Retained foreign bodies.

OBJECTIVE: To evaluate the frequency of occurrence and outcome of patients having retained foreign bodies after treatment in an urgent-care setting. MATERIALS AND METHODS: Closed case records from the files of the Medical Professional Mutual Insurance Company involving claims of retained foreign body were reviewed for a 7-year period. MAIN RESULTS: Thirty-two patients filed 54 claims against 32 physicians and 22 health care institutions. Defense costs were $298,906, and indemnity payments were $1,279,171. Glass was the most frequent retained foreign body, constituting 53% of claims. Despite the fact that glass is radiopaque, x-ray films were ordered for only 35% of these patients. Retention of glass fragments when no radiologic study was obtained resulted in unsuccessful defense of 60% of the claims and higher indemnity payments. Radiologic studies were ordered for only 31% of all patients. CONCLUSIONS: All wounds should be considered to be at risk for foreign body entry. Documentation in the medical record of wound exploration and patient follow-up, and ordering of plain films and other diagnostic imaging studies should be used more frequently toward this end.

The retained surgical sponge.

OBJECTIVE: A review was performed to investigate the frequency of occurrence and outcome of patients who have retained surgical sponges. METHODS: Closed case records from the files of the Medical Professional Mutual Insurance Company (ProMutual, Boston, MA) involving a claim of retained surgical sponges were reviewed for a 7-year period. RESULTS: Retained sponges occurred in 40 patients, comprising 48% of all closed claims for retained foreign bodies. A falsely correct sponge count after an abdominal procedure was documented in 76% of these claims. Ten percent of claims involved vaginal deliveries and minor non-body cavity procedures, for which no sponge count was performed. Total indemnity payments were $2,072,319, and defense costs were $572,079. In three cases, the surgeon was deemed responsible by the court despite the nursing staff's admitting liability and evidence presented that the surgeon complied completely with the standard of care. A wide range of indemnity payments was made despite a remarkable similarity of outcome in the patients studied. CONCLUSIONS: Despite the rarity of the reporting of a retained surgical sponge, this occurrence appears to be encountered more commonly than generally is appreciated. Operating teams should ensure that sponges be counted for all vaginal and any incisional procedures at risk for retaining a sponge. In addition, the surgeon should not unquestioningly accept correct count reports, but should develop the habit of performing a brief but thorough routine postprocedure wound/body cavity exploration before wound closure. The strikingly similar outcome for most patients would argue for a standardized indemnity payment being made without the need for adversarial legal procedures.

Hypoprothrombinemia and hemorrhage in a surgical patient treated with cefotetan.

For 4 days before surgical repair of a diverticulitic colovesical fistula and for 6 days after, a 63-year-old man was treated with 2 g of intravenous cefotetan disodium every 12 hours for associated urosepsis with bacteremia. Postoperatively, the patient followed a diet of intravenous nutrition only. Uneventful convalescence was interrupted by signs of sudden major blood loss, accompanied by prolonged prothrombin time. After stabilization with packed red blood cells, fresh plasma, crystalloids, and parenteral vitamin K, laparotomy revealed a huge intra-abdominal clot, which was evacuated. This case illustrates the risk of unexpected hypoprothrombinemia and hemorrhage in a cefotetan-treated surgical patient who demonstrated none of the usual comorbid conditions generally described in patients with antibiotic-induced hypoprothrombinemia. Like cefamandole nafate, cefoperazone sodium, moxalactam disodium, and other cephalosporins containing the methylthiotetrazole side chain, cefotetan appears to pose an unusual risk of major bleeding.

The spinal accessory nerve plexus, the trapezius muscle, and shoulder stabilization after radical neck cancer surgery.

