Postoperative pressure injuries in adults having surgery under general anaesthesia: systematic review of perioperative risk factors

BACKGROUND

Pressure injuries (PIs) after surgery affect thousands of people worldwide. Their management is expensive, a cost that can be reduced with proper preventive measures. Patients having surgery under general anaesthesia are at risk of developing PI, yet no specific tool has been developed to assess the risk in these patients. This review aimed to summarize the published data on perioperative risk factors associated with the development of PI in adults having surgery under general anaesthesia.

METHODS

All studies reporting on risk factors associated with the development of PI were included. Data were extracted from all articles and meta-analysis was performed when three or more studies reported on a specific variable.

RESULTS

The analysis identified five factors significantly associated with the development of PIs: cardiovascular disease, respiratory disease, diabetes mellitus, low haemoglobin level and longer duration of surgery. Factors not associated included serum albumin concentration, use of vasopressors during surgery, use of corticosteroids, sex and age.

CONCLUSION

Cardiovascular disease, respiratory disease, diabetes mellitus, anaemia and duration of surgery should be taken into consideration when trying to identify surgical patients at high risk of developing PIs. These factors could be used to predict PIs after surgery.

Temporal variation of Staphylococcus aureus clonal complexes in atopic dermatitis: a follow-up study

BACKGROUND

A strong link between disease severity and Staphylococcus aureus colonization of the skin has been reported in patients with atopic dermatitis (AD).

OBJECTIVES

To examine temporal variations in S. aureus colonization and S. aureus CC type in patients with AD, and to investigate links to disease severity, skin barrier properties and filaggrin gene (FLG) mutations.

METHODS

This was a follow-up study of a cohort of 101 adult patients with AD recruited from an outpatient clinic. Bacterial swabs were taken at baseline and follow-up from lesional skin, nonlesional skin and the nose. Swabs positive for S. aureus were characterized by spa and the respective clonal complex (CC) type was assigned. Patients were characterized with respect to disease severity [Scoring Atopic Dermatitis (SCORAD)], skin barrier properties [transepidermal water loss (TEWL), pH] and FLG mutations.

RESULTS

In total, 63 patients participated in a follow-up visit. Twenty-seven patients (43%) were colonized at both visits, 27 were colonized at only one visit and nine (14%) were not colonized at either visit. Of patients colonized at both visits, 52% remained colonized with the same CC type at follow-up. Change in CC type was related to an increase in SCORAD of 10·7 points; patients who carried the same CC type had a reduction in SCORAD of 4·4 points. Significantly higher skin pH was found in patients colonized at both visits, while change in CC type was not related to TEWL, pH or FLG mutations.

CONCLUSIONS

The data indicate that temporal variation in S. aureus CC type is linked to flares of the disease.

Effect of detergents on the physicochemical properties of skin stratum corneum: a two-photon excitation fluorescence microscopy study

OBJECTIVE

Understanding the structural and dynamical features of skin is critical for advancing innovation in personal care and drug discovery. Synthetic detergent mixtures used in commercially available body wash products are thought to be less aggressive towards the skin barrier when compared to conventional detergents. The aim of this work is to comparatively characterize the effect of a mild synthetic cleanser mixture (SCM) and sodium dodecyl sulphate (SDS) on the hydration state of the intercellular lipid matrix and on proton activity of excised skin stratum corneum (SC).

METHOD

Experiments were performed using two-photon excitation fluorescence microscopy. Fluorescent images of fluorescence reporters sensitive to proton activity and hydration of SC were obtained in excised skin and examined in the presence and absence of SCM and SDS detergents.

RESULTS

Hydration of the intercellular lipid matrix to a depth of 10 μm into the SC was increased upon treatment with SCM, whereas SDS shows this effect only at the very surface of SC. The proton activity of SC remained unaffected by treatment with either detergent.

CONCLUSION

While our study indicates that the SC is very resistant to external stimuli, it also shows that, in contrast to the response to SDS, SCM to some extent modulates the in-depth hydration properties of the intercellular lipid matrix within excised skin SC.

Waiting times for diagnosis and treatment of head and neck cancer in Denmark in 2010 compared to 1992 and 2002

BACKGROUND AND AIM

Significant tumour progression was observed during waiting time for treatment of head and neck cancer. To reduce waiting times, a Danish national policy of fast track accelerated clinical pathways was introduced in 2007. This study describes changes in waiting time and the potential influence of fast track by comparing waiting times in 2010 to 2002 and 1992.

METHODS

Charts of all new patients diagnosed with squamous cell carcinoma of the oral cavity, pharynx and larynx at the five Danish head and neck oncology centres from January to April 2010 (n=253) were reviewed and compared to similar data from 2002 (n=211) and 1992 (n=168).

