Risk factors for postoperative wound infections and prolonged hospitalization after ventral/incisional hernia repair.

PURPOSE: The purpose of this study was to identify predictive factors for postoperative surgical site infections (SSIs), and increased length of hospital stay (LOS) after ventral/incisional hernia repair (VIHR) using multi-center, prospectively collected data. STUDY DESIGN: Cases of VIHR from 2009 to 2010 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Using logistic regression, a prediction model utilizing 41 variables was developed to identify risk factors for postoperative SSIs, and increased LOS. Separate analyses were carried out for reducible and incarcerated/strangulated cases. RESULTS: A total of 28,269 cases of VIHR were identified, 25,172 of which met inclusion criteria. 18,263 cases were reducible hernias, and 6,909 cases were incarcerated/strangulated hernias. Our prediction model demonstrated that body mass index ≥30 kg/m(2), smoking, American Society of Anesthesiology (ASA) class 3, open surgical approach, prolonged operative times, and inpatient admission following VIHR were significant predictors of postoperative SSIs. In addition, risk factors associated with prolonged LOS included older age, African American ethnicity, history of alcohol abuse, ASA classes 3 and 4, poor functional status, operation within the last 30 days of the index operation, history of chronic obstructive pulmonary disease, congestive heart failure, and bleeding disorder, as well as open surgical approach, non-involvement of residents, prolonged operative times, recurrent hernia, emergency operation, and low preoperative serum albumin level. CONCLUSIONS: Obesity and smoking are modifiable risk factors for SSIs after VIHR, whereas a low serum albumin level is a modifiable risk factor for prolonged LOS. Addressing factors preoperatively might improve patient outcome, and reduce health care expenditures associated with VIHR. In addition, if feasible, the laparoscopic approach should be strongly considered.

Can ulnar artery velocity changes be used as a preoperative screening tool for radial artery grafting in coronary artery bypass?

Radial artery harvesting for coronary revascularization may result in digit ischemia if collateral circulation is inadequate. The purpose of this study was to compare changes in ulnar artery flow velocity during radial artery compression (RAC) with changes in first- and second-digit pressures during RAC, a previously validated predictor of digital ischemia. Photoplethysmography was used to measure first- and second-digit arterial pressures before and during RAC on 80 extremities. Color flow duplex imaging was used to measure distal ulnar artery peak systolic velocity before and during RAC. Seventy-eight of eighty extremities had a slight increase in ulnar artery velocity with RAC. There was no correlation between ulnar artery velocity changes and digit pressure changes. Measurement of ulnar artery velocity during RAC is not a useful predictor of digit pressure changes. Measurement of segmental upper extremity pressures with first- and second-digit pressure measurement during radial artery compression should remain the preferred preoperative screening tool for radial artery harvest prior to CABG.

Incidental discovery of an inferior vena cava aneurysm.

Inferior vena cava (IVC) aneurysms are extremely rare, with only 18 reported cases in the world literature. These aneurysms are categorized as acquired, congenital, or associated with arteriovenous fistulae. Thrombosis of an IVC aneurysm can lead to IVC syndrome characterized by massive lower extremity edema, pulmonary embolism, or even death. Therapeutic alternatives range from watchful waiting to operative resection. This report presents a case of an IVC aneurysm noted incidentally at the time of diagnostic computed tomography for the evaluation of blunt chest trauma following a motor vehicle collision. In addition, the classification, embryology, diagnosis, and management of this unusual clinical entity are reviewed.

Upper extremity venous gangrene following coronary artery bypass. A case report and review of the literature.

Acute symptomatic upper extremity deep vein thrombosis (DVT) are estimated to account for only 2-4% of all deep vein thrombosis. Upper extremity DVT leading to phlegmasia cerulea dolens (PCD) occurs in an estimated 2-5% of these cases. Progression of PCD to venous gangrene is extremely rare with only 16 previously reported cases in the literature. Only 7 of the cited cases document significant tissue loss. This report describes a 61-year-old male who developed upper extremity DVT complicated by PCD which led to venous gangrene and limb loss.

