A pilot study of sphincter-sparing management of adenocarcinoma of the rectum.

After analysis of 26 prospectively accrued patients with distal rectal adenocarcinomas who underwent sphincter preservation treatment, we have concluded that tumors that invade only the submucosa can safely be treated with surgery alone and that tumors that invade the muscularis or further can be safely treated with surgery combined with chemoradiotherapy. None of the patients had either local or distant recurrence, with a median follow-up of 21 months. All patients have been fully continent. The results, although preliminary, imply that resection of distal rectal adenocarcinoma with sphincter preservation, and adjuvant therapy when appropriate, have achieved local and distant control equal to the conventional Miles' abdominoperineal resection, but without the need for a permanent colostomy.

Comparison of nasal brush and nasopharyngeal aspirate techniques in obtaining specimens for detection of respiratory syncytial viral antigen by immunofluorescence.

Diagnosis of respiratory syncytial virus by antigen detection is dependent on obtaining adequate respiratory epithelial cells. Two specimen collection methods, nasopharyngeal aspiration (NPA) and nasal brushing (NB), were compared. Thirty-two pediatric patients with presumed viral pneumonia or bronchiolitis (34 episodes) had both NPA and NB performed. Of 34 specimens 15 were culture-positive for respiratory syncytial virus. Of these 12 NPA samples and 10 NB samples had viral inclusions by immunofluorescent antibody staining (IFA). Of culture-negative samples, 1 of 17 NB was positive by IFA. One specimen obtained by NB had too few cells to read by the IFA method. Sensitivity and specificity were 80 and 100% for NPA and 67 and 94% for NB. Total respiratory cells and IFA-positive cells (classified as few, moderate, or many) were greater with NPA; however, NB was also an effective procedure and was better tolerated by children, less expensive and easier to perform.

Effect of preoperative shampoos with chlorhexidine or iodophor on emergence of resident scalp flora in neurosurgery.

Wound contamination with endogenous bacterial scalp flora plays an important role in the pathogenesis of postoperative neurosurgical infections. To assess the effect of preoperative antiseptic shampoos on the emergence of resident scalp flora during surgery and subsequent wound contamination, we randomized 151 neurosurgical procedures into four study groups: group A--preoperative shampoos with chlorhexidine, surgical scalp preparation with chlorhexidine; group B--no shampoos, surgical preparation with chlorhexidine; group C--shampoos with iodophor, surgical preparation with iodophor; group D--no shampoos, surgical preparation with iodophor. Quantitative cultures of the scalp were obtained preoperatively and at the end of surgery, and qualitative wound cultures were taken prior to wound closure. Group A had the lowest concentration of bacteria on the scalp both preoperatively and postoperatively (median range = 30 [0-5.7 x 10(5)] and 0 [0-2.5 x 10(3)] respectively). Group A also had significantly fewer positive postoperative scalp cultures (29%) than groups B (51%), C (58%), and D (53%) (P less than 0.05), as well as fewer positive wound cultures (20% v 25%, 42%, and 30% respectively). A density of bacteria on the scalp of greater than 10(2)/4cm2 best predicted the presence of bacteria in the wound. Repeated preoperative shampoos with chlorhexidine reduce intraoperative emergence of resident skin flora and subsequent contamination of the wound.

Effect of preoperative shampoos with chlorhexidine or iodophor on emergence of resident scalp flora in neurosurgery.

Wound contamination with endogenous bacterial scalp flora plays an important role in the pathogenesis of postoperative neurosurgical infections. To assess the effect of preoperative antiseptic shampoos on the emergence of resident scalp flora during surgery and subsequent wound contamination, we randomized 151 neurosurgical procedures into four study groups: group A-preoperative shampoos with chlorhexidine, surgical scalp preparation with chlorhexidine; group B-no shampoos, surgical preparation with chlorhexidine; group C-shampoos with iodophor, surgical preparation with iodophor; group D-no shampoos, surgical preparation with iodophor. Quantitative cultures of the scalp were obtained preoperatively and at the end of surgery, and qualitative wound cultures were taken prior to wound closure. Group A had the lowest concentration of bacteria on the scalp both preoperatively and postoperatively (median range = 30 [0-5.7 x 10(5)] and 0 [0-2.5 x 10(3)] respectively). Group A also had significantly fewer positive postoperative scalp cultures (29%) than groups B (51%), C (58%), and D (53%) (P<0.05), as well as fewer positive wound cultures (20% v 25%, 42%, and 30% respectively). A density of bacteria on the scalp of < 10(2)/4 cm(2) best predicted the presence of bacteria in the wound. Repeated preoperative shampoos with chlorhexidine reduce intraoperative emergence of resident skin flora and subsequent contamination of the wound.

Coagulase-negative staphylococcal bacteremia in the changing neonatal intensive care unit population. Is there an epidemic?

A fivefold increase in the number of cases of nosocomial coagulase-negative staphylococcal bacteremia was investigated in a neonatal intensive care unit between 1975 and 1982. This apparent outbreak was not the result of increased isolation of coagulase-negative staphylococci from blood cultures nor an increased frequency with which blood cultures were obtained. Rather, it was attributable to a dramatic increase in the overall probability that a positive blood culture would be interpreted as "bacteremia" as opposed to a contaminant by both physicians and infection control staff. Specifically, there had been a 62.3% increase in neonatal intensive care unit bed use by very-low-birth-weight (less than 1000-g) infants between 1975 and 1982, and in both years, positive blood cultures were 3.8 times as likely to be perceived as clinically significant if obtained from such tiny infants. The growing number of very-low-birth-weight babies occupying neonatal intensive care unit beds, coupled with the observation that blood cultures positive for coagulase-negative staphylococci are almost four times as likely to be perceived as clinically significant if obtained from extremely premature infants, may account for the reported increase in nosocomial coagulase-negative staphylococcal bacteremia.

Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions.

To determine whether increased compliance with a policy of glove and gown isolation precautions could reduce the high rate of nosocomial respiratory syncytial virus (RSV) infection on an infant and toddler ward, we conducted a longitudinal intervention trial during three RSV seasons, from 1982 to 1985, with an intervention to increase compliance introduced midway through the second season. The risk of acquiring RSV infection in the hospital was adjusted for the intensity of nosocomial exposure to the virus by assigning each study week to one of five strata, defined by the proportion of hospital days on which virus was shed by children on the ward. Overall, 37 patients acquired nosocomial RSV infections during 7547 days at risk. The adjusted relative risk, comparing the infection rate in the period before the intervention (when compliance with isolation precautions was noted in only 38.5 percent of the observed patient contacts) with the infection rate in the postintervention period (when compliance more than doubled) was 2.9 (95 percent confidence interval, 1.5 to 5.7). Rates of nosocomial RSV infection increased linearly with increasing levels of exposure to patients shedding virus, but the rise in the infection rate with increasing exposure was less than one fourth as great (P less than 0.001) in the period after the intervention as it was before. We conclude that glove and gown precautions can substantially reduce the nosocomial transmission of RSV, particularly with increasing exposure to patients shedding the virus.