Surgical site infection in elderly patients with hip fractures, silver-coated versus regular dressings: a randomised prospective trial.

OBJECTIVE: Surgical site infection (SSI) after hip fracture surgery is a well-known complication with serious consequences for both the patient and the medical system. Silver ion treatment is considered an effective antibacterial agent, however, the use of silver dressing (SD) in the primary prevention of SSIs is controversial. The aims of this study were to compare SD with regular dressing (RD) in the prevention of SSI in elderly patients undergoing surgery for hip fractures, and to compare costs. METHOD: A matched group of 55 patients with hip fractures undergoing surgery with dynamic hip screw, cephalomedullary nail or hemiarthroplasty were randomised to either SD or RD groups. The dressings were applied in the operating theatre, and the patients were followed for one week for clinical signs of infection (discharge, erythema and fever). The RDs were replaced daily. The SDs were not removed for 5-7 days and kept moist. Skin swabs were taken from the wound surface on postoperative day 5-7 for bacterial skin colonisation. RESULTS: The SD (n=31) and RD (n=24) groups were similar in age, sex and comorbidities. Infection signs were seen in two (2/31, 6.4%) of the SD patients compared with 2 (2/24, 8.3%) RD patients (p=1.0). Skin colonisation by bacteria at postoperative day 5-7 was tested in 27 patients: it was higher in the SD group (positive skin swab, 12/19, 63.2%) compared to the RD group (4/8, 50%, p=0.67). The use of SD added ~US$5 (UK ~£3.19) per patient. CONCLUSION: The use of SD was associated with higher costs than RD, but not superior in preventing SSIs in elderly patients undergoing hemiarthroplasty or fixation of hip fractures. SD was also not effective in reducing bacterial skin colonisation following hip fracture and surgery.

Laparoscopic approach for rectosigmoidian resection in children.

Abdominoperineal approach for rectosigmoidian resection,first imagined and performed in 1948 by Orwar Swenson,was the surgical technique that opened the pathway in the treatment of congenital megacolon (1). B. Duhamel (1956) and F. Soave (1964) intended to correct the postoperative complications appeared after the Duhamel technique and proposed surgical procedures that keep the aganglionic rectum in transit (2,3). In 1994 K. Bax reproduces the Duhamel procedure using laparoscopic approach (4). K.Georgeson, in 1995, reproduced the Swenson technique for rectosigmoidian resection using minimal invasive surgery (5).Today, this approach represents the most frequently used procedure for the radical treatment of congenital megacolon.

In vitro human metabolism of permethrin isomers alone or as a mixture and the formation of the major metabolites in cryopreserved primary hepatocytes.

In vitro metabolism of permethrin, a pyrethroid insecticide, was assessed in primary human hepatocytes. In vitro kinetic experiments were performed to estimate the Michaelis-Menten parameters and the clearances or formation rates of the permethrin isomers (cis- and trans-) and three metabolites, cis- and trans-3-(2,2 dichlorovinyl)-2,2-dimethyl-(1-cyclopropane) carboxylic acid (cis- and trans-DCCA) and 3-phenoxybenzoic acid (3-PBA). Non-specific binding and the activity of the enzymes involved in permethrin's metabolism (cytochromes P450 and carboxylesterases) were quantified. Trans-permethrin was cleared more rapidly than cis-permethrin with a 2.6-factor (25.7±0.6 and 10.1±0.3 µL/min/10(6) cells respectively). A 3-factor was observed between the formation rates of DCCA and 3-PBA obtained from trans- and cis-permethrin. For both isomers, the rate of formation of DCCA was higher than the one of 3-PBA. The metabolism of the isomers in mixture was also quantified. The co-incubation of isomers at different ratios showed the low inhibitory potential of cis- and trans-permethrin on each other. The estimates of the clearances and the formation rates in the co-incubation condition did not differ from the estimates obtained with a separate incubation. These metabolic parameters may be integrated in physiologically based pharmacokinetic (PBPK) models to predict the fate of permethrin and metabolites in the human body.

Usefulness of exercise-induced ST-segment depression in the inferior leads during exercise testing as a marker for coronary artery disease.

