Purified Chlorine Dioxide as an Alternative to Chlorine Disinfection to Minimize Chlorate Formation During Postharvest Produce Washing.

The washwater used to wash produce within postharvest washing facilities frequently contains high chlorine concentrations to prevent pathogen cross-contamination. To address concerns regarding the formation and uptake of chlorate (ClO3-) into produce, this study evaluated whether switching to chlorine dioxide (ClO2) could reduce chlorate concentrations within the produce. Because ClO2 exhibits lower disinfectant demand than chlorine, substantially lower concentrations can be applied. However, ClO3- can form through several pathways, particularly by reactions between ClO2 and the chlorine used to generate ClO2 via reaction with chlorite (ClO2-) or chlorine that forms when ClO2 reacts with produce. This study demonstrates that purging ClO2 from the chlorine and ClO2- mixture used for its generation through a trap containing ClO2- can scavenge chlorine, substantially reducing ClO3- concentrations in ClO2 stock solutions. Addition of low concentrations of ammonia to the produce washwater further reduced ClO3- formation by binding the chlorine produced by ClO2 reactions with produce as inactive chloramines without scavenging ClO2. While chlorate concentrations in lettuce, kale, and broccoli exceeded regulatory guidelines during treatment with chlorine, ClO3- concentrations were below regulatory guidelines for each of these vegetables when treated with ClO2 together with these two purification measures. Switching to purified ClO2 also reduced the concentrations of lipid-bound oleic acid chlorohydrins and protein-bound chlorotyrosines, which are exemplars of halogenated byproducts formed from disinfectant reactions with biomolecules within produce.

Formation of Oleic Acid Chlorohydrins in Vegetables during Postharvest Chlorine Disinfection.

High chlorine doses (50-200 mg/L) are used in postharvest washing facilities to control foodborne pathogen outbreaks. However, chlorine can react with biopolymers (e.g., lipids) within the produce to form chlorinated byproducts that remain in the food. During chlorination of micelles of oleic acid, an 18-carbon alkene fatty acid, chlorine added rapidly across the double bond to form the two 9,10-chlorohydrin isomers at a 100% yield. The molar conversion of lipid-bound oleic acid to 9,10-chlorohydrins in chlorine-treated glyceryl trioleate and produce was much lower, reflecting the restricted access of chlorine to lipids. Yields from spinach treated with 100 mg/L chlorine at 7.5 °C for 2 min increased from 0.05% (0.9 nmol/g-spinach) for whole leaf spinach to 0.11% (2 nmol/g) when shredding increased chlorine access. Increasing temperature (21 °C) and chlorine contact time (15 min) increased yields from shredded spinach to 0.83% (22 nmol/g) at 100 mg/L chlorine and to 1.8% (53 nmol/g) for 200 mg/L chlorine. Oleic acid 9,10-chlorohydrin concentrations were 2.4-2.7 nmol/g for chlorine-treated (100 mg/L chlorine at 7.5 °C for 2 min) broccoli, carrots, and butterhead lettuce, but 0.5-1 nmol/g for cabbage, kale, and red leaf lettuce. Protein-bound chlorotyrosine formation was higher in the same vegetables (5-32 nmol/g). The Chinese hamster ovary cell chronic cytotoxicity LC50 value for oleic acid 9,10-chlorohydrins was 0.106 mM. The cytotoxicity associated with the chlorohydrins and chlorotyrosines in low masses (9-52 g) of chlorine-washed vegetables would be comparable to that associated with trihalomethanes and haloacetic acids at levels of regulatory concern in drinking water.

Evaluation of Histidine Reactivity and Byproduct Formation during Peptide Chlorination.

The covalent modifications resulting from chlorine reactions with peptide-bound amino acids contribute to pathogen inactivation and disinfection byproduct (DBP) formation. Previous research suggested that histidine is the third most reactive of the seven chlorine-reactive amino acids, leading to the formation of 2-chlorohistidine, 2-oxohistidine, or low-molecular-weight byproducts such as trihalomethanes. This study demonstrates that histidine is less reactive toward formation of chlorine transformation products (transformation time scale of hours to days) than five of the seven chlorine-reactive amino acids, including tyrosine (transformation time scale of minutes). Chlorine targeted tyrosine in preference to histidine within peptides, indicating that chlorine reactions with tyrosine and other more reactive amino acids could contribute more to the structural modifications to proteins over the short time scales relevant to pathogen inactivation. Over the longer time scales relevant to disinfection byproduct formation in treatment plants or distribution systems, this study identified ß-cyanoalanine as the dominant transformation product of chlorine reactions with peptide-bound histidine, with molar yields of ∼50% after 1 day. While a chlorinated histidine intermediate was observed at lower yields (maximum ∼5%), the cumulative concentration of the conventional low-molecular-weight DBPs (e.g., trihalomethanes) was ≤7%. These findings support the need to identify the high-yield initial transformation products of chlorine reactions with important precursor structures to facilitate the identification of unknown DBPs.