RESULTS

The median time to diagnosis was 13 days (2010) versus 17 days (2002; p<0.001) and 20 days (1992; p<0.001). Median days from diagnosis to treatment start were 25 (2010) versus 47 (2002; p<0.001) and 31 (1992; p<0.001). Total pre-treatment time was median 41 days in 2010 versus 69 days (2002) (p<0.001) and 50 days (1992; p<0.001). Significantly more diagnostic imaging was done in 2010 compared to 2002 and 1992. When compared to current fast track standards the adherence to diagnosis improved slightly from 47% (1992) to 51% (2002) and 64% (2010); waiting time for radiotherapy was within standards for 7%, 1% and 22% of cases, respectively; waiting time for surgery was within standards for 17%, 22% and 48%, respectively.

CONCLUSION

The study showed a significant reduction in delay of diagnosis and treatment of head and neck cancer in 2010, but still less than half of all patients start treatment within the current standards.

Sentinel lymph node biopsy in oral cancer: validation of technique and clinical implications of added oblique planar lymphoscintigraphy and/or tomography

PURPOSE

To validate lymphatic mapping combined with sentinel lymph node biopsy as a staging procedure, and to evaluate the possible clinical implications of added oblique lymphoscintigraphy and/or tomography and test the intra- and interobserver reproducibility of lymphoscintigraphy.

MATERIAL AND METHODS

Forty patients (17 F and 23 M, aged 32-90) with 24 T1 and 16 T2 squamous cell carcinoma of the oral cavity. Planar lymphoscintigraphy, emission and transmission tomography were performed. Detection and excision of the sentinel nodes were guided by a gamma probe. The sentinel nodes were step-sectioning and stained with hematoxylin and eosin and cytokeratin (CK 1). Histology and follow-up were used as "gold standard". Tumor location, number of sentinel lymph nodes, metastasis, and recurrences were registered. Two observers evaluated the lymphoscintigraphic images to assess the inter-rater agreement.

RESULTS

Eleven (28%) patients were upstaged. The sentinel lymph node identification rate was 97.5%. Sentinel lymph node biopsy significantly differentiated between patients with or without lymph node metastasis (P = 0.001). Lymphatic mapping revealed 124 hotspots and 144 hot lymph nodes were removed by sentinel lymph node biopsy. Three patients developed a lymph node recurrence close to the primary tumor site during follow-up. Added oblique lymphoscintigraphic images and/or tomography revealed extra hotspots in 15/40 (38%) patients. In 4/40 (10%), extra contralateral hotspots were detected.

CONCLUSION

Sentinel lymph node biopsy upstaged 28% of the patients. Sentinel lymph nodes close to the primary tumor were difficult to find. Added oblique planar images and/or tomographic images revealed extra clinical relevant hotspots in 38% of patients. Reproducibility proved excellent.

Staging N0 oral cancer: lymphoscintigraphy and conventional imaging

PURPOSE

To compare sentinel lymph node biopsy, magnetic resonance imaging (MRI), Doppler ultrasonography, and palpation as staging tools in patients with T1/T2 N0 cancer of the oral cavity.

MATERIAL AND METHODS

Forty consecutive patients were enrolled (17 F and 23 M, aged 32-90 years), 24 T1 and 16 T2 cN0 squamous cell carcinoma of the oral cavity. Palpation was carried out by two observers prior to inclusion. MRI, gray-scale and Doppler ultrasonography were performed. Lymphoscintigraphies were done after peritumoral injections of 99mTc labelled rheniumsulphide nanocolloid, followed by sentinel lymph node biopsy guided by a gamma probe and Patent Blue. Palpation, Doppler ultrasonography, MRI, and sentinel lymph node biopsy were compared to a combination of histopathology and follow-up. Diagnostic testing was performed using the x2 test.

RESULTS

Histopathological examination revealed metastatic spread to the neck in 14 of 40 patients. One patient had bilateral neck disease. Sentinel lymph node biopsy and ultrasonography were performed in 80 neck sides of 40 patients and MRI in 70 neck sides (5 patients were claustrophobic). SN revealed suspicious lymph nodes in 12 necks, ultrasonography in 23 necks, and MRI in 9 necks. The positive predictive value of sentinel lymph node biopsy was 100%, ultrasonography 57%, and MRI 56%. The respective negative predictive values were 96%, 96%, and 85%. The sensitivity of sentinel lymph node biopsy 80% was comparable to ultrasonography 87%, but the sensitivity of MRI 36% was low. The specificities were 100%, 85%, and 93%, respectively. By combined sentinel lymph node biopsy and ultrasonography the overall sensitivity could have been 100%.

