The point prevalence of wounds in a teaching hospital.

BACKGROUND: Wounds are a common problem, particularly in the elderly population. The scale of wound problems in hospital is largely unknown because wounds are widely dispersed. The present study examined the point prevalence of hospital wounds and undertook a pressure ulcer risk assessment of all patients on one day. METHODS: All 360 inpatients were surveyed and thoroughly examined. A risk scale for pressure sore development, the Norton score, was applied. When wounds were found, information was collected to determine their aetiology. RESULTS: Forty leg ulcers, 40 pressure sores, 85 surgical wounds and seven other types of wounds were found. Most leg ulcer and pressure sore cases were admitted for other reasons. The Norton score did not predict all cases of pressure ulceration. A total of 52% of wounds did not qualify for additional funding under current funding criteria. CONCLUSION: The prevalence of non-surgical wounds in Heidelberg Repatriation Hospital was easily underestimated. Wound care management can be optimized by staff education and protocol design, early identification of troublesome wounds and of at-risk patients, and a cross-sectional approach that incorporates wound-management teams.

Apoptosis is increased in a model of diabetes-impaired wound healing in genetically diabetic mice.

Impaired wound healing is a common complication of diabetes mellitus. The underlying pathophysiology of diabetes-impaired healing is poorly understood. In the present study we have compared cell proliferation rates, apoptosis (programmed cell death), the myofibroblast marker alpha-smooth muscle actin and procollagen I mRNA expression, between diabetic and control mice. Full-thickness skin wounds were made in non-obese diabetic (NOD) mice and C57B6 controls. NOD mice showed a marked retardation of wound healing at both 7 and 14 days after wounding. Comparison of cell proliferation rates 7 days after wounding, using 5-bromo-2'-deoxy-Uridine incorporation, showed higher rates of cell proliferation in controls (88.1 +/- 12.8) than in NOD wounds (52.1 +/- 9.9, p < 0.02, n = 4). Immunohistochemical detection of alpha-smooth muscle actin, showed a later onset in diabetic wounds, suggesting that wound contraction may be delayed in the diabetic animals. In situ hybridisation for alpha 1 (I) procollagen mRNA expression, showed reduced procollagen I expression in the diabetic wounds when compared with controls. Lastly, there appeared to be higher levels of apoptosis in diabetic wounds, shown by the terminal transferase mediated UTP nick end-labelling technique. Apoptotic cells were rare in control wounds confirming previous studies, which showed that apoptosis occurs late in normal wound healing as the wound matures into scar tissue. In conclusion, we hypothesize that reduced cell proliferation, retarded onset of the myofibroblast phenotype, reduced procollagen I mRNA expression and aberrant control of apoptotic cell death may contribute to impaired wound healing seen in this diabetic model.

Case survey of management of cellulitis in a tertiary teaching hospital.

OBJECTIVE: To examine management of cellulitis in a tertiary teaching hospital, identify inefficiencies and suggest revised management guidelines. DESIGN: Retrospective case survey, based on patient hospital records. SETTING: Heidelberg Repatriation Hospital, Melbourne, Victoria (a tertiary teaching hospital), in 1991 and 1992. SUBJECTS: All patients admitted with lower-limb cellulitis as the primary diagnosis. RESULTS: 118 patients were included. Underlying disease predisposing to cellulitis was found in 79%, but was adequately investigated in only 20% of these. Blood cultures were performed in 55%, all with negative results. Other microbiological investigations also had poor yields. Combination therapy with intravenous (i.v.) flucloxacillin and penicillin was given to 76%, with duration varying widely (mean, six days). Where documented (73%), most patients (94%) responded to antibiotics within five days. However, in 40% of patients i.v. therapy was continued for longer and in 10% for 10 days or more, with no significant difference in outcome. Length of hospital stay averaged 13 days, with prolonged stay often associated with surgical intervention or intercurrent problems. However, 15% of patients remained in hospital longer than 10 days for no clear indication. Outpatient review was common (75%), but persistence or relapse of cellulitis was found in only four patients on review. CONCLUSIONS: Management of inpatients with cellulitis is inefficient, with excessive use of microbiological investigations, inadequate investigation and treatment of underlying disease, prolonged use of intravenous antibiotics, unnecessarily long hospital stays, questionable use of combination antibiotic therapy and excessive outpatient review (rather than review by a local medical practitioner).

Optimizing the hospital management of leg ulcers.

