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.

Clinical experience with prophylactic antibiotic bowel suppression in burn patients.

An oral prophylactic antibiotic regimen (neomycin-erythromycin-nystatin) aimed at suppression of the bowel flora was utilized in 20 patients with thermal injury treated in a laminar flow burn unit with strict sterile technique and reverse isolation. The regimen was utilized for an average of 24 days. Surface cultures were obtained twice weekly from multiple areas of the burn wound, and burn wound biopsies were performed one to two times weekly. These patients were compared prospectively with a group of 10 patients treated in otherwise identical fashion, save for the omission of the antibiotic suppressive regimen. Bacterial colonization of the burn wound occurred an average of 19 days after admission in the group receiving antibiotics compared to 4 days after admission in the control group (p less than 0.01). Positive burn biopsies (more than 10(5) bacteria per gm of tissue) were observed twice as often in the group not receiving antibiotics (p less than 0.16) as were infectious complications of several types: bacteremia, burn wound sepsis, urinary tract infections, pneumonitis, cellulitis (0.10 less than p less than 0.20). Staphylococcal or fungal overgrowth were not encountered in the patients receiving prophylactic antibiotics, nor was there an adverse effect on serum creatinine levels with the prolonged use of neomycin.

Brachial artery reconstruction using the heparin-bonded Sundt shunt.

Fracture stabilization is often desirable prior to vascular repair in the management of major extremity injuries. This principle is particularly important when long vein grafts are required to minimize the risk of anastomotic disruption during the orthopedic portion of the procedure. However, in situations associated with prolonged periods of preoperative ischemia, early reperfusion of the injured extremity would be optimal. This report illustrates two cases of brachial artery injury in which heparin-bonded shunts were used to establish blood flow to the distal extremity before fracture fixation. The shunts were interposed between disrupted arterial segments and reestablished distal perfusion while associated fractures were internally stabilized. Thus, early revascularization allowed the orthopedic repair to proceed in an unhurried fashion. After adequate stabilization of the fracture, arterial reconstruction was completed using saphenous vein interposition grafts. This technique potentially could improve extremity salvage rates and facilitate the repair of arterial injuries associated with unstable long bone fractures.

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.

Toothbrush swallowing.

We encountered four cases of toothbrush swallowing and reviewed the literature on this subject. A total of 31 toothbrushes within the gastrointestinal tract have been reported. None have passed spontaneously. Several have caused significant complications related to pressure necrosis, including gastritis, mucosal tears, and perforation. The recommended treatment is endoscopic retrieval and postoperative monitoring for 24 hours in case of esophageal or gastric injury.

Soft-tissue fluid determination by dichromatic absorptiometry.

Dichromatic absorptiometry (DA) in a noninvasive method for individually determining the amount of lipid, bone mineral, and protein and water present in a mixture by differential attenuation of radiation beams emitted from a dual photon source. The physics involved permit these components to be determined extremely accurately and precisely. The present study investigated the ability of DA limb scans to measure changes in total body water produced in dogs and in patients. Dichromatic absorptiometry was determined to be a valid method of measuring changes in total body water content as reflected by limb fluid content changes. Precision was limited by the accuracy in positioning the limb for repeated scanning. Dichromatic absorptiometry has the potential of becoming a clinically useful instrument for measuring fluid content changes in limbs produced either by changes in total body water content or by conditions causing limb edema.

Is there a tardive dysmentia?

A change in the phenomenology of schizophrenia has been observed over the past several decades; affective disturbances and phasic courses have become more evident. Although there is no obvious single explanation for these changes, several ideas have been considered. The advent and use of antipsychotic drugs over the past 30 years stands out as the most significant change. Because it is well known that chronic treatment with antipsychotic drugs can induce tardive dyskinesia and has been hypothesized to induce a supersensitivity psychosis, it is reasonable to believe that other behavioral changes may occur over time. We here describe a behavioral disorder that we have termed tardive dysmentia, involving changes in affect, activation level, and interpersonal interaction. A relationship between tardive dysmentia and tardive dyskinesia is suggested. It is our hypothesis that tardive dysmentia contributes to the changing course of schizophrenia and occurs after long-term treatment with antipsychotic drugs.

Comparison of the plaque microflora in immunodeficient and immunocompetent dental patients.

The nature and extent of the immune dysfunctions in 20 immunodeficient patients, as well as the immunocompetence of 22 control subjects, were verified by cell-mediated responsiveness and immunoglobulin quantitations. Comparisons of the microbial composition of supragingival plaque between the two populations showed that a greater number of immunodeficient than control subjects harbored Candida sp. and Staphylococcus sp. Conversely, a lower number of immunodeficient than control subjects harbored Streptococcus mutans. Also, patients with immune dysfunctions had a lower dental caries experience than their immunocompetent counterparts.

Complete enteral support of thermally injured patients.

Total enteric nutritional support of thermally injured patients is a safe, effective means of providing adequate caloric and nitrogen requirements and avoiding the usual weight loss associated with burns. Protein and vitamin supplements and tube feeding, when indicated, are necessary adjuncts to the standard high protein, high calorie hospital diet. A team approach, consisting of physicians, nurses, dietitians, and patients, and careful daily monitoring of all parameters is essential to the success of this method.

The use of a laminar airflow isolation system for the treatment of major burns.

A laminar airflow isolation burn ward was designed which would maintain a sterile environment and also allow unrestricted burn care and rehabilitation to be performed. A very low rate of sepsis and sepsis-related complications have been found in the 115 patients treated in the unit. Patient cross contamination has been completely controlled under laminar airflow conditions. The incidence of burn colonization and infection by virulent gram-negative organisms, namely pseudomonas, serratia, klebsiella, and proteus, in these patients has been extremely low, particularly in comparison with burn patients managed in a non-laminar flow intensive care environment.