Compartment syndrome of the arm and disseminated intravascular coagulation.

We present the case of a woman who had coagulopathy and sepsis and who developed compartment syndrome of the arm. We discuss recognition and treatment of arm compartment syndrome and review the literature regarding this condition.

Sarcoidosis of the pancreas: case report and review of the literature.

Sarcoidosis involving the pancreas is rare. Patients can present with symptoms that mimic pancreatic cancer. We report a case of a male patient with clinical and radiographic findings suggestive of pancreatic cancer as the initial manifestation of sarcoidosis.

Treatment options for perianal Bowen's disease: survery of American Society of Colon and Rectal Surgeons Members.

The aim of this study was to determine current management practices of physicians caring for patients with perianal Bowen's disease. A questionnaire was sent to 1,499 members listed in the 1997 American Society of Colon and Rectal Surgeons Directory asking them how many patients they have treated and which operative or nonoperative treatment option they choose for small (< or =3 cm), large (> 3 cm), and microscopic lesions. Of 1,499, 663 (44.2%) surgeons responded. Not all respondents answered each item. Seventy-five per cent of surgeons surveyed (n = 653) devote greater than 75 per cent of their practice to colon and rectal surgery. Of 642 respondents, 552 (86%) managed a total of <10 patients, and 90/642 (14%), > or =10 patients. Ninety-six per cent of respondents use wide local excision for patients with small lesions. Eighty-seven per cent of respondents use wide local excision for patients with large lesions. Seventy-four per cent treat patients with microscopic disease conservatively and without wide excision. The majority of surgeons caring for patients with perianal Bowen's disease are performing wide local excision for both small and large lesions. Microscopic disease was usually treated conservatively with observation alone.

Prescribing exercise training for patients with defibrillators.

Patients with an implantable cardioverter defibrillator (ICD) often refrain from physical exercise for fear of precipitating a life-threatening arrhythmia or receiving an ICD shock. However, most of these patients are able to safely exercise if they are provided appropriate clinical guidelines. This review describes the factors that enter into the development of an exercise program for patients with an ICD.

Perianal Bowen's disease and anal intraepithelial neoplasia: review of the literature.

PURPOSE: The aim of this study was to review the literature with regard to perianal Bowen's disease and anal intraepithelial neoplasia. METHODS: A literature review was conducted from 1960 to 1999 using MEDLINE. RESULTS: Perianal Bowen's disease and anal intraepithelial neoplasia are precursors to squamous carcinoma of the anus. They are analogous to and are associated with cervical and vulvar intraepithelial neoplasia, and have human papillomavirus as a common cause. Biopsy and histopathologic examination is required for diagnosis and to distinguish other perianal dermatoses. Treatment options range from aggressive wide local excision of all disease with negative margins to observation alone for microscopic lesions not visible to the naked eye. The disease has a proclivity for recurrence and recalcitrance. CONCLUSIONS: Most surgeons caring for patients with perianal Bowen's disease and high-grade anal epithelial neoplasia use wide local excision, with an effort to obtain disease-free margins. Some authors have reported the advantages of ablative procedures such as laser ablation and cryotherapy. Microscopic disease found serendipitously in hemorrhoidectomy specimens can probably be treated conservatively with serial examinations alone. There is a lack of controlled data supporting an optimal treatment strategy. A multicenter controlled study comparing wide local excision with ablative procedures may be warranted.

Noninvasive evaluation of hand circulation before radial artery harvest for coronary artery bypass grafting.

