Intra-articular Calcaneal Fractures: A Report of Cases and Comments on Preoperative Management.

OBJECTIVES: To present a review of the clinical characteristics, preoperative and surgical management, and outcomes of patients with intra-articular calcaneal fractures who had open reduction and internal fixation (ORIF) and to offer some comments on and research ideas for the preoperative management of patients with these fractures. PATIENTS AND METHODS: We studied consecutive patients who had ORIF performed by a single surgeon for closed, intra-articular calcaneal fractures at our level-1 trauma center between 5/29/2012 and 3/20/2018. All inpatients were treated with a preoperative soft tissue management protocol, whereas outpatients were not. Data were obtained about demographic and clinical characteristics, times from injury to surgery, quality of fracture reductions, and complication rates. RESULTS: Mean follow-up for the 72 patients with 77 calcaneal fractures was 8.5 (range: 1-43) months, and 21 (27.3%) fractures received inpatient preoperative care with a soft tissue management protocol, while 56 (72.7%) received outpatient preoperative management. More of the fractures treated preoperatively as inpatients versus outpatients were classified as Sanders type III (66.7% vs. 32.1%) and type IV (8.9% vs. 4.8%) fractures and were associated with polytrauma (38.1% vs. 7.1%) and diabetes mellitus (9.5% vs. 5.4%), respectively. For all patients, the mean time from injury to surgery was 12.2 (range: 2.7-19.4) days, and the time was 6.3 days for inpatients and 14.4 days for outpatients, but the quality of fracture reductions and complication rates did not differ between these two groups. CONCLUSIONS: Patients with intra-articular calcaneal fractures treated as inpatients and receiving a preoperative soft tissue management protocol had outcomes after ORIF that were not inferior to those experienced by patients treated preoperatively as outpatients, despite a greater proportion of the inpatients having severe fractures, polytrauma, and diabetes mellitus. Dedicated preoperative soft tissue management protocols may be beneficial for patients with calcaneal fractures and warrant further study.

Postoperative complications after head and neck operations that require free tissue transfer - prevalent, morbid, and costly.

To understand and reduce the impact of postoperative complications, we studied 568 patients who had had operations over 72 months in our hospital. Multivariate analysis indicated that factors indicative of coexisting conditions (including activated systemic inflammation) and the complexity of the operation are primary determinants of postoperative complications. The enhanced recovery after surgery (ERAS) care pathway did not have an effect on their occurrence or severity. Systematic study of patients' toleration of major head and neck operations is required, as optimal perioperative care pathways remain elusive.

A Positive Node on Ultrasound-Guided Fine Needle Aspiration Predicts Higher Nodal Burden Than a Positive Sentinel Lymph Node Biopsy in Breast Carcinoma.

INTRODUCTION: Axillary status remains an important prognostic indicator in breast cancer. Certain patients with a positive sentinel node (SLNB) may not benefit from axillary clearance (AC). Uncertainty remains if this approach could be applied to patients diagnosed with axillary metastases on ultrasound-guided fine needle aspiration cytology (USFNAC). The aim of this study was to compare nodal burden in patients with positive USFNAC and a positive SLNB. METHODS: A retrospective study was performed involving all BC patients between 2007 and 2014 who had either pre-operative USFNAC or a SLNB. Patient/tumour characteristics and nodal burden were examined in all patients proceeding to AC. RESULTS: 974 patients were eligible for analysis. 439 patients (45 %) had positive USFNAC and 535 (55 %) had a positive SLNB. USFNAC-positive patients were more likely to undergo mastectomy (Chi-square test; p < 0.001), have extra-nodal extension (p < 0.001), be oestrogen receptor negative (p < 0.001) and be HER2 positive (p < 0.001). The median total number of lymph nodes (LNs) excised during AC was higher in the USFNAC group (Mann-Whitney test; 23 vs. 21; p < 0.001). The median total number of involved LNs was 3 (range 1-47) in FNAC-positive patients versus 1 (range 1-37) in SLNB-positive patients (p < 0.001). The median number of involved LNs in level 1 was 3 in FNAC-positive patients versus 1 in SLNB-positive patients (p < 0.001). Within the SLN-positive group, 49 % of the patients had only one involved LN, 28 % had two nodes involved and 23 % had ≥3. In comparison, within the FNAC-positive group only 13 % of the patients had one involved LN, 12 % had two nodes involved and 74 % had ≥3. CONCLUSION: Patients with positive USFNAC have more aggressive clinico-pathological characteristics and higher nodal burden compared to SLNB-positive patients. Currently, the authors advocate that patients not receiving neoadjuvant chemotherapy, with a positive USFNAC, should proceed directly to an axillary ALND.

