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.

A compartmental model of uranium in human hair for protracted ingestion of natural uranium in drinking water.

To predict uranium in human hair due to chronic exposure through drinking water, a compartment representing human hair was added into the uranium biokinetic model developed by the International Commission on Radiological Protection (ICRP). The hair compartmental model was used to predict uranium excretion in human hair as a bioassay indicator due to elevated uranium intakes. Two excretion pathways, one starting from the compartment of plasma and the other from the compartment of intermediate turnover soft tissue, are assumed to transfer uranium to the compartment of hair. The transfer rate was determined from reported uranium contents in urine and in hair, taking into account the hair growth rate of 0.1 g d(-1). The fractional absorption in the gastrointestinal tract of 0.6% was found to fit best to describe the measured uranium levels among the users of drilled wells in Finland. The ingestion dose coefficient for (238)U, which includes its progeny of (234)Th, (234m)Pa, and (234)Pa, was calculated equal to 1.3 x 10(-8) Sv Bq(-1) according to the hair compartmental model. This estimate is smaller than the value of 4.5 x 10(-8) Sv Bq(-1) published by ICRP for the members of the public. In this new model, excretion of uranium through urine is better represented when excretion to the hair compartment is accounted for and hair analysis can provide a means for assessing the internal body burden of uranium. The model is applicable for chronic exposure as well as for an acute exposure incident. In the latter case, the hair sample can be collected and analyzed even several days after the incident, whereas urinalysis requires sample collection shortly after the exposure. The model developed in this study applies to ingestion intakes of uranium.

Improvements in routine internal monitoring--an overview of the IDEA project.

The IDEA project aimed to improve the assessment of incorporated radionuclides through developments of advanced in vivo and bioassay monitoring techniques and making use of such enhancements for improvements in routine monitoring. Many of these findings are not new in the sense that they are being already employed in advanced laboratories or for specialised applications. The primary goal was to categorise those new developments regarding their potential and eligibility for the routine monitoring community. Attention has been given to in vivo monitoring techniques with respect to detector characteristics and measurement geometry to improve measurement efficiency with special attention to low energy gamma emitters. Calibration-specifically supported by or through methods of numerical simulation-have been carefully analysed to reduce overall measurement uncertainties and explore ways to accommodate the individual variability based on characteristic features of a given person. For bioassay measurements at low detection limits, inductively coupled plasma mass spectroscopy offers significant advantages both in accuracy, speed, and sample preparation. Specifically, the determination of U and Th in urine and the associated models have been investigated. Finally, the scientific achievements have been analysed regarding their potential to offer benefits for routine monitoring. These findings will be presented in greater detail in other papers at this conference, whereas this paper intends to give an overview and put both the scientific achievements as well as the derived benefits into perspective.

Potential of modern technologies for improvement of in vivo calibration.

In the frame of IDEA project, a research programme has been carried out to study the potential of the reconstruction of numerical anthropomorphic phantoms based on personal physiological data obtained by computed tomography (CT) and Magnetic Resonance Imaging (MRI) for calibration in in vivo monitoring. As a result, new procedures have been developed taking advantage of recent progress in image processing codes that allow, after scanning and rapidly reconstructing a realistic voxel phantom, to convert the whole measurement geometry into computer file to be used on line for MCNP (Monte Carlo N-Particule code) calculations. The present paper overviews the major abilities of the OEDIPE software studies made in the frame of the IDEA project, on the examples of calibration for lung monitoring as well as whole body counting of a real patient.

Biokinetic modelling of natural thorium in humans by ingestion.

The retention of naturally occurring thorium (228Th, 230Th, 232Th) in model compartments and its daily urinary and faecal excretion after acute and chronic injections and ingestions were calculated for male and female subjects of six age groups based on the current age-dependent biokinetic model for thorium (Th) recommended by the International Commission on Radiological Protection (ICRP). The results are tabulated in a database. The calculated contents of 228,230,232Th in organs or tissues using their reference concentrations in foodstuffs for the European population are compared with autopsy data. The model prediction of 232Th in whole body for a 50-year-old unexposed person is 22 mBq, 86% of that in skeleton, 9.7% in other soft tissues, 3.4% in liver, 0.7% in kidneys and 0.01% in blood. The modelling predicts lower contents of the natural Th isotopes in whole body, especially in blood compared with measured data for the unexposed public. Modelled 232Th daily urinary excretions are 5 to 10 times less than bio-assay data from the authors' own laboratory.