Comparison of survival of stage I-III colon cancer by travel distance and hospital volume.

BACKGROUND: Previous studies have demonstrated improved outcomes at high-volume colorectal surgery centers; however, the benefit for patients who live far from such centers has not been assessed relative to local, low-volume facilities. METHODS: The 2010-2015 National Cancer Database (NCDB) was queried for patients with stage I-III colon adenocarcinoma undergoing treatment at a single center. A 'local, low-volume' cohort was constructed of 12,768 patients in the bottom quartile of travel distance at the bottom quartile of institution surgical volume and a 'travel, high-volume' cohort of 11,349 patients in the top quartile of travel distance at the top quartile of institution surgical volume. RESULTS: In unadjusted analysis, patients in the travel cohort had improved rates of positive resection margins (3.7% vs. 5.5%, p < 0.001), adequate lymph-node harvests (92% vs. 83.6%, p < 0.001), and 30- (2.2% vs. 3.9%, p < 0.001) and 90-day mortality (3.7% vs. 6.4%, p < 0.001). On multivariable logistic regression analysis adjusting for patient demographic, tumor, and facility characteristics, the cohorts demonstrated equivalent overall survival (HR: 0.972, p = 0.39), with improved secondary outcomes in the 'travel' cohort of adequate lymph-node harvesting (OR: 0.57, p < 0.001), and 30- (OR 0.79, p = 0.019) and 90-day mortality (OR 0.80, p = 0.004). CONCLUSIONS: For patients with stage I-III colon cancer, traveling to high-volume institutions compared to local, low-volume centers does not convey an overall survival benefit. However, given advantages including 30- and 90-day mortality and adequate lymph-node harvest, nuanced patient recommendations should consider both these differences and the unquantified benefits to local care, including cost, travel time, and support systems.

Chlorotyrosines versus Volatile Byproducts from Chlorine Disinfection during Washing of Spinach and Lettuce.

Following the Food Safety Modernization Act of 2011 in the U.S., guidelines for disinfection washes in food packaging facilities are under consideration to control pathogen risks. However, disinfectant exposures may need optimization because the high concentrations of chlorine disinfectant promote the formation of high levels of disinfection byproducts (DBPs). When chlorine doses up through the 200 mg/L as Cl2 range relevant to the current practice were applied to spinach and lettuce, significant DBP formation was observed, even within 5 min at 7 °C. Concentrations of volatile chlorinated DBPs in washwater were far higher than typically observed in disinfected drinking water (e.g., 350 µg/L 1,1-dichloropropanone). However, these DBPs partitioned to the aqueous phase and so represent a greater concern for the disposal or reuse of washwater than for consumer exposure via food. The volatile DBPs represent the low-yield, final products of chlorination reactions with multiple biomolecular precursors. The initial, high-yield transformation products of such reactions may represent a greater concern for consumer exposure because they remain bound within the biopolymers in food and would be liberated during digestion. Using protein-bound tyrosine as an example precursor, the concentrations of the initial 3-chlorotyrosine and 3,5-dichlorotyrosine transformation products from this one precursor in the leaf phase were comparable to, and, in the case of some lettuces, exceeded, the aggregate aqueous concentration of volatile DBPs formed from multiple precursors. Chlorotyrosine formation increased when spinach was shredded due to the greater accessibility of chlorine to proteins in the leaf interiors. The cytotoxicity of chlorotyrosines to Chinese hamster ovary cells was higher than any of the trihalomethanes regulated in drinking water.

Association between neoadjuvant chemoradiation and survival for patients with locally advanced rectal cancer.

