Is there a need for postoperative surveillance after day case groin surgery in children?

There is increasing awareness of the value of day case paediatric surgery in fulfilling the needs of the community. Is this cost effective, are there hidden complications and is there a need for routine follow-up? Seven hundred and thirty-one children attending the Red Cross War Memorial Children's Hospital day surgery unit over a 32-month period, and undergoing 912 procedures confined to the inguinoscrotal region, were enrolled in the study. Surgical procedures performed included inguinal herniotomy, orchidopexy and circumcision. Of the 731 children, 159 consecutive children had their inguinal and perineal skin flora analysed preoperatively and in 59 of these children three skin swabs were taken from the groin area: before routine skin preparation for surgery, after the skin preparation and on completion of the operation. Staphylococcus epidermidis predominated as the normal skin flora (70%), followed by Escherichia coli (19%) and Proteus mirabilis (10%), while S. aureus was only found in 2.5% of cases. The efficacy of cleaning with 4% chlorhexidine and 2% povidone-iodine in 70% alcohol is shown by virtual complete eradication of the organisms isolated from the preoperative skin cultures. In only 2 cases (3.4%) were organisms (S. aureus and S. epidermidis respectively) isolated following skin preparation. Cultures taken at the end of operative procedures grew predominantly S. epidermidis (5 cases, 8.5%). Children were discharged from the day unit once they had taken fluids and had passed urine. The wounds were also checked for any evidence of bleeding. Follow-up was done 2 weeks later by means of a visit to the day unit where the same surgeon assessed wound healing according to the Southampton Wound Assessment Scale. Ninety-four per cent of the wounds had healed by primary intention; 4.5% had minor complications and 1.5% had septic complications. Our trial confirms that wound sepsis is an infrequent but significant complication of day case groin surgery. Routine follow-up by surgical day units of minor surgical cases is not warranted and will incur unnecessary cost. Only 1.5% of postoperative cases will require further medical attention and septic lesions in the lymphatic drainage area should be regarded as risk factors.

Cooling the burn wound: evaluation of different modalites.

A study was undertaken to investigate the cooling and healing effect of different modalities: Melaleuca Alternifolia Hydrogel (Levtrade International (Pty) Ltd.) was compared with tap water as a coolant following application onto a fresh deep partial thickness hot water burn in a porcine model. Four identical circular scalds were created on the backs of 10 pigs. One wound was not treated and served as a control. The other 3 wounds were either cooled with tap water (15 degrees C) or had Melaleuca Hydrogel dressing applied immediately, or after a 30 min delay. Intradermal temperatures were monitored in all wounds: preburn, during the burn and at regular intervals for 1 h. The wounds were biopsied for histological assessment. These samples were repeated at 24 h and 3 weeks. The mean decrease in final temperature at 1 h was in comparison to the preburn temperature; control +0.44 degrees C (i.e. a temperature increase); water -7.82 degrees C; Melaleuca Hydrogel -3.87 degrees C; Melaleuca Hydrogel after 30 min delay -2.67 degrees C. Clinical and histological assessment at 21 days indicated more rapid healing in both the Melaleuca Hydrogel and water-cooled burns compared with the untreated controls. Effective cooling of the burn wound and an increased rate of wound healing was achieved by both repeated tap water compresses and by immediate or delayed application of Melaleuca Hydrogel. Cooling is an effective means to reduce tissue damage and increase wound healing.

Perianal candidosis--a comparative study with mupirocin and nystatin.

