Severity of illness in intra-abdominal infection. A comparison of two indexes.

The severity of illness in 58 surgical patients with high-grade intra-abdominal infection was measured with two methods, an acute physiology score and a septic severity score. Both methods are the summed weight of derangements in physiologic factors representing the function of the major organ systems of the body. Sixteen patients died (28%). Score values with both methods were significantly higher for nonsurvivors than for survivors. There was good interrelation between the methods, and the scores correlated better with mortality than did age, chronic disease, anatomy, or cause. Three risk levels were recognized, low, high, and intermediate, with respective mortality rates of less than 10%, greater than 80%, and approximately 45%. Three-fourths of the patients were assigned to the same risk group with both methods. The severity of illness in patients with intra-abdominal infection can suitably be measured with both methods.

The kinetics of peritoneal clearance of Escherichia coli and Bacteroides fragilis and participating defense mechanisms.

In a study using pigs, we delineated the dynamic character and the interplay of defense mechanisms that operate in the peritoneal cavity and their effectiveness against Escherichia coli and Bacteroides fragilis. The bacteria were extensively cleared during the first three hours. The concentration of both organisms in the peritoneal fluid decreased by up to 300,000-fold, and the final concentration was a function of the inoculum given. Clearance efficiency did not differ between a bolus dose and prolonged bacterial administration. Peritoneal absorption was a major eliminating mechanism during the first three hours but was limited to bacterial concentrations exceeding approximately 10(9) colony-forming units per milliliter of peritoneal fluid. Intraperitoneal elimination started immediately and continued for approximately six hours. Thereafter, residual bacteria were not eliminated, even though the defense capacity was intact. Prolonged bacterial administration, however, protracted the period for active bacterial destruction.

Digital subtraction angiography versus standard contrast arteriography in evaluation of peripheral vascular disease.

Fifteen patients with lower limb ischemic disease were preoperatively assessed with both intravenous or intra-arterial digital subtraction angiography (DSA), and standard contrast angiography (SCA). The images were reviewed and the operative strategies, based on the clinical data and each of SCA and DSA, were compared. SCA provided more information than DSA in two patients, one of which had an incomplete DSA investigation. DSA provided more information than SCA in three patients. The distal crural vessels were better visualized with DSA in one patient, and popliteal lesions were demonstrated as being more severe using DSA than with SCA in two patients. The level of the distal anastomosis of the proposed bypass was lowered to below the knee as a result of DSA in these two patients. We conclude that comparable information is obtained using SCA or DSA, and that DSA, in particular the intraarterial technique, is a satisfactory alternative to SCA in preoperative evaluation of patients with lower limb ischemic disease.

Effect of buflomedil on cell metabolism in ischemic muscle.

The effect of Buflomedil on cell metabolism in ischemic muscle was studied in pigs. Six pigs received Buflomedil 6 mg per kg intravenously 30 minutes prior to induction of total leg ischemia, whereas 6 control animals were not premedicated. Arterial and venous blood samples and muscle specimens from the ischemic leg were collected prior to ischemia, after 5 hours of ischemia, and after 10 minutes and 30 minutes of reperfusion of the leg, and analysed for metabolic parameters. Similar decreases in local venous pH and PO2 indicated comparable and severe leg ischemia in both groups. Similar increases in venous and arterial concentrations of potassium and creatine kinase indicated a comparable degree of cell damage in the two groups. The ischemic muscle specimens in the Buflomedil group contained significantly higher phosphocreatine (PC) levels (p less than 0.01) and significantly lower lactate levels (p less than 0.01) than did the control group, whereas ATP levels were comparable in the two groups. We conclude that Buflomedil reduces PC-conversion, glucolytic activity and energy demands of the ischemic cell.

A new probe for ankle systolic pressure measurement using photoplethysmography (PPG).