AIM: To examine the overall survival differences for the following neoadjuvant therapy modalities - no therapy, chemotherapy alone, radiation alone and chemoradiation - in a large cohort of patients with locally advanced rectal cancer. METHOD: Adults with clinical Stage II and III rectal adenocarcinoma were selected from the National Cancer Database and grouped by type of neoadjuvant therapy received: no therapy, chemotherapy only, radiotherapy only or chemoradiation. Multivariable regression methods were used to compare adjusted differences in perioperative outcomes and overall survival. RESULTS: Among 32 978 patients included, 9714 (29.5%) received no neoadjuvant therapy, 890 (2.7%) chemotherapy only, 1170 (3.5%) radiotherapy only and 21 204 (64.3%) chemoradiation. Compared with no therapy, chemotherapy or radiotherapy alone were not associated with any adjusted differences in surgical margin positivity, permanent colostomy rate or overall survival (all P > 0.05). With adjustment, neoadjuvant chemoradiation vs no therapy was associated with a lower likelihood of surgical margin positivity (OR 0.74, P < 0.001), decreased rate of permanent colostomy (OR 0.77, P < 0.001) and overall survival [hazard ratio (HR) 0.79, P < 0.001]. When compared with chemotherapy or radiotherapy alone, chemoradiation remained associated with improved overall survival (vs chemotherapy alone HR 0.83, P = 0.04; vs radiotherapy alone HR 0.83, P < 0.019). CONCLUSION: Neoadjuvant chemoradiation, not chemotherapy or radiotherapy alone, is important for sphincter preservation, R0 resection and survival for patients with locally advanced rectal cancer. Despite this finding, one-third of patients in the United States with locally advanced rectal cancer fail to receive stage-appropriate chemoradiation.

Patterns of Use and Short-Term Outcomes of Minimally Invasive Surgery for Malignant Pheochromocytoma: A Population-Level Study.

BACKGROUND: Malignant pheochromocytoma is rare, and there is a scarcity of data on the use of minimally invasive surgery (MIS) for treatment. The aims of this study were to analyze patterns of use of MIS for malignant pheochromocytoma in the U.S. and compare short-term outcomes to those of open adrenalectomy. METHODS: Patients with malignant pheochromocytoma undergoing MIS, including laparoscopy, robotic assisted, laparoscopy converted to open, or open adrenalectomy, were culled from the National Cancer Database, from 1998 to 2011. Data were examined using simple summary statistics, Χ2 and student's t tests, Mann-Whitney test, and logistic regression. RESULTS: A total of 36 MIS and 67 open adrenalectomies were identified in 2010-2011. No significant differences were observed between the two treatment groups in demographic characteristics or comorbidities. Preoperative diagnosis of malignancy was made in 52.8% of MIS and 48.5% of open patients (p=NS). MIS and open adrenalectomies did not differ with respect to lymph node metastases, vascular invasion, extra-adrenal-extension, and distant metastases (all p=NS). MIS tended to more often be used to perform partial adrenalectomy (38.9 vs. 20.4% open, p=0.061); surgical margins, 30-day readmission and mortality rates were similar to open adrenalectomy (all p=NS). Tumors removed via MIS were smaller (48.7 vs. 73.3 mm open, p=0.003) and associated with a shorter length of stay. CONCLUSIONS: A significant proportion of patients with malignant pheochromocytomas underwent MIS, with short-term outcomes which are comparable to those of open surgery. Further studies focused on long-term survival and recurrence are needed to assess the role of MIS in the management of these rare tumors.

Who is monitoring your infections: shouldn't you be?

