Massive blood loss in elective spinal and orthopedic surgery: Retrospective review of intraoperative transfusion strategy.

PubMed

Rankin, Demicha; Zuleta-Alarcon, Alix; Soghomonyan, Suren; Abdel-Rasoul, Mahmoud; Castellon-Larios, Karina; Bergese, Sergio D

2017-02-01

To evaluate the perioperative dynamics of hematologic changes and transfusion ratio in patients undergoing a major spinal surgery accompanied with massive bleeding defined as blood loss >5 liters. Retrospective cohort study. Operating room of a university-affiliated hospital. Adult patients who underwent elective neurosurgical, orthopedic, or combined spinal surgical procedure between 2008 and 2012. Patients who underwent a major spinal or orthopedic surgery and who experienced major bleeding (>5 L) during surgery were identified and selected for final analysis. The following information was analyzed: demographics, clinical diagnoses, hematologic parameters, estimated intraoperative blood loss, blood product transfusions, and survival 1 year after surgery. During the study period, 25 patients, who underwent 28 spinal procedures, experienced intraoperative blood loss >5 L. Mean patient age was 50.5 years and 56.4% were males. The majority of patients underwent procedures to manage spinal metastases. Median estimated intraoperative blood loss was 11.25 L (IQR 6.35-22 L) and median number of units (U) transfused was 24.5 U (IQR 14.0-32.5 U) of packed red blood cells (RBCs), 24.5 U (IQR 14.0-34.0 U) of fresh frozen plasma (FFP), and 4.5 U (IQR 3.0-11.5 U) of platelets (PLTs). The blood product transfusion ratio was 1 and 4 for RBC:FFP, and RBC:PLT, respectively. Hematocrit, hemoglobin, PLTs, partial thromboplastin, prothrombin time, INR, and, fibrinogen varied significantly throughout the procedures. However, acid-base status did not change significantly during surgery. Patients' survival at 1 year was 79.17%. Our results indicate that a 1:1 RBC:FFP and 4:1 RBC:PLT transfusion ratio was associated with significant intraoperative variations in coagulation variables but stable intraoperative acid-base parameters. This transfusion ratio helped clinicians to achieve postoperative coagulation parameters not significantly different to those at baseline. Future studies should assess if more liberal transfusion strategies or point of care monitoring might be warranted in patients undergoing spinal surgery at risk of major blood loss. Copyright © 2016 Elsevier Inc. All rights reserved.

Managing hip fracture and lower limb surgery in the emergency setting: Potential role of non-vitamin K antagonist oral anticoagulants.

PubMed

Fisher, William

2017-06-01

Trauma, immobilization, and subsequent surgery of the hip and lower limb are associated with a high risk of developing venous thrombo-embolism (VTE). Individuals undergoing hip fracture surgery (HFS) have the highest rates of VTE among orthopedic surgery and trauma patients. The risk of VTE depends on the type and location of the lower limb injury. Current international guidelines recommend routine pharmacological thromboprophylaxis based on treatment with heparins, fondaparinux, dose-adjusted vitamin K antagonists and acetylsalicylic acid for patients undergoing emergency HFS; however, not all guidelines recommend pharmacological prophylaxis for patients with lower limb injuries. Non-vitamin K antagonist oral anticoagulants (NOACs) are indicated for VTE prevention after elective hip or knee replacement surgery, but at present are not widely recommended for other orthopedic indications despite their advantages over conventional anticoagulants and promising real-world evidence. In patients undergoing HFS or lower limb surgery, decisions on whether to anticoagulate and the most appropriate anti-coagulation strategy can be guided by weighing the risk of thromboprophylaxis against the benefit in relation to each patient's medical history and age. In addition, the nature and location of the fracture, operating times and times before fracture fixation should be considered. The current review discusses the need for anticoagulation in patients undergoing emergency HFS or lower limb surgery together with the current guidelines and available evidence on the use of NOACs in this setting. Appropriate thromboprophylactic strategies and practical advice on the peri-operative management of patients who present to the Emergency Department on a NOAC before emergency surgery are further outlined.

Survey of Intraoperative Bacterial Contamination in Dogs Undergoing Elective Orthopedic Surgery.

PubMed

Andrade, Natalia; Schmiedt, Chad W; Cornell, Karen; Radlinsky, MaryAnn G; Heidingsfelder, Lauren; Clarke, Kevin; Hurley, David J; Hinson, Whitney D

2016-02-01

To investigate the frequency, source, and risk factors of intraoperative (IO) surgeon and patient bacterial contamination during clean orthopedic surgeries, and to investigate the relationship between IO contamination and surgical site infection (SSI) in dogs. Prospective clinical study. Client-owned dogs undergoing stifle surgery (n = 100). IO cultures were taken in each case from surgical foot wrap, peri-incisional skin, surgical gloves, and the surgical team's hands. The environment (operating room [OR] lights, computers, scrub sink faucet, anesthesia gurney, and radiology table) was sampled every 5 months. Bacteria were identified and the contamination of each case was categorized. All gloves from the surgical team were collected and tested for perforations using a water infusion test. Cases were followed for at least 8 weeks to determine the presence or absence of SSI. Perioperative variables were evaluated for association with IO contamination and SSI. Bacterial isolates were yielded from 81% of procedures from 1 or more sources; 58% had positive hand cultures, 46% had positive glove cultures, 23% had positive patient skin cultures, and 12% had positive foot wrap cultures. Staphylococcus spp. was the most commonly recovered bacteria. There was no apparent association between IO contamination and SSI. The highest level of environmental contamination was associated with the scrub sink faucet, followed by the radiology table, anesthesia gurney, and OR computers. The IO glove perforation rate was 18%. Clean orthopedic procedures commonly had clinically insignificant bacterial contamination. In our study, bacteria responsible for SSI did not appear to colonize the patient in the OR. © Copyright 2016 by The American College of Veterinary Surgeons.

Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis.

PubMed

Opperer, Mathias; Poeran, Jashvant; Rasul, Rehana; Mazumdar, Madhu; Memtsoudis, Stavros G

2015-03-27

To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications. Retrospective cohort study of population based data between 2006 and 2013. Data from 510 different hospitals across the United States participating in the Premier Perspective database. 1,051,441 patients undergoing elective total hip and knee arthroplasties. Perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5%, or neither. Acute renal failure and thromboembolic, cardiac, and pulmonary complications. Compared with patients who received neither colloid, perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5% was associated with an increased risk of acute renal failure (odds ratios 1.23 (95% confidence interval 1.13 to 1.34) and 1.56 (1.36 to 1.78), respectively) and most other complications. A recent decrease in hydroxyethyl starch 6% use was noted, whereas that of albumin 5% increased. Similar to studies in critically ill patients, we showed that use of hydroxyethyl starch 6% was associated with an increased risk of acute renal failure and other complications in the elective perioperative orthopedic setting. This increased risk also applied to albumin 5%. These findings raise questions regarding the widespread use of these colloids in elective joint arthroplasty procedures. © Opperer et al 2015.

Second consultant opinion for elective orthopedic surgery.

PubMed Central

McCarthy, E G; Finkel, M L

1981-01-01

We abstracted records of 369 patients whose recommendations for elective orthopedic surgery were not confirmed by a second opinion consultant. Six months or more after the initial recommendation for surgery, 82 per cent had not had the operation performed, irrespective of the diagnosis and the characteristics of the physician recommending surgery. Reasons for consultant non-confirmation included: use of a cast, brace, or corrective footwear preferable (26.3 per cent), symptoms not severe enough (18.4 per cent), and physical therapy/exercises preferable (17.8 per cent). PMID:7294266

Neurological Complications Related to Elective Orthopedic Surgery: Part 1: Common Shoulder and Elbow Procedures.

PubMed

Dwyer, Tim; Henry, Patrick D G; Cholvisudhi, Phantila; Chan, Vincent W S; Theodoropoulos, John S; Brull, Richard

2015-01-01

Many anesthesiologists are unfamiliar with the rate of surgical neurological complications of the shoulder and elbow procedures for which they provide local anesthetic-based anesthesia and/or analgesia. Part 1 of this narrative review series on neurological complications of elective orthopedic surgery describes the mechanisms and likelihood of peripheral nerve injury associated with some of the most common shoulder and elbow procedures, including open and arthroscopic shoulder procedures, elbow arthroscopy, and total shoulder and elbow replacement. Despite the many articles available, the overall number of studied patients is relatively low. Large prospective trials are required to establish the true incidence of neurological complications following elective shoulder and elbow surgery. As the popularity of regional anesthesia increases with the development of ultrasound guidance, anesthesiologists should have a thoughtful understanding of the nerves at risk of surgical injury during elective shoulder and elbow procedures.

Comparison of ketoprofen and carprofen administered prior to orthopedic surgery for control of postoperative pain in dogs.

PubMed

Grisneaux, E; Pibarot, P; Dupuis, J; Blais, D

1999-10-15

To compare analgesic and adverse effects of ketoprofen and carprofen when used to control pain associated with elective orthopedic surgeries in dogs. Prospective randomized clinical trial. 93 client-owned dogs: 46 undergoing reconstruction of the cranial cruciate ligament, 47 undergoing femoral head and neck excision, and 15 control dogs anesthetized for radiographic procedures. Dogs undergoing surgery were randomly given ketoprofen, carprofen, or saline (0.9% NaCl) solution, SC, prior to surgery. Pain score and serum cortisol concentration were recorded for 12 hours after surgery for all dogs. When pain score was > or = 7, oxymorphone was administered i.m. Bleeding time was measured prior to and during surgery. The proportion of dogs that required oxymorphone was significantly higher for the carprofen and placebo groups than for the ketoprofen group. Pain score for the placebo group was significantly higher than for the ketoprofen and carprofen groups, 2, 8, and 9 hours after surgery. Cortisol concentration was significantly higher for the placebo group than for the carprofen group at 4 and 6 hours after surgery. Significant differences were not detected between ketoprofen and carprofen groups with respect to pain score and cortisol concentration. Bleeding time was significantly longer for the ketoprofen group than for the other groups during surgery. One dog treated with ketoprofen developed a hematoma at the surgical site. Ketoprofen and carprofen given prior to surgery were effective for postoperative pain relief in dogs. However, ketoprofen should not be used when noncompressible bleeding may be a problem.

Very-short-term perioperative intravenous iron administration and postoperative outcome in major orthopedic surgery: a pooled analysis of observational data from 2547 patients.

PubMed

Muñoz, Manuel; Gómez-Ramírez, Susana; Cuenca, Jorge; García-Erce, José Antonio; Iglesias-Aparicio, Daniel; Haman-Alcober, Sami; Ariza, Daniel; Naveira, Enrique

2014-02-01

Postoperative nosocomial infection (PNI) is a severe complication in surgical patients. Known risk factors of PNI such as allogeneic blood transfusions (ABTs), anemia, and iron deficiency are manageable with perioperative intravenous (IV) iron therapy. To address potential concerns about IV iron and the risk of PNI, we studied a large series of orthopedic surgical patients for possible relations between IV iron, ABT, and PNI. Pooled data on ABT, PNI, 30-day mortality, and length of hospital stay (LHS) from 2547 patients undergoing elective lower-limb arthroplasty (n = 1186) or hip fracture repair (n = 1361) were compared between patients who received either very-short-term perioperative IV iron (200-600 mg; n = 1538), with or without recombinant human erythropoietin (rHuEPO; 40,000 IU), or standard treatment (n = 1009). Compared to standard therapy, perioperative IV iron reduced rates of ABT (32.4% vs. 48.8%; p = 0.001), PNI (10.7% vs. 26.9%; p = 0.001), and 30-day mortality (4.8% vs. 9.4%; p = 0.003) and the LHS (11.9 days vs. 13.4 days; p = 0.001) in hip fracture patients. These benefits were observed in both transfused and nontransfused patients. Also in elective arthroplasty, IV iron reduced ABT rates (8.9% vs. 30.1%; p = 0.001) and LHS (8.4 days vs.10.7 days; p = 0.001), without differences in PNI rates (2.8% vs. 3.7%; p = 0.417), and there was no 30-day mortality. Despite known limitations of pooled observational analyses, these results suggest that very-short-term perioperative administration of IV iron, with or without rHuEPO, in major lower limb orthopedic procedures is associated with reduced ABT rates and LHS, without increasing postoperative morbidity or mortality. © 2013 American Association of Blood Banks.

Changes in quality of life after elective surgery: an observational study comparing two measures.

PubMed

Kronzer, Vanessa L; Jerry, Michelle R; Ben Abdallah, Arbi; Wildes, Troy S; McKinnon, Sherry L; Sharma, Anshuman; Avidan, Michael S

2017-08-01

Our main objective was to compare the change in a validated quality of life measure to a global assessment measure. The secondary objectives were to estimate the minimum clinically important difference (MCID) and to describe the change in quality of life by surgical specialty. This prospective cohort study included 7902 adult patients undergoing elective surgery. Changes in the Veterans RAND 12-Item Health Survey (VR-12), composed of a physical component summary (PCS) and a mental component summary (MCS), were calculated using preoperative and postoperative questionnaires. The latter also contained a global assessment question for quality of life. We compared PCS and MCS to the global assessment using descriptive statistics and weighted kappa. MCID was calculated using an anchor-based approach. Analyses were pre-specified and registered (NCT02771964). By the change in VR-12 scores, an equal proportion of patients experienced improvement and deterioration in quality of life (28% for PCS, 25% for MCS). In contrast, by the global assessment measure, 61% reported improvement, while only 10% reported deterioration. Agreement with the global assessment was slight for both PCS (kappa = 0.20, 57% matched) and MCS (kappa = 0.10, 54% matched). The MCID for the overall VR-12 score was approximately 2.5 points. Patients undergoing orthopedic surgery showed the most improvement in quality of life measures, while patients undergoing gastrointestinal/hepatobiliary or urologic surgery showed the most deterioration. Subjective global quality of life report does not agree well with a validated quality of life instrument, perhaps due to patient over-optimism.

Efficacy of maropitant in preventing vomiting in dogs premedicated with hydromorphone.

PubMed

Hay Kraus, Bonnie L

2013-01-01

The goal of this study was to evaluate the effectiveness of maropitant (Cerenia(®)) in preventing vomiting after premedication with hydromorphone. Randomized, blinded, prospective clinical study. Eighteen dogs ASA I/II admitted for elective orthopedic surgical procedures. The dogs were a mixed population of males and females, purebreds and mixed breeds, 1.0-10.2 years of age, weighing 3-49.5 kg. Dogs were admitted to the study if they were greater than 1 year of age, healthy and scheduled to undergo elective orthopedic surgery. Dogs were randomly selected to receive one of two treatments administered by subcutaneous injection. Group M received 1.0 mg kg(-1) of maropitant, Group S received 0.1 mL kg(-1) of saline 1 hour prior to anesthesia premedication. Dogs were premedicated with 0.1 mg kg(-1) of hydromorphone intramuscularly. A blinded observer documented the presence of vomiting, retching and/or signs of nausea for 30 minutes after premedication. All dogs in S vomited (6/9), retched (1/9) or displayed signs of nausea (2/9). None (0/9) of the dogs in M vomited, retched or displayed signs of nausea. Dogs in M had significantly fewer incidences of vomiting (p=0.0090), vomiting and retching (p=0.0023) and vomiting, retching and nausea (p<0.0001) when compared to S. Maropitant prevents vomiting, retching and nausea associated with intramuscular hydromorphone administration in dogs. © 2012 The Author. Veterinary Anaesthesia and Analgesia. © 2012 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesiologists.

Analysis of NHSLA claims in orthopedic surgery.

PubMed

Khan, Irfan H; Jamil, Wiqqas; Lynn, Sam Mathew; Khan, Osman H; Markland, Kate; Giddins, Grey

2012-05-01

National Health Service (NHS) statistics in the United Kingdom demonstrate an increase in clinical negligence claims over the past 30 years. Reasons for this include elements of a cultural shift in attitudes toward the medical profession and the growth of the legal services industry. This issue affects medical and surgical health providers worldwide.The authors analyzed 2117 NHS Litigation Authority (NHSLA) orthopedic surgery claims between 1995 and 2001 with respect to these clinical areas: emergency department, outpatient care, surgery (elective or trauma operations), and inpatient care. The authors focused on the costs of settling and defending claims, costs attributable to clinical areas, common causes of claims, and claims relating to elective or trauma surgery. Numbers of claims and legal costs increased most notably in surgery (elective and trauma) and in the emergency department. However, claims are being defended more robustly. The annual cost for a successful defense has remained relatively stable, showing a slight decline. The common causes of claims are postoperative complication; wrong, delayed, or failure of diagnosis; inadequate consent; and wrong-site surgery. Certain surgical specialties (eg, spine and lower-limb surgery) have the most claims made during elective surgery, whereas upper-limb surgery has the most claims made during trauma surgery.The authors recommend that individual trusts liaise with orthopedic surgeons to devise strategies to address areas highlighted in our study. Despite differences in health care systems worldwide, the underlying issues are common. With improved understanding, physicians can deliver the service they promise their patients. Copyright 2012, SLACK Incorporated.

Early Discharge Planning and Improved Care Transitions: Pre-Admission Assessment for Readmission Risk in an Elective Orthopedic and Cardiovascular Surgical Population

PubMed Central

Mola, Ana; Rosenfeld, Peri; Ford, Shauna

2016-01-01

Background/Methods: Readmission prevention is a marker of patient care quality and requires comprehensive, early discharge planning for safe hospital transitions. Effectively performed, this process supports patient satisfaction, efficient resource utilization, and care integration. This study developed/tested the utility of a predictive early discharge risk assessment with 366 elective orthopedic/cardiovascular surgery patients. Quality improvement cycles were undertaken for the design and to inform analytic plan. An 8-item questionnaire, which includes patient self-reported health, was integrated into care managers’ telephonic pre-admission assessments during a 12-month period. Results: Regression models found the questionnaire to be predictive of readmission (p ≤ .005; R2 = .334) and length-of-stay (p ≤ .001; R2 = .314). Independent variables of “lives-alone” and “self-rated health” were statistically significant for increased readmission odds, as was “self-rated health” for increased length-of-stay. Quality measures, patient experience and increased rates of discharges-to-home further supported the benefit of embedding these questions into the pro-active planning process. Conclusion: The pilot discharge risk assessment was predictive of readmission risk and length-of-stay for elective orthopedic/cardiovascular patients. Given the usability of the questionnaire in advance of elective admissions, it can facilitate pro-active discharge planning essential for producing quality outcomes and addressing new reimbursement methodologies for continuum-based episodes of care. PMID:27616965

Effectiveness of ketamine as an adjuvant to opioid-based therapy in decreasing pain associated with opioid tolerance in adults undergoing orthopedic surgery: a systematic review protocol.

PubMed

Bennett, Marsha; Bonanno, Laura; Kuhn, William

2016-10-01

The objective of this systematic review is to examine the best available evidence on the clinical effectiveness of ketamine as an adjuvant to opioid-based therapy versus opioid-based therapy alone in decreasing perioperative pain associated with opioid tolerance in adult patients, aged 18-70 years, undergoing orthopedic surgical procedures.The following question guides the systematic review: does the administration of ketamine as an adjuvant to opioid-based therapy, compared to opioid-based therapy alone, improve perioperative pain relief in opioid-tolerant adult patients undergoing orthopedic surgical procedures?

A Multi-Center, Randomized, Double-Blind Placebo-Controlled Trial of Intravenous-Ibuprofen (IV-Ibuprofen) for Treatment of Pain in Post-Operative Orthopedic Adult Patients

PubMed Central

Singla, Neil; Rock, Amy; Pavliv, Leo

2010-01-01

Objective To determine whether pre- and post-operative administration of intravenous ibuprofen (IV-ibuprofen) can significantly decrease pain and morphine use when compared with placebo in adult orthopedic surgical patients. Design This was a multi-center, randomized, double-blind placebo-controlled trial. Setting This study was completed at eight hospitals; six in the United States and two in South Africa. Patients A total of 185 adult patients undergoing elective orthopedic surgery. Interventions Patients were randomized to receive either 800 mg IV-ibuprofen or placebo every 6 hours, with the first dose administered pre-operatively. Additionally, all patients had access to intravenous morphine for rescue. Outcome Measures Efficacy of IV-ibuprofen was demonstrated by measuring the patient's self assessment of pain using a visual analog scale (VAS; assessed with movement and at rest) and a verbal response scale (VRS). Morphine consumption during the post-operative period was also assessed. Results In the immediate post-operative period, there was a 25.8% reduction in mean area under the curve-VAS assessed with movement (AUC-VASM) in patients receiving IV-ibuprofen (P < 0.001); a 31.8% reduction in mean AUC-VAS assessed at rest (AUC-VASR; P < 0.001) and a 20.2% reduction in mean VRS (P < 0.001) compared to those receiving placebo. Patients receiving IV-ibuprofen used 30.9% less morphine (P < 0.001) compared to those receiving placebo. Similar treatment emergent adverse events occurred in both study groups and there were no significant differences in the incidence of serious adverse events. Conclusion Pre- and post-operative administration of IV-ibuprofen significantly reduced both pain and morphine use in orthopedic surgery patients in this prospective randomized placebo-controlled trial. PMID:20609131

The use of Quincke and Whitacre 27-gauge needles in orthopedic patients: incidence of failed spinal anesthesia and postdural puncture headache.

PubMed

Lynch, J; Kasper, S M; Strick, K; Topalidis, K; Schaaf, H; Zech, D; Krings-Ernst, I

1994-07-01

This study examined the incidence of failed spinal anesthesia and postdural puncture headache using a 27-gauge Whitacre and a 27-gauge Quincke needle in patients undergoing elective inpatient orthopedic procedures. The overall rate of failed spinal anesthesia was 8.5% [95% confidence interval (CI) = 4.6%-12.4%] (n = 17) in the Quincke group (n = 199) and 5.5% [95% CI = 2.3%-8.7%] (n = 11) in the Whitacre group (n = 199). This difference was not statistically significant. The overall incidence of postdural puncture headache (PDPH) was 0.8%; 1.1% [95% CI = 0%-2.4%] (n = 2) in the Quincke group and 0.5% [95% CI = 0%-1.5%] (n = 1) in the Whitacre group. These differences were not statistically significant. All headaches were classified as mild and resolved spontaneously with conservative management. The mean time for withdrawal of the stylet to appearance of cerebrospinal fluid was 10.8 +/- 6.9 s in the Quincke (n = 31) and 10.7 +/- 6.8 s in the Whitacre group (n = 33). These differences were not statistically significant. Our results suggest that both needles are associated with a very low incidence of PDPH and an incidence of failed anesthesia of 5.5%-8.5%.

Prevalence of Recent Antimicrobial Exposure among Elective Surgical Patients.

PubMed

Guidry, Christopher A; Sawyer, Robert G

2017-10-01

The annual prevalence of antimicrobial exposure is high in the outpatient setting and should be a common exposure for surgical patients. Antimicrobials have negative side effects and may be associated with poor outcomes. Logically, one would expect surgical patients to be particularly susceptible to any negative effects of recent antimicrobial exposure. Despite these observations, however, the prevalence of recent antimicrobial exposure among surgical patients remains undefined. The purpose of this study is to define the prevalence of antimicrobial exposure in patients undergoing elective surgical procedures. Patients presenting for elective operations between August 4, 2015 and August 3, 2016 at our institution were asked prospectively about any antimicrobial exposure in the previous three months. Answers were recorded as either Yes, No, or Unsure. Patients were grouped according to age, American Society of Anesthesiologists (ASA) score, primary operative service, and post-operative destination. Descriptive statistics were employed using simple percentages and chi-square analysis when appropriate. Cochrane-Armitage test was used to evaluate temporal trends. There were 21,473 elective surgical procedures performed during the study period across 13 operative services. Answers were recorded for 91.2% cases. The overall prevalence of exposure during this period was 28.6%. Exposure varied with age, ASA score, and surgical specialty. Vascular and transplant operations had the highest prevalence of exposure while ophthalmology and pediatric orthopedic procedures had the lowest. Patients with recent antimicrobial exposure were less likely to be discharged home on the same day and more likely to be admitted to an intensive care or intermediate care unit than those who denied recent exposure. In this descriptive analysis, the prevalence of recent antimicrobial exposure is overall approximately 28.6% and is higher than anticipated. Further work is needed to determine to what extent, if any, recent antimicrobial exposure impacts post-operative outcomes.

Can Surgeon Demographic Factors Predict Postoperative Complication Rates After Elective Spinal Fusion?

PubMed

Chun, Danielle S; Cook, Ralph W; Weiner, Joseph A; Schallmo, Michael S; Barth, Kathryn A; Singh, Sameer K; Freshman, Ryan D; Patel, Alpesh A; Hsu, Wellington K

2018-03-01

Retrospective cohort. Determine whether surgeon demographic factors influence postoperative complication rates after elective spine fusion procedures. Surgeon demographic factors have been shown to impact decision making in the management of degenerative disease of the lumbar spine. Complication rates are frequently reported outcome measurements used to evaluate surgical treatments, quality-of-care, and determine health care reimbursements. However, there are few studies investigating the association between surgeon demographic factors and complication outcomes after elective spine fusions. A database of US spine surgeons with corresponding postoperative complications data after elective spine fusions was compiled utilizing public data provided by the Centers for Medicare and Medicaid Services (2011-2013) and ProPublica Surgeon Scorecard (2009-2013). Demographic data for each surgeon was collected and consisted of: surgical specialty (orthopedic vs. neurosurgery), years in practice, practice setting (private vs. academic), type of medical degree (MD vs. DO), medical school location (United States vs. foreign), sex, and geographic region of practice. General linear mixed models using a Beta distribution with a logit link and pairwise comparison with post hoc Tukey-Kramer were used to assess the relationship between surgeon demographics and complication rates. 2110 US-practicing spine surgeons who performed spine fusions on 125,787 Medicare patients from 2011 to 2013 met inclusion criteria for this study. None of the surgeon demographic factors analyzed were found to significantly affect overall complication rates in lumbar (posterior approach) or cervical spine fusion. Publicly available complication rates for individual spine surgeons are being utilized by hospital systems and patients to assess aptitude and gauge expectations. The increasing demand for transparency will likely lead to emphasis of these statistics to improve outcomes. We conclude that none of the surgeon demographic factors analyzed in this study are associated with differences in overall complications rates in patients undergoing elective spine fusion as published by the ProPublica Surgeon Scorecard. Level 3.

Self-efficacy is an independent predictor for postoperative six-minute walk distance after elective open repair of abdominal aortic aneurysm.

PubMed

Hayashi, Kazuhiro; Kobayashi, Kiyonori; Shimizu, Miho; Tsuchikawa, Yohei; Kodama, Akio; Komori, Kimihiro; Nishida, Yoshihiro

2018-05-01

Open surgery is performed to treat abdominal aortic aneurysm (AAA), although the subsequent surgical stress leads to worse physical status. Preoperative self-efficacy has been reported to predict postoperative physical status after orthopedic surgery; however, it has not been sufficiently investigated in patients undergoing abdominal surgery. The purpose of the present study is to investigate the correlation between preoperative self-efficacy and postoperative six-minute walk distance (6MWD) in open AAA surgery. Seventy patients who underwent open AAA surgery were included. Functional exercise capacity was measured using preoperative and 1 week postoperative 6MWD. Self-efficacy was preoperatively measured using self-efficacy for physical activity (SEPA). The correlations of postoperative 6MWD with age, height, BMI, preoperative 6MWD, SEPA, Hospital Anxiety and Depression Scale (HADS) score, operative time, and blood loss were investigated using multivariate analysis. Single regression analysis showed that postoperative 6MWD was significantly correlated with age (r = -0.553, p ≤ 0.001), height (r = 0.292, p = 0.014), Charlson's comorbidity index (r = -0.268, p = 0.025), preoperative 6MWD (r = 0.572, p ≤ 0.001), SEPA (r = 0.586, p ≤ 0.001), and HADS-depression (r = -0.296, p = 0.013). Multiple regression analysis showed that age (p = 0.002), preoperative 6MWD (p = 0.013), and SEPA (p = 0.043) score were significantly correlated with postoperative 6MWD. Self-efficacy was an independent predictor for postoperative 6MWD after elective open AAA surgery. This suggests the importance of assessing not only physical status but also psychological factors such as self-efficacy. Implications for Rehabilitation Preoperative self-efficacy has been limited to reports after orthopedic surgery. We showed that preoperative self-efficacy predicted postoperative 6MWD after AAA surgery. Treatment to improve self-efficacy might be useful in patients receiving AAA surgery in rehabilitation.

Regional variation in acute care length of stay after orthopaedic surgery total joint replacement surgery and hip fracture surgery.

PubMed

Fitzgerald, John D; Weng, Haoling H; Soohoo, Nelson F; Ettner, Susan L

2013-01-01

To examine change in regional variations in acute care length of stay (LOS) after orthopedic surgery following expiration of the New York (NY) State exemption to the Prospective Payment System and implementation of the Medicare Short Stay Transfer Policy. Time series analyses were conducted to evaluate change in LOS across regions after policy implementations. Small area analyses were conducted to examine residual variation in LOS. The dataset included A 100% sample of fee-for-service Medicare patients undergoing surgical repair for hip fracture or elective joint replacement surgery between 1996 and 2001. Data files from Centers for Medicare and Medicaid Services 1996-2001 Medicare Provider Analysis and Review file, 1999 Provider of Service file, and data from the 2000 United States Census were used for analysis. In 1996, LOS in NY after orthopedic procedures was much longer than the remainder of the country. After policy changes, LOS fell. However, significant residual variation in LOS persisted. This residual variation was likely partly explained by differences variation in regional managed care market penetration, patient management practices and unmeasured characteristics associated with the hospital location. NY hospitals responded to changes in reimbursement policy, reducing variation in LOS. However, even after 5 years of financial pressure to constrain costs, other factors still have a strong impact on delivery of patient care.

Orthopedic surgery in rheumatoid arthritis in the era of biologic therapy.

PubMed

Leon, Leticia; Abasolo, Lydia; Carmona, Loreto; Rodriguez-Rodriguez, Luis; Lamas, Jose Ramon; Hernandez-Garcia, Cesar; Jover, Juan Angel

2013-11-01

To analyze sociodemographic and clinic-related factors associated with the use of orthopedic surgical procedures in rheumatoid arthritis (RA), focusing on the potential role of new biologic therapies. A retrospective medical record review was performed in a probability sample of 1272 patients with RA from 47 units distributed in 19 Spanish regions. Sociodemographic and clinical features, use of drugs, and arthritis-related joint surgeries were recorded following a standardized protocol. A total of 94 patients (7.4%) underwent any orthopedic surgery during their disease course, with a total of 114 surgeries; 47 (41.2%) of these surgeries were total joint replacement (TJR). The median time to first orthopedic procedure was 7.9 years from the onset of RA symptoms, and the rate of orthopedic surgery (excluding TJR) was 4.5 procedures per 100 person-years from the beginning of RA, while the rate of TJR was 2.25 interventions per 100 person-years. A higher risk of undergoing an orthopedic surgical procedure was associated with taking nonsteroidal antiinflammatory drugs (NSAID) in the previous 2 years, female sex, longterm disease, and the presence of extraarticular complications. The risk factors for undergoing a TJR were being old, having a longterm disease, and taking biologic therapies. In the era of biologics, our national audit found a low percentage of patients who underwent orthopedic surgery, probably reflecting a thorough management of the RA. Sociodemographic factors, longterm RA, extraarticular complications, and NSAID were associated with orthopedic surgery.

Factors affecting interest in orthopedics among female medical students: a prospective analysis.

PubMed

Baldwin, Keith; Namdari, Surena; Bowers, Andrea; Keenan, Mary Ann; Levin, L Scott; Ahn, Jaimo

2011-12-06

The field of orthopedics has a limited ability to recruit high-quality female applicants. The purpose of this study was to determine whether early exposure to the field affects a woman's decision to pursue orthopedics. We performed a prospective, nonrandomized cohort study between academic years 2005 and 2009 and compared interest in orthopedic surgery among female (n=271) and male (n=71) medical students at 2 urban teaching institutions. Elective lectures and orthopedic literature were distributed via e-mail to the study participants. These materials included articles published in the medical literature, materials produced and distributed by the American Academy of Orthopaedic Surgeons, and Web sites providing educational materials. The primary outcome was the likelihood of application for orthopedic residency. We studied the influence of demographics, exposure, and attitudes on interest in pursuing an orthopedic career. Men had a significantly higher baseline level of interest in orthopedic surgery than women (P=.005). Younger age (P<.001) and personal (P<.001), independent (P<.001), and school (P=.023) exposures to orthopedics were significantly related to interest among women. At final follow-up, total personal exposures (P=.003) and total independent exposures (P<.001) in the form of our literature and lectures were correlated with final interest in women. Female interest was decreased by the long hours, physical demands, and predominantly male nature of the field. Early exposure to orthopedic educational resources may be useful in generating female interest. Perceptions and attitudes regarding orthopedic surgery must to be changed to attract the best and brightest minds, regardless of sex. Copyright © 2011, SLACK Incorporated.

Ankle Block vs Single-Shot Popliteal Fossa Block as Primary Anesthesia for Forefoot Operative Procedures: Prospective, Randomized Comparison.

PubMed

Schipper, Oliver N; Hunt, Kenneth J; Anderson, Robert B; Davis, W Hodges; Jones, Carroll P; Cohen, Bruce E

2017-11-01

Postoperative pain is often difficult to control with oral medications, requiring large doses of opioid analgesia. Regional anesthesia may be used for primary anesthesia, reducing the need for general anesthetic and postoperative pain medication requirements in the immediate postoperative period. The purpose of this study was to compare the analgesic effects of an ankle block (AB) to a single-shot popliteal fossa block (PFB) for patients undergoing orthopedic forefoot procedures. All patients having elective outpatient orthopedic forefoot procedures were invited to participate in the study. Patients were prospectively randomized to receive either an ultrasound-guided AB or PFB by a board-certified anesthesiologist prior to their procedure. Intraoperative conversion to general anesthesia and postanesthesia care unit (PACU) opioid requirements were recorded. Postoperative pain was assessed using the visual analog scale (VAS) at regular time intervals until 8 am on postoperative day (POD) 2. Patients rated the effectiveness of the block on a 1 to 5 scale, with 5 being very effective. A total of 167 patients participated in the study with 88 patients (53%) receiving an AB and 79 (47%) receiving a single-shot PFB. There was no significant difference in the rate of conversion to general anesthesia between the 2 groups (13.6% [12/88] AB vs 12.7% [10/79] PFB). PACU morphine requirements and doses were significantly reduced in the PFB group ( P = .004) when compared to the AB group. The VAS was also significantly lower for the PFB patients at 10 pm on POD 0 (4.6 vs 1.6, P < .001), 8 am on POD 1 (5.9 vs 4.2, P = .003), and 12 pm on POD 1 (5.4 vs 4.1, P = .01). Overall complication rates were similar between the groups (AB 9% vs PFB 10.1%, P = .51) and there were no significant differences in residual sensory paresthesias (AB 2.3% [2/88] vs PFB 5.1% [4/79], P = .29), motor loss (0% vs 0%), or block site pain and/or erythema (AB 6.9% [6/88] vs PFB 5.1% [4/79], P = .44). The analgesic effect of the PFB lasted significantly longer when compared to the ankle block (AB 14.5 hours vs PFB 20.9 hours, P < .001). There was no significant difference in patient-perceived effectiveness of the block between the 2 groups, with both blocks being highly effective (AB 4.79/5 vs PFB 4.82/5, P = .68). Regional anesthesia was a safe and reliable adjunct to perioperative pain management and highly effective in patients undergoing elective orthopedic forefoot procedures. However, patients who received a PFB had significantly better pain management and decreased opioid requirements in the immediate perioperative period than patients who received an ankle block. Level I, prospective randomized study.

Continuation of TNF blockade in patients with inflammatory rheumatic disease. An observational study on surgical site infections in 1,596 elective orthopedic and hand surgery procedures.

PubMed

Berthold, Elisabet; Geborek, Pierre; Gülfe, Anders

2013-10-01

Increased infection risk in inflammatory rheumatic diseases may be due to inflammation or immunosuppressive treatment. The influence of tumor necrosis factor (TNF) inhibitors on the risk of developing surgical site infections (SSIs) is not fully known. We compared the incidence of SSI after elective orthopedic surgery or hand surgery in patients with a rheumatic disease when TNF inhibitors were continued or discontinued perioperatively. We included 1,551 patients admitted for elective orthopedic surgery or hand surgery between January 1, 2003 and September 30, 2009. Patient demographic data, previous and current treatment, and factors related to disease severity were collected. Surgical procedures were grouped as hand surgery, foot surgery, implant-related surgery, and other surgery. Infections were recorded and defined according to the 1992 Centers for Disease Control definitions for SSI. In 2003-2005, TNF inhibitors were discontinued perioperatively (group A) but not during 2006-2009 (group B). In group A, there were 28 cases of infection in 870 procedures (3.2%) and in group B, there were 35 infections in 681 procedures (5.1%) (p = < 0.05). Only foot surgery had significantly more SSIs in group B, with very low rates in group A. In multivariable analysis with groups A and B merged, only age was predictive of SSI in a statistically significant manner. Overall, the SSI rates were higher after abolishing the discontinuation of anti-TNF perioperatively, possibly due to unusually low rates in the comparator group. None of the medical treatments analyzed, e.g. methotrexate or TNF inhibitors, were significant risk factors for SSI. Continuation of TNF blockade perioperatively remains a routine at our center.

The organizational and financial viability of an orthopedic trauma service.

PubMed

Harris, Mitchel B; Cayen, Barry

2009-12-01

This study was designed to explore the effect of establishing an Orthopedic Trauma Service (OTS) on departmental revenue within an academic orthopedic department. The effect of the OTS on physician and resident perceptions of job satisfaction, education, and quality of patient care were also evaluated. A proforma financial analysis was undertaken using an optimization model to predict the potential financial performance of an OTS before its implementation. Financial data were then collected prospectively for the first year of the OTS and compared with the preceding year's financial data. All residents and faculty in the department completed visual analog scale surveys after the formation of the service. While maintaining a fixed amount of work production (work relative value units [WRVUs]) per year, our model predicted an $111,000 increase in departmental charges as a result of a shift in the elective case mix. After implementation of the OTS, elective charges/WRVU increased by 7.4% while trauma charges/WRVU increased by 2.6%. This, combined with a minor increase in departmental work volume (115,661 WRVUs pre-OTS vs. 117,577 WRVUs post-OTS) and an improvement in collections/charge (47-48%), yielded a departmental collection increase of 11% ($1.1 million). Resident and faculty job satisfaction improved, as did the perception of the quality of trauma care that was being provided. The organization and implementation of an OTS within an academic orthopedic department can lead to an improved professional experience for residents and faculty, the perception of improved patient care for the trauma patient, and an increase in departmental revenue.

Factors affecting orthopedic residency selection: a cross-sectional survey

PubMed Central

Strelzow, Jason; Petretta, Robert; Broekhuyse, Henry M.

2017-01-01

Background Annually, orthopedic residency programs rank and recruit the best possible candidates. Little evidence exists identifying factors that potential candidates use to select their career paths. Recent literature from nonsurgical programs suggests hospital, social and program-based factors influence program selection. We sought to determine what factors influence the choice of an orthopedic career and a candidate’s choice of orthopedic residency program. Methods We surveyed medical student applicants to orthopedic programs and current Canadian orthopedic surgery residents (postgraduate year [PGY] 1–5). The confidential online survey focused on 3 broad categories of program selection: educational, program cohesion and noneducation factors. Questions were graded on a Likert Scale and tailed for mean scores. Results In total, 139 residents from 11 of 17 Canadian orthopedic programs (49% response rate) and 23 medical student applicants (88% response rate) completed our survey. Orthopedic electives and mandatory rotations were reported by 71% of participants as somewhat or very important to their career choice. Collegiality among residents (4.70 ± 0.6), program being the “right fit” (4.65 ± 0.53) and current resident satisfaction with their chosen program (4.63 ±0.66) were ranked with the highest mean scores on a 5-point Likert scale. Conclusion There are several modifiable factors that residency programs may use to attract applicants, including early availability of clerkship rotations and a strong mentorship environment emphasizing both resident–resident and resident–staff cohesion. Desirable residency programs should develop early access to surgical and operative skills. These must be balanced with a continued emphasis on top-level orthopedic training. PMID:28327273

Factors affecting orthopedic residency selection: a cross-sectional survey.

PubMed

Strelzow, Jason; Petretta, Robert; Broekhuyse, Henry M

2017-06-01

Annually, orthopedic residency programs rank and recruit the best possible candidates. Little evidence exists identifying factors that potential candidates use to select their career paths. Recent literature from nonsurgical programs suggests hospital, social and program-based factors influence program selection. We sought to determine what factors influence the choice of an orthopedic career and a candidate's choice of orthopedic residency program. We surveyed medical student applicants to orthopedic programs and current Canadian orthopedic surgery residents (postgraduate year [PGY] 1-5). The confidential online survey focused on 3 broad categories of program selection: educational, program cohesion and noneducation factors. Questions were graded on a Likert Scale and tailed for mean scores. In total, 139 residents from 11 of 17 Canadian orthopedic programs (49% response rate) and 23 medical student applicants (88% response rate) completed our survey. Orthopedic electives and mandatory rotations were reported by 71% of participants as somewhat or very important to their career choice. Collegiality among residents (4.70 ± 0.6), program being the "right fit" (4.65 ± 0.53) and current resident satisfaction with their chosen program (4.63 ±0.66) were ranked with the highest mean scores on a 5-point Likert scale. There are several modifiable factors that residency programs may use to attract applicants, including early availability of clerkship rotations and a strong mentorship environment emphasizing both resident-resident and resident-staff cohesion. Desirable residency programs should develop early access to surgical and operative skills. These must be balanced with a continued emphasis on top-level orthopedic training.

Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis.

PubMed

Tam, Vernissia; Luketich, James D; Winger, Daniel G; Sarkaria, Inderpal S; Levy, Ryan M; Christie, Neil A; Awais, Omar; Shende, Manisha R; Nason, Katie S

2017-01-01

Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting. We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined. Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair. Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.

Postoperative outcomes in patients with a do-not-resuscitate (DNR) order undergoing elective procedures.

PubMed

Brovman, Ethan Y; Walsh, Elisa C; Burton, Brittany N; Kuo, Christine E; Lindvall, Charlotta; Gabriel, Rodney A; Urman, Richard D

2018-05-18

Do-not-resuscitate (DNR) status has been shown to be an independent risk factor for mortality in the post-operative period. Patients with DNR orders often undergo elective surgeries to alleviate symptoms and improve quality of life, but there are limited data on outcomes for informed decision making. Retrospective cohort study. A multi-institutional setting including operating room, postoperative recovery area, inpatient wards, and the intensive care unit. A total of 566 patients with a DNR status and 316,431 patients without a DNR status undergoing elective procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2012. Patients undergoing elective surgical procedures. We analyzed the risk-adjusted 30-day morbidity and mortality outcomes for the matched DNR and non-DNR cohorts undergoing elective surgeries. DNR patients had significantly increased odds of 30-day mortality (OR 2.51 [1.55-4.05], p < 0.001) compared with non-DNR patients. In the DNR versus non-DNR cohort there was no significant difference in the occurrence of a number of 30-day complications, the rate of resuscitative measures undertaken, including cardiac arrest requiring CPR, reintubation, or return to the OR. The most common complications in both DNR and non-DNR patients undergoing elective procedures were transfusion, urinary tract infection, reoperation, and sepsis. Finally, the DNR patients had a significantly increased total length of hospital stay (7.65 ± 9.55 vs. 6.87 ± 9.21 days, p = 0.002). DNR patients, as compared with non-DNR patients, have increased post-operative mortality but not morbidity, which may arise from unmeasured severity of illness or transition to comfort care in accordance with a patient's wishes. The informed consent process for elective surgeries in this patient population should include a discussion of acceptable operative risk. Copyright © 2018 Elsevier Inc. All rights reserved.

Completion of Advance Directives: Do Social Work Preadmission Interviews Make a Difference?

ERIC Educational Resources Information Center

Johnson, Yvonne M.; Stadel, Vivian L.

2007-01-01

Objectives: This study tests the efficacy of a preadmission, educational interview on advance directives, in this case, health care proxies (HCPs) offered to elective, orthopedic patients. Method: Using a quasi-experimental design, participants (n = 54) are assigned to either treatment group (who received the educational interview, conducted by a…

Economic evaluation of major knee surgery with recombinant activated factor VII in hemophilia patients with high titer inhibitors and advanced knee arthropathy: exploratory results via literature-based modeling.

PubMed

Ballal, Rahul D; Botteman, Marc F; Foley, Isaac; Stephens, Jennifer M; Wilke, Caitlyn T; Joshi, Ashish V

2008-03-01

People with severe hemophilia suffer from frequent intra-articular hemorrhages, leading to pain, swelling, reduced flexion, and arthropathy. Elective orthopedic surgery using factor VIII (FVIII) replacement to prevent uncontrolled bleeding has been endorsed as an effective treatment option for patients with severe or advanced hemophilic arthropathy. These surgeries reduce pain, restore mobility and function, and reduce the frequency of recurrent joint bleeds. Unfortunately, some patients with hemophilia develop inhibitors to FVIII, which neutralize FVIII activity and render the use of even massive amounts of FVIII replacement ineffective and surgery very risky. For this reason, elective surgical procedures in high-titer inhibitor patients had largely been abandoned until the introduction of new agents, such as recombinant activated factor VII (rFVIIa, NovoSeven, Novo Nordisk A/S, Denmark). rFVIIa has been shown effective for prophylaxis during elective surgery and has therefore improved the feasibility of orthopedic surgery in hemophilia patients with high-titer inhibitors. The present research explored, from a modified US payer perspective, the direct economic and quality of life benefits of four different elective knee surgeries (total knee replacement [TKR], knee arthrodesis [KA], proximal tibial osteotomy, and distal femoral osteotomy) with rFVIIa coverage in hemophilia patients with high-titer inhibitors. An exploratory literature-based life-table model was developed to compare the direct medical costs and quality of life of two hypothetical cohorts of high-titer inhibitor patients with frequent bleeding episodes: one undergoing and the other not undergoing elective knee surgery. Knee surgery costs included perioperative rFVIIa costs, inpatient and rehabilitation care, and repeat procedures due to surgery failure, prosthesis loosening or deep infection. Based on efficacy studies, knee surgery was assumed to reduce mean annual bleeding episodes at the affected joint from 9.13 to 1.64. The cost of managing each bleeding episode was estimated at $15 298. Thus, by reducing bleeding episodes, surgery was expected to result in related cost offsets. All costs were expressed in 2006 US dollars. Surgery was also assumed to result in gains in quality of life by reducing pain and reducing bleeding episodes. The impact of pain reduction on quality of life and utility was estimated by simulating EQ-5D scores for a typical patient with and without knee surgery. Based on the model, average knee surgery costs are predicted to range from a low of $694 000 (for KA) to a high of $855 000 (for TKR). However, knee surgery is also expected to reduce the subsequent number of bleeding episodes and resultant costs, leading to long-term costs savings. Due to improvement in pain levels, surgical patients are expected to experience improvements in quality-adjusted life-years (QALYs). Thus, surgery appears to be the preferred strategy (i.e., saves costs and increases QALYs). Based on the assumptions used in the model, the initial cost of knee surgery was offset during the 8th and 10th years for KA and TKR, respectively, with intermediate break-even time for the other surgeries. As expected, cost savings and gains in QALYs increased over time, as well as the cost effective ness of knee surgery. Specifically, the cost per QALY with KA and TKR fell under $50 000/QALY during the 6th and 8th years, respectively, with intermediate time for the other surgeries. The present exploratory analysis is based on the long-term extrapolation of data from a small number of patients without inhibitors and short-term studies. It suggests that major knee surgery utilizing rFVIIa in hemophilia patients with inhibitors may be cost-effective on average, with expected cost savings apparent within a decade of knee surgery. The present exploratory results should be validated with real-world, longitudinal patient data.

Ambulatory surgery in orthopedics: experience of over 10,000 patients.

PubMed

Martín-Ferrero, M A; Faour-Martín, O; Simon-Perez, C; Pérez-Herrero, M; de Pedro-Moro, J A

2014-03-01

The concept of day surgery is becoming an increasingly important part of elective surgery worldwide. Relentless pressure to cut costs may constrain clinical judgment regarding the most appropriate location for a patient's surgical care. The aim of this study was to determine clinical and quality indicators relating to our experience in orthopedic day durgery, mainly in relation to unplanned overnight admission and readmission rates. Additionally, we focused on describing the main characteristics of the patients that experienced complications, and compared the patient satisfaction rates following ambulatory and non-ambulatory procedures. We evaluated 10,032 patients who underwent surgical orthopedic procedures according to the protocols of our Ambulatory Surgery Unit. All complications that occurred were noted. A quality-of-life assessment (SF-36 test) was carried out both pre- and postoperatively. Ambulatory substitution rates and quality indicators for orthopedic procedures were also determined. The major complication rate was minimal, with no mortal cases, and there was a high rate of ambulatory substitution for the procedures studied. Outcomes of the SF-36 questionnaire showed significant improvement postoperatively. An unplanned overnight admission rate of 0.14 % was achieved. Our institution has shown that it is possible to provide good-quality ambulatory orthopedic surgery. There still appears to be the potential to increase the proportion of these procedures. Surgeons and anesthesiologists must strongly adhere to strict patient selection criteria for ambulatory orthopedic surgery in order to reduce complications in the immediate postoperative term.

[What can we learn in future from the data of the German Arthroplasty Registry (EPRD) in comparison to other registries?].

PubMed

Jansson, V; Steinbrück, A; Hassenpflug, J

2016-06-01

The German Arthroplasty Registry (EPRD) was founded in 2010 and has been in full operation since 2014. Previous attempts at a systematic data collection of elective and non-elective knee and hip replacement in Germany failed mainly because of the long-term lack of funding. The EPRD is an interdisciplinary collaborative partnership between the German Association of Orthopedics and Orthopedic Surgery (DGOOC), all implant manufacturers of the German Medical Technology Association (BVMed), health insurers (AOK and the Association of Additional Healthcare Insurance) and hospitals (German Hospital Federation). As part of this cooperation a worldwide unique implant database has been set up, which includes all relevant components and a detailed description of implant specifications. This implant library enables a detailed evaluation of implant survival, revision rates and possible inferior implant performance of knee and hip replacements in Germany. At the end of 2015 the EPRD encompassed over 200,000 registered operations. Due to the high number of hip and knee arthroplasties in Germany with many different implants from different manufacturers there will be a rapid growth of data that are available for a national and also international comparison of the results.

Monitoring trends in waiting periods in Canada for elective surgery: validation of a method using administrative data.

PubMed

Shortt, Samuel E D; Shaw, Ralph A; Elliott, David; Mackillop, William J

2004-06-01

Provincial governments require timely, economical methods to monitor surgical waiting periods. Although use of prospective procedure-specific registers would be the ideal method, a less elaborate system has been proposed that is based on physician billing data. This study assessed the validity of using the date of the last service billed prior to surgery as a proxy for the beginning of the post-referral, pre-surgical waiting period. We examined charts for 31,824 elective surgical encounters between 1992 and 1996 at an Ontario teaching hospital. The date of the last service before surgery (the last billing date) was compared with the date of the consultant's letter indicating a decision to book surgery (i.e., to begin waiting). Several surgical specialties (but excluding cardiac, orthopedic and gynecologic) had a close correlation between the dates of the last pre-surgery visit and those of the actual decision to place the patient on the waiting list. Similar results were found for 12 of 15 individually studied procedures, including some orthopedic and gynecological procedures. Used judiciously, billing data is a timely, inexpensive and generally accurate method by which provincial governments could monitor trends in waiting times for appropriately selected surgical procedures.

[Management of Patients on Antithrombotic Agents Undergoing Endoscopy].

PubMed

Kim, Joon Sung; Kim, Byung Wook

2018-05-25

Antithrombotic agents are used increasingly in Asia. The management of patients on antithrombotics undergoing elective or emergency endoscopy has become an increasing clinical challenge for gastroenterologists. Current practice guidelines have been developed by societies from western countries. On the other hand, these guidelines cannot meet the specific needs of the Asian Pacific region, raising the need for separate guidelines in Asia. This review compares the recommendations of previous guidelines with the most recently published Asian guidelines regarding the management of patients on antithrombotic agents undergoing elective and emergency endoscopy.

Predicting Hospital Admissions With Poisson Regression Analysis

DTIC Science & Technology

2009-06-01

East and Four West. Four East is where bariatric , general, neurologic, otolaryngology (ENT), ophthalmologic, orthopedic, and plastic surgery ...where care is provided for cardiovascular, thoracic, and vascular surgery patients. Figure 1 shows a bar graph for each unit, giving the proportion of...provided at NMCSD, or a study could be conducted on the amount of time that patients generally wait for elective surgeries . There is also the

Study of the evolution and variability of nontraumatic orthopedic surgeries in Brazil-9 years of follow-up: A database study.

PubMed

Luciano, Alexandre de Paiva; Almeida, Tábata Cristina do Carmo; Dos Santos Figueiredo, Francisco Winter; Schoueri, Jean Henri Maselli; Abreu, Luiz Carlos de; Adami, Fernando

2018-05-01

In Brazil, there are no epidemiological statistics that map nontraumatic orthopedic injuries, their rate of variability, distribution by specialty, fatality rate, and the economic impact that these lesions and their consequences can bring to the country. The objective of this study was to evaluate the rates of variability for skills, deaths, mortality, and the economic impact of nontraumatic orthopedic surgeries in Brazil from 2008 to 2016.This is a descriptive study conducted through the analysis of data relating to the indicators of hospital production regarding orthopedic procedures of the Department of Informatics of the Unified Health System (Departamento de Informática do Sistema Único de saúde-DATASUS) between 2008 and 2016. The level of significance was 5%.There was a predominance of hospitalizations for surgery of the lower limbs, which also resulted in the largest number of deaths. The surgical mortality rate recorded for the hip also needs to be considered. In general, there is a national increase in the number of orthopedic surgeries performed, accompanied by a concomitant increase in the number of deaths and mortality of the population exposed.We observed a growing demand for hospitalization with a consequent increase in lethality and deaths. We can conclude that between 2008 and 2016, the number of hospitalizations for elective nontraumatic orthopedic surgical procedures increased significantly, driven mainly by lower limb surgeries, along with the cost of the Unified Health System (Sistema Único de Saúde-SUS) for these surgeries.

Comparison of ovarian stimulation response in patients with breast cancer undergoing ovarian stimulation with letrozole and gonadotropins to patients undergoing ovarian stimulation with gonadotropins alone for elective cryopreservation of oocytes†.

PubMed

Pereira, Nigel; Hancock, Kolbe; Cordeiro, Christina N; Lekovich, Jovana P; Schattman, Glenn L; Rosenwaks, Zev

2016-10-01

The primary objective of this study is to compare the oocyte yield in breast cancer patients undergoing controlled ovarian stimulation (COS) using letrozole and gonadotropins with patients undergoing COS with standard gonadotropins for elective cryopreservation of oocytes. Odds ratios (OR) for the number of mature oocytes were estimated. Pregnancy outcomes for breast cancer patients undergoing frozen-thawed 2-PN embryo transfers (FETs) after oncologic treatment were also noted. 220 and 451 cycles were identified in the breast cancer and the elective cryopreservation groups, respectively. Patients in the former group had lower peak estradiol levels [464.5 (315.5-673.8) pg/mL] compared to the latter [1696 (1058-2393) pg/mL; p < 0.01]. More oocytes were retrieved in the breast cancer group (12.3 ± 3.99) compared to the elective cryopreservation group (10.9 ± 3.86; p < 0.01). The odds for mature oocytes with letrozole and gonadotropins was 2.71 (95% CI 1.29-5.72; p = 0.01). Fifty-six FETs occurred in the breast cancer group. The clinical pregnancy and live birth rates per FET cycle were 39.7%, and 32.3%, respectively. Our findings suggest that COS with letrozole and gonadotropins yield more mature oocytes at lower estradiol levels compared to COS with gonadotropins alone. Breast cancer patients undergoing FET after oncologic treatment have live birth rates comparable to age-matched counterparts.

Results of a near-peer musculoskeletal medicine curriculum for senior medical students interested in orthopedic surgery.

PubMed

Schiff, Adam; Salazar, Dane; Vetter, Christopher; Andre, John; Pinzur, Michael

2014-01-01

It has been previously demonstrated that medical students do not achieve an adequate musculoskeletal knowledge base on graduation from American medical schools. Several curriculums have been developed to address this measured deficit. Students entering orthopedic surgery residencies have a better musculoskeletal knowledge foundation than their peers but still fail to achieve an acceptable level of proficiency on graduation from medical school. Fourth-year medical students participating in senior elective rotations in orthopedic surgery over a 2-year period were given a series of lectures developed and presented by post graduate year 3 orthopedic surgery residents. Students completed a validated musculoskeletal competency examination and a survey following the conclusion of their experience, evaluating the effect of this curriculum. A total of 71 students over 2 years participated in the near-peer curriculum, with all students completing the validated test. The mean score for the students was 83.6%. Of the 71 students, 60 (84.5%) scored more than the previously published passing rate of 73.1%. There was no correlation identified with the mean test scores and the number of previous orthopedic surgery rotations. From the survey, 96% of the students rated the near-peer curriculum as appropriate for their level, whereas 75% noted that their own medical school's musculoskeletal curriculum was too advanced for their level of training. A series of lectures was developed by midlevel orthopedic residents for students interested in pursuing a career in orthopedic surgery. After participation in the curriculum, students scored 30-percentage points higher than a previously published test. This study demonstrates that a resident-initiated, near-peer curriculum increases the fundamental knowledge level of students entering orthopedic surgery. An added benefit appeared to be the skills obtained by the residents who created and delivered the lecture series. Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Total Knee Arthroplasty.

PubMed

Soffin, Ellen M; Gibbons, Melinda M; Ko, Clifford Y; Kates, Stephen L; Wick, Elizabeth; Cannesson, Maxime; Scott, Michael J; Wu, Christopher L

2018-06-08

Enhanced recovery after surgery (ERAS) has rapidly gained popularity in a variety of surgical subspecialities. A large body of literature suggests that ERAS leads to superior outcomes, improved patient satisfaction, reduced length of hospital stay, and cost benefits, without affecting rates of readmission after surgery. These patterns have been described for patients undergoing elective total knee arthroplasty (TKA); however, adoption of ERAS to orthopedic surgery has lagged behind other surgical disciplines. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute (AI) for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. The program comprises a national effort to incorporate best practice in perioperative care and improve patient safety, for over 750 hospitals and multiple procedures over the next 5 years, including orthopedic surgery. We have conducted a full evidence review of anesthetic interventions to derive anesthesiology-related components of an evidence-based ERAS pathway for TKA. A PubMed search was performed for each protocol component, focusing on the highest levels of evidence in the literature. Search findings are summarized in narrative format. Anesthesiology components of care were identified and evaluated across the pre-, intra-, and postoperative phases. A summary of the best available evidence, together with recommendations for inclusion in ERAS protocols for TKA, is provided. There is extensive evidence in the literature, and from society guidelines to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for TKA.

Effect of marital status on the outcome of patients undergoing elective or urgent coronary revascularization.

PubMed

Barbash, Israel M; Gaglia, Michael A; Torguson, Rebecca; Minha, Sa'ar; Satler, Lowell F; Pichard, Augusto D; Waksman, Ron

2013-10-01

Marriage confers various health advantages in the general population. However, the added value of marriage among patients who undergo percutaneous coronary intervention (PCI) beyond the standard cardiovascular risk factors is not clear. This study aimed to assess the effects of marital status on outcomes of patients undergoing elective or urgent PCI. Clinical observational analysis of consecutive patients undergoing elective or urgent PCI from 1993 to 2011 was performed. Patients were stratified by marital status, comparing married to unmarried patients. Clinical outcome up to 12 months was obtained by telephone contact or office visit. A total of 11,216 patients were included in the present analysis; 55% were married and 45% unmarried. Significant differences in baseline characteristics were noted, including a lower prevalence of hypertension (86% vs 88%), diabetes (34% vs 38%), and smoking (19% vs 25%) among married vs unmarried patients, respectively (P < .001). However, married patients had a higher prevalence of hypercholesterolemia and family history of coronary artery disease. Early and late major adverse cardiac event rates were significantly lower for married vs unmarried patients up to 1 year (13.3% vs 8.2%, P < .001). Married status was independently associated with improved outcome in multivariable analysis (hazard ratio 0.7, 95% CI 0.6-0.9). Married patients who undergo urgent or elective PCI have superior short- and long-term outcomes up to 1 year when compared with unmarried patients. These benefits persist after adjustment for multiple traditional cardiovascular risk factors. © 2013.

The development and validation of a multivariable model to predict whether patients referred for total knee replacement are suitable surgical candidates at the time of initial consultation.

PubMed

Churchill, Laura; Malian, Samuel J; Chesworth, Bert M; Bryant, Dianne; MacDonald, Steven J; Marsh, Jacquelyn D; Giffin, J Robert

2016-12-01

In previous studies, 50%-70% of patients referred to orthopedic surgeons for total knee replacement (TKR) were not surgical candidates at the time of initial assessment. The purpose of our study was to identify and cross-validate patient self-reported predictors of suitability for TKR and to determine the clinical utility of a predictive model to guide the timing and appropriateness of referral to a surgeon. We assessed pre-consultation patient data as well as the surgeon's findings and post-consultation recommendations. We used multivariate logistic regression to detect self-reported items that could identify suitable surgical candidates. Patients' willingness to undergo surgery, higher rating of pain, greater physical function, previous intra-articular injections and patient age were the factors predictive of patients being offered and electing to undergo TKR. The application of the model developed in our study would effectively reduce the proportion of nonsurgical referrals by 25%, while identifying the vast majority of surgical candidates (> 90%). Using patient-reported information, we can correctly predict the outcome of specialist consultation for TKR in 70% of cases. To reduce long waits for first consultation with a surgeon, it may be possible to use these items to educate and guide referring clinicians and patients to understand when specialist consultation is the next step in managing the patient with severe osteoarthritis of the knee.

The development and validation of a multivariable model to predict whether patients referred for total knee replacement are suitable surgical candidates at the time of initial consultation

PubMed Central

Churchill, Laura; Malian, Samuel J.; Chesworth, Bert M.; Bryant, Dianne; MacDonald, Steven J.; Marsh, Jacquelyn D.; Giffin, J. Robert

2016-01-01

Background In previous studies, 50%–70% of patients referred to orthopedic surgeons for total knee replacement (TKR) were not surgical candidates at the time of initial assessment. The purpose of our study was to identify and cross-validate patient self-reported predictors of suitability for TKR and to determine the clinical utility of a predictive model to guide the timing and appropriateness of referral to a surgeon. Methods We assessed pre-consultation patient data as well as the surgeon’s findings and post-consultation recommendations. We used multivariate logistic regression to detect self-reported items that could identify suitable surgical candidates. Results Patients’ willingness to undergo surgery, higher rating of pain, greater physical function, previous intra-articular injections and patient age were the factors predictive of patients being offered and electing to undergo TKR. Conclusion The application of the model developed in our study would effectively reduce the proportion of nonsurgical referrals by 25%, while identifying the vast majority of surgical candidates (> 90%). Using patient-reported information, we can correctly predict the outcome of specialist consultation for TKR in 70% of cases. To reduce long waits for first consultation with a surgeon, it may be possible to use these items to educate and guide referring clinicians and patients to understand when specialist consultation is the next step in managing the patient with severe osteoarthritis of the knee. PMID:28234616

Risk of Osteosarcoma in Dogs After Open Fracture Fixation.

PubMed

Arthur, Elizabeth G; Arthur, Gerald L; Keeler, Matthew R; Bryan, Jeffrey N

2016-01-01

To critically evaluate whether open fracture fixation is a significant risk factor for latent osteosarcoma development. Case-control study. Dogs undergoing open fracture repair and dogs diagnosed with osteosarcoma. Records were retrieved from the Veterinary Medical Database VMDB (1970-2000) for dogs undergoing surgical repair of a fracture and dogs diagnosed with osteosarcoma. Dogs with open reduction of joint luxation, dogs diagnosed with bacterial cystitis, and dogs diagnosed with urinary bladder transitional cell carcinoma (UBTCC) were queried as comparison populations. Relative risk for osteosarcoma development was determined. From a population of 19,041 fractures treated surgically, 15 of those dogs subsequently appeared in the VMDB with osteosarcoma affecting the same bone. The relative risk of a fracture repair and associated orthopedic implants and osteosarcoma occurrence was equivalent to the relative risk of open joint reduction and osteosarcoma occurrence (95% confidence interval; 0.998-1.00). The relative risk of having bacterial cystitis and appearing again in the VMDB with UBTCC was higher than the risk of open fracture repair and a subsequent diagnosis of osteosarcoma (P < .02). The incidence of fracture-related osteosarcoma may be significantly less than previously estimated based on cases queried from the VMDB. Although possible cases of implant-associated osteosarcoma were identified, their occurrence was rare. Elective implant removal for the purpose of reducing the risk of osteosarcoma after fracture repair may not be warranted and merits further investigation. © Copyright 2015 by The American College of Veterinary Surgeons.

Monitoring trends in waiting periods in Canada for elective surgery: validation of a method using administrative data

PubMed Central

Shortt, Samuel E.D.; Shaw, Ralph A.; Elliott, David; Mackillop, William J.

2004-01-01

Background Provincial governments require timely, economical methods to monitor surgical waiting periods. Although use of prospective procedure-specific registers would be the ideal method, a less elaborate system has been proposed that is based on physician billing data. This study assessed the validity of using the date of the last service billed prior to surgery as a proxy for the beginning of the post-referral, pre-surgical waiting period. Method We examined charts for 31 824 elective surgical encounters between 1992 and 1996 at an Ontario teaching hospital. The date of the last service before surgery (the last billing date) was compared with the date of the consultant's letter indicating a decision to book surgery (i.e., to begin waiting). Results Several surgical specialties (but excluding cardiac, orthopedic and gynecologic) had a close correlation between the dates of the last pre-surgery visit and those of the actual decision to place the patient on the waiting list. Similar results were found for 12 of 15 individually studied procedures, including some orthopedic and gynecological procedures. Conclusion Used judiciously, billing data is a timely, inexpensive and generally accurate method by which provincial governments could monitor trends in waiting times for appropriately selected surgical procedures. PMID:15264378

Computer assisted outcomes research in orthopedics: total joint replacement.

PubMed

Arslanian, C; Bond, M

1999-06-01

Long-term studies are needed to determine clinically relevant outcomes within the practice of orthopedic surgery. Historically, the patient's subjective feelings of quality of life have been largely ignored. However, there has been a strong movement toward measuring perceived quality of life through such instruments as the SF-36. In a large database from an orthopedic practice results are presented. First, computerized data entry using touch screen technology is not only cost effective but user friendly. Second, patients undergoing hip or knee arthroplasty surgeries make statistically significant improvements in seven of the eight domains of the SF-36 in the first 3 months after surgery. Additional statistically significant improvements over the next 6 to 12 months are also seen. The data are presented here in detail to demonstrate the benefits of a patient outcomes program, to enhance the understanding and use of outcomes data and to encourage further work in outcomes measurement in orthopedics.

A pilot randomized trial of pentoxifylline for the reduction of periprocedural myocardial injury in patients undergoing elective percutaneous coronary intervention.

PubMed

Aslanabadi, Naser; Shirzadi, Hamid Reza; Asghari-Soufi, Hossein; Dousti, Samaneh; Ghaffari, Samad; Sohrabi, Bahram; Mashayekhi, Simin Ozar; Hamishehkar, Hadi; Entezari-Maleki, Taher

2015-02-01

Periprocedural myocardial injury (PMI) following percutaneous coronary intervention (PCI) has received great attention due to its significant association with mortality and morbidity. Accordingly, cardioprotection during PCI is one of the important therapeutic concerns. Regarding the potential cardiovascular benefits of pentoxifylline this study was performed to evaluate whether the pretreatment pentoxifylline could reduce PMI in patients who are undergoing elective PCI. A randomized clinical trial on 85 patients undergoing elective PCI was performed. The intervention group (n = 41) received 1200 mg pentoxifylline in divided doses plus the standard treatment before PCI, while the control group (n = 44) received the standard treatment. For assessing myocardial damage during PCI, the levels of CK-MB and troponin-I were measured at baseline, 8, and 24 h after the procedure. Then, patients were followed up for a 1-month period regarding the major adverse cardiac effect. Comparing with the control group, no significant change of CK-MB at 8 (p = 0.315) and 24 h (p = 0.896) after PCI was documented in pentoxifylline group. Similarly, no significant change was found in troponin-I at 8 (p = 0.141) and 24 h (p = 0.256) after PCI. This study could not support the pretreatment with pentoxifylline in the prevention of PMI in patients undergoing elective PCI. However, the trend was toward the potential benefit of pentoxifylline.

A pragmatic multi-centre randomised controlled trial of fluid loading and level of dependency in high-risk surgical patients undergoing major elective surgery: trial protocol

PubMed Central

2010-01-01

Background Patients undergoing major elective or urgent surgery are at high risk of death or significant morbidity. Measures to reduce this morbidity and mortality include pre-operative optimisation and use of higher levels of dependency care after surgery. We propose a pragmatic multi-centre randomised controlled trial of level of dependency and pre-operative fluid therapy in high-risk surgical patients undergoing major elective surgery. Methods/Design A multi-centre randomised controlled trial with a 2 * 2 factorial design. The first randomisation is to pre-operative fluid therapy or standard regimen and the second randomisation is to routine intensive care versus high dependency care during the early post-operative period. We intend to recruit 204 patients undergoing major elective and urgent abdominal and thoraco-abdominal surgery who fulfil high-risk surgical criteria. The primary outcome for the comparison of level of care is cost-effectiveness at six months and for the comparison of fluid optimisation is the number of hospital days after surgery. Discussion We believe that the results of this study will be invaluable in determining the future care and clinical resource utilisation for this group of patients and thus will have a major impact on clinical practice. Trial Registration Trial registration number - ISRCTN32188676 PMID:20398378

ANALYSIS OF SURGICAL SITE INFECTIONS IN PEDIATRIC PATIENTS AFTER ORTHOPEDIC SURGERY: A CASE-CONTROL STUDY

PubMed Central

Chagas, Mariana de Queiroz Leite; Costa, Ana Maria Magalhães; Mendes, Pedro Henrique Barros; Gomes, Saint Clair

2017-01-01

ABSTRACT Objectives: To describe the rate of surgical site infections in children undergoing orthopedic surgery in centers of excellence and analyze the patients’ profiles. Methods: Medical records of pediatric patients undergoing orthopedic surgery in the Jamil Haddad National Institute of Traumatology and Orthopedics from January 2012 to December 2013 were analyzed and monitored for one year. Patients diagnosed with surgical site infection were matched with patients without infection by age, date of admission, field of orthopedic surgery and type of surgical procedure. Patient, surgical and follow-up variables were examined. Descriptive, bivariate and correspondence analyses were performed to evaluate the patients’ profiles. Results: 347 surgeries and 10 surgical site infections (2.88%) were identified. There was association of infections with age - odds ratio (OR) 11.5 (confidence interval - 95%CI 1.41-94.9) -, implant - OR 7.3 (95%CI 1.46-36.3) -, preoperative period - OR 9.8 (95%CI 1.83-53.0), and length of hospitalization - OR 20.6 (95%CI 3.7-114.2). The correspondence analysis correlated the infection and preoperative period, weight, weight Z-score, age, implant, type of surgical procedure, and length of hospitalization. Average time to diagnosis of infection occurred 26.5±111.46 days after surgery. Conclusions: The rate of surgical site infection was 2.88%, while higher in children over 24 months of age who underwent surgical implant procedures and had longer preoperative periods and lengths of hospitalization. This study identified variables for the epidemiological surveillance of these events in children. Available databases and appropriate analysis methods are essential to monitor and improve the quality of care offered to the pediatric population. PMID:28977312

Short-term intravenous antimicrobial prophylaxis for elective rectal cancer surgery: results of a prospective randomized non-inferiority trial.

PubMed

Ishibashi, Keiichiro; Ishida, Hideyuki; Kuwabara, Kouki; Ohsawa, Tomonori; Okada, Norimichi; Yokoyama, Masaru; Kumamoto, Kensuke

2014-04-01

To investigate the non-inferiority of postoperative single-dose intravenous antimicrobial prophylaxis to multiple-dose intravenous antimicrobial prophylaxis in terms of the incidence of surgical site infections (SSIs) in patients undergoing elective rectal cancer surgery by a prospective randomized study. Patients undergoing elective surgery for rectal cancer were randomized to receive a single intravenous injection of flomoxef (group 1) or five additional doses (group 2) of flomoxef after the surgery. All the patients had received preoperative oral antibiotic prophylaxis (kanamycin and erythromycin) after mechanical cleansing within 24 h prior to surgery, and had received intravenous flomoxef during surgery. A total of 279 patients (including 139 patients in group 1 and 140 in group 2) were enrolled in the study. The incidence of SSIs was 13.7% in group 1 and 13.6% in group 2 (difference [95% confidence interval]: -0.2% [-0.9 to 0.7%]). The incidence of SSIs was not significantly different in patients undergoing elective rectal surgery who were treated using a single dose of postoperative antibiotics compared to those treated using multiple-dose antibiotics when preoperative mechanical and chemical bowel preparations were employed.

Associations between ASA Physical Status and postoperative mortality at 48 h: a contemporary dataset analysis compared to a historical cohort.

PubMed

Hopkins, Thomas J; Raghunathan, Karthik; Barbeito, Atilio; Cooter, Mary; Stafford-Smith, Mark; Schroeder, Rebecca; Grichnik, Katherine; Gilbert, Richard; Aronson, Solomon

2016-01-01

In this study, we examined the association between American Society of Anesthesiologists Physical Status (ASA PS) designation and 48-h mortality for both elective and emergent procedures in a large contemporary dataset (patient encounters between 2009 and 2014) and compared this association with data from a landmark study published by Vacanti et al. in 1970. Patient history, hospital characteristics, anesthetic approach, surgical procedure, efficiency and quality indicators, and patient outcomes were prospectively collected for 732,704 consecutive patient encounters between January 1, 2009, and December 31, 2014, at 233 anesthetizing locations across 19 facilities in two US states and stored in the Quantum™ Clinical Navigation System (QCNS) database. The outcome (death within 48 h of procedure) was tabulated against ASA PS designations separately for patients with and without "E" status labels. To maintain consistency with the historical cohort from the landmark study performed by Vacanti et al. on adult men at US naval hospitals in 1970, we then created a comparison cohort in the contemporary dataset that consisted of 242,103 adult male patients (with/without E designations) undergoing elective and emergent procedures. Differences in the relationship between ASA PS and 48-h mortality in the historical and contemporary cohorts were assessed for patients undergoing elective and emergent procedures. As reported nearly five decades ago, we found a significant trend toward increased mortality with increasing ASA PS for patients undergoing both elective and emergent procedures in a large contemporary cohort ( p  < 0.0001). Additionally, the overall mortality rate at 48 h was significantly higher among patients undergoing emergent compared to elective procedures in the large contemporary cohort (1.27 versus 0.03 %, p  < 0.0001). In the comparative analysis with the historical cohort that focused on adult males, we found the overall 48-h mortality rate was significantly lower among patients undergoing elective procedures in the contemporary cohort (0.05 % now versus 0.24 % in 1970, p  < 0.0001) but not significantly lower among those undergoing emergent procedures (1.88 % now versus 1.22 % in 1970, p  < 0.0001). The association between increasing ASA PS designation (1-5) and mortality within 48 h of surgery is significant for patients undergoing both elective and emergent procedures in a contemporary dataset consisting of over 700,000 patient encounters. Emergency surgery was associated with a higher risk of patient death within 48 h of surgery in this contemporary dataset. These data trends are similar to those observed nearly five decades ago in a landmark study evaluating the association between ASA PS and 48-h surgical mortality on adult men at US naval hospitals. When a comparison cohort was created from the contemporary dataset and compared to this landmark historical cohort, the absolute 48-h mortality rate was significantly lower in the contemporary cohort for elective procedures but not significantly lower for emergency procedures. The underlying implications of these findings remain to be determined.

Marijuana use and mortality following orthopedic surgical procedures.

PubMed

Moon, Andrew S; Smith, Walter; Mullen, Sawyer; Ponce, Brent A; McGwin, Gerald; Shah, Ashish; Naranje, Sameer M

2018-03-20

The association between marijuana use and surgical procedures is a matter of increasing societal relevance that has not been well studied in the literature. The primary aim of this study is to evaluate the relationship between marijuana use and in-hospital mortality, as well as to assess associated comorbidities in patients undergoing commonly billed orthopedic surgeries. The National Inpatient Sample (NIS) database from 2010 to 2014 was used to determine the odds ratios for the associations between marijuana use and in-hospital mortality, heart failure (HF), stroke, and cardiac disease (CD) in patients undergoing five common orthopedic procedures: hip (THA), knee (TKA), and shoulder arthroplasty (TSA), spinal fusion, and traumatic femur fracture fixation. Of 9,561,963 patients who underwent one of the five selected procedures in the four-year period, 26,416 (0.28%) were identified with a diagnosis of marijuana use disorder. In hip and knee arthroplasty patients, marijuana use was associated with decreased odds of mortality compared to no marijuana use (p<0.0001), and increased odds of HF (p = 0.018), stroke (p = 0.0068), and CD (p = 0.0123). Traumatic femur fixation patients had the highest prevalence of marijuana use (0.70%), which was associated with decreased odds of mortality (p = 0.0483), HF (p = 0.0076), and CD (p = 0.0003). For spinal fusions, marijuana use was associated with increased odds of stroke (p<0.0001) and CD (p<0.0001). Marijuana use in patients undergoing shoulder arthroplasty was associated with decreased odds of mortality (p<0.001) and stroke (p<0.001). In this study, marijuana use was associated with decreased mortality in patients undergoing THA, TKA, TSA and traumatic femur fixation, although the significance of these findings remains unclear. More research is needed to provide insight into these associations in a growing surgical population.

Cultural implications of differing rates of medically indicated and elective cesarean deliveries for foreign-born versus native-born taiwanese mothers.

PubMed

Huang, Chun-Che; Li, Chung-Yi; Yang, Chiang-Hsing

2012-07-01

The study aimed to assess the number of medically indicated and elective cesarean deliveries among foreign-born and native-born mothers in Taiwan. National Health Insurance (NHI) inpatient datasets in Taiwan between 2001 and 2003 showed 673,830 singleton deliveries, of which 66,687 were to foreign-born mothers and 607,143 were to Taiwan-born mothers. Univariate and multivariate logistic regression models were used to estimate the likelihood of using inpatient services for medically indicated and elective cesarean delivery. During the study period, foreign-born mothers were significantly less likely to undergo medically indicated (odds ratio [OR], 0.82; 95% confidence interval (95% CI), 0.79-0.85) and elective (OR, 0.50; 95% CI, 0.47-0.53) cesarean delivery than Taiwan-born mothers after adjusting for clinical and nonclinical factors. Foreign-born mothers aged 18-50 years are less likely to undergo medically indicated and elective cesarean delivery under Taiwan's NHI coverage. As the birth rate for immigrant women increases, cross-cultural maternity care during pregnancy and childbirth for immigrant mothers needs to be addressed.

Management of the patient with a total joint replacement: the primary care practitioner's role.

PubMed

Palmer, L M

1999-01-01

The primary care practitioner assumes chief responsibility for patients with arthritis. More than 40 million Americans experience some form of arthritis. Management of the patient with arthritis may include a referral to an orthopedic surgeon for surgical intervention. As estimated, up to 500,000 total joint replacement procedures are performed by orthopedic surgeons each year in the United States. Presurgical evaluation for a total joint replacement is imperative to ensure that the patient can safely undergo this surgical procedure. Postsurgical care of a patient with total joint replacement involves coordinating care with the physical therapist and orthopedic surgeon to ensure adequate follow-through with the recommended rehabilitation program, prophylactic antibiotic coverage, and observation for any complications including infection, deep-vein thrombosis, or loosening of the total-joint prosthesis.

The prevalence of iron deficiency anaemia in patients undergoing bariatric surgery.

PubMed

Khanbhai, M; Dubb, S; Patel, K; Ahmed, A; Richards, T

2015-01-01

As bariatric surgery rates continue to climb, anaemia will become an increasing concern. We assessed the prevalence of anaemia and length of hospital stay in patients undergoing bariatric surgery. Prospective data (anaemia [haemoglobin <12 g/dL], haematinics and length of hospital stay) was analysed on 400 hundred patients undergoing elective laparoscopic bariatric surgery. Results from a prospective database of 1530 patients undergoing elective general surgery were used as a baseline. Fifty-seven patients (14%) were anaemic pre-operatively, of which 98% were females. Median MCV (fL) and overall median ferritin (μg/L) was lower in anaemic patients (83 vs. 86, p=0.001) and (28 vs. 61, p<0.0001) respectively. In the elective general surgery patients, prevalence of anaemia was similar (14% vs. 16%) but absolute iron deficiency was more common in those undergoing bariatric surgery; microcytosis p<0.0001, ferritin <30 p<0.0001. Mean length of stay (days) was increased in the anaemic compared to in the non-anaemic group (2.7 vs. 1.9) and patients who were anaemic immediately post-operatively, also had an increased length of stay (2.7 vs. 1.9), p<0.05. Absolute iron deficiency was more common in patients undergoing bariatric surgery. In bariatric patients with anaemia there was an overall increased length of hospital stay. Copyright © 2013 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

Effect of Antibiotic Prophylaxis on Surgical Site Infections Following Removal of Orthopedic Implants Used for Treatment of Foot, Ankle, and Lower Leg Fractures: A Randomized Clinical Trial.

PubMed

Backes, Manouk; Dingemans, Siem A; Dijkgraaf, Marcel G W; van den Berg, H Rogier; van Dijkman, Bart; Hoogendoorn, Jochem M; Joosse, Pieter; Ritchie, Ewan D; Roerdink, W Herbert; Schots, Judith P M; Sosef, Nico L; Spijkerman, Ingrid J B; Twigt, Bas A; van der Veen, Alexander H; van Veen, Ruben N; Vermeulen, Jefrey; Vos, Dagmar I; Winkelhagen, Jasper; Goslings, J Carel; Schepers, Tim

2017-12-26

Following clean (class I, not contaminated) surgical procedures, the rate of surgical site infection (SSI) should be less than approximately 2%. However, an infection rate of 12.2% has been reported following removal of orthopedic implants used for treatment of fractures below the knee. To evaluate the effect of a single dose of preoperative antibiotic prophylaxis on the incidence of SSIs following removal of orthopedic implants used for treatment of fractures below the knee. Multicenter, double-blind, randomized clinical trial including 500 patients aged 18 to 75 years with previous surgical treatment for fractures below the knee who were undergoing removal of orthopedic implants from 19 hospitals (17 teaching and 2 academic) in the Netherlands (November 2014-September 2016), with a follow-up of 6 months (final follow-up, March 28, 2017). Exclusion criteria were an active infection or fistula, antibiotic treatment, reimplantation of osteosynthesis material in the same session, allergy for cephalosporins, known kidney disease, immunosuppressant use, or pregnancy. A single preoperative intravenous dose of 1000 mg of cefazolin (cefazolin group, n = 228) or sodium chloride (0.9%; saline group, n = 242). Primary outcome was SSI within 30 days as measured by the criteria from the US Centers for Disease Control and Prevention. Secondary outcome measures were functional outcome, health-related quality of life, and patient satisfaction. Among 477 randomized patients (mean age, 44 years [SD, 15]; women, 274 [57%]; median time from orthopedic implant placement, 11 months [interquartile range, 7-16]), 470 patients completed the study. Sixty-six patients developed an SSI (14.0%): 30 patients (13.2%) in the cefazolin group vs 36 in the saline group (14.9%) (absolute risk difference, -1.7 [95% CI, -8.0 to 4.6], P = .60). Among patients undergoing surgery for removal of orthopedic implants used for treatment of fractures below the knee, a single preoperative dose of intravenous cefazolin compared with saline did not reduce the risk of surgical site infection within 30 days following implant removal. clinicaltrials.gov Identifier: NCT02225821.

Gabapentin Does Not Appear to Improve Postoperative Pain and Sleep Patterns in Patients Who Concomitantly Receive Regional Anesthesia for Lower Extremity Orthopedic Surgery: A Randomized Control Trial

PubMed Central

Amin, Shawn; Reilly, Mark C.; Shulman, Steven

2017-01-01

In recent years, gabapentin has gained popularity as an adjuvant therapy for the treatment of postoperative pain. Numerous studies have shown a decrease in pain score, even with immediate postoperative activity, which is significant for early post-op ambulation and regaining functionality sooner. However, studies have been in conclusive in patients undergoing lower extremity orthopedic surgery. For this reason, we hoped to study the effect of gabapentin on postoperative pain in patients undergoing total knee arthroplasty, total hip arthroplasty, or a hip fracture repair. This was done in the setting of ensuring adequate postoperative analgesia with regional blocks and opioid PCA, as is protocol at our institution. Given the sedative effects of gabapentin and the potential for improving postoperative sleep patterns, we also studied the drug's effect on this aspect of our patient's postoperative course. We utilized the Pittsburg Sleep Quality Index and Visual Analog Scale for pain to obtain a more objective standardized score amongst our study population. Our results indicate that gabapentin does not offer any additional relief in pain or improve sleep habits in patients who have received either a femoral or lumbar plexus block for lower extremity orthopedic surgery. This trial is registered with NCT01546857. PMID:28348503

Burden of Surgical Site Infections Associated with Arthroplasty and the Contribution of Staphylococcus aureus.

PubMed

Patel, Harshila; Khoury, Hanane; Girgenti, Douglas; Welner, Sharon; Yu, Holly

2016-02-01

Patients undergoing arthroplasty are at considerable risk of experiencing post-operative complications, including surgical site infections (SSIs). In addition to potential economic consequences, SSIs can have a negative impact on patient outcomes and may potentially be life-threatening. Staphylococcus aureus has been consistently shown as the leading cause of SSIs associated with orthopedic surgery, with an important contribution from methicillin-resistant S. aureus (MRSA). This study evaluated the global burden of SSIs among patients undergoing orthopedic surgical procedures, and specifically those undergoing knee and hip arthroplasties. An extensive search of PubMed and recent conference proceedings was conducted. English articles published between 2003 and 2013 pertaining to SSI epidemiology, patient outcomes, and healthcare resource utilization and costs were reviewed. Overall, 81 studies were included, mainly from North America and Europe. Median SSI and S. aureus SSI rates, calculated as percentage of all arthroplasty procedures, were 1.7% (range: 0.25%-4.4%; 15 studies) and 0.6% (range: 0.1%-23%), respectively. Median SSI rates were 1.3% (range: 0.05%-19%; 22 studies) after knee arthroplasty, and 2.1% (range: 0.05%-28%; 24 studies) after hip arthroplasty. S. aureus SSI rates ranged from 0.2%-2.4% and 0.18%-3.8% for patients undergoing knee and hip arthroplasty, respectively. The percentage of S. aureus SSIs because of MRSA varied widely within each patient category. SSI-related mortality data (14 studies) showed that in-hospital mortality rates were low (1.2%-2.5%), but increased with time after index arthroplasty procedure (up to 56% over 1 y). Studies assessing healthcare resource utilization (n = 21) revealed that developing post-orthopedic SSIs resulted in a two- to three-fold increase in length of hospital stay (LOS) compared with non-infected patients (median LOS: 18.9 d vs. 6 d for non-SSI patients). Patients with SSIs because of methicillin-resistant staphylococci incurred greater mean LOS compared with SSIs because of methicillin-sensitive organisms. Readmission rates reported in 11 studies indicate a greater likelihood in the presence of SSIs; comparison across studies was not feasible because of differences in data reporting. Consistent with increased healthcare resource utilization (LOS and readmission) associated with SSIs, cost studies (n = 23) revealed that the presence of SSIs was associated with up to three-fold cost increase compared with the absence of SSI across all orthopedic patient categories assessed. SSIs are associated with increased morbidity, mortality rates, healthcare resource utilization, and costs. Despite the relatively low SSI incidence following orthopedic surgery and specifically arthroplasty, preventive methods, specifically those targeting S. aureus, would serve to minimize costs and improve patient outcomes.

Value Added: the Case for Point-of-View Camera use in Orthopedic Surgical Education.

PubMed

Karam, Matthew D; Thomas, Geb W; Taylor, Leah; Liu, Xiaoxing; Anthony, Chris A; Anderson, Donald D

2016-01-01

Orthopedic surgical education is evolving as educators search for new ways to enhance surgical skills training. Orthopedic educators should seek new methods and technologies to augment and add value to real-time orthopedic surgical experience. This paper describes a protocol whereby we have started to capture and evaluate specific orthopedic milestone procedures with a GoPro® point-of-view video camera and a dedicated video reviewing website as a way of supplementing the current paradigm in surgical skills training. We report our experience regarding the details and feasibility of this protocol. Upon identification of a patient undergoing surgical fixation of a hip or ankle fracture, an orthopedic resident places a GoPro® point-of-view camera on his or her forehead. All fluoroscopic images acquired during the case are saved and later incorporated into a video on the reviewing website. Surgical videos are uploaded to a secure server and are accessible for later review and assessment via a custom-built website. An electronic survey of resident participants was performed utilizing Qualtrics software. Results are reported using descriptive statistics. A total of 51 surgical videos involving 23 different residents have been captured to date. This includes 20 intertrochanteric hip fracture cases and 31 ankle fracture cases. The average duration of each surgical video was 1 hour and 16 minutes (range 40 minutes to 2 hours and 19 minutes). Of 24 orthopedic resident surgeons surveyed, 88% thought capturing a video portfolio of orthopedic milestones would benefit their education. There is a growing demand in orthopedic surgical education to extract more value from each surgical experience. While further work in development and refinement of such assessments is necessary, we feel that intraoperative video, particularly when captured and presented in a non-threatening, user friendly manner, can add significant value to the present and future paradigm of orthopedic surgical skill training.