A clinical and anatomic study of the spinal accessory, the eleventh cranial nerve, and trapezius muscle function of patients who had radical neck cancer surgery was conducted. This study was done not only to document the indispensibility of the trapezius muscle to shoulder-girdle stability, but also to clarify the role of the eleventh cranial nerve in the variable motor and sensory changes occurring after the loss of this muscle. Seventeen male patients, 49-69 years of age, (average of 60 years of age) undergoing a total of 23 radical neck dissections were examined for upper extremity function, particularly in regard to the trapezius muscle, and for subjective signs of pain. The eleventh nerve, usually regarded as the sole motor innervation to the trapezius, was cut in 17 instances because of tumor involvement. Dissection of four fresh and 30 preserved adult cadavers helped to reconcile the motor and sensory differences in patients who had undergone loss of the eleventh nerve. The dissections and clinical observations corroborate that the trapezius is a key part of a "muscle continuum" that stabilizes the shoulder. Variations in origins and insertions of the trapezius may influence its function in different individuals. As regards the spinal accessory nerve, it is concluded that varying motor and sensory connections form a plexus with the eleventh nerve, accounting, in part, for the variations in motor innervation and function of the trapezius, as well as for a variable spectrum of sensory changes when the eleventh nerve is cut. For this reason, it is suggested that the term "spinal accessory nerve plexus" be used to refer to the eleventh nerve when it is considered in the context of radical neck cancer surgery.

Distant nontraumatic clostridial myonecrosis and malignancy.

Distant nontraumatic clostridial myonecrosis in association with malignancy is an uncommon disorder, with only 14 well-documented cases previously reported in the English literature. Clostridium perfringens and C. septicum are the most common organisms, usually gaining access to the circulation through an ulcerated lesion of the small bowel or colon. A case report of this syndrome caused by C. histolyticum is presented with a review of the literature.

Modification of immunogenic tumor growth by adrenalectomy in a syngeneic murine system.

The immunosuppressive action of adrenal glucocorticosteroids is well-known, and depressed cell-mediated immunity and adrenal cortical hyperplasia have been described in tumor-bearing animals. This study was designed to evaluate the effect of removing the source of lympholytic steroids by adrenalectomy upon tumor growth rate, thymus weight, and thymocyte incorporation of iodine 125 (125I) deoxyuridine into DNA. Newly derived methylcholanthrene-induced immunogenic fibrosarcomas were used in male syngeneic mice. Log dosages of 10(4), 10(5), and 10(6) viable tumor cells as single cell suspension were injected subcutaneously into the popliteal space of adrenalectomized and control mice. Tumor size was followed serially with caliper measurements, and the animals were killed 4 weeks after inoculation. Adrenalectomized mice inoculated with 10(4) cells had smaller tumors (P less than 0.02), heavier thymi (P less than 0.01), and more thymic DNA synthesis (P less than 0.05) than their tumor-bearing controls. No differences were seen between populations receiving 10(5) or 10(6) tumor cell inoculations. A second experiment was carried out in which intact controls, adrenalectomized animals, and sham adrenalectomy animals were inoculated with 10(4) tumor cells and killed 28 days later. Tumor growth rate and volume were significantly decreased for the adrenalectomized mice, which had higher thymus weights and DNA synthesis. These findings suggest that pretreatment adrenalectomy slows the growth of antigenic tumor cells and prevents thymic involution after tumor growth in a syngeneic murine system.

Unusual foreign body in the urethra.

Numerous cases of intraurethral foreign bodies of great variety and unusual nature have been reported. Such foreign bodies are usually introduced for sexual stimulation and/or during an intoxicated or confused state. Resulting symptoms usually involve the urinary frequency, dysuria, nocturia, hematuria, gross bleeding per urethra, difficulty in voiding, or complete urinary retention. Depending on the type of foreign body and its location, various methods of removal have been described, including meatotomy, cystoscopy, internal or external urethrotomy, suprapubic cystostomy, Fogarty catheterization, and injection of solvents. The most frequent complications are urethritis, urethral tear with periurethral abscess and/or fistula, hemorrhage, and urethral diverticuli. We report a case of an intraurethral fishhook with its complications and treatment. The diagnosis should be considered in high-risk patients with lower and urinary tract signs and symptoms.

Gastric carcinoid (gastrinoma) associated with achlorhydria (pernicious anemia).

This report presents a case of multicentric gastric carcinoid (gastrin containing) tumors of the fundus associated with achlorhydria and pernicious anemia. It is suggested that stimulation of the antral G cells and possibly fundic argyrophilic cells by achlorhydria associated with atrophic gastritis may lead to hyperplasia, and eventually to neoplasia in the latter, in the form of gastric carcinoid with gastrin production.

Therapeutic considerations in the management of melanoma.

