Determination of amputation level in ischaemic limbs using tcPO2 measurement.

BACKGROUND: Determination of the optimal amputation level is essential for patients, morbidity and rehabilitation. Various non-invasive procedures have been proposed to determine the optimal level of amputation. There is no consensus on the minimal tcPO2 level that is required to predict the healing of the stump. Therefore we aimed to rank the probability of primary wound healing at the most distal level and to answer the question if there is a lower limit of tcPO2 below which healing cannot occur. PATIENTS AND METHODS: 56 consecutive patients undergoing amputation below the knee for ischaemic gangrene of limbs were prospectively enrolled in the study. 39 were men (18 of whom were diabetics) and 17 women (8 diabetics) whose ages ranged from 45 to 87 years (mean 73 years). The total of 71 amputations was performed on the 56 patients: 39 below-knee with primary healing and, in 16 patients the above-knee reamputation was performed, due to the non-healing wound on the below-knee stump. The level of the amputation (below or above the knee) was in all cases decided solely on clinical grounds. TcPO2 was measured on each patient prior to amputation, on the dorsum of the foot and 10 cm below the knee. RESULTS: The median tcPO2 value on the dorsum of the foot of diseased legs before amputation was 12 mm Hg (range from 0 to 22 mm Hg). At the anticipated level of the amputation of the shank, the median value of tcPO2 was 28 mm Hg (8-56 mm Hg). Patients with primary healing of postoperative wounds had significantly higher values of tcPO2 than patients with fialure to heal (37 mm Hg; range 15-56 mm Hg vs. 18 mm Hg; range 8-36 mm Hg, p < 0.01). The success rate increased with higher tcPO2 values at the level of amputation. The 15% prevalence of reamputations was obtained for tcPO2 values between 25 and 36 mm Hg (median value 33 mm Hg) and the threshold value of tcPO2 below which the stump failed to heal was 15 mm Hg. CONCLUSIONS: Our study showed that tcPO2 is a reliable indicator of local ischemia. The integration of this parameter with other personal clinical criteria may be a valuable help to the surgeon in decision making.

Subcutaneous myiasis caused by Dermatobia hominis.

A case of subcutaneous myiasis caused by the larvae of the Dermatobia hominis fly is described, involving the ankle region of a 25-y-old man who had returned from Peru. After removal of 4 larvae from the affected sites, the lesions healed in 2 weeks without further treatment. Because of the increasing number of people travelling to tropical America, physicians in Slovenia will have to consider Dermatobia myiasis in the differential diagnosis of furuncular lesions in patients with a relevant travel history.

Subcutaneous infection caused by Dirofilaria repens imported to Slovenia.

A case of human subcutaneous dirofilariasis is presented. A complete nematode removed from the tumour in the occipital region of a 61-year-old woman was identified, on the basis of its anatomical and histological characteristics, as a nongravid adult female of the species Dirofilaria repens. The patient had probably been infected on the Canary Islands, Spain, 7 months previously. In the future, the clinical and laboratory staff in Slovenia will have to be more alert to the possibility of dirofilariasis in patients with subcutaneous tumours, particularly in individuals who had travelled to endemic areas several months or years before the tumour was detected.

Chemoprophylaxis of postoperative infections in colorectal surgery.

Colorectal surgery involves a high risk of postoperative infections. The major risk factors can be reduced by appropriate preparation of the patient for the operation. Mechanical removal of gross faecal material from the bowel, possible before most elective operations, does not sufficiently reduce the incidence of postoperative infections. Prophylactic medication has not yet been widely accepted, although its effectiveness has been confirmed by a number of studies. Preoperative management of patients subjected to colorectal surgery at our institution in the last three years, consisted of mechanical cleansing of the intestinal tract for two days, followed by rapid intravenous administration of gentamicin 80 mg and metronidazole 500 mg in a single dose, 30 min to 1 h before the operation. From 1971 to 1973, the postoperative infection rate in 432 patients submitted to elective colorectal surgery was 29%. During the period 1981-1983, operations of the same kind were performed in 572 patients, the infection rate being 15%. Prophylactic single-dose administration of gentamicin in combination with metronidazole has proved to be very effective in reducing postoperative infections.

Susceptibility of anaerobic bacteria to metronidazole. A bacteriological and clinical study.

The activity of metronidazole was studied by the diffusion method using two discs on a model group of 40 anaerobic bacterial strains isolated recently from clinical specimens. The minimal inhibitory concentrations (MICs) were determined by the dilution method and regression curves by the method of minimum square errors. Some 82.5% of bacteria of the model group were susceptible to metronidazole. All the routinely isolated anaerobes (582 strains) were tested with metronidazole over a period of 20 months. Susceptibility was recorded in 469 strains (80.6%). The clinical study was carried out on two groups of inpatients with bacteriologically confirmed mixed aerobic and anaerobic infections. Subjects in Group 1 (25 patients) were given clindamycin and gentamicin and those in Group 2 (30 patients) metronidazole and gentamicin. The results showed that the two combinations of drugs had comparable effects.

[Rare causes of hemorrhage from the digestive tract]. / Retki izvori krvarenja iz probavnog trakta.

