Necessity of subcutaneous suction drains in ileostomy reversal (DRASTAR)-a randomized, controlled bi-centered trial.

PURPOSE: Data regarding length of hospital stay of patients undergoing ileostomy reversal are very heterogeneous. There are many factors that may have an influence on the length of postoperative hospital stay, such as postoperative wound infections. One potential strategy to reduce their incidence and to decrease hospital stay is to insert subcutaneous suction drains. The purpose of this study was to examine the influence of the insertion of subcutaneous suction drains on hospital stay and postoperative wound infections in ileostomy reversal. Risk factors for postoperative wound infection were determined. METHODS: This is a randomized controlled two-center non-inferiority trial with two parallel groups. The total length of hospital stay as primary endpoint and the occurrence of a surgical site infection, the colonization of the abdominal wall with bacteria, and the occurrence of hematomas/seromas as secondary endpoints were monitored. RESULTS: One hundred eighteen patients with elective ileostomy reversal were included. Fifty-nine patients were randomly assigned to insertion of a subcutaneous suction drain, and 59 patients were randomly assigned to receive no drain. After 3 months of follow-up, 50 patients in the group with drain and 53 patients in the group without drain could be analyzed. Median total length of hospital stay was 8 days in the SD group and 9 days in the group without SD (p = 0.17). Fourteen percent of patients with SD and 17 % without SD developed SSI, p = 0.68. Multivariate analysis revealed anemia (p < 0.01), intraoperative bowel perforation (p = 0.02) and resident (p = 0.04) or fellow (p = 0.048) performing the operation as risk factors for SSI. CONCLUSIONS: This trial shows that the omission of subcutaneous suction drains is not inferior to the use of subcutaneous suction drains after ileostomy reversal in terms of length of hospital stay, surgical site infections, and hematomas/seromas.

Risk factors for reoperation after ileostomy reversal - Results from a prospective cohort study.

BACKGROUND: Ileostomy reversal is frequently performed in abdominal surgery. Postoperative complications after ileostomy reversal are encountered in around 20% of patients. Data regarding risk factors for reoperation after ileostomy closure are scarce. The purpose of this prospective trial was to determine risk factors for operative revision after ileostomy closure. MATERIALS AND METHODS: This is an additional post hoc analysis of a two center prospective trial. After enrollment, patient characteristics and intraoperative details were analyzed. Patients were followed up at one postoperative visit before discharge and at a three months postoperative visit by standardized questionnaire. All reoperations occurring in the three months period after surgery were analyzed, and immediate reoperations which were directly related to the ileostomy reversal were analyzed separately. RESULTS: 118 patients with elective ileostomy reversal were included in the trial. 12 out of 106 patients (11.3%) underwent any reoperation within three months after surgery (Clavien-Dindo grade IIIb). On multivariate analysis, anemia was associated with any reoperation p = 0.004; OR 6.93 (95% CI 1.37-30.07). Six out of 114 patients (5.3%) required an immediate reoperation (small bowel perforation, anastomotic leakage, postoperative ileus, deep wound infection) due to surgical complications directly related to the ileostomy reversal. Higher body mass index and anemia were associated with immediate reoperations (BMI: p = 0.038; OR 0.73 (95% CI 0.55-0.98); anemia: p = 0.001; OR 25.50 (95% CI 3.87-168.21). CONCLUSION: Surgical complications after ileostomy reversal occurred to a substantial extent. Rate of reoperations was associated with anemia and high body mass index. Optimizing patients in terms of preoperative hemoglobin and BMI may reduce surgical complications after ileostomy closure.

Purification of thymidine phosphorylase from human amniochorion.

Thymidine phosphorylase (thymidine : orthophosphate deoxyribosyltransferase, EC 2.4.2.4) has been purified 1500-fold from extracts of human amniochorion. The purified enzyme catalyzes the phosphorolysis of deoxythymidine and to a lesser extent deoxyuridine but not deoxycytidine nor uridine. Discontinuous gel electrophoresis of the freshly purified enzyme shows a band containing 95% of the stainable protein. Gradient gel electrophoresis resolves the preparations into an active fraction with an apparent molecular weight of about 120 000 and a heavier less active or inactive fraction of about 180 000. Storage of the enzyme results in a decrease of the 120 000 dalton component, a loss in activity, and an apparent increase in the high molecular weight component. Sodium dodecyl sulfate gel electrophoresis shows only a single subunit of about 58 000 daltons which does not change on storage. These data are consistent with an active enzyme dimeric in structure which is capable of being converted to a less active form larger in molecular weight and possibly trimeric or tetrameric in structure.

Isolation of the polypeptide chains of prekeratin.

