Blood drawn through valved catheter hub connectors carries a significant risk of contamination.

Infection Control became concerned when bloodstream infection (BSI) rates increased after implementing a needleless valved hub connector. During a 21-month period three different needleless catheter hub connectors were evaluated by quantitatively culturing blood drawn through hub connectors that would have ordinarily been discarded (DBC). DBC drawn through Clearlink™ catheter hub connectors were found to be twice as likely to be positive as DBC drawn through Clave® or Q-syte™ hub connectors (P < 0.04). DBC grew pathogens 46% of the time and skin organisms 54% of the time. Patients with positive DBC were three times more likely to meet Centers for Disease Control (CDC) BSI criteria by DBC cultures than by physician-ordered blood cultures (CBC; P < 0.001). For patients growing pathogens in DBC, 64% had no CBC drawn, the average temperature was lower than for patients with pathogens in CBC (99.3 ± 1.5 ve 100.6 ± 1.9, P = 0.015), and 92% of discharged patients (11 out of 12) were not treated with an antibiotic active against the DBC pathogen. Drawing BC through a catheter hub connector carries a risk of false-positives that could increase BSI rates by up to 3-fold. Further work is necessary to evaluate this concern.

Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic.

CONTEXT: Under routine hospital conditions handwashing compliance of health care workers including nurses, physicians, and others (eg, physical therapists and radiologic technicians) is unacceptably low. OBJECTIVES: To investigate the efficacy of an education/ feedback intervention and patient awareness program (cognitive approach) on handwashing compliance of health care workers; and to compare the acceptance of a new and increasingly accessible alcohol-based waterless hand disinfectant (technical approach) with the standard sink/soap combination. DESIGN: A 6-month, prospective, observational study. SETTING: One medical intensive care unit (ICU), 1 cardiac surgery ICU, and 1 general medical ward located in a 728-bed, tertiary care, teaching facility. PARTICIPANTS: Medical caregivers in each of the above settings. INTERVENTIONS: Implementation of an education/ feedback intervention program (6 in-service sessions per each ICU) and patient awareness program, followed by a new, increasingly accessible, alcohol-based, waterless hand antiseptic agent, initially available at a ratio of 1 dispenser for every 4 patients and subsequently 1 for each patient. MAIN OUTCOME MEASURE: Direct observation of hand-washing for 1575 potential opportunities monitored over 120 hours randomized for both time of day and bed locations. RESULTS: Baseline handwashing compliance before and after defined events was 9% and 22% for health care workers in the medical ICU and 3% and 13% for health care workers in the cardiac surgery ICU, respectively. After the education/feedback intervention program, handwashing compliance changed little (medical ICU, 14% [before] and 25% [after]; cardiac surgery ICU, 6% [before] and 13% [after]). Observations after introduction of the new, increasingly accessible, alcohol-based, waterless hand antiseptic revealed significantly higher handwashing rates (P<.05), and handwashing compliance improved as accessibility was enhanced-before 19% and after 41% with 1 dispenser per 4 beds; and before 23% and after 48% with 1 dispenser for each bed. CONCLUSIONS: Education/feedback intervention and patient awareness programs failed to improve handwashing compliance. However, introduction of easily accessible dispensers with an alcohol-based waterless handwashing antiseptic led to significantly higher handwashing rates among health care workers.

Antibiotic therapy for urinary tract infections.

Loracarbef, a member of the carbacephem class of beta-lactam antibiotics, was tested in randomized, double-blind, parallel studies for the treatment of uncomplicated urinary tract infections (UTIs). In one study conducted in the United States, a 7-day course of once-daily doses of loracarbef (200 mg) was compared with a 7-day course of multiple daily doses of cefaclor (250 mg three times a day). Analysis of data from a small, homogeneous patient population of 108 college-aged women showed that loracarbef produced clinical and bacteriologic responses similar to those produced by cefaclor. At 5-9 days posttherapy, bacteriologic cure was observed in 96% of patients in the loracarbef group and 90% of patients in the cefaclor group (p = 0.614); at 4-6 weeks post-therapy, the same cure rate (81%) was observed in both groups. Analysis of the larger (333 patients) and more heterogeneous study population containing several male and elderly female patients showed that loracarbef again produced responses similar to those produced by cefaclor, with no statistically significant differences seen between the groups at 5-9 days or at 4-6 weeks posttherapy. The adverse events reported by the loracarbef and cefaclor groups were also comparable in both the small and large patient populations analyzed. Similarly favorable results were seen when a 7-day regimen of loracarbef (200 mg once a day) was compared with a 7-day regimen of norfloxacin (400 mg twice a day) in a large European study of approximately 300 patients with uncomplicated cystitis. These studies demonstrate that the safety and efficacy of once-daily loracarbef are comparable to the safety and efficacy of multiple-dose/day therapy with other antimicrobial agents commonly used in the treatment of uncomplicated UTIs.

