Global epidemiology of actinic keratosis in the general population: a systematic review and meta-analysis

BACKGROUND

Actinic keratosis (AK) is a common dermatological condition, and among the most common dermatological diagnoses in older populations. Although the prevalence of AK depends on demographic and environmental factors, little is known about the global context of AK.

OBJECTIVES

To provide a comprehensive and updated analysis of the global prevalence rate and incidence of AK in the general population through a systematic review and meta-analysis, and - through subgroup analyses - to identify high-risk phenotypes, demographic and lifestyle risk factors and regional variations in disease prevalence.

METHODS

A systematic search of Embase, MEDLINE, Web of Science and Google Scholar was performed on 20 May 2022. Two reviewers independently screened and assessed the quality of each study using a validated critical appraisal checklist. Epidemiological measurements (e.g. prevalence) from individual studies performed in the general population were then pooled in a random-effects meta-analysis. Subgroup analyses (i.e. population age, geographical region, occupation, sex and study quality) were conducted.

RESULTS

Of the 65 articles that made it through the full-text screening, 60 reported a point prevalence. A meta-analysis of these articles yielded an overall point prevalence of 14% [95% confidence interval (CI) 14-15]. In further analyses, the calculated prevalence rate varied depending on subgroup. The pooled incidence rate from the seven eligible studies analysed was 1928 per 100 000 person-years (PY; 95% CI -439 to 4294).

CONCLUSIONS

This comprehensive meta-analysis provides an updated global prevalence rate of AK of 14%, indicating a significant worldwide disease burden. The incidence rate of AK was found to be 1928 per 100 000 PY, emphasizing a growing public health concern. However, high heterogeneity among studies suggests that various factors influence the AK prevalence rate, necessitating further research to understand the observed differences.

Association between lifetime smoking and cutaneous squamous cell carcinoma: A 2-sample Mendelian randomization study

Background/Purpose

Cutaneous squamous cell carcinoma (cSCC) is one of the most common malignancies worldwide. While several environmental risk factors for cSCC are well established, there is conflicting evidence on cigarette smoking (and its potential causal effect) and cSCC risk. Furthermore, it is unclear if these potential associations represent causal, modifiable risk factors for cSCC development. This study aims to assess the nature of the associations between cigarette smoking traits (smoking initiation, amount smoked, and lifetime smoking exposure) and cSCC risk using two-sample Mendelian randomization analyses.

Methods

Genetic instruments, based on common genetic variants associated with cigarette smoking traits (P < 5 × 10-8), were derived from published genome-wide association studies (GWASs). For cSCC, we used GWAS summary statistics from the Kaiser Permanente GERA cohort (7701 cSCC cases and 60,167 controls; all non-Hispanic Whites).

Results

We found modest evidence that genetically determined lifetime smoking was associated with cSCC (inverse-variance weighted method: OR[95% CI] = 1.47[1.09-1.98]; P = .012), suggesting it may be a causal risk factor for cSCC. We did not detect any evidence of association between genetically determined smoking initiation or amount smoked and cSCC risk.

Conclusion

Study findings highlight the importance of smoking prevention and may support risk-stratified cSCC screening strategies based on carcinogen exposure and other genetic and clinical information.

Longitudinal Assessment of the Prevalence of Actinic Keratosis and Extensive Risk Factor Evaluation: An Update from the Rotterdam Study

Population-based studies available to analyze the prevalence, risk factors, and longitudinal outlook of actinic keratoses (AKs) are limited. These features mentioned earlier were assessed using Rotterdam study participants aged ≥40 years who underwent a full-body skin examination by a dermatology-trained physician. ORs with 95% confidence intervals were calculated for the associations between risk factors and the presence of AK. Among 8,239 eligible participants, the prevalence of one or more AKs was 21.1% (95% confidence interval = 20.2-22.0) and was higher in men. Male sex, age, lighter hair and eye color, baldness, genetic risk score, and digital photoaging measures (digitally assessed pigmented spots, telangiectasias, and global facial wrinkling) had a positive association with AK. Cigarette smokers had reduced odds of having AK, with current smokers having the lowest risk. Among patients with two AK assessments, there was no difference in the presence of AK during follow-up between treated and untreated participants. In conclusion, genetic risk score and digital photoaging measures showed associations with increased lesion count. At the individual level, patients were most likely to decrease in AK severity group over time, possibly regardless of whether or not participants were treated.

