MDCT of retractor-related hepatic injury following laparoscopic surgery: appearances, incidence, and follow-up.

AIMS: To investigate the postoperative computed tomography (CT) features resulting from the use of Nathanson retractors during laparoscopic upper gastro-intestinal surgery. MATERIALS AND METHODS: A 3-year retrospective study of 176 patients who had undergone laparoscopic upper gastro-intestinal surgery for bariatric or malignant disease was performed. Postoperative CT images [divided into early (≤ 30 days) and late (>30 days)] were assessed by a consultant radiologist and liver abnormalities recorded. RESULTS: The features of a retractor injury were a hypodense lesion, abutting the liver edge, usually triangular or linear in shape. Late postoperative features included focal subcapsular retraction and associated liver atrophy. Sixty-eight percent (52/77) of patients undergoing surgery for malignancy underwent postoperative CT, compared with 11% (11/99) of those undergoing bariatric surgery. Patients with malignancy were more likely to have retraction-related liver abnormalities (14/52, 27%) at postoperative CT than those in the bariatric group (2/11, 18%). CONCLUSION: Retractor-related liver injuries at MDCT are common following laparoscopic upper gastro-intestinal surgery. Recognition of the characteristic triad of features, a hypodense lesion abutting the liver edge with a triangular or linear shape, should allow confident diagnosis. CT follow-up reveals that over time these lesions may disappear, remain unchanged, or result in a focal subcapsular scar with associated atrophy.

The integration of transabdominal ultrasound simulators into an ultrasound curriculum.

INTRODUCTION: Simulation is increasingly used throughout medicine. Within ultrasound, simulators are more established for learning transvaginal and interventional procedures. The use of modern high-fidelity transabdominal simulators is increasing, particularly in centres with large trainee numbers. There is no current literature on the value of these simulators in gaining competence in abdominal ultrasound. The aim was to investigate the impact of a new ultrasound curriculum, incorporating transabdominal simulators into the first year of training in a UK radiology academy. METHODS: The simulator group included 13 trainees. The preceding cohort of 15 trainees was the control group. After 10 months, a clinical assessment was performed to assess whether the new curriculum resulted in improved ultrasound skills. Questionnaires were designed to explore the acceptability of simulation training and whether it had any impact on confidence levels. RESULTS: Trainees who had received simulator-enriched training scored higher in an objective clinical ultrasound assessment, which was statistically significant (p = 0.0463). End confidence scores for obtaining diagnostic images and demonstrating pathology were also higher in the simulation group. All trainees stated that transabdominal simulator training was useful in early training. CONCLUSIONS: This initial study shows that embedded into a curriculum, transabdominal ultrasound simulators are an acceptable training method that can result in improved ultrasound skills and higher confidence levels. Using simulators early in training could allow trainees to master the basics, improve their confidence, enabling them to get more educational value from clinical ultrasound experience while reducing the impact of training on service provision.

Building new hospitals: a UK infection control perspective.

Infection control input is vital throughout the planning, design and building stages of a new hospital project, and must continue through the commissioning (and decommissioning) process, evaluation and putting the facility into full clinical service. Many hospitals continue to experience problems months or years after occupying the new premises; some of these could have been avoided by infection control involvement earlier in the project. The importance of infection control must be recognized by the chief executive of the hospital trust and project teams overseeing the development. Clinical user groups and contractors must also be made aware of infection control issues. It is vital that good working relationships are built up between the infection control team (ICT) and all these parties. ICTs need the authority to influence the process. This may require their specific recognition by the Private Finance Initiative National Unit, the Department of Health or other relevant authorities. ICTs need training in how to read design plans, how to write effective specifications, and in other areas with which they may be unfamiliar. The importance of documentation and record keeping is paramount. External or independent validation of processes should be available, particularly in commissioning processes. Building design in relation to infection control needs stricter national regulations, allowing ICTs to focus on more local usage issues. Further research is needed to provide evidence regarding the relationship between building design and the prevalence of infection.

Evaluation of a new chromogenic medium, Uriselect 4, for the isolation and identification of urinary tract pathogens.

AIMS: To compare the performance of a new chromogenic medium, Uriselect 4, with cystine lactose electrolyte deficient (CLED) agar and an established chromogenic agar, CPS ID 2 medium, for detection of urinary tract pathogens. METHODS: Using a semiquantitative culture method, 777 samples were inoculated on to the three test media in duplicate. All bacterial strains that yielded a potentially significant growth were observed for colony colour and identified using standard methods. RESULTS: Of the 777 samples tested, 589 urine samples yielded potentially significant growth of at least one strain. A total of 811 strains were isolated on at least one of the three media. A total of 168 urine samples yielded a mixture of at least two strains. Uriselect 4 medium showed the best sensitivity of the three media and only failed to recover 14 strains (1.7%). CPS ID 2 medium failed to recover 22 strains (2.7%). CLED medium showed the worst recovery and failed to recover 74 strains (9.1%). Both chromogenic media allowed for identification of Escherichia coli with a high degree of specificity (98% for Uriselect 4, 99.7% for CPS ID 2). Inclusion of a spot indole test increased the specificity of both chromogenic media to 100% for E coli. CONCLUSIONS: Uriselect 4 and CPS ID 2 were superior to CLED medium for the isolation of urinary tract pathogens mainly because of their ability to discriminate mixed cultures. Both chromogenic media were also useful for the preliminary identification of the most common urinary tract pathogens.

Outbreak of gram-negative septicaemia caused by contaminated continuous infusions prepared in a non-clinical area.

