Hygiene monitoring in a hospital immunohaematological laboratory.

PURPOSE OF THE STUDY: Not only in blood donation services, but also in the immunohaematological laboratory of a hospital including the depository for blood products a hygiene plan must be drawn up and its realization has to be documented. MATERIAL AND METHODS: From 2011 to 2014, some equipment in the depository and in the immunohematological laboratory was microbiologically monitored once a year. The examinations were done by direct contact cultures taken from several places of each device. RESULTS: Most of the devices showed inconspicuous numbers of environmental microorganisms. Sometimes the refrigerators for fresh frozen plasma and a transport container for blood products revealed moderately, the incubator in the laboratory and a transport container for patient blood samples inadequately increased bacterial contamination. CONCLUSION: Microbiological examinations can detect critical points in the immunohaematological laboratory of a hospital. By communicating these results, the staff can be motivated to observe the regulations of the hygiene plan.

Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination (SOD).

OBJECTIVE: To determine the influence of selective oropharyngeal decontamination (SOD) on the rate of colonization and infection of the respiratory tract in intensive care patients requiring mechanical ventilation for more than 4 days. A financial assessment was also performed. DESIGN: Randomized, prospective, controlled study using amphotericin B, colistin sulfate (polymyxin E), and tobramycin applied to the oropharynx and systemic cefotaxime prophylaxis. SETTING: Anesthesiology intensive care unit (ICU) of a 1500-bed hospital. PATIENTS: A total of 88 patients admitted as emergencies and intubated within less than 24 h were enrolled. Fifty-eight patients received SOD and 30 patients served as controls. Randomization was in the proportion of 2 : 1 study patients to controls. INTERVENTIONS: Microbiological samples from the oropharynx and other infected sites were taken at the time of admission, then twice a week and after extubation. MEASUREMENTS AND RESULTS: With the use of SOD, colonization was significantly reduced. Furthermore, the infection rate decreased from 77% in the controls to 22% in the study patients. Staphylococcus aureus was the main potential pathogen causing colonization and pneumonia. Number of days in the ICU, duration of ventilation, and mortality were not significantly decreased. The total cost of antibiotics was reduced. Development of resistance was not observed. CONCLUSIONS: The use of SOD significantly reduced the colonization and pneumonia and the total charge for antibiotics. The length of stay in the ICU, duration of ventilation, and mortality were similar. No resistance was observed. Staphylococcus aureus was selected by SOD in some patients and the clinical relevance needs further observation.

Testicular trauma: potential impact on reproductive function.

PURPOSE: The long-term effects of testicular trauma on reproductive function are unknown. In an effort to define the relationship between testicular injury and fertility in humans, we identified patients with a history of testicular trauma and assessed parameters commonly associated with fertility. MATERIALS AND METHODS: We reviewed 15 patients 23 to 59 years old who underwent immediate exploration after testicular trauma between 1972 and 1991. Of the patients 11 were contacted and 8 returned for prospective followup. Reproductive and sexual histories, physical examination, measurements of serum hormones and antisperm antibodies, semen analysis and scrotal ultrasound were done. RESULTS: Of the 8 patients 1 (13%) achieved and 7 (87%) did not attempt conception. Hormonal status was normal in all 8 patients. Six men had objective evidence of subfertility by semen analysis only, although none had severe oligospermia or asthenospermia and only 1 had severe teratospermia. Five of 9 traumatized testes were atrophic. Interestingly, only 1 patient had antisperm antibodies, the levels of which were probably low enough to be clinically insignificant. CONCLUSIONS: There was definite evidence of subfertility as assessed by abnormal semen analyses and atrophic testes following testicular trauma. However, the subfertility did not appear to be immune mediated nor did the patients present with infertility. Since only 1 patient had severely compromised fertility according to semen analysis we conclude that early repair can help preserve hormonal function as well as fertility.

Lasers in urology.

Laser therapy has many applications in the treatment of urologic diseases. The advantages of laser treatment over conventional techniques are less bleeding and pain and a reduced need for anesthesia. The development of new fibers and right-angle delivery systems allows new applications for laser therapy. We review the current indications, advantages, and disadvantages of using lasers for the management of the various urogenital lesions.

Testicular carcinoma in situ and nonpalpable seminoma eight years after contralateral teratocarcinoma.

A thirty-five-year-old man had invasive seminoma and extensive carcinoma in situ in his remaining testicle eight years after orchiectomy and lymphadenectomy for Stage I teratocarcinoma. Beyond orchiectomy and hormone replacement, suitable treatment for such second neoplasms, which occur in at least 1 percent of patients, is not clear. More work also is needed to determine appropriate follow-up after treatment of the first cancer now that long-term survival of testicular cancer is the rule.