Nocturia and electrocardiographic abnormalities among patients at an inner-city cardiology clinic

AIMS

Nocturia has been increasingly recognized as a potential manifestation of cardiovascular disease. However, the relationship between nocturia and electrocardiographic (ECG) abnormalities has not been studied. This study aims to characterize the diagnostic utility of nocturia in identifying left ventricular hypertrophy (LVH), left atrial enlargement (LAE), and prolonged QTc on ECG.

METHODS

Retrospective analysis of nocturnal voiding frequency and contemporaneous ECG data from consecutive patients evaluated at a university-based outpatient cardiology clinic. Three sets of three incremental binary multiple logistic regression models controlling for (1) age, (2) sex and race, and (3) body mass index, hypertension, diabetes mellitus, and diuretic utilization were performed to determine whether nocturia was predictive of LVH, LAE, and prolonged QTc.

RESULTS

Included patients (n = 143, 77.6% nocturia) were predominantly African-American (89.5%), female (74.1%), and obese (61.5%), of whom 44.1%, 41.3%, and 27.3% had LVH, LAE, and prolonged QTc, respectively. Older age, African-American race, obesity, hypertension, diuretic use, LVH, and LAE were significantly associated with nocturia on univariate analysis. No significant differences were observed in the strength of associations between nocturia and LVH, LAE, or QTc prolongation based on age. Nocturia independently predicted LVH in Models I-III (odds ratios [ORs], 2.99-3.20; relative risks [RRs], 1.18 for all, p ≤ .046) and LAE in Models I-III (ORs, 4.24-4.72; RRs, 1.21 for all, p ≤ .015). No significant associations were observed between nocturia and prolonged QTc.

CONCLUSIONS

Nocturia may be a risk marker for underlying structural cardiac abnormalities.

Sodium restriction improves nocturia in patients at a cardiology clinic

This study aims to determine whether dietary sodium restriction counseling decreases nocturnal voiding frequency in cardiology patients with concomitant nocturia. Patients who had established care at a cardiology clinic from 2015 to 2018 reporting ≥1 average nocturnal void(s) underwent a comprehensive sodium intake interview by their cardiologist, who provided them with individualized strategies for dietary sodium reduction and assessed adherence at follow-up. Average nocturnal voiding frequency and dietary adherence were documented in the medical record. A nocturia database was compiled for retrospective analysis. A total of 74 patients were included. Patients considered to be adherent with dietary sodium restriction at follow-up (n = 56) demonstrated a decrease in median nocturia frequency (2.5 [2.3-3.0] vs 1.0 [1.0-2.0] voids, P < .001). Among nonadherent patients (n = 18), median nocturia frequency did not significantly change from baseline to follow-up (2.0 [1.5-3.8] vs 2.0 [1.5-4.8] voids, P = .423). Median changes were significantly different between the adherent and nonadherent groups (P < .001). Examination of second follow-up available from 37 patients showed a continued effect. In conclusion, adherence with dietary sodium counseling appears to improve nocturia. Accordingly, dietary modification may represent an important adjunct therapy to lifestyle and pharmacologic interventions for decreasing nocturia frequency. Reduction in nocturnal voiding frequency may also reflect an additional benefit of dietary sodium restriction in accordance with best practice standards for cardiovascular disease.

Polyploid Superficial Cells that Maintain the Urothelial Barrier Are Produced via Incomplete Cytokinesis and Endoreplication

The urothelium is an epithelia barrier lined by a luminal layer of binucleated, octoploid, superficial cells. Superficial cells are critical for production and transport of uroplakins, a family of proteins that assemble into a waterproof crystalline plaque that helps protect against infection and toxic substances. Adult urothelium is nearly quiescent, but rapidly regenerates in response to injury. Yet the mechanism by which binucleated, polyploid, superficial cells are produced remains unclear. Here, we show that superficial cells are likely to be derived from a population of binucleated intermediate cells, which are produced from mononucleated intermediate cells via incomplete cytokinesis. We show that binucleated intermediate and superficial cells increase DNA content via endoreplication, passing through S phase without entering mitosis. The urothelium can be permanently damaged by repetitive or chronic injury or disease. Identification of the mechanism by which superficial cells are produced may be important for developing strategies for urothelial repair.

