bluuebunny/crossref_metadata_2025 huggingface dataset:
Catching Goldfish: Quality in Qualitative Research
Authors: Dingwall Robert , Murphy Elizabeth , Watson Pamela , Greatbatch David , Parker Susan
Published: January 2017

This paper reviews the contribution of qualitative methods to health services research (HSR) and discusses some of the issues involved in recognizing quality in such work. The place of qualitative work is first defined by reference to Archie Cochrane's agenda for HSR and the limitations of the recent focus on randomized trials as the standard method. Health care practice involves large elements of improvisation which cannot be captured by evidence-based approaches. Qualitative methods offer ways of understanding this improvisation and of identifying more efficient and effective practices, as well as considering the traditional topics of equity and humanity. The methodological procedures of qualitative work reflect a long-established inductive tradition in scientific practice. The logic of grounded theory provides a contemporary specification. In its application, it is quite different from the methodological anarchy of postmodernism. The use of qualitative research and the theoretically stated generalizations which arise from it inform reflective work by health service managers, planners and clinicians.
Managed Care: US Research Evidence and its Lessons for the NHS
Authors: Steiner Andrea , Robinson Ray
Published: January 2017

Objectives:

To review the high quality US evidence on performance of managed health care organisations and the available US evidence on specific managed care techniques; namely, financial incentives, utilisation management and review, physician profiling and disease management.

Methods:

Literature searches were conducted using numerous databases including Medline, Embase, the Social Sciences Citation Index and the National Health Service (NHS) Centre for Reviews and Dissemination library. For inclusion of evaluations of overall performance, studies had to use a comparison group (typically fee-for-service patients), make appropriate statistical adjustments for differences between groups, and be published in a peer-reviewed journal from 1980 forward. For assessments of techniques, less-demanding inclusion criteria reflected the paucity of generalisable literature; however, more current results were required (1990 forward).

Results:

We identified 70 articles for systematic review, covering 18 dimensions of performance (e.g. utilisation, quality of care, consumer satisfaction, equity). The strength of the evidence varied by dimension. It was strongest for utilisation and quality. In general, managed care seems to reduce hospitalisation and use of high-cost discretionary services, to increase preventive screening, and to be neutral in terms of patient outcomes. As for specific techniques, we identified 19 articles for review, but limitations of these studies prevented our drawing any definite conclusions about techniques' effectiveness. This is an important, if somewhat negative, conclusion.

Conclusions:

Applying US evidence is complicated by an irrelevant comparator and a higher baseline of utilisation. Managed care brought Americans the familiar NHS practices of population-based health care and resource management through gatekeeping; hence, changes due to UK adoption of managed care techniques may be modest. US evidence should be used to generate hypotheses, not to predict UK behaviour.
Do Minutes Count? Consultation Lengths in General Practice
Authors: Carr-Hill Roy , Jenkins-Clarke Sue , Dixon Paul , Pringle Mike
Published: January 2017

Objective:

To document the variability in consultation length and to examine the relative weight of different kinds of characteristics (of the patients, of the general practitioner (GP), or of the practice) in affecting consultation length, and, thus, to assess whether consultation length can legitimately be used as a quality marker.

Design:

A multilevel statistical analysis of 836 consultations across 51 GPs in ten practices.

Setting and subjects:

Ten general practices across four regions in England with varying list sizes, number of partners and fundholding status.

Main outcome measures:

Length of time face-to-face with patients in consultation measured in minutes and fractions of minutes.

Results:

There is substantial inter-practice variation in consultation length, from a mean of 5.7 minutes to one of 8.5 minutes. In some practices the longest average GP consultation time is about twice that of the shortest. Trainees and new partners spend, on average, about 1 minute less than their longer-serving colleagues. Consultation lengths for individual GPs range from a mean of 4.4 minutes to 11 minutes. Late middle-aged women (55–64 years) receive the longest consultations, followed by elderly people, with children receiving the shortest consultations. The number of topics raised affects the length of the consultation by about 1 minute per additional topic. When female patients consult female GPs, approximately 1 minute is added to the average consultation. A significant fraction of the variability in consultation lengths can be explained in terms of characteristics of patients, of GPs and of practices.

Conclusions:

The fact that there is little unexplained variation in GP consultation lengths that might be attributable to variations in quality (i.e. GP-related) throws doubt on the proposition that length of consultation can be used as a marker for quality of consultation in general practice.
Does New Technology Increase or Decrease Health Care Costs? The Treatment of Peptic Ulceration
Authors: Murphy Shaun
Published: January 2017

Objectives:

To determine whether new technology increases or decreases formal health care costs, with reference to the diagnosis and treatment of peptic ulcers.

Methods:

A costing method has been devised which is designed to investigate directly the way in which the costs to formal health services of diagnosing and treating an individual illness have changed with changes in technology.

