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PubMed2006

A psycho-educational video used in the emergency department provides effective treatment for whiplash injuries.

STUDY DESIGN: Randomized control trial conducted between June 2000 and September 2002. OBJECTIVE: To determine whether a short psycho-educational video shown in the Emergency Department shortly after the injury would produce follow-up pain reductions and reduced medical utilization. SUMMARY OF BACKGROUND DATA: Chronic pain following a whiplash injury is one example of the massive medical/legal problem of chronic muscular pain. Approaches using local pain sources (trigger points) have shown promise as treatment models for this type of pain. METHODS: 1) SETTING: Emergency Departments (ED) and urgent care (UC) facilities. 2) PATIENTS: 126 patients entering EDs or UCs. 3) INTERVENTION: PATIENTS assigned to 12-minute video or care as usual. 4) MAIN OUTCOME MEASURES: Short Form Musculoskelatal Function Assessment (SMFA), phone questionnaires assessing: narcotics use, ER use, UC use, surgical consultations, etc. RESULTS AND CONCLUSIONS: PATIENTS viewing the video had dramatically lower pain ratings at a 1-month follow (6.09 [10.6] vs. 21.23 [17.4], P < 0.001) and this pattern held for the 3- and 6-month follow-up period. Similarly, for 17 of 21 items asked at follow-up, the video group showed superior outcomes (chi2 ranged from 5 to 35, P < 0.05, all). For example, 4% of video patients were using narcotics at 6 month post ED visit compared with 36% of controls. The brief psycho-educational video had a profound effect on subsequent pain and medical utilization.

Adult↗

PubMed1990

Pressure transducers: an overlooked source of sepsis in the intensive care unit.

Between January 1988 and May 1989 twenty cases of bacteremia due to Flavobacterium sp. occurred in 17 patients admitted to a surgical intensive care unit. Epidemiologic studies disclosed that the source of the Flavobacterium bacteremias was contaminated reusable pressure transducers. Despite the use of disposable domes spread of the bacteria from the contaminated transducer heads to the fluids given to the patients occurred. An indirect contamination by hands at the time the equipment was initially assembled must have been the mode of transmission. Reinstitution of routine disinfection of the transducer heads controlled the outbreak. Disposable domes failed to prevent septicemia from contaminated pressure transducers.

Cross Infection↗

PubMed2002

Modified technique of percutaneous dilational tracheostomy in 600 cases.

Tracheostomy is frequently required for the treatment of critically ill patients to prevent the complications with prolonged translaryngeal intubation. It may facilitate airway suctioning and improve patient comfort during the process of weaning. The purpose of the study was to introduce a new modified technique for percutaneous dilational tracheostomy (MPDT) and assess its advantages. From November 1997 through December 2000, a series of 600 patients (350 men, 250 women; mean age 44.5 years) underwent MPDT in our department. The technique we used is a combination of the Seldinger and Schachner techniques with an incision of 2 to 3 cm between the cricoid cartilage and the notch. Using a small automatic retractor, the thyroid muscles were dissected with the help of a curved mosquito clamp. This gave us the opportunity to control the isthmus and offered the possibility of ligation when the thyroid was large, providing a good operative field directly on the trachea. Hence we avoided traumatizing the isthmus, which is the main source of hemorrhage during this procedure. The mean operating time was 4.5 minutes. The morbidity rate was 0.04%. One patient developed a subcutaneous emphysema and in three cases we had to ligate the external jugular vein. The surgical incision was completely healed within 3 to 4 days after removing the tracheostoma. No tracheal stenoses were observed during the follow-up. MPDT is a safe, applicable technique that can be performed quickly even by a nonsurgeon in the intensive care unit and emergency department, with a low risk of complications because there is a direct view of the trachea and minimal trauma.

Adult↗

PubMed1982

Generalized peritonitis. To irrigate or not to irrigate the abdominal cavity.