Exercise Preferences and Barriers in Urban African Americans With Type 2 Diabetes

PURPOSE

The purpose of this study was to determine physical activity preferences and barriers to exercise in an urban diabetes clinic population.

METHODS

A survey was conducted of all patients attending the clinic for the first time. Evaluation measures were type and frequency of favorite leisure-time physical activity, prevalence and types of reported barriers to exercise, and analysis of patient characteristics associated with reporting an obstacle to exercise.

RESULTS

For 605 patients (44% male, 89% African American, mean age = 50 years, mean duration of diabetes = 5.6 years), the average frequency of leisure activity was 3.5 days per week (mean time = 45 minutes per session). Walking outdoors was preferred, but 52% reported an exercise barrier (predominantly pain). Patients who cited an impediment to physical activity exercised fewer days per week and less time each session compared with persons without a barrier. Increasing age, body mass index, college education, and being a smoker increased the odds of reporting a barrier; being male decreased the chances. Men reported more leisure-time physical activity than women. Exercise preferences and types of barriers changed with age.

CONCLUSIONS

Recognition of patient exercise preferences and barriers should help in developing exercise strategies for improving glycemic control.

Limited health care access impairs glycemic control in low income urban African Americans with type 2 diabetes

Limited access to health care is associated with adverse outcomes, but few studies have examined its effect on glycemic control in minority populations. Our observational cross-sectional study examined whether differences in health care access affected hemoglobin A1c (HbA1c) levels in 605 patients with diabetes (56% women; 89% African American; average age, 50 years; 95% with type 2 diabetes) initially treated at a municipal diabetes clinic. Patients who had difficulty obtaining care had higher A1c levels (9.4% vs. 8.7%; p=0.001), as did patients who used acute care facilities (9.5%; p<0.001) or who had no usual source of care (10.3%; p<0.001) compared with those who sought care at doctors' offices or clinics (8.6%). In adjusted analyses, HbA1c was higher in persons who gave a history of trouble obtaining medical care (0.57%; p=0.04), among persons who primarily used an acute care facility to receive their health care (0.49%; p=0.047), and in patients who reported not having a usual source of care (1.08%; p=0.009). Policy decisions for improving diabetes outcomes should target barriers to health care access and focus on developing programs to help high-risk populations maintain a regular place of health care.

Barriers to diabetes education in urban patients: perceptions, patterns, and associated factors

PURPOSE

This study explored patients' perceptions of barriers to diabetes education among a mostly African American population of adults with diabetes.

METHODS

A survey was conducted among 605 new patients attending an urban outpatient diabetes clinic. The questionnaire gathered information on issues patients believed would adversely affect their ability to learn about diabetes. The type and frequency of education barriers were evaluated, and variables associated with reporting an obstacle were analyzed.

RESULTS

Average patient age was 50 years, diabetes duration was 5.6 years, body mass index was 32 kg/m2, and hemoglobin A1C was 9.1%. The majority (56%) were women, 89% were African American, and 95% had type 2 diabetes. Most respondents (96%) had received some prior instruction in diabetes care; however, 53% anticipated future difficulties learning about diabetes. The most commonly cited concerns were poor vision (74%) and reading problems (29%). Patients with a perceived barrier to diabetes education were older (P < .001) than were persons without a barrier, and they differed in both employment and educational status (both P < .001). In adjusted analyses, older age, male gender, being disabled, and having an elementary education or less were associated with a significantly increased likelihood of having a barrier to diabetes education, whereas having a college education decreased the odds. Higher hemoglobin A1C levels also tended to be associated with a greater chance of reporting an education barrier (P = .05).

CONCLUSIONS

A substantial number of persons anticipated a barrier to diabetes education. Interventions at multiple levels that address the demographic and socioeconomic obstacles to diabetes education are needed to ensure successful self-management training.