In ovo exposure to a triazine herbicide: effects of atrazine on circulating reproductive hormones and gonadal histology in young Japanese quail.

The triazine herbicide, atrazine, has come under scrutiny for its reported feminizing effects in amphibians. To date, there is little information concerning the effects of atrazine on reproduction in avian species. The current study examined the putative reproductive toxicity of atrazine after exposure in ovo. Atrazine at 504, 246, and 123 microg/kg was administered to Japanese quail eggs before incubation. The eggs were hatched and the birds raised to 14 days of age. Indices of hatchability, sex ratios, and growth were determined. Furthermore, circulating concentrations of reproductive hormones (estradiol, progesterone, and testosterone) and gonadal histology were examined. Atrazine at 504 microg/kg decreased 14-day hatchling weight by 13.1% versus controls. However, no detrimental effects on hatchability or sex ratios were observed. In female birds, atrazine at 504 microg/kg decreased ovarian weights and circulating concentrations of progesterone to 48.3% and 73.3%, respectively, versus control. However, concentrations of estradiol and testosterone did not differ from controls. In male quail, at all doses tested, atrazine had no effect on gonadal weights or circulating concentrations of estradiol, testosterone, or progesterone. Moreover, no incidences of left ovotestis formation were observed. In contrast, 10 ng/kg ethinylestradiol (a positive control) induced the formation of a left ovotestis in four of eight birds analyzed. The current results may suggest that exposure to atrazine in ovo at concentrations above ecologic relevance exerts effects on the reproductive system of young Japanese quail. However, no evidence is presented that atrazine induces feminization of the testis in male quail.

Screening for celiac disease in children with recurrent abdominal pain.

BACKGROUND: The clinical presentation of celiac disease--a life-long gluten intolerance--may be characterized by chronic abdominal pain. The objective of this study was to determine if children with recurrent abdominal pain had a higher prevalence of antiendomysial antibodies (a serologic marker of celiac disease) compared with healthy children. METHODS: Children with recurrent abdominal pain and healthy control participants were recruited from the offices of community pediatricians. Serum samples were drawn and antiendomysial antibodies were measured in both groups. Demographic data included age, gender, height, and weight. RESULTS: A total of 200 children were recruited, of whom 173 (87%) had serum samples drawn. Of these, 92 were children with recurrent abdominal pain and 81 were control participants. Only 2 of the 173 samples (1.2%) were positive for antiendomysial antibody. The frequency of antiendomysial antibody positivity in children with recurrent abdominal pain was 1 in 92 (1%; 95% confidence interval, 0-6%) compared with 1 in 81 (1%; 95% confidence interval, 0-7%) in control participants. CONCLUSIONS: This community-based case-control study found no association between recurrent abdominal pain and the prevalence of antiendomysial antibody. Therefore, these data do not support screening for celiac disease in the child with classic recurrent abdominal pain in the primary care setting.

The urinary glycoprotein GP51 as a clinical marker for interstitial cystitis.

