Abdominal wound dehiscence is dangerous: a nationwide study of 14,169 patients undergoing elective open resection for colonic cancer.

PURPOSE: The potential impact of abdominal wound dehiscence on long-term survival after elective abdominal surgery is largely unknown. The aim of this study was to examine the impact of abdominal wound dehiscence on survival and incisional hernia repair after elective, open colonic cancer resection. METHODS: This was a nationwide cohort study based on merged data from Danish national registries, comprising patients subjected to elective, open resection for colonic cancer between May 1, 2001 and January 1, 2016. Multivariable Cox Regression analysis and propensity score matching was applied to adjust for confounding. The associations of abdominal wound dehiscence with 90-day mortality and subsequent incisional hernia repair were also examined. RESULTS: A total of 14,169 patients were included in the cohort, of which 549 (3.9%) developed abdominal wound dehiscence. The 5-year survival was significantly decreased in patients with abdominal wound dehiscence (42.4%, 95% CI 38.1-46.7 vs. 53.4%, 52.6-54.3, P < 0.001), which was confirmed in the multivariable analysis (HR 1.22, CI 1.06-1.39, P = 0.004). Abdominal wound dehiscence was significantly associated with increased risk of 90-day mortality (OR 1.60, CI 1.12-2.27, P = 0.009) as well as subsequent incisional hernia repair (HR 1.80, CI 1.07-3.01, P = 0.026). CONCLUSIONS: Abdominal wound dehiscence was significantly associated with decreased survival. Fascial closure after open colonic cancer resection should be given high priority to improve the long-term survival.

The Incidence and Disease Course of Perianal Crohn's Disease: A Danish Nationwide Cohort Study, 1997-2015.

BACKGROUND AND AIMS: Perianal Crohn's disease [CD] places a considerable burden on patients' quality of life and is complex to treat. Despite its impact and high frequency, few studies have investigated the incidence and disease course of perianal CD. The aim of this study was to assess the incidence and disease course of perianal CD in adult patients throughout a 19-year period. METHODS: The cohort comprised all individuals aged 18 years or older who were diagnosed with CD in Denmark between January 1, 1997, and December 31, 2015, according to the National Patient Registry [NPR]. RESULTS: A total of 1812 [19%] out of 9739 patients with CD were found to have perianal CD. Perianal fistulas were the most common manifestation, accounting for 943 [52%] cases. The incidence of perianal CD remained stable over time. Patients with perianal CD were found to have an increased risk of undergoing major abdominal surgery compared with patients without perianal CD (hazard ratio: 1.51, 95% confidence interval [CI]: 1.40 to 1.64, p <0.001) in a multivariate Cox regression analysis. The incidence rate ratios of anal and rectal cancer in perianal CD patients were 11.45 [95% CI: 4.70 to 27.91, p <0.001] and 2.29 [95% CI: 1.25 to 4.20, p = 0.006], respectively, as compared with non-IBD matched controls. CONCLUSIONS: In this nationwide study, 19% of CD patients developed perianal disease. Patients with perianal CD were at increased risk of undergoing major surgery compared with non-perianal CD patients. The risk of anal and rectal cancer was increased in patients with perianal CD compared with non-IBD matched controls. PODCAST: This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.

Anastomotic leak after surgery for colon cancer and effect on long-term survival.

AIM: An anastomotic leak after surgery for colon cancer is a recognized complication but how it may adversely affect long-term survival is less clear because data are scarce. The aim of the study was to investigate the long-term impact of Grade C anastomotic leak in a large, population-based cohort. METHOD: Data on patients undergoing resection for Stage I-III colon cancer between 2008 and 2012 were collected from the Swedish, Norwegian and Danish Colorectal Cancer Registries. Overall relative survival and conditional 5-year relative survival, under the condition of surviving 1 year, were calculated for all patients and stratified by stage of disease. RESULTS: A total of 22 985 patients were analysed. Anastomotic leak occurred in 849 patients (3.7%). Five-year relative survival in patients with anastomotic leak was 64.7% compared with 87.0% for patients with no leak (P < 0.001). Five-year relative survival among the patients who survived the first year was 88.6% vs 81.3% (P = 0.003). Stratification by cancer stage showed that anastomotic leak was significantly associated with decreased relative survival in patients with Stage III disease (P = 0.001), but not in patients with Stage I or II (P = 0.950 and 0.247, respectively). CONCLUSION: Anastomotic leak after surgery for Stage III colon cancer was associated with significantly decreased long-term relative survival.