Evolving demographics and disparities in an urban diabetes clinic: implications for diabetes education and treatment

OBJECTIVES

To compare demographics and disease characteristics in a multiethnic diabetes clinic population to identify changes over time.

DESIGN

Analysis and comparison of demographics and disease characteristics of diabetes patients, recorded electronically at intake over 10 years.

SETTING

An urban outpatient diabetes clinic.

PATIENTS

A total of 8,551 African-American (88%), White (7%), or Hispanic (3%) patients (average age, 52 years; mean diabetes duration, 5.1 years; 59% women).

MAIN OUTCOME MEASURES

Proportion of patients by ethnic group, age, diabetes duration, initial hemoglobin A1c, and body mass index.

RESULTS

Between 1992 and 2001, the percentage of African-American patients was relatively unchanged (from 87.6% to 87.2%; P=.2), White patients decreased (from 9% to 5%; P=.0006), and Hispanic patients increased (from 1.3% to 5.5%; P<.0001). Among African-American patients, average age decreased from 52 to 50 years (P=.015), diabetes duration decreased from 5.6 years to 4.3 years (P=.0003), initial hemoglobin A1c decreased from 9.3% to 8.8% (P<.0001), and body mass index increased from 31 kg/m2 to 32.1 kg/m2 (P=.0001). Compared with African-American and White patients, Hispanic patients were younger (P<.0001) and had a lower body mass index (P<.0001) but had hemoglobin A1c comparable to that of African-American patients (9.3% vs 9.1%; P=.45) and higher than that of White patients (9.3% vs 8.7%; P=.0022).

CONCLUSIONS

The demographic and disease profiles of patients in this urban diabetes clinic have shifted, and disparities in glycemic control and obesity exist. Modifications in treatment and education approaches may be necessary to compensate for a changing patient population.

Management of insulin therapy in urban diabetes patients is facilitated by use of an intelligent dosing system

The Intelligent Dosing System (IDS, Dimensional Dosing Systems, Inc., Wexford, PA) is a software suite that incorporates patient-specific, dose-response data in a mathematical model, and then calculates the new dose of agent needed to achieve the next desired therapeutic goal. We evaluated use of the IDS for titrating insulin therapy. The IDS was placed on handheld platforms and provided to practitioners to use in adjusting total daily insulin dose. Fasting glucose, random glucose, and hemoglobin A1c were used as markers against which insulin could be adjusted. Values of markers expected at the next follow-up visit, as predicted by the model, were compared with levels actually observed. For 264 patients, 334 paired visits were analyzed. Average age was 54 years, diabetes' duration was 10 years, and body mass index was 33.2 kg/m(2); 57% were female, 88% were African American, and 92% had type 2 diabetes. The correlation between IDS suggested and actual prescribed total daily dose was high (r = 0.99), suggesting good acceptability of the IDS by practitioners. Significant decreases in fasting glucose, random glucose, and hemoglobin A1c levels were seen (all P < 0.0001). No significant difference between average expected and observed follow-up fasting glucose values was found (145 vs. 149 mg/dL, P = 0.42), and correlation was high (r = 0.79). Mean observed random glucose value at follow-up was comparable to the IDS predicted level (167 vs. 168 mg/dL, P = 0.97), and correlation was high (r = 0.73). Observed follow-up hemoglobin A1c was higher than the value expected (7.9% vs. 7.4%, P < 0.0055), but correlation was good (r = 0.70). These analyses suggest the IDS is a useful adjunct for decisions regarding insulin therapy even when using a variety of markers of glucose control, and can be used by practitioners to assist in attainment of glycemic goals.

An audit of job application forms in response to adverts in the British Medical Journal

OBJECTIVE

The aim of this study was to examine the speed of response of human resources departments to requests for job application forms for posts advertised in the British Medical Journal (BMJ). Of particular interest was the closing date for applications, postage cost, and the period to reply.

DESIGN

Twenty posts were randomly selected and application forms requested by telephone and then 20 by letter on two separate dates from the BMJ Classified (issues of 21 July 2001 and 28 July 2001). During the first week the forms were requested by telephone on receipt of the BMJ (Friday afternoon). During the second week the forms were requested by first class post. All letters were sent out on Saturday morning.