OBJECTIVE: To assess the efficacy and clinical outcome of 2% mupirocin in a polyethylene glycol base and nystatin cream as treatment regimens in diaper candidosis. DESIGN: A prospective randomized comparative study. METHODS: In vitro. The susceptibility of 20 clinical isolates of Candida albicans to 2% mupirocin, nystatin, and five additional antifungal agents was evaluated using the Nathan agar-well diffusion assay. The minimum inhibitory concentration (MIC) of mupirocin against the Candida species was determined using a tube dilution method. In vivo. Twenty patients (mean age, 12 months; range, 1 month to 4 years) with moderate to severe Monilia diaper dermatitis either had mupirocin ointment or nystatin cream applied to the infected area every 8 h or after every diaper change for a period of 7 days. Microscopic examination of skin scrapings and mycologic and microbiological cultures were performed before treatment and daily for 7 days, and progress was clinically assessed. RESULTS: In vitro. Topical mupirocin produced a greater zone of inhibition than nystatin cream, i.e. a mean of 27.2 mm (SD 1.55) compared with a mean of 17.3 mm (SD 1.08) for nystatin cream. MIC for mupirocin of 512 microg/mL in one case, 256 microg/mL in six cases, 200 microg/mL in 10 cases and 400 microg/mL in three cases were obtained for the 20 clinical isolates. C. albicans also displayed a universal sensitivity to mupirocin and nystatin. In vivo. Eradication of all Candida organisms was achieved within 2-6 days (mean, 2.6 days) in 10 patients receiving topical mupirocin therapy with rapid healing of the excoriated wounds (mean, 4.7 days). Both Gram-positive and Gram-negative bacteria were eradicated from the infected area within the trial period. Ten patients received topical nystatin cream and, in each case, Candida was successfully cleared within 5 days (mean, 2.8 days). Only three wounds were clinically healed within the trial period, however. The remaining seven wounds showed evidence of improved, but ongoing excoriated dermatitis and a heavy growth of polymicrobial organisms. CONCLUSIONS: Both agents eradicated Candida, the major difference being the marked response of the diaper dermatitis to mupirocin. Mupirocin should be applied topically 3-4 times daily or with each diaper change and is an excellent antifungal agent.

Early detection of poor fetal prognosis by serial Doppler velocimetry in high-risk pregnancies.

Fifty-three high-risk pregnancies were followed up serially with Doppler velocimetry of the umbilical artery and uterine vessels from early on to investigate whether abnormalities in Doppler waveforms can predict the outcome of pregnancy accurately before other clinical signs develop. Results of Doppler velocimetry were withheld from the clinicians managing the patients. When the absence of end-diastolic velocities was first detected (in 13 fetuses) (AEDV group) there was no clinical difference between these pregnancies and those in which end-diastolic velocities were present (EDV group). Nine of the 13 fetuses with AEDVs died, compared with 3 of 40 with EDVs (P less than 0.0001). In deaths associated with AEDVs, the latter were detected a median of 5.5 (range 3-11) weeks before death and are present from the first Doppler examination. In the 4 fetuses with AEDVs that survived, the AEDVs were not persistent. The only significant association of Doppler velocimetry of the uterine vessels was with proteinuric hypertension (P less than 0.05), but the prediction was not strong enough to be of clinical value. Persistent AEDVs of the umbilical artery are an accurate predictor of poor fetal outcome and occur before other clinical signs of impending problems.

Microcirculation of the rat omentum studied by means of corrosion casts.

A study of the microvasculature of the omentum using corrosion casts was undertaken. The object was to supply information regarding the morphology of the three-dimensional structure of the microvasculature, information which may be valuable in understanding the functions of the omentum. Corrosion casts of rat omenta were prepared and studied. Characteristic glomerular-like capillary beds were identified. Some of these beds were densely and others loosely arranged. Two types of capillaries made up these beds, tortuous and straight capillaries. These beds also showed a planate surface giving the impression that they lie directly under the mesothelium.

Bactericidal efficacy of 5 per cent povidone iodine cream in Pseudomonas aeruginosa burn wound infection.

A new topical antiseptic agent, 5 per cent polyvinylpyrrolidone-iodine (PVP-I) cream, with altered physicochemical properties, incorporated in a different carrier base has proved in vivo to be more effective in controlling burn wound infections than 10 per cent PVP-I ointment. Important biodynamic properties of the new formulation have not, however, been elucidated in vivo. Hence the need for a controlled study to evaluate the bioavailability of the active component after penetration through burn eschar; the bactericidal efficacy of the cream and determination of the bactericidal time of the cream in comparison with 10 per cent PVP-I ointment. A modified Walker burn wound model was used to define the rate of trans-eschar penetration, biodynamic availability and bactericidal efficacy of 5 per cent povidone iodine cream in established Pseudomonas aeruginosa burn wound infection. In vitro penetration confirmed the effective diffusion of PVP-I cream through 1.5 mm eschar within 6 h. A single topical application of PVP-I cream resulted in a 98.8 per cent (6.088 x 10(9) c.f.u./g of tissue to 7.367 x 10(7) c.f.u./g of tissue) reduction in intra-eschar viable organisms within 18 h after application. A second topical application of PVP-I cream at 18 h resulted in a total reduction of 99.8 per cent in viable organisms (2.90 x 10(9) c.f.u./g of tissue to 7.009 x 10(6) c.f.u./g of tissue) within 48 h. Comparing the in vitro bactericidal time of povidone iodine ointment with cream against Pseudomonas aeruginosa, Staphylococcus aureus and a Klebsiella pneumoniae revealed that the PVP-I cream killed organisms ten-fold more quickly than the ointment.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiology of the brain of the baboon Papio ursinus, the vervet monkey Cercopithecus pygerithrus, and the bushbaby Galago senegalensis.

