Several articles have been published about the reorganisation of surgical activity during the COVID-19 pandemic but few, if any, have focused on the impact that this has had on emergency and trauma ...surgery. Our aim was to review the most current data on COVID-19 to provide essential suggestions on how to manage the acute abdomen during the pandemic.
A systematic review was conducted of the most relevant English language articles on COVID-19 and surgery published between 15 December 2019 and 30 March 2020.
Access to the operating theatre is almost exclusively restricted to emergencies and oncological procedures. The use of laparoscopy in COVID-19 positive patients should be cautiously considered. The main risk lies in the presence of the virus in the pneumoperitoneum: the aerosol released in the operating theatre could contaminate both staff and the environment.
During the COVID-19 pandemic, all efforts should be deployed in order to evaluate the feasibility of postponing surgery until the patient is no longer considered potentially infectious or at risk of perioperative complications. If surgery is deemed necessary, the emergency surgeon must minimise the risk of exposure to the virus by involving a minimal number of healthcare staff and shortening the occupation of the operating theatre. In case of a lack of security measures to enable safe laparoscopy, open surgery should be considered.
Bone allografts are harvested and transplanted under sterile conditions. However, the risk of bacterial contamination of grafts during these processes is a health concern. Bioburden testing and ...bacterial contamination detection are conducted to ensure allograft sterility. The present study aimed to determine the incidence of bacterial contamination in bone allografts based on different classifications. A PROSPERO registration number was received for the study. Systematic searches were conducted in PubMed and EMBASE databases with relevant keywords from January 2000 to March 2021. After choosing related studies according to the PRISMA flow diagram, Stata software was used for data analysis. We considered I2˃50% as heterogeneity between studies. The overall incidence of bacterial contamination was 12.6% (95% confidence interval 0.100, 0.152) among 19,805 bone allografts of 17 studies. The bacterial contamination rate among bone allografts was 10.8% before 2010 and 14.7% from January 2010 to March 2021. The contamination frequency in Asia, Europe, and Australia was 11.5%, 14.3% and 5.2%, respectively. Bone contamination rates were higher in cadaver donors (19.9%), retrieval time sampling (13.5%), and swab samples (13.2%) compared with those in living donors (7.5%), implantation time sampling (6.9%), and bone fragments cultures (6.3%). Bacterial contamination was recovered 24.4%, 19.7%, 13.2%, and 21% from tibia, fibula, femoral, and other bones, respectively. Staphylococcus spp. was the predominant isolated bacteria from bones (63.2% of all isolated genera), followed by Propionibacterium spp. (10.6%). In conclusion, the high contamination of bone allografts is a health concern, indicating the need for more health monitoring and improvement of standards.
Background
Minimally invasive techniques for treating pilonidal disease are safe and effective alternatives to conventional surgery, with improved recovery time, cosmetic results, and pain control. ...The aim of this study was to evaluate the 5-year surgical outcomes of a single-center case series treated with endoscopic pilonidal sinus treatment (EPSiT).
Methods
We conducted a retrospective single-center analysis of all patients treated with EPSiT, by a single surgical team, from March 2015 to December 2019, for primary or recurrent pilonidal disease. The primary outcomes were recurrence, persistence and treatment failure. The secondary outcomes were postoperative pain, painkiller use, time off work, satisfaction, complications, wound healing time, time to persistence or recurrence.
Results
Forty-two patients underwent 46 EPSiT procedures 34 males, 8 females, median age 25 (IQR 13.75) years for primary (47.8%) or recurrent pilonidal disease (52.2%). All patients completed the follow-up median 62 (IQR 43) months. The single procedure healing rate was 76.1%. The healing rate for the first procedures plus the second EPSiT procedure (performed in 4 cases) was 83.3%. Among the 46 EPSiT procedures, we recorded six cases of persistence (13.0%) and five cases of recurrence (10.9%) The median operative time was 32.5 (IQR 18.75) minutes, the median pain score (visual analog scale) in week 1 was 2 (IQR 2), and the median time off work was 4 (IQR 2) days. Four patients (8.7%) experienced complications: serosanguineous (
n
= 2) or seropurulent discharge (
n
= 2). The satisfaction rate was 95.7%.