An outbreak of Gram-negative septicaemia due to cross infection on an acute cardiology ward is reported. This outbreak was facilitated by two factors: first, an area originally designed for non-clinical purposes was converted into a clean utility area without consulting the infection control team, and second, changes in staff had taken place at the same time. This outbreak emphasizes the importance of continuous staff training in infection control, the involvement of the infection control team in all building alterations and the need to improve recommendations by the Department of Health in the design of clean utility areas.

A novel selective medium for the detection of methicillin-resistant Staphylococcus aureus enabling result reporting in under 24 h.

A simple selective broth was devised to indicate the presence of methicillin resistant Staphylococcus aureus (MRSA) in clinical samples. The broth comprised nutrient broth supplemented with sodium chloride, ciprofloxacin, colistin and aztreonam as selective agents and also mannitol, trehalose and phenol red as an indicator system. In a preliminary study using 228 clinical samples this selective mannitol broth (SMB) proved to be more sensitive than other selective agars for detection of MRSA within 24 h. In an extended study of a further 1124 clinical samples from 470 randomly selected patients, SMB detected 85.1% of MRSA strains present with a specificity of 43.6%. We conclude that SMB offers a convenient, inexpensive and sensitive method for high-throughput screening for MRSA.

Survival of enterococci during hospital laundry processing.

Much remains to be elucidated about the epidemiology of nosocomial enterococcal infections. Enterococci are, however, known to be relatively thermotolerant, and several studies have shown that under laboratory conditions many strains are able to survive the time/temperature combinations of the UK Department of Health recommendations for the decontamination of used linen (HSG(95)18). We therefore wished to investigate the efficacy of decontamination of enterococci from hospital linen in working hospital laundries. The thermotolerance of 40 strains of Enterococcus faecalis and Enterococcus faecium was first determined. Reduction by a factor of greater than 10(5) was achieved in only two of 40 strains after 3 min at 71 degrees C or 10 min at 65 degrees C, the time/temperature combinations specified by the Department of Health for the disinfection of used linen. During experimental challenge of 10 working hospital laundries, however, we demonstrated successful decontamination of laundry artificially contaminated with enterococci. This was shown to take place during the washing stage. Our study suggests that, despite the relative thermotolerance of enterococci, the time/temperature combinations specified in HSG(95)18 should be adequate for their decontamination in hospital laundries.

Evaluation of tube coagulase and a fluorogenic substrate for rapid detection of methicillin-resistant Staphylococcus aureus from selective enrichment broth in an outbreak of EMRSA 15.

We investigated the use of tube coagulase and a fluorescent substrate, N-t-BOC-val-pro-arg-7-amido-4-methylcoumarin for the rapid detection of MRSA in selective broth enrichment cultures during an outbreak. These methods were compared with direct plating of swabs and plating a selective broth enrichment culture using 200 screening swabs collected from forty patients during the investigation of an outbreak of E-MRSA 15. Overall 66 swabs were positive for MRSA following subculture of broth enrichment culture. Direct plating detected 25 (38%) positives, tube coagulase 37 (56%), and fluorescent substrate 49 (74%) respectively, although nine of the 49 turned out to be false reactions. When detection from individual patients was analyzed, selective broth subculture identified 28 patients colonized with MRSA. Direct plating detected only 12 (43%) of these patients. The tube coagulase and fluorescence methods detected MRSA in 17 (60%) and 19 (68%) patients respectively. The tube coagulase method was found to be 100% specific for MRSA suggesting its use as a rapid method for the detection of MRSA from selective enrichment broth.

A mass in the liver.

We report a case of alveolar echinococcosis. To our knowledge this is the first report of human alveolar echinococcosis to be confirmed in the UK and if contracted in Afghanistan the first report for that country.

Outcome of Toxoplasma gondii mismatches in heart transplant recipients over a period of 8 years.

Donor-related infection due to Toxoplasma gondii is a well-recorded complication of cardiac transplantation. In order to assess the efficacy of co-trimoxazole in small doses as prophylaxis for primary Toxoplasma gondii infection in seronegative heart and heart-lung transplant recipients receiving organs from seropositive donors, we reviewed the serostatus and clinical outcome of all such mismatched transplants performed at our unit over a period of 8 years. Of 310 transplants performed between May 1985 and May 1993, donor and recipient serum samples were available for 257 heart and 33 heart-lung transplants. Of these, 13 (4.5%) were toxoplasma mismatches. Post-transplant review serum samples were available for 3 months or longer for nine of the 13 mismatches. The first three patients received co-trimoxazole 480 mg bd orally for 3 months (regimen A) while the remainder received only the standard prophylaxis designed for Pneumocystis carinii i.e., 960 mg bd orally three times per week for 3 months (regimen B). Seroconversion was demonstrated in only one patient (regimen A). Furthermore, none of the mismatched patients developed serious infection compatible with primary toxoplasmosis. We therefore conclude that in centres with a low prevalence of toxoplasma seropositivity, testing of donor and recipient serum for Toxoplasma gondii antibody should be performed only when clinically indicated and, in addition, standard prophylaxis for Pneumocystis carinii may be adequate for preventing primary toxoplasmosis.

Tuberculosis transmitted through transplantation.

Tuberculosis in solid organ transplant recipients is associated with relatively high morbidity and mortality and is often extra-pulmonary. Reactivation of dormant infection is the usual mode of acquisition with donor and nosocomial transmission occurring infrequently. We report two cases of probable donor transmitted extra-pulmonary infection where both isolates of Mycobacterium tuberculosis proved to be indistinguishable using hemi-nested inverse PCR of the IS 6110 region.