Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey

Purpose

Evidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent.

Methods

Surgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined.

Results

The study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these.

Conclusion

In the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.

Ion trap MS(n) genealogical mapping-approaches for structure elucidation of novel products of consecutive fragmentations of morphinans

The analysis of data within multi-generational, genealogical, electrospray ionization/MS(n) fragmentation maps is discussed in reference to the structure elucidation of morphinans, an important class of pharmacological compounds. Various general approaches to separate and understand observed processes are discussed. These include: (1) Simple synthetic schemes incorporating deuterium and (13)C into morphinans to study later-generation, O-methyl group migration; (2) labeling to understand 'intense' signals for even-electron to odd-electron ion 'switching' events; (3) gas phase 'synthesis' of proposed MS(3) ions via an independent route, using chemical ionization (CI) MS/MS of naphthalenes and analysis via a bench-top El/Cl ion trap; (4) a useful synthetic paradigm for generating proposed carbonium ion structures at MS(4) via electrospray ionization (ESI) of easily synthesized amines; (5) the analysis of an oxidation product and correlation of MS(n) data of a switched, odd-electron species with electron ionization and low-pressure, low-energy charge exchange data; and (6) a new way of summarizing MS(n) data. Copyright -Copyright 2000 John Wiley & Sons, Ltd.

Ultrafast Optical Excitation of a Combined Coherent-Squeezed Phonon field in SrTiO3

We have simultaneously excited a coherent and a squeezed phonon field in SrTiO3 using femtosecond laser pulses and stimulated Raman scattering. The frequency of the coherent state (a 1.3 THz) is that of the A1g-component of the soft mode responsible for the cubic-tetragonal phase transformation at approximately 110 K. The squeezed field involves a continuum of transverse acoustic phonons dominated by a narrow peak in the density of states at a 6.9 THz.

Use of the laser in the oral cavity

Literature on head and neck oncology continues to support the use of lasers in surgery of malignant and premalignant lesions of the oral cavity. This article explores the indications, techniques, results, and complications of laser use for surgery involving these lesions. Highlighted is the carbon dioxide laser, which is well suited for transoral resections of premalignant lesions and early carcinomas in the oral cavity. In this study the local control, the 5-year survival rates, and the postoperative function with the carbon dioxide laser are at least comparable with those obtained using other surgical methods. The neodymium:yttrium-aluminum-garnet laser, which has specific advantages in the treatment of large vascular malformations of the oral cavity because of its unique characteristics, is also discussed.

A new lease of life. Nursing care of elderly surgical patients

Advances in surgical techniques have meant more elderly people can now be operated on. Older people are, however, more prone to postoperative complications and require greater preoperative preparation. Forward planning and setting high standards for nursing care are prerequisites in this area of care.

Pseudallescheria boydii keratitis

We treated a case of post-traumatic keratitis caused by the soil saprophyte, Pseudallescheria boydii. The injury was caused by a wood splinter which produced a perforating corneal laceration that was primarily repaired. Signs of corneal infection were not evident until the fourth postoperative week. The organism was eradicated by topical miconazole and natamycin. Subsequent penetrating keratoplasty combined with cataract extraction and intraocular lens implantation has achieved a good visual outcome.

Use of skin staplers in experimental gastrointestinal injuries

Undocumented reports exist concerning use of skin staplers to close small perforations of the gut. This study examined use of this device in experimental gastrointestinal injuries in dogs. In 18 anesthetized mongrel dogs, matching uniform perforations were made with a sterile leather punch; one perforation of each pair was closed with 3-0 silk and the other with a skin stapler. A total of 80 stomach, 238 small intestine, and 140 colon perforations were created. Hole sizes progressed from 1.9 to 5.0 mm. Unrepaired intestinal wounds leaked and were lethal. No leaks were identified in wounds closed with either sutures or staples provided that closure was complete. Speed of staple closure was faster than that of suture closure (1.2 vs. 16.0 seconds), but ease of closure was similar. It is concluded that skin staplers are safe for repair of small wounds, created under ideal conditions, in canine gastrointestinal tracts. Similar injuries in traumatized humans deserve study, but existing skin staplers may be ineffective for human intestine since gut wall thickness in humans is less than that in dogs.