OUTCOME MEASURES

The date of receipt of the application form/information pack, the cost of postage, and the closing date for application were recorded for each position.

RESULTS

Fifteen forms were received after the telephone application and 18 forms after the letter applications. One trust sent two replies spaced one week apart for the same job and two replies contained job application forms for the wrong job. The response rates to telephone requests varied from four to 10 days and by letter from three to 12 days. The minimum time between the reply being received and the closing date was one day, and the maximum 21 days. The time between the closing date for applications and the start date of the job varied from minus one week (closing date before advertisement) to three months. Thirteen replies gave no indication of the start date of the job. The cost of postage varied from 27p to pound 1.90. Thirty one trusts used first class postage.

CONCLUSION

There is very limited scope to return job application forms on time, and significant delays in sending out application forms and information packs compound this problem. It is recommended that trust human resources departments place advertisements early and respond promptly to requests for application forms.

Case report: An unusual arrival of a hydrocoele

Acute hydrocoele is a previously unreported complication of herniography that may be explained on the basis of inguinal-scrotal embryology.

Intra-articular dislocation of the patella: two cases and literature review

Intra-articular dislocation of the patella remains uncommon and is generally thought to be a problem of young adolescent males. This report reminds emergency physicians that it can occur in the arthritic knee, and it should be considered in the differential diagnosis of locked knee in the elderly. Closed reduction should be attempted in these cases, because the dislocation is liable to be held in place by osteophytes rather than impaction of the patella deep in the intercondylar notch and a good functional outcome can be expected.

Digital sialography: imaging and intervention

Digital subtraction imaging (DSI) has been widely used in angiography but less commonly applied to sialography. Over a 3-year period 109 patients referred for sialography, 42 males and 67 females with a mean age of 44 years (range 8-85 years), were examined using a digital subtraction imaging technique. 13 patients went on to have an interventional procedure, stone removal or duct dilatation. The role of DSI imaging in sialography and its use in facilitating interventional procedures on the salivary glands are discussed.

The radiological features of adult T-cell leukaemia/lymphoma

Adult T-cell leukaemia/lymphoma (ATLL) results from a monoclonal expansion of T-cells infected with the human T-cell lymphotropic virus type 1 (HTLV-1). Six cases of ATLL, three males and three females all from the Caribbean and with a mean age of 55 years, have been reviewed retrospectively, illustrating the wide spectrum of radiological changes. One patient had extensive mediastinal adenopathy, hitherto an unrecorded finding in ATLL.

Balloon dilatation of the pharynx

Balloon dilatation has become a widely accepted technique in the management of oesophageal and other gastrointestinal strictures. The use of this procedure in the pharynx has rarely been reported. We have performed 55 balloon dilatations on 13 patients with pharyngeal strictures. In three patients all symptoms were permanently abolished after one dilatation. Seven patients were successfully managed with repeated, regular dilatations. Two patients had a good initial response but this was not maintained and one patient had no relief of symptoms. Balloon dilatation is minimally invasive, less traumatic than rigid pharyngoscopy with dilatation, and well tolerated. It may be frequently repeated, and has successfully relieved dysphagia caused by benign and malignant strictures of the pharynx, including instances where previous rigid bouginage had failed.

Bowel preparation before intravenous urography: is it necessary?

Whether or not bowel preparation should be used before intravenous urography (IVU) remains a controversial issue. Despite strongly held views on both sides there is little scientific evidence to support either viewpoint. We have conducted a prospective randomized study designed to test the hypothesis that adequate bowel preparation before IVU facilitates better quality studies requiring fewer films and consequently less time and a lower radiation exposure. Data on 188 patients were analysed; 90 patients received bowel preparation and 98 received no bowel preparation. There was no difference between the groups in terms of the number of films taken, the duration of the procedure, the visibility of the renal tracts or the overall quality of the studies. The prepared group did have significantly less faecal residue than the unprepared group. However, the renal tract visibility was no greater, as the combination of gas and haustral folds seen after bowel preparation obscured fine detail of the urinary tract as effectively as faecal residue. The hypothesis that adequate bowel preparation before IVU facilitates better quality studies must therefore be rejected.

