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PubMed1999

Sensitivity of noncontrast helical computerized tomography and plain film radiography compared to flexible nephroscopy for detecting residual fragments after percutaneous nephrostolithotomy.

PURPOSE: We prospectively compared plain film radiography and noncontrast, thin cut helical computerized tomography (CT) to flexible nephroscopy for detecting residual stones after percutaneous nephrostolithotomy. MATERIALS AND METHODS: We prospectively evaluated 36 patients (41 renal units) undergoing percutaneous nephrostolithotomy for large (greater than 3 cm., 23 renal units) or staghorn (18 renal units) calculi. All patients underwent postoperative imaging with plain film of the kidneys, ureters and bladder and noncontrast helical CT, and flexible nephroscopy on postoperative day 2 or 3. The size and location of residual fragments determined radiographically and identified by flexible nephroscopy were compared. RESULTS: Plain film radiography and CT detected an average of 0.7 and 3.4 stones per renal unit, respectively. With a mean operating time plus or minus standard deviation of 77.3+/-35 minutes and a mean fluoroscopy time of 7.6+/-6.7 minutes, an average of 2.3 stones per renal unit were retrieved at flexible nephroscopy. In 90.2% of renal units all calices could be directly inspected. The sensitivity and specificity were 46% and 82% for plain film radiography, and 100% and 62% for CT, respectively, using flexible nephroscopy as the gold standard for detecting residual stones. The overall stone-free rate after flexible nephroscopy was 92.6%. The cost of this procedure is $5,625.13 compared to $220 for CT, including the interpretation fee, at our institution. CONCLUSIONS: Selective use of flexible nephroscopy after percutaneous nephrostolithotomy based on positive CT findings will avoid an unnecessary operation in 20% of patients. The rate of unnecessary procedures is 32% if all patients undergo flexible nephroscopy, regardless of radiographic findings. At our institution this strategy will result in a cost savings of $109,687 per 100 patients.

Costs and Cost Analysis↗

PubMedDate not supplied

Intraoral and oropharyngeal reconstruction using a de-epithelialized forearm flap.

We have used free forearm flaps for closure of various intraoral and oropharyngeal defects after radical ablation of tumors. A problem remained, however, in that split-thickness skin grafts required to close the forearm defect had to be obtained from other areas. To avoid this disadvantage, we de-epithelialized forearm flaps and the donor defects were closed with the split-thickness skin obtained from flap de-epithelialization. As a result of this procedure, unnecessary scarring has been avoided and postoperative management has been simplified. Such complications as flap loss, fistulae, or scar contracture have not occurred with greater frequency than is seen in normal circumstances. The de-epithelialized forearm flap procedure is explained. Histological findings concerning the de-epithelialized forearm flap are described, and the advantages of this method stated.

Adult↗

PubMed1997

[Hygiene in the surgical department--recommendations by the National Reference Center for Hospital Hygiene].

Many hygienic procedures performed in operation units are not supported by scientific investigations. The following recommendations by the National Reference Center for Hospital Epidemiology, founded by the German Ministry of Health in 1996, are based on the scientific literature and separate necessary from less necessary and unnecessary procedures.

Centers for Disease Control and Prevention, U.S.↗

PubMed1997

Is a gastric drainage procedure necessary at the time of antireflux surgery?

BACKGROUND: Gastroesophageal reflux is part of a generalized foregut motility disorder, which may also include delayed gastric emptying. With persistence of gastroesophageal reflux, or the presence of complications, including recurrent aspiration syndrome and esophageal stricture formation, surgical correction may be indicated. It is uncertain whether a procedure to resolve delayed gastric emptying is indicated at this time as well. METHODS: Sixty-seven children with proven gastroesophageal reflux had preoperative gastric emptying assessed using 99Technetium-Sn-colloid labelled milk. Delayed gastric emptying was defined as a gastric residual activity of more than 40% at 2 hours after feeding. The antireflux operation was a partial anterior fundoplication. Postoperative milk scans assessed the effect of surgery on gastric emptying. RESULTS: Gastric emptying at 2 hours improved overall from a median of 22% before surgery to 17% after surgery. In 17 patients delayed gastric emptying was identified before surgery; in 15 of those it returned to within normal limits after surgery. In 50 children with normal gastric emptying before surgery (gastric residual activity at 2 hours 16%), 14 (28%) showed delayed gastric emptying in the postoperative scan. CONCLUSIONS: Delayed gastric emptying is common in children who undergo surgery for gastroesophageal reflux disease. A partial anterior fundoplication antireflux operation improves gastric emptying to within normal limits in the majority (88%) in this group, rendering a synchronous gastric drainage procedure unnecessary.