Value Added: the Case for Point-of-View Camera use in Orthopedic Surgical Education

PubMed Central

Thomas, Geb W.; Taylor, Leah; Liu, Xiaoxing; Anthony, Chris A.; Anderson, Donald D.

2016-01-01

Abstract Background Orthopedic surgical education is evolving as educators search for new ways to enhance surgical skills training. Orthopedic educators should seek new methods and technologies to augment and add value to real-time orthopedic surgical experience. This paper describes a protocol whereby we have started to capture and evaluate specific orthopedic milestone procedures with a GoPro® point-of-view video camera and a dedicated video reviewing website as a way of supplementing the current paradigm in surgical skills training. We report our experience regarding the details and feasibility of this protocol. Methods Upon identification of a patient undergoing surgical fixation of a hip or ankle fracture, an orthopedic resident places a GoPro® point-of-view camera on his or her forehead. All fluoroscopic images acquired during the case are saved and later incorporated into a video on the reviewing website. Surgical videos are uploaded to a secure server and are accessible for later review and assessment via a custom-built website. An electronic survey of resident participants was performed utilizing Qualtrics software. Results are reported using descriptive statistics. Results A total of 51 surgical videos involving 23 different residents have been captured to date. This includes 20 intertrochanteric hip fracture cases and 31 ankle fracture cases. The average duration of each surgical video was 1 hour and 16 minutes (range 40 minutes to 2 hours and 19 minutes). Of 24 orthopedic resident surgeons surveyed, 88% thought capturing a video portfolio of orthopedic milestones would benefit their education Conclusions There is a growing demand in orthopedic surgical education to extract more value from each surgical experience. While further work in development and refinement of such assessments is necessary, we feel that intraoperative video, particularly when captured and presented in a non-threatening, user friendly manner, can add significant value to the present and future paradigm of orthopedic surgical skill training. PMID:27528828

Infant orthopedics has no effect on maxillary arch dimensions in the deciduous dentition of children with complete unilateral cleft lip and palate (Dutchcleft).

PubMed

Bongaarts, Catharina A M; van 't Hof, Martin A; Prahl-Andersen, Birte; Dirks, Iris V; Kuijpers-Jagtman, Anne M

2006-11-01

Evaluation of the effect of infant orthopedics on maxillary arch dimensions in the deciduous dentition in patients with unilateral cleft lip and palate. Prospective two-arm randomized controlled clinical trial with three participating cleft palate centers. Cleft palate centers of the Radboud University Nijmegen Medical Center, Academic Center of Dentistry Amsterdam, and University Medical Center Rotterdam, the Netherlands. Children with complete unilateral cleft lip and palate (n = 54) were included. Patients were randomly divided into two groups. Half of the patients (IO+) had a presurgical orthopedic plate until surgical closure of the soft palate at the age of 52 weeks; the other half (IO-) did not undergo presurgical orthopedics. Maxillary arch dimensions were assessed on dental casts at 4 and 6 years of age with measurements for arch width, arch depth, arch length, arch form, and the vertical position of the lesser segment. Contact and collapse were assessed also. There were no clinically significant differences found between IO+ and IO- for any of the variables. Infant orthopedics had no observable effect on the maxillary arch dimensions or on the contact and collapse scores in the deciduous dentition at the ages of 4 and 6 years. Considering the Dutchcleft results to date, there is no need to perform infant orthopedics for unilateral cleft lip and palate patients.

Contributions of tidal lung inflation to human R-R interval and arterial pressure fluctuations

NASA Technical Reports Server (NTRS)

Koh, J.; Brown, T. E.; Beightol, L. A.; Eckberg, D. L.

1998-01-01

We studied the effects of mechanical lung inflation on respiratory frequency R-R interval and arterial pressure fluctuations in nine healthy young adults undergoing elective orthopedic surgery. We conducted this research to define the contribution of pulmonary and thoracic stretch receptor input to respiratory sinus arrhythmia. We compared fast Fourier transform spectral power during three modes of ventilation: (1) spontaneous, frequency-controlled (0.25 Hz) breathing, (2) intermittent positive pressure ventilation (0.25 Hz, with a tidal volume of 8 ml/kg) and (3) high frequency jet ventilation (5.0 Hz, 2.5 kg/cm2), after sedation and vecuronium paralysis. Mean R-R intervals, arterial pressures and arterial blood gas levels were comparable during all three breathing conditions. Respiratory frequency systolic pressure spectral power was comparable during spontaneous breathing and conventional mechanical ventilation, but was significantly reduced during high frequency jet ventilation (P < 0.05). Respiratory frequency R-R interval spectral power (used as an index of respiratory sinus arrhythmia) declined dramatically with sedation and muscle paralysis (P < 0.05), but was greater during conventional mechanical, than high frequency jet ventilation (P < 0.05). These results suggest that although phasic inputs from pulmonary and thoracic stretch receptors make a statistically significant contribution to respiratory sinus arrhythmia, that contribution is small.

Selective Methicillin-Resistant Staphylococcus Aureus (MRSA) screening of a high risk population does not adequately detect MRSA carriers within a country with low MRSA prevalence.

PubMed

de Wouters, Solange; Daxhelet, Jérémy; Kaminski, Ludovic; Thienpont, Emmanuel; Cornu, Olivier; Yombi, Jean Cyr

2015-12-01

Methicillin-Resistant Staphylococcus Aureus (MRSA) has been widely recognized as a serious problem in hospital settings. The purpose of this study is to evaluate the predictive value of MRSA colonization factors in the detection of MRSA carriers in an orthopedic ward. A systematic MRSA detection strategy was set up to assess the predictive value of MRSA colonization factors among 554 patients undergoing elective knee arthroplasty. In total 116 patients were found positive for Staphylococcus Aureus; among those 110/116 patients were found positive for Methicillin-Sensitive Staphylococcus Aureus (MSSA) and 6/116 for MRSA. Only one patient out of six presented two risk factors according to MRSA risk factors. In this study, no correlation was found between the remaining conventional risk factors, according to Belgian guidelines, defined to target high-risk populations and to identify MRSA carriers. Established criteria for selective MRSA screening do not allow detecting MRSA carriers. The objective of detecting MRSA carriers is not correctly met by the actual applied criteria (Belgian consensus) for a selective screening policy. Future studies should aim at identifying the right risk factors, depending of the country's prevalence of MRSA, to improve the ability to predict the risk of MRSA carriage at hospital admission.

Clinical applicability of nursing outcomes in the evolution of orthopedic patients with Impaired Physical Mobility.

PubMed

da Silva, Marcos Barragan; Almeida, Miriam de Abreu; Panato, Bruna Paulsen; Siqueira, Ana Paula de Oliveira; da Silva, Mariana Palma; Reisderfer, Letícia

2015-01-01

to evaluate the clinical applicability of outcomes, according to the Nursing Outcomes Classification (NOC) in the evolution of orthopedic patients with Impaired Physical Mobility longitudinal study conducted in 2012 in a university hospital, with 21 patients undergoing Total Hip Arthroplasty, evaluated daily by pairs of trained data collectors. Data were collected using an instrument containing five Nursing Outcomes, 16 clinical indicators and a five point Likert scale, and statistically analyzed. The outcomes Body Positioning: self-initiated, Mobility, Knowledge: prescribed activity, and Fall Prevention Behavior presented significant increases in mean scores when comparing the first and final evaluations (p<0.001) and (p=0.035). the use of the NOC outcomes makes it possible to demonstrate the clinical progression of orthopedic patients with Impaired Physical Mobility, as well as its applicability in this context.

The Institute for Global Orthopedics and Traumatology: A Model for Academic Collaboration in Orthopedic Surgery.

PubMed

Conway, Devin James; Coughlin, Richard; Caldwell, Amber; Shearer, David

2017-01-01

In 2006, surgeons at the University of California, San Francisco (UCSF) established the Institute for Global Orthopedics and Traumatology (IGOT), an initiative within the department of orthopedic surgery. The principal aim of IGOT is to create long-term, sustainable solutions to the growing burden of musculoskeletal injury in low- and middle-income countries (LMICs) through academic partnership. IGOT currently has relationships with teaching hospitals in Ghana, Malawi, Tanzania, Nicaragua, and Nepal. The organizational structure of IGOT is built on four pillars: Global Surgical Education (GSE), Global Knowledge Exchange (GKE), Global Research Initiative (GRI), and Global Leadership and Advocacy. GSE focuses on increasing surgical knowledge and technical proficiency through hands-on educational courses. The GKE facilitates the mutual exchange of surgeons and trainees among IGOT and its partners. This includes a global resident elective that allows UCSF residents to complete an international rotation at one of IGOT's partner sites. The GRI strives to build research capacity and sponsor high-quality clinical research projects that address questions relevant to local partners. The fourth pillar, Global Leadership and Advocacy aims to increase awareness of the global impact of musculoskeletal injury through national and international courses and events, such as the Bay Area Global Health Film Festival. At the core of each tenet is the collaboration among IGOT and its international partners. Over the last decade, IGOT has experienced tremendous growth and maturation in its partnership model based on cumulative experience and the needs of its partners.

The Institute for Global Orthopedics and Traumatology: A Model for Academic Collaboration in Orthopedic Surgery

PubMed Central

Conway, Devin James; Coughlin, Richard; Caldwell, Amber; Shearer, David

2017-01-01

In 2006, surgeons at the University of California, San Francisco (UCSF) established the Institute for Global Orthopedics and Traumatology (IGOT), an initiative within the department of orthopedic surgery. The principal aim of IGOT is to create long-term, sustainable solutions to the growing burden of musculoskeletal injury in low- and middle-income countries (LMICs) through academic partnership. IGOT currently has relationships with teaching hospitals in Ghana, Malawi, Tanzania, Nicaragua, and Nepal. The organizational structure of IGOT is built on four pillars: Global Surgical Education (GSE), Global Knowledge Exchange (GKE), Global Research Initiative (GRI), and Global Leadership and Advocacy. GSE focuses on increasing surgical knowledge and technical proficiency through hands-on educational courses. The GKE facilitates the mutual exchange of surgeons and trainees among IGOT and its partners. This includes a global resident elective that allows UCSF residents to complete an international rotation at one of IGOT’s partner sites. The GRI strives to build research capacity and sponsor high-quality clinical research projects that address questions relevant to local partners. The fourth pillar, Global Leadership and Advocacy aims to increase awareness of the global impact of musculoskeletal injury through national and international courses and events, such as the Bay Area Global Health Film Festival. At the core of each tenet is the collaboration among IGOT and its international partners. Over the last decade, IGOT has experienced tremendous growth and maturation in its partnership model based on cumulative experience and the needs of its partners. PMID:28713803

Hypobaric spinal anesthesia in the operative management of orthopedic emergencies in geriatric patients.

PubMed

Sidi, A; Pollak, D; Floman, Y; Davidson, J T

1984-07-01

Hypobaric spinal anesthesia was administered to 40 patients undergoing lower limb surgery. Twenty-nine of the patients were debilitated geriatric patients who presented with orthopedic emergencies, in most cases a fractured hip. Hypobaric spinal anesthesia was found to be a simple and safe procedure that provided adequate analgesia. Due to its inherent nature, hypobaric spinal anesthesia does not necessitate positioning of the patient on the injured, painful side (unlike hyperbaric spinal or epidural anesthesia) and, therefore, facilitates a smooth and painless transfer of the patient to the operating table. Complications encountered were similar to those following hyperbaric anesthesia.

Trends in Total Hip Arthroplasty Under the Patient Protection and Affordable Care Act: A National Database Analysis Between 2008 and 2015.

PubMed

Etcheson, Jennifer I; George, Nicole E; Gwam, Chukwuweike U; Nace, James; Caughran, Alexander T; Thomas, Melbin; Virani, Sana; Delanois, Ronald E

2018-05-16

The Patient Protection and Affordable Care Act expanded health coverage for low-earning individuals and families. With more Americans having access to care, the use of elective procedures, such as total hip arthroplasty (THA), was expected to increase. Therefore, the aim of this study was to evaluate trends in THA before and after the initiation of the Patient Protection and Affordable Care Act regarding race, age, body mass index, and sex between 2008 and 2015. The National Surgical Quality Improvement Program database was queried for all individuals who had undergone primary THA between 2008 and 2015. This yielded a total of 104,209 patients. Descriptive statistics were used to analyze patient-level data. A Cochran-Armitage test assessed trends in categorical data points over time. Analysis indicated an increased percentage of blacks or African Americans undergoing THA (7.8% vs 9.2%, P<.001), followed by Native Americans or Pacific Islanders (0.0% vs 0.4%, P<.001), American Indians or Alaskan Natives (0.3% vs 0.5%, P=.016), and Asians (1.4% vs 1.5%, P=.002). An increased percentage of patients 55 to 80 years old received THAs (68.6% vs 74.1%, P<.001). The percentage of patients with a body mass index of 25.0 to 29.9 kg/m 2 , 30.0 to 34.9 kg/m 2 , and 35.0 to 39.9 kg/m 2 increased (32.9% vs 33.1%, 24.2% vs 25.6%, 12.6% vs 13.3%, respectively, P<.001 for all). These findings may provide insight on the changing patient characteristics for orthopedic surgeons performing THA. Furthermore, these findings may inform health policy makers interested in increasing access to procedures underutilized by specific patient populations and the creation of strategies to meet increased demand. [Orthopedics. 201x; xx(x):xx-xx.]. Copyright 2018, SLACK Incorporated.

Assessment of perioperative minute ventilation in obese versus non-obese patients with a non-invasive respiratory volume monitor.

PubMed

Mehta, Jaideep H; Cattano, Davide; Brayanov, Jordan B; George, Edward E

2017-04-26

Monitoring the adequacy of spontaneous breathing is a major patient safety concern in the post-operative setting. Monitoring is particularly important for obese patients, who are at a higher risk for post-surgical respiratory complications and often have increased metabolic demand due to excess weight. Here we used a novel, noninvasive Respiratory Volume Monitor (RVM) to monitor ventilation in both obese and non-obese orthopedic patients throughout their perioperative course, in order to develop better monitoring strategies. We collected respiratory data from 62 orthopedic patients undergoing elective joint replacement surgery under general anesthesia using a bio-impedance based RVM with an electrode PadSet placed on the thorax. Patients were stratified into obese (BMI ≥ 30) and non-obese cohorts and minute ventilation (MV) at various perioperative time points was compared against each patient's predicted minute ventilation (MV PRED ) based on ideal body weight (IBW) and body surface area (BSA). The distributions of MV measurements were also compared across obese and non-obese cohorts. Obese patients had higher MV than the non-obese patients before, during, and after surgery. Measured MV of obese patients was significantly higher than their MV PRED from IBW formulas, with BSA-based MV PRED being a closer estimate. Obese patients also had greater variability in MV post-operatively when treated with standard opioid dosing. Our study demonstrated that obese patients have greater variability in ventilation post-operatively when treated with standard opioid doses, and despite overall higher ventilation, many of them are still at risk for hypoventilation. BSA-based MV PRED formulas may be more appropriate than IBW-based ones when estimating the respiratory demand of obese patients. The RVM allows for the continuous and non-invasive assessment of respiratory function in both obese and non-obese patients.

Prevalence of unrecognized diabetes, prediabetes and metabolic syndrome in patients undergoing elective percutaneous coronary intervention.

PubMed

Balakrishnan, Revathi; Berger, Jeffrey S; Tully, Lisa; Vani, Anish; Shah, Binita; Burdowski, Joseph; Fisher, Edward; Schwartzbard, Arthur; Sedlis, Steven; Weintraub, Howard; Underberg, James A; Danoff, Ann; Slater, James A; Gianos, Eugenia

2015-09-01

Diabetes mellitus (DM) and metabolic syndrome are important targets for secondary prevention in cardiovascular disease. However, the prevalence in patients undergoing elective percutaneous coronary intervention is not well defined. We aimed to analyse the prevalence and characteristics of patients undergoing percutaneous coronary intervention with previously unrecognized prediabetes, diabetes and metabolic syndrome. Data were collected from 740 patients undergoing elective percutaneous coronary intervention between November 2010 and March 2013 at a tertiary referral center. Prevalence of DM and prediabetes was evaluated using Haemoglobin A1c (A1c ≥ 6.5% for DM, A1c 5.7-6.4% for prediabetes). A modified definition was used for metabolic syndrome [three or more of the following criteria: body mass index ≥30 kg/m2; triglycerides ≥ 150 mg/dL; high density lipoprotein <40 mg/dL in men and <50 mg/dL in women; systolic blood pressure ≥ 130 mmHg and/or diastolic ≥ 85 mmHg; and A1c ≥ 5.7% or on therapy]. Mean age was 67 years, median body mass index was 28.2 kg/m(2) and 39% had known DM. Of those without known DM, 8.3% and 58.5% met A1c criteria for DM and for prediabetes at time of percutaneous coronary intervention. Overall, 54.9% met criteria for metabolic syndrome (69.2% of patients with DM and 45.8% of patients without DM). Among patients undergoing elective percutaneous coronary intervention, a substantial number were identified with a new DM, prediabetes, and/or metabolic syndrome. Routine screening for an abnormal glucometabolic state at the time of revascularization may be useful for identifying patients who may benefit from additional targeting of modifiable risk factors. Copyright © 2015 John Wiley & Sons, Ltd.

Cardiac magnetic resonance findings predict increased resource utilization in elective coronary artery bypass grafting.

PubMed

Berry, Colin; Zimmerli, Lukas U; Steedman, Tracey; Foster, John E; Dargie, Henry J; Berg, Geoffrey A; Dominiczak, Anna F; Delles, Christian

2008-03-01

Morbidity following CABG (coronary artery bypass grafting) is difficult to predict and leads to increased healthcare costs. We hypothesized that pre-operative CMR (cardiac magnetic resonance) findings would predict resource utilization in elective CABG. Over a 12-month period, patients requiring elective CABG were invited to undergo CMR 1 day prior to CABG. Gadolinium-enhanced CMR was performed using a trueFISP inversion recovery sequence on a 1.5 tesla scanner (Sonata; Siemens). Clinical data were collected prospectively. Admission costs were quantified based on standardized actual cost/day. Admission cost greater than the median was defined as 'increased'. Of 458 elective CABG cases, 45 (10%) underwent pre-operative CMR. Pre-operative characteristics [mean (S.D.) age, 64 (9) years, mortality (1%) and median (interquartile range) admission duration, 7 (6-8) days] were similar in patients who did or did not undergo CMR. In the patients undergoing CMR, eight (18%) and 11 (24%) patients had reduced LV (left ventricular) systolic function by CMR [LVEF (LV ejection fraction) <55%] and echocardiography respectively. LE (late enhancement) with gadolinium was detected in 17 (38%) patients. The average cost/day was $2723. The median (interquartile range) admission cost was $19059 ($10891-157917). CMR LVEF {OR (odds ratio), 0.93 [95% CI (confidence interval), 0.87-0.99]; P=0.03} and SV (stroke volume) index [OR 1.07 (95% CI, 1.00-1.14); P=0.02] predicted increased admission cost. CMR LVEF (P=0.08) and EuroScore tended to predict actual admission cost (P=0.09), but SV by CMR (P=0.16) and LV function by echocardiography (P=0.95) did not. In conclusion, in this exploratory investigation, pre-operative CMR findings predicted admission duration and increased admission cost in elective CABG surgery. The cost-effectiveness of CMR in risk stratification in elective CABG surgery merits prospective assessment.

Clinical applicability of nursing outcomes in the evolution of orthopedic patients with Impaired Physical Mobility 1

PubMed Central

da Silva, Marcos Barragan; Almeida, Miriam de Abreu; Panato, Bruna Paulsen; Siqueira, Ana Paula de Oliveira; da Silva, Mariana Palma; Reisderfer, Letícia

2015-01-01

AIM: to evaluate the clinical applicability of outcomes, according to the Nursing Outcomes Classification (NOC) in the evolution of orthopedic patients with Impaired Physical Mobility METHOD: longitudinal study conducted in 2012 in a university hospital, with 21 patients undergoing Total Hip Arthroplasty, evaluated daily by pairs of trained data collectors. Data were collected using an instrument containing five Nursing Outcomes, 16 clinical indicators and a five point Likert scale, and statistically analyzed. RESULTS: The outcomes Body Positioning: self-initiated, Mobility, Knowledge: prescribed activity, and Fall Prevention Behavior presented significant increases in mean scores when comparing the first and final evaluations (p<0.001) and (p=0.035). CONCLUSION: the use of the NOC outcomes makes it possible to demonstrate the clinical progression of orthopedic patients with Impaired Physical Mobility, as well as its applicability in this context. PMID:25806631

Studies on biodegradation of crosslinked hydroxy terminated-poly(proplyene fumarate) and formation of scaffold for orthopedic applications.

PubMed

Shalumon, K T; Jayabalan, M

2009-12-01

Biodegradation of crosslinked-hydroxy terminated-poly(proplyene fumarate) (X-HTPPF) has been studied in simulated physiological media to assess the formation of porous scaffold structure for bone growth and remodeling in load bearing orthopedic applications. Variation in crosslink density and surface hydrophilicity of X-HTPPF are observed due to non-stoichiometric mass of reacting partners. These variations influence absorption of the medium and biodegradation during aging. Though the initial absorption of medium is relatively higher with the crosslinked polymer (PNVP1) having 63.6% HT-PPF and 36.4% comonomer n-vinyl pyrrolidone (NVP) during the initial period of aging, the weight loss due to subsequent degradation with time is relatively lesser. PNVP1 undergo slow degradation with formation of fibril structure on the surface. The present crosslinked material PNVP1 is a candidate for the load bearing orthopedic applications.

The peri-operative management of anti-platelet therapy in elective, non-cardiac surgery.

PubMed

Alcock, Richard F; Naoum, Chris; Aliprandi-Costa, Bernadette; Hillis, Graham S; Brieger, David B

2013-07-31

Cardiovascular complications are important causes of morbidity and mortality in patients undergoing elective non-cardiac surgery, with adverse cardiac outcomes estimated to occur in approximately 4% of all patients. Anti-platelet therapy withdrawal may precede up to 10% of acute cardiovascular syndromes, with withdrawal in the peri-operative setting incompletely appraised. The aims of our study were to determine the proportion of patients undergoing elective non-cardiac surgery currently prescribed anti-platelet therapy, and identify current practice in peri-operative management. In addition, the relationship between management of anti-platelet therapy and peri-operative cardiac risk was assessed. We evaluated consecutive patients attending elective non-cardiac surgery at a major tertiary referral centre. Clinical and biochemical data were collected and analysed on patients currently prescribed anti-platelet therapy. Peri-operative management of anti-platelet therapy was compared with estimated peri-operative cardiac risk. Included were 2950 consecutive patients, with 516 (17%) prescribed anti-platelet therapy, primarily for ischaemic heart disease. Two hundred and eighty nine (56%) patients had all anti-platelet therapy ceased in the peri-operative period, including 49% of patients with ischaemic heart disease and 46% of patients with previous coronary stenting. Peri-operative cardiac risk score did not influence anti-platelet therapy management. Approximately 17% of patients undergoing elective non-cardiac surgery are prescribed anti-platelet therapy, the predominant indication being for ischaemic heart disease. Almost half of all patients with previous coronary stenting had no anti-platelet therapy during the peri-operative period. The decision to cease anti-platelet therapy, which occurred commonly, did not appear to be guided by peri-operative cardiac risk stratification. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Association Between Baseline Affective Disorders and 30-Day Readmission Rates in Patients Undergoing Elective Spine Surgery.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2016-10-01

There is a growing understanding of the prevalence and impact of affective disorders on perception of health status in patients undergoing elective spine surgery. However, the role of these disorders in early readmission is unclear. The aim of this study is to investigate the influence of psychiatric comorbidities on 30-day all-cause readmissions after elective spine surgery. The medical records of 400 patients undergoing elective spine surgery at a major academic medical center were reviewed, of which 107 patients had comprehensive 1- and 2-year patient-reported outcomes data. We identified all unplanned readmissions within 30 days of discharge. The prevalence of affective disorders, such as depression and anxiety, were also assessed. All-cause readmissions within 30 days of discharge was the primary outcome variable. Baseline characteristics were similar between groups. Approximately 6% of patients in this study were readmitted within 30 days of discharge. The rate of readmission was 3-fold more for individuals with a psychiatric comorbidity compared with those without a psychiatric comorbidity (10.34% vs. 3.84%, P = 0.03). In a univariate analysis, race, body mass index, gender, patient age, smoking, diabetes, and fusion levels were associated with increased 30-day readmission rates. However, in a multivariate logistic regression model, depression was an independent predictor of readmission within 30 days of discharge. In addition, there was no significant difference in baseline, 1- and 2-year patient-reported outcomes measures between groups. Our study suggests that psychologic disorders, like depression and anxiety, are independently associated with higher all-cause 30-day readmission rates after elective spine surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Mortality and Rates of Secondary Intervention After EVAR in an Unselected Population: Influence of Simple Clinical Categories and Implications for Surveillance

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hammond, Christopher J., E-mail: christopherhammond@nhs.net; Shah, Asim H.; Snoddon, Andrew

IntroductionPost-EVAR surveillance has a major impact upon patients, carers and healthcare resources. We hypothesised that elective indication, on-IFU anatomy, use of a modern device or normal first CTA, or a combination of these categories, might predict a rate of secondary intervention low enough to alter current surveillance protocols.MethodsPatients undergoing EVAR in our institution between 01.05.2007 and 28.02.2013 were assessed. Data on indication (elective, emergency), anatomy relative to IFU, device, first month CTA result, secondary intervention and mortality were obtained. Kaplan–Meier charts of mortality and freedom from secondary intervention were produced. Statistical analysis was by log-rank test and Cox proportional hazardmore » modelling.Results234 patients underwent EVAR (188 elective, 208 on-IFU). Most implants were Endurant (106) or Talent (98). 151 patients had a normal first CTA. By median follow-up of 38.6 months, 39 patients underwent secondary intervention. A normal first CTA and elective indication were significantly associated with reduced risk of secondary intervention (p < 0.001 and p = 0.042 respectively), but device type and placement on- or off-IFU were not. Elective placement with a normal first CTA was 93 % predictive of freedom from secondary intervention by 32 months post-EVAR. Of nine patients undergoing secondary intervention in this group, eight presented symptomatically.DiscussionIn optimal procedural circumstances with normal post-procedural imaging, only 7 % of patients undergoing EVAR require secondary intervention, a minority of which is driven by surveillance. These data support a change to surveillance more tailored to the individual patient, and highlight the need for further qualitative and quantitative research.« less

[EFFECTS OF CANNABIS EXTRACT PREMEDICATION ON ANESTHETIC DEPTH].

PubMed

Ibera, Carlos; Shalom, Ben; Saifi, Fayez; Shruder, Joshua; Davidson, Elyad

2018-03-01

Cannabis is the most widely used illicit drug in the world, used by approximately 2.7-4.9% of the world's population, and 7.6-10.2% of Israel's adults. During the past few years, legal systems around the world have enacted large scale adoption of the legalization of both medical and recreational cannabis. Anesthetists should therefore be prepared to treat patients who used cannabis and are undergoing elective or emergency operations. However, the interactions between cannabinoids and general anesthetic agents and the possible implications for patient care are not yet fully understood. The study aimed to examine how preoperative use of cannabis affects the anesthesia process, and whether this use requires special attention by the anesthesiologists during surgery. Hence, we examined the effect of preoperative administration of cannabis extract Sativex (nabiximols) on obtained BIS value relative to the concentration of anesthetic gases. This study is a double-blind randomized controlled trial. Twenty-seven patients undergoing elective orthopedic surgery under general anesthesia were randomly allocated to one of the following regimes: high dose cannabis (6), low dose cannabis (8), active placebo (6) and placebo (7). The study drugs were administered as premedication 20 minutes before induction of general anesthesia in a double-blind fashion. Cannabis was administered in the form of nabiximols (Sativex®), which is a highly-standardized extract of cannabis plants containing known drug dosages. During the surgery, hemodynamic parameters were monitored, and the anesthesia depth was measured using a BIS monitor, which is based on brain activity analysis. We found a significant effect of treatment groups on bispectral index (BIS) after controlling for minimum alveolar concentration (MAC). The average BIS values, as measured during steady state anesthesia, were significantly higher in the high dose cannabis treatment group. This study provides the first evidence that cannabinoids may affect the BIS. We speculate that the cannabinoid-induced increase in BIS may be the result of changes in EEG activity rather than an indication of a shallower anesthetic state. However, this hypothesis should be examined in further studies. The clinical importance of this study is that with patients who use cannabis adjacent to general anesthesia induction, one cannot rely on the BIS monitoring for the purpose of determining the patient sedative state.

Frequency of vomiting during the postoperative period in hydromorphone-treated dogs undergoing orthopedic surgery.

PubMed

Stern, Leah C; Palmisano, Matthew P

2012-08-01

To determine the frequency of postoperative vomiting in dogs undergoing routine orthopedic surgery that were treated with hydromorphone and whether that frequency would vary on the basis of administration route. Noncontrolled clinical trial. Animals-58 client-owned dogs with cranial cruciate ligament deficiency. Before surgery, all dogs received hydromorphone (0.1 mg/kg [0.045 mg/lb], IM or IV) and 41 dogs also received acepromazine. Anesthesia was induced with diazepam and propofol and maintained with isoflurane in oxygen. Dogs subsequently underwent surgical stabilization of the stifle joint. After surgery, dogs were randomly assigned to receive hydromorphone (0.1 mg/kg) via one of the following routes: IM, IV quickly (for 1 to 2 seconds), or IV slowly (for approx 1 minute). Dogs were monitored for vomiting. A median of 4 doses of hydromorphone/dog was administered after surgery. One dog was observed to regurgitate once prior to postoperative IM administration of hydromorphone; no dogs vomited at any point during the study period, regardless of the method of hydromorphone administration. The method of hydromorphone administration had no apparent effect on the likelihood of dogs vomiting. Because no dogs vomited, a particular administration method cannot be recommended. However, findings suggested that hydromorphone can be administered to dogs following orthopedic surgery without a clinically important risk of vomiting or regurgitation.

Elective induction of labor.

PubMed

Moore, Lisa E; Rayburn, William F

2006-09-01

Induction of labor rates have more than doubled nationwide in the past 15 years. The increase in medically induced inductions was slower than the overall increase, suggesting that inductions for marginal or elective reasons rose more rapidly. Elective inductions seem to account for at least half of all inductions and 10% of all deliveries. Whether the experience of an elective induction is satisfactory to the patient, obstetrician, and intrapartum crew warrants more widespread attention. Cesarean rates are high for nulliparas undergoing an induction with an unfavorable cervix. Prospective studies are limited or nonexistent to recommend induction of labor for elective or marginal indications. Until more prospective work is performed, it will be difficult to evaluate the true impact of the elective induction of labor on population-wide cesarean delivery rates. Strategies for increased obstetrician awareness are proposed through practice guidelines and through clinical research trials.

Elective Stoma Reversal Has a Higher Incidence of Postoperative Clostridium Difficile Infection Compared With Elective Colectomy: An Analysis Using the American College of Surgeons National Surgical Quality Improvement Program and Targeted Colectomy Databases.

PubMed

Skancke, Matthew; Vaziri, Khashayar; Umapathi, Bindu; Amdur, Richard; Radomski, Michal; Obias, Vincent

2018-05-01

Clostridium difficile infection is caused by the proliferation of a gram-positive anaerobic bacteria after medical or surgical intervention and can result in toxic complications, emergent surgery, and death. This analysis evaluates the incidence of C difficile infection in elective restoration of intestinal continuity compared with elective colon resection. This was a retrospective database review of the 2015 American College of Surgeons National Surgical Quality Improvement Project and targeted colectomy database. The intervention cohort was defined as the primary Current Procedural Terminology codes for ileostomy/colostomy reversal (44227, 44620, 44625, and 44626) and International Classification of Diseases codes for ileostomy/colostomy status (VV44.2, VV44.3, VV55.2, VV55.3, Z93.2, Z93.3, Z43.3, and Z43.2). A total of 2235 patients underwent elective stoma reversal compared with 10403 patients who underwent elective colon resection. Multivariate regression modeling of the impact of stoma reversal on postoperative C difficile infection risk was used as the study intervention. The incidence of C difficile infection in the 30 days after surgery was measured. The incidence of C difficile infection in the 30-day postoperative period was significantly higher (3.04% vs 1.25%; p < 0.001) in patients undergoing stoma reversal. After controlling for differences in cohorts, regression analysis suggested that stoma reversal (OR = 2.701 (95% CI, 1.966-3.711); p < 0.001), smoking (OR = 1.520 (95% CI, 1.063-2.174); p = 0.022), steroids (OR = 1.677 (95% CI, 1.005-2.779); p = 0.048), and disseminated cancer (OR = 2.312 (95% CI, 1.437-3.719); p = 0.001) were associated with C difficile infection incidence in the 30-day postoperative period. The study was limited because it was a retrospective database review with observational bias. Patients who undergo elective stoma reversal have a higher incidence of postoperative C difficile infection compared with patients who undergo an elective colectomy. Given the impact of postoperative C difficile infection, a heightened sense of suspicion should be given to symptomatic patients after stoma reversal. See at Video Abstract at http://links.lww.com/DCR/A553.

Acetaminophen and Meloxicam Inhibit Platelet Aggregation and Coagulation in Blood Samples from Humans

DTIC Science & Technology

2014-01-01

not change by acetaminophen at any of the tested doses. Consistent to our results, prolonged aPTT from meloxicam has been reported in dogs undergoing...orthopedic surgery [16] as well as in healthy dogs [17]. The significant changes in aPTT and lack of changes in PT by meloxicam suggest that melox- icam...Papazoglou LG, Rallis T, Tsimopoulos G, Adamama-Moraitou K, Tea A. Effects of meloxicam on the haemostatic profile of dogs undergoing orthopaedic

The effect of intravenous paracetamol for the prevention of rocuronium injection pain.

PubMed

Uzun, Sennur; Erden, Ismail A; Canbay, Ozgur; Aypar, Ulku

2014-11-01

Rocuronium is a nondepolarizing neuromuscular blocking agent used in anesthesia induction and is associated with considerable discomfort and burning pain during injection, which is reported to occur in 50-80% of patients. This study was carried out to investigate the effectiveness of intravenous paracetamol pretreatment compared with lidocaine and normal saline to prevent rocuronium injection pain. The study included 150 ASA I-II patients undergoing elective orthopedic, gastrointestinal, and gynecological procedures under general anesthesia. They were allocated into three groups according to pretreatment drugs: lidocaine (40 mg) (n = 50), paracetamol (n = 50), and normal saline group (n = 50). Before anesthesia induction with propofol, all patients were pretreated with rocuronium. The pain caused by the injection was evaluated. Local signs were assessed on the arm at the end of the injection, as well as 24 hours after recovery from anesthesia. There were no patients with blurred speech or vision and there was no respiratory depression in any group after pretreatment with the study drug. The level of pain on injection was statistically lower in those who had received paracetamol compared to normal saline (p = 0.009). There were more patients in the saline group with severe pain (p < 0.001). Paracetamol relieved the rocuronium injection pain better than normal saline but lidocaine was the best of the three drugs (p < 0.001). Copyright © 2014. Published by Elsevier Taiwan.

Physical activity after total knee arthroplasty: A critical review

PubMed Central

Paxton, Roger J; Melanson, Edward L; Stevens-Lapsley, Jennifer E; Christiansen, Cory L

2015-01-01

Total knee arthroplasty (TKA) is the most commonly performed elective surgery in the United States. TKA typically improves functional performance and reduces pain associated with knee osteoarthritis. Little is known about the influence of TKA on overall physical activity levels. Physical activity, defined as “any bodily movement produced by skeletal muscles that results in energy expenditure”, confers many health benefits but typically decreases with endstage osteoarthritis. The purpose of this review is to describe the potential benefits (metabolic, functional, and orthopedic) of physical activity to patients undergoing TKA, present results from recent studies aimed to determine the effect of TKA on physical activity, and discuss potential sources of variability and conflicting results for physical activity outcomes. Several studies utilizing self-reported outcomes indicate that patients perceive themselves to be more physically active after TKA than they were before surgery. Accelerometry-based outcomes indicate that physical activity for patients after TKA remains at or below pre-surgical levels. Several different factors likely contributed to these variable results, including the use of different instruments, duration of follow-up, and characteristics of the subjects studied. Comparison to norms, however, suggests that daily physical activity for patients following TKA may fall short of healthy age-matched controls. We propose that further study of the relationship between TKA and physical activity needs to be performed using accelerometry-based outcome measures at multiple post-surgical time points. PMID:26396937

Hospitalization Costs for Patients Undergoing Orthopedic Surgery Treated With Intravenous Acetaminophen (IV-APAP) Plus Other IV Analgesics or IV Opioid Monotherapy for Postoperative Pain.

PubMed

Maiese, Brett A; Pham, An T; Shah, Manasee V; Eaddy, Michael T; Lunacsek, Orsolya E; Wan, George J

2017-02-01

To assess the impact on hospitalization costs of multimodal analgesia (MMA), including intravenous acetaminophen (IV-APAP), versus IV opioid monotherapy for postoperative pain management in patients undergoing orthopedic surgery. Utilizing the Truven Health MarketScan ® Hospital Drug Database (HDD), patients undergoing total knee arthroplasty (TKA), total hip arthroplasty (THA), or surgical repair of hip fracture between 1/1/2011 and 8/31/2014 were separated into postoperative pain management groups: MMA with IV-APAP plus other IV analgesics (IV-APAP group) or an IV opioid monotherapy group. All patients could have received oral analgesics. Baseline characteristics and total hospitalization costs were compared. Additionally, an inverse probability treatment weighting [IPTW] with propensity scores analysis further assessed hospitalization cost differences. The IV-APAP group (n = 33,954) and IV opioid monotherapy group (n = 110,300) differed significantly (P < 0.0001) across baseline characteristics, though the differences may not have been clinically meaningful. Total hospitalization costs (mean ± standard deviation) were significantly lower for the IV-APAP group than the IV opioid monotherapy group (US$12,540 ± $9564 vs. $13,242 ± $35,825; P < 0.0001). Medical costs accounted for $701 of the $702 between-group difference. Pharmacy costs were similar between groups. Results of the IPTW-adjusted analysis further supported the statistically significant cost difference. Patients undergoing orthopedic surgery who received MMA for postoperative pain management, including IV-APAP, had significantly lower total costs than patients who received IV opioid monotherapy. This difference was driven by medical costs; importantly, there was no difference in pharmacy costs. Generalizability of the results may be limited to patients admitted to hospitals similar to those included in HDD. Dosing could not be determined, so it was not possible to quantify utilization of IV-APAP or ascertain differences in opioid consumption between the 2 groups. This study did not account for healthcare utilization post-discharge.

Outcomes of surgery in patients aged ≥90 years in the general surgical setting.

PubMed

Sudlow, A; Tuffaha, H; Stearns, A T; Shaikh, I A

2018-03-01

Introduction An increasing proportion of the population is living into their nineties and beyond. These high risk patients are now presenting more frequently to both elective and emergency surgical services. There is limited research looking at outcomes of general surgical procedures in nonagenarians and centenarians to guide surgeons assessing these cases. Methods A retrospective analysis was conducted of all patients aged ≥90 years undergoing elective and emergency general surgical procedures at a tertiary care facility between 2009 and 2015. Vascular, breast and endocrine procedures were excluded. Patient demographics and characteristics were collated. Primary outcomes were 30-day and 90-day mortality rates. The impact of ASA (American Society of Anesthesiologists) grade, operation severity and emergency presentation was assessed using multivariate analysis. Results Overall, 161 patients (58 elective, 103 emergency) were identified for inclusion in the study. The mean patient age was 92.8 years (range: 90-106 years). The 90-day mortality rates were 5.2% and 19.4% for elective and emergency procedures respectively (p=0.013). The median survival was 29 and 19 months respectively (p=0.001). Emergency and major gastrointestinal operations were associated with a significant increase in mortality. Patients undergoing emergency major colonic or upper gastrointestinal surgery had a 90-day mortality rate of 53.8%. Conclusions The risk for patients aged over 90 years having an elective procedure differs significantly in the short term from those having emergency surgery. In selected cases, elective surgery carries an acceptable mortality risk. Emergency surgery is associated with a significantly increased risk of death, particularly after major gastrointestinal resections.

Myenteric plexitis: A frequent feature in patients undergoing surgery for colonic diverticular disease

PubMed Central

Villanacci, Vincenzo; Sidoni, Angelo; Nascimbeni, Riccardo; Dore, Maria P; Binda, Gian A; Bandelloni, Roberto; Salemme, Marianna; Del Sordo, Rachele; Cadei, Moris; Manca, Alessandra; Bernardini, Nunzia; Maurer, Christoph A; Cathomas, Gieri

2015-01-01

Background Diverticular disease of the colon is frequent in clinical practice, and a large number of patients each year undergo surgical procedures worldwide for their symptoms. Thus, there is a need for better knowledge of the basic pathophysiologic mechanisms of this disease entity. Objectives Because patients with colonic diverticular disease have been shown to display abnormalities of the enteric nervous system, we assessed the frequency of myenteric plexitis (i.e. the infiltration of myenteric ganglions by inflammatory cells) in patients undergoing surgery for this condition. Methods We analyzed archival resection samples from the proximal resection margins of 165 patients undergoing left hemicolectomy (60 emergency and 105 elective surgeries) for colonic diverticulitis, by histology and immunochemistry. Results Overall, plexitis was present in almost 40% of patients. It was subdivided into an eosinophilic (48%) and a lymphocytic (52%) subtype. Plexitis was more frequent in younger patients; and it was more frequent in those undergoing emergency surgery (50%), compared to elective (28%) surgery (p = 0.007). All the severe cases of plexitis displayed the lymphocytic subtype. Conclusions In conclusion, myenteric plexitis is frequent in patients with colonic diverticular disease needing surgery, and it might be implicated in the pathogenesis of the disease. PMID:26668745

Myenteric plexitis: A frequent feature in patients undergoing surgery for colonic diverticular disease.

PubMed

Bassotti, Gabrio; Villanacci, Vincenzo; Sidoni, Angelo; Nascimbeni, Riccardo; Dore, Maria P; Binda, Gian A; Bandelloni, Roberto; Salemme, Marianna; Del Sordo, Rachele; Cadei, Moris; Manca, Alessandra; Bernardini, Nunzia; Maurer, Christoph A; Cathomas, Gieri

2015-12-01

Diverticular disease of the colon is frequent in clinical practice, and a large number of patients each year undergo surgical procedures worldwide for their symptoms. Thus, there is a need for better knowledge of the basic pathophysiologic mechanisms of this disease entity. Because patients with colonic diverticular disease have been shown to display abnormalities of the enteric nervous system, we assessed the frequency of myenteric plexitis (i.e. the infiltration of myenteric ganglions by inflammatory cells) in patients undergoing surgery for this condition. We analyzed archival resection samples from the proximal resection margins of 165 patients undergoing left hemicolectomy (60 emergency and 105 elective surgeries) for colonic diverticulitis, by histology and immunochemistry. Overall, plexitis was present in almost 40% of patients. It was subdivided into an eosinophilic (48%) and a lymphocytic (52%) subtype. Plexitis was more frequent in younger patients; and it was more frequent in those undergoing emergency surgery (50%), compared to elective (28%) surgery (p = 0.007). All the severe cases of plexitis displayed the lymphocytic subtype. In conclusion, myenteric plexitis is frequent in patients with colonic diverticular disease needing surgery, and it might be implicated in the pathogenesis of the disease.

The effect of a multimedia health educational program on the postoperative recovery of patients undergoing laparoscopic cholecystectomy.

PubMed

Stergiopoulou, Antonia; Birbas, Konstantinos; Katostaras, Theophanis; Diomidous, Mariana; Mantas, John

2006-01-01

Aim of this study is the evaluation of the impact of preoperative informative session using a Multimedia Health Educational Program (MHEP) on patients undergoing elective Laparoscopic Cholecystectomy (LC) for cholelithiasis, preoperative anxiety and postoperative pain and nausea. Sixty consecutive patients scheduled for elective LC were considered for enrollment in the trial. Patients were assigned randomly to four groups: Group A included 15 patients, preoperatively informed regarding LC through the MHEP presented by a Registered Nurse (RN). Group B included 15 patients preoperatively informed through a leaflet (designed and developed using the exact contents of the MHEP). In Group C, there were 15 patients who were being informed verbally from the RN. Finally, the control Group D included 15 patients, who had the conventional preoperative information about the operation and postoperative course by the attending surgeon and anesthesiologist, as every other patient included in groups A, B, C. Preoperative assessment of patient's knowledge about cholelithiasis and LC was performed after informative session, and was based on a specifically developed "closed, true-false" questionnaire. Preliminary results suggest that conventional information provided by the attending surgeon (Group D) is inadequate. Specifically developed informative sessions with the contribution of MHEP seems to be effective on reducing preoperative anxiety and postoperative pain, in patients undergoing elective LC.

Influence of preoperative emotional state on postoperative pain following orthopedic and trauma surgery.

PubMed

Robleda, Gemma; Sillero-Sillero, Amalia; Puig, Teresa; Gich, Ignasi; Baños, Josep-E

2014-10-01

To analyze the relationship between preoperative emotional state and the prevalence and intensity of postoperative pain and to explore predictors of postoperative pain. Observational retrospective study undertaken among 127 adult patients of orthopedic and trauma surgery. Postoperative pain was assessed with the verbal numeric scale and with five variables of emotional state: anxiety, sweating, stress, fear, and crying. The Chi-squared test, Student's t test or ANOVA and a multivariate logistic regression analysis were used for the statistical analysis. The prevalence of immediate postoperative pain was 28%. Anxiety was the most common emotional factor (72%) and a predictive risk factor for moderate to severe postoperative pain (OR: 4.60, 95% CI 1.38 to 15.3, p<0.05, AUC: 0.72, 95% CI: 0.62 to 0.83). Age exerted a protective effect (OR 0.96, 95% CI: 0.94-0.99, p<0.01). Preoperative anxiety and age are predictors of postoperative pain in patients undergoing orthopedic and trauma surgery.

Functional Decline in Children Undergoing Selective Dorsal Rhizotomy after Age 10

ERIC Educational Resources Information Center

MacWilliams, Bruce A.; Johnson, Barbara A.; Shuckra, Amy L.; D'Astous, Jacques L.

2011-01-01

Aim: To compare function and gait in a group of children older than most children who received selective dorsal rhizotomy (SDR) with age- and function-matched peers who received either orthopedic surgery or no surgical intervention. Method: A retrospective study examined ambulatory children with diplegic cerebral palsy, aged between 10 years and…

Anesthetic management with sevoflurane combined with alfaxalone-medetomidine constant rate infusion in a Thoroughbred racehorse undergoing a long-time orthopedic surgery

PubMed Central

WAKUNO, Ai; MAEDA, Tatsuya; KODAIRA, Kazumichi; KIKUCHI, Takuya; OHTA, Minoru

2017-01-01

ABSTRACT A three-year old Thoroughbred racehorse was anesthetized with sevoflurane and oxygen inhalation anesthesia combined with constant rate infusion (CRI) of alfaxalone-medetomidine for internal fixation of a third metacarpal bone fracture. After premedication with intravenous (IV) injections of medetomidine (6.0 µg/kg IV), butorphanol (25 µg/kg IV), and midazolam (20 µg/kg IV), anesthesia was induced with 5% guaifenesin (500 ml/head IV) followed immediately by alfaxalone (1.0 mg/kg IV). Anesthesia was maintained with sevoflurane and CRIs of alfaxalone (1.0 mg/kg/hr) and medetomidine (3.0 µg/kg/hr). The total surgical time was 180 min, and the total inhalation anesthesia time was 230 min. The average end-tidal sevoflurane concentration during surgery was 1.8%. The mean arterial blood pressure was maintained above 70 mmHg throughout anesthesia, and the recovery time was 65 min. In conclusion, this anesthetic technique may be clinically applicable for Thoroughbred racehorses undergoing a long-time orthopedic surgery. PMID:28955163

D-dimer as an applicable test for detection of posttraumatic deep vein thrombosis in lower limb fracture.

PubMed

Bakhshi, Hooman; Alavi-Moghaddam, Mostafa; Wu, Karin C; Imami, Mohammad; Banasiri, Mohammad

2012-06-01

Measuring the plasma levels of D-dimer is an accurate and easy modality to detect deep vein thrombosis (DVT) in nontraumatic settings. However, the diagnostic reliability of D-dimer assays in detecting posttraumatic DVT among patients with lower limb fracture undergoing orthopedic surgery is not validated. In this study, 141 patients with lower limb fracture admitted through the emergency department and undergoing orthopedic surgery were enrolled. Postoperative venous blood samples for D-dimer assay were taken on the 1st, 7th, and 28th postoperative days. Color Doppler sonography examination of both lower limbs was performed at the same time as a standard test. Eight out of the 141 patients (6%) had acute DVT based on Color Doppler sonography. Mean D-dimer was 2160 ng/mL in DVT positive patients and 864 in DVT negative patients. D-dimer levels greater than 1000 ng/mL were 100% sensitive and 71% specific for detecting postoperative DVT. D-dimer assay is a useful and sensitive test for detecting posttraumatic DVT.

Resource utilization and charges of patients with and without diagnosed venous thromboembolism during primary hospitalization and after elective inpatient surgery: a retrospective study.

PubMed

Sepassi, Aryana; Chingcuanco, Francine; Gordon, Ronald; Meier, Angela; Divino, Victoria; DeKoven, Mitch; Ben-Joseph, Rami

2018-06-01

To assess incremental charges of patients experiencing venous thromboembolisms (VTE) across various types of elective inpatient surgical procedures with administration of general anesthesia in the US. The authors performed a retrospective study utilizing data from a nationwide hospital operational records database from July 2014 through June 2015 to compare a group of inpatients experiencing a VTE event post-operatively to a propensity score matched group of inpatients who did not experience a VTE. Patients included in the analysis had a hospital admission for an elective inpatient surgical procedure with the use of general anesthesia. Procedures of the heart, brain, lungs, and obstetrical procedures were excluded, as these procedures often require a scheduled ICU stay post-operatively. Outcomes examined included VTE events during hospitalization, length of stay, unscheduled ICU transfers, number of days spent in the ICU if transferred, 3- and 30-day re-admissions, and total hospital charges incurred. The study included 17,727 patients undergoing elective inpatient surgical procedures. Of these, 36 patients who experienced a VTE event were matched to 108 patients who did not. VTE events occurred in 0.2% of the study population, with most events occurring for patients undergoing total knee replacement. VTE patients had a mean total hospital charge of $60,814 vs $48,325 for non-VTE patients, resulting in a mean incremental charge of $11,979 (p < .05). Compared to non-VTE patients, VTE patients had longer length of stay (5.9 days vs 3.7 days, p < .001), experienced a higher rate of 3-day re-admissions (3 vs 0 patients) and 30-day re-admissions (7 vs 2 patients). Patients undergoing elective inpatient surgical procedures with general anesthesia who had a VTE event during their primary hospitalization had a significantly longer length of stay and significantly higher total hospital charges than comparable patients without a VTE event.

Prevention of VTE in Orthopedic Surgery Patients

PubMed Central

Francis, Charles W.; Johanson, Norman A.; Curley, Catherine; Dahl, Ola E.; Schulman, Sam; Ortel, Thomas L.; Pauker, Stephen G.; Colwell, Clifford W.

2012-01-01

Background: VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT. Methods: The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results: In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava filter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lower-extremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B). Conclusions: Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches. PMID:22315265

The incidence and causative organisms of infection in elective shoulder surgery.

PubMed

Mayne, Alistair I W; Bidwai, Amit S; Clifford, Rachael; Smith, Matthew G; Guisasola, Inigo; Brownson, Peter

2018-07-01

Deep infection remains a serious complication of orthopaedic surgery. Knowledge of infection rates and causative organisms is important to guide infection control measures. The aim of the present study was to determine infection rates and causative organisms in elective shoulder surgery. Cases complicated by infection were identified and prospectively recorded over a 2-year period. All patients undergoing elective shoulder surgery in the concurrent period at a single Specialist Upper Limb Unit in the UK were identified from the hospital electronic database. In total, 1574 elective shoulder cases were performed: 1359 arthroscopic (540 with implant insertion) and 215 open (197 with implant insertion). The overall infection rate in open surgery of 2.5% was significantly higher than arthroscopic implant cases at 0.7% ( p  < 0.005). The overall infection rate in implant arthroscopic surgery was significantly higher at 0.7% compared to 0% in non-implant related surgery. ( p  < 0.05). Patients undergoing open shoulder surgery have a significantly higher risk of infection compared to arthroscopic shoulder surgery. Arthroscopic surgery with implant insertion has a statistically significantly higher risk of developing deep infection compared to procedures with no implant insertion. We recommend prophylactic antibiotics in open shoulder surgery and arthroscopic shoulder surgery with implant insertion.

Oocyte vitrification for elective fertility preservation: the past, present, and future.

PubMed

Gunnala, Vinay; Schattman, Glenn

2017-02-01

Oocyte cryopreservation is no longer experimental and one of its rapidly growing indications is elective fertility preservation. Currently there is no sufficient evidence to support its practice and therefore its place in IVF remains uncertain. Vitrification has superior post-thaw survival and fertilization outcomes compared with oocytes that were frozen with the slow-freeze technique. Oocyte vitrification produces similar IVF outcomes compared with fresh oocytes and is not associated with further obstetrical or perinatal morbidity. Undergoing elective oocyte cryopreservation between ages 35 and 37 will optimize live birth rates as well as cost effectiveness from mathematical models. In women who delay child bearing, elective oocyte cryopreservation in the mid 30s may be beneficial in terms of live birth rates and cost effectiveness. Prospective studies of women who have undergone oocyte cryopreservation and are now attempting conception are needed before official recommendations can be made regarding elective egg freezing.

Impact of mechanical bowel preparation in elective colorectal surgery: A meta-analysis.

PubMed

Rollins, Katie E; Javanmard-Emamghissi, Hannah; Lobo, Dileep N

2018-01-28

To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery. Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. A total of 36 studies (23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates (OR = 0.90, 95%CI: 0.74 to 1.10, P = 0.32), surgical site infection (OR = 0.99, 95%CI: 0.80 to 1.24, P = 0.96), intra-abdominal collection (OR = 0.86, 95%CI: 0.63 to 1.17, P = 0.34), mortality (OR = 0.85, 95%CI: 0.57 to 1.27, P = 0.43), reoperation (OR = 0.91, 95%CI: 0.75 to 1.12, P = 0.38) or hospital length of stay (overall mean difference 0.11 d, 95%CI: -0.51 to 0.73, P = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlled trials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery.

Circulating maternal cortisol levels during vaginal delivery and elective cesarean section.

PubMed

Stjernholm, Ylva Vladic; Nyberg, Annie; Cardell, Monica; Höybye, Charlotte

2016-08-01

Maternal S-cortisol levels increase throughout pregnancy and peak in the third trimester. Even higher levels are seen during the physical stress of delivery. Since analgesia for women in labor has improved, it is possible that maternal stress during labor is reduced. The aim of this study was to compare maternal S-cortisol during vaginal delivery and elective cesarean section. Twenty healthy women with spontaneous vaginal delivery and healthy women (n = 20) undergoing elective cesarean section were included in the study. S-cortisol was measured during three stages of spontaneous vaginal delivery (tvd1, tvd2 and tvd3), as well as before and after elective cesarean section (tcs1 and tcs2). In the vaginal delivery group, mean S-cortisol at tvd1 was 1325 ± 521 nmol/L, at tvd2 1559 ± 591 nmol/L and at tvd3 1368 ± 479 nmol/L. In the cesarean section group, mean S-cortisol at tcs1 was 906 ± 243 nmol/L and at tcs2 831 ± 257 nmol/L. S-cortisol was higher in the vaginal delivery group at the onset of labor as compared to the cesarean section preoperative group (p = 0.006). There were also significant differences between S-cortisol levels postpartum as compared to postoperatively (p < 0.001). Maternal S-cortisol was higher during vaginal delivery compared to elective cesarean section, indicating higher stress levels. A reduction in the hydrocortisone dose at childbirth in women with adrenal insufficiency should be considered, particularly in women undergoing an elective cesarean section.

Detection of resistance to linezolid in Staphylococcus aureus infecting orthopedic patients.

PubMed

Thool, Vaishali U; Bhoosreddy, Girish L; Wadher, Bharat J

2012-01-01

In today's medical scenario, the human race is battling the most intelligent enemy who has unending alternatives to combat with the potent elements they have produced against it. To study the resistance to linezolid among Staphylococcus aureus isolated from pus samples of orthopedic patients. Pus samples were collected from dirty wounds of orthopedic patients undergoing long antimicrobial treatment programs. The sampling period was from July 2010 to June 2011. The samples were collected from different orthopedic hospitals of Nagpur (central India) representing a mixed sample of patients. One hundred pus samples were screened for S. aureus, by growth on mannitol salt agar (MSA), Baird-Parker agar (BPA), deoxyribonuclease test, tube coagulase test, and HiStaph latex agglutination test. Fifty-one S. aureus isolates were obtained which were further subjected to antimicrobial susceptibility testing by Kirby-Bauer disc diffusion method (DDM). Minimal inhibitory concentrations (MICs) were determined by an automated system, the VITEK 2 system. Also, Ezy MIC strip method was carried out in accordance with Clinical and Laboratory Standards Institute (CLSI) guidelines. Twelve linezolid-resistant S. aureus (LRSA) isolates were recovered from 51 S. aureus cultures tested for susceptibility to linezolid using the DDM, VITEK 2 system, and Ezy MIC strip method. The emergence of resistance suggests nosocomial spread and abuse of antibiotic.

The effect of blood transfusion on short-term, perioperative outcomes in elective spine surgery.

PubMed

Seicean, Andreea; Alan, Nima; Seicean, Sinziana; Neuhauser, Duncan; Weil, Robert J

2014-09-01

Studies in various surgical procedures have shown that transfusion of red blood cells (RBC) increases the risk of postoperative morbidity and mortality. Impact of blood transfusion in patients undergoing spine surgery is not well-described. We assessed the impact of intra and postoperative transfusion on postoperative morbidity and mortality in patients undergoing elective spine surgery. We used the American College of Surgeons' National Surgical Quality Improvement Program to identify a retrospective cohort of 36,901 adult patients who underwent elective spine surgery between 2006 and 2011. Patients who received intra or postoperative transfusion (n=3262) were matched to those who did not using propensity scores. Logistic regression predicted adverse postoperative outcomes. We conducted sensitivity analysis in a subset of patients in whom the number of intraoperatively transfused units of RBC or whole blood was known. Upon matching, preoperative hematocrit, length of surgery, and percentage of spinal fusion surgery were not significantly different between transfused and non-transfused patients. After matching, transfusion remained adversely associated with prolonged length of stay (LOS) in hospital (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.3-2.9), postoperative complications (OR 1.6, 95% CI 1.4-1.9), and an increased 30 day return to operation room (OR 1.7, 95% CI 1.3-2.2). Transfusion of even one unit of blood intraoperatively was associated with prolonged LOS (OR 2.0, 95% CI 1.5-2.6) and minor complications (OR 2.4, 95% CI 1.3-4.3). Therefore, transfusion of RBC or whole blood, even a single unit, increased LOS and postoperative morbidity in patients undergoing elective spine surgery, independent of preoperative hematocrit level and patient comorbidities. Copyright © 2014 Elsevier Ltd. All rights reserved.

Gender disparities in the utilization of laparoscopic groin hernia repair.

PubMed

Thiels, Cornelius A; Holst, Kimberly A; Ubl, Daniel S; McKenzie, Travis J; Zielinski, Martin D; Farley, David R; Habermann, Elizabeth B; Bingener, Juliane

2017-04-01

Clinical treatment guidelines have suggested that laparoscopic hernia repair should be the preferred approach in both men and women with bilateral or recurrent elective groin hernias. Anecdotal evidence suggests, however, that women are less likely to undergo a laparoscopic repair than men, and therefore, we aimed to delineate if these disparities persisted after controlling for patient factors and comorbidities. The American College of Surgeons National Surgical Quality Improvement Project data were abstracted for all elective groin hernia repairs between 2005 and 2014. Univariate analysis was used to compare rates of laparoscopic surgery between men and women. Multivariable analysis was performed, controlling for patient demographics, preoperative comorbidities, and year of surgery. Over the 10-y period, 141,490 patients underwent elective groin hernia repair, of which 13,325 were women (9.4%). The rate of general anesthesia utilization was high in both men (81.3%) and women (77.2%) with 75.1% of open repairs being performed under general anesthesia. Overall, 20.2% of women underwent laparoscopic repair compared with 28.0% of men (P < 0.01). Women tended to be older, had a lesser body mass index, and slightly greater American Anesthesia Association (all P < 0.05). On multivariable regression, women had decreased odds of undergoing a laparoscopic approach compared with men (odds ratio: 0.70; 95% confidence interval, 0.67-0.73, P < 0.01). In the elective setting, women were less likely to undergo laparoscopic repair of groin hernias than men. Although we are unable to ascertain underlying causes for these gender disparities, these data suggest that there remains a disparity in the management of groin hernias in women. Copyright © 2016 Elsevier Inc. All rights reserved.

Effect of Structured Touch and Guided Imagery for Pain and Anxiety in Elective Joint Replacement Patients--A Randomized Controlled Trial: M-TIJRP.

PubMed

Forward, John Brent; Greuter, Nancy Elizabeth; Crisall, Santa J; Lester, Houston F

2015-01-01

Postoperative management of pain after total joint arthroplasty remains a challenge despite advancements in analgesics. Evidence shows that complementary modalities with mind-body and tactile-based approaches are valid and effective adjuncts to reduce pain and anxiety postoperatively. To investigate the effectiveness of the "M" Technique (M), a registered method of structured touch using a set sequence and number of strokes, and a consistent level of pressure on hands and feet, compared with guided imagery and usual care, for the reduction of pain and anxiety in patients undergoing elective total knee or hip replacement surgery. Randomized controlled trial: M-TIJRP (MiTechnique and guided Imagery in Joint Replacement Patients [Mighty Junior P]). At a community hospital, 225 male and female patients, aged 38 to 90 years, undergoing elective total hip or knee replacement were randomly assigned to 1 of 3 groups (75 patients in each): M, guided imagery, or usual care. They were blinded to their assignment until the intervention. Reduction of pain and anxiety postoperatively. Secondary outcomes measured use of pain medication and patient satisfaction. This study yielded positive findings for the management of pain and anxiety in patients undergoing elective joint replacement using M and guided imagery for 18 to 20 minutes compared with usual care. M showed the largest predicted decreases in both pain and anxiety between groups. There was no significant difference in narcotic pain medication use between groups. Patient satisfaction survey ratings were highest for M, followed by guided imagery. The benefit of M may be because of the specifically structured sequence of touch by competent caring, trained providers.

Effect of Structured Touch and Guided Imagery for Pain and Anxiety in Elective Joint Replacement Patients—A Randomized Controlled Trial: M-TIJRP

PubMed Central

Forward, John Brent; Greuter, Nancy Elizabeth; Crisall, Santa J; Lester, Houston F

2015-01-01

Context: Postoperative management of pain after total joint arthroplasty remains a challenge despite advancements in analgesics. Evidence shows that complementary modalities with mind-body and tactile-based approaches are valid and effective adjuncts to reduce pain and anxiety postoperatively. Objective: To investigate the effectiveness of the “M” Technique (M), a registered method of structured touch using a set sequence and number of strokes, and a consistent level of pressure on hands and feet, compared with guided imagery and usual care, for the reduction of pain and anxiety in patients undergoing elective total knee or hip replacement surgery. Methods: Randomized controlled trial: M-TIJRP (MiTechnique and guided Imagery in Joint Replacement Patients [Mighty Junior P]). At a community hospital, 225 male and female patients, aged 38 to 90 years, undergoing elective total hip or knee replacement were randomly assigned to 1 of 3 groups (75 patients in each): M, guided imagery, or usual care. They were blinded to their assignment until the intervention. Main Outcome Measures: Reduction of pain and anxiety postoperatively. Secondary outcomes measured use of pain medication and patient satisfaction. Results: This study yielded positive findings for the management of pain and anxiety in patients undergoing elective joint replacement using M and guided imagery for 18 to 20 minutes compared with usual care. M showed the largest predicted decreases in both pain and anxiety between groups. There was no significant difference in narcotic pain medication use between groups. Patient satisfaction survey ratings were highest for M, followed by guided imagery. Conclusion: The benefit of M may be because of the specifically structured sequence of touch by competent caring, trained providers. PMID:26222093

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery.

PubMed

Boland, M R; Reynolds, I; McCawley, N; Galvin, E; El-Masry, S; Deasy, J; McNamara, D A

2017-02-01

INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.

Poor Performance on a Preoperative Cognitive Screening Test Predicts Postoperative Complications in Older Orthopedic Surgical Patients.

PubMed

Culley, Deborah J; Flaherty, Devon; Fahey, Margaret C; Rudolph, James L; Javedan, Houman; Huang, Chuan-Chin; Wright, John; Bader, Angela M; Hyman, Bradley T; Blacker, Deborah; Crosby, Gregory

2017-11-01

The American College of Surgeons and the American Geriatrics Society have suggested that preoperative cognitive screening should be performed in older surgical patients. We hypothesized that unrecognized cognitive impairment in patients without a history of dementia is a risk factor for development of postoperative complications. We enrolled 211 patients 65 yr of age or older without a diagnosis of dementia who were scheduled for an elective hip or knee replacement. Patients were cognitively screened preoperatively using the Mini-Cog and demographic, medical, functional, and emotional/social data were gathered using standard instruments or review of the medical record. Outcomes included discharge to place other than home (primary outcome), delirium, in-hospital medical complications, hospital length-of-stay, 30-day emergency room visits, and mortality. Data were analyzed using univariate and multivariate analyses. Fifty of 211 (24%) patients screened positive for probable cognitive impairment (Mini-Cog less than or equal to 2). On age-adjusted multivariate analysis, patients with a Mini-Cog score less than or equal to 2 were more likely to be discharged to a place other than home (67% vs. 34%; odds ratio = 3.88, 95% CI = 1.58 to 9.55), develop postoperative delirium (21% vs. 7%; odds ratio = 4.52, 95% CI = 1.30 to 15.68), and have a longer hospital length of stay (hazard ratio = 0.63, 95% CI = 0.42 to 0.95) compared to those with a Mini-Cog score greater than 2. Many older elective orthopedic surgical patients have probable cognitive impairment preoperatively. Such impairment is associated with development of delirium postoperatively, a longer hospital stay, and lower likelihood of going home upon hospital discharge.

Semuloparin for prevention of venous thromboembolism after major orthopedic surgery: results from three randomized clinical trials, SAVE-HIP1, SAVE-HIP2 and SAVE-KNEE.

PubMed

Lassen, M R; Fisher, W; Mouret, P; Agnelli, G; George, D; Kakkar, A; Mismetti, P; Turpie, A G G

2012-05-01

Semuloparin is a novel ultra-low-molecular-weight heparin under development for venous thromboembolism (VTE) prevention in patients at increased risk, such as surgical and cancer patients. Three Phase III studies compared semuloparin and enoxaparin after major orthopedic surgery: elective knee replacement (SAVE-KNEE), elective hip replacement (SAVE-HIP1) and hip fracture surgery (SAVE-HIP2). All studies were multinational, randomized and double-blind. Semuloparin and enoxaparin were administered for 7-10 days after surgery. Mandatory bilateral venography was to be performed between days 7 and 11. The primary efficacy endpoint was a composite of any deep vein thrombosis, non-fatal pulmonary embolism or all-cause death. Safety outcomes included major bleeding, clinically relevant non-major (CRNM) bleeding, and any clinically relevant bleeding (major bleeding plus CRNM). In total, 1150, 2326 and 1003 patients were randomized in SAVE-KNEE, SAVE-HIP1 and SAVE-HIP2, respectively. In all studies, the incidences of the primary efficacy endpoint were numerically lower in the semuloparin group vs. the enoxaparin group, but the difference was statistically significant only in SAVE-HIP1. In SAVE-HIP1, clinically relevant bleeding and major bleeding were significantly lower in the semuloparin vs. the enoxaparin group. In SAVE-KNEE and SAVE-HIP2, clinically relevant bleeding tended to be higher in the semuloparin group, but rates of major bleeding were similar in the two groups. Other safety parameters were generally similar between treatment groups. Semuloparin was superior to enoxaparin for VTE prevention after hip replacement surgery, but failed to demonstrate superiority after knee replacement surgery and hip fracture surgery. Semuloparin and enoxaparin exhibited generally similar safety profiles. © 2012 International Society on Thrombosis and Haemostasis.

Why group & save? Blood transfusion at low-risk elective caesarean section.

PubMed

Stock, Owen; Beckmann, Michael

2014-06-01

Women undergoing elective caesarean section (CS) routinely have a group and save ordered as part of their preoperative assessment, whereas women with expected vaginal birth do not. Our aim was therefore to determine the rate of blood transfusion at elective CS compared with vaginal birth in a large Australian maternity hospital. A retrospective cohort study was performed using routinely collected de-identified data of 35 477 women, over 4 years, who delivered at the Mater Mothers' Hospital, Brisbane, Australia. After excluding women with established risk factors for transfusion, the likelihood of blood transfusion following elective CS was significantly lower compared to vaginal birth (aOR 0.47 (0.29, 0.77)). © 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Outcomes after elective abdominal aortic aneurysm repair in obese versus nonobese patients.

PubMed

Locham, Satinderjit; Rizwan, Muhammad; Dakour-Aridi, Hanaa; Faateh, Muhammad; Nejim, Besma; Malas, Mahmoud

2018-06-07

Obesity is a worldwide epidemic, particularly in Western society. It predisposes surgical patients to an increased risk of adverse outcomes. The aim of our study was to use a nationally representative vascular database and to compare in-hospital outcomes in obese vs nonobese patients undergoing elective open aortic repair (OAR) and endovascular aneurysm repair (EVAR). All patients undergoing elective abdominal aortic aneurysm repair were identified in the Vascular Quality Initiative database (2003-2017). Obesity was defined as body mass index ≥30 kg/m 2 . Univariable (Student t-test and χ 2  test) and multivariable (logistic regression) analyses were implemented to compare in-hospital mortality and any major complications (wound infection, renal failure, and cardiopulmonary failure) in obese vs nonobese patients. We identified a total of 33,082 patients undergoing elective OAR (nonobese, n = 4605 [72.4%]; obese, n = 1754 [27.6%]) and EVAR (nonobese, n = 18,338 [68.6%]; obese, n = 8385 [31.4%]). Obese patients undergoing OAR and EVAR were relatively younger compared with nonobese patients (mean age [standard deviation], 67.55 [8.26] years vs 70.27 [8.30] years and 71.06 [8.22] years vs 74.55 [8.55] years), respectively; (both P < .001). Regardless of approach, obese patients had slightly longer operative time (OAR, 259.02 [109.97] minutes vs 239.37 [99.78] minutes; EVAR, 138.27 [70.64] minutes vs 134.34 [69.98] minutes) and higher blood loss (OAR, 2030 [1823] mL vs 1619 [1642] mL; EVAR, 228 [354] mL vs 207 [312] mL; both P < .001). There was no significant difference in mortality between the two groups undergoing OAR and EVAR (OAR, 2.9% vs 3.2% [P = .50]; EVAR, 0.5% vs 0.6% [P = .76]). On multivariable analysis, obese patients undergoing OAR had 33% higher odds of renal failure (adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 1.09-1.63; P = .006) and 75% higher odds of wound infections (adjusted OR, 1.75; 95% CI, 1.11-2.76; P = .02) compared with nonobese patients. However, in patients undergoing EVAR, no association was seen between obesity and any major complications. A significant interaction was found between obesity and surgical approach in the event of renal failure, in which obese patients undergoing OAR had significantly higher odds of renal failure compared with those in the EVAR group (OR interaction , 1.36; 95% CI, 1.05-1.75; P = .02). Using a large nationally representative database, we demonstrated an increased risk of renal failure and wound infections in obese patients undergoing OAR compared with nonobese patients. On the other hand, obesity did not seem to increase the odds of major adverse outcomes in patients undergoing EVAR. Further long-term prospective studies are needed to verify the effects of obesity after abdominal aortic aneurysm repair and the implications of these findings in clinical decision-making. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Clinical use of parnaparin in major and minor orthopedic sugery: a review

PubMed Central

Bugamelli, Stefano; Zangheri, Elena; Montebugnoli, Milena; Guerra, Lucia

2008-01-01

Patients undergoing arthroplasty or other orthopedic surgery show a high risk of venous thromboembolism (VTE), involving mortality, morbidity, and social costs; however, the risk for VTE in minor orthopedic surgery should not be underestimated and antithrombotic prophylaxis may be required. According to the literature, low-molecular-weight heparins (LMWHs) are more effective in preventing VTE than unfractionated heparins (UFHs) or vitamin K antagonists, and have a lower hemorrhagic risk. By comparing different prophylactic regimens, it has been shown that starting the prophylaxis near the time of the operation is the most critical point for efficacy, whether or not the first dose is administered pre- or post-operatively. Moreover, most thromboembolic complications are observed after discharge and, therefore, many clinicians advocate continuing prophylaxis for longer times (6–8 weeks) in order to further reduce the rate for VTE. The literature on parnaparin, a new LMWH, in VTE prophylaxis was reviewed. Parnaparin is equally effective as UFH, but it offers the advantages of a once-daily administration and improved tolerability, thus allowing the home management of patients with no need for laboratory coagulation tests. PMID:19183746

Airway management after maxillectomy with free flap reconstruction.

PubMed

Brickman, Daniel S; Reh, Douglas D; Schneider, Daniel S; Bush, Ben; Rosenthal, Eben L; Wax, Mark K

2013-08-01

Maxillectomy defects require complex 3-dimensional reconstructions often best suited to microvascular free tissue transfer. Postoperative airway management during this procedure has little discussion in the literature and is often dictated by surgical dogma. The purpose of this article was to review our experience in order to evaluate the effect of airway management on perioperative outcomes in patients undergoing maxillectomy with free flap reconstruction. A retrospective chart review was performed on patients receiving maxillectomy with microvascular reconstruction at 2 institutions between 1999 and 2011. Patient's airways were managed with or without elective tracheotomy at the surgical team's discretion and different perioperative outcomes were measured. The primary outcome was incidence of airway complication including pneumonia and need for further airway intervention. Secondary outcome was measured as factors leading to perioperative performance of the tracheotomy. Seventy-nine of 143 patients received elective tracheotomy perioperatively. The incidence of airway complication was equivalent between groups (10.1% vs 9.4%; p = .89). Patients with cardiopulmonary comorbidities were more likely to receive perioperative tracheotomy (74.1% vs 50.9%; p = .03) without a difference in airway complications. Other patient cofactors did not have an impact on perioperative tracheotomy or airway complication rate. Elective tracheotomy may safely be avoided in a subset of patients undergoing maxillectomy with microvascular reconstruction. Elective tracheotomy should be considered in patients with cardiopulmonary risk factors. Copyright © 2012 Wiley Periodicals, Inc.

Adult patient with Becker dystrophy undergoing orthopedic surgery: an anesthesia challenge.

PubMed

Parish, Masoud; Farzin, Haleh

2018-01-01

Muscular dystrophies are considered to be a series of neuromuscular diseases with genetic causes and are characterized by progressive muscle weakness and degeneration of the skeletal muscle. The case of an adult man with Becker dystrophy referred for repair of the patella tendon tearing and patella fracture is described. He underwent successful surgery using total intravenous anesthesia without any complications.

Acupuncture and PC6 stimulation for the prevention of postoperative nausea and vomiting in patients undergoing elective laparoscopic resection of colorectal cancer: a study protocol for a three-arm randomised pilot trial.

PubMed

Kim, Kun Hyung; Kim, Dae Hun; Bae, Ji Min; Son, Gyung Mo; Kim, Kyung Hee; Hong, Seung Pyo; Yang, Gi Young; Kim, Hee Young

2017-01-04

This study aims to assess the feasibility of acupuncture and a Pericardium 6 (PC6) wristband as an add-on intervention of antiemetic medication for the prevention of postoperative nausea and vomiting (PONV) in patients undergoing elective laparoscopic colorectal cancer resection. A total of 60 participants who are scheduled to undergo elective laparoscopic resection of colorectal cancer will be recruited. An enhanced recovery after surgery protocol using standardised antiemetic medication will be provided for all participants. Participants will be equally randomised into acupuncture plus PC6 wristband (Acupuncture), PC6 wristband alone (Wristband), or no acupuncture or wristband (Control) groups using computer-generated random numbers concealed in opaque, sealed, sequentially numbered envelopes. For the acupuncture combined with PC6 wristband group, the embedded auricular acupuncture technique for preoperative anxiolysis and up to three sessions of acupuncture treatments with manual and electrical stimulation within 48 hours after surgery will be provided by qualified Korean medicine doctors. The PC6 wristband will be applied in the Acupuncture and Wristband groups, beginning 1 hour before surgery and lasting 48 hours postoperatively. The primary outcome will be the number of participants who experience moderate or severe nausea, defined as nausea at least 4 out of 10 on a severity numeric rating scale or vomiting at 24 hours after surgery. Secondary outcomes, including symptom severity, participant global assessments and satisfaction, quality of life, physiological recovery, use of medication and length of hospital stay, will be assessed. Adverse events and postoperative complications will be measured for 1 month after surgery. All participants will provide written informed consent. The study has been approved by the institutional review board (IRB). This pilot trial will inform a full-scale randomised trial of acupuncture combined with PC6 stimulation for the prevention of PONV in patients undergoing elective laparoscopic colorectal cancer surgery. NCT02509143. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Effects of preanesthetic administration of morphine on gastroesophageal reflux and regurgitation during anesthesia in dogs.

PubMed

Wilson, Deborah V; Evans, A Tom; Miller, RoseAnn

2005-03-01

To determine the effect of morphine administered prior to anesthesia on the incidence of gastroesophageal reflux (GER) in dogs during the subsequent anesthetic episode. 90 dogs (30 dogs/group). The randomized prospective clinical study included healthy dogs with no history of vomiting. Dogs were scheduled to undergo elective orthopedic surgery. Food was withheld for (mean+/-SD) 17.8+/-4.1 hours prior to induction of anesthesia. The anesthetic protocol included acepromazine maleate, thiopental, and isoflurane. Dogs were randomly selected to receive morphine at various dosages (0, 0.22, or 1.10 mg/kg, IM) concurrent with acepromazine administration prior to induction of anesthesia. A sensor-tipped catheter was used to measure esophageal pH, and GER was defined as a decrease in pH to < 4 or an increase to > 7.5. 40 dogs had acidic reflux, and 1 had biliary reflux. Proportions of dogs with GER were 8 of 30 (27%), 15 of 30 (50%), and 18 of 30 (60%) for morphine dosages of 0, 0.22, and 1.10 mg/kg, respectively. Mean duration of GER was 91.4+/-56.8 minutes. There was no significant association between GER and age, weight, vomiting after preanesthetic medication, administration of antimicrobials, or start of surgery. Most healthy dogs vomit after a large dose of morphine, but vomiting does not increase the likelihood of GER during the subsequent anesthetic episode. Administration of morphine prior to anesthesia substantially increases the incidence of GER during the subsequent anesthetic episode.

Pre-operative assessment and post-operative care in elective shoulder surgery.

PubMed

Akhtar, Ahsan; Macfarlane, Robert J; Waseem, Mohammad

2013-01-01

Pre-operative assessment is required prior to the majority of elective surgical procedures, primarily to ensure that the patient is fit to undergo surgery, whilst identifying issues that may need to be dealt with by the surgical or anaesthetic teams. The post-operative management of elective surgical patients begins during the peri-operative period and involves several health professionals. Appropriate monitoring and repeated clinical assessments are required in order for the signs of surgical complications to be recognised swiftly and adequately. This article examines the literature regarding pre-operative assessment in elective orthopaedic surgery and shoulder surgery, whilst also reviewing the essentials of peri- and post-operative care. The need to recognise common post-operative complications early and promptly is also evaluated, along with discussing thromboprophylaxis and post-operative analgesia following shoulder surgery.

Impact of the Medicare Short Stay Transfer Policy on Patients undergoing Major Orthopedic Surgery

PubMed Central

FitzGerald, John D; John Boscardin, W; Hahn, Bevra H; Ettner, Susan L

2007-01-01

Objective To examine the impact of the Short Stay Transfer Policy (SSTP) on practice patterns. Data Sources This study uses data from the Centers for Medicare and Medicaid Services Medicare Provider Analysis and Review (MEDPAR) file, Home Health Standard Analytical File, 1999 Provider of Service file, and data from the 2000 United States Census. Study Design An interrupted time-series analysis was used to examine the length of stay (LOS) and probability of “early” discharge to post acute care (PAC). Data Collection Separate 100percent samples of all fee-for-service Medicare recipients undergoing either elective joint replacement (JR) surgery or surgical management of hip fracture (FX) between January 1, 1996 and December 31, 2000 were selected. Principal Findings Prior to implementation of the SSTP. LOS had been falling by 0.37 and 0.30 days per year for JR and FX patients respectively. After implementation of the SSTP, there was an immediate increase in LOS by 0.20 and 0.17 days, respectively. Thereafter, LOS remained flat. The proportion of patients discharged “early” to PAC had been rising by 4.4 and 2.6 percentage points per year for JR and FX patients respectively, to a peak of 28.8percent and 20.4percent early PAC utilization in September 1998. Immediately after implementation of the SSTP, there was a 4.3 and 3.0 percentage point drop in utilization of “early” PAC. Thereafter utilization of early PAC increased at a much slower rate (for JR) or remained flat (for FX). There was significant regional variation in the magnitude of response to the policy. Conclusion Implementation of the SSTP reduced the financial incentive to discharge patients early to PAC. This was accomplished primarily through longer LOS without meaningful change in PAC utilization. With the recent expansion of the SSTP to 29 DRGs (representing 34percent of all discharges), these findings have important implications regarding patient care. PMID:17355580

Impact of changes in Medicare Home Health care reimbursement on month-to-month Home Health utilization between 1996 and 2001 for a national sample of patients undergoing orthopedic procedures.

PubMed

FitzGerald, John D; Mangione, Carol M; Boscardin, John; Kominski, Gerald; Hahn, Bevra; Ettner, Susan L

2006-09-01

Beginning October 1, 1997, Medicare implemented a series of major changes to the Home Health (HH) reimbursement system. Reimbursements were first significantly reduced under the Interim Payment System (IPS) and then relaxed slightly until implementation of the HH Prospective Payment System (PPS) on October 1, 2000. The objective of this study was to examine the impact of reimbursement policy on HH care utilization. We postulated that in response to the initial changes, there would be reductions in both the probability of any HH use and the number of HH visits per HH user. Under PPS, we postulated there would be further reduction in number of HH visits. We tested whether the policy response differed by HH agency structure and whether subgroups of patients were differentially affected. An interrupted time-series analysis was conducted to examine month-to-month probability of HH selection and the number of HH visits among users. A 100% sample of all Medicare recipients undergoing either elective joint replacement (1.6 million hospital discharges) or surgical management of hip fracture (1.2 million hospital discharges) between January 1996 and December 2001 was selected. Under the IPS, the probability of any HH use and number of visits per episode of HH care fell until the IPS was refined in October 1998. With implementation of the PPS, HH visits fell commensurately. Differentially larger reductions in care were noted at for-profit HH agencies, for the elderly, women, patients receiving state assistance, and patients first discharged to skilled nursing facility or rehabilitation hospitals. Changes in month-to-month utilization of HH services were sharp and well correlated with policy implementation dates, strengthening the evidence for a causal association between policy and patient care in the midst of a sea of concurrent policy changes. Greater reductions in HH visits were noted for vulnerable groups.

Acute confusional states in patients undergoing hip surgery. a prospective observation study.

PubMed

Duppils, G S; Wikblad, K

2000-01-01

There is general agreement that acute confusional state (ACS) is common among elderly patients admitted to hospital, although exact figures are difficult to obtain. The objective of the current study was to investigate the onset of ACS during hospital stay and to isolate possible predisposing, facilitating and precipitating factors associated with the onset of ACS. Non-confused patients, greater than or = 65 years of age, undergoing orthopedic hip surgery, were consecutively included in the study (n = 225). Of these, 149 patients were operated on because of acute hip fracture and 76 underwent elective hip-replacement surgery. ACS was diagnosed by the DSM-IV criteria for delirium. Structured observations of ACS onset were performed every 2nd to every 4th hour during the patients' entire hospital stay. A protocol was used to document the observations on sleep, activities, well being and behavior. The Mini-Mental State Examination was used to measure cognitive functioning. Of 225 patients 20% were diagnosed with ACS. The incidence of ACS was 24.3% in the group of hip-fractured patients and 11.7% in the hip-replacement surgery patients. The onset of ACS was postoperative (mean 24 +/- 21 h after surgery) in all but 8 patients. The duration of ACS among recovered patients was generally less than 48 h (mean 42 +/- 43 h). Predisposing factors were older age, cognitive impairment and pre-existing cerebrovascular or other brain diseases. Facilitating factors related to ACS were associated with communication and social isolation, e.g. impaired hearing and sight, reticence and passivity. One precipitating factor, besides surgery, may be the use of psychopharmacological drugs. The incidence of ACS was 20% among hip surgery patients. Older age and social isolation were factors associated with ACS. Increased attention and interaction with older patients could be of value in avoiding ACS during hospitalization.

Periodontal evaluation in patients undergoing maxillary expansion.

PubMed

Carmen, M; Marcella, P; Giuseppe, C; Roberto, A

2000-09-01

Maxillary transverse diameter expansion is a treatment various authors have claimed is related to the development of gingival recession on the teeth of the upper arch. The aim of the present study was to compare such an incidence in two different groups of patients: those treated with surgically assisted rapid maxillary expansion and orthopedic expansion, respectively. Both treatments achieved the goal of expanding the transverse dimension (5.3 and 4.4 mm, respectively), but a significant difference was shown by the chi 2 test for the incidence of gingival recession of premolar/molar upper teeth, more than double for the latter than for the former. Therefore, surgically assisted rapid maxillary expansion seems to be an orthodontically effective procedure, safer than the orthopedic treatment regarding the possible development of mucogingival problems.

Association of Intended Route of Delivery and Maternal Morbidity in Twin Pregnancy.

PubMed

Easter, Sarah Rae; Robinson, Julian N; Lieberman, Ellice; Carusi, Daniela

2017-02-01

To evaluate maternal morbidity in twin pregnancies according to intended mode of delivery. We assembled a 7-year retrospective cohort (2007-2014) of women delivering viable, vertex-presenting twins at or beyond 32 weeks of gestation without contraindication to labor or uterine scar. We classified women as undergoing a trial of labor to attempt vaginal birth or choosing an elective cesarean delivery. Our primary outcome was a measure of composite maternal morbidity including death, postpartum hemorrhage, infection, major procedure, readmission for infection or reoperation, need for dilation and evacuation for hemorrhage or infection, venous thromboembolism, small bowel obstruction or ileus, or intensive care unit admission. Postpartum hemorrhage was defined as estimated blood loss greater than or equal to 1,500 mL or need for transfusion. The rate of lacerations in each group was also determined. Using logistic regression to control for confounders, we examined the odds of maternal morbidity according to intended mode of delivery. Of 2,272 twin pregnancies at or beyond 32 weeks of gestation, 1,140 (50%) met inclusion criteria with 571 (50%) electing cesarean delivery and 569 (50%) undergoing a trial of labor to attempt vaginal birth. Vaginal delivery of both twins was achieved in 74% (n=418) of women choosing a trial of labor. The rate of maternal morbidity was 12.3% in the trial of labor group compared with 9.1% in the elective cesarean delivery group (P=.08, adjusted odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.4). Postpartum hemorrhage was more common among women who attempted vaginal delivery (n=52) compared with those electing cesarean delivery (n=28) with rates of 9.1% compared with 4.9%, respectively (P<.01, adjusted OR 2.2, 95% CI 1.4-3.6) and was responsible for the difference in the composite morbidity rate between groups. When adjustment is made for potential confounders, women undergoing a trial of labor with twins experience a higher odds of maternal morbidity than those electing cesarean delivery, primarily as a result of hemorrhage. In pragmatic terms, the tradeoff for a 74% chance of vaginal delivery is a 4% absolute increase in the rate of serious postpartum hemorrhage.

The effect of economic downturn on the volume of surgical procedures: A systematic review.

