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Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Background and Hypothesis: The inflammatory response was targeted by unsuccessful therapies but ignored pathogen. We hypothesized that the inflammatory response differs according to organism in human septic shock. Materials and Methods: We measured 39 cytokines at baseline and 24 h in patients (n = 363) in the Vasopressin and Septic Shock Trial (VASST). We compared cytokine profiles (cytokine functional class) at baseline and at 24 h by organism and used hierarchical clustering to classify cytokines according to 28-day outcomes. Results: In 363 patients, 88 and 176 patients had at least 1 species isolated from blood and other sites, respectively. Cytokine levels differed significantly according to organism: Neisseria meningitidis and Streptococcus pneumoniae had the highest (baseline and at 24 h), while Enterococcus faecalis (blood) had the lowest mean cytokine levels. N. meningitidis and Klebsiella pneumoniae had significantly higher cytokine levels at baseline versus 24 h (p = 0.01 and 0.02, respectively); E. faecalis had significantly higher cytokine levels at 24 h versus baseline. Hierarchical clustering heat maps showed that pathogens elicited similar cytokine responses not related to the functional cytokine class. Conclusion: The organism type induces different cytokine profiles in septic shock. Specific gram-positive and gram-negative pathogens stimulated similar plasma cytokine-level patterns.

Routine postoperative radiographs are commonly obtained at the initial postoperative visit. The purpose of this study was to demonstrate the clinical utility of routine postoperative radiographs and quantify the radiation exposure and cost to the health care system. All orthopaedic surgeries performed during 2007 at a level I trauma center were retrospectively analyzed. Surgical procedures that were likely to require follow-up radiographs were included. Analysis demonstrated 878 procedures with 471 procedures (54%) receiving initial postoperative radiographs. Routine radiographs were performed in 455 (96.6%) procedures with 4/455 (0.879%) resulting in a change in management. Nonroutine radiographs were performed in 16 (3.40%) procedures with 2/16 (12.5%) triggering a change in management. Subjects receiving radiographs at the initial postoperative visit obtained a mean of 2.54 radiographs per procedure with a mean exposure of 0.199 mSv with a median cost of $29.98 per radiographic series in 2013 Medicare reimbursement dollars. (Journal of Surgical Orthopaedic Advances.

Submacular membranectomy has been suggested as an alternative treatment for subfoveal choroidal neovascularization (CNV). Clinicopathologic features of the right eye of a 59-year-old man with recurrent subfoveal CNV who underwent submacular membranectomy after two unsuccessful laser photocoagulation treatments are reported.The surgically excised subfoveal membrane was sectioned serially and evaluated by light microscopy. The globes were obtained postmortem and serial sectioned through the macula and optic nerve head for light microscopy. Ultrastructural study of a tissue section in the center of the lesion was performed.Histopathologic study of the surgically excised membrane disclosed a thin two-component fibrovascular membrane with the larger component internal to residual retinal pigment epithelium and basal laminar deposit. Photoreceptor outer segments were present on the internal surface of the membrane near one margin. Light and electron microscopic study of the postmortem globe revealed a very thin subfoveal subretinal pigment epithelial fibrovascular membrane with loss of photoreceptor cell layer in a central 0.5 mm area, loss of outer segments, reduction of inner segments, and thinning of the outer nuclear layer in the remainder of the lesion. There was moderate retinal pigment epithelial attenuation and mild basal laminar and basal linear deposits.Submacular membranectomy for recurrent subfoveal CNV secondary to age-related macular degeneration after two unsuccessful laser photocoagulation treatments appeared to be effective with repopulation of two thirds of the area of membranectomy by extension of attenuated retinal pigment epithelium from adjacent areas. There was, however, persistence or recurrence of CNV, moderate atrophy of the overlying retina with total loss of the photoreceptor cells over the central 0.5 mm of the membrane, and moderate loss of the photoreceptor cells over the remaining area.

Although protection against ionizing radiation by compounds containing sulfhydryl (SN) groups, such as cysteine, has been reported, these agents have been unsuccessful to date in protecting mammals against non-ionizing radiation (>200nm). This study describes successful photoprotection by dithiothreitol (DTT) and glycerol against porphyrin photosensitization having an action spectrum of 400nm. Test models used were red blood cells (RBC) obtained from patients with erythropoietic protoporphyria (EPP) and mice photo-sensitized by hematoporphyrin (HP). A mortality rate approaching a lethal dose in 50% of the animals in 1 day (LD50/24 hrs) was established in 100 white mice that had received an intraperitoneal injection of 100mg HP/kg body wt., and were then irradiated with 5 × 106 ergs/cm2 from a fluorescent light source emitting 320-450nm radiation. Another 100 mice were treated in an identical manner except that they received, in addition to HP, 80mg DTT/kg body weight in a 5.5% glycerol solution. This group showed 75% reduction in mortality (p < 0.03). No lethal effects were observed in animals treated with DTT and glycerol or HP in the above concentrations without 400nm irradiation. RBC obtained from patients with EPP and exposed to 107 ergs/mm2 of 400nm radiation showed 100% hemolysis after 180min. These cells, when irradiated under identical conditions except for the addition of DTT, manifested only 19% hemolysis during this period of time. Measurements of SH groups of RBC from patients with EPP showed a progressive decrease during photohemolysis. Comparison of the rate of photohemolysis of normal and glucose-6-phosphate dehydrogenase (G6PD) deficient RBC irradiated in the presence of protoporphyrin IX revealed that G6PD deficient RBC, which have an impaired ability to produce reduced glutathione (GSH), were more susceptible to porphyrin-induced photohemolysis. These studies demonstrate that DTT and glycerol offer photoprotection in an in vivo mammalian system against porphyrin photosensitization. It is suggested that the mechanism of the photoprotective action against 320-450nm radiation has many features similar to that of radioprotection by thiols and glycerol against ionizing radiation.