An automated method for ankle systolic pressure measurement, less operator dependent than the standard continuous wave (CW) Doppler technique, would imply an advantage both in patient measurements and in epidemiological studies. We present a new photoplethysmographic (PPG) probe that uses near-infrared light (880 nm) to detect pulsatory blood flow underneath the distal end of a standard pneumatic cuff. The probe is adapted to the anatomical conditions at the ankle, permitting recording of pressures in both ankle arteries separately. The validity of the equipment was tested with CW Doppler-derived systolic pressures and invasive blood pressure measurements for reference. In 20 healthy subjects, visual analysis of the PPG curves revealed a mean difference between CW Doppler and PPG measurements of -0.5 mmHg (SD 6.9). Corresponding results for the anterior and posterior tibial arteries separately were -1.8 mmHg (SD 6.2) and 0.9 mmHg (SD 7.3), respectively. A correct probe position was essential for the results. In direct recordings from the dorsalis pedis artery in 10 intensive care patients, PPG underestimated systolic pressure in the anterior tibial artery by 4.5 mmHg (SD 12.1). With further development, the PPG probe, integrated in the pneumatic cuff, may simplify measurements of ankle systolic pressures.

Automatic ankle pressure measurements using PPG in ankle-brachial pressure index determination.

OBJECTIVE: To evaluate a new technique using a photoplethysmographic (PPG) probe for automatic ankle pressure measurements. DESIGN: Comparative study on two techniques for ankle pressure measurement. SETTING: University hospital. MATERIAL: Thirty-five patients with leg arterial disease and eight healthy volunteers. Ankle-brachial indices (ABPI) were measured using conventional CW Doppler technique and PPG-based prototype equipment for the ankle pressure recordings. CHIEF OUTCOME MEASURES: ABPIs calculated from CW Doppler and PPG ankle pressure measurements. The PPG signals were analysed both by visual judgement and by a software based, automatic algorithm. MAIN RESULTS: The mean difference between ABPIs calculated from CW Doppler recordings and PPG (visual analysis) was -0.01 (limits of agreement (+/-two standard deviations) +0.16 to -0.19). The correlation coefficient was 0.93. When the algorithm was used, the mean difference (CW Doppler-PPG) was 0.05 (limits of agreement 0.28 to -0.18, r=0.89). CONCLUSIONS: The PPG method is a promising technique with an inherent potential for automatisation of the ankle pressure measurements, thereby reducing the observer-dependency in ABPI recordings.

Spontaneous peritonitis and rheumatoid arthritis--a case report.

An unusual case in which an adult patient with rheumatoid arthritis developed a fulminant spontaneous gram-positive bacterial peritonitis and underwent emergency laparotomy for this condition is presented. Spontaneous peritonitis in adult patients was previously seen only in patients with liver disease, nephrotic syndrome or systemic lupus erythematosus.

Prevalence of symptomatic leg ischaemia in a Swedish community--an epidemiological study.

The prevalence of symptomatic leg ischaemia (SLI) was studied using a standardised postal questionnaire and by measuring ankle systolic blood pressure among those with leg pain. All individuals, aged 50-89 years, of both sexes (n = 2748) in a community of 7524 inhabitants were included. The overall questionnaire response rate was 92%, of whom 441 (17%) reported any form of leg pain. Ankle systolic blood pressure (ASBP) was measured in 353 (80%) of those. Ankle/brachial index (ABI) < or = 0.8 was chosen as the criterion for verified SLI. One hundred and seven (30%) had a verified SLI (ABI < or = 0.8). Hospital records could be reviewed in 83% of the non-responders, and revealed corresponding distributions of risk factors among the non-responders and the questionnaire-responders. Risk factor frequencies among ASBP-examined and not examined individuals were also comparable. The overall prevalence of SLI in the age 50-89 years was 4.1%, ranging from 1.5% in the age decade of 50-59 years, to maximum 7.1% in the decade 70-79 years. A slight but not significant male predominance was recorded, except for the age decade 70-79 years. The prevalence of SLI in the whole community population was approximately 2000/100,000 of which 5% were possible candidates for vascular intervention.

Epithelioid sarcoma in the hand.

