Blood transfusions increase the risk of venous thromboembolism following ventral hernia repair.

BACKGROUND: Blood transfusions can affect the clotting cascade, leading to a hypercoagulable state. The association of a venous thromboembolic (VTE) event and perioperative blood transfusion has been identified previously in surgical patients, but not after ventral hernia repair (VHR). The aim of this study was to evaluate the risk of VTE in VHR patients who receive a perioperative blood transfusion. METHODS: The American College of Surgeons National Surgery Quality Improvement Program was queried for open (n = 34,687) and laparoscopic (n = 11,544) VHRs that occurred from 2013 to 2015. Regression analyses were used to determine factors predictive of VTE within 30-day post-operatively, the impact of bleeding requiring blood transfusion, and the influence of surgical approach on VTE. RESULTS: Post-operative VTE occurred in 246 (0.5%) VHR patients. Among those patients, 53.0% occurred after discharge. Increased age, operative time, and comorbidities increased the risk of VTE (p < 0.05). Controlling for surgical approach, perioperative blood transfusion increased the risk of VTE 10.2-fold (p < 0.0001) in open and 12.2-fold in laparoscopic VHR (p < 0.0001). CONCLUSION: Perioperative blood transfusions are associated with an increased rate of VTE following VHR, more than 50% of which occur after discharge. This study highlights the importance of identifying quality initiatives for at risk patients, including adequate VTE screening and potential prophylaxis for those who receive perioperative blood transfusions.

Laparoscopic hernia complexity predicts operative time and length of stay.

PURPOSE: Laparoscopic ventral hernia repair (LVHR) is associated with shorter hospitalization and lower complication rates compared to open ventral hernia repair. We sought to determine if hernia-related factors, such as defect size and re-operative status correlate with postoperative complications, operative times and length of stay (LOS). METHODS: The study is a retrospective review of 30-day perioperative outcomes following LVHR in 91 patients who underwent surgery at a single institution from August 2009 through June 2012. A single surgeon performed all procedures. RESULTS: Indications for surgery were recurrent incisional hernia in 33 % of patients and primary incisional or ventral abdominal hernias in the rest. Coated polyester mesh with an average size of 348 cm(2) (±214; range 113-1,036) was used. Mean operative time was 132 min (±66.1; range 53-412). The mean LOS was 4.0 days (±3.5; range 1-22). Complications occurred in 13 patients for overall morbidity of 16.5 % and no mortality. There was one recurrence in 30 days (1.1 %). Patients who had a surgery >120 min or a LOS >1 day were statistically more likely to have multiple hernias, larger defect sizes (>40 cm(2)), larger mesh sizes (>300 cm(2)) or a history of recurrent hernia (P < 0.05). No other clinical or demographic variable evaluated in this study correlated with operative time or LOS. CONCLUSIONS: LVHR is safe with a low incidence of perioperative complications. Patients with multiple, larger and recurrent hernias have longer operative times and LOS. This information can be used to guide preoperative planning for the patient, surgeon and treating institution.

The effects of windrow composting on the viability of Parascaris equorum eggs.