Implementation of bioassay methods to improve assessment of incorporated radionuclides.

The present work which was carried out in the framework of an EU project (IDEA: Internal Dosimetry-Enhancements in Application; Contract Number: FIKR CT2001 00164) shall provide commonly acceptable guidelines for optimum performance of ICP-MS measurements with focus on urinary measurements of uranium, thorium and actinides. From the results of this work it is recommended that, whenever feasible, 24 h urine sampling should be conducted to avoid large uncertainties in the quantitation of daily urinary excretion values. For storage, urine samples should be acidified and kept frozen before analysis. Measurement of total uranium in urine by ICP-MS at physiological levels (<10 ng.l(-1)) requires no sample preparation besides UV photolysis and/or dilution. For the measurement of thorium in urine by ICP-MS, it can be concluded, that salt removal from the urine samples is not recommended. For the measurement of actinides in urine it is shown that ICP-MS is well-suited and a good alternative to alpha-spectrometry for isotopes with T1/2>5x10(4) years. In general, ICP-MS measurements are an easy, fast and cost-saving methodology. New improved measuring techniques (HR-SF-ICP-MS) with detection limits in urine of 150 pg.l(-1) (1.9 microBq.l(-1)) for 238U, 30 pg.l(-1) (2.4 microBq.l(-1)) for 235U and 100 pg.l(-1) (0.4 microBq.l(-1)) for (232)Th, respectively, meet all necessary requirements. This method should therefore become the routine technique for incorporation monitoring of workers and of members of the general public, in particular for uranium contamination.

Practical implications of procedures developed in IDEA project--comparison with traditional methods.

The idea of the IDEA project aimed to improve assessment of incorporated radionuclides through developments of more reliable and possibly faster in vivo and bioassay monitoring techniques and making use of such enhancements for improvements in routine monitoring. In direct in vivo monitoring technique the optimum choice of the detectors to be applied for different monitoring tasks has been investigated in terms of material, size and background in order to improve conditions namely to increase counting efficiency and reduce background. Detailed studies have been performed to investigate the manifold advantageous applications and capabilities of numerical simulation method for the calibration and optimisation of in vivo counting systems. This calibration method can be advantageously applied especially in the measurement of low-energy photon emitting radionuclides, where individual variability is a significant source of uncertainty. In bioassay measurements the use of inductively coupled plasma mass spectrometry (ICP-MS) can improve considerably both the measurement speed and the lower limit of detection currently achievable with alpha spectrometry for long-lived radionuclides. The work carried out in this project provided detailed guidelines for optimum performance of the technique of ICP-MS applied mainly for the determination of uranium and thorium nuclides in the urine including sampling procedure, operational parameters of the instruments and interpretation of the measured data. The paper demonstrates the main advantages of investigated techniques in comparison with the performances of methods commonly applied in routine monitoring practice.

Overview of active personal dosemeters for individual monitoring in the European Union.

In 2001, the European Radiation Dosimetry Group, EURADOS, started a working group on 'Harmonisation of Individual Monitoring in Europe and the Dissemination of Information on New Techniques in this Field'. Within this group, one of the projects consisted of analysing the status of active personal dosemeters (APDs) in Europe. This paper reviews the regulatory requirements for APDs in 15 EU member states and summarises the main characteristics of commercial and new developments in this field. In particular, it focuses on the comparison of APD performance and standard passive dosimetry systems. Based on this information, an evaluation is initiated to establish why several countries are reluctant to accept APDs for dose records.

Aspects of harmonisation of individual monitoring for external radiation in Europe: conclusions of a EURADOS action.

Following the publication of the EU Council Directive 96/29, EURADOS coordinated two working groups (WGs) for promoting the process of harmonisation on individual monitoring of occupationally exposed persons in Europe. An overview of the major findings of the second WG is presented. Information on the technical and quality standards and on the accreditation and approval procedures has been compiled. The catalogue of dosimetric services has been updated and extended. An overview of national regulations and standards for protection from radon and other natural sources in workplaces has been made, attempting to combine the results from individual monitoring for external, internal and workplace monitoring. A first status description of the active personal dosemeters, including legislative and technical information, and their implementation has been made. The importance of practical factors on the uncertainty in the dose measurement has been estimated. Even if a big progress has been made towards harmonisation, there is still work to be done.

