Randomised controlled study of seroma rates after mastectomy with and without quilting the skin flap to pectoralis muscle.

AIMS: The aim of this study was to determine whether seroma formation was affected by reduction of the potential dead space with the flap fixation method and obliteration of the axillary region in patients with breast cancer who underwent either mastectomy and axillary lymph node dissection or sentinel lymph node biopsy. A total of 105 patients with breast cancer were divided into two groups according to wound closure patterns. PATIENTS AND METHODS: The operating time, postoperative pain and complications, time to drain removal, seroma formation, amount of fluid aspirated and number of aspirations were recorded prospectively. RESULTS: No significant difference was found between groups in the rates of seroma development (P = 0.7), complication rates (P = 0.6), time to drain removal (P = 0.5), length of hospital stay (P = 0.3) or numbers of aspiration (P = 0.7). The operating time for fixation was determined to be longer than that of the classic procedure (P = 0.02). CONCLUSIONS: Reducing potential dead space with flap fixation and obliteration of the axillary region may be useful in decreasing the development of seroma in patients who have undergone mastectomy because of breast cancer. However, surgical technique must be careful, and appropriate patient follow-up must be conducted.

Connecting quantum dots with enzymes: mediator-based approaches for the light-directed read-out of glucose and fructose oxidation.

The combination of the biocatalytic features of enzymes with the unique physical properties of nanoparticles in a biohybrid system provides a promising approach for the development of advanced bioelectrocatalytic devices. This study describes the construction of photoelectrochemical signal chains based on CdSe/ZnS quantum dot (QD) modified gold electrodes as light switchable elements, and low molecular weight redox molecules for the combination with different biocatalysts. Photoelectrochemical and photoluminescence experiments verify that electron transfer can be achieved between the redox molecules hexacyanoferrate and ferrocene, and the QDs under illumination. Since for both redox mediators a concentration dependent photocurrent change has been found, light switchable enzymatic signal chains are built up with fructose dehydrogenase (FDH) and pyrroloquinoline quinone-dependent glucose dehydrogenase ((PQQ)GDH) for the detection of sugars. After immobilization of the enzymes at the QD electrode the biocatalytic oxidation of the substrates can be followed by conversion of the redox mediator in solution and subsequent detection at the QD electrode. Furthermore, (PQQ)GDH has been assembled together with ferrocenecarboxylic acid on top of the QD electrode for the construction of a funtional biohybrid architecture, showing that electron transfer can be realized from the enzyme over the redox mediator to the QDs and subsequently to the electrode in a completely immobilized fashion. The results obtained here do not only provide the basis for light-switchable biosensing and bioelectrocatalytic applications, but may also open the way for self-driven point-of-care systems by combination with solar cell approaches (power generation at the QD electrode by enzymatic substrate consumption).

A pilot study to examine the effect of the Tulip oropharyngeal airway on ventilation immediately after mask ventilation following the induction of anaesthesia.

The Tulip airway is an adult, disposable, single-sized oropharyngeal airway, that is connectable to an anaesthetic circuit. After a standardised induction of anaesthesia in 75 patients, the ease of insertion, intracuff pressure and intracuff volume were measured, as were the end-tidal carbon dioxide levels, airway pressures and tidal volumes over three breaths. Successful first-time insertion was achieved in 72 patients (96%, CI 88.8-99.2%) and after two attempts in 74 patients (99%, CI 92.8-100%). There was outright failure only in one patient. In 60 patients (80%, CI 72.2-90.4%), the Tulip airway provided a patent airway without additional manoeuvres, but in 14 patients, jaw thrust or head extension was necessary for airway patency. The main need for these adjuncts appeared to be an initial under-inflation of the cuff. These promising results are consistent with recent manikin studies using this device.

Coitus to expedite the onset of labour: a randomised trial.