Animals↗

PubMed2002

Association of cervical cryotherapy with inadequate follow-up colposcopy.

OBJECTIVES: We studied the anatomic changes that occur in the ectocervix after cryotherapy and the role these changes play in the adequacy of follow-up colposcopic examination. STUDY DESIGN: We retrospectively reviewed patients' charts. POPULATION: Between January 1, 1991, and December 1, 1995, 268 women underwent 2 colposcopic examinations in 7 state-run public health clinics. OUTCOMES MEASURED: The likelihood that a follow-up colposcopic examination would be inadequate. RESULTS: Of the 268 women who underwent 2 colposcopic examinations during the study period, 83 had cryotherapy, 24 had loop excision of the ectocervical portion or cervical conization, and 96 had no procedure. Sixty-five were excluded because of missing data. Subjects were similar with respect to age, whether endocervical curettage was performed, cervical dysplasia, presence of human papilloma virus, and whether glandular involvement was noted. Patients who had cryotherapy had an increased likelihood of inadequate follow-up colposcopic examination compared with women who had no procedure (adjusted odds ratio = 18.7, 95% confidence interval = 7.0-49.8). CONCLUSIONS: Undergoing cryotherapy of the uterine cervix increases the risk that a follow-up colposcopic examination will be inadequate. Given the reported high rates of regression of mild and moderate cervical dysplasia and the risks posed by possibly unnecessary procedures performed after inadequate colposcopic examination, a trend toward less aggressive therapy and watchful waiting may be appropriate but should be investigated in a controlled clinical trial.

Adult↗

PubMed2003

A modified method for ICSI in the pig: injection of head membrane-damaged sperm using a 3-4 micro m diameter injection pipette.

BACKGROUND: Conventional ICSI to date was focused only on tail membrane damage to achieve sperm immobilization and disruption of the plasma membrane, even though liberation of soluble sperm factors is achieved by disruption of the sperm head membrane. METHODS: A modified method for ICSI was developed: head membrane-damaged spermatozoa aspirated tail or head first were injected into the ooplasm using a 3-4 micro m diameter injection pipette connected to an open-ended aspiration tube regulated by mouth. The efficiency of this modified ICSI was compared with that of conventional ICSI and IVF. RESULTS: When spermatozoa aspirated tail first were injected, a decondensed sperm head was more frequently observed in the oocyte cytoplasm with the modified ICSI (80.0%) than with conventional ICSI (55.7%) or IVF (63.5%) (P < 0.001). The rates of male pronucleus (MPN) formation in the modified ICSI or IVF were significantly higher (50.7 and 39.7%, respectively) than in conventional ICSI (27.9%) (P < 0.001). The rates of survival, cleavage and embryo development to blastocyst were significantly higher in the modified ICSI (71.7, 60.6 and 17.5%) than in conventional ICSI (48.1, 48.7 and 10.5%) (P < 0.001). No significant differences in MPN formation and embryo development to blastocyst were observed between the tail- and head-first sperm aspiration. CONCLUSION: Our results demonstrated that, in the pig, the procedures of pursuing, capturing and immobilizing a spermatozoon and producing deliberate damage to the tail membrane in conventional ICSI were not required in the modified ICSI. We believe that the present study provides sufficient technical advancement to replace conventional ICSI with the modified ICSI, which is more effective and also avoids unnecessary procedures involved in conventional ICSI.

Animals↗

PubMed2001

Patients' experiences of intervention trials on the treatment of myocardial infarction: is it time to adjust the informed consent procedure to the patient's capacity?