BACKGROUND: Leg ulcers are common and are often the cause of a long hospital admission. However, little information is available on the efficacy and efficiency of inpatient leg ulcer management. The inpatient management of leg ulceration was examined and areas for improvement were sought. METHODS: The management of patients admitted to a teaching hospital with a primary diagnosis of leg ulceration was examined, the costs estimated and areas for improvement identified. A retrospective analysis of 174 admissions to Heidelberg Repatriation Hospital between 1 January 1991 and 31 December 1992 was performed. RESULTS: Of 119 patients, 61 had ulcers due to arterial disease and 34 due to venous disease. Over 2 years, leg ulcers accounted for 5259 inpatient bed days, a mean of 44.2 days per patient. The estimated cost exceeded $2,750,000, averaging over $12,000 per admission. Thirty-three percent of patients had no recorded investigations into the cause of their ulcer and fewer than 50% had documented improvement at discharge. CONCLUSIONS: Leg ulcers are costly due to their extended treatment on an inpatient basis. Unfortunately, hospital admission does not guarantee optimal wound healing rates. A leg ulcer protocol is proposed to minimize inpatient stay and improve investigation and management in an outpatient or community setting.

Formal teaching of basic surgical skills.

Attainment of the practical skills in surgery is an integral part of surgical training. Basic skills must be mastered prior to attempting more complex tasks and bad habits learned early are difficult to correct. A survey of advanced surgical trainees at this hospital demonstrated that skills were usually acquired during sessions in the operating theatre, often in an ad hoc manner. We report our experience in establishing a workshop-based skills course. The program included handling of instruments, knot tying, types and applications of needles and suture materials, wound care, ligation of vessels, and assisting at operation. Following completion of the course and demonstration of their competence, participants were awarded a certificate in basic skills. Participants reported increased confidence and involvement in operative surgery after the course and an increased interest in a career in surgery. We believe the intern year is the most appropriate time to teach such skills, but tuition need not to be restricted to this group. Teaching basic surgical skills in the workshop setting is feasible and advantageous.

Chronic leg ulceration--the hidden epidemic.

Despite advances in our understanding of wound repair processes and improved pharmaceuticals, chronic leg ulceration continues to be a burden on the Australian health dollar. The simple management protocol presented here would considerably improve this unsatisfactory situation.

Transplantation studies of the role of the kidney in long-term blood pressure reduction following brief ACE inhibitor treatment in young spontaneously hypertensive rats.

1. Brief treatment with angiotensin-converting enzyme (ACE) inhibitors in young spontaneously hypertensive rats (SHR) causes a persistent reduction in blood pressure associated with a relatively selective reduction in renal vascular resistance. 2. To study the possible role of the kidney in this long-term hypotensive effect, we transplanted kidneys from untreated SHR into SHR that had been treated with perindopril (3 mg/kg per day) between 6 and 10 weeks of age and also transplanted kidneys from perindopril-pretreated SHR into untreated SHR. After transplantation, the remaining native kidney was removed so that only donor kidneys remained. 3. Untreated SHR that received kidneys from perindopril-pretreated SHR showed an initial fall in blood pressure followed by a rapid increase in pressure, weight loss and early death. 4. The transplantation of kidneys from control SHR into perindopril-pretreated SHR resulted in a rise in blood pressure that obviated the long-term reduction seen normally in these animals. 5. Kidneys from perindopril-pretreated SHR may be susceptible to the high blood pressure in untreated SHR. 6. The blood pressure increase in perindopril-pretreated SHR that accompanies substitution of the native kidneys by kidneys from untreated SHR further supports the hypothesis that the kidney is responsible for the long-term pressure effects following ACE inhibition in young SHR.

Attitudes towards liver transplantation in Victoria, Australia.

