Glove powder increases Staphylococcus aureus abscess rate in a rat model.

BACKGROUND: Glove powder is used as a lubricant on the inner surface of many surgical gloves to aid in donning. Although surgeons routinely wash or wipe their gloves to remove the powder, studies in patients have shown that, at the conclusion of operations in which powdered gloves have been used, the wound retains a substantial amount of residual powder granules. Furthermore, the amount of residual granules is in proportion to the number of gloves that the operating room staff wear. We determined whether glove powder in combination with Staphylococcus aureus when injected into the subcutaneous tissue of the dorsum of the rat would potentiate abscess formation. METHODS: We combined methicillin-susceptible S. aureus (MSSA) in concentrations of 0, 10(2), 10(3), 10(4), and 10(5) colony forming units (cfu)/mL and starch powder in concentrations of 0, 10, 50, and 100 mg/mL and injected the inoculum into each flank of 105 Sprague-Dawley rats. Animals were euthanized 7 to 10 days after inoculation and examined for signs of abscess formation. Wounds were cultured to verify S. aureus as the causative organism. RESULTS: No abscesses formed in our control animals (sterile inoculum). Increasing concentrations of MSSA and increasing starch powder led to more-frequent abscess formation. The presence of high concentration of starch (100 mg/mL) decreased the inoculum of bacteria needed to produce an abscess from 10(4) to 10(2) cfu/mL. The presence of starch, regardless of concentration, increased the likelihood of abscess formation in the presence of bacteria (odds ratio = 1.8, 95% confidence interval = 1.06, 2.57). CONCLUSION: Surgical glove power reduces the inoculum of bacteria needed to produce an abscess and increases the likelihood of abscess formation in Sprague-Dawley rats.

Definitive risk factors for anastomotic leaks in elective open colorectal resection.

HYPOTHESIS: Anastomotic leaks following elective colorectal resections increase morbidity, mortality, and the need for additional interventions. An accurate understanding of risk factors would potentially reduce anastomotic leaks and/or allow appropriate selection of patients for diverting stomas. DESIGN: Prospective review of patient and operative characteristics that contribute to anastomotic leaks. SETTING: Fifty-one sites within the United States (May 2002-March 2005). PATIENTS: Six hundred seventy-two patients who participated in a trial comparing preoperative antimicrobials in elective open colorectal surgery. MAIN OUTCOME MEASURES: Anastomotic leaks were diagnosed using clinical findings and were confirmed with imaging. We examined 20 variables possibly affecting anastomotic healing in univariate and multivariate analyses. RESULTS: There were 24 anastomotic leaks in 672 patients (3.6%) undergoing elective colorectal resection. There were 10 deaths (1.5%). A baseline albumin level of less than 3.5 g/dL (to convert to grams per liter, multiply by 10) (P = .04) and male sex (P = .03) were associated with anastomotic leaks in both univariate and multivariate analyses (adjusted odds ratios, 2.56 and 3.12, respectively). Increased duration of surgery (SD, 60 minutes; odds ratio, 1.53; 95% confidence interval, 1.06-2.22; P = .03) and steroid use at the time of surgery (odds ratio, 3.85; 95% confidence interval, 1.24-11.93; P = .02) were significant in univariate analysis. Surgical procedure with rectal resection; prophylaxis with ertapenem (vs cefotetan); or history of obesity, tobacco use, or diabetes was not associated with anastomotic leaks. CONCLUSIONS: Significant risk factors for anastomotic leaks include low preoperative serum albumin level, steroid use, male sex, and increased duration of surgery. Appreciation of risk factors provides a rational basis for temporary diversion.

Concordance of interrater assessments of surgical methods to achieve source control of intra-abdominal infections.