Transcervical resection of uterine myomas with a resectoscope.

As a surgical option, transcervical resection of uterine myomas is in the early stages of development. Although promising and a logical extension of the increasing reliance on hysteroscopy in gynecology, the comparison with the surgical standards of care for myomas (hysterectomy and hysterotomy) remains incomplete. The safety of the procedure, in the hands of a skillful resectionist, should be equivalent to that of a transurethral prostatectomy or bladder tumor resection. Postoperative management remains anecdotal, however, as the value of perioperative antibiotics, uterine stenting, or the administration of hormones to promote uterine healing has not been established.

Erectile impotence: evaluation and management.

Dramatic progress in the understanding and treatment of erectile impotence has occurred over the past decade. Most cases have an organic cause that is related to vascular (arterial or venous) supply, innervation, or the hormonal milieu of the penis. Multifactorial causes of organic impotence are common and include diabetes mellitus, alcoholism, renal failure, and liver failure. Medications may cause impotence by a variety of mechanisms. The history and physical examination, along with simple laboratory tests, are the mainstay of evaluation and may be performed appropriately by family physicians. Successful new forms of nonsurgical treatment include penile self-injection with papaverine (sometimes with phentolamine) and penile-suction devices. Penile prostheses have been improved greatly in recent years. The patient may select among semirigid, multicomponent inflatable, and self-contained inflatable devices. New surgical treatments include penile arterial revascularization (for atherosclerosis) and ligation of the dorsal vein of the penis (for venous leak).

Deaths from urologic injury due to external trauma.

The priority for treatment of a urologic injury in multiple injured patients from external trauma should be determined by the frequency of death from the urologic injury. The medical records of 2,058 patients with urologic injury from external trauma including 214 deaths were reviewed. Four deaths were attributed mainly to the urologic injury; one early in the postinjury period from continued severe hemorrhage from a ruptured kidney managed conservatively and three 6 to 8 weeks after injury from sepsis with a pelvic abscess from a ruptured urethra or bladder. The remaining 210 deaths were attributed to the associated injuries and occurred in the more severely injured older patients compared to the survivors. Death in multiple injured patients was rarely due to the urologic injury.

Utricular papilloma.

A benign prostatic utricular papilloma was found in a twenty-seven-year-old man complaining of urethral bleeding and intermittent hematuria after sexual intercourse. Local endoscopic resection was performed. Since the natural history of this lesion is not known, follow-up cystourethroscopy will be performed.

Long-term results of conservative and surgical management of blunt renal lacerations.

In the management of renal lacerations most attention has centered on surgical or non-surgical treatment and little attention has been given to the long-term results. We have evaluated the medical records and radiographs of 70 patients with blunt renal lacerations; 30 had initial non-surgical management and 40 had initial surgical management. Patients with initial non-surgical management were followed up for an average of 40.4 months. Normal blood pressure and/or radiological evaluation of the kidney were noted in 22% of those who had non-surgical management (hypertension in 55%) and in 75% of those who had delayed renal surgery (hypertension in 29%). Patients with immediate surgical management were followed up for an average of 49.6 months and normal blood pressure and/or radiological evaluation of the kidney were present in 83% (no hypertension). On long-term follow-up, patients with non-surgical management had a much higher rate of hypertension and/or abnormal radiological evaluation of the kidney than those with immediate surgical management.

Management of urinary calculi in pregnancy.

When a calculus is present in the upper urinary tract during pregnancy, the upper tract dilatation seen on radiography and ultrasonography can be due to the calculus or to the pregnancy. This makes the decision on management difficult unless there are associated clinical findings of pain or sepsis. The records of 24 pregnant patients with proved urinary calculi were reviewed. The stone passed spontaneously in 18 patients, and procedures to remove the stone were required in 6 for pain and/or sepsis. With an upper urinary tract calculus and dilatation during pregnancy the deciding factors for intervention were the clinical findings of pain and/or sepsis and not the dilatation alone.

Clinical indications for radiographic evaluation of blunt renal trauma.

The evaluation of patients with blunt renal trauma has become controversial. We tested the hypothesis that renal contusion can be diagnosed clinically and that these patients do not require radiographic evaluation. To evaluate the association of microhematuria without shock and with renal contusion, we reviewed the medical records of 831 patients with hematuria following blunt renal trauma. Microscopic hematuria without shock was noted in 160 of 241 patients without and 334 of 590 with associated injuries. Of the former 160 patients 159 had renal contusion and 1 had a renal laceration, while of the latter 334 patients 329 had renal contusion, 3 had renal laceration, 1 had renal rupture and 1 had a pedicle injury. Most patients with microscopic hematuria and no shock after blunt renal trauma had a renal contusion, especially those with no associated injury. All of the patients with renal contusions experienced no complications from nonoperative management. However, avoiding a radiographic evaluation in patients with blunt renal trauma plus microhematuria and no shock would miss a few cases of severe renal injury.