BACKGROUND: In the era of pay for performance and outcome comparisons among institutions, it is imperative to have reliable and accurate surveillance methodology for monitoring infectious complications. The current monitoring standard often involves a combination of prospective and retrospective analysis by trained infection control (IC) teams. We have developed a medical informatics application, the Surgical Intensive Care-Infection Registry (SIC-IR), to assist with infection surveillance. The objectives of this study were to: (1) Evaluate for differences in data gathered between the current IC practices and SIC-IR; and (2) determine which method has the best sensitivity and specificity for identifying ventilator-associated pneumonia (VAP). METHODS: A prospective analysis was conducted in two surgical and trauma intensive care units (STICU) at a level I trauma center (Unit 1: 8 months, Unit 2: 4 months). Data were collected simultaneously by the SIC-IR system at the point of patient care and by IC utilizing multiple administrative and clinical modalities. Data collected by both systems included patient days, ventilator days, central line days, number of VAPs, and number of catheter-related blood steam infections (CR-BSIs). Both VAPs and CR-BSIs were classified using the definitions of the U.S. Centers for Disease Control and Prevention. The VAPs were analyzed individually, and true infections were defined by a physician panel blinded to methodology of surveillance. Using these true infections as a reference standard, sensitivity and specificity for both SIC-IR and IC were determined. RESULTS: A total of 769 patients were evaluated by both surveillance systems. There were statistical differences between the median number of patient days/month and ventilator-days/month when IC was compared with SIC-IR. There was no difference in the rates of CR-BSI/1,000 central line days per month. However, VAP rates were significantly different for the two surveillance methodologies (SIC-IR: 14.8/1,000 ventilator days, IC: 8.4/1,000 ventilator days; p = 0.008). The physician panel identified 40 patients (5%) who had 43 VAPs. The SIC-IR identified 39 and IC documented 22 of the 40 patients with VAP. The SIC-IR had a sensitivity and specificity of 97% and 100%, respectively, for identifying VAP and for IC, a sensitivity of 56% and a specificity of 99%. CONCLUSIONS: Utilizing SIC-IR at the point of patient care by a multidisciplinary STICU team offers more accurate infection surveillance with high sensitivity and specificity. This monitoring can be accomplished without additional resources and engages the physicians treating the patient.

Fever and leukocytosis in critically ill trauma patients: it is not the blood.

The diagnosis of bacteremia in critically ill patients is classically based on fever and/or leukocytosis. The objectives of this study were to determine 1) if our intensive care unit obtains blood cultures based on fever and/or leukocytosis over the initial 14 days of hospitalization after trauma; and 2) the efficacy of this diagnostic workup. An 18-month retrospective cohort analysis was performed on consecutively admitted trauma patients. Data collected included demographics, injuries, and the first 14 days maximal daily temperature, leukocyte count, and results of blood and catheter tip cultures. Fever was defined as a maximum daily temperature of 38.5 degrees C or greater and leukocytosis as a leukocyte count 12,000/mm3 or greater of blood. Five hundred ten patients were evaluated for a total of 3,839 patient-days. The mean age and injury severity score were 49 +/- 1 years and 19 +/- 1, respectively. Four hundred twenty-five blood culture episodes were obtained and 25 (6%) bacteremias were identified in 23 patients (5%). A significant association was found between obtaining blood cultures in patients with fever (relative risk [RR], 7.7), leukocytosis (RR, 1.3), and fever + leukocytosis (RR, 3.2). However, no significant association was found between these clinical signs and the diagnosis of bacteremia. In fact, fever alone was inversely associated with bacteremia. Our intensive care unit follows the common "fever workup" practice and obtains blood cultures based on the presence of fever and leukocytosis. However, fever and leukocytosis were not associated with bacteremia, suggesting inefficiency and that other factors are more important after trauma.

The Surgical Intensive Care-infection Registry: a research registry with daily clinical support capabilities.

Infections in the surgical and trauma intensive care unit (STICU) are responsible for significant patient morbidity and mortality. Research into these infectious complications often uses administrative databases or clinical information systems designed for documenting and billing daily patient care. Neither of these sources is intended for research, and many investigators have questioned their accuracy. The Surgical Intensive Care-Infection Registry (SIC-IR) was developed as a research data repository to use to monitor STICU infections. SIC-IR is a relational database application designed to collect quality data and to integrate with daily patient care. SIC-IR prospectively collects and archives more than 100 clinical variables daily on each STICU patient to ensure completeness and correctness of the registry. Furthermore, SIC-IR aids in clinical activities by providing patient summaries and medical record documentation. SIC-IR provides accurate data for STICU infection research and enables the users to easily undertake quality-of-care improvement initiatives.

Serum electrolytes can promote hydroxyl radical-initiated biomolecular damage from inflammation.