Pulmonary hypertension in HIV infection: a prospective echocardiographic study.

OBJECTIVES: While idiopathic pulmonary arterial hypertension (PAH) is a rare disease, it is seen more frequently in patients with HIV infection. The aim of this study was to evaluate the prevalence of pulmonary hypertension (PH) in patients with HIV infection by echocardiographic screening. METHODS: Echocardiography and N-terminal of the prohormone brain natriuretic peptide measurement were used to examine the prevalence of PH prospectively in HIV-positive patients (n = 374) during routine follow-up visits for HIV disease. RESULTS: In echocardiographic screening, PH was detected in a total of 23 of 374 HIV-infected patients (6.1%). Of these, three patients (13%) presented with symptoms of dyspnoea and fatigue, and diagnosis of PAH was confirmed by right heart catheterization. Patients with systolic pulmonary artery pressure (sPAP) > 30 mmHg were more likely to be female, to have a history of injecting drug use and to originate from high-prevalence countries (HPCs). CONCLUSIONS: Echocardiographic screening detected PH in a substantial proportion of HIV-positive patients. Female gender, a history of injecting drug use and HPC origin were associated with a higher prevalence of HIV-associated PH. The relevance and long-term outcome of these findings need to be validated in follow-up studies, which are ongoing.

[Endometriosis]. / Endometriose.

The major symptom is dysmenorrhea. Chronic, sometimes non-cyclic pain due to pelvic adhesions is often seen in the long course of the disease. Infiltration into the blader or bowel is a rare but serious complication. A group of patients presents with sterility. Endometriosis histologically resembles endometrium. There can be ovarian cysts and foci either on the peritoneum or in the muscularis of the uterus. The etiology is unknown. There are a number of existing theories. A rare condition is an endometriosis caused iatrogen during a caesarean section. It can develop between uterus and bladder or within the suture or scar tissue. Since we know so little, the treatment options are unsatisfying. Operative resection followed by endocrine medication is the standard therapy. Alternative medicine can be an useful additional factor in the treatment concept.

VentEx: an on-line knowledge-based system to support ventilator management.

This paper will demonstrate the clinical application of a knowledge-based decision-support system called VentEx for ventilator management. VentEx has been implemented using a knowledge-based development tool on a PC under the Microsoft Windows multitasking environment. It is integrated into a computer aided ventilator system including the Siemens Elema Servo Ventilator 900 C equipped with a Servo Computer Module 990 and the CO2 analyser 930. The system provides advanced ventilator monitoring with expert advice concerning ventilator strategy and settings based on data from on-line monitoring. The knowledge base has been primarily validated and the system has been clinically tested by the intensive care unit staff. Different approaches such as knowledge acquisition, representation and system integration have been outlined and discussed.

Management of prelabor rupture of membranes at term. A randomized study.

OBJECTIVE: To compare the rate of obstetric interventions, length of labor, and maternal morbidity in pregnancies with prelabor rupture of membranes at term after either early or late induction of labor in both primiparous and pluriparous women. DESIGN: Prospective, randomized study. SUBJECTS: 362 women with singleton pregnancies, cephalic presentations, gestational age of 36 completed weeks or more were allocated at random to induction with oxytocin either 6 hours after PROM (n = 62) (early) or 24 hours (n = 62) (late). Those eligible, but not participating in the study, totalled 238 women. MAIN OBSTETRIC MEASURES: Time of spontaneous labor in the late induction group, length of labor, obstetric intervention rate, maternal morbidity, and the degree of histologic chorioamnionitis. RESULTS: The length of labor was longer in the late induction group than in the early induction group in both primiparous and pluriparous (p < 0.05). There were no overall differences in the rate of obstetric interventions or maternal morbidity, but there were marked differences between primiparous and pluriparous women. Increasing time span between the period from rupture of membranes to delivery increased the degree of histologic chorioamnionitis. CONCLUSION: If a woman wants a short labor, she will benefit from early induction. We did not find statistical differences in the rate of obstetric intervention or in the maternal morbidity, but there was a tendency towards adverse effects of late induction.