An illustrative case of epithelioid sarcoma in the hand of a young man, causing considerable diagnostic problems, is presented. Epithelioid sarcoma is a malignant lesion, first described by Enzinger in 1970. Although epithelioid sarcoma is the third commonest soft tissue sarcoma in the upper extremity (Bryan, 1974) it still causes confusion in differential diagnosis, both to the surgeon and to the pathologist. Because of its deceptively harmless appearance during the initial period and its clinical and microscopical similarity to an inflammatory process, it is often mistaken for a benign lesion. The purpose of our paper is to draw attention to this rare malignant tumour. This case illustrates a course similar to those described previously. (Enzinger, 1970: Santiago, 1972).

Outcome of symptomatic leg ischaemia: four year morbidity and mortality in Vadstena, Sweden.

OBJECTIVE: To quantify cardiovascular morbidity and mortality including the incidence of vascular surgery and amputations, among individuals with symptomatic leg ischaemia. DESIGN: Prospective cohort study. MATERIAL: Inhabitants 50-89 years of age (n = 2784) of Vadstena community, Ostergötland, Sweden, with 4 years of follow-up. 107 subjects with symptomatic leg ischaemia (SLI), selected by a postal questionnaire and ankle pressure measurements, and an age and sex matched control group of 214 individuals. CHIEF OUTCOME MEASURES: Cardiovascular morbidity and mortality, all cause mortality, surgical procedures for leg ischaemia, major amputations, ankle brachial pressure index. MAIN RESULTS: Age and sex adjusted all-cause mortality risk in the SLI-group was increased by 1.9. This was most prominent among men in their sixties and women in their seventies. Cardiovascular mortality was increased by 1.9 (95% confidence interval 1.1-3.3). Relative risks for acute myocardial infarction and cerebrovascular events were 2.4 (1.1-5.1) and 1.7 (0.9-3.2), respectively. The increase in age and sex adjusted incidence of primary reconstructive surgery during the first year after initial examination was 67-fold compared to the total population of Vadstena 50-89 years old, and 18 fold for the whole observation period, while the increase in risk for major amputation during the observation period was 12-fold. Median ankle brachial index improved significantly during follow-up among the individuals alive and not subjected to vascular surgery. CONCLUSIONS: Among the SLI-subjects identified in a general population, the overall risk for cardiovascular morbidity and mortality over 4 years was significantly increased compared to normals.

Ankle-brachial index and mortality in a cohort of questionnaire recorded leg pain on walking.

OBJECTIVE: To study the association between the ankle-brachial pressure index (ABPI), premature death and the need for surgical treatment for lower limb ischaemia. DESIGN: Population based cohort study. SUBJECTS: Three hundred and fifty-three men and women, 50-89 years old, underwent a leg pain questionnaire and measurement of ABPI and was then followed for 10 years. OUTCOME MEASURES: All cause mortality, vascular procedures and major amputations. RESULTS: A low ABPI was independently associated with premature all cause mortality in the multiple regression analysis, carrying a relative risk of 3.4 (95% confidence interval 2.0-5.9) and 2.1 (1.3-3.3) for ABPIs or=1.0. Individuals with an ABPI in the interval 0.81-0.99 suffered only a slight, not statistically significant risk increase compared to normals. A low ABPI at baseline implied a continuous constant increased risk of death throughout the study period. The same risk was observed among elderly (70-89, median 77 years), and in the middle aged (50-69, median 63 years) individuals. The vast majority of those subjected to vascular intervention or major amputation during follow-up had an ABPI

Isolated aneurysms of the iliac artery: what are the chances of rupture?

Sixteen patients with 22 isolated aneurysms of the common or external iliac artery were treated between 1974 and 1986. There were ten men and six women with a median age of 69 years. The aneurysm was discovered incidentally in seven patients; and in nine patients it was diagnosed upon rupture. A pulsating abdominal tumour was palpable in 12 patients seven of whom had a ruptured aneurysm. Common symptoms included urological and neurological problems and abdominal pain. Of the seven patients in whom the diagnosis was confirmed prior to rupture, three were operated upon successfully and four were not. Of the latter, two died within 3 months due to coexisting disease while two remain alive after one and 6 years. Of the nine patients with a ruptured aneurysm only four survived. The high risk of rupture justifies elective operation of an aneurysm of the iliac artery in the majority of cases.