Multiple lead systems are shown to have a higher sensitivity than that of single leads for detecting coronary artery disease (CAD) during exercise testing, but the value of ST-segment depression isolated to the inferior leads is questionable. To ascertain the diagnostic accuracy of inferior limb lead II compared with that of precordial lead V5, a retrospective analysis of 173 men was performed (108 in a training population and 65 in a validation cohort). All patients had a standard exercise test and underwent diagnostic coronary angiography within 15 days of the exercise test (range 1 to 65). Sixty-three patients had greater than or equal to 1 coronary stenoses greater than or equal to 70%, or left main lesion greater than or equal to 50%, whereas 45 patients in the training population did not. Exclusion criteria were female sex, left ventricular hypertrophy, left bundle branch block or resting ST-segment depression on the baseline electrocardiogram, previous myocardial infarction or revascularization procedures, and any significant valvular or congenital heart disease. Lead V5 had a better combination of sensitivity (65%) and specificity (84%) (chi-square = 24.11; p less than 0.001) than that of lead II (sensitivity 71%, specificity 44%) (chi-square = 2.25; p = 0.13) at a single cut point, and this improved specificity was substantial (95% confidence interval for observed difference 22 to 58%). Receiver-operating characteristic curve analysis also revealed that lead V5 (area = 0.759) was markedly superior to lead II (area = 0.582) over multiple cut points (z = 3.032; 2p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Immunohistochemical localisation of tenascin in invasive ductal carcinoma of the breast.

BACKGROUND: The association of TN expression, tumour grading and expression of commonly used histopathologic prognostic factors (p53 and estrogen receptor) was examined in 62 cases of invasive ductal carcinoma of the breast. MATERIAL AND METHODS: Following histological grading immunohistochemical reactions were undertaken on routine histopathologic samples and the results semiquantitatively evaluated. RESULTS: Strong TN expression was found in close proximity of the neoplastic epithelial cells in each case, but not in other areas of the stroma. In 10 (16%) cases TN expression was detected to the neoplastic epithelial cells as well. There was no statistically significant difference in the extent of stromal TN immunoreaction between tumours of different grades. A significant difference was found in p53 and estrogen receptor immunoreactions by tumour grade (p = 0.05). TN immunoreaction in the stroma did not correlate with the nuclear expression of p53, Ki-67 and estrogen receptor in the tumour cells. CONCLUSIONS: TN immunoreactivity does not seem to correlate with currently used prognostic factors. The increased expression of stromal TN in invasive breast ductal carcinomas is an other indicator of possible role played by the extracelular matrix components in cancer development.

Arterial remodeling following mechanical injury. The role and nature of smooth muscle cells.

The main feature of an atherosclerotic plaque is the formation of a new tissue in the arteries. In this respect atherosclerosis is similar to other conditions where non-neoplastic tissue formation occurs like in embryogenesis, in healing or in repair processes. A progressive intimal thickening occurs in the early phase of human atherosclerotic lesions and also in certain experimental models. Long-standing aortic intimal thickening could be induced by mechanical injury to the inner surface of the aorta with a microsurgical instrument, which causes controlled endothelial denudation. The injury is followed by an arterial remodeling. The latter process is caused by the development of an intimal plaque which consists of two main components: the smooth muscle cell (SMC) and the intercellular matrix. The matrix components are mostly synthetized by the SMC. Two distinct SMC populations could be distinguished by morphological means in the intimal proliferation: the synthetizing type and the proliferating type. Their role will be discussed and their morphological appearance will be compared with SMC present in other lesions.

Tenascin expression and angiogenesis in breast cancers.

The expression and the distribution of tenascin as well as the extent of blood vessel formation (angiogenesis) were investigated in 70 invasive human breast carcinomas. Formalin-fixed, paraffin-embedded specimens were stained with monoclonal antibody against tenascin-C (DAKO and Biogenex). Anti-CD31 antibody (Biogenex), an acknowledged marker of stromal angiogenesis, was used to detect endothelial cells. Tenascin immunostaining was positive in the tumours around the persisting normal ducts, around tumour-cell nests, in the neostroma, in some tumour cells, and it was found in or around vascular channels. Tumour vascularity was assessed by quantitative vascular grading (Chalkley point count) and was related to the localization and intensity of tenascin immunoreactivity. 19 tumours (27.1%) were scored as low, 35 (50%) as medium, and 16 (22.9%) as having a high vascular grade. The positive correlation between the vascular grade and the tenascin immunopositivity in tumour stroma was observed. Our results suggest that tenascin expression may be associated with endothelial cell activation and may play an important role in tumour angiogenesis.