Muscle protein synthesis is impaired in nephrotic rats.

Muscle protein synthesis is impaired in nephrotic rats: muscle and hepatic protein synthesis was measured as the incorporation of [3H]phenylalanine [3H]phe) into muscle and liver in male Sprague-Dawley rats with passive Heymann nephritis (HN) in comparison to both normal male (SDM) and female Sprague-Dawley rats (SDF). Incorporation of [3H]phe was significantly less muscle in HN (1.55 +/- 0.08 x 10(4) cpm/g muscle/h) than in SDM (2.55 +/- 0.14 x 10(4), p < 0.01) and no different than in SDF (1.64 +/- 0.23 x 10(4)). Growth rate was also significantly less in SDF and HN compared to SDM. Total [3H]phe incorporation and the % of [3H]phe incorporated into muscle correlated inversely with urinary albumin excretion in HN (p < 0.01) but not with serum albumin. In contrast, [3H]phe incorporation was increased in livers of HN (13.89 +/- 0.99 x 10(3) cpm/g rat/h) compared to either SDM (5.96 +/- 0.38 x 10(3), p < 0.01) or SDF (4.71 +/- 0.35 x 10(3), p < 0.01). Total liver mass, liver protein content, and the ratio of liver weight/body weight were all increased in HN. There were no differences in liver weight, liver protein content, or the ratio of liver weight/body weight between SDM and SDF. We have previously shown that decreased muscle protein accrual in HN cannot be overcome by increasing dietary protein intake. Hepatic protein synthesis and mass are increased in proteinuric rats while muscle protein synthesis is reduced. As a consequence growth rate and muscle protein accrual are diminished in nephrosis. The mechanism responsible for reduced muscle protein synthesis in the nephrotic syndrome is unknown.

Multivariable optimization of mechanical ventilation. A linear programming approach.

The proposed method aims at improved ventilatory care with reduced morbidity. It combines two important aspects of mechanical ventilation: gas exchange and lung mechanics. A single criterion was selected as optimization index of lung trauma: peak respiratory power (PRP) defined as the maximum product of pressure times flow during inspiration. Arterial blood gases reflect gas exchange and constitute the constraints of the problem. The constraints as well as the optimization index are expressed as linear functions of the input variables (frequency of breathing, tidal volume, and positive end expiratory pressure). A linear programming approach can therefore be used to determine the values of input variables that minimize PRP and at the same time keep arterial blood gases within the prescribed limits. The coefficients of the constraints and the optimization index equation are found by manipulating input variables in order to obtain four different values of PaO2, PaCO2 and PRP (there are four coefficients in each equation). The coefficients can then be calculated and the optimization procedure run. In a pilot study 5 patients suffering from diseases of varying pulmonary pathology were investigated with this method. In 4 out of 5 the ventilator treatment improved in terms of blood gas values (mean increase in PaO2 was 4.7%) and reduction of mechanical load on the lungs (mean PRP reduction was 20%). Lower PRP is accompanied by lower mean power and pressure values, which results in increased cardiac output. Presently, the main problem is the time it takes to determine the patient coefficients (approx one hour), a procedure that needs to be simplified.

[Immunomodulation by cryosurgery in malignant melanoma]. / Immunmodulation durch Kryochirurgie beim malignen Melanom.

