Basics of surveillance--an overview

Surveillance of nosocomial infections is the foundation of an infection control program. This article describes components of a surveillance system, methods for surveillance, methods for case-finding, and data sources. We encourage the epidemiology team to use this background information as they design surveillance systems that meet the goals of their individual institution's infection control program.     

Basics of cutaneous wound repair

BACKGROUND: Cutaneous wound repair consists of multiple integrated networks of cell-matrix-cytokine interactions. It is generally believed that a better understanding of these networks will lead to improved care of cutaneous wounds, whether freshly made by the surgeon's scalpel or previously existing and not healing secondary to underlying abnormalities. OBJECTIVE: This review is intended to update the readership in some of the salient aspects of wound repair networks. METHODS: To facilitate the review of multiple integrated networks, cutaneous wound repair was arbitrarily divided into three phases: inflammation, tissue regeneration including re-epithelialization and granulation tissue formation, and tissue reorganization. RESULTS: Throughout the entire process of wound repair it is clear that cells produce or alter various cytokines and extracellular matrix. The cytokines and matrix in turn alter the behavior of the producer cells (autocrine response) or neighbor cells (paracrine response). CONCLUSION: The dynamic reciprocity among cells, cytokines, and matrix material helps explain how integrated wound healing networks are sequential as well as tightly controlled.     

Diagnosis and therapy of constipation

Prevalence of chronic constipation is around 3% in youth, 8% in middle age, and 20% in the elderly, respectively. There are three etiologic groups: 1. Diet poor in fibre. Most constipated persons, however, do not eat less fibre than controls. 2. Organic diseases accompanied by constipation such as autonomous neuropathies (e.g. in diabetes), endocrine disorders, and neurologic diseases (e.g. Parkinsons disease). 3. Functional outlet obstruction. This may be due to disturbed sphincter function, internal rectal prolapse, or rectocele. The basic treatment of all forms of constipation consists in a diet rich in fibre. In selected cases of functional outlet obstruction, surgery may be successful. Otherwise, treatment with laxatives is justified.     

Biofeedback for constipation?

Magnetic resonance imaging showed transient regression of the lesion after intravenous steroid administration in a patient with intracranial multifocal germ cell tumour. Prominent lymphocyte infiltration of the tumour was seen at histological examination and presumably accounts for the regression. Germ cell tumour must be included in the differential diagnosis of intracranial mass lesions sensitive to steroids.     

Irritable colon and constipation

Irritable bowel syndrome is a very common clinical problem with a broad spectrum of severity. The management includes a combination of positive diagnosis of typical symptoms with limited investigations to exclude underlying structural or biochemical disorders. Therapeutic trials focus on the relief of predominant symptoms. Identification and modification of factors exacerbating symptoms, behavioural techniques and pharmacologic agents directed to the presumed gastrointestinal motor dysfunction are required. Psychological support by the physician is the most important part of treatment. Chronic constipation may be the predominant symptom of irritable bowel syndrome. Underlying organic disorders must be excluded by clinical examination and endoscopy. Severe chronic constipation requires further investigation of colonic motility and defecation. High fibre diet, osmotic laxatives and procinetic agents may lead to an improvement. In rare cases surgery may be indicated.     

Treatment of constipation in older people

Constipation is a common experience for a wide range of client groups. However, it is often badly managed, and research into effective treatment of constipation is sparse. This article summarises a systematic review carried out for the NHS health Technology Assessment programme. There is some evidence that laxatives can improve frequency and consistency of defecation and symptoms in older people with constipation.     

Preventing constipation in older people

Laxative misuse is widespread in hospitals and nursing homes throughout the UK. Nurses rarely consider bowel management as central to their role. There is much nurses can do to prevent constipation in their patients/clients.     

Surgery for constipation: a review

PURPOSE: Constipation is related to intestinal motility disorders (colonic inertia (CI)), pelvic floor disturbances (pelvic outlet obstruction), or a combination of both problems. This review summarizes the physiologic and pathophysiologic changes in patients with intractable constipation and gives an overview of surgical treatment options. RESULTS: Although subtotal colectomy with ileorectal anastomosis is the best surgery for CI, there are still approximately 10 percent of patients who will complain of pain and constipation. A completion proctectomy and an ileoanal pouch procedure may be a viable option in a highly select group of patients. In patients with megabowel, reported results are mixed. Subtotal colectomy, partial colectomy for megacolon, and the Duhamel procedure for megarectum have all been reported with variable results. In patients with an isolated distended sigmoid colon, sigmoid colectomy has achieved good results. Anorectal myectomy has not been proven to be successful in the long term. However, in patients with adult short segment Hirschsprung's disease, myectomy can be successful. Patients with pelvic outlet obstruction can be successfully treated with biofeedback. In a small group of patients with a rectocele or a third degree sigmoidocele, surgical intervention yields a high success rate. Division or resection of the puborectalis muscle is not recommended. In patients with a mixed pattern of CI and pelvic outlet obstruction, surgical intervention alone is often not successful. These patients achieve better results by conservative treatment of pelvic outlet obstruction, followed by a colectomy. CONCLUSION: Surgical intervention for patients with intractable constipation is rarely necessary. However, thorough preoperative physiologic testing is mandatory for a successful outcome.     