OBJECTIVE: To evaluate the effect of suggesting coitus as a safe and effective means to expedite labour on pregnancy duration and requirement for labour induction. DESIGN: A randomised trial. SETTING: Antenatal clinic in a university hospital in Malaysia. POPULATION: Women from 35 weeks of gestation with an uncomplicated singleton pregnancy. METHODS: The advise-coitus arm was counselled that coitus at term is a safe, natural and effective means to initiate labour and to avoid labour induction. The control arm was told coitus was safe. Both arms were asked to record coital activity. MAIN OUTCOME MEASURES: Pregnancy duration and labour induction. RESULTS: The intervention to delivery interval (mean ± SD) was 3.2 ± 1.4 versus 3.3 ± 1.3 weeks (P = 0.417), with a gestational age at delivery of 39.4 ± 1.2 versus 39.5 ± 1.2 weeks (P = 0.112), and with labour induction rates of 126/574 (22.0%) versus 120/576 (20.8%) (P = 0.666) for the advise-coitus and control arms, respectively, with no statistical difference between the groups. Coitus prior to delivery was more often reported in the advise-coitus arm compared with the control arm: 481/574 (85.3%) versus 458/576 (79.9%) (RR 1.5, 95% CI 1.1-2.0, P = 0.019). Also, the median (interquartile range) reported number of coital acts of 3 (2-5) versus 2 (1-4) (P = 0.006) was higher for the advise-coitus arm. Other pregnancy and neonatal outcomes did not differ between the groups. CONCLUSIONS: Labour onset and labour induction did not differ in the advise-coitus arm.

A pro forma and review process for the assessment of standards of care in stillbirths.

Stillbirth rates do not address deficiencies in care. We collected information on stillbirths from 2004 to 2009 using a standardised pro forma. A local panel used the pro forma to grade the level of care received by the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) categorisation. Comparison using kappa scores showed agreement between local and external multidisciplinary panels of similar referral patterns (n = 47, κ = 0.7), and that the categorisation was unaffected by the individual who fills out the pro forma (n = 17, κ = 0.5). There was less agreement between the local panel and adverse event review (n = 100, κ = 0.45). This report represents a validation of the pro forma and the review process for standard use in all units.

Determination of trimester specific reference intervals for thyroid hormones during pregnancy in Malaysian women.

OBJECTIVE: To establish trimester specific reference intervals for thyroid hormones during pregnancy in Malaysian women. STUDY DESIGN: Cross-sectional observational study performed in the Obstetric Clinic, University Malaya Medical Centre. A single blood sample from 626 women at various trimesters of pregnancy was analyzed for thyroid function. TSH, FT4, TT4, FT3 and TT3 values at each trimester of pregnancy were calculated. RESULTS: From the TSH, FT4, TT4, FT3 and TT3 results, reference values based on mean +/- 2SD was calculated for the hormones at each trimester of pregnancy. CONCLUSION: We calculated clinically relevant trimester-specific reference values for thyroid function tests through pregnancy to facilitate improved management of thyroid disease in pregnancy in our local population.

Pneumosinus dilatans and multiplex: report of three rare cases and review of the literature.

Pneumosinus dilatans is a term used to describe a localized abnormal dilatation of one or more paranasal sinuses without radiological evidence of localized bone destruction, hyperostosis or mucous membrane thickening. The involvement of all paranasal sinuses and mastoid air cells has been named pneumosinus dilatans multiplex. Although the involvement of one or more paranasal sinuses has been reported widely, all paranasal sinuses and the concomitant involvement of mastoid air cells has been reported in only one case. Herein, we present three unusual cases of pneumosinus dilatans (one is a second case of pneumosinus dilatans multiplex in English literature, another is the first reported case of a frontal pneumosinus dilatans case associated with frontoethmoidal meningocele, mental retardation and facial asymmetry and the third one is pneumosinus dilatans with a huge arachnoid cyst) along with the review of relevant literature.

Ultrasonographic and biochemical evaluation of visceral obesity in obese women with non-alcoholic fatty liver disease.

