The bacteriology of primary wound sepsis in potentially contaminated abdominal operations: the effect of irrigation, povidone-iodine and cephaloridine on the sepsis rate assessed in a clinical trial

Two hundred and nine potentially contaminated abdominal operations were randomly allocated to prophylaxis with a single dose of 1 g cephaloridine intraincisionally, irrigation of the wound at the end of the operation with saline or spraying of the wound with povidone-iodine. In high risk operations (ileocolorectal or those in obese patients) the rate of major wound sepsis in those protected by cephaloridine was 3.8% compared with 13.2% in the irrigation and 16.7% in the povidone-iodine groups. In low risk operations no significant differences in sepsis rates were found. Bacteriological studies of incised organs, subcutaneous fat and pus showed that the majority of wound infections arose from endogenous sources. The outstanding problem remains that of prevention of contamination of the abdominal wall during surgery.

Abdominal wound closure: a trial of nylon, polyglycolic acid and steel sutures

Failures after abdominal wound closure (early dehiscences and late incisional hernias) are due to breakage of sutures, slippage of knots or tearing out of sutures from the tissues. The suture-holding capacity of the entire thickness of muscle and aponeurosis is nearly twice that of the anterior rectus sheath, and deep bites (1-0 cm from the cut edges) are nearly twice as secure as bites of 0-5 cm. In a random controlled clinical trial of 357 major laparotomies, closure with either layered monofilament nylon or mass polyglycolic acid or steel resulted in 2 burst abdomens (0-56%), 10 incisional hernias due to suture failure (3-4%) and 8 incisional hernias caused by deep sepsis (2-7%). There were no statistically significant differences among the treatment groups, but 1 patient in the nylon and 3 in the steel groups had persistent sinuses until their sutures were removed.

Primary hyperparathyroidism in a child. Use of jugular venous catheterization in diagnosis

A 10-year-old boy with a parathyroid ademona is reported. Parathyroid hormone estimations of samples obtained by selective jugular venous catheterization were useful in diagnosis and for localizing the tumour before operation.

Single dose intra-incisional antibiotic prophylaxis of surgical wound sepsis: a controlled trial of cephaloridine and ampicillin

In a series of 410 consecutive potentially contaminated operations, we have compared the relative efficacy of intra-incisional cephaloridine and ampicillin in single doses of 1 g in 2 ml of water. In high risk operations (ileocolorectal surgery, perforated appendicitis, or when the patient has 2-5 cm or more of subcutaneous fat at the site of the incision) cephaloridine prophylaxis resulted in a primary sepsis rate of 14 per cent compared with 36 per cent for ampicillin. In all other patients the two antibiotics were equally effective. Secondary sepsis, following discharge from the wound of a substance other than pus, was equally common in the two groups.

Wound sepsis after cholecystectomy: effect of incidental appendicectomy

The records of a consecutive series of 224 patients were analysed to discover the effect of incidental appendicectomy on the wound sepsis rate after cholecystectomy. One hundred and five patients had had a cholecystectomy alone and 119 cholecystectomy with incidental appendicectomy. The incidence of wound sepsis in patients not given adequate antibiotic prophylaxis was significantly lower (16-1%) when cholecystectomy alone was carried out than when the appendix was removed as well (41-1%).

The acute effects of ethanol on liver and brain tryptophan metabolism

1. The effects of acute ethanol administration of liver and brain tryptophan metabolism are reviewed. 2. Ethanol enhances the activity of rat liver tryptophan pyrrolase by increasing the availability of circulating free tryptophan to the liver by catecholamine-mediated lipolysis followed by displacement of protein-bound serum tryptophan. 3. The response of the mouse liver enzyme to ethanol is strain-dependent. Ethanol activates the enzyme in CBA/CA but not in C57/BL mice. 4. Ethanol exerts a biphasic effect on the concentrations of rat brain tryptophan, 5-hydroxytryptamine and 5-hydroxyindol-3-ylacetic acid. 5. Both aspects of this biphasic effect are associated with an altered availability of circulating free tryptophan. 6. The initial enhancement by ethanol of brain tryptophan metabolism may be due to the above-mentioned lipolytic mechanism, whereas the subsequent decrease in brain indoles may be caused by the enhanced tryptophan pyrrolase activity. 7. Brain tryptophan metabolism is decreased by ethanol in CBA/CA whereas no change is observed in that in C57/BL mice. 8. These results are discussed in relation to previous work on the acute effects of ethanol on rat and mouse brain 5-hydroxytryptamine metabolism.