Liver transplantation commenced on a regular basis in Australia in 1985. This followed the first successful orthotopic transplant in Brisbane in 1985 and the setting up of a National Centre for Liver Transplantation in Sydney in 1985 with clinical transplantation beginning there in 1986. A centre was subsequently developed in Melbourne in 1988. As this procedure was perceived to be expensive, and because of discussion on rationing of medical services, the authors were prompted to test the Victorian community awareness and attitude to government funding of transplantation. One year after the establishment of the Victorian Liver Transplantation Programme, a random survey of the Victorian population and of general practitioners in Melbourne was conducted with the assistance of a professional polling company. Sixty-five per cent of the Victorian population knew liver transplantation was available in Victoria, 12% said it was not available and 23% did not know. Among general practitioners, 79% knew liver transplantation was available 14% said it was not available and 7% did not know. Eighty-eight per cent of Victorians and a similar proportion of general practitioners said the State Government should provide funding. Forty-seven per cent of the Victorian population said government should provide total funding and a further 39% funding of more than 50%. Among general practitioners, 33% said total funding should be provided and a further 46% thought that more than 50% of funding should be provided. This survey has revealed convincingly that Victorians have decided that their health care should include the expense of liver transplantation paid for by government. Awareness of the availability of the operation of liver transplantation is developing rapidly.

Duplex scanning and light reflection rheography in the assessment of the severity of short saphenous vein incompetence.

BACKGROUND: Duplex ultrasound assessment of veins in the popliteal fossa is an accepted alternative to venography. Light reflection rheography provides additional quantitative information on venous reflux in chronic venous insufficiency. OBJECTIVE: To use duplex ultrasound and light reflection rheography to study the venous reflux patterns in the popliteal fossa in a group of patients. METHODS: Duplex ultrasound examination and light reflection rheography were used in the assessment of the severity of short saphenous vein incompetence. RESULTS: The study revealed that any associated deep venous reflux which was detectable beyond the saphenopopliteal junction represented a more advanced stage of superficial venous insufficiency. CONCLUSIONS: Light reflection rheography, as a semiquantitative test, provided useful additional information to duplex scan findings in assessing venous reflux of the popliteal fossa. Short saphenous vein reflux with functional deep venous incompetence was associated with shorter venous refilling times and clinically represented a more advanced stage of primary varicose vein disease.

Renal transplantation between male and female spontaneously hypertensive rats.

The higher blood pressures of male compared with female spontaneously hypertensive rats (SHR) are the result of the inheritance of different sex chromosomes, although the pathophysiology has not been defined clearly. The reported hypertensive effect of kidneys transplanted from male SHR raises the possibility of a sex-specific renal abnormality, but the effects of transplanting female SHR kidneys have not been studied. To test this hypothesis, single kidneys were transplanted from male SHR into female SHR recipients and vice versa, followed by removal of the native kidneys of the recipients. Male and female SHR that had undergone uninephrectomy were used as controls. After surgery at 14 weeks of age, systolic blood pressures were measured each week until 30 weeks of age. The replacement of a SHR female kidney with a SHR male kidney was not associated with any significant rise in blood pressure, and the replacement of a SHR male kidney with a kidney from a female SHR was not associated with any reduction in blood pressure. These results indicate that the sexual dimorphism of SHR blood pressure is not the result of intrinsic renal differences between males and females and that nonrenal factors would be more likely to explain the blood pressure differences between the sexes.

The role of endogenous prostaglandins in hormone-stimulated pancreatic exocrine secretion.

The authors have previously shown that neurotensin and secretin inhibit gastric acid secretion in the dog and that these actions are inhibited by the prostaglandin synthesis inhibitor indomethacin. Conversely, neurotensin and secretin share similar stimulatory effects on pancreatic exocrine secretion. In the present study, the effects of blockade of prostaglandin synthesis by indomethacin on neurotensin-, cholecystokinin-, and secretin-stimulated exocrine secretion are examined along with the effects of these same agents on the release of pancreatic polypeptide. The studies were performed on conscious dogs with chronic gastric and pancreatic cannulas. Dose-dependent increases in pancreatic exocrine secretion of water and bicarbonate were observed with IV infusion of neurotensin or secretin; however, inhibition of prostaglandin synthesis by indomethacin abolished this response. Protein secretion stimulated by either neurotensin or cholecystokinin was not affected by prostaglandin inhibition. Cholecystokinin and neurotensin infusion stimulated release of pancreatic polypeptide; only neurotensin-stimulated release of pancreatic polypeptide was inhibited by indomethacin treatment. It is concluded that intact prostaglandin synthesis is necessary for the actions of neurotensin and secretin (but not that of cholecystokinin) on pancreatic exocrine secretion of water and bicarbonate and for neurotensin- (but not cholecystokinin-) stimulated release of pancreatic polypeptide.

Cysteamine can induce duodenal ulceration in rats without depletion of immunoreactive somatostatin.