OBJECTIVE: Identification of specific origin of lipid accumulation in the liver of patients with non-alcoholic fatty liver disease (NAFLD) is the most important step in preventing this condition. Because liver steatosis, in the obese patients without any systemic disease, can be graded easily by ultrasonography (US), we aimed to demonstrate the degree of liver steatosis and abdominal fat distribution by US, furthermore evaluate biochemical, anthropometrical measurements, and define the possible relationship between these parameters in obese women with different grades of liver steatosis. METHODS: In this controlled clinical study, according to US evaluation of liver steatosis, the patients were divided into four groups: control (no steatosis), mild, moderate and severe steatosis groups. Demographic, biochemical and anthropometric measurements were done. Insulin resistance was determined by using homeostasis model assessment (HOMA-IR). Liver steatosis and abdominal fat distributions were evaluated by US. RESULTS: The subcutaneous and preperitoneal fat layer measurements did not show any significant difference between the groups. The visceral fat layer thickness was significantly higher in severe liver steatosis group compared to the control and steatosis groups. The highest serum fasting insulin, uric acid levels and HOMA-IR index were observed in the severe liver steatosis group. Visceral fat thickness was positively correlated with serum UA levels and HOMA-IR CONCLUSIONS: This study suggests that visceral adipose tissue, HOMA-IR and serum uric acid levels are the main determinants of NAFLD in obese patients.

Comparison of ultrasonographic and anthropometric methods to assess body fat in childhood obesity.

BACKGROUND: Pattern of fat distribution rather than obesity is of importance for cardiovascular morbidity and mortality. The accurate measurement of total and regional fat mass requires sophisticated and often expensive methods that have limited applicability in the clinical setting. OBJECTIVE: The aim of this study is to evaluate body fat distributions by ultrasound (US) as a gold standard method for measuring visceral, preperitoneal and subcutaneous fat layers and comparing with anthropometric results, and then to find the most reliable anthropometric measurement in childhood obesity. MATERIALS AND METHODS: Study group of 51 obese children (21 F, 30 M) (mean age+/-s.d.: 11.5+/-2.6 years) and control group of 33 non-obese children (17 F, 16 M) (mean age+/-s.d.: 12.2+/-2.7 years) were recruited for this study. Anthropometric measurements as body mass index (BMI), waist circumference (WC), waist/hip ratio (WHR), triceps and subscapular skinfold thicknesses were taken from all the participants. Abdominal preperitoneal (P), subcutaneous (S) fat at their maximum (max) and minimum (min) thickness sites, visceral (V), triceps (TrUS) and subscapular (SsUS) fat thicknesses were also measured ultrasonographically. RESULTS: In the obese group, BMI was significantly correlated with US measurements of fat thicknesses, except Pmin and SsUS, whereas in the control group, BMI was significantly correlated with all US fat measurements. The relation of US measurements with skinfold thickness and WC was more significant in the control than in the obese group. No relation between WHR and US fat thickness measurements was found in both groups. Multiple regression analysis, using V as the dependent variable and anthropometric parameters, gender and the group as the independent variables, revealed BMI was the best single predictor of V (R(2): 0.53). CONCLUSION: This study suggests that the validity of the anthropometric skinfold thickness in the obese children is low. Despite the limitations reported in the literature, in our study, BMI provides the best estimate of body fat. WHR in children and adolescents is not a good index to show intra-abdominal fat deposition.

A national survey of obstetric anaesthetic handovers.

The handover of patient information between shifts enables continuity of care and increases patient safety. We surveyed UK practice during handovers in obstetric anaesthesia. A questionnaire was sent to 239 lead consultant obstetric anaesthetists to record routine practice in their unit and individual opinion about handover procedures. Responses were received from 168 anaesthetists, a 70% response rate. Handover policies were available in 10% of units. Most (76%) responding units had an allocated time for handover. In most units (76%), the duration of handover was reported as being < 15 min but the actual duration and depth of any discussion involved were not specified. Handovers were rarely documented in writing (7%). Consultant anaesthetists were most likely to be present at the morning handover and few handovers were multidisciplinary. Four percent of units reported critical incidents following inadequate handovers in the past 12 months. We identify features in handover procedures that could be improved.

