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PubMedDate not supplied

Induction of controlled cardiac tamponade in the management of massive unexplained postcardiotomy bleeding. Case report and review of the literature.

Massive unexplained bleeding is a catastrophic complication of open heart surgery. The following paper describes a successful attempt to terminate such a hemorrhage by induction of controlled cardiac tamponade which caused augmentation of mediastinal pressure without hemodynamic decompensation, thereby aiding in hemostasis. This modality has not previously reported. Few events in clinical medicine are so ominous as the major unexplained hemorrhage. Diffuse bleeding from multiple transected small vessels may be controlled by mechanical techniques which apply pressure directly over the bleeding area. However, where the mediastinum is the source of bleeding, application of such a direct pressure with a closed chest, is both technically difficult and potentially risky. Reported attempts to stop bleeding by increasing the mediastinal pressure included the induction of pneumothorax, and the increase of positive end expiratory pressure (PEEP) has been published. To the best of our knowledge, a deliberate induction of controlled cardiac tamponade in order to terminate prolonged unexplained massive postcardiotomy hemorrhage has not been reported so far.

Aged↗

PubMed1988

Multiple intensive care unit outbreak of Acinetobacter calcoaceticus subspecies anitratus respiratory infection and colonization associated with contaminated, reusable ventilator circuits and resuscitation bags.

PURPOSE: Acinetobacter calcoaceticus subspecies anitratus (A. anitratus) can cause nosocomially and community acquired pneumonia. Source identification of the organism is often difficult. An outbreak of respiratory infection and colonization with A. anitratus affecting 93 ventilated patients in all six of a hospital's intensive care units (ICUs) over 10 months is described. PATIENTS AND METHODS: In April 1984, the infection control staff started to review positive culture results from all patients in all ICUs. At this point, information on significant isolates was recorded by patient, site, date, genus and species, and antimicrobial susceptibility. During the month of August 1984, an increased number of A. anitratus isolates from sputum began to be detected. Information was expanded to include the date of hospital admission, ICU admission, intubation, and extubation; the dates and types of all surgical procedures; the results and dates of all prior sputum cultures; and the use of nebulized bronchodilator medications. Monthly numbers of cases were compared for four months prior to the outbreak, during the outbreak, and for seven months after the outbreak. Plasmid DNA from isolates was prepared, electrophoresed, and visualized. Isolates were designated according to the molecular weights of visualized plasmids. RESULTS: Barrier precautions and improved staff handwashing did not diminish the frequency of new cases. When pasteurized, reusable ventilator circuits and resuscitation bags were cultured for the possibility of low-level contamination, 18 percent were positive for A. anitratus. Terminal ethylene oxide sterilization of these devices was associated with prompt control of the outbreak. Plasmid DNA analysis of isolates from patients involved in the outbreak, contaminated devices, and the hands of personnel responsible for device disinfection revealed two predominant plasmid profiles. After outbreak control, isolates with these profiles were found much less frequently in patient specimens. CONCLUSION: Contaminated, reusable ventilator support equipment may be a leading cause for the extent of A. anitratus in the sputum of intubated patients. This problem is potentially correctable by the use of terminal etyhlene oxide sterilization of reusable ventilator circuits and resuscitation bags.

Acinetobacter↗

PubMed2001

A review of the medical treatment of primary aldosteronism.