Stratum corneum alpha protein, the principal structural protein of the epidermis, and its precursor prekeratin have been studied. Both proteins have similar patterns on sodium dodecyl sulfate electrophoresis and consist of several polypeptide chains (designated A, A', B, B'). These subunits have been isolated by chromatography on diethylaminoethyl cellulose in 8 M urea and characterized. Immunological studies have shown that the four subunits could be grouped into two distinct immunological groups referred to as the A and B groups and analysis of the cyanogen bromide fragments of purified components appeared to support such a hypothesis. X-ray diffraction studies have shown that at least one A component and one B component are necessary for the production of a typical alpha X-ray diffraction pattern. Circular dichroism studies have shown that the polypeptide chains of either class have low ellipticity when compared to the intact molecule, indicating that both chains are necessary for the formation of an alpha-helical structure.

Fibrous protein of human epidermis.

The fibrous proteins of the malpighian layer of human epidermis (prekeratin) have been isolated with citrate buffer, pH 2.65, and shown to consist of 7 polypeptide chains varying in molecular weight from 45,000 daltons to 67,000. Some variation in the number and amount of the components was observed in prekeratin prepared from the epidermis of different individuals. The fibrous proteins of the stratum corneum were isolated with Tris buffer, pH 9.0, containing 6 M urea and 0.1 M mercapto-ethanol and were found to have a pattern similar to prekeratin but not identical to it. However, fibrous protein isolated from the superficial layers of the stratum showed a considerably different pattern indicating that there was post-translational modification of the protein in the late stages of keratinization. These data show that human keratin has the same heterogeneity which was observed previously in cow epidermis. This was further confirmed by studying the polypeptide chain content of prekeratin from a large number of lesions showing benign epidermal hyperplasia, where considerable variation in composition was observed.

The fibrous proteins of stratum corneum.

The proteins of cow snout stratum corneum can be extracted in part with Tris buffer, pH 9.0, containing 6 M urea. Sodium dodecyl sulfate (SDS)-polyacrylamide gel electrophoresis shows that about half the extracted material migrates as prekeratin when the extract is treated with both SDS and mercaptoethanol; only trace amounts of the proteins migrating as prekeratin are seen when SDS alone is used. The urea extract gives precipitin lines to an antibody against prekeratin. After exhaustive extraction with the Tris-urea buffer an additional amount of protein is solubilized by extraction with buffer containing mercaptoethanol. This extract shows an electrophoretic pattern similar but not identical to prekeratin. These results suggest that the stratum corneum contains fibrous proteins with different degrees of cross-linking. An analogous system has also been observed in human stratum corneum.

Immunology of epidermal fibrous proteins.

This report describes the preparation and detection of antibodies to chemically unmodified prekeratin and stratum corneum proteins of cow and human epidermis. The antibodies are specific for epidermal fibrous proteins and do not cross-react with those of hair and nail which have the same molecular configuration but but distinctive physical and chemical properties. The antibodies did cross-react with epidermal fibrous proteins from a number of other vertebrate sources indicating an immunologic relationship among epidermal proteins whose polypeptide compositions and amino acid contents are somewhat dissimilar. Both antibodies give intense immunofluorescence localized to the malpighian layers but not to the stratum corneum. The antigenic sites in the native configuration of the stratum corneum layer may be buried, since denatured stratum corneum proteins react readily with the antibody. These antibodies have permitted the first detection of a form of keratin whose solubility properties are quite different from either prekeratin or stratum corneum proteins.

The fibrous proteins in various types of ichthyosis.

The stratum corneum of individuals with ichthyosis vulgaris, sex-linked ichthyosis, lamellar ichthyosis, and epidermolytic hyperkeratosis has been studied. An alpha x-ray diffraction pattern has been observed in all specimens and the solubility of the alpha fibrous proteins appears to be the same as in normal stratum corneum. Sodium dodecyl sulfate (SDS)-polyacrylamide electrophoresis of the fibrous proteins showed variable patterns within the different types of ichthyosis, while amino acid analyses of the proteins were quite similar to those from normal stratum corneum. These data suggest that the fibrous proteins in the ichthyosis are not abnormal, but further studies on the individual polypeptide chains are necessary to rule out more subtle differences.

The keratin polypeptides of psoriatic epidermis.

The polyacrylamide SDS electrophoretic pattern of protein extracted from the stratum corneum obtained by scraping the surface of involved skin of patients with psoriasis was different from that of uninvolved skin and normal controls. The pattern from superficial scales was similar to that of whole stratum corneum in the case of involved psoriatic epidermis but different in uninvolved and normal epidermis. These data indicate that the changes which are observed in the structural proteins during normal keratinization are not seen in involved psoriatic epidermis. In addition, the relative proportion of keratin polypeptides was different in involved psoriatic epidermis compared to normal skin. That these changes are not specific for psoriasis was shown by finding similar electrophoretic patterns with stratum corneum proteins from patients with other keratinizing disorders.

Comparison of stratum corneum and hair fibrous proteins.