The investigation was undertaken to compare the blood supply and venous drainage of the brain of the baboon P. ursinus, the vervet monkey C. pygerithrus, and the bushbaby G. senegalensis with that of man, because these animals are extensively used as research models. The blood supply of the three primates was found to be similar in each case. Like man they have a complete circulus arteriosus; but they have a single anterior cerebral artery, whereas man has paired anterior cerebral arteries. The arterial supply to the cerebellum in the primates is similar to that in man, the main difference being a "common inferior cerebellar artery" which bifurcates to form the anterior inferior cerebellar and posterior inferior cerebellar arteries. In man, these arteries arise separately from the basilar artery and vertebral arteries, respectively. The dural venous drainage was also found to be similar in these primates but was far more extensive than in man. The primates have additional sinuses--the more important of these being the "basisphenoid sinus" and the petrosquamous sinus. The former drains the basilar sinus and is itself drained via the vertebral venous plexus and internal jugular vein. The latter drains via the petrosquamous foramen into the retromandibular vein. The petrosquamous sinus has a rostral extension which drains through the foramen ovale and two lateral and medial connecting sinuses which drain the cavernous and basilar sinuses, respectively. These sinuses are not found in man.

Efficacy of mupirocin in methicillin-resistant Staphylococcus aureus burn wound infection.

Methicillin-resistant Staphylococcus aureus strains (MRSA) have become increasingly prevalent as nosocomial pathogens, especially in burn wounds. MRSA constituted 38% of all S. aureus isolates in our 25-bed burns unit despite the utilization of a combination of 1% silver sulfadiazine and 0.2% chlorhexidine as topical therapy. Mupirocin, a new antibiotic, has proved in vitro and in vivo to be highly effective in the treatment of MRSA infections. A prospective clinical trial with mupirocin ointment in MRSA burn wound infection was untertaken. Forty-five children with 59 discrete burn wounds and from whom MRSA were isolated were treated with 2% mupirocin ointment under occlusive dressings, applied twice daily for 5 days. The average burned area treated was 8% (range, 2 to 20%) of the total body surface area. The burn wounds were assessed clinically and bacteriologically daily. Mupirocin eliminated MRSA in all 59 wounds treated, with the maximum therapeutic response seen within 4 days. In three wounds, gram-negative organisms persisted after 5 days of topical therapy. Treatment was well tolerated by all children. We recommend that mupirocin in its present polyethylene glycol base should be used only on a selective basis, when current prophylactic topical therapy has failed to control MRSA infection in burns of less than 20% of the total body surface area, and that it should be applied only for a limited period of 5 days. The safety and the efficacy of mupirocin in burns exceeding 20% of the total body surface area need to be established.

Bactericidal efficacy of mupirocin in multi-antibiotic resistant Staphylococcus aureus burn wound infection.

Methicillin resistant Staphylococcus aureus strains (MRSA) have become increasingly prevalent as pathogenic organisms, especially in burn wounds, with an associated mortality of 20-40% among those clinically infected. Mupirocin ointment, a new topical antibiotic, has proved in vitro and in vivo to be highly effective in the treatment of MRSA infections. A modified Walker burn wound model was used to define the rate of trans-eschar penetration, biodynamic availability and bactericidal efficacy of 2% mupirocin ointment in established MRSA burn wound infection. In-vitro penetration trials confirmed the effective diffusion of mupirocin through 1.5 mm eschar within 2 h. A single topical application of mupirocin resulted in a 98.3% (5.67 x 10(8) cfu/g of tissue--1.0 x 10(7) cfu/g of tissue) reduction in intra-eschar viable organisms within 36 h post application. A second topical application of mupirocin at 24 h resulted in a total reduction of 99.6% in viable intra-eschar organisms (1.85 x 10(8) cfu/gram of tissue--6.76 x 10(5) cfu/g of tissue). It is concluded that mupirocin is highly effective in controlling MRSA burn wound infection and should be applied topically every 24 h.

Toxicity of Diplodia maydis in farm and laboratory animals.