PubMed

Fujihara, Nasa; Lark, Meghan E; Fujihara, Yuki; Chung, Kevin C

2017-08-01

Economic downturn can have a wide range of effects on medicine at both individual and national levels. We aim to describe these effects in relation to surgical volume to guide future planning for physician specialization, patient expectations in the face of economic crises, or estimating healthcare expenditure. We hypothesized that because of high out-of-pocket costs, cosmetic procedure volumes would be most affected by economic decline. A systematic review was conducted using MEDLINE, Embase, and ABI/INFORMS. The main search terms were "economic recession" and "surgical procedures, operative". Studies were included if surgical volumes were measured and economic indicators were used as predictors of economic conditions. Twelve studies were included, and the most common subject was cosmetic (n = 5), followed by orthopedic (n = 2) and cardiac surgeries (n = 2). The majority of studies found that in periods of economic downturn, surgical volume decreased. Among the eight studies using Pearson's correlation analysis, there were no significant differences between cosmetic procedures and other elective procedures, indicating that cosmetic procedures may display trends similar to those of non-cosmetic elective procedures in periods of economic downturn. Surgical volume generally decreased when economic indicators declined, observed for both elective and non-elective surgery fields. However, a few specific procedure volumes such as vasectomy and caesarean section for male babies increased during the economic downturn. Knowledge of these trends can be useful for future surgical planning and distribution of healthcare resources. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Severity of chronic obstructive pulmonary disease is associated with adverse outcomes in patients undergoing elective abdominal aortic aneurysm repair.

PubMed

Stone, David H; Goodney, Philip P; Kalish, Jeffrey; Schanzer, Andres; Indes, Jeffrey; Walsh, Daniel B; Cronenwett, Jack L; Nolan, Brian W

2013-06-01

Although chronic obstructive pulmonary disease (COPD) has been implicated as a risk factor for abdominal aortic aneurysm (AAA) rupture, its effect on surgical repair is less defined. Consequently, variation in practice persists regarding patient selection and surgical management. The purpose of this study was to analyze the effect of COPD on patients undergoing AAA repair. We reviewed a prospective regional registry of 3455 patients undergoing elective open AAA repair (OAR) and endovascular AAA repair (EVAR) from 23 centers in the Vascular Study Group of New England from 2003 to 2011. COPD was categorized as none, medical (medically treated but not oxygen [O2]-dependent), and O2-dependent. End points included in-hospital death, pulmonary complications, major postoperative adverse events (MAEs), extubation in the operating room, and 5-year survival. Survival was determined using life-table analysis based on the Social Security Death Index. Predictors of in-hospital and long-term mortality were determined by multivariate logistic regression and Cox proportional hazards analysis. During the study interval, 2043 patients underwent EVAR and 1412 patients underwent OAR with a nearly equal prevalence of COPD (35% EVAR vs 36% OAR). O2-dependent COPD (4%) was associated with significantly increased in-hospital mortality, pulmonary complications, and MAE and was also associated with significantly decreased extubation in the operating room among patients undergoing both EVAR and OAR. Five-year survival was significantly diminished among all patients undergoing AAA repair with COPD (none, 78%; medical, 72%; O2-dependent, 42%; P < .001). By multivariate analysis, O2-dependent COPD was independently associated with in-hospital mortality (odds ratio 2.02, 95% confidence interval, 1.0-4.0; P = .04) and diminished 5-year survival (hazard ratio, 3.02; 95% confidence interval, 2.2-4.1; P < .001). Patients with O2-dependent COPD undergoing AAA repair suffer increased pulmonary complications, overall MAE, and diminished long-term survival. This must be carefully factored into the risk-benefit analysis before recommending elective AAA repair in these patients. Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Cardiac Emergencies in Neurosurgical Patients

PubMed Central

Petropolis, Andrea; Cappellani, Ronald B.

2015-01-01

Perioperative safety concerns are a major area of interest in recent years. Severe cardiac perturbation such as cardiac arrest is one of the most dreaded complications in the intraoperative period; however, little is known about the management of these events in the patients undergoing elective neurosurgery. This special group needs further attention, as it is often neither feasible nor appropriate to apply conventional advanced cardiac life support algorithms in patients undergoing neurosurgery. Factors such as neurosurgical procedure and positioning can also have a significant effect on the occurrence of cardiac arrest. Therefore, the aim of this paper is to describe the various causes and management of cardiac emergencies with special reference to cardiac arrest during elective neurosurgical procedures, including discussion of position-related factors and resuscitative considerations in these situations. This will help to formulate possible guidelines for management of such events. PMID:25692145

Communication with Orthopedic Trauma Patients via an Automated Mobile Phone Messaging Robot.

PubMed

Anthony, Chris A; Volkmar, Alexander; Shah, Apurva S; Willey, Mike; Karam, Matt; Marsh, J Lawrence

2017-12-20

Communication with orthopedic trauma patients is traditionally problematic with low response rates (RRs). The purpose of this investigation was to (1) evaluate the feasibility of communicating with orthopedic trauma patients postoperatively, utilizing an automated mobile phone messaging platform; and (2) assess the first 2 weeks of postoperative patient-reported pain and opioid use after lower extremity orthopedic trauma procedures. This was a prospective investigation at a Level 1 trauma center in the United States. Adult patients who were capable of mobile phone messaging and were undergoing common, lower extremity orthopedic trauma procedures were enrolled in the study. Patients received a daily mobile phone message protocol inquiring about their current pain level and amount of opioid medication they had taken in the past 24 h starting on postoperative day (POD) 3 and continuing through POD 17. Our analysis considered (1) Patient completion rate of mobile phone questions, (2) Patient-reported pain level (0-10 scale), and (3) Number and percentage of daily prescribed opioid medication patients reported taking. Twenty-five patients were enrolled in this investigation. Patients responded to 87.5% of the pain and opioid medication inquiries they received over the 2-week study period. There were no differences in RRs by patient age, sex, or educational attainment. Patient-reported pain decreased over the initial 2-week study period from an average of 4.9 ± 1.7 on POD 3 to 3 ± 2.2 on POD 16-17. Patients took an average of 68% of their maximum daily narcotic prescription on POD 3 compared with 35% of their prescribed pain medication on POD 16-17. We found that in orthopedic trauma patients, an automated mobile phone messaging platform elicited a high patient RR that improved upon prior methods in the literature. This method may be used to reliably obtain pain and medication utilization data after trauma procedures.

Surgical residency training and international volunteerism: a national survey of residents from 2 surgical specialties.

PubMed

Matar, Wadih Y; Trottier, Daniel C; Balaa, Fady; Fairful-Smith, Robin; Moroz, Paul

2012-08-01

Many low- and middle-income countries (LMICs) lack basic surgical resources, resulting in avoidable disability and mortality. Recently, residents in surgical training programs have shown increasing interest in overseas elective experiences to assist surgical programs in LMICs. The purpose of this study was to survey Canadian surgical residents about their interest in international volunteerism. We sent a web-based survey to all general and orthopedic surgery residents enrolled in surgical training programs in Canada. The survey assessed residents' interests, attitudes and motivations, and perceived barriers and aids with respect to international volunteerism. In all, 361 residents completed the survey for a response rate of 38.0%. Half of the respondents indicated that the availability of an international surgery elective would have positively influenced their selection of a residency program. Excluding the 18 residents who had volunteered during residency, 63.8% of the remaining residents confirmed an interest in international volunteering with "contributing to an important cause," "teaching" and "tourism/cultural enhancement" as the leading reasons for their interest. Perceived barriers included "lack of financial support" and "lack of available organized opportunities." All (100%) respondents who had done an international elective during residency confirmed that they would pursue such work in the future. Administrators of Canadian surgical programs should be aware of strong resident interest in global health care and accordingly develop opportunities by encouraging faculty mentorships and resources for global health teaching.

Cost effectiveness of drug eluting coronary artery stenting in a UK setting: cost-utility study.

PubMed

Bagust, A; Grayson, A D; Palmer, N D; Perry, R A; Walley, T

2006-01-01

To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK. Cost-utility analysis of audit based patient subgroups by means of a simple economic model. Tertiary care. 12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002. Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost-utility ratio and threshold price premium. Four factors were identified for patients undergoing elective surgery (n = 1951) and two for non-elective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the non-elective surgery group with 9.9% risk). Modelled cost-utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be 112 pound sterling (212 USD, 162 pound sterling) (sirolimus stents) or 89 pound sterling (167 USD, 130 pound sterling) (paclitaxel stents). At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially.

Abdominal girth and vertebral column length aid in predicting intrathecal hyperbaric bupivacaine dose for elective cesarean section

PubMed Central

Wei, Chang-Na; Zhou, Qing-He; Wang, Li-Zhong

2017-01-01

Abstract Currently, there is no consensus on how to determine the optimal dose of intrathecal bupivacaine for an individual undergoing an elective cesarean section. In this study, we developed a regression equation between intrathecal 0.5% hyperbaric bupivacaine volume and abdominal girth and vertebral column length, to determine a suitable block level (T5) for elective cesarean section patients. In phase I, we analyzed 374 parturients undergoing an elective cesarean section that received a suitable dose of intrathecal 0.5% hyperbaric bupivacaine after a combined spinal-epidural (CSE) was performed at the L3/4 interspace. Parturients with T5 blockade to pinprick were selected for establishing the regression equation between 0.5% hyperbaric bupivacaine volume and vertebral column length and abdominal girth. Six parturient and neonatal variables, intrathecal 0.5% hyperbaric bupivacaine volume, and spinal anesthesia spread were recorded. Bivariate line correlation analyses, multiple line regression analyses, and 2-tailed t tests or chi-square test were performed, as appropriate. In phase II, another 200 parturients with CSE for elective cesarean section were enrolled to verify the accuracy of the regression equation. In phase I, a total of 143 parturients were selected to establish the following regression equation: YT5 = 0.074X1 − 0.022X2 − 0.017 (YT5 = 0.5% hyperbaric bupivacaine volume for T5 block level; X1 = vertebral column length; and X2 = abdominal girth). In phase II, a total of 189 participants were enrolled in the study to verify the accuracy of the regression equation, and 155 parturients with T5 blockade were deemed eligible, which accounted for 82.01% of all participants. This study evaluated parturients with T5 blockade to pinprick after a CSE for elective cesarean section to establish a regression equation between parturient vertebral column length and abdominal girth and 0.5% hyperbaric intrathecal bupivacaine volume. This equation can accurately predict the suitable intrathecal hyperbaric bupivacaine dose for elective cesarean section. PMID:28834913

Abdominal girth and vertebral column length aid in predicting intrathecal hyperbaric bupivacaine dose for elective cesarean section.

PubMed

Wei, Chang-Na; Zhou, Qing-He; Wang, Li-Zhong

2017-08-01

Currently, there is no consensus on how to determine the optimal dose of intrathecal bupivacaine for an individual undergoing an elective cesarean section. In this study, we developed a regression equation between intrathecal 0.5% hyperbaric bupivacaine volume and abdominal girth and vertebral column length, to determine a suitable block level (T5) for elective cesarean section patients.In phase I, we analyzed 374 parturients undergoing an elective cesarean section that received a suitable dose of intrathecal 0.5% hyperbaric bupivacaine after a combined spinal-epidural (CSE) was performed at the L3/4 interspace. Parturients with T5 blockade to pinprick were selected for establishing the regression equation between 0.5% hyperbaric bupivacaine volume and vertebral column length and abdominal girth. Six parturient and neonatal variables, intrathecal 0.5% hyperbaric bupivacaine volume, and spinal anesthesia spread were recorded. Bivariate line correlation analyses, multiple line regression analyses, and 2-tailed t tests or chi-square test were performed, as appropriate. In phase II, another 200 parturients with CSE for elective cesarean section were enrolled to verify the accuracy of the regression equation.In phase I, a total of 143 parturients were selected to establish the following regression equation: YT5 = 0.074X1 - 0.022X2 - 0.017 (YT5 = 0.5% hyperbaric bupivacaine volume for T5 block level; X1 = vertebral column length; and X2 = abdominal girth). In phase II, a total of 189 participants were enrolled in the study to verify the accuracy of the regression equation, and 155 parturients with T5 blockade were deemed eligible, which accounted for 82.01% of all participants.This study evaluated parturients with T5 blockade to pinprick after a CSE for elective cesarean section to establish a regression equation between parturient vertebral column length and abdominal girth and 0.5% hyperbaric intrathecal bupivacaine volume. This equation can accurately predict the suitable intrathecal hyperbaric bupivacaine dose for elective cesarean section.

Prediction of contrast-induced nephropathy in diabetic patients undergoing elective cardiac catheterization or PCI: role of volume-to-creatinine clearance ratio and iodine dose-to-creatinine clearance ratio.

PubMed

Worasuwannarak, Surapong; Pornratanarangsi, Suwatchai

2010-01-01

To assess a role of volume-to-creatinine clearance ratio (V/CrCl) and iodine dose-to-creatinine clearance ratio (I-dose/CrCl) in predicting contrast- induced nephropathy (CIN) in diabetic patients undergoing elective cardiac catheterization or percutaneous coronary intervention (PCI). In diabetic patients undergoing cardiac catheterization or PCI, the incidence of CIN is higher than in non-diabetic patients. High doses of contrast media also increase the likelihood of renal dysfunction. The ratio of the volume of contrast media to creatinine clearance (V/CrCl) and iodine dose-to-creatinine clearance (I-dose/CrCl) has been shown to correlate with the area under the curve of contrast media concentration over time and was used to predict the occurrence of CIN in unselected patients. No study has been conducted specifically in diabetic patients undergoing cardiac catheterization or PCI before. We conducted a prospective, single center study. The V/CrCl and I-dose/CrCl were calculated in diabetic patients undergoing elective cardiac catheterization or PCI. An increase in serum creatinine of > 0.5 mg/dl or > 25% by 7 days from baseline was considered CIN. The incidence of CIN was determined. The predictive value of V/CrCl and I-dose/CrCl for CIN were assessed using multivariable logistic regression. The total number of patients that had been enrolled in the study was 248; Male 50.8%. The overall incidence of CIN was 5.2%. The mean age for the entire population was 65 +/- 9 years; the mean body mass index was 25.6 +/- 4.0 kg/m2; and the mean creatinine clearance was 60.6 +/- 27.4 ml/min. The mean values of V/CrCl for patients with and without CIN were 3.7 +/- 2.9 and 2.2 +/- 1.7 (p = 0.041). The mean values of I-dose/CrCl for patients with and without CIN were 1.31 +/- 0.94 and 0.82 +/- 0.63 (p = 0.042). The receiver-operator characteristic curve analysis indicated that a V/CrCl ratio of 2.60 and I-dose/CrCl of 0.98 were fair predictors of CIN. After adjusting for other known predictors of CIN, a V/CrCl ratio > or = 2.60 remained the only significant predictor of CIN (Odds ratio 5.8; 95% confidence interval 1.7-19.4, p = 0.005). A V/CrCl ratio > or = 2.60 was a significant predictor of CIN in diabetic patients undergoing elective cardiac catheterization or PCI.

Increased risk for complications following removal of hardware in patients with liver disease, pilon or pelvic fractures: A regression analysis.

PubMed

Brown, Bryan D; Steinert, Justin N; Stelzer, John W; Yoon, Richard S; Langford, Joshua R; Koval, Kenneth J

2017-12-01

Indications for removing orthopedic hardware on an elective basis varies widely. Although viewed as a relatively benign procedure, there is a lack of data regarding overall complication rates after fracture fixation. The purpose of this study is to determine the overall short-term complication rate for elective removal of orthopedic hardware after fracture fixation and to identify associated risk factors. Adult patients indicated for elective hardware removal after fracture fixation between July 2012 and July 2016 were screened for inclusion. Inclusion criteria included patients with hardware related pain and/or impaired cosmesis with complete medical and radiographic records and at least 3-month follow-up. Exclusion criteria were those patients indicated for hardware removal for a diagnosis of malunion, non-union, and/or infection. Data collected included patient age, gender, anatomic location of hardware removed, body mass index, ASA score, and comorbidities. Overall complications, as well as complications requiring revision surgery were recorded. Statistical analysis was performed with SPSS 20.0, and included univariate and multivariate regression analysis. 391 patients (418 procedures) were included for analysis. Overall complication rates were 8.4%, with a 3.6% revision surgery rate. Univariate regression analysis revealed that patients who had liver disease were at significant risk for complication (p=0.001) and revision surgery (p=0.036). Multivariate regression analysis showed that: 1) patients who had liver disease were at significant risk of overall complication (p=0.001) and revision surgery (p=0.039); 2) Removal of hardware following fixation for a pilon had significantly increased risk for complication (p=0.012), but not revision surgery (p=0.43); and 3) Removal of hardware for pelvic fixation had a significantly increased risk for revision surgery (p=0.017). Removal of hardware following fracture fixation is not a risk-free procedure. Patients with liver disease are at increased risk for complications, including increased risk for needing revision surgery following hardware removal. Patients having hardware removed following fixation for pilon fractures also are at increased risk for complication, although they may not require a return trip to the operating room. Finally, removal of pelvic hardware is associated with a higher return to the operating room. Copyright © 2017 Elsevier Ltd. All rights reserved.

Red Blood Cell Transfusion Need for Elective Primary Posterior Lumbar Fusion in A High-Volume Center for Spine Surgery

PubMed Central

Ristagno, Giuseppe; Beluffi, Simonetta; Tanzi, Dario; Belloli, Federica; Carmagnini, Paola; Croci, Massimo; D’Aviri, Giuseppe; Menasce, Guido; Pastore, Juan C.; Pellanda, Armando; Pollini, Alberto; Savoia, Giorgio

2018-01-01

(1) Background: This study evaluated the perioperative red blood cell (RBC) transfusion need and determined predictors for transfusion in patients undergoing elective primary lumbar posterior spine fusion in a high-volume center for spine surgery. (2) Methods: Data from all patients undergoing spine surgery between 1 January 2014 and 31 December 2016 were reviewed. Patients’ demographics and comorbidities, perioperative laboratory results, and operative time were analyzed in relation to RBC transfusion. Multivariate logistic regression analysis was performed to identify the predictors of transfusion. (3) Results: A total of 874 elective surgeries for primary spine fusion were performed over the three years. Only 54 cases (6%) required RBC transfusion. Compared to the non-transfused patients, transfused patients were mainly female (p = 0.0008), significantly older, with a higher ASA grade (p = 0.0002), and with lower pre-surgery hemoglobin (HB) level and hematocrit (p < 0.0001). In the multivariate logistic regression, a lower pre-surgery HB (OR (95% CI) 2.84 (2.11–3.82)), a higher ASA class (1.77 (1.03–3.05)) and a longer operative time (1.02 (1.01–1.02)) were independently associated with RBC transfusion. (4) Conclusions: In the instance of elective surgery for primary posterior lumbar fusion in a high-volume center for spine surgery, the need for RBC transfusion is low. Factors anticipating transfusion should be taken into consideration in the patient’s pre-surgery preparation. PMID:29385760

A randomized placebo-controlled trial of preoperative tranexamic acid among women undergoing elective cesarean delivery.

PubMed

Maged, Ahmed M; Helal, Omneya M; Elsherbini, Moutaz M; Eid, Marwa M; Elkomy, Rasha O; Dahab, Sherif; Elsissy, Maha H

2015-12-01

To study the efficacy and safety of preoperative intravenous tranexamic acid to reduce blood loss during and after elective lower-segment cesarean delivery. A single-blind, randomized placebo-controlled study was undertaken of women undergoing elective lower-segment cesarean delivery of a full-term singleton pregnancy at a center in Cairo, Egypt, between November 2013 and November 2014. Patients were randomly assigned (1:1) using computer-generated random numbers to receive either 1g tranexamic acid or 5% glucose 15 minutes before surgery. Preoperative and postoperative complete blood count, hematocrit values, and maternal weight were used to calculate the estimated blood loss (EBL) during cesarean, which was the primary outcome. Analyses included women who received their assigned treatment, whose surgery was 90 minutes or less, and who completed follow-up. Analyses included 100 women in each group. Mean EBL was significantly higher in the placebo group (700.3 ± 143.9 mL) than in the tranexamic acid group (459.4 ±7 5.4 mL; P<0.001). Only six women, all in the placebo group, experienced an EBL of more than 1000 mL. There were no reports of thromboembolic events up to 4 weeks postoperatively. Preoperative administration of tranexamic acid safely reduces blood loss during elective lower-segment cesarean delivery. Australian New Zealand Clinical Trials Registry:ACTRN12615000312549. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

[Orthopedic surgical implants and allergies. Joint statement by the Implant Allergy Working Group (AK 20) of the DGOOC (German Association of Orthopedics and Orthopedic Surgery), DKG (German Contact Dermatitis Research Group) and DGAKI (German Society for Allergology and Clinical Immunology)].

PubMed

Thomas, P; Schuh, A; Ring, J; Thomsen, M

2008-03-01

Materials used in osteosynthesis or artificial joint replacement are usually well tolerated. Complaints after such operations are mostly related to infection or mechanical problems but may also be caused by allergic reactions. The latter encompass skin changes, e.g., eczema, delayed wound/bone healing, recurrent effusion, pain, or implant loosening. In contrast to the high incidence of cutaneous metal contact allergy, allergies associated with implants are a rare condition. However, epidemiological data on the incidence of implant-related allergic reactions are still missing. Typical elicitors are nickel, chromium, cobalt, and constituents of bone cement (acrylates und additives such as gentamicin or benzoyl peroxide). After exclusion of the most common differential diagnoses, allergy diagnostic procedures are primarily based on patch tests including a metal and bone cement component series. Additional analysis of periimplant tissue is recommended. However, further studies are necessary to show the significance of the histologic findings and the role of the lymphocyte transformation test (LTT). Which combinations of factors will induce allergic sensitization to implants or trigger periimplant allergic reactions in the case of preexisting cutaneous metal allergy is still unknown. Titanium-based osteosynthesis materials are recommended for metal allergic patients. In elective hip replacements, a ceramic/polyethylene (PE) articulation should be used, and in knee replacements "alternative materials". If a regular, potentially applicable CoCr/PE articulation is preferred, the patient must be well informed and must give his/her written consent.

Systematization of Nursing Care in undergraduate training: the perspective of Complex Thinking.

PubMed

da Silva, Josilaine Porfírio; Garanhani, Mara Lucia; Peres, Aida Maris

2015-01-01

to evaluate the clinical applicability of outcomes, according to the Nursing Outcomes Classification (NOC) in the evolution of orthopedic patients with Impaired Physical Mobility longitudinal study conducted in 2012 in a university hospital, with 21 patients undergoing Total Hip Arthroplasty, evaluated daily by pairs of trained data collectors. Data were collected using an instrument containing five Nursing Outcomes, 16 clinical indicators and a five point Likert scale, and statistically analyzed. The outcomes Body Positioning: self-initiated, Mobility, Knowledge: prescribed activity, and Fall Prevention Behavior presented significant increases in mean scores when comparing the first and final evaluations (p<0.001) and (p=0.035). the use of the NOC outcomes makes it possible to demonstrate the clinical progression of orthopedic patients with Impaired Physical Mobility, as well as its applicability in this context.

Incidence of cervical lymph node metastasis and its association with outcomes in patients with adenoid cystic carcinoma. An international collaborative study

PubMed Central

Amit, Moran; Binenbaum, Yoav; Sharma, Kanika; Ramer, Naomi; Ramer, Ilana; Agbetoba, Abib; Glick, Joelle; Yang, Xinjie; Lei, Delin; Bjørndal, Kristine; Godballe, Christian; Mücke, Thomas; Wolff, Klaus-Dietrich; Fliss, Dan; Eckardt, André M.; Copelli, Chiara; Sesenna, Enrico; Palmer, Frank; Ganly, Ian; Patel, Snehal; Gil, Ziv

2016-01-01

Background The patterns of regional metastasis in adenoid cystic carcinoma (ACC) of the head and neck and its association with outcome is not established. Methods We conducted a retrospective multicentered multivariate analysis of 270 patients who underwent neck dissection. Results The incidence rate of neck metastases was 29%. The rate observed in the oral cavity is 37%, and in the major salivary glands is 19% (p = .001). The rate of occult nodal metastases was 17%. Overall 5-year survival rates were 44% in patients undergoing therapeutic neck dissections, and 65% and 73% among those undergoing elective neck dissections, with and without nodal metastases, respectively (p = .017). Multivariate analysis revealed that the primary site, nodal classification, and margin status were independent predictors of survival. Conclusion Our findings support the consideration of elective neck treatment in patients with ACC of the oral cavity. PMID:25060927

Hemodynamic and oxidative mechanisms of tourniquet-induced muscle injury: near-infrared spectroscopy for the orthopedics setting

NASA Astrophysics Data System (ADS)

Shadgan, Babak; Reid, W. Darlene; Harris, R. Luke; Jafari, Siavash; Powers, Scott K.; O'Brien, Peter J.

2012-08-01

During orthopedic procedures, the tourniquets used to maintain bloodless surgical fields cause ischemia and then reperfusion (I/R), leading to oxidative muscle injury. Established methods exist neither for monitoring orthopedic I/R nor for predicting the extent of tourniquet-associated oxidative injury. To develop a predictive model for tourniquet-associated oxidative muscle injury, this study combined real-time near-infrared spectroscopy (NIRS) monitoring of I/R with Western blotting (WB) for oxidized proteins. We hypothesized strong correlations between NIRS-derived I/R indices and muscle protein oxidation. In 17 patients undergoing ankle fracture repair, a thigh tourniquet was inflated on the injured limb (300 mmHg). Using a continuous-wave (CW) NIRS setup, oxygenated (O2Hb), deoxygenated (HHb), and total (tHb) hemoglobin were monitored bilaterally (tourniquet versus control) in leg muscles. Leg muscle biopsies were collected unilaterally (tourniquet side) immediately after tourniquet inflation (pre) and before deflation (post). Average ischemia duration was 43.2±14.6 min. In post-compared to pre-biopsies, muscle protein oxidation (quantified using WB) increased 172.3%±145.7% (P<0.0005). Changes in O2Hb and tHb were negatively correlated with protein oxidation (respectively: P=0.040, R2=0.25 and P=0.003, R2=0.58). Reoxygenation rate was positively correlated with protein oxidation (P=0.041, R2=0.25). These data indicate that using CW NIRS, it is possible to predict orthopedic tourniquet-associated muscle oxidative injury noninvasively.

Comparison between wait-and-see policy and elective neck dissection in clinically N0 cutaneous squamous cell carcinoma of head and neck.

PubMed

Xiao, Yan; Yuan, Shuai; Liu, Fei; Liu, Bing; Zhu, Juanfang; He, Wei; Li, Wenlu; Kan, Quancheng

2018-06-01

To analyze the superiority of wait-and-see policy and elective neck dissection in treating cN0 patients with facial cutaneous cell carcinoma (cSCC).Patients with clinically negative parotid and neck metastasis disease were prospectively enrolled. Three groups were divided based on whether the patient received an operation of superficial parotidectomy or/and elective dissection, and regional control and disease-specific survival rates were compared.The occult parotid and neck metastasis rate was 20% and 16%, respectively. There was neck node metastasis without parotid metastasis in only 1 patient. All the node metastasis occurred in level II. Regional recurrence was noted in 16 (16%) patients, and 6 patients died of the disease. In the group undergoing superficial parotidectomy and elective neck dissection, 2 patients had neck node metastasis, and there was no disease-related death, further survival analysis indicated it had better regional control and disease-specific survival rates compared with the other 2 groups.Superficial parotidectomy and elective neck dissection are suggested for patients with T3-4 facial cutaneous squamous cell carcinoma.

Paradoxical Cerebral Fat Embolism in Revision Hip Surgery

PubMed Central

Piuzzi, Nicolás S.; Zanotti, Gerardo; Comba, Fernando M.; Buttaro, Martin A.; Piccaluga, Francisco

2014-01-01

The incidence of clinical fat embolism syndrome (FES) is low (<1%) whilst fat embolism (FE) of marrow fat appears to occur more often (Mellor and Soni (2001)). Paradoxical brain FE may occur in patients undergoing hip orthopedic surgery who have an undocumented patent foramen ovale (PFO). We report a case of an eighty-year-old male patient, who underwent a scheduled revision hip surgery suffering a paradoxical cerebral FE. PMID:25184065

Cranberry juice capsules and urinary tract infection post surgery: Results of a randomized trial

PubMed Central

Foxman, Betsy; Cronenwett, Ms. Anna E.W.; Spino, Cathie; Berger, Mitchell B.; Morgan, Daniel M.

2015-01-01

Objective The risk of urinary tract infection (UTI) among women undergoing elective gynecologic surgery where a catheter is placed is high: 10 to 64% following catheter removal. We conducted the first randomized, double-blind, placebo-controlled trial of the therapeutic efficacy of cranberry juice capsules in preventing UTI post surgery. Study Design We recruited patients from a single hospital between August 2011 and January 2013. Eligible participants were undergoing elective gynecologic surgery that did not involve a fistula repair or vaginal mesh removal. 160 patients were randomized and received two cranberry juice capsules two times a day, equivalent to two 8-ounce servings of cranberry juice, for 6 weeks after surgery, or matching placebo. The primary endpoint was the proportion of participants who experienced clinically-diagnosed and treated UTI with or without positive urine culture. Kaplan-Meier plots and logrank tests compared the two treatment groups. Results The occurrence of UTI was significantly lower in the cranberry treatment group compared to the placebo group (15/80 (19%) versus 30/80 (38%); OR=0.38; 95% CI: 0.19, 0.79; p=0.008). After adjustment for known confounders, including frequency of intermittent self-catheterization in the post- operative period, the protective effects of cranberry remained (OR=0.42; 95% CI: 0.18, 0.94). There were no treatment differences in the incidence of adverse events; including gastrointestinal upset (56% vs. 61% for cranberry vs. placebo). Conclusions Among women undergoing elective benign gynecologic surgery involving urinary catheterization, use of cranberry extract tablets during the postoperative period reduced the rate of UTI by half. PMID:25882919

Preoperative oral carbohydrates and postoperative insulin resistance.

PubMed

Nygren, J; Soop, M; Thorell, A; Sree Nair, K; Ljungqvist, O

1999-04-01

Infusions of carbohydrates before surgery have been shown to reduce postoperative insulin resistance. Presently, we investigated the effects of a carbohydrate drink, given shortly before surgery, on postoperative insulin sensitivity. Insulin sensitivity and glucose turnover ([6, 6,(2)H(2)]-D-glucose) were measured using hyper-insulinemic, normoglycemic clamps before and after elective surgery. Sixteen patients undergoing total hip replacement were randomly assigned to preoperative oral carbohydrate administration (CHO-H, n = 8) or the same amount of a placebo drink (placebo, n = 8) before surgery. Insulin sensitivity was measured before and immediately after surgery. Patients undergoing elective colorectal surgery were studied before surgery and 24 h postoperatively (CHO-C (n = 7), and fasted (n = 7), groups). The fasted group underwent surgery after an overnight fast. In both studies, the CHO groups received 800 ml of an isoosmolar carbohydrate rich beverage the evening before the operation (100g carbohydrates), as well as another 400 ml (50g carbohydrates) 2 h before the initiation of anesthesia. Immediately after surgery, insulin sensitivity was reduced 37% in the placebo group (P < 0.05 vs. preoperatively) while no significant change was found in the CHO-H group (-16%, p = NS). During clamps performed 24h postoperatively, insulin sensitivity and whole-body glucose disposal was reduced in both groups, but the reduction was greater compared to that in the CHO-C group (-49 +/- 6% vs. -26 +/- 8%, P> 0.05 fasted vs. CHO-C). Patients given a carbohydrate drink shortly before elective surgery displayed less reduced insulin sensitivity after surgery as compared to patients undergoing surgery after an overnight fast. Copyright 1999 Harcourt Publishers Ltd.

When should ulcerative colitis patients undergo colectomy for dysplasia? Mismatch between patient preferences and physician recommendations.

PubMed

Siegel, Corey A; Schwartz, Lisa M; Woloshin, Steven; Cole, Elisabeth B; Rubin, David T; Vay, Tegan; Baars, Judith; Sands, Bruce E

2010-10-01

If dysplasia is found on biopsies during surveillance colonoscopy for ulcerative colitis (UC), many experts recommend colectomy given the substantial risk of synchronous colon cancer. The objective was to learn if UC patients' perceptions of their colon cancer risk and if their preferences for elective colectomy match with physicians' recommendations if dysplasia was found. A self-administered written survey included 199 patients with UC for at least 8 years (mean age 49 years, 52% female) who were recruited from Dartmouth-Hitchcock (n = 104) and the University of Chicago (n = 95). The main outcome was the proportion of patients who disagree with physicians' recommendations for colectomy because of dysplasia. Almost all respondents recognized that UC raised their chance of getting colon cancer. In all, 74% thought it was "unlikely" or "very unlikely" to get colon cancer within the next 10 years and they quantified this risk to be 23%; 60% of patients would refuse a physician's recommendation for elective colectomy if dysplasia was detected, despite being told that they had a 20% risk of having cancer now. On average, these patients would only agree to colectomy if their risk of colon cancer "right now" were at least 73%. UC patients recognize their increased risk of colon cancer and undergo frequent surveillance to reduce their risk. Nonetheless, few seem prepared to follow standard recommendations for elective colectomy if dysplasia is found. This may reflect the belief that surveillance alone is sufficient to reduce their colon cancer risk or genuine disagreement about when it is worth undergoing colectomy.

Use of Epidural Analgesia as an Adjunct in Elective Abdominal Wall Reconstruction: A Review of 4983 Cases.

PubMed

Karamanos, Efstathios; Dream, Sophie; Falvo, Anthony; Schmoekel, Nathan; Siddiqui, Aamir

2017-01-01

Use of epidural analgesia in patients undergoing elective abdominal wall reconstruction is common. To assess the impact of epidural analgesia in patients undergoing abdominal wall reconstruction. All patients who underwent elective ventral hernia repair from 2005 to 2014 were retrospectively identified. Patients were divided into two groups by the postoperative use of epidural analgesics as an adjunct analgesic method. Preoperative comorbidities, American Society of Anesthesiologists status, operative findings, postoperative pain management, and venothromboembolic prophylaxis were extracted from the database. Logistic regressions were performed to assess the impact of epidural use. Severity of pain on postoperative days 1 and 2. During the study period, 4983 patients were identified. Of those, 237 patients (4.8%) had an epidural analgesic placed. After adjustment for differences between groups, use of epidural analgesia was associated with significantly lower rates of 30-day presentation to the Emergency Department (adjusted odds ratio [AOR] = 0.53, 95% confidence interval [CI] = 0.32-0.87, adjusted p = 0.01). Use of epidural analgesia resulted in higher odds of abscess development (AOR = 5.89, CI = 2.00-17.34, adjusted p < 0.01) and transfusion requirement (AOR = 2.92, CI = 1.34-6.40, adjusted p < 0.01). Use of epidural analgesia resulted in a significantly lower pain score on postoperative day 1 (3 vs 4, adjusted p < 0.01). Use of epidural analgesia in patients undergoing abdominal wall reconstruction may result in longer hospital stay and higher incidence of complications while having no measurable positive clinical impact on pain control.

[A case of extensive pulmonary atelectasis after intubation in a patient undergoing elective tympanoplasty].

PubMed

Sugimoto, Kenzaburo; Satoh, Masaaki; Kai, Makiko; Sata, Naho; Takeuchi, Mamoru

2013-10-01

A 33-year-old male, without significant medical history, underwent elective tympanoplasty. It was difficult to manage his airway because of overbites, small jaw, and short neck. After intubation, his left chest revealed obvious abnormality in sound and movement, and showed free air in the mediastinum on X ray. CT revealed extensive atelectasis. Although he is a current smoker, the length of preoperative smoking cessation necessary to decrease postoperative pulmonary complications is not clear. This case demonstrates the importance of preoperative preparation including education in smoking damage.

Special Blood Donation Procedures

MedlinePlus

... blood. For example, in the weeks before undergoing elective surgery, a person may donate several units of blood ... rigorous donor screening and testing. In addition, elderly patients may not tolerate donating blood before surgery because they are more likely to have side ...

Response to ovarian stimulation is not impacted by a breast cancer diagnosis.

PubMed

Quinn, Molly M; Cakmak, Hakan; Letourneau, Joseph M; Cedars, Marcelle I; Rosen, Mitchell P

2017-03-01

Does a breast cancer diagnosis impact ovarian function in the setting of fertility preservation? Ovarian reserve and ovarian stimulation outcomes are similar in patients with a new diagnosis of breast cancer and patients undergoing elective fertility preservation. Prior studies, with small study populations, lack of controlling for individual differences in ovarian reserve and infertile controls, have reported conflicting outcomes for cancer patients undergoing ovarian stimulation for fertility preservation. This retrospective cohort analysis included 589 patients undergoing ovarian stimulation for fertility preservation between 2009 and 2015. Women with a recent breast cancer diagnosis (n = 191) and women desiring elective fertility preservation (n = 398) underwent ovarian stimulation with an antagonist protocol at an academic medical center. The aromatase inhibitor letrozole was administered to breast cancer patients with estrogen-sensitive disease. Baseline antral follicle count (AFC) was not different between the breast cancer patients and controls (15.4 ± 10.4 [mean ± SD] vs 15.4 ± 10.0, P = NS), even after categorization by age. Total (19.4 ± 0.9 [mean ± SEM] vs 17.0 ± 0.5, P = NS) and mature (MII) oocytes retrieved (13.7 ± 0.7 vs 13.2 ± 0.4, P = NS), adjusted for age, BMI and total gonadotropin dose, were also similar between the two groups. Letrozole use was associated with a decreased maturity rate (MII/total oocytes retrieved) compared to elective cryopreservation (0.71 ± 0.01 vs 0.77 ± 0.01, P < 0.001), although the mature oocyte yield [MII/AFC] was comparable (1.01 ± 0.06 vs 0.93 ± 0.03, P = NS). The single center design may impact generalizability. Additionally, the lack of subsequent embryo and pregnancy data is an inherent weakness. In females, a breast cancer diagnosis does not impact gonadal function as measured by AFC or ovarian stimulation outcomes. Breast cancer patients should be counseled that their response to ovarian stimulation for fertility preservation is similar to that of patients undergoing elective oocyte cryopreservation. None. N/A. © The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

The impact of intra-operative interruptions on surgeons' perceived workload: an observational study in elective general and orthopedic surgery.

PubMed

Weigl, Matthias; Antoniadis, Sophia; Chiapponi, Costanza; Bruns, Christiane; Sevdalis, Nick

2015-01-01

Surgeons' intra-operative workload is critical for effective and safe surgical performance. Detrimental conditions in the operating room (OR) environment may add to perceived workload and jeopardize surgical performance and outcomes. This study aims to evaluate the impact of different intra-operative workflow interruptions on surgeons' capacity to manage their workload safely and efficiently. This was an observational study of intra-operative interruptions and self-rated workload in two surgical specialties (general, orthopedic/trauma surgery). Intra-operative interruptions were assessed via expert observation using a well-validated observation tool. Surgeons, nurses, and anesthesiologists assessed their intra-operative workload directly after case completion based on three items of the validated Surgery Task Load Index (mental demand, situational stress, distraction). A total of 56 elective cases (35 open, 21 laparoscopic) with 94 workload ratings were included. Mean intra-operative duration was 1 h 37 min. Intra-operative interruptions were on average observed 9.78 times per hour. People who entered/exited the OR (30.6 %) as well as telephone-/beeper-related disruptions (23.6 %) occurred most often. Equipment and OR environment-related interruptions were associated with highest interference with team functioning particularly in laparoscopic procedures. After identifying task and procedural influences, partial correlational analyses revealed that case-irrelevant communications were negatively associated with surgeons' mental fatigue and situational stress, whereas surgeons' reported distraction was increased by case-irrelevant communication and procedural disruptions. OR nurses' and anesthesiologists' perceived workload was also related to intra-operative interruption events. Our study documents the unique contribution of different interruptions on surgeons' workload; whereas case-irrelevant communications may be beneficial for mental fatigue and stress in routine cases, procedural interruptions and case-irrelevant communication may contribute to surgeons' mental focus deteriorating. Well-designed OR environments, surgical leadership, and awareness can help to control unnecessary interruptions for effective and safe surgical care.

A Tale of Two Methods: Chart and Interview Methods for Identifying Delirium

PubMed Central

Saczynski, Jane S.; Kosar, Cyrus M.; Xu, Guoquan; Puelle, Margaret R.; Schmitt, Eva; Jones, Richard N.; Marcantonio, Edward R.; Wong, Bonnie; Isaza, Ilean; Inouye, Sharon K.

2014-01-01

Background Interview and chart-based methods for identifying delirium have been validated. However, relative strengths and limitations of each method have not been described, nor has a combined approach (using both interviews and chart), been systematically examined. Objectives To compare chart and interview-based methods for identification of delirium. Design, Setting and Participants Participants were 300 patients aged 70+ undergoing major elective surgery (majority were orthopedic surgery) interviewed daily during hospitalization for delirium using the Confusion Assessment Method (CAM; interview-based method) and whose medical charts were reviewed for delirium using a validated chart-review method (chart-based method). We examined rate of agreement on the two methods and patient characteristics of those identified using each approach. Predictive validity for clinical outcomes (length of stay, postoperative complications, discharge disposition) was compared. In the absence of a gold-standard, predictive value could not be calculated. Results The cumulative incidence of delirium was 23% (n= 68) by the interview-based method, 12% (n=35) by the chart-based method and 27% (n=82) by the combined approach. Overall agreement was 80%; kappa was 0.30. The methods differed in detection of psychomotor features and time of onset. The chart-based method missed delirium in CAM-identified patients laacking features of psychomotor agitation or inappropriate behavior. The CAM-based method missed chart-identified cases occurring during the night shift. The combined method had high predictive validity for all clinical outcomes. Conclusions Interview and chart-based methods have specific strengths for identification of delirium. A combined approach captures the largest number and the broadest range of delirium cases. PMID:24512042

Sensitivity of the Saline Load Test for Traumatic Arthrotomy of the Ankle With Ankle Arthroscopy Simulation.

PubMed

Bohl, Daniel D; Frank, Rachel M; Lee, Simon; Hamid, Kamran S; Holmes, George B; Lin, Johnny; Lee, Simon

2018-06-01

The saline load test has been used to evaluate for traumatic arthrotomy in orthopedics. The purpose of this study was to determine the volume of saline required to detect traumatic arthrotomy of the ankle. Forty-two patients undergoing elective ankle arthroscopy were prospectively enrolled. For each patient, a standard 4-mm anteromedial portal was established. Next, an 18-gauge needle was inserted at the site of the anterolateral portal. Sterile saline was slowly injected through the needle until saline extravasated from the anteromedial portal. Saline volumes at the time of extravasation were recorded and analyzed. The saline volume required to achieve extravasation ranged from 0.2 to 60.0 mL. The median saline volume required to achieve extravasation was 9.7 mL (interquartile range, 3.8-29.6 mL); however, 5 of 42 patients required volumes between 50.0 and 60.0 mL. A total of 50.0 mL was required to achieve 90% sensitivity, 55.0 mL to achieve 95% sensitivity, and 60.0 mL to achieve 99% sensitivity. The previously recommended 30 mL of saline required to reliably detect traumatic arthrotomy of the ankle may be too small a volume. The present study suggests that clinicians should attempt to inject 60 mL of saline to effectively rule out a traumatic arthrotomy injury. Because of the study's methods involving an anteromedial arthrotomy with anterolateral saline injection, these findings may be most valid for arthrotomies on the medial side of the ankle.

Changes in transthoracic impedance during sequential biphasic defibrillation.

PubMed

Deakin, Charles D; Ambler, Jonathan J S; Shaw, Steven

2008-08-01

Sequential monophasic defibrillation reduces transthoracic impedance (TTI) and progressively increases current flow for any given energy level. The effect of sequential biphasic shocks on TTI is unknown. We therefore studied patients undergoing elective cardioversion using a biphasic waveform to establish whether this is a phenomenon seen in the clinical setting. Adults undergoing elective DC cardioversion for atrial flutter or fibrillation received sequential transthoracic shocks using an escalating protocol (70J, 100J, 150J, 200J, and 300J) with a truncated exponential biphasic waveform. TTI was calculated through the defibrillator circuit and recorded electronically. Successful cardioversion terminated further defibrillation shocks. A total of 58 patients underwent elective cardioversion. Cardioversion was successful in 93.1% patients. First shock TTI was 92.2 [52.0-126.0]Omega (n=58) and decreased significantly with each sequential shock. Mean TTI in patients receiving five shocks (n=5) was 85.0Omega. Sequential biphasic defibrillation decreases TTI in a similar manner to that seen with monophasic waveforms. The effect is likely during defibrillation during cardiac arrest by the quick succession in which shocks are delivered and the lack of cutaneous blood flow which limits the inflammatory response. The ability of biphasic defibrillators to adjust their waveform according to TTI is likely to minimise any effect of these findings on defibrillation efficacy.

Systematization of Nursing Care in undergraduate training: the perspective of Complex Thinking 1

PubMed Central

da Silva, Josilaine Porfírio; Garanhani, Mara Lucia; Peres, Aida Maris

2015-01-01

AIM: to evaluate the clinical applicability of outcomes, according to the Nursing Outcomes Classification (NOC) in the evolution of orthopedic patients with Impaired Physical Mobility METHOD: longitudinal study conducted in 2012 in a university hospital, with 21 patients undergoing Total Hip Arthroplasty, evaluated daily by pairs of trained data collectors. Data were collected using an instrument containing five Nursing Outcomes, 16 clinical indicators and a five point Likert scale, and statistically analyzed. RESULTS: The outcomes Body Positioning: self-initiated, Mobility, Knowledge: prescribed activity, and Fall Prevention Behavior presented significant increases in mean scores when comparing the first and final evaluations (p<0.001) and (p=0.035). CONCLUSION: the use of the NOC outcomes makes it possible to demonstrate the clinical progression of orthopedic patients with Impaired Physical Mobility, as well as its applicability in this context. PMID:25806632

Oral hydration for prevention of contrast-induced acute kidney injury in elective radiological procedures: a systematic review and meta-analysis of randomized controlled trials.

PubMed

Cheungpasitporn, Wisit; Thongprayoon, Charat; Brabec, Brady A; Edmonds, Peter J; O'Corragain, Oisin A; Erickson, Stephen B

2014-12-01

The reports on efficacy of oral hydration treatment for the prevention of contrast-induced acute kidney injury (CIAKI) in elective radiological procedures and cardiac catheterization remain controversial. The objective of this meta-analysis was to assess the use of oral hydration regimen for prevention of CIAKI. Comprehensive literature searches for randomized controlled trials (RCTs) of outpatient oral hydration treatment was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials Systematic Reviews, and clinicaltrials.gov from inception until July 4(th), 2014. Primary outcome was the incidence of CIAKI. Six prospective RCTs were included in our analysis. Of 513patients undergoing elective procedures with contrast exposures,45 patients (8.8%) had CIAKI. Of 241 patients with oral hydration regimen, 23 (9.5%) developed CIAKI. Of 272 patients with intravenous (IV) fluid regimen, 22 (8.1%) had CIAKI. Study populations in all included studies had relatively normal kidney function to chronic kidney disease (CKD) stage 3. There was no significant increased risk of CIAKI in oral fluid regimen group compared toIV fluid regimen group (RR = 0.94, 95% confidence interval, CI = 0.38-2.31). According to our analysis,there is no evidence that oral fluid regimen is associated with more risk of CIAKI in patients undergoing elective procedures with contrast exposures compared to IV fluid regimen. This finding suggests that the oral fluid regimen might be considered as a possible outpatient treatment option for CIAKI prevention in patients with normal to moderately reduced kidney function.

Surgical Management and Reconstruction Training (SMART) Course for International Orthopedic Surgeons.

PubMed

Wu, Hao-Hua; Patel, Kushal R; Caldwell, Amber M; Coughlin, R Richard; Hansen, Scott L; Carey, Joseph N

The burden of complex orthopedic trauma in low- and middle-income countries (LMICs) is exacerbated by soft-tissue injuries, which can often lead to amputations. This study's purpose was to create and evaluate the Surgical Management and Reconstruction Training (SMART) course to help orthopedic surgeons from LMICs manage soft-tissue defects and reduce the rate of amputations. In this prospective observational study, orthopedic surgeons from LMICs were recruited to attend a 2-day SMART course taught by plastic surgery faculty in San Francisco. Before the course, participants were asked to assess the burden of soft-tissue injury and amputation encountered at their respective sites of practice. A survey was then given immediately and 1-year postcourse to evaluate the quality of instructional materials and the course's effect in reducing the burden of amputation, respectively. Fifty-one practicing orthopedic surgeons from 25 countries attended the course. No participant reported previously attempting a flap reconstruction procedure to treat a soft-tissue defect. Before the course, participants cumulatively reported 580-970 amputations performed annually as a result of soft-tissue defects. Immediately after the course, participants rated the quality and effectiveness of training materials to be a mean of ≥4.4 on a Likert scale of 5 (Excellent) in all 14 instructional criteria. Of the 34 (66.7%) orthopedic surgeons who completed the 1-year postcourse survey, 34 (100%, P < 0.01) reported performing flaps learned at the course to treat soft-tissue defects. Flap procedures prevented 116 patients from undergoing amputation; 554 (93.3%) of the cumulative 594 flaps performed by participants 1 year after the course were reported to be successful. Ninety-seven percent of course participants taught flap reconstruction techniques to colleagues or residents, and a self-reported estimate of 28 other surgeons undertook flap reconstruction as a result of information dissemination by 1 year postcourse. The SMART Course can give orthopedic surgeons in LMICs the skills and knowledge to successfully perform flaps, reducing the self-reported incidence of amputations. Course participants were able to disseminate flap reconstructive techniques to colleagues at their home institution. While this course offers a collaborative, sustainable approach to reduce global surgical disparities in amputation, future investigation into the viability of teaching the SMART course in LMICs is warranted. Copyright © 2016. Published by Elsevier Inc.

The use of rifaximin in pre-operative period of patients with tumors of the gastrointestinal tract - a retrospective study (2013-2016).

PubMed

Moroz, Nina; Sitarz, Robert; Mruk, Andrzej; Bakalarz, Robert; Maciąg, Ewa; Litwiński, Jakub; Wierzbicki, Ryszard

2018-02-28

ntroduction: One of the most important goals of preparing a patient for elective gastrointestinal cancer surgery is prevention of postoperative complications. The literature gives many ways to prepare for surgery, but only a few suggests that pre-operative use of rifaximin provides benefits in the form of fewer perioperative complications and reduces the severity of pain during this period. O bjective: The presented project is a retrospective analysis of the effectiveness of rifaximin in the prevention of perioperative complications in patients treated in the Unit of General Surgery with the Orthopedic and Urology in the Hospital of the Ministry of the Interior and Administration in Lublin, and a review of international literature in this subject. A retrospective analysis of the results of pre-operative use of rifaximin was performed in 181 patients scheduled for rectal and colorectal cancer between 2013 and 2016 in the General Surgery Unit with the Orthopedic and Urology in the Hospital of the Ministry of Interior and Administration in Lublin. Patients undergoing urgent surgery were excluded from the study. Patients were divided into 2 groups. The first group of 139 patients - patients operated on for rectal and colorectal cancer in 2013 until 2015, in whom rifaximine was not used in the preoperative period. The second group is 42 patients, operated on in 2016, in which the rifaximin was used in the pre-operative period at a dose of 2x2 tablets (400 mg) per day, 12-hour interval, for 7 days before the planned operation. Additionally, a probiotic was administered for 7 days. Drugs were ordained at the Oncological Outpatient Clinic as part of the pre-hospitalization check. R esults: The use of rifaximin in the preoperative period in patients with colorectal cancer had an effect on shortening the time of post-operative hospitalization and reduced post-surgical pain in comparison with the control group. The analysis of the cynumber and intensity of surgical complications in both groups did not differ. C onclusions: Large studies on the influence of rifaximin on the development of colorectal cancer have not been published so far. Only single reports suggest that its use has a positive effect on the perioperative period of patients treated for colorectal cancer including rectum and our retrospective analysis confirms these observations.

Surgical residency training and international volunteerism: a national survey of residents from 2 surgical specialties

PubMed Central

Matar, Wadih Y.; Trottier, Daniel C.; Balaa, Fady; Fairful-Smith, Robin; Moroz, Paul

2012-01-01

Background Many low- and middle-income countries (LMICs) lack basic surgical resources, resulting in avoidable disability and mortality. Recently, residents in surgical training programs have shown increasing interest in overseas elective experiences to assist surgical programs in LMICs. The purpose of this study was to survey Canadian surgical residents about their interest in international volunteerism. Methods We sent a web-based survey to all general and orthopedic surgery residents enrolled in surgical training programs in Canada. The survey assessed residents’ interests, attitudes and motivations, and perceived barriers and aids with respect to international volunteerism. Results In all, 361 residents completed the survey for a response rate of 38.0%. Half of the respondents indicated that the availability of an international surgery elective would have positively influenced their selection of a residency program. Excluding the 18 residents who had volunteered during residency, 63.8% of the remaining residents confirmed an interest in international volunteering with “contributing to an important cause,” “teaching” and “tourism/cultural enhancement” as the leading reasons for their interest. Perceived barriers included “lack of financial support” and “lack of available organized opportunities.” All (100%) respondents who had done an international elective during residency confirmed that they would pursue such work in the future. Conclusion Administrators of Canadian surgical programs should be aware of strong resident interest in global health care and accordingly develop opportunities by encouraging faculty mentorships and resources for global health teaching. PMID:22854155

Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals

PubMed Central

Hong, Juliette S.; Carey, Evan; Grunwald, Gary K.; Joynt Maddox, Karen; Maddox, Thomas M.

2018-01-01

Importance The Veterans Affairs (VA) Community Care (CC) Program supplements VA care with community-based medical services. However, access gains and value provided by CC have not been well described. Objectives To compare the access, cost, and quality of elective coronary revascularization procedures between VA and CC hospitals and to evaluate if procedural volume or publicly reported quality data can be used to identify high-value care. Design, Setting, and Participants Observational cohort study of veterans younger than 65 years undergoing an elective coronary revascularization, controlling for differences in risk factors using propensity adjustment. The setting was VA and CC hospitals. Participants were veterans undergoing elective percutaneous coronary intervention (PCI) and veterans undergoing coronary artery bypass graft (CABG) procedures between October 1, 2008, and September 30, 2011. The analysis was conducted between July 2014 and July 2017. Exposures Receipt of an elective coronary revascularization at a VA vs CC facility. Main Outcomes and Measures Access to care as measured by travel distance, 30-day mortality, and costs. Results In the 3 years ending on September 30, 2011, a total of 13 237 elective PCIs (79.1% at the VA) and 5818 elective CABG procedures (83.6% at the VA) were performed in VA or CC hospitals among veterans meeting study inclusion criteria. On average, use of CC was associated with reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG surgery compared with VA-only care. Adjusted 30-day mortality after PCI was higher in CC compared with VA (1.54% for CC vs 0.65% for VA, P < .001) but was similar after CABG surgery (1.33% for CC vs 1.51% for VA, P = .74). There were no differences in adjusted 30-day readmission rates for PCI (7.04% for CC vs 7.73% for VA, P = .66) or CABG surgery (8.13% for CC vs 7.00% for VA, P = .28). The mean adjusted PCI cost was higher in CC ($22 025 for CC vs $15 683 for VA, P < .001). The mean adjusted CABG cost was lower in CC ($55 526 for CC vs $63 144 for VA, P < .01). Neither procedural volume nor publicly reported mortality data identified hospitals that provided higher-value care with the exception that CABG mortality was lower in small-volume CC hospitals. Conclusions and Relevance In this veteran cohort, PCIs performed in CC hospitals were associated with shorter travel distance but with higher mortality, higher costs, and minimal travel savings compared with VA hospitals. The CABG procedures performed in CC hospitals were associated with shorter travel distance, similar mortality, and lower costs. As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending. PMID:29299607

Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals.

PubMed

Barnett, Paul G; Hong, Juliette S; Carey, Evan; Grunwald, Gary K; Joynt Maddox, Karen; Maddox, Thomas M

2018-02-01

The Veterans Affairs (VA) Community Care (CC) Program supplements VA care with community-based medical services. However, access gains and value provided by CC have not been well described. To compare the access, cost, and quality of elective coronary revascularization procedures between VA and CC hospitals and to evaluate if procedural volume or publicly reported quality data can be used to identify high-value care. Observational cohort study of veterans younger than 65 years undergoing an elective coronary revascularization, controlling for differences in risk factors using propensity adjustment. The setting was VA and CC hospitals. Participants were veterans undergoing elective percutaneous coronary intervention (PCI) and veterans undergoing coronary artery bypass graft (CABG) procedures between October 1, 2008, and September 30, 2011. The analysis was conducted between July 2014 and July 2017. Receipt of an elective coronary revascularization at a VA vs CC facility. Access to care as measured by travel distance, 30-day mortality, and costs. In the 3 years ending on September 30, 2011, a total of 13 237 elective PCIs (79.1% at the VA) and 5818 elective CABG procedures (83.6% at the VA) were performed in VA or CC hospitals among veterans meeting study inclusion criteria. On average, use of CC was associated with reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG surgery compared with VA-only care. Adjusted 30-day mortality after PCI was higher in CC compared with VA (1.54% for CC vs 0.65% for VA, P < .001) but was similar after CABG surgery (1.33% for CC vs 1.51% for VA, P = .74). There were no differences in adjusted 30-day readmission rates for PCI (7.04% for CC vs 7.73% for VA, P = .66) or CABG surgery (8.13% for CC vs 7.00% for VA, P = .28). The mean adjusted PCI cost was higher in CC ($22 025 for CC vs $15 683 for VA, P < .001). The mean adjusted CABG cost was lower in CC ($55 526 for CC vs $63 144 for VA, P < .01). Neither procedural volume nor publicly reported mortality data identified hospitals that provided higher-value care with the exception that CABG mortality was lower in small-volume CC hospitals. In this veteran cohort, PCIs performed in CC hospitals were associated with shorter travel distance but with higher mortality, higher costs, and minimal travel savings compared with VA hospitals. The CABG procedures performed in CC hospitals were associated with shorter travel distance, similar mortality, and lower costs. As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending.

Identifying gaps in the surgical training curriculum in Rwanda through evaluation of operative activity at a teaching hospital.

PubMed

Rickard, Jennifer L; Ntakiyiruta, Georges; Chu, Kathryn M

2015-01-01

To define the operations performed by surgical residents at a tertiary referral hospital in Rwanda to help guide development of the residency program. Cross-sectional study of all patients operated by surgical residents from October 2012 to September 2013. University Teaching Hospital of Kigali (Centre Hospitalier Universitaire de Kigali [CHUK]), a public, tertiary referral hospital in Kigali, Rwanda. All patient data were entered into the operative database by surgical residents at CHUK. A total of 2833 cases were entered into the surgical database. Of them, 53 cases were excluded from further analysis because no surgical resident was listed as the primary or assistant surgeon, leaving 2780 cases for analysis. There were 2780 operations involving surgical residents. Of them, 51% of procedures were classified under general surgery, 38% orthopedics, 7% neurosurgery, and 4% urology. Emergency operations accounted for 64% of the procedures, with 56% of those being general surgery and 35% orthopedic. Further, 50% of all operations were trauma, with 71% of those orthopedic and 21% general surgery. Surgical faculty were involved in 45% of operations as either the primary or the assistant surgeons, while the remainder of operations did not involve surgical faculty. Residents were primary surgeons in 68% of procedures and assistant surgeons in 84% of procedures. The operative experience of surgery residents at CHUK primarily involves emergency and trauma procedures. Although this likely reflects the demographics of surgical care within Rwanda, more focus should be placed on elective procedures to ensure that surgical residents are broadly trained. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The Impact of Prediabetes on Two-Year Clinical Outcomes in Patients Undergoing Elective Percutaneous Coronary Intervention.

PubMed

Choi, Woong Gil; Rha, Seung Woon; Choi, Byoung Geol; Choi, Se Yeon; Byun, Jae Kyeong; Mashaly, Ahmed; Park, Yoonjee; Jang, Won Young; Kim, Woohyeun; Choi, Jah Yeon; Park, Eun Jin; Na, Jin Oh; Choi, Cheol Ung; Kim, Eung Ju; Park, Chang Gyu; Seo, Hong Seog

2018-06-01

Prediabetes is an independent risk factor for cardiovascular disease. However, data on the long term adverse clinical outcomes of prediabetic patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) are scarce. The study population comprised 674 consecutive non-diabetic patients who underwent elective PCI between April 2007 and November 2010. Prediabetes was defined as hemoglobin A1c (HbA1c) of 5.7% to 6.4%. Two-year cumulative clinical outcomes of prediabetic patients (HbA1c of 5.7% to 6.4%, n=242) were compared with those of a normoglycemic group (<5.7%, n=432). Baseline clinical and angiographic characteristics were similar between the two groups, except for higher glucose levels (104.8±51.27 mg/dL vs. 131.0±47.22 mg/dL, p<0.001) on admission in the prediabetes group. There was no significant difference between the two groups in coronary angiographic parameters, except for a higher incidence of diffuse long lesion in the prediabetes group. For prediabetic patients, trends toward higher incidences of binary restenosis (15.6% vs. 9.8 %, p=0.066) and late loss (0.71±0.70 mm vs. 0.59±0.62 mm, p=0.076) were noted. During the 24 months of follow up, the incidence of mortality in prediabetic patients was higher than that in normoglycemic patients (5.5% vs. 1.5%, p=0.007). In our study, a higher death rate and a trend toward a higher incidence of restenosis in patients with prediabetes up to 2 years, compared to those in normoglycemic patients, undergoing elective PCI with contemporary DESs. © Copyright: Yonsei University College of Medicine 2018.

A randomised controlled pilot trial to evaluate and optimize the use of anti-platelet agents in the perioperative management in patients undergoing general and abdominal surgery--the APAP trial (ISRCTN45810007).

PubMed

Antolovic, D; Rakow, A; Contin, P; Ulrich, A; Rahbari, N N; Büchler, M W; Weitz, J; Koch, M

2012-02-01

Surgeons are increasingly confronted by patients on long-term low-dose acetylsalicylic acid (ASA). However, owing to a lack of evidence-based data, a widely accepted consensus on the perioperative management of these patients in the setting of non-cardiac surgery has not yet been reached. Primary objective was to evaluate the safety of continuous versus discontinuous use of ASA in the perioperative period in elective general or abdominal surgery. Fifty-two patients undergoing elective cholecystectomy, inguinal hernia repair or colonic/colorectal surgery were recruited to this pilot study. According to cardiological evaluation, non-high-risk patients who were on long-term treatment with low-dose ASA were eligible for inclusion. Patients were allocated randomly to continuous use of ASA or discontinuation of ASA intake for 5 days before until 5 days after surgery. The primary outcome was the incidence of major haemorrhagic and thromboembolic complications within 30 days after surgery. A total of 26 patients were allocated to each study group. One patient (3.8%) in the ASA continuation group required re-operation due to post-operative haemorrhage. In neither study group, further bleeding complications occurred. No clinically apparent thromboembolic events were reported in the ASA continuation and the ASA discontinuation group. Furthermore, there were no significant differences between both study groups in the secondary endpoints. Perioperative intake of ASA does not seem to influence the incidence of severe bleeding in non-high-risk patients undergoing elective general or abdominal surgery. Further, adequately powered trials are required to confirm the findings of this study.

Cranberry juice capsules and urinary tract infection after surgery: results of a randomized trial.

PubMed

Foxman, Betsy; Cronenwett, Anna E W; Spino, Cathie; Berger, Mitchell B; Morgan, Daniel M

2015-08-01

The risk of urinary tract infection (UTI) among women undergoing elective gynecological surgery during which a catheter is placed is high: 10-64% following catheter removal. We conducted the first randomized, double-blind, placebo-controlled trial of the therapeutic efficacy of cranberry juice capsules in preventing UTI after surgery. We recruited patients from a single hospital between August 2011 and January 2013. Eligible participants were undergoing elective gynecological surgery that did not involve a fistula repair or vaginal mesh removal. One hundred sixty patients were randomized and received 2 cranberry juice capsules 2 times a day, equivalent to 2 8 ounce servings of cranberry juice, for 6 weeks after surgery or matching placebo. The primary endpoint was the proportion of participants who experienced clinically diagnosed and treated UTI with or without positive urine culture. Kaplan-Meier plots and log rank tests compared the 2 treatment groups. The occurrence of UTI was significantly lower in the cranberry treatment group compared with the placebo group (15 of 80 [19%] vs 30 of 80 [38%]; odds ratio, 0.38; 95% confidence interval, 0.19-0.79; P = .008). After adjustment for known confounders, including the frequency of intermittent self-catheterization in the postoperative period, the protective effects of cranberry remained (odds ratio, 0.42; 95% confidence interval, 0.18-0.94). There were no treatment differences in the incidence of adverse events, including gastrointestinal upset (56% vs 61% for cranberry vs placebo). Among women undergoing elective benign gynecological surgery involving urinary catheterization, the use of cranberry extract capsules during the postoperative period reduced the rate of UTI by half. Copyright © 2015 Elsevier Inc. All rights reserved.

When Should Ulcerative Colitis Patients Undergo Colectomy for Dysplasia? Mismatch Between Patient Preferences and Physician Recommendations

PubMed Central

Siegel, Corey A.; Schwartz, Lisa M.; Woloshin, Steven; Cole, Elisabeth B.; Rubin, David T.; Vay, Tegan; Baars, Judith; Sands, Bruce E.

2010-01-01

Background If dysplasia is found on biopsies during surveillance colonoscopy for ulcerative colitis (UC), many experts recommend colectomy given the substantial risk of synchronous colon cancer. The objective was to learn if UC patients’ perceptions of their colon cancer risk and if their preferences for elective colectomy match with physicians’ recommendations if dysplasia was found. Methods A self-administered written survey included 199 patients with UC for at least 8 years (mean age 49 years, 52% female) who were recruited from Dartmouth-Hitchcock (n = 104) and the University of Chicago (n = 95). The main outcome was the proportion of patients who disagree with physicians’ recommendations for colectomy because of dysplasia. Results Almost all respondents recognized that UC raised their chance of getting colon cancer. In all, 74% thought it was “unlikely” or “very unlikely” to get colon cancer within the next 10 years and they quantified this risk to be 23%; 60% of patients would refuse a physician’s recommendation for elective colectomy if dysplasia was detected, despite being told that they had a 20% risk of having cancer now. On average, these patients would only agree to colectomy if their risk of colon cancer “right now” were at least 73%. Conclusions UC patients recognize their increased risk of colon cancer and undergo frequent surveillance to reduce their risk. Nonetheless, few seem prepared to follow standard recommendations for elective colectomy if dysplasia is found. This may reflect the belief that surveillance alone is sufficient to reduce their colon cancer risk or genuine disagreement about when it is worth undergoing colectomy. PMID:20186940

Effects of Lignocaine Administered Intravenously or Intratracheally on Airway and Hemodynamic Responses during Emergence and Extubation in Patients Undergoing Elective Craniotomies in Supine Position.

PubMed

Shabnum, Tabasum; Ali, Zulfiqar; Naqash, Imtiaz Ahmad; Mir, Aabid Hussain; Azhar, Khan; Zahoor, Syed Amer; Mir, Abdul Waheed

2017-01-01

Sympathoadrenergic responses during emergence and extubation can lead to an increase in heart rate (HR) and blood pressure whereas increased airway responses may lead to coughing and laryngospasm. The aim of our study was to compare the effects of lignocaine administered intravenously (IV) or intratracheally on airway and hemodynamic responses during emergence and extubation in patients undergoing elective craniotomies. Sixty patients with physical status American Society of Anaesthesiologists Classes I and II aged 18-70 years, scheduled to undergo elective craniotomies were included. The patients were randomly divided into three groups of twenty patients; Group 1 receiving IV lignocaine and intratracheal placebo (IV group), Group 2 receiving intratracheal lignocaine and IV placebo (I/T group), and Group 3 receiving IV and intratracheal placebo (placebo group). The tolerance to the endotracheal tube was monitored, and number of episodes of cough was recorded during emergence and at the time of extubation. Hemodynamic parameters such as HR and blood pressure (systolic, diastolic, mean arterial pressure) were also recorded. There was a decrease of HR in both IV and intratracheal groups in comparison with placebo group ( P < 0.005). Rise in blood pressure (systolic blood pressure, diastolic blood pressure and mean arterial pressure) was comparable in both Groups 1 and 2 but was lower in comparison with placebo group ( P < 0.005). Cough suppression was comparable in all the three groups. Grade III cough (15%) was documented only in placebo group. Both IV and intratracheal lignocaine are effective in attenuation of hemodynamic response if given within 20 min from skull pin removal to extubation. There was comparable cough suppression through intratracheal route and IV routes than the placebo group.

End Tidal Carbon Dioxide as a Screening Tool for Computed Tomography Angiogram in Postoperative Orthopaedic Patients Suspected of Pulmonary Embolism.

PubMed

Ramme, Austin J; Iturrate, Eduardo; Dweck, Ezra; Steiger, David J; Hutzler, Lorraine H; Fang, Yixin; Wang, Binhuan; Bosco, Joseph A; Sigmund, Alana E

2016-10-01

Computed tomography pulmonary angiography (CTA) is the gold standard for diagnosing pulmonary embolism (PE) but involves radiation and iodinated contrast exposure. Of orthopedic patients evaluated for PE, a minority have a positive CTA study. Herein, we evaluate end tidal carbon dioxide (ETCO2) as a method to identify patients at low risk for PE and may not require a CTA. We hypothesize that ETCO2 will be useful for predicting the absence of PE in postoperative orthopedic patients. In this prospective study, all patients older than 18 years who were admitted for orthopedic surgery and who had a CTA performed for PE were eligible. These patients underwent an ETCO2 measurement. Patients were determined to have PE if they had a positive PE-protocol CT. Between May 2014 and April 2015, 121 patients met the inclusion criteria for the study. Of these patients, 84 had a negative CTA examination, 25 had a positive examination, and 12 had a nondiagnostic examination. We found a statistically significant difference (P = .03) when comparing the average ETCO2 values for the positive and negative CTA groups. An ETCO2 cutoff value of 43 mm Hg was 100% sensitive with a negative predictive value of 100% for absence of PE on CTA. This study demonstrates a significant difference in ETCO2 measurements between postoperative orthopedic patients with and without CTA-detected PE. A cutoff value of >43 mm Hg may be useful in excluding patients from undergoing CTA. Copyright © 2016 Elsevier Inc. All rights reserved.

Active Ankle Movements Prevent Formation of Lower-Extremity Deep Venous Thrombosis After Orthopedic Surgery

PubMed Central

Li, Ye; Guan, Xiang-Hong; Wang, Rui; Li, Bin; Ning, Bo; Su, Wei; Sun, Tao; Li, Hong-Yan

2016-01-01

Background The aim of this study was to assess the preventive value of active ankle movements in the formation of lower-extremity deep venous thrombosis (DVT), attempting to develop a new method for rehabilitation nursing after orthopedic surgery. Material/Methods We randomly assigned 193 patients undergoing orthopedic surgery in the lower limbs into a case group (n=96) and a control group (n=97). The control group received routine nursing while the case group performed active ankle movements in addition to receiving routine nursing. Maximum venous outflow (MVO), maximum venous capacity (MVC), and blood rheology were measured and the incidence of DVT was recorded. Results On the 11th and 14th days of the experiment, the case group had significantly higher MVO and MVC than the control group (all P<0.05). The whole-blood viscosity at high shear rate and the plasma viscosity were significantly lower in the case group than in the control group on the 14th day (both P<0.05). During the experiment, a significantly higher overall DVT incidence was recorded in the control group (8 with asymptomatic DVT) compared with the case group (1 with asymptomatic DVT) (P=0.034). During follow-up, the case group presented a significantly lower DVT incidence (1 with symptomatic DVT and 4 with asymptomatic DVT) than in the control group (5 with symptomatic DVT and 10 with asymptomatic DVT) (P=0.031). Conclusions Through increasing MVO and MVC and reducing blood rheology, active ankle movements may prevent the formation of lower-extremity DVT after orthopedic surgery. PMID:27600467

High-dose, single-bolus eptifibatide: a safe and cost-effective alternative to conventional glycoprotein IIb/IIIa inhibitor use for elective coronary interventions.

PubMed

Fischell, Tim A; Attia, Tamer; Rane, Santosh; Salman, Waddah

2006-10-01

Adjunctive pharmacotherapy with eptifibatide, a glycoprotein (GP) IIb/IIIa inhibitor, as an intravenous bolus followed by infusion has been shown to improve outcomes in elective coronary interventions (PCI). However, bleeding complications and costs have limited the routine adoption of this regimen. The goal of this study was to examine the safety, efficacy and cost-effectiveness of high-dose, single-bolus eptifibatide, without post-intervention infusion, in "real-world" patients undergoing elective PCI. We studied 401 patients with stable and unstable angina who were treated with a high-dose (20 mg), single bolus of eptifibatide plus heparin prior to the start of elective PCI. Exclusion criteria included recent MI, stenting of bypass graft(s), rotational atherectomy and/or brachytherapy. The primary study endpoints were major adverse clinical events (MACE), defined as the in-hospital and 30-day incidence of death from any cause, Q-wave or non-Q-wave MI, repeat target vessel revascularization and/or major bleeding complications. Relevant demographic and procedural characteristics included mean age: 66.4 +/- 11.2; male gender: 242/401 (61%); number of vessels treated per patient: 1.46 +/- 0.42; and number of stents deployed per patient: 1.82 +/- 0.65. In-hospital non-Q-wave MI (CPK and/or CPK-MB > 3 times the upper limit of normal) occurred in 7/401 patients (1.75%) and MACE was 2.25%. Major bleeding complications were seen in 2/401 patients (0.49%). There were 4 additional MACE events at 30-day follow up (total MACE and bleeding = 3.25%). The average anticoagulation cost was 66 dollars/patient. Intravenous eptifibatide, administered as a high-dose (20 mg) single-vial bolus, is a safe, effective and highly cost-effective alternative to the conventional regimens of bolus plus prolonged intravenous GP IIb/IIIa inhibitor infusion for patients undergoing elective PCI.

First Trimester Pregnancy Loss and the Expression of Alternatively Spliced NKp30 Isoforms in Maternal Blood and Placental Tissue

PubMed Central

Shemesh, Avishai; Tirosh, Dan; Sheiner, Eyal; Benshalom-Tirosh, Neta; Brusilovsky, Michael; Segev, Rotem; Rosental, Benyamin; Porgador, Angel

2015-01-01

Capsule: We observed that first trimester pregnancy loss is associated with an altered expression profile of the three isoforms of the NK receptor NKp30 expressed by NKs in PBMC and placental tissue. In this study, we aimed to investigate whether first trimester pregnancy loss is associated with differences in expression of NKp30 splice variants (isoforms) in maternal peripheral blood or placental tissue. We conducted a prospective case–control study; a total of 33 women undergoing dilation and curettage due to first trimester pregnancy loss were further subdivided into groups with sporadic or recurrent pregnancy loss. The control group comprises women undergoing elective termination of pregnancy. The qPCR approach was employed to assess the relative expression of NKp30 isoforms as well as the total expression of NKp30 and NKp46 receptors between the selected groups. Results show that in both PBMC and placental tissue, NKp46 and NKp30 expressions were mildly elevated in the pregnancy loss groups compared with the elective group. In particular, NKp46 elevation was significant. Moreover, expression analysis of NKp30 isoforms manifested a different profile between PBMC and the placenta. NKp30-a and NKp30-b isoforms in the placental tissue, but not in PBMC, showed a significant increase in the pregnancy loss groups compared with the elective group. Placental expression of NKp30 activating isoforms-a and -b in the pregnancy loss groups was negatively correlated with PLGF expression. By contrast, placental expression of these isoforms in the elective group was positively correlated with TNFα, IL-10, and VEGF-A expression. The altered expression of NKp30 activating isoforms in placental tissue from patients with pregnancy loss compared to the elective group and the different correlations with cytokine expression point to the involvement of NKp30-mediated function in pregnancy loss. PMID:26082773

Tendon Volume Determination on Magnetic Resonance Imaging of Supraspinatus Tendinopathy.

PubMed

Spall, Benjamin F; Fransson, Boel A; Martinez, Steve A; Wilkinson, Thomas E

2016-04-01

To determine the supraspinatus tendon volume using magnetic resonance imaging (MRI) in dogs with non-calcified supraspinatus tendinopathy (NCST), in dogs with orthopedic disease other than NCST, and in healthy dogs. Case series. Twenty-two dogs (18 client-owned dogs; 4 purpose-bred dogs). Dogs undergoing shoulder MRI were categorized as NCST if they were diagnosed with NCST only, had histologic confirmed diagnosis, underwent surgical treatment, and were available for follow-up longer than 4 months. Dogs with MRI performed for a forelimb lameness because of a diagnosis other than NCST were categorized as orthopedic control (OC). Healthy dogs from an unrelated study were categorized as healthy controls (HC). Tendon volume was determined from MRI using public domain software and compared across categories. The study included 9 NCST dogs, 9 OC dogs, and 4 HC dogs. The median tendon volume for NCST was 1,323 mm(3), OC was 630 mm(3), and HC was 512 mm(3). The volume was significantly higher in the NCST than OC (P = .0012) and HC (P = .003). There was no difference between OC and HC (P = .76). Dogs diagnosed with NCST had higher supraspinatus tendon volumes compared to dogs with other orthopedic disorders and healthy dogs. © Copyright 2016 by The American College of Veterinary Surgeons.

Same versus next day discharge after elective transradial PCI: The RAdial SAme Day DischArge after PCI trial. (The RASADDA-PCI trial).

PubMed

Rodriguez-Araujo, Gerardo; Cilingiroglu, Mehmet; Mego, David; Hakeem, Abdul; Lendel, Vasili; Cawich, Ian; Paixao, Andre; Marmagkiolis, Konstantinos; Flaherty, Patrick; Rollefson, William

2018-06-02

Transradial percutaneous coronary intervention (TR-PCI) has been increasingly popular over the last decade in the US. Previous studies have shown that same-day (SD) discharge after elective PCI is as safe as overnight (ON) observation. Our study was performed to assess the clinical and financial impact of early discharge in patients undergoing TR-PCI. This is a single center registry of patients undergoing elective TR-PCI. Timing of discharge was determined by the treating physician. (Groups: Same Day Discharge -SD-; Overnight Stay -ON-). Demographic data, procedural characteristics and adverse outcomes were recorded. Outcomes included 30 day-MACE and procedure- related complications, as well as total operative costs in patients from both groups. Propensity score matching for patient demographics, coronary symptoms and procedure indicators was used to compare both groups. The entire cohort included 852 patients (429 in SD group and 423 in ON group) and the propensity score matched groups of 245 patients in the SD group and 245 patients in the ON group. The two groups had no significant baseline clinical differences, and had similar clinical outcomes. Specifically, no significant difference was noted in procedural complications (3.7% vs 2.5%, p = 0.43), re-hospitalization (4.1% vs 4.1%, p = 0.92), re-intervention (2.5% vs 2.1%, p = 0.77), myocardial infarction (0% vs 0.08%, p = 0.15), stroke (0% vs 0%, p = 1.0) and all-cause mortality (0% vs 0%, p = 1.0). SD Group patients had a significant lower procedure-related cost compared to overnight stay patients ($3,346.45 vs $4,681.99, p < 0.0001) and lower 30-day post procedure-associated cumulative costs/total operating costs ($4,493.22 vs $7,112.21, p < 0.0001). In elective patients undergoing low risk TR-PCI, same-day discharge seems to be a safe and feasible clinical practice, with significant potential savings to the US healthcare system. Copyright © 2018 Elsevier Inc. All rights reserved.

Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery.

PubMed

Kim, David H; Spencer, Maureen; Davidson, Susan M; Li, Ling; Shaw, Jeremy D; Gulczynski, Diane; Hunter, David J; Martha, Juli F; Miley, Gerald B; Parazin, Stephen J; Dejoie, Pamela; Richmond, John C

2010-08-04

Surgical site infection has been identified as one of the most important preventable sources of morbidity and mortality associated with medical treatment. The purpose of the present study was to evaluate the feasibility and efficacy of an institutional prescreening program for the preoperative detection and eradication of both methicillin-resistant and methicillin-sensitive Staphylococcus aureus in patients undergoing elective orthopaedic surgery. Data were collected prospectively during a single-center study. A universal prescreening program, employing rapid polymerase chain reaction analysis of nasal swabs followed by an eradication protocol of intranasal mupirocin and chlorhexidine showers for identified carriers, was implemented. Surgical site infection rates were calculated and compared with a historical control period immediately preceding the start of the screening program. During the study period, 7019 of 7338 patients underwent preoperative screening before elective surgery, for a successful screening rate of 95.7%. One thousand five hundred and eighty-eight (22.6%) of the patients were identified as Staphylococcus aureus carriers, and 309 (4.4%) were identified as methicillin-resistant Staphylococcus aureus carriers. A significantly higher rate of surgical site infection was observed among methicillin-resistant Staphylococcus aureus carriers (0.97%; three of 309) compared with noncarriers (0.14%; seven of 5122) (p = 0.0162). Although a higher rate of surgical site infection was also observed among methicillin-sensitive Staphylococcus aureus carriers (0.19%; three of 1588) compared with noncarriers, this difference did not achieve significance (p = 0.709). Overall, thirteen cases of surgical site infection were identified during the study period, for an institutional infection rate of 0.19%. This rate was significantly lower than that observed during the control period (0.45%; twenty-four cases of surgical site infection among 5293 patients) (p = 0.0093). Implementation of an institution-wide prescreening program for the identification and eradication of methicillin-resistant and methicillin-sensitive Staphylococcus aureus carrier status among patients undergoing elective orthopaedic surgery is feasible and can lead to significant reductions in postoperative rates of surgical site infection. Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Cone-Beam Computed Tomography and Interdisciplinary Dentofacial Therapy: An American Academy of Periodontology Best Evidence Review Focusing on Risk Assessment of the Dentoalveolar Bone Changes Influenced by Tooth Movement.

PubMed

Mandelaris, George A; Neiva, Rodrigo; Chambrone, Leandro

2017-10-01

The aim of this systematic review is to evaluate whether cone-beam computed tomography (CBCT) imaging can be used to assess dentoalveolar anatomy critical to the periodontist when determining risk assessment for patients undergoing orthodontic therapy using fixed or removable appliances. Both observational and interventional trials reporting on the use of CBCT imaging assessing the impact of orthodontic/dentofacial orthopedic treatment on periodontal tissues (i.e., alveolar bone) were included. Changes in the alveolar bone thickness and height around natural teeth as well as treatment costs were evaluated. MEDLINE (via PubMed) and EMBASE databases were searched for articles published in the English language, up to and including July 2016, and extracted data were organized into evidence tables. Thirteen studies were included in this systematic review describing the positive or deleterious changes on the alveolar bone surrounding natural teeth undergoing orthodontic tooth movement or influenced by orthopedic forces through fixed appliances. Clinical recommendation summaries presenting the strengths and weaknesses of the evidence in terms of benefits and harms were generated. CBCT imaging can improve the periodontal diagnostic acumen regarding alveolar bone alterations influenced by orthodontic tooth movement and can help determine risk assessment prior to such intervention. Clinicians are also better informed to determine risk assessment and develop preventative or plan interceptive periodontal augmentation (soft tissue and/or bone augmentation) therapies for patients undergoing orthodontic tooth movement. These considerations are recognized as being especially critical for treatment approaches in patients where buccal tooth movement (expansion) is planned in the anterior mandible or involving the maxillary premolars.

Systematic Review: Audiovisual Interventions for Reducing Preoperative Anxiety in Children Undergoing Elective Surgery

PubMed Central

Van Lieshout, Ryan J.; Schmidt, Louis A.; Dobson, Kathleen G.; Buckley, Norman

2016-01-01

Objective To examine the effectiveness of Audiovisual (AV) interventions at reducing preoperative anxiety and its associated outcomes in children undergoing elective surgery. Methods A systematic review of randomized controlled trials (RCTs) and nonrandomized studies where the primary outcome was children’s preoperative anxiety was conducted. Secondary outcomes included postoperative pain, behavioral changes, recovery, induction compliance, satisfaction, and cost-effectiveness. The risk of bias of each study was assessed. Results In all, 18 studies were identified. A meta-analytic approach and narrative synthesis of findings were used to summarize the results of the studies. Conclusions This systematic review suggests that AV interventions can be effective in reducing children’s preoperative anxiety. Videos, multi-faceted programs, and interactive games appear to be most effective, whereas music therapy and Internet programs are less effective. While AV interventions appear potentially useful, adequately powered RCTs are required to conclusively pinpoint the components and mechanisms of the most effective AV interventions and guide practice. PMID:26476281

Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective non-cardiac surgery.

PubMed

Mehdi, Zehra; Birns, Jonathan; Partridge, Judith; Bhalla, Ajay; Dhesi, Jugdeep

2016-12-01

It is increasingly common for physicians and anaesthetists to be asked for advice in the medical management of surgical patients who have an incidental history of stroke or transient ischaemic attack (TIA). Advising clinicians requires an understanding of the common predictors, outcomes and management of perioperative stroke. The most important predictor of perioperative stroke is a previous history of stroke, and outcomes associated with such an event are extremely poor. The perioperative management of this patient group needs careful consideration to minimise the thrombotic risk and a comprehensive, individualised approach is crucial. Although there is literature supporting the management of such patients undergoing cardiac surgery, evidence is lacking in the setting of non-cardiac surgical intervention. This article reviews the current evidence and provides a pragmatic interpretation to inform the perioperative management of patients with a history of stroke and/or TIA presenting for elective non-cardiac surgery. © Royal College of Physicians 2016. All rights reserved.

Retrospective cohort study of an enhanced recovery programme in oesophageal and gastric cancer surgery

PubMed Central

Gatenby, PAC; Shaw, C; Hine, C; Scholtes, S; Koutra, M; Andrew, H; Hacking, M; Allum, WH

2015-01-01

Introduction Enhanced recovery programmes have been established in some areas of elective surgery. This study applied enhanced recovery principles to elective oesophageal and gastric cancer surgery. Methods An enhanced recovery programme for patients undergoing open oesophagogastrectomy, total and subtotal gastrectomy for oesophageal and gastric malignancy was designed. A retrospective cohort study compared length of stay on the critical care unit (CCU), total length of inpatient stay, rates of complications and in-hospital mortality prior to (35 patients) and following (27 patients) implementation. Results In the cohort study, the median total length of stay was reduced by 3 days following oesophagogastrectomy and total gastrectomy. The median length of stay on the CCU remained the same for all patients. The rates of complications and mortality were the same. Conclusions The standardised protocol reduced the median overall length of stay but did not reduce CCU stay. Enhanced recovery principles can be applied to patients undergoing major oesophagogastrectomy and total gastrectomy as long as they have minimal or reversible co-morbidity. PMID:26414360

Effects of acepromazine and trazodone on anesthetic induction dose of propofol and cardiovascular variables in dogs undergoing general anesthesia for orthopedic surgery.

PubMed

Murphy, Lindsey A; Barletta, Michele; Graham, Lynelle F; Reichl, Lorna J; Duxbury, Margaret M; Quandt, Jane E

2017-02-15

OBJECTIVE To compare the doses of propofol required to induce general anesthesia in dogs premedicated with acepromazine maleate or trazodone hydrochloride and compare the effects of these premedicants on cardiovascular variables in dogs anesthetized for orthopedic surgery. DESIGN Prospective, randomized study. ANIMALS 30 systemically healthy client-owned dogs. PROCEDURES 15 dogs received acepromazine (0.01 to 0.03 mg/kg [0.005 to 0.014 mg/lb], IM) 30 minutes before anesthetic induction and 15 received trazodone (5 mg/kg [2.27 mg/lb] for patients > 10 kg or 7 mg/kg [3.18 mg/lb] for patients ≤ 10 kg, PO) 2 hours before induction. Both groups received morphine sulfate (1 mg/kg [0.45 mg/lb], IM) 30 minutes before induction. Anesthesia was induced with propofol (4 to 6 mg/kg [1.82 to 2.73 mg/lb], IV, to effect) and maintained with isoflurane or sevoflurane in oxygen. Bupivacaine (0.5 mg/kg [0.227 mg/lb]) and morphine (0.1 mg/kg [0.045 mg/lb]) were administered epidurally. Dogs underwent tibial plateau leveling osteotomy (n = 22) or tibial tuberosity advancement (8) and were monitored throughout anesthesia. Propofol induction doses and cardiovascular variables (heart rate and systemic, mean, and diastolic arterial blood pressures) were compared between groups. RESULTS The mean dose of propofol required for anesthetic induction and all cardiovascular variables evaluated did not differ between groups. Intraoperative hypotension developed in 6 and 5 dogs of the acepromazine and trazodone groups, respectively; bradycardia requiring intervention developed in 3 dogs/group. One dog that received trazodone had priapism 24 hours later and was treated successfully. No other adverse effects were reported. CONCLUSIONS AND CLINICAL RELEVANCE At the described dosages, cardiovascular effects of trazodone were similar to those of acepromazine in healthy dogs undergoing anesthesia for orthopedic surgery.

Incidence of intraoperative seizures during motor evoked potential monitoring in a large cohort of patients undergoing different surgical procedures.