PURPOSE: Use of the aldosterone-to-renin ratio (ARR) has suggested that at least one in 10 hypertensive subjects have primary aldosteronism (PA). There is thus a timely need to review the literature for effective drug therapies and to speculate on other therapeutic options by taking into account recent advances in understanding of the PA disease pathophysiological process. DATA SOURCE: A MEDLINE and EMBASE search of all articles published from the start of the databases until July 1999 and reviews of the bibliographies of textbooks. STUDY SELECTION: Primary research articles on the medical treatment of PA with emphasis on diagnosis, treatment option, drug dosage, therapeutic response and adverse drug effect. DATA EXTRACTION: Study design and quality were assessed. Relevant data on diagnostic methodology, drug usage and response were analysed and compared. DATA SYNTHESIS: A select number of subjects with aldosterone-producing adenoma (APA) can be expected to respond well to surgical treatment For the majority of PA cases especially subjects with idiopathic hyperaldosteronism (IHA), long-term medical treatment is now safe and feasible although no randomized controlled trials have been carried out to date. The best therapeutic response is obtained by directly antagonizing aldosterone at the receptor level using medium to low dose spironolactone and this response can be predicted by a raised ARR. The response to other potassium-sparing diuretics and calcium channel blockers are modest. IHA responds better than angiotensin II-unresponsive APA to angiotensin converting enzyme inhibitors and this may also be true with angiotensin II receptor blockers. The discovery of the aldosterone synthase gene opens up the possibility for gene therapy. CONCLUSION: The diagnosis of PA allows appropriate management with resultant blood pressure control in many hypertensive subjects who otherwise have resistant hypertension despite multiple drug therapy.

Aldosterone↗

PubMed2004

Robotic prostatectomy - a review.

OBJECTIVE: To review the current medical literature on robotic prostatectomy (RP) and report clinical outcomes of this newly developed technique. DATA SOURCE: A MEDLINE search was performed using the following headings: prostate cancer, radical prostatectomy, robotics, robot assisted, laparoscopy, telesurgery. In addition, recently published abstracts on RP were reviewed. STUDY SELECTION: Studies that reported clinical and pathological variables of patients undergoing RP were included in this meta-analysis. DATA EXTRACTION: Data were extracted from published articles and abstracts. DATA SYNTHESIS: Robotic systems enhance surgeons' technical abilities and offer the potential of precise surgical technique. Short-term follow-up studies demonstrate that RP is at least comparable in efficacy to open and laparoscopic prostatectomy, including clinical and pathologic parameters. RP has benefits of minimal invasiveness, decreased blood loss, and quicker recovery compared with open surgery. Functional and cancer control results are still immature, but most studies reported favorable outcomes. CONCLUSIONS: RP is a promising minimally invasive surgical approach for men with prostate cancer. Short-term clinical and pathological results are comparable to those with open and laparoscopic prostatectomy.

Humans↗

PubMed2003

Surgical informatics on the Internet: any improvement?

PURPOSE: The Internet is a popular, but ungoverned, source of medical information. This study tracked the change in performance of commonly available search engines and the quality of medical data therein over a four-year period. METHODS: We compared the accuracy of information on a commonly performed surgical procedure (vasectomy) using six standard search engines in a four-year period and with two recently developed search engines. The top 25 ranked sites cited by each search engine were scored for description of the procedure, post-operative instructions, complications and unproven associations. RESULTS: There was no improvement in quality of individual sites over the study period. Additionally, the hit rate of search engines remained poor with 27 sites cited (40%) in 2002 either irrelevant or unavailable. DISCUSSION: Few useful sites with accurate information on surgical procedures are available on the Internet and simple search strategies fail to identify site quality or relevancy. CONCLUSION: At present, the Internet cannot be recommended as a reliable resource for many aspects of health information for patients. The onus is on health-care providers to provide high quality sites and direct patients to these sources of reliable information

Humans↗

PubMed1989

Catheter ablation of canine myocardium with radiofrequency energy.

High energy direct-current shocks delivered via an electrode catheter have been used to ablate the atrioventricular junction since 1981. This technique has also been adapted for ablation of other cardiac tissues including the atrium, posterior interatrial septum and ventricular myocardium. The limitations of this technique include inadequate control of the energy source, poor understanding of the mechanisms of myocardial injury, and untoward complications possibly related to barotraumatic injury. Radiofrequency energy has been shown to create ablative injury when delivered to the myocardium via standard electrode catheters. This report will review our experience with radiofrequency catheter ablation of the canine myocardium with specific emphasis on the biophysical aspects of lesion formation.