OBJECTIVE: To investigate how patients included in trials on treatment in the early phase of acute myocardial infarction experience the consent procedure. DESIGN: A combined qualitative and quantitative interview concerning the patients' knowledge of the trial, their feelings about being asked to participate, and their attitudes towards the consent procedure. SETTING: Tertiary referral centre. PATIENTS: 31 patients who had given written informed consent for their participation in randomised intervention trials of acute myocardial infarction. RESULTS: The patients interviewed had only fragmentary knowledge about the trial they were involved in. Most considered that reading and signing a consent form was an unwanted or unnecessary procedure. Instead, they would have preferred to have been given concise verbal information about the study. Most were willing to allow a physician to decide for them in the event of their being too ill to be asked about their participation. CONCLUSIONS: Patients who are asked to participate in intervention trials in the early phase of acute myocardial infarction often appear to lack sufficient knowledge to reach an autonomous choice. There were problems and disadvantages associated with the process of obtaining written informed consent in this particular situation, especially regarding the need for the patient to sign a consent form during the acute phase of the disease.

Abciximab↗

PubMed1990

[Focal liver lesion as an incidental finding. 1: Diagnostic management--procedure in sonographically echo-free tumors].

The spread of diagnostic ultrasound has led to an increase in the incidental detection of lesions of the liver in patients with unrelated symptoms and no history of tumor disease. In this article, suggestions are made on how to proceed with the further diagnostic workup of such patients. In part 1 these suggestions are aimed at identifying patients who might benefit from further investigation, while at the same time avoiding unnecessary procedures.

Biopsy↗

PubMed1979

Rates of surgical care in prepaid group practices and the independent setting: what are the reasons for the differences?

The Seattle Prepaid Health Care Evaluation Project is a comparative study designed to assess the care received by persons enrolled in either a large prepaid group practice (PGP) or in a prepaid, independent practice setting in which physicians are reimbursed on a fee-for-service basis (IPP). As part of the study we assessed the patterns of surgical care for hysterectomy, cholecystectomy, appendectomy, and tonsillectomy/adenoidectomy. Overall, there were 215 such procedures with an exposure adjusted rate being five times higher in the IPP than in the PGP. After eliminating 43 per cent of procedures in the IPP and 22 per cent in the PGP which did not meet specified criteria for either necessary, appropriate or justifiable surgery, the exposure-adjusted rate differential was 3.9 times higher in the IPP with the difference in the rates being mainly attributable to hysterectomy and tonsillectomy/adenoidectomy. We conclude there were more unnecessary procedures in the IPP, but the fact that a significant difference in the incidence of surgery persisted even after elimination of such cases suggests that the differences in rates of surgery between the IPP and PGP cannot be solely attributed to a higher rate of inappropriate surgery in the IPP.

Adenoidectomy↗

PubMed1997

Persistent cerebrospinal fluid otorrhea: a case of Munchausen's syndrome by proxy.

A case is presented of a young child who initially presented with recurrent bacterial meningitis 1 year after significant head trauma and was found to have cerebrospinal fluid (CSF) leakage into the middle ear. Surgical procedures were devised to attempt to stop this abnormal flow, but inexplicably clear otorrhea biochemically identical to CSF persisted for weeks. The child's mother was apparently soaking the surgical dressings with CSF obtained through a lumbar drain and confessed to this activity after she was found to have tampered with an intravenous catheter. This activity resulted in a prolonged hospital stay and several presumably unnecessary procedures. Munchausen's syndrome, typified by intentional mimicry of symptoms of serious illness backed by plausible medical history, is well-described. Rarer is the syndrome by proxy, where parents and/or caregivers, by falsifying histories, fabricating laboratory evidence, or deliberately generating bodily lesions, cause unneeded diagnostic and therapeutic procedures to be performed on their young victims. This form of child abuse is hidden by the perpetrator's apparent concern and involvement in the care of the victim. The literature is reviewed, this form of abuse is discussed, and the role of communication of suspicion between the various health care workers is stressed. The medical and social settings in which this disorder is prevalent are covered. Early detection of this entity is essential in rescuing the victim from life-threatening abuse and in obtaining appropriate therapy for the abuser.