The role of free serum tryptophan in the biphasic effect of acute ethanol administration on the concentrations of rat brain tryptophan, 5-hydroxytryptamine and 5-hydroxyindol-3-ylacetic acid

1. Acute administration of ethanol exerts a biphasic effect on the concentrations of rat brain tryptophan, 5-hydroxytryptamine and 5-hydroxyindol-3-ylacetic acid. Both effects are associated with corresponding changes in the availability of circulating free tryptophan. 2. The initial increases in the above concentrations are prevented by ergotamine, are unaltered by allopurinol and are potentiated by theophylline, whereas the later decreases are prevented by both ergotamine and allopurinol. 3. It is suggested that the initial enhancement by ethanol of brain tryptophan metabolism is caused by catecholamine-mediated lipolysis followed by displacement of protein-bound serum tryptophan, whereas the activation of liver tryptophaan pyrrolase, which is produced by the same mechanism, leads to the later decreases in the brain concentrations of tryptophan and its metabolites. 4. The initial effects of ethanol can be reproduced by an equicaloric dose of sucrose, and a comparison of the two treatments alone could therefore be misleading. 5. The effects of ethanol on liver and brain tryptophan metabolism have also been examined in mice, and a comparison of the results with those previously reported suggests that the ethanol effects are strain-dependent.

Animal liver tryptophan pyrrolases: Absence of apoenzyme and of hormonal induction mechanism from species sensitive to tryptophan toxicity

1. Liver tryptophan pyrrolase exists as holoenzyme and apoenzyme in rat, mouse, pig, turkey, chicken and possibly man. 2. The apoenzyme is absent from cat, frog, gerbil, guinea pig, hamster, ox, sheep and rabbit. 3. The hormonal mechanism of induction of the pyrrolase is absent from species lacking the apoenzyme. 4. The concentrations of tryptophan in livers and sera of these species are lower than in species possessing the apoenzyme. 5. Species lacking the apoenzyme or the hormonal induction mechanism have a deficient kynurenine pathway and are sensitive to the toxicity of tryptophan. 6. It is suggested that these species are not suitable as models for studying human tryptophan metabolism. 7. The possible significance of these findings in relation to veterinary and human neonatal care is discussed.

The regulation of rat liver tryptophan pyrrolase activity by reduced nicotinamide-adenine dinucleotide (phosphate). Experiments with glucose and nicotinamide

1. Chronic administration of glucose or nicotinamide in drinking water inhibits the activity of rat liver tryptophan pyrrolase, and subsequent withdrawal causes an enhancement. The enzyme activity is also inhibited by administration in drinking water of sucrose, but not fructose, which is capable of preventing the glucose effect. 2. The inhibition by glucose or nictinamide is not due to a defective apoenzyme synthesis nor a decreased cofactor availability. 3. The inhibition by nicotinamide is reversed by regeneration of liver NAD+ and NADP+ in vivo by administration of fructose, pyruvate or phenazine methosulphate. Inhibition by glucose is also reversed by the above agents and by NH4Cl. Reversal of inhibition by glucose or nicotinamide is also achieved in vitro by addition of NAD+ or NADP+. 4. Glucose or nicotinamide increases liver [NADPH]. [NADP+] is also increased by nicotinamide. [NADPH] is also increased by sucrose, but not by fructose, which prevents the glucose effect. Phenazine methosulphate prevents the increase in [NADPH] caused by both glucose and nicotinamide. 5. It is suggested that the inhibition of tryptophan pyrrolase activity by glucose or nicotinamide is mediated by both NADPH and NADH.

Predictive value of cervical dilatation rates. I. Primipara labor

A modified version of Philpott's partogram was used to analyze primipara labor in Israel. The rate of cervical dilatation measure early in the active phase of labor (initial rate) is an accurate indicator of the outcome of labor. Ninety-three percent of primiparas with an initial cervical dilatation rate of 1.00 cm/hour or more delivered spontaneously. Seventy-six percent of those with an initial cervical dilatation rate of less than 1.00 cm/hour required an assisted delivery (forceps or vacuum) or cesarean section. The mean cervical dilatation rate for spontaneous deliveries as measured early in the active phase was 1.75 cm/hour. Patients needing an assisted delivery had a mean cervical dilatation rate of 0.93 cm/hour, and for cesarean section deliveries the mean rate was 0.42 cm/hour. No significant differences were observed among patients of different ethnic origins. The initial cervical dilatation rate proves to be useful in early identification of those patients who deliveries were complicated. The method avoids complicated cervicographs and is simple and reliable.