Animals↗

PubMed1995

The diagnosis and management of breast problems during pregnancy and lactation.

BACKGROUND: In addition to mastitis, lactational breast abscesses, and several other benign conditions unique to the puerperium, pregnant women may develop any of the other breast problems seen in the nonpregnant female population. This review deals with the diagnosis and management of breast problems during pregnancy and lactation. DATA SOURCES: A literature review of the evaluation, technique of biopsy, and treatment of cancer in pregnant women was conducted. CONCLUSIONS: The most common problems fall into a spectrum of infectious complications from milk stasis or mastitis to frank abscess formation. Galactoceles, noninfected milk-filled cysts, present as tender masses; aspiration is both diagnostic and curative. Benign fibroadenomas occasionally enlarge significantly or infarct during pregnancy. A physiologic nipple discharge is common during pregnancy, and may be bloody. Rare cases of massive breast hypertrophy during pregnancy have been reported. The mortality of breast cancer during pregnancy is related to delay: compared stage-for-stage with nonpregnant controls, the prognosis is similar. As a general rule, the cancer should be treated surgically and the pregnancy may be allowed to progress.

Abscess↗

PubMed2006

The clinical and cost-effectiveness of oxaliplatin and capecitabine for the adjuvant treatment of colon cancer: systematic review and economic evaluation.

OBJECTIVES: To assess the clinical and cost-effectiveness of oxaliplatin in combination with 5-fluorouracil/leucovorin (5-FU/LV), and capecitabine monotherapy (within their licensed indications), as adjuvant therapies in the treatment of patients with Stage III (Dukes' C) colon cancer after complete surgical resection of the primary tumour, as compared with adjuvant chemotherapy with an established fluorouracil-containing regimen. DATA SOURCES: Ten electronic bibliographic databases were searched from inception to January 2005. Searches were supplemented by hand searching relevant articles, sponsor and other submissions of evidence to the National Institute of Health and Clinical Excellence and conference proceedings. REVIEW METHODS: A systematic review and meta-analysis (where appropriate) of clinical efficacy evidence and a cost-effectiveness review and economic modelling were carried out. Marginal costs, life years gained and cost-effectiveness acceptability curves were estimated. Probabilistic sensitivity analysis was used to generate information on the likelihood that each of the interventions was optimal. RESULTS: Three randomised active-controlled trials, of varying methodological quality, were included in the review. The MOSAIC trial and NSABP C-07 study considered the addition of oxaliplatin to adjuvant treatment (albeit administered in different 5-FU/LV regimens) and the X-ACT study compared oral capecitabine with bolus 5-FU/LV alone. A review of the available evidence indicated that in patients with Stage III colon cancer, oxaliplatin in combination with an infusional de Gramont schedule of 5-FU/LV (FOLFOX4) was more effective in preventing and delaying disease recurrence than infusional 5-FU/LV alone (de Gramont regimen). Serious adverse events and treatment discontinuations due to toxicity were more evident with oxaliplatin-based regimens (FOLFOX4 and FLOX regimen) than infusional or bolus 5-FU/LV alone (de Gramont and Roswell Park regimen). Oral capecitabine was at least equivalent in disease-free survival to the bolus Mayo Clinic 5-FU/LV regimen for patients with resected Stage III colon cancer. Although, the safety and tolerability profile of capecitabine was superior to that of the Mayo Clinic 5-FU/LV regimen, it has not been evaluated in comparison with other less toxic 5-FU/LV regimens currently in common use in the UK. Based on the assumptions and survival analysis methods used, the cost-effectiveness analysis using economic modelling estimated that capecitabine was a dominating strategy and resulted in a cost-saving of approximately pound 3320 per patient in comparison with the Mayo Clinic 5-FU/LV regimen, while also providing an additional 0.98 quality-adjusted life-years (QALYs) over a 50-year model time horizon. Oxaliplatin in combination with 5-FU/LV (FOLFOX4 regimen) is estimated to cost an additional pound 2970 per QALY gained when compared with the de Gramont 5-FU/LV regimen and demonstrated superior survival outcomes with marginal costs. The uncertainty analysis suggests that both interventions have a high probability of being cost-effective at a threshold of both pound 20,000 and pound 30,000. An indirect comparison of the FOLFOX4 and Mayo Clinic 5-FU/LV regimens suggests that the use of FOLFOX4 in place of the Mayo Clinic 5-FU/LV regimen would cost an additional pound 5777 per QALY gained. An incremental cost-effectiveness ratio (ICER) is estimated to be approximately pound 13,000 per QALY gained from treatment with FOLFOX4 compared with capecitabine. However, if the Mayo Clinic and the de Gramont 5-FU/LV regimens are assumed to be equivalent in terms of effectiveness, the ICER of FOLFOX4 in comparison with capecitabine may be greater than pound 30,000 per QALY. CONCLUSIONS: The evidence suggests that both capecitabine and FOLFOX4 are clinically effective and cost-effective in comparison with 5-FU/LV regimens (Mayo Clinic and de Gramont schedules). Further research is suggested into the effectiveness, tolerability, patient acceptability and costs of different oxaliplatin/fluoropyrimidine schedules in the adjuvant setting; the effects of treatment duration on efficacy; adverse events; resource data collection strategies and reporting of summary statistics; subgroups benefiting most from adjuvant chemotherapy; and methods for estimating mean survival.