Some rare causes of intestinal bleeding, where diagnosing is difficult, have been shown. Cases of Meckel's diverticulum, leiomyoma and angiomas have been reported. The considerable help which can be expected from modern diagnostic procedures has been stressed, from screening using 99 m Tc Pertechnetate in diagnosing the Meckel's diverticulum and from selective angiography in diagnosing the other pathologic changes, mainly arteriovenous malformations.

[The importance of the use of antibiotics after surgical procedures on the abdominal cavity]. / Smislena uporaba antibiotikov po kirurskih posegih v trebusni votlini.

Surgical drainage is the most important treatment of infections of the abdomen. In severe cases supplementary antibiotic treatment is needed. Rational selection of antimicrobial therapy is based on a thorough knowledge of the invading pathogens. It should be taken into account that most abdominal infections are polymicrobic from which both aerobes, mainly enterobacteria, and anaerobes, mainly bacteria of the genus Bacteroides, are isolated. Such infections are synergistic processes, in which multiple bacteria act together to produce the disease. A group of 75 patients with infections following abdominal surgery was entered into the study. The in vitro results demonstrated that cefoxitin with or without an aminoglycoside or clindamycin plus an aminoglycoside was effective against the isolated bacteria. Cefoxitin was active against 94.7% of strains Bacteroides, against 98.1% of strains E. coli and against the majority of other (less frequent) bacteria, except against Pseudomonas aeruginosa, Enterococci and Peptococci. Clindamycin was active against anaerobic bacteria, and against some aerobic bacteria too; but it had no effect against E. coli and the majority of other enterobacteria. The aminoglycoside were effective against enterobacteria but they showed no activity against Gram-negative non-sporing anaerobes. The clinical outcome demonstrated that clindamycin plus an aminoglycoside and cefoxitin without or (sometimes) with an aminoglycoside were effective in the therapy of mixed abdominal infections.

[Spenic abscesses]. / Absces vranice.

Abscess of the spleen is an uncommon entity that seems even less common as it still represents a diagnostic problem. The most common cause of splenic abscess is metastatic hematogenous seeding of the diseased spleen especially of the infarcted areas or traumatic hematomas. It can result also from the direct spread of infection from surrounding structures. Many patients with splenic abscess have a rapidly progressive generalized sepsis and even the combination of well-timed surgery and antibiotic therapy is not always curative. Local symptoms may be mild and overlooked and there may be only general symptoms of suppuration present. X-rays investigations often yield valuable information about the location of the abscess. By far the most promising technique is splenic scanning with the use of radioisotopes. Our case of splenic abscess following appendicitis has been described. The course and the diagnosis has been established using liver-spleen scanning. The patient was treated with Obracin and Dalacin and the diseased spleen has been removed. After drainage of the left subphrenic abscess the recovery was uneventful.

The mechanisms of the action of electrical stimulation of muscles.

The mechanisms of the action of electrical stimulation of muscles are discussed. We believe that the principal cause for the good results obtained in cases of stress incontinence with electrical stimulation must be due to the formation of a better reflex in contraction of the muscles of the pelvic floor. This, however, envolves changes at the level of the spinal cord. By the help of stimulation the patient learns to use the urethral sphincter and secondary forces of retention in a better and a more proper way. The good results obtained in the treatment of some cases of nocturnal enuresis by anal plugs require yet another explanation. It can be considered that in nocturnal enuresis the unconscious inhibition of the reflex mechanism for emptying the bladder is not developed enough. From the experience we know that vigorous voluntary activation of the muscles of the pelvic floor inhibits the contraction of the detrusor muscle. In this way it is possible to depress the urging sensation to urinate. In the paper we have tried to demonstrate this mechanism objectively. On the basis of our findings we believe that the good results in treating nocturnal enuresis may be due to this mechanism of stimulation.

Reflex electrical stimulation for urinary incontinence.

Our previous observations have shown that the electrical stimulation of muscles is prevalently reflex. One of the advantages of reflex stimulation is that it activates not only a limited number of motor units, but rather a number of muscles connected by the same reflex from a single stimulation site. Consequently, it is not necessary to place electrodes into the muscle to be activated. They can be put elsewhere provided that the same effect is obtained and that it is more convenient for the patient. Such an opportunity arises when treating urinary incontinence which involves not only the urethral sphincter but also the group of synergistic muscles of the pelvic floor. Our experiments with several patients suffering stress incontinence have shown that indirect stimulation of the levator ani with a vaginal stimulator and especially of the anal sphincter with an anal stimulator affects the urethral sphincter in the same way as direct stimulation. These findings are significant since they enable us to use external instead of implantable stimulators. External stimulation is worth trying in all cases of stress incontinence where conservative measures have failed. In our cases, the results have been very satisfactory.

Reflex electrical stimulation for urinary incontinence.

Experiments with several patients suffering from stress incontinence have shown that indirect stimulation of the levator ani with a vaginal stimulator and especially of the anal sphincter with an anal stimulator affects the urethral sphincter in the same way as direct stimulation. These findings are significant since they enable us to avoid the use of implantable stimulators by substituting external ones. External stimulation is worth trying in all cases of stress incontinence, where other conservative measures have failed. In our cases the results have been very satisfactory.