The objectives of surgery for generalized peritonitis are to eliminate the source of continual bacterial contamination and to prevent septicemia and intra-abdominal abscess formation. A prospective randomized study of three different operative approaches of treating residual peritoneal contamination was undertaken: group 1, no peritoneal irrigation (14 patients); group 2, intraoperative peritoneal irrigation (15 patients); group 3, both intraoperative and postoperative peritoneal irrigation (15 patients). The mortality in groups 1, 2, and 3 was 28.5%, 26.6%, and 33%, respectively. The overall incidence of septicemia and intra-abdominal abscesses in groups 1, 2, and 3 was 23%, 22%, and 17%, respectively. In those patients who survived, the incidence of intra-abdominal abscesses, wound infection, and septicemia was 6%, 23%, and 13%, respectively. In this series, there was no detectable difference in the mortality and infectious complications between the three treatment groups. The only clinical factors that adversely affected mortality and morbidity were peritonitis originating from the colon and age greater than 60 years. Early surgical intervention with removal of the source of peritonitis, debridement of all necrotic tissue, and drainage of abscesses remain the cornerstones of successful therapy in generalized peritonitis.

Abdomen↗

PubMedDate not supplied

Compressed-air power tools in orthopaedic surgery: exhaust air is a potential source of contamination.

OBJECTIVES: To determine if the exhaust from surgical compressed-air power tools contains bacteria and if the exhaust leads to contamination of sterile surfaces. DESIGN: Bacteriologic study of orthopaedic power tools. SETTING: Level I trauma center operative theater. PATIENTS/PARTICIPANTS: None. INTERVENTION: Part I. Exhaust from two sterile compact air drills was sampled directly at the exhaust port. Part II. Exhaust from the drills was directed at sterile agar plates from varying distances. The agar plates represented sterile surfaces within the operative field. Part III. Control cultures. A battery-powered drill was operated over open agar plates in similar fashion as the compressed-air drills. Agar plates left open in the operative theater served as controls to rule out atmospheric contamination. Random cultures were taken from agar plates, gloves, drills, and hoses. MAIN OUTCOME MEASUREMENT: Incidence of positive cultures. RESULTS: In Part I, all filters from both compressed-air drill exhausts were culture negative ( = 0.008). In Part II, the incidence of positive cultures for air drills number one and number two was 73% and 82%, respectively. The most commonly encountered organisms were, coagulase-negative Staphylococcus, and Micrococcus species. All control cultures from agar plates, battery-powered drill, gloves, and hoses were negative ( < 0.01). CONCLUSIONS: Exhaust from compressed-air power tools in orthopaedic surgery may contribute to the dissemination of bacteria onto the surgical field. We do not recommend the use of compressed-air power tools that do not have a contained exhaust.

Air Microbiology↗

PubMed2004

Pseudomonas infections in the thermally injured patient.

Pseudomonas aeruginosa, remains a serious cause of infection and septic mortality in burn patients, particularly when nosocomially acquired. A prototypic burn patient who developed serious nosocomially acquired Pseudomonas infection is described as an index case which initiated investigations and measures taken to identify the source of the infection. The effect of changes in wound care to avoid further nosocomial infections was measured to provide data on outcome and cost of care. The bacteriology of Pseudomonas is reviewed to increase the burn care providers understanding of the behaviour of this very common and serious pathogen in the burn care setting, before reviewing the approach to detection of the organism and treatment both medically and surgically. After controlling the nosocomial spread of Pseudomonas in our burn unit, we investigated the morbidity and mortality associated with nosocomial infection with an aminoglycoside resistant Pseudomonas and the associated costs compared to a group of case-matched control patients with similar severity of burn injury, that did not acquire resistant Pseudomonas during hospitalization at our institution. We found a significant increase in the mortality rate in the Pseudomonas group compared to controls. The morbidity in terms of length of stay, ventilator days, number of surgical procedures, and the amount of blood products used were all significantly higher in the Pseudomonas group compared to controls. Costs associated with antibiotic requirements were also significantly higher in the Pseudomonas group. Despite this increased resource consumption necessary to treat Pseudomonas infections, these efforts did not prevent significantly higher mortality rates when compared to control patients who avoided infection with the resistant organism. Thus, in addition to the specific measures required to identify and treat nosocomial Pseudomonas infections in burn patients, prevention of infection through modification of treatment protocols together with continuous infection control measures to afford early identification and eradication of nosocomial Pseudomonas infection are critical for cost-effective, successful burn care.