Loracarbef (LY163892) versus cefaclor and norfloxacin in the treatment of uncomplicated pyelonephritis.

Optimal therapy for pyelonephritis requires the immediate administration of an effective broad-spectrum antibiotic. Because conventional oral antibiotics such as the sulfonamides and the aminopenicillins are limited by the development of resistant bacteria associated with this common disease, the therapeutic effectiveness of a new oral carbacephem antibiotic was investigated. Two double-blind, randomized clinical trials of loracarbef (LY163892) were conducted. A total of 245 patients (greater than or equal to 18 years old) with uncomplicated pyelonephritis were enrolled in parallel studies. One study compared loracarbef with cefaclor; the other compared loracarbef with norfloxacin. In the combined patient population, 119 patients were treated with loracarbef (400 mg twice daily), 43 with cefaclor (500 mg three times daily), and 83 with norfloxacin (400 mg twice daily). All treatment regimens continued for greater than or equal to 14 days. A total of 68 patients in the loracarbef group, 25 in the cefaclor group, and 43 in the norfloxacin group qualified for efficacy analysis. Escherichia coli was the causative pathogen in 85.0% of these patients. Successful posttherapy clinical and bacteriologic responses were similar for all three study drugs: 94.1 and 86.8%, 96.0 and 80.0%, 97.7 and 88.4% for loracarbef, cefaclor, and norfloxacin, respectively. Late posttherapy clinical responses were 87.4, 83.3, and 91.7% for the loracarbef, cefaclor, and norfloxacin groups, respectively. Bacteriologic responses for the three groups were 79.6, 60.0, and 88.9%. The most frequent adverse effects (headache, diarrhea, and nausea) were experienced by three patients (2.5%) in the loracarbef group; headaches were noted in two (4.7%) cefaclor patients, diarrhea was noted in three (7.0%) patients in the cefaclor group, and nausea was noted in four (9.3%). Gastrointestinal events were noted in four patients (4.8%) in the norfloxacin group. The data demonstrate that loracarbef is comparable in efficacy and safety to both cefaclor and norfloxacin as oral therapy for uncomplicated pyelonephritis.

Gatifloxacin 200 mg or 400 mg once daily is as effective as ciprofloxacin 500 mg twice daily for the treatment of patients with acute pyelonephritis or complicated urinary tract infections.

The efficacy and safety of two oral dosing regimens of gatifloxacin were compared to ciprofloxacin in the treatment of complicated urinary tract infection in a randomised, double-blind multi-centre trial. One thousand one hundred and twenty-three adult patients with complicated urinary tract infection (70%) or pyelonephritis (30%) were initially enrolled, 1122 were treated. Of these, 824 were included in a modified ITT population: gatifloxacin 200 mg (274 patients) or 400 mg (280 patients) once daily or ciprofloxacin 500 mg twice daily for 5-14 days (269 patients). Bacteriological and clinical responses were assessed 7-9 days after the end of treatment (EOT) and 4-6 weeks post-treatment (end of study visit, EOS). The bacteriological response rates per patient at EOT in the gatifloxacin 400 mg, gatifloxacin 200 mg and ciprofloxacin groups were 77% (207/269), 78% (208/268) and 73% (190/259), respectively. At EOS they were slightly lower: 70% (184/262), 71% (176/248) and 69% (174/252), respectively. The clinical responses at EOT were 69% (190/277), 70% (190/273) and 65% (174/266). At EOS they were 71% (193/273), 70% (182/259) and 74% (190/258). The overall eradication rates of initial pathogens at EOT and EOS were 85.3% and 88.4% in the gatifloxacin 400 mg group; 84.1 and 90.1% in the gatifloxacin 200 mg group and 85.1 and 91.4% in the ciprofloxacin group. Both oral regimens of gatifloxacin were as effective as that of ciprofloxacin. All treatment groups showed a similar safety profile, nausea being the most frequently reported adverse event.

Influence of arginine, omega-3 fatty acids and nucleotide-supplemented enteral support on systemic inflammatory response syndrome and multiple organ failure in patients after severe trauma.