Antimetabolites, Antineoplastic↗

PubMedDate not supplied

[Gunshot injuries in the pediatric area].

Gunshot and air weapon wounds in children have become a significant source of morbidity and mortality in our community in the last four years. Ninety five children, 15 years of age and younger, were admitted to the Pediatric Surgical Service for gunshot and air mechanism wounds during this period. Review of the circumstances of injury revealed that more than 50% were accidental 71% were male patients, and 65% were caused by gunshots and outside of the home. Thoracic region was affected in 42%; abdomen, 20%; skull, face and neck, 13.4%; lower extremities, 13.4%; upper extremities 9%; genitalia, 2.0%; and perineal region, 0.8%. Rapid resuscitation and triage of major injury allowed us a survival of 97%. Social service intervention and educational task can offer significant benefit to these children but, ultimately gun control laws with strict enforcement are needed to stop this type of violence toward children.

Adolescent↗

PubMed1985

Surgical sympathectomy increases pancreatic polypeptide response to food.

Numerous studies in man and animals suggest that beta-adrenergic receptors stimulate pancreatic polypeptide (PP) release whereas alpha-adrenergic receptors inhibit PP release. This study was undertaken to further clarify the role of the adrenergic nervous system in regulating PP release. We evaluated the effects of stellatectomy and celiacectomy on resting and meat meal-stimulated PP release in the dog. PP release was studied in three stages--control, poststellatectomy, and poststellatectomy plus celiacectomy in five dogs. The meat meal caused a prompt and prolonged increase in plasma levels of PP. Stellatectomy did not alter the control PP response. However, celiacectomy increased basal and peak PP levels and enhanced the early and late phases of delta-integrated PP release. The data suggest that the celiac and superior mesenteric ganglia are the main source of the adrenergic innervation of the pancreas and that this innervation is primarily an inhibitor of PP release.

Animals↗

PubMed2003

Systematic review of the clinical effectiveness and cost-effectiveness of tension-free vaginal tape for treatment of urinary stress incontinence.