Results:

The cost of diagnosis has increased almost entirely as a result of the high cost of endoscopy compared with X-ray examination. The introduction of H2-receptor antagonist drugs increased the cost of treatment compared with the earlier phases of surgical treatment. Subsequently, Helicobacter pylori eradication treatment has reduced the cost of treatment compared with all earlier phases of technology.

Conclusions:

A method has been devised that allows the impact of changes in medical technology on formal health care costs to be investigated for individual illnesses. In the treatment of peptic ulceration, the current technology, H. pylori eradication, has lower treatment costs than all previous technologies. The evidence from previous studies and this study is insufficient to support the assertion that new technology in general leads either to an increase or to a decrease in health care costs.
Can Lower Limb Ultrasonography Replace Arteriography?
Authors: London Nick JM , Sensier Yvonne , Hartshorne Tim
Published: January 2017

Although duplex ultrasonography offers a number of theoretical and practical advantages over arteriography for the assessment of lower limb arterial disease, it has not yet been widely accepted into clinical practice. This article reviews the current status of lower limb arterial duplex and concludes that arteriography should no longer be regarded as the diagnostic ‘gold-standard’ and that duplex ultrasonography should now be the first line investigation in patients with lower limb arterial disease.
Quality Control during Carotid Endarterectomy
Authors: Naylor A Ross , Gaunt Michael E
Published: January 2017

Although some form of quality control assessment is standard practice following virtually all forms of peripheral vascular reconstruction, it is seldom applied to carotid endarterectomy. This is despite the fact that the complications following endarterectomy can be catastrophic, are often related to technical error and are not easily remedied. A number of novel quality control techniques are now available. This review article summarizes the application of these methods to ensuring optimal surgical practice in patients undergoing carotid endarterectomy.
The Pentoxifylline Experience: Exercise Testing Reconsidered
Authors: Lindgärde F , Labs KH , Rößner M
Published: January 2017

This paper critically reviews the methodology used in clinical trials in chronic occlusive arterial disease (COAD) stage II (intermittent claudication) patients. The reasons for choosing internationally accepted standard treadmill settings as well as its limitations are discussed. Emphasis is put on the discussion of valid trial endpoints such as hemodynamic surrogates and clinically oriented parameters. Reasons for a spontaneous and treatment-unrelated improvement in claudication distance are elucidated, and variables which may be used for the definition of patient subsamples showing a high frequency of a pronounced treatment response (treatment responder populations) are presented. The magnitude of claudication distance improvement that might be considered clinically relevant is discussed in the light of the European Union guidelines for clinical trials in COAD patients. Results achieved with pentoxifylline are presented in context with all variables mentioned above.
Liver Operations in Sweden in 1987–99
Authors: Jersenius U. , Granath F. , Arvidsson D. , Blomqvist P.
Published: January 2017

Background and Aims:

Liver surgery is developing with new techniques and treatment modalities. The aim of this study is to describe liver surgery over a long period of time in a country with a public health care system.

Patients and Method:

A register study including adult patients admitted for liver resection in Sweden (population 8.8 million) selected from the Inpatient Register 1987–99. Additional data were collected from the Swedish Cancer Register and the Cause of Death Register. Analyses of the patients, indications, mortality and causes of death are presented.

Results:

2,405 operations were performed (21 per million per year). The most frequent indication was colorectal metastases (27 %). The 5-year survival after an operation for primary liver cancer and colorectal liver metastases was 27 % and 26 %, respectively.

Conclusions:

Few patients were admitted for liver operations compared to expected figures. The survival rates are in conformity with those previously published. With an increasing awareness of the relatively favourable prognosis and the introduction of new methods, the volume of liver operations will probably increase in Sweden.
Pneumatosis Intestinalis — A Pitfall for Surgeons?
Authors: Braumann C. , Menenakos C. , Jacobi C. A.
Published: January 2017

Pneumatosis intestinalis (PI) is characterized by multiple gas cysts in the wall of the gastrointestinal tract. Primary PI is extremely rare. In most of the cases PI is due to an underlying disease (traumatic and mechanical, inflammatory and autoimmune diseases, infectious and pulmonary diseases, drug induced, immunosuppression, transplantation, or neoplasm). A 69-year-old woman was treated with mixed connective tissue disease and PI twice operatively and once conservatively in our department. Review of the english literature showed 13 more cases of PI with underlying mixed connective tissue disease.

Most published cases of pneumatosis intestinalis with radiological finding of pneumoperitoneum were treated conservatively and should have not been considered as a reason for surgery. Therefore, the treatment of PI can present as a major dilemma for the surgeon.
Etiology and Outcome of Burns in Tabriz, Iran an Analysis of 2963 Cases
Authors: Maghsoudi H. , Pourzand A. , Azarmir G.
Published: January 2017

Background and aims:

Burn injuries still produce a significant morbidity and mortality in Iran. A 3-year retrospective review of burn victims hospitalized at a major burn center was conducted to determine the etiology and outcome of patients in Tabriz.