This study investigated the influence of an enteral diet supplemented with arginine, omega-3 fatty acids, and nucleotides (Impact, Sandoz Nutrition, Berne, Switzerland) on the incidence of systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) in patients after severe trauma. Thirty-two patients with an injury-severity score > 20 were included in this prospective, randomized, double-blind, controlled study. Primary endpoints were the incidence of SIRS and MOF. Secondary endpoints were parameters of acute phase and immune response as well as infection rate, mortality, and hospital stay. For statistical analysis 29 patients (test group n = 16, control n = 13) were eligible. In the test group, significantly fewer SIRS days per patient were found during 28 d. The difference was highly significant between d 8-14 (P < 0.001). MOF score was significantly lower in the test group on d 3 and d 8-11 (P < 0.05). Acute phase parameters showed lower C-reactive protein serum levels (significant on D day 4) and fibrinogen plasma levels (significant on d 12 and 14; P < 0.05). HLA-DR expression on monocytes showed significantly higher fluorescence activity on d 7. No significant difference was found for T-lymphocyte CD4/CD8 ratio, interleukin-2 receptor expression, infection rate, mortality (2/16 vs. 4/13), and hospital stay. The results of the study provide further support for beneficial effects of arginine, omega-3-fatty acids and nucleotide-supplemented enteral diet in critically ill patients.

[Correlation between microangiography and histological findings in renal carcinomas (author's transl)]. / Mikroangiographische und korrelierende histologische Untersuchungen bei hypernephroiden Nierenkarzinomen

Arterial, venous and simultaneous arterial and venous injections with radio-opaque dyes were carried out under manometric control on three renal cell carcinomas following nephrectomy. The micro-angiographic appearances were then correlated with the histological findings. The radiologically abnormal vessels correspond with sinusoids with thin, capillary-like walls containing localised areas of thickening in a collagen-rich stroma. Both micro-angiographically and histologically, the sinusoidal connections can be demonstrated between the edge of the tumour and normal tissue. Arterio-venous anastomoses were not found. The angio architecture and micro-angiographic pattern in renal cell carcinomas is described. The significance of these changes in the circulation is discussed and its significance in carrying out pharmaco-angiography and retrograde phlebography is pointed out.

[Arterio-venous angioma of the kidney: embolisation and two year follow-up (author's transl)]. / Arteriovenöses Angiom der Niere: Embolisation und 2jähriger Verlauf.

Successful embolisation of an arteriovenous angioma of the kidney with gel foam suspension is described, with a two year follow-up. Embolisation cured hypertension, which had otherwise resisted treatment, and stopped haematuria. The need for careful follow-up is stressed with long-term observations using both angiography and scintigraphy of the affected kidney. The intra-arterial embolisation with gel foam resulted in a redistribution of blood-flow which led to complete success of treatment even thought the vascular malformation had not been totally obliterated.

[Concentration of antibiotics in long term embolized kidneys (author's transl)]. / Experimentelle Untersuchungen zur Antibiotikakonzentration in embolisierten Nieren.

In 7 dogs renal arterial embolization was performed using Seldinger technique and inflatable Swan Ganz balloon catheter by injection of methyl methacrylate/butyl 2 cyano acrylat. Six months later tissue concentration of cefazolin was measured in the embolized and kontralateral kidneys and in serum two hours after a short infusion of 1 g of Cefazolin. The concentrations in serum and homogenized kidney tissue were determined by means of the agar well diffusion method. Angiography studies showed no vessels in the embolized kidneys. Histologically there was total atrophy of the tissue especially the tubular system. The mean tissue level of Cefazolin in the embolized kidney was 70% of serum. The tissue concentration was always above 10 microgram/g. This concentration is high enough to inhibit nearly all strains of E. coli, Klebsiella, Salmonella, Shigella and a large part of Proteus mirabilis, whereas nearly all gram-positive bacteria are inhibit at a lower concentration. Value and necessity of antibiotic therapy in embolized kidney cancer is discussed.

[Evaluation of experimental arterial occlusion, with special reference to its complications (micro-spheres, Histo-Acryl, Paladur, alternating and direct currents (author's transl)]. / Die Wertigkeit experimenteller Arterienverschlüsse unter besonderer Berücksichtigung ihrer Komplikationen (Mikrospheren, Histo-Acryl, Paladur, Wechsel- und Gleichstrom)

Permanent arterial occlusion can be obtained experimentally by using plastic micro-spheres, polymerising materials (Histo-Acryl, Paladur) and direct current thrombosis. Certain limitations in their use arise from the properties of the substances. In our experience, plastic microspheres are not suitable for blocking entire organs or large vascular territories. They are more appropriate for occlusion of individual, small vessels by super-selective injections. Sole use of polymerising materials is not possible; they are best used in combination with other techniques (magnets, balloon catheters). Induction of thrombosis by small direct currents (50 volt, 10 mA). produces permanent and complete occlusion. The method can be used selectively or super-selectively. Unwanted thrombosis can be avoided by using catheters with the smallest possible external diameters.

[Indications and value of treatment by catheter occlusion (author's transl)]. / Indikation und Wert der Katheterverschlussbehandlung.