OBJECTIVES: To evaluate the effectiveness and cost-effectiveness of tension-free vaginal tape (TVT) in comparison with the standard surgical interventions currently used. DATA SOURCES: Literature searches were carried out on electronic databases and websites for data covering the period 1966--2002. Other sources included references lists of relevant articles; selected experts in the field; abstracts of a limited number of conference proceedings titles; and the Internet. REVIEW METHODS: A systematic review of studies including comparisons of TVT with any of the comparators was conducted. Alternative treatments considered were abdominal retropubic colposuspension (including both open and laparoscopic colposuspension), traditional suburethral sling procedures and injectable agents (periurethral bulking agents). The identified studies were critically appraised and their results summarised. A Markov model comparing TVT with the comparators was developed using the results of the review of effectiveness and data on resource use and costs from previously conducted studies. The Markov model was used to estimate costs and quality-adjusted life-years for up to 10 years following surgery and it incorporated a probabilistic analysis and also sensitivity analysis around key assumptions of the model. RESULTS: Based on limited data from direct comparisons with TVT and from systematic reviews, laparoscopic colposuspension and traditional slings have broadly similar cure rates to TVT and open colposuspension, whereas injectable agents appear to have lower cure rates. TVT is less invasive than colposuspension and traditional sling procedures, and is also usually performed under regional or local anaesthesia. The principal operative complication is bladder perforation. There are currently no randomised controlled trial (RCT) data beyond 2 years post-surgery, and long-term effects are therefore currently not known reliably. TVT was more likely to be considered cost-effective compared with the other surgical procedures. Increasing the absolute probability of cure following TVT reduced the likelihood that TVT would be considered cost-effective. CONCLUSIONS: The long-term performance of TVT in terms of both continence and unanticipated adverse effects is not known reliably at the moment. Despite relatively few robust comparative data, it appears that in the short to medium term TVT's effectiveness approaches that of alternative procedures currently available, and is of lower cost. As TVT is a less invasive procedure, it is possible that some women who would currently be managed non-surgically will be considered eligible for TVT. Increased adoption of TVT will require additional surgeons proficient in the technique. It is likely that some of the higher rates of complications, e.g. bladder perforation, reported for TVT are associated with a 'learning curve'. Appropriate training will therefore be needed for surgeons new to the operation, in respect of both the technical aspects of the procedure and the choice of women suitable for the operation. Further research suggestions include unbiased assessments of longer term performance from follow-up of controlled trials or population-based registries; more data from methodologically sound RCTs using standard outcome measures; a surveillance system to detect longer term complications, if any, associated with the use of tape; and rigorous evaluation before extending the use of TVT to women who are currently managed non-surgically.

Colposcopy↗

PubMed1992

Treatment of non-small cell lung cancer with external beam radiotherapy and high dose rate brachytherapy.

Between August 1985 and September 1989, 62 patients with medically inoperable or surgically unresectable, non-small cell lung cancer were treated with both external beam radiotherapy and high dose rate bronchial brachytherapy. Treatment consisted of external beam radiotherapy (5000-6000 cGy in 5-6 1/2 weeks) and weekly high dose rate bronchial brachytherapy (three to five fractions, 500 cGy at 1 cm from the source) delivered either concurrently or sequentially. Median survival for all patients was 13 months (m). Stage I and Stage IIIA-B patients had median survivals of 20 m and 10 m, respectively. Patients without nodal disease (No) had a significantly longer median survival compared to patients with regional node metastases (N1-3), 17 m versus 9 m. A total of 54 patients were evaluable for local tumor control analysis. Local tumor control was achieved in six of eight patients who had a normal pre-treatment radiograph. Patients with measurable tumor on the pre-treatment radiograph and negative regional nodes had local tumor control in eight of twenty-two (36%) cases. In patients with regional lymphadenopathy, loco-regional tumor control was achieved in four of eight cases. Additionally, there were sixteen patients with non-measurable tumor due to associated effusion, atelectasis and/or infiltrate. Four of these (25%) were considered to have local tumor control. Of 60 evaluable patients, there were nine occurrences of fatal hemorrhage, one of whom was disease-free (NED) at autopsy. The remaining eight patients had either clinical or pathological evidence of recurrent or persistent tumor. Patients who had follow up bronchoscopies were found to have varying degrees of concentric narrowing in the treated areas. One such patient had total lung collapse with no evidence of tumor. While this form of treatment may yield high local control rates in earlier stages, this study suggests the potential risk of fatal complication. Additional studies are warranted to further investigate the use of this modality in the treatment of lung cancer.

