John C. Hall

A prospective randomized trial of enteral glutamine in critical illness

ObjectiveTo assess the influence of enteral glutamine on the incidence of severe sepsis and death in critically ill patients.DesignThis two-armed clinical trial was triple blind (patients, attending staff, research nurse).SettingThe 10 bed general ICU at Royal Perth Hospital, Western Australia.PatientsThis trial evaluated 363 patients requiring mechanical ventilation (median APACHE II score=14); of these, 85 had trauma.InterventionThe intervention solution contained 20xa0g/l glutamine and the control solution was isojoulic and isonitrogenous.Measurements and resultsThe groups had similar characteristics at baseline, and they also received equivalent amounts of protein and energy. Patients in the glutamine group received a median of 19xa0g/glutamine per day and 91% (332 of 363) of the patients were fed via a nasogastric tube (median duration=10xa0days). The outcomes were similar in the two groups: (a) death within 6xa0months: glutamine group 15% (27 of 179) vs control group 16% (30 of 184); p=0.75; relative risk, 0.95 (95% confidence interval, 0.71–1.28); and (b) severe sepsis: glutamine group 21% (38 of 179) vs control group 23% (43 of 184); p=0.62; relative risk, 0.94 (95% confidence interval, 0.72–1.22). There was also no discernable difference in the secondary outcomes relating to infections, febrile period, antimicrobial therapy, and consumption of inotropes.ConclusionThis clinical trial did not support the use of enteral glutamine supplements in similar cohorts of critically ill patients.

Surgeons and cognitive processes.

The surgical mind is geared to make important decisions and perform highly skilled tasks. The aim of this review is to explore the cognitive processes that link these actions.

The influence of lavage on peritonitis.

Lavage was adopted by surgeons around the turn of the century for managing patients with peritonitis. In 1906, Franz Torek from the New York PostGraduate Medical School described how “the salt water is poured into all recesses” and “the hand, by some gentle to-and-fro motions, assists it in washing all parts” and pus was “dipped out, rather than wiped out, as the latter procedure would be more likely to injure the peritoneum.” Over the years, support for its use has fluctuated, depending largely on opinions rather than evidence. Lavage is currently widely used in the treatment of patients with peritonitis either from bowel perforation or from acute pancreatitis. Early opponents of the use of lavage claimed that it served to spread infection. In the first half of this century, Rodney Maingot commented that, “Irrigation of the peritoneal cavity for cleansing purposes is, in my opinion, never justified, even in the presence of gross fecal contamination.” Burnett and coworkers in 1957 reintroduced peritoneal lavage as a treatment option in patients with peritonitis in association with high concentrations of antibiotics. He commented that “lavage removes large quantities of toxins from a great absorptive area and many bacteria which would have otherwise have to be dealt with by the body’s defenses.” The primary role of the surgeon in managing patients with peritonitis is to control the source of contamination. Failure to do so results in septicemia and a universally poor prognosis. Secondary treatment aims include reducing the bacterial load in the peritoneal cavity by lavage, antibiotics, or both. Lavage is claimed to remove not only bacteria but also material that may promote bacterial proliferation (eg, blood) and proinflammatory cytokines that may enhance local inflammation. The objective of this article is, first, to give an overview of peritoneal defense mechanisms and how lavage may influence the resolution of peritonitis; and second, to review the relevant surgical literature and to perform a combined analysis of available randomized prospective clinical trials, to evaluate whether lavage influences mortality and morbidity in patients with bacterial peritonitis.

Imagery practice and the development of surgical skills

BACKGROUNDnThe purpose of this review is to explore the potential role of imagery practice during the acquisition of surgical skills, imagery practice being the mental rehearsal of a skill.nnnMETHODSnThe core of this review is derived from a literature search of a computer database (Medline).nnnFINDINGSnThe cognitive processing that occurs during times of intense learning involves processes such as dream enactment behavior and imagery practice. These processes complement and augment the more usual forms of practice.nnnCONCLUSIONSnImagery practice provides a mechanism for the explicit learning of surgical skills.

Role of peritoneal mesothelial cells in peritonitis

Peritoneal mesothelial cells have a remarkable capacity to respond to peritoneal insults. They generate an intense biological response and play an important role in the formation of adhesions. This review describes these activities and comments on their relationship to surgical drainage, peritoneal lavage and laparostomy in the management of patients with peritonitis.

A meta-analysis of peritoneal lavage for acute pancreatitis.

It has been postulated that continuous irrigation of the peritoneal cavity with crystalloid solutions in patients with acute pancreatitis can improve mortality and morbidity. The aim of the study is to perform a meta‐analysis of available randomized prospective clinical trials, to evaluate whether lavage influences mortality and morbidity in patients with acute pancreatitis.

Randomized clinical trial of single-dose antibiotic prophylaxis for non-reconstructive breast surgery

The aim of this randomized clinical trial was to determine whether a single intravenous dose of 2 g flucloxacillin could prevent wound infection after primary non‐reconstructive breast surgery.

Peritoneal mesothelial cells produce inflammatory related cytokines

Background:u2003 Peritonitis involves cascading interactions between cytokines that initiate robust signalling processes via the interferon‐g and nuclear factor kappa B pathways. The present study evaluates the interplay between various putative inducers of peritonitis and a battery of inflammation‐related cytokines.

Evolution of methodological standards in surgical trials.

Background:u2003 The Consolidated Standards of Reporting Trials (CONSORT) Statement outlines acceptable ways of performing and reporting clinical trials. The objective of the present study was to identify evolving patterns in the methodological standards of surgical trials.

TUMOUR NECROSIS FACTOR: IMPLICATIONS FOR SURGICAL PATIENTS

Tumour necrosis factor alpha (TNF‐α) is an inflammatory cytokine primarily produced by macrophages. It is a unique protein with contradictive properties; it has the ability to induce cellular death by apoptosis and oncosis, but can also induce cellular regeneration and growth. Genetic polymorphisms in TNFA have been associated with poor outcome in some surgical patients and this may provide a useful tool to screen for high‐risk patients. Manipulating TNF‐α levels in vivo may influence the progression of several pathological conditions. TNF‐α has anti‐cancer properties and has been used to treat cancer patients. Treatment with anti‐TNF‐α drugs and antibodies has been successful in rheumatoid arthritis and other autoimmune diseases, but disappointing in the management of patients with sepsis. This review article focuses on the biological activities, genetic polymorphism of TNFA and the role of TNF‐α and anti‐TNF‐α treatments, based on animal experiments and clinical trials.