Focus on the prophylaxis, epidemiology and therapy of methicillin-resistant Staphylococcus aureus surgical site infections and a position paper on associated risk factors: the perspective of an Italian group of surgeons.

BACKGROUND: The aim of this research was to study the epidemiology, microbiology, prophylaxis, and antibiotic therapy of surgical site infections (SSIs), especially those caused by methicillin-resistant Staphylococcus aureus (MRSA), and identify the risk factors for these infections. In Italy SSIs occur in about 5 % of all surgical procedures. They are predominantly caused by staphylococci, and 30 % of them are diagnosed after discharge. In every surgical specialty there are specific procedures more associated with SSIs. METHODS: The authors conducted a systematic review of the literature on SSIs, especially MRSA infections, and used the Delphi method to identify risk factors for these resistant infections. RESULTS: Risk factors associated with MRSA SSIs identified by the Delphi method were: patients from long-term care facilities, recent hospitalization (within the preceding 30 days), Charlson score > 5 points, chronic obstructive pulmonary disease and thoracic surgery, antibiotic therapy with beta-lactams (especially cephalosporins and carbapenem) and/or quinolones in the preceding 30 days, age 75 years or older, current duration of hospitalization >16 days, and surgery with prothesis implantation. Protective factors were adequate antibiotic prophylaxis, laparoscopic surgery and the presence of an active, in-hospital surveillance program for the control of infections. MRSA therapy, especially with agents that enable the patient's rapid discharge from hospital is described. CONCLUSION: The prevention, identification and treatment of SSIs, especially those caused by MRSA, should be implemented in surgical units in order to improve clinical and economic outcomes.

Verrucous carcinoma of the foot with bone invasion: a case report.

Verrucous carcinoma of the foot often affects deep structures such as tendons, muscles, or bones. A 74-year-old man presented with a foot lesion that had been diagnosed as a skin infection 7 years earlier. He was treated with multiple excisions and superficial biopsies associated with antibiotic therapy without success. In our department he underwent an aggressive and accurate debridement with marginal excision harvesting multiple biopsies. Pathological evaluation of tissue at the time of operation confirmed the diagnosis of verrucous carcinoma of the foot. Therefore, the patient underwent an amputation below knee, and there were no postoperative complications; the patient was able to walk with the aid of a prosthesis with no signs of recurrence. The lesion follows a chronic course evolving from a discrete focal lesion to a large fungating deeply penetrating mass often compromised by local infection. The slow growth and confusing early-stage appearances can lead to delays in diagnosis of 8 to 15 years causing the extracutaneous involvement that requires a leg amputation. Many patients are initially treated with many topical medications without success, and most tumors have been treated as recalcitrant warts or corns for some time, whereas the basic approach is surgical.

Distal tibial and fibular epiphyseal fractures in children: prognostic criteria and long-term results in 158 patients.

From 1974 to 1993, 158 injuries of the ankle joint were treated at the Department of Orthopedics and Traumatology of Santobono Children's Hospital. One hundred thirty-two patients were treated conservatively; 26 patients underwent surgical treatment. Fibular fractures of the malleolus without epiphyseal separation or dislocation (68 patients) were excluded from this review. Of the 158 patients, 113 (70%) were available for follow-up. The mean age of patients was 11 years. The mean follow-up was 6 years (range 3-15 years). In this review, the authors compare, based on the degree of epiphyseal separation or dislocation, the Carothers-Crenshaw classification, which is based on the mechanism of trauma, with the Salter-Harris classification, which is based on anatomical-radiographic criteria. The aim is to review the authors' patients based on these classifications, to verify the prognostic ability of these criteria and thus to establish a better and more viable treatment for these injuries. Therefore, two fundamental factors should be considered for the prognosis: the mechanism of trauma and damage to the epiphyseal plate. Compressive trauma and adduction-supination trauma are the most dangerous types of injury, and any damage or gap in the physis should be perfectly reduced, by open means if necessary, to prevent a bone bridge from forming.

The use of external fixators in femur fractures in children.