PURPOSE: GP51 is a urinary glycoprotein with a molecular weight of 51 kDa. This glycoprotein is produced and secreted by the transitional epithelium of the genitourinary tract, and has been isolated from human urine. Studies have demonstrated that GP51 levels are decreased in bladder biopsies of patients with interstitial cystitis. We evaluated urinary GP51 in a noninvasive manner as a clinical marker of interstitial cystitis. MATERIALS AND METHODS: Urinary GP51 levels were measured using antigen inhibition enzyme-linked immunosorbent assay. In blinded fashion we analyzed for quantitative differences 24-hour urine samples of 36 patients with interstitial cystitis and 23 normal controls who were age matched within 5 years (mean age 47.3). We also evaluated GP51 in random urine specimens of 17 normal controls, 14 patients with interstitial cystitis and 11 subjects who had undergone cystectomy to determine whether urinary GP51 is mainly produced by the bladder, which is the site of interstitial cystitis. To ascertain the specificity of urinary GP51 to interstitial cystitis urine samples of 34 patients with other urological diseases were measured and compared with findings in the samples of 15 with interstitial cystitis. RESULTS: Low GP51 levels appeared to be unique to the interstitial cystitis state compared to normal (p = 0.008). GP51 in patients with interstitial cystitis and in those who underwent cystectomy was lower (p < 0.001) than in normal controls. These findings suggest that the major source of urinary GP51 is the bladder. Also, we observed lower GP51 levels in interstitial cystitis than in other urinary tract diseases (p < 0.0001). CONCLUSIONS: Our study substantiates the possibility of using GP51 as a clinical marker for diagnosing interstitial cystitis by a noninvasive urinary assay.

Transverse preputial flap for ventral penile skin coverage in hypospadias surgery.

A dartos-based transverse skin flap for ventral penile skin coverage is used as an adjunct to hypospadias surgery. The technique is simple and reliable. After completing the primary repair of the penis, the ventral skin defect is assessed. A dartos pedicle is developed, and the flap of dorsal penile skin is transferred ventrally along either side of the shaft. To date, 63 boys (ages 6 to 78 months) have undergone this type of penile skin reconstruction. Our transverse preputial flap has been used as an adjunct to hypospadias repair (28 boys), correction of chordee (26 boys), and release of concealed penis (9 boys). During a follow-up period of 6 to 74 months, 52 patients (83%) had a favorable cosmetic result. One patient experienced a significant loss of epithelium in the early postoperative course. Another patient developed a moderate penile torsion, which required subsequent revision of the repair. Two patients developed moderate scar indentations of the repair. Seven patients demonstrated a moderate redundancy of the flap with time. The transverse preputial flap is a reliable and cosmetically superior alternative to ventral skin coverage in hypospadias surgery, repair of chordee, and in the release of concealed penis.

Medical and surgical supply costs. Case study of a costly low-cost technology.

There is a paucity of research regarding the contribution of "low-cost" technologies to the escalation of medical costs in the United States. We examined total charges for medical and surgical supplies (MSS) among all hospitalized Medicare beneficiaries in 1994; a total of US $16.8 billion was spent on MSS, or $1,397 per hospitalization. For selected surgical procedures, both the proportion of total hospital charges attributed to MSS and the mean charge per hospitalization were considerably higher. Concerns regarding excessive payments for MSS and the lack of accountability by the Medicare program are discussed. Itemization of MSS supplies may serve to eliminate wasteful use and lead to decreased costs.

Vasopressor therapy for hypotension during epidural anesthesia for cesarean section: effects on maternal and fetal flow velocity ratios.

The purpose of this study was to identify the influence of hypotension as a result of epidural anesthesia and of its treatment with either ephedrine or methoxamine on uteroplacental and umbilical flow velocity ratios and fetal acid-base status. Fifty healthy women with an uncomplicated full-term pregnancy were studied during elective cesarean section under epidural anesthesia. A method of continuously recording flow velocity waveforms was used that allowed the identification of simultaneous values of maternal and fetal Doppler indices related to events during the induction of anesthesia. In 15 patients in whom arterial blood pressure did not decrease, the uteroplacental pulsatility index (UtPI) did not change, but the umbilical pulsatility index (UmPI) decreased from a mean (95% confidence interval) of 0.98 (0.88-1.09) to 0.91 (0.82-0.99) (P less than 0.05). In 32 patients who experienced hypotension of at least 15%, the UtPI increased from 0.82 (0.76-0.89) to 1.04 (0.92-1.17) (P less than 0.01). Treatment with ephedrine had no influence on either the UtPI or UmPI, but treatment with methoxamine resulted in brief increases in the UtPI of 0.47 (0.24-0.69) during the first 5 min after its administration; the increases were brief and resolved within 2 min. The choice of vasopressor drug had no influence on the UtPI recorded just before surgery commenced (final UtPI), but those patients who experienced hypotension had significantly larger final UtPIs (1.02 (0.91-1.10)) than those who never became hypotensive (0.86 (0.72-0.99)), and this was associated with significantly increased placental hydrogen ion gradients. The choice of vasopressor drug appears to be of minor importance compared with the avoidance of hypotension.