CONCLUSION

Sentinel lymph node biopsy improved staging of patients with small N0 oral cancers. Combined sentinel lymph node biopsy and Doppler ultrasonography may further improve staging. MRI and simple palpation results were poor.

Loss of heterozygosity at 9q33 and hypermethylation of the DBCCR1 gene in oral squamous cell carcinoma

The DBCCR1 gene at chromosome 9q33 has been identified as a candidate tumour suppressor, which is frequently targeted by promoter hypermethylation in bladder cancer. Here, we studied the possible involvement of DBCCR1 in the development of oral squamous cell carcinoma. DNA from 34 tumours was examined for loss of heterozygosity (LOH) at three markers surrounding DBCCR1 and for hypermethylation of the DBCCR1 promoter, using methylation-specific PCR and methylation-specific melting-curve analysis. LOH was found in 10 of 31 cases (32%), and DBCCR1 hypermethylation was present in 15 of 34 cases (44%). Hypermethylation of DBCCR1 was also present in three of seven epithelial tissues adjacent to the tumours, including two hyperplastic and one histologically normal epithelia. Furthermore, of four oral leukoplakias with dysplasia, one showed LOH at 9q33 and two showed DBCCR1 hypermethylation. These data suggest that LOH at 9q33 and hypermethylation of the DBCCR1 promoter are frequent and possibly early events in oral malignant development.

An in vivo study of the gastrointestinal absorption site for zinc chloride in mice

The experimental model presented below enables quantitation of the uptake of zinc (Zn++) into gastrointestinal mucosal cells in vivo using gamma-counting of 65Zn. Experiments were performed in mice fed their normal diet under natural physiological conditions. The in vivo site(s) of significant zinc absorption may thereby be identified. Absorption of zinc was extensive during the first hour after administration of a single oral dose of ZnCl2. Apparently, absorption continued during at least eight hours postdosage, and probably continued for 48 hours. The intestinal mucosal labelling profile for zinc did not depend on dose size or the mode of administration (single oral doses or in drinking water). The duodenum and ileum were important sites for rapid zinc absorption. A continuous, slower absorption of zinc may take place in the jejunum. The stomach, caecum and colon appeared to be insignificant sites of zinc absorption. The transit time for zinc was very short as large quantities of zinc passed through the small intestine within one hour. In contrast to other studies, the intestinal labelling profile or the extent of zinc absorption were not changed in mice that received Tetraethylthiuram disulfide (TTD) in their food.

Papillary thyroid carcinoma: correlations between prognosis, age, and clinicopathological and histomorphological findings

The age influence on the prognosis of papillary thyroid carcinoma was analyzed in a group of 67 patients. A marked decline in cause-specific survival was found for patients older than 60 years of age at the time of diagnosis. In order to find a tumor-biological explanation of the prognostic difference between patients below and above 60 years of age, several clinicopathological and histomorphological features were analyzed. Tumors from patients older than 60 years of age showed significantly more mitotic activity and nuclear polymorphism, fewer psammoma bodies, and more frequent extrathyroidal invasion and distant metastases. The results indicate that 60 years of age the time of diagnosis may be the "prognostic break-point" for papillary thyroid carcinoma.

Importance of the time interval between radiotherapy and surgery in oral cancer

From 1969 to 1985, 62 patients with squamous cell carcinoma of the oral cavity received preoperative radiotherapy (RT) 40-50 Gy before radical surgery. The time interval between the end of the RT and surgery varied from 4 to 49 days (median 19 days). The cancer specific survival rate was significantly lower for the 32 patients with intervals longer than or equal to 19 days compared with patients with shorter intervals (P = 0.001). The reason for choosing a longer interval between the treatment modalities was not related to stage or performance status, however, a possibility that patients in poor condition were preferentially allocated to the long intertreatment interval group cannot be ruled out. This study suggests that when using combined modalities any effort should be exercised to reduce the time interval between the modalities.

Localization of gastrointestinal deposition of mercuric chloride studied in vivo

During the last 5 years, the site of gastrointestinal absorption of inorganic mercury has been attempted identified mainly by experiments using perfused intestinal segments in vitro or in situ. The present investigation will discuss the localization of the absorption site for mercuric chloride based on a completely undisturbed in vivo experimental model in mice. As the mice were allowed to eat their normal diet during the experimental period, the present results would independently add to existing knowledge on intestinal absorption sites for inorganic mercury. The mice were given 203Hg labelled mercuric chloride orally, either through stomach tube or in the drinking water, and were killed after various time intervals. Mercury was localized and quantified in various segments of the gastrointestinal tract by gamma-counting. Time course analysis of the segmental deposition of mercury demonstrated that the deposition mainly takes place in the proximal jejunum and suggested that a larger part of the jejunum than previously reported is involved in absorption of mercury. Using this in vivo model, tetraethylthiuram disulfide was demonstrated to increase the intestinal deposition and absorption without changing the site of deposition.

