The effects of volume of blood, number of consecutive cultures, and incubation time on pathogen recovery were evaluated for 37,568 blood cultures tested with the automated BACTEC 9240 instrument (Becton Dickinson Diagnostic Instrument Systems) at a tertiary care center over the period of 12 June 1996 through 12 October 1997. When the results for this study were compared with previous data published for manual broth-based blood culture systems and patient samples obtained in the 1970s and 1980s, the following were found: (1) the percentage increase in pathogen recovery per milliliter of blood is less, ( 2) more consecutive blood culture sets over a 24-h period are required to detect bloodstream pathogens, and ( 3) a shorter duration of incubation is required to diagnose bloodstream infections. Guidelines developed in the 1970s and 1980s for processing and culturing blood may require revision.

HYPOTHESISFor temporary fecal diversion, transverse colostomy (TC) has superior safety, but loop ileostomy (LI) has superior management qualities.METHODSOf patients with TC or LI seen between 1988 and 1997, 63 patients were matched for diagnosis, operative procedure, and date of surgery. The 2 groups were then compared for hospital/postoperative mortality and morbidity and stoma complications.RESULTSMortality rates were 6.3% for the TC group and 1.6% for the LI group (P =.25). Morbidity rates for stoma creation and for stoma closure were 47.6% and 10% (P =.19), respectively, for the TC group, and 36.5% and 6.3% (P>.99), respectively, for the LI group. Most morbidity events were minor, and neither procedure-related nor other medical complications showed a significant difference between the groups. However, patients with a TC were significantly more likely to experience skin trouble around the stoma (TC vs LI, 15.9% vs 3.2%) and leakage around the stoma (TC vs LI, 12.7% vs 1.6%).CONCLUSIONSRegarding safety, TC and LI should be considered equivalent options for temporary fecal diversion. We recommend further study comparing the 2 procedures with regard to patient perception and quality of life.

Aims: Describe the characteristics of extraintestinal manifestations complicating ulcerative colitis present preoperatively and determine their evolution after surgery. Methods: Between 1976 and 1986, 281 patients with ulcerative colitis exhibiting one or more extraintestinal manifestations (EIM) before either IPAA (n = 147), Brooke ileostomy (n = 71), Kock pouch (n = 48) or ileorectostomy (n = 15) were assessed retrospectively. The clinical evolution of each manifestation was classified as having disappeared, improved, remained unchanged or aggravated postoperatively. An efficacy index was designed to assess the ratio of the number of cases cured or improved over the number of cases unchanged or aggravated. The relationship between EIM and gender, age, duration of disease and the type of surgery was also ascertained. Results: 433 EIM were observed in 281 patients. The most common were arthralgias of the large joints (n = 146), of the sacroiliac joint (n = 59) and the small joints (n = 51). In comparison to patients without EIM having received the same operation during the same period of time, EIM were seen more often in women, younger patients, than those with longer duration of disease and the ileoanal anastomosis group. 60% had only one EIM at a time. Based on the efficacy index, thromboembolic accidents and erythema nodosum were the most commonly cured or improved. Ocular manifestations and primary sclerosing cholangitis were unaffected. The other EIM responded favorably but variably with improvement in two thirds of patients. The presence of a rectal remnant (IRA) or ileal reservoir did not affect the evolution of the EIM. Conclusions: Thromboembolic complications which are life-threatening, erythema nodosum and arthralgia of the small and large joints which impair quality of life, benefited the most from proctocolectomy. Those conditions may be considered preoperatively when making the decision for surgery.

The replication of beta-herpesviruses-cytomegalovirus (CMV), human herpesvirus (HHV)-6, and HHV-7-and their association with CMV disease and response to antiviral therapy were prospectively investigated in 33 liver transplant recipients not given antiviral prophylaxis. CMV, HHV-6, and HHV-7 DNA were detected within 8 weeks after transplantation in 70%, 33%, and 42% of the patients, respectively. The univariate association between CMV disease and the 3 beta-herpesviruses was more significant by virus load quantitation than by qualitative detection of DNA. This association with high levels of CMV, HHV-6, and HHV-7 (P<.001,.022, and.001, respectively) occurred mainly in CMV-seronegative recipients of transplants from CMV-seropositive donors. Antiviral therapy with ganciclovir (Gcv) reduced the load of CMV and HHV-6 and HHV-7. These results suggest that CMV disease in transplant recipients is related to the unique interaction of the 3 beta-herpesviruses and is ultimately reduced after intravenous Gcv treatment.