Between 1988 and 1993, 81 children with 82 femur fractures were treated with external fixators at the Santobono Children's Hospital of Naples. This technique was reserved for children older than 6 years with open fractures, multiple fractures, multiple trauma, and unstable fractures. The patients were placed in skin traction on admission, and after 24-48 h, the external fixator was applied under general anesthesia. Therefore, within 1 week the children were able to take care of themselves and to attend school. The fixator was very well tolerated and was removed 8-9 weeks later. The fractures healed with good alignment, no complications with few cases of superficial infections, and less overgrowth. The use of external fixation is recommended for its simplicity and lack of complications.

Is gentle manipulative reduction and percutaneous fixation with a single screw the best management of acute and acute-on-chronic slipped capital femoral epiphysis? A report of 70 patients.

We report the results of the management of acute and acute-on-chronic slipped capital femoral epiphysis (SCFE) for 70 patients (81 hips) with an average follow-up of 6 years (range 1-15 years). We clinically reviewed 51 patients (55 hips) with acute or acute-on-chronic slip treated in our department from 1978 to 1993 with clinical and radiographic examination. Of these, 10 patients (11 hips) underwent a three-dimensional computed tomography (CT) scan to provide more details of the remodeling process. Percutaneous pinning with one cannulated screw appears to offer significant advantages. It is stable, safe, and reliable; there is no blood loss; the scar is small; hospital stay is brief; and early weightbearing is possible 2 weeks after the procedure, with low incidence of complications. Last, but not least, children can soon return to school. We conclude that preoperative reduction with very gentle manipulation and percutaneous pinning with a single screw is the best treatment for SCFE.

Infantile type of Blount's disease: considerations concerning etiopathogenesis and treatment.

The proper treatment of the infantile type of Blount's disease is still a controversial issue. We postulate the hypothesis of the etiopathogenesis of the infantile type of Blount's disease as a disease related to a dysplastic linkage between epiphysis and metaphysis. Therefore, considering the radiographic observations of a 26-month-old girl admitted in our department in 1986 with the infantile type of Blount's disease (type II Langenskiold--tibial femoral angle 24 degrees), the consequential optimal management of this condition is the need to apply a treatment consisting of the epiphyseal distraction capable of interrupting this dysplastic linkage, avoiding recurrences and damage to the growth cartilage. This child was treated with early, slow, and monocompartmental distraction by Ilizarov apparatus for 11 weeks. When the Ilizarov apparatus was removed, full recovery was achieved, the leg was clinically straight, and the mechanical axis was restored. The long-term follow-up (7 years) confirms this operation as a definitive treatment. It was less traumatic for the child, without recurrences or disorders of growth cartilage, supporting the dysplastic origin of infantile type of Blount's disease and the efficacy of this type of treatment.

The electrical and sodium transport characteristics of sutured premalignant mouse colon.

Depolarization of the plasma membrane and increased sodium influx have both been suggested as mitogenic signals. Following bowel resection the intestinal suture line has been reported a fertile site for tumor recurrence. Whether alterations in cell surface signaling occur at suture lines has not been previously examined the electrical changes of sodium transport occurring at a suture line in an animal model of large bowel cancer. Forty-eight female CF1 mice underwent colotomies with repair utilizing silk or chromic sutures. Twenty-four mice underwent sham operations to serve as controls. The mice were injected subcutaneously with the carcinogen DMH (1,2-dimethylhydrazine) 20 mg/kg or an identical volume of 0.9% saline for 6 weeks and were sacrificed 1 week after the last injection. The sites of the sutured colotomies or a piece of distal colon from the sham-operated mice were mounted in a modified Ussing chamber and the electrical properties and unidirectional sodium fluxes were measured. The potential difference (pd) across the distal colon was not significantly different in any suture group compared to that in sham-operated controls when treated with saline (pd sham, -2.3 +/- 0.2 mV (mean +/- SEM); silk, -1.7 +/- 0.3 mV, chromic, -1.9 +/- 0.3 mV, P greater than 0.05, unpaired Student t test). The potential difference was significantly lowered in both suture groups compared to sham operated animals after treatment with DMH (pd sham, -2.6 +/- 0.3 mV; silk, -1.5 +/- 0.2 mV, P less than 0.05; chromic, -1.6 +/- 0.4 mV, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Homodigital neurovascular island flaps for digital pulp loss.