Abdominal musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and pubalgia.

There has been increasing interest within the European sports medicine community regarding the etiology and treatment of groin pain in the athlete. Groin pain is most commonly caused by musculotendinous strains of the adductors and other muscles crossing the hip joint, but may also be related to abdominal wall abnormalities. Cases may be termed "pubalgia" if physical examination does not reveal inguinal hernia and there is an absence of other etiology for groin pain. We present nine cases of patients who underwent herniorrhaphies for groin pain. Two patients had groin pain without evidence of a hernia preoperatively (pubalgia). In the remaining seven patients we determined the presence of a hernia by physical examination. At operation, eight patients were found to have inguinal hernias. One patient had no hernia but had partial avulsion of the internal oblique fibers from their insertion at the public tubercle. The average interval from operation to return to full activity was 11 weeks. All patients returned to full activity within 3 months of surgery. One patient had persistent symptoms of mild incisional tenderness, but otherwise there were no recurrences, complications, or persistence of symptoms. Abnormalities of the abdominal wall, including inguinal hernias and microscopic tears or avulsions of the internal oblique muscle, can be an overlooked source of groin pain in the athlete. Operative treatment of this condition with herniorrhaphy can return the athlete to his sport within 3 months.

The relationship between face or skull fractures and cervical spine and spinal cord injuries: a review of 13,834 patients.

A state trauma registry database containing 13,834 patients was evaluated to determine the relationship among 1,062 skull fractures, 1,329 facial fractures, 339 cervical spine injuries, and 299 spinal cord injuries. Categories studied were all trauma patients, motor vehicle crashes, automobile crashes (drivers, passengers, unknown), and belted and unbelted victims. Odds ratios calculated demonstrated that patients with skull and/or facial fractures did not have a higher likelihood of cervical spine or spinal cord injury as has been suggested. The lack of a relationship emphasizes the need for a greater vigilance for cervical spine and spinal cord injury in the group without facial or skull fractures. It appears that the pathological biomechanical forces causing each injury are a reflection of the different multiple forces associated with motor vehicle trauma.

Evaluation of hospital-based aeromedical transport programs using therapeutic intervention scoring.

The number of patients transported by hospital-based aeromedical transport programs is increasing rapidly across the country. How many of these patients really need this kind of transport and how to compare the performance of different services in this regard remain controversial issues. We examined these questions in a prospective analysis of 1,081 flights in 5 aeromedical transport programs using the Therapeutic Intervention Scoring System (TISS) as the basis for an index of appropriateness. An average of 41.5% of flights in all programs were clearly appropriate according to the index, i.e., had scores associated with a 99% probability of validation by direct review. Another 34.9% of flights had a greater than 50% probability of being appropriate. From 18 to 28% of flights had scores associated with only a 20% probability of justification. Although TISS scoring, which is carried out after transfer, cannot provide a means of selecting individual patients for aeromedical transfer, a TISS-based index appears to be a simple and useful method for examining overall appropriateness of program activity, and could be used to set objective standards of appropriateness for evaluation and comparison of aeromedical programs.

Trauma injuries. Triage and stabilization for safe transfer.

Categorization of trauma injuries and identification of special resources and facilities for treatment of major injuries have markedly affected morbidity and mortality. Reduction in trauma morbidity and mortality depends on early identification of severely injured patients, proper initial stabilization, and safe interhospital transfer. The trauma score and the American College of Surgeons anatomical injury categorization are valuable triage tools. Protocols for initial stabilization and for safe transfer have been described to assist the primary referring physician in providing optimal early care.

Problems of aging: diagnosing and treating leg pain due to arteriosclerosis obliterans.

Management of patients with arteriosclerosis obliterans begins with organization of the history, results of physical examination, and blood flow measurements into a patient profile. This approach permits the practicing physician to monitor the progression of the obstructive process over time. With close observation, a controlled exercise program, and properly timed surgical intervention, if necessary, patients with arterioslcerosis obliterans can enjoy a full and productive life.

Traumatic injuries: office treatment of minor burns.

While minor burns are not life threatening, they may result in significant morbidity, such as loss of function, prolonged healing time, and scarring. Proper office care is mandatory if such complications are to be prevented.

Emergency care of chemical burns.

Because of the large number of potentially injurious chemicals present in the home and workplace, chemical burns pose a unique challenge to the health care professional. For the majority of injuries, prompt and prolonged hydrotherapy is the cornerstone of therapy. The clinician needs to remember that the extent and depth of chemical injuries are difficult to assess in the acute phase; therefore, careful monitoring of blood values, urine output, and other parameters is necessary to gauge the volume of fluid required with major injury.

[Importance of surgical gowns and drapes as barriers for prevention of postoperative infections]. / L'importanza di camici e teli come barriera per prevenire le infezioni post-operatorie.

The gown and drape barrier system has been shown to be an important factor in the prevention of wound infection. Performance differences between disposable and reusable materials as influencing wound infections were demonstrated. A disposable spun-bonded olefin gown and drape system significantly reduced the postoperative wound infection rate. No therapeutic benefit in clean surgical operations was observed for either the preoperative antibiotic group of local wound irrigation group. Factors indicating populations at higher risks for wound infection include age, sex and those requiring long and an emergency type operations. Special attention should be given to the infection prone groups. Unless factors, such as percentage of type of operation, emergency nature, age and sex, are weighed, a comparison of wound infections between hospitals is invalid.