[Peritonsillar abscess. Occurrence of disease requiring surgery in the remaining tonsil after unilateral tonsillectomy à chaud]

The occurrence of disease requiring surgery of the remaining tonsil after unilateral tonsillectomy à chaud in the treatment of peritonsillar abscess was studied in 536 patients. None of the patients histories of previous severe tonsillitis at the time of the unilateral had tonsillectomy. 9.3% of the patients under 30 years of age were readmitted for surgery on the remaining tonsil during the follow up period. Only 0.5% of the patients over 30 years were readmitted. Previous investigations have shown increasing frequency of pharyngitis after bilateral tonsillectomy. The present authors suggest bilateral tonsillectomy in all patients under 30 years of age who suffer from peritonsillar abscess irrespectively of previous tonsillar disease. In patients over 30 years, unilateral ablation is recommended unless clear indication for bilateral tonsillectomy are present.

Peritonsillar abscess: risk of disease in the remaining tonsil after unilateral tonsillectomy à chaud

The occurrence of disease in the remaining tonsil after unilateral tonsillectomy à chaud in the treatment of peritonsillar abscess, was studied in 536 patients. No patient had a history of previous severe tonsillitis at the time of the unilateral tonsillectomy, 6.1 per cent of the patients were readmitted for surgery of the remaining tonsil during the follow-up period. Ninety-seven per cent of these patients were younger than 30 years of age. Previous investigations have shown increasing frequency by age of pharyngitis after bilateral tonsillectomy. We suggest bilateral tonsillectomy in all cases of patients younger than 30 years old who suffer from peritonsillar abscess irrespective of previous tonsillar disease. Patients older than 30 should be treated with unilateral ablation, unless there is a clear indication for bilateral tonsillectomy.

Effects of diethyldithiocarbamate and tetraethylthiuram disulfide on zinc metabolism in mice

Chronic alcoholics with cirrhosis often develop symptoms of zinc deficiency. Tetraethylthiuram disulfide (TTD) is metabolized to two molecules of diethyldithiocarbamate (DDC). DDC chelates divalent metal ions, including zinc, by forming highly lipophilic neutral bis(dithiocarbamate)-metal complexes. DDC could therefore enhance the intestinal zinc uptake or increase the rate of zinc excretion. Accordingly, treatment of alcoholism with TTD could either aggravate or alleviate zinc deficiency. The present study investigated effects of DDC and TTD on intestinal zinc uptake and on the rate of zinc excretion in mice. When given as very high single oral doses, DDC and TTD increased the intestinal uptake of a single oral dose of zinc. When added to the diet and administered in lower doses, closer to those administered to humans for treatment of alcohol abuse, both compounds were without effect on the rate of excretion of the body's zinc stores. In a long-term experiment, where 65Zn was administered in the drinking water, these doses of TTD and DDC reduced the whole-body retention of 65Zn. No treatment changed the organ distribution of zinc in any of the experiments. In conclusion strong indications emerge from the present study that TTD treatment of alcoholism is more likely to reduce the intestinal zinc absorption than to enhance it as has been suggested by other authors. Thus, the widely used experimental model using single oral exposure to metal and chelator conceivably may give erroneous results, when used to predict effects of prolonged exposures.

[Congenital laryngo-tracheo-esophageal cleft]

A typical case of congenital laryngo-trachea-esophageal cleft (LTEC) is presented with a Review of the literature. LTEC is a rare congenital anomaly caused by defective fusion of the septum between larynx/trachea and hypopharynx/esophagus. The septum is formed by fusion of two lateral folds growing medially in very early foetal life. Fusion progresses in a cranial direction. Disturbances in septum formation result in LTEC. The disease gives respiratory problems with aspiration and excessive salivary production. The diagnosis is best made by intubating the larynx and examining the postcricoid region and anterior wall of the esophagus endoscopically. Stapling of the stomach, tracheostomy and secondary operative closure of the cleft has proved effective in the treatment of LTEC.

Apocrine carcinoma of the axillae. Case report

A case of recurrent apocrine carcinoma of the axilla is presented. Following numerous excisions and exairesis of the regional glands, treatment with Tamoxifen was tried unsuccessfully. Local radiation therapy proved efficient. It is suggested that primary local radiation therapy be used as a supplement to aggressive surgery in the treatment of these tumors.