Abdominal ultrasound in Noonan syndrome: a study of 44 patients

Noonan syndrome affects approximately 1 in 1500 live births. Affected individuals may have characteristic phenotypic features some of which are shared with Turner syndrome, although in Noonan syndrome the karyotype is normal, unlike the 45X karyotype of Turner syndrome. Renal anomalies have been described in both syndromes and in Turner syndrome they are both common and frequently severe. The frequency and spectrum of renal anomalies in Noonan syndrome have not been well documented. Upper abdominal ultrasound was performed to establish the frequency of renal anomalies in Noonan syndrome. Forty-four individuals with Noonan syndrome, aged between 9 months and 38 years, were studied. Sixteen scans (36%) were normal and 28 (64%) were abnormal. Five patients (11%) had renal anomalies. Twenty-three patients (53%) had splenomegaly, 6 of these with associated hepatomegaly. One patient had a choledochal cyst and a midgut malrotation. The frequency of renal anomalies in Noonan syndrome is 11%, which is lower than that seen in Turner syndrome. However, splenomegaly with or without hepatomegaly occurs commonly. Choledochal cyst and solitary kidney, previously unreported in Noonan syndrome, are documented.

Thrombolysis and the femorofemoral bypass graft: a new technique

Two patients with acutely thrombosed femorofemoral bypass grafts are presented. Recombinant human tissue-type plasminogen activator (rt-PA) was used successfully in thrombolysis of the occluded grafts. Utilizing a new technique the grafts were punctured directly and bolus doses of rt-PA administered.

Accelerated thrombolysis using pulsed intra-thrombus recombinant human tissue type plasminogen activator (rt-PA)

The efficacy of regional thrombolysis for treating leg ischaemia is well established, but the duration of infusion and the frequent complications remain major disadvantages. By delivering recombinant human tissue type plasminogen activator (rt-PA) as pulsed intra-thrombus 5-mg aliquots combined with catheter manipulation to maintain an intra-thrombus location, the average time taken to achieve thrombolysis in 20 consecutive patients with infra-aortic occlusions was 109 min. Immediate thrombolysis was achieved in every case. Pulsed delivery of high dose rt-PA significantly accelerates thrombolysis, decreases dose and reduces costs.

Parotid haemangioma in infants: MR imaging at 1.5T

Parotid gland neoplasms are uncommon and account for less than 2% of human tumours. Haemangiomas account for about 50% of parotid tumours in infants and children compared to only 2% in adults. As the clinical course of infantile haemangiomas may be self limiting and the initial treatment is expectant, early and accurate diagnosis is essential. We report 3 cases of paediatric parotid haemangioma and discuss the Magnetic Resonance (MR) characteristics of these tumours. In two cases the diagnosis was proven histologically and in one case Computed Tomography (CT) was also performed.

An experimental assessment of the effect of blood transfusion on susceptibility to bacterial infection

Clinical investigations in patients who have undergone transplantation and patients with cancer and infection suggest that blood transfusions have an immunosuppressive effect. To investigate the impact on responses to infection, an experimental transfusion model was developed in the rat with allogeneic or syngeneic transfusions. Animals were given either a moderate or severe bacterial challenge, both simulating a clinical surgical infection, immediately after transfusion or 1 week later; hypotension and hemodilution were especially avoided. Blood transfusion adversely affected the animals' capacity to resist immediate moderate challenge, but not a later one. The effect was maximized by allogeneic transfusion but was not demonstrable after severe bacterial challenge, whether immediate or late.

Subcutaneous sarcoidosis mimicking carcinoma of the breast

A 65 year old woman presented with bilateral breast lumps. Clinical examination suggested a diagnosis of mammary carcinoma, but a histological diagnosis of sarcoidosis was made. Subsequent investigations revealed evidence of pulmonary sarcoidosis.

