Outcomes-based systematic review for management of massive intra-cardiac or pulmonary thrombotic emboli during surgery.

INTRODUCTION: The management of massive intra-operative embolism remains controversial. Our hypothesis was that either surgical or medical thrombectomy offers survival benefit in these patients. METHODS: Published case reports were reviewed for intra-operative intra-cardiac or pulmonary embolism and outcomes for the following four intervention groups were evaluated for mortality benefit: surgical embolectomy; thrombolysis; anticoagulation; supportive care alone. We also assessed whether the use of diagnostic modalities prior to each embolism event resulted in a mortality benefit and, separately, whether post-intervention improvement in physiologic parameters resulted in improvement in outcomes. Univariate analyses and logistic regression were performed to assess the impact of the four primary interventions on mortality, the primary outcome. RESULTS: Seventy-eight cases were reviewed and therapeutic interventions resulted in improved survival (70%) compared to supportive care (45%), odds ratio=0.38[0.15-0.98], p=0.04. Univariate analysis of primary interventions with death as a primary outcome resulted in a lack of significantly different outcomes (p=0.08). Mortality rates were 71% in the thrombolytic; 28% in surgical embolectomy; 18% in anticoagulation and 43% in the supportive care groups. The routine pre-event use of trans-esophageal echocardiography was not related with improved outcomes (p=0.36) but the use of pulmonary artery or central venous catheters was (p=0.035). Post-intervention improvements in the physiologic parameters of each diagnostic modality were associated with an improvement in mortality (p<0.05). CONCLUSIONS: Our data present some important trends among the intervention groups, raising significant concerns about the safety for the use of thrombolytics in the management of intra-operative embolism.

[An epidemic of acute enterocolitis caused by enterotoxigenic Escherichia coli]. / Epidemija akutnog enterokolitisa izazvana enterotoksigenom eserihijom koli.

In an epidemic of enterocolitis on a military ship which lasted two days, 13 (54%) out of 24 soldiers became ill. The clinical picture was mild with predomination of diarrhoea and abdominal pain, and the troubles in all ill persons ended within 48 hours with administration of symptomatic therapy. Since routinely examined causative agents of infectious diseases were not detected, detailed examination of 13 Escherichia coli strains isolated from stools of the ill persons as well as 8 strains from stools of healthy but exposed soldiers, revealed that 7 of them produced enterotoxins; 5 strains produced heat-labile (LT) and heat-stabile (ST) enterotoxins, and 2 strains ST only. Enterotoxigenic strains were isolated from stools of 5 (38.5%) ill persons and 2 (25%) healthy persons. According to epidemiological investigations, infection was transmitted by secondary contaminated food due to its mishandling. The presented results prove that enterotoxigenic E. coli play a role as a causative agent in epidemics of acute enterocolitis in adults.