Material and Methods:

Two thousand nine hundred sixty + three patients were iden tified and stratified by age, sex, burn size, presence or absence of inhalation injury, cause of burn. There is one burn center in the East Azarbygan province serving 3.3 million people over an area of 47,830 sq.km.

Results:

The overall incidence rates of hospitalization and death were 30.5 % and 5.6 % per 100000 person years. The mean patient age was 22 years, and the male: female ratio was 1.275. There were 555 deaths altogether (18.7 %). The highest incidence of burns was in the 1–9 age group (29.2 %). Patients with less than 40 percent of burned surface constituted 79.8 % of injuries. The most common cause of burns was kerosene accident in adults and scald injuries in children. The mean length of hospitalization was 13 days. The mean body surface area burned was larger with higher mortality in females than in males (p < 0.001). Inhalation injuries were strongly associated with large burns and were present in all flame-burn fatalities.

Conclusion:

In our opinion, social factors are the main drive leading to an unacceptably high rate of burn injuries in our societies. Most of the burn injuries were caused by domestic accidents and were, therefore, preventable; educational programs might reduce the incidence of burn injuries.
Major Amputation Incidence Decreases Both in Non-Diabetic and in Diabetic Patients in Helsinki
Authors: Eskelinen E. , Eskelinen A. , Albäck A. , Lepäntalo M.
Published: January 2017

Background and Aims:

The aim of the study was to assess the changes in diabetes-related lower extremity amputations and to compare it with the development of amputations for critical leg ischaemia in patients without diabetes.

Material and Methods:

Clinical records of 1094 patients undergoing major lower limb amputations for vascular disease in the town of Helsinki during 13 years from 1990 to 2002 were analyzed retrospectively. Data concerning patient factors, diagnosis, existence of diabetes and amputation level were recorded. The study period was divided into three parts (1990–1994, 1995–1998 and 1999–2002) and results were compared between diabetic and nondiabetic vascular amputees during these time periods.

Results:

From 1990 through 2002, 561 of patients undergoing major lower limb amputation had diabetes mellitus. The overall incidence of major amputations of diabetics reduced from the first time period to the last period by 23%. At the same time, the incidence of amputations in non-diabetic patient group decreased 40%. If the incidence rate for amputations is expressed per million individuals with diabetes, 33% decrease was observed during the study period.

Conclusions:

The decrease in major amputation rates among diabetic as well as non-diabetic patients can be attributed to the increased interest in amputation prevention, with a contribution by vascular surgeons being made in both groups.
Growth Hormone is a Stimulating but Not An Essential Factor in Healing of Colon
Authors: Tei T. M. , Kissmeyer-Nielsen P. , Flyvbjerg A. , Christensen H.
Published: January 2017

Background:

Growth hormone (GH) has been implicated as an important factor in the healing and previous studies showed significant strength acceleration of experimental intestinal anastomoses.

Aim:

To study the healing of experimental colonic anastomoses in GH-deficient rats and to study the potential physiological effects of GH-substitution on healing parameters.

Conclusion:

Exogenous rhGH treatment started 7 days prior to surgery and continued until day 4 postoperatively accelerates the strength development of the experimental colonic anastomoses in dwarf rats indicating a potent role of growth hormone in colonic healing. However, GH is not essential in the healing process, since anastomotic healing in GH-deficient dwarf rats is like rats with normal pituitary function.
Adjuvant Intraperitoneal Chemotherapy for Advanced Primary Gastric Cancer
Authors: Sugarbaker P. H.
Published: January 2017

Background:

For gastric cancer dissemination to the peritoneal cavity is a large part of the natural history. Also, cancer dissemination caused from the trauma of cancer resection can release viable cancer cells into the free peritoneal cavity; these cells implant and then progress as peritoneal carcinomatosis.

Methods:

From the medical literature a compilation of the results of adjuvant treatment of gastric cancer were reviewed and critically analyzed. A surgical rationale for integrating intraperitoneal chemotherapy into the management of advanced primary gastric cancer was sought.

Results:

A theoretical basis for the application of cytotoxic effects of cancer chemotherapy within the peritoneal cavity as a part of the primary management of gastric cancer was explored. Numerous manuscripts suggested that there was an increased morbidity and mortality with perioperative intraperitoneal chemotherapy but the added number of complications was manageable. These data suggest that intraperitoneal chemotherapy is of benefit in an adjuvant setting in gastric cancer patients who have a complete resection but who are at high likelihood of local-regional recurrence.