OBJECTIVE: Radial artery harvesting for coronary artery bypass may lead to digit ischemia if collateral hand circulation is inadequate. The modified Allen's test is the most common preoperative screening test used. Unfortunately, this test has high false-positive and false-negative rates. The purpose of this study was to compare the results of a modified Allen's test with digit pressure change during radial artery compression for assessing collateral circulation before radial artery harvest. METHODS: One hundred twenty-nine consecutive patients were studied before coronary artery bypass operations. A modified Allen's test was performed with Doppler ultrasound to assess blood flow in the superficial palmar arch before and during radial artery compression. A decreased audible Doppler signal after radial artery compression was considered a positive modified Allen's test. First and second digit pressures were measured before and during radial artery compression. A decrease in digit pressure of 40 mm Hg or more (digit DeltaP) with radial artery compression was considered positive. RESULTS: Seven of 14 dominant extremities (50%) and 8 of the 16 nondominant extremities (50%) with a positive modified Allen's test had a digit DeltaP of less than 40 mm Hg (false positive). Sixteen of 115 dominant extremities (14%) and 5 of 112 nondominant extremities (4%) with a negative Allen's test had a digit DeltaP of 40 mm Hg or more with radial artery compression (false negative). CONCLUSION: Use of the modified Allen's test for screening before radial artery harvest may unnecessarily exclude some patients from use of this conduit and may also place a number of patients at risk for digit ischemia from such harvest. Direct digit pressure measurement is a simple, objective method that may more precisely select patients for radial artery harvest. Additional studies are needed to define objective digital pressure criteria that will accurately predict patients at risk for hand ischemia after radial harvest.

Metronidazole may inhibit intestinal colonization with Clostridium difficile.

PURPOSE: Antibiotics suppress normal gut flora, allowing overgrowth of acquired or native Clostridium difficile, with release of toxins that cause mucosal inflammation. Oral metronidazole is used to treat antibiotic-associated colitis (pseudomembranous colitis). This study was designed to determine whether oral metronidazole, as part of preoperative bowel preparation, prevents or decreases incidence of antibiotic-associated colitis after elective colonic and rectal procedures. METHODS: Eighty-two patients (40 men) were prospectively, randomly assigned to receive one of two oral antibiotic regimens before colorectal surgery. All patients underwent mechanical bowel preparation with polyethylene glycol-electrolyte lavage solution before administration of oral antibiotics. Group 1 (n = 42) patients received three doses (1 g/dose) of neomycin and erythromycin. Group 2 (n = 40) patients received three doses (1 g/dose) of neomycin and metronidazole. Both groups received one preoperative and three postoperative doses of intravenous cefotetan (2 g/dose). Both groups had stool samples tested for C. difficile toxin in the preoperative and postoperative periods by enzyme-linked immunoabsorbent assay or by tissue culture cytotoxicity. Patients with preoperative stool studies positive for C. difficile were excluded from the study. RESULTS: Treatment groups were not different for age, gender, or surgical procedure. Mean age +/- 1 standard deviation was 67.6 +/- 13.6 (range, 34-94) years in Group 1 and 62.1 +/- 13.5 (range, 35-84) years in Group 2 (P = 0.069). Mean length of hospital stay +/- 1 standard deviation was 9.76 +/- 4.9 (range, 4-28) days for Group 1 and 8.05 +/- 2.6 (range, 3-14) days for Group 2 (P = 0.053). Five patients in Group 1 (neomycin and erythromycin) and one patient in Group 2 (neomycin and metronidazole) had positive stool studies for C. difficile. Relative risk of colonization with C. difficile in Group 1 was 4.76 times that in Group 2 (95 percent confidence interval, 0.581, 39). This difference was not statistically significant (P = 0.202). There were no significant differences in C. difficile colonization rates with respect to age, length of stay, or gender. CONCLUSIONS: This study suggests that there may be a clinical association between use of metronidazole preoperatively and inhibition of intestinal colonization by C. difficile in this patient population undergoing colonic and rectal surgery.

Exercise prescription for chronically ill patients.

Although patients with chronic illnesses typically refrain from exercise, many of them could benefit significantly from mild, long-term exercise therapy. While factors such as pain or weakness often discourage the chronically ill person from being physically active, lack of motivation and lack of knowledge are the primary obstacles. An effective way of overcoming these obstacles is to provide an individualized exercise regimen that both motivates and instructs. Patients who receive an exercise prescription enjoy this individualized approach, tend to exercise safely and quickly become aware of the benefits of exercise therapy as an adjuvant to their medical treatment.

Incidence and pathophysiologic significance of infected carotid artery plaque.