The investigation of chronic constipation for surgical management

Organic solvents, such as ethanol or dimethyl sulphoxide (DMSO), have been used in liquid embolic agents. To investigate the effects of these solvents on the cerebral blood vessels and cerebral tissue, we subjected Wistar rats weighing 250-300 g to internal carotid artery infusion of 0.2 ml diluted ethanol (10%, 40% or 70%) or anhydrous DMSO (100%). Some rats were sacrificed 5 min after the infusion and the remainder at 10 days. Rats injected with ethanol at high concentration or DMSO showed extensive exudation of Evans blue at the site of injection 5 min after infusion, together with full-thickness necrosis of the wall of vessels and swelling of brain cells. In contrast, rats injected with 10% or 40% ethanol solution showed necrosis of only the intimal layer and partial necrosis of the medial layer and no brain swelling was observed. These findings suggest that ethanol at low concentration can be used as a relatively safe solvent for liquid embolic substances.     

The intestinal ecosystem in chronic functional constipation

Chronic functional constipation is common in infants, and the bacterial composition of stools in this condition is not known. The study aims were to: (i) investigate the composition of the intestinal ecosystem in chronic functional constipation; (ii) establish whether the addition of the water-holding agent calcium polycarbophil to the diet induces an improvement in constipation; and (iii) determine the composition of the intestinal ecosystem after the use of this agent. In total, 42 children (20F, 22M; mean age: 8.6 +/- 2.9 y) were studied. Twenty-eight children with functional chronic constipation without anatomical disorders were treated double-blind in random sequence for 1 month with an oral preparation of calcium polycarbophil (0.62 g/twice daily) or placebo. Intestinal flora composition was evaluated by standard microbiological methods and biochemical assays on faecal samples collected before and after treatment. Fourteen healthy children were studied as controls. The results show that (i) the constipated children presented a significant increase in clostridia and bifidobacteria in faeces compared to healthy subjects--different species of clostridia and enterobacteriaceae were frequently isolated; no generalized overgrowth was observed; Clostridia outnumbered bacteroides and E. coli mean counts by 2-3log, while bacteroides and E. coli counts were similar (5-6 log10/g fresh faeces); these intestinal disturbances could be defined as a dysbiosis, i.e. a quantitative alteration in the relative proportions of certain intestinal bacterial species. (ii) Clinical resolution of constipation was achieved only in 43% of treated children and an improvement in 21% (one bowel movement every 2 d). (iii) Calcium polycarbophil treatment induced no significant changes in the composition of the intestinal ecosystem, nor in blood chemistry parameters.     

Outcome and predictors of success of biofeedback for constipation

BACKGROUND: A study was undertaken to determine outcome and to identify predictors of success for biofeedback for constipation. METHODS: Patients who had at least one biofeedback session were evaluated whether or not they completed a treatment course. Parameters assessed included use of cathartics, number of spontaneous bowel movements per week, presence of rectal pain, number of biofeedback sessions and results of anorectal physiology. RESULTS: A total of 194 patients (59 male, 135 female) of median age 71 (range 11-96) years, including 30 with concomitant rectal pain, were treated. The median number of spontaneous bowel movements per week before treatment was 0. Some 35 per cent of patients had complete success (three or more spontaneous bowel movements per week with discontinuation of cathartics), 13 per cent had partial success (fewer than three spontaneous bowel movements per week with continued use of cathartics) and 51 per cent had no improvement. Neither patient age, sex nor duration of symptoms significantly affected outcome. Only 18 per cent of patients who had between two and four sessions had complete success, compared with 44 per cent of those who had five or more (P < 0.001). A total of 63 per cent of patients who completed the treatment protocol experienced complete success, compared with 25 per cent of those who self-discharged (P < 0.0001). CONCLUSIONS: This large study indicates that the success rate of biofeedback for patients with constipation is less than previously reported. However, the success rate improves significantly after five or more sessions and is significantly related to the patient's willingness to complete treatment.     

Pilot study of pathophysiology of constipation among community diabetics

We aimed to compare gastrointestinal transit and defecatory function in a random sample of people with or without diabetes mellitus in a US community who reported constipation or laxative use. In this pilot study we measured: gastric, small bowel, and colonic transit by scintigraphy; vector manometry of anal sphincters at rest and during squeeze; defecatory dynamics by balloon expulsion test; and scintigraphic measurement of anorectal angle at rest and during defecation. Autonomic function tests were performed in diabetics. Diabetics with constipation had a higher prevalence of abnormal evacuation or prolonged colonic transit during the first 24 hr than controls (P = 0.07): three had prolonged 24-hr colonic transit, and three abnormal evacuation. Among constipated controls, only one had anismus. Overall, diabetics had slower colonic transit during the first 24 hr than nondiabetics (P < 0.05). Community diabetics who experience constipation or use laxatives have a greater prevalence of delayed 24-hr colonic transit or evacuatory dysfunction than community controls.