Adjuvant intraperitoneal chemotherapy for advanced primary gastric cancer has a strong rationale. Numerous reports have established benefit. Wider application of this treatment modality is necessary through education, through additional clinical trials, and through continued publications from peritoneal surface malignancy treatment centers around the world.
Operation for Primary Hyperparathyroidism: The New versus the Old Order
Authors: Aarum S. , Nordenström J. , Reihnér E. , Zedenius J. , Jacobsson H. , Danielsson R. , Bäckdahl M. , Lindholm H. , Wallin G. , Hamberger B. , Farnebo L.-O.
Published: January 2017

Background and Aims:

In patients with primary hyperparathyroidism (PHPT), parathyroid imaging is nowadays routinely used for the purpose to perform a focused unilateral minimally invasive operation. The outcome of this new strategy has, however, not been established in randomised trials.

Material and Methods:

Patients were randomised to either preoperative localisation with sestamibi scintigraphy and ultrasonography (group I) or no preoperative localisation (group II). In group I, a minimally invasive parathyroidectomy was performed in patients in whom both localisation studies were consistent with a single pathological gland, whereas a conventional bilateral neck exploration was performed in cases with negative localisation findings. In group II all patients underwent conventional bilateral neck exploration. Primary outcome measure was normocalcaemia at 6 months postoperatively.

Results:

In the preoperative localisation group (group I) 23/50 (46%) of the patients could be operated on with the focused operation whereas 26/50 (52%) were operated on by bilateral neck exploration. All patients in the no localisation group (group II; n=50) were operated on with the intended bilateral neck operation. Normocalcaemia was obtained in 96% and 94% in group I and II, respectively. Total (localisation and operative) costs were 21% higher in group I.

Conclusions:

Routine preoperative localisation, with the intention to perform minimally invasive parathyroidectomy, is not cost effective if concordant results of scintigraphy and ultrasonography are a prerequisite for the focused operation. Less than half of the patients were successfully managed with this strategy, at a higher cost and without obtaining a more favourable clinical outcome.
Minilaparotomy Cholecystectomy as a Day Surgery Procedure: A Prospective Clinical Pilot Study
Authors: Harju J. , Pääkkönen M. , Eskelinen M.
Published: January 2017

Background and Aims:

In some studies minilaparotomy cholecystectomy (MC) has been shown to be as good as laparoscopic cholecystectomy (LC) in the surgical treatment of cholecystolithiasis. To our knowledge, the MC operation is rarely considered as a day surgery procedure.

Patients and Methods:

Thirty elective symptomatic non-complicated patients were included in the study during the end of the year 2004 to June 2005. The mean age of patients was 52 years (range 27–68), the mean body mass index 29 kg/m2 (range 19–41). Gallstones were confirmed with ultrasound and the pre-operative liver laboratory tests were normal in all patients. A five (+/-2) centimetre-long incision was used avoiding to split the rectus abdominis muscle. All patients were re-evaluated four weeks postoperatively with the follow-up letter.

Results:

The average operating time was 51 minutes (range 30–105 minutes). Day surgery was possible in 25 cases (83%). Five patients (17%) stayed over night at the hospital. There were four (13%) conversions to conventional cholecystectomy. The average postoperative sick leave was 16 days (range 14–30). Two patients returned to hospital. One patient had wound pain, but no complication was found, and the patient was not admitted. One patient had a wound infection and spent 6 days in the hospital. Twenty-nine (97%) patients were satisfied with the operation and were ready to recommend it for other patients.

Conclusions:

The results of this study support the suitability of MC as a day surgery procedure, but a prospective randomised trial is needed to evaluate the relative advantages of MC and LC.
Multidisciplinary Approach for the Management of Complex Hepatic Injuries AAST-OIS Grades IV—V: A Prospective Study
Authors: Asensio J. A. , Petrone P. , Garcí-Núñez L. , Kimbrell B. , Kuncir E.
Published: January 2017

Background:

Complex hepatic injuries grades IV—V are highly lethal. The objective of this study is to assess the multidisciplinary approach for their management and to evaluate if survival could be improved with this approach.

Study Design:

Prospective 54-month study of all patients sustaining hepatic injuries grades IV—V managed operatively at a Level I Trauma Center. Main outcome measure: survival. Statistical analysis: univariate and stepwise logistic regression.

Results:

Seventy-five patients sustained penetrating (47/63%) and blunt (28/37%) injuries. Seven (9%) patients underwent emergency department thoracotomy with a mortality of 100%. Out of the 75 patients, 52 (69%) sustained grade IV, and 23 (31%) grade V. The estimated blood loss was 3,539±-3,040 ml. The overall survival was 69%, adjusted survival excluding patients requiring emergency department thoracotomy was 76%. Survival stratified to injury grade: grade IV 42/52–81%, grade V 10/23–43%. Mortality grade IV versus V injuries (p <0.002; RR 2.94; 95% CI 1.52–5.70). Risk factors for mortality: packed red blood cells transfused in operating room (p=0.024), estimated blood loss (p<0.001), dysryhthmia (p<0.0001), acidosis (p=0.051), hypothermia (p=0.04). The benefit of angiography and angioembolization indicated: 12% mortality (2/17) among those that received it versus a 36% mortality (21/58) among those that did not (p=0.074; RR 0.32; 95% CI 0.08–1.25). Stepwise logistic regression identified as significant independent predictors of outcome: estimated blood loss (p=0.0017; RR 1.24; 95% CI 1.08–1.41) and number of packed red blood cells transfused in the operating room (p=0.0358; RR 1.16; 95% CI 1.01–1.34).