It is unknown whether an association exists between infectious microorganisms and atherosclerosis. Eighty consecutive patients undergoing carotid endarterectomy were studied to detect for bacterial or virus infections in removed carotid atherosclerotic plaques. Twenty-one patients (25%) were found to have positive cultures for bacteria of the carotid plaques. Three patients (4%) did not have bacterial contamination of controlled cultures of the skin. Of these three patients, two grew diptheroids and one grew staphylococcus. The control cultures of the skin demonstrated that 25 patients (31%) grew diphtheroids and 29 (36%) grew staphylococcus. Five patients grew both organisms. There was no evidence of colonization within the atheromatous plaque material in histologic studies of the three patients that had positive cultures of their plaque. All viral cultures were negative. The positive carotid cultures found were most likely due to contamination from the skin. This study demonstrates the unlikelihood of bacterial or virus infections as either an etiologic or a pathogenetic factor in carotid artery atherogenesis.

Exercise testing and training of persons with dysvascular amputation: safety and efficacy of arm ergometry.

Recent studies indicate that most persons with dysvascular amputation also have moderate to severe cardiovascular disease with impairment in functional capacity. This may limit the ability to achieve optimal function with their prosthesis because of inadequate conditioning. We developed an exercise testing and training program using arm ergometry in conjunction with standard rehabilitation for persons with acute dysvascular amputation who were profoundly deconditioned after complicated perioperative courses. The program consisted of daily arm ergometry, performed on an interval basis, at an intensity individually optimized through exercise testing. Twenty-five patients, with a mean age of 63 years, completed the inpatient program with pretest and discharge work performance assessment. There was no significant difference between pretest and discharge assessment of baseline or peak heart rate, systolic blood pressure, diastolic blood pressure, or Borg rating of perceived exertion. Peak systolic blood pressure was elevated at discharge compared to admission testing (p less than .04). Heart rate responses were decreased during the early stages of testing when comparing discharge telemetry to admission findings. The duration of exercise increased from 12.6 minutes to 16.3 minutes (p less than .0004), and the maximum work output increased from 17.1 watts to 23.5 watts (p less than .0004). There was no significant morbidity associated with either arm ergometry testing or the exercise program. We conclude that arm ergometry testing and training is a safe and effective method for improving the efficiency of arm work in the patient with acute dysvascular amputation.

Effects of exercise training on glucose control, lipid metabolism, and insulin sensitivity in hypertriglyceridemia and non-insulin dependent diabetes mellitus.

Exercise training has potential benefits for patients with hyperlipidemia and/or non-insulin dependent diabetes mellitus. In nondiabetic, nonobese subjects with hypertriglyceridemia, exercise training alone increased insulin sensitivity, improved glucose tolerance, and lowered serum triglyceride and cholesterol levels. These improvements did not occur when exercise training alone was given to similar patients with impaired glucose tolerance. In severely obese (X = 125 kg) subjects without diabetes melitus, a 600 calorie diet alone decreased glucose and insulin concentrations and improved glucose tolerance but did not increase insulin sensitivity. The addition of exercise training improved insulin sensitivity. Obese, non-insulin dependent diabetes mellitus subjects on sulfonylurea therapy alone increased insulin levels but failed to improve insulin sensitivity or glucose levels. In contrast, the addition of exercise training to this medication resulted in improved insulin sensitivity and lowered glucose levels. We conclude that exercise training has major effects on lowering triglyceride levels in hyperlipidemic subjects and can potentiate the effect of diet or drug therapy on glucose metabolism in patients with non-insulin dependent diabetes mellitus.

Exercise testing and training in patients with peripheral vascular disease and lower extremity amputation.