Comparison of antibody response with delayed hypersensitivity in severely injured patients

Twenty-seven severely injured patients had antibody response to gram-negative organisms measured of whom 25 also had skin testing. Twenty-three patients (92%) were anergic at admission. Injury Severity Scores were greater in patients who remained anergic for three weeks compared with patients whose skin tests became positive. Patients with major infection had longer anergy duration than uninfected patients. Twenty-two (81%) of 27 anergic patients mounted antibody responses. Initial bacterial contamination determined the clinical outcome and antibody response. Six of eight patients with moderate contamination mounted IgM responses to all organisms and/or an IgG response to Escherichia coli, and they remained uninfected. Of the other two patients, one died, and the other developed chronic infection. Seven of eight patients with heavy contamination developed major sepsis despite mounting several antibody responses. Six patients without contamination mounted no antibody responses and remained uninfected.

The use of a new assay for detecting antibody to Staphylococcus aureus in severely injured patients

Investigation of the antibody response to Staphylococcus aureus infection has been hindered by lack of a simple and specific assay. We report an enzyme-linked immunosorbent assay (ELISA) using a strain of S. aureus devoid of Protein A, a frequent cause of false positive results in ELISAs, and have used this assay to study antibody responses of 23 severely injured patients. This IgM ELISA had a diagnostic sensitivity for major Staphylococcal infection of 70% (seven of ten patients with major infection) and a specificity of 92% (12 of 13 patients without major infection). Of three patients with major Staphylococcal infections who mounted no IgM response, two died and the other developed severe chronic Staphylococcal infection, and hence prompt initiation of appropriate therapy was necessary. Furthermore, the ability to mount IgM response to Staphylococcal infections appears to contribute to an orchestrated host defense response against this organism.

An outcome predictive score for sepsis and death following injury

Injury is an important cause of both morbidity and mortality, particularly in the young. Scoring systems have been developed to establish guidelines of transfer and compare patient outcome, but no scoring system as yet has been constructed that focuses upon immune capability of these patients. We report an outcome predictive score (OPS) which appears to distinguish good outcome from sepsis in patients who survive, and between patients with sepsis who survive from patients with sepsis who die. The score is based on (1) Injury severity score (ISS) expressed as percentage of the 50 per cent lethal dose of injury for age (%LD50), (2) Degree of bacterial contamination at initial injury, (3) The patient's monocyte DR antigen expression. Fifty-one severely injured patients were divided into three groups: (1) A group without infection (N = 15), (2) A major sepsis group which survived (N = 24), (3) A group who died (N = 12). There was no difference between the ISS of these groups. The mean OPS of the good outcome group was significantly less than the mean OPS of both the septic (P less than 0.0002) and dead (P less than 0.00001) groups. The mean OPS of the septic group was also significantly less than the mean of the group that died (P less than 0.002). Identification of high risk patients may be important to determine priority of patient care and to institute additional therapeutic measures.

The response of immunoglobulins to infection after thermal and nonthermal injury

Traumatic and thermal injuries are leading causes of mortality and morbidity due to their high incidence of infection. Host defense is vital to recovery in these patients yet incompletely understood. On days 1, 7, and 14, serum immunoglobulins of the IgA, IgG, and IgM classes were measured in 46 consecutive patients who sustained severe trauma with an injury severity score of at least 20. The patients were divided into four groups: 1) an uneventful recovery group (n = 11) of nonthermal trauma patients who did not become infected; 2) an infected nonthermal group without splenectomy; 3) an infected group of burn patients; and 4) 12 patients who underwent splenectomy of which nine became infected following nonthermal trauma. In each patient group, IgA, IgG, and IgM were all reduced, and group 1 had a steady return to normal range. Group 2 patients exhibited supranormal responses in all 3 classes at one week and supranormal IgA and IgG responses at two weeks. In contrast, both infected burn and splenectomized patients had markedly reduced IgG and IgM levels compared with the group 2 patients (P less than 0.05). Splenectomy sharply reduced IgM response to infection at 7 and 14 days compared with nonsplenectomized infected posttraumatic patients. Immunoglobulin response after trauma depended on the type of injury, presence of infection, splenic function, and type of immunoglobulin. Recognition of immunoglobulin deficiencies in both the burn and splenectomized patient may permit focused therapy, such as specific replacement of these proteins.

