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Eight patients with a pyogenic infection of the sacroiliac joint are compared to 200 published cases. In all our patients the disease began with fever and immobilizing low back and buttock pain. All had bacterial growth in the blood cultures. Five out of 6 patients did not show inflammatory signs in the initial plain roentgenogram. Tc-99m scan was initially positive in 4 out of 6 patients. In 2 patients only the second scan, at 13 and 15 days respectively, was positive. All but one patient had a 4-6 week course of intravenous antibiotics. Three patients underwent surgery for abscesses or intraarticular sequestra. One patient with a small psoas abscess had only medical treatment under CT monitoring. All the patients recovered. From our observations and the literature we conclude that pyogenic sacroiliitis is often not recognized initially. Wrong diagnoses such as sepsis of unknown origin, appendicitis, discal hernia etc. can be avoided if pyogenic sacroiliitis is sought in a systematic fashion. The clinical diagnosis can be confirmed by bone scan, to be repeated at a later stage of disease (i.e. two weeks after onset) if the first examination is inconclusive.
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PMID:[Pyogenic sacroiliitis. Review of 8 personal cases and 200 cases from the literature]. 329 Nov 6

Prospective randomization of 360 patients undergoing abdominal surgery determined whether a standard lateral paramedian incision was made (group A) or one of two modifications in which the anterior sheath was incised medially and posterior sheath incised laterally (group B) or vice versa (group C), in order to determine the necessity for incising both layers laterally to provide the shutter mechanism which is held responsible for the integrity of this wound. Medial incision of the anterior rectus sheath significantly reduced the time required to perform the incision (P less than 0.02) and tended to reduce wound sepsis rate. However, this was achieved at the cost of a higher incisional hernia rate (0 per cent, 2.9 per cent and 4.6 per cent in groups A, B and C respectively, P less than 0.02). We conclude that lateral incision of both anterior and posterior rectus sheath is necessary to obviate the risk of wound hernia with the lateral paramedian incision.
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PMID:Lateral paramedian incision. 330 91

In a national registry, data were collected on 715 newborn patients with severe respiratory failure supported by extracorporeal membrane oxygenation (ECMO) in 18 neonatal centers. This represents almost all infants treated with ECMO between 1980 and 1987. Eighty-one percent of the patients survived. This result is statistically significantly better than any other treatment which produces less than 78.4% survival. The most common diagnoses were meconium aspiration (310 patients, 91% survived), respiratory distress syndrome (96 patients, 78% survived), diaphragmatic hernia (121 patients, 65% survived), and sepsis (64 patients, 72% survived). Average pre-ECMO characteristics were: age 59 hours; PaO2 42 torr, PaCO2 41 torr, pH 7.40; ventilator settings FiO2 1.0, pressure 45/4 cmH2O, rate 93. Technical complications occurred in 23.1%, and physiologic complications occurred in 65.6%. Results improved with experience. Survival rate for the first ten patients from each center was 73.5% compared to 83.7% for all subsequent patients. Survival rate did not, however, significantly differ after an institutional experience of 20 patients. These observations were made on a large cohort that could not be accumulated at an individual center. These results indicate that ECMO and lung rest is appropriate and successful treatment for newborn respiratory failure unresponsive to other means of management, and that almost all respiratory failure is reversible in near-term neonates.
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PMID:National experience with extracorporeal membrane oxygenation for newborn respiratory failure. Data from 715 cases. 337 Jan 75

