Comparison of skin closure using continuous and interrupted nylon sutures: McLean NR, Fyfe AHB,...

ABSTRACTS Peter Rosen, M D - editor

Director of the Division of Emergency Medicine, Denver General Hospital

Frank J. Baker, II, M D - assistant editor Associate Professor and Director, Department of Emergency Medicine,

University of Chicago Hospitals and Clinics

Comparison of skin closure using continuous and interrupted nylon sutures. McLean NR, Fyfe AHB, Flint EF, et al, Br J Surg 67:633-635, 1980.

The authors a t tempt to compare the use of in ter rupted versus continuous nylon skin closure of laparotomy incisions in 105 consecutive patients. Evaluat ion of the wounds was done be- ginning three days after closure by one of the authors and wounds were inspected up to one month after discharge. Only the inspection one month after discharge was done by an in- dependent observer. The authors found no difference in the wound infection rate in wounds closed with continuous or in- terrupted skin sutures, a l though there were a greater num- ber of contaminated and potentially contaminated incisions closed with the continuous technique. The authors note tha t the low incidence of infection (4%) in the study makes this statistic insignificant. Two significant resul ts were found. Less t ime was spent sutur ing the skin with continuous skin sutures (31% of wound closure t ime versus 45%), and the cost of suture mater ia l per wound was over twice as much with interrupted sutures. One month after discharge, there was no difference in the heal ing of the wounds of the two groups. All pat ients were satisfied with the cosmetic results of ei ther type of suture technique. (Edi tor ' s note: We have used run- ning facial skin sutures where appropriate for many years with no increase in cosmetic difficulties or wound healing. This indeed saved many man-hours in placement and the con- tinuous suture is no more difficult to remove.)

John Tucker, MD suturing, nylon

The falling incidence of appendicitis. Raguveer-Saran MK, Keddie N, Br J Surg 69:681, 1980.

The authors reveal the rapid fall in the incidence of acute appendicitis in England and Wales, and compare this finding with the statistics of an u rban and rural area general hospi- tal. They find a similar reduction in the number of cases of acute appendicitis, yet note t ha t the population served by the hospital has not varied. They also note t ha t the incidence of histologically normal appendices has not changed (between 16% and 23%) and t ha t the drop in incidence does not affect any particular age group or sex. Finally, the authors specu- late on the cause of the fall ing incidence (an increase of di- etary fiber), but provide only ci rcumstant ia l and anecdotal evidence to support this speculation. (Edi tor ' s note: As the incidence falls, the diff iculty o f correct diagnosis does not abate. This disease still remains a difficulty, especially at the ends of the age spectrum and in female patients.)

John Tucker, MD appendicitis, incidence

Intravenous aminophylline therapy for asthma: a comparison of two methods of administration in chil- dren. Goldberg P, Leffert F, Gonzalez M, et al, Am J Dis Child 134:596-599, 1980.

An optimal method for intravenous adminis t ra t ion of ami-

nophylline in children has not been defined. Current ly two approaches are used: injection of a bolus dosage at regular intervals, or injection of a loading dosage followed by a con- s tan t infusion of the drug. The authors studied a group of 11 children, ages seven to 15 years. Each subject received both forms of therapy on two separate occasions. In te rmi t ten t ad- minis t ra t ion consisted of a dosage of 4 mg/kg of aminophyl- line in 25-ml volume given over five minutes and repeated every four hours for 24 hours. Continuous infusion consisted of 6 mg/kg of aminophyll ine in 25-ml volume given over five minutes and followed by a constant infusion of 1.1 mg/kg/hr for 24 hours. A marked superiority of continuous infusion over i n t e rmi t t en t injection was evident in some children, while others showed li t t le difference in the i r responses. The overall results of the study suggest t ha t use of a loading dose followed by continuous infusion will give a bet ter pulmonary response than will in te rmi t ten t injection, a l though intermit- tent adminis t ra t ion is still a useful a l ternat ive approach in si tuations in which the infusion technique cannot be safely and rel iably implemented. (Ed i tor ' s note: As the authors poin t out, their chi ldren were not in s tatus asthmaticus; moreover, the dosage schedule was not comparable. Thus the study does not answer the question posed, namely the optimal methods of aminophylline administration.) T. Tercier, MD asthma, therapy

Indications for admission to a coronary care unit in patients with unstable angina. Nattel S, Wamica JW, Ogilvie RI, Can Med Assoc J 122:180-184, (Jan) 1980.

The authors reviewed all pat ients admit ted to the CCU dur- ing a six-month period with diagnosis of unstable angina. The diagnoses were based on increasing frequency, severity, or duration of chest pain in the absence of new ST segment elevation on ECG. The parameters studied were: 1) prolonged durat ion of chest pain (longer than 30 minutes); 2) presence of nonspecific ischemic ECG changes; and 3) presence of di- aphoresis . The sensi t ivi ty, specificity, posi t ive predict ive value, and nega t ive predict ive value were calculated for these parameters to determine the i r usefulness in predicting which pa t i en t s in i t i a l ly diagnosed wi th uns tab le ang ina would develop an MI. Myocardial infarct ions were subse- quently documented in 20% of the pat ients on the basis of new Q waves or enzyme elevation. Myocardial infarction was more likely to develop in pat ients with prolonged chest pain (P<0.05) , i schemic ECG changes (P<0.02) , or w i t h di- aphoresis (P<0.05) t han in pat ients without these criteria. If a pat ient had only one of these criteria, there was 100% nega- t ive predictive value, ie, none of these developed an MI. The presence of all three factors had the highest positive predic- live value (38%); however, th is set of cri teria was only 65% sensitive. Tachydysrhythmias were more likely when pain was prolonged (P<0.01) and when ischemic changes were present (P<0.01) Diaphoresis was equally common whether or not pat ients subsequently developed tachydysrhythmias. Ten percent of those who did not develop MI experienced ven- tr icular tachycardia. All had both prolonged chest pain and ischemic changes on ECG. (Edi tor ' s note: In this study, the marker for determining appropriateness of admission to the

86/342 Ann Emerg Med 10:6 (June) 1981