Conclusions
In our experience, EPSiT is safe, well accepted. and associated with a low level of postoperative pain, short hospitalization, short time off work, as well as optimal cosmetic results. Its failure rate is similar to that of excisional surgery.
Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The ...diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.
This study investigated the in vitro susceptibility of ceftobiprole and its potential synergistic activity in combination with other antimicrobials against 46 selected Gram-positive pathogens ...displaying resistance or decrease susceptibility to several drugs. The gradient-cross method was used to assess synergism between ceftobiprole and daptomycin, levofloxacin, linezolid, rifampicin and piperacillin/tazobactam. Time-kill curves were performed for seven representative isolates. Ceftobiprole MICs ranged from 0.25–6 mg/L for staphylococci; 4–≥32 mg/L for Enterococcus faecalis, and 0.38–≥32 mg/L for E. faecium. Ceftobiprole plus daptomycin was synergistic against all isolates. Ceftobiprole plus linezolid was synergistic against 4 isolates belonging to different species. Ceftobiprole plus levofloxacin was synergistic only against enterococci. In conclusion, ceftobiprole exhibited a potent in vitro antibacterial activity and exhibited synergy with daptomycin against all Gram-positive isolates, despite their antibiotic resistance phenotypes. The use of ceftobiprole in combination may provide a promising alternative therapy for the treatment of resistant Gram-positive infections.
•High in-vitro activity of ceftobiprole against Gram-positive isolates.•Synergistic activity was observed with daptomycin against all resistance phenotypes.•Promising alternative drug for the treatment of resistant Gram-positive strains.
Hemicolectomy is the treatment of choice for intestinal obstruction from right colon cancer. This review compares the laparoscopic vs open access in hemicolectomy for patients with right colon ...cancer.
A systematic review and meta-analysis of clinical studies published after January 2017 was performed according to the Prisma guidelines. The study has been recorded on the Prospero register (CRD42016044108).
Five studies were included for review. Only one anastomotic leak was reported in conventional open anastomosis group (1.9%) and none of the studies included in the meta-analysis reported re-operations during the first 30 postoperative days. The 30-day postoperative mortality did not differ between the two groups. The length of incision, blood loss, early mobilization after surgery, the 30-day postoperative overall complication rate and hospital length of stay were significantly shorter in the laparoscopic group. The difference in the duration of procedure was statistically significant in favor of the open group. The number of dissected lymph nodes, the overall survival at 5 years and time to flatus were described only in one study, without any significant difference. Finally, none of the trials reported any information concerning differences in the costs between the two techniques.
The better outcomes described in this study achieved with laparoscopy, must be interpreted with caution because of the small number of patients involved, the selection and publication bias and the low level of evidence of the analysed trials. Indeed, the advantages of a minimally invasive approach, which have been demonstrated by the present meta-analysis, should encourage the use of laparoscopy also in emergency setting.