The capacity of serum to support neutrophil phagocytosis is a vital host defense mechanism in severely injured patients

The opsonic capacity of patient serum was studied in 43 trauma patients of whom 13 recovered uneventfully, 21 developed major infection, and nine died, mostly of infection. Blood samples were taken within 24 hours of injury. Fifteen patients were studied serially of whom 14 developed severe infection and/or died. Opsonic capacity was determined by flow cytometry and measured as the ability of normal neutrophils to phagocytose killed bacteria previously incubated with patient serum. The most dilute sera reflected changes for better and worse most clearly. On initial assessment, those who died of sepsis showed a 61% mean fluorescent intensity (MFI), which was significantly lower than the 99% MFI for those who survived infection (p less than 0.01) and the 78% MFI of those who developed no infection (p less than 0.05). Serial samples demonstrated a super serum response in four of seven patients surviving major sepsis but in none of the seven who died of infection.

A randomized, double-blind trial of single dose piperacillin versus multidose cefoxitin in alimentary tract operations

For elective alimentary tract operations in which contamination is moderate, single dose prophylaxis with piperacillin is equivalent to triple dose cefoxitin, a well established and effective regimen. Both methods failed to control infection arising in the perineal wound after abdominoperineal resection. Just as is the case with drain site infection, such infection often evolves from postoperative contamination and, indeed, is in theory and in fact unlikely to be controlled by perioperative prophylaxis. This study is among the first of several examining the issue of single dose prophylaxis and will be the harbinger of other studies from other groups examining whether or not the course of therapeutic antibiotics can be safely shortened in patients with peritoneal contamination.

A systematic study of host defense processes in badly injured patients

A prospective study of factors predisposing to infection in badly injured patients has disclosed: the dominant roles of two specific parameters: monocyte antigen presenting capacity, and opsonic capacity of diluted serum; the potential value of further assessment of: the predictive value of plots of activated T-cells/total T-cells versus monocyte antigen presenting capacity, the apparent protective effect of the ability to sharply increase specific IgM in response to infection, and the apparent protective effect of cytomegalovirus (CMV) infection in the first 28 days after injury against major bacterial infection; the lack of value of analysis of other T- and B-cell subsets in such patients; and the need to clarify CMV and transfusion status with respect to interpretation of such data. The specific role of variable transfusion and of specific serum immunoglobulins will require further and more discriminating study.

Immunologic effects of blood transfusion upon renal transplantation, tumor operations, and bacterial infections

Blood transfusions appear to exert a suppressive effect on many aspects of the immune system. In transplantation, this has been used to advantage; in other areas, the consequences can be deleterious. It is likely that various components of the immune system are affected by different mechanisms and possibly by different components of transfused blood. Before rational strategies can be evolved for minimizing the deleterious effects of blood transfusions, it is essential that these mechanisms be clearly defined. Studies must take into account any influence the underlying disease state might have on the immune system. In the absence of any satisfactory substitute, blood transfusion remains an essential therapeutic modality in the management of surgical patients. With current evidence, however, it seems reasonable to avoid the administration of small-volume transfusions whenever possible and encourage the use of autodonated blood for elective surgery.

The results of incisional hernia repair: a twelve year review

A series of 81 incisional hernia repairs is presented. Two main types of repair were performed, the 'keel' repair and a mass closure repair. In both repairs monofilament nylon was used. The recurrence rate was 46% (37 patients), the major predisposing factor being postoperative wound infection or haematoma formation. Subsequent repairs were no more successful. These poor results are compared with other published series.

Incisional hernias: when do they occur?

Incisional herniation remains a major problem for the general surgeon. Most published studies have followed up patients for 6-12 months after operation. In this study, 363 patients, known not to have an incisional hernia at 1 year, were reviewed between 2.5 and 5.5 years after operation. Twenty-one patients (5.8 per cent) were found to have developed incisional hernias. None of the causal factors previously implicated in the aetiology of incisional herniation (wound infection, male sex, obesity, age, postoperative chest infection or abdominal distension), was found to be associated with the development of these 'late hernias'.