: The role of a temporary defunctioning stoma in patients undergoing coloanal anastomosis remains controversial. Previous experimental studies have shown that the defunctioned colon is more resistant to neoplasia. The aim of this study was to investigate whether a defunctioning stoma was able to decrease complication rates and, also, to evaluate whether it had any impact on recurrence and survival rates in patients who underwent coloanal anastomosis. The records of 173 patients, 54 with benign rectal disease and 119 patients with cancer, operated on between 1980 and 1996, were retrospectively reviewed. Eighty-nine patients had a defunctioning stoma, 34 in the benign rectal disease and 55 in the cancer group. Mean age was 57.2 years (range 17–88). There were 126 men and 47 women. Follow-up was 57.2 month (range 17–88). There were 126 men and 47 women. Follow-up was done by clinical examination, telephone or mailed questionnaire. Mean time of follow-up was 3.8 years (range 0–13 years). There was no operative mortality. Non-stoma patients tended to have more early complications (pelvic sepsis and obstruction) and more probability of having a permanent stoma than the stoma group, but no significant differences could be found between the two groups ( P > 0.05). The probability of being free of stricture was greater in the non-stoma group (stoma 62.6%; non-stoma 78.5%; P < 0.05). Probability of disease-free survival, at 5 years, for rectal cancer patients, was 73.7% for the stoma group and 53.6% for non-stoma group ( P = 0.02). After coloanal anastomosis, defunctioning stomas may decrease postoperative complications, increase the likelihood of anastomosis structure and allow a greater disease-free survival.

Surgery is the only treatment that can cure most patients with colorectal cancer. Radiation therapy (pre or postoperative) has been shown to improve results by decreasing local recurrence and improving survival. Our aim was to analyze whether postoperative radiation influenced long-term functional outcomes and the probability of stricture of anastomosis in patients who underwent coloanal anastomosis for rectal cancer. Methods: The records of 84 patients with coloanal anastomosis for rectal cancer were studied between 1980 and 1996. There were 82 males and 28 females. Mean age was 57.8 years (range 24 to 78 years). Mean distal resection margin was 2.6 cm (range 0 to 14cm). Twenty-three patients received postoperative irradiation therapy. Patients who received chemotherapy were not included in the study. Results were analysed by examination , telephone or questionnaire. Mean follow-up was 3.8 years (range 0 to 13 years). Results: There was no operative mortality. Functional variables were much better in non-irradiated patients. The irradiated group had more number of stools/day (p>0.05), more number of stools/ night (p>0.05), more incontinence/day (p<0.05) and more incontinence/night (p<0.05). Irradiated patients also wore more pads (p<0.05) than non-irradiated patients. The probability of remaining free of stricture at 5 years was slightly better in non-irradiated (72 percent) than in irradiated patients (65 percent, p>0.05). Conclusion: Postoperative irradiation after colo-anal anastomosis for rectal cancer is safe, but may increase the risk of stricture of anastomosis and does affect functional results adversely.

We performed a comprehensive analysis of the molecular, serological, and clinical features of 16 consecutive cases of invasive streptococcal disease (ISD), The majority of cases were linked to two group A streptococcus (GAS) clones closely related by pulsed-field gel electrophoresis (PFGE) and designated as PFGE-1 and PFGE-1.1. These clones, serotyped as M-3, T-3/B3264, carried an allelic variant of the gene that encodes pyrogenic exotoxin A (speA3) and the gene that encodes streptococcal superantigen (SSA) but different emm alleles that encode M-protein. The characteristics and clinical features of patients were similar to those described in previous reports, regardless of the responsible GAS clone. However, worse clinical outcomes (shock and death) were more frequent when patients infected with PFGE1/1.1 clones were considered as a group and compared with all other patients as a group. One striking feature in some patients with deep tissue infection was a lack of inflammatory cells despite the presence of numerous streptococci. An evaluation of PFGE profiles of GAS isolated elsewhere demonstrated that the PFGE-1 clone has caused invasive disease in other locations in the United States and in Japan.