Cryosurgery is a well-known, established method for the local destruction of tumor tissue by freezing. The assumption that, in addition to a physical and blood vascular phase, an immunological phase exists, has been discussed by many authors and tested using animal models. These results can only be transferred to humans in a limited sense. During the last year, we initiated a randomized study "Cryosurgery versus Conventional Surgery", whereby the peripheral blood and the normal skin from the areas surrounding the resection were compared. We were able to demonstrate in the peripheral blood of 8 cryosurgery patients a postoperative increase in the total and helper T-cells, HLA-DR-positive cells, and the ratio helper/suppressor T-cells in comparison to preoperative values. In the 8 patients treated with conventional surgery, these parameters decreased slightly or remained the same. The differences were highly significant (p = 0.001) to significant (p = 0.01). The results from the first 16 are patients studied presented and discussed here.

Fluorescence-activated cell analysis of P-fimbriae receptor accessibility on uroepithelial cells of patients with renal scarring.

Pyelonephritogenic Escherichia coli possess P-fimbriae that bind to uroepithelial cells by recognizing a receptor containing the alpha-D-Galp-(1-4)-beta-D-Galp carbohydrate structure. The accessibility of P-fimbriae receptors was determined using uroepithelial cells from 19 female patients with verified renal scarring and a history of febrile urinary tract infection, and 13 healthy controls. The binding of fluorescein isothiocyanate labeled P-fimbriated Escherichia coli to a large number of uroepithelial cells from each individual was studied using the method of fluorescence-activated cell sorting analysis, which allows examination of a large number of cells and selection of cells of a given size. The uroepithelial cells from the patients exhibited a significantly higher binding capacity to P-fimbriated Escherichia coli than did uroepithelial cells from healthy controls (p less than 0.01). The determination of P-fimbriae receptor accessibility on uroepithelial cells may be useful for detecting risk groups among patients with recurrent urinary tract infections.

Phorbol esters inhibit the functional activation of cytotoxic precursors in mixed lymphocyte cultures.

We have investigated the effect of phorbol esters on T cell activation and generation of suppressor and cytotoxic activity in mixed lymphocyte cultures (MLC). The presence of 30 nM P(Bu)2 during the sensitization phase inhibited the generation of allospecific cytotoxicity and also decreased the killing potential against NK-sensitive targets. The inhibition was not mediated by direct blocking of the lytic capacity nor by suppression of clonal expansion of cytotoxic cells through modulation of lymphokine production. The presence of P(Bu)2 enhanced cell proliferation, but inhibited the functional activation of lymphocytes and consequent generation of Dr antigen-positive T cells. Because the presence of the compound did not affect the MLC-induced generation of suppressor activity, it is likely that P(Bu)2 selectively blocks the maturation of cytotoxic precursors. Surface-marker analysis with OKT monoclonal antibodies revealed that the effects on lymphocyte activation were associated with a decrease in OKT3 and OKT4 reactivity and an increase in the percentage of OKT8-positive cells. The decrease in OKT4 reactivity was not due to selective loss of this lymphocyte subpopulation, because P(Bu)2 was equally mitogenic for the purified OKT4- and OKT8-positive subsets. The results suggest that the effect of P(Bu)2 on cell differentiation and its ability to modulate the expression of functional markers in lymphocyte subsets may interfere with T-T cell cooperation that controls the functional maturation of cytotoxic precursors.

The B cell mass at the clinical onset of type I diabetes.

In a case of type I diabetes with a duration of 7 days the distribution and volume of the pancreatic endocrine cells were studied using immunocytochemical techniques combined with morphometry. The PP cell rich lobe, making up about 10% of the total pancreatic volume, was not considered in this examination. The volume density and the absolute volume of the B cells was found to be reduced to about one third to one seventh of the values determined in three controls of a similar age and pancreatic volume. The A cell volume was also diminished, whereas the D and PP cell volume remained constant. As B cell necroses could not be detected and insulitis affected only few islets, it was concluded that the destruction of B cells proceeds slowly in type I diabetes and, in the majority of cases, probably starts years before the clinical onset.