Parascaris equorum generally infects horses less than 18 months old and its pathological effects can be severe. Infection occurs when larvated eggs, present in pastures, paddocks, stalls, and on feeding and watering equipment are ingested. The purpose of this study was to examine the effects of windrow composting on the viability of P. equorum eggs at a cooperating central Kentucky horse farm. Three grams of feces containing 2216 P. equorum eggs per gram were sealed in filter bag sentinel chambers. Chambers were exposed to 1 of 3 treatments: constant exposure or intermittent exposure to the interior of the windrow; controls were stored at 4°C. At day 0, all chambers in the experimental treatments were placed in the center of 10 locations of the windrow. On subsequent days when the windrow was turned, chambers in the constant exposure treatment were returned to the interior of the windrow and chambers in the intermittent exposure treatment were alternated between resting on top of, or inside, the windrow. Chambers from each treatment and control chambers were removed at days 2, 4, 6, 8, 10, 12, 14, and 18; and incubated for 21 days at room temperature (24°C). After incubation, eggs were recovered from the chambers using double centrifugation flotation. Eggs were evaluated microscopically, staged according to development and classified as viable or nonviable based on whether embryonation to the larval stage had occurred. Results were reported as the mean percent viable eggs for each treatment and time point. A mixed linear model with repeated measures was used to evaluate the influence of experimental day and treatment on the percent viability of P. equorum eggs. Chambers treated with constant exposure contained 10.73% (SD=0.29) viable eggs on day 2 and declined to an average of 0.00% by day 8. Chambers exposed to the intermittent treatment contained 16.08% (SD=0.26) viable eggs on day 2 and decreased to 0.00% by day 6. Control chambers for days 2, 4, 6, 8, 10, 12, 14, and 18 all had viabilities above 79.00%. A significant fixed effect of experimental day (p<0.0001) and compost treatment (p<0.0001) was observed. There was no significant interaction between experimental day and compost treatment (p>0.7459). The results of this study demonstrate that windrow composting was effective at rendering P. equorum eggs nonviable when it was tested under the conditions at a working horse farm.

Measuring laparoscopic operative skill in a video trainer.

BACKGROUND: Laparoscopic surgery requires a unique set of technical skills. More experienced laparoscopic surgeons perform certain tasks more efficiently in a video trainer than less experienced laparoscopic surgeons. The presumption is that the experienced surgeon possesses more of the skill required to complete the task. This study sought to determine the degree to which previous laparoscopic operative experience influenced the performance of selected video trainer tasks of varying complexity. METHODS: In this study, 19 general surgery residents with varying levels of laparoscopic operative case experience (as defined by operative case logs) were timed performing five tasks in a video trainer. The tasks were rope pass, peg drop, peg exchange, needle pass, and knot tie. All the residents watched a video demonstration of each skill before testing. None of the residents had previous exposure to video trainers, and no practice was allowed before testing. A composite score for all tasks was calculated for each resident as a measure of overall performance. RESULTS: There was a strong correlation between operative experience and time required for successful completion of each task, with the exception of the rope pass. The magnitude of correlation increased with tasks of increasing complexity. Composite scores were correlated with operative experience. Significant interval improvements in performance were observed for increasing experience up to a level of approximately 100 previous laparoscopic cases. CONCLUSIONS: Overall composite scores and time required for the completion of each individual video trainer task (with the exception of the rope pass) may be an accurate reflection of laparoscopic surgical skill acquired in the operating room. A resident may need as many as 100 laparoscopic cases for full development of a basic skill set in the operating room. A more efficient and safe method of training, such as a validated skills curriculum conducted in a dry lab, is a desirable alternative to developing skill exclusively in the operating room.

Computer-assisted robotic antireflux surgery.

Robotic surgical systems are relatively new technical devices designed to address several of the limitations inherent to standard laparoscopy. Since the 1(st) report of a computer-assisted fundoplication in 1997, numerous authors have reported their experiences with these devices in antireflux surgery. While there are several advantages to robotic when compared to standard laparoscopic antireflux surgery, there are also some distinct drawbacks. Robotic surgical systems allow the surgeon to perform more complex maneuvers with increased precision and accuracy, and without tremor. The image is high-definition and the surgeon operates in a more ergonomic position. These systems are also costly to purchase and maintain, they are large and may limit access to the patient during surgery, they provide a narrower field of view of the operative site, and they provide the surgeon with essentially no tactile feedback. Clinical outcomes of robotic fundoplication seem to be very similar to those of standard laparoscopic fundoplication, although the operating times in many series are increased when using the robot. The role of computer-assisted fundoplication in general practice, at least at the current level of robotic technology, remains to be defined.

Tension pneumopericardium after blunt chest trauma.

We present a case of tension pneumopericardium in a patient involved in a motor vehicle crash. This patient was treated initially with a percutaneously placed drain and then definitively by a video assisted thoracoscopic pericardial window.