Conclusions:

The multidisciplinary approach to the management of these severe grades of injuries appears to improve survival in these highly lethal injuries. A prospective multi-institutional study is needed to validate this approach.
Hormonal Stress Response and Hemodynamic Stability in Patients Undergoing Endovascular vs. Conventional Abdominal Aortic Aneurysm Repair
Authors: Kataja J. , Chrapek W. , Kaukinen S. , Pimenoff G. , Salenius J.-P.
Published: January 2017

Background and Aims:

To investigate the effect of two different surgical techniques with different anesthetic modes on intraoperative and postoperative hormonal stress response, hemodynamic stability, fluid loading and renal function in patients scheduled for elective infrarenal abdominal aortic aneurysm (AAA) repair.

Materials and Methods:

Forty consecutive patients scheduled for elective infrarenal AAA repair were allocated without randomizing into two groups: an endovascular (EVAR, n=20) and a conventional (CAR, n=20) aneurysm repair group according to aneurysm morphology as determined by pre-operative computed tomography and angiography. The EVAR group were operated under spinal anesthesia and the CAR group using general anesthesia with epidural blockade.

Results:

Patients undergoing CAR showed lower intraoperative mean arterial pressure and significantly higher plasma norepinephrine before aortic cross-clamping and significantly higher lactate after aortic declamping and postoperatively than patients in the EVAR group. Postoperatively, vasopressin and serum cortisol were also significantly higher in the CAR group. Fluid loading and estimated blood loss were more excessive in the CAR group.

Conclusions:

Stress response was lower and hemodynamic stability and lower body perfusion superior and renal function also better maintained in patients undergoing EVAR under spinal anesthesia as compared to those undergoing CAR using general anesthesia with epidural blockade.
Bioactive Glass Granules as Extender of Autogenous Bone Grafting in Cementless Intercalary Implant of the Canine Femur
Authors: Keränen P. , Itälä A. , Koort J. , Kohonen I. , Dalstra M. , Kommonen B. , Aro H. T.
Published: January 2017

Background and Aims:

Ceramic bone graft substitutes have a potential to be used as replacement of allogeneic bone grafting and, under optimal distribution of particle size, they may even provide mechanical support. The current study examined the efficacy of bioactive glass granules as an extender of autogenous bone grafting in a segmental bone replacement model of the canine femur.

Material and Method:

A 16 mm long segment of the femur shaft was bilaterally replaced with an intercalary titanium implant in eight animals. The implant had cementless grooved proximal and distal stems. In one leg, the peri-implant space was packed with composite graft consisting of a mixture of bioactive glass granules and autogenous bone graft in proportion of 50:50. In the opposite leg, the peri-implant space was treated with autogenous bone graft alone. After surgery, unlimited functional loading was allowed. The outcome was evaluated at three months.

Results:

Eight out of sixteen autografted implants and seven out of sixteen composite-grafted implants were radiographically incorporated and clinically stable at three months. In the paired comparison, the proximal components of composite-grafted implants showed lower maximum load under torsional testing (p=0.068), less new bone in the longitudinal grooves of the stems (p=0.036) and lower affinity of new bone to implant surface (p=0.046). The distal components of the two sides showed a similar trend for less new bone in the grooves and lower bone affinity of new bone in the distal composite-grafted components.

Conclusions:

The current study suggests that supplementation of periprosthetic bone graft with bioactive ceramic particles may not help to promote healing of cementless implants under high dynamic loading conditions.
Multidisciplinary Approach for Patients with Pelvic Fractures and Hemodynamic Instability
Authors: Stein D. M. , O'Toole R. , Scalea T. M.
Published: January 2017

The hemodynamically unstable patient with a pelvic fracture presents a diagnostic and therapeutic challenge. The care of these patients requires a unique multidisciplinary approach with input and expertise from many different specialists. An understanding of pelvic anatomy and fracture patterns can help guide the diagnostic evaluation and treatment plan. The initial management of these patients must focus on rapid airway and hemorrhage control while preparing for ongoing blood loss. Rapid temporary fracture stabilization with simple bedside modalities is crucial in limiting additional blood loss. An exhaustive search must also be performed to evaluate for concomitant injuries that commonly accompany major pelvic fractures and the treatment of these other injuries must be appropriately prioritized. For patients who are unresponsive to standard resuscitation and bedside attempts at limiting hemorrhage, angiographic embolization is often utilized as the next step to attain hemodynamic stability. The key to successful management of these patients lies in the careful coordination of different specialists and the expertise that each brings to the clinical care of the patient.
Telemedicine and Telepresence for Trauma and Emergency Care Management
Authors: Latifi R. , Weinstein R. S. , Porter J. M. , Ziemba M. , Judkins D. , Ridings D. , Nassi R. , Valenzuela T. , Holcomb M. , Leyva F.
Published: January 2017