Adenocarcinoma↗

PubMedDate not supplied

Axial pattern flap based on the cutaneous branch of the superficial temporal artery in dogs: an experimental study and case report.

OBJECTIVE: To determine the anatomic guidelines and viability of an axial pattern flap based on the cutaneous branch of the superficial temporal artery (STA) in dogs. Application of the flap in a clinical patient is reported. STUDY DESIGN: Flap viability in control and experimental groups was determined 7 days postoperatively. ANIMALS: A total of 14 mature, mesaticephalic dogs; 1 clinical patient. METHODS: The cutaneous branch of the STA and vein were incorporated in the flaps of the experimental groups (group A, n = 5; group B, n = 4) and were ligated in the control group (n = 5). Flap length was extended in experimental group B. Seven days postoperatively, the length and area of tissue that remained viable in each flap was determined and compared with similar measurements performed intraoperatively. Cutaneous fluorescence was also used postoperatively to assess flap perfusion. The flap used in the clinical patient had the same dimensions as flaps developed in group A. RESULTS: Mean survival length (+/- SD) of STA flaps [group A, 9.1 (0.8) cm], was significantly increased (P < .05) compared with control flaps [7.0 (0.6) cm]. Percentage flap length survival (+/- SD) of STA flaps [group A, 91.8 (8.9)%], was significantly increased (P < .05) compared with control flaps [71.6 (7.0)%]. Mean percentage area of survival (+/- SD) of STA flaps [group A, 93.1 (7.5)%], was significantly increased (P < .05) compared with control flaps [73.5 (7.4)%]. Group B flaps had a mean survival length of 10.4 (1.1) cm, percentage flap length survival of 69.5 (4.8)%, and mean percentage area of survival of 69.1 (6.5)%. There was no positive correlation between the area of flap fluorescence at days 0, 1, and 3, and the area of flap survival. Application of the flap in a clinical patient allowed primary wound reconstruction with 100% survival. CONCLUSION: A flap based on the cutaneous branch of the STA may be a source of skin for reconstructive procedures of the maxillofacial region in dogs. CLINICAL RELEVANCE: Knowledge of the anatomic landmarks and expected viability of a STA axial pattern flap is essential before consideration of its use as a reconstructive surgical technique.

Animals↗

PubMed1999

Occupational Exposure to HIV in an Urban University Hospital Setting.

In response to the potential transmission of the human immunodeficiency virus in a hospital setting, an occupational exposure assessment program was established at a New York City university hospital in 1990. During the first year, 322 potential exposures to blood or body secretions in 313 health care workers (HCWs) were reported. Exposures occurred most frequently on the surgical service (36%), and in patients' rooms (37%). Nurses accounted for 53% and physicians 25% of reported exposures. A percutaneous injury was reported by 78% of HCWs. Human error was responsible for the exposure in 54% of HCWs and was associated with a break in universal precautions in one-third. The immune status for HIV antibody, hepatitis B antigen and hepatitis C antibody was positive in 11%, 3% and 9% in source patients, respectively. However, the immune status for these potential nosocomially transmitted pathogens was not determined in 12%-26% of source patients. Based on the source patients HIV antibody status and the extent of injury, zidovudine was recommended to 39 HCWs; 12 refused prophylaxis. HIV seroconversion was not documented in those HCW who returned for follow-up testing. A similar assessment program for medical students rotating on the surgical service revealed that two-thirds were exposed to blood or body fluids while in the operating room. Only 16% of sharps injuries were self-inflicted, whereas 66% were caused by another HCWs, usually a surgical attending or houseofficer. These data underscore the necessity for institutional programs regarding management of HCWs potentially exposed to HIV. Such programs not only provide an indispensable service to the exposed HCW and medical student, but also a means by which infection control policies and educational programs may be monitored and implemented.