Effects of polychlorinated biphenyls on thyroid hormones and liver type I monodeiodinase in the chick embryo.

Polychlorinated biphenyls (PCBs) are widespread environmental contaminants which can biomagnify to higher tropic level organisms including birds. Circulating thyroid hormones (TH) and growth are decreased by PCB exposure. The first set of studies investigated the effects of PCBs on an enzyme responsible for TH homeostasis, hepatic type I monodeiodinase (MDI) in chicken embryos. Fertile chicken eggs were injected with Aroclor 1242, Aroclor 1254, 2,2',6, 6'-tetrachlorobiphenyl (TCB), 3,3',4,4'-TCB, or 3,3',5,5'-TCB on Day 0 and studies were terminated on Incubation Day 21. Hepatic MDI activity was reduced in embryos treated with the Aroclor mixtures. No effects on MDI activities were observed after PCB isomer treatment. Liver weights from embryos treated with Aroclor 1242 were decreased. In the second study, chick embryos were exposed to these same PCBs in order to evaluate their effect on circulating THs and growth. Treatment with PCBs had no effect on body weight. Femur length were decreased with Arcolor 1242 treatment. A decrease in plasma concentration of thyroxine was observed after treatment with Aroclor 1242 and Aroclor 1254. Based on these findings, it is evident that PCBs alter the thyroid axis. Bird circulating TH levels, which are generally reported, may not be a good biomarker for low-dose exposure to PCBs. However, the reduction in MDI activity was more sensitive to PCB mixture exposure and may be a useful biomarker.

Bisphenol A interacts with the estrogen receptor alpha in a distinct manner from estradiol.

We investigated the interaction of bisphenol A (BPA, an estrogenic environmental contaminant used in the manufacture of plastics) with the estrogen receptor alpha (ERalpha) transfected into the human HepG2 hepatoma cell line and expanded the study in vivo to examine the effect of BPA on the immature rat uterus. Bisphenol A was 26-fold less potent in activating ER-WT and was a partial agonist with the ERalpha compared to E2. The use of ERalpha mutants in which the AF1 or AF2 regions were inactivated has permitted the classification of ER ligands into mechanistically distinct groups. The pattern of activity of BPA with the ERalpha mutants differed from the activity observed with weak estrogens (estrone and estriol), partial ERalpha agonists (raloxifene or 4-OH-tamoxifen), or a pure antagonist (ICI 182, 780). Intact immature female Sprague-Dawley rats were exposed to BPA alone or with E2 for 3 days. Unlike E2, BPA had no effect on uterine weight; however, like E2, both peroxidase activity and PR levels were elevated, though not to the level induced by E2. Following simultaneous administration, BPA antagonized the E2 stimulatory effects on both peroxidase activity and PR levels but did not inhibit E2-induced increases of uterine weight. These results demonstrate that BPA is not merely a weak estrogen mimic but exhibits a distinct mechanism of action at the ERalpha.

Effects of polychlorinated biphenyl mixtures and three specific congeners on growth and circulating growth-related hormones.

Polychlorinated biphenyls (PCB) are ubiquitous environmental contaminants that bioaccumulate in avian species. Exposure to PCBs can result in decreased growth. Thyroid hormones and growth hormone (GH) are important for normal growth. The present studies employed the chicken embryo to investigate effects of Aroclor 1242, Aroclor 1254, 2,2',6,6'-tetrachlorobiphenyl (TCB), 3,3',4,4'-TCB, and 3,3',5,5'-TCB on growth and growth-related hormones. The following indices were measured: embryo mortality, body weights, bone length, pituitary GH content, and plasma concentrations of triiodothyronine (T3), thyroxine (T4), GH, and insulin-like growth factor-1 (IGF-1). Fertile eggs were injected with PCBs on Day 0 and indices determined on Day 17 of incubation. Unexpectedly, 3,3',5,5'-TCB or low-dose Aroclor 1242 treatment increased body weight and bone length (P < 0.05), whereas Aroclor 1242 (high dose), 3,3,4,4'-TCB, or Aroclor 1254 treatment reduced body weights and/or bone length (P < 0.05). Aroclor 1242 or 3,3',4,4'-TCB (low-dose treatment) elevated plasma T4 concentrations (P < 0.05). Both growth and pituitary GH content were increased (P < 0.05) by 3,3',5,5'-TCB (low dose) or Aroclor 1242 treatment. Despite marked differences in growth rates, plasma T3, GH, and IGF-I concentrations were unaffected by PCB treatment. Growth-related hormones may not be responsible for the growth depression observed after PCB treatment. Possibly the decrease in growth occurred because of general toxicity. The importance of chlorine position in causing thyroid hormone axis alterations was not clearly established.