Cerebrospinal Fluid Otorrhea↗

PubMed2002

Open access endoscopy in rural and remote Western Australia: does it work?

BACKGROUND: Access to diagnostic endoscopy is limited in rural and remote Western Australia. Published reports suggest open access referrals may result in over-servicing, this is reduced by adherence to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. The aim was to assess whether an outreach surgical service offering open access endoscopy to rural areas was being over utilized. METHODS: Prospective data collection from all patients undergoing upper and lower endoscopy procedures between January 1996 and June 2000 were included in the present study. Indications for referral between the general practitioners and the visiting surgeons were reviewed in patient records and assessed for compliance with the ASGE guidelines. The groups were analysed for appropriateness of referrals and frequency of positive pathology investigations. Records for all patients undergoing colonoscopy were reviewed to determine the reason and number of cancelled procedures. RESULTS: A total of 772 endoscopies were performed and 75% were booked as open access services. The referral rate for procedures was greater for general practitioners (583) compared to the visiting surgeons (189), the overall compliance rate for approved indications using the ASGE guidelines for both groups was 92%. There was no significant difference in pathology found between groups. CONCLUSION: The present study shows that an outreach rural surgical service programme in Western Australia offering open access endoscopy conforms to international guidelines and does not induce unnecessary procedures. Rural patients benefit from a personal cost savings and convenience. There is an associated reduction in government-assisted travel costs to larger centres as well as decreased waiting lists.

Colonoscopy↗

PubMed2005

Breast conservation after neoadjuvant chemotherapy.

BACKGROUND: Tumor downstaging by preoperative neoadjuvant chemotherapy in patients with locally advanced breast tumors allows breast conservation in women who were previously candidates for mastectomy. Nevertheless, lumpectomy success in such cases cannot be fully achieved. The aim of this study was to create a quantitative tool for preoperative evaluation of the success of breast conservation in such patients. METHODS: The study population included 100 consecutive patients with stage II and III breast cancer who were designated for lumpectomy and 19 patients who were designated for mastectomy. All patients received neoadjuvant therapy. Breast-conserving surgery was offered in accordance with clinical and esthetic criteria. Demographic details and clinical, imaging, and pathologic information were collected from medical files. A decision protocol for classifying patients to lumpectomy or mastectomy was built by using the Classification and Regression Trees procedure based on preoperative characteristics. RESULTS: Three factors were found to be the main predictors for successful breast conservation: absence of diffuse microcalcifications as seen in the pretreatment mammogram, a postchemotherapy tumor size of < 25 mm, and the existence of a circumscribed lesion on mammography. CONCLUSIONS: The use of these criteria as a basis for decision on the type of surgery may decrease the performance of unnecessary procedures.

Adult↗

PubMed2001

[Knee arthroscopy in children].

PURPOSE OF THE STUDY: Between 1990 and 1998, 110 knee arthroscopies were performed in children. We analyzed the epidemiology and diagnostic data and studied the correlation between clinical and radiographic findings and the final diagnosis after arthroscopy in order to establish a consensus on use of knee arthroscopy in children. MATERIAL AND METHODS: We made a retrospective analysis of 110 knee arthroscopies performed in children, classing the patients in three age groups: 0-5 years, 5-10 years, 10-17 years. Clinical and radiological findings were compared with the arthroscopy findings. RESULTS: One or more arthroscopies were performed in 56 boys and 48 girls. Mean age at the time of the procedure was 12 years 4 months. There were 11 children aged 0-5 years, 14 aged 5-10 years and 85 aged 10-17 years. The main pathology was arthritis in the 0-5 year and 5-10 year age groups. Trauma was more frequent in the older children. Knee arthroscopy was found to be normal in 19 cases. DISCUSSION: For most surgery teams, arthroscopy is indicated for arthritis of the knee. Arthroscopy may also be needed for hemarthrosis. In these contexts, arthroscopy is both a diagnostic and therapeutic procedure. Our analysis demonstrates that emergency arthroscopy is only warranted for free floating osteochondral fractures and fractures of the tibial articular surfaces, with the exception of the tibial spines. Arthroscopy may be performed later in other cases after careful physical examination and radiographic series. We had 19 normal arthroscopies and 10 that showed femoropatellar chondropathies and plicas that could explain knee pain. We recommend arthrography before arthroscopy to avoid unnecessary procedures. CONCLUSION: Arthritis of the knee is an excellent indication for arthroscopy. Painful and acute hemarthrosis requires attentive physical exams and x-rays before making the decision for surgery.