Elimination patterns of Escherichia coli and bacteroides fragilis from the peritoneal cavity. Studies with experimental peritonitis in pigs.

An animal model for study of bacterial elimination from the peritoneal cavity is presented. Using Escherichia coli and Bacteroides fragilis as infecting agents, two elimination patterns emerged. The patterns were related to the surface properties of the micro-organisms. The concentration of both species was greatly reduced within 2 to 4 hours after peritoneal contamination with 10(10) CFU. The elimination of B. fragilis was contemporaneous with mobilization of granulocytes into the peritoneal cavity, and was probably attributable to bactericidal action of the granulocytes. Most of the E. coli inoculum, however, was cleared before the granulocyte mobilization. Cell-free peritoneal fluid was found to have a bactericidal effect against a rough strain of E. coli, but not against a smooth strain, as demonstrated in vitro. This effect was inhibited by pretreatment of the peritoneal fluid with EDTA, EGTA or heat, which suggested that the alternate pathway of the complement system was involved. In vivo the rough strain of E. coli was rapidly eliminated, while elimination of the smooth strain followed the B. fragilis pattern. It is concluded that bacterial surface properties are important in bacterial peritonitis.

Outcome of intra-abdominal infection in pigs depends more on host responses than on microbiology.

OBJECTIVE: To assess the effects of mortality of the presence and proliferation of bacteria, and the host's response to infection, in pigs with peritonitis. DESIGN: Laboratory study. SETTING: University hospital. MATERIAL: 71 Swedish Landrace pigs, 63 with peritonitis and 8 without (controls). INTERVENTIONS: Induction of peritonitis by intraperitoneal infusion of equal amounts of Escherichia coli and Bacteroides fragilis (10(9) to 10(11) bacteria/animal); sterile faeces were added in half the experiments. MAIN OUTCOME MEASURES: Microbiological events were quantified as the area under the bacterial concentration curve from 0-6 hours. Host responses were quantified with a score of 8 physiological variables measured between 4-6 hours after the induction of peritonitis. RESULTS: Of the 63 infected animals, 37 (59%) died within 6-24 hours and both the physiological response and the bacterial load were significantly higher in those that died. Logistic regression analysis with death as the dependent variable showed that the physiology score carried more predictive information than the quantification of bacterial load. CONCLUSION: The quantification of local events within the abdomen is of only limited predictive value compared with the extent of the physiological alterations.

The dynamics of intraperitoneal growth and elimination of Escherichia coli and Bacteroides fragilis in porcine faecal peritonitis treated with fosfomycin.

The kinetics of intraperitoneal killing of proliferating bacteria was studied in pigs given fosfomycin. Eight animals were given intra-abdominal injection of Escherichia coli and Bacteroides fragilis (10(9) cfu of each species) mixed in sterile faces. Three hours later, half of the animals received an intravenous dose of 1 g fosfomycin (0.05 g/kg). Host defences rapidly decreased the density of E. coli in all animals in the first hour. After 2h, growth of E. coli started and continued throughout the experiment in pigs not receiving fosfomycin. B. fragilis was slowly eliminated in the first 5 6 h, then numbers increased in all animals. Fosfomycin caused a reduction in E. coli density, by 10(2.19) +/- 0.29 (mean +/- S.E.M.) cfu/ml, or more than 150 times within 1 h, while the concentration of B. fragilis was unaltered. After 10 h the difference in E. coli density between fosfomycin treated and untreated animals was 10(4.96) cfu/ml (P less than 0.01). Fosfomycin eradicated E. coli in faecal peritonitis but not B. fragilis, which is resistant in vitro. There was a prolonged elimination of the drug from peritoneal exudate in pigs infected with bacteria in sterile faeces compared to the elimination in uninfected pigs or pigs infected only with bacteria.