[INTRAOPERATIVE RADIOTHERAPY (IORT) IN EARLY BREAST CANCER - 500 PATIENTS, ONE CENTER'S EXPERIENCE]

AIMS

To present our Institute's experience with intraoperative radiotherapy in this selected population by collecting and analyzing clinical data, including long-term follow-up.

BACKGROUND

Breast-conserving therapy is the standard treatment for early-stage breast cancer. The treatment includes tumor resection and a whole breast irradiation. Intraoperative radiotherapy is a single dose of irradiation given to the tumor bed immediately after it is removed. This treatment is suitable for a selected population of patients with early stage breast cancer, which constitutes about 20% of all breast cancer patients and is supposed to replace the standard whole breast radiation treatment.

METHODS

Between the years 2006-2017, 737 women with early breast cancer were treated in Carmel Medical Center with intraoperative radiotherapy. We herein report the results of the first 500 patients who were treated until 2015.

RESULTS

In 13.8% of the patients, additional breast treatment was recommended due to poor pathological characteristics of the disease in final pathological examination. During a median follow-up period of 74 months (1-136), recurrence was observed in 22 patients (4.4%), and in 7 patients (1.4%) recurrence was observed in regional lymph nodes; 13 patients (2.6%) developed metastatic disease. Risk factors for regional recurrence were identified: tumor size greater than 2 cm, lack of adjuvant therapy and poor genetic profile of the disease.

CONCLUSIONS

Intraoperative radiotherapy is feasible and may offer an alternative to the standard whole breast radiotherapy, in low risk early breast cancer patients. The patients should be selected according to known risk factors.

SEIS: Insight's Seismic Experiment for Internal Structure of Mars

By the end of 2018, 42 years after the landing of the two Viking seismometers on Mars, InSight will deploy onto Mars' surface the SEIS (Seismic Experiment for Internal Structure) instrument; a six-axes seismometer equipped with both a long-period three-axes Very Broad Band (VBB) instrument and a three-axes short-period (SP) instrument. These six sensors will cover a broad range of the seismic bandwidth, from 0.01 Hz to 50 Hz, with possible extension to longer periods. Data will be transmitted in the form of three continuous VBB components at 2 sample per second (sps), an estimation of the short period energy content from the SP at 1 sps and a continuous compound VBB/SP vertical axis at 10 sps. The continuous streams will be augmented by requested event data with sample rates from 20 to 100 sps. SEIS will improve upon the existing resolution of Viking's Mars seismic monitoring by a factor of ∼ 2500 at 1 Hz and ∼ 200 000 at 0.1 Hz. An additional major improvement is that, contrary to Viking, the seismometers will be deployed via a robotic arm directly onto Mars' surface and will be protected against temperature and wind by highly efficient thermal and wind shielding. Based on existing knowledge of Mars, it is reasonable to infer a moment magnitude detection threshold of M w ∼ 3 at 40 ∘ epicentral distance and a potential to detect several tens of quakes and about five impacts per year. In this paper, we first describe the science goals of the experiment and the rationale used to define its requirements. We then provide a detailed description of the hardware, from the sensors to the deployment system and associated performance, including transfer functions of the seismic sensors and temperature sensors. We conclude by describing the experiment ground segment, including data processing services, outreach and education networks and provide a description of the format to be used for future data distribution.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s11214-018-0574-6) contains supplementary material, which is available to authorized users.

Four steps to clean hospitals: LOOK, PLAN, CLEAN and DRY

BACKGROUND

Now that cleaning and decontamination are recognized as integral to infection control, it is timely to examine the process in more detail. This is because cleaning practices vary widely within healthcare districts, and it is likely that both time and energy are needlessly wasted with ill-defined duties. Furthermore, inadequate cleaning will not reduce the risk of infection but may even enhance it. The process would benefit from a systematic appraisal, with each component placed within an evidence-based and ordered protocol.

METHODS

A literary search was performed on 'hospital cleaning', focusing on manual aspects of cleaning, pathogen reservoirs and transmission, hand hygiene, staff responsibilities and patient comfort.