Chronic inflammatory disorders are associated with biomolecular damage attributed partly to reactions with Reactive Oxygen Species (ROS), particularly hydroxyl radicals (•OH). However, the impacts of serum electrolytes on ROS-associated damage has received little attention. We demonstrate that the conversion of •OH to carbonate and halogen radicals via reactions with serum-relevant carbonate and halide concentrations fundamentally alters the targeting of amino acids and loss of enzymatic activity in catalase, albumin and carbonic anhydrase, three important blood proteins. Chemical kinetic modeling indicated that carbonate and halogen radical concentrations should exceed •OH concentrations by 6 and 2 orders of magnitude, respectively. Steady-state γ-radiolysis experiments demonstrated that serum-level carbonates and halides increased tyrosine, tryptophan and enzymatic activity losses in catalase up to 6-fold. These outcomes were specific to carbonates and halides, not general ionic strength effects. Serum carbonates and halides increased the degradation of tyrosines and methionines in albumin, and increased the degradation of histidines while decreasing enzymatic activity loss in carbonic anhydrase. Serum electrolytes increased the degradation of tyrosines, tryptophans and enzymatic activity in the model enzyme, ketosteroid isomerase, predominantly due to carbonate radical reactions. Treatment of a mutant ketosteroid isomerase indicated that preferential targeting of the active site tyrosine accounted for half of the total tyrosine loss. The results suggest that carbonate and halogen radicals may be more significant than •OH as drivers for protein degradation in serum. Accounting for the selective targeting of biomolecules by these daughter radicals is important for developing a mechanistic understanding of the consequences of oxidative stress.

Heparin-induced thrombocytopenia: a stoichiometry-based model to explain the differing immunogenicities of unfractionated heparin, low-molecular-weight heparin, and fondaparinux in different clinical settings.

INTRODUCTION: Heparin-induced thrombocytopenia (HIT) is caused by platelet-activating antibodies that recognize platelet factor 4 (PF4)/heparin complexes. The frequency of HIT is highly variable in different clinical settings, and is more frequent with unfractionated heparin (UFH) than with low-molecular-weight heparin (LMWH), despite the in vitro observation that HIT antibodies activate platelets similarly well with LMWH as with UFH. An important difference between UFH, LMWH, and fondaparinux is their widely differing plasma concentrations. We aimed to provide a model that included anticoagulant concentrations and PF4 availability as risk factors influencing the anti-PF4/heparin immune response. MATERIALS AND METHODS: By photon correlation spectroscopy we determined the concentrations at which UFH, LMWH, and fondaparinux form complexes optimally with PF4. Plasma concentrations of UFH and LMWH were calculated based on ex vivo pharmacokinetic data, with information on fondaparinux and PF4 concentrations taken from the literature. RESULTS AND CONCLUSIONS: The main features of our model are: optimal complex formation occurs at prophylactic-dose UFH and high PF4 levels, whereas therapeutic-dose LMWH concentrations are too high for optimal complex formation; in contrast, concentrations of fondaparinux are usually below the optimal stoichiometric range. Thus, immunization should occur more often in situations with major rather than minor platelet activation, and--for a given degree of platelet activation (PF4 availability)--as: prophylactic-dose UFH>therapeutic-dose UFH>prophylactic-dose LMWH, fondaparinux>therapeutic-dose LMWH. Our model provides a framework for explaining empirical observations that LMWH induces less anti-PF4/heparin antibodies than does UFH, and that anti-PF4/heparin antibodies are more often found in patients undergoing major surgery than in medical patients.

Fever and leukocytosis in critically ill trauma patients: it's not the urine.

BACKGROUND: Infectious complications are a major cause of morbidity and mortality in critically ill trauma patients. Therefore, fever and leukocytosis often trigger an extensive laboratory workup that includes a urine culture (UCx). The purposes of this study were to: 1) Define the current practice for obtaining UCxs in trauma patients admitted to the surgical and trauma intensive care unit (STICU); and 2) determine if there is an association between fever or leukocytosis and urinary tract infections (UTIs) during the initial 14 hospital days. METHODS: An 18-month retrospective cohort analysis was performed on consecutive trauma patients admitted for at least two days to the STICU at a level I trauma center. Data collected included demographics, injuries, and daily maximal temperature (T(max)), leukocyte count, and UCx results for the first 14 days. Fever and leukocytosis were defined as T(max) > or =38.5 degrees C and leukocyte count > or =12,000/mm(3), respectively. Urinary tract infections were diagnosed with a positive UCx (> or =10(5) organisms/mL of urine). RESULTS: Five hundred ten patients were evaluated for a total of 3,839 patient-days. Their mean age and Injury Severity Score were 49 +/- 1 years and 19 +/- 1 points, respectively. Seventy-two percent were men, and 91% had sustained blunt injuries. Four hundred seven UCxs were obtained; 42 patients (8%) had 60 UTIs. The cohort had an indwelling urinary catheter for 97% of the patient-days, yielding an infection density of 16 UTIs/1,000 urinary catheter-days. There was a significant association between obtaining a UCx and fever and between fever and leukocytosis (both, p < 0.001), but no association of UTI with fever, leukocytosis, or the combination of fever and leukocytosis. Analysis using temperature and leukocyte count as continuous variables identified no temperature or leukocyte range associated with UTIs. Independent risk factors for UTI calculated by logistic regression were female sex, older age, low Injury Severity Score, and no antibiotics within 24 h before the UCx was obtained. CONCLUSIONS: The practice of obtaining a UCx from the STICU trauma patient was related to fever and fever with leukocytosis. However, neither fever nor leukocytosis nor both were associated with UTIs. These data suggest that there is an unnecessary emphasis on UTI as a source of fever and leukocytosis in injured patients during their first 14 STICU days. Our results suggest that the paradigm for evaluating UTI as a cause of fever needs to be reevaluated in critically ill trauma patients.