The use of telemedicine is long-standing, but only in recent years has it been applied to the specialities of trauma, emergency care, and surgery. Despite being relatively new, the concept of teletrauma, telepresence, and telesurgery is evolving and is being integrated into modern care of trauma and surgical patients. This paper will address the current applications of telemedicine and telepresence to trauma and emergency care as the new frontiers of telemedicine application The university Medical Center and the Arizona Telemedicine Program (ATP) in Tucson, Arizona have two functional teletrauma and emergency telemedicine programs and one ad-hoc program, the mobile telemedicine program. The Southern Arizona Telemedicine and Telepresence (SATT) program is an inter-hospital telemedicine program, while the Tucson ER-link is a link between prehospital and emergency room system, and both are built upon a successful existing award winning ATP and the technical infrastructure of the city of Tucson. These two programs represent examples of integrated and collaborative community approaches to solving the lack of trauma and emergency care issue in the region. These networks will not only be used by trauma, but also by all other medical disciplines, and as such have become an example of innovation and dedication to trauma care. The first case of trauma managed over the telemedicine trauma program or “teletrauma” was that of an 18 month- old girl who was the only survival of a car crash with three fatalities. The success of this case and the pilot project of SATT that ensued led to the development of a regional teletrauma program serving close to 1.5 million people. The telepresence of the trauma surgeon, through teletrauma, has infused confidence among local doctors and communities and is being used to identify knowledge gaps of rural health care providers and the needs for instituting new outreach educational programs.
Heredity and Familial Tendency of Acute Appendicitis
Authors: Ergul E.
Published: January 2017

Background:

Although inflammatory disease of the vermiform appendix has been recognized as such for more than 100 years, its etiology remains a subject of controversy. The notion that appendicitis is familial, is not only important for understanding the etiology of the condition but might contribute substantially to the diagnosis and thus provide an indication for early surgical intervention.

Methods:

An extensive Medline search, textbooks, scientific reports and scientific journals are the data sources.

Conclusions:

In the light of past studies, we can suggest that almost half of the variability in risk of acute appendicitis is due to genetic factors. A positive family history increases the relative risk of being acute appendicitis nearly 3 times.
Natural Course of Incisional Hernia and Indications for Repair
Authors: Nieuwenhuizen J. , Halm J. A. , Jeekel J. , Lange J. F.
Published: January 2017

Background:

Incisional hernias and incisional hernia repair can be a significant challenge for both surgeon and patient. Despite the growing amount of literature describing various methods of surgical techniques, little has been published the natural course of an incisional hernia and regarding indications for incisional hernia repair.

Methods:

An internet database search was performed to identify articles describing symptoms presented by patients and indications for incisional hernia repair.

Results:

Various symptoms and indications regarding incisional hernia repair and the natural course of an incisional hernia are mentioned in the literature. Nevertheless, published data accurately describing these symptoms and indications are rare.

Conclusion:

A prospective trial monitoring incisional hernias as well as comparing conservative treatment with repair should be performed.
Robotics in Cardiac Surgery
Authors: Rodriguez E. , Chitwood W. R.
Published: January 2017

Minimally invasive surgery has revolutionized the surgical field over the last two decades. Robotic assisted surgery is the latest iteration towards less invasive techniques. Cardiac surgeons have slowly adapted minimally invasive and robotics techniques into their armamentarium. In particular, minimally invasive mitral valve surgery has evolved over the last decade and become the preferred method of mitral valve repair and replacement at certain specialized centres worldwide because of excellent results. We have developed a robotic mitral valve surgery program which utilizes the da Vinci® telemanipulation system allowing the surgeon to perform complex mitral valve repairs through 5mm port sites rather than a traditional median sternotomy. in this rapidly evolving field, we review the evolution and clinical results of robotically-assisted mitral valve surgery and take a look at the other cardiac surgical procedures for which da Vinci® is currently being used.
Predictors for the Immediate and Long-Term Outcome of Avascular Surgical Procedure
Authors: Virkkunen J. , Venermo M. , Saarinen J. , Salenius J.
Published: January 2017

Background and Aims:

The ability to predict post-operative mortality reliably will be of assistance in making decisions concerning the treatment of an individual patient. The aim of this study was to test the GAS score as a predictor of post-operative mortality in vascular surgical patients.