The chest radiographs of 26 newborns treated with extracorporeal membrane oxygenation (ECMO) for intractable respiratory failure were reviewed. The typical radiographic appearance of the lungs in these patients is that of diffuse pulmonary opacification with variable volume loss. Air bronchograms and patchy basilar atelectasis are also common findings. Generally, decreasing ECMO requirements were reflected in improving chest radiographs with radiographic improvement lagging behind clinical improvement. Of 167 chest radiographs available for evaluation, 105 (62.8%) reflected changes in ECMO flow rates. Radiographs in patients with individual diagnoses of hyaline membrane disease, meconium aspiration syndrome and sepsis showed the best correlation with clinical improvement (95 [69%] of 137 radiographs). Those obtained in patients with congenital diaphragmatic hernia and persistent pulmonary hypertension of the newborn alone showed the poorest correlation (10 [30%] of 30 of radiographs). Neither the absolute degree of radiographic abnormality nor degree of radiographic improvement correlated well with ECMO requirements. Initial radiographs were useful in confirming the position of bypass cannulae and respiratory tubes. Routine daily examinations did not reveal unexpected abnormalities. However, radiographs taken during periods of increased ECMO requirements due to patent ductus arteriosus or volume overload showed worsening lung opacification.
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PMID:Extracorporeal membrane oxygenation: radiographic appearance of the neonatal chest. 348 68

Extracorporeal membrane oxygenation (ECMO) was used in the treatment of 100 newborn infants with respiratory failure in three phases: Phase I (50 moribund patients to determine safety, efficacy, and risks); Phase II (30 high risk patients to compare ECMO to conventional ventilation); and Phase III (20 moderate to high risk patients, the current protocol). Seventy-two patients survived including 54% in Phase I, 90% in Phase II, and 90% in Phase III. The major complication was intracranial bleeding, which occurred in 89% of premature infants (less than 35 weeks) and 15% of full-term infants. Best survival results were in persistent fetal circulation (10, 10 survived), followed by congenital diaphragmatic hernia (9, 7 survived), meconium aspiration (44, 37 survived), respiratory distress syndrome (26, 13 survived), and sepsis (8, 3 survived). There were seven late deaths; in follow-up, 63% are normal or near normal, 17% had moderate to severe central nervous system dysfunction, and 8% had severe pulmonary dysfunction. ECMO is now used in several neonatal centers as the treatment of choice for full-term infants with respiratory failure that is unresponsive to conventional management. The success of this technique establishes prolonged extracorporeal circulation as a definitive means of treatment in reversible vital organ failure.
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PMID:Extracorporeal membrane oxygenation (ECMO) in neonatal respiratory failure. 100 cases. 353 Jan 51

The work describes an epidemic infection by Methicillin-Resistant S. aureus in a N.I.C.U. which took place during the first six months of 1986. Hospital systemic infection supported by M.R.S.A. are frequently noticed in N.I.C.U. This is related, on the one side with a selection of antibiotic resistant bacterial strains inside the hospital premises and, on the other side with increased survival of high infectious risk neonates who are subjected to invasive medical manoeuvres. The cases reported include 7 neonates (5 of which were preterms) who were affected by a severe sepsis. From an epidemiological study it appeared that M.R.S.A. strain was introduced in N.I.C.U. by a neonate coming from the surgery after being operated for a diaphragmatic hernia. The isolation and the treatment of the carriers, the severe asepsis and the systematic disinfection of the Unit made it possible to eradicate the infectious strain. The infected neonates have been treated with an aimed antibiotic therapy, especially with Vancomycin, administration of blood and/or fresh plasma and/or immunoglobulins and/or concentrated granulocytes. The outcome was favourable for 3 neonates; of the others, 1 showed post-infectious neurological sequelae and 3 died (they were however affected by other severe associated diseases).
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PMID:[Epidemics of Staphylococcus aureus in a neonatal care unit]. 360 18