RESULTS

No articles providing an evidence-based practical approach to systematic cleaning in hospitals were identified. This review therefore proposes a simple four-step guide for daily cleaning of the occupied bed space. Step 1 (LOOK) describes a visual assessment of the area to be cleaned; Step 2 (PLAN) argues why the bed space needs preparation before cleaning; Step 3 (CLEAN) covers surface cleaning/decontamination; and Step 4 (DRY) is the final stage whereby surfaces are allowed to dry.

CONCLUSION

Given the lack of articles providing practical cleaning guidance, this review proposes a four-step protocol based on evidence if available, or justified where not. Each step is presented, discussed and risk-assessed. It is likely that a systematic cleaning process would reduce the risk of healthcare-associated infection for everyone, including outbreaks, in addition to heightened confidence in overall quality of care.

[Spectrum of pathogens in postoperative complications of visceral surgery : The problem of multidrug resistance]

In general surgery the etiology of surgical site infections has not significantly changed over the last 30 years. Gram-positive bacteria, e.g. coagulase negative staphylococci (CNS), Staphylococcus aureus and Enterococcus spp. as well as Gram-negative bacteria, e.g. Escherichia coli, Enterobacter spp., Klebsiella spp. and Pseudomonas aeruginosa, are the most common findings. Although in general surgery 10% of the S. aureus causing postoperative wound infections were methicillin resistant (MRSA), no cases of multidrug-resistant Gram-negative (MRGN) bacteria were reported. Yeasts (particularly Candida spp.) are rarely the pathogen causing surgical site infections (≤3%) and concomitant risk factors are typical (e.g. diabetes, chemotherapy, immunosuppression and malnutrition). Viruses are rarely the cause of surgical site infections. Transmission can occur by HBV, HCV or HIV positive surgical staff or in organ transplantations and postoperative reactivation of persistent infections is possible (especially for HBV, HCV, CMV, EBV and HIV). The principles for prevention of surgical site infections are dealt with as consequences of preoperative colonization by MRSA, methicillin-sensitive S. aureus (MSSA) and MRGN and reviewed with respect to screening, perioperative antibiotic prophylaxis and decolonization. In nosocomial peritonitis, the selection of antibiotics should consider previous antibiotic treatment. A single intra-abdominal detection of Candida spp. usually does not require antimycotic treatment in postoperatively stable and immunocompetent patients but is recommended in severe community-acquired or nosocomial peritonitis. Viral infections can be avoided by screening of organ donors and serological surveillance of surgery personnel.

[Enterococci and surgical site infections : Causal agent or harmless commensals?]

BACKGROUND

The role of enterococci in the context of peritonitis and surgical site infections (SSI) has not yet been definitively clarified but enterococci are being detected more frequently. Numerous resistances reduce the available antibiotic options.

OBJECTIVE

This article gives an overview of the pathogenic importance of enterococci and of current recommendations for therapy and prophylaxis. On the basis of our own data we discuss the relevance of enterococci for SSI.

MATERIAL AND METHODS

All colorectal resections carried out between January 2008 and September 2016 were retrospectively documented. Revision surgery, SSI and intra-abdominally or subcutaneously detected pathogens were recorded.

RESULTS

A total of 2713 interventions were evaluated with 28.3% having primary peritonitis. In 587 patients (21.6%) SSI followed, and pathogen determination was possible in 431 cases (73.4%). Enterococci were frequently found in re-operations (58.4%) and SSI (46.1%), with E. faecalis and E. faecium in approximately equal proportions. If intra-abdominal enterococci were detectable in patients with primary peritonitis, it was more common to develop SSI and enterococci were more frequently detected subcutaneously. Enterococci in SSI were found to be significantly more frequent in left hemicolectomies as well as in pre-existing renal insufficiency.

CONCLUSION

It can be inferred that enterococci are not adequately covered by commonly used perioperative antibiotic therapy or preoperative prophylaxis, which increases the risk for SSI by enterococci. This could be favored by selection of these pathogens due to the use of antibiotics without enterococcal efficacy (e. g. cephalosporins). The consideration in the choice of perioperative antibiotic prophylaxis by the additional administration of ampicillin or vancomycin could be advantageous.