Evaluation of chemicals with endocrine modulating activity in a yeast-based steroid hormone receptor gene transcription assay.

There is a concern that chemicals in our environment are affecting human health by disrupting normal endocrine function. Much of the concern has focused on chemicals that can interact directly with steroid hormone receptors. We have used a yeast-based assay to assess chemical interactions with the estrogen, androgen, and progesterone receptors. The yeast transformants used in this study contained the human estrogen, androgen, or progesterone receptor along with the appropriate steroid responsive elements upstream of the beta-galactosidase reporter gene. Chemicals were added to yeast cultures in doses ranging from 10(-12) to 10(-4) M and following incubation, the yeasts were then lysed and assayed for beta-galactosidase activity. Diethylstilbesterol and 17-beta estradiol were most active in the estrogen receptor assay, followed by the phytoestrogen, coumestrol. p-Nonylphenol and bisphenol A were approximately 5000- and 15,000-fold less active, respectively, than estradiol. Methoxychlor, DDT and its metabolites, o,p'-DDD, and o,p'-DDE ranged in potency from 5 to 24 X 10(6) less potent than estradiol. Testosterone and dihydrotestosterone were most potent in the androgen receptor assay, followed by estradiol and progesterone. p,p'-DDE was approximately 10(6)-fold less potent than testosterone. None of the industrial chemicals tested interacted with the progesterone receptor. These data demonstrate the utility of using yeast-based receptor assays for detecting chemical interaction with steroid receptors and these assays should serve as a useful component of an in vitro-in vivo strategy to assess the effects of chemicals on endocrine function.

Antibiotic compared with antiseptic prophylaxis for prostatic surgery.

Two different regimens of cephalosporin antibiotic prophylaxis were compared with antiseptic lubricating jelly to try to prevent infection and complications in 196 men after prostatic surgery. Pre-operative urine was cultured and prostatic chips (170 cases) were also cultured to define the source of any infection. The use of antibiotics was associated with a reduced risk of postoperative bacteriuria. No serious complications occurred, although 1 patient in the antiseptic treated group developed rigors; 79 of 170 patients (46%) had positive prostatic chip cultures, of whom 74 had sterile pre-operative urine. There was no association between the result of chip culture and the presence of a pre-operative catheter. Culture positive patients had an increased risk of post-operative urine infection, although the same organism was found in the prostate and urine in only 36% of cases of post-operative bacteriuria and in 43 (54%) the organism cultured from the prostate was Staphylococcus albus. This study provides further evidence of the benefit of true prophylactic antibiotic therapy for transurethral prostatic surgery and the prostatic chip data suggest that some of the risk is due to pre-operative contamination of the prostate in the absence of per-operative urinary infection or catheterisation.

Antibiotic prophylaxis for prostatic surgery. Single-dose cephradine compared with single-dose cefotaxime.

Several previous studies have attested to the value of antibiotic prophylaxis for prostatic surgery. We report a prospective randomised study which compared a single dose of cefotaxime with a single dose of cephradine given with the induction of anaesthesia. There was little difference between these regimens and it was concluded that either may be used, depending on availability and cost of the antibiotic. We have now completed a 5-year study of antibiotic prophylaxis for prostatic surgery and we also report the results of a long-term survey of the ward flora. There has been no significant change and there is no evidence for the emergence of resistant strains.