Connexin 43 expression in rat aortic smooth muscle after ovariectomy and hormonal replacement.

The purpose of this study was to determine the effects of ovariectomy and long-term combined sexual hormone replacement on the gap junctional protein, connexin 43 (Cx43) of aortic medial smooth muscle cells in rats. Twenty non-pregnant mature Wistar female rats were divided into five groups (four animals in each group). Group A underwent ovariectomy, Group B underwent ovariectomy and received estradiol propionate, Group C underwent ovariectomy and received medroxyprogesterone acetate and Group D underwent ovariectomy and received both hormones. Group E was sham-operated and used as control. After 15 weeks of treatment, thoracic aortas were removed and immunohistochemistry was carried out using a specific fluorescent antibody against Cx43. Tissue sections were examined by confocal laser scanning microscopy and analysed by the Scion Image program. All five different groups had the same distribution and extent of Cx43 in the aorta. Neither the ovariectomy nor the hormone replacement had any effect on the Cx43 expression of aortic smooth muscle cells in rats as compared to control animals. These results indicate that sexual steroids do not influence the gap junctional protein Cx43 of the medial layer of aorta in rats. They may suggest that the beneficial effects of estrogen are not mediated via gap junctions in the human aorta either.

Atherosclerosis in amputated legs of patients with and without diabetes mellitus.

BACKGROUND: The aim of this study was to compare the histomorphologic appearance of atherosclerosis in amputated legs of diabetic and non-diabetic patients. METHODS: Twenty-eight legs amputated below the knee for chronic ischaemia were studied. Fourteen legs were amputated in patients with diabetes (10 Type II, 4 nonclassified) and 14 in non-diabetics. The mean age of patients at the time of the amputation was 63.3 years in diabetics and 63.9 years in non-diabetics. Samples were taken from the main arteries at the following levels: the midleg, 5 cm above the ankle, 3 cm below the ankle and 10 cm below the ankle. Cross-sections of the arteries were examined with light microscopy and the severity of the occlusive disease determined using morphometric analysis. Medial calcification and chronic inflammation were assessed semiquantitatively. RESULTS: Arteries at 5 cm above the ankle were more severely stenotic in diabetics than in non-diabetics (p<0.05). In both diabetics and non-diabetics the posterior tibial and plantar arteries appeared to be the most stenotic. Medial calcification tended to be more prominent in diabetics than in non-diabetics. Chronic inflammation in the arterial wall occurred at the same degree in diabetics and non-diabetics. In non-diabetics chronic inflammation was more severe in the posterior tibial and plantar arteries than in the anterior tibial and dorsalis pedis arteries (p<0.04). Chronic arterial inflammation correlated with the severity of chronic arterial occlusive disease (p<0.0002). CONCLUSIONS: In diabetics occlusive disease in amputated legs is more severe in arteries above the ankle than in non-diabetics. However, no difference was demonstrated in this series in arteries of the ankle and foot. Diabetics are likely to have more medial calcification in the arteries than non-diabetics. Chronic inflammation in the arterial wall is associated with more severe stenosis.

Effect on postoperative pain after local application of bupivacaine in the tonsillar fossa; a prospective single blind controlled trial.

