To evaluate the clinical benefits, primarily tolerability and reduction in pain levels, associated with the use of a PHMB-impregnated biosynthetic cellulose dressing (Suprasorb X + PHMB) on ...paediatric heel lacerations.
These lacerations were caused when children, who were being transported on their parents' bicycles, got their heels trapped in the wheel spokes. Where these injuries just comprised skin contusion and laceration, treatment had previously comprised cleansing followed by application of conventional dressings and moist wound healing dressings. However, the high incidence of infection necessitated regular dressing changes, which caused parents and children stress and anxiety. This clinical evaluation assessed the benefits of a new treatment protocol, where the PHMB-impregnated biocellulose dressing was applied and left in situ until epithelialisation occurred. A cork splint was used for 3 days to prevent pes equinus and to let the ankle joint rest. Change in wound size (cm²), incidence of local infection, wound bed characteristics and pain levels (measured on a 0-10 paediatric pain scale) were assessed at 3-day intervals during the 14-day treatment period. Satisfaction with the dressing was also evaluated.
Twenty children (mean age 5.6 years (± 1.33) were recruited into the study and included in the analysis. The mean baseline wound area was 8.60cm² (± 6.57). The mean time to complete wound closure was 12.95 days (± 7.69) with a mean total of 4.70 visits (± 1.56). The mean VAS pain score was 9.55 (± 0.69), compared with 0.15 (± 0.37) on day 14 (p<0.003). At the second visit (after 3 days) 17 of the 20 children were reported to be free of pain. No cases of local infection were noted.
The dressing was found to be child and parent friendly. The evaluation also showed that it was well tolerated and achieved good healing outcome. It has now been incorporated into the clinic's treatment protocol for these wounds.
None. The authors have no relevant financial interest in this article. All authors were involved in the critical revision of the manuscript for important intellectual content.
Background
Antibiotics are advised in most guidelines on acute diverticulitis, despite a lack of evidence to support their routine use. This trial compared the effectiveness of a strategy with or ...without antibiotics for a first episode of uncomplicated acute diverticulitis.
Methods
Patients with CT‐proven, primary, left‐sided, uncomplicated, acute diverticulitis were included at 22 clinical sites in the Netherlands, and assigned randomly to an observational or antibiotic treatment strategy. The primary endpoint was time to recovery during 6 months of follow‐up. Main secondary endpoints were readmission rate, complicated, ongoing and recurrent diverticulitis, sigmoid resection and mortality. Intention‐to‐treat and per‐protocol analyses were done.
Results
A total of 528 patients were included. Median time to recovery was 14 (i.q.r. 6–35) days for the observational and 12 (7–30) days for the antibiotic treatment strategy, with a hazard ratio for recovery of 0·91 (lower limit of 1‐sided 95 per cent c.i. 0·78; P = 0·151). No significant differences between the observation and antibiotic treatment groups were found for secondary endpoints: complicated diverticulitis (3·8 versus 2·6 per cent respectively; P = 0·377), ongoing diverticulitis (7·3 versus 4·1 per cent; P = 0·183), recurrent diverticulitis (3·4 versus 3·0 per cent; P = 0·494), sigmoid resection (3·8 versus 2·3 per cent; P = 0·323), readmission (17·6 versus 12·0 per cent; P = 0·148), adverse events (48·5 versus 54·5 per cent; P = 0·221) and mortality (1·1 versus 0·4 per cent; P = 0·432). Hospital stay was significantly shorter in the observation group (2 versus 3 days; P = 0·006). Per‐protocol analyses were concordant with the intention‐to‐treat analyses.
Conclusion
Observational treatment without antibiotics did not prolong recovery and can be considered appropriate in patients with uncomplicated diverticulitis. Registration number: NCT01111253 (http://www.clinicaltrials.gov).
Antibiotics not needed
To investigate the oncological safety and potential cost savings of selective histopathological examination after appendectomy.
The necessity of routine histopathological examination after ...appendectomy has been questioned, but prospective studies investigating the safety of a selective policy are lacking.
In this multicenter, prospective, cross-sectional study, inspection and palpation of the (meso)appendix was performed by the surgeon in patients with suspected appendicitis. The surgeon's opinion on additional value of histopathological examination was reported before sending all specimens to the pathologist. Main outcomes were the number of hypothetically missed appendiceal neoplasms with clinical consequences benefiting the patient (upper limit two-sided 95% confidence interval below 3:1000 considered oncologically safe) and potential cost savings after selective histopathological examination.
Seven thousand three hundred thirty-nine patients were included. After a selective policy, 4966/7339 (67.7%) specimens would have been refrained from histopathological examination. Appendiceal neoplasms with clinical consequences would have been missed in 22/4966 patients. In 5/22, residual disease was completely resected during additional surgery. Hence, an appendiceal neoplasm with clinical consequences benefiting the patient would have been missed in 1.01:1000 patients (upper limit 95% confidence interval 1.61:1000). In contrast, twice as many patients (10/22) would not have been exposed to potential harm due to re-resections without clear benefit, whereas consequences were neither beneficial nor harmful in the remaining seven. Estimated cost savings established by replacing routine for selective histopathological examination were €725,400 per 10,000 patients.