PubMed

Ulkatan, Sedat; Jaramillo, Ana Maria; Téllez, Maria J; Kim, Jinu; Deletis, Vedran; Seidel, Kathleen

2017-04-01

OBJECTIVE The purpose of this study was to investigate the incidence of seizures during the intraoperative monitoring of motor evoked potentials (MEPs) elicited by electrical brain stimulation in a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. METHODS The authors retrospectively analyzed data from 4179 consecutive patients who underwent surgery or an interventional radiology procedure with MEP monitoring. RESULTS Of 4179 patients, only 32 (0.8%) had 1 or more intraoperative seizures. The incidence of seizures in cranial procedures, including craniotomies and interventional neuroradiology, was 1.8%. In craniotomies in which transcranial electrical stimulation (TES) was applied to elicit MEPs, the incidence of seizures was 0.7% (6/850). When direct cortical stimulation was additionally applied, the incidence of seizures increased to 5.4% (23/422). Patients undergoing craniotomies for the excision of extraaxial brain tumors, particularly meningiomas (15 patients), exhibited the highest risk of developing an intraoperative seizure (16 patients). The incidence of seizures in orthopedic spine surgeries was 0.2% (3/1664). None of the patients who underwent surgery for conditions of the spinal cord, neck, or peripheral nerves or who underwent cranial or noncranial interventional radiology procedures had intraoperative seizures elicited by TES during MEP monitoring. CONCLUSIONS In this largest such study to date, the authors report the incidence of intraoperative seizures in patients who underwent MEP monitoring during a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. The low incidence of seizures induced by electrical brain stimulation, particularly short-train TES, demonstrates that MEP monitoring is a safe technique that should not be avoided due to the risk of inducing seizures.

COMMUNICATION: Drug loading of nanoporous TiO2 films

NASA Astrophysics Data System (ADS)

Ayon, Arturo A.; Cantu, Michael; Chava, Kalpana; Mauli Agrawal, C.; Feldman, Marc D.; Johnson, Dave; Patel, Devang; Marton, Denes; Shi, Emily

2006-12-01

The loading of therapeutic amounts of drug on a nanoporous TiO2 surface is described. This novel drug-loading scheme on a biocompatible surface, when employed on medical implants, will benefit patients who require the deployment of drug-eluting implants. Anticoagulants, analgesics and antibiotics can be considered on the associated implants for drug delivery during the time of maximal pain or risk for patients undergoing orthopedic procedures. Therefore, this scheme will maximize the chances of patient recovery.

The Relationship between Esmolol and the Onset and Duration of Action of Succinylcholine in Patients Undergoing General or Orthopedic Surgery

DTIC Science & Technology

1983-05-01

mg intravenous (IV). Thirteen experimental subjects (Group I) received an infusion of esmolol 500 mcg/kg/min for 4 minutes prior to induction. The...fasciculations (Coppage. Wolfson, & Siker. 1972). Succinylcholine. Sch is a depolarizing muscle relaxant. In 1906. Reid. Hunt. and de Taveau experimented ...with Sch, however, these researchers described only the cardiovascular effects of the compound. Since their experiments were on animals paralyzed with

Oral Hydration for Prevention of Contrast-Induced Acute Kidney Injury in Elective Radiological Procedures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PubMed Central

Cheungpasitporn, Wisit; Thongprayoon, Charat; Brabec, Brady A.; Edmonds, Peter J.; O'Corragain, Oisin A.; Erickson, Stephen B.

2014-01-01

Background: The reports on efficacy of oral hydration treatment for the prevention of contrast-induced acute kidney injury (CIAKI) in elective radiological procedures and cardiac catheterization remain controversial. Aims: The objective of this meta-analysis was to assess the use of oral hydration regimen for prevention of CIAKI. Materials and Methods: Comprehensive literature searches for randomized controlled trials (RCTs) of outpatient oral hydration treatment was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials Systematic Reviews, and clinicaltrials.gov from inception until July 4th, 2014. Primary outcome was the incidence of CIAKI. Results: Six prospective RCTs were included in our analysis. Of 513patients undergoing elective procedures with contrast exposures,45 patients (8.8%) had CIAKI. Of 241 patients with oral hydration regimen, 23 (9.5%) developed CIAKI. Of 272 patients with intravenous (IV) fluid regimen, 22 (8.1%) had CIAKI. Study populations in all included studies had relatively normal kidney function to chronic kidney disease (CKD) stage 3. There was no significant increased risk of CIAKI in oral fluid regimen group compared toIV fluid regimen group (RR = 0.94, 95% confidence interval, CI = 0.38-2.31). Conclusions: According to our analysis,there is no evidence that oral fluid regimen is associated with more risk of CIAKI in patients undergoing elective procedures with contrast exposures compared to IV fluid regimen. This finding suggests that the oral fluid regimen might be considered as a possible outpatient treatment option for CIAKI prevention in patients with normal to moderately reduced kidney function. PMID:25599049

Enhanced recovery after elective coronary revascularization surgery with minimal versus conventional extracorporeal circulation: a prospective randomized study.

PubMed

Anastasiadis, Kyriakos; Asteriou, Christos; Antonitsis, Polychronis; Argiriadou, Helena; Grosomanidis, Vassilios; Kyparissa, Magdalena; Deliopoulos, Apostolos; Konstantinou, Dimitrios; Tossios, Paschalis

2013-10-01

A minimal extracorporeal circulation (MECC) circuit integrates the advances in cardiopulmonary bypass (CPB) technology into a single circuit and is associated with improved short-term outcome. The aim of this study was to prospectively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures. Prospective randomized study. All patients scheduled for elective coronary artery surgery were evaluated, excluding those considered particularly high risk for fast-track failure. The fast-track protocol included careful preoperative patient selection, a fast-track anesthetic technique based on minimal administration of fentanyl, surgery at normothermia, early postoperative extubation in the cardiac recovery unit, and admission to the cardiothoracic ward within the first 24 hours postoperatively. One hundred twenty patients were assigned randomly into 2 groups (60 in each group). Group A included patients who were operated on using the MECC circuit, whereas patients in Group B underwent surgery on conventional CPB. Incidence of fast-track recovery was significantly higher in patients undergoing MECC (25% v 6.7%, p = 0.006). MECC also was recognized as a strong independent predictor of early recovery, with an odds ratio of 3.8 (p = 0.011). Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion, duration of inotropic support, need for an intra-aortic balloon pump, and development of postoperative atrial fibrillation and renal failure. MECC promotes successful early recovery after elective coronary revascularization procedures, even in a nondedicated cardiac intensive care unit setting. Copyright © 2013 Elsevier Inc. All rights reserved.

Chewing Xylitol Gum could Accelerate Bowel motility Recovery after Elective Open Proctectomy for Rectal Cancer.

PubMed

Yang, Ping; Long, Wu Jun; Wei, Li

2018-01-01

A number of studies with conflicting results have evaluated the effect of chewing gum on post-operative gastrointestinal recovery in patients after major colorectal surgery. The objective of the study was to study the efficacy of chewing gum in patients with rectal cancer after elective open proctectomy only. A randomized controlled clinical trial was performed. We recruited patients who would undergo elective open proctectomy for rectal cancer in Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital. Patients in the intervention arm received chewing gum 3 times a day postoperatively. All patients in the trial were placed on the same perioperative management and standardized post-operative care plans. The primary outcome was time to the first peristalsis sounds, time to first flatus and the first defecation. A total of 89 patients were recruited. The time to the first flatus was 42.33 ± 3.46 h in the gum group and 49.20 ± 1.42 h in the control group (p < 0.05). The time to the first defecation was significantly shorter in the gum-chewing group than in the control group (66.07 ± 2.36 vs. 78.37 ± 1.62 h; p < 0.05). Post-operative ileus (POI) was confirmed in 2 patients in the gum-chewing group and in 7 in the control group (7.0% vs. 23.9%; p = 0.028). The present study suggests that chewing gum is a method to reduce the time to first flatus, time to first defecation and POI in patients undergoing elective open proctectomy for rectal cancer. Copyright: © 2017 SecretarÍa de Salud.

Comparison of 7.2% hypertonic saline - 6% hydroxyethyl starch solution and 6% hydroxyethyl starch solution after the induction of anesthesia in patients undergoing elective neurosurgical procedures.

PubMed

Shao, Liujiazi; Wang, Baoguo; Wang, Shuangyan; Mu, Feng; Gu, Ke

2013-01-01

The ideal solution for fluid management during neurosurgical procedures remains controversial. The aim of this study was to compare the effects of a 7.2% hypertonic saline - 6% hydroxyethyl starch (HS-HES) solution and a 6% hydroxyethyl starch (HES) solution on clinical, hemodynamic and laboratory variables during elective neurosurgical procedures. Forty patients scheduled for elective neurosurgical procedures were randomly assigned to the HS-HES group orthe HES group. Afterthe induction of anesthesia, patients in the HS-HES group received 250 mL of HS-HES (500 mL/h), whereas the patients in the HES group received 1,000 mL of HES (1000 mL/h). The monitored variables included clinical, hemodynamic and laboratory parameters. Chictr.org: ChiCTR-TRC-12002357 The patients who received the HS-HES solution had a significant decrease in the intraoperative total fluid input (p<0.01), the volume of Ringer's solution required (p<0.05), the fluid balance (p<0.01) and their dural tension scores (p<0.05). The total urine output, blood loss, bleeding severity scores, operation duration and hemodynamic variables were similar in both groups (p>0.05). Moreover, compared with the HES group, the HS-HES group had significantly higher plasma concentrations of sodium and chloride, increasing the osmolality (p<0.01). Our results suggest that HS-HES reduced the volume of intraoperative fluid required to maintain the patients undergoing surgery and led to a decrease in the intraoperative fluid balance. Moreover, HS-HES improved the dural tension scores and provided satisfactory brain relaxation. Our results indicate that HS-HES may represent a new avenue for volume therapy during elective neurosurgical procedures.

Comparison of 7.2% hypertonic saline - 6% hydroxyethyl starch solution and 6% hydroxyethyl starch solution after the induction of anesthesia in patients undergoing elective neurosurgical procedures

PubMed Central

Shao, Liujiazi; Wang, Baoguo; Wang, Shuangyan; Mu, Feng; Gu, Ke

2013-01-01

OBJECTIVE: The ideal solution for fluid management during neurosurgical procedures remains controversial. The aim of this study was to compare the effects of a 7.2% hypertonic saline - 6% hydroxyethyl starch (HS-HES) solution and a 6% hydroxyethyl starch (HES) solution on clinical, hemodynamic and laboratory variables during elective neurosurgical procedures. METHODS: Forty patients scheduled for elective neurosurgical procedures were randomly assigned to the HS-HES group or the HES group. After the induction of anesthesia, patients in the HS-HES group received 250 mL of HS-HES (500 mL/h), whereas the patients in the HES group received 1,000 mL of HES (1000 mL/h). The monitored variables included clinical, hemodynamic and laboratory parameters. Chictr.org: ChiCTR-TRC-12002357 RESULTS: The patients who received the HS-HES solution had a significant decrease in the intraoperative total fluid input (p<0.01), the volume of Ringer's solution required (p<0.05), the fluid balance (p<0.01) and their dural tension scores (p<0.05). The total urine output, blood loss, bleeding severity scores, operation duration and hemodynamic variables were similar in both groups (p>0.05). Moreover, compared with the HES group, the HS-HES group had significantly higher plasma concentrations of sodium and chloride, increasing the osmolality (p<0.01). CONCLUSION: Our results suggest that HS-HES reduced the volume of intraoperative fluid required to maintain the patients undergoing surgery and led to a decrease in the intraoperative fluid balance. Moreover, HS-HES improved the dural tension scores and provided satisfactory brain relaxation. Our results indicate that HS-HES may represent a new avenue for volume therapy during elective neurosurgical procedures. PMID:23644851

Perioperative management of diabetes in elective patients: a region-wide audit.

PubMed

Jackson, M J; Patvardhan, C; Wallace, F; Martin, A; Yusuff, H; Briggs, G; Malik, R A

2016-04-01

Ten percent of elective surgical patients have diabetes. These patients demonstrate excess perioperative morbidity and mortality. National guidance on the management of adults with diabetes undergoing surgery was published in 2011. We present a region-wide audit of adherence to this guidance across the North Western Deanery. Local teams prospectively collected data according to a locally approved protocol. Pregnant, paediatric and non-elective patients were excluded from this audit. Patient characteristics, type of surgery and aspects of perioperative management were collated and centrally analysed against audit criteria based upon national recommendations. 247 patients with diabetes were identified. HbA1c was recorded in 71% of patients preoperatively; 9% of patients with an abnormal HbA1c were not known by, or referred to, the diabetes team. 17% of patients were admitted the evening preceding surgery. The mean fasting time was 12:20(4) h. Variable rate i.v. insulin infusions (VRIII) were not used when indicated in 11%. Only 8% of patients received the recommended substrate fluid, along with the VRIII (5% glucose in 0.45% saline). Intra-operative capillary blood glucose (CBG) was measured hourly in 56% of patients. Intra-operative CBG was within the acceptable range (4-12 mmol.L(-1)) in 85% of patients. 73% of patients had a CBG measurement performed in recovery. The WHO checklist was used in 95% of patients. National perioperative guidelines were not adhered to in a substantial proportion of patients with diabetes undergoing elective surgery. This study represents a template for future trainee networks. © The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Reduction of operative mortality after implementation of Surgical Outcomes Monitoring and Improvement Programme by Hong Kong Hospital Authority.

PubMed

Yuen, W C; Wong, K; Cheung, Y S; Lai, P Bs

2018-04-01

Since 2008, the Hong Kong Hospital Authority has implemented a Surgical Outcomes Monitoring and Improvement Programme (SOMIP) at 17 public hospitals with surgical departments. This study aimed to assess the change in operative mortality rate after implementation of SOMIP. The SOMIP included all Hospital Authority patients undergoing major/ultra-major procedures in general surgery, urology, plastic surgery, and paediatric surgery. Patients undergoing liver or renal transplantation or who had multiple trauma or massive bowel ischaemia were excluded. In SOMIP, data retrieval from the Hospital Authority patient database was performed by six full-time nurse reviewers following a set of precise data definitions. A total of 230 variables were collected for each patient, on demographics, preoperative and operative variables, laboratory test results, and postoperative complications up to 30 days after surgery. In this study, we used SOMIP cumulative 5-year data to generate risk-adjusted 30-day mortality models by hierarchical logistic regression for both emergency and elective operations. The models expressed overall performance as an annual observed-to-expected mortality ratio. From 2009/2010 to 2015/2016, the overall crude mortality rate decreased from 10.8% to 5.6% for emergency procedures and from 0.9% to 0.4% for elective procedures. From 2011/2012 to 2015/2016, the risk-adjusted observed-to-expected mortality ratios showed a significant downward trend for both emergency and elective operations: from 1.126 to 0.796 and from 1.150 to 0.859, respectively (Mann- Kendall statistic = -0.8; P<0.05 for both). The Hospital Authority's overall crude mortality rates and risk-adjusted observed-to-expected mortality ratios for emergency and elective operations significantly declined after SOMIP was implemented.

The role of colonic mast cells and myenteric plexitis in patients with diverticular disease.

PubMed

Bassotti, Gabrio; Villanacci, Vincenzo; Nascimbeni, Riccardo; Antonelli, Elisabetta; Cadei, Moris; Manenti, Stefania; Lorenzi, Luisa; Titi, Amin; Salerni, Bruno

2013-02-01

Gut mast cells represent an important cell population involved in intestinal homeostasis and inflammatory processes. However, their possible role has not to date been investigated in colonic diverticular disease. This study aims to evaluate colonic mast cells in patients undergoing surgery for diverticular disease. Surgical resection samples from 27 patients undergoing surgery for diverticular disease (12 emergency procedures for severe disease and 15 elective procedures) were evaluated. The number of mast cells was assessed in the various layers by means of a specific antibody (tryptase) and compared with those evaluated in ten controls. In patients with mast cells degranulation, double immunohistochemistry, also assessing nerve fibres, was carried out. In addition, the presence of myenteric plexitis was sought. Compared with controls, the number of mast cells in diverticular patients was significantly increased, both as an overall figure and in the various layers of the large bowel. In patients in whom mast cells degranulation was present, these were always closed to nerve fibres. No differences were found between the two subgroups of patients with respect to the number and distribution of mast cells; however, all patients undergoing emergency surgery (but none of those undergoing elective procedures) had myenteric plexitis, represented by lymphocytic infiltration in 67 % and eosinophilic infiltration in 33 % of cases. Patients with diverticular disease display an increase of mast cells in the large bowel. The presence of myenteric plexitis in those with complicated, severe disease, suggest that this could represent a histopathologic marker of more aggressive disease.

The Epidemiology and Outcomes of Percutaneous Coronary Intervention Before High‐Risk Noncardiac Surgery in Contemporary Practice: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) Registry

PubMed Central

Muthappan, Palaniappan; Smith, Dean; Aronow, Herbert D.; Eagle, Kim; Wohns, David; Fox, James; Share, David; Gurm, Hitinder S.

2014-01-01

Background Percutaneous coronary intervention (PCI) is sometimes performed with the intent to lower cardiovascular risk before high‐risk noncardiac surgery (HRNCS). There are limited data on the frequency and outcome of PCIs performed in this setting. Methods and Results We assessed the frequency, characteristics, and in‐hospital outcomes of patients undergoing PCI as part of the preoperative workup for HRNCS among all 61 145 elective PCIs performed between 2002 and 2009 at 14 hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Propensity matching was performed to compare outcomes of patients undergoing PCI before HRNCS with all other elective PCI patients. The frequency of PCI before HRNCS was low (4.2%). Patients undergoing PCI before HRNCS were older (67.3 versus 64.9 years, P<0.0001) and had a greater burden of comorbidity. Patients undergoing PCI before HRNCS had an increase in unadjusted major adverse cardiovascular events, postprocedure transfusion, contrast‐induced nephropathy, nephropathy requiring dialysis, and same‐admission coronary artery bypass graft surgery, but there was no difference in mortality (0.27% versus 0.14%, P=0.11). However, in propensity score–matched samples, there was a significant difference only in nephropathy requiring dialysis. Conclusions The incidence of PCI performed in preparation for high‐risk noncardiac surgery is low, and these procedures are currently being performed on a highly selected high‐risk patient population. PMID:24820654

Coagulation management in patients undergoing neurosurgical procedures.

PubMed

Robba, Chiara; Bertuetti, Rita; Rasulo, Frank; Bertuccio, Alessando; Matta, Basil

2017-10-01

Management of coagulation in neurosurgical procedures is challenging. In this contest, it is imperative to avoid further intracranial bleeding. Perioperative bleeding can be associated with a number of factors, including anticoagulant drugs and coagulation status but is also linked to the characteristic and the site of the intracranial disorder. The aim of this review will be to focus primarily on the new evidence regarding the management of coagulation in patients undergoing craniotomy for neurosurgical procedures. Antihemostatic and anticoagulant drugs have shown to be associated with perioperative bleeding. On the other hand, an increased risk of venous thromboembolism and hypercoagulative state after elective and emergency neurosurgery, in particular after brain tumor surgery, has been described in several patients. To balance the risk between thrombosis and bleeding, it is important to be familiar with the perioperative changes in coagulation and with the recent management guidelines for anticoagulated patients undergoing neurosurgical procedures, in particular for those taking new direct anticoagulants. We have considered the current clinical trials and literature regarding both safety and efficacy of deep venous thrombosis prophylaxis in the neurosurgical population. These were mainly trials concerning both elective surgical and intensive care patients with a poor grade intracranial bleed or multiple traumas with an associated severe traumatic brain injury (TBI). Coagulation management remains a major issue in patients undergoing neurosurgical procedures. However, in this field of research, literature quality is poor and further studies are necessary to identify the best strategies to minimize risks in this group of patients.

Effects of carprofen and meloxicam on C-reactive protein, ceruloplasmin, and fibrinogen concentrations in dogs undergoing ovariohysterectomy.

PubMed

Kum, Cavit; Voyvoda, Huseyin; Sekkin, Selim; Karademir, Umit; Tarimcilar, Tugrul

2013-10-01

To evaluate the effects of perioperative oral administration of carprofen and meloxicam on concentrations of 3 acute-phase proteins in dogs undergoing elective ovariohysterectomy (OVH). 18 healthy adult anestrous female dogs undergoing elective OVH. Dogs were allocated to 3 groups (6 dogs/group). A placebo treatment, carprofen (2.0 mg/kg), or meloxicam (0.2 mg/kg) was orally administered to the dogs of the respective groups. The initial doses were administered 30 minutes before premedication prior to OVH; additional doses were administered once daily for 4 days after surgery. Blood samples were collected 45 minutes before premedication and 4, 8, 12, 24, 36, 48, 72, 96, and 120 hours after the end of OVH; samples were used for measurement of total WBC and neutrophil counts and concentrations of C-reactive protein (CRP), ceruloplasmin, and fibrinogen. Values did not differ significantly among groups for WBC and neutrophil counts, serum concentrations of CRP and ceruloplasmin, and plasma concentrations of fibrinogen. Concentrations of all inflammatory markers, except serum ceruloplasmin, increased significantly following OVH, but in a similar manner for each group. No significant changes were detected in serum ceruloplasmin concentrations over time. Perioperative administration of both carprofen and meloxicam did not significantly affect the concentrations of CRP, ceruloplasmin, and fibrinogen in dogs undergoing OVH. Thus, use of carprofen or meloxicam should not affect clinical interpretation of results for these 3 acute-phase proteins.

Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

PubMed Central

Smaill, Fiona M; Gyte, Gillian ML

2014-01-01

Background The single most important risk factor for postpartum maternal infection is cesarean section. Routine prophylaxis with antibiotics may reduce this risk and should be assessed in terms of benefits and harms. Objectives To assess the effects of prophylactic antibiotics compared with no prophylactic antibiotics on infectious complications in women undergoing cesarean section. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (May 2009). Selection criteria Randomized controlled trials (RCTs) and quasi-RCTs comparing the effects of prophylactic antibiotics versus no treatment in women undergoing cesarean section. Data collection and analysis Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Main results We identified 86 studies involving over 13,000 women. Prophylactic antibiotics in women undergoing cesarean section substantially reduced the incidence of febrile morbidity (average risk ratio (RR) 0.45; 95% confidence interval (CI) 0.39 to 0.51, 50 studies, 8141 women), wound infection (average RR 0.39; 95% CI 0.32 to 0.48, 77 studies, 11,961 women), endometritis (RR 0.38; 95% CI 0.34 to 0.42, 79 studies, 12,142 women) and serious maternal infectious complications (RR 0.31; 95% CI 0.19 to 0.48, 31 studies, 5047 women). No conclusions can be made about other maternal adverse effects from these studies (RR 2.43; 95% CI 1.00 to 5.90, 13 studies, 2131 women). None of the 86 studies reported infant adverse outcomes and in particular there was no assessment of infant oral thrush. There was no systematic collection of data on bacterial drug resistance. The findings were similar whether the cesarean section was elective or non elective, and whether the antibiotic was given before or after umbilical cord clamping. Overall, the methodological quality of the trials was unclear and in only a few studies was it obvious that potential other sources of bias had been adequately addressed. Authors’ conclusions Endometritis was reduced by two thirds to three quarters and a decrease in wound infection was also identified. However, there was incomplete information collected about potential adverse effects, including the effect of antibiotics on the baby, making the assessment of overall benefits and harms complicated. Prophylactic antibiotics given to all women undergoing elective or non-elective cesarean section is clearly beneficial for women but there is uncertainty about the consequences for the baby. PMID:20091635

Influences on Early and Medium-Term Survival Following Surgical Repair of the Aortic Arch

PubMed Central

Bashir, Mohamad; Field, Mark; Shaw, Matthew; Fok, Matthew; Harrington, Deborah; Kuduvalli, Manoj; Oo, Aung

2014-01-01

Objectives: It is now well established by many groups that surgery on the aortic arch may be achieved with consistently low morbidity and mortality along with relatively good survival compared to estimated natural history for a number of aortic arch pathologies. The objectives of this study were to: 1) report, compare, and analyze our morbidity and mortality outcomes for hemiarch and total aortic arch surgery; 2) examine the survival benefit of hemiarch and total aortic arch surgery compared to age- and sex-matched controls; and 3) define factors which influence survival in these two groups and, in particular, identify those that are modifiable and potentially actionable. Methods: Outcomes from patients undergoing surgical resection of both hemiarch and total aortic arch at the Liverpool Heart and Chest Hospital between June 1999 and December 2012 were examined in a retrospective analysis of data collected for The Society for Cardiothoracic Surgeons (UK). Results: Over the period studied, a total of 1240 patients underwent aortic surgery, from which 287 were identified as having undergone hemi to total aortic arch surgery under deep or moderate hypothermic circulatory arrest. Twenty three percent of patients' surgeries were nonelective. The median age at the time of patients undergoing elective hemiarch was 64.3 years and total arch was 65.3 years (P = 0.25), with 40.1% being female in the entire group. A total of 140 patients underwent elective hemiarch replacement, while 81 underwent elective total arch replacement. Etiology of the aortic pathology was degenerative in 51.2% of the two groups, with 87.1% requiring aortic valve repair in the elective hemiarch group and 64.2% in the elective total arch group (P < 0.001). Elective in-hospital mortality was 2.1% in the hemiarch group and 6.2% (P = 0.15) in the total arch group with corresponding rates of stroke (2.9% versus 4.9%, P = 0.47), renal failure (4.3% versus 6.2%, P = 0.54), reexploration for bleeding (4.3% versus 4.9%, P > 0.99), and prolonged ventilation (8.6% versus 16.1%, P = 0.09). Overall mortality was 20.9% at 5 years, while it was 15.7% in the elective hemiarch and 25.9% in the total arch group (P = 0.065). Process control charts demonstrated stability of annualized mortality outcomes over the study period. Survival curve was flat and parallel compared to age- and sex-matched controls beyond 2 years. Multivariate analysis demonstrated the following independent factors associated with survival: renal dysfunction [hazard ratio (HR) = 3.11; 95% confidence interval (CI) = 1.44-6.73], New York Heart Association (NYHA) class ≥ III (HR = 2.25; 95% CI = 1.38-3.67), circulatory arrest time > 100 minutes (HR = 2.92; 95% CI = 1.57-5.43), peripheral vascular disease (HR = 2.44; 95% CI = 1.25-4.74), and concomitant coronary artery bypass graft operation (HR = 2.14; 95% CI = 1.20-3.80). Conclusions: Morbidity, mortality, and medium-term survival were not statistically different for patients undergoing elective hemi-aortic arch and total aortic arch surgery. The survival curve in this group of patients is flat and parallel to sex- and age-matched controls beyond 2 years. Multivariate analysis identified independent influences on survival as renal dysfunction, NYHA class ≥ III, circulatory arrest time (> 100 min), peripheral vascular disease, and concomitant coronary artery bypass grafting. Focus on preoperative optimization of some of these variables may positively influence long-term survival. PMID:26798716

Does use of intraoperative cell-salvage delay recovery in patients undergoing elective abdominal aortic surgery?

PubMed

Tavare, Aniket N; Parvizi, Nassim

2011-06-01

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether the use of intraoperative cell-salvage (ICS) leads to negative outcomes in patients undergoing elective abdominal aortic surgery? Altogether 305 papers were found using the reported search, of which 10 were judged to represent the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. None of the 10 papers included in the analysis demonstrated that ICS use led to significantly higher incidence of cardiac or septic postoperative complications. Similarly, length of intensive treatment unit (ITU) or hospital stay and mortality in elective abdominal aortic surgery were not adversely affected. Indeed two trials actually show a significantly shorter hospital stay after ICS use, one a shorter ITU stay and another suggests lower rates of chest sepsis. Based on these papers, we concluded that the use of ICS does not cause increased morbidity or mortality when compared to standard practise of transfusion of allogenic blood, and may actually improve some clinical outcomes. As abdominal aortic surgery inevitably causes significant intraoperative blood loss, in the range of 661-3755 ml as described in the papers detailed in this review, ICS is a useful and safe strategy to minimise use of allogenic blood.

Patient and family satisfaction levels in the intensive care unit after elective cardiac surgery: study protocol for a randomised controlled trial of a preoperative patient education intervention

PubMed Central

Leung, Patricia; Chiu, Chun Hung; Ho, Ka Man; Gomersall, Charles David; Underwood, Malcolm John

2016-01-01

Introduction Patients and their families are understandably anxious about the risk of complications and unfamiliar experiences following cardiac surgery. Providing information about postoperative care in the intensive care unit (ICU) to patients and families may lead to lower anxiety levels, and increased satisfaction with healthcare. The objectives of this study are to evaluate the effectiveness of preoperative patient education provided for patients undergoing elective cardiac surgery. Methods and analysis 100 patients undergoing elective coronary artery bypass graft, with or without valve replacement surgery, will be recruited into a 2-group, parallel, superiority, double-blinded randomised controlled trial. Participants will be randomised to either preoperative patient education comprising of a video and ICU tour with standard care (intervention) or standard education (control). The primary outcome measures are the satisfaction levels of patients and family members with ICU care and decision-making in the ICU. The secondary outcome measures are patient anxiety and depression levels before and after surgery. Ethics and dissemination Ethical approval has been obtained from the Joint Chinese University of Hong Kong—New Territories East Cluster Clinical Research Ethics Committee (reference number CREC 2015.308). The findings will be presented at conferences and published in peer-reviewed journals. Study participants will receive a 1-page plain language summary of results. Trial registration number ChiCTR-IOR-15006971. PMID:27334883

A single-center retrospective study of pregnancy outcomes after emergency cerclage for cervical insufficiency.

PubMed

Wang, Sheng; Feng, Ling

2017-10-01

To compare maternal and perinatal outcomes after emergency cerclage with those after elective cerclage. In a retrospective review, data were assessed from women with a viable singleton pregnancy who underwent elective or emergency cerclage for cervical insufficiency at the Tongji Hospital, Wuhan, China, between January 2010 and July 2015. Subgroup analyses based on cervical length (CL; ≤15, 15-25, and 25-30 mm) were also conducted among women undergoing emergency cerclage. In total, 68 women underwent elective cerclage and 53 underwent emergency cerclage. The suture-to-delivery interval was significantly longer in the elective group (19.17 ± 5.86 weeks) than in the emergency group (11.29 ± 7.27 weeks; P<0.001). There was no difference between the elective and emergency groups in mean pregnancy length at delivery, frequency of Apgar score below 7 at 5 minutes (live births only), or birth weight (live births only). An inverse trend in the degree of CL shortening with pregnancy outcomes was observed; women with a CL of 25-30 mm had the best outcomes. Pregnancy outcomes were similar after emergency and elective cerclage. There was an inverse trend in the degree of CL shortening with pregnancy outcomes in the emergency cerclage group, with better outcomes observed for women with longer CL. © 2017 International Federation of Gynecology and Obstetrics.

Effects of auditory and audiovisual presentations on anxiety and behavioral changes in children undergoing elective surgery.

PubMed

Hatipoglu, Z; Gulec, E; Lafli, D; Ozcengiz, D

2018-06-01

: Preoperative anxiety is a critical issue in children, and associated with postoperative behavioral changes. : The purpose of the current study is to evaluate how audiovisual and auditory presentations about the perioperative period impact preoperative anxiety and postoperative behavioral disturbances of children undergoing elective ambulatory surgery. : A total of 99 patients between the ages of 5-12, scheduled to undergo outpatient surgery, participated in this study. Participants were randomly assigned to one of three groups; audiovisual group (Group V, n = 33), auditory group (Group A, n = 33), and control group (Group C, n = 33). During the evaluation, the Modified Yale Preoperative Anxiety Scale (M-YPAS) and the posthospitalization behavioral questionnaire (PHBQ) were used. : There were no significant differences in demographic characteristics between the groups. M-YPAS scores were significantly lower in Group V than in Groups C and A (P < 0.001 and P < 0.001, respectively). PHBQ scores in Group C were statistically higher than in Groups A and V, but, no statistical difference was found between Groups A and V. Compared to auditory presentations, audiovisual presentations, in terms of being memorable and interesting, may be more effective in reducing children's anxiety. In addition, we can suggest that both methods can be equally effective for postoperative behavioral changes.

The effectiveness of age-appropriate pre-operative information session on the anxiety level of school-age children undergoing elective surgery in Jordan.

PubMed

Shaheen, Abeer; Nassar, Omayyah; Khalaf, Inaam; Kridli, Suha Al-Oballi; Jarrah, Samiha; Halasa, Suhaila

2018-06-01

Undergoing surgery is an anxious experience for children. Applying anxiety reduction age-appropriate programs by nurses would be beneficial in reducing anxiety to children. To test the effectiveness of age-appropriate preoperative information session in reducing anxiety levels of school-age children undergoing elective surgery in Jordan. The study used a quasi-experimental design. One hundred and twenty-six children were recruited from an educational hospital in Amman from January to June 2012 and were randomly assigned to intervention and control groups. The anxiety levels of children were assessed using the State Anxiety Scale for children, and children's levels of cooperation after surgery were assessed using Children Emotional Manifestation Scale. The heart rate and blood pressure of children were also measured 1 hour before going to operation room. The study results revealed that children in the intervention group reported lower anxiety levels and more cooperation than children in the control group. Also, they displayed lower heart rate and blood pressure than children in the control group. The application of age-appropriate preoperative intervention for children could be beneficial in decreasing anxiety levels and increasing their cooperation post surgery. © 2018 John Wiley & Sons Australia, Ltd.

Thromboprophylaxis With Apixaban in Patients Undergoing Major Orthopedic Surgery: Meta-Analysis and Trial-Sequential Analysis.

PubMed

Caldeira, Daniel; Rodrigues, Filipe B; Pinto, Fausto J; Ferreira, Joaquim J; Costa, João

2017-01-01

Venous thromboembolism (VTE) is a potentially fatal complication of orthopedic surgery, and until recently, few antithrombotic compounds were available for postoperative thromboprophylaxis. The introduction of the non-vitamin K antagonists oral anticoagulants (NOAC), including apixaban, has extended the therapeutic armamentarium in this field. Therefore, estimation of NOAC net clinical benefit in comparison with the established treatment is needed to inform clinical decision making. Systematic review to assess the efficacy and safety of apixaban 2.5 mg twice a day versus low-molecular-weight heparins (LMWH) for thromboprophylaxis in patients undergoing knee or hip replacement. MEDLINE, Embase, and CENTRAL were searched from inception to September 2016, other systematic reviews, reference lists, and experts were consulted. All major orthopedic surgery randomized controlled trials comparing apixaban 2.5 mg twice daily with LMWH, reporting thrombotic and bleeding events. Two independent reviewers, using a predetermined form. The Cochrane tool to assess risk bias was used by two independent authors. RevMan software was used to estimate pooled risk ratio (RR) and 95% confidence intervals (95% CI) using random-effects meta-analysis. Trial sequential analysis (TSA) was performed in statistical significant results to evaluate whether cumulative sample size was powered for the obtained effect. Overall confidence in cumulative evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group methodology. Four studies comparing apixaban 2.5 mg twice daily with LMWH were included, with a total of 11.828 patients (55% undergoing knee and 45% hip replacement). The overall risk of bias across studies was low. In comparison with LMWH (all regimens), apixaban showed a significantly lower risk of VTE events and overall mortality combined (RR: 0.63, 95% CI: 0.42-0.95, I 2 = 84%, n = 8346), but not of major VTE events (RR: 0.62, 95% CI: 0.32-1.19, I 2 = 63%, n = 9493), or of symptomatic VTE events and VTE-related mortality combined (RR: 1.14, 95% CI: 0.68-1.90, I 2 = 0%, n = 11 879). Trial sequential analysis showed that the risk reduction obtained for VTE and mortality was based on underpowered cumulative sample size and effect dimension. Subgroup analysis according to LMWH regimens showed that apixaban reduced the risk of VTE events and overall mortality, and major VTE events, when compared with LMWH once daily, without differences between apixaban and LMWH twice daily. There is low to moderate evidence that in patients undergoing knee or hip replacement, apixaban seems equally effective and safe to LMWH twice a day. When compared with LMWH once a day, apixaban seems a superior thromboprophylaxis option. However, the results are underpowered which precludes definite answers regarding the true net clinical benefit of apixaban versus LMWH in this clinical context.

Prevalence and extent of obstructive coronary artery disease among patients undergoing elective coronary catheterization in New York State and Ontario.

PubMed

Ko, Dennis T; Tu, Jack V; Austin, Peter C; Wijeysundera, Harindra C; Samadashvili, Zaza; Guo, Helen; Cantor, Warren J; Hannan, Edward L

2013-07-10

Prior studies have shown that physicians in New York State (New York) perform twice as many cardiac catheterizations per capita as those in Ontario for stable patients. However, the role of patient selection in these findings and their implications for detection of obstructive coronary artery disease (CAD) are largely unknown. To evaluate the extent of obstructive CAD and to compare the probability of detecting obstructive CAD for patients undergoing cardiac catheterization. An observational study was conducted involving patients without a history of cardiac disease who underwent elective cardiac catheterization between October 1, 2008, and September 30, 2011. Obstructive CAD was defined as diameter stenosis of 50% or more in the left main coronary artery or stenosis of 70% or more in a major epicardial vessel. Observed rates and predicted probabilities of obstructive CAD. Predicted probabilities were estimated using logistic regression models. A total of 18,114 patients from New York and 54,933 from Ontario were included. The observed rate of obstructive CAD was significantly lower in New York at 30.4% (95% CI, 29.7%-31.0%) than in Ontario at 44.8% (95% CI, 44.4%-45.3%; P < .001). The percentage of patients with left main or 3-vessel CAD was also significantly lower in New York than in Ontario (7.0% [95% CI, 6.6%-7.3%] vs 13.0% [95% CI, 12.8%-13.3%]; P < .001). In New York, a substantially higher percentage of patients with low predicted probability of obstructive CAD underwent cardiac catheterization; for example, only 19.3% (95% CI, 18.7%-19.9%) of patients undergoing cardiac catheterization in New York had a greater than 50% predicted probability of having obstructive CAD than those in Ontario at 41% (95% CI, 40.6%-41.4%; P < .001). At 30 days, crude mortality for patients undergoing cardiac catheterization was slightly higher in New York at 0.65% (90 of 13,824; 95% CI, 0.51%-0.78%) than in Ontario at 0.38% (153 of 40,794; 95% CI, 0.32%-0.43%; P < .001). In Ontario compared with New York State, patients undergoing elective cardiac catheterization were significantly more likely to have obstructive CAD. This appears to be related to a higher percentage of patients in New York with low predicted probability of CAD undergoing cardiac catheterization.

Advanced Age: Is It an Indication or Contraindication for Laparoscopic Ventral Hernia Repair?

PubMed Central

Elgamal, Mohamed H.; Mancl, Tara B.; Norman, Earl; Boros, Michael J.

2008-01-01

Introduction: Ventral hernias are common surgical problems in the geriatric population. Although ventral hernias are electively repaired in younger patients, the safety and efficacy of elective laparoscopic hernia repair in the geriatric age group is not well documented in the literature. Methods: A review of 155 patients undergoing laparoscopic ventral hernia repair was undertaken. The patients were classified according to their age into 2 groups, Group A (n=126) for those who are ≤65 years old and Group B (n=29) for those who are >65 years old. The patient demographics, comorbidities, hernia characteristics, and operative and postoperative data were compared. Results: Younger patients were found to have a significantly increased BMI, while the older group had an increased number of comorbidities. No difference was found in the complication or recurrence rates between the 2 groups. Conclusion: Elective laparoscopic ventral hernia repair in senior citizens is safe and feasible in our experience. We believe that the decision to perform an elective hernia repair in this patient population should be based on the general condition of the patient rather than the patient's chronological age. PMID:18402738

Reducation of Anxiety in Children Facing Hospitalization and Surgery by Use of Filmed Modeling

ERIC Educational Resources Information Center

Melamed, Barbara G.; Siegel, Lawrence J.

1975-01-01

A group of children (N=60) about to undergo elective surgery for hernias, tonsillectomies, or urinary-genital tract difficulties were shown on hospital admission either a relevant peer modeling film of a child being hospitalized and receiving surgery or an unrelated control film. (Author)

7 CFR 457.124 - Raisin crop insurance provisions.

Code of Federal Regulations, 2012 CFR

2012-01-01

... maximum dollar amount. The value per ton established by FCIC and shown in the actuarial documents... insured tonnage by the reference maximum dollar amount, by the coverage level percentage you elect, and by... maximum dollar amount, except if your damaged production undergoes a USDA inspection and is stored by your...

7 CFR 457.124 - Raisin crop insurance provisions.

Code of Federal Regulations, 2013 CFR

2013-01-01

... maximum dollar amount. The value per ton established by FCIC and shown in the actuarial documents... insured tonnage by the reference maximum dollar amount, by the coverage level percentage you elect, and by... maximum dollar amount, except if your damaged production undergoes a USDA inspection and is stored by your...

7 CFR 457.124 - Raisin crop insurance provisions.

Code of Federal Regulations, 2014 CFR

2014-01-01

... maximum dollar amount. The value per ton established by FCIC and shown in the actuarial documents... insured tonnage by the reference maximum dollar amount, by the coverage level percentage you elect, and by... maximum dollar amount, except if your damaged production undergoes a USDA inspection and is stored by your...

7 CFR 457.124 - Raisin crop insurance provisions.

Code of Federal Regulations, 2011 CFR

2011-01-01

... maximum dollar amount—The value per ton established by FCIC and shown in the actuarial documents... insured tonnage by the reference maximum dollar amount, by the coverage level percentage you elect, and by... maximum dollar amount, except if your damaged production undergoes a USDA inspection and is stored by your...

Outpatient repair for inguinal hernia in elderly patients: still a challenge?

PubMed

Palumbo, Piergaspare; Amatucci, Chiara; Perotti, Bruno; Zullino, Antonio; Dezzi, Claudia; Illuminati, Giulio; Vietri, Francesco

2014-01-01

Elective inguinal hernia repair as a day case is a safe and suitable procedure, with well-recognized feasibility. The increasing number of elderly patients requiring inguinal hernia repair leads clinicians to admit a growing number of outpatients. The aim of the current study was to analyze the outcomes (feasibility and safety) of day case treatment in elderly patients. Eighty patients >80 years of age and 80 patients ≤55 years of age underwent elective inguinal hernia repairs under local anesthesia. There were no mortalities or major complications in the elderly undergoing inguinal herniorraphies as outpatients, and only one unanticipated admission occurred in the younger age group. Elective inguinal hernia repair in the elderly has a good outcome, and age alone should not be a drawback to day case treatment. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Is there a role for neck dissection in T1 oral tongue squamous cell carcinoma? The UCLA experience.

PubMed

Peng, Kevin A; Chu, Alan C; Lai, Chi; Grogan, Tristan; Elashoff, David; Abemayor, Elliot; St John, Maie A

2014-01-01

We sought to examine prognostic and therapeutic implications, including cost-effectiveness, of elective neck dissection in the management of patients with clinically-determined T1N0 oral tongue carcinoma. A retrospective review of patients with cT1N0 oral tongue squamous cell carcinoma who underwent surgical extirpation of primary tumor, with or without elective neck dissection, at UCLA Medical Center from 1990 to 2009 was performed. Cox proportional hazards regression was used to assess effects of variables on time to first loco-regional recurrence. A healthcare costs analysis of elective neck dissection was performed by querying the SEER-Medicare linked database. Of the 123 patients identified with cT1N0 squamous cell carcinoma of the oral tongue, 88 underwent elective neck dissection at the time of tumor resection while 35 did not. For all patients, disease-free survival at 3, 5, and 10 years was 93%, 82%, and 79%. Of the 88 patients undergoing elective neck dissection, 20 (23%) demonstrated occult metastatic disease. Male gender, tumor size, perineural invasion, and occult metastatic disease were individually associated with higher rates of loco-regional recurrence. There was no significant difference in loco-regional recurrence between those who underwent elective neck dissection and those who did not (HR=0.76, p=0.52). On cost analysis, neck dissection was not associated with any significant difference in Medicare payments. The high rate of occult metastasis (23%) following elective neck dissection, which did not confer additional healthcare costs, leads to the recommendation of elective neck dissection in patients with cT1N0 oral tongue squamous cell carcinoma. Copyright © 2014 Elsevier Inc. All rights reserved.

[Locomotor development in infants with developmental dysplasia of the hip or idiopathic clubfoot undergoing orthopedic treatment. Prospective comparative study].

PubMed

Masquijo, J J; Campos, L; Torres-Gómez, A; Allende, V

2013-10-01

Several disorders of early childhood, such as developmental dysplasia of the hip (DDH) and clubfoot, requires orthopedic treatment that limits active mobility of the lower extremities for a period of time. The aim of our study was to evaluate the impact on locomotor development of the orthopedic treatment in infants less than one year-old. The study included a prospective cohort of consecutive patients diagnosed with developmental dysplasia of the hip (Group A, 24 patients), and clubfoot (Group B, 32 patients) treated from January 2007 to June 2009. A third group (Group C) of 50 healthy children was used as control. The variables evaluated were: months with a brace, age to sit without support, age at the start of crawling, and age at the beginning of walking. The results obtained were analyzed. Comparisons between the three groups were performed using the Kruskal-Wallis test and Mann-Whitney test. We chose a value of P<.05 as level of statistical significance. The analysis of independent samples showed that the mean age at which the patients began to sit were similar: 6.12, 6.42 and 6.19 months, respectively (P=.249). The mean age for crawling was similar, although with a slight trend toward statistical significance: 8.84, 9.38 and 9.17 months, respectively (P=.08). The age at which they started walking was different between the three groups: 12.14, 13.21 and 12.41 months, respectively (P<.001). Orthopedic treatment of DDH and clubfoot in children less than one year-old slightly slows down the course of normal locomotor development. Copyright © 2012 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.

Comparison of Dexmedetomidine and Fentanyl as an Adjuvant to Ropivacaine for Postoperative Epidural Analgesia in Pediatric Orthopedic Surgery.

PubMed

Park, Sang Jun; Shin, Seokyung; Kim, Shin Hyung; Kim, Hyun Woo; Kim, Seung Hyun; Do, Hae Yoon; Choi, Yong Seon

2017-05-01

Opioids are commonly used as an epidural adjuvant to local anesthetics, but are associated with potentially serious side effects, such as respiratory depression. The aim of this study was to compare the efficacy and safety of dexmedetomidine with that of fentanyl as an adjuvant to epidural ropivacaine in pediatric orthopedic surgery. This study enrolled 60 children (3-12 years old) scheduled for orthopedic surgery of the lower extremities and lumbar epidural patient-controlled analgesia (PCA). Children received either dexmedetomidine (1 μg/kg) or fentanyl (1 μg/kg) along with 0.2% ropivacaine (0.2 mL/kg) via an epidural catheter at 30 minutes before the end of surgery. Postoperatively, the children were observed for ropivacaine consumption via epidural PCA, postoperative pain intensity, need for rescue analgesics, emergence agitation, and other adverse effects. The mean dose of bolus epidural ropivacaine was significantly lower within the first 6 h after surgery in the dexmedetomidine group, compared with the fentanyl group (0.029±0.030 mg/kg/h vs. 0.053±0.039 mg/kg/h, p=0.012). The median pain score at postoperative 6 h was also lower in the dexmedetomidine group, compared to the fentanyl group [0 (0-1.0) vs. 1.0 (0-3.0), p=0.039]. However, there was no difference in the need for rescue analgesia throughout the study period between groups. The use of dexmedetomidine as an epidural adjuvant had a significantly greater analgesic and local anesthetic-sparing effect, compared to fentanyl, in the early postoperative period in children undergoing major orthopedic lower extremity surgery. © Copyright: Yonsei University College of Medicine 2017

Comparison of Dexmedetomidine and Fentanyl as an Adjuvant to Ropivacaine for Postoperative Epidural Analgesia in Pediatric Orthopedic Surgery

PubMed Central

Park, Sang Jun; Shin, Seokyung; Kim, Shin Hyung; Kim, Hyun Woo; Kim, Seung Hyun; Do, Hae Yoon

2017-01-01

Purpose Opioids are commonly used as an epidural adjuvant to local anesthetics, but are associated with potentially serious side effects, such as respiratory depression. The aim of this study was to compare the efficacy and safety of dexmedetomidine with that of fentanyl as an adjuvant to epidural ropivacaine in pediatric orthopedic surgery. Materials and Methods This study enrolled 60 children (3–12 years old) scheduled for orthopedic surgery of the lower extremities and lumbar epidural patient-controlled analgesia (PCA). Children received either dexmedetomidine (1 µg/kg) or fentanyl (1 µg/kg) along with 0.2% ropivacaine (0.2 mL/kg) via an epidural catheter at 30 minutes before the end of surgery. Postoperatively, the children were observed for ropivacaine consumption via epidural PCA, postoperative pain intensity, need for rescue analgesics, emergence agitation, and other adverse effects. Results The mean dose of bolus epidural ropivacaine was significantly lower within the first 6 h after surgery in the dexmedetomidine group, compared with the fentanyl group (0.029±0.030 mg/kg/h vs. 0.053±0.039 mg/kg/h, p=0.012). The median pain score at postoperative 6 h was also lower in the dexmedetomidine group, compared to the fentanyl group [0 (0–1.0) vs. 1.0 (0–3.0), p=0.039]. However, there was no difference in the need for rescue analgesia throughout the study period between groups. Conclusion The use of dexmedetomidine as an epidural adjuvant had a significantly greater analgesic and local anesthetic-sparing effect, compared to fentanyl, in the early postoperative period in children undergoing major orthopedic lower extremity surgery. PMID:28332374

Glycoprotein IIB/IIIA inhibitor to reduce postpercutaneous coronary intervention myonecrosis and improve coronary flow in diabetics: the 'OPTIMIZE-IT' pilot randomized study.

PubMed

Talarico, Giovanni Paolo; Brancati, Marta; Burzotta, Francesco; Porto, Italo; Trani, Carlo; De Vita, Maria; Todaro, Daniel; Giammarinaro, Maura; Leone, Antonio Maria; Niccoli, Giampaolo; Andreotti, Felicita; Mazzari, Mario Attilio; Schiavoni, Giovanni; Crea, Filippo

2009-03-01

Subgroup analyses of trials enrolling acute coronary syndrome patients suggest that inhibition of glycoprotein IIb/IIIa can improve the outcome of diabetic patients undergoing percutaneous coronary interventions (PCIs), possibly by improving microvascular perfusion. However, the efficacy of small-molecule IIb/IIIa receptor inhibitors to improve microvascular perfusion in stable diabetic patients undergoing elective PCI has not been specifically investigated. We randomized consecutive stable diabetic patients, undergoing elective PCI, to tirofiban or placebo groups along with double antiplatelet therapy. High-dose bolus (25 microg/kg per 3 min) of tirofiban was administered immediately before PCI followed by 8 h continuous infusion (0.15 microg/kg per min). Postprocedural myonecrosis was assessed prospectively by measurement of cardiac troponin T (cTnT) at 6 and 24 h after PCI. The primary end-points were post-PCI coronary flow estimated by corrected thrombolysis in myocardial infarction frame count and post-PCI myocardial infarction. Platelet aggregation was measured by platelet function analyser-100 values. Forty-six patients entered the study (22 randomized to placebo and 24 randomized to tirofiban). The study drug was associated with a significant increase of platelet function analyser-100 values that peaked immediately after PCI and was maintained at 6 h (pre-PCI: 131 +/- 65 s; post-PCI: 222 +/- 49 s; after 6 h: 219 +/- 55 s).Post-PCI corrected thrombolysis in myocardial infarction frame count was similar in tirofiban and in placebo groups (10.2 +/- 3.6 vs. 12.0 +/- 7.6, P = 0.30, respectively). The prevalence of raised cTnT levels was similar in the two groups (25 vs. 30%, P = 0.56, respectively). At multivariate analysis, direct stenting (associated with reduced myonecrosis) and postdilatation (associated with increased myonecrosis) predicted cTnT elevation. A high-dose bolus of tirofiban in stable diabetic patients undergoing elective PCI, along with double antiplatelet therapy, was associated with a significant further inhibition of platelet aggregation which, however, did not translate in a lower incidence of post-PCI distal embolization.

Preprocedural High-Sensitivity Cardiac Troponin T and Clinical Outcomes in Patients With Stable Coronary Artery Disease Undergoing Elective Percutaneous Coronary Intervention.

PubMed

Zanchin, Thomas; Räber, Lorenz; Koskinas, Konstantinos C; Piccolo, Raffaele; Jüni, Peter; Pilgrim, Thomas; Stortecky, Stefan; Khattab, Ahmed A; Wenaweser, Peter; Bloechlinger, Stefan; Moschovitis, Aris; Frenk, Andre; Moro, Christina; Meier, Bernhard; Fiedler, Georg M; Heg, Dik; Windecker, Stephan

2016-06-01

Cardiac troponin detected by new-generation, highly sensitive assays predicts clinical outcomes among patients with stable coronary artery disease (SCAD) treated medically. The prognostic value of baseline high-sensitivity cardiac troponin T (hs-cTnT) elevation in SCAD patients undergoing elective percutaneous coronary interventions is not well established. This study assessed the association of preprocedural levels of hs-cTnT with 1-year clinical outcomes among SCAD patients undergoing percutaneous coronary intervention. Between 2010 and 2014, 6974 consecutive patients were prospectively enrolled in the Bern Percutaneous Coronary Interventions Registry. Among patients with SCAD (n=2029), 527 (26%) had elevated preprocedural hs-cTnT above the upper reference limit of 14 ng/L. The primary end point, mortality within 1 year, occurred in 20 patients (1.4%) with normal hs-cTnT versus 39 patients (7.7%) with elevated baseline hs-cTnT (P<0.001). Patients with elevated hs-cTnT had increased risks of all-cause (hazard ratio 5.73; 95% confidence intervals 3.34-9.83; P<0.001) and cardiac mortality (hazard ratio 4.68; 95% confidence interval 2.12-10.31; P<0.001). Preprocedural hs-TnT elevation remained an independent predictor of 1-year mortality after adjustment for relevant risk factors, including age, sex, and renal failure (adjusted hazard ratio 2.08; 95% confidence interval 1.10-3.92; P=0.024). A graded mortality risk was observed across higher tertiles of elevated preprocedural hs-cTnT, but not among patients with hs-cTnT below the upper reference limit. Preprocedural elevation of hs-cTnT is observed in one fourth of SCAD patients undergoing elective percutaneous coronary intervention. Increased levels of preprocedural hs-cTnT are proportionally related to the risk of death and emerged as independent predictors of all-cause mortality within 1 year. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02241291. © 2016 American Heart Association, Inc.

The "July effect" in total shoulder arthroplasty.

PubMed

Rao, Allison J; Bohl, Daniel D; Frank, Rachel M; Cvetanovich, Gregory L; Nicholson, Gregory P; Romeo, Anthony A

2017-03-01

New medical doctors enter their residency fields in July, a time in the hospital in which patient morbidity and mortality rates are perceived to be higher. It remains controversial whether a "July effect" exists in different areas of medicine and surgery, including in orthopedic surgery. The purpose of this study is to test for the July effect in patients undergoing primary total shoulder arthroplasty (TSA). Patients who underwent primary TSA from 2005-2012 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Cases were categorized as involving residents or fellows and as occurring during the first academic quarter. Rates of composite and any adverse event outcomes were compared between patient groups using multivariate logistic regression. A total of 1591 patients met the inclusion criteria. Of these cases, 711 (44.7%) had resident or fellow involvement and 390 (24.5%) were performed in the first academic quarter. There were few demographic and comorbidity differences between cases with and without residents or fellows or between cases performed during the first quarter and during the rest of the year. Overall, the rate of serious adverse events was 1.6% and the rate of any adverse events was 6.5%. Using one of the largest cohorts of primary TSA patients, this study could not provide evidence for a July effect. In the context of the recent growth in the volume of TSA procedures, these findings provide important reassurance to patients that it is safe to schedule their elective procedures at training institutions during the first part of the academic year. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Polymers as Carriers of Gentamicin in Traumatology and Orthopedic Surgery - Current State Of Knowledge.

PubMed

Witkowski, Jarosław; Wnukiewicz, Witold; Reichert, Paweł

2016-01-01

Osteomyelitis in patients undergoing surgery because of injuries and diseases of the musculoskeletal system is a serious clinical, economic and social problem. It is one of the greatest therapeutic challenges in traumatology and orthopedic surgery. To achieve the best results in the treatment of osteomyelitis, surgical debridement and intravenous antibiotic therapy is supported by local antibiotic delivery. Many different substances can be used as drug carriers. In this study we present and compare some polymers used as carriers of gentamicin. Some of them, such as poly(methyl methacrylate), are well known and have been used for 30 years, and others, such as polycaprolactone, polyacrylic acid, polyanhydrides, poly-trimethylene carbonate, polylactide, polyglycolide and poly(trimethylene carbonate), are perspectives for the future. In this study, we have tried to briefly present all of these polymers and compare some of their features. We have concentrated on the pharmacokinetics and bioactivity of such implants, which are important aspects for their potential practical use.

[Music therapy and regional anesthesia in orthopedic surgery].

PubMed

Rupérez Ruiz, Ma Pilar; De San José, Isabel; Hermoso Montoya, Anna; Ferreira Valencia, Teresa; Gómez Sanz, Amelia; López Gutiérrez, Anna

2014-06-01

To evaluate the sedative effects, intra-operation, of music therapy in orthopedic surgery patients with locoregional anesthesia in the Hospital Clínic i Provincial of Barcelona. Prospective comparative study on a random sample of 110 patients undergoing or not music therapy. The degree of anxiety was assessed with the Questionnaire STAIC. The application of the music was done with a MP3 player and headphones. The collected data were analyzed with Excel. For the statistical analysis we used the SPSS-18 software and Chi-square test to test the hypothesis of whether there was relationship between the level of peace and music therapy. After the analysis, the results of Chi-square were in the group of no sedation with/without music Chi2 = 2.01, P = 0.35. The statistical significance level was p < 0.05. No relationship was found between hearing music or not and the patient's comfort level. Most patients recommend listening to music in the operating room despite the sounds around do not bother them.

Effects of total knee and hip arthroplasty on body weight.

PubMed

Duchman, Kyle R; Gao, Yubo; Phisitkul, Phinit

2014-03-01

Patients frequently report functional and subjective improvement following total hip (THA) and knee arthroplasty (TKA), but these improvements do not correlate with decreased body weight at 1- and 2-year follow-up. The purpose of this retrospective study was to investigate changes in body weight following THA and TKA at longer follow-up than the 1- to 2-year follow-up frequently reported in the literature. A retrospective review of patients undergoing THA and TKA, as well as other commonly performed lower extremity orthopedic surgeries, was completed for January 2002 to October 2011 at a single tertiary care facility. Adults who underwent a single lower extremity orthopedic procedure during that time period were included in the study. Patients undergoing THA and TKA were analyzed for clinically and statistically significant weight changes at 1- and minimum 2-year follow-up. At a mean follow-up of 4.82 years, TKA resulted in a statistically significant decrease in mean body weight (1.47 kg; P=.0109). This finding was unique to TKA. The proportion of individuals who experienced clinically significant weight loss between the 1- and minimum 2-year follow-up was higher than the proportion of individuals who gained clinically significant weight over the same time period following THA and TKA. The results of this study suggest that clinically significant weight loss may continue for several years beyond the 1- and 2-year follow-up that is frequently reported in the literature. Copyright 2014, SLACK Incorporated.

Comparing multiple competing interventions in the absence of randomized trials using clinical risk-benefit analysis

PubMed Central

2012-01-01

Background To demonstrate the use of risk-benefit analysis for comparing multiple competing interventions in the absence of randomized trials, we applied this approach to the evaluation of five anticoagulants to prevent thrombosis in patients undergoing orthopedic surgery. Methods Using a cost-effectiveness approach from a clinical perspective (i.e. risk benefit analysis) we compared thromboprophylaxis with warfarin, low molecular weight heparin, unfractionated heparin, fondaparinux or ximelagatran in patients undergoing major orthopedic surgery, with sub-analyses according to surgery type. Proportions and variances of events defining risk (major bleeding) and benefit (thrombosis averted) were obtained through a meta-analysis and used to define beta distributions. Monte Carlo simulations were conducted and used to calculate incremental risks, benefits, and risk-benefit ratios. Finally, net clinical benefit was calculated for all replications across a range of risk-benefit acceptability thresholds, with a reference range obtained by estimating the case fatality rate - ratio of thrombosis to bleeding. Results The analysis showed that compared to placebo ximelagatran was superior to other options but final results were influenced by type of surgery, since ximelagatran was superior in total knee replacement but not in total hip replacement. Conclusions Using simulation and economic techniques we demonstrate a method that allows comparing multiple competing interventions in the absence of randomized trials with multiple arms by determining the option with the best risk-benefit profile. It can be helpful in clinical decision making since it incorporates risk, benefit, and personal risk acceptance. PMID:22233221

Continuous Self-Selection Processes in Teacher Education: The Way for Survival.

ERIC Educational Resources Information Center

Zak, Itai

1981-01-01

Three selection phases were found in a study investigating the selection process of students into the teaching profession: (1) self selection by the potential teacher; (2) admission to the teacher-training program; and (3) election to undergo the course of instruction. Results suggest that personality traits are more important than cognitive…

Risk of deep venous thrombosis in elective neurosurgical procedures: a prospective, Doppler ultrasound-based study in children 12 years of age or younger.

PubMed

Scherer, Andrea G; White, Ian K; Shaikh, Kashif A; Smith, Jodi L; Ackerman, Laurie L; Fulkerson, Daniel H

2017-07-01

OBJECTIVE The risk of venous thromboembolism (VTE) from deep venous thrombosis (DVT) is significant in neurosurgical patients. VTE is considered a leading cause of preventable hospital deaths and preventing DVT is a closely monitored quality metric, often tied to accreditation, hospital ratings, and reimbursement. Adult protocols include prophylaxis with anticoagulant medications. Children's hospitals may adopt adult protocols, although the incidence of DVT and the risk or efficacy of treatment is not well defined. The incidence of DVT in children is likely less than in adults, although there is very little prospectively collected information. Most consider the risk of DVT to be extremely low in children 12 years of age or younger. However, this consideration is based on tradition and retrospective reviews of trauma databases. In this study, the authors prospectively evaluated pediatric patients undergoing a variety of elective neurosurgical procedures and performed Doppler ultrasound studies before and after surgery. METHODS A total of 100 patients were prospectively enrolled in this study. All of the patients were between the ages of 1 month and 12 years and were undergoing elective neurosurgical procedures. The 91 patients who completed the protocol received a bilateral lower-extremity Doppler ultrasound examination within 48 hours prior to surgery. Patients did not receive either medical or mechanical DVT prophylaxis during or after surgery. The ultrasound examination was repeated within 72 hours after surgery. An independent, board-certified radiologist evaluated all sonograms. We prospectively collected data, including potential risk factors, details of surgery, and details of the clinical course. All patients were followed clinically for at least 1 year. RESULTS There was no clinical or ultrasound evidence of DVT or VTE in any of the 91 patients. There was no clinical evidence of VTE in the 9 patients who did not complete the protocol. CONCLUSIONS In this prospective study, no DVTs were found in 91 patients evaluated by ultrasound and 9 patients followed clinically. While the study is underpowered to give a definitive incidence, the data suggest that the risk of DVT and VTE is very low in children undergoing elective neurosurgical procedures. Prophylactic protocols designed for adults may not apply to pediatric patients. Clinical trial registration no.: NCT02037607 (clinicaltrials.gov).

External validation of a 5-year survival prediction model after elective abdominal aortic aneurysm repair.

PubMed

DeMartino, Randall R; Huang, Ying; Mandrekar, Jay; Goodney, Philip P; Oderich, Gustavo S; Kalra, Manju; Bower, Thomas C; Cronenwett, Jack L; Gloviczki, Peter

2018-01-01

The benefit of prophylactic repair of abdominal aortic aneurysms (AAAs) is based on the risk of rupture exceeding the risk of death from other comorbidities. The purpose of this study was to validate a 5-year survival prediction model for patients undergoing elective repair of asymptomatic AAA <6.5 cm to assist in optimal selection of patients. All patients undergoing elective repair for asymptomatic AAA <6.5 cm (open or endovascular) from 2002 to 2011 were identified from a single institutional database (validation group). We assessed the ability of a prior published Vascular Study Group of New England (VSGNE) model (derivation group) to predict survival in our cohort. The model was assessed for discrimination (concordance index), calibration (calibration slope and calibration in the large), and goodness of fit (score test). The VSGNE derivation group consisted of 2367 patients (70% endovascular). Major factors associated with survival in the derivation group were age, coronary disease, chronic obstructive pulmonary disease, renal function, and antiplatelet and statin medication use. Our validation group consisted of 1038 patients (59% endovascular). The validation group was slightly older (74 vs 72 years; P < .01) and had a higher proportion of men (76% vs 68%; P < .01). In addition, the derivation group had higher rates of advanced cardiac disease, chronic obstructive pulmonary disease, and baseline creatinine concentration (1.2 vs 1.1 mg/dL; P < .01). Despite slight differences in preoperative patient factors, 5-year survival was similar between validation and derivation groups (75% vs 77%; P = .33). The concordance index of the validation group was identical between derivation and validation groups at 0.659 (95% confidence interval, 0.63-0.69). Our validation calibration in the large value was 1.02 (P = .62, closer to 1 indicating better calibration), calibration slope of 0.84 (95% confidence interval, 0.71-0.97), and score test of P = .57 (>.05 indicating goodness of fit). Across different populations of patients, assessment of age and level of cardiac, pulmonary, and renal disease can accurately predict 5-year survival in patients with AAA <6.5 cm undergoing repair. This risk prediction model is a valid method to assess mortality risk in determining potential overall survival benefit from elective AAA repair. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Perioperative psychological and music interventions in elderly patients undergoing spinal anesthesia: effect on anxiety, heart rate variability, and postoperative pain.

PubMed

Wang, Yisha; Dong, Youjing; Li, Yang

2014-07-01

The aim of this study was to evaluate the effects of perioperative psychological and music interventions in elderly patients undergoing elective surgery on anxiety, post-operative pain, and changes in heart rate variability (HRV) to ascertain if perioperative psychological and music interventions can affect overall anxiety levels. Fourty elderly patients undergoing elective surgery were randomized to two groups; one group received psychological and music intervention, and the other was the control. The intervention group underwent psychological intervention and listening to music for 30 min before surgery. The mean change in HRV as determined by low frequency (LF) power measurements. After the intervention, the ratio of mean LF to high frequency (HF) power decreased significantly in the intervention group compared to before the intervention (p<0.05). In the control group, mean LF measurements and the ratio of LF:HF did not change significantly. In the intervention group, mean HF power was significantly higher after the procedure than before (p<0.01). Moreover, the mean self-rating anxiety score of the intervention group decreased after the procedure compared to before (p<0.05). The mean visual analogue score of the intervention group 6 hours after surgery was significantly lower than that of the control group (p<0.01). Perioperative psychological and music interventions can reduce anxiety and postoperative pain in elderly patients.

A pragmatic multi-centre randomised controlled trial of fluid loading in high-risk surgical patients undergoing major elective surgery--the FOCCUS study.

PubMed

Cuthbertson, Brian H; Campbell, Marion K; Stott, Stephen A; Elders, Andrew; Hernández, Rodolfo; Boyers, Dwayne; Norrie, John; Kinsella, John; Brittenden, Julie; Cook, Jonathan; Rae, Daniela; Cotton, Seonaidh C; Alcorn, David; Addison, Jennifer; Grant, Adrian

2011-01-01

Fluid strategies may impact on patient outcomes in major elective surgery. We aimed to study the effectiveness and cost-effectiveness of pre-operative fluid loading in high-risk surgical patients undergoing major elective surgery. This was a pragmatic, non-blinded, multi-centre, randomised, controlled trial. We sought to recruit 128 consecutive high-risk surgical patients undergoing major abdominal surgery. The patients underwent pre-operative fluid loading with 25 ml/kg of Ringer's solution in the six hours before surgery. The control group had no pre-operative fluid loading. The primary outcome was the number of hospital days after surgery with cost-effectiveness as a secondary outcome. A total of 111 patients were recruited within the study time frame in agreement with the funder. The median pre-operative fluid loading volume was 1,875 ml (IQR 1,375 to 2,025) in the fluid group compared to 0 (IQR 0 to 0) in controls with days in hospital after surgery 12.2 (SD 11.5) days compared to 17.4 (SD 20.0) and an adjusted mean difference of 5.5 days (median 2.2 days; 95% CI -0.44 to 11.44; P = 0.07). There was a reduction in adverse events in the fluid intervention group (P = 0.048) and no increase in fluid based complications. The intervention was less costly and more effective (adjusted average cost saving: £2,047; adjusted average gain in benefit: 0.0431 quality adjusted life year (QALY)) and has a high probability of being cost-effective. Pre-operative intravenous fluid loading leads to a non-significant reduction in hospital length of stay after high-risk major surgery and is likely to be cost-effective. Confirmatory work is required to determine whether these effects are reproducible, and to confirm whether this simple intervention could allow more cost-effective delivery of care. Prospective Clinical Trials, ISRCTN32188676.

Effects of Esmolol on the Prevention of Haemodynamic Responses to Tracheal Extubation after Craniotomy Operations

PubMed Central

Alkaya, Murat Alp; Saraçoğlu, Kemal Tolga; Pehlivan, Gökhan; Eti, Zeynep; Göğüş, Fevzi Yılmaz

2014-01-01

Objective The aim of this study was to evaluate the effects of esmolol infusion on the prevention of haemodynamic responses to tracheal extubation in patients undergoing elective craniotomy. Methods With approval from the Medical School Ethics Committee at Marmara University and the patients’ written consent, 30 patients between 20–65 years of age undergoing elective craniotomy were randomly placed in either the Group Esmolol (n=15) or the Group Control (n=15). Anaesthesia was induced with 5–7 mg kg−1 thiopental sodium, 1 μg kg−1 remifentanil, and 0.1 mg kg−1 vecuronium bromide iv, and was maintained with 1 MAC sevoflurane in oxygen-air mixture (50:50) and 0.25 μg kg−1 min−1 remifentanil infusion. At the end of the operation, patients inhaled 100% oxygen after the discontinuation of the anaesthetic agents. For Group Esmolol, 5 min before extubation 2 mg kg−1 esmolol in 50 mL was infused over 10 min (0.2 μg kg−1 min−1), while for Group Control, 50 mL saline was infused over 10 min. The quality of extubation was evaluated with a 5 point scale, recording heat rate, systolic, diastolic, and mean arterial pressures before infusion, 1 min after infusion, during extubation, and at 1, 3, 5, and 10 min after extubation. Results In the esmolol group, systolic, diastolic, and mean arterial pressures, as well as heart rate, decreased significantly after esmolol infusion and were significantly lower than in the control group after extubation (p<0.05). The ratio of patients with an extubation score of one was significantly higher in the esmolol group than in the control group (p<0.05). Conclusion We concluded that 2 mg kg−1 esmolol infusion before extubation can prevent hypertension and tachycardia caused by extubation in patients undergoing elective craniotomy. PMID:27366396

A pragmatic multi-centre randomised controlled trial of fluid loading in high-risk surgical patients undergoing major elective surgery - the FOCCUS study

PubMed Central

2011-01-01

Introduction Fluid strategies may impact on patient outcomes in major elective surgery. We aimed to study the effectiveness and cost-effectiveness of pre-operative fluid loading in high-risk surgical patients undergoing major elective surgery. Methods This was a pragmatic, non-blinded, multi-centre, randomised, controlled trial. We sought to recruit 128 consecutive high-risk surgical patients undergoing major abdominal surgery. The patients underwent pre-operative fluid loading with 25 ml/kg of Ringer's solution in the six hours before surgery. The control group had no pre-operative fluid loading. The primary outcome was the number of hospital days after surgery with cost-effectiveness as a secondary outcome. Results A total of 111 patients were recruited within the study time frame in agreement with the funder. The median pre-operative fluid loading volume was 1,875 ml (IQR 1,375 to 2,025) in the fluid group compared to 0 (IQR 0 to 0) in controls with days in hospital after surgery 12.2 (SD 11.5) days compared to 17.4 (SD 20.0) and an adjusted mean difference of 5.5 days (median 2.2 days; 95% CI -0.44 to 11.44; P = 0.07). There was a reduction in adverse events in the fluid intervention group (P = 0.048) and no increase in fluid based complications. The intervention was less costly and more effective (adjusted average cost saving: £2,047; adjusted average gain in benefit: 0.0431 quality adjusted life year (QALY)) and has a high probability of being cost-effective. Conclusions Pre-operative intravenous fluid loading leads to a non-significant reduction in hospital length of stay after high-risk major surgery and is likely to be cost-effective. Confirmatory work is required to determine whether these effects are reproducible, and to confirm whether this simple intervention could allow more cost-effective delivery of care. Trial registration Prospective Clinical Trials, ISRCTN32188676 PMID:22177541

Short-Term High-Dose Vitamin E to Prevent Contrast Medium-Induced Acute Kidney Injury in Patients With Chronic Kidney Disease Undergoing Elective Coronary Angiography: A Randomized Placebo-Controlled Trial.

PubMed

Rezaei, Yousef; Khademvatani, Kamal; Rahimi, Behzad; Khoshfetrat, Mehran; Arjmand, Nasim; Seyyed-Mohammadzad, Mir-Hossein

2016-03-15

Contrast medium-induced acute kidney injury (CIAKI) is a leading cause of acquired renal impairment. The effects of antioxidants have been conflicting regarding the prevention of CIAKI. We performed a study of vitamin E use to decrease CIAKI in patients undergoing elective coronary angiography. In a placebo-controlled randomized trial at 2 centers in Iran, 300 patients with chronic kidney disease-defined as estimated glomerular filtration rate <60 mL/min per 1.73 m(2)-were randomized 1:1 to receive 0.9% saline infusion 12 hours prior to and after intervention combined with 600 mg vitamin E 12 hours before plus 400 mg vitamin E 2 hours before coronary angiography or to receive placebo. The primary end point was the development of CIAKI, defined as an increase ≥0.5 mg/dL or ≥25% in serum creatinine that peaked within 72 hours. Based on an intention-to-treat analysis, CIAKI developed in 10 (6.7%) and 21 (14.1%) patients in the vitamin E and placebo groups, respectively (P=0.037). Change in white blood cell count from baseline to peak value was greater in the vitamin E group compared with the placebo group (-500 [-1500 to 200] versus 100 [-900 to 600]×10(3)/mL, P=0.001). In multivariate analysis, vitamin E (odds ratio 0.408, 95% CI 0.170-0.982, P=0.045) and baseline Mehran score (odds ratio 1.257, 95% CI 1.007-1.569; P=0.043) predicted CIAKI. Prophylactic short-term high-dose vitamin E combined with 0.9% saline infusion is superior to placebo for prevention of CIAKI in patients undergoing elective coronary angiography. URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02070679. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Near-death experience in a boy undergoing uneventful elective surgery under general anesthesia.

PubMed

Lopez, Ursula; Forster, Alain; Annoni, Jean-Marie; Habre, Walid; Iselin-Chaves, Irène A

2006-01-01

Near-death experience (NDE) is a complex subjective experience, which may include affective elements such as a sense of peacefulness, paranormal components such as a sensation of floating out of the body, and a perception of being in a dark tunnel and seeing a brilliant light. It is usually reported to occur in association with a wide range of life-threatening situations, as for instance, cardiopulmonary resuscitation. We report on an episode of NDE that occurred in a 12-year-old boy who underwent a general anesthesia for an elective uncomplicated surgery. To our knowledge, this is the first case of NDE in a child that has been reported in this context.

Health plan joins with physical therapy facility to manage back and neck pain.

PubMed

Tomlinson, Charles M; Gray, Chad; Kane, Tom

2008-06-01

Twenty-five billion dollars is spent each year on the medical care of back pain, and $50 billion is lost in productivity. Primary care physicians might have difficulty providing thorough counseling and treatment to their patients about the condition. In 2006, Capital Health Plan (CHP) partnered with Orthopedic and Sports Physical Therapy, which employed the mechanical diagnosis and therapy (MDT) technique. After undergoing this technique, members experienced a 79% improvement in pain scores and a 54% improvement in function scores, compared to when they started treatment.

New clinical trial opens to determine safety and efficacy of PROSTVAC, nivolumab and ipilimumab in men with localized prostate cancer | Center for Cancer Research

Cancer.gov

A new study is now open to evaluate the safety and effectiveness of a treatment regimen that combines PROSTVAC with ipilimumab and/or nivolumab in men with localized prostate cancer who have elected to undergo surgical resection (prostatectomy).  Learn more...

Mechanical bowel preparation in colorectal surgery.

PubMed

Kolovrat, Marijan; Busić, Zeljko; Lovrić, Zvonimir; Amić, Fedor; Cavka, Vlatka; Boras, Zdenko; Servis, Drazen; Lemac, Domagoj; Busić, Njegoslav

2012-12-01

The aim of this study was to assess the use of mechanical bowel preparation (MBP) and antimicrobial prophylaxis in elective colorectal surgery regarding still existing controversies. A prospective study of 85 patients undergoing elective colon and rectal surgery during 2 years period was performed, divided in two groups. Group A (N = 46) with patients who underwent mechanical bowel preparation, and group B (N = 39) patients without mechanical bowel preparation. We analysed: gender, age, preoperative difficulties, diagnostic colonoscopy, tumor localization, operation performed, pathohystological findings, Dukes classification, number of lymphonodes inspected, liver metastasis, other organ infiltrations, mean time of surgery, length of hospital stay, postoperative complications and mortality. Demographic characteristics, pathohystological findings, the site of malignancy, and type of surgical procedure did not significantly differentiate the two groups. The only significance revealed in mean time of surgery (138/178 minutes) in favor of patients with MBP (p = 0.017). Mechanical bowel preparation (MBP) for elective colorectal surgery is not advantageous. It does not influence radicalism of the procedure, does not decrease neither postoperative complications, nor hospital mortality.

Randomised clinical trial: prucalopride, a colonic pro-motility agent, reduces the duration of post-operative ileus after elective gastrointestinal surgery.

PubMed

Gong, J; Xie, Z; Zhang, T; Gu, L; Yao, W; Guo, Z; Li, Y; Lu, N; Zhu, W; Li, N; Li, J

2016-04-01

Previous studies have shown that recovery of colonic transit is a major determinant of post-operative ileus and clinical recovery after gastrointestinal surgery. Prucalopride is a highly selective 5-hydroxytryptamine receptor-4 agonist with colonic pro-motility effects. To evaluate the effect and safety of prucalopride on post-operative ileus and surgical outcomes after elective gastrointestinal surgery. In this phase II randomised clinical trial, 110 patients undergoing elective gastrointestinal surgery were randomised to either oral prucalopride (2 mg/day) (n = 55) or placebo (n = 55). Intervention was started 24 h after surgery and stopped after defecation or maximally at 7 days. The primary outcome was time to defecation. Secondary outcomes included time to first passage of flatus, tolerance of solid food, nasogastric tube reinsertion, post-operative length of stay, hospital readmission, overall cost, time to walk independently, surgical complications and inflammatory parameters. Patients who received prucalopride had a shorter time to defecation (65.0 vs. 94.5 h, P = 0.001), passage of flatus (53.0 vs. 73.0 h, P < 0.001), and post-operative length of stay (7.0 vs. 8.0 days, P = 0.001) than controls. The number of patients with prolonged ileus (>5 days) (16.4% vs. 34.5%, P = 0.026) and the C-reactive protein level on post-operative day 5 (35.67 vs. 59.07 mg/L, P = 0.040) were lower in the prucalopride group. There was no significant difference in post-operative Clavien-Dindo grade III and IV complications (P = 0.606) between the groups. Prucalopride is a safe and effective treatment to reduce post-operative ileus and systemic inflammation without affecting post-operative complications in patients undergoing elective gastrointestinal surgery. ClinicalTrials.gov: NCT02004652. © 2016 John Wiley & Sons Ltd.

A comparison of equivolume, equiosmolar solutions of hypertonic saline and mannitol for brain relaxation during elective supratentorial craniotomy.

PubMed

Hernández-Palazón, Joaquín; Fuentes-García, Diego; Doménech-Asensi, Paloma; Piqueras-Pérez, Claudio; Falcón-Araña, Luis; Burguillos-López, Sebastián

2016-01-01

Hyperosmolar solutions have been used in neurosurgery to reduce brain volume and facilitate surgical exposure. The purpose of this study was to compare the effects of equivolume, equiosmolar solutions of mannitol and hypertonic saline (HS) on brain relaxation, intensive care unit (ICU) and hospital stay, postoperative outcomes and incidence of side-effects in patients undergoing elective supratentorial craniotomy. In a randomised, prospective, double-blind study, 60 patients undergoing elective supratentorial craniotomy were randomised 1:1 to receive 3 ml/kg of either 20% mannitol or 3% HS. The primary outcome was the surgical condition of the brain assessed by the neurosurgeon using a 4-point scale after opening the dura (1 = relaxed, 2 = satisfactory, 3 = firm and 4 = bulging). Secondary outcomes were electrolytes, blood gases, plasma osmolality and haemodynamic variables measured at 0 min, 30 min, 2 h and 6 h after infusion. Also, predefined postoperative complications, length of ICU and hospital stay were recorded. Appropriate statistical tests were used for comparison; p < 0.05 was considered significant. There was no difference in brain relaxation [mannitol, 1(1-3) versus HS, 1(1.4) points; p = 0.55]. Patients with brain midline shift showed a worse response to hyperosmolar solutions than those without midline shift: 37% versus 8%, respectively; OR = 6.6 (95% CI, 1.54-28.83); p = 0.006. Plasma osmolality increased during the study period (6 h) in both the groups (p < 0.05 compared with baseline). No significant differences in postoperative complications or length of ICU and hospital stay were observed between the groups. Single doses of 3 ml/kg of 20% mannitol and 3% HS are safe and effective for intraoperative brain debulking during elective supratentorial craniotomy, but less effective in patients with pre-existing mass effect and midline shift.

MRI Before Radiography for Patients With New Shoulder Conditions.

PubMed

Small, Kirstin M; Rybicki, Frank J; Miller, Lindsay R; Daniels, Stephen D; Higgins, Laurence D

2017-06-01

To assess the patterns of Appropriate Criteria application among orthopedic specialists and other fields of medicine for use of MRI and radiography and the subsequent necessity for surgical intervention. The hospital electronic medical record was used to identify all shoulder MRI studies at a single large urban teaching hospital between January 2, 2011, and June 30, 2011. For each study, variables collected included ordering department, patient age, patient gender, patient's self-reported race/ethnicity, whether the patient obtained surgery for an issue related to the MRI diagnosis, the type of MRI ordered, the date of pain onset, the date of x-ray (if any), and the date of the MRI. A total of 475 patients who underwent shoulder MRI were included in our study. We found significant associations between a patient having had a prior x-ray and ordering department (P < .0001), male gender (P = .0005), and subjects who had subsequent surgery (P = .0006). Neither age nor race and ethnicity had an influence on x-ray before MRI. Orthopedic specialists ordering MRIs had the highest percentage of patients undergo subsequent surgery (33.3%) compared with the second-most, primary care (18.4%), and all other ordering departments (P = .0009). Detailed analysis suggests that providers who do not have specific training in shoulder pathology should consider consultation with an orthopedic surgeon before ordering shoulder MRI for patients who may need additional imaging after radiography. Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Why Some Mastectomy Patients Opt to Undergo Delayed Breast Reconstruction: Results of a Long-Term Prospective Study.

PubMed

Metcalfe, Kelly A; Semple, John; Quan, May-Lynn; Holloway, Claire; Wright, Frances; Narod, Steven; Hofer, Stefan; Bagher, Shaghayegh; Zhong, Toni

2017-02-01

Delayed breast reconstruction is an option for women who have undergone mastectomy; however, uptake is low. The purpose of this study was to identify premastectomy and postmastectomy demographic, clinical, and psychosocial predictors of uptake of delayed breast reconstruction in the long-term survivorship period. This was a prospective longitudinal survey study of mastectomy patients in which a repeated measures design was used to evaluate uptake of delayed breast reconstruction. Demographic, clinical, and psychosocial variables were collected before mastectomy and 1 year after mastectomy. Information regarding uptake of delayed breast reconstruction was collected at approximately 6 years after mastectomy. A predictive model was designed using a multivariate logistic regression model and Akiake information criterion stepwise algorithm. Ninety-six mastectomy patients were followed from before mastectomy to 75.2 months after mastectomy, and 35 women (36.5 percent) underwent delayed breast reconstruction. Women who elected for delayed breast reconstruction experienced worsening of body concerns from before mastectomy to 1 year after mastectomy, compared with women who did not elect to undergo delayed breast reconstruction (p = 0.03). Mean scores for psychological distress were significantly worse both before mastectomy and 1 year after mastectomy in women who went on to undergo delayed breast reconstruction compared with those who did not undergo delayed breast reconstruction (p = 0.034 and p = 0.022, respectively). A predictive model for the uptake of delayed breast reconstruction was developed using demographic, clinical, and psychosocial characteristics. The area under the receiver operating characteristic curve was 85 percent, indicating good precision. Women who are experiencing higher levels of distress, anxiety, and body concerns both before and after mastectomy appear to be significantly likely to select delayed breast reconstruction. This may have implications for postreconstruction satisfaction and psychosocial functioning. Risk, III.

The impact of a 600-mg loading dose of clopidogrel in diabetic and non-diabetic patients undergoing elective PCI.

PubMed

Mohareb, Mina W; Abd Elghany, Mohamed; Sabry, Nirmeen A; Farid, Samar F

2016-08-01

High platelet reactivity (HPR) and suboptimal response to dual antiplatelet therapy (DAPT) may explain high recurrent rates of ischemic events in type 1 and 2 diabetes mellitus (DM) patients undergoing percutaneous coronary intervention (PCI). The aim of this study was to determine the effect of diabetes mellitus on clopidogrel activity in cardiac patients undergoing PCI. This is an observational study. Patients were categorized according to DM status into diabetic group (N.=30) and non-diabetic group (N.=33). All patients received clopidogrel in a loading dose of 600 mg before PCI. Platelet function was assessed using light transmittance aggregometry (LTA) technique at baseline (before clopidogrel administration), 24 hour after clopidogrel loading dose administration and 7-10 days after PCI. All patients were followed up for at least one year after PCI for recurrence of acute cardiac events. There was no statistically significant difference between the two groups with respect to 10 µm adenosine diphosphate (ADP)-induced platelet aggregation measured at baseline (P=0.64), 24 hours after PCI (P=0.874), and 7-10 days after PCI (0.643). Diabetics were not significantly different from non-diabetics in terms of post-PCI acute stent thrombosis (P=0.945), sub-acute stent thrombosis (P=0.945), unstable angina (P=0.29) and cardiac death (P=0.64). There was a statistically significant difference between patients with and without post-PCI acute events regarding ADP aggregation measured 24 hours and 7-10 days after PCI. The use of a high loading dose of clopidogrel (600 mg) in patients undergoing elective PCI can overcome the significant increase in post-PCI platelet aggregation and rate of acute cardiac events induced by diabetes mellitus as co-morbidity in those patients.

The use of lipid-lowering therapy for secondary prevention in patients undergoing percutaneous coronary intervention

PubMed Central

Ma, Jessica M; Jackevicius, Cynthia A; Genus, Uchenwa; Dzavik, Vladimir

2006-01-01

BACKGROUND Recent literature suggests that lipid-lowering therapy may have an early beneficial effect among patients undergoing percutaneous coronary intervention (PCI) because the therapy decreases cardiac mortality, morbidity and possibly restenosis. OBJECTIVE The primary objective of the present study was to determine the proportion of PCI patients receiving lipid-lowering therapy at a large, tertiary-care referral centre. METHODS Patients undergoing a first PCI between August 2000 and August 2002 with corresponding inpatient medication information were included in the study. Patient demographics, procedural variables, and lipid-lowering and other evidence-based cardiac medication data were collected. A multiple logistical regression model was constructed to evaluate the factors associated with the use of lipid-lowering therapy. RESULTS Of the 3254 cases included in the analyses, 52% were elective, 44% were urgent or salvage, and 4% were emergent. The mean patient age was 63 years, and 73% of patients were male. Over 76% of patients were receiving lipid-lowering therapy at the time of PCI. Patient use of other medications was as follows: acetylsalicylic acid in 96%, beta-blocker in 80% and angiotensin-converting enzyme inhibitor in 59%. In the multiple regression analysis, variables significantly associated with lipid-lowering therapy use included hypercholesterolemia, beta-blocker use, angiotensin-converting enzyme inhibitor use, case urgency, prior coronary artery bypass graft surgery, age and sex. CONCLUSION Lipid-lowering therapy use rates exceeded those previously reported in the literature. Women and patients undergoing elective procedures appear to be treated less often with lipid-lowering therapy. There remains an opportunity to further optimize use in this high-risk cohort at time of PCI. PMID:16639478

Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance?

PubMed

Brandstrup, B; Svendsen, P E; Rasmussen, M; Belhage, B; Rodt, S Å; Hansen, B; Møller, D R; Lundbech, L B; Andersen, N; Berg, V; Thomassen, N; Andersen, S T; Simonsen, L

2012-08-01

We aimed to investigate whether fluid therapy with a goal of near-maximal stroke volume (SV) guided by oesophageal Doppler (ED) monitoring result in a better outcome than that with a goal of maintaining bodyweight (BW) and zero fluid balance in patients undergoing colorectal surgery. In a double-blinded clinical multicentre trial, 150 patients undergoing elective colorectal surgery were randomized to receive fluid therapy after either the goal of near-maximal SV guided by ED (Doppler, D group) or the goal of zero balance and normal BW (Zero balance, Z group). Stratification for laparoscopic and open surgery was performed. The postoperative fluid therapy was similar in the two groups. The primary endpoint was postoperative complications defined and divided into subgroups by protocol. Analysis was performed by intention-to-treat. The follow-up was 30 days. The trial had 85% power to show a difference between the groups. The number of patients undergoing laparoscopic or open surgery and the patient characteristics were similar between the groups. No significant differences between the groups were found for overall, major, minor, cardiopulmonary, or tissue-healing complications (P-values: 0.79; 0.62; 0.97; 0.48; and 0.48, respectively). One patient died in each group. No significant difference was found for the length of hospital stay [median (range) Z: 5.00 (1-61) vs D: 5.00 (2-41); P=0.206]. Goal-directed fluid therapy to near-maximal SV guided by ED adds no extra value to the fluid therapy using zero balance and normal BW in patients undergoing elective colorectal surgery.