Single subcutaneous administration of cysteamine (2-aminoethanethiol, CSH) produces duodenal ulceration in rats within 24 h. Depletion of circulating and tissue somatostatin (SOM), hypergastrinemia and gastric acid hypersecretion have all been postulated as the pathophysiological response to CSH leading to ulceration. The purpose of this study was to analyze the synthesis, storage and secretion of gastrin and SOM as well as structural changes in SOM peptide after CSH treatment. Injection of 300 mg/kg (s.c.) of CSH caused macroscopic duodenal ulcers in seven out of eight rats at 24 h. Hypergastrinemia was seen within 30 min (from 23 +/- 4 to 74 +/- 20 pmol/l), and persisted for 4 h. Antral gastrin content was elevated at 30 min (2539 +/- 114 pmol/g) when compared to saline controls (1589 +/- 101 pmol/g). Plasma SOM did not change over the 24 h but antral SOM increased at 30 min (from 120 +/- 3 to 230 +/- 23 pmol/g) and remained elevated at 2 h (374 +/- 48 pmol/g) and 4 h (357 +/- 37 pmol/g). Fundic and duodenal SOM followed a similar pattern. Antral SOM mRNA was also elevated over the first 4 h (3-fold increase, P less than 0.05). HPLC analysis of antral tissue extracts revealed the presence of additional molecular forms of SOM which, however, differed from the major products of in vitro reduction with either CSH or dithiothreitol. Thus, the in vivo effect of CSH on SOM cannot be solely explained by a reductive opening of the disulphide bond. These results suggest that duodenal ulceration in rats treated with CSH is not related in a simple fashion to depletion of immunoreactive SOM. Early induction of hypergastrinemia may be important in the onset of ulceration. The value of CSH as a SOM depleting tool in gastrointestinal tissue must remain in doubt.

Laparoscopic cholecystectomy: initial experience.

Twenty-five consecutive patients underwent percutaneous laparoscopic cholecystectomy (PCC). The gallbladder was removed successfully in 18 patients. The mean postoperative hospital stay was 1.4 days and patients returned to normal activity at a mean 8 days after operation. Postoperative pain was minimal. Formal laparotomy was performed in 7 patients due to: bleeding (3 patients), stone spillage (3 patients) and exploration of the common bile duct (1 patient). Complications were reduced with experience and strict adherence to the described operative technique. With obvious advantages for the patient, hospitals and the community an increased demand for PCC is inevitable. However, its role in the management of cholelithiasis and overall safety have yet to be determined. There is a significant learning curve and proper training is necessary. The widespread introduction of PCC has immediate implications for surgical training.

Spontaneous paracentesis following rupture of an umbilical hernia.

Spontaneous paracentesis following a ruptured umbilical hernia is a rare but dramatic event. Only 58 cases have been recorded in the English language literature. We describe here the management and successful outcome of one such case with documented substantial paracentesis of approximately 11 L.

In vivo comparison of inhibition with proglumide and CR-1409 of cholecystokinin-induced pressure in the biliary tract of the guinea pig.

This study was done to compare the effects of two cholecystokinin antagonists, proglumide and CR-1409, on cholecystokinin-induced changes in intrabiliary pressure in vivo. We have substantially modified the constant infusion biliary manometry model, successfully used in large animals, to measure contractility of the gallbladder in guinea pigs. A silicone catheter for manometry was placed in the fundus of the gallbladder of an anesthetized guinea pig, and the biliary tree was constantly infused at 0.1 milliliter per minute with normal saline solution. The intraluminal pressure of the system was continuously recorded. The model was used to demonstrate a dose-response curve to bolus administration of exogenous cholecystokinin (0.01 to 1.0 nanomole per kilogram) and also to study the actions of proglumide, an antagonist to gastrin and cholecystokinin, and CR-1409, a newer, specific cholecystokinin antagonist, on cholecystokinin-induced contraction of the gallbladder of the guinea pig in vivo. Proglumide, at a dose of 5 millimoles per kilogram, completely abolished increases in intrabiliary pressure caused by cholecystokinin (0.5 nanomole per kilogram), whereas this effect was achieved by only 5 micromoles per kilogram of CR-1409. In both, there was full recovery from cholecystokinin antagonism within one hour. CR-1409 is one thousand times more potent than proglumide against cholecystokinin-induced changes in intrabiliary pressure in vivo and appears to be a useful pharmacologic reagent to study cholecystokinin-mediated components of physiologic contraction of the gallbladder.