transposed short segment colon.

Ambulatory manometry and pH-metry were performed on 10 asymptomatic patients who had undergone lower oesophageal replacement with the left hemicolon between two and 20 years previously. Recording of the ambient pH in the intrathoracic colon was carried out simultaneously. In every patient the recording, which lasted approximately eight hours, included upright, supine, prandial, and post-prandial periods. The results were analysed both visually and by computer. The emerging motility patterns showed three basic types of wave, based on amplitudes--low amplitude contractions (LAC) measuring < 60 mm Hg, medium amplitude contractions (MAC) of 60-100 mm Hg, and high amplitude contractions (HAC) of 100-200 mm Hg. Additional subtypes were identified in the LACs and MACs. Using software primarily designed for oesophageal motility, the proportion of propulsive (6%-55%) waves could be distinguished from simultaneous or mixed waves, or both. A proportion of propulsive waves was noted in patients who had undergone surgery 10 or more years previously. It is concluded that the transposed colon retains its normal motility pattern but some adaptation to its new location may occur in the long term.

Thoracoplasty in the context of current surgical practice.

Although widely employed for well over a century as a procedure for reducing the capacity of the thoracic cavity, thoracoplasty in current practice has become a rarity. A retrospective analysis of 37 patients (29 men, 8 women) who underwent the procedure under the care of one thoracic surgeon in a 16-year period provides the basis for this presentation. Ages ranged from 23 to 82 years with a mean age of 58 +/- 12.8. The mean follow-up was 8.5 years. Nineteen patients underwent the procedure for complications after lung resection for lung cancer. There were four perioperative deaths in this group (21.1%) and 6 long-term survivors (31.6%). Eighteen patients without lung cancer underwent thoracoplasty as a planned treatment or for complications. There were no perioperative deaths, two late deaths, and 16 long-term survivors (88.9%) in the group. In the entire series, the overall perioperative mortality rate was 10.8% with no major long-term morbidity. Although proper timing and proper patient selection are essential in the use of thoracoplasty as a procedure to cope with the septic complications of lung cancer resection, it is overall a safe and successful procedure that has a relatively low mortality and that leads to considerable improvement in quality of life.

Carcinoma developing in the neo-oesophagus following gastroplasty.

Carcinoma developing after gastroplasty and fundoplication has been documented in only five cases. We report a further case occurring in a patient 4 years after initial surgery. The tumour originated in the newly created tubular extension. There was no evidence of a columnar lining in the true oesophagus prior to surgery. The development, technique and complications of gastroplasty and partial fundoplication are discussed with special mention of the diagnostic problems when a tumour develops in a patient who has undergone this procedure.

Plasma fibronectin (Fn) study in homozygous beta-thalassemia: relation to splenectomy and transfusion.

The concentration of plasma Fn was determined in non-splenectomized and splenectomized patients with homozygous beta-thalassemia, before and 7-10 days after blood transfusion. The mean Fn concentration of non-splenectomized patients before transfusion did not differ from that of matched normal controls but appeared significantly decreased following blood transfusion. On the other hand, in splenectomized thalassemics, Fn levels were increased but were unrelated to transfusion. It is concluded that Fn plays some homeostatic function when RES activity of thalassemic patients is altered either as a result of splenectomy or blood transfusion.