Transcutaneous iodine absorption in infants undergoing cardiac operation.

Povidone-iodine is an effective antiseptic, but its topical use has been associated with a number of adverse reactions in burn patients and in neonates as a result of transcutaneous absorption. In particular, high plasma iodine concentrations are known to cause renal failure, metabolic acidosis, and thyroid suppression. Because of the permeable nature of the skin in small infants and the large areas cleaned before cardiac operations, it is possible that significant transcutaneous iodine absorption might occur in this situation. We have studied 17 infants, less than 3 months of age, who were undergoing closed cardiac or thoracic procedures. After povidone-iodine skin preparation in 15 (covering 20% to 30% of body surface area), plasma total iodine concentrations rose fourfold (range, 160% to 1,440%). This increase was significantly different from the preoperative level at 6, 12, 18, and 24 hours. There was no increase in plasma iodine concentration in 2 patients who were not exposed to povidone-iodine or any other iodine-containing compound. We discuss the implications for a topical antisepsis policy in infants.

Transmural surgical gown pressure measurements in the operating theater.

Transmural gown pressures encountered when the surgeon comes into contact with a patient were measured in the operating theater. The surgical gown industry has assumed these pressures to be less than 5 psi in testing the efficacy of the gown and drape barrier material to impede bacterial transmission through its pores. In this study, pressure-sensitive contact film and resistive strain gauge recordings made from the surgeon's abdominal region and forearms indicated peak contact pressures in excess of 60 psi. This report indicates a need to reassess the basis of test utilization in evaluating barrier materials used in gowns and drapes.

Trimetrexate in prostatic cancer: preliminary observations on the use of prostate-specific antigen and acid phosphatase as a marker in measurable hormone-refractory disease.

Thirty-one patients with bidimensionally measurable hormone-refractory prostatic cancer received trimetrexate (TMTX). Serial values of prostate-specific antigen (PSA) and acid phosphatase (SAP) were correlated with response. Five patients (17%; 95% confidence interval, 3% to 30%) achieved a partial remission for a median of 3 months (range, 3 to 7.5 months). Marker levels showed large variations with no discernible patterns. Serial PSA and SAP in 19 patients with abnormal baseline values showed a correlation with measurable disease response in only 68% (13 of 19) and 47% (nine of 19) of patients, respectively. Values were then smoothed using an exploratory data analysis technique of running medians and averages. Trends in marker changes were much more apparent. Several "decision rules" were evaluated for use of markers as indices of disease progression. A 50% increase from the patient's minimum value in either PSA or SAP on two successive determinations correlated with progression in 90% of cases in this trial. TMTX has modest activity in prostatic cancer, and further trials are not warranted. Biochemical markers do not uniformly reflect disease activity in hormone-refractory disease, and changes in biochemical markers must be interpreted cautiously when used as the sole end point to assess efficacy in clinical trials.

MR imaging of stump neuroma.

Painful stump neuromas in the postamputation patient are difficult to diagnose and treat. We report a case in which magnetic resonance allowed precise preoperative diagnosis and localization of such a lesion. Magnetic resonance, with its ability for long axis imaging in the extremity, is ideally suited for the workup of stump neuromas.

Acupuncture prophylaxis of cancer chemotherapy-induced sickness.

In a multi-facet study we evaluated the efficacy of P6 electroacupuncture (10 Hz applied for 5 min) as an antiemetic in patients receiving a variety of cancer chemotherapy drugs. The study involved 130 (15 in an open pilot study, 10 in a randomized placebo controlled crossover study and 105 in a definitive study) patients who had a history of distressing sickness after previous treatment, and who, on the basis of a previous survey, would be expected to have a 96% chance of this with subsequent therapy. Sickness was either completely absent or reduced considerably in 97% of patients and no side effects were encountered. The limited crossover study, using a 'dummy' acupuncture (ACP) point showed that the beneficial effects were limited to the P6 point. Logistic and ethical considerations excluded the possibility of carrying out a larger placebo-controlled study. While in our hands P6 ACP was an effective antiemetic in patients having cancer chemotherapy, because of the time involved and the brevity of the action (8 h) an alternative approach to electro-ACP is required before this technique is adopted clinically.