The value of the catheter occlusion therapy is analyzed in 92 cases retrospectively, and the indication, and complication risk of these procedures are considered. In the following vessel areas occlusion with different methods have been performed with decreasing frequency; kidneys, pelvis, legs, gastrointestinal tract, external carotid and internal carotid artery. Serious complications have been observed in therapeutic investigations at the head, especially in occlusions of the external carotid artery. In this group embolisation therapy should be performed with strict indication only.

3.75 and 7.5 mg leuprorelin acetate depot in the treatment of advanced prostatic cancer: preliminary report. German Leuprorelin Study Group.

In an on-going, non-comparative, open, multicentre phase III study in Germany, 190 patients with advanced prostatic cancer were treated with 3.75 or 7.5 mg leuprorelin acetate depot given subcutaneously or intramuscularly once monthly, with or without concomitant antiandrogen or cytostatic therapy. The two doses and the different routes of administration did not have any significant effects on serum testosterone, dihydrotestosterone, follicle stimulating hormone and luteinizing hormone concentrations, tumour activity or clinical tolerance. Using either dose, the 'no progression' rate (complete remission plus partial remission plus stable disease) was 88.5% overall and was 88.2% in T1-T2 disease and 82.5% in T3-T4 disease after 12 months' treatment. It is concluded that the depot formulation of leuprorelin acetate offers an important alternative in the treatment of advanced prostatic cancer.

[Single-dose treatment of acute cystitis with norfloxacin. 1st report]. / Einzeldosisbehandlung der akuten Zystitis mit Norfloxazin. Erste Ergebnisse.

25 women with acute uncomplicated cystitis were treated with a single dose of 800 mg norfloxacin orally. Urinary checkups were performed 3 and 8 days after therapy and 4 and 8 weeks later. Urinary cultures, bacterial identification and antibiotic testing were performed. Success rate as based on the bacterial results was 96%. Reinfection occurred in one case only over the follow-up period of 8 weeks. This high success rate is due to strict selection of patients with truly uncomplicated cystitis and the beneficial chemotherapeutic effect of norfloxacin.

[Indication for vascular reconstructive operations in radical tumor surgery]. / Zur Indikation gefässrekonstruktiver Operationen in der radikalen Tumorchirurgie.

First experiences concerning reconstructive vascular surgery in malignant tumor surgery are presented. In order to improve total tumor excision, the resection of great veins or nutritive arteries may become necessary. In some cases the reconstruction of vascular defects together with tumor resection may be indicated. Only in the case of younger patients vascular reconstruction of essential vessels seems to be indicated.

[Artificial embolization before septic amputation]. / Die KUnstliche arterielle Embolisierung vor septischer Amputation.

By artificial embolization before extensive septic amputation arrosion bleedings that are otherwise noncontrollable can be prevented. Resorbable gelatine (Gelforam) is suitable for embolization. For safety one can leave a balloon catheter above the embolized vessel segment for several days.

[Necrosis of the prostate and the urinary bladder during kumarin therapy (author's transl)]. / Prostata- und Harnblasenteilnekrose unter Cumarintherapie

The very first case of part necrosis of the ruinary bladder and prostate during therapy with kumarin is presented. The pathogenesis of kumarin induced necrosis is discussed. Apart from other findings there was histologically proved thrombosis of arteries and veins.

[Successful intra-arterial embolization of bleeding carcinoma of the prostate (author's transl)]. / Embolisation eines blutenden Prostata-Carcinoms

The very first case of successful therapeutic embolization for hematuria from carcinoma of the prostate is presented. In a 76-year-old patient with necrotic carcinoma of the prostate, stage D transurethral operations showed no success. By selective intra-arterial embolization via the internal iliac arteries (using Gelfoam), hematuria could be stopped definitely and did not occur any more. Follow-up study showed no complications or necrosis in this procedure.

[Epispadia without bladder extrophy in a female (author's transl)]. / Epispadie ohne Blasenexstrophie bei einem weiblichen Säugling

A very rare case of female epispadia without bladder extrophy is presented. The main symptoms with this malformation is incontinence and the presence of a bifid clitoris. The therapy of choice is the operative reconstruction of the urethra and reforming the bladder neck. This should not be carried out before the age of three years since the post operative bladder continence training is important for the success. Lasting urinary continence can only be expected in less than 50% of the cases.

[Permanent stop of renal circulation by embolisation with microspheres. Preliminary report (author's transl)]. / Dauerhafte Ausschaltung der Nierendurchblutung durch Embolisation mit Mikrospheren

The risk of tumor cell dislodgement during operative removal of carcinoma of the kidney is reduced by preoperative occlusion of the renal arteries. After the intraarterial injection of 250 mu microspheres a complete blockage of the intrarenal circulation was found in all three experimental animals for at least 2 hrs. In the other two dogs the blockage remained unchanged over 24 hrs. Subsequent experiments shall demonstrate that the simple embolisation technique using microspheres is more stable than other methods.