Changing patterns of bacterial resistance in relation to prophylactic use of cephaloridine and therapeutic use of ampicillin

Antibiotic sensitivities of 15302 organisms of common pathogenic species isolated in one hospital pathology department in 1971 and 1974 have been studied. Resistance to cephaloridine did not change materially. The proportion of strains resistant to ampicillin did, however, increase, and this is attributed to the widespread therapeutic use of the antibiotic. Cephaloridine, on the other hand, was largely used in the hospital as a single-dose, intra-incisional prophylactic against surgical wound sepsis.

Regulation of rat liver tryptophan pyrrolase by its cofactor haem: Experiments with haematin and 5-aminolaevulinate and comparison with the substrate and hormonal mechanisms

1. The administration of haematin or 5-aminolaevulinate to rat enhances the activity of liver tryptophan pyrrolase; both endogenous and newly formed apoenzymes become strongly haem-saturated. Haem activation does not stabilize tryptophan pyrrolase. 2. Actinomycin D, puromycin or cycloheximide prevent the activation of the enzyme by 5-aminolaevulinate but not that by haematin. The latter is inhibited by haem-destroying porphyrogens. 3. The combined injection of either haematin or 5-aminolaevulinate with cortisol does not produce an additive effect, whereas potentation is observed when tryptophan is jointly given with either the cofactor or the haem precursor. 4. Further experiments on the substrate (tryptophan) mechanism of pyrrolase regulation are reported, and a comparison between this and the cofactor and hormonal mechanisms is made. 5. It is suggested that the substrate mechanism may also involve increased haem synthesis. 6. The role of tryptophan pyrrolase in the utilization of liver haem, and as a possible model for the exacerbation by drugs of human hepatic porphyrias, is discussed.

The effects of acute and chronic nicotine hydrogen (+)-tartrate administration and subsequent withdrawal on rat liver tryptophan pyrrolase activity and their comparison with those of morphine, phenobarbitone and ethanol

Acute administration of nicotine hydrogen (+)-tartrate enhances the activity of rat liver tryptophan pyrrolase by a hormonal mechanism. Chronic nicotine treatment inhibits, and subsequent withdrawal enhances, the pyrrolase activity. The inhibition during chronic treatment is not due to a defective apoenzyme synthesis nor a decreased cofactor availability. Regeneration of liver NADP+ in vitro and in vivo reverses the inhibition. Chronic nicotine administration increases the liver NADPH concentration. The above effects of nicotine resemble to a remarkable degree those previously shown for morphine, phenobarbitone and ethanol. All effects are compared, and their possible significance in relation to drug dependence is discussed.

Povidone-iodine for the control of surgical wound infection: a controlled clinical trial against topical cephaloridine

One hundred and ninety-two operation wounds ina general surgical practice were randomly allocated to receive either topical cephaloridine or a providone-iodine spray, and the rate of wound sepsis was studied. In all types of operation cephaloridine proved superior to providone-iodine as a prophylactic, the difference reaching a significant level in potentially contaminated wounds.

Prophylaxis of postoperative leg vine thrombosis by low dose subcutaneous heparin or peroperative calf muscle stimulation: a controlled clinical trial

In a randomized, controlled clinical trial of two methods of preventing postoperative leg vein thrombosis patients undergoing major surgery were divided into three groups. One received intermittent electrical calf muscle stimulation during surgery, the second subcutaneous heparin calcium 5000 IU every eight hours for six days, and the third no specific prophylaxis. Leg vein thrombosis was detected by the 125-I-fibrinogen uptake test. Neither method was effective in patients undergoing open bladder or prostatic surgery. Stimulation did not reduce the incidence of leg vein thrombosis in patients with malignant disease undergoing laparotomy, but heparin calcium was highly successful in this group (P smaller than 0-001). When the laparotomy was for a benign condition, however, both heparin calcium (P smaller than 0-001) and stimulation (P smaller than 0-01) were effective.