Rapid detection of herpes simplex virus (HSV) antigen in human ocular infections.

The new HERPCHEK (Dupont, No. Billerica, MA) enzyme immunosorbent assay (EIA) was used in a double-blind clinical study for rapid and specific detection of ocular herpes simplex virus (HSV) infection. This 4-hour assay can be used to demonstrate conclusively the presence of HSV antigen without culture and thereby rapidly differentiate between HSV and other clinically similar ocular infectious diseases. Ocular samples were collected from 180 individuals including 30 patients with acute HSV, 90 with latent HSV (ie, currently asymptomatic but with a positive history), 11 with acute or latent varicella zoster virus, 30 with nonherpetic infections (due to adenovirus, Acanthamoeba or bacteria), and 19 normal controls. A clinical diagnosis was made by one of us (DPL) and duplicate tear-film samples obtained by swabbing the conjunctival cul-de-sac and cornea. Coded samples were tested by routine viral culture on Vero cell monolayers and also were run independently in the HERPCHEK test. During active HSV infection, the HERPCHEK correlated 100% with clinical diagnosis, and virus culture correlated 90% with clinical diagnosis. In all latent HSV ocular infections, other nonherpetic ocular infections and normal samples, both the HERPCHEK and culture assays were negative.

Factors improving survival in multisystem trauma patients.

This report analyzes the effect of air versus ground interhospital transport on survival following multisystem injury. There were 136 air-transported patients versus 194 ground-transported patients. The groups were similar in trauma scores, ages, mechanism of injury, and organ systems injured. There was a statistically significant survival advantage for air-transported patients with trauma scores between 10 and 5 (82.8% survival vs. 53.5%, p = less than 0.001). The time interval between accident and admission to the authors' institution was similar for both groups. Important therapeutic interventions contributing to better survival by the air-transported group included higher incidences of endotracheal intubation (50% vs. 25%), blood transfusions (32% vs. 10%), larger volumes of electrolyte fluid (3.3 L per patient vs. 2.1 L per patient) as well as the use of MAST trousers (60.3% vs. 34.9%). Transport charges for both ground and air services were similar. However, helicopter charges met only 15% of the operational budget of the aeromedical service. The remainder of the costs were generated from hospital patient revenues. Overall, total hospital charges were similar for both groups and were influenced by the variability of length of stay, particularly for orthopedic patients.

Midazolam sedation following open heart surgery.

Midazolam given as hourly intermittent injections was compared with the same dose given by infusion for postoperative sedation in patients after cardiopulmonary bypass. A stable concentration was rapidly attained with the infusion whereas 6-8 h was required to attain stable plasma (trough) concentrations in the intermittent injection group. Plasma concentrations decreased rapidly to low values within 6 h of discontinuation of therapy. High plasma concentrations and a long (16 h) half-life were noted in one patient who may be a slow metabolizer of the drug.

Reducing wound infections. Improved gown and drape barrier performance.

A 21-month study involving 2181 clean and clean-contaminated general surgical procedures was performed to evaluate the effectiveness of a commercially available disposable gown and drape system vs a cotton system in reducing wound infection. The series in which the disposable spun-laced fiber system was used had a significantly lower overall infection rate (2.83% vs 6.5%) as well as better rates in clean (1.8% vs 3.8%) and clean-contaminated (4.8% vs 11.4%) procedures. This effect was independent of all other factors. The odds of developing a wound infection was 2 1/2 times higher with a cotton system than with a disposable system. Actual cost analysis from three types of hospitals showed lower costs with utilization of disposable gown and drape systems. Hospital charges were significantly higher for those patients developing wound infections. The results of the study demonstrated not only significant reduction in wound infection rates but also major cost savings when a disposable gown and drape system was used in the operating room.