Patient and family satisfaction levels in the intensive care unit after elective cardiac surgery: study protocol for a randomised controlled trial of a preoperative patient education intervention.

PubMed

Lai, Veronica Ka Wai; Lee, Anna; Leung, Patricia; Chiu, Chun Hung; Ho, Ka Man; Gomersall, Charles David; Underwood, Malcolm John; Joynt, Gavin Matthew

2016-06-22

Patients and their families are understandably anxious about the risk of complications and unfamiliar experiences following cardiac surgery. Providing information about postoperative care in the intensive care unit (ICU) to patients and families may lead to lower anxiety levels, and increased satisfaction with healthcare. The objectives of this study are to evaluate the effectiveness of preoperative patient education provided for patients undergoing elective cardiac surgery. 100 patients undergoing elective coronary artery bypass graft, with or without valve replacement surgery, will be recruited into a 2-group, parallel, superiority, double-blinded randomised controlled trial. Participants will be randomised to either preoperative patient education comprising of a video and ICU tour with standard care (intervention) or standard education (control). The primary outcome measures are the satisfaction levels of patients and family members with ICU care and decision-making in the ICU. The secondary outcome measures are patient anxiety and depression levels before and after surgery. Ethical approval has been obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (reference number CREC 2015.308). The findings will be presented at conferences and published in peer-reviewed journals. Study participants will receive a 1-page plain language summary of results. ChiCTR-IOR-15006971. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Disparities in Outcomes for Blacks versus Whites Undergoing Total Hip Arthroplasty: A Systematic Literature Review.

PubMed

Mehta, Bella Y; Bass, Anne R; Goto, Rie; Russell, Linda A; Parks, Michael L; Figgie, Mark P; Goodman, Susan M

2018-05-01

Total hip replacement (THA) surgery is a successful procedure, yet blacks in the United States undergo THA less often and reflect poorer outcomes than whites. The purpose of this study is to systematically review the literature on health-related quality of life after THA, comparing blacks and whites. A librarian-assisted search was performed in Medline through PubMed, Embase, and Cochrane Library on February 27, 2017. Original cohort studies examining pain, function, and satisfaction in blacks and whites 1 year after elective THA were included. Using the Patient/Population-Intervention-Comparison/Comparator-Outcome (PICO) process format, our population of interest was US black adults, our intervention was elective THA, our comparator was white adults, and our outcomes of interest were pain, function, and satisfaction after elective THA. The protocol was registered under the PROSPERO international register, and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Of the articles, 4739 were screened by title, 180 by abstract, 25 by full text, and 4 remained for analysis. The studies represented 1588 THA patients, of whom 240 (15%) were black. All studies noted more pain and worse function for blacks; although differences were statistically significant, they were not clinically significant. One study sought and identified less satisfaction for blacks after THA, and 1 study showed worse fear and anxiety scores in blacks. When measured, there are small differences in THA outcomes between blacks and whites, but most studies do not analyze/collect race. Future studies should address the effect of race and socioeconomic factors on healthcare disparities.

Lateral gastrocnemius myocutaneous flap transposition to the midlateral femur: extending the arc of rotation.

PubMed

Agarwal, Rishi Raj; Broder, Kevin; Kulidjian, Anna; Bodor, Richard

2014-05-01

We report the successful use of an extended lateral gastrocnemius myocutaneous flap for coverage of the midlateral femur using successive delayed elevations. A 62-year-old man underwent wide resection of a liposarcoma of the right anterior thigh with free flap reconstruction and subsequent radiation therapy 10 years before. Four years later, the patient fractured his irradiated femur and was treated with a retrograde intramedullary nail, which subsequently became infected, causing osteomyelitis of the distal femur, septic arthritis of the knee joint, and nonunion of his pathologic fracture. Although advised by numerous surgeons to undergo above-knee amputation, we offered our motivated patient a multidisciplinary approach to clear his infection and pathology; implanted new orthopedic hardware; performed delayed flap reconstruction; and rehabilitated him back to painless, unassisted ambulation. The extended lateral gastrocnemius myocutaneous flap used provided perfused soft tissues and durable coverage for the patient's exposed orthopedic hardware of the midlateral femur, 14 cm above the joint line of the knee. By using this flap to cover a femur defect well above published heights, our patient avoided amputation after years of worsening incapacitation.

An unanticipated cardiac arrest and unusual post-resuscitation psycho-behavioural phenomena/near death experience in a patient with pregnancy induced hypertension and twin pregnancy undergoing elective lower segment caesarean section.

PubMed

Panditrao, Mridul M; Singh, Chanchal; Panditrao, Minnu M

2010-09-01

A case report of a primigravida, who was admitted with severe pregnancy induced hypertension (BP 160/122 mmHg) and twin pregnancy, is presented here. Antihypertensive therapy was initiated. Elective LSCS under general anaesthesia was planned. After the birth of both the babies, intramyometrial injections of Carboprost and Pitocin were administered. Immediately, she suffered cardiac arrest. Cardio pulmonary resucitation (CPR) was started and within 3 minutes, she was successfully resuscitated. The patient initially showed peculiar psychological changes and with passage of time, certain psycho-behavioural patterns emerged which could be attributed to near death experiences, as described in this case report.

Preoperative Antibiotics and Mortality in the Elderly

PubMed Central

Silber, Jeffrey H.; Rosenbaum, Paul R.; Trudeau, Martha E.; Chen, Wei; Zhang, Xuemei; Lorch, Scott A.; Kelz, Rachel Rapaport; Mosher, Rachel E.; Even-Shoshan, Orit

2005-01-01

Objective and Background: It is generally thought that the use of preoperative antibiotics reduces the risk of postoperative infection, yet few studies have described the association between preoperative antibiotics and the risk of dying. The objective of this study was to determine whether preoperative antibiotics are associated with a reduced risk of death. Methods: We performed a multivariate matched, population-based, case-control study of death following surgery on 1362 Pennsylvania Medicare patients between 65 and 85 years of age undergoing general and orthopedic surgery. Cases (681 deaths within 60 days from hospital admission) were randomly selected throughout Pennsylvania using claims from 1995 and 1996. Models were developed to scan Medicare claims, looking for controls who did not die and who were the closest matches to the previously selected cases based on preoperative characteristics. Cases and their controls were identified, and charts were abstracted to define antibiotic use and obtain baseline severity adjustment data. Results: For general surgery, the odds of dying within 60 days were less than half in those treated with preoperative antibiotics within 2 hours of incision as compared with those without such treatment: (odds ratio = 0.44; 95% confidence interval, 0.32–0.60), P < 0.0001). For orthopedic surgery, no significant mortality reduction was observed (OR = 0.85; 95% confidence interval, 0.54–1.32; P < 0.464). Interpretation: Preoperative antibiotics are associated with a substantially lower 60-day mortality rate in elderly patients undergoing general surgery. In patients who appear to be comparable, the risk of death was half as large among those who received preoperative antibiotics. PMID:15973108

Organization of Hospital Nursing and 30-Day Readmissions in Medicare Patients Undergoing Surgery.

PubMed

Ma, Chenjuan; McHugh, Matthew D; Aiken, Linda H

2015-01-01

Growing scrutiny of readmissions has placed hospitals at the center of readmission prevention. Little is known, however, about hospital nursing—a critical organizational component of hospital service system—in relation to readmissions. To determine the relationships between hospital nursing factors—nurse work environment, nurse staffing, and nurse education—and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery. We linked Medicare patient discharge data, multistate nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania). Risk-adjusted robust logistic regressions were used for analyses. The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR=1.03; 95% CI, 1.00-1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR=0.97; 95% CI, 0.95-0.99). Administrative support to nursing practice (OR=0.96; 95% CI, 0.94-0.99) and nurse-physician relations (OR=0.97; 95% CI, 0.95-0.99) were 2 main attributes of the work environment that were associated with readmissions. Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.

The Dose-response of Intrathecal Ropivacaine Co-administered with Sufentanil for Cesarean Delivery under Combined Spinal-epidural Anesthesia in Patients with Scarred Uterus

PubMed Central

Xiao, Fei; Xu, Wen-Ping; Zhang, Yin-Fa; Liu, Lin; Liu, Xia; Wang, Li-Zhong

2015-01-01

Background: Spinal anesthesia is considered as a reasonable anesthetic option in lower abdominal and lower limb surgery. This study was to determine the dose-response of intrathecal ropivacaine in patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia. Methods: Seventy-five patients with scarred uterus undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this randomized, double-blinded, dose-ranging study. Patients received 6, 8, 10, 12, or 14 mg intrathecal hyperbaric ropivacaine with 5 μg sufentanil. Successful spinal anesthesia was defined as a T4 sensory level achieved with no need for epidural supplementation. The 50% effective dose (ED50) and 95% effective dose (ED95) were calculated with a logistic regression model. Results: ED50 and ED95 of intrathecal hyperbaric ropivacaine for patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia (CSEA) were 8.28 mg (95% confidence interval [CI]: 2.28–9.83 mg) and 12.24 mg (95% CI: 10.53–21.88 mg), respectively. Conclusion: When a CSEA technique is to use in patients with scarred uterus for an elective cesarean delivery, the ED50 and ED95 of intrathecal hyperbaric ropivacaine along with 5 μg sufentanil were 8.28 mg and 12.24 mg, respectively. In addition, this local anesthetic is unsuitable for emergent cesarean delivery, but it has advantages for ambulatory patients. PMID:26415793

Cryopreservation of Autologous Blood (Red Blood Cells, Platelets and Plasma)

NASA Astrophysics Data System (ADS)

Ebine, Kunio

Prevention of post-transfusion hepatitis is still a problem in cardiovascular surgery. We initiated the cryopreservation of autologous blood for the transfusion in elective cardiovascular surgery since 1981. This study includes 152 surgical cases in which autologous frozen, allogeneic frozen, and/or allogeneic non-frozen blood were used. In the 152 surgical cases, there were 69 cases in which autologous blood only (Group I) was used; 12 cases with autologous and allogeneic frozen blood (Group II); 46 cases with autologous and allgeneic frozen plus allogeneic non-frozen blood (Group III); and 25 cases with allogeneic frozen plus allogeneic non-frozen blood (Group IV). No hepatitis developed in Groups I (0%) and II (0%), but there was positive hepatitis in Groups III (4.3%) and IV (8.0%) . In 357 cases of those who underwent surgery with allogeneic non-frozen whole blood during the same period, the incidence rate of hepatitis was 13.7% (49/357). Patients awaiting elective surgery can store their own blood in the frozen state. Patients who undergo surgery with the cryoautotransfusion will not produce any infections or immunologic reactions as opposed to those who undergo surgery with the allogeneic non-frozen blood.

Clinical assessment scoring system for tracheostomy (CASST) criterion: Objective criteria to predict pre-operatively the need for a tracheostomy in head and neck malignancies.

PubMed

Gupta, Karan; Mandlik, Dushyant; Patel, Daxesh; Patel, Purvi; Shah, Bankim; Vijay, Devanhalli G; Kothari, Jagdish M; Toprani, Rajendra B; Patel, Kaustubh D

2016-09-01

Tracheostomy is a mainstay modality for airway management for patients with head-neck cancer undergoing surgery. This study aims to define factors predicting need of tracheostomy and define an effective objective criterion to predict tracheostomy need. 486 patients undergoing composite resections were studied. Factors analyzed were age, previous surgery, extent of surgery, trismus, extent of mandibular resection and reconstruction etc. Factors were divided into major and minor, using the clinical assessment scoring system for tracheostomy (CASST) criterion. Sixty seven (13.7%) patients required tracheostomy for their peri-operative management. Elective tracheostomies were done in 53 cases during surgery and post-operatively in 14 patients. All patients in whom tracheostomies were anticipated had a score of seven or more. A decision on whether or not an elective tracheotomy in head and neck surgery is necessary and can be facilitated using CASST criterion, which has a sensitivity of 95.5% and a negative predictive value (NPV) of 99.3%. It may reduce post-operative complications and contribute to safer treatment. Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Nursing students' perceptions of clients undergoing elective cosmetic surgery.

PubMed

Cooper, Leah Beth

2007-01-01

Aesthetic obsession is commonplace in current society. Supermarket a isles dedicated to beauty products, makeup, and anti-aging creams seem to expand daily. Television and publications flood the public with messages of what constitutes beauty and how to achieve the ideal. Surgical alteration of the body is swiftly becoming a form of self-care technique along with other heath-promoting behavior. Since 2003, the general acceptance of plastic surgery among all Americans surpassed 50% (American Society for Aesthetic Plastic Surgery, 2003). Elective cosmetic surgical procedures have increased by an astounding 444% since 1997 (American Society of Plastic Surgeons, 2006). This quest for body satisfaction based on modern cultural norms increases the public's need for accurate information and understanding from those in the healthcare profession. Despite a transformation in the general population's conception of cosmetic surgery and its clients, stigma still lies in many individuals, including those in the healthcare profession. As this progressively growing patient population emerges, many in healthcare question their attitudes toward plastic surgery and the patients receiving aesthetic operations. With clients undergoing plastic surgery becoming increasingly visible within the healthcare system, some unique aspects of patient care must be addressed.

Vanishing large ovarian cyst with thyroxine therapy.

PubMed

Dharmshaktu, Pramila; Kutiyal, Aditya; Dhanwal, Dinesh

2013-01-01

A 21-year-old female patient recently diagnosed with severe hypothyroidism was found to have a large ovarian cyst. In view of the large ovarian cyst, she was advised to undergo elective laparotomy in the gynaecology department. She was further evaluated in our medical out-patient department (OPD), and elective surgery was withheld. She was started on thyroxine replacement therapy, and within a period of 4 months, the size of the cyst regressed significantly, thereby improving the condition of the patient significantly. This case report highlights the rare and often missed association between hypothyroidism and ovarian cysts. Although very rare, profound hypothyroidism that can cause ovarian cysts in an adult should always be kept in the differential diagnosis to avoid unnecessary ovarian surgery. Hypothyroidism should be considered in the differential diagnosis of adult females presenting with multicystic ovarian tumours.Adequate thyroid hormone replacement therapy can prevent these patients from undergoing unnecessary and catastrophic ovarian resection.Surgical excision should be considered only when adequate thyroid replacement therapy fails to resolve ovarian enlargement.In younger women with ovarian cysts, it is also desirable to avoid unnecessary surgery so as to not compromise fertility in the future.

Vanishing large ovarian cyst with thyroxine therapy

PubMed Central

Dharmshaktu, Pramila; Kutiyal, Aditya; Dhanwal, Dinesh

2013-01-01

Summary A 21-year-old female patient recently diagnosed with severe hypothyroidism was found to have a large ovarian cyst. In view of the large ovarian cyst, she was advised to undergo elective laparotomy in the gynaecology department. She was further evaluated in our medical out-patient department (OPD), and elective surgery was withheld. She was started on thyroxine replacement therapy, and within a period of 4 months, the size of the cyst regressed significantly, thereby improving the condition of the patient significantly. This case report highlights the rare and often missed association between hypothyroidism and ovarian cysts. Although very rare, profound hypothyroidism that can cause ovarian cysts in an adult should always be kept in the differential diagnosis to avoid unnecessary ovarian surgery. Learning points Hypothyroidism should be considered in the differential diagnosis of adult females presenting with multicystic ovarian tumours.Adequate thyroid hormone replacement therapy can prevent these patients from undergoing unnecessary and catastrophic ovarian resection.Surgical excision should be considered only when adequate thyroid replacement therapy fails to resolve ovarian enlargement.In younger women with ovarian cysts, it is also desirable to avoid unnecessary surgery so as to not compromise fertility in the future. PMID:24683475

Medical Crowdfunding for Patients Undergoing Orthopedic Surgery.

PubMed

Durand, Wesley M; Johnson, Joseph R; Eltorai, Adam E M; Daniels, Alan H

2018-01-01

Crowdfunding for medical expenses is growing in popularity. Through several websites, patients create public campaign profiles to which donors can contribute. Research on medical crowdfunding is limited, and there have been no studies of crowdfunding in orthopedics. Active medical crowdfunding campaigns for orthopedic trauma, total joint arthroplasty, and spine surgery were queried from a crowdfunding website. The characteristics and outcomes of crowdfunding campaigns were abstracted and analyzed. For this study, 444 campaigns were analyzed, raising a total of $1,443,528. Among the campaigns that received a donation, mean amount raised was $4414 (SE, $611). Multivariate analysis showed that campaigns with unspecified location (odds ratio, 0.26; P=.0008 vs West) and those for total joint arthroplasty (odds ratio, 0.35; P=.0003 vs trauma) had significantly lower odds of receipt of any donation. Description length was associated with higher odds of donation receipt (odds ratio, 1.13 per +100 characters; P<.0001). Among campaigns that received any donation, those with Southern location (-65.5%, P<.0001), international location (-68.5%, P=.0028), and unspecified location (-63.5%, P=.0039) raised lower amounts compared with campaigns in the West. Goal amount was associated with higher amount raised (+3.2% per +$1000, P<.0001). Resources obtained through crowdfunding may be disproportionately available to patients with specific diagnoses, those from specific regions, those who are able to craft a lengthy descriptive narrative, and those with access to robust digital social networks. Clinicians are likely to see a greater proportion of patients turning to crowdfunding as it grows in popularity. Patients may ask physicians for information about crowdfunding or request testimonials to support campaigns. Surgeons should consider their response to such requests individually. These findings shed light on the dynamics of medical crowdfunding and support robust personal and professional deliberation. [Orthopedics. 2018; 41(1):e58-e63.]. Copyright 2017, SLACK Incorporated.

Validity of subjective smoking status in orthopedic patients.

PubMed

Bender, Daniel; Haubruck, Patrick; Boxriker, Sonja; Korff, Sebastian; Schmidmaier, Gerhard; Moghaddam, Arash

2015-01-01

In this level 1 diagnostic study, we analyzed the validity of subjective smoking status and, as secondary research question, the smoking cessation adherence in orthopedic patients during a routine hospital stay of nonunion patients by measuring serum cotinine. We included patients undergoing revision surgery due to nonunion of long bones. Patients were interviewed about their smoking status. Blood samples were taken from all the patients prior to surgery and for an additional 6 weeks following surgery. Serum levels of cotinine were measured, and coherence between subjective smoking status and objective cotinine analysis was evaluated. Between March 2012 and August 2014, we enrolled 136 patients. Six of the 26 "previous smokers" (23%) and four of the 65 "nonsmokers" (6%) had serum cotinine above cutoff levels. In self-labeled smokers, serum cotinine levels averaged at 2,367.4±14,885.9 ng/mL (with a median of 100 ng/mL), whereas in previous smokers the levels averaged at 4,270±19,619.4 ng/mL (with a median of 0 ng/mL) and in the nonsmokers group the levels averaged at 12±53.9 ng/mL (with a median of 0.03 ng/mL). Overall, the subjective smoking status matched serum cotinine testing in 88% of the cases. Sensitivity was 79.6% and specificity was 93.1%. Ninety-one percent of the patients with preoperative positive serum values were still positive at follow-up. In this study, we could show that subjective smoking status in orthopedic patients is predominantly reliable as validated by objective cotinine measurements; however, patients who declare themselves as "previous smokers" are at elevated risk for underreporting continued smoking and patients who smoked preoperatively are at high risk for continuing their habit. In the future, caregivers should consider introducing effective treatments for smoking cessation to smokers and furthermore offer effective treatments to maintain smoking cessation in previous smokers during their routine consultation prior to orthopedic and trauma surgery.

Spinal Surgeon Variation in Single-Level Cervical Fusion Procedures: A Cost and Hospital Resource Utilization Analysis.

PubMed

Hijji, Fady Y; Massel, Dustin H; Mayo, Benjamin C; Narain, Ankur S; Long, William W; Modi, Krishna D; Burke, Rory M; Canar, Jeff; Singh, Kern

2017-07-01

Retrospective analysis. To compare perioperative costs and outcomes of patients undergoing single-level anterior cervical discectomy and fusions (ACDF) at both a service (orthopedic vs. neurosurgical) and individual surgeon level. Hospital systems are experiencing significant pressure to increase value of care by reducing costs while maintaining or improving patient-centered outcomes. Few studies have examined the cost-effectiveness cervical arthrodesis at a service level. A retrospective review of patients who underwent a primary 1-level ACDF by eight surgeons (four orthopedic and four neurosurgical) at a single academic institution between 2013 and 2015 was performed. Patients were identified by Diagnosis-Related Group and procedural codes. Patients with the ninth revision of the International Classification of Diseases coding for degenerative cervical pathology were included. Patients were excluded if they exhibited preoperative diagnoses or postoperative social work issues affecting their length of stay. Comparisons of preoperative demographics were performed using Student t tests and chi-squared analysis. Perioperative outcomes and costs for hospital services were compared using multivariate regression adjusted for preoperative characteristics. A total of 137 patients diagnosed with cervical degeneration underwent single-level ACDF; 44 and 93 were performed by orthopedic surgeons and neurosurgeons, respectively. There was no difference in patient demographics. ACDF procedures performed by orthopedic surgeons demonstrated shorter operative times (89.1 ± 25.5 vs. 96.0 ± 25.5 min; P = 0.002) and higher laboratory costs (Δ+$6.53 ± $5.52 USD; P = 0.041). There were significant differences in operative time (P = 0.014) and labor costs (P = 0.034) between individual surgeons. There was no difference in total costs between specialties or individual surgeons. Surgical subspecialty training does not significantly affect total costs of ACDF procedures. Costs can, however, vary between individual surgeons based on operative times. Variation between individual surgeons highlights potential areas for improvement of the cost effectiveness of spinal procedures. 4.

Tethered cord release: a long-term study in 114 patients.

PubMed

Bowman, Robin M; Mohan, Avinash; Ito, Joy; Seibly, Jason M; McLone, David G

2009-03-01

All children born with a myelomeningocele at the authors' institution undergo aggressive treatment to maintain or improve functional outcome. Consequently, when any neurological, orthopedic, and/or urological changes are noted, a search for the cause is initiated. The most common cause of decline in a child born with a myelomeningocele is shunt malfunction. The second most common cause is tethering of the distal spinal cord at the site of the original back closure. In this report, the authors review the indicators of symptomatic spinal cord tethering and discuss the surgical interventions and outcomes in the children with myelomeningocele who underwent treatment at Children's Memorial Hospital from 1975 to 2008. Among the 502 children who underwent original closure at Children's Memorial Hospital, a symptomatic tethered spinal cord developed in 114 (23%). Eighty-one patients (71%) have undergone 1 untethering procedure, and 33 patients (29%) have undergone multiple untetherings, for a total of 163 total surgeries. The indicators of symptomatic spinal cord tethering include scoliosis, decline in lower-extremity (LE) motor strength, LE contractures, LE spasticity, gait change, urinary changes, and pain. Pain has shown the best response to surgical untethering, with 100% of children experiencing postoperative improvement. The results of long-term follow-up (average 12 years, range 1 month-23.3 years) in this cohort demonstrated scoliosis progression after surgical untethering in 52% of patients, with 28% requiring spinal fusion. On the 3-month postoperative manual muscle test, 70% of patients showed improved LE muscle strength compared to preoperatively. Gait was also similarly improved after untethering as evaluated by an orthopedic surgeon. Spasticity improved in two-thirds of the cohort, and as expected, LE contractures were stable (78%) postoperatively, as assessed by orthopedic and rehabilitation medicine specialists. Urologically, 64% of patients showed improvements on postoperative bladder evaluation. Although this is a clinical outcome study with no control group, the authors' experience has been that tethered cord release is beneficial in maintaining neurological, urological, and orthopedic functioning in children born with a myelomeningocele.

[Effect of wound healing of orthopedic surgery in human immunodeficiency virus infected patients with perioperative adjuvant treatments].

PubMed

Sun, Sheng; Zhang, Yaoshen; Zhang, Qiang; Li, Xin; Wan, Gang; Zhao, Changsong; Cai, Juan; Yuan, Zheng

2014-08-05

To observe the early wound healing of orthopedic surgery in human immunodeficiency virus (HIV) carrier patients treated with optimized auxiliary treatments. During a period of 48 months, according to the inclusion and exclusion criteria plus CD4⁺ T lymphocyte count, the patients scheduled for orthopedic surgery (including HIV positive and negative) were divided into group A (HIV positive, CD4<500/ml) with optimized auxiliary treatments, group B (HIV positive, CD4 ≥ 500/ml) and group C (HIV negative) on prophylactic antibiotic therapy alone. Wound healing of 3 groups were observed postoperatively. The rates of clinical wound infection were compared among 3 groups. A total of 471 cases (n = 79, HIV+; n = 392, HIV-) were selected due to fresh fracture (n = 544, 77.28%), fracture of spine (n = 57, 12.31%), mal-union (n = 13, 2.76%), aseptic necrosis (n = 15, 3.18%) and osteoarthritis (n = 21, 4.46%). During surgery, early open reduction and plate screw internal fixation (group A, n = 23; group B, n = 21; group C, n = 274); pedicle screw internal fixation (group A, n = 5; group B, n = 6; group C, n = 47); total joint replacement (group A, n = 3; group B, n = 4; group C, n = 8); interlocking intramedullary nail fixation (group A, n = 7; group B, n = 4; group C, n = 35) and other operations (group A, n = 3; group B, n = 3; group C, n = 28). For infections, 2 cases (4.88%) were observed in group A, 3 (5.26%) in group B and 26 (6.63%) in group C. The differences were statistically insignificant. Reasonable perioperative adjuvant treatments, including use of antibiotic, nutritional supports, immunomodulators and anti-retroviral drugs, are offered to HIV infected patients undergoing orthopedic surgery. Their risks of postoperative wound infection may be controlled.

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

PubMed Central

Carroli, Guillermo; Zavaleta, Nelly; Donner, Allan; Wojdyla, Daniel; Faundes, Anibal; Velazco, Alejandro; Bataglia, Vicente; Langer, Ana; Narváez, Alberto; Valladares, Eliette; Shah, Archana; Campodónico, Liana; Romero, Mariana; Reynoso, Sofia; de Pádua, Karla Simônia; Giordano, Daniel; Kublickas, Marius; Acosta, Arnaldo

2007-01-01

Objective To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery. Design Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health. Setting 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data Participants 106 546 deliveries reported during the three month study period, with data available for 97 095 (91% coverage). Main outcome measures Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics. Results Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective. Conclusions Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations. PMID:17977819

Effectiveness and cost-effectiveness of a group-based pain self-management intervention for patients undergoing total hip replacement: feasibility study for a randomized controlled trial.

PubMed

Wylde, Vikki; Marques, Elsa; Artz, Neil; Blom, Ashley; Gooberman-Hill, Rachael

2014-05-20

Total hip replacement (THR) is a common elective surgical procedure and can be effective for reducing chronic pain. However, waiting times can be considerable. A pain self-management intervention may provide patients with skills to more effectively manage their pain and its impact during their wait for surgery. This study aimed to evaluate the feasibility of conducting a randomized controlled trial to assess the effectiveness and cost-effectiveness of a group-based pain self-management course for patients undergoing THR. Patients listed for a THR at one orthopedic center were posted a study invitation pack. Participants were randomized to attend a pain self-management course plus standard care or standard care only. The lay-led course was delivered by Arthritis Care and consisted of two half-day sessions prior to surgery and one full-day session after surgery. Participants provided outcome and resource-use data using a diary and postal questionnaires prior to surgery and one month, three months and six months after surgery. Brief telephone interviews were conducted with non-participants to explore barriers to participation. Invitations were sent to 385 eligible patients and 88 patients (23%) consented to participate. Interviews with 57 non-participants revealed the most common reasons for non-participation were views about the course and transport difficulties. Of the 43 patients randomized to the intervention group, 28 attended the pre-operative pain self-management sessions and 11 attended the post-operative sessions. Participant satisfaction with the course was high, and feedback highlighted that patients enjoyed the group format. Retention of participants was acceptable (83% of recruited patients completed follow-up) and questionnaire return rates were high (72% to 93%), with the exception of the pre-operative resource-use diary (35% return rate). Resource-use completion rates allowed for an economic evaluation from the health and social care payer perspective. This study highlights the importance of feasibility work prior to a randomized controlled trial to assess recruitment methods and rates, barriers to participation, logistics of scheduling group-based interventions, acceptability of the intervention and piloting resource use questionnaires to improve data available for economic evaluations. This information is of value to researchers and funders in the design and commissioning of future research. Current Controlled Trials ISRCTN52305381.

Health economic review of recombinant activated factor VII for treatment of bleeding episodes in hemophilia patients with inhibitors.

PubMed

Stephens, Jennifer M; Joshi, Ashish V; Sumner, Michael; Botteman, Marc F

2007-06-01

Severe hemophilia with inhibitors is a rare disease with substantial clinical, humanistic and economic consequences. This review provides an overview of the role of recombinant activated factor VII (rFVIIa) versus plasma-derived bypassing agents for hemophilia with inhibitors and summarizes the 13 formal economic analyses (6 burden of illness and 7 comparative studies) that have been published in this indication. The findings suggest that the economic impact of rFVIIa has occurred primarily during hospitalization to manage major bleeding episodes and to allow for elective orthopedic surgeries that would not have been attempted prior to rFVIIa. Comparative analyses for on-demand treatment suggest that the total cost of treating a bleeding episode with rFVIIa may be lower than with plasma-based agents due to faster bleeding resolution, higher initial efficacy rates and avoidance of second and third lines of treatment.

Anaemia in elective orthopaedic surgery - Royal Adelaide Hospital, Australia.

PubMed

Kearney, B; To, J; Southam, K; Howie, D; To, B

2016-01-01

An anaemia clinic was established to improve the preoperative management of elective orthopaedic patients scheduled for arthroplasty. This paper is a report on the first 100 patients assessed. To assess the incidence and causes of anaemia in patients on a waiting list for elective arthroplasty in a public hospital and to assess the impact of anaemia detection in this patient population. Patients attending an Anaemia Clinic for elective orthopaedic surgical patients, during March 2010 to June 2013 were studied. Outcome measures included change in haemoglobin preoperative results and perioperative transfusion rates by preoperative haemoglobin. Seventeen per cent of patients scheduled for elective surgery were found to be anaemic. Of the 100 patients who attended, approximately half were found to be iron deficient and the remainder had anaemia of chronic disease. Serum ferritin <30 µg/L alone did not identify iron deficiency in 80% of patients with iron deficiency. Patients with iron deficient anaemia were able to be treated, in all cases, to achieve a significant increase in preoperative haemoglobin. The general unavailability of erythropoietin limited effective intervention for the non-iron-deficient anaemic patients. Seven patients had their surgery cancelled because of the screening programme. Half of the anaemic patients in a joint replacement screening clinic were iron deficient, and treatment was effective in improving the pre-operative haemoglobin and reducing perioperative transfusion rates. This screening process should improve patient outcome. Another important finding in this group of patients is that ferritin levels cannot be reliably used as the sole indicator in the diagnosis of iron deficiency anaemia in this group of patients undergoing elective arthroplasty. © 2015 Royal Australasian College of Physicians.

Racial Disparities in 30-Day Readmission Rates After Elective Spine Surgery: A Single Institutional Experience.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Mehta, Ankit I; Cheng, Joseph; Bagley, Carlos A; Karikari, Isaac O

2016-11-01

Retrospective cohort review. The aim of this study is to investigate whether patient race is an independent predictor of unplanned 30-day hospital readmission after elective spine surgery. Racial disparities are known to exist for many aspects of surgical care. However, it is unknown if disparities exist in 30-day readmissions after elective spine surgery, an area that is becoming a prime focus for clinical leaders and policymakers. Records of 600 patients undergoing elective spine surgery at a major academic medical center were reviewed. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient's records were reviewed to determine the cause of readmission and the length of hospital stay. The main outcome measure was risk-adjusted odds of all-cause 30-day readmission. We used multivariate logistic regression to determine if Black patients had an increased likelihood of 30-day readmission compared with White patients. Baseline characteristics were similar between both groups. Black patients had higher readmission rates than White patients (10.56% vs. 7.86%, P = 0.04). In a univariate analysis, race, body mass index, sex, patient age, smoking, diabetes, and fusion levels were associated with increased 30-day readmission rates. However, in a multivariate logistic regression model, race was an independent predictor of 30-day readmission after elective spine surgery. In addition, no significant differences in baseline, 1-year and 2-year patient reported outcomes measures were observed between both groups. This study suggests that Black patients are more likely to be readmitted within 30-days of discharge after elective spine surgery. Efforts at reducing disparities should focus not only on race-based measures but also effective post discharge care. 3.

Transfusion-Free Calvarial Vault Reconstruction Using Multimodal Blood Conservation Strategies in Two Pediatric Jehovah's Witness Patients With Craniosynostosis.

PubMed

Reddy, Srijaya K; Swink, Jonathan M; Rogers, Gary F; Myseros, John S; Keating, Robert F; Santos, Domiciano N

2016-07-15

Transfusion-free surgery for the Jehovah's Witness patient has been described, but there are few reports in pediatric patients undergoing major elective surgery. We present 2 patients of the Jehovah's Witness faith affected with craniosynostosis who underwent transfusion-free calvarial vault reconstructions using several blood conservation approaches, including the use of antifibrinolytic ε-aminocaproic acid.

Using Six Sigma and Lean methodologies to improve OR throughput.

PubMed

Fairbanks, Catharine B

2007-07-01

Improving patient flow in the perioperative environment is challenging, but it has positive implications for both staff members and for the facility. One facility in vermont improved patient throughput by incorporating Six Sigma and Lean methodologies for patients undergoing elective procedures. The results of the project were significantly improved patient flow and increased teamwork and pride among perioperative staff members. (c) AORN, Inc, 2007.

Antenatal Corticosteroids for Reducing Adverse Maternal and Child Outcomes in Special Populations of Women at Risk of Imminent Preterm Birth: A Systematic Review and Meta-Analysis

PubMed Central

Amiya, Rachel M.; Mlunde, Linda B.; Ota, Erika; Swa, Toshiyuki

2016-01-01

Background This study synthesizes available evidence on antenatal corticosteroids (ACS) use among special subgroups of women at risk of imminent preterm birth, including those (1) with pregestational and gestational diabetes mellitus, (2) undergoing elective caesarean section (CS) in late preterm (34 to<37 weeks), (3) with chorioamnionitis, and (4) with growth-restricted fetuses. Methods A systematic search of MEDLINE, EMBASE, CINAHL, Cochrane Library, POPLINE, and World Health Organization Regional Databases was conducted for all comparative studies. Two reviewers independently determined study eligibility, extracted data, and assessed study quality. Pooled mean differences and odds ratios with 95% confidence intervals were estimated from available data, based on fixed- and random-effects models, as appropriate. Results No eligible studies were identified for ACS use in diabetic pregnant women or those undergoing elective CS at late preterm. Nine studies each on ACS use in women with chorioamnionitis and in women with fetal growth restriction met inclusion criteria; eight studies were separately included in the meta-analyses for the two subpopulations. For ACS administration in women with chorioamnionitis, pooled analyses showed reductions in neonatal mortality (OR: 0.49, 95% CI: 0.34–0.73), respiratory distress syndrome (OR: 0.58, 95% CI: 0.44–0.76), intraventricular haemorrhage (OR: 0.41, 95% CI: 0.24–0.69), and severe intraventricular haemorrhage (OR: 0.40, 95% CI: 0.24–0.69). Maternal and long-term newborn outcomes were not reported. Effects of ACS use were inconclusive for cases with fetal growth restriction. Conclusion Direct evidence on the effectiveness and safety of ACS is lacking for diabetic pregnant women at risk of preterm birth and those undergoing elective late-preterm CS, though this does not necessarily recommend against their use in diabetic women. While evidence remains inconclusive for women with growth-restricted preterm neonates, ACS appears to benefit preterm neonates delivered by women with chorioamnionitis. High-quality studies on maternal and long-term child outcomes in more diverse settings are needed to establish the balance of potential harms versus benefits in using ACS for these understudied subgroups. PMID:26841022

Prevalence of Internet and Social Media Usage in Orthopedic Surgery

PubMed Central

Curry, Emily; Nguyen, Joseph; Matzkin, Elizabeth

2014-01-01

Prior studies in other specialties have shown that social networking and Internet usage has become an increasingly important means of patient communication and referral. The purpose of this study is to evaluate the prevalence of Internet or social media usage in new patients referred to a major academic orthopedics center and to identify new avenues to optimize patient recruitment and communication. New patients were surveyed (n=752) between December 2012 to January 2013 in a major academic orthopaedic center to complete a 15-item questionnaire including social media and Internet usage information. Data was collected for all orthopaedic sub-specialties and statistical analysis was performed. Fifty percent of patients use social networking sites, such as Facebook. Sports medicine patients tend to be higher social networking users (35.9%) relative to other services (9.8-17.9%) and was statistically higher when compared to the joints/tumor service (P<0.0001). Younger age was the biggest indicator predicting the use of social media. Patients that travelled between 120 to 180 miles from the hospital for their visits were significantly more likely to be social media users, as were patients that did research on their condition prior to their new patient appointment. We conclude that orthopedic patients who use social media/Internet are more likely to be younger, researched their condition prior to their appointment and undergo a longer average day’s travel (120-180 miles) to see a physician. In an increasingly competitive market, surgeons with younger patient populations will need to utilize social networking and the Internet to capture new patient referrals. PMID:25317312

Prevalence of internet and social media usage in orthopedic surgery.

PubMed

Curry, Emily; Li, Xinning; Nguyen, Joseph; Matzkin, Elizabeth

2014-08-08

Prior studies in other specialties have shown that social networking and Internet usage has become an increasingly important means of patient communication and referral. The purpose of this study is to evaluate the prevalence of Internet or social media usage in new patients referred to a major academic orthopedics center and to identify new avenues to optimize patient recruitment and communication. New patients were surveyed (n=752) between December 2012 to January 2013 in a major academic orthopaedic center to complete a 15-item questionnaire including social media and Internet usage information. Data was collected for all orthopaedic sub-specialties and statistical analysis was performed. Fifty percent of patients use social networking sites, such as Facebook. Sports medicine patients tend to be higher social networking users (35.9%) relative to other services (9.8-17.9%) and was statistically higher when compared to the joints/tumor service (P<0.0001). Younger age was the biggest indicator predicting the use of social media. Patients that travelled between 120 to 180 miles from the hospital for their visits were significantly more likely to be social media users, as were patients that did research on their condition prior to their new patient appointment. We conclude that orthopedic patients who use social media/Internet are more likely to be younger, researched their condition prior to their appointment and undergo a longer average day's travel (120-180 miles) to see a physician. In an increasingly competitive market, surgeons with younger patient populations will need to utilize social networking and the Internet to capture new patient referrals.

Physical characteristics of a low-dose gas microstrip detector for orthopedic x-ray imaging

DOE Office of Scientific and Technical Information (OSTI.GOV)

Despres, Philippe; Beaudoin, Gilles; Gravel, Pierre

2005-04-01

A new scanning slit gas detector dedicated to orthopedic x-ray imaging is presented and evaluated in terms of its fundamental imaging characteristics. The system is based on the micromesh gaseous structure detector and achieves primary signal amplification through electronic avalanche in the gas. This feature, together with high quantum detection efficiency and fan-beam geometry, allows for imaging at low radiation levels. The system is composed of 1764 channels spanning a width of 44.8 cm and is capable of imaging an entire patient at speeds of up to 15 cm/s. The resolution was found to be anisotropic and significantly affected bymore » the beam quality in the horizontal direction, but otherwise sufficient for orthopedic studies. As a consequence of line-by-line acquisition, the images contain some ripple components due to mechanical vibrations combined with variations in the x-ray tube output power. The reported detective quantum efficiency (DQE) values are relatively low (0.14 to 0.20 at 0.5 mm{sup -1}) as a consequence of a suboptimal collimation geometry. The DQE values were found to be unaffected by the exposure down to 7 {mu}Gy, suggesting that the system is quantum limited even for low radiation levels. A system composed of two orthogonal detectors is already in use and can produce dual-view full body scans at low doses. This device could contribute to reduce the risk of radiation induced cancer in sensitive clientele undergoing intensive x-ray procedures, like young scoliotic women.« less

Glycopeptides versus β-lactams for the prevention of surgical site infections in cardiovascular and orthopedic surgery: a meta-analysis.

PubMed

Saleh, Anas; Khanna, Ashish; Chagin, Kevin M; Klika, Alison K; Johnston, Douglas; Barsoum, Wael K

2015-01-01

To compare the efficacy of glycopeptides and β-lactams in preventing surgical site infections (SSIs) in cardiac, vascular, and orthopedic surgery. The cost-effectiveness of switching from β-lactams to glycopeptides for preoperative antibiotic prophylaxis has been controversial. β-Lactams are generally recommended in clean surgical procedures, but they are ineffective against resistant gram-positive bacteria. PubMed, International Pharmaceuticals Abstracts, Scopus, and Cochrane were searched for randomized clinical trials comparing glycopeptides and β-lactams for prophylaxis in adults undergoing cardiac, vascular, or orthopedic surgery. Abstracts and conference proceedings were included. Two independent reviewers performed study selection, data extraction, and assessment of risk of bias. Fourteen studies with a total of 8952 patients were analyzed. No difference was detected in overall SSIs between antibiotic types. However, compared with β-lactams, glycopeptides reduced the risk of resistant staphylococcal SSIs by 48% (relative risk, 0.52; 95% confidence interval, 0.29-0.93; P = 0.03) and enterococcal SSIs by 64% (relative risk, 0.36; 95% confidence interval, 0.16-0.80; P = 0.01), but increased respiratory tract infections by 54% (relative risk, 1.54; 95% confidence interval, 1.19-2.01; P ≤ 0.01). Subgroup analysis of cardiac procedures showed superiority of β-lactams in preventing superficial and deep chest SSIs, susceptible staphylococcal SSIs, and respiratory tract infections. Glycopeptides reduce the risk of resistant staphylococcal SSIs and enterococcal SSIs, but increase the risk of respiratory tract infections. Additional high-quality randomized clinical trials are needed as these results are limited by high risk of bias.

Is the treatment gap in knee osteoarthritis real? A qualitative study of surgeons' perceptions.

PubMed

Li, Chuan Silvia; Pathy, Rubini; Adili, Anthony; Avram, Victoria; Barasi, Mohamed A; Mundi, Raman; Niroopan, Gavinn; Bhandari, Mohit

2013-01-01

Knee osteoarthritis (OA) is a chronic condition characterized by loss of joint cartilage that leads to persistent pain, loss of function, and disability. It has been reported that a treatment gap exists in a subset of knee OA patients who are unresponsive to conservative treatment yet are unsuitable for or unwilling to undergo more invasive, irreversible, surgical procedures. Ten orthopedic healthcare professionals participated in a focus group (n=5) and semistructured interviews (n=5). We explored their perceptions on the treatment gap in knee OA patients and their opinions of the KineSpring® Knee Implant System. Among the responses of orthopedic healthcare professionals, we identified seven themes: (1) Delaying operative treatment for knee OA patients is very important. (2) Unrealistic expectations of younger patients play an important role in management of knee OA. (3) A treatment gap does exist. (4) Management of knee OA should be tailored to the individual patient. (5) The ability to delay total knee replacement without compromising the ability to do it in the future is important for the acceptance of the KineSpring System. (6) Improving patient lives by decreasing pain, improving function, and potentially delaying arthroplasty is important. (7) A well-designed randomized control trial and further evidence regarding the KineSpring System is desired. Orthopedic healthcare professionals are enthusiastic about the prospect of the KineSpring System as an option to help close the treatment gap in knee OA. Focusing only on clinical trials with long-term data may be impractical and deprive patients and society of benefits that can be gained while trial data are maturing.

EVALUATION OF THE KNOWLEDGE ON COST OF ORTHOPEDIC IMPLANTS AMONG ORTHOPEDIC SURGEONS

PubMed Central

Arliani, Gustavo Gonçalves; Sabongi, Rodrigo Guerra; Batista, Alysson Ferreira; Astur, Diego Costa; Falotico, Guilherme Guadagnini; Cohen, Moises

2016-01-01

ABSTRACT Objective: To determine the knowledge of Brazilian Orthopedic Surgeons on the costs of orthopedic surgical devices used in surgical implants. Methods: A questionnaire was applied to Brazilian Orthopedic Surgeons during the 46th Brazilian Congress on Orthopedics and Traumatology. Results: Two hundred and one Orthopedic Surgeons completely filled out the questionnaire. The difference between the average prices estimated by the surgeons and the average prices provided by the supplier companies was 47.1%. No differences were found between the orthopedic specialists and other subspecialties on the prices indicated for specific orthopedic implants. However, differences were found among orthopedic surgeons who received visits from representatives of implant companies and those who did not receive those visits on prices indicated for shaver and radiofrequency device. Correlation was found between length of orthopedic experience and prices indicated for shaver and interference screw, and higher the experience time the lower the price indicated by Surgeons for these materials. Conclusion: The knowledge of Brazilian Orthopedic Surgeons on the costs of orthopedic implants is precarious. Reduction of cost of orthopedics materials depends on a more effective communication and interaction between doctors, hospitals and supplier companies with solid orientation programs and awareness for physicians about their importance in this scenario.Level of Evidence III, Cross-Sectional Study. PMID:28243178

Vascular access site complication in transfemoral coronary angiography between uninterrupted warfarin and heparin bridging.

PubMed

Wongcharoen, Wanwarang; Pinyosamosorn, Kittipong; Gunaparn, Siriluck; Boonnayhun, Suchada; Thonghong, Tasalak; Suwannasom, Pannipa; Phrommintikul, Arintaya

2017-08-01

Warfarin discontinuation with heparin bridging is a common practice in patients receiving warfarin prior to elective coronary angiography (CAG). The uninterrupted warfarin strategy has been suggested to be alternative option for patients with high thromboembolic risk. Therefore, we aimed to assess the safety of elective transfemoral CAG during uninterrupted warfarin therapy compared to heparin bridging. This study was a randomized open-label design with blinded event evaluation. The 110 consecutive patients (age ≥ 18 years) receiving warfarin before the planned transfemoral CAG were randomly assigned to either heparin bridging or uninterrupted warfarin with targeted INR (2.0-3.0). The primary outcome was the incidence of major vascular access site complications. The baseline characteristics were comparable between two groups (mean age was 60.1 ± 7.8 years, 49 males). The mean INR on the day of CAG of heparin bridging and uninterrupted warfarin groups was 1.2 ± 0.3 and 2.2 ± 0.5 (P < 0.001). The major vascular access site complications occurred in 3 of 55 (5.5%) heparin-bridging patients and in none of 55 uninterrupted warfarin patients (P = 0.243). The total vascular access site complications occurred in 6 (10.9%) heparin-bridging and one (1.8%) uninterrupted warfarin patients (P = 0.113). No patient developed either other bleeding or thromboembolic events during 7 days after CAG. We demonstrated that an uninterrupted warfarin strategy did not increase vascular access site complications in patients undergoing transfemoral CAG compared to heparin bridging therapy. Due to the safety and the ease of uninterrupted warfarin strategy, this approach should be encouraged in patients receiving long-term warfarin who undergo elective transfemoral CAG. © 2017, Wiley Periodicals, Inc.

Perioperative management of vitamin K antagonists in patients with low thromboembolic risk undergoing elective surgery: A prospective experience.

PubMed

Becerra, Ana Florencia; Cornavaca, María Teresita; Revigliono, José Ignacio; Contreras, Alejandro; Albertini, Ricardo; Tabares, Aldo Hugo

2017-10-11

To quantify thromboembolic and bleeding events in patients with low thromboembolic risk, who were chronically receiving vitamin K antagonists and undergoing elective surgery. A descriptive, prospective, single-center study was conducted between December 2010 and July 2014. Patients aged over 18 years old, chronically anticoagulated with vitamin K antagonists and admitted for elective surgery were included in the study. We excluded patients with a creatinine clearance<30ml/min, a body weight>120kg, heparin-induced thrombocytopenia, pregnant women, carriers of an epidural catheter for analgesia, patients who underwent unscheduled surgery and high thromboembolic risk-patients. Vitamin K antagonists were discontinued 5 days prior to the procedure without administering anticoagulant enoxaparin. The NIR was measured 24h before the procedure. A single dose of 3mg of vitamin K was administered in cases of a NIR>1.5. Vitamin K antagonists was resumed according to the surgical bleeding risk. Events were registered between 5 days prior to the procedure until 30 days after it. A total of 75 procedures were included in the study. Fifty-six patients (74.7%) received vitamin K antagonists for atrial fibrillation, 15 suffered from venous thromboembolism (20%) and 4 had mechanical heart valves (5.3%). Twenty-six patients (34.5%) underwent high-bleeding risk surgeries and 49 (65.5%) underwent low risk procedures. No thromboembolic event was recorded. Four bleeding events (5.3%) were reported, 3 of which were considered major bleeding events (2 fatal). Suspending vitamin K antagonists with no bridging therapy performed in patients with a low thromboembolic risk does not expose such patients to a significant risk of embolic events. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Drivers of 30-Day Readmission in Elderly Patients (>65 Years Old) After Spine Surgery: An Analysis of 500 Consecutive Spine Surgery Patients.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Han, Jing; Karikari, Isaac O; Cheng, Joseph; Bagley, Carlos A

2017-01-01

Early readmission after spine surgery is being used as a proxy for quality of care. One-fifth of patients are rehospitalized within 30 days after spine surgery, and more than one-third within 90 days; however, there is a paucity of data about the cause of early readmissions in elderly patients after elective spine surgery. A total of 500 elderly patients (>65 years old) undergoing elective spine surgery at a major academic hospital were included in the study. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient records were reviewed to determine the cause of readmission and the length of hospital stay. A total of 50 (10%) unplanned early readmissions were identified. The mean ± SD age was 72.54 ± 5.84 years. The mean ± SD number of days from discharge to readmission was 11.02 ± 7.25 days, and the average length of hospital stay for the readmissions was 7.7 days. The majority of patients that were readmitted presented to the emergency department from home (46%), whereas 38% were readmitted from a skilled nursing facility. The most common causes for readmission were infection or a concern for infection (42%) and pain (14%), with 32% of readmissions requiring a return to the operating room. Our study suggests that in elderly patients undergoing elective spine surgery, infection or a concern for infection, pain, and altered mental status were the most common primary reasons for unplanned readmission. Copyright © 2016 Elsevier Inc. All rights reserved.

Implementation of Preoperative Screening Criteria Lowers Infection and Complication Rates Following Elective Total Hip Arthroplasty and Total Knee Arthroplasty in a Veteran Population.

PubMed

Nussenbaum, Fernando D; Rodriguez-Quintana, David; Fish, Sara M; Green, David M; Cahill, Catherine W

2018-01-01

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common procedures with a risk of complications. Attempting to minimize complications, our institution implemented preoperative screening criteria for patients undergoing elective total joint replacement. Our study aimed to determine if screening criteria lowered total complications and/or surgical site infections (SSI). Two groups of consecutive patients undergoing TKA and THA at a single Veterans Affairs facility were evaluated prior to and after implementation of screening criteria, 520 and 475 respectively. Screening criteria included hemoglobin A1c ≤7, hemoglobin ≥11, body mass index ≤35, and albumin ≥3.5. Groups were analyzed for demographics, preoperative comorbidities, and postoperative complications. Rates of total complications and SSI were compared. Average follow-up was at least 2 years with minimum of 1 year. Demographics and comorbidities outside the screening criteria were similar. Total complication rate was reduced from 35.4% to 14.8% (P < .01) after implementation of screening criteria. For TKA, total complications were reduced from 33.1% to 15.0% (P < .01) and for THA they were reduced from 42.4% to 14.2% (P < .01). SSI rates for combined TKA and THA were reduced from 4.4% to 1.3% (P < .01). For knees, SSI was reduced from 4.6% to 1.3% (P = .01) and was statistically significant. For THA, SSI decreased from 3.8% to 1.2% (P < .05). Our institution saw a statistically significant decrease in both SSI and total complications following implementation of preoperative screening criteria for elective TKA and THA. Published by Elsevier Inc.

Conservative management of vestibular schwannoma: Predictors of growth and hearing.

PubMed

Jethanamest, Daniel; Rivera, Andrew M; Ji, Hongzhao; Chokkalingam, Venkatakarthikeyan; Telischi, Fred F; Angeli, Simon I

2015-09-01

To describe the clinical outcomes of patients undergoing serial observation for vestibular schwannoma (VS) and identify factors that may predict tumor growth or hearing loss. Retrospective review. A retrospective review was conducted of patients seen at a tertiary care medical center between 2002 and 2013 with an International Classification of Diseases-9 diagnosis code of 225.1. Patients electing observation as initial management, with at least two documented imaging results, were included. Exclusion criteria comprised bilateral VS, diagnosis of neurofibromatosis type 2, and neoplasms other than VS. Decline in serviceable hearing, tumor growth, and changes in management strategy were recorded. Survival analysis to assess median time to outcomes and multiple logistic regression analyses were performed. A total of 94 patients met inclusion criteria. While undergoing observation, 22.3% of patients underwent a change in management strategy to microsurgical excision or stereotactic radiotherapy. For patients with initial serviceable hearing, 24.3% observed a decline to a nonserviceable level. No significant clinical factors were identified to predict changes in hearing. Survival analysis revealed that an estimated 69.1% of patients electing observation as initial management continued to do so at 5 years. Imbalance or disequilibrium at presentation was found to be associated with an increased adjusted odds ratio (OR) (OR 2.96; 95% confidence interval, 1.03-8.50; P = 0.04) for tumor growth. Serial observation of VS is a viable treatment strategy for selected patients, with two-thirds of patients electing to continue this management option after 5 years. Disequilibrium as a presenting symptom may be associated with subsequent tumor growth. 4. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

A cost-effectiveness analysis of a proactive management strategy for the Sprint Fidelis recall: a probabilistic decision analysis model.

PubMed

Bashir, Jamil; Cowan, Simone; Raymakers, Adam; Yamashita, Michael; Danter, Matthew; Krahn, Andrew; Lynd, Larry D

2013-12-01

The management of the recall is complicated by the competing risks of lead failure and complications that can occur with lead revision. Many of these patients are currently undergoing an elective generator change--an ideal time to consider lead revision. To determine the cost-effectiveness of a proactive management strategy for the Sprint Fidelis recall. We obtained detailed clinical outcomes and costing data from a retrospective analysis of 341 patients who received the Sprint Fidelis lead in British Columbia, where patients younger than 60 years were offered lead extraction when undergoing generator replacement. These population-based data were used to construct and populate a probabilistic Markov model in which a proactive management strategy was compared to a conservative strategy to determine the incremental cost per lead failure avoided. In our population, elective lead revisions were half the cost of emergent revisions and had a lower complication rate. In the model, the incremental cost-effectiveness ratio of proactive lead revision versus a recommended monitoring strategy was $12,779 per lead failure avoided. The proactive strategy resulted in 21 fewer failures per 100 patients treated and reduced the chance of an additional complication from an unexpected surgery. Cost-effectiveness analysis suggests that prospective lead revision should be considered when patients with a Sprint Fidelis lead present for pulse generator change. Elective revision of the lead is justified even when 25% of the population is operated on per year, and in some scenarios, it is both less costly and provides a better outcome. © 2013 Heart Rhythm Society Published by Heart Rhythm Society All rights reserved.

Laparoscopic colon resection: To prep or not to prep? Analysis of 1535 patients.

PubMed

Allaix, Marco Ettore; Arolfo, Simone; Degiuli, Maurizio; Giraudo, Giuseppe; Volpatto, Silvio; Morino, Mario

2016-06-01

Mechanical bowel preparation (MBP) before elective open colon resection does not reduce the rate of postoperative anastomotic leakage. However, MBP is still routinely used in many countries, and there are very limited data regarding the utility of preoperative MBP in patients undergoing laparoscopic colon resection (LCR). The aim of this study was to challenge the use of MBP before elective LCR. It is a retrospective analysis of a prospectively collected database. All patients undergoing elective LCR with primary anastomosis and no stoma were included. Preoperative MBP with polyethylene glycol solution was used routinely between April 1992 and December 2004, and then it was abandoned. The early postoperative outcomes in patients who had preoperative MBP (MBP group) and in patients who underwent LCR without preoperative MBP (No-MBP group) were compared. From April 1992 to December 2014, 1535 patients underwent LCR: 706 MBP patients and 829 No-MBP patients. There were no differences in demographic data, indication for surgery and type of procedure performed between MBP and No-MBP group patients. The incidence of anastomotic leakage was similar between the two groups (3.4 vs. 3.6 %, p = 0.925). No differences were observed in intra-abdominal abscesses (0.6 vs. 0.8 %, p = 0.734), wound infections (0.6 vs. 1.4 %, p = 0.149), infectious extra-abdominal complications (1.8 vs. 3 %, p = 0.190), and non-infectious complications (6.1 vs. 6.8 %, p = 0.672). The overall reoperation rate was 4.6 % for MBP patients and 5 % for No-MBP patients (p = 0.813). The use of preoperative MBP does not seem to be associated with lower incidence of intra-abdominal septic complications after LCR.

Prediction of myocardial functional recovery by noninvasive evaluation of Basal and hyperemic coronary flow in patients with previous myocardial infarction.

PubMed

Djordjevic-Dikic, Ana; Beleslin, Branko; Stepanovic, Jelena; Giga, Vojislav; Tesic, Milorad; Dobric, Milan; Stojkovic, Sinisa; Nedeljkovic, Milan; Vukcevic, Vladan; Dikic, Nenad; Petrasinovic, Zorica; Nedeljkovic, Ivana; Tomasevic, Miloje; Vujisic-Tesic, Bosiljka; Ostojic, Miodrag

2011-05-01

The aim of this study was to evaluate the relation of basal and hyperemic coronary flow with myocardial functional improvement in patients with previous myocardial infarction undergoing elective percutaneous coronary intervention (PCI). Coronary flow was measured using transthoracic Doppler echocardiography in 50 patients (41 men; mean age, 53 ± 8 years) with previous myocardial infarction before, 24 hours, and 3 months after elective PCI. Diastolic deceleration time (DDT) was measured from the peak diastolic velocity to the point of intercept of initial decay slope with baseline. Coronary flow reserve (CFR) was calculated as the ratio of hyperemic to basal peak diastolic flow velocities. In comparison with patients without improvements in left ventricular function, patients with recovered left ventricular function had longer DDTs before angioplasty (841 ± 286 vs. 435 ± 80 msec, P < .001). CFR was significantly higher in recovered compared with nonrecovered patients (2.60 ± 0.70 vs. 2.16 ± 0.34, P = .034) 24 hours after PCI. Global and regional wall motion scores before PCI, end-diastolic and end-systolic volumes, and CFR 24 hours after PCI and DDT before PCI were univariate predictors of left ventricular functional recovery. By multivariate analysis, DDT and regional wall motion score before PCI were independent predictors of left ventricular recovery in the follow-up period (P = .003 and P = .007, respectively). In patients with previous myocardial infarction undergoing elective PCI, evaluation of basal coronary flow pattern and measurement of DDT before angioplasty may predict functional improvement of myocardium in the follow-up period and could be useful quantitative parameters in the evaluation of potential improvement in myocardial function. Copyright © 2011 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.

Declining rates of sterilisation reversal procedures in western Australian women from 1990 to 2008: the relationship with age, hospital type and government policy changes.

PubMed

Jama-Alol, Khadra A; Bremner, Alexandra P; Pereira, Gavin; Stewart, Louise M; Malacova, Eva; Moorin, Rachael; Preen, David B

2017-11-25

Female sterilisation is usually performed on an elective basis at perceived family completion, however, around 1-3% of women who have undergone sterilisation elect to undergo sterilisation reversal (SR) at a later stage. The trends in SR rates in Western Australia (WA), proportions of SR procedures between hospital types (public and private), and the effects of Federal Government policies on these trends are unknown. Using records from statutory state-wide data collections of hospital separations and births, we conducted a retrospective descriptive study of all women aged 15-49 years who underwent a SR procedure during the period 1st January 1990 to 31st December 2008 (n = 1868 procedures). From 1991 to 2007 the annual incidence rate of SR procedures per 10,000 women declined from 47.0 to 3.6. Logistic regression modelling showed that from 1997 to 2001 the odds of women undergoing SR in a private hospital as opposed to all other hospitals were 1.39 times higher (95% CI 1.07-1.81) and 7.51 times higher (95% CI 5.46-10.31) from 2002 to 2008. There were significant decreases in SR rates overall and among different age groups after the Federal Government interventions. Rates of SR procedures in WA have declined from 1990 to 2008, particularly following policy changes such as the introduction of private health insurance (PHI) policies. This suggests decisions to undergo SR may be influenced by Federal Government interventions.

Investigation of the immediate pre-operative physical capacity of patients scheduled for elective abdominal surgery using the 6-minute walk test.

PubMed

Soares, S M T P; Jannuzzi, H P C; Kassab, M F O; Nucci, L B; Paschoal, M A

2015-09-01

To evaluate the effects of repetition of the 6-minute walk test in patients scheduled to undergo abdominal surgery within the next 48 hours, and to verify the physical capacity of these subjects before surgery. Cross-sectional study. University teaching hospital. Forty-two patients scheduled for elective abdominal surgery within the next 48 hours. Distance walked in the 6-minute walk test, heart rate, peripheral oxygen saturation, dyspnoea and leg fatigue. Thirty-one patients (74%) were able to walk for a longer distance when the test was repeated. In these subjects, the mean increase in distance walked was 35.4 [standard deviation (SD) 19.9]m. Heart rate, dyspnoea and leg fatigue increased significantly over time on both tests (P<0.05). The mean heart rate at the end of the sixth minute was significantly higher on the second test (P=0.022). Peripheral oxygen saturation remained above 90% in both tests. The furthest distance walked was, on average, 461.3 (SD 89.7)m. This value was significantly lower than that predicted for the sample (P<0.001). Patients scheduled to undergo abdominal surgery were able to walk further when they performed a second 6-minute walk test. Moreover, they showed reduced physical ability before surgery. These findings suggest that repetition of the 6-minute walk test may increase the accuracy of the distance walked, which is useful for studies assessing the physical capacity of patients undergoing abdominal surgery. Copyright © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

The Weekend Effect in AAA Repair.

PubMed

O'Donnell, Thomas F X; Li, Chun; Swerdlow, Nicholas J; Liang, Patric; Pothof, Alexander B; Patel, Virendra I; Giles, Kristina A; Malas, Mahmoud B; Schermerhorn, Marc L

2018-04-18

Conflicting reports exist regarding whether patients undergoing surgery on the weekend or later in the week experience worse outcomes. We identified patients undergoing abdominal aortic aneurysm (AAA) repair in the Vascular Quality Initiative between 2009 and 2017 [n = 38,498; 30,537 endovascular aneurysm repair (EVAR) and 7961 open repair]. We utilized mixed effects logistic regression to compare adjusted rates of perioperative mortality based on the day of repair. Tuesday was the most common day for elective repair (22%), Friday for symptomatic repairs (20%), and ruptured aneurysms were evenly distributed. Patients with ruptured aneurysms experienced similar adjusted mortality whether they underwent repair during the week or on weekends. Transfers of ruptured AAA were more common over the weekend. However, patients transferred on the weekend experienced higher adjusted mortality than those transferred during the week (28% vs 21%, P = 0.02), despite the fact that during the week, transferred patients actually experienced lower adjusted mortality than patients treated at the index hospital (21% vs 31%, P < 0.01). Among symptomatic patients, adjusted mortality was higher for those undergoing repair over the weekend than those whose surgeries were delayed until a weekday (7.9% vs 3.1%, P = 0.02). Adjusted mortality in elective cases did not vary across the days of the week. Results were consistent between open and EVAR patients. We found no evidence of a weekend effect for ruptured or symptomatic AAA repair. However, patients with ruptured AAA transferred on the weekend experienced higher mortality than those transferred during the week, suggesting a need for improvement in weekend transfer processes.

Population pharmacokinetics of intravenous acetaminophen in Japanese patients undergoing elective surgery.

PubMed

Imaizumi, Tsuyoshi; Obara, Shinju; Mogami, Midori; Iseki, Yuzo; Hasegawa, Makiko; Murakawa, Masahiro

2017-06-01

Intravenous (i.v.) acetaminophen is administered during surgery for postoperative analgesia. However, little information is available on the pharmacokinetics of i.v. acetaminophen in Japanese patients undergoing surgery under general anesthesia. The study was approved by the Institutional Review Board and registered at UMIN-CTR (UMIN000013418). Patients scheduled to undergo elective surgery under general anesthesia were enrolled after obtaining written informed consent. During surgery, 1 g of i.v. acetaminophen was administered over 15, 60, or 120 min. Acetaminophen concentrations (15 or 16 samples per case) were measured at time points from 0-480 min after the start of administration (liquid chromatography-mass spectrometry/tandem mass spectrometry; limit of quantitation 0.1 μg/mL). The predictive performance of three published pharmacokinetic models was evaluated. Population pharmacokinetics were also analyzed using a nonlinear mixed-effect model based on the NONMEM program. Data from 12 patients who underwent endoscopic or lower limb procedures were analyzed (male/female = 7/5, median age 55 years, weight 63 kg). Anesthesia was maintained with remifentanil and propofol or sevoflurane. The pharmacokinetic model of i.v. acetaminophen reported by Würthwein et al. worked well. Using 185 datapoints, the pharmacokinetics of i.v. acetaminophen were described by a two-compartment model with weight as a covariate but not age, sex, or creatinine clearance. The median prediction error and median absolute prediction error of the final model were -1 and 10%, respectively. A population pharmacokinetic model of i.v. acetaminophen in Japanese patients was constructed, with performance within acceptable ranges.

Brief reports: plasma ropivacaine concentrations after ultrasound-guided rectus sheath block in patients undergoing lower abdominal surgery.

PubMed

Wada, Morito; Kitayama, Masato; Hashimoto, Hiroshi; Kudo, Tsuyoshi; Kudo, Mihoko; Takada, Norikazu; Hirota, Kazuyoshi

2012-01-01

A rectus sheath block can provide postoperative analgesia for midline incisions. However, information regarding the pharmacokinetics of local anesthetics used in this block is lacking. In this study, we detail the time course of ropivacaine concentrations after this block. Thirty-nine patients undergoing elective lower abdominal surgery were assigned to 3 groups receiving rectus sheath block with 20 mL of different concentrations of ropivacaine. Peak plasma concentrations were dose dependent, and there were no significant differences in the times to peak plasma concentrations. The present data also suggested a slower absorption kinetics profile for ropivacaine after rectus sheath block than other compartment blocks.

Antimicrobial efficacy of preoperative skin antisepsis and clonal relationship to postantiseptic skin-and-wound flora in patients undergoing clean orthopedic surgery.

PubMed

Daeschlein, G; Napp, M; Layer, F; von Podewils, S; Haase, H; Spitzmueller, R; Assadian, O; Kasch, R; Werner, G; Jünger, M; Hinz, P; Ekkernkamp, A

2015-11-01

Nosocomial surgical site infections (SSI) are still important complications in surgery. The underlying mechanisms are not fully understood. The aim of this study was to elucidate the possible role of skin flora surviving preoperative antisepsis as a possible cause of SSI. We conducted a two-phase prospective clinical trial in patients undergoing clean orthopedic surgery at a university trauma center in northern Germany. Quantitative swab samples were taken from pre- and postantiseptic skin and, additionally, from the wound base, wound margin, and the suture of 137 patients. Seventy-four patients during phase I and 63 during phase II were investigated. Microbial growth, species spectrum, and antibiotic susceptibility were analyzed. In phase two, the clonal relationship of strains was additionally analyzed. 18.0 % of the swab samples were positive for bacterial growth in the wound base, 24.5 % in the margin, and 27.3 % in the suture. Only 65.5 % of patients showed a 100 % reduction of the skin flora after antisepsis. The microbial spectrum in all postantiseptic samples was dominated by coagulase-negative staphylococci (CoNS). Clonally related staphylococci were detected in ten patients [nine CoNS, one methicillin-susceptible Staphylococcus aureus (MSSA)]. Six of ten patients were suspected of having transmitted identical clones from skin flora into the wound. Ethanol-based antisepsis results in unexpected high levels of skin flora, which can be transmitted into the wound during surgery causing yet unexplained SSI. Keeping with the concept of zero tolerance, further studies are needed in order to understand the origin of this flora to allow further reduction of SSI.

Pain and Opioid Use After Total Shoulder Arthroplasty With Injectable Liposomal Bupivacaine Versus Interscalene Block.

PubMed

Angerame, Marc R; Ruder, John A; Odum, Susan M; Hamid, Nady

2017-09-01

Postoperative pain control is a significant concern after total shoulder arthroplasty. Injectable periarticular liposomal bupivacaine, which has been found to decrease opioid use after orthopedic procedures, has been proposed as a viable alternative to regional anesthesia. This study compared the efficacy of liposomal bupivacaine vs interscalene block among patients undergoing total shoulder arthroplasty. A retrospective review was conducted of 79 patients who underwent anatomic total shoulder arthroplasty performed by a single surgeon between January 2013 and April 2015. Patient demographics, in-hospital Numeric Pain Rating Scale (NPRS) score obtained at 12-hour intervals, length of stay, and total in-hospital morphine equivalents in both the bupivacaine (n=25) and block (n=44) groups were recorded. Differences in length of stay, morphine equivalents, and age were assessed with Wilcoxon tests. Sex differences were assessed with the chi-square test. Repeated measures analysis with least square means was used to assess longitudinal changes in NPRS scores. No significant differences were found between groups for sex (P=.89), age (P=.81), American Society of Anesthesiologists classification (P=.50), preoperative opioid use (P=.41), length of stay (P=.32), or morphine equivalents (P=.71). The average NPRS score in the first 12 hours was 3.01 for the bupivacaine group and 4.41 for the interscalene block group (P=.25). By 48 hours postoperatively, average NPRS scores were similar (P=.93) for the 2 groups, 4.90 for the bupivacaine group and 4.19 for the interscalene block group. The findings for this cohort of patients undergoing anatomic total shoulder arthroplasty showed no significant difference for pain scores, postoperative narcotic use, or length of stay with injectable liposomal bupivacaine vs interscalene block. [Orthopedics. 2017; 40(5):e806-e811.]. Copyright 2017, SLACK Incorporated.

Variance in elective surgery for chronic pancreatitis.

PubMed

Shah, Nehal S; Siriwardena, Ajith K

2009-01-08

Evidence to guide selection of optimal surgical treatment for patients with painful chronic pancreatitis is limited. Baseline assessment data are limited and thus patients in different centres may be presenting at different stages of their illness. This study undertakes a systematic overview of reports of elective surgical intervention in chronic pancreatitis with particular reference to reporting of quality of life and baseline assessment and relation between disease and type of procedure. A computerised search of the PubMed, Embase and Cochrane databases was undertaken for the period January 1997 to March 2007 yielding 46 manuscripts providing data on 4,626 patients undergoing elective surgery for chronic pancreatitis. The median number of patients per study was 71 (range: 4-484). The median period for recruitment of patients was 10 years (range: 2-36 years). An externally validated quality of life questionnaire is reported in 8 (17.4%) of 46 manuscripts covering 441 (9.5%) of 4,626 patients. Formal comparison of pre-operative and post-operative pain scores was provided in 15 (32.6%) of manuscripts. Only seven (15.2%) reports provide a formal rationale or indication for selection of the type of elective surgical procedure for a stated disease variant and these papers cover 481 (10.4%) patients. In conclusion, this study demonstrates that there is a lack of standardization between units of the criteria for operative intervention in painful chronic pancreatitis. At a minimum, formal quality of life testing using a validated system should be undertaken in all patients prior to elective surgery for painful chronic pancreatitis.

Success of elective cholecystectomy treatment plans after emergency department visit.

PubMed

Bingener, Juliane; Thomsen, Kristine M; McConico, Andrea; Hess, Erik P; Habermann, Elizabeth B

2015-01-01

Differentiation between patients with acute cholecystitis and patients with severe biliary colic can be challenging. Patients with undiagnosed acute cholecystitis can incur repeat emergency department (ED) visits, which is resource intensive. Billing records from 2000-2013 of all adults who visited the ED in the 30 d preceding their cholecystectomy were analyzed. Patients who were discharged from the ED and underwent elective cholecystectomy were compared with those who were discharged and returned to the ED within 30 d. T-tests, chi-square tests, and multivariable analysis were used as appropriate. From 2000-2013, 3138 patients (34%) presented to the ED within 30 d before surgery, 63% were women, mean age 51 y, and of those 1625 were directly admitted from the ED for cholecystectomy, whereas 1513 patients left the ED to return for an elective cholecystectomy. Patients who were discharged were younger (mean age 49 versus 54 y, P < 0.001) and had shorter ED stays (5.9 versus 7.2 h, P < 0.001) than the patients admitted immediately. Of the discharged patients, 303 (20%) returned to the ED within 30 d to undergo urgent cholecystectomy. Compared with patients with successful elective cholecystectomy after the ED visit, those who failed the pathway were more likely to have an American Society of Anesthesiologists score ≥3 and were <40 or ≥60 compared with the successful group. One in five patients failed the elective cholecystectomy pathway after ED discharge, leading to additional patient distress and use of resources. Further risk factor assessment may help design efficient care pathways. Copyright © 2015 Elsevier Inc. All rights reserved.

Targeted Next Generation Sequencing with ThyroSeq v2.1 for Indeterminate Thyroid Nodules in Clinical Practice.

PubMed

Witt, Robert L

2016-12-01

To determine if patients elect molecular testing over diagnostic surgery or repeat fine needle aspiration for indeterminate thyroid nodules. Can ThyroSeq v2.1 molecular testing reduce diagnostic thyroid surgery and rule out cancer? Retrospective review Setting: Single institution, single-practice surgeon. Fifteen month retrospective review of indeterminate thyroid nodules that went on to ThyroSeq v2.1 testing. 286 patients met American Thyroid Association guideline criteria for surgeon- performed, ultrasound-guided fine needle aspiration for a thyroid nodule with on-site cytopathology. The indeterminate (Bethesda III or IV) fine needle aspiration cytology rate was 9.1 percent. Prevalence of malignancy in indeterminate nodules was 19 percent. 26/26 (100 percent) patients with indeterminate thyroid nodules elected molecular testing. 16 patients had no mutation, 9 had one or more mutations, and I had no result. 16 of 25 (64 percent) patients with no mutation elected not to undergo diagnostic surgery for indeterminate thyroid nodules. Patients demonstrated a strong preference for molecular testing instead of diagnostic thyroid surgery for indeterminate thyroid nodules. All patients in this series, 25/25 (100 percent) with indeterminate thyroid nodules elected molecular testing instead of repeat biopsy or diagnostic thyroid surgery. 16 of 25 (64 percent) patients tested had no mutation. All 16/16 (100 percent) patients with no mutation on ThyroSeq "rule out" testing elected active surveillance rather than surgery or biopsy, reducing diagnostic surgery. The risk of malignancy among mutation negative patients was not definitively established. There are a number of factors currently that may mute the power of "rule in" testing.

The 2014 governors' races and health care: a campaign web site analysis.

PubMed

Scott, Kirstin W; Blendon, Robert J; Sommers, Benjamin D

2015-01-01

The November 2014 midterm election was the first election since key coverage provisions of the Affordable Care Act (ACA) were implemented, including the Medicaid expansion and creation of the health insurance exchanges. The pre-election variability in the states' implementation of these provisions coupled with the large number of states selecting their next governor made the election important at the state level. To better understand the role of health care in the recent gubernatorial elections, we analyzed health policy content presented by 71 candidates for governor on their campaign Web sites. Nearly 80% of all candidates discussed health policy on their Web site, including the subset of the 36 winning governors. The predominant focus of health policy content was on the ACA as a whole or its provisions. Medicaid was discussed more often by candidates in non-expansion states than those from expansion states. Based on the statements of winning governors, we expect serious consideration of the Medicaid expansion to occur in at least 4 states, whereas 2 states may make efforts to reverse course. Relatively few winning governors (33%) mentioned the exchanges. Only 1 expressed interest in switching from the federal exchange to a state exchange, which has particular relevance given the Supreme Court's pending decision on King v. Burwell that could invalidate tax credits on the federal exchange. The prominence of health care in the gubernatorial campaigns strengthens the likelihood that governors will play an influential role in the health system's future, especially as the ACA undergoes further federal debate. © The Author(s) 2015.

Evaluating compliance with institutional preoperative testing guidelines for minimal-risk patients undergoing elective surgery.

PubMed

Siriussawakul, Arunotai; Nimmannit, Akarin; Rattana-arpa, Sirirat; Chatrattanakulchai, Siritda; Saengtawan, Puttachard; Wangdee, Aungsumat

2013-01-01

Few investigations preoperatively are important for low-risk patients. This study was designed to determine the level of compliance with preoperative investigation guidelines for ASA I patients undergoing elective surgery. Secondary objectives included the following: to identify common inappropriate investigations, to evaluate the impact of abnormal testing on patient management, to determine factors affecting noncompliant tests, and to estimate unnecessary expenditure. This retrospective study was conducted on adult patients over a one-year period. The institute's guidelines recommend tests according to the patients' age groups: a complete blood count (CBC) for those patients aged 18-45; CBC, chest radiograph (CXR) and electrocardiography (ECG) for those aged 46-60; and CBC, CXR, ECG, electrolytes, blood glucose, blood urea nitrogen (BUN), and creatinine (Cr) for patients aged 61-65. The medical records of 1,496 patients were reviewed. Compliant testing was found in only 12.1% (95% CI, 10.5-13.9). BUN and Cr testings were the most frequently overprescribed tests. Overinvestigations tended to be performed on major surgery and younger patients. Overall, overinvestigation incurred an estimated cost of US 200,000 dollars during the study period. The need to utilize the institution's preoperative guidelines should be emphasized in order to decrease unnecessary testing and the consequential financial burden.

Evaluation of peripheral muscle strength of patients undergoing elective cardiac surgery: a longitudinal study

PubMed Central

Santos, Kelli Maria Souza; de Cerqueira Neto, Manoel Luiz; Carvalho, Vitor Oliveira; de Santana Filho, Valter Joviniano; da Silva Junior, Walderi Monteiro; Araújo Filho, Amaro Afrânio; Cerqueira, Telma Cristina Fontes; Cacau, Lucas de Assis Pereira

2014-01-01

Introduction Peripheral muscle strength has been little explored in the literature in the context of cardiac rehabilitation. Objective To evaluate the peripheral muscle strength of patients undergoing elective cardiac surgery. Methods This was a longitudinal observational study. The peripheral muscle strength was measured using isometric dynamometry lower limb (knee extensors and flexors) at three different times: preoperatively (M1), the day of discharge (M2) and hospital discharge (M3). Participants received physiotherapy pre and postoperatively during the days of hospitalization during the morning and afternoon. Results Twenty-two patients were evaluated. The values of peripheral muscle strength of knee extensors preoperative found were about 50% lower than those predicted for the healthy population. When comparing muscle strength prior (M1), with the remaining evaluation, found himself in a fall of 29% for the movement of knee extension and 25% for knee flexion in M2 and a decrease of 10% movement for knee extension and 13% for knee flexion in M3 when comparing with M1. Conclusion The values of peripheral muscle strength prior of the study patients were lower than predicted for the healthy population of the same age. After the surgical event this reduction is even more remarkable, being reestablished until the time of discharge, to values close to baseline. PMID:25372909

Evaluation of peripheral muscle strength of patients undergoing elective cardiac surgery: a longitudinal study.

PubMed

Santos, Kelli Maria Souza; Cerqueira Neto, Manoel Luiz de; Carvalho, Vitor Oliveira; Santana Filho, Valter Joviniano de; Silva Junior, Walderi Monteiro da; Araújo Filho, Amaro Afrânio; Cerqueira, Telma Cristina Fontes; Cacau, Lucas de Assis Pereira

2014-01-01

Peripheral muscle strength has been little explored in the literature in the context of cardiac rehabilitation. To evaluate the peripheral muscle strength of patients undergoing elective cardiac surgery. This was a longitudinal observational study. The peripheral muscle strength was measured using isometric dynamometry lower limb (knee extensors and flexors) at three different times: preoperatively (M1), the day of discharge (M2) and hospital discharge (M3). Participants received physiotherapy pre and postoperatively during the days of hospitalization during the morning and afternoon. Twenty-two patients were evaluated. The values of peripheral muscle strength of knee extensors preoperative found were about 50% lower than those predicted for the healthy population. When comparing muscle strength prior (M1), with the remaining evaluation, found himself in a fall of 29% for the movement of knee extension and 25% for knee flexion in M2 and a decrease of 10% movement for knee extension and 13% for knee flexion in M3 when comparing with M1. The values of peripheral muscle strength prior of the study patients were lower than predicted for the healthy population of the same age. After the surgical event this reduction is even more remarkable, being reestablished until the time of discharge, to values close to baseline.

Frequency & specificity of RBC alloantibodies in patients due for surgery in Iran.

PubMed

Reyhaneh, Khademi; Ahmad, Gharehbaghian; Gharib, Karimi; Vida, Vafaiyan; Raheleh, Khademi; Mehdi, Tabrizi Namini

2013-01-01

Red blood cell alloimmunization is common in patients receiving multiple blood transfusions. Since the probability of repeat transfusion increases with longer life expectancy, it is important to study to which extent alloimmunized patients with a history of transfusion are prone to form alloantibodies after transfusion events. The aim of this study was to retrospectively analyze the alloimmunization against RBCs among transfused patients who were to undergo elective surgery in Tehran, Iran. A total of 3092 occasionally transfused patients, who were to undergo elective surgery, in four hospitals in Tehran were included in the study. For patients with alloantibodies, the data about sex, date of birth, history of transfusion, surgery, abortion and alloantibody specificity were collected. Clinically significant alloantibodies were found in 30 patients. The presence of positive antibodies in the patients for whom cross-match had been done was one per cent. Most of them had surgery history or transfusion record during the preceding year. The three most frequent alloantibodies were anti-K (23.53%), anti- E (20.59%) and anti-c (17.56%). The most common clinically significant alloantibodies identified in men and women were anti-K and anti-E, respectively. The most common causes of alloimmunization for men were surgery history and transfusion record and for women pregnancy.

[What preoperative information do the parents of children undergoing surgery want?].

PubMed

Sartori, Josefina; Espinoza, Pilar; Díaz, María Soledad; Ferdinand, Constanza; Lacassie, Héctor J; González, Alejandro

2015-01-01

Parents feel fear and anxiety before surgery is performed on their child, and those feelings could obstruct their preparation for the surgery. Preoperative information could relieve those feelings. To determine the preoperative information needs of parents of children undergoing elective surgery. A study was conducted on the parents of children who underwent elective surgery. Demographic data of parents were recorded. Preoperative information received or would like to have received was assessed in terms of contents, methods, opportunity, place and informant. Descriptive statistics were used. Thirteen hundred parents were surveyed. More than 80% of them want preoperative information about anaesthesia, surgery, preoperative fasting, drugs and anaesthetic complications, monitoring, intravenous line management, pain treatment, postoperative feeding, anxiety control, hospitalisation room, recovery room, and entertainment in recovery room. Most want to be informed verbally, one to two weeks in advance and not on the same day of surgery. The informant should be the surgeon and in his office. In addition, they want information through leaflets, videos and simulation workshops, or guided tours. Parents need complete preoperative information about anesthesia, surgery and postoperative care, received verbally and in advance. Copyright © 2015 Sociedad Chilena de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

Prophylactic Diclectin reduces the incidence of postoperative vomiting.

PubMed

Reeve, Brenda K; Cook, Deborah J; Babineau, Denise; Scholes, L Cory; Buckley, D Norman

2005-01-01

Diclectin(R) (DCL) is an effective antiemetic used for relief of nausea and vomiting in pregnancy. It is unknown whether DCL is effective in the prevention of postoperative nausea and vomiting (PONV). We conducted a randomized, stratified, double-blind placebo-controlled trial to examine the incidence of PONV in women undergoing elective laparoscopic tubal ligation in the day surgery setting. DCL (doxylamine succinate 10 mg and pyridoxine hydrochloride 10 mg) was administered orally the night before surgery, the morning of surgery, and upon hospital discharge. We enrolled 146 women in the trial, 127 of whom were included in the effectiveness analysis and 102 of whom were included in the efficacy analysis. We did not detect a difference in the incidence of nausea and vomiting in the first six hours postoperatively after adjusting for additional antiemetics administered. Patients receiving DCL as compared with placebo were significantly less likely to experience vomiting six to 24 hr postoperatively [5/59 (8.5%) vs 14/55 (25.4%), P < 0.017]. Treated patients tended to return to work earlier than those who received placebo (1.74 vs 3.7 days P = NS). Perioperative oral DCL reduces the incidence of postoperative vomiting in women undergoing elective laparoscopic tubal ligation, and may accelerate return to work.

Instrumental delivery of the fetal head at the time of elective repeat cesarean: a randomized pilot study.

PubMed

Bofill, J A; Lencki, S G; Barhan, S; Ezenagu, L C

2000-01-01

We sought to ascertain whether the routine use of instruments, forceps or vacuum, at the time of elective repeat cesarean delivery, permits a delivery that is as safe for mother and infant and as easy for mother and physician as traditional manual delivery of the fetal head. In this prospective study 44 women undergoing elective repeat cesarean were randomized to deliver by Vacuum (V), Forceps (F), or by Manual (M) means. Groups were compared with regard to demographic variables and maternal and neonatal outcomes. Deliveries were timed from entry into the uterus until full delivery of the infant. Maternal pain scores were assessed using a 10-cm visual analog scale. There were no differences in demographic variables except that the M group had fewer women with up to two cesareans. A large percentage of women in each group were delivered with the randomized instrument. Use of the V did not demonstrate fewer extensions of the uterine incision or lesser amounts of blood loss as measured by serial hemoglobin determinations. There was a trend for the F group to require a longer period of time for delivery (p = 0.061). Women in the V group reported significantly lower pain scores (p = 0.015). There were no serious neonatal injuries. The routine use of instruments at the time of elective repeat cesarean delivery appears safe and effective.

Elective neck management for high-grade salivary gland carcinoma.

PubMed

Herman, Michael P; Werning, John W; Morris, Christopher G; Kirwan, Jessica M; Amdur, Robert J; Mendenhall, William M

2013-01-01

To determine whether patients with clinically node negative (cNo) high grade salivary gland carcinomas benefit from an elective neck dissection prior to postoperative radiotherapy (RT). Between October 1964 and October 2009, 59 previously untreated patients with cNo high-grade salivary gland carcinomas (squamous cell carcinomas were excluded) were treated with curative intent using elective neck dissection (END; n=41), or elective neck irradiation (ENI; n=18) at the University of Florida College of Medicine (Gainesville, FL). All patients underwent resection of the primary cancer followed by postoperative RT. The median follow-up period was 5.2years (range, 0.3-34years). Occult metastases were found in 18 (44%) of the 41 patients in the END group. There were 4 recurrences (10%) in the END group and 0 recurrence in the ENI group. Neck control rates at 5years were: END, 90%; ENI, 100%; and overall, 93% (p=0.1879). Cause-specific survival was 94% in the ENI group, 84% in the END group, and 86% for all patients (p=0.6998). There were 3 reported grade 3 or 4 toxicities. Two patients had a postoperative fistula and one patient had a grade 4 osteoradionecrosis that required a partial mandibulectomy. Patients with cNo high grade salivary gland carcinomas who are planned to undergo surgery and postoperative RT likely do not benefit from a planned neck dissection. Copyright © 2013 Elsevier Inc. All rights reserved.

[The beginnings of orthopedic surgery in Israel].

PubMed

Tauber, Chanan

2013-08-01

In early mandatory Israel, orthopedics was mainly conservative, The first modern orthopedic surgeon was Ernst Spira from Czechoslovakia who established an orthopedic service at the Beilinson Hospital in Petah Tikva and left in 1948 to establish the Orthopedic Department and the Rehabilitation Center in Tel Hashomer, which treated the War of Independence casualties including amputees and victims of spinal cord injuries. A second orthopedic department was opened in Tel Hashomer by Shmuel Weissman who left in 1961 to open the Orthopedic Department at the Ichilov hospital in Tel Aviv. Shmuel Weissman became the first Chairman of Orthopedic Surgery at the Tel Aviv University medical school. In 1955, Myer Makin opened a modern orthopedic department in the Hadassah Hospital in Jerusalem and the Alyn Hospital for crippled children. In 1951, Assaf Harofeh Hospital opened the Department of Orthopedic Surgery headed by Anatol Axer who specialized in the treatment and rehabilitation of polio patients. The majority of the second generation of orthopedic department directors was trained by these four surgeons. Major developments in the 1960s and 1970s were the introduction of the AO system revolutionizing fracture treatment from conservative to operative treatment, the advent of total hip and knee replacements, Harrington instrumentation in spinal surgery and arthroscopy were major advances in orthopedic patient care brought to Israel by the aforementioned second generation of orthopedic surgeons. Hand surgery became an independent subspecialty of orthopedics and was lead by the internationally renowned hand surgeon, Isidore Kessler.

Sonication technique improves microbiological diagnosis in patients treated with antibiotics before surgery for prosthetic joint infections.

