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Background. The systemic and local tissue repair responses of radiation in combination with surgery are still unclear. We have studied the effect of fractionated pre-operative radiotherapy with or without subsequent laparotomy on collagen accumulation using a rodent model. Materials and methods. Thirty-two male Sprague-Dawley rats were divided into four groups (eight rats per group): 1) sham radiation and sham laparotomy (control); 2) sham radiation and laparotomy; 3) radiation and sham laparotomy; and 4) radiation followed by laparotomy. Expanded polytetrafluoroethylene (ePTFE) tubes were implanted subcutaneously in the abdominal wall in the radiotherapy field and on the back outside the radiotherapy field day 0. The abdomen (3 cm x 4 cm) was irradiated day 3 (10 Gy) and again day 7 (10 Gy). On day 10, implants were extirpated, laparotomy undertaken in groups 2 and 4 and new ePTFE tubes implanted subcutaneously. The second implants were extirpated on day 20. Implants were analyzed for hydroxyproline, total protein and transforming growth factor-ss 1 (TGF-ss 1) levels. Results. On day 10, hydroxyproline (P < 0.05) and TGF-ss 1 (P < 0.001) were lower in ePTFE tubes in irra-diated compared with non-irradiated rats. On day 20, the abdominal ePTFE hydroxyproline remained low (P < 0.001) in animals subjected to laparotomy and pre-operative irradiation while hydroxyproline levels of rats subjected to irradiation only were similar to controls. The effects of radiation on hydroxyproline were confined to the irradiated abdominal area. There was a positive correlation between hydroxyproline and TGF-ss 1 levels in the abdominal wall implant day 20 (r = 0.53, P < 0.005). Conclusion. A clinically relevant fractionated radiation scheme reduced subcutaneous collagen accumulation pre-operatively and profoundly within the radiation field post-operatively after laparotomy, possibly because of lowered TGF ss 1 levels. (c) 2006 Elsevier Inc. All rights reserved.

Lack of courses in emergency medicine for doctors under training is currently a problem in Sweden. Only 10 percent will have these courses early under their internship. The University hospital in Malmoe has therefore decided to create a course for doctors under training and to offer it early in their education. The curriculum is based on a problem-based learning concept using a modified case methodology that has been used since the 1920's at Harvard Business school in Boston. The course integrates doctors from different specialties with experienced nurses from the emergency ward. The five day course comprises; three theoretical days where cases from the emergency room are discussed with the case methodology, followed by two days of practical training. Our results from 100 participants over a period of two years is very encouraging, over 85 percent of the participants were very satisfied with the course. The multidisciplinary discussion about different cases was much appreciated. Our experience of this problem-based learning concept is very good, since it promotes deep rather than surface learning and promotes an in-depth collaboration between disciplines.

Hypothesis Placing stitches close to the cut wound edge does not produce low wound bursting strength in midline laparotomy incisions closed with a suture length:wound length ratio of 4. Design Experimental study in rats. Methods Midline incisions were closed with a running suture in 51 Sprague-Dawley rats. A suture length:wound length ratio of 4 was used and stitches were placed at a distance of 3, 6, or 10 mm from the wound edge. Wound bursting strength was studied immediately after and 4 days after wound closure. Results Immediately after wound closure, bursting pressure was higher with stitches placed 10 mm from the wound edge than those at a distance of 3 mm. After 4 days, bursting pressure and bursting volume were lower with stitches placed 10 mm from the wound edge than those at a distance of 3 or 6 mm. The abdominal wall ruptured outside the suture line in 14 of 17 wounds closed with 21 stitches, in 11 of 17 wounds closed with 16 stitches, and in 6 of 17 wounds closed with 11 stitches ( P = .02). Conclusions Four days after closure of midline laparotomy incisions using a suture length–wound length ratio of 4, wound bursting strength is higher with stitches placed 3 to 6 mm from the wound edge than those at a distance of 10 mm. Wound bursting strength increases with the number of stitches used.