A randomized trial of 48 hours of prophylactic cefotaxime versus single dose in transurethral prostatic surgery.

A previous randomized trial from this department demonstrated that there was significant reduction in morbidity and post-operative bacteriuria when men undergoing transurethral prostatectomy were given a prophylactic perioperative regimen of 48 h of cefotaxime compared with a no treatment control group. In this paper we report the results of a new randomized trial to determine whether a single dose of cefotaxime given with the induction of anaesthesia would be of equal efficacy to the previous 48 h regimen. We also investigated the ward bacterial flora for cefotaxime resistance before and during the trial. The 48 h regimen was significantly superior to the single dose in terms of the number of men who developed post operative complications and there was also a small but significant reduction in post-operative hospital stay. Forty-eight hours of prophylaxis covers the normal time of post-operative urethral catheterization and this may explain our findings. There was no evidence of emergence of cefotaxime resistant strains.

The efficacy of a new formulation of trimethoprim and sulphadiazine in acute exacerbations of chronic bronchitis.

Thirty-four acute exacerbations of chronic bronchitis were treated using a new formulation of trimethoprim and sulphadiazine. Significant bacterial isolates were obtained in 18 exacerbations of which 12 comprised Haemophilus influenzae. Adverse effects of treatment, principally nausea, occurred in 5 patients. A satisfactory clinical response in association with the achievement of mucoid sputum was obtained in 94% and the mean time for sputum conversion of 3.8 days compares favourably with other antibiotics.

Short-term prophylaxis with cefotaxime for prostatic surgery.

A randomised controlled trial of a new cephalosporin, cefotaxime, was carried out in men undergoing transurethral resection of the prostate. The purpose of the trial was to determine whether 48-hour prophylaxis with this new broad-spectrum, non-nephrotoxic cephalosporin would reduce postoperative bacteriuria and postoperative complications. The treated patients fared significantly better than the non-treated patients in having fewer febrile episodes, fewer episodes of tachycardia, a lower incidence of appreciable bacteriuria postoperatively, and fewer complications, and spending on average one day less in hospital. There was no difference in postoperative urea and creatinine concentrations between the groups, and no other side effects of cefotaxime occurred in this elderly population. Prophylaxis with cefotaxime would appear to make prostatic surgery safer.

Absorption of penicillin and paracetamol after small intestinal bypass surgery.

Drug absorption was studied in morbidly obese patients before and after jejunoileal bypass. The absorption of phenoxymethyl penicillin was considerably increased whilst that of paracetamol was unchanged.

A comparison of ampicillin, erythromycin and erythromycin with sulphametopyrazine in the treatment of infective exacerbations of chronic bronchitis.

A comparative study of ampicillin (500 mg four times daily), erythromycin (500 mg four times daily) and sulphametopyrazine (1 g at start of exacerbation) followed by erythromycin (500 mg four times daily) was carried out in infective exacerbations of chronic bronchitis. Ampicillin and erythromycin were found to be equally effective, but the combination of erythromycin and sulphametopyrazine was significantly less effective. Unwanted effects were more frequent with ampicillin and with erythromycin plus sulphametopyrazine than with erythromycin alone.

Erythromycin in respiratory tract infection.

One of the main uses of erythromycin in respiratory tract infection has been in the treatment of acute streptococcal tonsillitis as an alternative to penicillin. Studies on the quantitative bacteriology of tonsils obtained at tonsillectomy have shown large numbers of both haemolytic streptococci and Haemophilus species in most samples and these organisms can be effectively reduced in number by preoperative treatment with antibiotics such as erythromycin. Such investigations suggest that erythromycin might have wider use in the treatment of respiratory tract infections, particularly where Haemophilus influenzae and other Haemophilus species are involved. Apart from specific infections such as those due to Mycoplasma pneumoniae, erythromycin is effective in the treatment of acute pneumonia due to organisms such as the pneumococcus, and this paper reports the further use of erythromycin in the treatment of acute exacerbations of chronic bronchitis where the clinical and bacteriological effects of treatment with this antibiotic are compared with those of ampicillin.