Journal Article↗

PubMed2003

Nasal and hand carriage of Staphylococcus aureus in staff at a Department for Thoracic and Cardiovascular Surgery: endogenous or exogenous source?

OBJECTIVE: To investigate the rates of Staphylococcus aureus carriage on the hands and in the noses of healthcare workers (HCWs) and the relatedness of S. aureus isolates found in the two sites. DESIGN: Point-prevalence study. SETTING: Department for Thoracic and Cardiovascular Surgery at the University Hospital of Uppsala, Uppsala, Sweden. SUBJECTS AND METHODS: Samples were obtained from 133 individuals, 18 men and 115 women, using imprints of each hand on blood agar and a swab from the nose. S. aureus isolates were identified by standard methods and typed by pulsed-field gel electrophoresis. RESULTS: S. aureus was found on the hands of 16.7% of the men and 9.6% of the women, and in the noses of 33.3% of the men and 17.4% of the women. The risk ratio for S. aureus carriage on the hands with nasal carriage was 7.4 (95% confidence interval, 2.7 to 20.2; P < .001). Among the 14 HCWs carrying S. aureus on their hands, strain likeness to the nasal isolate was documented for 7 (50%). CONCLUSIONS: Half of the HCWs acquired S. aureus on the hands from patients or the environment and half did so by apparent self-inoculation from the nose. Regardless of the source of contamination, good compliance with hand hygiene is needed from all HCWs to protect patients from nosocomial infections. The moderate rate of S. aureus carriage on hands in this setting could be the result of the routine use of alcoholic hand antisepsis.

Adult↗

PubMed2003

Methodologic assessment of studies on endoscopic sinus surgery.

BACKGROUND: Functional endoscopic sinus surgery (ESS) has become the procedure of choice for surgical treatment of chronic rhinosinusitis. Does the published literature support the claims of greater efficacy than medical treatment alone or older sinus procedures? OBJECTIVE: To analyze the methodology of the published literature regarding the efficacy of ESS. DATA SOURCES: MEDLINE search for primary studies published in 1987 through 2001, written in the English language, reporting results on more than 100 patients, using the MeSH (medical subject headings) terms sinusitis [subheadings surgery or therapy] and endoscopy. STUDY SELECTION: Of 512 studies initially identified, 29 studies met the inclusion and exclusion criteria for further assessment of methodologic criteria. An additional 6 studies were found when the reference lists of reviews or included studies were searched. DATA EXTRACTION: Articles were evaluated for 4 core (inclusion/exclusion criteria, control group, intervention, and clear outcome measure) methodologic criteria essential to the determination of efficacy of ESS. Eight additional methodologic criteria were also used to rate the articles. DATA SYNTHESIS: Three studies met all 4 core methodologic criteria. Only 4 of 35 studies used a control group to evaluate efficacy of ESS to treat chronic sinusitis. Mean number of criteria met was 7.2, with a range of 2 to 11. CONCLUSIONS: Absence of a control group is the most important reason that studies are unable to scientifically assess the comparative efficacy of ESS to medical therapy or other sinus procedures. The methodologic criteria described here can be used to evaluate studies of interventions for other disorders.

Comorbidity↗

PubMed2003

Annulus cells release ATP in response to vibratory loading in vitro.

