Surgical face masks in the operating theatre.
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Humans↗
Biomedical subjects
R N Merchant
Publications and source records attributed to R N Merchant.
Special challenges with new digital anesthesia machines.
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Anesthesiology↗
Treatment of polycystic ovary disease with laparoscopic low-watt bipolar electrocoagulation of the ovaries.
STUDY OBJECTIVE: To assess the efficacy of laparoscopic low-watt bipolar electrocoagulation of the ovaries in women with polycystic ovary disease (PCOD). DESIGN: Prospective case series. SETTING: Hospital-based infertility clinic. PATIENTS: Seventy-four consecutive infertile women with PCOD resistant to conventional ovulation-induction regimens. INTERVENTIONS: Laparoscopic bipolar low-watt electrocoagulation of the ovarian surface (25 W for 5-12 sec/cyst). MEASUREMENTS AND MAIN RESULTS: Postoperative follow-up ranged from 18 months to 7 years. Menstrual rhythm returned to normal in all 74 women. All 40 women in whom infertility was solely due to anovulation eventually conceived. Overall, 62 (84%) of the 74 women conceived, 42 spontaneously after surgery and 20 after supplementation with clomiphene. These 62 women had a total of 93 pregnancies: 79 singleton live births, 4 sets of twins, and 10 miscarriages. Twenty-five women conceived twice and three conceived three times. At second-look laparoscopy or cesarean section in 20 women, fine stringlike adhesions on the ovaries were found in 2. CONCLUSION: Laparoscopic low-watt bipolar electrocoagulation of the ovaries is an effective treatment for women with PCOD who fail medical therapy.
Adult↗
Early postoperative ulnar neuropathies following coronary artery bypass surgery.
Ulnar neuropathies following surgery are common. However, they often go undetected during the early postoperative period, because the patient may be unaware of symptoms related to the neuropathy. Nerve conduction studies are useful in localizing the lesion, but are usually employed only in cases developing signs and symptoms. We undertook this study to determine the incidence, time of onset, and outcome of clinical and subclinical ulnar neuropathies. Electrophysiological studies were carried out preoperatively, immediately following surgery, and 4 to 6 weeks postoperatively in 20 coronary artery bypass patients. Conduction velocity across the elbow was reduced in 3 limbs (8%) postoperatively, all of which were detected immediately following surgery. One patient developed conduction block and weakness in ulnar supplied intrinsic hand muscles. Denervation was seen in 2 cases and, in 1 case (5%), a right brachial plexus injury was clinically evident 5 days following surgery. All newly developing ulnar neuropathies were asymptomatic, with most recovering to their preoperative electrophysiological status at follow-up.
Brachial Plexus↗
The Canadian four-centre study of anaesthetic outcomes: I. Description of methods and populations.
The objectives of this study were first to develop and institute a methodology for the study of anaesthetic outcome for parallel use in four teaching hospitals in Canada and second, to compare rates of morbidity and mortality associated with anaesthesia between the four centres. The basic design of the study was occurrence screening with anaesthetists entering data on patient demographics, anaesthetic and surgical factors. Research nurses reviewed anaesthetic records and hospital charts and interviewed patients postoperatively. Data on 37,665 anaesthetics were collected during 1988-89 in the four teaching centres. There were major differences found across the hospitals, particularly with regard to volume, patient case-mix, anaesthetic drugs and monitoring used. The use of parallel training, repeated consultations and use of rounds and inservices contributed to the reliability and validity of the data collection. We conclude that outcome surveillance can be instituted in different hospital Departments of Anaesthesia with sufficient confidence to form the basis of comparison of anaesthetic outcome.
Anesthesia↗
The Canadian four-centre study of anaesthetic outcomes: II. Can outcomes be used to assess the quality of anaesthesia care?