The utilization of Breslow-Clark microstaging has proved helpful in deciding whether or not to perform elective regional node dissection for patients with melanoma. The marked biologic diversity of the disease, however, mandates a strict therapeutic policy of individualization with respect to prognostic variables and special clinical presentation. Specifically, melanomas associated with ulcerations, truncal location, and regional node involvement appear to be more aggressive. Lesions with cutaneous penetration more than 1.5 mm in depth, and showing blood and lymphatic vessel invasion are more often associated with regional node involvement and worse prognosis. The association of any of these adverse prognostic signs with an intermediate thickness lesion (0.76-1.5 mm) may justify elective node dissecton. Head and neck, mucosal, and subungual melanomas are all associated with poor prognosis due to rapid growth and early dissemination. The role of elective node dissection in these patients in unclear.

Arterial embolus as a complication of staging laparotomy.

Staging laparotomy is widely utilized in the management of selected patients with Hodgkin disease. The local trauma produced by extensive en bloc periaortic node removal for detection of subdiaphragmatic disease may predispose the patient to arterial thromboembolic events. This procedure seems undesirable and unnecessary especially in patients known to have lymphocyte-depleted and mixed-cellularity-type disease or in those found to have splenic involvement by intraoperative sectioning. These patients will often have microscopic tumor in their random needle and wedge liver biopsies taken at surgery; extensive periaortic tissue sampling is therefore unnecessary. A further concern is that such patients are likely to receive postoperative steroid chemotherapy, which has been associated with a hypercoagulative state.

Choice of route for central venous cannulation: subclavian or internal jugular vein? A prospective randomized study.

The clinical need for central venous cannulation has been well established. The usual route for catheter placement is by either the subclavian or internal jugular vein. No randomized, prospective evaluation has been yet conducted to determine which of these approaches, if either, is better with respect to reliability, placement, and frequency of nonseptic complications. One hundred consecutive patients requiring elective central venous cannulation were randomized to either the subclavian or internal jugular route. Successful venipuncture and catheter passage were significantly more common with the subclavian route, and in the absence of special clinical situations, it appears to be the route of choice.

Complications from staging laparotomy for Hodgkin disease.

Nonspecific complications from staging laparotomy are usually related to general anesthesia or abdominal exploration. Specific complications for the procedure do exist: intubation difficulties during administration of anesthesia to patients with untreated mediastinal disease, sepsis in up to 20% of patients, depending on stage of disease and intensity of postoperative chemotherapy and radiotherapy, arterial and possibly venous thromboemboli from extensive retroperitoneal node dissection, pancreatitis, small bowel obstruction from adhesions to node biopsy sites, operative mishaps, subphrenic abscesses, and bleeding from liver biopsies. Certain patient subpopulations are at especially high risk for some of these complications and their identification and possible measures to minimize such problems are proposed.

In vitro stimulation of murine lymphoid cell cultures by levamisole.

Levamisole has been reported to act as an immunological adjuvant. Experiments reported here on the effect of this agent on a variety of murine lymphoid culture systems were designed to gain an insight into its mechanism of action. We have found levamisole to be a weak mitogen for mouse spleen cells producing a dose related response which peaks at 48 hr in culture. The drug acted to augment the response of spleen cells to sub-optimal concentrations of concanavalin A, but had no unusual effect on the lipopolysaccharide stimulation of B-cell DNA synthesis in vitro. Levamisole was directly stimulatory on enriched T-cell populations and was found to have two actions: (1) to stimulate a subpopulation of T cells and (2) to augment the response of suboptimal mitogen concentrations of concanavalin A. In addition, we have found that murine thymocytes stimulated by concanavalin A were greatly potentiated in the presence of levamisole, but this population of cells could not be stimulated directly by the drug.

Efficacy of intravenous clindamycin and methicillin in gram-positive soft tissue infections.

In a comparative study on a general surgical service, intravenous clindamycin phosphate or methicillin was used to treat a variety of soft tissue infections due to gram-positive organisms, chiefly staphylococci. The infections were rated according to severity, responsible organisms, and site of the infection. Excellent or good clinical and bacteriologic responses were obtained with both clindamycin and methicillin as adjuncts to basic surgical therapy in these soft tissue infections. The adverse effects of each drug were detailed, and were comparable. Clindamycin phosphate is a satisfactory substitute for methicillin in soft tissue infections secondary to gram-positive organisms.