Patients with peripheral vascular disease have a high risk of coronary artery disease. The risk is even greater when the peripheral vascular disease leads to lower extremity amputation. Exercise testing using lower extremity exercise has been the "gold standard" for screening for coronary artery disease, but many patients with peripheral vascular disease and those with amputations have difficulty doing this type of exercise. Arm exercise ergometry has been shown to be a safe and effective alternative for the detection of coronary artery disease in patients who cannot do leg exercise. This test has also been used to determine safe exercise levels and may be able to predict the ultimate level of prosthetic use in amputees. Exercise training with arm ergometry also improves cardiovascular efficiency and upper body strength in poorly conditioned patients. Studies are needed to appreciate fully the role of exercise testing and training in the recovery of these patients after amputation.

Arm ergometry exercise testing in patients with dysvascular amputations.

The purpose of this study was to test the agreement between the heart rate (HR) response and rating of perceived exertion (RPE) on an arm ergometry graded exercise test (GXT) in deconditioned persons with acute dysvascular amputations before and after an inpatient rehabilitation program. Twenty-six men were studied at admission, and 11 were retested after completion of the program. After obtaining resting measurements of HR and systolic and diastolic blood pressures, each patient performed the GXT using an arm ergometer. Patients maintained a cranking rate of 50rpm, which was monitored electronically. The workloads started with a warm-up period of 0 watts (stage 1) and increased by increments of 5 watts. Each stage lasted three minutes-2.5 minutes of exercise and 30 seconds of rest. The RPE was taken five seconds before the end of each exercise stage. During the rest period, HR and blood pressures were recorded. Scatter plots and linear regression analyses revealed no statistically significant relationship, either at early stages of GXT or at peak work, between HR and RPE. The results suggest that RPE cannot be used reliably as a surrogate for direct pulse measurement in exercise training of persons with acute dysvascular amputations.

Arthritis and Aerobic Exercise: A Review.

In brief: Despite increasing evidence that regular aerobic exercise yields many benefits for patients with arthritis, patients often are advised to curtail physical activity. Findings from studies of patients with either rheumatoid arthritis or osteoarthritis who participated in an aerobic exercise program show that the subjects made significant gains in aerobic capacity, functional status, muscle strength, and other aspects of performance. In addition, they improved in subjective aspects that might have a positive impact on quality of life, including pain tolerance, joint pain, mood, and social activity. The authors discuss some questions that remain unanswered and present guidelines for physicians who wish to prescribe aerobic exercise for their arthritis patients.

Evaluating and prescribing exercise for elderly patients.

Research has demonstrated that exercise training benefits the elderly, just as it does younger age groups. Among benefits reported are improved cardiovascular and respiratory function, reduced coronary artery disease risk, decreased body fat and increased lean body mass, increased bone mass, increased work capacity, greater flexibility, reduced susceptibility to depression, improved self-esteem, and more independence. Before starting a vigorous training program, however, the elderly should undergo a thorough physical examination, including medical history, and an exercise stress test to evaluate cardiovascular status. These test results should be used to indicate intensity, duration, and frequency of exercise, as well as reassure patients of its safety. With this approach, full benefits of regular endurance exercise can be realized.

Papillary mechanics and cardiac morphology of infarcted rat hearts after training.

Infarction of the left ventricle was induced by ligation of the coronary artery in male Sprague-Dawley rats under ketamine-xylazine anesthesia. Three weeks after surgery, animals were assigned to a trained (n = 21; running at 20 m/min, 10% grade, 1 h/day, 5 days/wk) or nontrained group (n = 23) for an additional 8 wk. A third, sham-operated control group (n = 16) remained cage sedentary for 11 wk. Ventricular mass was greater in the trained and nontrained infarct groups [1,335 +/- 57.3 and 1,414 +/- 56.1 mg, respectively (mean +/- SE)] compared with the control group (1,155 +/- 50.9 mg) (P less than or equal to 0.05). The diameter of septal fibers was 13% greater in the trained and 17% greater in the nontrained infarct groups compared with control. The specific peak developed force and maximum rate of force development of left ventricular papillary muscle in vitro were 75 and 62% greater in both infarcted groups compared with the control group; these variables were unaffected by training. Myofibrillar adenosine triphosphatase activity of septum was 20% lower in both infarct groups compared with sham-operated animals. We conclude that exercise training did not alter the magnitude of morphological and physiological adaptations to infarction.