Coloanal anastomosis is a well-established technique for resecting very low rectal cancer The aim of this study is to determine whether the addition of a colonic pouch improves functional outcomes.Methods: The records of 104 patients with rectal cancer, in whom a coloanal anastomosis was performed between 1980 and 1993, were reviewed.A colonic pouch was constructed in 14%.Functional results were measured by determining patients' satisfaction.Follow-up was done by exam, telephone and/or questionnaire.Results: There was no operative mortality.Minor complications were present in 20%, and major complications in 47% of the patients who had a pouch.This difference was not statistically significant when compared with the group of patients without a pouch (p>0.05).Stool frequency was greater than three movements per day in only 11% of the patients with a pouch and in 52% of those with a straight coloanal anastomosis.This difference was statistically significant (p<0.05).Satisfactory continence was achieved by all the patients with a colonic pouch and by 85% without a pouch (p>0.05).Conclusion: Pouch coloanal anastomosis appears to improve defecatory function, without increased operative mortality and/or morbidity.

OBJECTIVES To determine the long-term disease-free and overall survivals for patients undergoing hepatic resection for colorectal cancer metastases and to define significant predictors of improved patients survival. DESIGN Retrospective review. SETTING Single tertiary care center. PATIENTS Two hundred eighty consecutive patients underwent hepatic resection for colorectal cancer metastases at the Mayo Clinic from 1960 to 1987. Fifty patients alive at the completion of the study had a mean follow-up of 11.3 years (median, 121 months). MAIN OUTCOME MEASURES Disease-free interval following initial hepatic resection and death. RESULTS The overall 5-year survival of the 280 patients was 27%. Twenty-eight patients were alive at 10 years from the time of hepatic resection, and the 10-year actuarial survival was 20%. Only 2 patients alive and free of disease at 5 years had recurrent disease. For all other patients who were free of disease more than 5 years after hepatic resection and died, the cause of death was not cancer related. No patients characteristics or features of the primary tumor affected survival. Clinical presentation of metastatic disease, configuration of hepatic lesions, the presence of extrahepatic lymph node involvement, and the existence of resectable extrahepatic disease significantly affected long-term patient survival. Need for perioperative blood product transfusion was associated with a lower probability of long-term survival. CONCLUSIONS Disease-free patient survival beyond 5 years from surgical resection of colorectal cancer metastases to the liver represents patient cure in nearly all instances.

Objective. To review care provided by orthopedists and non-orthopedists for a variety of common acute injuries to the shoulder, knee, and ankle; and to evaluate the difficulties in assessing results from diagnostic data collected for administrative reporting by comparing these data with data collected by medical record abstraction for the same patients.Methods. The Rochester Epidemiology Project database was used to identify new cases of Colles fracture, knee sprain, ankle sprain, and shoulder sprain/rotator cuff injury among Olmsted county residents >18 years of age, who were evaluated between January 1, 1990 and December 31, 1992. Data were collected from an administrative database and medical records.Results. Although the diagnoses recorded in the administrative database and those obtained from medical record review were the same in 94% of the 500 cases reviewed, only 270 (67.7%) actually represented acute injuries. Medical record review showed that (for the shoulder and ankle) injury severity was highly correlated with treatment specialty: 13 of 15 severe injuries were cared for by orthopedists, while 64 of 68 mild injuries were treated by non-orthopedists. Diagnostic uncertainty was more common among non-orthopedists; in 21 of the 149 patients treated by non-orthopedists (15.1%), the final (i.e., recorded for coding) diagnosis was different from the initial diagnosis. In 14 of these cases, an orthopedist made the final diagnosis. None of the diagnoses made by orthopedists were revised.Conclusion. Current diagnostic coding does not capture injury acuity, severity or diagnostic uncertainty Studies that limit themselves to such data for diagnostic information are likely to suffer from biases which can skew results in unpredictable ways. Conclusions drawn from such studies are likely to be flawed.