Active personal dosemeters for individual monitoring and other new developments.

In this paper, we will present a first (but not complete) status description of active personal dosemeters (APDs) and their implementation in European countries. In modern radiation protection practices, APDs are becoming absolutely necessary operational tools for satisfying the ALARA principle. Despite their success, they are relatively new for individual monitoring of workers. Regulation, legal requirements and calibration procedures are different in European member states. A catalogue of commercially available and prototype devices is presented. Improvement on devices and in implementation of calibration method are expected in the forthcoming years. End-user feedback experience and requirements are reported.

Developments in internal monitoring techniques.

In an effort to increase accuracy and speed, improve detection limits and reduce uncertainties in internal dosimetry, laboratories have developed improved or new internal monitoring techniques in both in vivo measurements and bioassay analyses. Most of these techniques have not yet entered routine monitoring programmes. This paper intends to summarise these new techniques, show their potential improvements compared to the currently employed monitoring routines and discuss the main aspects of the EC-funded IDEA project, which aims at a comprehensive assessment of these techniques and the enhancements necessary to bring them to broader acceptance in the routine monitoring community.

Estimation of human exposure to natural radionuclides using in vivo skull measurements.

In a preliminary study, in vivo skull measurements and in vitro urine measurements of 210Pb and nulU have been performed to find out the individual, chronic exposure to waterborne natural radionuclides of a small group of Finnish people. For their domestic water, the studied individuals use water from drilled wells containing elevated concentrations of natural uranium and its daughter nuclides ((234,235,238)U, 222Rn, (226,228)Ra, 210Po, 210Pb). Enhanced 210Pb and 235U activities were observed in several people. A positive correlation is observed between the U concentration in urine (microg d(-1)) and the number of counts (cpm) in the gamma ray energy peaks originating from the decay of 235U and 234Th respectively. Calibration of the detector set-up and the determination of background sources are in progress.

A three si detector system for personnel neutron dosimetry developed by means of Monte Carlo simulation calculations.

The aim of this study was the development of an electronic detection system for personnel neutron dosimetry. Converter type silicon detectors were used for neutron detection. Measurements to obtain pulse height distributions were performed in neutron fields in the energy range from thermal to 14.8 MeV. They were compared with pulse height distributions calculated by means of Monte Carlo simulation programs, and their shapes and total count responses agreed very well. Based on these calculations a three-detector system for the measurement of the individual dose equivalent, Hp(10), was developed. Response functions of the system were calculated, and their dependence on angles from 0 degrees to 75 degrees was investigated. The detector system was exposed in several neutron fields and the agreement of the determined dose values with the reference dose values (0.1 mSv to 6 mSv) was better than a factor of 2, even for quasi-monoenergetic neutrons, and for angles in the range of 0 degrees, 30 degrees and 60 degrees. The detector system should be able to measure a dose range down to 10 microSv depending on the neutron energy.

Venous thrombosis incidence in burn patients: preliminary results of a prospective study.

There are few prospective data on the incidence of deep venous thrombosis (DVT) in burn patients. In an on-going prospective study, hospitalized burn patients 18 years or older with an expected hospital length of stay more than 72 hours were imaged with baseline venous duplex ultrasound of all extremities within the first 48 hours after admission and weekly until discharge. Patient demographics and clinical risk factors for DVT were assessed. At the time of submission, 40 patients met screening criteria, and 30 were enrolled. Ultrasound diagnosed seven patients with 11 acute DVT for an incidence of 23%. One pulmonary embolism was documented. DVT patients had a mean age of 49 +/- 23 years with an average TBSA burn of 15 +/- 4% compared with those without thrombosis with a mean age of 44 +/- 17 years (P = NS) and TBSA burn of 18 +/- 25% (P = NS). There were no statistically significant differences for DVT patients in terms of age, number of central line days, hospital length of stay, or TBSA burned. Given the preliminary findings of this small study, we believe that all hospitalized burn patients are at risk for DVT. On-going investigation will be helpful in defining level of risk and improved prevention strategies for thromboembolic complications in burn patients.

The utility of endovascular stents in the treatment of blunt arterial injuries.