Material and Methods:

A total of 157 consecutive patients who underwent an elective vascular surgical procedure were included in the study. The Cox proportional hazards model was used in analyzing the importance of various preoperative risk factors for the postoperative outcome. ASA and GAS were tested in predicting the short and long-term outcome. On the basis of the GAS cut-off value 77, patients were selected into low-risk (GAS low: GAS < 77) and high-risk (GAS high: GAS > = 77) groups, and the examined risk factors were analyzed to determine which of them had predictive value for the prognosis.

Results:

None of the patients in the GAS low group died, and mortality in the GAS high group was 4.8% (p = 0.03) at 30 days' follow-up. The 12-month survival rates were 98.6% and 78.6% (p = 0.0001), respectively, with the respective 5-year survival rates of 76.7% and 44.0% (p = 0.0001). The only independent risk factor for 30-day mortality was the renal risk factor (OR 20.2). The combination of all three GAS variables(chronic renal failure, cardiac disease and cerebrovascular disease), excluding age, was associated with a 100% two-year mortality.

Conclusions:

Mortality is low for patients with GAS<77. For the high-risk patients (GAS> = 77), due to its low predictive value for death, GAS yields limited value in clinical practice. In cases of patients with all three risk factors (renal, cardiac and cerebrovascular), vascular surgery should be considered very carefully.
Cervical Hip Fracture in Afinnish Population: Incidence and Mortality
Authors: Panula J. , Pihlajamäki H. , Sävelä M. , Jaatinen P. T. , Vahlberg T. , Aarnio P. , Kivelä S.-L.
Published: January 2017

Background and Aims:

Our aim was to describe the incidence of cervical hip fractures and to describe the relationships between selected background variables and mortality at 30 days, 6 months, and 3 years postoperatively.

Material and Methods:

The basic material consisted of population-based data set of patients aged 65 years or older who had sustained a hip fracture and were treated operatively between 1999 and 2000. Out of these, we identified 266 consecutive patients with cervical hip fracture.

Results:

The age-adjusted incidence of cervical hip fractures in women was 1.3-fold compared to men. In age-adjusted analysis, occurrence of chronic lung disease, cardiovascular disease or 2–5 comorbidities, male gender, the need for 2-person mobility assistance, and poor ambulation postoperatively were associated with excess mortality at least at one evaluation point.

Conclusions:

Only chronic lung disease and male gender were independent predictors of increased mortality at each follow-up assessment in multivariate analysis.
Comparison of Standard Anteroposterior Knee and Hip-to-Ankle Radiographs in Determining the Lower Limb and Implant Alignment after Total Knee Arthroplasty
Authors: Skyttä E. T. , Lohman M. , Tallroth K. , Remes V.
Published: January 2017

Background and Aims:

The coronal alignment of the lower limb is important for planning and assessing outcome after total knee arthroplasty. This study compared postoperative estimation of alignment and measurement of angles using both hip-to-ankle radiographs and anteroposterior (AP) knee radiographs in standing position.

Patients and Methods:

Consecutive standard AP knee and hip-to-ankle radiographs in 83 patients (103 knees) after total knee arthroplasty were analyzed.

Results:

The tibiofemoral angle measured from both hip-to-ankle and knee radiographs correlated moderately with the mechanical axis (r = 0.646 and r = 0.540, respectively). The correlation between tibiofemoral angles in the two radiographs was excellent (r = 0.860). Furthermore, measurements of tibial and femoral component alignment between the two radiographs correlated highly (r = 0.718 and r = 0.773, respectively). Intra- and interobserver correlations were high in all analyses.

Conclusions:

The standard AP knee radiograph appears to be a valid alternative to the hip-to-ankle radiograph for determining knee coronal plane alignment in routine follow-up after total knee arthroplasty. However, the hip-to-ankle radiograph alone provides accurate information on weight-bearing mechanical axis in patients with suspected lower limb malalignment.
Neurogenic Bladder in Children: Basic Principles, New Therapeutic Trends
Authors: Guys J. M. , Hery G. , Haddad M. , Borrionne C.
Published: January 2017

Diagnosis of neurogenic bladder is straightforward in children with myelomeningocele. However, recognition is more difficult in patients with occult dysraphism or central nervous system disorders since clinico-anatomical correlations are poor. Careful clinical examination and urodynamic exploration are mandatory for diagnosis and follow-up.

Even if urinary leak is the first symptom, the main goal of the pediatric surgeon must be to preserve the upper urinary tract. The ideal protection strategy consists of ensuring that micturition is voluntary and complete and that the bladder capacity is sufficient with adequate compliance and sphincter outlet resistances. Balancing these functions requires a combination of medical and surgical treatment.

A variety of techniques can be used depending on gender and age of the patient and social environment. In most cases, intermittent bladder catheterization is necessary to obtain complete evacuation of the bladder. Bladder capacity can be increased by anticholinergic drugs, injection of botulinum toxin into the bladder, and augmentation cystoplasty. Augmentation of bladder outlet resistances requires endoscopic injection of bulking agents, surgical bladder neck reconstruction and urethral lengthening, bladder neck suspension, and artificial urinary sphincter. In difficult cases, continent cystostomy with closure of the bladder neck can achieve definitive continence.