BACKGROUND: Perianal Bowen's disease (BD) is an intraepithelial nonkeratinizing carcinoma, associated historically with internal tumors. METHODS: A review of patients with perianal BD presenting consecutively during a 25-year span was undertaken, excluding Bowenoid papulosis and contiguous genital BD. Histologic slides were resubmitted for review by an experienced pathologist, in a ''blind'' fashion among other slides. Follow-up was updated in every patient. Survival and recurrence curves were generated by the Kaplan-Meier method and were compared with a normal age-matched population (log-rank test). RESULTS: Nineteen patients were identified; 15 of them were females. Mean age +/- standard deviation was 49.6 +/- 10.6 years. Five patients had a coincidental diagnosis (hemorrhoidectomy or wart excision). No associated carcinomas were found; however, eight patients had isolated ED of the vulva. Eleven patients had a history of anal warts, cervical/vulvar dysplasia, or both. Wide resection, including V-Y flaps, was performed in 18 patients without dysfunction. One-year and five-year recurrence was 16 and 31 percent. Recurrence was treated in all but one case by wider resection. Mean follow-up was 8.4 years. Five-year survival was 75 percent, lower than the matched population (P = 0.001); however, only one death was related to ED. CONCLUSIONS: Perianal ED has no association with internal tumors. Despite a high rate of recurrence, perianal ED can be treated by local excision. An increased rate of human papilloma virus-related entities was found, which could suggest a causative role.

BACKGROUND:A clinical prediction model to identify malignant nodules based on clinical data and radiological characteristics of lung nodules was derived using logistic regression from a random sample of patients (n = 419) and tested on data from a separate group of patients (n = 210).OBJECTIVE:To use multivariate logistic regression to estimate the probability of malignancy in radiologically indeterminate solitary pulmonary nodules (SPNs) in a clinically relevant subset of patients with SPNs that measured between 4 and 30 mm in diameter.PATIENTS AND METHODS:A retrospective cohort study at a multispecialty group practice included 629 patients (320 men, 309 women) with newly discovered (between January 1, 1984, and May 1, 1986) 4- to 30-mm radiologically indeterminate SPNs on chest radiography. Patients with a diagnosis of cancer within 5 years prior to the discovery of the nodule were excluded. Clinical data included age, sex, cigarette-smoking status, and history of extrathoracic malignant neoplasm, asbestos exposure, and chronic interstitial or obstructive lung disease; chest radiological data included the diameter, location, edge characteristics (eg, lobulation, spiculation, and shagginess), and other characteristics (eg, cavitation) of the SPNs. Predictors were identified in a random sample of two thirds of the patients and tested in the remaining one third.RESULTS:Sixty-five percent of the nodules were benign, 23% were malignant, and 12% were indeterminate. Three clinical characteristics (age, cigarette-smoking status, and history of cancer [diagnosis, > or = 5 years ago]) and 3 radiological characteristics (diameter, spiculation, and upper lobe location of the SPNs) were independent predictors of malignancy. The area (+/-SE) under the evaluated receiver operating characteristic curve was 0.8328 +/- 0.0226.CONCLUSION:Three clinical and 3 radiographic characteristics predicted the malignancy in radiologically indeterminate SPNs.

