No abstract

Objective-To determine the utility of adding oral non-absorbable antibiotics to the bowel prep prior to elective colon surgery Summary background data-Bowel preparation prior to colectomy remains controversial. We hypothesized that mechanical bowel preparation with oral antibiotics (compared to without) was associated with lower rates of SSI. Methods-24Michigan hospitals participated in the Michigan Surgical Quality CollaborativeColectomy Best Practices Project. Standard peri-operative data, bowel preparation process measures and C.difficile colitis outcomes were prospectively collected. Among patients receiving mechanical bowel preparation, a logistic regression model generated a propensity score that allowed us to match cases differing only in whether or not they had received oral antibiotics.Results-Overall, 2011 elective colectomies were performed over 16 months. Mechanical bowel prep without oral antibiotics was administered to 49.6% of patients, while 36.4% received a mechanical prep and oral antibiotics. Propensity analysis created 370 paired cases (differing only in receiving oral antibiotics). Patients receiving oral antibiotics were less likely to have any SSI (4.5% vs.11.8%, p = 0.0001), to have an organ space infection (1.8% vs. 4.2%, p = 0.044) and to have a superficial SSI (2.6% vs. 7.6%, p = 0.001). Patients receiving bowel prep with oral antibiotics were also less likely to have a prolonged ileus (3.9% vs. 8.6%, p = 0.011) and had similar rates of C. difficile colitis (1.3% vs. 1.8%, p = 0.58).Conclusions-Most patients in Michigan receive mechanical bowel preparation prior to elective colectomy. Oral antibiotics may reduce the incidence of SSI.

The platelet function analyzer (PFA)-100 is a newly developed instrument that provides a rapid, in vitro, quantitative measurement of platelet adhesion and aggregation in whole blood flowing through a small aperture under high shear conditions. Thirty patients undergoing percutaneous transluminal coronary angioplasty (PTCA) and ten normal individuals were included in this study. In vitro and in vivo studies were conducted to discern the effect of combinations of antiplatelet drugs (aspirin, ticlopidine, abciximab) and heparin on the performance of the device as well as the effects of preanalytical variables, such as method of sample collection and ex vivo anticoagulants. Studies were also conducted examining the effect of aperture size (standard 150 microns vs. smaller 120 microns) on the ability of the device to detect the effect of antiplatelet drugs. There was no difference in mean PFA-100 closure time with citrate versus PPACK anticoagulants or with venipuncture vs. sheath sampling. Closure times did not vary with heparin administration. Closure times were slightly longer for patients taking aspirin plus ticlopidine compared to aspirin alone (p = NS). In contrast adenosine disphosphate (ADP) induced platelet aggregation was significantly less in patients that took aspirin plus ticlopidine vs. aspirin alone (p = .0005). In vitro, there was a dose-dependent increase in closure time for both aperture sizes with increasing abciximab concentration. Although both cartridges showed infinite closure times at an abciximab concentration of 2.25 micrograms/mL, there was a slight benefit to using the 120 microns aperture cartridges at abciximab concentrations of 1.75 to 2.0 micrograms/mL. In ten patients who were followed during abciximab therapy to assess the effect of aperture size, the PFA-100 was able to detect in vivo platelet inhibition by abciximab, but detection of recovery from abciximab-induced platelet dysfunction was slightly better for the PFA-100 with the 120 microns aperture compared to the standard 150 microns aperture collagen/ADP cartridge.

Death in children with epilepsy is profoundly disturbing, with lasting effects on the family, community, and health care providers. The overall risk of death for children with epilepsy is about ten times that of the general population. However, the risk of premature death for children without associated neurological comorbidities is similar to that of the general population, and most deaths are related to the cause of the epilepsy or associated neurological disability, not seizures. The most common cause of seizure-related death in children with epilepsy is sudden unexpected death in epilepsy (SUDEP). SUDEP is relatively uncommon in childhood, but the risk increases if epilepsy persists into adulthood. Although the direct cause of SUDEP remains unknown, most often death follows a generalized convulsive seizure and the risk of SUDEP is strongly related to drug-resistant epilepsy and frequent generalized tonic-clonic seizures. The most effective SUDEP prevention strategy is to reduce the frequency of seizures, although a number of seizure detection devices are under development and in the future may prove to be useful for seizure detection for those at particularly high risk. There are distinct benefits for health care professionals to discuss mortality with the family soon after the diagnosis of epilepsy. An individual approach is appropriate. When a child with epilepsy dies, particularly if the death was unexpected, family grief may be profound. Physicians and other health care professionals have a critical role in supporting families that lose a child to epilepsy. This review will provide health care providers with information needed to discuss the risk of death in children with epilepsy and support families following a loss.