Mechanical forces regulate the developmental path and phenotype of a variety of tissues and cultured cells. Vibratory loading as a mechanical stimulus occurs in connective tissues due to energy returned from ground reaction forces, as well as a mechanical input from use of motorized tools and vehicles. Structures in the spine may be particularly at risk when exposed to destructive vibratory stimuli. Cells from many tissues respond to mechanical stimuli, such as fluid flow, by increasing intracellular calcium concentration ([Ca(2+)](ic)) and releasing adenosine 5'-triphosphate (ATP), extracellularly, as a mediator to activate signaling pathways. Therefore, we examined whether ATP is released from rabbit (rAN) and human (hAN) intervertebral disc annulus cells in response to vibratory loading. ATP release from annulus cells by vibratory stimulation as well as in control cells was quantitated using a firefly luciferin-luciferase assay. Cultured hAN and rAN cells had a basal level of extracellular ATP ([ATP](ec)) in the range of 1-1.5 nM. Vibratory loading of hAN cells stimulated ATP release, reaching a net maximum [ATP] within 10 min of continuous vibration, and shortly thereafter, [ATP] declined and returned to below baseline level. [ATP] in the supernatant fluid of hAN cells was significantly reduced compared to the control level when the cells received vibration for longer than 15 min. In rAN cells, [ATP] was increased in response to vibratory loading, attaining a level significantly greater than that of the control after 30 min of continuous vibration. Results of the current study show that resting annulus cells secrete ATP and maintain a basal [ATP](ec). Annulus cells may use this nucleotide as a signaling messenger in an autocrine/paracrine fashion in response to vibratory loading. Rapid degradation of ATP to ADP may alternatively modulate cellular responses. It is hypothesized that exposure to repetitive, complex vibration regimens may activate signaling pathways that regulate matrix destruction in the disc. As in tendon cells, ATP may block subsequent responses to load and modulate the vibration response. Rabbit annulus cells were used as a readily obtainable source of cells in development of an animal model for testing effects of vibration on the disc. Human cells obtained from discarded surgical specimens were used to correlate responses of animal to human cells.

Adenosine Triphosphate↗

PubMed1996

[Acute spinal subdural hematoma after attempted spinal anesthesia].

This is a report of a case of a subdural haematoma with resulting paraplegia after attempted spinal anaesthesia. Epidural and subdural haematomas are rare complications after central neural blockade. The complication described here was the result of an unsuccessful attempt to puncture the spinal channel. The patient was a 72-year-old woman with a fracture of the left femoral neck, which it was intended to stabilize operatively. Findings that made lumbar spinal puncture difficult were severe overweight, and lordosis and scoliosis of the lumbar spine resulting from degenerative changes. Spinal anaesthesia was suggested because the patient had eaten shortly before and because she suffered from asthma. From the aspect of haemostasis no contraindications were present, and the anaesthesist was experienced in spinal anaesthesia even under difficult anatomical conditions. Several unsuccessful attempts were made to puncture the lumbar spinal channel while the patient was lying on her right side. It was also impossible to reach the spinal channel from a median or left paramedian approach. We used atraumatic pencil-point needles (Sprotte gauge 24, 90 mm). No blood was aspirated during any of the attempts. The surgical intervention was finally performed under a general anaesthetic in view of the urgency. No significant complications occurred during the operation, and no neurological abnormalities were observed immediately after or in the next 8 h after the operation. At 12 h after the operation a paraparesis was found caudal to L3. After this had been verified by radiological and neurological tests, neurosurgical decompression was carried out as quickly as possible. During the operation a distinct subdural haematoma without any detectable source of bleeding was discovered. Even after surgical revision and evacuation of the remaining haematoma it was not possible to reverse the paraplegia, in spite of rehabilitation measures. Despite a certain fragility of the vessel and pretreatment with pentoxifylline and thromboembolic prophylaxis with low-molecular heparin starting postoperatively, it must be assumed that a vessel accompanying one of the spinal nerves was punctured, possibly, the radiculomedullary vessel of Adamkiewicz. A similar case was published in 1988 by Parker. In the present case it must be assumed that the vessel was punctured during a paramedian approach in the area of the foramen intervertebrale, as the spinal channel was definitely not entered. Although this is an extremely rare complication, we conclude that close neurological controls are essential at least during the first 24 h after surgery, even after an unsuccessful attempt at central neural blockade.

Aged↗