A natural way to go? Death and bereavement in old age

Death in old age is viewed as 'natural', and bereavement is seen as one of the many losses encountered in later life. All too often, little thought is given to the specific needs of older people in these circumstances. This article seeks to give an overview of their situation, looking at the special features of death and dying in later life. Particular attention will be paid to people who are cared for at home or in community long-stay homes.

Natural family planning

It is now well accepted that a woman can conceive from an act of intercourse for a maximum of only about 7 days of her menstrual cycle. The reliability of natural family planning depends on identifying this window of fertility without ambiguity. Several symptomatic markers, cervical mucus and basal body temperature, have been used extensively and with considerable success in most women but failures occur. Ovarian and pituitary hormone production show characteristic patterns during the cycle. Urinary estrogen and pregnanediol measurements yield reliable information concerning the beginning, peak, and end of the fertile period, provided that the assays are accurate and performed on timed specimens of urine. We have developed such enzyme immunoassays for urinary estrogen and pregnanediol glucuronides that can be performed at home. In the early versions of the assays, enzyme reaction rates were measured by eye, but more recently, a simple photoelectronic rate meter has been used. The final problem to be solved is not technologic but whether women are sufficiently motivated to expend the same time and effort each day for 10 days a month, with less cost, on fertility awareness as they spend on making a cup of tea.

Computed axial tomography in musculoskeletal trauma

In the evaluation of patients with musculoskeletal trauma routine X-ray studies are often limited by difficulty in delineating overlapping structures and tissues of similar density. Computerized axial tomography (CT) has proven to be of great value in many diagnostic situations in orthopaedic surgery, particularly in the evaluation of mass lesions. This new technique resolves many of the problems of standard X-rays. It is noninvasive, and can be safely employed in the evaluation of critically ill patients. To assess the usefulness of this technique to trauma, computerized axial tomography has been employed in the diagnosis of injuries of the spine and acetabulum. CT studies of 26 patients with spinal injuries demonstrated accurate localization of displaced bone fragments and other elements of fracture anatomy, obviating the need for myelography. CT scanning of 28 fractures of the acetabulum defined intra-articular fragments and precise details of fracture lines. The additional data provided by CT scanning in these patients was a major asset in the management of their injuries. It influenced the decisions in regard to the need for surgery, and when surgery was indicated, the data helped to define the most appropriate operative approach. Use of the CT did not delay therapy or cause any complications. This experience with spinal injuries and fractures of the acetabulum indicates that computerized axial tomography is a valuable adjunct to the management of musculoskeletal trauma.

Response of lymph node metastasis to sequential estrogen and radiation therapy in prostate carcinoma

Increasingly sophisticated diagnostic studies have shown a high incidence of tumor spread to the regional lymph nodes. The status of the lymph nodes has been evaluated by noninvasive diagnostic procedures such as lymphangiography and computerized axial tomography. The applicability of these procedures has been enhanced by the use of stringent criteria. Gross lymph node metastasis can be diagnosed with considerable confidence. Serial observations of lymphangiograms and computerized axial tomograms before and two months after the administration of estrogens provide an added dimension to the interpretation of lymph node metastasis. The nature and range of the response of lymph node metastasis were observed. Survival of patients with gross lymph node metastasis treated by sequential estrogen and radiation therapy was evaluated. A total of 11/18 (61 per cent) of patients remained free of symptoms, 8/11 (74 per cent) with a favorable lymph node metastasis responsive to estrogen therapy, and 3/7 (42 per cent) with lymph node metastasis refractory to estrogen therapy. Follow-up computerized axial tomograms of the lymph nodes done at one and two years after irradiation showed a persistent favorable response. Five patients are alive with disease, and 2 patients died of the disease.

Western equine encephalitis with rapid onset of parkinsonism

A patient with confirmed western equine encephalitis had the rapid onset of postencephalitic parkinsonian sequelae. This observation corroborates similar previous but rare reports. Response to therapy with levodopa, dopa decarboxylase inhibitor, and trihexyphenidyl was dramatic. However, remission maintained for 12 months without medication suggests that the parkinsonism would have remitted spontaneously. In either case, this has not previously been reported with the western equine togavirus.