Terminal amputations with loss of the distal pulp are common injuries. This report analyses 64 consecutive cases of advanced or exchanged homodigital neurovascular island flaps operated on by one surgeon between 1981-1986. The surgical technique, indications, contra-indications and five year results are evaluated. Overall, these flaps provide reliable vascularity as well as normal sensibility at the distal end of the finger where high quality perception is required.

Small bowel obstruction and its management.

We present a retrospective analysis of 105 instances of small bowel obstruction (SBO) in 80 patients admitted to our hospital over a ten year period. Adhesions accounted for 73% of the cases and secondary involvement by malignancy for 13%. Appendectomy, colorectal and other pelvic procedures were the most frequent surgical antecedents responsible for the adhesions. In the 86% of cases with a temperature over 100 degrees F there was significant morbidity, mortality and/or strangulation, and this sign also foretold a prolonged hospital stay. Leukocytosis, when present along with abdominal tenderness also predicted a prolonged hospital stay. Strangulation occurred in 4.7% of the instances and was accompanied by at least one of the "classical symptoms". Fourty-five percent of the instances were successfully managed by conservative measures alone, whereas 55% had had surgical treatment. The mean hospital stay for all cases was 15.3 days. The morbidity rate for this series was 21% with a mortality of 3.8%. The largest single cause of death was related to malignant disease (three of four cases). When post-operative adhesions were the etiology, the hospital stay was 8.5 +/- 1.3 days for those treated with conservative measures compared with 16.5 +/- 1.8 days for those in whom a surgical procedure was performed (p less than 0.0001). This latter group also has a higher morbidity (32% compared to 5% for the non-operative group).

Epithelial impedance analysis in experimentally induced colon cancer.

Epithelial impedance analysis was used to measure the alterations in resistance of the large bowel in a murine model of large bowel cancer. The technique was able to resolve the epithelial resistance from the total resistance of the bowel wall. A progressive decrease in resistance of the bowel epithelium occurs during carcinogenesis induced with dimethyhydrazine. About a 21% decrease in epithelial resistance from 22.0 +/- 1.3 omega.cm-2 to 17.5 +/- 1.1 omega cm-2 (p less than 0.025) was observed after 20 wk of carcinogen administration. The sensitivity of the technique in detecting altered epithelial resistance in premalignant bowel mucosa was improved by examining the impedance profile in a sodium-free Ringer's solution where the epithelium of control colons had a resistance of 24.4 +/- 1.8 omega.cm-2 compared with 19.0 +/- 1.1 omega.cm-2 (p less than 0.02) in colons from animals treated for only 4 wk with the carcinogen. Epithelial impedance analysis would seem to be a sensitive technique capable of identifying changes in the electrical properties or the large bowel early in disease states.

Colonic epithelial impedance analysis in a murine model of large-bowel cancer.

Death rates from large-bowel cancer have remained essentially unchanged over the past 40 years because the diagnosis is made late, after the tumor has spread to other sites. This study was undertaken to examine whether alterations in mucosal electrical capacitance precede the development of gross malignancy, since this parameter may reflect functional or structural changes in the colonocyte plasma membrane, which is of importance in the regulation of cell growth. Distal colonic mucosal capacitance was decreased at low frequencies after only four weeks of treatment with the carcinogen dimethylhydrazine in C1 mice. Alterations in electrical capacitance may be a useful marker in identifying patients with a propensity to develop large-bowel cancer.

Efficacy of Dexon microsutures in rat major abdominal vessel anastomosis. I: Application to heterotopic heart transplant.

A total of 52 syngeneic heterotopic heart transplants were performed using 9-0 Dexon microsutures to see if these anastomoses could be tolerable when challenged by the burden of transplanted heart and lung. Eighteen long-term surviving transplants were verified by reliable ECG, Doppler tracings, and direct palpation of the heart grafts. Animals sacrificed at monthly intervals beginning 3 to 6 months posttransplantation were free of thrombus, lung abscesses, and separation at the anastomoses. Even though foreign body reaction was still present up to 5 months posttransplantation, no actual sutures were present after 3 months. From these observations, Dexon microsuture is acceptable in organ transplantation procedures.