Comparison of chlorhexidine–isopropanol with isopropanol skin antisepsis for prevention of surgical-site infection after abdominal surgery

Background

Prevention of surgical-site infection (SSI) has received increasing attention. Clinical trials have focused on the role of skin antisepsis in preventing SSI. The benefit of combining antiseptic chlorhexidine with alcohol has not been compared with alcohol-based skin preparation alone in a prospective controlled clinical trial.

Methods

Between August and October 2014, patients undergoing abdominal surgery received preoperative skin antisepsis with 70 per cent isopropanol (PA). Those treated between November 2014 and January 2015 received 2 per cent chlorhexidine with 70 per cent isopropanol (CA). The primary endpoint was SSI on postoperative day (POD) 10, which was evaluated using univariable analysis, and a multivariable logistic regression model correcting for known independent risk factors for SSI. The study protocol was published in the German Registry of Clinical Studies (DRKS00011174).

Results

In total, 500 patients undergoing elective midline laparotomy were included (CA 221, PA 279). The incidence of superficial and deep SSIs was significantly different on POD 10: 14 of 212 (6·6 per cent) among those treated with CA and 32 of 260 (12·3 per cent) in those who received PA (P = 0·038). In the multivariable analysis, skin antisepsis with CA was an independent factor for reduced incidence of SSI on POD 10 (P = 0·034).

Conclusion

This study showed a benefit of adding chlorhexidine to alcohol for skin antisepsis in reducing early SSI compared with alcohol alone.

Effect of antiseptic irrigation on infection rates of traumatic soft tissue wounds: a longitudinal cohort study

OBJECTIVE

Acute traumatic wounds are contaminated with bacteria and therefore an infection risk. Antiseptic wound irrigation before surgical intervention is routinely performed for contaminated wounds. However, a broad variety of different irrigation solutions are in use. The aim of this retrospective, non-randomised, controlled longitudinal cohort study was to assess the preventive effect of four different irrigation solutions before surgical treatment, on wound infection in traumatic soft tissue wounds.

METHOD

Over a period of three decades, the prophylactic application of wound irrigation was studied in patients with contaminated traumatic wounds requiring surgical treatment, with or without primary wound closure. The main outcome measure was development of wound infection. From 1974-1983, either 0.04 % polihexanide (PHMB), 1 % povidone-iodine (PVP-I), 4 % hydrogen peroxide, or undiluted Ringer's solution were concurrently in use. From 1984-1996, only 0.04 % PHMB or 1 % PVP-I were applied. From 1997, 0.04 % PHMB was used until the end of the study period in 2005.

RESULTS

The combined rate for superficial and deep wound infection was 1.7 % in the 0.04 % PHMB group (n=3264), 4.8 % in the 1 % PVP-I group (n=2552), 5.9 % in the Ringer's group (n=645), and 11.7 % in the 4 % hydrogen peroxide group (n=643). Compared with all other treatment arms, PHMB showed the highest efficacy in preventing infection in traumatic soft tissue wounds (p<0.001). However, compared with PVP-I, the difference was only significant for superficial infections.

CONCLUSION

The large patient numbers in this study demonstrated a robust superiority of 0.04 % PHMB to prevent infection in traumatic soft tissue wounds. These retrospective results may further provide important information as the basis for power calculations for the urgently needed prospective clinical trials in the evolving field of wound antisepsis.