The Tris-urea-mercaptoethanol (pH 9) soluble fibrous proteins of hair and stratum corneum have been compared in a number of animals. The 2 tissues show different urea (pH 8.3) and SDS polyacrylamide gel electrophoretic patterns and vary in amino acid composition. Cyanogen bromide cleavage was done on human stratum corneum and hair fibrous proteins and found to give different fragments by electrophoresis. Antibodies to stratum corneum protein did not react with hair protein and vice versa. Although the 2 types of fibrous proteins have the same helical structure as shown by x-ray diffraction analysis, their differences in composition may be important for specific interactions with other macromolecules.

The use of denaturing conditions for gel diffusion of insoluble epidermal proteins.

Modifications of the classical technique for double diffusion in agar plates are presented. These procedures allow insoluble proteins to be dissolved in a variety of denaturing solvents and antibody production specificity to be monitored by the appearance of precipitin lines in agarose gels as in the conventional Ouchterlony method. Results obtained using the insoluble proteins of bovine epidermis are summarized.

Rocket immunoelectrophoresis in the presence of denaturing agents.

Modifications of the Laurel rocket technique for assaying antigen antibody reactions are described. These procedures allow insoluble proteins to be dissolved in a variety of denaturing solvents (e.g., SDS and urea) and subjected to electroimmunoassay without loss of sensitivity or specificity. Methods are also presented for obtaining rockets using gel slices from polyacrylamide gel electrophoresis either in the presence of urea or SDS. Results obtained using keratins, the insoluble proteins of epidermis, hair and nail are summarized.

Rudimentary polydactyly presenting as a claw.

A patient with a congenital claw-like lesion of the finger was studied to determine the nature of the tissue. A variety of biochemical techniques and histological examinations indicated that the lesion was an example of rudimentary polydactyly covered with stratum corneum rather than an accessory nail.

Validation of a frequency database for four STR loci for use in casework in the Strathclyde Police Forensic Science Laboratory.

Data for four STR loci have been collected from 400 samples taken from complainers and suspects encountered in casework at the Strathclyde Police Forensic Science Laboratory (SPFSL). This paper describes statistical testing which demonstrates that its use will provide operationally robust procedures. Comparisons made with data collected from other British samples confirmed no practical differences between the different frequency distributions. This work provides further confirmation of the reliability of the so-called "product rule' in estimating the frequency of multilocus genotypes in British forensic casework.

A study of independence between STR and conventional blood type loci.

Blood samples from approximately 200 Scottish Caucasian individuals were typed at conventional loci (PGM, Gc and EAP) and also with a four locus STR multiplex. Tests of the data are described which demonstrate that the assumptions of between locus independence are robust for use in forensic casework.

Unusual results due to transfused blood.

During a murder enquiry, the forensic science investigation used PGM and EAP blood grouping systems and detected a mixture of blood on the deceased's jacket. The blood groups matched those of the deceased and accused. The results of DNA analysis, however, proved that only a single source of DNA, matching the deceased, was present. Supplementary information relating to the transfusion of the individual whilst still wearing his clothing led the authors to conclude that a mixture of transfused blood and the individual's own blood had effused from his body via a stab wound, and onto his clothing.

A genetic electrophoretic variant of human hair alpha polypeptides.

The structural proteins of hair were solubilized by reduction of disulfide bonds in 6 M urea at alkaline pH. Following conversion of the proteins to the S-carboxy-methyl derivatives, disc electrophoresis was done in 6 M urea at pH 8.3. In about 5% of the individuals studied, a variation in the normal electrophoretic pattern was observed, and this was true of hair from different body sites. An autosomal dominant mode of inheritance was found in the four families investigated. The variant pattern was not associated with any detectable change in the color, shape, stree-strain characteristics, X-ray diffraction pattern, or amino acid composition of the hair. A similar variant pattern was also observed in nail. The most likely hypothesis is that there is a polymorphism of one of the alpha polypeptides, although a mutation of a rate-determining gene cannot be excluded.

Intraspecies heterogeneity of epidermal keratins isolated from bovine hoof and snout.

The alpha-keratins, the principal components of the tonafilaments, were extracted, characterized and compared in bovine hoof and snout epidermis. The alpha-fibrous proteins of these tissues are similar with respect to their molecular weights, amino acid composition and percentage of helical structure. However, distinct differences in the polypeptides comprising these proteins were observed. Sodium dodecyl sulphate/polyacrylamide-gel electrophoresis of these proteins consistently showed that the polypeptide chain in snout, designated as band B (mol.wt. 67,000), was completely absent from hoof preparations. This was confirmed with several alternative preparative procedures. The peptides produced by digestion of the intact keratins from hoof and snout with CNBr were distinctly different. Finally, digestion of keratins from hoof and snout with trypsin yielded products that differed in size and resistance to further digestion. Thus, in addition to the interspecies polypeptide heterogeneity documented in the literature, this report establishes the intraspecies heterogeneity of keratins and suggests that these differences are due to either the expression of different gene products or differences in post-translational modifications in these two tissues.