PubMed

Scorzolini, Laura; Lichtner, Miriam; Iannetta, Marco; Mengoni, Fabio; Russo, Gianluca; Panni, Alfredo Schiavone; Vasso, Michele; Vasto, Michele; Bove, Marco; Villani, Ciro; Mastroianni, Claudio M; Vullo, Vincenzo

2014-07-01

Microbiological diagnosis is crucial for the appropriate management of implant-associated orthopedic infections (IAOIs). Sonication of biomaterials for microbiological diagnosis has not yet been introduced in routine clinical practice. Aim of this study was to describe the advantages and feasibility of this procedure in the clinical setting. We prospectively studied 56 consecutive patients undergoing revision because of IAOI and compared the sensitivity of sonication of explanted orthopedic implants with standard cultures. Patients were divided into two groups: those with foreign body infection (FBI, 15 patients) and those with prosthetic joint infection (PJI, 41 patients). Clinical, radiological and microbiological features were recorded. In the PJI group the sensitivity of sonication in detecting bacterial growth was higher than conventional culture (77% vs 34.1% respectively, p<0.002), while no difference was observed in the FBI group (85.7% vs 86% respectively, p>0.05). Coagulase-negative Staphylococci accounted for 90% of the bacteria detected by sonication. Moreover, we found that in the PJI group the sensitivity of sonication was not affected by the timing of antibiotic interruption before surgery. Sonication remains an important tool to improve microbiological diagnosis in PJIs, especially in patients who received previous antimicrobial treatment.

Anesthesia for the patient undergoing total knee replacement: current status and future prospects

PubMed Central

Turnbull, Zachary A; Sastow, Dahniel; Giambrone, Gregory P; Tedore, Tiffany

2017-01-01

Total knee arthroplasty (TKA) has become one of the most common orthopedic surgical procedures performed nationally. As the population and surgical techniques for TKAs have evolved over time, so have the anesthesia and analgesia used for these procedures. General anesthesia has been the dominant form of anesthesia utilized for TKA in the past, but regional anesthetic techniques are on the rise. Multiple studies have shown the potential for regional anesthesia to improve patient outcomes, such as a decrease in intraoperative blood loss, length of stay, and patient mortality. Anesthesiologists are also moving toward multimodal analgesia, which includes peripheral nerve blockade, periarticular injection, and preemptive analgesia. The goal of multimodal analgesia is to improve perioperative pain control while minimizing systemic narcotic consumption. With improved postoperative pain management and rapid patient rehabilitation, new clinical pathways have been engineered to fast track patient recovery after orthopedic procedures. The aim of these clinical pathways was to improve quality of care, minimize unnecessary variations in care, and reduce cost by using streamlined procedures and protocols. The future of TKA care will be formalized clinical pathways and tracks to better optimize perioperative algorithms with regard to pain control and perioperative rehabilitation. PMID:28331362

Anesthesia for the patient undergoing total knee replacement: current status and future prospects.

PubMed

Turnbull, Zachary A; Sastow, Dahniel; Giambrone, Gregory P; Tedore, Tiffany

2017-01-01

Total knee arthroplasty (TKA) has become one of the most common orthopedic surgical procedures performed nationally. As the population and surgical techniques for TKAs have evolved over time, so have the anesthesia and analgesia used for these procedures. General anesthesia has been the dominant form of anesthesia utilized for TKA in the past, but regional anesthetic techniques are on the rise. Multiple studies have shown the potential for regional anesthesia to improve patient outcomes, such as a decrease in intraoperative blood loss, length of stay, and patient mortality. Anesthesiologists are also moving toward multimodal analgesia, which includes peripheral nerve blockade, periarticular injection, and preemptive analgesia. The goal of multimodal analgesia is to improve perioperative pain control while minimizing systemic narcotic consumption. With improved postoperative pain management and rapid patient rehabilitation, new clinical pathways have been engineered to fast track patient recovery after orthopedic procedures. The aim of these clinical pathways was to improve quality of care, minimize unnecessary variations in care, and reduce cost by using streamlined procedures and protocols. The future of TKA care will be formalized clinical pathways and tracks to better optimize perioperative algorithms with regard to pain control and perioperative rehabilitation.

Femoral Reconstruction Using External Fixation

PubMed Central

Palatnik, Yevgeniy; Rozbruch, S. Robert

2011-01-01

Background. The use of an external fixator for the purpose of distraction osteogenesis has been applied to a wide range of orthopedic problems caused by such diverse etiologies as congenital disease, metabolic conditions, infections, traumatic injuries, and congenital short stature. The purpose of this study was to analyze our experience of utilizing this method in patients undergoing a variety of orthopedic procedures of the femur. Methods. We retrospectively reviewed our experience of using external fixation for femoral reconstruction. Three subgroups were defined based on the primary reconstruction goal lengthening, deformity correction, and repair of nonunion/bone defect. Factors such as leg length discrepancy (LLD), limb alignment, and external fixation time and complications were evaluated for the entire group and the 3 subgroups. Results. There was substantial improvement in the overall LLD, femoral length discrepancy, and limb alignment as measured by mechanical axis deviation (MAD) and lateral distal femoral angle (LDFA) for the entire group as well as the subgroups. Conclusions. The Ilizarov external fixator allows for decreased surgical exposure and preservation of blood supply to bone, avoidance of bone grafting and internal fixation, and simultaneous lengthening and deformity correction, making it a very useful technique for femoral reconstruction. PMID:21991425

Single-injection femoral nerve block. Effects on the independence level in functional activities in the early postoperative period in patients with total knee arthroplasty.

PubMed

Tugay, Nazan; Saricaoglu, Fatma; Satilmis, Tulin; Alpar, Ulku; Akarcali, Inci; Citaker, Seyit; Tugay, Umut; Atilla, Bulent; Tokgozoglu, Mazhar

2006-07-01

To investigate the efficacy of single injection femoral nerve block (FNB) on the independence level in functional activities in the early postoperative period in patients with total knee arthroplasty (TKA). We conducted this prospective, randomized, blinded trial in the Department of Orthopedics and Traumatology, Hacettepe University Hospital Ankara, Turkey, between June 2003 and April 2004. Twenty-three patients scheduled for elective TKA were randomly divided into 3 groups. Group I received preemptive single injection FNB, group II received postoperative single injection FNB, and group III served as a control group. Intravenous morphine patient controlled analgesia (PCA) was used following surgery in all groups. Morphine dose and pain score defined by the visual analog scale (VAS) were recorded postoperatively at the 15th minute, 30th minute, 1st, 4th, 6th, 12th, 24th, and 48th hours. A standard rehabilitation protocol was applied for all patients. The independence level in functional activities was assessed during the first 2 postoperative days and at discharge with the Iowa Level of Assistance Scale (ILAS) and the Iowa Ambulation Speed Scale (IASS). Physical therapists that enrolled in the study were blinded to the groups. Pain scores were significantly different between the groups (p<0.05). The preemptive and postoperative FNB group`s VAS scores were both significantly lower than the control group (p<0.05). However, there was no significant difference in VAS scores between preemptive and postoperative FNB groups (p>0.05). There was no statistically significant difference between the groups in any of the functional scores in the first 2 postoperative days, and at discharge (p>0.05). Single injection FNB provided effective analgesia in patients undergoing TKA. However, the independence level in functional activities in the early postoperative period was not influenced by the analgesia method.

Pre-anesthetic meperidine: associated vomiting and gastroesophageal reflux during the subsequent anesthetic in dogs.

PubMed

Wilson, Deborah V; Tom Evans, A; Mauer, Whitney A

2007-01-01

To determine the effect of meperidine administered prior to anesthesia on the incidence of vomiting before, and gastroesophageal reflux (GER) and regurgitation during, the subsequent period of anesthesia in dogs. Randomized, controlled trial. A total of 60 healthy dogs, 4.3 +/- 2.3 years old, and weighing 35.5 +/- 13.1 kg. Dogs were admitted to the study if they were healthy, had no history of vomiting, and were scheduled to undergo elective orthopedic surgery. The anesthetic protocol used was standardized to include thiopental and isoflurane in oxygen. Dogs were randomly selected to receive one of the following pre-medications: morphine (0.66 mg kg(-1) IM) with acepromazine (0.044 mg kg(-1) IM), meperidine (8.8 mg kg(-1) IM) with acepromazine (0.044 mg kg(-1) IM) or meperidine alone (8.8 mg kg(-1) IM). A sensor-tipped catheter was placed to measure esophageal pH during anesthesia. Gastro-esophageal reflux was judged to have occurred if there was a decrease in esophageal pH below four or an increase above 7.5. No dogs vomited after the administration of meperidine, but 50% of dogs vomited after the administration of morphine. When compared with morphine, treatment with meperidine alone or combined with acepromazine before anesthesia was associated with a 55% and 27% reduction in absolute risk of developing GER, respectively. Dogs receiving meperidine alone were significantly less sedate than other dogs in the study, and required more thiopental to induce anesthesia. Arterial blood pressure and heart rate were not significantly different between groups at the start of the measurement period. Cutaneous erythema and swelling were evident in four dogs receiving meperidine. Administration of meperidine to healthy dogs prior to anesthesia was not associated with vomiting and tended to reduce the occurrence of GER, but produced less sedation when compared with morphine. Meperidine is not a useful addition to the anesthetic protocol if prevention of GER is desired.

The Effect of Advancing Age on Total Joint Replacement Outcomes

PubMed Central

Noiseux, Nicolas; Linson, Eric; Cram, Peter

2015-01-01

Objective: To describe age-related differences in outcomes among older adults undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Design: Retrospective study. Participants: A total of 1792 patients who underwent primary THA or TKA at the University of Iowa Hospitals and Clinics between 2010 and 2013 were identified in the University HealthSystem Consortium Database and University of Iowa Orthopedics Joint Replacement Registry. Main Outcome Measures: Hospital length of stay (LOS), 30-day readmission rate, in-hospital mortality, number of days admitted to intensive care unit (ICU discharge disposition), in-hospital complications (pulmonary embolism, deep vein thrombosis, wound infection, hemorrhage, sepsis, or myocardial infarction), quality of life (measured using Short-Form 36 [SF-36]), discharge disposition (home, home with home health, nursing home, inpatient rehabilitation, transfer to another acute care hospital, and dead), and total patient level observed hospital cost (based on hospital charge information from each revenue code and estimated labor costs). Outcomes were compared in patients stratified by age and categorized by decade (ie, ≤50, 51-60, 61-70, 71-80, and ≥81). Results: A total of 871 THAs and 921 TKAs were performed. The mean age of our cohort was 60.5 years and 56.1% were women. In-hospital complication rates and ICU utilization progressively increased with increasing age. There was also a higher likelihood of skilled nursing facility placement and longer LOS. There was no increase in 30-day readmissions, mortality, or total cost. Improvements in patient reported outcomes (SF-36) scores were similar for all age-groups. Conclusions: Compared to younger patients, older THA and TKA recipients were more likely to experience postoperative complications, admission to the ICU, discharge to a skilled care facility, and had longer hospital LOS. Improvements in patient-related outcomes were similar across all age-groups. These findings may be helpful when counseling older patients regarding elective total joint arthroplasty. PMID:26328232

Postoperative incentive spirometry use.

PubMed

Hassanzadeh, Hamid; Jain, Amit; Tan, Eric W; Stein, Benjamin E; Van Hoy, Megan L; Stewart, Nadine N; Lemma, Mesfin A

2012-06-01

The authors hypothesized that the use of incentive spirometry by orthopedic patients is less than the recommended level and is affected by patient-related factors and type of surgery. To determine its postoperative use, the authors prospectively surveyed all patients in their institution's general orthopedic ward who had undergone elective spine surgery or total knee or hip arthroplasty during a consecutive 3-month period in 2010, excluding patients with postoperative delirium or requiring a monitored bed. All 182 patients (74 men, 108 women; average age, 64.5 years; range, 32-88 years; spine group, n=55; arthroplasty group, n=127), per protocol, received preoperative spirometry education by a licensed respiratory therapist (recommended use, 10 times hourly) and reinforcement education by nurses. Patients were asked twice daily (morning and evening) regarding their spirometry use during the previous 1-hour period by a registered nurse on postoperative days 1 through 3. All data were collected by the same 2 nurses using the same standardized questionnaire. Spirometry use was correlated with surgery type, postoperative day/time, and patient's age and sex. Student's t test, Spearman test, and one-way analysis of variance were used to compare differences (P<.05). Spirometry use averaged 4.1 times per hour (range, 0-10 times). No statistical correlations were found between spirometry use and age. Sex did not influence spirometry use. The arthroplasty group reported significantly higher use than did the spine group: 4.3 and 3.5 times per hour, respectively. Mean use increased significantly between postoperative days 1, 2, and 3. Copyright 2012, SLACK Incorporated.

Perceived barriers among physicians for stopping non-cost-effective blood-saving measures in total hip and total knee arthroplasties.

PubMed

Voorn, Veronique M A; Marang-van de Mheen, Perla J; Wentink, Manon M; Kaptein, Ad A; Koopman-van Gemert, Ankie W M M; So-Osman, Cynthia; Vliet Vlieland, Thea P M; Nelissen, Rob G H H; van Bodegom-Vos, Leti

2014-10-01

Despite evidence that the blood-saving measures (BSMs) erythropoietin (EPO) and intra- and postoperative blood salvage are not (cost-)effective in primary elective total hip and knee arthroplasties, they are used frequently in Dutch hospitals. This study aims to assess the impact of barriers associated with the intention of physicians to stop BSMs. A survey among 400 orthopedic surgeons and 400 anesthesiologists within the Netherlands was performed. Multivariate logistic regression was used to identify barriers associated with intention to stop BSMs. A total of 153 (40%) orthopedic surgeons and 100 (27%) anesthesiologists responded. Of all responders 67% used EPO, perioperative blood salvage, or a combination. After reading the evidence on non-cost-effective BSMs, 50% of respondents intended to stop EPO and 53% to stop perioperative blood salvage. In general, barriers perceived most frequently were lack of attention for blood management (90% of respondents), department priority to prevent transfusions (88%), and patient characteristics such as comorbidity (81%). Barriers significantly associated with intention to stop EPO were lack of interest to save money and the impact of other involved parties. Barriers significantly associated with intention to stop perioperative blood salvage were concerns about patient safety, lack of alternatives, losing experience with the technique, and lack of interest to save money. Physicians experience barriers to stop using BSMs, related to their own technical skills, patient safety, current blood management policy, and lack of interest to save money. These barriers should be targeted in strategies to make BSM use cost-effective. © 2014 AABB.

Traffic in the operating room during joint replacement is a multidisciplinary problem

PubMed Central

Bédard, Martin; Pelletier-Roy, Rémi; Angers-Goulet, Mathieu; Leblanc, Pierre-Alexandre; Pelet, Stéphane

2015-01-01

Background Door openings disrupt the laminar air flow and increase the bacterial count in the operating room (OR). We aimed to define the incidence of door openings in the OR during primary total joint arthroplasty (TJA) surgeries and determine whether measures were needed and/or possible to reduce OR staff traffic. Methods We recorded the number of door openings during 100 primary elective TJA surgeries; the OR personnel were unaware of the observer’s intention. Operating time was divided into the preincision period, defined as the time from the opening of surgical trays to skin incision, and the postincision period, defined as time from incision to dressing application. Results The mean number of door openings during primary TJA was 71.1 (range 35–176) with a mean operative time of 111.9 (range 53–220) minutes, for an average of 0.64 (range 0.36–1.05) door openings/min. Nursing staff were responsible for 52.2% of total door openings, followed by anesthesia staff at 23.9% and orthopedic staff at 12.7%. In the preincision period, we observed an average of 0.84 door openings/min, with nursing and orthopedic personnel responsible for most of the door openings. The postincision period yielded an average of 0.54 door openings/min, with nursing and anesthesia personnel being responsible for most of the door openings. Conclusion There is a high incidence of door openings during TJA. Because we observed a range in the number of door openings per surgery, we believe it is possible to reduce this number during TJA. PMID:26022153

Patients' perception of noise in the operating room--a descriptive and analytic cross-sectional study.

PubMed

Hasfeldt, Dorthe; Maindal, Helle Terkildsen; Toft, Palle; Birkelund, Regner

2014-10-01

Noise is a general stressor that affects the cardiovascular system, resulting in increased blood pressure and heart rate, both of which can be problematic for the patient preparing for anesthesia and surgery. The purpose of this study was to investigate the patient's perception of noise in the OR before anesthesia, the correlation between the actual noise levels and the patient's perception of noise, and if there are particular patient subgroups that are especially vulnerable to noise. This cross-sectional study was performed within a mixed descriptive and analytical design, including 120 patients (60 acute/60 elective) undergoing general anesthesia for orthopaedic surgery. Data collection consisted of registration of demographic variables and measurements of noise levels in the OR combined with a questionnaire. Results showed that 10% of the patients perceived noise levels in the OR as very high and experienced the noise as annoying, disruptive, and stressful. There was no correlation between the actual noise levels to which patients were exposed and their perception of noise. Acute patients perceived significantly more noise than elective patients (P<.01), although they were actually exposed to less noise. Of the acute patients, those undergoing major surgery perceived more noise than patients undergoing minor surgery (P<.01), although actually exposed to less noise. There was a significant correlation between patients' sense of coherence (SOC) and their perception of noise (P<.01). Most patients who perceived noise levels as very high had a SOC below 50 (scale: 13-91). Perianesthesia nurses need to maintain their focus on keeping noise levels in the OR as low as possible. When caring for acute patients, patients undergoing major surgery and patients with a low SOC perianesthesia nurses should be particularly aware, as these patients might be more vulnerable to noise. Copyright © 2014 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Early recovery following lower limb arthroplasty: Qualitative interviews with patients undergoing elective hip and knee replacement surgery. Initial phase in the development of a patient-reported outcome measure.

PubMed

Strickland, Louise H; Kelly, Laura; Hamilton, Thomas W; Murray, David W; Pandit, Hemant G; Jenkinson, Crispin

2017-09-27

To explore the patients' perspective of surgery and early recovery when undergoing lower limb (hip or knee) arthroplasty. Lower limb arthroplasty is a commonly performed procedure for symptomatic arthritis, which has not responded to conservative medical treatment. Each patient's perspective of the surgical process and early recovery period impacts on their quality of life. Open, semistructured qualitative interviews were used to allow for a deeper understanding of the patient perspective when undergoing a hip or knee arthroplasty. Following ethical approval, 30 patients were interviewed between August and November 2016 during the perioperative period while undergoing an elective hip or knee arthroplasty (n = 30). The interviews were performed between the day of surgery and a nine-week postoperative clinic appointment. Data were analysed using an in-depth narrative thematic analysis method. NVivo qualitative data analysis software was used. Seven main themes evolved from the interviews: "improving function and mobility", "pain", "experiences of health care", "support from others", "involvement and understanding of care decisions", "behaviour and coping" and "fatigue and sleeping". The early postoperative recovery period is of vital importance to all surgical patients. This is no different for the orthopaedic patient. However, identifying key self-reported areas of importance from patients can guide clinical focus for healthcare professionals. To have specific patient-reported information regarding key areas of importance during the perioperative phase is invaluable when caring for the orthopaedic surgical patient. It gives insight and understanding in to this increasing population group. This study has also served as a starting point in the development of a questionnaire which could be used to assess interventions in the lower limb arthroplasty population. These results will influence both items and content of the questionnaire. © 2017 John Wiley & Sons Ltd.

The prevalence of undiagnosed pre-surgical cognitive impairment and its post-surgical clinical impact in elderly patients undergoing surgery for adult spinal deformity.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Lydon, Emily; Vuong, Victoria D; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2017-09-01

Pre-existing cognitive impairment (CI) is emerging as a predictor of poor post-operative outcomes in elderly patients. Little is known about impaired preoperative cognition and outcomes after elective spine surgery in this patient population. The purpose of this study was to assess the prevalence of neuro CI in elderly patients undergoing deformity surgery and its impact on postoperative outcomes. Elderly subjects undergoing elective spinal surgery for correction of adult degenerative scoliosis were enrolled in this study. Pre-operative baseline cognition was assessed using the Saint Louis Mental Status (SLUMS) test. SLUMS consists of 11 questions, which can give a maximum of 30 points. Mild CI was defined as a SLUMS score between 21-26 points, while severe CI was defined as a SLUMS score of ≤20 points. Normal cognition was defined as a SLUMS score of ≥27 points. Complication rates, duration of hospital stay, and 30-day readmission rates were compared between patients with and without baseline CI. Eighty-two subjects were included in this study, with mean age of 73.26±6.08 years. Fifty-seven patients (70%) had impaired cognition at baseline. The impaired cognition group had the following outcomes: increased incidence of one or more postoperative complications (39% vs. 20%), higher incidence of delirium (20% vs. 8%), and higher rate of discharge institutionalization at skilled nursing or acute rehab facilities (54% vs. 30%). The length of hospital stay and 30-day hospital readmission rates were similar between both cohorts (5.33 vs. 5.48 days and 12.28% vs. 12%, respectively). CI is highly prevalent in elderly patients undergoing surgery for adult degenerative scoliosis. Impaired cognition before surgery was associated with higher rates of post-operative delirium, complications, and discharge institutionalization. CI assessments should be considered in the pre-operative evaluations of elderly patients prior to surgery.

Clinical predictors of elective total joint replacement in persons with end-stage knee osteoarthritis.

PubMed

Zeni, Joseph A; Axe, Michael J; Snyder-Mackler, Lynn

2010-05-06

Arthritis is a leading cause of disability in the United States. Total knee arthroplasty (TKA) has become the gold standard to manage the pain and disability associated with knee osteoarthritis (OA). Although more than 400,000 primary TKA surgeries are performed each year in the United States, not all individuals with knee OA elect to undergo the procedure. No clear consensus exists on criteria to determine who should undergo TKA. The purpose of this study was to determine which clinical factors will predict the decision to undergo TKA in individuals with end-stage knee OA. Knowledge of these factors will aid in clinical decision making for the timing of TKA. Functional data from one hundred twenty persons with end-stage knee OA were obtained through a database. All of the individuals complained of knee pain during daily activities and had radiographic evidence of OA. Functional and clinical tests, collectively referred to as the Delaware Osteoarthritis Profile, were completed by a physical therapist. This profile consisted of measuring height, weight, quadriceps strength and active knee range of motion, while functional mobility was assessed using the Timed Up and Go (TUG) test and the Stair Climbing Task (SCT). Self-perceived functional ability was measured using the activities of daily living subscale of the Knee Outcome Survey (KOS-ADLS). A logistic regression model was used to identify variables predictive of TKA use. Forty subjects (33%) underwent TKA within two years of evaluation. These subjects were significantly older and had significantly slower TUG and SCT times (p < 0.05). Persons that underwent TKA were also significantly weaker, had lower self-reported function and had less knee extension than persons who did not undergo TKA. No differences between groups were seen for BMI, gender, knee flexion ROM and unilateral versus bilateral joint disease. Using backward regression, age, knee extension ROM and KOS-ADLS together significantly predicted whether or not a person would undergo TKA (p

Is orthopedics more competitive today than when my attending matched? An analysis of National Resident Matching Program data for orthopedic PGY1 applicants from 1984 to 2011.

PubMed

Karnes, Jonathan M; Mayerson, Joel L; Scharschmidt, Thomas J

2014-01-01

This study evaluated supply and demand trends for orthopedic postgraduate year 1 (PGY1) positions from 1984 to 2011 for the purpose of estimating national intercandidate competition over time. National Resident Matching Program (NRMP) data for orthopedic surgery from 1984 to 2011 were collected. Proxy variables including (total number of orthopedic applicants/number of orthopedic PGY1 positions), (number of US senior applicants to orthopedics/number of orthopedic PGY1 positions), (number of US seniors matching into orthopedics/number of US senior orthopedic applicants), (total number of matched orthopedic applicants/total number of orthopedic applicants), and (total number of US applicants who fail to match into orthopedics/total number of US senior applicants into orthopedics) as well as average United States Medical Licensing Examination Step 1 scores were used to gauge the level of competition between candidates and were compared over time. Academic medical center in the Midwestern United States. Medical professors and medical students. The NRMP data suggested that the number of positions per applicant decreased or remained stable since 1984 and that the percentage of applicants who did not match was no higher now than in the past. This finding was primarily because of the relative decrease in the ratio of applicants to available PGY1 positions, which stems from the number of positions increasing more rapidly than the number of applicants. The NRMP data from 1984 to 2011 supported our hypothesis that intercandidate competition intensity for orthopedic PGY1 positions has not increased over time. The misconception that orthopedics is becoming more competitive likely arises from the increased number of applications submitted per candidate and the resulting relative importance placed on objective criteria such as United States Medical Licensing Examination Step 1 scores when programs select interview cohorts. Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Osteograft, plastic material for regenerative medicine

NASA Astrophysics Data System (ADS)

Zaidman, A. M.; Korel, A. V.; Shevchenko, A. I.; Shchelkunova, E. I.; Sherman, K. M.; Predein, Yu. A.; Kosareva, O. S.

2016-08-01

Creating tissue-engineering constructs based on the mechanism of cartilage-bone evolution is promising for traumatology and orthopedics. Such a graft was obtained from a chondrograft by transdifferentiation. The hondrograft placed in osteogenic medium is undergoing osteogenic differentiation for 14-30 days. Tissue specificity of the osteograft was studied by morphology, immunohistochemistry, electron microscopy, and the expression of the corresponding genes was estimated. The expression of osteonectin, fibronectin, collagen of type I, izolektin and CD 44 is determined. Alkaline phosphatase and matrix vesicles are determined in osteoblasts. Calcificates are observed in the matrix. Chondrogenic proteins expression is absent. These findings evidence the tissue specificity of the developed osteograft.

[Research and analysis to Shui nationality medicine treatment orthopedics & traumatology].

PubMed

Hu, Jian-Shan; Li, Pu; Yang, Yong; Chen, Xin-Chun; Lin, Li

2013-05-01

To investigated Shui nationality folk medicine's awareness to orthopedics & traumatology, the history of orthopedics & traumatology treatment, Shui nationality folk doctors' practicing medicine, heritage, diagnosis and treatment methods and tools, etc, through investigated drug resources category and distribution characteristics of Shui nationality medicine to orthopedics & traumatology treatment, explored and finished Shui nationality medicine orthopedics & traumatology treatment theoretical system. After more than 5 years' exploration and finishing, preliminarily formed the theoretical system framework and medicine application characteristics of Shui nationality medicine treating orthopedics & traumatology. Shui nationality medicine treatment orthopedics & traumatology has distinctive national style, and worthy to further exploration and research.

An Overview of the History of Orthopedic Surgery.

PubMed

Swarup, Ishaan; O'Donnell, Joseph F

Orthopedic surgery has a long and rich history. While the modern term orthopedics was coined in the 1700s, orthopedic principles were beginning to be developed and used during primitive times. The Egyptians continued these practices, and described ways to recognize and manage common orthopedic conditions. The Greeks and Romans subsequently began to study medicine in a systematic manner, and greatly improved our understanding of orthopedic anatomy and surgical technique. After a period of little progress during the Middle Ages, rapid advancement was noted during the Renaissance, including the description of various injuries, improvements in surgical technique, and development of orthopedic hospitals. Collectively, these advances provided the foundation for modern orthopedics. Currently, orthopedic surgery is a rapidly developing field that has benefited from the works of numerous scholars and surgeons. It is important to recognize the successes and failures of the past, in order to advance research and practice as well as improve patient care and clinical outcomes.

Bioactive antibiotic levels in the human aorta.

PubMed

Mutch, D; Richards, G; Brown, R A; Mulder, D S

1982-12-01

A new bioassay was used to determine the level of active antibiotic within the aortic wall in 24 patients undergoing elective aortic surgery involving prosthetic grafts. The patients were divided into three groups and received either cefazolin, clindamycin, or cefoxitin intravenously at the induction of general anesthesia. Cefazolin and cefoxitin attained satisfactory tissue levels. Clindamycin did not reach therapeutic levels in the aortic wall. Blood levels did not correlate well with tissue levels.

Influence of orthopedic reinforced gloves versus double standard gloves on contamination events during small animal orthopedic surgery.

PubMed

Hayes, Galina; Singh, Ameet; Gibson, Tom; Moens, Noel; Oblak, Michelle; Ogilvie, Adam; Reynolds, Debbie

2017-10-01

To determine the influence of orthopedic reinforced gloves on contamination events during small animal orthopedic surgery. Prospective randomized controlled trial SAMPLE POPULATION: Two hundred and thirty-seven pairs of orthopedic gloves (474 gloves) and 203 pairs of double standard gloves (812 gloves) worn during 193 orthopedic procedures. Primary and assistant surgeons were randomized to wear either orthopedic reinforced gloves or double gloves. Gloves were leak tested to identify perforations at the end of procedures. Perforations detected intraoperatively or postoperatively were recorded. A contamination event was defined as at least one perforation on either hand for orthopedic reinforced gloves, or a perforation of both the inner and outer glove on the same hand for double gloves. Baseline characteristics between the 2 intervention groups were similar. There was no difference in contamination events between the double-gloved and orthopedic gloved groups (OR = 0.95, 95% CI = 0.49-1.87, P = .89). The same percentage of contamination events (8% glove pairs used) occurred in the double gloved group (17 contamination events) and in the orthopedic gloved group (19 contamination events). The odds of a contamination event increased by 1.02 (95% CI 1.01-1.03, P < .001) with each additional minute of surgery. Orthopedic reinforced gloves and double standard gloving were equally effective at preventing contamination events in small animal orthopedic procedures. Surgeons reluctant to double glove due to perceptions of decreased dexterity and discomfort may safely opt for wearing orthopedic gloves, which may improve their compliance. © 2017 The American College of Veterinary Surgeons.

Splash in elective primary knee and hip replacement: are we adequately protected?

PubMed

Singh, V K; Kalairajah, Y

2009-08-01

An intra-operative splash is a common occurrence in elective knee and hip replacement surgery and can potentially transmit bloodborne diseases, with devastating consequences. This study aimed to quantify the risk of a splash and to assess its correlation with body mass index, duration of surgery and the volume of lavage fluid used. Between December 2007 and April 2008, 62 consecutive patients (38 women, 24 men) undergoing an elective total knee or total hip replacement (TKR, THR) were recruited into the study (32 TKRs and 30 THRs) after appropriate consent. A splash occurred in all 62 cases. A THR had a slightly higher risk of a splash than a TKR, but this was not statistically significant (p = 0.27). The correlation between body mass index, duration of surgery and the amount of pulse lavage used with a splash was r = 0.013, (non-significant), r = 0.52, (significant) and r = 0.92 (highly significant), respectively. A high number of splashes are generated during a TKR and a THR. The simple visor mask fails to protect the surgeon, the assistant or the patient from the risk of a splash and reverse splash, respectively.

Motives for cosmetic procedures in Saudi women.

PubMed

Al-Natour, Sahar H

2014-01-01

The media-fuelled obsession with beauty in modern society has led more women to seek elective cosmetic procedures to meet the portrayed ideals of beauty in different cultures. This study gives insights into incentives and desires to undergo cosmetic procedures in a conservative society with strict religious practices where women are veiled. Questionnaire data were obtained from 509 Saudi women who responded to a survey distributed randomly to a sample of Saudi women aged 17 to 72 years. At least 1 elective cosmetic procedure was performed in 42% of the women, of whom 77.8% wore a veil. Another 33% considered having a procedure. The motives for seeking a cosmetic procedure were to improve self-esteem in 83.7%, attract a husband in 63.3%, or prevent a husband from seeking another wife in 36.2%. The decision to seek a procedure was affected by the media, with high peer influence. Motivation for elective cosmetic procedures in Saudi women is influenced by a combination of emotional and cultural factors, level of education, marital status, and religious beliefs. The veil is not an impediment for seeking such procedures. The limitation of the study was missing data analysis as some items in the questionnaire were completed inaccurately or left unanswered.

Insurance Status is Associated with Acuity of Presentation and Outcomes for Thoracic Aortic Operations

PubMed Central

Andersen, Nicholas D.; Brennan, J. Matthew; Zhao, Yue; Williams, Judson B.; Williams, Matthew L.; Smith, Peter K.; Scarborough, John E.; Hughes, G. Chad

2014-01-01

Background Non-elective procedure status is the greatest risk factor for postoperative morbidity and mortality in patients undergoing thoracic aortic operations. We hypothesized that uninsured patients were more likely to require non-elective thoracic aortic operation due to decreased access to preventative care and elective surgical services. Methods and Results An observational study of the Society of Thoracic Surgeons Database identified 51,282 patients who underwent thoracic aortic surgery between 2007–2011 at 940 North American centers. Patients were stratified by insurance status (private insurance, Medicare, Medicaid, other insurance, or uninsured) as well as age < 65 years or age ≥ 65 years to account for differences in Medicare eligibility. The need for non-elective thoracic aortic operation was highest for uninsured patients (71.7%) and lowest for privately insured patients (36.6%). The adjusted risks of non-elective operation were increased for uninsured patients (adjusted risk ratio [ARR], 1.77; 95% confidence interval [CI], 1.70–1.83 for age < 65 years; ARR, 1.46; 95% CI, 1.29–1.62 for age ≥ 65 years) as well as Medicaid patients age < 65 years (ARR, 1.18; 95% CI, 1.10–1.26) when compared to patients with private insurance. The adjusted odds of major morbidity and/or mortality were further increased for all patients age < 65 years without private insurance (ARRs between 1.13 and 1.27). Conclusions Insurance status was associated with acuity of presentation and major morbidity and mortality for thoracic aortic operations. Efforts to reduce insurance-based disparities in the care of patients with thoracic aortic disease appear warranted and may reduce the incidence of aortic emergencies and improve outcomes after thoracic aortic surgery. PMID:24714600

Serum C-reactive protein in patients undergoing elective shoulder arthroplasty. Prospective study.

PubMed

Torrens, Carlos; Santana, Fernando; Marí, Raquel; Puig, Lluis; Alier, Albert

2017-09-01

The objective of the study was to determine the normalization curve of the serum C-reactive protein (CRP) in elective shoulder arthroplasty. A prospective study including 58 consecutive patients who had undergone elective shoulder arthroplasty. Forty-one patients had received a Reverse Shoulder Arthroplasty, 13 a Total Shoulder Arthroplasty and 4 a Hemiarthroplasty. Based on a pilot study, blood samples to determine CRP values were obtained at baseline (1 h before surgery), on the 1st, 2nd, 6th, 8th and 14th postoperative days. All the patients included presented no postoperative complications during inpatient stay or any re-admission during the three months after surgery. Mean CRP values showed a rapid increase on the 1st postoperative day (7-fold higher than the baseline in cuff tear arthropathy, 11-fold higher in primary osteoarthritis, 1-fold higher in acute fracture) and reached a peak on the 2nd postoperative day (14-fold higher than the baseline in cuff tear arthropathy, 24-fold higher in primary osteoarthritis and 2-fold higher in acute fracture). After the 2nd postoperative day CRP values began to slowly decrease reaching the normal range in the 14th postoperative day. Serum CRP levels after elective shoulder arthroplasty rapidly increase to reach a maximum peak after the 2nd surgery day and then slowly decrease to return to normality on the 14th day. Knowing the normalization curve of CRP can be a helpful tool to help in the diagnosis of acute infections in elective shoulder arthroplasty. Copyright © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

The impact of endovascular aneurysm repair on mortality for elective abdominal aortic aneurysm repair in England and the United States.

PubMed

Karthikesalingam, Alan; Holt, Peter J; Vidal-Diez, Alberto; Bahia, Sandeep S; Patterson, Benjamin O; Hinchliffe, Robert J; Thompson, Matthew M

2016-08-01

Procedural mortality is of paramount importance for patients undergoing elective abdominal aortic aneurysm (AAA) repair. Previous comparative studies have demonstrated international differences in the care of ruptured AAA. This study compared the use of endovascular aneurysm repair (EVAR) and in-hospital mortality for elective AAA repair in England and the United States. The English Hospital Episode Statistics and the U.S. Nationwide Inpatient Sample (NIS) were interrogated for elective AAA repair from 2005 to 2010. In-hospital mortality and the use of EVAR were analyzed separately for each health care system, after within-country risk adjustment for age, gender, year, and an accepted national comorbidity index. The study included 21,272 patients with AAA in England, of whom 86.61% were male, with median (interquartile range) age of 74 (69-79) years. There were 196,113 AAA patients in the United States, of whom 76.14% were male, with median (interquartile range) age of 73 (67-78) years. In-hospital mortality was greater in England (4.09% vs 1.96 %; P < .01) and EVAR less common (37.33% vs 64.36%; P < .01). These observations persisted in age- and gender-matched comparison. In both countries, lower mortality and greater use of EVAR were seen in centers performing greater numbers of AAA repairs per annum. In England, lower mortality and greater use of EVAR were seen in teaching hospitals with larger bed capacity. In-hospital survival and the uptake of EVAR are lower in England than in the United States. In both countries, mortality was lowest in high-caseload centers performing a greater proportion of cases with endovascular repair. These common factors suggest strategies for improving outcomes for patients requiring elective AAA repair. Copyright © 2016. Published by Elsevier Inc.

Sleep Trajectories of Women Undergoing Elective Cesarean Section: Effects on Body Weight and Psychological Well-Being.

PubMed

Tzeng, Ya-Ling; Chen, Shu-Ling; Chen, Chuen-Fei; Wang, Fong-Chen; Kuo, Shu-Yu

2015-01-01

After cesarean section (CS), women may be at great risk for sleep disturbance, but little is known about temporal changes in their sleep patterns and characteristics. We had two aims: 1) to identify distinct classes of sleep-disturbance trajectories in women considering elective CS from third-trimester pregnancy to 6 months post-CS and 2) to examine associations of sleep trajectories with body mass index (BMI), depressive symptoms, and fatigue scores. We analyzed data from a prospective cohort study of 139 Taiwanese pregnant women who elected CS. Sleep components were assessed using the Pittsburgh Sleep Quality Index in third-trimester pregnancy, 1 day, 1 week, 1 month, and 6 months post-CS. Data were collected on depressive symptoms, fatigue symptoms, and BMI. Sleep-quality trajectories were identified by group-based trajectory modeling. We identified three distinct trajectories: stable poor sleep (50 women, 36.0%), progressively worse sleep (67 women, 48.2%), and persistently poor sleep (22 women, 15.8%). Poor sleep was significantly associated with pre-pregnancy BMI and more baseline (third-trimester pregnancy) depressive and fatigue symptoms. At 6 months post-CS, women classified as progressively worse or persistently poor sleepers showed a trend toward higher BMI (p<0.03), more depressive symptoms (p<0.001), and higher fatigue scores (p<0.001) than those with stable poor sleep. Women had three distinct sleep-disturbance trajectories before and after elective CS. These poor-sleep courses were associated with BMI and psychological well-being. Our findings suggest a need to continuously assess sleep quality among women considering elective CS and up to 6 months post-CS.

Clinicopathological analysis of colorectal cancer: a comparison between emergency and elective surgical cases.

PubMed

Ghazi, Sam; Berg, Elisabeth; Lindblom, Annika; Lindforss, Ulrik

2013-06-11

Approximately 15 to 30% of colorectal cancers present as an emergency, most often as obstruction or perforation. Studies report poorer outcome for patients who undergo emergency compared with elective surgery, both for their initial hospital stay and their long-term survival. Advanced tumor pathology and tumors with unfavorable histologic features may provide the basis for the difference in outcome. The aim of this study was to compare the clinical and pathologic profiles of emergency and elective surgical cases for colorectal cancer, and relate these to gender, age group, tumor location, and family history of the disease. The main outcome measure was the difference in morphology between elective and emergency surgical cases. In total, 976 tumors from patients treated surgically for colorectal cancer between 2004 and 2006 in Stockholm County, Sweden (8 hospitals) were analyzed in the study. Seventeen morphological features were examined and compared with type of operation (elective or emergency), gender, age, tumor location, and family history of colorectal cancer by re-evaluating the histopathologic features of the tumors. In a univariate analysis, the following characteristics were found more frequently in emergency compared with elective cases: multiple tumors, higher American Joint Committee on Cancer (AJCC), tumor (T) and node (N) stage, peri-tumor lymphocytic reaction, high number of tumor-infiltrating lymphocytes, signet-ring cell mucinous carcinoma, desmoplastic stromal reaction, vascular and perineural invasion, and infiltrative tumor margin (P<0.0001 for AJCC stage III to IV, N stage 1 to 2/3, and vascular invasion). In a multivariate analysis, all these differences, with the exception of peri-tumor lymphocytic reaction, remained significant (P<0.0001 for multiple tumors, perineural invasion, infiltrative tumor margin, AJCC stage III, and N stage 1 to 2/3). Colorectal cancers that need surgery as an emergency case generally show a more aggressive histopathologic profile and a more advanced stage than do elective cases. Essentially, no difference was seen in location, and therefore it is likely there would be no differences in macro-environment either. Our results could indicate that colorectal cancers needing emergency surgery belong to an inherently specific group with a different etiologic or genetic background.

Protocol for a single-centre, randomised controlled study of a preoperative rehabilitation bundle in the frail and elderly undergoing abdominal surgery

PubMed Central

Lien, Victoria Peixin; Ong, Hwee Kuan; Er, Pei Ling; Hao, Ying; Khan, Shariq Ali; Liu, Christopher Weiyang

2017-01-01

Introduction Frail patients have decreased physiological reserves and consequently, they are unable to recover as quickly from surgery. Frailty, as an entity, is a risk factor of increased morbidity and mortality. It is also associated with a longer time to discharge. This trial is undertaken to determine if a novel prehabilitation protocol (10-day bundle of interventions—physiotherapy, nutritional supplementation and cognitive training) can reduce the postoperative length of stay of frail patients who are undergoing elective abdominal surgery, compared with standard care. Methods and analysis This is a prospective, single-centre, randomised controlled trial with two parallel arms. 62 patients who are frail and undergoing elective abdominal surgery will be recruited and randomised to receive either a novel prehabilitation protocol or standard care. Participants will receive telephone reminders preoperatively to encourage protocol compliance. Data will be collected for up to 30 days postoperatively. The primary outcome of the trial will be the postoperative length of stay and the secondary outcomes are the postoperative complications and functional recovery during the hospital admission. Ethics and dissemination This study has been approved by the Singapore General Hospital Institutional Review Board (CIRB Ref: 2016/2584). The study is also listed on ClinicalTrials.gov (Trial number: NCT02921932). All participants will sign an informed consent form before randomisation and translators will be made available to non-English speaking patients. The results of this study will be published in peer-reviewed journals as well as national and international conferences. The data collected will also be made available in a public data repository. Trial registration number NCT02921932 (ClinicalTrials.gov) PMID:28778994

Reduced 30-day mortality in men after elective coronary artery bypass surgery with minimized extracorporeal circulation-a propensity score analysis

PubMed Central

2012-01-01

Background Impact of minimized extracorporeal circulation (MECC) for coronary surgery on mortality remains controversial and gender significantly influence outcome. Methods We analyzed 3,139 male patients undergoing elective coronary surgery between 01/2004 and 05/2009. Using propensity score matching after binary logistic regression, 1,005 patients (from 1,119 patients) undergoing surgery with MECC could be matched with 1,005 patients (from 2,020 patients) undergoing surgery with conventional extracorporeal circulation (CECC). Primary outcome was 30-day mortality. Results Unadjusted 30-day mortality was 2.7% in patients with CECC and 0.8% in those with MECC (mean difference -1.9%; p < 0.001). The adjusted mean difference (average treatment effect of the treated) after matching was -1.5% (95% confidence interval (CI) -2.6 to -0.4; p = 0.006). Postoperative hospital stay was shorter in patients operated with minimized systems (adjusted mean difference -0.8 days; 95% CI -1.46 to -0.09; p = 0.03) and incidence of postoperative neurocognitive dysfunction was also lower (adjusted mean difference -1.3%; 95% CI -2.2 to -0.4; p = 0.001). Chest tube drainage (adjusted mean difference +22 mL; 95% CI -47 to 91; p = 0.5) and risk for acute kidney injury, kidney injury and failure according to RIFLE criteria (adjusted mean difference -1.0%; 95% CI -2.5 to 0.6; p = 0.24) proved to be insignificant between both groups. Apart from reduced 30-day mortality, however, average treatment effects for intensive care unit stay, postoperative hospital stay, chest tube drainage and kidney injury did not significantly differ. Conclusion Using propensity score analysis, we observed an association between MECC and reduced 30-day mortality in men, but our results call for further analysis. PMID:22424497

Can the combination of laparoscopy and enhanced recovery improve long-term survival after elective colorectal cancer surgery?

PubMed

Curtis, N J; Taylor, M; Fraser, L; Salib, E; Noble, E; Hipkiss, R; Allison, A S; Dalton, R; Ockrim, J B; Francis, Nader K

2018-02-01

Enhanced recovery after surgery (ERAS) programmes and laparoscopic techniques both provide short-term benefits to patients undergoing colorectal cancer surgery. ERAS protocol compliance may improve long-term survival in those undergoing open colorectal resection but as laparoscopic data has not been reported. Therefore, we aimed to investigate the impact of the combination of laparoscopy and ERAS management on 5-year overall survival. A dedicated prospectively populated colorectal cancer surgery database was reviewed. Patient inclusion criteria were biopsy-proven colorectal adenocarcinoma, undergoing elective surgery undertaken with curative intent. All patients were managed within an established ERAS programme and routinely followed up for 5 years. Overall survival was measured using the log-rank Kaplan-Meier method at 5 years. Eight hundred fifty-four patients met the inclusion criteria. Four hundred eighty-one (56%) cases were laparoscopic with 98 patients (20%) requiring conversion. There were no differences in patient or tumour demographics between the surgical groups. Median ERAS protocol compliance was 93% (range 53-100%). Five-year overall survival was superior in laparoscopic cases compared with that of converted and open surgery (78 vs 68 vs 70%, respectively, p < 0.007). An open approach (HR 1.55, 95%CI 1.16-2.06, p = 0.002) and delayed hospital discharge (> 7 days, HR 1.5, 95%CI 1.13-1.9, p = 0.003) were the only modifiable risk factors associated with poor survival. The use of a laparoscopic approach with enhanced recovery after surgery management appears to have long-term survival benefits following colorectal cancer resection.

Preoperative conditioning with oral carbohydrate loading and oral nutritional supplements can be combined with mechanical bowel preparation prior to elective colorectal resection.

PubMed

Hendry, P O; Balfour, A; Potter, M A; Mander, B J; Bartolo, D C C; Anderson, D N; Fearon, K C H

2008-11-01

Preoperative conditioning with oral fluid and carbohydrate (CHO) loading allows the patient to undergo surgery in the fed state and is associated with reduced postoperative insulin resistance. Further benefit may accrue from oral nutritional supplements (ONS) to counteract the fasting associated with mechanical bowel preparation (MBP). In this study we assess the ability to prescribe, dispense and have patients comply with a protocol combining preoperative ONS and CHO/fluid loading during MBP. One hundred and forty-seven patients undergoing elective left colonic or rectal resection were recruited to an Enhanced Recovery after Surgery (ERAS) programme. All patients were prescribed MBP (2 sachets Picolax). On the daytime prior to surgery, eligible patients were prescribed 2 x 200 ml of ONS (Fortijuice, Nutricia) and in the evening 800 ml oral CHO/fluid loading (Preop(R), Nutricia,). Patients were prescribed a further 400 ml of oral/CHO/fluid on the morning of surgery 2 h prior to induction of anaesthesia. Protocol compliance was audited prospectively. One hundred and forty-seven patients received MBP. Twenty-three patients were ineligible for oral CHO/fluid loading [diabetes (n = 22), allergy to lemon flavoured drinks (n = 1)]. Fourteen patients did not receive the preoperative CHO drinks due to failure to prescribe (n = 8) or dispense (n = 6). One hundred and ten patients were dispensed the combined ONS and CHO/fluid loading regimen, compliance rates were 83% with ONS, 80% with CHO/fluid loading and 74% with both. Approximately 74% of patients undergoing MBP can comply with preoperative conditioning with ONS and CHO/fluid loading. Prescription and dispensing requires close attention to detail.

Impact of high lipoprotein(a) levels on in-stent restenosis and long-term clinical outcomes of angina pectoris patients undergoing percutaneous coronary intervention with drug-eluting stents in Asian population.

PubMed

Park, Sang-Ho; Rha, Seung-Woon; Choi, Byoung-Geol; Park, Ji-Young; Jeon, Ung; Seo, Hong-Seog; Kim, Eung-Ju; Na, Jin-Oh; Choi, Cheol-Ung; Kim, Jin-Won; Lim, Hong-Euy; Park, Chang-Gyu; Oh, Dong-Joo

2015-06-01

Lipoprotein(a) (Lp(a)) is known to be associated with cardiovascular complications and atherothrombotic properties in general populations. However, it has not been examined whether Lp(a) levels are able to predict adverse cardiovascular outcomes in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). A total of 595 consecutive patients with angina pectoris who underwent elective PCI with DES were enrolled from 2004 to 2010. The patients were divided into two groups according to the levels of Lp(a): Lp(a) < 50 mg/dL (n = 485 patients), and Lp(a) ≥ 50 mg/dL (n = 111 patients). The 6-9-month angiographic outcomes and 3-year cumulative major clinical outcomes were compared between the two groups. Binary restenosis occurred in 26 of 133 lesions (19.8%) in the high Lp(a) group and 43 of 550 lesions (7.9%) in the low Lp(a) group (P = 0.001). In multivariate analysis, the reference vessel diameter, low density lipoprotein cholesterol, total lesion length, and Lp(a) ≥ 50 mg/dL were predictors of binary restenosis. In the Cox proportional hazards regression analysis, Lp(a) > 50 mg/dL was significantly associated with the 3-year adverse clinical outcomes including any myocardial infarction, revascularization (target lesion revascularization (TLR) and target vessel revascularization (TVR)), TLR-major adverse cardiac events (MACEs), TVR-MACE, and All-MACEs. In our study, high Lp(a) level ≥ 50 mg/dL in angina pectoris patients undergoing elective PCI with DES was significantly associated with binary restenosis and 3-year adverse clinical outcomes in an Asian population. © 2015 Wiley Publishing Asia Pty Ltd.

Plasma Ropivacaine Concentrations Following Local Infiltration Analgesia in Total Knee Arthroplasty: A Pharmacokinetic Study to Determine Safety Following Fixed-Dose Administration.

PubMed

Miller, Reuben J; Cameron, Andrew J; Dimech, Julian; Orec, Robert J; Lightfoot, Nicholas J

2018-05-01

The primary aim of this study was to examine the pharmacokinetics of ropivacaine in patients undergoing elective total knee arthroplasty with local infiltration analgesia as the primary analgesic method. We also sought to determine the incidence of biochemical toxicity through measurement of plasma ropivacaine concentrations over the first 24 hours postoperatively. This was a prospective, observational study of 15 patients undergoing elective total knee arthroplasty. Local infiltration analgesia was administered by standard technique with 300 mg ropivacaine and epinephrine 5 μg/mL. Total ropivacaine concentrations were taken at specified time intervals in the 24 hours after tourniquet release and analyzed by liquid chromatography-mass spectrometry. Fifteen patients were enrolled into the study. The median peak ropivacaine concentration was 0.57 μg/mL, with a range of 0.32 to 0.88 μg/mL, and occurred between 6 and 24 hours. Age (P = 0.04), weight (P = 0.04), creatinine (P = 0.02), and female sex (P = 0.03) were important predictors of peak concentration. Age (P = 0.02), female sex (P = 0.01), and baseline α1 acid glycoprotein concentrations (P = 0.03) were important predictors for the area under the curve from a ropivacaine concentration versus time plot. The peak total ropivacaine concentration was below quoted toxic concentrations (2.2 μg/mL) in all patients. This peak occurred later than has previously been described in those undergoing neuraxial or peripheral nerve block, occurring between 6 and 24 hours. The influence of age, weight, and renal function on systemic ropivacaine concentration should be considered when planning local infiltration analgesia. Female sex is a factor that has not previously been associated with peak ropivacaine concentrations.

Protocol for a single-centre, randomised controlled study of a preoperative rehabilitation bundle in the frail and elderly undergoing abdominal surgery.

PubMed

Abdullah, Hairil Rizal; Lien, Victoria Peixin; Ong, Hwee Kuan; Er, Pei Ling; Hao, Ying; Khan, Shariq Ali; Liu, Christopher Weiyang

2017-08-04

Frail patients have decreased physiological reserves and consequently, they are unable to recover as quickly from surgery. Frailty, as an entity, is a risk factor of increased morbidity and mortality. It is also associated with a longer time to discharge. This trial is undertaken to determine if a novel prehabilitation protocol (10-day bundle of interventions-physiotherapy, nutritional supplementation and cognitive training) can reduce the postoperative length of stay of frail patients who are undergoing elective abdominal surgery, compared with standard care. This is a prospective, single-centre, randomised controlled trial with two parallel arms. 62 patients who are frail and undergoing elective abdominal surgery will be recruited and randomised to receive either a novel prehabilitation protocol or standard care. Participants will receive telephone reminders preoperatively to encourage protocol compliance. Data will be collected for up to 30 days postoperatively. The primary outcome of the trial will be the postoperative length of stay and the secondary outcomes are the postoperative complications and functional recovery during the hospital admission. This study has been approved by the Singapore General Hospital Institutional Review Board (CIRB Ref: 2016/2584). The study is also listed on ClinicalTrials.gov (Trial number: NCT02921932). All participants will sign an informed consent form before randomisation and translators will be made available to non-English speaking patients. The results of this study will be published in peer-reviewed journals as well as national and international conferences. The data collected will also be made available in a public data repository. NCT02921932 (ClinicalTrials.gov). © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Wholistic orthopedics: Is this the right way to treat geriatric orthopedic patients?

PubMed Central

Ebnezar, John; Bali, Yogita; John, Rakesh

2017-01-01

Geriatric orthopedic problems poses different challenges in their management. Conventional treatment methods like drugs, physiotherapy and surgeries are inadequate. A Geriatric orthopedic patient suffers as a whole and not in isolation. This article highlights the importance of managing geriatric orthopedic patients as a whole and outlines the various steps of wholistic management. PMID:28149067

Wholistic orthopedics: Is this the right way to treat geriatric orthopedic patients?

PubMed

Ebnezar, John; Bali, Yogita; John, Rakesh

2017-01-01

Geriatric orthopedic problems poses different challenges in their management. Conventional treatment methods like drugs, physiotherapy and surgeries are inadequate. A Geriatric orthopedic patient suffers as a whole and not in isolation. This article highlights the importance of managing geriatric orthopedic patients as a whole and outlines the various steps of wholistic management.

Orthopedic surgery.

PubMed

Gehrig, Laura M B

2011-09-01

Orthopedic surgery is a specialty of surgery dedicated to the prevention, diagnosis, and treatment of diseases and injuries of the musculoskeletal system in all age groups. Careers in orthopedic surgery span the spectrum from general orthopedics to those of subspecialty expertise in orthopedic trauma, hand, pediatrics, total joint, foot and ankle, sports medicine, and oncology to name a few. Copyright © 2011. Published by Elsevier Inc.

Impact of a Musculoskeletal Clerkship on Orthopedic Surgery Applicant Diversity.

PubMed

London, Daniel A; Calfee, Ryan P; Boyer, Martin I

Orthopedic surgery lacks racial and sexual diversity, which we hypothesized stems from absence of exposure to orthopedics during medical school. We conducted a study to determine whether diversity of matched orthopedic surgery residency applicants increased after introduction of a required third-year rotation. We compared 2 groups: precurriculum and postcurriculum. The postcurriculum group was exposed to a required 1-month musculoskeletal rotation during the third year of medical school. Comparisons were made of percentage of total students exposed to orthopedics, percentage who applied to and matched to orthopedic surgery, and proportion of women and underrepresented minorities. A prospective survey was used to determine when students chose orthopedics and what influenced their decisions. The required rotation increased the percentage of third-year students rotating on orthopedics (25%) with no change in application rate (6%). It also led to an 81% relative increase in the proportion of female applicants and a 101% relative increase in underrepresented minority applicants. According to survey data, 79% of students chose orthopedics during their third year, and 88% thought they were influenced by their rotation. A required third-year rotation exposes more medical students to orthopedics and increases the diversity of matching students.

High-Dose Statin Pretreatment Decreases Periprocedural Myocardial Infarction and Cardiovascular Events in Patients Undergoing Elective Percutaneous Coronary Intervention: A Meta-Analysis of Twenty-Four Randomized Controlled Trials

PubMed Central

Wang, Le; Peng, Pingan; Zhang, Ou; Xu, Xiaohan; Yang, Shiwei; Zhao, Yingxin; Zhou, Yujie

2014-01-01

Background Evidence suggests that high-dose statin pretreatment may reduce the risk of periprocedural myocardial infarction (PMI) and major adverse cardiac events (MACE) for certain patients; however, previous analyses have not considered patients with a history of statin maintenance treatment. In this meta-analysis of randomized controlled trials (RCTs), we reevaluated the efficacy of short-term high-dose statin pretreatment to prevent PMI and MACE in an expanded set of patients undergoing elective percutaneous coronary intervention. Methods We searched the PubMed/Medline database for RCTs that compared high-dose statin pretreatment with no statin or low-dose statin pretreatment as a prevention of PMI and MACE. We evaluated the incidence of PMI and MACE, including death, spontaneous myocardial infarction, and target vessel revascularization at the longest follow-up for each study for subgroups stratified by disease classification and prior low-dose statin treatment. Results Twenty-four RCTs with a total of 5,526 patients were identified. High-dose statin pretreatment was associated with 59% relative reduction in PMI (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.34–0.49; P<0.00001) and 39% relative reduction in MACE (OR: 0.61; 95% CI: 0.45–0.83; P = 0.002). The benefit of high-dose statin pretreatment on MACE was significant for statin-naive patients (OR: 0.69; 95% CI: 0.50–0.95; P = 0.02) and prior low dose statin-treated patients (OR: 0.28; 95% CI: 0.12–0.65; P = 0.003); and for patients with acute coronary syndrome (OR: 0.52; 95% CI: 0.34–0.79; P = 0.003), but not for patients with stable angina (OR: 0.71; 95% CI 0.45–1.10; P = 0.12). Long-term effects on survival were less obvious. Conclusions High-dose statin pretreatment can result in a significant reduction in PMI and MACE for patients undergoing elective PCI. The positive effect of high-dose statin pretreatment on PMI and MACE is significant for statin-naïve patients and patients with prior treatment. The positive effect of high-dose statin pretreatment on MACE is significant for patients with acute coronary syndrome. PMID:25473831

Empirical analysis of domestic medical travel for elective cardiovascular procedures.

PubMed

Langley, Jacob D; Johnson, Tricia J; Hohmann, Samuel F; Meurer, Steve J; Garman, Andy N

2013-10-01

To investigate whether domestic medical travel (DMT; traveling outside of one's home region but within the United States for medical care) and surgeon volume affect clinical outcomes and costs for patients undergoing elective cardiovascular procedures. Retrospective, cross-sectional analysis of patient discharge data from US academic medical centers. Patients were classified as medical travelers if they received elective, nonemergent care more than 250 miles from home. High-volume surgeons (HVSs) were those above the 75th percentile compared with other study surgeons in the annual number of cardiovascular surgeries performed. Multivariable regression models were fit to test the relationships among complications, mortality, length of stay (LOS), cost, DMT status, and surgeon volume, controlling for sociodemographic and clinical factors. Patients who traveled to HVSs were more likely to be male, white, have lower severity of illness, and have health insurance through an indemnity plan or preferred provider organization with coverage outside of the patient's home region. Patients who traveled to HVSs had shorter LOS and fewer complications than those who received care from local, low-volume surgeons. There was no significant difference in mortality between travelers and nontravelers. Patients who travelled to HVSs for elective cardiovascular procedures had outcomes similar to or better than those of patients who received care locally from low-volume surgeons. We found no increase in complications or LOS, despite potentially complex logistical arrangements required by travelers. More work is needed to evaluate the potential of DMT to improve the value of care provided for selected procedures.

Textbook Outcome: A Composite Measure for Quality of Elective Aneurysm Surgery.

PubMed

Karthaus, Eleonora G; Lijftogt, Niki; Busweiler, Linde A D; Elsman, Bernard H P; Wouters, Michel W J M; Vahl, Anco C; Hamming, Jaap F

2017-11-01

To investigate a new composite quality measurement, which comprises a desirable outcome for elective aneurysm surgery, called "Textbook Outcome" (TO). Single-quality indicators in vascular surgery are often not distinctive and insufficiently reflect the quality of care. All patients undergoing elective abdominal aortic aneurysm repair, registered in the Dutch Surgical Aneurysm Audit between 2014 and 2015 were included. TO was defined as the percentage of patients who had abdominal aortic aneurysm-repair without intraoperative complications, postoperative surgical complications, reinterventions, prolonged hospital stay [endovascular aneurysm repair (EVAR) ≤4 d, open surgical repair (OSR) ≤10 d], readmissions, and postoperative mortality (≤30 d after surgery/at discharge). Case-mix adjusted TO rates were used to compare hospitals and to compare individual hospital results for different procedures. Five thousand one hundred seventy patients were included, of whom 4039 were treated with EVAR and 1131 with OSR. TO was achieved in 71% of EVAR and 53% of OSR. Important obstacles for achieving TO were a prolonged hospital stay, postoperative complications, and readmissions. Adjusted TO rates varied from 38% to 89% (EVAR) and from 0% to 97% (OSR) between individual hospitals. Hospitals with a high TO for OSR also had a high TO for EVAR; however, a high TO for EVAR did not implicate a high TO for OSR. TO generates additional information to evaluate the overall quality of the care of elective aneurysm surgery, which subsequently can be used by hospitals to improve the quality of their care.

Randomised clinical trial of chest drainage systems.

PubMed Central

Graham, A N; Cosgrove, A P; Gibbons, J R; McGuigan, J A

1992-01-01

BACKGROUND: Problems in the management of thoracic trauma have stimulated the search for an alternative to underwater seals for drainage of the pleural cavity. A chest drainage bag incorporating a one way flutter valve has been compared with underwater seal drains in a randomised clinical trial. METHODS: During June-December 1989 119 patients undergoing elective thoracotomy were randomised to receive postoperative chest drainage by drainage bags (56 patients, 87 drains) or by underwater seal drains (63 patients, 98 drains). Daily drainage volumes, the requirement for pleural suction, mobility, and complications were recorded prospectively. RESULTS: There was no significant difference between the two groups in the mean volume drained, the requirements for pleural suction, or the occurrence of complications. Patients with drainage bags were fully mobile 23 hours (95% confidence interval 0-47 hours) earlier than the others. CONCLUSIONS: When used after elective thoracotomy drainage bags are safe and effective and permit earlier mobility than underwater seal drains. PMID:1496507

Medical students' and interns' interest in orthopedic surgery: the gender factor.

PubMed

Schroeder, Joshua E; Zisk-Rony, Rachel Y; Liebergall, Meir; Tandeter, Howard; Kaplan, Leon; Weiss, Yoram G; Weissman, Charles

2014-01-01

There is an extremely small proportion of female medical students choosing to specialize in orthopedic surgery. The aim of the study was to assess medical students' and interns' interests and perceptions of orthopedic surgery and explore why women are not interested in orthopedic surgery. Questionnaires were distributed to final-year medical students and interns assessing their interests and perception of orthopedic surgery. Final-year medical students and interns. Responses were obtained from 317 students and 199 interns. Among the medical students, 15% were interested in orthopedic surgery, but only 2% were women. Both male and female students perceived orthopedics as an "action"-packed, procedure-based profession, providing instant gratification, time in the operating room, high income, and the option for private practice. Female medical students considered it boring. Among interns, 11% were interested in orthopedic surgery; however, only 2% were women. When compared with the interns who were not interested in orthopedic surgery, a greater number of the interns interested in orthopedic surgery rated time with family and a procedure-intensive profession as important. Female students and interns were also interested in other surgical fields. The increasing majority of women among medical students will reshape the future of physician workforce by dictating changes in workforce participation, working conditions, and intercollegial relationships. Orthopedic surgery will need to adapt to these realities. Published by Elsevier Inc.

Karl Ludloff (1864-1945): An Inventive Orthopedic Surgeon, His Work and His Surgical Technique for the Correction of Hallux Valgus.

PubMed

Markatos, Konstantinos; Karaoglanis, Georgios; Damaskos, Christos; Garmpis, Nikolaos; Tsourouflis, Gerasimos; Laios, Konstantinos; Tsoucalas, Gregory

2018-05-01

The purpose of this article is to summarize the work and pioneering achievements in the field of orthopedic surgery of the German orthopedic surgeon Karl Ludloff. Ludloff had an impact in the diagnostics, physical examination, orthopedic imaging, and orthopedic surgical technique of his era. He was a pioneer in the surgical treatment of dysplastic hip, anterior cruciate ligament reconstruction, and hallux valgus. His surgical technique for the correction of hallux valgus, initially stabilized with plaster of Paris, remained unpopular among other orthopedic surgeons for decades. In the 1990s, the advent and use of improved orthopedic materials for fixation attracted the interest of numerous orthopedic surgeons in the Ludloff osteotomy for its ability to correct the deformity in all 3 dimensions, its anatomic outcomes, and its low recurrence rate and patient satisfaction.

Homeopathic arnica for prevention of pain and bruising: randomized placebo-controlled trial in hand surgery

PubMed Central

Stevinson, C; Devaraj, V S; Fountain-Barber, A; Hawkins, S; Ernst, E

2003-01-01

Homeopathic arnica is widely believed to control bruising, reduce swelling and promote recovery after local trauma; many patients therefore take it perioperatively. To determine whether this treatment has any effect, we conducted a double-blind, placebo-controlled, randomized trial with three parallel arms. 64 adults undergoing elective surgery for carpal tunnel syndrome were randomized to take three tablets daily of homeopathic arnica 30C or 6C or placebo for seven days before surgery and fourteen days after surgery. Primary outcome measures were pain (short form McGill Pain Questionnaire) and bruising (colour separation analysis) at four days after surgery. Secondary outcome measures were swelling (wrist circumference) and use of analgesic medication (patient diary). 62 patients could be included in the intention-to-treat analysis. There were no group differences on the primary outcome measures of pain (P=0.79) and bruising (P=0.45) at day four. Swelling and use of analgesic medication also did not differ between arnica and placebo groups. Adverse events were reported by 2 patients in the arnica 6C group, 3 in the placebo group and 4 in the arnica 30C group. The results of this trial do not suggest that homeopathic arnica has an advantage over placebo in reducing postoperative pain, bruising and swelling in patients undergoing elective hand surgery. PMID:12562974

Homeopathic arnica for prevention of pain and bruising: randomized placebo-controlled trial in hand surgery.

PubMed

Stevinson, C; Devaraj, V S; Fountain-Barber, A; Hawkins, S; Ernst, E

2003-02-01

Homeopathic arnica is widely believed to control bruising, reduce swelling and promote recovery after local trauma; many patients therefore take it perioperatively. To determine whether this treatment has any effect, we conducted a double-blind, placebo-controlled, randomized trial with three parallel arms. 64 adults undergoing elective surgery for carpal tunnel syndrome were randomized to take three tablets daily of homeopathic arnica 30C or 6C or placebo for seven days before surgery and fourteen days after surgery. Primary outcome measures were pain (short form McGill Pain Questionnaire) and bruising (colour separation analysis) at four days after surgery. Secondary outcome measures were swelling (wrist circumference) and use of analgesic medication (patient diary). 62 patients could be included in the intention-to-treat analysis. There were no group differences on the primary outcome measures of pain (P=0.79) and bruising (P=0.45) at day four. Swelling and use of analgesic medication also did not differ between arnica and placebo groups. Adverse events were reported by 2 patients in the arnica 6C group, 3 in the placebo group and 4 in the arnica 30C group. The results of this trial do not suggest that homeopathic arnica has an advantage over placebo in reducing postoperative pain, bruising and swelling in patients undergoing elective hand surgery.

Pre-procedural antibiotics for endoscopic urological procedures: Initial experience in individuals with spinal cord injury and asymptomatic bacteriuria.

PubMed

Chong, Julio T; Klausner, Adam P; Petrossian, Albert; Byrne, Michael D; Moore, Jewel R; Goetz, Lance L; Gater, David R; Grob, B Mayer

2015-03-01

The objective of this study was to compare the safety, efficacy, quality-of-life impact, and costs of a single dose or a longer course of pre-procedural antibiotics prior to elective endoscopic urological procedures in individuals with spinal cord injury and disorders (SCI/D) and asymptomatic bacteriuria. A prospective observational study. Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA. Sixty persons with SCI/D and asymptomatic bacteriuria scheduled to undergo elective endoscopic urological procedures. A single pre-procedural dose of antibiotics vs. a 3-5-day course of pre-procedural antibiotics. Objective and subjective measures of health, costs, and quality of life. There were no significant differences in vital signs, leukocytosis, adverse events, and overall satisfaction in individuals who received short-course vs. long-course antibiotics. There was a significant decrease in antibiotic cost (33.1 ± 47.6 vs. 3.6 ± 6.1 US$, P = 0.01) for individuals in the short-course group. In addition, there was greater pre-procedural anxiety (18 vs. 0%, P < 0.05) for individuals who received long-course antibiotics. SCI/D individuals with asymptomatic bacteriuria may be able to safely undergo most endoscopic urological procedures with a single dose of pre-procedural antibiotics. However, further research is required and even appropriate pre-procedural antibiotics may not prevent severe infections.

Probiotics and Synbiotics Decrease Postoperative Sepsis in Elective Gastrointestinal Surgical Patients: a Meta-Analysis.

PubMed

Arumugam, Sudha; Lau, Christine S M; Chamberlain, Ronald S

2016-06-01

The health benefits of probiotics and synbiotics are well established in healthy adults, but their role in preventing postoperative sepsis remains controversial. This meta-analysis assesses the impact of probiotics and synbiotics on the incidence of postoperative sepsis in gastrointestinal (GI) surgical patients. A comprehensive literature search of all published randomized control trials (RCTs) was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Inclusion criteria included RCTs comparing the use of any strain or dose of a specified probiotic/synbiotic with placebo or a "no treatment" control group. The incidence of postoperative sepsis (within 1 month of surgery) and postoperative mortality were analyzed. Fifteen RCTs involving 1201 patients (192 receiving probiotics, 413 receiving synbiotics, and 596 receiving placebo) were analyzed. Overall, probiotic and synbiotic uses significantly reduced the risk of developing postoperative sepsis by 38 % (relative risk (RR) = 0.62, 95 % confidence interval (CI) 0.52-0.74, p < 0.001). The use of probiotic/synbiotic supplementation is associated with a significant reduction in the risk of developing postoperative sepsis in patients undergoing elective GI surgery. Probiotic/synbiotic supplementation is a valuable adjunct in the care of patients undergoing GI surgery. Additional studies are required to determine the optimal dose and strain of probiotic/synbiotic.

Labelling as reference Centre of GRACE (Groupe francophone de Réhabilitation Améliorée après ChirurgiE) for colorectal surgery: its impact on the implementation of enhanced recovery programme at the University Hospital of Liège.

PubMed

Daenen, Coralie; Coimbra, Carla; Hans, Grégory; Joris, Jean

2018-01-15

Enhanced recovery programme (ERP) has been used in our hospital since 2005 for selected colorectal surgeries. Since October 2015, after labelling as GRACE reference centre, we included all patients scheduled for elective colorectal surgery in this programme. We assessed the impact of our labelling on the implementation of ERP. Results of our first 100 patients entered in the GRACE database were analyzed: length of stay, complications, readmission, adherence to the protocol. These results are compared to those of the last 100 patients undergoing colorectal surgery before our labelling. Patients' characteristics in both groups were similar. The complications rate was similar in both groups. The global length of hospital stay was 4 [5] days vs. 8.5 [8] (median [IQR]), respectively after and before labelling; p < .001. The duration of hospitalization for the different subgroups (age, surgical approach, types of surgery) were significantly shorter after our labelling (respectively: p < .001, p < .01, and p < .05). Our results demonstrate that labelling as reference centre increases the efficiency of the implementation of ERP. The fact that all subgroups of patients benefit from ERP must encourage inclusion of all patients undergoing elective colorectal surgery in ERP.

The clinical effect of nicorandil on perioperative myocardial protection in patients undergoing elective PCI: A Systematic Review and Meta-Analysis.

PubMed

Ye, Ziliang; Su, Qiang; Li, Lang

2017-03-21

Many scholars have studied the effect of nicorandil on perioperative myocardial protection in patients undergoing elective percutaneous coronary intervention (PCI), but results are inconsistent. Therefore, we performed this meta-analysis. Finally, 16 articles, including 1616 patients, were included into this meta-analysis. Meta-analysis results showed that: (1) Nicorandil can reduce the level of CK-MB after PCI, including at 6 hours, 12 hours, 18 hours and 24 hours. (2) Nicorandil can reduce the level of TnT after PCI, including at 6 hours, 12 hours, 18 hours and 24 hours. (3) Nicorandil can reduce the incidence of adverse reactions after PCI. (4) Nicorandil cannot reduce the level of MVP after PCI, including at 12 hours and 24 hours. (5) Subgroup analysis showed that nicorandil can reduce CK-MB and TnT level at 24 hours after PCI for Chinese's population (P < 0.05), but can not reduce CK-MB and TnT level at 24 hours after PCI for non Chinese's population (P > 0.05). Our meta-analysis indicate that nicorandil can reduce myocardial injury and reduce the incidence of adverse reaction caused by PCI for Chinese's population, but is not obvious for non Chinese's population. However, this conclusion still needs to be confirmed in the future.

Fiberoptic intubation in 327 neurosurgical patients with lesions of the cervical spine.

PubMed

Fuchs, G; Schwarz, G; Baumgartner, A; Kaltenböck, F; Voit-Augustin, H; Planinz, W

1999-01-01

In patients with lesions of the cervical spine, direct laryngoscopy for endotracheal intubation entails the risk of injuring the spinal cord. In an attempt to avoid this complication, the authors used flexible fiberoptic nasal intubation in a series of 327 patients with cervical lesions undergoing elective neurosurgical procedures. The nasal route was preferred for laryngeal intubation because it is easier than the oral route and a restraining collar or halo device does not impair the intubating maneuver. Bronchoscopic intubation was possible in all patients. In 12 patients (3.6%), anatomic abnormalities prevented transnasal insertion of the endotracheal tube, and transoral fiberoptic intubation was necessary. Endotracheal intubation was graded as slightly difficult in 85 patients (26%). The minimal peripheral oxygen saturation during intubation exceeded 90% in 289 patients (88%). In the other 38 patients, the mean O2 saturation was 84.2+/-4.3% (range, 72-89%). Intubation was well tolerated by all patients and none had recall of the procedure. Cervical stabilizers did not have to be removed for intubation in any patient. None of the patients had postoperative neurologic deficits attributable to the intubation procedure. The authors consider fiberoptic transnasal intubation to be a useful alternative to direct laryngoscopic tracheal intubation in patients undergoing elective surgical procedures on the cervical spine to avoid potential injury to the cervical spinal cord.

The effect of interactive multimedia on preoperative knowledge and postoperative recovery of patients undergoing laparoscopic cholecystectomy.

PubMed

Stergiopoulou, A; Birbas, K; Katostaras, T; Mantas, J

2007-01-01

Aim of this study is the evaluation of the impact of a multimedia CD (MCD) on preoperative anxiety and postoperative recovery of patients undergoing elective laparoscopic cholecystectomy (LC). Sixty consecutive candidates for elective LC were randomly assigned to four groups. Group A included 15 patients preoperatively informed regarding LC through the MCD presented by Registered Nurse (RN). Patients in group B (n = 15) were informed through a leaflet. Patients in group C (n = 15) were informed verbally from a RN. Finally, the control Group D included 15 patients informed conventionally by the attending surgeon and anesthesiologist, as every other patient included in groups A, B, and C. Preoperative assessment of knowledge about LC was performed after each informative session through a questionnaire. Evaluation of preoperative anxiety was conducted using APAIS scale. Postoperative pain and nausea scores were measured using an NRS scale, 16 hours after the patient had returned to the ward. Statistical processing of the results (single linear regression) showed that patients in groups A, B, and C achieved a higher knowledge score, less preoperative anxiety score and less postoperative pain and nausea, compared to Group D. In multiple regression analysis, group A had a higher knowledge score compared to the four groups (p < 0.001 r(2) = 0.41). Informative sessions using MCD is an effective means of improving patient's preoperative knowledge, especially in day-surgery cases, like LC.

Effects of preoperative oral carbohydrate supplementation on postoperative metabolic stress response of patients undergoing elective abdominal surgery.

PubMed

Viganò, Jacopo; Cereda, Emanuele; Caccialanza, Riccardo; Carini, Roberta; Cameletti, Barbara; Spampinato, Marcello; Dionigi, Paolo

2012-08-01

The goal of the present study was to evaluate the effects of preoperative oral carbohydrate supplementation (OCH) on the postoperative metabolic stress response of patients undergoing elective abdominal surgery. The study was designed as a controlled, prospective, cohort study including 38 patients treated with OCH (800 mL the day before surgery and 400 mL within 3 h before the induction of anesthesia) and 38 controls matched for surgical procedure. Fasting glucose, insulin, insulin resistance (HOMA-IR index), cortisol, and interleukin 6 (IL-6) were assessed before and after surgery (postoperative day (POD) 1, 2, and 3). The administration of OCH resulted in lower fasting glucose, HOMA-IR index, cortisol, and IL-6 on both POD 1 and POD 2. At multivariable regression analyses, the reduction of these parameters was independent of sex, age, body mass index, and major abdominal surgery. Particularly, models including OCH treatment explained 70, 63, and 66 % of the variance of the increase in IL-6 levels at POD 1, POD 2, and POD 3, respectively. The effect of OCH on changes in glucose, insulin resistance, and cortisol on POD 1 and POD 2 disappeared after the inclusion of IL-6 in the models. Treatment with OCH was associated with attenuation of the postoperative metabolic stress response. We hypothesize that modulation of the inflammatory response is one of the mechanisms involved.

Validation of COLA score for predicting wound infection in patients undergoing surgery for rectal cancer.

PubMed

Saylam, Baris; Tez, Mesut; Comcali, Bulent; Vural, Veli; Duzgun, Arife Polat; Ozer, Mehmet Vasfi; Coskun, Faruk

2017-01-01

The purpose of our study was to estimate the incidence of SSI (Surgical site infection) and the effect of COLA (contamination, obesity, laparotomy and ASA grade) score on SSI in patients undergoing rectal surgical procedures for rectal cancer. A total of 92 patients who underwent operation for rectum cancer were enrolled in this study. Wound surveillance was performed in all patients by a staff surgeon identified infected wounds during the hospital stay, and collected information for up to 30 days after operation. The overall rate of incisional SSI and organ/space SSI was 22.8% and 7.6% respectively. Surgical site infection rates were 14.2%, 20.58%, 40.7%, 57.1% for COLA 1,2,3 and 4 scores respectively. The area under the receiver/ operator characteristic curve for the score was 0,660. COLA scoring systems predict, with reasonable accuracy, the risk of SSI in rectal cancer patients undergoing elective rectal surgery. COLA score Rectal surgery, Surgical site infection, Risk prediction, Wound infection.

Osteograft, plastic material for regenerative medicine

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zaidman, A. M., E-mail: AZaydman@niito.ru; Korel, A. V., E-mail: AKorel@niito.ru; Shchelkunova, E. I., E-mail: EShelkunova@niito.ru

Creating tissue-engineering constructs based on the mechanism of cartilage-bone evolution is promising for traumatology and orthopedics. Such a graft was obtained from a chondrograft by transdifferentiation. The hondrograft placed in osteogenic medium is undergoing osteogenic differentiation for 14–30 days. Tissue specificity of the osteograft was studied by morphology, immunohistochemistry, electron microscopy, and the expression of the corresponding genes was estimated. The expression of osteonectin, fibronectin, collagen of type I, izolektin and CD 44 is determined. Alkaline phosphatase and matrix vesicles are determined in osteoblasts. Calcificates are observed in the matrix. Chondrogenic proteins expression is absent. These findings evidence the tissuemore » specificity of the developed osteograft.« less

Development and validation of a predictive model for 90-day readmission following elective spine surgery.

PubMed

Parker, Scott L; Sivaganesan, Ahilan; Chotai, Silky; McGirt, Matthew J; Asher, Anthony L; Devin, Clinton J

2018-06-15

OBJECTIVE Hospital readmissions lead to a significant increase in the total cost of care in patients undergoing elective spine surgery. Understanding factors associated with an increased risk of postoperative readmission could facilitate a reduction in such occurrences. The aims of this study were to develop and validate a predictive model for 90-day hospital readmission following elective spine surgery. METHODS All patients undergoing elective spine surgery for degenerative disease were enrolled in a prospective longitudinal registry. All 90-day readmissions were prospectively recorded. For predictive modeling, all covariates were selected by choosing those variables that were significantly associated with readmission and by incorporating other relevant variables based on clinical intuition and the Akaike information criterion. Eighty percent of the sample was randomly selected for model development and 20% for model validation. Multiple logistic regression analysis was performed with Bayesian model averaging (BMA) to model the odds of 90-day readmission. Goodness of fit was assessed via the C-statistic, that is, the area under the receiver operating characteristic curve (AUC), using the training data set. Discrimination (predictive performance) was assessed using the C-statistic, as applied to the 20% validation data set. RESULTS A total of 2803 consecutive patients were enrolled in the registry, and their data were analyzed for this study. Of this cohort, 227 (8.1%) patients were readmitted to the hospital (for any cause) within 90 days postoperatively. Variables significantly associated with an increased risk of readmission were as follows (OR [95% CI]): lumbar surgery 1.8 [1.1-2.8], government-issued insurance 2.0 [1.4-3.0], hypertension 2.1 [1.4-3.3], prior myocardial infarction 2.2 [1.2-3.8], diabetes 2.5 [1.7-3.7], and coagulation disorder 3.1 [1.6-5.8]. These variables, in addition to others determined a priori to be clinically relevant, comprised 32 inputs in the predictive model constructed using BMA. The AUC value for the training data set was 0.77 for model development and 0.76 for model validation. CONCLUSIONS Identification of high-risk patients is feasible with the novel predictive model presented herein. Appropriate allocation of resources to reduce the postoperative incidence of readmission may reduce the readmission rate and the associated health care costs.

PREPARE: the prevalence of perioperative anaemia and need for patient blood management in elective orthopaedic surgery: a multicentre, observational study.

PubMed

Lasocki, Sigismond; Krauspe, Rüdiger; von Heymann, Christian; Mezzacasa, Anna; Chainey, Suki; Spahn, Donat R

2015-03-01

Patient blood management (PBM) can prevent preoperative anaemia, but little is known about practice in Europe. To assess the pre and postoperative prevalence and perioperative management of anaemia in patients undergoing elective orthopaedic surgery in Europe. An observational study; data were collected from patient records via electronic case report forms. Seventeen centres in six European countries. Centres were stratified according to whether they had a PBM programme or not. One thousand five hundred and thirty-four patients undergoing major elective hip, knee or spine surgery [49.9% hip, 37.2% knee, 13.0% spine; age 64.0 years (range 18 to 80), 61.3% female]. Prevalence of preoperative (primary endpoint) and postoperative anaemia [haemoglobin (Hb) <13 g dl (male), Hb <12 g dl (female)], perioperative anaemia management, time to first blood transfusion and number of transfused units. Data are shown as mean (SD) or median (interquartile range). Anaemia prevalence increased from 14.1% preoperatively to 85.8% postoperatively. Mean Hb decrease was 1.9 (1.5) and 3.0 (1.3) g dl in preoperatively anaemic and nonanaemic patients, respectively (P < 0.001). In PBM (n = 7) vs. non-PBM centres, preoperative anaemia was less frequent (8.0 vs. 18.5%; P < 0.001) and iron status was assessed more frequently (ferritin 11.0 vs. 2.6%, transferrin saturation 11.0 vs. 0.1%; P < 0.001). Perioperative anaemia correction (mainly transfusion) was given to 34.3%. Intraoperatively, 14.8% of preoperatively anaemic and 2.8% of nonanaemic patients received transfusions [units per patient: 2.4 (1.5) and 2.2 (1.4), median time to first intraoperative transfusion: 130 (88, 158) vs. 179 (135, 256) min; P < 0.001]. Postoperative complications were more frequent in preoperatively anaemic vs. nonanaemic patients (36.9 vs. 22.2%; P = 0.009). Most patients who underwent elective orthopaedic surgery had normal preoperative Hb levels but became anaemic after the procedure. Those who were anaemic prior to surgery had an increased intraoperative transfusion risk and postoperative complication rate. PBM measures such as iron status assessment and strategies to avoid transfusion are still underused in Europe.

The Impact of Deep Versus Moderate Hypothermia on Postoperative Kidney Function After Elective Aortic Hemiarch Repair.

PubMed

Arnaoutakis, George J; Vallabhajosyula, Prashanth; Bavaria, Joseph E; Sultan, Ibrahim; Siki, Mary; Naidu, Suveeksha; Milewski, Rita K; Williams, Matthew L; Hargrove, W Clark; Desai, Nimesh D; Szeto, Wilson Y

2016-10-01

There remains concern that moderate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) may provide suboptimal distal organ protection compared with deep hypothermic circulatory arrest (DHCA) with retrograde cerebral perfusion (RCP). We compared postoperative acute kidney injury (AKI) in in patients who underwent elective hemiarch repair with either DHCA/RCP or MHCA/ACP. This was a retrospective review of all patients undergoing elective aortic hemiarch reconstruction for aneurysmal disease between 2009 and 2014. Patients were stratified according to the use of DHCA/RCP versus MHCA/ACP. The primary outcome was the occurrence of AKI at 48 hours, as defined by the Risk, Injury, Failure, Loss, End-Stage (RIFLE ) criteria. A multivariable logistic regression identified risk factors for AKI. One hundred eighteen patients who underwent ACP and 471 patients who underwent RCP were included. The mean lowest temperature was 26.4°C in patients who underwent MHCA/ACP and 17.5°C in patients who underwent DHCA/RCP. Baseline demographics were similar except that patients who underwent DHCA/RCP were more likely to have peripheral arterial disease or bicuspid aortic valves. Cardiopulmonary bypass and aortic cross-clamp times were shorter in the MHCA/ACP group. AKI occurred in 19 (16.2%) patients who underwent MHCA/ACP and 67 (14.3%) patients who underwent DHCA/RCP. Four (0.8%) patients who underwent DHCA/RCP required postoperative dialysis. In-hospital mortality tended to increase with increasing RIFLE classification (RIFLE class-0 (No AKI) = 0.41%; Risk = 1.35%, and Injury = 10.0%; p = 0.09). On multivariable analysis, the lowest temperature and cerebral perfusion strategy were not significant predictors of AKI. Lower baseline glomerular filtration rate (GFR), lower preoperative ejection fraction, and longer cardiopulmonary bypass (CPB) time were independently associated with higher AKI. We applied the sensitive RIFLE criteria to examine AKI in patients undergoing elective aortic hemiarch replacement for aneurysmal disease. Baseline renal dysfunction, lower ejection fraction, and longer CPB time are independent predictors of AKI. Compared with DHCA/RCP, our data suggest that an MHCA/ACP cerebral protection strategy does not appear to be associated with worse postoperative renal outcomes. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Patient-reported opioid analgesic requirements after elective inguinal hernia repair: A call for procedure-specific opioid-administration strategies.

PubMed

Mylonas, Konstantinos S; Reinhorn, Michael; Ott, Lauren R; Westfal, Maggie L; Masiakos, Peter T

2017-11-01

A better understanding of the analgesia needs of patients who undergo common operative procedures is necessary as we address the growing opioid public health crisis in the United States. The aim of this study was to evaluate patient experience with our opioid prescribing practice after elective inguinal hernia repairs. A prospective, observational study was conducted between October 1, 2015, and September 30, 2016, in a single-surgeon, high-volume, practice of inguinal hernia operation. Adult patients undergoing elective inguinal herniorrhaphy under local anesthesia with intravenous sedation were invited to participate. All patients were prescribed 10 opioid analgesic tablets postoperatively and were counseled to reserve opioids for pain not controlled by nonopioid analgesics. Their experience was captured by completing a questionnaire 2 to 3 weeks postoperatively during their postoperative visit. A total of 185 patients were surveyed. The majority of the participants were males (177, 95.7%) and ≥60 years old (96, 51.9%). Of the 185 patients, 159 (85.9%) reported using ≤4 opioid tablets; 110 patients (59.5%) reported that they used no opioid analgesics postoperatively. None of the patients was taking opioids within 7 days of their postoperative appointment. Of the 147 patients who were employed, 111 (75.5%) reported missing ≤3 work days, 57 of whom (51.4%) missed no work at all. Patients who were employed were more likely to take opioid analgesics postoperatively (P = .049). Patients who took no opioid analgesics experienced less maximum (P < .001) and persistent groin pain (P = .037). Pain interfered less with daily activities (P = .012) and leisure activities (P = .018) for patients who did not use opioids. The majority of our patients reported that they did not require any opioid analgesics, and nearly all of those who thought that they did need opioids used <5 tablets. Our data suggest that for elective inguinal hernia repair under a local anesthetic with intravenous sedation, a policy of low opioid analgesic prescribing is achievable; these findings call for further investigation of how to best prescribe opioid medications to patients after an inguinal herniorrhaphy. Copyright © 2017 Elsevier Inc. All rights reserved.

Periprocedural use of tirofiban in elective percutaneous coronary intervention for long coronary lesions in stable patients with overlapping drug-eluting stents--the PETITION study: a prospective, randomized, multicenter study.