Acute Disease↗

PubMed1994

Comparison of minimally invasive surgery and laparotomy in the treatment of adnexal masses.

STUDY OBJECTIVE: To compare the outcome of laparoscopic treatment of adnexal masses with treatment by laparotomy. The procedures, their duration, and associated complications also were evaluated. DESIGN: Women were randomized to undergo either procedure based on the ward to which they were admitted. SETTING: A university teaching hospital. PATIENTS: The 192 patients were admitted with a preoperative diagnosis of adnexal mass. INTERVENTIONS: Surgical procedures were cystectomy, salpingectomy, oophorectomy, and unilateral or bilateral salpingo-oophorectomy. Organ-preserving techniques were used wherever possible. All tissue specimens were examined histologically. MEASUREMENTS AND MAIN RESULTS: The mean duration of surgery was statistically not significantly different between the groups, 96.8 minutes for minimally invasive surgery, and 116 minutes for laparotomy. Organ preservation did reach statistical significance at 65.7% and 17.2% respectively (p <0.001). Postoperative morbidity was statistically lower in patients undergoing minimally invasive procedures. Preoperative tumor marker levels did not correlate well with postoperative histology. One woman in the laparotomy group had histologically proved ovarian cancer. Minimally invasive surgery was converted to laparotomy in three patients in whom malignancy was suspected at the start of operation. CONCLUSIONS: Laparoscopic management of adnexal masses has definite advantages over laparotomy, for example, lower postoperative morbidity. In addition, intraoperative endoscopic diagnosis is highly accurate, and the frequency of unnecessary procedures is lower.

Adolescent↗

PubMed1999

[Need for a pre-deposit autotransfusion program for patients undergoing elective surgery].

INTRODUCTION: Preoperative autologous hemodonation is a very useful procedure, but it is not exempt from risks. To reduce them we must ascertain the frequency of autologous donation and the amount of blood needed for each intervention. The objective of this work is to know which are the subsidiary interventions of autotransfusion, which are true necessities of blood for them. PATIENTS AND METHODS: All the crossmatched blood units preserved for surgical procedures that might be allocated for autotransfusion were controlled. The source service, the type of intervention, and the number of units requested and transfused were identified. RESULTS: 269 surgical interventions were controlled. For these interventions, 666 units of blood were reserved. No blood transfusion was necessary in 69% of the surgical operations. The number of units transfused was 229 (26.28%). Traumatology and Heart Surgery were the services that demanded more blood. The procedure with greatest requirements of blood units was the total knee replacement. Hysterectomy was the intervention with the lowest percentage of utilization of reserved blood (5.26%). CONCLUSIONS: Autotransfusion should be offered to all patient in need of knee or hip replacement and those who are subjected to heart surgery with extracorporeal circulation. Patients who are programmed for interventions with a low percentage of utilization of blood, should know these findings, in order that they don't feel subjected to unnecessary procedures.

Arthroplasty, Replacement, Hip↗

PubMedDate not supplied

Oral dyskinesia: a clinical overview.