Management of perirenal hematoma found during laparotomy in patient with multiple injuries.

The medical records of 158 patients with perirenal hematoma found during laparotomy for intra-abdominal injury from external trauma were analyzed. Small perirenal hematomas were usually associated with renal contusions and renal artery thrombosis, while large perirenal hematomas often were present with large renal lacerations, renal ruptures, and renal pedicle injuries with rupture of the renal vein, renal artery, polar artery, or branch of the renal artery. The management of the perirenal hematoma found during laparotomy depends on the degree of the underlying renal injury and not on the size or extent of the perirenal hematoma.

Renal trauma found during laparotomy for intra-abdominal injury.

Whether renal injury found during a laparotomy for intra-abdominal injury should have surgical or nonsurgical management is controversial. Five hundred twenty-one renal injuries were found during laparotomy for such injury in 513 patients. Blunt external trauma was the cause in 88%. A modified operating room table enabled performance of immediate intravenous pyelogram during the laparotomy. More severe degrees of renal injury (laceration, rupture, pedicle injury) were present in 135 (26%) of the renal injuries. Immediate surgical management of 102 more severe renal injuries resulted in nephrectomies in 37 (36%), delayed renal surgery in one (0.9%), and renal salvage in five of 18 (27%) main renal artery and/or vein injuries. Nonsurgical management of the remaining 23 resulted in nephrectomies in three (13%), delayed renal surgery in six (26%), total renal loss in seven of seven (100%) main renal artery injuries and an overall nephrectomy/total renal loss rate of 39%. With immediate surgical management of the more severe degrees of renal injury there was a slight increase in the salvage of kidneys and a marked decrease in delayed renal surgery and morbidity.

Type of blunt renal injury rather than associated extravasation should determine treatment.

The significance of extravasation of dye during excretion urography in blunt renal injuries has been controversial, with some believing that extravasation, even if copious, is largely innocuous and characterized by spontaneous resolution, and others believing extravasation is an indication for surgical correction of the underlying blunt renal injury. Thirty-two patients with extravasation diagnosed on excretion urography after blunt external trauma were evaluated. Immediate surgical management of the renal injury was performed in 18 patients who had a contusion in 1, laceration in 13, rupture in 3, and pedicle injury in 1, and averaged 2.0 associated injuries per patient. Conservative management of the renal injury was performed in 14 patients who averaged 1.1 associated injuries per patient. Ten of the 14 patients had a large renal laceration splitting the kidney or disrupting a pole with extravasation and none settled to normal. The data showed that extravasation with a small laceration resolved spontaneously while extravasation with a major disruption of the kidney did not settle to normal.

Renal pedicle injury in patients with multiple injuries.

In a study of 41 patients seen over 24 years, renal pedicle injuries were associated with life-threatening multiple system injuries and the immediate surgical management of these associated injuries by general surgeons took precedence over that of the renal pedicle injury. The result was the delayed diagnosis of the renal pedicle injury with loss of function of the kidney. In an effort to improve the renal salvage rate aggressive management of renal pedicle injuries with immediate radiologic evaluation and early surgical treatment was instituted in 1969. The records of 41 renal pedicle injuries from 1959 to 1983 were evaluated. Blunt external trauma was the cause in 76%. All 41 patients had multiple system injuries, averaging 3.7 associated injuries per patient, with 35 (85%) having a laparotomy for intra-abdominal injuries and an overall mortality rate of 44%. Conservative management was followed in 13 patients, with injury to the renal artery in nine and a branch of the renal artery in four, with a renal loss/delayed nephrectomy rate of nine of nine (100%) renal artery injuries. Immediate surgical management was performed in 23 patients, with injury to the renal artery in nine, the renal artery and renal vein in four, a branch of the renal artery in two, and the renal vein in eight, with a renal salvage rate of seven of 21 (33%) renal artery and/or vein injuries. Five patients died on admission or on the operating room table. A significant renal salvage rate resulted from immediate radiologic evaluation and early surgical treatment of renal artery/vein injuries compared to zero salvage rate with conservative management.

Male genital injuries from external trauma.

External trauma from a variety of causes, some unusual and bizarre, affect the male genitalia. Certain injuries are more common, have more severe consequences, or their management may be controversial. Seventy male genital injuries from external trauma are reported and include vacuum cleaner injuries, fracture of penis and the tourniquet syndrome.