Gene transfer by retrovirus vectors occurs only in cells that are actively replicating at the time of infection.

Previous reports have shown that retrovirus infection is inhibited in nonreplicating (stationary-phase [hereafter called stationary]) cells. Infection of stationary cells was shown to occur when the cells were allowed to replicate at times up to a week after infection, suggesting that an unintegrated retrovirus could persist in a form that was competent to integrate after release of the block to replication. However, those studies were complicated by the use of replication-competent virus, which can spread in the infected cells. We have used a replication-defective retrovirus vector to compare the efficiency of gene transfer in stationary and replicating rat embryo fibroblasts. In agreement with previous results, gene transfer was inhibited 100-fold in stationary versus replicating cells. In contrast to previously reported results, the block to infection could not be relieved by stimulating stationary cells to divide at times from 6 h to 10 days after infection. Thus, for successful retroviral infection, the infected cells must be replicating at the time of infection. These results have important implications for the use of retroviral vectors for gene transfer.

Premarital HIV screening in Johor--(2002-2004).

A descriptive study was conducted on premarital HIV screening programme in Johor over a three year period. HIV screenings were done at government clinics and confirmed by accredited laboratories. As a result, 123 new HIV cases were detected (0.17%) from 74,210 respondents. In 2004, 24 cases (64.9%) advanced to marriage (n = 37) after they underwent counselling and six of them married among themselves. Positivity rate from this programme (0.17%) is higher than antenatal screening (0.05%). Despite the implementation of the premarital HIV screening programme, marriage application in Johor rose 2.8% in 2004 compared with 2002. This programme had partly contributed to public awareness against HIV and provides another option in early detection of the disease.

R-region cDNA inserts in retroviral vectors are compatible with virus replication and high-level protein synthesis from the insert.

Protein expression from retroviral vectors is often highest when the expressed cDNA is driven by the retroviral promoter. However, the typical retroviral vector design places the cDNA downstream of the retroviral packaging signal and far from the retroviral promoter. In an attempt to improve protein production levels from cDNAs expressed in retroviral vectors, we inserted the MyoD or the purine nucleoside phosphorylase (PNP) cDNAs into the R regions of both retroviral LTRs, close to the retroviral promoter and just upstream of the polyadenylation signal present in each long terminal repeat (LTR). These R-region double-copy vectors could be produced in unrearranged form, although the titer was about seven-fold lower than that of typical vectors. R-region positioning of the MyoD cDNA resulted in five-fold higher MyoD expression compared to MyoD expression in a typical vector, whereas PNP expression was not improved. Thus, R-region double-copy vectors provide an alternative vector design that can improve protein expression from some cDNAs.

Substituted benzamides. 1. Potential nondopaminergic antagonists of chemotherapy-induced nausea and emesis.

A series of new substituted benzamides has been synthesized and evaluated for dopamine antagonist activity and for antagonism of cisplatin-induced emesis in the dog and in the ferret. It was found that modification of the 2-methoxy substituent of metoclopramide was detrimental to dopaminergic D2 antagonism but not necessarily to antagonism of cisplatin-induced emesis. A number of analogues having a beta-keto, beta-hydroxy, beta-methoxy, beta-imino, or beta-unsaturated alkyloxy substituent instead of methoxy have shown equal or superior protection from emesis to that of metoclopramide. At the same time these compounds were found to be free of dopaminergic D2 antagonism in both in vitro ([3H]spiperone binding) and in vivo tests (rat catalepsy, antagonism of apomorphine-induced stereotypy in the rat, and apomorphine-induced emesis in the dog).