Selective histopathological examination after appendectomy for suspected appendicitis is oncologically safe and will likely result in a reduction of pathologists' workload, less costs, and fewer re-resections without clear benefit.
The introduction of self-expandable metal stents has offered a promising alternative for palliation of malignant left-sided colonic obstruction. This randomized clinical trial aimed to assess whether ...a nonsurgical policy, with endoluminal stenting, is superior to surgical treatment in patients with stage IV left-sided colorectal cancer and imminent obstruction.
Patients with incurable left-sided colorectal cancer who fulfilled the study criteria were randomly assigned to nonsurgical or surgical treatment. The primary outcome measure was survival in good health out of hospital (World Health Organization performance scores 0 or 1).
A high number of serious adverse events in the nonsurgical arm led to premature closure of the trial. Ten patients were allocated to surgical treatment and 11 patients to nonsurgical palliation. The median survival in good health out of hospital during the first year was 56 days (interquartile range 7.5 - 338.5 days) in the surgical arm vs. 38 days (interquartile range 5.25 - 288.75 days) in the nonsurgical arm (P = 0.68). Eleven adverse events (six perforations) occurred in the nonsurgical arm vs. one adverse event in the surgical arm (P < 0.001). Of the six perforations, two were stent-related because they occurred at the proximal edge of the stent by erosion through a normal colon wall; one was probably stent-related (it was located in the region of the proximal half of the stent); one was a colon blowout; and two were late tumor perforations in patients on chemotherapy.
The unexpected high rate of perforation in the nonsurgical arm might be specifically WallFlex-related or enteral stent-related in patients on chemotherapy and warrants attention.
To investigate whether a single pre-operative dose of 120
mg acetylsalicylic acid (ASA) decreased either (1) emboli rate, as detected by transcranial Doppler (TCD), during and early after carotid ...endarterectomy (CEA) and (2) clinical intra- and post-operative signs suggestive of embolism or increased bleeding tendency.
Prospective, double-blind placebo controlled trial.
One-hundred consecutive patients were randomised to receive either 120
mg ASA (
n=48) or placebo (
n=49) by suppository on the night before CEA; three patients were excluded. Emboli were counted and expressed as emboli rate (ER). The incidence of bleeding complications was assessed. Surgeons were asked to indicate which patients had received ASA or placebo.
There were no significant differences between the ASA and placebo groups in ER in the intraoperative and postoperative periods. ER higher than 0.9
min
−1 was associated with a significantly increased risk of complications (26 vs. 0%,
P<0.01). No extra bleeding complications were observed in the ASA group. Surgeon assessment of whether or not ASA had been administered had a sensitivity of 42% and a specificity of 70%.
A single pre-operative dose of ASA (120
mg) did not reduce significantly the emboli rate during and after CEA and surgeons could not correctly identify whether or not ASA had been administered.
Vascular complications of isolated limb perfusion Klicks, R.J.; Vrouenraets, B.C.; Nieweg, O.E. ...
European journal of surgical oncology,
08/1998, Letnik:
24, Številka:
4
Journal Article, Conference Proceeding
Recenzirano
Isolated limb perfusion (ILP) is a complex vascular procedure which uses an extracorporeal circuit with high doses of cytostatic drugs and often hyperthermia for the treatment of extremity tumours. ...Our study investigated the incidence, treatment and subsequent outcome of vascular complications after ILP, about which little is known.
A retrospective study was performed, in which we found 10 vascular complications after 466 ILPs (2.1%).
In eight patients, acute arterial obstruction developed in the immediate post-operative period, resulting from a thrombus at the arteriotomy site. Prompt reintervention with thrombectomy restored the circulation in all patients. One patient developed an arterial thrombus in the brachial artery due to compression of the surrounding tumour 12 days after ILP, which was successfully treated with thrombectomy and freeing the artery from the tumour. One patient was treated conservatively for digital micro-emboli. All complications occurred in women, maybe because of their generally smaller vessel size. No limbs were lost and all patients were free of any vascular problem after a median follow-up of 3.6 years.
We conclude that vascular complications after ILP are rare, consist mainly of thrombosis at the arteriotomy site and can be successfully treated by prompt thrombectomy. Therefore, close observation of the peripheral circulation after ILP is necessary.
We present a case history of a patient admitted with a Salmonella infection of the lymph nodes in the right groin. After 5 days a false aneurysm of the right common femoral artery developed. The ...patient was successfully treated with an extra-anatomic (obturator) bypass, isolation of the aneurysm, and local as well as systemic antibiotic therapy.