Malign cystic glucagonoma presented with diabetic ketoacidosis: case report with an update.

A 44-year-old woman was diagnosed with type II diabetes in 1998 and 1 year later she developed necrolytic migratory erythema, which is a specific skin lesion of glucagonoma. During the clinical investigation, a nodular 6 cm mass in the distal pancreatic region and multiple cystic liver metastases were found. She was operated on, and glucagonoma was detected and the long-acting, repeatable, octreotide treatment was started. 3 years after resection of a pancreatic glucagonoma she presented to a hospital emergency department with diabetic ketoacidosis. Hepatic multiple cystic metastases were visualized by computed tomography. During hospitalization she developed severe pulmonary embolism and deep-venous thrombosis of the lower extremities. Indium-labeled octeotide scintigraphy showed multiple cystic lesions in the liver with additional lesions in the iliocecal region, which had not been visualized by computed tomography. Despite somatostatin therapy the tumor had expanded in the liver. Arterial chemoembolization was performed but 6 months later she died.

Impact of antibiotic usage on resistance in microorganisms; urinary tract infections with E-coli as a case in point.

OBJECTIVES: In this study, we sought to establish a correlation between consumption of flouoroquinolones in our hospital and the emergence of ofloxacin resistant strains of E. coli in the urinary specimens. Data of all urinary samples, received at Aga Khan University Hospital between January 1995 and December 2002, was retrieved and analyzed. Specimens yielding E-coli as an isolate were included in this study. METHODS: E. coli Isolates showing >103 colonies were identified using standard microbiological techniques. Antibiotic susceptibility of E. coli was tested using Kirby Bauer disc diffusion method. Antimicrobial usage data, obtained through hospital Pharmacy as unit utilized per year for Quinolones in different medical and surgical units was available only for the period of 1997- 2002. RESULTS: Among 32,722 urinary specimens E. coli (53%) was the most frequent isolate. Steady increase in the number of ofloxacin resistant E. coli was noted, 24% in 1995 to 55% in 2002. Maximum quinolone resistant E. coli have been observed in Medical units, 41% in 1997 increasing to 70% in 2002, followed by Surgery units (35% to 54%) and Pediatrics (12 to 38%). Sharp increase in ofloxacin consumption in our hospital, 1997 (28613 units) to 2002 (96880 units) has been observed. Trends in quinolone resistance correlate significantly with utilization in the same period as shown by linear regression. CONCLUSION: E. coli resistance against most antibiotics has been on a rise particularly for quinolones. The utilization of quinolones correlates with increasing resistance in our hospitalized patients.

Correlation of abdominal fat accumulation and liver steatosis: importance of ultrasonographic and anthropometric measurements.

PURPOSE: This study has two objectives: (1) using ultrasound (US) as a tool for measuring subcutaneous (S) and intra-abdominal; preperitoneal (P) and visceral (V) fat thickness. (2) Assessing the relationship between selected anthropometrical variables and US-measured S, P and V fat also evaluating the contribution of abdominal fat accumulation in development of liver steatosis. METHODS AND MATERIALS: Sixty-eight obese patients (aged 43.9+/-9.3 years) and 40 non-obese subjects (aged 34.03+/-9.0 years) were recruited to this study. Height, weight (W), waist (WC) and hip circumferences were measured. Body mass index (BMI) and waist to hip ratio (WHR) were calculated. A linear-array probe (7.5 MHz) was used to measure S and P. A convex-array probe (3.5 MHz) was used for measuring V and assessing liver fatty infiltration. RESULTS: In 45 (66%) patients, there were diffuse liver fatty changes. Liver steatosis showed significant correlation with V (r=0.57), P (r=0.38) and S (r=0.37). It also correlated with W (r=0.52), BMI (r=0.6), WC (r=0.45) (P<0.0001). V positively correlated with BMI (r=0.62), W (r=0.55), WC (r=0.52) and WHR (r=0.33). P correlated with WC (r=0.29), WHR (r=0.36) and W (r=0.34), but not with BMI, height and age. A significant correlation was found between S and BMI (r=0.73), W (r=0.65), and WC (r=0.57) (P<0.0001). CONCLUSION: Obese patients showed thicker S, P, and V. Liver steatosis correlates significantly with both anthropometrical data; BMI, WHR, WC, and W, and with abdominal V, P, and S fat. V fat can be used as a good predictor for the possibility of different metabolic disorders and liver disturbances as steastosis.