BACKGROUNDA retrospective study was performed to evaluate our recent results of curative gastric resections for adenocarcinoma.METHODSBetween 1979 and 1988, 187 patients fulfilled study entry criteria. This group of patients composes 64% of all patients with tumors arising distal to the gastroesophageal junction. Tumors arising in the region of the gastroesophageal junction were excluded. Patients were classified according to the American Society of Anesthesiologists physical status classification ( > or = 3, 56%) and Eastern Cooperative Oncology Group performance status ( > or = 2, 44%). Histologic characteristics were re-reviewed.INTERVENTIONSSubtotal and total gastrectomies were performed in 78% and 22% of the patients, respectively. Extended lymph node dissections were performed selectively (5%). Adjuvant chemotherapy and radiotherapy were employed in 3% and 2% of patients, respectively.RESULTSPostoperative morbidity and mortality were 27% and 4%, respectively. Synchronous splenectomy (P = .06) and type of gastric resection (P = .06) showed a borderline association with postoperative complications, but did not affect postoperative mortality. With a median follow-up time of 47 months in all patients, and a median of 9 years in patients still alive, the 5- and 10-year overall survival rates (Kaplan-Meier method) were 48% and 32%, respectively. In univariate survival analysis, age, American Society of Anesthesiologists classification, stage, tumor diameter, serosal extension of tumor lymph node metastases, and type of resection showed prognostic significance. In the Cox multivariate analysis, however, only serosal extension of tumor (P < .001) and lymph node metastases (P = .02) were independent prognostic factors.CONCLUSIONSDespite the older age and comorbid conditions of patients with gastric cancer, 5-year survival was achieved in half the patients by standard radical operations. Until appropriate controlled prospective studies are performed, total gastrectomy, splenectomy, and extended lymph node dissection should not be routinely adopted, given their unproven efficacy and potentially increased morbidity and mortality.

OBJECTIVE:To determine, among persons who have had a large colon polyp, the risk of subsequent colon cancer at a site distant from that polyp.METHODS:Follow-up was done for 226 persons at the Mayo Clinic who had had a > or = 1-cm polyp demonstrated on barium enema between 1965 and 1970 and for whom yearly colon surveillance examination was recommended. Information was collected from Mayo Clinic records and from contact with patients, physicians, and other hospitals regarding the results of surveillance examinations and the development of colon cancer. Colon surveillance was routinely done at the Mayo Clinic using the technique of single contrast barium enema with vigorous manual fluoroscopic examination and proctoscopy. The expected rate of colorectal cancer (CRC) was calculated based on previously published rates for this community.RESULTS:Patients received, on average, four colon examinations in addition to the examination that discovered the index polyp. During 2126 person-years of follow-up, 16 persons developed a colon cancer at a location other than the site of the index polyp, in comparison with 4.0 expected cases, for a standardized incidence ratio of 4.0 (95% CI,2.3, 6.4). The cancers were large (mean 4.5cm) at presentation, and eight of the 16 cancers had been preceded within 3 yr by at least one negative barium enema.CONCLUSIONS:The rate to develop colon cancer in persons who have had a large colon polyp es about 4 times the expected rate, suggesting that such persons should be considered for aggressive colonoscopic surveillance. The failure to detect early cancer or its precursors by surveillance barium enema is probably explained by inherent insensitivity of single contrast barium enema.

OBJECTIVE:To determine if the presence of duodenal diverticula predisposes to the development of common bile duct stones.DESIGN:Cohort study; median follow-up, 10.0 years (25th and 75th percentiles, 5.2 and 16.1 years, respectively).SETTING:Tertiary care center.PATIENTS:One hundred fifty-seven patients with radiologically diagnosed duodenal diverticula who had undergone cholecystectomy from 1950 through 1987 and were asymptomatic at the initiation of follow-up.MAIN OUTCOME MEASURES:All patients were followed up for evidence of recurrent biliary tract disease to the following end points: (1) evidence of choledocholithiasis demonstrated by radiologic surgical, or biochemical means and (2) clinical or biochemical evidence of biliary pancreatitis.RESULTS:Of the 157 patients in the study cohort, 13 patients were categorized as having had recurrent biliary tract disease. Using the Kaplan-Meier survivorship method, the cumulative probabilities of recurrent biliary tract disease in patients with radiologically diagnosed duodenal diverticula were 3.6% at 5 years (95% confidence interval, 0.5-6.9), 5.5% at 10 years (95% confidence interval, 1.5-9.4), and 10.2% at 15 years (95% confidence interval, 3.8-16.7). Age, common bile duct exploration and choledochotomy, and the presence of common bile duct dilatation were not found to be significantly associated with recurrence based on a univariate analysis of risk factors by means of the log-rank statistic.CONCLUSIONS:For patients with radiologically diagnosed, second-portion duodenal diverticula, the risk of developing recurrent bile duct stones after cholecystectomy is lower than has been suggested in previous studies. In the absence of concurrent choledocholithiasis, sphincterotomy or biliary bypass at the time of cholecystectomy seems unwarranted.