Adult↗

PubMed1999

Omphalocele delivery enigma: the best mode of delivery still remains dubious.

OBJECTIVE: To determine an optimal route of delivery for fetuses with prenatally diagnosed omphalocele. DATA SOURCE: MEDLINE search of years 1966-1996. RESULTS: Descriptive retrospective analyses do not support the idea that cesarean delivery of fetuses with omphalocele is associated with an improved survival rate. However, most of those studies do not control for confounding variables like type and severity of associated anomalies, omphalocele size, prematurity rate, presence of trial of vaginal delivery, rate of intrapartum sac rupture, tertiary treatment centers accessibility, time and type of surgical correction, and postoperative morbidity. There is no evidence that vaginal delivery is safer than cesarean for fetuses with isolated small omphalocele. Fetuses with giant (>5 cm) omphalocele should be delivered by cesarean section. Vaginal delivery at term is offered for fetuses with coexisting life-threatening anomalies. CONCLUSIONS: We propose that until randomized trial of vaginal and cesarean delivery for fetal omphalocele is available, the preferred mode of delivery would be the vaginal route as that is safer for the mother.

Abnormalities, Multiple↗

PubMed2000

Role of xanthine oxidase in small bowel mucosal dysfunction after surgical stress.

BACKGROUND: The small intestine is highly susceptible to surgical stress even at remote locations. An earlier study using a rat model indicated that oxidative stress plays an important role in this process. The enzyme xanthine oxidase is an important source of free radicals in the small intestine. The role of this enzyme in intestinal damage after surgical stress was examined. METHODS: Rats pretreated with xanthine oxidase inhibitors were subjected to surgical stress by opening the abdomen and handling the intestine, as done during laparotomy. Enterocytes at various stages of differentiation were isolated and the protection offered by xanthine oxidase inhibitors against damage due to surgical stress was determined and compared with normal controls. Protection against ultrastructural changes to the mucosa, as well as mitochondrial function was examined. RESULTS: Surgical stress affected both the villus as well as crypt cells, causing increased superoxide generation, accompanied by increased activity of xanthine oxidase. Xanthine oxidase inhibitors ameliorated the increased superoxide generation, and protected against mitochondrial damage and ultrastructural changes in the intestine. CONCLUSION: Surgical stress affects both the villus and crypt cell populations in the small intestine. The enzyme xanthine oxidase maybe an important mediator of surgical stress in the intestine.

Animals↗

PubMed1994

Asphyxial death caused by postextraction hematoma.

A 71-year-old man was admitted to an emergency room because of postextraction hemorrhage and died of asphyxia caused by airway obstruction. About 40 days earlier, he had had 11 carious teeth removed without postextraction bleeding. At autopsy, liver cirrhosis was found, but examination of his previous extractions and postmortem external findings did not show a general hemorrhagic tendency. The surgical incision in the gingiva had been sutured, and no damage to the bony socket or large vasculature was found. We could not determine the etiologic source of the decedent's rapidly increasing hematoma. Postextraction hemorrhage or hematoma is a common complication in routine dental extraction, but marked hematoma formation around the airway may cause critical respiratory problems in the short run. In such cases, the maintenance of the airway, including control of hemorrhage, is necessary at an early stage.

Aged↗

PubMed1999

Perioperative fractionated high-dose rate brachytherapy for malignant bone and soft tissue tumors.