Can magnetic resonance imaging predict the success of parturition in oxytocin-induced pregnant women?

The aim of this study was to assess whether magnetic resonance imaging could predict the outcome of attempted vaginal delivery in a group of pregnant women whose parturition had to be induced by oxytocin. The signal intensity and morphology alterations in the cervix of 21 full-term pregnant women were analyzed before the induction of parturition. T2-weighted gradient echo sequences were utilized and signal intensity in the cervix was measured from the anterior and posterior lips of the cervix. An index indicating the brightness range of the cervix was formulated to overcome the effects of the individual intensity changes. Imaging features including the signal intensity and the evidence of effacement were correlated with the actual type of delivery performed. Images were also assessed visually by two independent radiologists. Statistical analysis of brightness indexes that were considered to have a predictive value as an indicator for possible delivery was not significant. However, visually assessed signal intensity of the cervix correlated strongly with the type of delivery. Effacement itself was the most reliable parameter in predicting the progress of the delivery. In conclusion, MR imaging seems to be useful for predicting normal parturition in full-term pregnant women who need oxytocin induction. However, the presence of effacement seems to be a more reliable and practical parameter that will be preferred in that prediction.

Magnetic resonance imaging with rectal Gd-DTPA: new tool for the diagnosis of perianal fistula.

This study investigated the effectiveness of magnetic resonance imaging (MRI) with rectal administration of the enteral contrast agent gadolinium diethylene triamine pentaacetic acid (Gd-DTPA) in the diagnosis of recurrent perianal fistulae, assessing the number, anatomical extent, location, and signal intensities of various lesions. Fistulas were examined by MRI before and after rectal administration of Gd-DTPA in 50 patients (excluding fistulas due to inflammatory bowel disease). Surgical findings were compared with both pre- and postcontrast T1-weighted, T2-weighted, and short T1 inversion recovery (STIR) sequences. Of the 68 fistulous tracts detected surgically, precontrast imaging identified 16 by T1-weighted images (hypointense), 27 by T2-weighted images (hyperintense or iso- to weakly hyperintense), and 54 by STIR. Postcontrast imaging identified 29 by T1-weighted images, 58 by T2-weighted, and 54 by STIR. MRI with rectal administration of Gd-DTPA thus facilitates determination of fistula tracts, which are better resolved by precontrast STIR than by either precontrast T1- or T2-weighted images. Postcontrast T2-weighted images were substantially superior to T1-weighted. Both noncontrast STIR and postcontrast T2-weighted sequences were adequate for classifying fistulas in ano, but in complex recurrent anal fistula postcontrast T2-weighted images were more helpful.

Postoperative wound infections.

A prospective study of postoperative wound infection was carried out over a two year period in Cumhuriyet University Medicine Faculty Hospital in Sivas, Turkey. Examination of wounds, with cultures of all suspicious wounds using standard bacteriological methods was performed. Of a total of 4146 surgical wounds, 188 (4.53%), became infected. High infection rates were noted after colon resection (32.1%), gastric and oesophageal operations (21.1%), cholesystectomy (17.2%), and splenectomy (10.2%). Low infection rates were noted after thyroidectomy, mastectomy, caesarean section and abdominal hysterectomy. The commonest causative organisms were coagulase-negative staphylococci 21.7%, Staphylococcus aureus 19.7%, Escherichia coli 19.7%, Enterobacter spp. 17.6%, and Pseudomonas spp. 10.7%.