Aortic endothelial mitosis and Evans blue uptake in cholesterol-fed subscorbutic guinea-pigs

SUMMARY

Groups of ovalbumin sensitised, subscorbutic guinea-pigs were subjected to various regimens for 8-10 weeks. Group 1 were given 0.25 mg/100 g body wt. cholesterol by mouth daily and were stressed with intraperitoneal injections of ovalbumin twice weekly. Group 2 received the cholesterol only and Group 3 were stressed only. Group 4 on the low vitamin C diet only acted as controls. Evans blue uptake tests and tritiated thymidine autoradiographs of Häutchen preparations of aortic endothelium were made on each animal. Endothelial mitosis was greatest in those areas of the aorta that had taken up the Evans blue most avidly. This was most apparent in Group 1, though to a lesser extent in Groups 2 and 3 also. Group 4 showed no dye uptake and the mitotic index was not raised. Blood ascorbic acid and plasma cholesterol levels are given for the various groups.

The incidence and causes of postoperative jaundice. A prospective study

Jaundice often complicates recovery after surgery. We have studied 180 patients undergoing 218 major operations and found an incidence of 3.7% severe jaundice and 16.5% mild jaundice. The causes of the jaundice were diverse, but the most important was a bilirubin overload (primarily from blood transfusion) which could not be excreted effectively by a liver whose cellular metabolism was disturbed. We found no evidence of a relationship between halothane and liver damage.

Guinea-pig liver tryptophan pyrrolase. Absence of detectable apoenzyme activity and of hormonal induction by cortisol and possible regulation by tryptophan

1. When assayed in fresh homogenates, guinea-pig liver tryptophan pyrrolase exists only as holoenzyme. It does not respond to agents that activate or inhibit the rat liver enzyme in vitro. Only by aging (for 30min at 5 degrees C) does the guinea-pig enzyme develop a requirement for ascorbate. 2. The guinea-pig liver enzyme is activated by the administration of tryptophan but not cortisol, salicylate, ethanol or 5-aminolaevulinate. 3. The tryptophan enhancement of the guinea-pig liver pyrrolase activity is prevented by 0, 34 and 86% by pretreatment with actinomycin D, cycloheximide or allopurinol respectively. 4. The guinea-pig liver tryptophan pyrrolase is more sensitive to tryptophan administration than is the rat enzyme. On the other hand, the concentrations of tryptophan in sera and livers of guinea pigs are 45-52% less than those in rats. 5. It is suggested that tryptophan may regulate the activity of guinea-pig liver tryptophan pyrrolase by mobilizing a latent form of the enzyme whose primary function is the detoxication of its substrate.

The effects of chemical porphyrogens and drugs on the activity of rat liver tryptophan pyrrolase

1. Drugs such as phenobarbitone and phenylbutazone, which increase the concentration of microsomal haem and cytochrome P-450, also increase the saturation of rat liver apo-(tryptophan pyrrolase) with its haem activator, as does the haem precursor 5-aminolaevulinate. 2. At 4h after the administration of the porphyrogens 2-allyl-2-isopropylacetamide, 3,5-diethoxycarbonyl-1,4-dihydrocollidine and griseofulvin, the total pyrrolase activity is increased whereas the haem saturation of the apoenzyme is decreased. This decreased saturation is prevented by pretreatment of the animals with the inhibitor of drug-metabolizing enzymes, SKF 525-A. 3. Pretreatment of rats with the above porphyrogens inhibits the rise in holo-(tryptophan pyrrolase) activity produced by subsequent administration of cortisol, tryptophan and 5-aminolaevulinate with two single exceptions, the possible reasons for which are discussed. 4. At 24h after the administration, in starved rats, of a single daily injection of the above porphyrogens for 1 or 2 days, the holoenzyme activity is significantly increased. 5. It is suggested that the saturation of rat liver apo-(tryptophan pyrrolase) with its haem activator can be modified by treatment known to cause destruction, inhibition of synthesis, increased utilization and enhanced synthesis of liver haem. The possible involvement of the latter phenomenon in the aetiology of mental disorders in some patients with porphyria is discussed.

The effects of therapeutic decrease in packed cell volume on the responses to exercise of patients with polycythaemia secondary to lung disease

1. Progressive exercise and circulatory studies are reported on a selected group of patients with hypoxaemia and secondary polycythaemia before and after therapeutic decrease of packed cell volume.

2. A significant increase in exercise tolerance was demonstrated in a group of seven patients who claimed subjective benefit from the treatment.

3. No important circulatory changes were detected at rest after treatment.

4. During steady exercise mean pulmonary artery pressure at any given cardiac out-put was lower after treatment suggesting a fall in pulmonary vascular resistance.

5. During steady exercise oxygen consumption was increased in five of six patients subjectively improved by the treatment but no consistent changes in arterial lactate concentration or lactate/pyruvate ratio were observed.