PURPOSE: To investigate the viability of perioperative fractionated HDR brachytherapy for malignant bone and soft tissue tumors, analyzing the influence of surgical margin. METHODS AND MATERIALS: From July 1992 through May 1996, 16 lesions of 14 patients with malignant bone and soft tissue tumors (3 liposarcomas, 3 MFHs, 2 malignant schwannomas, 2 chordomas, 1 osteosarcoma, 1 leiomyosarcoma, 1 epithelioid sarcoma, and 1 synovial sarcoma) were treated at the Osaka University Hospital. The patients' ages ranged from 14 to 72 years (median: 39 years). Treatment sites were the pelvis in 6 lesions, the upper limbs in 5, the neck in 4, and a lower limb in 1. The resection margins were classified as intracapsular in 5 lesions, marginal in 5, and wide in 6. Postoperative fractionated HDR brachytherapy was started on the 4th-13th day after surgery (median: 6th day). The total dose was 40-50 Gy/7-10 fr/4-7 day (bid) at 5 or 10 mm from the source. Follow-up periods were between 19 and 46 months (median: 30 months). RESULTS: Local control rates were 75% at 1 year and 48% in 2 years, and ultimate local control was achieved in 8 (50%) of 16 lesions. Of the 8 uncontrolled lesions, 5 (63%) had intracapsular (macroscopically positive) resection margins, and all the 8 controlled lesions (100%) had marginal (microscopically positive) or wide (negative) margins. Of the total, 3 patients died of both tumor and metastasis, 3 of metastasis alone, 1 of tumor alone, and 7 showed no evidence of disease. Peripheral nerve palsy was seen in one case after this procedure, but no infection or delayed wound healing caused by tubing or irradiation has occurred. CONCLUSION: Perioperative fractionated HDR brachytherapy is safe, well tolerated, and applicable to marginal or wide surgical margin cases.

Adolescent↗

PubMed2001

Epidemiology and infection control implications of Acinetobacter spp. in Hong Kong.

In a previous study, we showed that Acinetobacter genomic DNA group 3 was the most common species among blood culture isolates and was commonly found on superficial carriage sites of the healthy and the sick, which are different findings from those reported in Europe and North America. We used amplified ribosomal DNA restriction analysis and pulsed-field gel electrophoresis to study further the molecular epidemiology of acinetobacters in our region. Over a study period of 6 weeks with 136 consecutive routine clinical isolates (1.33% of all specimens), genomic DNA groups 2 (Acinetobacter baumannii), 3, and 13TU were obtained from 59 of 69 positive patients. There is a significant difference in the specimen sources of the three genomic DNA groups, with group 13TU being significantly associated with the respiratory tract (chi-square exact test, P = 0.0064). Settle plates showed a significantly heavier environmental load from the intensive care unit (ICU) than from the four surgical wards examined (22 of 70 versus 76 of 120 plates with <5 colonies; chi-square test, P < 0. 0001). Genomic group 3 accounted for 6 of 12 clusters of possibly related strains among patients, between patients and the ICU environment, and in the ICU environment. Genomic groups 2 and 3 accounted for 21% of the 132 genomically identified isolates recovered from 21 of 41 local vegetables, 53 of 74 fish and meat samples, and 22 of 60 soil samples. Group 13TU was present only in patients' immediate surroundings. The role played by the environment and by human carriage should be evaluated in order to devise a cost-effective infection control program pertinent to our situation of acinetobacter endemicity.

Acinetobacter↗

PubMed2000

Pericardial patch for rapid and effective hemostasis of cardioplegia injection site.

Cardioplegia injection site may be the source of serious haemorrhagic complications either intraoperatively or during the early postoperative period. Here we describe a simple technique that allows a rapid control of hemostasis at this site. An autologous pericardial patch is used to repair and strengthen the aortic wall.

Aorta, Thoracic↗

PubMed1986

Carotid surgery, cognitive function, and cerebral blood flow in patients with transient ischemic attacks.

Psychological testing, cerebral blood flow (CBF) measurement, and computed tomographic scan were performed before and 3 months after operation in 31 patients subjected to endarterectomy of the internal carotid artery (ICA) because of transient ischemic attacks and in 11 control patients operated on for atherosclerosis of the lower extremities. In preoperative psychological testing both carotid surgery patients and controls performed somewhat below the normal level for their age group. Postoperatively, cognitive functions improved in the carotid surgery group but not in the control group. The improvement was related to the laterality of the operation, being more marked in verbal tests in patients with left ICA operation and in visuospatial tests in patients with right ICA operation. Postoperatively regional CBF improved in 2 patients only. Hence the intellectual improvement could not be related to changes in CBF. Intellectual deterioration in patients with internal carotid atherosclerosis may be delayed or terminated by surgical abolition of the source of multiple cerebral embolizations.