Evaluation of trauma registry data in Asir region.

OBJECTIVE: To analyze and report trauma registry data; to assess the validity, reliability, and feasibility of the trauma registry; and to discuss lessons learned from this event. METHODS: A pre-designed trauma registry data was used for all injured patients admitted to Asir Central hospital after being involved in a major motor vehicle accident. A survey team registered and analyzed the trauma registry data using the statistics software SPSS for windows. RESULTS: Eighty-five patients were admitted to the hospital with different injuries. All victims were males with a mean age of 27 years. Injuries were dominated by musculo-skeletal trauma followed by neurotrauma, thoracic, and abdominal trauma respectively. Pre-hospital data was deficient and most of the hospital in-patient's information was taken from the nurse's notes. Standard elements of the trauma registry were found essential for optimal trauma care. Morbidity was related mainly to neurological trauma. Mortality was related to head injury followed by thoracic and abdominal injuries. CONCLUSION: Trauma registry was valid, reliable, and feasible. A national trauma registry program should be established. Trauma registry, prehospital care, and disaster planning and management should be integral parts of a regionalized trauma care system. Successful trauma care systems have shown significant reductions in morbidity and mortality from trauma.

Evaluation of trauma registry data in Asir region.

OBJECTIVE: To analyze and report trauma registry data; to assess the validity, reliability, and feasibility of the trauma registry; and to discuss lessons learned from this event. METHODS: A pre-designed trauma registry data was used for all injured patients admitted to Asir Central hospital after being involved in a major motor vehicle accident. A survey team registered and analyzed the trauma registry data using the statistics software SPSS for windows. RESULTS: Eighty-five patients were admitted to the hospital with different injuries. All victims were males with a mean age of 27 years. Injuries were dominated by musculo-skeletal trauma followed by neurotrauma, thoracic, and abdominal trauma respectively. Pre-hospital data was deficient and most of the hospital in-patient`s information was taken from the nurse`s notes. Standard elements of the trauma registry were found essential for optimal trauma care. Morbidity was related mainly to neurological trauma. Mortality was related to head injury followed by thoracic and abdominal injuries. CONCLUSION: Trauma registry was valid, reliable, and feasible. A national trauma registry program should be established. Trauma registry, prehospital care, and disaster planning and management should be integral parts of a regionalized trauma care system. Successful trauma care systems have shown significant reductions in morbidity and mortality from trauma.

Assessing the impact of short-term surgical education on practice: a retrospective study of the introduction of mesh for inguinal hernia repair in sub-Saharan Africa.

PURPOSE: Inguinal hernia repair is the most common general surgery operation performed globally. However, the adoption of tension-free hernia repair with mesh has been limited in low-income settings, largely due to a lack of technical training and resources. The present study evaluates the impact of a 2-day training course instructing use of polypropylene mesh for inguinal hernia repair on the practice patterns of sub-Saharan African physicians. METHODS: A surgical training course on tension-free mesh repair of hernias was provided to 16 physicians working in rural Ghanaian and Liberian hospitals. Three physicians were requested to prospectively record all their inguinal hernia surgeries, performed with or without mesh, during the 14-month period following the training. Demographic variables, diagnoses, and complications were collected by an independent data collector for mesh and non-mesh procedures. RESULTS: Surgery with mesh increased significantly following intervention, from near negligible levels prior to the training to 8.1 % of all inguinal hernia repairs afterwards. Mesh repair accounted for 90.8 % of recurrent hernia repairs and 2.9 % of primary hernia repairs after training. Overall complication rates between mesh and non-mesh procedures were not significantly different (p = 0.20). CONCLUSIONS: Three physicians who participated in an intensive education course were routinely using mesh for inguinal hernia repair 14 months after the training. This represents a significant change in practice pattern. Complication rates between patients who underwent inguinal hernia repairs with and without mesh were comparable. The present study provides evidence that short-term surgical training initiatives can have a substantial impact on local healthcare practice in resource-limited settings.