BACKGROUND: Source control, any procedure used to control the source of a major infection, is critical to the resolution of intra-abdominal infections. We sought to characterize whether surgeons agree on methods of source control for patients who had persistent infection despite initial surgical treatment and antimicrobials. METHODS: We analyzed source control decisions in a trial comparing tigecycline with imipenem in the treatment of intra-abdominal infections for patients who were clinical failures and had persistent abdominal infections after treatment with antibiotics and undergoing source control. RESULTS: We found that source control agreement was least among patients who had Acute Physiology and Chronic Health Evaluation (APACHE) II scores greater than 15 (kappa = -.17, P = .533) and those with complicated appendicitis (kappa = .08, P = .446). There was excellent agreement in the source control decisions for perforation (kappa = .76, P = 0.002) and diverticulitis (kappa = 1.00, P = .005). CONCLUSIONS: Agreement on source control is lacking on more severely ill patients and those with complicated appendicitis. These data should be used to seek optimal management for these conditions and to minimize variability in future clinical trials of intra-abdominal infection.

Increased endovascular interventions decrease the rate of lower limb artery bypass operations without an increase in major amputation rate.

Progression of peripheral vascular disease may lead to major amputations. We sought to understand whether more frequent endovascular angioplasty and stenting in patients with limb-threatening ischemia would affect the number of major amputations. We retrospectively reviewed the effects of implementing more frequent endovascular intervention for the 4 years 2003-2006 at the Veterans Affairs Medical Center in Long Beach, California. During this interval angioplasty became the preferred method for the treatment of infrainguinal vascular disease. Open bypass procedures were performed for patients with limb-threatening ischemia and extensive lesions that could not be treated by angioplasty. Patients were on average 68 +/- 1 years, and 96% were male. The patients were 45% active smokers, with 43% diabetics. There was 0% 30-day mortality for both groups over the 4 years. the number of below-the-knee, above-the-knee, and transmetatarsal amputations for fiscal years 2003, 2004, 2005, and 2006 were, 42, 50, 62, and 41, respectively. Concurrently, there has been a reduction in open femoral to popliteal or trifurcation vessel bypasses with 37, 43, 28, and 14 procedures for 2003, 2004, 2005, and 2006. Angioplasty and stenting increased from 12, 12, 24, to 59 over the same period. Patients who had a femoral to distal bypass were more likely to have an amputation than those undergoing angioplasty (odds ratio = 4.2, 95% confidence interval 1.6-11.5) for those with at least 1 year of follow-up, likely due to these patients having more severe disease. Increasing the frequency of angioplasty for infrainguinal vascular lesions did not increase the number of major lower extremity amputations in our stable patient population.

Strategies for management of ischemic steal syndrome.

Constructing vascular access for hemodialysis causes changes in blood flow to the extremity, which can lead to distal ischemia. Ischemic steal syndrome is manifested by pain; weakness; pallor; and, in severe cases, ulceration and tissue loss. Severe ischemia, requiring reintervention, has an incidence of 4%, although some degree of ischemia causing pain or parasthesias occurs in 10% to 20% of patients following access construction. Pathophysiology may be on the basis of inadequate arterial collateral inflow due to occlusive disease, particularly involving the medium-sized vessels, or high flow in a fistula exceeding the inflow capacity in the absence of intrinsic occlusive disease of the inflow arteries. Predicting steal remains difficult, although certain patient characteristics and preoperative techniques can help identify those patients in whom arteriovenous fistulas have an increased risk of causing steal. Patients with diabetes, multiple access procedures, and constructions based on proximal arteries are more prone to ischemia. Ultrasonography and digital-brachial indices measured by photoplethysmography or Doppler techniques have been used to predict fistulas that are more likely to cause ischemia, but these fall short of reliability. Operative techniques for correcting steal include arteriovenous fistula ligation, percutaneous transluminal angioplasty, banding or restrictive procedures, and distal revascularization interval ligation or modifications of this technique. Operative intervention for ischemic steal syndrome successfully resolves ischemia in 80% to 95% of patients. Some patients can have persistent pain despite healing of ulceration.

Sperm granuloma of the inguinal vas deferens mimicking recurrent incarcerated inguinal hernia.

Masses of the spermatic cord are rare and can be neoplastic or inflammatory lesions. We present a case of a sperm granuloma of the inguinal vas deferens presenting as a recurrent incarcerated inguinal hernia in a 42-year-old man.