PubMed

Zhang, Qi; Wang, Xiao Long; Liao, Min Lei; Hu, Jian; Yang, Zhen Kun; Ding, Feng Hua; Zhang, Jian Sheng; Du, Run; Zhu, Tian Qi; Shen, Wei Feng; Zhang, Rui Yan

2015-03-01

Patients are at risk of developing periprocedural myonecrosis after percutaneous coronary intervention (PCI). We investigated whether the use of the platelet glycoprotein (GP) IIb/IIIa receptor inhibitor tirofiban could reduce periprocedural myocardial infarction (PMI) in patients with stable coronary artery disease undergoing elective PCI with overlapping stent implantation for long lesions. A total of 748 stable angina patients with long lesions (≥ 40 mm in length) treated with overlapping stent implantation were randomly assigned to receive tirofiban (tirofiban group; n = 373) or conventional therapy (control group; n = 375). Intravenous tirofiban was initiated before PCI and maintained for 12 hr after the procedure. The primary endpoint was PMI, defined as an elevation in CK-MB > 3 times the upper limit of normal 12 hr after the index procedure. The secondary endpoint was major adverse cardiac events (MACE), including cardiac death, target vessel revascularization, and recurrent MI (re-MI), at one-year of clinical follow-up. The safety end-points included Thrombolysis in Myocardial Infarction (TIMI) major bleeding and stent thrombosis. Despite comparable angiographic and procedural characteristics, in the intention-to-treatment analysis, the primary endpoint was significantly reduced in the tirofiban group (4.0% vs. 11.5%, P < 0.001). Multivariate analysis revealed that the adjunctive use of tirofiban was the only negative predictor of PMI (OR 0.41, 95% CI 0.28-0.81, P < 0.01). At one-year of clinical follow-up, the overall occurrence of MACE was significantly lower in the tirofiban group (13.4% vs. 22.7%, P = 0.001). The rate of TIMI major bleeding and stent thrombosis did not differ significantly between the two groups. Our results show that the adjunctive use of tirofiban reduces the occurrence of PMI and MACE at one year in stable coronary artery disease patients undergoing elective PCI for long lesions with overlapping stent implantation. © 2015 Wiley Periodicals, Inc.

Variations in 30-day readmissions and length of stay among spine surgeons: a national study of elective spine surgery among US Medicare beneficiaries.

PubMed

Singh, Siddhartha; Sparapani, Rodney; Wang, Marjorie C

2018-06-01

OBJECTIVE Pay-for-performance programs are targeting hospital readmissions. These programs have an underlying assumption that readmissions are due to provider practice patterns that can be modified by a reduction in reimbursement. However, there are limited data to support the role of providers in influencing readmissions. To study this, the authors examined variations in readmission rates by spine surgeon within 30 days among Medicare beneficiaries undergoing elective lumbar spine surgery for degenerative conditions. METHODS The authors applied validated ICD-9-CM algorithms to 2003-2007 Medicare data to select beneficiaries undergoing elective inpatient lumbar spine surgery for degenerative conditions. Mixed models, adjusting for patient demographics, comorbidities, and surgery type, were used to estimate risk of 30-day readmission by the surgeon. Length of stay (LOS) was also studied using these same models. RESULTS A total of 39,884 beneficiaries were operated on by 3987 spine surgeons. The mean readmission rate was 7.2%. The mean LOS was 3.1 days. After adjusting for patient characteristics and surgery type, 1 surgeon had readmission rates significantly below the mean, and only 5 surgeons had readmission rates significantly above the mean. In contrast, for LOS, the patients of 288 surgeons (7.2%) had LOS significantly lower than the mean, and the patients of 397 surgeons (10.0%) had LOS significantly above the mean. These findings were robust to adjustments for surgeon characteristics and clustering by hospital. Similarly, hospital characteristics were not significantly associated with readmission rates, but LOS was associated with hospital for-profit status and size. CONCLUSIONS The authors found almost no variations in readmission rates by surgeon. These findings suggest that surgeon practice patterns do not affect the risk of readmission. Likewise, no significant variation in readmission rates by hospital characteristics were found. Strategies to reduce readmissions would be better targeted at factors other than providers.

Site-directed topical lidocaine spray attenuates perioperative respiratory adverse events in children undergoing elective surgery.

PubMed

Li, Li-Wei; He, Long; Ai, Yanqiu; Chu, Qinjun; Zhang, Wei

2016-06-01

Perioperative respiratory adverse events (PRAEs) are a major cause of morbidity and mortality associated with pediatric anesthesia. Topical lidocaine administration reduces risk of PRAE in children undergoing elective endotracheal intubation. However, definitive evidence of its efficacy remains elusive, due, in part, to the wide variability in the methodology for spraying topical lidocaine. In this randomized controlled double-blind clinical trial, we sought to evaluate the effect of site-directed topical airway lidocaine, sprayed directly onto supraglottic, glottis, and subglottic areas, on the incidence of PRAE. The study population consisted of 322 children (age range, 6 mo-12 y), who were scheduled for an elective surgical procedure under general anesthesia with endotracheal intubation. Patients were randomly assigned to receive topical spray of lidocaine (group L) or saline (group S) over the supraglottic, glottis and subglottic areas under direct vision before tracheal intubation. Incidence of PRAE and time to extubation was recorded. There were no statistically significant intergroup differences with regard to baseline demographics, patient characteristics, and surgical parameters. Group L was associated with a significantly lower incidence of PRAE as compared with group S (12.80% versus 38.13%, respectively; P < 0.001). Similarly, the incidence of laryngospasm (1.7% versus 8.1%; P = 0.01), excessive coughing (4.3% versus 13.2%; P = 0.005), and oxygen desaturation <95% (6.8% versus 16.9%; P = 0.005), respectively, was significantly lower in group L. However, time to extubation was longer in group L as compared with that in group S (18.6 ± 7.7 min versus 21.3 ± 8.9 min; P = 0.03). Site-directed topical spray of lidocaine over supraglottic, glottis, and subglottic areas before tracheal intubation significantly reduced the incidence of PRAE and a prolongation of extubation time in children. Copyright © 2016 Elsevier Inc. All rights reserved.

Risk Factors and Independent Predictors of 30-Day Readmission for Altered Mental Status After Elective Spine Surgery for Spine Deformity: A Single-Institutional Study of 1090 Patients.

PubMed

Elsamadicy, Aladine A; Adogwa, Owoicho; Reddy, Gireesh B; Sergesketter, Amanda; Warwick, Hunter; Jones, Terrell; Cheng, Joseph; Bagley, Carlos A; Karikari, Isaac O

2017-05-01

Altered mental status (AMS) has been associated with inferior surgical outcomes. The factors leading to AMS after spine surgery are unknown. The aim of this study is to determine the risk factors and independent predictors of 30-day readmission for AMS in patients with spine deformity after undergoing elective spine surgery. The medical records of 1090 adult (≥18 years old) patients with spine deformity undergoing elective spine surgery at a major academic institution from 2005 to 2015 were reviewed. We identified 18 patients (1.65%) who had AMS as the primary driver for 30-day readmission after surgery. Patient demographics, comorbidities, and intraoperative and postoperative complication rates were collected for each patient. The primary outcome investigated in this study was risk factors associated with 30-day readmission for AMS. Patient demographics and comorbidities were similar between both groups, with the AMS cohort being significantly older than the no-AMS cohort (70.11 vs. 61.93; P = 0.003). There were no significant differences in intraoperative variables and complication rates within the cohorts. The AMS cohort had a significantly higher proportion of patients transferred to the intensive care unit (AMS, 61.11% vs. no-AMS, 19.76%; P = 0.0002) and rate of pulmonary embolism (AMS, 11.11 vs. no-AMS, 0.93; P = 0.02) after surgery. Other postoperative complication rates were similar between the cohorts. In a multivariate stepwise regression analysis, age (P = 0.013) and ICU transfer (P = 0.0002) were independent predictors of 30-day readmission for AMS. Our study suggests that increasing age and intensice care unit transfer are independent predictors of 30-day readmission for AMS after spine surgery in patients with spine deformity. Copyright © 2017 Elsevier Inc. All rights reserved.

Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials.

PubMed

Rollins, Katie E; Lobo, Dileep N

2016-03-01

To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols. Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality. A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66-0.89, P = 0.0007), hospital length of stay (LOS; mean difference -1.55 days, 95% CI -2.73 to -0.36, P = 0.01), intensive care LOS (mean difference -0.63 days, 95% CI -1.18 to -0.09, P = 0.02), and time to passage of feces (mean difference -0.90 days, 95% CI -1.48 to -0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference -0.63 days, 95% CI -0.94 to -0.32, P < 0.0001) and time to passage of feces (mean difference -1.09 days, 95% CI -2.03 to -0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to -0.84, P = 0.0002) and total hospital LOS (mean difference -2.14, 95% CI -4.15 to -0.13, P = 0.04). GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting.

Adoption of Laparoscopy for Elective Colorectal Resection: A Report from Surgical Care and Outcomes Assessment Program

PubMed Central

Kwon, Steve; Billingham, Richard; Farrokhi, Ellen; Florence, Michael; Herzig, Daniel; Horvath, Karen; Rogers, Terry; Steele, Scott; Symons, Rebecca; Thirlby, Richard; Whiteford, Mark; Flum, David

2012-01-01

Background The purpose of this study was to evaluate the adoption of laparoscopic colon surgery and assess its impact in the community at large. Study Design The Surgical Care and Outcomes Assessment Program (SCOAP) is a quality improvement (QI) benchmarking initiative in the Northwest using medical record-based data. We evaluated the use of laparoscopy and a composite of adverse events (CAE; death or clinical reintervention) for patients undergoing elective colorectal surgery at 48 hospitals from 4th quarter of 2005 through 4th quarter of 2010. Results Of the 9,705 patients undergoing elective colorectal surgeries (mean age 60.6 ± 15.6 (SD) yrs; 55.2% women), 38.0% were performed laparoscopically (17.8% laparoscopic procedures converted to open). The use of laparoscopic procedures increased from 23.3% in 2005 quarter 4 to 41.6% in 2010 quarter 4 (trend over study period, p<0.001). After adjustment (age, sex, albumin levels, diabetes, body mass index, comorbidity index, cancer diagnosis, year, hospital bed size and urban vs. rural location), the risk of transfusions [odds ratio (OR) 0.52, 95% CI 0.39–0.7], wound infections (OR 0.45, 95% CI 0.34–0.61), and CAEs (OR 0.58; 95%CI 0.43–0.79) were all significantly lower with laparoscopy. Within those hospitals that had been in SCOAP since 2006, hospitals where laparoscopy was most commonly used also had a significant increase in the volume of all types of colon surgery (202 cases per hospital in 2010 from 112 cases per hospital in 2006, 80.4% increase), and in particular the number of resections for non-cancer diagnoses and right sided pathology. Conclusions The use of laparoscopic colorectal resection increased in the Northwest. Increased adoption of laparoscopic colectomies was associated with greater use of all types of colorectal surgery. PMID:22533998

Suture repair of umbilical hernia during caesarean section: a case-control study.

PubMed

Steinemann, D C; Limani, P; Ochsenbein, N; Krähenmann, F; Clavien, P-A; Zimmermann, R; Hahnloser, D

2013-08-01

The objective of this study was to investigate the additional burdens in terms of pain, prolongation of surgery and morbidity which is added to elective caesarean section if umbilical hernia suture repair is performed simultaneously. Secondly, patient's satisfaction and hernia recurrence rate were assessed. Consecutive women with symptomatic umbilical hernia undergoing internal or external suture repair during elective caesarean were included in this retrospective cohort-control study. Data on post-operative pain, duration of surgery and morbidity of a combined procedure were collected. These patients were matched 1:10 to women undergoing caesarean section only. Additionally, two subgroups were assessed separately: external and internal suture hernia repair. These subgroups were compared for patient's satisfaction, cosmesis, body image and recurrence rate. Fourteen patients with a mean age of 37 years were analysed. Internal suture repair (n = 7) prolonged caesarean section by 20 min (p = 0.001) and external suture repair (n = 7) by 34 min (p < 0.0001). Suture repair did not increase morphine use (0.38 ± 0.2 vs. 0.4 ± 02 mg/kg body weight), had no procedure-related morbidity and prolonged hospitalization by 0.5 days (p = 0.01). At a median follow-up of 37 (5-125) months, two recurrences in each surgical technique, internal and external suture repair, occurred (28 %). Body image and cosmesis score showed a higher level of functioning in internal suture repair (p = 0.02; p = 0.04). Despite a high recurrence rate, internal suture repair of a symptomatic umbilical hernia during elective caesarean section should be offered to women if requested. No additional morbidity or scar is added to caesarean section. Internal repair is faster, and cosmetic results are better, additional skin or fascia dissection is avoided, and it seems to be as effective as an external approach. Yet, women must be informed on the high recurrence rate.

Economic analysis of athletic team coverage by an orthopedic practice.

PubMed

Lombardi, Nicholas; Freedman, Kevin; Tucker, Brad; Austin, Luke; Eck, Brandon; Pepe, Matt; Tjoumakaris, Fotios

2015-11-01

Coverage of high school football by orthopedic sports medicine specialists is considered standard of care in many localities. Determining the economic viability of this endeavor has never been investigated. The primary purpose of the present investigation was to perform an economic analysis of local high school sports coverage by an orthopedic sports medicine practice. From January 2010 to June 2012, a prospective injury report database was used to collect sports injuries from five high school athletic programs covered by a single, private orthopedic sports medicine practice. Patients referred for orthopedic care were then tracked to determine expected cost of care (potential revenue). Evaluation and management codes and current procedure terminology codes were obtained to determine the value of physician visits and surgical care rendered. Overhead costs were calculated based on historical rates within our practice and incorporated to determine estimated profit. 19,165 athletic trainer contacts with athletes playing all sports, including both those 'on-field' and in the training room, resulted in 473 (2.5%) physician referrals. The covering orthopedic practice handled 89 (27.9%) of the orthopedic referrals. Of orthopedic physician referrals, 26 (5.4%) required orthopedic surgical treatment. The covering team practice handled 17/26 (65%) surgical cases. The total revenue collected by the covering team practice was $26,226.14. The overhead cost of treatment was $9441.41. Overall estimated profit of orthopedic visits and treatment during this period for the covering practice was $16,784.73. The covering team practice handled 28% of the orthopedic referrals, 65% of the surgical cases and captured 59% of the potential profit. An increase in physician referrals could increase the benefit for orthopedic surgeons.

Opioid use among same-day surgery patients: Prevalence, management and outcomes

PubMed Central

Wilson, Jennifer LC; Poulin, Patricia A; Sikorski, Robert; Nathan, Howard J; Taljaard, Monica; Smyth, Catherine

2015-01-01

OBJECTIVES: To determine whether the prevalence of opioid use among patients requiring elective same-day admission (SDA) surgery is greater than the 2.5% prevalence found in the general population. Secondary objectives were to assess compliance with expert recommendations on acute pain management in opioid-tolerant patients and to examine clinical outcomes. METHODS: A retrospective review of 812 systematically sampled adult SDA surgical cases between April 1, 2008 and March 31, 2009 was conducted. RESULTS: Among 798 eligible patients, 148 (18.5% [95% CI 15.9% to 21.2%]) were prescribed opioids, with 4.4% prescribed long-acting opioids (95% CI 3.0% to 5.8%). Use of opioids was most prevalent among orthopedic and neurosurgery patients. Among the 35 patients on long-acting opioids who had a high likelihood of being tolerant, anesthesiologists correctly identified 33, but only 13 (37%) took their usual opioid preoperatively while 22 (63%) had opioids continued postoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered preoperatively in 18 (51%), 15 (43%) and 18 (51%) cases, respectively, while ketamine was used in 15 (43%) patients intraoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered postoperatively in 31 (89%), 15 (43%) and 17 (49%) of the cases, respectively. No differences in length of stay, readmissions and emergency room visits were found between opioid-tolerant and opioid-naïve patients. CONCLUSION: Opioid use is more common in SDA surgical patients than in the general population and is most prevalent within orthopedic and neurosurgery patients. Uptake of expert opinion on the management of acute pain in the opioid tolerant patient population is lacking. PMID:26357683

Characteristics of Orthopedic Publications in High-Impact General Medical Journals.

PubMed

Nwachukwu, Benedict U; Kahlenberg, Cynthia A; Lehman, Jason D; Lyman, Stephen; Marx, Robert G

2017-05-01

Orthopedic studies are occasionally published in high-impact general medical journals; these studies are often given high visibility and have significant potential to impact health care policy and inform clinical decision-making. The purpose of this review was to investigate the characteristics of operative orthopedic studies published in high-impact medical journals. The number of orthopedic studies published in high-impact medical journals is relatively low; however, these studies demonstrate methodological characteristics that may bias toward nonoperative treatment. Careful analysis and interpretation of orthopedic studies published in these journals is warranted. [Orthopedics. 2017; 40(3):e405-e412.]. Copyright 2017, SLACK Incorporated.

Trends in Medicare Reimbursement for Orthopedic Procedures: 2000 to 2016.

PubMed

Eltorai, Adam E M; Durand, Wesley M; Haglin, Jack M; Rubin, Lee E; Weiss, Arnold-Peter C; Daniels, Alan H

2018-03-01

Understanding trends in reimbursement is critical to the financial sustainability of orthopedic practices. Little research has examined physician fee trends over time for orthopedic procedures. This study evaluated trends in Medicare reimbursements for orthopedic surgical procedures. The Medicare Physician Fee Schedule was examined for Current Procedural Terminology code values for the most common orthopedic and nonorthopedic procedures between 2000 and 2016. Prices were adjusted for inflation to 2016-dollar values. To assess mean growth rate for each procedure and subspecialty, compound annual growth rates were calculated. Year-to-year dollar amount changes were calculated for each procedure and subspecialty. Reimbursement trends for individual procedures and across subspecialties were compared. Between 2000 and 2016, annual reimbursements decreased for all orthopedic procedures examined except removal of orthopedic implant. The orthopedic procedures with the greatest mean annual decreases in reimbursement were shoulder arthroscopy/decompression, total knee replacement, and total hip replacement. The orthopedic procedures with the least annual reimbursement decreases were carpal tunnel release and repair of ankle fracture. Rate of Medicare procedure reimbursement change varied between subspecialties. Trauma had the smallest decrease in annual change compared with spine, sports, and hand. Annual reimbursement decreased at a significantly greater rate for adult reconstruction procedures than for any of the other subspecialties. These findings indicate that reimbursement for procedures has steadily decreased, with the most rapid decrease seen in adult reconstruction. [Orthopedics. 2018; 41(2):95-102.]. Copyright 2018, SLACK Incorporated.

Trends in the orthopedic job market and the importance of fellowship subspecialty training.

PubMed

Morrell, Nathan T; Mercer, Deana M; Moneim, Moheb S

2012-04-01

Previous studies have examined possible incentives for pursuing orthopedic fellowship training, but we are unaware of previously published studies reporting the trends in the orthopedic job market since the acceptance of certain criteria for fellowship programs by the Accreditation Council for Graduate Medical Education (ACGME) in 1985. We hypothesized that, since the initiation of accredited postresidency fellowship programs, job opportunities for fellowship-trained orthopedic surgeons have increased and job opportunities for nonfellowship-trained orthopedic surgeons have decreased. We reviewed the job advertisements printed in the Journal of Bone and Joint Surgery, American Volume, for the years 1984, 1994, 2004, and 2009. We categorized the job opportunities as available for either a general (nonfellowship-trained) orthopedic surgeon or a fellowship-trained orthopedic surgeon. Based on the advertisements posted in the Journal of Bone and Joint Surgery, American Volume, a trend exists in the orthopedic job market toward seeking fellowship-trained orthopedic surgeons. In the years 1984, 1994, 2004, and 2009, the percentage of job opportunities seeking fellowship-trained orthopedic surgeons was 16.7% (95% confidence interval [CI], 13.1%-20.3%), 40.6% (95% CI, 38.1%-43.1%), 52.2% (95% CI, 48.5%-55.9%), and 68.2% (95% CI, 65.0%-71.4%), respectively. These differences were statistically significant (analysis of variance, P<.05). Fellowship training is thus a worthwhile endeavor. Copyright 2012, SLACK Incorporated.

Geriatric comanagement reduces perioperative complications and shortens duration of hospital stay after lumbar spine surgery: a prospective single-institution experience.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Vuong, Victoria D; Moreno, Jessica; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2017-12-01

OBJECTIVE Geriatric patients undergoing lumbar spine surgery have unique needs due to the physiological changes of aging. They are at risk for adverse outcomes such as delirium, infection, and iatrogenic complications, and these complications, in turn, contribute to the risk of functional decline, nursing home admission, and death. Whether preoperative and perioperative comanagement by a geriatrician reduces the incidence of in-hospital complications and length of in-hospital stay after elective lumbar spine surgery remains unknown. METHODS A unique model of comanagement for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Perioperative Optimization of Senior Health (POSH) program was launched with the aim of improving outcomes in elderly patients (> 65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, in addition to performing routine preoperative anesthesia surgical screening, and comanages them daily throughout the course of their hospital stay to manage medical comorbid conditions and coordinate multidisciplinary rehabilitation along with the neurosurgical team. The first 100 cases were retrospectively reviewed after initiation of the POSH protocol and compared with the immediately preceding 25 cases to assess the incidence of perioperative complications and clinical outcomes. RESULTS One hundred twenty-five patients undergoing lumbar decompression and fusion were enrolled in this pilot program. Baseline characteristics were similar between both cohorts. The mean length of in-hospital stay was 30% shorter in the POSH cohort (6.13 vs 8.72 days; p = 0.06). The mean duration of time between surgery and patient mobilization was significantly shorter in the POSH cohort compared with the non-POSH cohort (1.57 days vs 2.77 days; p = 0.02), and the number of steps ambulated on day of discharge was 2-fold higher in the POSH cohort (p = 0.04). Compared with the non-POSH cohort, the majority of patients in the POSH cohort were discharged to home (24% vs 54%; p = 0.01). CONCLUSIONS Geriatric comanagement reduces the incidence of postoperative complications, shortens the duration of in-hospital stay, and contributes to improved perioperative functional status in elderly patients undergoing elective spinal surgery for the correction of adult degenerative scoliosis.

The Effects of Preoperative Volume Replacement in Diabetic Patients Undergoing Coronary Artery Bypass Grafting Surgery: Protocol for a Randomized Controlled Trial (VeRDiCT Trial)

PubMed Central

Clout, Madeleine; Harris, Tracy; Rogers, Chris; Culliford, Lucy; Taylor, Jodi; Angelini, Gianni; Narayan, Pradeep; Reeves, Barnaby; Hillier, James; Ashton, Kate; Sarkar, Kunal

2017-01-01

Background Diabetes mellitus is a major risk factor for prolonged hospital stays, renal failure, and mortality in patients having coronary artery bypass grafting (CABG). Complications pose a serious threat to patients and prolong intensive care and hospital stays. Low glomerular filtration rate (GFR) due to existing renal impairment or volume depletion may exacerbate acute renal impairment/failure in these patients. Preoperative volume replacement therapy (VRT) is reported to increase the GFR and we hypothesize that VRT will reduce renal impairment and related complications in diabetic patients. Objective The objective of this study is to establish the efficacy of preoperative VRT in reducing postoperative complications in diabetic patients undergoing CABG surgery. Time to “fit for discharge”, incidence of postoperative renal failure, cardiac injury, inflammation, and other health outcomes will be investigated. Methods In this open parallel group randomized controlled trial, 170 diabetic patients undergoing elective or urgent CABG surgery received 1 mL/kg/hour of Hartmann’s solution for 12 consecutive hours prior to surgery, versus routine care. The primary outcome was time until participants were “fit for discharge”, which is defined as presence of: normal temperature, pulse, and respiration; normal oxygen saturation on air; normal bowel function; and physical mobility. Secondary outcomes included: incidence of renal failure; markers of renal function, inflammation, and cardiac damage; operative morbidity; intensive care stay; patient-assessed outcome, including the Coronary Revascularization Outcome Questionnaire; and use of hospital resources. Results Recruitment started in July 2010. Enrolment for the study was completed in July 2014. Data analysis commenced in December 2016. Study results will be submitted for publication in the summer of 2017. Conclusions VRT is a relatively easy treatment to administer in patients undergoing surgical procedures who are at risk of renal failure. This experimental protocol will increase scientific and clinical knowledge of VRT in diabetic patients undergoing elective or urgent CABG surgery. Findings supporting the efficacy of this intervention could easily be implemented in the health care system. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 02159606; http://www.controlled-trials.com/ISRCTN02159606 (Archived by WebCite at http://www.webcitation.org/6rDkSSkkK) PMID:28630035

76 FR 20690 - International Consortium of Orthopedic Registries; Public Workshop

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-13

... orthopedic implant information and create a research network to advance the methodology and conduct of research related to orthopedic device performance. Date and Time: The public workshop will be held on May 9... discussion among FDA and international orthopedic registries and develop a research consortium (ICOR) that...

21 CFR 888.5850 - Nonpowered orthopedic traction apparatus and accessories.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Nonpowered orthopedic traction apparatus and accessories. 888.5850 Section 888.5850 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND... orthopedic traction apparatus and accessories. (a) Identification. A nonpowered orthopedic traction apparatus...

21 CFR 888.5850 - Nonpowered orthopedic traction apparatus and accessories.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Nonpowered orthopedic traction apparatus and accessories. 888.5850 Section 888.5850 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND... orthopedic traction apparatus and accessories. (a) Identification. A nonpowered orthopedic traction apparatus...

Some patients don't need analgesics after surgery.

PubMed Central

McQuay, H J; Bullingham, R E; Moore, R A; Evans, P J; Lloyd, J W

1982-01-01

Postoperative analgesic requirements of 410 patients undergoing elective orthopaedic limb surgery were studied. Premedication and anaesthetic were standardized with no narcotic. Twenty-three patients required no analgesic at all during their hospital stay. The importance of acknowledging the existence of this group of patients is discussed. The distribution of time to first analgesic requirement for the other patients was obtained. The importance of knowing the distribution for particular operative procedures and the effect of analgesic interventions such as premedication is discussed. PMID:7120254

[Diverticular disease of the large bowel - surgical treatment].

PubMed

Levý, M; Herdegen, P; Sutoris, K; Simša, J

2013-07-01

Surgical treatment, despite the rapid development of the numerous modern miniinvasive intervention techniques, remains essential in the treatment of complicated diverticular disease. The aim of this work is to summarize indications for surgical treatment in both acute and elective patients suffering from diverticular disease of the large bowel. Review of the literature and recent findings concerning indications for surgical intervention in patients with diverticulosis of the colon. The article describes indications, types of procedures, techniques and postoperative care in patients undergoing surgical intervention for diverticular disease.

David Livingstone's uvulectomy.

PubMed

Larner, A J

2006-05-01

In April 1852 in Cape Town, South Africa, Dr David Livingstone, then 39 years of age and yet to commence the explorations of Africa which would bring him to public attention, underwent the surgical procedure of uvulectomy. This article reviews the history of Livingstone's uvulectomy and its indications and outcome, as documented by his own writings. The practice of uvulectomy in indigenous African societies and some contemporary ideas about uvulectomy are also considered in order to try to ascertain why Livingstone elected to undergo this procedure.

Preoperative Screening.

PubMed

Marwell, Julianna G; Heflin, Mitchell T; McDonald, Shelley R

2018-02-01

Older adults undergoing elective surgical procedures suffer higher rates of morbidity and mortality than younger patients. A geriatric-focused preoperative evaluation can identify risk factors for complications and opportunities for health optimization and care coordination. Key components of a geriatric preoperative evaluation include (1) assessments of function, mobility, cognition, and mental health; (2) reviews of medical conditions and medications; and (3) discussion of risks, preferences, and goals of care. A geriatric-focused, team-based approach can improve surgical outcomes and patient experience. Published by Elsevier Inc.

Effectiveness of the Saline Load Test in Diagnosis of Traumatic Elbow Arthrotomies

DTIC Science & Technology

2011-11-01

load test for the knee, using 80 knees in patients undergoing elective knee arthroscopy . A fixed volume of 60 mL of saline was injected while observing... Arthroscopy . 1990;6:100–103. 10. Voit GA, Irvine G, Beals RK. Saline load test for penetration of periarticular lacerations. J Bone Joint Surg Br. 1996;78:732...318. 12. Plancher KD, Shariff KB. Basics of elbow arthroscopy : setup, portals, and technique. Tech Orthop. 2006;21:239–249. 13. Marvel JE, Marsh HO

Airport detection of implanted orthopedic devices.

PubMed

Ostrum, Robert F

2006-10-01

Since the attacks of September 11, 2001, the United States and other countries have increased airport security. Metal detectors (archway and handheld wand) are used to detect potentially dangerous instruments during airport screening. One consequence is that orthopedic implants are sometimes detected, and patients are detained and searched. The orthopedic literature is inconsistent in its reports on airport screening of patients with orthopedic implants. In this article, I review that literature and examine the factors that make detection of orthopedic implants a less than consistent science.

Contrast induced nephropathy in hypertensive patients after elective percutaneous coronary intervention

NASA Astrophysics Data System (ADS)

Aryfa Andra, Cut; Khairul, Andi; Aria Arina, Cut; Mukhtar, Zulfikri; Nyak Kaoy, Isfanuddin

2018-03-01

Contrast induced nephropathy (CIN) is the third lead cause of hospital acquired renal failure and was associated with significant morbidity and mortality. We hypothesized that hypertension is an independent risk factor for the development of CIN in patients undergoing elective percutaneous coronary intervention (PCI). The case-control method was used, 138 patients scheduled for elective PCI. We measured serum creatinine at baseline and after 24 hours of the procedure. CIN was defined as arising in serum creatinine of at least 44 μmol/l (0,5 mg/dl) or 25% rise from baseline. All patients received low osmolality nonionic contrast during PCI. Hypertension was defined as self-reported a history of treated or untreated diagnosed high blood pressure. One hundred thirty-eight patients (74,6%) were male, and 35 patients (25,4%) were female. Among the 138 patients, 86 (62,3%) were hypertensive patients whereas 52 (37,7%) were nonhypertensive patients. There was no difference in baseline serum creatinine levels and the amount of contrast media in patient with and without CIN. CIN developed in 42 patients, 39 patients (92,9%) were hypertensive compared to 3 patients (7,1%) without hypertension with p value < 0,05. (Odds ratio 16,8, 95% CI 4.542 - 62,412). This study showed that hypertension was a risk factor for the development of CIN

THE EFFECTS OF INTRATHECAL NEOSTIGMINE ADDED TO BUPIVACAINE ON POSTOPERATIVE ANALGESIC REQUIREMENT IN PATIENTS UNDERGOING LOWER LIMB ORTHOPEDIC SURGERY.

PubMed

Kayalha, Hamid; Mousavi, Zinat; Sadat Barikani, Ameneh; Yaghoobi, Siamak; Khezri, Marzieh Beigom

2015-06-01

Several additives have been suggested to enhance analgesic effect of local anesthetic agents to decrease the adverse effects of them and increase the degree of satisfaction. We designed this randomized double-blind controlled study to evaluate the analgesic efficacy of the neostigmine added to bupivacaine using spinal anesthesia in patients undergoing lower limb orthopedic surgery. Sixty patients 18-80 yr old American Society of Anesthesiologists (ASA) physical status I or II, scheduled for femur surgery under spinal anesthesia, were recruited in a prospective, double-blinded, randomized way. The patients were randomly allocated to one of two groups of 30 each. The neostigmine group (group N) received bupivacaine 20 mg combined with 25 µg neostigmine, and the placebo group (group C) received bupivacaine 20 mg combined with 0.5ml distilled water (intrathecally) 5 minutes prior to surgery. The time to the first analgesic request, analgesic requirement in the first 12 hours after surgery, the duration of sensory and motor blockade, the incidence of adverse effects such as nausea,vomiting,hypotension, ephedrine requirements, bradycardia, and hypoxemia were recorded. Patients receiving neostigmine had a significantly prolonged duration of motor block (C95% CI 30.27 to 87.65; P < 0.001) and sensory block (C95% CI 101.04 to 224.64; P < 0.001) compared to the control group. The difference of the mean time to the first analgesic request was also significantly longer in neostigmine group (C95% CI 83.139 to 208.526; P < 0.001). The total analgesic consumption during the first 12 hours after surgery was devoid of any significant difference between groups N and C (p = 0.41).The two groups were not significantly different in terms of intraoperative and postoperative side effects. Intrathecal neostigmine 25 µg with bupivacaine caused a prolonged time to the first analgesic request and its use was not associated with any side effects.

A comparative study of efficacy and safety of flupirtine versus piroxicam in postoperative pain in patients undergoing lower limb surgery

PubMed Central

Chinnaiyan, Sowmya; Sarala, Narayana; Arun, Heddur Shanthappa

2017-01-01

Background Effective control of pain postoperatively is essential in providing enhanced patient care and a cost-effective hospital stay. Though many treatment modalities exist for postoperative pain management in orthopedic surgeries they are often accompanied by adverse effects. This study was carried out to assess the efficacy of flupirtine and piroxicam in postoperative pain reduction using visual analog scale (VAS) score. Materials and methods An open-label, parallel group, comparative study was conducted on patients undergoing lower limb orthopedic surgery, randomized into two groups of 38 patients each. They received either flupirtine 100 mg or piroxicam 20 mg 6 hours after surgery and then twice daily orally for 5 days. Pain was measured using VAS score, total pain relief score (TOTPAR24), and patient satisfaction score (PSS); the other scales used were behavioral pain assessment scale (BPAS) and functional activity score (FAS). Rescue medication used was tramadol 100 mg intravenously. WHO causality scale was used for assessing adverse effects. Descriptive and inferential statistics were used for assessment of various parameters. Results A total of 76 patients with mean ± standard deviation age of 35.08±10.3 years were recruited; 34 in the flupirtine and 37 in the piroxicam groups completed the study. Patients in both groups were comparable in baseline characteristics. Flupirtine and piroxicam reduced VAS score 48 hours postoperatively compared to baseline (p=0.006 and 0.001) and piroxicam produced significant reduction in pain at 8, 12, and 120 hours compared to flupirtine (p=0.028, 0.032, 0.021). TOTPAR24 and PSS at 24 hours were comparable between the treatments. BPAS scores at 24 hours were reduced significantly in patients receiving either drug (p=0.001). FAS improved at 72 hours in patients receiving piroxicam. Adverse effects were similar with both the medications. Conclusion Flupirtine and piroxicam reduced pain effectively but the onset of pain relief was earlier with piroxicam. PMID:29081669

General anesthesia versus segmental thoracic or conventional lumbar spinal anesthesia for patients undergoing laparoscopic cholecystectomy.

PubMed

Yousef, Gamal T; Lasheen, Ahmed E

2012-01-01

Laparoscopic cholecystectomy became the standard surgery for gallstone disease because of causing less postoperative pain, respiratory compromise and early ambulation. This study was designed to compare spinal anesthesia, (segmental thoracic or conventional lumbar) vs the gold standard general anesthesia as three anesthetic techniques for healthy patients scheduled for elective laparoscopic cholecystectomy, evaluating intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction. A total of 90 patients undergoing elective laparoscopic cholecystectomy, between January 2010 and May 2011, were randomized into three equal groups to undergo laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum under segmental thoracic (TSA group) or conventional lumbar (LSA group) spinal anesthesia or general anesthesia (GA group). To achieve a T3 sensory level we used (hyperbaric bupivacaine 15 mg, and fentanyl 25 mg at L2/L3) for LSAgroup, and (hyperbaric bupivacaine 7.5 mg, and fentanyl 25 mg at T10/T11) for TSAgroup. Propofol, fentanyl, atracurium, sevoflurane, and tracheal intubation were used for GA group. Intraoperative parameters, postoperative recovery and analgesia, complications as well as patient and surgeon satisfaction were compared between the three groups. All procedures were completed laparoscopically by the allocated method of anesthesia with no anesthetic conversions. The time for the blockade to reach T3 level, intraoperative hypotensive and bradycardic events and vasopressor use were significantly lower in (TSA group) than in (LSA group). Postoperative pain scores as assessed throughout any time, postoperative right shoulder pain and hospital stay was lower for both (TSA group) and (LSA group) compared with (GA group). The higher degree of patients satisfaction scores were recorded in patients under segmental TSA. The present study not only confirmed that both segmental TSA and conventional lumber spinal anesthesia (LSA) are safe and good alternatives to general anesthesia (GA) in healthy patients undergoing laparoscopic cholecystectomy but also showed better postoperative pain control of both spinal techniques when compared with general anesthesia. Segmental TSA provides better hemodynamic stability, lesser vasopressor use and early ambulation and discharge with higher degree of patient satisfaction making it excellent for day case surgery compared with conventional lumbar spinal anesthesia.

Delay to orthopedic consultation for isolated limb injury

PubMed Central

Rouleau, Dominique M.; Feldman, Debbie Ehrmann; Parent, Stefan

2009-01-01

ABSTRACT OBJECTIVE To describe referral mechanisms for referral to orthopedic surgery for isolated limb injuries in a public health care system and to identify factors affecting access. DESIGN Cross-sectional survey. SETTING Orthopedic surgery service in a level 1 trauma centre in Montreal, Que. PARTICIPANTS We conducted a prospective study of 166 consecutive adults (mean age 48 years) referred to orthopedic surgery for isolated limb injuries during a 4-month period. MAIN OUTCOME MEASURES Self-reported data on the nature of the trauma, the elapsed time between injury and orthopedic consultation, the number and type of previous primary care consultations, sociodemographic characteristics, and the level of satisfaction with care. RESULTS Average time between the injury and orthopedic consultation was 89 hours (range 3 to 642), with an average of 68 hours (range 0 to 642) for delay between primary care consultation and orthopedic consultation. A total of 36% of patients with time-sensitive diagnoses had unacceptable delays to orthopedic consultation according to the Quebec Orthopaedic Association guidelines. Lower limb injury, consulting first at another hospital, living far from the trauma centre, patient perception of low severity, and having a soft tissue injury were associated with longer delays. CONCLUSION Identifying gaps and risk factors for slower access might help improve referral mechanisms for orthopedic consultation. PMID:19826162

The efficiency of a dedicated staff on operating room turnover time in hand surgery.

PubMed

Avery, Daniel M; Matullo, Kristofer S

2014-01-01

To evaluate the effect of orthopedic and nonorthopedic operating room (OR) staff on the efficiency of turnover time in a hand surgery practice. A total of 621 sequential hand surgery cases were retrospectively reviewed. Turnover times for sequential cases were calculated and analyzed with regard to the characteristics of the OR staff being primarily orthopedic or nonorthopedic. A total of 227 turnover times were analyzed. The average turnover time with all nonorthopedic staff was 31 minutes, for having only an orthopedic surgical technician was 32 minutes, for having only an orthopedic circulator was 25 minutes, and for having both an orthopedic surgical technician and a circulator was 20 minutes. Statistical significance was seen when comparing only an orthopedic surgical technician versus both an orthopedic circulator and a surgical technician and when comparing both nonorthopedic staff versus both an orthopedic circulator and a surgical technician. OR efficiency is being increasingly evaluated for its effect on hospital revenue and OR staff costs. Reducing turnover time is one aspect of a multifaceted solution in increasing efficiency. Our study showed that, for hand surgery, orthopedic-specific staff can reduce turnover time. Economic/Decision Analysis III. Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Does age at the time of elective cardiac surgery or catheter intervention in children influence the longitudinal development of psychological distress and styles of coping of parents?

PubMed

Utens, Elisabeth M; Versluis-Den Bieman, Herma J; Witsenburg, Maarten; Bogers, Ad J J C; Hess, John; Verhulst, Frank C

2002-12-01

To assess the influence of age at a cardiac procedure of children, who underwent elective cardiac surgery or interventional cardiac catheterisation for treatment of congenital cardiac defects between 3 months and 7 years of age, on the longitudinal development of psychological distress and styles of coping of their parents. We used the General Health Questionnaire to measure psychological distress, and the Utrecht Coping List to measure styles of coping. Parents completed questionnaires on average respectively 5 weeks prior to, and 18.7 months after, cardiac surgery or catheter intervention for their child. Apart from one exception, no significant influence was found of the age at which children underwent elective cardiac surgery or catheter intervention on the pre- to postprocedural course of psychological distress and the styles of coping of their parents. Across time, parents of children undergoing surgery reported, on average, significantly higher levels of psychological distress than parents of children who underwent catheter intervention. After the procedure, parents of children who underwent either procedure reported significantly lower levels of psychological distress, and showed a weaker tendency to use several styles of coping, than did their reference groups. Age of the children at the time of elective cardiac surgery or catheter intervention did not influence the course of psychological distress of their parents, nor the styles of coping used by the parents. Future research should investigate in what way the age at which these cardiac procedures are performed influences the emotional and cognitive development of the children.

Inpatient mortality after elective primary total hip and knee joint arthroplasty in Botswana.

PubMed

Lisenda, Laughter; Mokete, Lipalo; Mkubwa, Joseph; Lukhele, Mkhululi

2016-12-01

Total hip and knee joint arthroplasty (TJA) rank among the most successful orthopaedic operations. Several developing countries in Africa have started to perform these procedures that are routine in developed countries. The aims of this study were to measure the incidence and assess the determinants of in-hospital mortality after elective primary TJA in our unit and compare it with published data. This was a retrospective study of the first consecutive cohort of patients who underwent elective primary TJA in Princess Marina Hospital, Botswana between March 2009 and October 2015 (6.5 years). 346 elective joint replacements were performed comprising 153 total hip arthroplasties (THA) and 193 total knee arthroplasties (TKA); 36 % of the THA were in female patients and 82 % of TKA were in females. The mean age was 64.5 years (range 26-86). Three patients died giving an inpatient mortality rate of 0.86 %. These three mortalities represent 1.55 % (three out of 193) of all the TKA. There were no deaths after THA. The cause of mortality in two patients was an adverse cardiac event while the third mortality was due to pulmonary embolism. The inpatient mortality rate of 0.86 % following TJA is higher than the reported rates in the developed countries but comparable with data from other developing countries. The inpatient mortality rate following TKA was higher than that following THA and cardiovascular events proved to be the main cause of death. We recommend formal cardiology assessment and close peri-operative monitoring of all patients with a history of cardiovascular disease undergoing TJA.

The cost of ignoring acute cholecystectomy.

PubMed

Garner, J P; Sood, S K; Robinson, J; Barber, W; Ravi, K

2009-01-01

Biliary symptoms whilst awaiting elective cholecystectomy are common, resulting in hospital admission, further investigation and increased hospital costs. Immediate cholecystectomy during the first admission is safe and effective, even when performed laparoscopically, but acute laparoscopic cholecystectomy has only recently become increasingly commonplace in the UK. This study was designed to quantify this problem in our hospital and its cost implications. The case notes of all patients undergoing laparoscopic cholecystectomy in our hospital between January 2004 and June 2005 were examined for details of hospital admissions with biliary symptoms or complications whilst waiting for elective cholecystectomy. Additional bed occupancy and radiological investigations were recorded and these costs to the trust calculated. We compared the potential tariff income to the hospital trust for the actual management of these patients and if a policy of acute laparoscopic cholecystectomy on first admission were in place. In the 18-month study period, 259 patients (202 females) underwent laparoscopic cholecystectomy. Of these, 147 presented as out-patients and only 11% required hospital admission because of biliary symptoms whilst waiting for elective surgery. There were 112 patients who initially presented acutely and were managed conservatively. Twenty-four patients were re-admitted 37 times, which utilised 231 hospital bed-days and repeat investigations costing over 40,000 pounds. There would have been a marginal increase in tariff income if a policy of acute laparoscopic cholecystectomy had been in place. Adoption of a policy of acute laparoscopic cholecystectomy on the index admission would result in substantial cost savings to the trust, reduce elective cholecystectomy waiting times and increase tariff income.

Equiosmolar Solutions of Hypertonic Saline and Mannitol Do Not Impair Blood Coagulation During Elective Intracranial Surgery.

PubMed

Hernández-Palazón, Joaquín; Fuentes-García, Diego; Doménech-Asensi, Paloma; Piqueras-Pérez, Claudio; Falcón-Araña, Luis; Burguillos-López, Sebastián

2017-01-01

The authors investigated the effect of equiosmolar, equivolemic solutions of 3% hypertonic saline (HS) and 20% mannitol on blood coagulation assessed by rotational thromboelastometry (ROTEM) and standard coagulation tests during elective craniotomy. In a prospective, randomized, double-blind trial, 40 patients undergoing elective craniotomy were randomized to receive 5 mL/kg of either 20% mannitol or 3% HS for intraoperative brain relaxation. Fibrinogen, activated partial thromboplastin time, prothrombin time, hemoglobin, hematocrit, and platelet count were simultaneously measured intraoperatively with ROTEM for EXTEM, INTEM, and FIBTEM analysis. ROTEM parameters were: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), and α-angle. No significant differences between groups were found in ROTEM variables CT, CFT, MCF, α-angle (EXTEM and INTEM), and MCF (FIBTEM) nor standard coagulation tests. ROTEM parameters did not show changes after administration of hyperosmolar solutions relating to basal values, except for an increase of CFT EXTEM (118±28 vs. 128±26 s) and decrease of CT INTEM (160±18 vs. 148±15 s) with values within normal range. Significant decreases from baseline levels were observed for hematocrit (-7%), platelet count (-10%), and fibrinogen (-13%) after HS infusion, and hematocrit (-9%), platelet count (-13%), and fibrinogen (-9%) after mannitol infusion, but remaining normal. The use of 5 mL/kg of equiosmolar solutions of 3% HS and 20% mannitol applied to reach a brain relaxation during elective craniotomy does not induce coagulation impairment as evidenced by ROTEM and standard coagulation tests.

Preoperative predictive model for acute kidney injury after elective cardiac surgery: a prospective multicentre cohort study.

PubMed

Callejas, Raquel; Panadero, Alfredo; Vives, Marc; Duque, Paula; Echarri, Gemma; Monedero, Pablo

2018-05-11

Predictive models of CS-AKI include emergency surgery and patients with haemodynamic instability. Our objective was to evaluate the performance of validated predictive models (Thakar and Demirjian) in elective cardiac surgery and to propose a better score in the case of poor performance. A prospective, multicentre, observational study was designed. Data were collected from 942 patients undergoing cardiac surgery, after excluding emergency surgery and patients with an intraaortic balloon pump. The main outcome measure was CS-AKI defined by the composite of requiring dialysis or doubling baseline creatinine values. Both models showed poor discrimination in elective surgery (Thakar's model, AUROC = 0.57, 95% CI = 0.50-0.64 and Demirjian's model, AUROC= 0.64, 95% CI = 0.58-0.71). We generated a new model whose significant independent predictors were: anaemia, age, hypertension, obesity, congestive heart failure, previous cardiac surgery and type of surgery. It classifies patients with scores 0-3 as low risk (< 5%), scores 4-7 as medium risk (up to 15%) and scores > 8 as high risk (>30%) of developing CS-AKI with a statistically significant correlation (p <0.001). Our model reflects acceptable discriminatory ability (AUC = 0.72, 95% CI = 0.66-0.78) which is significantly better than Thakar and Demirjian's models (p<0.01). We developed a new simple predictive model of CS-AKI in elective surgery based on available preoperative information. Our new model is easy to calculate and can be an effective tool for communicating risk to patients and guiding decision-making in the perioperative period. The study requires external validation.

Four quadrant transversus abdominis plane block and continuous transversus abdominis plane analgesia: a 3-year prospective audit in 124 patients.

PubMed

Niraj, G; Kelkar, Aditi; Hart, Elaine; Kaushik, Vipul; Fleet, Danny; Jameson, John

2015-11-01

Transversus abdominis plane (TAP) blocks have been reported to be an effective method of providing analgesia after abdominal surgery. To perform a prospective audit on the effectiveness of a novel technique of providing continuous transversus abdominis plane (TAP) analgesia in patients undergoing emergency and elective abdominal surgery. Prospective single center audit over a 3-year period. University hospital. One hundred twenty-four American Society of Anesthesiologists I to IV adult patients presenting for elective as well as emergency abdominal surgery in whom epidural analgesia was contraindicated or refused. Four quadrant TAP blocks and continuous TAP analgesia. Numerical rating scale pain scores at rest and on coughing, nausea scores, satisfaction scores, complications, frequency of analgesia failure, therapeutic failure with continuous TAP analgesia and opioid consumption. One hundred twenty-four patients who received continuous TAP analgesia were audited. This included 34 patients for elective open surgery, 36 patients for emergency laparotomy, and 54 patients who underwent elective laparoscopic colorectal surgery. Surgical incision was within the dermatomal limit of the block in 70% of the patients (88/124). Therapeutic failure with the technique was 10%. Frequency of analgesic failure over the 48-hour period was none in 39% and below 5 episodes in 57%. Four quadrant transversus abdominis plane blocks and continuous TAP analgesia is an effective technique for providing postoperative analgesia after abdominal surgery. It has the potential to be used as a sole analgesic technique when the surgical incision is within its dermatomal limit. Copyright © 2015 Elsevier Inc. All rights reserved.

Motivating factors for seeking cosmetic surgery: a synthesis of the literature.

PubMed

Haas, Cynthia Figueroa; Champion, Angela; Secor, Danielle

2008-01-01

The fascination in physical beauty is becoming more and more prevalent in today's society. Beauty in American culture is defined by the media through magazines, television, and music. The perfect career, the perfect family, social status, and high self-esteem all revolve around having an impeccable figure. Research shows that 94% of the covers of women's magazines showcase a woman with a thin physique (A. R., Malkin, K., Wornian, & J. C. Chrisler, 1999). Therefore, it is not surprising that year after year, millions of people elect for cosmetic surgery. According to the , approximately 11.7 million cosmetic surgical and nonsurgical procedures were performed and Americans spent $13.2 billion on these procedures. This is a 457% increase since 1997. As the demand for elective cosmetic surgery continues to rise, it is important for healthcare employees to recognize the motive behind the decision to seek cosmetic surgery. The purpose of this literature review project was to ascertain those factors that influence or motivate patients to seek cosmetic surgery. This project investigated physical, psychiatric, and psychosocial factors associated with individuals who undergo elective cosmetic surgery. It has been shown that the motivation for cosmetic surgery is based on a combination of psychological and emotional factors. Researchers surmise that body image, teasing history, and self-esteem were associated with motivational factors for those patients who elected to seek cosmetic surgery (T. Soest, I. L. Kvalem, K. C. Skolleborg, & H. E. Roald, 2006). In addition, the researchers concluded that body dysmorphic disorder, education, and culture are also predicting factors in the decision to have cosmetic surgery.

Billing and coding knowledge: a comparative survey of professional coders, practicing orthopedic surgeons, and orthopedic residents.

PubMed

Wiley, Kevin F; Yousuf, Tariq; Pasque, Charles B; Yousuf, Khalid

2014-06-01

Medical knowledge and surgical skills are necessary to become an effective orthopedic surgeon. To run an efficient practice, the surgeon must also possess a basic understanding of medical business practices, including billing and coding. In this study, we surveyed and compared the level of billing and coding knowledge among current orthopedic residents PGY3 and higher, academic and private practice attending orthopedic surgeons, and orthopedic coding professionals. According to the survey results, residents and fellows have a similar knowledge of coding and billing, regardless of their level of training or type of business education received in residency. Most residents would like formal training in coding, billing, and practice management didactics; this is consistent with data from previous studies.

The economic implications of a multimodal analgesic regimen for patients undergoing major orthopedic surgery: a comparative study of direct costs.

PubMed

Duncan, Christopher M; Hall Long, Kirsten; Warner, David O; Hebl, James R

2009-01-01

Total knee and total hip arthoplasty (THA) are 2 of the most common surgical procedures performed in the United States and represent the greatest single Medicare procedural expenditure. This study was designed to evaluate the economic impact of implementing a multimodal analgesic regimen (Total Joint Regional Anesthesia [TJRA] Clinical Pathway) on the estimated direct medical costs of patients undergoing lower extremity joint replacement surgery. An economic cost comparison was performed on Mayo Clinic patients (n = 100) undergoing traditional total knee or total hip arthroplasty using the TJRA Clinical Pathway. Study patients were matched 1:1 with historical controls undergoing similar procedures using traditional anesthetic (non-TJRA) techniques. Matching criteria included age, sex, surgeon, type of procedure, and American Society of Anesthesiologists (ASA) physical status (PS) classification. Hospital-based direct costs were collected for each patient and analyzed in standardized inflation-adjusted constant dollars using cost-to-charge ratios, wage indexes, and physician services valued using Medicare reimbursement rates. The estimated mean direct hospital costs were compared between groups, and a subgroup analysis was performed based on ASA PS classification. The estimated mean direct hospital costs were significantly reduced among TJRA patients when compared with controls (cost difference, 1999 dollars; 95% confidence interval, 584-3231 dollars; P = 0.0004). A significant reduction in hospital-based (Medicare Part A) costs accounted for the majority of the total cost savings. Use of a comprehensive, multimodal analgesic regimen (TJRA Clinical Pathway) in patients undergoing lower extremity joint replacement surgery provides a significant reduction in the estimated total direct medical costs. The reduction in mean cost is primarily associated with lower hospital-based (Medicare Part A) costs, with the greatest overall cost difference appearing among patients with significant comorbidities (ASA PS III-IV patients).

Perspectives of Orthopedic Surgeons on Racial/Ethnic Disparities in Care.

PubMed

Adelani, Muyibat A; O'Connor, Mary I

2017-08-01

Racial/ethnic disparities in healthcare, including orthopedics, have been extensively documented. However, the level of knowledge among orthopedic surgeons regarding racial/ethnic disparities is unknown. The purpose of this study is to determine the views of orthopedic surgeons on (1) the extent of racial/ethnic disparities in orthopedic care, (2) patient and system factors that may contribute, and (3) the potential role of orthopedic surgeons in the reduction of disparities. Three hundred five members of the American Orthopaedic Association completed a survey to assess their knowledge of racial/ethnic disparities and their perceptions about the underlying causes. Twelve percent of respondents believe that patients often receive different care based on race/ethnicity in healthcare in general, while 9 % believe that differences exist in orthopedic care in general, 3 % believe that differences exist within their hospitals/clinics, and 1 % reported differences in their own practices. Despite this, 68 % acknowledge that there is evidence of disparities in orthopedic care. Fifty-one percent believe that a lack of insurance significantly contributes to disparities. Thirty-five percent believe that diversification of the orthopedic workforce would be a "very effective" strategy in addressing disparities, while 25 % percent believe that research would be "very effective" and 24 % believe that surgeon education would be "very effective." Awareness regarding racial/ethnic disparities in musculoskeletal care is low among orthopedic surgeons. Additionally, respondents were more likely to acknowledge disparities within the practices of others than their own. Increased diversity, research, and education may help improve knowledge of this problem.

Orthopedic Surgery Resident Debt Load and Its Effect on Career Choice.

PubMed

Johnson, Joey P; Cassidy, Dale B; Tofte, Josef N; Bariteau, Jason T; Daniels, Alan H

2016-05-01

Student loan debt has become a topic of discussion and debate among physicians and legislators. This study seeks to assess the level of debt of orthopedic surgery residents and to determine whether debt burden affects the career choice of orthopedic trainees. A 26-question, anonymous survey was distributed via email to resident trainees enrolled in different medical and surgical specialty training programs across the United States. Orthopedic trainees were compared with trainees in other specialties using comparative statistics. Of the approximately 13,503 residents who were sent the survey, a total of 3076 responded, including 167 of an estimated 580 orthopedic residents, for approximate response rates of 22.8% and 28.8%, respectively. On average, orthopedic surgery residents were at a later post-graduate year than overall respondents (P<.025). When asked if student loan debt would influence the next step in their career, nonorthopedic residents were statistically more likely to respond "yes" compared with orthopedic surgery residents (57.21% vs 49.08%, respectively; P=.041). More than 50% of all respondents agreed that student loan debt would affect their type or location of practice. The majority of orthopedic residents take student loan debt into consideration when determining their final location and type of practice, although less so for orthopedic trainees compared with other specialties. As medical education continues to become more expensive and the threat of dropping physician reimbursement looms on the horizon, student debt may become a primary driving factor for young American physicians' career plans. [Orthopedics. 2016; 39(3):e438-e443.]. Copyright 2016, SLACK Incorporated.

Risk score for peri-interventional complications of carotid artery stenting.

PubMed

Hofmann, Robert; Niessner, Alexander; Kypta, Alexander; Steinwender, Clemens; Kammler, Jürgen; Kerschner, Klaus; Grund, Michael; Leisch, Franz; Huber, Kurt

2006-10-01

Routinely available independent risk factors for the peri-interventional outcome of patients undergoing elective carotid artery stenting (CAS) are lacking. The rationale of the study was to create a risk score identifying high-risk patients. We prospectively enrolled 606 consecutive patients assigned to CAS at a secondary care hospital. Various biochemical, clinical, and lesion-related risk factors were prospectively defined. The primary end point reflecting periprocedural complications encompassed minor and major stroke, nonfatal myocardial infarction and all-cause mortality within 30 days. Three percent of patients (n=18) experienced a nonfatal minor (n=13) or major (n=5) stroke. 1.3% of patients (n=8) died from fatal stroke (n=4) or other causes (n=4). No myocardial infarction was observed within 30 days after stenting. Multivariable analysis revealed diabetes mellitus with inadequate glycemic control (HbA1c > 7%), age > or = 80 years, ulceration of the carotid artery stenosis, and a contralateral stenosis > or = 50% as independent risk factors. A risk score formed with these variables showed a superior predictive value (C-statistic = 0.73) compared with single risk factors. The presence of 2 or more of these risk factors identified patients with a risk of 11% for a periprocedural complication compared with 2% in patients with a score of 0 or 1. In patients undergoing elective CAS, a risk score based on routinely accessible variables was able to identify patients at high-risk for atherothrombotic events and all-cause death within 30 days after the intervention.

[Effects of perioperative thermoregulation on patients' body temperature, peripheral circulation and blood coagulation time in patients undergoing elective vertical hemi laryngectomy].

PubMed

Zheng, X; Sun, D; Zhou, F; Zhang, Y J

2017-07-20

Objective: To compare the effects of different thermal insulation measures on perioperative body temperature, peripheral circulation and blood coagulation time in patients undergoing vertical hemi laryngectomy. Method: Sixty eligible patients with elective vertical hemi laryngectomy were randomly divided into 3 groups: preoperative inflatable heating blanket group (A group, n=20), warmed irrigation group (B group, n=20), and control group (C group, n=20). The core temperature were recorded after entering the operating room, before induction, 20th minute during operation, entering PACU and 2nd hour after operation respectively. Blood samples were got at the end of operation to test pH, lactic acid, PT and APTT. After waking patients' SpO₂ and thermal comfort were recorded. Result: The core temperatures at time points of 20th minute during operation and entering PACU were significantly different between C group and A group, C group and B group. There were significant difference in lactic acid, PT, APTT and SpO₂ between C group and A group, C group and B group. Patients' thermal comfort in all three groups were different. Conclusion: Inflatable heating blanket during operation combined with using it before operation or fluid warmers during operation for perioperative body temperature protection duringelective vertical partial laryngectomy surgery can effectively prevent perioperative hypothermia, improve peripheral circulation and blood coagulation time changes, improve patients' comfort after operation. Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.

Venous thromboembolism in women undergoing pelvic reconstructive surgery with mechanical prophylaxis alone.

PubMed

Montoya, T Ignacio; Leclaire, Edgar L; Oakley, Susan H; Crane, Andrea K; Mcpencow, Alexandra; Cichowski, Sara; Rahn, David D

2014-07-01

The objective of this study was determine the frequency of symptomatic perioperative venous thromboembolism (VTE) and risk factor(s) associated with VTE occurrence in women undergoing elective pelvic reconstructive surgery using only intermittent pneumatic compression (IPC) for VTE prophylaxis. A multi-center case-cohort retrospective review was conducted at six clinical sites over a 66-month period. All sites utilize IPC as standard VTE prophylaxis for urogynecological surgery. VTE cases occurring during the same hospitalization and up to 6 weeks postoperatively were identified by ICD9 code query. Four controls were temporally matched to each case. Information collected included demographics, medical history, route of surgery, operative time, and intraoperative characteristics. Univariate and multivariate backward stepwise logistic regression analyses were performed to identify potential risk factors for VTE. Symptomatic perioperative VTE was diagnosed in 27 subjects from a cohort of 10,627 women who underwent elective urogynecological surgery (0.25 %). Univariate analysis identified surgical route (laparotomy vs others), type of surgery ("major" vs "minor"), history of gynecological cancer, surgery time, and patient age as risk factors for VTE (P < 0.05). Multivariate analysis identified increased frequency of VTE with laparotomy, age ≥ 70, and surgery duration ≥ 5 h. In our study cohort, the frequency of symptomatic perioperative VTE was low. Laparotomy, age ≥ 70 years, and surgery duration ≥ 5 h were associated with VTE occurrence.

Case Report of a Patient With Idiopathic Hypersomnia and a Family History of Malignant Hyperthermia Undergoing General Anesthesia: An Overview of the Anesthetic Considerations.

PubMed

Aflaki, Sena; Hu, Sally; Kamel, Rami A; Chung, Frances; Singh, Mandeep

2017-05-01

The pathophysiologic underpinnings of idiopathic hypersomnia and its interactions with anesthetic medications remain poorly understood. There is a scarcity of literature describing this patient population in the surgical setting. This case report outlines the anesthetic considerations and management plan for a 55-year-old female patient with a known history of idiopathic hypersomnia undergoing an elective shoulder arthroscopy in the ambulatory setting. In addition, this case offers a unique set of considerations and conflicts related to the patient having a family history of malignant hyperthermia. A combined technique of general and regional anesthesia was used. Anesthesia was maintained with total intravenous anesthesia via the use of propofol and remifentanil. The depth of anesthesia was monitored with entropy. There were no perioperative complications.

In elective arch surgery with circulatory arrest, does the arterial cannulation site really matter? A propensity score analysis of right axillary and innominate artery cannulation.

PubMed

Preventza, Ourania; Price, Matt D; Spiliotopoulos, Konstantinos; Amarasekara, Hiruni S; Cornwell, Lorraine D; Omer, Shuab; de la Cruz, Kim I; Zhang, Qianzi; Green, Susan Y; LeMaire, Scott A; Rosengart, Todd K; Coselli, Joseph S

2018-05-01

The preferred arterial cannulation site for elective proximal aortic procedures requiring circulatory arrest varies, and different sites have been tried. We evaluated the relationships between arterial cannulation site and adverse outcomes, including stroke, in patients undergoing elective aortic arch surgery. We reviewed the records of 938 patients who underwent elective hemiarch or total arch surgery with circulatory arrest between 2006 and 2016. Five cannulation sites were used: the right axillary (n = 515; 54.9%), innominate (n = 376; 40.1%), and right common carotid arteries (n = 15; 1.6%), each with a side graft; the ascending aorta (n = 19; 2.0%); and the femoral artery (n = 13; 1.4%). Multivariable logistic regression analysis was used to model the effects of cannulation site on adverse outcomes for the entire cohort and for a subcohort of 891 patients who underwent innominate or axillary artery cannulation. Propensity-matching yielded 564 patients (282 pairs) from the right axillary and innominate artery groups. For the entire cohort, mortality, stroke, and composite adverse outcome (operative death or persistent stroke or renal failure at hospital discharge) rates were 7.0%, 4.1%, and 9.8%. In the multivariable analysis of the axillary/innominate subcohort, cannulation site did not independently predict operative mortality, persistent stroke, or composite adverse event. These results were confirmed with the propensity-matched analysis, where both axillary and innominate artery cannulation provided equivalent composite adverse event rates, operative death rates, and overall stroke rates. During elective arch surgery, right axillary artery cannulation and innominate artery cannulation (both via a side graft) produce excellent results and can be used interchangeably. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Aspirin reload before elective percutaneous coronary intervention: impact on serum thromboxane b2 and myocardial reperfusion indexes.

PubMed

Basili, Stefania; Tanzilli, Gaetano; Raparelli, Valeria; Calvieri, Camilla; Pignatelli, Pasquale; Carnevale, Roberto; Dominici, Marcello; Placanica, Attilio; Arrivi, Alessio; Farcomeni, Alessio; Barillà, Francesco; Mangieri, Enrico; Violi, Francesco

2014-08-01

Microvascular obstruction seems to predict poor outcome in patients undergoing elective percutaneous coronary intervention (PCI), but the underlying mechanism is still unclear. We analyzed whether serum thromboxane B2, a stable metabolite of thromboxane A2, may be implicated in post-PCI microvascular obstruction. We enrolled 91 patients (74 males, 66±10 years) on chronic low-dose aspirin therapy (aspirin, 100 mg daily) scheduled for elective PCI and randomly assigned to receive aspirin reload (325 mg orally, n=46) or no reload (control group, n=45) ≥1 hour before elective PCI. Serum levels of thromboxane B2, reperfusion indexes (corrected Thrombolysis In Myocardial Infarction frame count and myocardial blush grade), and serum cardiac troponin I were assessed before and after PCI. Serum thromboxane B2 significantly increased after 120 minutes (P=0.0447) from PCI in control but not in aspirin reload group. After PCI, both groups showed a statistically significant reduction in corrected Thrombolysis In Myocardial Infarction frame count more evident in aspirin reload group (P=0.0023). Moreover, after PCI, 61% of patients allocated to aspirin reload and only 32% of patients allocated to control group reached normal microcirculatory reperfusion (myocardial blush grade=3); patients with myocardial blush grade=3 exhibited lower values of serum thromboxane B2 compared with those with myocardial blush grade <3 (P=0.05). Periprocedural cardiac troponin I significantly increased (F=3.64; P=0.01334) and correlated with serum thromboxane B2 (ρ=0.31; P=0.0413) in control but not in aspirin reload group. In addition, left ventricular ejection fraction significantly increased after PCI only in the aspirin reload group (P=0.0005). Aspirin loading dose before elective PCI improves myocardial reperfusion and injury indexes, suggesting a possible role of platelet thromboxane A2 in microvascular occlusion. http://www.clinicaltrials.gov. Unique identifier: NCT01374698. © 2014 American Heart Association, Inc.

Preoperative anemia increases postoperative morbidity in elective cranial neurosurgery

PubMed Central

Bydon, Mohamad; Abt, Nicholas B.; Macki, Mohamed; Brem, Henry; Huang, Judy; Bydon, Ali; Tamargo, Rafael J.

2014-01-01

Background: Preoperative anemia may affect postoperative mortality and morbidity following elective cranial operations. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to identify elective cranial neurosurgical cases (2006-2012). Morbidity was defined as wound infection, systemic infection, cardiac, respiratory, renal, neurologic, and thromboembolic events, and unplanned returns to the operating room. For 30-day postoperative mortality and morbidity, adjusted odds ratios (ORs) were estimated with multivariable logistic regression. Results: Of 8015 patients who underwent elective cranial neurosurgery, 1710 patients (21.4%) were anemic. Anemic patients had an increased 30-day mortality of 4.1% versus 1.3% in non-anemic patients (P < 0.001) and an increased 30-day morbidity rate of 25.9% versus 14.14% in non-anemic patients (P < 0.001). The 30-day morbidity rates for all patients undergoing cranial procedures were stratified by diagnosis: 26.5% aneurysm, 24.7% sellar tumor, 19.7% extra-axial tumor, 14.8% intra-axial tumor, 14.4% arteriovenous malformation, and 5.6% pain. Following multivariable regression, the 30-day mortality in anemic patients was threefold higher than in non-anemic patients (4.1% vs 1.3%; OR = 2.77; 95% CI: 1.65-4.66). The odds of postoperative morbidity in anemic patients were significantly higher than in non-anemic patients (OR = 1.29; 95% CI: 1.03-1.61). There was a significant difference in postoperative morbidity event odds with a hematocrit level above (OR = 1.07; 95% CI: 0.78-1.48) and below (OR = 2.30; 95% CI: 1.55-3.42) 33% [hemoglobin (Hgb) 11 g/dl]. Conclusions: Preoperative anemia in elective cranial neurosurgery was independently associated with an increased risk of 30-day postoperative mortality and morbidity when compared to non-anemic patients. A hematocrit level below 33% (Hgb 11 g/dl) was associated with a significant increase in postoperative morbidity. PMID:25422784

Patient Body Mass Index is an Independent Predictor of 30-Day Hospital Readmission After Elective Spine Surgery.

PubMed

Elsamadicy, Aladine A; Adogwa, Owoicho; Vuong, Victoria D; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2016-12-01

Hospital readmission within 30 days of index surgery is receiving increased scrutiny as an indicator of poor quality of care. Reducing readmissions achieves the dual benefit of improving quality and reducing costs. With the growing prevalence of obesity, understanding its impact on 30-day unplanned readmissions and patients' perception of health status is important for appropriate risk stratification of patients. The aim of this study was to determine if obesity is an independent risk factor for unplanned 30-day readmissions after elective spine surgery. The medical records of 500 patients (nonobese, n = 281; obese, n = 219) undergoing elective spine surgery at a major academic medical center were reviewed. Preoperative body mass index (BMI) was measured on all patients. BMI that was ≥30 kg/m 2 was classified as obese. Patient demographics, comorbidities, and postoperative complication rates were collected. The primary outcome investigated was unplanned all-cause 30-day hospital readmission. The association between preoperative obesity and 30-day readmission rate was assessed via multivariate logistic regression analysis. Baseline characteristics and operative variables and complication profiles were similar between both cohorts. Overall, 8.6% of patients were readmitted within 30 days of discharge; obese patients experienced a 2-fold increase in 30-day readmission rates (obese 12.33% vs. nonobese 5.69%, P = 0.01). In a multivariate logistic regression analysis, preoperative obesity (BMI ≥30 kg/m 2 ) was found to be an independent predictor of 30-day readmission after elective spine surgery (P = 0.001). Preoperative obesity is an independent risk factor for readmission within 30 days of discharge after elective spine surgery. In a cost-conscious health care climate, preoperative BMI can identify patients at risk for early unplanned hospital readmission. Copyright © 2016 Elsevier Inc. All rights reserved.

The Highest-Impact Combat Orthopedic and Extremity Injury Articles in the Past 70 Years: A Citation Analysis.

PubMed

Nam, Jason; Do, Woo S; Stinner, Daniel J; Wenke, Joseph C; Orman, Jean A; Kragh, John F

The objective of this study was to identify the most-cited peer-reviewed combat orthopedic and extremity injury articles published during the past 70 years. Orthopedic trauma presents ongoing challenges to both US civilian and military healthcare personnel. Improvements in combat trauma and extremity injury survival and quality of life are the result of advances in orthopedic trauma research. The Web of Science (including Science Citation Index) was searched for the most cited articles related to combat orthopedic trauma, published from 1940 to 2013. The most-cited article was by Owens et al. (Journal of Orthopaedic Trauma, 2007; 137 citations). Between the 1990s and 2000s, there was a 256% increase in the number of highly cited publications. A total of 69% of the articles were on the topics of comorbid vascular trauma (25%), epidemiology (23%), or orthopedic trauma (21%). This study identifies some of the most important contributions to combat orthopedic trauma and research and the areas of greatest scientific interest to the specialty during the past seven decades and highlights key research that has contributed to the evolution of modern combat orthopedic traumatology. 2017.

Comparative study of scientific publications in orthopedics journals originating from USA, Japan and China (2000-2012).

PubMed

Lao, Li-Feng; Daubs, Michael David; Phan, Kevin H; Wang, Jeffrey C

2013-11-01

To compare orthopedics publications from USA, Japan and China. Scientific papers belong to ''Orthopedics'' category of Science Citation Index Expanded subject categories were retrieved from the "PubMed'' and ''Web of Knowledge'' online databases. In the field of orthopedics, the annual number increased significantly from 2000 to 2012 in the three countries (p<0.001). The share of articles increased significantly in China, but decreased significantly in Japan and USA (p<0.05). In 2012, USA contributed 35.3% of the total world output in orthopedics field and ranked 1st; Japan contributed 5.9% and ranked 4th; China contributed 5.2% and ranked 5th. Publications from USA had the highest accumulated IFs and the highest total citations of articles (USA > Japan > China, p<0.001). Average IF from USA was much higher than Japan and China (p<0.001). USA published the most articles in the top ten orthopedics journals (USA (14355) > Japan (1702) > China (487), p<0.01). Although China has undergone significant increase in annual number and percentage of scientific publication in orthopedics journals, it still lags far behind USA and Japan in the field of orthopedics in terms of quantity and quality.

Innovation and Entrepreneurship: Perspectives From Orthopedic Surgery.

PubMed

Campbell, Kevin J; Louie, Philip K; Khorsand, Derek A; Frisch, Nicholas B; Gerlinger, Tad L; Levine, Brett R

2018-05-01

Orthopedic surgeons are tasked with treating complex patients while employing critical surgical skills, clinical knowledge, and new technologies. The constant inundation of information, coupled with hours in the hospital setting, provides unique perspectives on various aspects of how health care is delivered, thereby creating a milieu ripe for innovation. The rigors of an orthopedic career make it challenging for physicians to translate an idea into a great product. Through the authors' experiences at a tertiary orthopedic practice, they review the process of taking an idea from concept to fruition. [Orthopedics. 2018; 41(3):135-140.]. Copyright 2018, SLACK Incorporated.

Orthobiologics in Pediatric Orthopedics.

PubMed

Murphy, Robert F; Mooney, James F

2017-07-01

Orthobiologics are biologic devices or products used in orthopedic surgery to augment or enhance bone formation. The use of orthobiologics in pediatric orthopedics is less frequent than in other orthopedic subspecialties, mainly due to the naturally abundant healing potential and bone formation in children compared with adults. However, orthobiologics are used in certain situations in pediatric orthopedics, particularly in spine and foot surgery. Other uses have been reported in conjunction with specific procedures involving the tibia and pelvis. The use of bioabsorable implants to stabilize children's fractures is an emerging concept but has limited supporting data. Copyright © 2017 Elsevier Inc. All rights reserved.

Dealing with innovation and costs in orthopedics: a conversation with Dane Miller. Interview by Lawton R Burns.

PubMed

Miller, Dane

2006-01-01

Rob Burns talks with Dane Miller, former CEO of Biomet, about challenges posed by new technology in the orthopedic devices area. One key challenge is the rising cost and use of orthopedic devices at a time when providers are facing decreased profitability and reimbursement for orthopedic services. Another challenge is the long-term time horizon needed to gauge product success that contrasts with payers' and providers' short-term horizon. A third challenge is heightened governmental scrutiny of device makers' relationships with orthopedic surgeons. This interview was conducted before Miller left Biomet in March 2006.

Surgical approach to gallbladder disease in rural Guatemala.

PubMed

Imran, Jonathan B; Ochoa-Hernandez, Annie; Herrejon, Juan; Madni, Tarik D; Clark, Audra T; Huerta, Sergio

2017-10-01

In this article, we report the current surgical approach to gallbladder disease at a major referral hospital in rural Guatemala. Complications in a cohort of patients undergoing open versus laparoscopic cholecystectomy were catalogued. We reviewed cholecystectomies performed by surgeons at the Hospital Nacional de San Benito in El Peten, Guatemala, after the adoption of the laparoscopic approach. Laparoscopic cholecystectomies (LCs) between 2014 and 2015 (n = 42) were reviewed and matched by 58 randomly selected open cholecystectomies (OCs) during the same period. Patient demographics were similar in the LC and OC groups. Of the 63 patients who had elective surgery, 43 (68%) underwent OC. Conversion rate, hospital length of stay, and readmission rate were 4%, 4.8 days, and 5%, respectively. Complications were similar between groups. Despite the low number of LCs, their complications were not different from that of OCs. During the study period, a large number of cholecystectomies continued to be open, even in the elective setting. Published by Elsevier Inc.

Are we jumping the gun with pharmaconutrition (immunonutrition) in gastrointestinal onoclogical surgery?

PubMed

Osland, Emma Jane; Memon, Muhammed Ashraf

2011-09-15

Over the last 20 years there has been considerable research into the use of immunonutrition, also referred to as pharmaconutrition, in the management of patients undergoing and recovering from elective gastrointestinal surgery for malignancy. In this group of patients, the use of pharmaconutrition seems to confer superior outcomes to standard nutrition formulations with regards to postoperative infective complications and length of hospital stay. It is therefore frequently recommended for use in elective gastrointestinal oncological surgical populations. However, it remains unclear whether the data supporting these recommendation is robust. Studies reporting improved outcomes with pharmaconutrition frequently compare this intervention with non-equivalent control groups, do not report on the actual nutritional provision received by study participants, overlook the potential impact of industry funding on the conduct of research and do not adopt a multi-disciplinary approach to the research undertaken. For these reasons, an urgent critical re-appraisal of the use and recommendations of pharmaconutrition in this group of patients is warranted to resolve some of the above mentioned issues.

Further evidence of psychological factors underlying choice of elective cesarean delivery (ECD) by primigravidae.

PubMed

Matinnia, Nasrin; Haghighi, Mohammad; Jahangard, Leila; Ibrahim, Faisal B; Rahman, Hejar A; Ghaleiha, Ali; Holsboer-Trachsler, Edith; Brand, Serge

2018-01-01

Requests for elective cesarean delivery (ECD) have increased in Iran. While some sociodemographic and fear-related factors have been linked with this choice, psychological factors such as self-esteem, stress, and health beliefs are under-researched. A total of 342 primigravidae (mean age = 25 years) completed questionnaires covering psychological dimensions such as self-esteem, perceived stress, marital relationship quality, perceived social support, and relevant health-related beliefs. Of the sample, 214 (62.6%) chose to undergo ECD rather than vaginal delivery (VD). This choice was associated with lower self-esteem, greater perceived stress, belief in higher susceptibility to problematic birth and barriers to an easy birth, along with lower perceived severity of ECD, fewer perceived benefits from VD, lower self-efficacy and a lower feeling of preparedness. No differences were found for marital relationship quality or perceived social support. The pattern suggests that various psychological factors such as self-esteem, self-efficacy, and perceived stress underpin the decision by primigravidae to have an ECD.

Limited effects of micronutrient supplementation on strength and physical function after abdominal aortic aneurysmectomy.

PubMed

Watters, James M; Vallerand, Andrew; Kirkpatrick, Susan M; Abbott, Heather E; Norris, Sonya; Wells, George; Barber, Graeme G

2002-08-01

Tissue injury following ischemia-reperfusion is mediated in part by free oxygen radicals. We hypothesized that perioperative micronutrient supplementation would augment antioxidant defenses, minimize muscle injury, and minimize postoperative decreases in muscle strength and physical function following abdominal aortic aneurysmectomy. A university-affiliated hospital and regional referral center. A randomized, double-blind, placebo-controlled trial of supplementation with beta-carotene, vitamins C and E, zinc, and selenium for a period of 2-3 weeks prior to surgery and 1 week thereafter. Patients undergoing elective abdominal aortic aneurysmectomy (n=18 per group). Handgrip and other measures of strength and physical function. Handgrip and quadriceps strength decreased following surgery, but not to a significantly different extent in the placebo and supplemented groups. Self-rated physical function decreased following surgery in the placebo group and was preserved in the supplemented group. Perioperative supplementation with micronutrients with antioxidant properties has limited effects on strength and physical function following major elective surgery.

Elective Surgery of Umbilical Hernia as a First Clinical Manifestation of a Gastrointestinal Stromal Tumor (Gist) - Case Report.

PubMed

Cybułka, Bartosz; Golański, Maciej; Rapeła, Jacek; Wach, Andrzej

2016-09-01

Gastrointestinal stromal tumor is a rare pathology. GISTs account for 0.3-1% of all tumors of the gastrointestinal tract. At the same time, this type of cancer is the most common, malignant, non-epithelial tumor of the gastrointestinal tube. Over 90% of GISTs are found in the stomach and small intestine. This cancer usually develops without characteristic clinical symptoms and is diagnosed incidentally. This clinical situation, in which the first symptom of a GIST-pattern tumor includes a fully-symptomatic, non-complicated umbilical hernia, is an unprecedented anomaly. This work presents a case report of a 77-year old female patient undergoing elective surgery, in which the contents of the hernial sac included a stromal tumor. Disseminated, multi-focal progression of the disease was found intraoperatively. Postoperative histopathology and immunohistochemistry revealed a gastrointestinal stromal tumor GIST of the spindle cell type, showing a CD-117, CD-34, SMA expression with possible starting point in the small intestine.

Less is more: limiting narcotic prescription quantities for common orthopedic procedures.

PubMed

O'Neill, Daniel Fulham; Webb Thomas, Christopher

2014-11-01

Clinicians are now appreciating that the perception of pain is a multifaceted, biopsychosocial construct. Expectation of postsurgical pain is part of this construct and should be considered preoperatively. It is our belief that by establishing reasonable expectations with preoperative teaching, we can minimize narcotic use and lessen untoward issues that can potentially follow. With this goal in mind, we have been using a comprehensive pre- and postoperative program for our outpatient orthopedic surgery patients for the last 5 years, which includes physical, pharmacologic, and simple sport psychological techniques. We reviewed postoperative prescription narcotic purchases in 133 consecutive surgical patients during the last year (2013). All patients were given a prescription postoperatively for 10 hydrocodone 5-mg/acetaminophen 500-mg tablets, with 1 refill. We then contacted the patients' pharmacies to assess the actual amount purchased. Data were available for 100 patients. Of these, 62 patients had undergone "simple" arthroscopies and 38 had had "open" procedures, including 25 anterior cruciate ligament reconstructions, 4 tibial tubercle osteotomies, and various other surgeries. Of the 62 arthroscopies, 24 patients (39%) refilled their prescriptions, with 4 patients (6%) needing > 1 refill. Of the 38 open procedures, 16 patients (42%) refilled their medications, 2 (5%), more than once. Thus, 89% of patients required ≤ 20 narcotic tablets after undergoing common orthopedic operations. No patient needed chronic narcotic medication. Pain is a complex issue and patient expectation of postoperative pain is one aspect that can potentially affect the amount of narcotics used. By preparing the patient both physically and psychologically, we believe the amount of narcotics used postoperatively can be decreased without affecting pain control. As a result, the multiple possible detriments of having more narcotics available than actually necessary would be lessened. By limiting the overall number of narcotic tablets prescribed, decreased use by the patient when such a medication may no longer be appropriate, and minimized use by others in the household who might have access to it would decrease.

Does Administration of Oral Versus Intravenous Antibiotics for Third Molar Removal Have an Effect on the Incidence of Alveolar Osteitis or Postoperative Surgical Site Infections?

PubMed

Reiland, Matthew D; Ettinger, Kyle S; Lohse, Christine M; Viozzi, Christopher F

2017-09-01

To compare the incidence of postoperative alveolar osteitis (AO) and surgical site infections (SSIs) in 2 separate cohorts of patients undergoing elective third molar removal: those who received postoperative oral (PO) antibiotics and those who received perioperative intravenous (IV) antibiotics. A retrospective cohort study of all patients 14 to 30 years old undergoing elective outpatient third molar removal under a single surgeon's service over a 12-year period was completed. Patients undergoing third molar removal during the first 72 months received postoperative PO antibiotics alone. Patients undergoing third molar removal during the second 72 months received perioperative IV antibiotics alone. The primary predictor variable for the study was the antibiotic regimen used at the time of third molar removal. The primary outcome variable was the postoperative development of AO or SSI. Covariates included age and gender. Univariable and multivariable regression models assessed for associations between the antibiotic regimen used and the presence of AO and SSI. The study sample consisted of 1,895 patients (1,020 patients receiving postoperative PO antibiotics and 875 patients receiving perioperative IV antibiotics). Of patients receiving postoperative PO antibiotics, 6.4% developed AO an average of 5.7 days after the procedure and 2.6% developed an SSI an average of 23.2 days after the procedure. Of patients receiving perioperative IV antibiotics, 5.5% developed AO an average of 6.2 days after the procedure and 3.3% developed an SSI an average of 18.2 days after the procedure. No statistically significant associations between the antibiotic regimen used and the presence of AO or SSI were identified in univariable (P = 0.42 for AO, P = 0.32 for SSI) or multivariable (P = 0.65 for AO, P = 0.26 for SSI) analyses. In the postoperative PO antibiotic cohort, older age (P < .001) and female gender (P < .001) were significantly associated with the development of AO, and female gender (P = .015) was significantly associated with the presence of an SSI. In the perioperative IV antibiotic cohort, female gender was significantly associated with the development of AO (P = .011), and younger age was significantly associated with the presence of an SSI (P = .011). The use of a postoperative PO versus a perioperative IV antibiotic regimen does not significantly alter the incidence of AO or SSI after elective third molar removal. If the surgeon chooses to use antibiotics in the setting of third molar surgery, then perioperative IV antibiotics are preferable over postoperative PO antibiotics because they obviate any issues with patient compliance and might be less costly. Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Medical Issues: Orthopedics

MedlinePlus

... Cure SMA Store Volunteer Donate Learn About SMA Research Support & Care Get Involved Donate About Us News www.curesma.org > support & care > living with sma > medical issues > orthopedics Orthopedics In SMA, muscle weakness can cause several ...

A New Culture of Transparency: Industry Payments to Orthopedic Surgeons.

PubMed

Lopez, Joseph; Ahmed, Rizwan; Bae, Sunjae; Hicks, Caitlin W; El Dafrawy, Mostafa; Osgood, Greg M; Segev, Dorry L

2016-11-01

Under the Physician Payments Sunshine Act, "payments or transfers of value" by biomedical companies to physicians must be disclosed through the Open Payments Program. Designed to provide transparency of financial transactions between medication and device manufacturers and health care providers, the Open Payments Program shows financial relationships between industry and health care providers. Awareness of this program is crucial because its interpretation or misinterpretation by patients, physicians, and the general public can affect patient care, clinical practice, and research. This study evaluated nonresearch payments by industry to orthopedic surgeons. A retrospective cross-sectional review of the first wave of Physician Payments Sunshine Act data (August through December 2013) was performed to characterize industry payments to orthopedic surgeons by subspecialty, amount, type, origin, and geographic distribution. During this 5-month period, orthopedic surgeons (n=14,828) received $107,666,826, which included 3% of those listed in the Open Payments Program and 23% of the total amount paid. Of orthopedic surgeons who received payment, 45% received less than $100 and 1% received $100,000 or more. Median payment (interquartile range) was $119 ($34-$636), and mean payment was $7261±95,887. The largest payment to an individual orthopedic surgeon was $7,849,711. The 2 largest payment categories were royalty or license fees (68%) and consulting fees (13%). During the study period, orthopedic surgeons had substantial financial ties to industry. Of orthopedic surgeons who received payments, the largest proportion (45%) received less than $100 and only 1% received large payments (≥$100,000). The Open Payments Program offers insight into industry payments to orthopedic surgeons. [Orthopedics. 2016; 39(6):e1058-e1062.]. Copyright 2016, SLACK Incorporated.

Does topical lidocaine before tracheal intubation attenuate airway responses in children? An observational audit.

PubMed

Hamilton, Nigel D; Hegarty, Mary; Calder, Alyson; Erb, Thomas O; von Ungern-Sternberg, Britta S

2012-04-01

The use of topical lidocaine, applied to the airways with various administration techniques, is common practice in pediatric anesthesia in many institutions. However, it remains unclear whether these practices achieve their intended goal of reducing the risk of perioperative respiratory adverse events (PRAE) in children undergoing elective endotracheal intubation without neuromuscular blockade (NMB). The relative frequency of PRAE (laryngospasm, coughing, desaturation <95%) associated with no use of topical airway lidocaine (TAL), with TAL sprayed directly onto the vocal cords, and TAL administered blindly into the pharynx was assessed. This prospective audit involved 1000 patients undergoing general anesthesia with elective endotracheal intubation without NMB. Patients with suspected difficult airways or undergoing airway surgery were excluded. The use of TAL and the mode of administration were recorded. Respiratory adverse events were recorded in the perioperative period. Two hundred and fifty-four patients had the vocal cords sprayed under direct vision, 236 had lidocaine blindly dripped into the pharynx, and 510 received no TAL. The mean age and known risk factors for PRAE (asthma, recent upper respiratory tract infection (≤2 weeks), passive smoking, hayfever, past or present eczema, nocturnal dry cough) were similar among the groups. The proportion of patients with desaturation (<95%) between induction of anesthesia and discharge from the recovery room was higher in the two groups who received TAL (data combined for all patients receiving lidocaine regardless of administration method, P = 0.01) compared to those who received no TAL. No difference in the rates of laryngospasm (P = 0.13) or cough (P = 0.07) was observed among the groups. There was no difference in the rates of PRAE between the groups given TAL directly onto the vocal cords and in those whom received TAL blindly. The incidence of desaturation was higher in patients receiving TAL compared with children who did not. This association should perhaps be considered when contemplating the use of this technique. © 2011 Blackwell Publishing Ltd.

Effect of pre-operative octenidine nasal ointment and showering on surgical site infections in patients undergoing cardiac surgery.