Since anaesthesia, unlike medical or surgical specialties, does not constitute treatment, this study sought to determine if methods used to assess medical or surgical outcomes (that is the determination of adverse outcome) are applicable to anaesthesia. Anaesthetists collected information on patient, surgical and anaesthetic factors while data on recovery room and postoperative events were evaluated by research nurses. Data on 27,184 inpatients were collected and the analysis of outcomes determined for the intraoperative, post-anaesthetic care unit and postoperative time periods. Logistic regression was used to control for differences in patient populations across the four hospitals. In addition, a random selection of 115 major events was classified by a panel of anaesthetists into anaesthesia, surgical and patient-disease contributions. Across the three time periods, large variations in minor outcomes were found across the four hospitals; these variations ranged from two- to five-fold after case-mix adjustment (age, physical status, sex, emergency versus elective and length of anaesthesia). The rates of major events and deaths were similar across three hospitals; one hospital had a lower mortality rate (P less than 0.001) but had a higher rate of all major events (P less than 0.0001). Of major events assessed by physician panels, 18.3% had some anaesthetic involvement and no deaths were attributable partially or wholly to anaesthesia. Possible reasons to account for these variations in outcome include compliance in recording events, inadequate case-mix adjustment, differences in interpretation of the variables (despite guidelines) and institutional differences in monitoring, charting and observation protocols. The authors conclude that measuring quality of care in anaesthesia by comparing major outcomes is unsatisfactory since the contribution of anaesthesia to perioperative outcomes is uncertain and that variations may be explained by institutional differences which are beyond the control of the anaesthetist. It is suggested that minor adverse events, particularly those of concern to the patient, should be the next focus for quality improvement in anaesthesia.
Anesthesia↗
The Canadian four-centre study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice?
To understand better the factors important to the safety of anaesthesia provided for day surgical procedures, we analyzed the intraoperative and immediate postoperative course of patients at four Canadian teaching hospitals' day treatment centres. After excluding those who received only monitored anaesthesia care, there were 6,914 adult (non-obstetrical) patients seen over a twelve-month period in 1988-89. The rate of adverse outcome consequent to their care was identified by a comprehensive surveillance system which included review of anaesthetic records (four hospitals) and follow-up telephone calls (two hospitals). The relationship between adverse events and preoperative factors was determined by using a multiple logistic regression analysis that included age, sex, duration of the procedure and the hospital care. There were no deaths during the study period and major morbid events were infrequent. Patient preoperative disease was predictive of some intraoperative events relating to the same organ system, but not to events in the PACU. Some unexpected relationships emerged including preoperative hypertension being related to a greater risk of difficult intubation, and neurological disease to perioperative cardiac abnormalities. Patients judged obese, or inadequately fasted, were found to experience a greater rate of recovery problems as well as discomfort. While the low response rate (36%) to the telephone interviews created a sampling bias, the high rate of patient dissatisfaction among those reached is disconcerting. We conclude that day surgical patients with preoperative medical conditions, even when optimally managed, are at higher risk for adverse events in the perioperative period.
Adult↗
Long-term cognitive and social sequelae of general versus regional anesthesia during arthroplasty in the elderly.
This study compared the effects of general and regional anesthesia on cognitive and psychosocial functioning in elderly persons. Sixty-four patients between 60 and 86 yr of age undergoing knee arthroplasty were randomly assigned to receive either general or regional anesthesia. A battery of psychometric tests, including the Satz-Mogel form of the Wechsler Adult Intelligence Scale-Revised, the Wechsler Memory Scale-Revised and the Sickness Impact Profile, and various neuropsychological measures were administered by a blinded observer just before surgery and again 3 months later. Analyses of covariance revealed improvements in most measures that were equivalent between groups. The results indicated that there were no cognitive or psychosocial effects of general or regional anesthesia after 3 months in elderly persons undergoing knee arthroplasty. In this patient population, general anesthesia poses no more risk to long-term mental function than regional anesthesia.
Aged↗
Succinylcholine does not increase serum potassium levels in patients with acutely ruptured cerebral aneurysms.
Succinylcholine-induced hyperkalemia has been reported to occur in many neurological disorders including subarachnoid hemorrhage. The purpose of this study was to compare the effect of succinylcholine on serum potassium levels in patients with ruptured cerebral aneurysms undergoing either early (less than or equal to 4 days; n = 14) or delayed (5-16 days; n = 20) surgery. Thirty-four patients were classified according to the number of days from subarachnoid hemorrhage to surgery. Arterial serum potassium levels were measured after induction of anesthesia but before succinylcholine, and 1, 5, and 10 min after the administration of succinylcholine. The electrocardiogram was continuously monitored. The mean ( +/- SD) increase in serum potassium level of 0.4 +/- 0.2 mmol/L occurred at 10 min but was not statistically significant, nor was there any statistically significant difference in serum potassium levels related to time between subarachnoid hemorrhage and administration of succinylcholine. We found no evidence of succinylcholine-induced hyperkalemia in patients undergoing either early or delayed cerebral aneurysm surgery.
Adult↗
Peripheral nerve injuries in cardiac anaesthesia.