OBJECTIVE: To assess the effect on postoperative pain after local application of bupivacaine in the tonsillar fossa. METHODS: Seventy two patients were recruited in this prospective single blind controlled trial. There were 45 females and 27 males between the ages of 7 and 35 years. After tonsillectomy the right tonsillar fossae (subject fossae) were packed with tonsillar gauze soaked in 2 mls of 0.5% Abbocaine (bupivacaine) solution and kept in situ for five minutes. The left fossae (control fossae) were packed with the similar tonsillar swab soaked in 0.9% normal saline. RESULTS: The main outcome measure was severity of pain by using visual analogue score. The measurements were taken at various intervals, i.e. after 4 hours, before bed, before breakfast, before lunch and before discharge. The mean post-operative pain scores for the subject fossa after 4 hours, before bed, before breakfast, before lunch and before discharge were 3.09 (+/- 0.85), 3.25 (+/- 0.64), 2.89 (+/- 0.72), 2.47 (+/- 0.67) and 2.37 (+/- 0.57) respectively. The mean post-operative pain scores for control fossa after 4 hours, before bed, before breakfast, before lunch and before discharge were 5.78 (+/- 1.51), 5.50 (+/- 1.29), 4.34 (+/- 1.13), 3.29 (+/- 0.91) and 2.73 (+/- 0.81) respectively. There was significant difference between subject and control fossae scores at all the stages up to discharge of patients, showing better pain relief with bupivacaine. CONCLUSION: Topical application of bupivacaine to the tonsillar fossa can reduce post-operative pain and facilitate early eating and drinking during the post-operative period.

[Diagnosis of coronary stenosis by clinical data and computer-assisted analysis of stress test]. / A koszorúér-szükület diagnózisának felállítása klinikai jellemzök és a terheléses vizsgálat adatainak számítógépes elemzésével.

A probability algorithm (PA) was developed and tested using the clinical, exercise test and coronary arteriography (CA) data of 543 patients (pts) studied with the suspicion of coronary artery disease (CAD). The algorithm was constructed from the data of 361 consecutive pts and tested on a separate group of 182 pts. The two pts groups were comparable in all respect. The sensitivity of Pain the diagnosis of CAD was higher compared to the exercise test alone (73% versus 68%, p less than 0.05). The numbers of variables used for the PA didn't influence of the sensitivity. The authors suggest to use the probability algorithms in the clinical practice.

[Detection of Chlamydia trachomatis in chronic prostatitis by in situ hybridization (preliminary methodical report)]. / Chlamydia trachomatis kimutatása in situ hibridizációval krónikus prostatitisben (metodikai elözetes közlemény).

(Preliminary methodical report). In situ hybridization of Chlamydia trachomatis in formalin fixed, paraffin embedded specimens from the Urology Clinic were performed in 2nd Department of Pathology Semmelweis University of Medicine by a biotin labelled DNA probe. Chlamydia trachomatis is suspected to be responsible for the chronic abacterial inflammation of the prostate besides Ureaplasma urealyticum and Mycoplasmae. According to our retrospective study out of 79 biopsy specimens 34 had the diagnosis of chronic abacterial prostatitis. We examined 11 specimens of them. Bacteria were not identified. Three specimens were positive for Chlamydia trachomatis which were improved by transmission electron microscope. The age of patients was between 59 and 81 years. The detection of chlamydia infection rises the suspicion of a "healthy" career and especially at younger age could cause Chlamydia trachomatis associated genital disease. The undiagnosed and untreated diseases may lead to infertility.

[Ergometry-induced silent ischemia--clinical and angiographic features]. / Az ergometriás terheléssel provokált silent ischaemia--klinikai és angiográfiás jellemzök.

This study was planned to clarify the clinical and angiographic attributes of patients with exercise induced silent myocardial ischaemia. The study sample consisted of 102 patients who had ischaemic exercise electrograms (greater than = 1 mm ST segment depression) and significant angiographic stenosis (greater than = 50% diameter stenosis), in at least one of the major coronary arteries. In 61 patients (60%) painful ischaemia was observed during exercise (group A) while in 41 patients (40%) only SD depression (silent ischaemia) occurred (group B). The groups were similar with respect to age, sex, history of diabetes and all angiographic parameters including the Gensini coronary score. A history of prior myocardial infarctions was observed more frequently (p less than 0.01) in patients with silent ischaemia (group B). Prior myocardial infarction may be a factor causing silent myocardial ischaemia.

[Comparison of ST depression and various exercise test indices in the diagnosis of coronary stenosis]. / Az ST depresszió és a különbözö terheléses score értékek összehasonlító vizsgálata a koszorúér-szükület felismerésében.