PubMed

Reiser, M; Scherag, A; Forstner, C; Brunkhorst, F M; Harbarth, S; Doenst, T; Pletz, M W; Hagel, S

2017-02-01

To evaluate the effect of pre-operative octenidine (OCT) decolonization on surgical site infection (SSI) rates. Before-and-after cohort study. Patients undergoing an elective isolated coronary artery bypass graft (CABG) procedure: control group (1 st January to 31 st December 2013), N=475; intervention group (1 st January to 31 st December 2014), N=428. The intervention consisted of nasal application of OCT ointment three times daily, beginning on the day before surgery, and showering the night before and on the day of surgery with OCT soap. A median sternotomy was performed in 805 (89.1%) patients and a minimally invasive direct coronary artery bypass procedure was performed in 98 (10.9%) patients. Overall, there was no difference in SSI rates between the control and intervention groups (15.4% vs 13.3%, P=0.39). The rate of harvest site SSIs was significantly lower in patients in the intervention group (2.5% vs 0.5%, P=0.01). Patients who had undergone a median sternotomy in the intervention group had a significantly lower rate of organ/space sternal SSIs (1.9% vs 0.3%, P=0.04). However, there was a trend towards an increased rate of deep incisional sternal SSIs (1.2% vs 2.9%, P=0.08). Multi-variate analysis did not identify a significant protective effect of the intervention (odds ratio 0.79, 95% confidence interval 0.53-1.15, P=0.27). Pre-operative decolonization with OCT did not reduce overall SSI rates in patients undergoing an elective isolated CABG procedure, but significantly decreased harvest site and organ/space sternal SSIs. Randomized controlled trials, including controlled patient adherence to the intervention, are required to confirm these observations and to determine the clinical utility of OCT in pre-operative decolonization. Copyright © 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Total Thrombus-formation Analysis System Predicts Periprocedural Bleeding Events in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention.

PubMed

Oimatsu, Yu; Kaikita, Koichi; Ishii, Masanobu; Mitsuse, Tatsuro; Ito, Miwa; Arima, Yuichiro; Sueta, Daisuke; Takahashi, Aya; Iwashita, Satomi; Yamamoto, Eiichiro; Kojima, Sunao; Hokimoto, Seiji; Tsujita, Kenichi

2017-04-24

Periprocedural bleeding events are common after percutaneous coronary intervention. We evaluated the association of periprocedural bleeding events with thrombogenicity, which was measured quantitatively by the Total Thrombus-formation Analysis System equipped with microchips and thrombogenic surfaces (collagen, platelet chip [PL]; collagen plus tissue factor, atheroma chip [AR]). Between August 2013 and March 2016, 313 consecutive patients with coronary artery disease undergoing elective percutaneous coronary intervention were enrolled. They were divided into those with or without periprocedural bleeding events. We determined the bleeding events as composites of major bleeding events defined by the International Society on Thrombosis and Hemostasis and minor bleeding events (eg, minor hematoma, arteriovenous shunt and pseudoaneurysm). Blood samples obtained at percutaneous coronary intervention were analyzed for thrombus formation area under the curve (PL 24 -AUC 10 for PL chip; AR 10 -AUC 30 for AR chip) by the Total Thrombus-formation Analysis System and P2Y12 reaction unit by the VerifyNow system. Periprocedural bleeding events occurred in 37 patients. PL 24 -AUC 10 levels were significantly lower in patients with such events than those without ( P =0.002). Multiple logistic regression analyses showed association between low PL 24 -AUC 10 levels and periprocedural bleeding events (odds ratio, 2.71 [1.22-5.99]; P =0.01) and association between PL 24 -AUC 10 and periprocedural bleeding events in 176 patients of the femoral approach group (odds ratio, 2.88 [1.11-7.49]; P =0.03). However, PL 24 -AUC 10 levels in 127 patients of the radial approach group were not significantly different in patients with or without periprocedural bleeding events. PL 24 -AUC 10 measured by the Total Thrombus-formation Analysis System is a potentially useful predictor of periprocedural bleeding events in coronary artery disease patients undergoing elective percutaneous coronary intervention. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Bispectral index values during sevoflurane-nitrous oxide general anesthesia in women undergoing cesarean delivery: a comparison between women with and without prior labor.

PubMed

Yoo, Kyung Y; Jeong, Cheol W; Kang, Myung W; Kim, Seok J; Chung, Sung T; Shin, Min H; Lee, JongUn

2008-06-01

An end-tidal concentration of 1% sevoflurane (1% ET(SEVO)) in 50% nitrous oxide (N(2)O) during elective cesarean delivery has been associated with bispectral index (BIS) values >60, which are associated with an increased risk of awareness. We hypothesized that BIS values during sevoflurane-N(2)O general anesthesia for cesarean delivery would be lower in women with prior labor compared with women without prior labor. Forty patients undergoing cesarean delivery were enrolled in this observational study. One group had urgent surgery after labor (labor group, n = 20) and the other had elective surgery without labor (control group, n = 20). General anesthesia was induced with thiopental 4 mg/kg, followed by succinylcholine 1.5 mg/kg, and maintained with 1% ET(SEVO) and 50% N(2)O in oxygen. BIS values, systolic arterial blood pressure, heart rate, plasma stress hormone concentrations, Apgar scores, and postoperative analgesia variables were assessed and compared between groups. BIS values during the period between intubation and delivery were lower in the labor group than in the control group (P < 0.001). Plasma norepinephrine concentrations increased at delivery compared with baseline in both groups. They were higher in the labor group than in the control group both at baseline and at delivery. Systolic arterial blood pressure, heart rate, Apgar scores, surgical characteristics, and plasma concentrations of vasopressin and cortisol were not different between groups. Postoperative visual analog scale pain scores were similar between groups, while the labor group consumed less analgesics (P < 0.01) during the first 24 h after the operation. Prior labor was associated with lower intraoperative BIS values during sevoflurane/N(2)O general anesthesia and reduced postoperative analgesic consumption in women undergoing cesarean delivery compared with women without prior labor.

Primary and Secondary Prevention of Cardiovascular Disease

PubMed Central

Vandvik, Per Olav; Lincoff, A. Michael; Gore, Joel M.; Gutterman, David D.; Sonnenberg, Frank A.; Alonso-Coello, Pablo; Akl, Elie A.; Lansberg, Maarten G.; Guyatt, Gordon H.

2012-01-01

Background: This guideline focuses on long-term administration of antithrombotic drugs designed for primary and secondary prevention of cardiovascular disease, including two new antiplatelet therapies. Methods: The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results: We present 23 recommendations for pertinent clinical questions. For primary prevention of cardiovascular disease, we suggest low-dose aspirin (75-100 mg/d) in patients aged > 50 years over no aspirin therapy (Grade 2B). For patients with established coronary artery disease, defined as patients 1-year post-acute coronary syndrome, with prior revascularization, coronary stenoses > 50% by coronary angiogram, and/or evidence for cardiac ischemia on diagnostic testing, we recommend long-term low-dose aspirin or clopidogrel (75 mg/d) (Grade 1A). For patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI) with stent placement, we recommend for the first year dual antiplatelet therapy with low-dose aspirin in combination with ticagrelor 90 mg bid, clopidogrel 75 mg/d, or prasugrel 10 mg/d over single antiplatelet therapy (Grade 1B). For patients undergoing elective PCI with stent placement, we recommend aspirin (75-325 mg/d) and clopidogrel for a minimum duration of 1 month (bare-metal stents) or 3 to 6 months (drug-eluting stents) (Grade 1A). We suggest continuing low-dose aspirin plus clopidogrel for 12 months for all stents (Grade 2C). Thereafter, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy (Grade 1B). Conclusions: Recommendations continue to favor single antiplatelet therapy for patients with established coronary artery disease. For patients with acute coronary syndromes or undergoing elective PCI with stent placement, dual antiplatelet therapy for up to 1 year is warranted. PMID:22315274

PAs in orthopedics in the VHA's community-based outpatient clinics.

PubMed

Reed, Daniel O; Hooker, Roderick S

2017-04-01

In the Veterans Health Administration (VHA) system, most orthopedic care takes place in the VA medical centers (VAMCs). Because most patients receiving orthopedic care were referred by adult medicine providers, more widely deploying physician assistants (PAs) in orthopedic medicine might help offset this workload. An orthopedic medicine demonstration project recruited, trained, and positioned PAs in community-based outpatient clinics (CBOCs) to improve access to care. The project involved surgeons at the Houston VAMC instructing five newly employed PAs in a wide range of orthopedic evaluation and management strategies before their assignment to a CBOC. An administrative assessment compared encounter data pre- and postproject (2012 and 2014) to determine if this strategy modified orthopedic workload and improved patient access to care. By 2014, orthopedic patient visit volume had increased 31%-10% at the VAMC and 21% at the five CBOCs. Overall, the five deployed PAs managed 28% of all orthopedic encounters spread over 1 year and only 3.2% of visits required VAMC referral for further evaluation or treatment. During the project, the total volume of patient visits increased throughout the Houston VAMC region but access to care for this specialty service also increased, with more veteran musculoskeletal care being met at the five CBOCs, off-loading visit demand centrally. The adaptability and flexibility of new roles has been identified as one of the defining characteristics of PAs. That the VHA can take advantage of this role malleability suggests that employing PAs is useful in meeting medical service needs of veterans.

Declining trends in invasive orthopedic interventions for people with hemophilia enrolled in the Universal Data Collection program (2000–2010)

PubMed Central

TOBASE, P.; LANE, H.; SIDDIQI, A.-E-A.; INGRAM-RICH, R.; WARD, R. S.

2016-01-01

Introduction Recurrent joint hemarthroses due to hemophilia (Factor VIII and Factor IX deficiency) often lead to invasive orthopedic interventions to decrease frequency of bleeding and/or to alleviate pain associated with end-stage hemophilic arthropathy. Aim Identify trends in invasive orthopedic interventions among people with hemophilia who were enrolled in the Universal Data Collection (UDC) program during the period 2000–2010. Methods Data were collected from 130 hemophilia treatment centers in the United States annually during the period 2000–2010, in collaboration with the Centers for Disease Control and Prevention (CDC). The number of visits in which an invasive orthopedic intervention was reported was expressed as a proportion of the total visits in each year of the program. Invasive orthopedic interventions consisted of arthroplasty, arthrodesis, and synovectomy. Joints included in this study were the shoulder, elbow, hip, knee, and ankle. Results A 5.6% decrease in all invasive orthopedic interventions in all joints of people with hemophilia enrolled in the UDC program over the 11-year study period was observed. Conclusions These data reflect a declining trend in invasive orthopedic interventions in people with hemophilia. Further research is needed to understand the characteristics that may influence invasive orthopedic interventions. PMID:27030396

Declining trends in invasive orthopedic interventions for people with hemophilia enrolled in the Universal Data Collection program (2000-2010).

PubMed

Tobase, P; Lane, H; Siddiqi, A-E-A; Ingram-Rich, R; Ward, R S

2016-07-01

Recurrent joint hemarthroses due to hemophilia (Factor VIII and Factor IX deficiency) often lead to invasive orthopedic interventions to decrease frequency of bleeding and/or to alleviate pain associated with end-stage hemophilic arthropathy. Identify trends in invasive orthopedic interventions among people with hemophilia who were enrolled in the Universal Data Collection (UDC) program during the period 2000-2010. Data were collected from 130 hemophilia treatment centers in the United States annually during the period 2000-2010, in collaboration with the Centers for Disease Control and Prevention (CDC). The number of visits in which an invasive orthopedic intervention was reported was expressed as a proportion of the total visits in each year of the program. Invasive orthopedic interventions consisted of arthroplasty, arthrodesis, and synovectomy. Joints included in this study were the shoulder, elbow, hip, knee, and ankle. A 5.6% decrease in all invasive orthopedic interventions in all joints of people with hemophilia enrolled in the UDC program over the 11-year study period was observed. These data reflect a declining trend in invasive orthopedic interventions in people with hemophilia. Further research is needed to understand the characteristics that may influence invasive orthopedic interventions. © 2016 John Wiley & Sons Ltd.

Orthopaedic jack for scoliosis surgery purposes: Concept and design

NASA Astrophysics Data System (ADS)

Supriadi, Sugeng; Radhana, Rakha M.; Hidayanto, Taufik Eko; Whulanza, Yudan; Ali, Notario, Nanda; Rahyussalim

2017-02-01

Scoliosis surgery is one of the most difficult orthopedic surgery that have been committed today as the failure rate of orthopedic surgery for adult patients is 15%. Aside from the long duration of surgery, this surgical failure is caused by failure in biomedical instrumentation. Furthermore, this kind of failure is causing inefficiency of the surgery. With current known orthopedic surgery method, three surgeons are needed in a single orthopedic surgery. In fact, a single surgery can take up to 8 hours to be done, which increases the risk of surgical failure. Based on this problem, authors hope that our orthopedic jacks could solve the problem.

Safety and effectiveness of predeposit autologous transfusions in preteen and adolescent children.

PubMed

Silvergleid, A J

1987-06-26

Although there is documentation in the literature of the safety and effectiveness of predeposit autologous transfusions among adult patients contemplating surgery, there are no comparable data for preteen and teenage children. We report our experience with 180 children between the ages of 8 and 18 years participating in a community blood center-based predeposit autologous transfusion program. Children as young as 8 years old and weighing as little as 27 kg predonated a prescribed amount of blood prior to elective orthopedic (169) or plastic (11) surgery. Only four children experienced a donor reaction; none of them was severe. No child was unable to donate the prescribed number of units. Eighty-eight percent of the children were able to supply their complete blood requirements, thus avoiding exposure to homologous blood. Our experience documents both the safety and effectiveness of predeposit autologous transfusions in preteen and adolescent children and should encourage existing predeposit autologous transfusion programs to extend participation to thousands of children for whom the opportunity to use their own blood is currently denied.

Efficacy of granisetron in preventing postanesthetic shivering.

PubMed

Sajedi, Parvin; Yaraghi, Ahmad; Moseli, Heidar Ali

2008-12-01

Recently, 5-hydroxytryptamine 3 (5-HT3) receptor antagonists have been reported to prevent postanesthetic shivering. This placebo-controlled study was performed to evaluate the efficacy of granisetron, a 5-HT3 antagonist, in comparison with meperidine and tramadol in preventing postanesthetic shivering. In this prospective, randomized, double-blind study, 132 ASA I and II patients undergoing elective orthopedic surgery under standardized general anesthesia were included. At the end of surgery, patients were randomly assigned to one of four groups (each group n = 33) using a double-blinded protocol. Group T received 1 mg/kg tramadol, group G received 40 microg/kg granisetron (an antiemetic dose), group M received 0.4 mg/kg meperidine, and group P received saline 0.9% as placebo. Shivering was graded according to the following: 0 = no shivering; 1 = piloerection, peripheral vasoconstriction or peripheral cyanosis without other cause; 2 = visible muscular activity confined to one muscle group; 3 = visible muscular activity in more than one muscle group; and 4 = gross muscular activity involving the entire body. The emergence time from anesthesia, defined as the time between withdrawal of isoflurane and tracheal extubation, was documented. The number of patients with observable shivering was 19 in group P, nine in group G, seven in group T and six in group M. Granisetron significantly reduced the incidence of shivering in comparison with placebo (p = 0.013). Although the frequency of shivering was higher with granisetron in comparison to tramadol and meperidine, it was not statistically significant (p > 0.05). The number of patients with a shivering score of 2, 3 and 4 was significantly higher in group P compared with the other groups (p = 0.001). Both meperidine and tramadol caused a significantly prolonged emergence time (20.58 +/- 3.56 and 16.45 +/- 4.13 minutes, respectively) as opposed to granisetron (13.58 +/- 3.41 minutes) and placebo (12.61 +/- 3.31 minutes). The prophylactic use of granisetron 40 microg/kg is as effective as meperidine (0.4 mg/kg) and tramadol (0.1 mg/kg) in preventing postanesthetic shivering without prolonging the emergence time from anesthesia.

Conventional Landmark-Guided Midline Versus Preprocedure Ultrasound-Guided Paramedian Techniques in Spinal Anesthesia.

PubMed

Kallidaikurichi Srinivasan, Karthikeyan; Iohom, Gabriella; Loughnane, Frank; Lee, Peter J

2015-10-01

Multiple passes and attempts while administering spinal anesthesia are associated with a greater incidence of postdural puncture headache, paraesthesia, and spinal hematoma. We hypothesized that the routine use of a preprocedural ultrasound-guided paramedian technique for spinal anesthesia would reduce the number of passes required to achieve entry into the subarachnoid space when compared with the conventional landmark-guided midline approach. One hundred consenting patients scheduled for elective total joint replacements (hip and knee) were randomized into group C (conventional) and group P (preprocedural ultrasound-guided paramedian technique) with 50 in each group. The patients were blinded to the study group. All spinal anesthetics were administered by a consultant anesthesiologist. In group C, spinal anesthetic was done via the midline approach using clinically palpated landmarks. In group P, a preprocedural ultrasound scan was used to mark the paramedian insertion site, and spinal anesthetic was performed via the paramedian approach. The average number of passes (defined as the number of forward advancements of the spinal needle in a given interspinous space, i.e., withdrawal and redirection of spinal needle without exiting the skin) in group P was approximately 0.34 times that in group C, a difference that was statistically significant (P = 0.01). Similarly, the average number of attempts (defined as the number of times the spinal needle was withdrawn from the skin and reinserted) in group P was approximately 0.25 times that of group C (P = 0.0021). In group P, on an average, it took 81.5 (99% confidence interval, 68.4-97 seconds) seconds longer to identify the landmarks than in group C (P = 0.0002). All other parameters, including grading of palpated landmarks, time taken for spinal anesthetic injection, periprocedural pain scores, periprocedural patient discomfort visual analog scale score, conversion to general anesthetic, paresthesia, and radicular pain during needle insertion, were similar between the 2 groups. Routine use of paramedian spinal anesthesia in the orthopedic patient population undergoing joint replacement surgery, guided by preprocedure ultrasound examination, significantly decreases the number of passes and attempts needed to enter the subarachnoid space.

The Thai anesthesia incident monitoring study (Thai AIMS): an analysis of perioperative myocardial ischemia/infarction.

PubMed

Ngamprasertwong, Pornswan; Kositanurit, Inthiporn; Yokanit, Preechayuth; Wattanavinit, Rhuthai; Atichat, Sunida; Lapisatepun, Worawut

2008-11-01

To analyze the clinical course, outcome, contributing factors and factors minimizing the incidents of perioperative myocardial ischemia or infarction (PMI) from Thai AIMS study. The present study was a prospective multicenter study. Data was collected from 51 hospitals in Thailand during a six-month period. The participating anesthesia provider completed the standardized incident report form of the Thai AIMS as soon as they found the PMI incident. Each incident was reviewed by three peer reviewers for clinical courses, contributing factors, outcome and minimizing factors of PMI. From the Thai AIMS incident report, the authors found 25 suspected PMI cases which was 0.9% of the 2,669 incidents reported in the present study. Most of the PMI occurred in elective cases (84%) and orthopedic procedures (56%). The majority of PMI was reported from the patients undergoing general anesthesia (72%). Suspected PMI occurred mostly during operations (56%). New ST-T segment change was detected in 92% of these patients. The most common immediate outcome of PMI was major physiological change (88%). The most common management effect of PMI was unplanned ICU admission (64%); the others were prolonged ventilatory support (12%) and prolonged hospital stay (16%). Four patients (16%) died after the suspected PMI. Most of the events occurred spontaneously and were unpreventable (80%). Patient factors (100%), anesthesia factors (72%), surgical factors (32%) and system factors (8%) were all judged as a precipitating factor for PMI. Human factors were the most common contributing factors which included poor preoperative evaluation, inexperience and improper decision. The three most common factors minimizing the adverse incidents included prior experienced, high awareness and experienced assistance. The recommended corrective strategies were guideline practice, quality assurance activity, improvement of supervision and additional training. Perioperative myocardial ischemia/infarction was infrequent but may be lethal. Patient factors were the most common precipitating cause. The morbidity and mortality could be reduced by high quality preoperative evaluation and preparation, early detection and appropriate treatment. Guideline practice, quality assurance activity, improvement of supervision and additional training were suggested corrective strategies.

Antibiotic concentrations in intestinal mucosa.

PubMed

Malmborg, A S

1985-01-01

The concentrations in the intestinal mucosa after the initial dose of cefoxitin, piperacillin and clindamycin have been studied. The antibiotics were given at the induction of anesthesia as prophylaxis to patients undergoing elective colorectal surgery. The concentrations of the antibiotics in serum and intestinal mucosa taken during the operation were determined by the microbiological agar diffusion method. Therapeutic concentrations in intestinal mucosa were maintained during the major part of the operation period. The mean mucosa/serum concentration ratios were for cefoxitin 0.4, for piperacillin 0.5 and for clindamycin 1.2.

Colorectal cancer associated with abdominal aortic aneurysm: results of EVAR followed by colectomy.

PubMed

Illuminati, Giulio; Ceccanei, Gianluca; Pacilè, Maria A; Pizzardi, Giulia; Palumbo, Piergaspare; Vietri, Francesco

2013-01-01

The association of colorectal cancer and abdominal aortic aneurysm (AAA) is infrequent but poses special problems of priority of treatment under elective circumstances. The purpose of this study was to retrospectively evaluate the outcome of 16 consecutive patients undergoing endovascular aneurysm repair (EVAR) followed by colectomy. Operative mortality was nil. Operative morbidity included two transient rise of serum creatinine level and one extraperitoneal anastomotic leakage which evolved favourably with conservative treatment. EVAR allowed a very short delay of treatment of colorectal cancer after aneurysm repair, minimizing operative complications.

Impact of pharmacist interventions on rational prophylactic antibiotic use and cost saving in elective cesarean section.

PubMed

Wang, Jingwen; Dong, Mohan; Lu, Yang; Zhao, Xian; Li, Xin; Wen, Aidong

2015-08-01

To assess the impact of pharmacist interventions on rational use of prophylactic antibiotics and cost saving in elective cesarean section and the economic outcomes of implementing pharmacist interventions. A pre-to-post intervention design was applied to the practices of prophylactic antibiotic use in the department of gynecology and obstetrics in a Chinese tertiary hospital. Patients admitted during a 3-month period from June to August 2012 and during that from October to December 2012 undergoing elective cesarean section were assigned to the pre-intervention and the post-intervention group, respectively. Pharmacist interventions were performed in the post-intervention group, including obstetrician education, realtime monitoring of clinical records and making recommendations to obstetricians on prophylactic antibiotic prescription based on the criteria set at the beginning of the study. Data from the two groups were then compared to evaluate the outcomes of pharmacist interventions. Cost-outcome analysis was performed to determine the economic effect of implementing pharmacist interventions in preoperative antibiotic prophylaxis. Pharmacist interventions led to significant reductions in antibiotic usage cost/patient-day (p < 0.001), mean antibiotic cost (p < 0.001), mean total drug cost (p < 0.001), mean total hospitalization cost (p < 0.001), the duration of prophylaxis antibiotics (p < 0.001) and a significant increase by 19.29% in the percentage of cases adhering to all of the four criteria (p < 0.001). The ratio of the saving in antibiotic use to the cost of pharmacist time was 27.23 : 1 and the net cost benefit was $65,255.84. This study provides evidence that pharmacist interventions promoted rational use of prophylactic antibiotics and substantial cost saving in elective cesarean section.

Safety of low dose heparin in elective coronary angioplasty.

PubMed Central

Koch, K. T.; Piek, J. J.; de Winter, R. J.; David, G. K.; Mulder, K.; Tijssen, J. G.; Lie, K. I.

1997-01-01

OBJECTIVES: To evaluate the safety of a low dose of heparin in consecutive stable patients undergoing elective percutaneous transluminal coronary angioplasty (PTCA). DESIGN: Open prospective study in a single centre. PATIENTS: 1375 consecutive patients had elective PTCA (1952 lesions: type A 11%, B1 34%, B2 36%, and C 19%). There were no angiographic exclusion criteria. INTERVENTIONS: A bolus of 5000 IU heparin was used as the standard anticoagulation regimen during PTCA. The sheaths were removed immediately after successful completion of the procedure. Prolongation of heparin treatment was left to the operator's discretion. MAIN OUTCOME MEASURES: Procedural success was defined as < 50% residual stenosis without death from any cause, acute myocardial infarction, urgent coronary bypass surgery, or repeat angioplasty within 48 hours for acute recurrent ischaemia; the need for prolonged heparinisation; and the occurrence of puncture site complications. RESULTS: Procedural success without clinical events was achieved in 90% of patients. Mortality was 0.3%; coronary bypass surgery was performed in 1.7% of the procedures. The rate of myocardial infarction was 3.3%; repeat angioplasty within 48 hours was carried out in 0.7% of patients. A total of 89.1% of the patients were treated according to the protocol. Prolonged treatment with heparin was considered necessary in 123 patients (8.9%). Repeat angioplasty for abrupt closure was performed in two patients shortly after sheath removal and in two during prolonged heparinisation. Puncture site complications occurred in 2.1% of patients (low dose heparin 1.9% and prolonged heparinisation 4.9%). CONCLUSION: Elective PTCA can be safely performed using a low dose of heparin, with a negligible risk for subacute closure. Low dose heparin may reduce the incidence of puncture site complications, shorten hospitalisation, and enable out-patient angioplasty. PMID:9227294

Investigation of change in cardinal symptoms of chronic rhinosinusitis after surgical or ongoing medical management.

PubMed

DeConde, Adam S; Mace, Jess C; Alt, Jeremiah A; Soler, Zachary M; Orlandi, Richard R; Smith, Timothy L

2015-01-01

Chronic rhinosinusitis (CRS) has been defined as inflammation of the paranasal sinuses lasting at least 12 weeks with corresponding 2 or more "cardinal symptoms" that include: (1) nasal obstruction; (2) thick nasal discharge; (3) facial pain/pressure; and (4) reduction or loss of sense of smell. Although prior studies have investigated symptoms of CRS after sinus surgery, none have compared the outcomes of these specific symptoms to ongoing medical therapy. Patients with CRS were prospectively enrolled into a multi-institutional, comparative effectiveness, cohort study. Subjects elected either continued medical management or endoscopic sinus surgery (ESS). Baseline characteristics and objective clinical findings were collected. Cardinal symptoms of CRS were operationalized by 4 questions on the 22-item Sino-Nasal Outcome Test (SNOT-22). Symptom improvement was evaluated in subjects with at least 6-month follow-up. A total of 342 subjects were enrolled, with 69 (20.2%) electing continued medical management, whereas 273 (79.8%) elected ESS. Subjects electing surgical therapy were more likely to have a higher baseline aggregate SNOT-22 score (44.3 (18.9) vs 53.6 (18.8); p < 0.001). All subjects improved across all cardinal symptoms; however, subjects undergoing ESS were significantly more likely (p ≤ 0.013) to experience improvement in thick nasal discharge (odds ratio [OR] = 4.36), facial pain/pressure (OR = 3.56), and blockage/congestion of nose (OR = 2.76). Subjects with nasal polyposis were significantly more likely to report complete resolution of smell/taste following ESS compare to medical management (23.8% vs 4.0%; p = 0.026). Across a large population, surgical management is more effective at resolving the cardinal symptoms of CRS than ongoing medical management with the exception of sense of smell/taste. © 2014 ARS-AAOA, LLC.

Use of preimplantation genetic diagnosis and preimplantation genetic screening in the United States: a Society for Assisted Reproductive Technology Writing Group paper.

PubMed

Ginsburg, Elizabeth S; Baker, Valerie L; Racowsky, Catherine; Wantman, Ethan; Goldfarb, James; Stern, Judy E

2011-10-01

To comprehensively report Society for Assisted Reproductive Technology (SART) member program usage of preimplantation genetic testing (PGT), preimplantation genetic diagnosis (PGD) for diagnosis of specific conditions, and preimplantation genetic screening for aneuploidy (PGS). Retrospective study. United States SART cohort data. Women undergoing a PGT cycle in which at least one embryo underwent biopsy. PGT. PGT use, indications, and delivery rates. Of 190,260 fresh, nondonor assisted reproductive technology (ART) cycles reported to SART CORS in 2007-2008, 8,337 included PGT. Of 6,971 cycles with a defined indication, 1,382 cycles were for genetic diagnosis, 3,645 for aneuploidy screening (PGS), 527 for translocation, and 1,417 for elective sex election. Although the total number of fresh, autologous cycles increased by 3.6% from 2007 to 2008, the percentage of cycles with PGT decreased by 5.8% (4,293 in 2007 and 4,044 in 2008). As a percentage of fresh, nondonor ART cycles, use dropped from 4.6% (4,293/93,433) in 2007 to 4.2% (4,044/96,827) in 2008. The primary indication for PGT was PGS: cycles performed for this indication decreased (-8.0%). PGD use for single-gene defects (+3.2%), elective sex selection (+5.3%), and translocation analysis (+0.5%) increased. PGT usage varied significantly by geographical region. PGT usage in the United States decreased between 2007 and 2008 owing to a decrease in PGS. Use of elective sex selection increased. High transfer cancellation rates correlated with reduced live-birth rates for some PGT indications. Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.

PubMed

Childers, Christopher P; Siletz, Anaar E; Singer, Emily S; Faltermeier, Claire; Hu, Q Lina; Ko, Clifford Y; Golladay, Gregory J; Kates, Stephen L; Wick, Elizabeth C; Maggard-Gibbons, Melinda

2018-01-01

Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery-a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/ Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

The influence of lunar phases and zodiac sign 'Leo' on perioperative complications and outcome in elective spine surgery.

PubMed

Joswig, Holger; Stienen, Martin N; Hock, Carolin; Hildebrandt, Gerhard; Surbeck, Werner

2016-06-01

Many people believe that the moon has an influence on daily life, and some even request elective surgery dates depending on the moon calendar. The aim of this study was to assess the influence of 'unfavorable' lunar or zodiac constellations on perioperative complications and outcome in elective surgery for degenerative disc disease. Retrospective database analysis including 924 patients. Using uni- and multivariate logistic regression, the likelihood for intraoperative complications and re-do surgeries as well as the clinical outcomes at 4 weeks was analyzed for surgeries performed during the waxing moon, full moon, and dates when the moon passed through the zodiac sign 'Leo.' In multivariate analysis, patients operated on during the waxing moon were 1.54 times as likely as patients who were operated on during the waning moon to suffer from an intraoperative complication (OR 1.54, 95 % CI 1.07-2.21, p = 0.019). In contrast, there was a trend toward fewer re-do surgeries for surgery during the waxing moon (OR 0.51, 95 % CI 0.23-1.16, p = 0.109), while the 4-week responder status was similar (OR 0.73, 95 % CI 0.47-1.14, p = 0.169). A full moon and the zodiac sign Leo did not increase the likelihood for complications, re-do surgeries or unfavorable outcomes. We found no influence of 'unfavorable' lunar or zodiac constellations on the 4-week responder status or the revision rate that would justify a moon calendar-based selection approach to elective spine surgery dates. However, the fact that patients undergoing surgery during the waxing moon were more likely to suffer from an intraoperative complication is a surprising curiosity and defies our ability to find a rational explanation.

Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: prospective randomized trial.

PubMed

Sadahiro, Sotaro; Suzuki, Toshiyuki; Tanaka, Akira; Okada, Kazutake; Kamata, Hiroko; Ozaki, Toru; Koga, Yasuhiro

2014-03-01

We have already reported that, for patients undergoing elective colon cancer operations, perioperative infection can be prevented by a single intravenous dose of an antibiotic given immediately beforehand if mechanical bowel preparation and the administration of oral antibiotics are implemented. Synbiotics has been reported to reduce the rate of infection in patients after pancreatic cancer operations. The effectiveness of oral antibiotics and probiotics in preventing postoperative infection in elective colon cancer procedures was examined in a randomized controlled trial. Three hundred ten patients with colon cancer randomly were assigned to one of three groups. All patients underwent mechanical bowel preparation and received a single intravenous dose of flomoxef immediately before operation. Probiotics were administered in Group A; oral antibiotics were administered in Group B; and neither probiotics nor oral antibiotics were administered in Group C. Stool samples were collected 9 and 2 days before and 7 and 14 days after the procedure. Clostridium difficile toxin and the number of bacteria in the intestine were determined. The rates of incisional surgical-site infection were 18.0%, 6.1%, and 17.9% in Groups A, B, and C, and the rates of leakage were 12.0%, 1.0%, and 7.4% in Groups A, B, and C, respectively, indicating that both rates were lesser in Group B than in Groups A and C (P = .014 and P = .004, respectively). The detection rates of C. difficile toxin were not changed among the three groups. We recommend oral antibiotics, rather than probiotics, as bowel preparation for elective colon cancer procedures to prevent surgical-site infections. Copyright © 2014 Mosby, Inc. All rights reserved.

The sociocultural effects on orthopedic surgeries in Taiwan

PubMed Central

Chiu, Shin-Lin; Chu, Chiao-Lee; Lan, Shou-Jen; Chen, Chiu-Liang

2018-01-01

Various sociocultural factors affect healthcare-seeking behaviors. In Taiwanese society, superstitions and lunar festivals play important roles in people’s lives. We investigated the impact of “Ghost Month” (the 7th lunar month) and Chinese New Year (the 12th lunar month and the 1st lunar month of the following year) on the number of elective surgeries and emergent surgeries in Taiwan. The number of total knee replacement (TKR) surgeries and proximal femur fracture (PFF) surgeries in each lunar month from 2000 to 2011 were extracted from the Taiwan National Health Insurance Database, a computerized and population-based database. Patients were then sorted by location of residence or gender. The average number of TKR surgeries performed was significantly lower during the 1st, 7th, and 12th lunar months in urban areas, whereas in rural areas this trend was only evident in the 7th and 12th lunar months. There was however, no significant difference in the average number of PFF surgeries in each lunar month except for an increase seen in the 1st lunar month in rural patients (p<0.05). When sorted by gender, the average number of TKR surgeries was significantly decreased in the 7th and 12th lunar months in male patients, and decreased in the 1st, 7th, and 12th lunar months in female patients. In contrast, there was no difference in the average numbers of PFF surgeries in the 7th and 12th lunar months either in male or female patients. We proposed that the timing of elective surgeries such as TKR might be influenced by Ghost Month and Chinese New Year; however, emergent PFF surgeries were not significantly influenced by sociocultural beliefs and taboos in Taiwan. PMID:29596539

Potential cost saving of Epoetin alfa in elective hip or knee surgery due to reduction in blood transfusions and their side effects: a discrete-event simulation model.

PubMed

Tomeczkowski, Jörg; Stern, Sean; Müller, Alfred; von Heymann, Christian

2013-01-01

Transfusion of allogeneic blood is still common in orthopedic surgery. This analysis evaluates from the perspective of a German hospital the potential cost savings of Epoetin alfa (EPO) compared to predonated autologous blood transfusions or to a nobloodconservationstrategy (allogeneic blood transfusion strategy)during elective hip and knee replacement surgery. Individual patients (N = 50,000) were simulated based on data from controlled trials, the German DRG institute (InEK) and various publications and entered into a stochastic model (Monte-Carlo) of three treatment arms: EPO, preoperative autologous donation and nobloodconservationstrategy. All three strategies lead to a different risk for an allogeneic blood transfusion. The model focused on the costs and events of the three different procedures. The costs were obtained from clinical trial databases, the German DRG system, patient records and medical publications: transfusion (allogeneic red blood cells: €320/unit and autologous red blood cells: €250/unit), pneumonia treatment (€5,000), and length of stay (€300/day). Probabilistic sensitivity analyses were performed to determine which factors had an influence on the model's clinical and cost outcomes. At acquisition costs of €200/40,000 IU EPO is cost saving compared to autologous blood donation, and cost-effective compared to a nobloodconservationstrategy. The results were most sensitive to the cost of EPO, blood units and hospital days. EPO might become an attractive blood conservation strategy for anemic patients at reasonable costs due to the reduction in allogeneic blood transfusions, in the modeled incidence of transfusion-associated pneumonia andthe prolongedlength of stay.

Preoperative carbohydrate treatment for enhancing recovery after elective surgery.

PubMed

Smith, Mark D; McCall, John; Plank, Lindsay; Herbison, G Peter; Soop, Mattias; Nygren, Jonas

2014-08-14

Preoperative carbohydrate treatments have been widely adopted as part of enhanced recovery after surgery (ERAS) or fast-track surgery protocols. Although fast-track surgery protocols have been widely investigated and have been shown to be associated with improved postoperative outcomes, some individual constituents of these protocols, including preoperative carbohydrate treatment, have not been subject to such robust analysis. To assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing elective surgery. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 3), MEDLINE (January 1946 to March 2014), EMBASE (January 1947 to March 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1980 to March 2014) and Web of Science (January 1900 to March 2014) databases. We did not apply language restrictions in the literature search. We searched reference lists of relevant articles and contacted known authors in the field to identify unpublished data. We included all randomized controlled trials of preoperative carbohydrate treatment compared with placebo or traditional preoperative fasting in adult study participants undergoing elective surgery. Treatment groups needed to receive at least 45 g of carbohydrates within four hours before surgery or anaesthesia start time. Data were abstracted independently by at least two review authors, with discrepancies resolved by consensus. Data were abstracted and documented pro forma and were entered into RevMan 5.2 for analysis. Quality assessment was performed independently by two review authors according to the standard methodological procedures expected by The Cochrane Collaboration. When available data were insufficient for quality assessment or data analysis, trial authors were contacted to request needed information. We collected trial data on complication rates and aspiration pneumonitis. We included 27 trials involving 1976 participants Trials were conducted in Europe, China, Brazil, Canada and New Zealand and involved patients undergoing elective abdominal surgery (18), orthopaedic surgery (4), cardiac surgery (4) and thyroidectomy (1). Twelve studies were limited to participants with an American Society of Anaesthesiologists grade of I-II or I-III.A total of 17 trials contained at least one domain judged to be at high risk of bias, and only two studies were judged to be at low risk of bias across all domains. Of greatest concern was the risk of bias associated with inadequate blinding, as most of the outcomes assessed by this review were subjective. Only six trials were judged to be at low risk of bias because of blinding.In 19 trials including 1351 participants, preoperative carbohydrate treatment was associated with shortened length of hospital stay compared with placebo or fasting (by 0.30 days; 95% confidence interval (CI) 0.56 to 0.04; very low-quality evidence). No significant effect on length of stay was noted when preoperative carbohydrate treatment was compared with placebo (14 trials including 867 participants; mean difference -0.13 days; 95% CI -0.38 to 0.12). Based on two trials including 86 participants, preoperative carbohydrate treatment was also associated with shortened time to passage of flatus when compared with placebo or fasting (by 0.39 days; 95% CI 0.70 to 0.07), as well as increased postoperative peripheral insulin sensitivity (three trials including 41 participants; mean increase in glucose infusion rate measured by hyperinsulinaemic euglycaemic clamp of 0.76 mg/kg/min; 95% CI 0.24 to 1.29; high-quality evidence).As reported by 14 trials involving 913 participants, preoperative carbohydrate treatment was not associated with an increase or a decrease in the risk of postoperative complications compared with placebo or fasting (risk ratio of complications 0.98, 95% CI 0.86 to 1.11; low-quality evidence). Aspiration pneumonitis was not reported in any patients, regardless of treatment group allocation. Preoperative carbohydrate treatment was associated with a small reduction in length of hospital stay when compared with placebo or fasting in adult patients undergoing elective surgery. It was found that preoperative carbohydrate treatment did not increase or decrease postoperative complication rates when compared with placebo or fasting. Lack of adequate blinding in many studies may have contributed to observed treatment effects for these subjective outcomes, which are subject to possible biases.

An Assessment of the Safety of an Orthopedic Specialty Hospital: A 5-Year Experience.

PubMed

Padegimas, Eric M; Ramsey, Matthew L; Austin, Matthew; Parvizi, Javad; Williams, Gerald R; Doyle, Kelly; West, Michael E; Rothman, Richard H; Vaccaro, Alexander R; Namdari, Surena

2017-07-01

One of the goals of orthopedic specialty hospitals is to provide safe and efficient care to medically optimized patients. The authors' orthopedic specialty hospital is a physician-owned, 24-bed facility that accommodates a multispecialty orthopedic practice in the areas of spine, hip and knee arthroplasty, shoulder and elbow, sports, foot and ankle, and hand surgery. The purpose of this study was to examine the first 5 years of an institutional experience with an orthopedic specialty hospital and to determine if any procedures were at increased risk of postoperative transfer. When higher-level emergency treatment was required, patients were appropriately and expeditiously transferred and treated at an acute care facility. Length of stay compared favorably with that in traditional acute care hospitals. The specialty hospital may be an appropriate model for delivery of care to medically screened patients in the United States. [Orthopedics. 2017; 40(4):223-229.]. Copyright 2017, SLACK Incorporated.

Behavioral alterations and severity of pain in cats recovering at home following elective ovariohysterectomy or castration.

PubMed

Väisänen, Misse A-M; Tuomikoski, Suvi K; Vainio, Outi M

2007-07-15

To identify behavioral alterations in client-owned cats recovering at home following elective ovariohysterectomy or castration and determine owner perceptions regarding severity of postoperative pain. Cohort study. Animals-145 cats undergoing elective ovariohysterectomy (n = 80) or castration (65) at 4 veterinary clinics in Finland. Owners were asked to complete a questionnaire on their cats' behavior during the 3 days after surgery. Owners were also asked to indicate their perceptions of the severity of postoperative pain during these days by use of a 100-mm visual analog scale. Owners consistently indicated that there were changes in their cats' behavior, with the most commonly reported alterations being a decrease in overall activity level, an increase in the amount of time spent sleeping, a decrease in playfulness, and altered way of movement. Changes (ie, either an increase or decrease) in aggressive behavior were rare. Median pain score the day of surgery was 15.0 mm for male cats and 25.0 mm for female cats. Behavior score was significantly associated with day of observation, type of surgery (ovariohysterectomy vs castration), owner-assigned pain score, and veterinary clinic. Results suggested that behavioral alterations can be detected for several days after surgery in cats recovering at home following ovariohysterectomy or castration and emphasized owner concerns about the existence of postoperative pain.

C-reactive protein and procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery: pilot study in 100 patients.

PubMed

Lagoutte, N; Facy, O; Ravoire, A; Chalumeau, C; Jonval, L; Rat, P; Ortega-Deballon, P

2012-10-01

Anastomotic leakage is the most important complication after colorectal surgery. Its prognosis depends on its early diagnosis. C-reactive protein (CRP) has already shown its usefulness for the early detection of anastomotic leaks. Procalcitonin (PCT) is widely used in intensive care units and is more expensive, but its usefulness in the postoperative period of digestive surgery is not well established. Between May 2010 and June 2011, 100 patients undergoing elective colorectal surgery were prospectively included in a database. CRP and PCT were measured before surgery and daily until postoperative day 4. All intraabdominal infections were considered as anastomotic leaks, regardless of their clinical impact and their management. The kinetics of PCT and CRP were recorded, as well as their accuracy for the detection of anastomotic fistula. The incidence of fistula was 13% and the overall mortality rate was 2%. Both CRP and PCT were significantly higher in patients with leakage. Areas under the receiver-operating characteristics (ROC) for CRP were higher than those for PCT each day. The best accuracy was obtained for CRP on postoperative day 4 (areas under the ROC curve were 0.869 for CRP and 0.750 for PCT). Procalcitonin is neither earlier nor more accurate than CRP for the detection of anastomotic leakage after elective colorectal surgery. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Short-term versus long-term administration of single prophylactic antibiotic in elective gastric tumor surgery.

PubMed

Wang, Fang; Chen, Xin-Zu; Liu, Jie; Yang, Kun; Zhang, Bo; Chen, Zhi-Xin; Chen, Jia-Ping; Hu, Jian-Kun; Zhou, Zong-Guang; Mo, Xian-Min; Mo, Xian-Min

2012-09-01

To evaluate short-term versus long-term single prophylactic antibiotic for elective gastric tumor surgery. Patients in a single surgical team undergoing elective gastric tumor surgery were enrolled from November 2009 to December 2010. The included patients were aged from 18 to 70 years without conditions as severe comorbidity, preoperative infectious diseases, antibiotic administration 48 h before surgery, exploratory laparotomy only or combined colorectal resection, neoadjuvant chemotherapy, or steroid administration before surgery. The overall and infection-related postoperative complications and also economic outcomes were analyzed. The software SPSS 17.0 and TreeAge Pro 2007 were used for statistics. Patients (n=158 (45 vs. 113)) were enrolled in short-term and long-term groups. No death cases occurred. Overall postoperative complication rates were 8.9% and 8.0%, respectively (p=1.000). The rates of infection related complications were 8.9% and 4.4%, respectively (p=0.231). No surgical site infection (SSI) occurred in the short-term group, whereas SSI was 1.8% in the long-term group. Total hospitalization cost (THC) of short-term branch was 36,557RMB per patients and preferable against 39,523RMB of long-term branch. Incremental cost-effectiveness analysis showed there was a 10 times interval between the extra healthcare expenditure of benefit and harm. Short-term administration did not increase the risk of postoperative complications and was more cost-effective.

The effects of preoperative cardiology consultation prior to elective abdominal aortic aneurysm repair on patient morbidity.

PubMed

Boniakowski, Anna E; Davis, Frank M; Phillips, Amanda R; Robinson, Adina B; Coleman, Dawn M; Henke, Peter K

2017-08-01

Objectives The relationship between preoperative medical consultations and postoperative complications has not been extensively studied. Thus, we investigated the impact of preoperative consultation on postoperative morbidity following elective abdominal aortic aneurysm repair. Methods A retrospective review was conducted on 469 patients (mean age 72 years, 20% female) who underwent elective abdominal aortic aneurysm repair from June 2007 to July 2014. Data elements included detailed medical history, preoperative cardiology consultation, and postoperative complications. Primary outcomes included 30-day morbidity, consult-specific morbidity, and mortality. A bivariate probit regression model accounting for the endogeneity of binary preoperative medical consult and patient variability was estimated with a maximum likelihood function. Results Eighty patients had preoperative medical consults (85% cardiology); thus, our analysis focuses on the effect of cardiac-related preoperative consults. Hyperlipidemia, increased aneurysm size, and increased revised cardiac risk index increased likelihood of referral to cardiology preoperatively. Surgery type (endovascular versus open repair) was not significant in development of postoperative complications when controlling for revised cardiac risk index ( p = 0.295). After controlling for patient comorbidities, there was no difference in postoperative cardiac-related complications between patients who did and did not undergo cardiology consultation preoperatively ( p = 0.386). Conclusions When controlling for patient disease severity using revised cardiac risk index risk stratification, preoperative cardiology consultation is not associated with postoperative cardiac morbidity.

A meta-analysis of the efficacy of prophylactic alpha-blockade for the prevention of urinary retention following primary unilateral inguinal hernia repair.

PubMed

Clancy, C; Coffey, J C; O'Riordain, M G; Burke, J P

2017-03-14

Urinary retention following inguinal hernia surgery is common and is believed to be associated with adrenergic over-stimulation of the smooth muscle in the bladder neck and prostate. The efficacy of prophylactic alpha-blockade in the prevention of urinary retention following elective inguinal hernia repair in males is unknown. A comprehensive literature search was performed adhering to PRISMA guidelines. Each study was reviewed and data were extracted. Random-effects models were used to combine data. Five randomized studies describing 456 patients were identified. General or spinal anaesthetic were used. Prophylactic alpha-blockade decreases the risk of urinary retention requiring catheterisation following elective unilateral inguinal hernia repair compared to control groups (OR:0.179, 95% CI:0.043-0.747, p:0.018). Rates of urinary retention between treatment and control groups are reduced by 20.6%. No serious complications relating to alpha blockade occurred. Prophylactic alpha-blockade reduces urinary retention following elective inguinal hernia surgery under general or spinal anaesthetic. Urinary retention is common following inguinal hernia surgery. It is believed to be associated with adrenergic over-stimulation of the smooth muscle in the bladder neck and prostate. Prophylactic alpha-blockade reduces the rates of urinary retention by 20.6% in adult males undergoing general or spinal anaesthetic with minimal associated side effects. Copyright © 2017. Published by Elsevier Inc.

The case against primary endoscopic realignment of pelvic fracture urethral injuries

PubMed Central

Tausch, Timothy J.; Morey, Allen F.

2015-01-01

Objectives To review previous reports and present our experience on the outcomes after treating pelvic fracture urethral injuries (PFUIs) with primary endoscopic realignment (PER) vs. placing a suprapubic tube (SPT) with elective bulbomembranous anastomotic urethroplasty (BMAU). Methods We reviewed previous reports and identified articles that reported outcomes after PER vs. SPT and elective BMAU for patients who sustained PFUIs. We also present our institutional experience of treating patients who were referred after undergoing either form of treatment. Results The success rates for PER after PFUI are wide-ranging (11–86%), with variable definitions for a successful outcome. At our institution, for patients treated by SPT/BMAU, the mean time to a definitive resolution of stenosis was dramatically shorter (6 months, range 3–15) than for those treated with PER (122 months, range 4–574; P < 0.01). The vast majority of patients treated by PER required multiple endoscopic urethral interventions (median 4, range 1–36;P < 0.01) and/or had various other adverse events that were rare among the SPT/BMAU group (14/17, 82%, vs. 2/23, 9%;P < 0.05). Conclusion While PER occasionally results in urethral patency with no need for further intervention, the risk of delay in definitive treatment and the potential for adverse events have led to a preference for SPT and elective BMAU at our institution. PMID:26019972

Management of Complications Following Emergency and Elective Surgery for Diverticulitis.

PubMed

Holmer, Christoph; Kreis, Martin E

2015-04-01

The clinical spectrum of sigmoid diverticulitis (SD) varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications. Sigmoid colectomy with restoration of continuity has been the prevailing modality for treating acute and recurrent SD, and is often performed as a laparoscopy-assisted procedure. For elective sigmoid colectomy, the postoperative morbidity rate is 15-20% whereas morbidity rates reach up to 30% in patients who undergo emergency surgery for perforated SD. Some of the more common and serious surgical complications after sigmoid colectomy are anastomotic leaks and peritonitis, wound infections, small bowel obstruction, postoperative bleeding, and injuries to the urinary tract structures. Regarding the management of complications, it makes no difference whether the complication is a result of an emergency or an elective procedure. The present work gives an overview of the management of complications in the surgical treatment of SD based on the current literature. To achieve successful management, early diagnosis is mandatory in cases of deviation from the normal postoperative course. If diagnostic procedures fail to deliver a correlate for the clinical situation of the patient, re-laparotomy or re-laparoscopy still remain among the most important diagnostic and/or therapeutic principles in visceral surgery when a patient's clinical status deteriorates. The ability to recognize and successfully manage complications is a crucial part of the surgical treatment of diverticular disease and should be mastered by any surgeon qualified in this field.

A qualitative and quantitative needs assessment of pain management for hospitalized orthopedic patients.

PubMed

Cordts, Grace A; Grant, Marian S; Brandt, Lynsey E; Mears, Simon C

2011-08-08

Despite advances in pain management, little formal teaching is given to practitioners and nurses in its use for postoperative orthopedic patients. The goal of our study was to determine the educational needs for orthopedic pain management of our residents, nurses, and physical therapists using a quantitative and qualitative assessment. The needs analysis was conducted in a 10-bed orthopedic unit at a teaching hospital and included a survey given to 20 orthopedic residents, 9 nurses, and 6 physical therapists, followed by focus groups addressing barriers to pain control and knowledge of pain management. Key challenges for nurses included not always having breakthrough pain medication orders and the gap in pain management between cessation of patient-controlled analgesia and ordering and administering oral medications. Key challenges for orthopedic residents included treating pain in patients with a history of substance abuse, assessing pain, and determining when to use long-acting vs short-acting opioids. Focus group assessments revealed a lack of training in pain management and the need for better coordination of care between nurses and practitioners and improved education about special needs groups (the elderly and those with substance abuse issues). This needs assessment showed that orthopedic residents and nurses receive little formal education on pain management, despite having to address pain on a daily basis. This information will be used to develop an educational program to improve pain management for postoperative orthopedic patients. An integrated educational program with orthopedic residents, nurses, and physical therapists would promote understanding of issues for each discipline. Copyright 2011, SLACK Incorporated.

Assessing the evolution of scientific publications in orthopedics journals from mainland China, Hong Kong, and Taiwan: a 12-year survey of the literature.

PubMed

Jiang, Hua; Nong, Bingjin; Yang, Lijing; Zong, Shaohui; Zhan, Xinli; Wei, Qingjun; Xiao, Zengming

2016-06-17

In China, the field of orthopedics has experienced significant growth over the past 12 years. However, the recent status of research on orthopedics among individuals in mainland China, Hong Kong, and Taiwan is unknown. In this study, we investigated characteristics and trends of orthopedics publications from these three regions. Between 2003 and 2014, all articles published in 63 orthopedics journals originating from mainland China, Hong Kong, and Taiwan were identified via Science Citation Index Expanded (SCIE) database. A survey was conducted to systematically analyze the published orthopedics articles from the three regions according to the numbers of articles, study design, impact factors (IFs), citations, most prolific authors, and institutions. Additionally, we evaluated global trends in orthopedics publications, and ranked top 10 countries in terms of the total number of published articles over 12 years and the number of published articles per year. A total number of 123,317 articles were published in the 63 orthopedics journals between 2003 and 2014. The worldwide number of annually published orthopedics articles tended to increase during the study period. The total number of orthopedics publications from the three regions, especially in mainland China, increased markedly from 2003 to 2014. The annual number of orthopedics articles from mainland China increased from 6 in 2003 to 813 in 2014, Hong Kong increased from 32 in 2003 to 71 in 2014, and Taiwan increased from 68 in 2003 to 168 in 2014. For accumulated IFs and total citations of articles, mainland China ranked the first place, followed by Taiwan and Hong Kong. However, publications from Taiwan had the highest average citations per article, and publications from Hong Kong had the highest average IFs. Among the top 10 most prolific authors and institutions, 4 authors and 4 institutions were from Taiwan, 3 authors and 4 institutions were from mainland China, and 3 authors and 2 institutions were from Hong Kong. The quantity of articles published in international orthopedics journals from mainland China presented a remarkable upward trend during the past 12 years. Given the relative size of the populations, it should be emphasized that mainland China still has a long way to go to achieve the academic performance of Hong Kong and Taiwan.

[Protocol for peripheral parenteral nutrition management ready to use in surgical patients].

PubMed

Pinzón Espitia, Olga Lucia; Varón Vega, Martha Liliana

2014-10-03

Patients undergoing elective surgery, require a comprehensive clinical treatment that tends to maintain or prevent deterioration of nutritional status and promote clinical outcomes, and in turn improve the safety of parenteral nutrition therapy through optimization of technology, as a option aimed at minimizing risk and lower operating costs in institutions providing health services. To review the literature in order to study the requirements and recommendations of peripheral parenteral nutritional support and / or complementary ready to use in people undergoing surgery. Data synthesis after reviewing the relevant literature, to allow the protocol design. The search was conducted in the following databases: PubMed, Medline, Embase and ScienceDirect. Peripheral parenteral nutrition is a ready to use alternative nutritional support that improves the contribution Protein-Energy and demonstrate improvements in patient safety, decrease costs and increase patient satisfaction. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

Dexmedetomidine, Ketamine, and Midazolam for Oral Rehabilitation: A Case Report

PubMed Central

Kim, Bill W. S.; Peskin, Robert M.

2015-01-01

Intravenous sedation is frequently provided by anesthesiologists for phobic patients undergoing elective dental treatment in outpatient settings. Propofol is one of the most commonly used anesthetic agents that can result in apnea and respiratory depression, thereby posing potential difficulties with perioperative airway management. Dexmedetomidine has been utilized successfully in intravenous sedation for a wide variety of procedures and holds potential as an alternative to propofol in outpatient dental settings. However, as a single agent, it may not provide adequate depth of sedation and analgesia for oral rehabilitation. In this case report we demonstrate an effective alternative intravenous deep-sedation technique for an adult phobic patient undergoing oral rehabilitation utilizing 3 agents in combination: dexmedetomidine, ketamine, and midazolam. This combination of agents may be especially useful for those patients with a history of substance abuse, where administration of opioids may be undesirable or contraindicated. PMID:25849472

Dexmedetomidine, ketamine, and midazolam for oral rehabilitation: a case report.

PubMed

Kim, Bill W S; Peskin, Robert M

2015-01-01

Intravenous sedation is frequently provided by anesthesiologists for phobic patients undergoing elective dental treatment in outpatient settings. Propofol is one of the most commonly used anesthetic agents that can result in apnea and respiratory depression, thereby posing potential difficulties with perioperative airway management. Dexmedetomidine has been utilized successfully in intravenous sedation for a wide variety of procedures and holds potential as an alternative to propofol in outpatient dental settings. However, as a single agent, it may not provide adequate depth of sedation and analgesia for oral rehabilitation. In this case report we demonstrate an effective alternative intravenous deep-sedation technique for an adult phobic patient undergoing oral rehabilitation utilizing 3 agents in combination: dexmedetomidine, ketamine, and midazolam. This combination of agents may be especially useful for those patients with a history of substance abuse, where administration of opioids may be undesirable or contraindicated.

The Effects of Preoperative Volume Replacement in Diabetic Patients Undergoing Coronary Artery Bypass Grafting Surgery: Protocol for a Randomized Controlled Trial (VeRDiCT Trial).

PubMed

Clout, Madeleine; Harris, Tracy; Rogers, Chris; Culliford, Lucy; Taylor, Jodi; Angelini, Gianni; Narayan, Pradeep; Reeves, Barnaby; Hillier, James; Ashton, Kate; Sarkar, Kunal; Ascione, Raimondo

2017-06-19

Diabetes mellitus is a major risk factor for prolonged hospital stays, renal failure, and mortality in patients having coronary artery bypass grafting (CABG). Complications pose a serious threat to patients and prolong intensive care and hospital stays. Low glomerular filtration rate (GFR) due to existing renal impairment or volume depletion may exacerbate acute renal impairment/failure in these patients. Preoperative volume replacement therapy (VRT) is reported to increase the GFR and we hypothesize that VRT will reduce renal impairment and related complications in diabetic patients. The objective of this study is to establish the efficacy of preoperative VRT in reducing postoperative complications in diabetic patients undergoing CABG surgery. Time to "fit for discharge", incidence of postoperative renal failure, cardiac injury, inflammation, and other health outcomes will be investigated. In this open parallel group randomized controlled trial, 170 diabetic patients undergoing elective or urgent CABG surgery received 1 mL/kg/hour of Hartmann's solution for 12 consecutive hours prior to surgery, versus routine care. The primary outcome was time until participants were "fit for discharge", which is defined as presence of: normal temperature, pulse, and respiration; normal oxygen saturation on air; normal bowel function; and physical mobility. Secondary outcomes included: incidence of renal failure; markers of renal function, inflammation, and cardiac damage; operative morbidity; intensive care stay; patient-assessed outcome, including the Coronary Revascularization Outcome Questionnaire; and use of hospital resources. Recruitment started in July 2010. Enrolment for the study was completed in July 2014. Data analysis commenced in December 2016. Study results will be submitted for publication in the summer of 2017. VRT is a relatively easy treatment to administer in patients undergoing surgical procedures who are at risk of renal failure. This experimental protocol will increase scientific and clinical knowledge of VRT in diabetic patients undergoing elective or urgent CABG surgery. Findings supporting the efficacy of this intervention could easily be implemented in the health care system. International Standard Randomized Controlled Trial Number (ISRCTN): 02159606; http://www.controlled-trials.com/ISRCTN02159606 (Archived by WebCite at http://www.webcitation.org/6rDkSSkkK). ©Madeleine Clout, Tracy Harris, Chris Rogers, Lucy Culliford, Jodi Taylor, Gianni Angelini, Pradeep Narayan, Barnaby Reeves, James Hillier, Kate Ashton, Kunal Sarkar, Raimondo Ascione. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 19.06.2017.

Influence of podiatry on orthopedic surgery at a level I trauma center.

PubMed

Jakoi, Andre M; Old, Andrew B; O'Neill, Craig A; Stein, Benjamin E; Stander, Eric P; Rosenblatt, Joseph; Herman, Martin J

2014-06-01

Level I trauma centers frequently see trauma at or below the ankle, which requires consultation with the orthopedic surgery department. However, as podiatry programs begin to firmly establish themselves in more Level I trauma centers, their consultations increase, ultimately taking those once seen by orthopedic surgery. A review of the literature demonstrates that this paradigm shift has yet to be discussed. The purpose of this study was to determine how many, if any, lower extremity fracture consultations a newly developed podiatry program would take from the orthopedic surgery department. A retrospective review was performed of emergency department records from January 2007 to December 2011. Seventeen different emergency department diagnoses were used to search the database. Ultimately, each patient's emergency department course was researched. Several trends were noted. First, if trauma surgery was involved, only the orthopedic surgery department was consulted for any injuries at or below the ankle. Second, the emergency department tended to consult the podiatry program only between the hours of 8 am and 6 pm. Third, as the podiatry program became more established, their number of consultations increased yearly, and, coincidentally, the orthopedic surgery department's consultations decreased. Finally, high-energy traumas involved only the orthopedic surgery department. Whether the orthopedic surgery department or podiatry program is consulted regarding trauma surgery is likely hospital dependent. Copyright 2014, SLACK Incorporated.

Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis.

PubMed

Watt, Jennifer; Tricco, Andrea C; Talbot-Hamon, Catherine; Pham, Ba'; Rios, Patricia; Grudniewicz, Agnes; Wong, Camilla; Sinclair, Douglas; Straus, Sharon E

2018-04-01

Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery. Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates. Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3-23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2-17.9), frailty (OR 4.1, 95% CI 1.4-11.7), cognitive impairment (OR 2.7, 95% CI 1.9-3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6-2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3-2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4-3.6) and smoking status (OR 1.8 95% CI 1.3-2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52-0.91). Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care.

Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery

PubMed Central

Rollins, Katie E.; Lobo, Dileep N.

2016-01-01

Objectives: To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols. Methods: Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality. Results: A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66–0.89, P = 0.0007), hospital length of stay (LOS; mean difference −1.55 days, 95% CI −2.73 to −0.36, P = 0.01), intensive care LOS (mean difference −0.63 days, 95% CI −1.18 to −0.09, P = 0.02), and time to passage of feces (mean difference −0.90 days, 95% CI −1.48 to −0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference −0.63 days, 95% CI −0.94 to −0.32, P < 0.0001) and time to passage of feces (mean difference −1.09 days, 95% CI −2.03 to −0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to −0.84, P = 0.0002) and total hospital LOS (mean difference −2.14, 95% CI −4.15 to −0.13, P = 0.04). Conclusions: GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting. PMID:26445470

Protocol for the PREHAB study—Pre-operative Rehabilitation for reduction of Hospitalization After coronary Bypass and valvular surgery: a randomised controlled trial

PubMed Central

Stammers, Andrew N; Kehler, D Scott; Afilalo, Jonathan; Avery, Lorraine J; Bagshaw, Sean M; Grocott, Hilary P; Légaré, Jean-Francois; Logsetty, Sarvesh; Metge, Colleen; Nguyen, Thang; Rockwood, Kenneth; Sareen, Jitender; Sawatzky, Jo-Ann; Tangri, Navdeep; Giacomantonio, Nicholas; Hassan, Ansar; Duhamel, Todd A; Arora, Rakesh C

2015-01-01

Introduction Frailty is a geriatric syndrome characterised by reductions in muscle mass, strength, endurance and activity level. The frailty syndrome, prevalent in 25–50% of patients undergoing cardiac surgery, is associated with increased rates of mortality and major morbidity as well as function decline postoperatively. This trial will compare a preoperative, interdisciplinary exercise and health promotion intervention to current standard of care (StanC) for elective coronary artery bypass and valvular surgery patients for the purpose of determining if the intervention improves 3-month and 12-month clinical outcomes among a population of frail patients waiting for elective cardiac surgery. Methods and analysis This is a multicentre, randomised, open end point, controlled trial using assessor blinding and intent-to-treat analysis. Two-hundred and forty-four elective cardiac surgical patients will be recruited and randomised to receive either StanC or StanC plus an 8-week exercise and education intervention at a certified medical fitness facility. Patients will attend two weekly sessions and aerobic exercise will be prescribed at 40–60% of heart rate reserve. Data collection will occur at baseline, 1–2 weeks preoperatively, and at 3 and 12 months postoperatively. The primary outcome of the trial will be the proportion of patients requiring a hospital length of stay greater than 7 days. Potential impact of study The healthcare team is faced with an increasingly complex older adult patient population. As such, this trial aims to provide novel evidence supporting a health intervention to ensure that frail, older adult patients thrive after undergoing cardiac surgery. Ethics and dissemination Trial results will be published in peer-reviewed journals, and presented at national and international scientific meetings. The University of Manitoba Health Research Ethics Board has approved the study protocol V.1.3, dated 11 August 2014 (H2014:208). Trial registration number The trial has been registered on ClinicalTrials.gov, a registry and results database of privately and publicly funded clinical studies (NCT02219815). PMID:25753362

Preoperative frailty assessment predicts loss of independence after vascular surgery.

PubMed

Donald, Graham W; Ghaffarian, Amir A; Isaac, Farid; Kraiss, Larry W; Griffin, Claire L; Smith, Brigitte K; Sarfati, Mark R; Beckstrom, Julie L; Brooke, Benjamin S

2018-05-14

Frailty, a clinical syndrome associated with loss of metabolic reserves, is prevalent among patients who present to vascular surgery clinics for evaluation. The Clinical Frailty Scale (CFS) is a rapid assessment method shown to be highly specific for identifying frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to predict loss of independence after major vascular procedures. We identified all patients living independently at home who were prospectively assessed using the CFS before undergoing an elective major vascular surgery procedure (admitted for >24 hours) at an academic medical center between December 2015 and December 2017. Patient- and procedure-level clinical data were obtained from our institutional Vascular Quality Initiative registry database. The composite outcome of discharge to a nonhome location or 30-day mortality was evaluated using bivariate and multivariate regression models. A total of 134 independent patients were assessed using the CFS before they underwent elective open abdominal aortic aneurysm repair (8%), endovascular aneurysm repair (26%), thoracic endovascular aortic repair (6%), suprainguinal bypass (6%), infrainguinal bypass (16%), carotid endarterectomy (19%), or peripheral vascular intervention (20%). Among 39 (29%) individuals categorized as being frail using the CFS, there was no significant difference in age or ASA physical status compared with nonfrail patients. However, frail patients were significantly more likely to need mobility assistance after surgery (62% frail vs 22% nonfrail; P < .01) and to be discharged to a nonhome location (22% frail vs 6% nonfrail; P = .01) or to die within 30 days after surgery (8% frail vs 0% nonfrail; P < .01). Preoperative frailty was associated with a >12-fold higher risk (odds ratio, 12.1; 95% confidence interval, 2.17-66.96; P < .01) of 30-day mortality or loss of independence, independent of the vascular procedure undertaken. The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective major vascular surgery and can be used to predict likelihood of requiring discharge to a nursing facility or death after surgery. The identification of frail patients before major surgery can help manage postoperative expectations and optimize transitions of care. Published by Elsevier Inc.

Characteristics and trends of orthopedic publications between 2000 and 2009.

PubMed

Lee, Kyoung Min; Ryu, Mi Sun; Chung, Chin Youb; Choi, In Ho; Kwon, Dae Gyu; Kim, Tae Won; Sung, Ki Hyuk; Seo, Sang Gyo; Park, Moon Seok

2011-09-01

This study was undertaken to investigate the trends of orthopedic publications during the last decade, and to document the country of origin, journal, funding source, and language of contribution using PubMed. Orthopedic articles published between 2000 and 2009 were retrieved from PubMed using the following search terms: "orthopaedic[Affiliation] AND ("2000/1/1"[PDAT]: "2009/12/31"[PDAT])" and "orthopedic[Affiliation] AND ("2000/1/1"[PDAT]: "2009/12/31"[PDAT])." The articles were downloaded in XML file format, which contained the following information: article title, author names, journal names, publication dates, article types, languages, authors' affiliations and funding sources. These information was extracted, sorted, and rearranged using the database's management software. We investigated the annual number of published orthopedic articles worldwide and the annual rate of increase. Furthermore, the country of publication origin, journal, funding source, and language of contribution were also investigated. A total of 46,322 orthopedic articles were published and registered in PubMed in the last 10 years. The worldwide number of published orthopedic articles increased from 2,889 in 2000 to 6,909 in 2009, showing an annual increase of 384.6 articles, or an annualized compound rate of 10.2%. The United States ranked highest in the number of published orthopedic articles, followed by Japan, the United Kingdom, Germany, and the Republic of Korea. Among the orthopedic articles published worldwide during the last 10 years, 37.9% pertained studies performed in the United States. Fifty-seven point three percent (57.3%) of articles were published in journals established in the United States. Among the published orthopaedic articles, 4,747 articles (10.2%) disclosed financial support by research funds, of which 4,688 (98.8%) articles utilized research funds from the United States. Most articles were published in English (97.2%, 45,030 articles). The number of published orthopedic articles has been increasing over the last decade. The number of orthopedic articles, journals publication, and funding sources were dominated by research conducted in the United States, while share and growth of Asian countries including Japan, the Republic of Korea, and China were notable.

Characteristics and Trends of Orthopedic Publications between 2000 and 2009

PubMed Central

Lee, Kyoung Min; Ryu, Mi Sun; Chung, Chin Youb; Choi, In Ho; Kwon, Dae Gyu; Kim, Tae Won; Sung, Ki Hyuk; Seo, Sang Gyo

2011-01-01

Background This study was undertaken to investigate the trends of orthopedic publications during the last decade, and to document the country of origin, journal, funding source, and language of contribution using PubMed. Methods Orthopedic articles published between 2000 and 2009 were retrieved from PubMed using the following search terms: "orthopaedic[Affiliation] AND ("2000/1/1"[PDAT]: "2009/12/31"[PDAT])" and "orthopedic[Affiliation] AND ("2000/1/1"[PDAT]: "2009/12/31"[PDAT])." The articles were downloaded in XML file format, which contained the following information: article title, author names, journal names, publication dates, article types, languages, authors' affiliations and funding sources. These information was extracted, sorted, and rearranged using the database's management software. We investigated the annual number of published orthopedic articles worldwide and the annual rate of increase. Furthermore, the country of publication origin, journal, funding source, and language of contribution were also investigated. Results A total of 46,322 orthopedic articles were published and registered in PubMed in the last 10 years. The worldwide number of published orthopedic articles increased from 2,889 in 2000 to 6,909 in 2009, showing an annual increase of 384.6 articles, or an annualized compound rate of 10.2%. The United States ranked highest in the number of published orthopedic articles, followed by Japan, the United Kingdom, Germany, and the Republic of Korea. Among the orthopedic articles published worldwide during the last 10 years, 37.9% pertained studies performed in the United States. Fifty-seven point three percent (57.3%) of articles were published in journals established in the United States. Among the published orthopaedic articles, 4,747 articles (10.2%) disclosed financial support by research funds, of which 4,688 (98.8%) articles utilized research funds from the United States. Most articles were published in English (97.2%, 45,030 articles). Conclusions The number of published orthopedic articles has been increasing over the last decade. The number of orthopedic articles, journals publication, and funding sources were dominated by research conducted in the United States, while share and growth of Asian countries including Japan, the Republic of Korea, and China were notable. PMID:21909470

Awareness campaign. Orthopedic Hospital of Oklahoma launches awareness campaign.

PubMed

2007-01-01

The Orthopedic Hospital of Oklahoma is a 25-bed inpatient and outpatient center with one focus: Orthopedics. To acquaint people with its services and build brand awareness to drive market share, the hospital launched a print campaign featuring actual patients.

A sample of Canadian orthopedic surgeons expressed willingness to participate in osteoporosis management for fragility fracture patients

PubMed Central

Bogoch, Earl R.; Snowden, Elizabeth

2008-01-01

Objective The orthopedic community is in a unique position to initiate and provide osteoporosis care in fragility fracture patients to prevent future hip fractures in a high-risk population. The attitudes and intentions of Canadian orthopedic surgeons in the domain of osteoporosis care are unknown. Our objective was to identify current attitudes and osteoporosis management practices and to determine their overall willingness to participate in osteoporosis care for fragility fracture patients. Methods A real-time interactive polling session was conducted at the 58th Annual Meeting of the Canadian Orthopaedic Association. Results Of the orthopedic surgeons who responded, 90.4% agreed that the current emphasis on osteoporosis in orthopedic practice is appropriate; 85.2% of surgeons indicated that they currently refer or personally investigate for osteoporosis, or both, in fragility fracture patients. Conclusion Most of the Canadian orthopedic surgeons sampled consider themselves to be currently engaged or ready to engage in osteoporosis care for fragility fracture patients. Focus should now shift from education and persuasion to program support through provision of resources and system modification that will enable Canadian orthopedic surgeons to effectively manage osteoporosis in their fracture patients. PMID:18248700

Orthopedic injuries associated with backyard trampoline use in children.

PubMed

Black, G Brian; Amadeo, Ryan

2003-06-01

Trampolining on an outdoor oval or circular trampoline is a popular activity for children but is associated with a number of orthopedic injuries, especially in children between the ages of 5 and 15 years. In this paper we review the orthopedic injuries in children associated with backyard trampoline use, through our experience with a series of children admitted to the Winnipeg Children's Hospital, the only tertiary care pediatric centre in Manitoba. We reviewed the charts, x-ray films and operative reports for 80 children under 16 years old (mean 9 yr, with 14 [18%] children between 2 and 4 yr) with an orthopedic injury sustained when using a trampoline in the backyard. We noted the mechanism of injury and type and severity of orthopedic injury sustained. Fifty-two (65%) children were injured on the trampoline mat, and 24 (30%) were injured when they were ejected from the trampoline. Sixty (75%) children sustained a fracture or fracture-dislocation. Forty-eight (80%) orthopedic injuries occurred in the upper extremity. No child died as a result of a trampoline injury. The use of the "backyard" trampoline by young children can cause significant orthopedic injury.

Orthopedic injuries associated with backyard trampoline use in children

PubMed Central

Black, G. Brian; Amadeo, Ryan

2003-01-01

Introduction Trampolining on an outdoor oval or circular trampoline is a popular activity for children but is associated with a number of orthopedic injuries, especially in children between the ages of 5 and 15 years. In this paper we review the orthopedic injuries in children associated with backyard trampoline use, through our experience with a series of children admitted to the Winnipeg Children's Hospital, the only tertiary care pediatric centre in Manitoba. Methods We reviewed the charts, x-ray films and operative reports for 80 children under 16 years old (mean 9 yr, with 14 [18%] children between 2 and 4 yr) with an orthopedic injury sustained when using a trampoline in the backyard. We noted the mechanism of injury and type and severity of orthopedic injury sustained. Results Fifty-two (65%) children were injured on the trampoline mat, and 24 (30%) were injured when they were ejected from the trampoline. Sixty (75%) children sustained a fracture or fracture-dislocation. Forty-eight (80%) orthopedic injuries occurred in the upper extremity. No child died as a result of a trampoline injury. Conclusion The use of the “backyard” trampoline by young children can cause significant orthopedic injury. PMID:12812242

Using Aerospace Technology To Design Orthopedic Implants

NASA Technical Reports Server (NTRS)

Saravanos, D. A.; Mraz, P. J.; Davy, D. T.

1996-01-01

Technology originally developed to optimize designs of composite-material aerospace structural components used to develop method for optimizing designs of orthopedic implants. Development effort focused on designing knee implants, long-term goal to develop method for optimizing designs of orthopedic implants in general.

21 CFR 888.1 - Scope.

Code of Federal Regulations, 2011 CFR

2011-04-01

... DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ORTHOPEDIC DEVICES General Provisions § 888.1 Scope. (a) This part sets forth the classification of orthopedic... to other devices, as required by § 807.87. (c) To avoid duplicative listings, an orthopedic device...

21 CFR 888.1 - Scope.

Code of Federal Regulations, 2013 CFR

2013-04-01

... DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ORTHOPEDIC DEVICES General Provisions § 888.1 Scope. (a) This part sets forth the classification of orthopedic... to other devices, as required by § 807.87. (c) To avoid duplicative listings, an orthopedic device...

21 CFR 888.1 - Scope.

Code of Federal Regulations, 2012 CFR

2012-04-01

... DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ORTHOPEDIC DEVICES General Provisions § 888.1 Scope. (a) This part sets forth the classification of orthopedic... to other devices, as required by § 807.87. (c) To avoid duplicative listings, an orthopedic device...

21 CFR 888.1 - Scope.

Code of Federal Regulations, 2014 CFR

2014-04-01

... DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ORTHOPEDIC DEVICES General Provisions § 888.1 Scope. (a) This part sets forth the classification of orthopedic... to other devices, as required by § 807.87. (c) To avoid duplicative listings, an orthopedic device...

38 CFR 3.810 - Clothing allowance.

Code of Federal Regulations, 2014 CFR

2014-07-01

... prosthetic or orthopedic appliance (including, but not limited to, a wheelchair) which tends to wear or tear... service-connected disability or disabilities, wears or uses one qualifying prosthetic or orthopedic... allowance for each prosthetic or orthopedic appliance (including, but not limited to, a wheelchair) or...

78 FR 17940 - Certain Computerized Orthopedic Surgical Devices, Software, Implants, and Components Thereof...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-25

..., Software, Implants, and Components Thereof; Notice of Receipt of Complaint; Solicitation of Comments... Certain Computerized Orthopedic Surgical Devices, Software, Implants, and Components Thereof, DN 2945; the... importation of certain computerized orthopedic surgical devices, software, implants, and components thereof...

Client counseling in orthopedic emergencies.

PubMed

Brackenridge, S S; Kirby, B M; Johnson, S W

1995-09-01

Important client communication issues associated with most orthopedic emergencies are addressed. Information on client communication and support, providing a prognosis, discussing economic concerns, discharge planning, euthanasia, and client grief is presented. The issue of animal abuse as a cause of orthopedic emergencies also is examined.

Pharmacokinetics and pharmacodynamics of rocuronium in young adult and elderly patients undergoing elective surgery.

PubMed

Varrique, Renan M; Lauretti, Gabriela R; Matsumoto, Julia A; Lanchote, Vera L; de Moraes, Natalia V

2016-11-01

To evaluate the impact of advanced age on rocuronium kinetic disposition in ASA I-III patients undergoing elective surgeries. Young adult (20-50 years, n = 15) and elderly patients (65-85 years, n = 14) submitted to surgery under general anaesthesia were investigated. All patients were induced with individual intravenous doses of midazolam, rocuronium, fentanyl and propofol. Rocuronium-induced neuromuscular block was monitored by train of four stimulations of the adductor muscle of the thumb on the ulnar nerve. The pharmacokinetic parameters were calculated by non-compartmental analysis. The relationship between rocuronium plasma concentration and the neuromuscular blockade was described by a sigmoidal Emax model. Elderly patients presented decreased Cl (2.1 ml/kg per min vs 2.8 ml/kg per min; P = 0.0123); increased AUC/dose (507.8 μg min/ml (mg/kg) vs 392.2 μg min/ml/(mg/kg); P = 0.0168) and reduced volume of distribution (285.4 ml/kg vs 435.6 ml/kg, P = 0.0434) compared to young adults. The concentrations required to achieve 50% of maximum neuromuscular block (EC50) were similar for young adult (338.8 ng/ml) and elderly (462.7 ng/ml) patients (P > 0.05). Elderly patients showed increased AUC/D and reduced total Cl compared to young adult patients due to the age-related reduced renal function. Differences in the PK-PD properties of rocuronium in elderly population are due to changes in drug disposition rather than to alterations in the sensitivity to the drug. © 2016 Royal Pharmaceutical Society.

Infection Rate in 1033 Elective Neurosurgical Procedures at a University Hospital in South China.

PubMed

Zhu, Hongwei; Liu, Xiyao; Wang, Zhanxiang

2017-09-01

Objective  Infection following surgery is a serious complication, especially in neurosurgery. The aim of the study is to report the change of incidence rates of infection in patients undergoing elective neurosurgical procedures at a university hospital in South China as well as the risk factors. Material and Methods  The medical records and postoperative courses for patients undergoing 1,033 neurosurgical procedures from 2008 to 2014 were reviewed retrospectively to determine the incidence of neurosurgical infection, the identity of the offending organisms, and the factors associated with infection. Results  A total of 33 patients (40 cases) experienced postoperative infection representing 3.19% of the study population. Twenty cases were incision infections (1.94%), and 20 were cranial/spinal infections (1.94%) including 15 intracranial infections and 5 intraspinal infections. The 2.4-fold greater incidence of postoperative infection in 2008 to 2010 was compared with that in 2011 to 2014 with perioperative antibiotic prophylaxis ( p <0.01). The neurosurgical procedure associated with the highest rate of infection was cranioplasty (6.85%); the lowest rate of infection was associated with functional neurosurgery (1.08%). The most common offending organism was Staphylococcus aureus (27.5%). Foreign body implantation, operative time > 4 hours, and cerebrospinal fluid (CSF) leak (13 infections in 158 patients; p <0.001) were risk factors for infections ( p <0.05). Conclusion  The neurosurgical infection rate is usually low with perioperative antibiotic prophylaxis even in developing countries. Less foreign body implantation, shorter operative times, and controlling CSF leak could reduce infection rates. Georg Thieme Verlag KG Stuttgart · New York.

The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review.

PubMed

de Almeida, Cesar Cimonari; Boone, M Dustin; Laviv, Yosef; Kasper, Burkhard S; Chen, Clark C; Kasper, Ekkehard M

2018-02-01

Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.

Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery.

PubMed

Breuer, Jan-P; von Dossow, Vera; von Heymann, Christian; Griesbach, Markus; von Schickfus, Michael; Mackh, Elise; Hacker, Cornelia; Elgeti, Ulrike; Konertz, Wolfgang; Wernecke, Klaus-D; Spies, Claudia D

2006-11-01

In this study we investigated the effects of preoperative oral carbohydrate administration on postoperative insulin resistance (PIR), gastric fluid volume, preoperative discomfort, and variables of organ dysfunction in ASA physical status III-IV patients undergoing elective cardiac surgery, including those with noninsulin-dependent Type-2 diabetes mellitus. Before surgery, 188 patients were randomized to receive a clear 12.5% carbohydrate drink (CHO), flavored water (placebo), or to fast overnight (control). CHO and placebo were treated in double-blind format and received 800 mL of the corresponding beverage in the evening and 400 mL 2 h before surgery. Patients were monitored from induction of general anesthesia until 24 h postoperatively. Exogenous insulin requirements to control blood glucose levels

Predictive Factors of Postoperative Pain and Postoperative Anxiety in Children Undergoing Elective Circumcision: A Prospective Cohort Study

PubMed Central

Tsamoudaki, Stella; Ntomi, Vasileia; Yiannopoulos, Ioannis; Christianakis, Efstratios; Pikoulis, Emmanuel

2015-01-01

Background Although circumcision for phimosis in children is a minor surgical procedure, it is followed by pain and carries the risk of increased postoperative anxiety. This study examined predictive factors of postoperative pain and anxiety in children undergoing circumcision. Methods We conducted a prospective cohort study of children scheduled for elective circumcision. Circumcision was performed applying one of the following surgical techniques: sutureless prepuceplasty (SP), preputial plasty technique (PP), and conventional circumcision (CC). Demographics and base-line clinical characteristics were collected, and assessment of the level of preoperative anxiety was performed. Subsequently, a statistical model was designed in order to examine predictive factors of postoperative pain and postoperative anxiety. Assessment of postoperative pain was performed using the Faces Pain Scale (FPS). The Post Hospitalization Behavior Questionnaire study was used to assess negative behavioral manifestations. Results A total of 301 children with a mean age of 7.56 ± 2.61 years were included in the study. Predictive factors of postoperative pain measured with the FPS included a) the type of surgical technique, b) the absence of siblings, and c) the presence of postoperative complications. Predictive factors of postoperative anxiety included a) the type of surgical technique, b) the level of education of mothers, c) the presence of preoperative anxiety, and d) a history of previous surgery. Conclusions Although our study was not without its limitations, it expands current knowledge by adding new predictive factors of postoperative pain and postoperative anxiety. Clearly, further randomized controlled studies are needed to confirm its results. PMID:26495079

How Useful are Orthopedic Surgery Residency Web Pages?

PubMed

Oladeji, Lasun O; Yu, Jonathan C; Oladeji, Afolayan K; Ponce, Brent A

2015-01-01

Medical students interested in orthopedic surgery residency positions frequently use the Internet as a modality to gather information about individual residency programs. Students often invest a painstaking amount of time and effort in determining programs that they are interested in, and the Internet is central to this process. Numerous studies have concluded that program websites are a valuable resource for residency and fellowship applicants. The purpose of the present study was to provide an update on the web pages of academic orthopedic surgery departments in the United States and to rate their utility in providing information on quality of education, faculty and resident information, environment, and applicant information. We reviewed existing websites for the 156 departments or divisions of orthopedic surgery that are currently accredited for resident education by the Accreditation Council for Graduate Medical Education. Each website was assessed for quality of information regarding quality of education, faculty and resident information, environment, and applicant information. We noted that 152 of the 156 departments (97%) had functioning websites that could be accessed. There was high variability regarding the comprehensiveness of orthopedic residency websites. Most of the orthopedic websites provided information on conference, didactics, and resident rotations. Less than 50% of programs provided information on resident call schedules, resident or faculty research and publications, resident hometowns, or resident salary. There is a lack of consistency regarding the content presented on orthopedic residency websites. As the competition for orthopedic websites continues to increase, applicants flock to the Internet to learn more about orthopedic websites in greater number. A well-constructed website has the potential to increase the caliber of students applying to a said program. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

A novel phased-concept course for the delivery of anatomy and orthopedics training in medical education.

PubMed

Klima, Stefan; Hepp, Pierre; Löffler, Sabine; Cornwall, Jon; Hammer, Niels

2017-07-01

Integration of anatomy and clinical teaching is a theoretical ideal, yet there is a worldwide paucity of such amalgamation. These teaching models provide support for medical trainees, an important element in Germany where orthopedic intern numbers have declined and anecdotal evidence suggests disinterest in orthopedics. The aim of the study was to develop an integrated anatomy-surgical course for undergraduate medical training, assess the model developed, and explore how medical students perceive orthopedics as a career. The course was to deliver medical anatomy and clinical orthopedic training, focusing on interdisciplinary teaching and learning, vertical integration of clinical knowledge and skills, and professional interaction. Survey evaluation of the course and students' perceptions of orthopedic careers was performed, including Likert-type responses rating variables of interest. A phased-concept program of five courses, each optional and under one-week in duration, was developed parallel to the undergraduate medical program. Delivered by anatomists and surgeons, courses included biomechanics, advanced dissection, surgical approaches, casts and implants, and sports medicine. Course data indicate positive support for course format, stimulation of interest, and high clinical relevance. Students are generally interested in surgery, and identify hierarchy, lawsuits, bureaucracy and physical stress as barriers to orthopedic careers. This novel phased-concept successfully delivers combined anatomy and surgery training in a vertically-integrated format while addressing students' clinical and professional skills. The format facilitates an appreciation of potential career options in orthopedics, while fostering professional skills during medical training. Barriers to careers in orthopedics can now be addressed in future courses. Anat Sci Educ 10: 372-382. © 2016 American Association of Anatomists. © 2016 American Association of Anatomists.

[Daily routine in orthopedics and traumatology - results of a nationwide survey of residents].

PubMed

Merschin, D; Münzberg, M; Stange, R; Schüttrumpf, J P; Perl, M; Mutschler, M

2014-10-01

The subject orthopedics and traumatology suffers by a loss of attractiveness which results in a lack of young blood. The aim of this study of the Youth Forum of the German Society of Orthopedics and Traumatology (DGOU) is to register the working conditions of residents in orthopedics. In the months September and October 2013 we performed a survey on members of the following German societies: German Society of Orthopedics and Traumatology (DGOU), German Society of Traumatology (DGU) and the German Society of Orthopedics and Orthopedic Surgery (DGOOC), (age < 40). Our questionnaire includes 15 questions. We achieved 28,9 % (n = 331) answered questionnaires. The mean working time per week is 55 hours. 73 % of all participants do more than 5 emergency services per month. 52 % are more than 3 times on duty for 24 hours. Only 13 % of all residents have well ordered working hours. Normally working time is divided into three parts: one third for bureaucracy, one for operation theatre and the last for other activities (e.g. ward round). 35,6 % do only one surgery per week, 12 % do not perform any surgeries. An annual report is performed only in 45 %. A structured concept of training only exists in 16 % of all hospitals. In addition to clinical work 45 % are involved in scientific projects, mostly in their spare-time. Finally 58 % of all surgeons would still recommend orthopedics and traumatology. In order to maintain orthopedics and traumatology as an attractive it is necessary to implement flexible working time models and to reorganize and improve training-concepts. Georg Thieme Verlag KG Stuttgart · New York.

Orthopaedic Teaching in United Kingdom Medical Schools.

ERIC Educational Resources Information Center

Di Paola, M; And Others

1986-01-01

Describes a study of medical students' training in orthopedics. Discusss discrepancies between course content and duration and the deficiencies that exist in basic knowledge of anatomy relevant to orthopedics. Recommends that orthopedic courses should appear earlier in the curriculum and practice should be emphasized. (TW)

Medical photography: principles for orthopedics.

PubMed

Uzun, Metin; Bülbül, Murat; Toker, Serdar; Beksaç, Burak; Kara, Adnan

2014-04-05

Medical photography is used clinically for patient evaluation, treatment decisions, and scientific documentation. Although standards for medical photography exist in many branches of medicine, we have not encountered such criteria in publications in the area of orthopedics. This study aims to (1) assess the quality of medical images used in an orthopedic publication and (2) to propose standards for medical photography in this area. Clinical photographs were reviewed from all issues of a journal published between the years 2008 and 2012. A quality of clinical images was developed based on the criteria published for the specialties of dermatology and cosmetic surgery. All images were reviewed on the appropriateness of background, patient preparation, and technique. In this study, only 44.9% of clinical images in an orthopedic publication adhered to the proposed conventions. Standards have not been established for medical photography in orthopedics as in other specialty areas. Our results suggest that photographic clinical information in orthopedic publications may be limited by inadequate presentation. We propose that formal conventions for clinical images should be established.