Introduction: Millions of vulnerable, elderly individuals live in coastal areas susceptible to hurricanes and are at risk for adverse health outcomes. The purpose of this study was to determine the status of preparedness for and possible health consequences of a hurricane on a vulnerable, but experienced, elderly population.Problem: Preparedness guidelines have been published, but it is unclear how well-prepared elderly individuals are for hurricanes, and what impact hurricanes may have on their health.Methods: Five hundred forty-seven ambulatory patients who attended an urban teaching hospital's geriatrics clinic in Florida were surveyed. A 25-question survey that asked whether subjects followed the American Red Cross guidelines for hurricane preparation was developed. The participants were asked what hurricane supplies they had, and whether they would need to evacuate or utilize storm-proof window shutters. They also were queried about definitions and their understanding of hurricane warnings. Three possible health impacts during the two weeks following Hurricane Wilma in 2005 were asked: (1) falls; (2) missed medication; and (3) missed doctor's appointments. An additional 105 patients in the same clinic were asked about the same three health outcomes one and one-half years after the hurricane struck.Results: Two-thirds of respondents were missing at least one supply item. A multivariate analysis indicated that there was no relationship between the subjects' demographic characteristics and the possession of the suggested disaster supplies. Although 36% would need to evacuate, only 56% of these 36% had a plan. Only 63% had storm-proof windows or shutters, and of these, only 46% could install them. Gasoline-powered electrical generators can be useful, but also a source of morbidity or mortality following a hurricane. For example, this study found that 28% of respondents had generators, but only 46% knew how to use them. Subjects immediately after the hurricane rmsstd fewer doses of medication than at other times (3.4% vs. 6.7%; p <0.0001) and fell slighdy less often (8.8% vs. 12.9%; p <0.0001). However, there were significandy more missed doctors appointments after the hurricane (11.6% vs. 0.1%, p <0.0001).Conclusions: The survey indicated that even a well-experienced population lacks adequate hurricane preparation. Most still are vulnerable in at least one aspect of preparation. The elderly may be more likely to miss medical appointments immediately following a hurricane. Interventions to improve hurricane preparedness should be piloted.

SummaryHeparin-induced thrombocytopenia (HIT) is an important complication following administration of heparin. Platelet activation and aggregation induced by heparin/platelet factor 4/immunoglobulin complexes are thought to be the underlying mechanism for this condition, so it was hypothesized that abciximab (a humanized murine monoclonal antibody directed against the glycoprotein IIb/IIIa receptor) would prevent heparin-induced platelet aggregation and activation in plasma from patients with HIT. Platelet aggregation was tested in vitro with platelet-poor plasma (obtained from 23 patients with HIT), platelet-rich plasma (from normal donors with known reactivity), heparin (0.5 U/ml), and ascending doses of abciximab (0.07-0.56 μg/ml). The ability of abciximab to prevent platelet activation was also evaluated using flow cytometry (P selectin expression, mepacrine release, microparticle formation) and platelet factor 4 immunoassay. In vitro, abciximab inhibited heparin-induced platelet aggregation in a dose-dependent fashion (IC50 0.103 μg/ml) and inhibited microparticle formation, the expression of P-selectin, release of mepacrine and platelet factor 4. These findings suggest that abciximab may be useful in treatment of patients with HIT and warrants further clinical evaluation.

Secondary prevention measures are improving, especially in prophylactic prescribing, lipid management and smoking cessation, although scope for further improvement remains. No difference was seen between the patient subgroups. Lifestyle measures need to be addressed to gain maximum benefit in addressing overall cardiovascular risk.

Although hirudin did not prevent generation of new thrombin, it appeared to inhibit thrombin activity more than did heparin and produced slower increases in thrombin formation after discontinuation. The reelevation of thrombotic markers after stopping intravenous antithrombin therapy and the tendency toward increased thrombotic events with post-treatment increases in marker levels suggest an ongoing, clinically significant prothrombotic state. These results raise the possibility of improving on current antithrombotics by preventing thrombin generation and thrombin activity and by sustained suppression of the prothrombotic state.