Twenty-eight consecutive patients with infected pancreatic necrosis were managed by extensive unroofing of the superior retroperitoneum, blunt pancreatic sequestrectomy, laparotomy pad packing of the lesser sac over a layer of Adaptic gauze, and scheduled re-explorations at intervals of 2-3 days (open drainage). Wounds were permitted to heal by secondary intention. All patients were maintained on intravenous hyperalimentation. Three of the 28 patients died (11%); none died of sepsis. Procedure-specific complications included: pancreatic fistula (10 patients), incisional hernia (8 patients), persistent functional gastric outlet obstruction (2 patients), retroperitoneal venous hemorrhage (2 patients), and intestinal fistula (1 patient). Limited initial experience with dynamic pancreatography and serial monitoring of acute phase reactants as indicators of pancreatic necrosis is promising. Compared with historic controls, open drainage of infected pancreatic necrosis represents a significant advance over more conventional surgical approaches. Controlled studies and more widespread experience are necessary for further evaluation of this procedure.
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PMID:Management of infected pancreatic necrosis by open drainage. 366 63

Two previously healthy children, 7 and 12 months old, respectively, presented with respiratory distress and severe sepsis. Chest x-rays were suggestive of inflammatory disease of the left lung. At operation, necrotic bowel was found to be herniated through a left congenital posterolateral diaphragmatic hernia. These patients illustrate the difficulty in establishing the diagnosis of strangulated congenital diaphragmatic hernia and the grave consequences when operation is delayed.
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PMID:Strangulated congenital diaphragmatic hernia in infants. 399 67

To assess the suitability of latamoxef (moxalactam) as single agent chemoprophylaxis in elective colorectal surgery, 120 consecutive patients were randomized to receive latamoxef (L) 1 g or cephazolin 1 g and metronidazole 500 mg (CM) administered intravenously at induction of anaesthesia and 6 and 12 h postoperatively. The groups were well matched for age, sex, pathology and procedures. Serum and tissue levels of latamoxef were well above the MIC90 for most bowel organisms. Inpatient stay was similar for both groups. Pyrexia was seen in 44 patients (11 L, 23 CM) and eight developed a wound infection (3 L, 5 CM). Major intra-abdominal sepsis occurred in seven patients (2 L, 5 CM), secondary to anastomotic leakage in four (1 L, 3 CM). Twenty patients developed a chest infection (5 L, 15 CM) and eight urinary sepsis (2 L, 6 CM). No bleeding complication occurred, and there was no difference in clotting function between the two groups. Six patients died prior to follow-up at six weeks (1 L, 5 CM), two from anastomotic dehiscence. All but three wounds had healed (1 L, 2 CM) and one further patient had an incisional hernia (CM). These results suggest that latamoxef is an efficient chemoprophylactic agent in elective colorectal surgery, and is marginally better than cephazolin plus metronidazole.
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PMID:Latamoxef: single agent prophylaxis in colorectal surgery. 404 62

In an effort to avoid the failures of perineal wound healing that are common after proctectomy, 57 patients who had abdominoperineal resection of the rectum or total proctocolectomy for ulcerative colitis (35 patients), Crohn's colitis (12), or carcinoma (10) had primary closure of the levator muscles and perineal tissues. No attempt was made to approximate the pelvic peritoneum. The small bowel was allowed to fill the pelvic space, which was also drained by suction catheters brought out through the lower abdominal wall. The skin and subcutaneous tissues were allowed to heal by secondary intention in seven patients who had excessive preoperative perineal sepsis from fistulas, deep fissures, and abscesses. All seven wounds healed within 2 months. Of the other 50 patients, whose wounds were closed to the skin, 48 were discharged with completely healed perineal wounds. Two patients had sterile pelvic hematomas that drained through the perineum and delayed wound healing 1 month and 2 months. There were no postoperative perineal, pelvic, or intraabdominal abscesses. Immediate postoperative ambulation was allowed. There was no increased short-term or long-term incidence of small bowel obstruction related to this procedure, nor did perineal hernia occur after long-term observation (mean: 5.3 years). This method of accomplishing perineal wound healing is simpler, safer, more comfortable, and remarkably effective in eliminating the prolonged morbidity of an unhealed perineal wound. It is superior to any other reported method of managing the perineal wound in patients with inflammatory bowel disease and may be applicable to the treatment of cancer without compromising the chances for cure.
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PMID:Improved management of the perineal wound after proctectomy. 407 88


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