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OBJECTIVES: To evaluate the impact of implementation of guidelines aimed at reducing the use of laboratory and diagnostic preoperative tests in patients with low anesthesiologic risk, admitted to six public hospital of Ente Ospedaliero Cantonale in Cantone Ticino (Switzerland). DESIGN: Observational study. METHODS: Time series analysis of patterns of use of preoperative tests, on 14,585 patients admitted to public hospitals form March 1996 to June 1998. PRINCIPAL OUTCOME MEASURE: Proportion of patients undergoing a laboratory or other diagnostic tests during three six months periods before guidelines implementation (baseline), during the six months of the implementation phase and during the following four months of adoption of the guidelines in the participating centres. RESULTS: During the four months following the implementation, we observed a reduction of 15% (95% CI: 1%-27%) in the use of azotemia, and a reduction of 34% (95% CI: 18%-50%) for coagulation tests. Corresponding figures for glycemia and chest x-ray indicated a reduction of 44% (95% CI: 32%-54%) and of 22% (95% CI: 8%-34%), respectively. As for other tests (creatinine, ECG), no statistically significant reduction was observed. Most of the observed effect was explained by a reduction in use in patients at a low risk (ASA 1 and 2). In addition, guidelines appeared to have a greater impact in the four small (i.e. < 200 beds) hospitals, as compared with the two centres of greater size. CONCLUSIONS: Consistently with the empirical evidence available in this area, this study suggests that guidelines can change clinical practice, when they are implemented through a strategy taking into account adaptation of the recommendations to local circumstances and involvement of health professionals.

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The splenic cyst occurs rarely, is benign and often asymptomatic. Surgery is the therapy of choice as soon as the size reaches 2 centimeters. Following the exclusion of an echinococcus infection, the cyst can be treated either by complete resection or by fenestration. Recently laparoscopy has been demonstrated to be a useful alternative to open surgery in the treatment of selected splenic cysts. We report 3 cases successfully operated with conventional surgical procedures and, based on the literature, we review the history, the physical signs, the investigations and the surgical procedures.

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The PEG-ileus is a complication of the intestinal migration of the "bumper". The resulting obstruction or perforation is usually located in the ileum. Patients with hernias, who have a possible or known intrinsic or extrinsic stenosis or who have been X-rayed in the area of the small pelvis, are not suitable for the application of Korula's "migration"-technique with the scheduled intestinal elimination of the "bumper". "Bumpers" that are allowed to remain in the stomach for a long time lose their elasticity and frequently cause a PEG-ileus. When choosing the type of gastrostomy, we should consider which technique could be used in the case of a change or a removal of the material.

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The purpose of this study was to determine retrospectively some subjective and objective parameters following the operative treatment of 32 patients with "complex" (intraarticular and/or comminuted) fractures of the distal radius using the small AO external fixation device. The mean follow-up period was 20 months (minimum 4, maximum 48) and the mean age of the subjects was 62 years (minimum 27, maximum 91). Subjective results such as "general feeling", mobility, strength and pain, expressed with a scoring system (% of maximum obtainable points), showed an overall good result and ranged between 71% (pain), 81% (strength) and 91% (mobility and "general feeling"). Regarding the objective results, no major skin or soft tissue distress (Sudeck dystrophy) was noted. However, there was a general tendency towards a mobility deficit of the wrist operated on, which was statistically significant (P < 0.01) for flexion, extension, supination and abduction (respectively, -17.7%, -12.4%, -7.1% and -12.5%). The late standard radiological and lateral controls showed a mean radial angle of +2.13 degrees (B or lateral radial angle) and +23.13 degrees (A or AP angle), respectively. The analysis of data, as expressed by time after operation (< or > than 10 months), showed no relevant difference between the two groups (age of both similar), as expressed by age (< or > than 60 years); the data only showed differences in strength and pain (scores by 92% vs 82% for force and 92% vs 76% for pain) and in flexion and extension (-22.8% and -14%, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

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We describe a case of severe hypothermia in a 32-year-old patient who fell into a crevasse. Three hours later he was rescued and flown to a district hospital. On arrival he was apparently dead, with cadaveric skin, dilated and fixed pupils, pulseless and in respiratory arrest. His rectal temperature was 26 degrees C. On the ECG monitor there was first ventricular fibrillation, then, after several unsuccessful attempts at defibrillation, the heart became asystolic. Cardiopulmonary resuscitation was begun with orotracheal intubation and external cardiac compression, which eventually lasted 4 hours and continuously required a team of 6 persons. Only at a temperature of 32.5 degrees C could the patient be defibrillated with success. In the absence of extracorporeal circulation (ECC) the victim was rewarmed by warm-air breathing and by instillation of warm saline in peritoneum, stomach and bladder. In this way the rewarming velocity was 1.8 degrees C/hour. The postacute course was characterized by severe rhabdomyolysis (CK of 100,000 U/L) with non-oliguric renal failure, which necessitated several sessions of hemodialysis. Four months later the asymptomatic patient returned to work. Our case shows that a severely hypothermic patient can successfully be treated in a primary hospital not equipped with an ECC, provided that there is a sufficiently large team. Further, uninterrupted external cardiac compression guarantees efficient circulation even over several hours. Electric defibrillation in a hypothermic patient is ineffective unless normal body temperature has been reached. Lastly, every effort to continue resuscitation must be made in the still hypothermic patient whose absence of clinical response may obscure the real possibility of complete recovery.

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In the search for an appropriate antibiotic to reduce the rate of postoperative wound infection in patients with acute appendicitis, we have randomized 150 patients preoperatively in a prospective 3-arm study. The operation technique was standardized for all patients and involved the use of plastic wound protectors. Bacterial contamination was documented by 3 swabs taken during operation. In 2 arms, patients received short-term adjuvant prophylaxis with either cefazolin or clindamycin/tobramycin. The third arm served as a control. Wound contamination ws proven in 33% of all cases but only 4% developed a real wound infection. The rate of infection was almost identical in all groups, without a statistically significant difference in the chi2 test. It is concluded that wound infection after appendectomy cannot be prevented by prophylactic use of antibiotics. Careful operation technique with local protective steps is quite sufficient. Antibiotics should therefore be reserved for special indications.

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