BACKGROUND: The objective of this review is to evaluate our institutional experience with percutaneously placed vascular stents in multiply injured patients with blunt arterial injuries. METHODS: Patients were identified through our trauma registry from 9/95 through 12/99. All injuries were diagnosed by angiography. Palmaz and Wallstent prostheses were used. RESULTS: Six patients had blunt arterial injuries. Age ranged from 20 to 67 years (average, 45). Each patient had one or more stents placed. There were no immediate complications related to stent placement. There were no deaths or complications attributable to stent placement. All of the patients survived to leave the hospital. Follow-up ranged from 1 month to 2 years with no occlusion, stenosis, or stent malfunction. CONCLUSION: The use of interventional angiography and endovascular stenting is safe and efficacious in treating arterial injuries in certain circumstances.

[Status of discontinuity resection in septic diverticular complications. History or a still current procedure?]. / Stellenwert der Diskontinuitätsresektionen bei septischen Divertikelkomplikationen. Historie oder eine weiterhin aktuelle Vorgehensweise?

Primary anastomosis is becoming increasingly favoured because of the shorter hospital stay even in emergency operations on the colon and rectum. This appears entirely justified when an objective of cost-effective medicine has been set. At our hospital between September 1985 and February 1999, 365 patients were operated on because of diverticular disease. The data from 346 of these patients were evaluated. 202 of these cases were elective; 144 were carried out on an emergency or urgent basis. In 223 cases, a primary anastomosis (Stage I and II according to Hinchey) and in 56 patients a double-barreled colostomy with a distal mucus fistula were performed. 57 patients had a too short rectum-sigma stump and were operated in two stages, according to Hartmann. Of 223 patients with a primary anastomosis, 6 (2.7%) developed an insufficiency of the anastomosis, whereby 3 (1.3%) of these patients subsequently died. Of the patients with Hartmann operation, 11 (19.3%) died due to the sequelae of peritonitis and only 2 patients died following insufficiency of the Hartmann's stump. Of the patients with a mucus fistula, 10 patients (17.9%) died as a result of complications of peritonitis. Of the 113 patients (21 died) with a discontinuity resection, 66 (71%) had their colostomy closed. There were no cases of anastomosis insufficiency and no patient died as a result of the colostomy closure. In the interest of the patients in septic diverticulitis the safest surgical procedure, the discontinuity resection, should be chosen.

Potential risk factors for deep venous thrombosis in burn patients.

Risk factors and prophylaxis for prevention of deep venous thrombosis (DVT) and pulmonary embolism remain controversial in burn patients. From January 1996 through June 1999, we reviewed all adult burn patients admitted to our burn center with the in-hospital diagnosis of DVT and assessed each affected patient for DVT risk factors. There were 8 symptomatic DVTs and 2 pulmonary embolisms detected in 327 adult burn patients (2.4% incidence). No DVT patient had the risk factors of morbid obesity, previous DVT, congestive heart failure, or neoplastic disease. One patient was older than 65 years. All of the DVTs occurred in veins draining a burned extremity. Seven of 8 patients had burn wound infections as complications. Burns on the extremity developing the DVT as well as the diagnosis of a burn wound infection were significant risk factors for DVT formation. These findings prompt us to consider routine screening for DVT in burn patients with these risk factors.

Changes in the extracellular matrix of the vein wall--the cause of primary varicosis?

BACKGROUND: Conflicting theories on the development of primary varicosis have led to the molecular biological investigation of the vein wall or, more accurately, of the extracellular matrix. It was the aim of this study to quantify matrix expression and to compare pathological changes in the vein wall with valve-orientated staging of varicosis, in order to determine indicators of the primary cause of varicosis. MATERIALS AND METHODS: Three hundred seventy-two tissue specimens of greater saphenous veins were obtained from 17 patients with varicosities and categorised according to Hach stage and procurement site. The specimens were compared with 36 specimens collected from six patients without varicosities, incubated with fluorescence-stained antibodies for collagen 4, laminin, fibronectin and tenascin prior to being assessed with confocal laser scan microscopy. In addition, 22 vein specimens (16 varicose, 6 normal veins) serving as negative controls were investigated. RESULTS: Image analysis and statistical evaluation showed that compared with normal veins, varicose veins are associated with a significant increase in matrix protein expression for collagen 4, laminin and tenascin. A trend towards an increase in matrix expression was further observed for fibronectin. There was, however, no difference between varicose veins and clinically healthy vein segments inferior to a varicose segment. CONCLUSION: If the findings of the present investigation can be confirmed by other studies, alterations in the vein wall may be regarded as the primary cause of varicosis and valvular insufficiency as the result of these changes.