[Acute therapeutic measures for limb salvage Part 2 : Debridement, lavage techniques and anti-infectious strategies]

The quality of the primary care of Gustilo-Anderson (GA) type IIIB and IIIC extremity injuries is crucial to the success of the limb salvage procedure. This article provides a compilation of consistent, but often controversially discussed aspects of initial debridement, modern techniques of lavage and wound closure, in addition to current issues on the application of antibiotics and antiseptics, based on our own experiences and the latest literature. The following points should be stressed. Severe extremity injuries with gross contamination (GA IIIA, B, and C) will still be associated with an infection rate of up to 60 %. The initial debridement should be performed as soon as an experienced trauma surgeon is available. Tissue that is definitely avital will have to be removed, whereas traumatized but potentially surviving tissue will have to be re-evaluated during a second-look operation after 36-48 h. Given a high enough level of contamination, biofilms will form after as few as 6 h. The perioperative antibiotic prophylaxis has to be initiated early and should be continued for at least 24 h (GA I/II) or up to 5 days (GA III). In cases of bacterial contamination, wound irrigation will be useful with additives such as polyhexanide, octenidine or superoxidized water. Rinsing of the wound should be performed with 3-9 L and only slight manual pressure (no jet lavage). The definitive primary closure of a wound should be achieved in the initial operation, but only in the case of certain "decontamination" and overall vitality of the wound (GA I and II). In the presence of high-grade injuries, a temporary vacuum sealing technique can be used until the earliest possible definitive plastic surgical wound closure.

Conditioning hops increase triceps surae muscle force and Achilles tendon strain energy in the stretch-shortening cycle

Postactivation potentiation can improve athletic performance, but the underlying mechanisms are poorly understood. This study investigated the effect of conditioning hops on triceps surae muscle force and tendon strain and its contribution to potentiated stretch-shortening cycle (SSC) performance. Thirty-two subjects participated in two experiments. In both experiments, subjects performed three drop jumps (DJs) after prior conditioning with 10 maximal hops, three unconditioned DJs served as control. Ground reaction forces, kinematics, and triceps surae electromyographic activity were recorded. Ultrasound imaging was used to determine fascicle lengths (FASC) of the gastrocnemius (GM) and soleus muscles (experiment 1) and the length of the Achilles tendon (experiment 2) during the DJs. DJ height after the conditioning hops was significantly higher compared to control DJs (experiment 1: +12% and experiment 2: +19%). A significantly shorter GM FASC during the DJs performed after the conditioning hops coincided with an increased force acting on the triceps surae muscle. Moreover, the triceps surae muscle-tendon unit (MTU) showed increased energy absorption during the eccentric phase of the DJs and increased energy release during the concentric phase. The second experiment revealed a higher Achilles tendon strain in DJs performed after the conditioning hops compared to control DJs. No significant differences in muscle activities were observed. The shorter FASC in GM and the larger Achilles tendon strain facilitated MTU energy transfer from the eccentric to the concentric phase during the DJ. Thereby, conditioning hops improved SSC efficacy and DJ performance.

Postactivation potentiation can counteract declines in force and power that occur after stretching

Stretching can decrease a muscle's maximal force, whereas short but intense muscle contractions can increase it. We hypothesized that when combined, postactivation potentiation induced by reactive jumps would counteract stretch-induced decrements in drop jump (DJ) performance. Moreover, we measured changes in muscle twitch forces and ankle joint stiffness (K_Ankle ) to examine underlying mechanisms. Twenty subjects completed three DJs and 10 electrically evoked muscle twitches of the triceps surae subsequent to four different conditioning activities and control. The conditioning activities were 10 hops, 20s of static stretching of the triceps surae muscle, 20s of stretching followed by 10 hops, and vice versa. After 10 hops, twitch peak torque (TPT) was 20% and jump height 5% higher compared with control with no differences in K_Ankle . After stretching, TPT and jump height were both 9% and K_Ankle 6% lower. When hops and stretching were combined as conditioning activities, jump height was not different compared with control but significantly higher (11% and 8%) compared with stretching. TPTs were 16% higher compared with control when the hops were performed after stretching and 9% higher compared with the reverse order. K_Ankle was significantly lower when stretching was performed after the hops (6%) compared with control, but no significant difference was observed when hops were performed after stretching. These results demonstrate that conditioning hops can counteract stretch-related declines in DJ performance. Furthermore, the differences in TPTs and K_Ankle between combined conditioning protocols indicate that the order of conditioning tasks might play an important role at the muscle-tendon level.