Our aim was to describe the clinical and microbiological features of four cases of severe vancomycin-susceptible methicillin-resistant
Staphylococcus aureus
(MRSA) infections in which the vancomycin ...non-susceptibility development and daptomycin resistance occurred under therapy with teicoplanin (three cases) and daptomycin switched to vancomycin (one case). Clinical data were retrospectively reviewed. On nine clinical epidemiologically unrelated daptomycin-susceptible (DAP-S) and daptomycin-resistant (DAP-R) MRSA, we performed: (i) DAP-VAN-TEC-CFX-RIF minimum inhibitory concentrations (MICs); (ii) glycopeptide resistance detection (GRD) by δ-hemolysis; (iii) glycopeptide population analysis; (iv) molecular characterization by PFGE-MLST-SCC
mec
-
agr
-typing; (v)
rpo
B and
mpr
F single nucleotide polymorphisms (SNPs); (vi)
dlt
A-
mpr
F-
atl
-
sce
D expression by real-time quantitative polymerase chain reaction (qPCR). Three out of the four patients did not survive despite salvage treatment; two died with active MRSA infection and one died because of
Stenotrophomonas maltophilia
sepsis. The fourth patient, in which a reversion to a DAP-S phenotype occurred, survived with daptomycin plus trimethoprim/sulfamethoxazole and oxacillin treatment, and endovascular device removal. Daptomycin resistance development was preceded by a stable heterogeneous vancomycin-intermediate
S. aureus
(hVISA) or VISA phenotype acquisition, while in one case, daptomycin resistance was preceded by an unstable daptomycin heteroresistance (hDAP) behavior reverting to DAP-S during vancomycin plus rifampin therapy followed by high doses of daptomycin. All DAP-R strains showed hVISA or DAP-R traits, including mutations and/or up-regulation of genes involved in cell wall turnover and cell membrane perturbation. In our study, daptomycin resistance arose during glycopeptide therapy. The emergence of DAP-R isolates was preceded by a stable VISA or hVISA phenotype or by instability reverting to a DAP-S heteroresistant phenotype. Daptomycin, as first-line therapy for the treatment of severe MRSA infections, should be used at optimal dosage combined with other agents such as beta-lactams, to prevent daptomycin resistance occurrence.
Bloodstream infections due to
Staphylococcus aureus
(BSI) are serious infections both in hospitals and in the community, possibly leading to infective endocarditis (IE). The use of glycopeptides has ...been recently challenged by various forms of low-level resistance. This study evaluated the distribution of MSSA and MRSA isolates from BSI and IE in 4 Italian hospitals, their antibiotic susceptibility—focusing on the emergence of hVISA—and genotypic relationships. Our results demonstrate that the epidemiology of MRSA is changing versus different STs possessing features between community-acquired (CA)- and hospital-acquired (HA)-MRSA groups; furthermore, different MSSA isolated from BSI and IE were found, with the same backgrounds of the Italian CA-MRSA. The hVISA phenotype was very frequent (19.5%) and occurred more frequently in isolates from IE and in both the MSSA and MRSA strains. As expected, hVISA were detected in MRSA with vancomycin minimum inhibitory concentrations (MICs) of 1–2 mg/l, frequently associated with the major SCC
mec
I and II nosocomial clones; this phenotype was also detected in some MSSA strains. The few cases of MR-hVISA infections evaluated in our study demonstrated that 5 out of 9 patients (55%) receiving a glycopeptide, died. Future studies are required to validate these findings in terms of clinical impact.
If a structural system has to be subjected to high loads and large geometry changes, according to the state of the art, articulated systems with discrete actuators are used, with the articulated ...systems consisting of stiff members connected by hinges. As an alternative, smart structures technologies can supply solutions based on the deliberate use of structural flexibility and on distributed actuation. In order to assess the advantages, which can be expected from such solutions, a thorough comparison must be made between the properties of compliant mechanisms and the conventional ones. A crucial aspect of this comparison, on which this contribution is focused, is the impact on the system’s structural weight.
The first part of the paper deals with the relevance of weight penalty effects in shape-adaptable systems, with a special focus on airfoil shape control. A quantitative analysis of weight penalty effects in pin-jointed articulated structures follows. The criterion on which this analysis is based allows a characterization of general validity, not restricted to a particular example, and can be applied to other mechanisms or hinge architectures, providing a sound way of assessing the lightweight potential of a given concept and allowing a consistent comparison between different design philosophies. An extension to weight penalty effects in compliant systems shows a higher degree of complexity and could not be addressed in the same detail in this study. Anyway, some peculiar aspects are discussed in the final part of the paper, which can serve as a basis for future developments in this sense. In particular, the dependence of weight penalty effects on the system’s range of motion as well as on the load-dependence of the mechanism’s kinematics is addressed.
Even if the presented results can be of direct significance to the designer of conventional articulated mechanisms, the primary relevance of this work is to be seen in the long term. Its main target is to provide a basis for the analysis of the potential offered by the compliant mechanisms and smart materials for the realization of light shape-adaptable structures and to give an impulse to research efforts aiming at developing suitable optimization procedures as well as formulating proper design rules for such kind of systems.
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