Adult↗

PubMed2005

Management of delayed visceral arterial bleeding after pancreatic head resection.

Despite low mortality, postoperative complications are still relatively frequent after pancreatic head resection. The occurrence of delayed visceral arterial bleeding from erosions or pseudoaneurysms of branches of the celiac trunk or from the stump of the gastroduodenal artery is a rare but life-threatening complication and is probably underreported in the literature. During a 10-year period, we diagnosed and treated 12 patients (three referred from other hospitals) with severe visceral arterial bleeding, presenting 7 to 85 days after pancreatic head resection. Clinical presentation was gastrointestinal bleeding (seven patients) or abdominal bleeding (five patients). The bleeding source was identified by angiography in 10 of the 12 cases. Definitive bleeding control was achieved by angiography in six of the 12 patients (stent 2, coiling 4), or by surgery in five patients. None of the six patients with successful angiographic intervention required further surgery for bleeding control. One patient died due to hemorrhage before bleeding was controlled. Median transfusion requirement was 12.5 (range 3-37) units. Of five patients with interventional or surgical occlusion of the common hepatic artery, three developed hepatic abscesses and two had complications of the hepaticojejunostomy. One of those five patients died four months after definitive bleeding control because of recurrent hepatic abscesses. All other patients eventually recovered completely. We conclude that delayed arterial bleeding from visceral arteries is a rare but life-threatening complication after pancreatic head resection. Angiographic stenting with preservation of hepatic blood flow, if technically possible, represents the best treatment option.

Aged↗

PubMed2003

A guide to developing a systematic review.

Systematic reviews are used to gather information from a variety of sources and distill information based on best evidence synthesis, while also excluding poor quality studies via explicit validity checks. This article provides a roadmap to conducting a systematic review with the Cochrane Collaboration and uses an example of a completed systematic review. The literature is drawn upon to provide rationale for the processes undertaken. The aim of the sample systematic review was to identify and review all randomized controlled trials evaluating disposable surgical face masks worn by surgical team members during clean surgery to prevent postoperative surgical wound infection.

Female↗

PubMed2006

Early treatment of skeletal open-bite malocclusion.

DATA SOURCES: Studies were identified by searching the Cochrane Controlled Clinical Trials Register and Medline. STUDY SELECTION: Randomised clinical trials (RCT), prospective and retrospective studies that had concurrent untreated as well as normal controls, and clinical trials that compared at least two treatment strategies but did not have any untreated or normal control group were included. The following were excluded: case series; descriptive studies; case reports; studies concerning treatment in the permanent dentition/ adult patients, surgically assisted treatment, treatment combined with extractions, treatment with full-fixed appliances; and discussion or debate articles. DATA EXTRACTION AND SYNTHESIS: Year of publication, study design, materials, dropouts, measurements, treatment time, success rate, decrease of open bite and divergence, side effects, costs, and authors' conclusions were recorded. Two independent reviewers assessed the articles independently and a quality evaluation and qualitative summary were performed. RESULTS: A total of 1049 articles were identified of which seven were included in the review. No RCT of early treatment of anterior open bite have been performed. Two controlled clinical trials of early anterior open bite were identified, and these both indicated the effectiveness of treatment in the mixed dentition with headgear or functional appliances (or both). Most of the studies had serious problems with lack of power because of small sample size, bias and confounding variables; lack of method-error analysis or blinding in measurements; and deficient or lack of statistical methods. CONCLUSIONS: The quality of the studies was insufficient to allow any evidence-based conclusions to be drawn. RCT of sufficient sample size are still needed to determine which treatment is the most effective for early correction of skeletal open bite. Future studies should also include the assessment of long-term stability as well as an analysis of the cost and side-effects of the interventions.