UNLABELLED: Various modifications and refinements have been proposed to improve the diagnostic accuracy of standard ST-segment criteria for identifying coronary artery disease using exercise testing. To ascertain if the treadmill exercise score (TES), the ST integral, or the ST/HR index are significantly better markers for coronary disease the standard ST analysis, measured visually or by computer, a retrospective study of 173 male patients was performed. Exclusions were clinical or electrocardiographic evidence of prior myocardial infarction, left ventricular hypertrophy, left bundle branch block, or resting ST segment depression on their baseline electrocardiogram, digitalis, previous revascularization procedure or any significant valvular or congenital heart disease. Ninety-six patients (55.5%) had at least one epicardial coronary stenosis (more than 70% diameter stenosis). Cutpoints were chosen for each method, that maximized their best combination of sensitivity and specificity. There were no statistically significant differences between any of the five methods (TES, ST integral, ST/HR index, standard and computer ST analysis) for identifying any coronary disease. CONCLUSION: careful visual or ST-segment analysis continues to be the simplest as well most effective marker for coronary disease during exercise testing.

[Symptomless (silent) myocardial ischemia and its prognostic significance]. / A panaszmentes ("silent") szívizom ischaemia és prognosztikus jelentösége.

The authors studied the prognostic significance of Silent myocardial ischemia. To study the correlation between the silent ischemia before the operation of coronary revascularization and the perioperative complications (infarction, mortality) Holter-monitoring (HM) was performed with 26 patients. The average time of HM was 43 +/- 3.1 h. During the observation period total 138 silent ischemic episodes were registered with 7 patients. The average heart rate observed during the ischemic event did not differ from that observed in other periods. Three myocardial infarctions occurred in the perioperative period one of them was of lethal outcome. Silent ischemia was detected in 2 of 3 patients before operation. The patient who displayed the gravest ischemic alteration died of perioperative myocardial infarction. On the basis of their observations the authors attribute prognostic significance to the preoperative silent myocardial ischemia.

[A case of successful operation of left atrial myxoma causing cerebral embolism]. / Cerebralis emboliát okozó bal pitvari myxoma sikeresen operált esete.

The authors describe the case report of a young woman in whom a left atrial myxoma causing cerebral embolism was diagnosed by echocardiography. On the ninth day after the development of neurologic symptoms the tumor was excised by an emergency intervention. After the operation the condition of the patient improved considerably. In connection with the case the authors underline the role of echocardiography in the detection of sources of embolism.

Activation of anorexigenic pro-opiomelanocortin neurones during refeeding is independent of vagal and brainstem inputs.

After fasting, satiety is observed within 2 h after reintroducing food, accompanied by activation of anorexigenic, pro-opiomelanocortin (POMC)-synthesising neurones in the arcuate nucleus (ARC), indicative of the critical role that α-melanocyte-stimulating hormone has in the regulation of meal size during refeeding. To determine whether refeeding-induced activation of POMC neurones in the arcuate is dependent upon the vagus nerve and/or ascending brainstem pathways, bilateral subdiaphragmatic vagotomy or transection of the afferent brainstem input to one side of the ARC was performed. One day after vagotomy or 2 weeks after brain surgery, animals were fasted and then refed for 2 h. Sections containing the ARC from vagotomised animals or animals with effective transection were immunostained for c-Fos and POMC to detect refeeding-induced activation of POMC neurones. Quantitative analyses of double-labelled preparations demonstrated that sham-operated and vagotomised animals markedly increased the number of c-Fos-immunoreactive (-IR) POMC neurones with refeeding. Furthermore, transection of the ascending brainstem pathway had no effect on diminishing c-Fos-immunoreactivity in POMC neurones on either side of the ARC, although it did diminish activation in a separate, subpopulation of neurones in the dorsomedial posterior ARC (dmpARC) on the transected side. We conclude that inputs mediated via the vagus nerve and/or arising from the brainstem do not have a primary role in refeeding-induced activation of POMC neurones in the ARC, and propose that these neurones may be activated solely by direct effects of circulating hormones/metabolites during refeeding. Activation of the dmpARC by refeeding indicates a previously unrecognised role for these neurones in appetite regulation in the rat.