The acute toxicity of maize culture material of eight strains of Diplodia maydis in ducklings, as well as the ability of five of these strains to induce typical diplodiosis (a neuromuscular disease) in cattle and sheep was shown. Typical diplodiosis was induced in 17 sheep and 11 cattle. Two of the five toxic strains were isolated from maize involved in diploidiosis outbreaks, the others from commercial maize. Strains inducing diplodiosis could be isolated from commercial maize from the USA, Argentina and South Africa. There was no correlation between the toxicity of D. maydis strains in ducklings and their ability to induce diplodiosis in cattle and sheep. Some isolates were acutely toxic to ducklings and rats but were unable to induce diplodiosis in either cattle or sheep. Others, equally toxic to ducklings and rats, induced diplodiosis in cattle and sheep at low dose levels. Two doses, each of 5 g/kg, of maize culture material of isolates from the USA, Argentina and South Africa induced diplodiosis in sheep. Culture material incubated for less than 8 wk could not induce diplodiosis in cattle. Acute toxicity in ducklings and rats also increased with longer incubation periods. Cultures of non-sporulating and profusely sporulating strains were equally toxic to ducklings. Heat treatment of culture material for 48 days at 45 degrees C failed to reduce toxicity in ducklings.

The ultrastructure of the 'peripheral resistance' and the precapillary sphincters.

The vascularization of the primary somaesthetic cortex of the albino rat was studied by snap-fixing of the vessels with a constant infusion of glutaraldehyde through the left ventricle of the heart, followed by injection of a resin under a constant pressure and flow rate directly into the aorta. The vibrissae on one side were stimulated both before and during the fixing procedure. Specimens of the appropriate area of the cortex were taken and treated for viewing by scanning electron microscopy. The apparent morphological changes are described and illustrated by micrographs.

Surgical approach to the rostral cranial fossa by radical transfrontal craniotomy in the dog.

To overcome the problems of restricted visibility and surgical mobility, as well as those posed by anatomical features oif the canine subfrontal sinus region and associated dura mater, aggravated by hazards of infection from potentially infected frontal sinuses, of uncontrollable haemorrhage and post-operative brain compression, a radical approach was devised, combining invasion of the frontal sinus with a lateral rostrotentorial craniotomy. This offers adequate surgical manoeuvring space, excellent visualisation of the rostral cranial fossa and its contents, proper asepsis, minimal haemorrhage and no untoward after-effects. The technique lends itself to diverse neurosurgical applications in the rostral cranial fossa of the dog. Particulars of instrumentation, and pre-operative, operative and post-operative procedures, done on 3 Beagles with excellent results, are described.

Procedures and modifications for reliable use of the unidirectional microflow respirator in the investigation of the carotid body of Gallus domesticus.

An artificial respirator was used to ensure successful and precise artificial respiration in short and long term experiments during radical exposure of the caudal cervical region and thoracic cavity to investigate cytological changes in the carotid body of mature chickens (Gallus domesticus). Modification of the respirator to stabilize gas flow, temperature and humidity consisted of replacing the ball check valve in the heating and humidifying cylinder with a fine regulating stopcock in the water outlet of the cylinder and inserting eight glass rods in a circle inside the cylinder. Accumulation of water condensate in the trachea and lungs during long term experiments was prevented by inserting a cotton filter moisture trap in the tracheal cannula.

An experimental evaluation of the germicidal efficacy of three topical antimicrobial agents in burns.

The bacteriocidal effect of three substances is discussed: 10% povidone iodine ointment (Betadine, betaisodona), 11,2% mafenide acetate (Naplatan) and silver sulphadiazine (Flamazine, Silvadene, Silvertone). A modified Walker burn model using male Long-Evans rats was studied. The infections were produced with a solution of 3 times 10(8) Pseudomonas aeruginosa pyocin type H. organisms. The authors described the pharmacological properties of the three substances and report the following results. All three substances are able to penetrate third degree burns. It takes 4 hours for povidone iodone, 12 for mafenide acetate and 24 for silver sulphadiazine to penetrate the burn. Mafenide acetate and silver sulphadiazine were the most useful agents after 12 and 24 hours respectively. When the substances were applied for a second time 24 hours after the first application only mafenide acetate was highly effective. The effectiveness of povidone iodine and silver sulphadiazine decreased by half when compared with the first application. For practical purposes the following recommendations are made: For deep burns povidone iodine should be applied every 4--6 hours, mafenide acetate every 12--18 hours and silver sulphadiazine once every 24 hours in order to ensure an antibacterial effect.

The determination of total cholinesterase in rectal biopsy tissue from patients with Hirschsprung's disease.

A spectrophotometric method is described for the quantitative biochemical assay of total cholinesterase in rectal biopsy tissue. Significantly increased enzyme activity was found in this tissue from patients with Hirschsprung's disease, suggesting that the assay has diagnostic value.