Comment↗

PubMed2003

The outcome in Australian children with hyperinsulinism of infancy: early extensive surgery in severe cases lowers risk of diabetes.

AIMS: Hyperinsulinism of infancy (HI) is characterized by unregulated insulin secretion in the presence of hypoglycaemia, often resulting in brain damage. Pancreatic resection for control of hypoglycaemia is frequently resisted because of the risk of diabetes mellitus (DM). We investigated retrospectively 62 children with HI from nine Australian treatment centres born between 1972 and 1998, comparing endocrine and neurological outcome in 28 patients receiving medical therapy alone with 34 who required pancreatic resection to control their hypoglycaemia. METHODS: History, treatment and clinical course were ascertained from file audit and interview. Risk of DM (hazard ratio) attributable to age at surgery (< vs. > or = 100 days at last pancreatectomy) and extent of resection (< vs. > or = 95%) were calculated using Cox proportional hazards regression and categorical variables compared by the chi2-test. Neurological outcome (normal, mild deficit or severe deficit) was derived from the most authoritative source. RESULTS: Surgically treated patients had a greater birthweight, earlier presentation and higher plasma insulin levels. Of 18 infants < 100 days and 16 > or = 100 days of age at surgery, four (all > or = 100 days) became diabetic as an immediate consequence of surgery and five (two < 100 days and three > or = 100 days) became diabetic 7-18 years later. Surgery > or = 100 days and pancreatectomy > or = 95% were associated with development of diabetes (HR = 12.61, CI 1.53-104.07 and HR = 7.03, CI 1.43-34.58, respectively). Neurodevelopmental outcome was no different between the surgical and medical groups with 44% overall with neurological deficits. Patients euglycaemic within 35 days of the first symptom of hypoglycaemia (Group A) had a better neurodevelopmental outcome than those still hypoglycaemic > 35 days from first presentation (Group B) (P = 0.007). Prolonged hypoglycaemia in Group B was due either to delayed diagnosis or to need for repeat surgery because of continued hypoglycaemia. Within Group A, medically treated patients (who presented later with apparently milder disease) had a higher incidence of neurodevelopmental deficit (n = 15, four mild, three severe deficit) compared with surgically treated patients (n = 18, two mild, none severe deficit) (P < 0.025). CONCLUSIONS: Poor neurodevelopmental outcome remains a major problem in hyperinsulinism of infancy. Risk of diabetes mellitus with pancreatectomy varies according to age at surgery and extent of resection. Patients presenting early with severe disease have a better neurodevelopmental outcome and lower risk of diabetes if they are treated with early extensive surgery.

Age of Onset↗

PubMed1994

Therapeutic lamellar keratectomy in the management of experimental keratomycosis.

Keratomycosis, a vision-threatening corneal infection, is a challenge to the ophthalmologist because it is often refractory to medical treatment. Surgical keratectomy may not only debulk the major infectious source but potentiate the intracorneal penetration of the antifungal agents. To evaluate the efficacy of keratectomy in managing the fungal corneal ulcer, three common keratomycosis models, Candida, Fusarium, and Aspergillus keratitis, were established in 46 eyes of 23 rabbits (each group had 14, 16 and 16 eyes respectively). Within each keratitis group, the infected eyes were randomly divided into equally numbered experimental and control subgroups. The eyes of the experimental subgroups underwent therapeutic lamellar keratectomy once the typical fungal corneal infection had developed after inoculation. Following keratectomy, eyes of both the treated and control groups received natamycin eyedrops and were regularly examined biomicroscopically. Our results showed that therapeutic lamellar keratectomy is beneficial in chronic, indolent keratitis, such as Candida and Fusarium keratitis, where it promoted corneal healing and shortened the duration of treatment required. The procedure is a valuable adjunctive measure for antifungal agents in these two types of keratitis. However, acute keratitis of the Aspergillus group did not benefit from keratectomy; in these cases, surgery may actually increase the risk of corneal perforation.

Animals↗