PURPOSE: Dentists may be the first health care professionals to recognize unusual and abnormal oral movements collectively termed oral dyskinesias. The aims of this clinical overview are to raise the dental community's awareness about this important and complex topic and describe the clinical features and management of the main entities. MATERIALS AND METHODS: A MEDLINE search of the different entities reported in the English and French literature was conducted. The main findings of a field study on oral dyskinesia were also reviewed. RESULTS: Involuntary movement disorders are often drug related. In other cases, excessive oral movements may occur at any age in relation to various neuropsychiatric conditions. Orofacial dystonia apparently triggered by dental procedures has also been reported. Edentulousness has been associated with oral stereotypes. In a survey of 352 edentulous elderly individuals attending daycare centers, only 7% displayed visible oral sterotypes, and ill-fitting dentures were suggested as a possible triggering factor for the majority. CONCLUSION: A multidisciplinary evaluation is desirable in the care of individuals with oral dyskinesia and in the selection of those who may benefit from a prosthodontic approach. A good knowledge of potentially offending drugs may allow avoidance of unnecessary procedures.

Bruxism↗

PubMedDate not supplied

The diagnosis and treatment of Munchausen's syndrome.

Patients with Munchausen's syndrome--a syndrome characterized by the intentional production of physical symptoms to gain the sick role-present a variety of challenges to health care providers. Their treaters quickly become frustrated by their demanding interpersonal styles, by deception and manipulation, and by multiple unrevealing diagnostic procedures. These difficulties can lead to poor outcomes for patients and staff alike. We present the case of a young woman whose presentation and subsequent evaluation led to significant distress among the hospital staff responsible for her care, and discuss the epidemiology, diagnosis, and management of patients with Munchausen's syndrome. The most important role of the psychiatrist in the treatment of Munchausen's syndrome is to help the primary treatment team manage the patient in the safest and most appropriate way. Such management includes avoiding unnecessary procedures, preventing further self-harm, and avoiding angry or threatening interactions with the patient. The prognosis for patients with Munchausen's syndrome appears to be poor; flexible and creative approaches that emphasize consistency of care and regular outpatient psychiatric treatment have had the greatest success.

Adult↗

PubMed2001

Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy.

OBJECT: The authors undertook a study to evaluate the effectiveness of endoscopic third ventriculostomy in the management of hydrocephalus before and after surgical intervention for posterior fossa tumors in children. METHODS: Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at Hĵpital Necker-Enfants Malades in Paris. Excluded were 10 patients in whom shunts had been placed at the referring hospital. The medical records and neuroimaging studies of the remaining 196 patients were reviewed and categorized into three groups: Group A, 67 patients with hydrocephalus present on admission in whom endoscopic third ventriculostomy was performed prior to tumor removal; Group B, 82 patients with hydrocephalus who did not undergo preliminary third ventriculostomy but instead received conventional treatment; and Group C, 47 patients in whom no ventricular dilation was present on admission. There were no significant differences between patients in Group A or B with respect to the following variables: age at presentation, evidence of metastatic disease, extent of tumor resection, or follow-up duration. In patients in Group A, however, more severe hydrocephalus was demonstrated (p < 0.01): the patients in Group C were in this respect different from those in the other two groups. Ultimately, there were only four patients (6%) in Group A compared with 22 patients (26.8%) in Group B (p = 0.001) in whom progressive hydrocephalus required treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence reported in the literature and significantly different from that demonstrated in Group A (p < 0.016). The other six patients (7.3%) were treated by endoscopic third ventriculostomy after tumor resection. In Group C, two patients (4.3%) with postoperative hydrocephalus underwent endoscopic third ventriculostomy. In three patients who required placement of CSF shunts several episodes of shunt malfunction occurred that were ultimately managed by endoscopic third ventriculostomy and definitive removal of the shunt. There were no deaths; however, there were four cases of transient morbidity associated with third ventriculostomy. CONCLUSIONS: Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. The procedure provides a valid alternative to placement of a permanent shunt in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions. Furthermore, in patients in whom CSF has caused spread of the tumor at presentation, third ventriculostomy allows chemotherapy to be undertaken prior to tumor excision by controlling hydrocephalus. Although the authors acknowledge that the routine application of third ventriculostomy in selected patients results in a proportion of patients undergoing an "unnecessary" procedure, they believe that because patients' postoperative courses are less complicated and because the incidence of morbidity is low and the success rate is high in those patients with severe hydrocephalus that further investigation of this protocol is warranted.

Adolescent↗