Clinical nerve damage in patients undergoing CABG is frequent (15% of patients), while subclinical changes in ulnar nerve function are more common (40% here). Not all injuries develop in the early perioperative period. Most injuries are located at the elbow, and most recover without sequelae. Larger patients appear to be at most risk, but this study does not identify specific interventions which might decrease the risk of injury.
Anesthesia, General↗
Perinatal mortality in abnormal presentations.
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Female↗
Clinico-pathological study of fallopian tubes after transcervical insertion of quinacrine hydrochloride pellets.
This study lends support to others indicating the apparent safety and effectiveness of multiple transcervical insertions of quinacrine hydrochloride as pellets in 240 mg dosage to achieve permanent sterilization. In order to study the effects of the number of quinacrine pellet insertions and the site of placement of the pellets in the uterus of prehysterectomy volunteers, a scoring system of histological changes in the Fallopian tube was designed. Quinacrine pellets were deposited at the fundus using a straight inserter in 16 women, and at the cornua using a curved inserter in 17 women. Each group had at least five women receiving one, two or three insertions at one-week intervals. Results indicate that neither the number of insertions nor the place of deposition of the pellets affects the degree of tubal inflammation and fibrosis.
Adult↗
An IUD to fit any uterus.
A new copper intrauterine device is described. Experience during 40 000 woman-months of use indicates that there have been no pregnancies and only 0.4 expulsions. At the end of 30 months of follow-up, 87.5% of the women are still wearing the device.
Adult↗
Computerized tomography in the diagnosis of lymphangioleiomyomatosis.
We describe a subject with lymphangioleiomyomatosis who presented with chylothorax but who had an otherwise normal chest radiograph. The diagnosis was established by means of whole-body computerized tomographic scanning, which demonstrated asymptomatic involvement of the lungs, lymphatics, and kidneys. This diagnostic modality offers the potential for noninvasive serial monitoring of this rare condition, and in doing so provides an opportunity to obtain a better understanding of the disease process.
Adult↗
Uterotubal junction--morphology and clinical aspects.
A morphological and histological study of the uterotubal junction was undertaken in order to explain its behaviour in various clinical conditions related to fertility and sterility. The study comprises 150 uterotubal junctions obtained from 75 uteri removed at surgery from women of reproductive age-group. In the study the cornua were subjected to hysteroscopy, hysterosalpingography, naked eye dissection, and light microscopy with serial sectioning. The study reveals the following: The uterotubal junction is the same as the intramural portion of the tube which commences at the tip of an endometrial funnel and ends at the outer border of the uterus to become the isthmus. The length of the intramural tube is, on an average, only 8 mm. Its course is either straight, arched, or convoluted. Peculiar to this part of the tube are the autochthonous muscle layers-an inner longitudinal immediately surrounding the mucosa and an outer circular layer. The uterine musculature, which is fairly thick around the endometrial funnel, suddenly reduces markedly in thickness as the isthmus approaches. We attempt to explain the behaviour of this area in various clinical conditions in the light of the histoanatomic findings.
Adult↗
Clinicopathologic study of fallopian tube closure after single transcervical insertion of quinacrine pellets.
OBJECTIVE: To determine the effect on tubal closure of intrauterine quinacrine by dose and time from administration. DESIGN AND PARTICIPANTS: Subjects included 33 women of reproductive age who were awaiting hysterectomy for nonmalignant conditions at a Bombay, India medical college. Ten women received 252 mg quinacrine as pellets using a modified Copper-T IUD inserter followed by hysterectomy within 6 weeks, and 23 women received 324 mg quinacrine followed by hysterectomy 6 to 20 weeks post-insertion. Hysterosalpingograms were done before insertion, prior to surgery and on the fresh surgical specimen. The uteri and tubes were subjected to histology studies, including grading of tubal damage. For study of dose, an additional 7 women receiving 100 mg quinacrine (and previously reported) were included. MAIN OUTCOME MEASURE: Tubal closure rates by hysterosalpingogram and tubal histology. RESULTS AND CONCLUSION: Tubal closures were directly related to quinacrine dose and length of insertion-hysterectomy interval. For the 252 mg quinacrine dose, 55.0% of intramural tubal segments and 5.9% of isthmic segments showed histologic evidence of closure. For the 324 mg dose, all intramural tubal segments and 58.8% of isthmic segments showed histologic evidence of closure. Clinical conditions, such as dysfunctional uterine bleeding, were associated with lower tubal closure rates. Multivariate discriminant analysis showed quinacrine dose to be more important than quinacrine-hysterectomy interval.
Adult↗