At the beginning endoscopic treatment combining anti reflux procedure, injection of the bladder neck and botulinum toxin can be considered as a “total endoscopic management” and should be our first line. Other techniques are under evaluation. Sacral neuromodulation has given promising results. Artificial tissue engineering will probably be used in the next future.

Management of neurogenic bladder is not limited to urological considerations. Orthopedic, digestive, and sexual problems must also be taken into account in order to obtain an “acceptable quality of life”.
Child Abuse and Neglect
Authors: Lane W. , Bair-Merritt M. H. , Dubowitz H.
Published: January 2017

It is important for surgeons to be able to accurately assess and diagnose child abuse. While they are generally not the only medical professionals involved in the care of children with suspected abuse, they are highly regarded by hospital and social service staff, and their input regarding the cause of injury is unlikely to be ignored. Appropriate diagnosis of abusive injury can prevent future morbidity and mortality in these vulnerable patients, and can also reduce the trauma to families from false accusations of abuse. A sensitive and open-ended history, thorough physical examination, appropriate diagnostic workup with consideration of child abuse as an underlying cause, appropriate documentation of findings, and determination of safety for discharge can greatly improve an abused child's current and future health and safety.
Current Controversies in the Surgical Treatment of Esophageal Atresia
Authors: Tovar J. A. , Fragoso A. C.
Published: January 2017

Background and Aims:

Esophageal atresia (EA) with or without tracheo-esophageal fistula (TEF) is a rare condition that can be nowadays succesfully treated. The current interest therefore is focused on the management of the difficult cases, on thoracoscopic approach, and on some aspects of the long-term results.

Methods:

The current strategies for the difficult or impossible anastomoses in pure and long-gap EA, the introduction of thoracoscopic repair and the causes, mechanisms and management of post-operative gastro-esophageal reflux (GER) are reviewed.

Results:

Methods of esophageal elongation and multi-staged repair of pure and long-gap EA allow anastomosis but with functional results that are often poor. Esophageal replacement with colon or stomach achieves at least similar results and often requires less procedures. Thoracoscopic repair is a promising adjunct, but the difficulties for setting it as a gold-standard are pointed out. GER is a part of the disease and its surgical treatment, that is often required, is burdened by high failure rates.

Conclusions:

EA with or without TEF can be successfully treated in most cases, but a number of unsolved issues remain and the current approach to difficult cases will certainly evolve in the future.
Sexual Violence Against Older People: A Review of the Empirical Literature
Authors: Bows Hannah
Published: January 2017

Aging and sexual violence are both established areas of research, but little attention has been paid to research into sexual violence against older people. This article presents a critical review of the literature reporting empirical research in three overlapping fields of inquiry: elder abuse, domestic violence, and sexual violence, identifying points of theoretical and methodological similarity and difference across academic disciplines. Using a range of search terms combining age, sexual violence, and elder abuse, the following databases were searched: EBSCOHOST, Ingenta-Ingenta connect, and JSTOR. In total, the databases searches returned 31 relevant articles and an additional 9 relevant articles were found through manual searches of bibliographies and Google searches, which were grouped into three categories: elder abuse, domestic violence in later life, and sexual violence against older people. Four themes common across these fields emerged: prevalence, characteristics of victims and risk factors, impacts and coping strategies, and perpetrator and assault characteristics. The findings in each area are discussed in detail, exposing gaps in knowledge and understandings of sexual violence against older women. The article ends by defining a future research agenda for this underexplored phenomenon that is of increasing importance in a context of global aging.
Pedophiles and Stalkers as Transplant Candidates: One Program's Experience
Authors: Paris Wayne , Miller Rachel , Hille Cheryl , Nour Bakr , Griggs Johnny
Published: January 2017

Transplant assessment of pedophiles and stalkers presents a challenge for clinicians and requires the ability to separate the science from the hysteria. Although rarely seen in organ transplant clinics, the presence of psychosexual disorders can result in both criminal charges and harsh societal reactions. Clinicians must be able to assess and make informed recommendations about the suitability of the candidate and any potential risks for staff, other patients, and society at large. Six patients (5 pedophiles and 1 stalker) were assessed at our major regional multiorgan transplant program; each patient presented with unique and challenging assessment, treatment, and selection issues for the transplant team. The objectives of this article are to raise awareness of the issues associated with pedophiles and stalkers, and to provide the basis for better-informed discussions based on one program's struggles with its candidate selection and follow-up.
Social Work Interventions with Living Related Liver Donors: The Implications for Practice
Authors: Schnurman Kelli Kalimi , Zilberfein Felice , Augurt Antonia , Brosnan Mary , Song Yu Mee
Published: January 2017

Living related liver donations are increasingly used to address the lack of organs available to patients faced with end-stage liver disease. A significant need exists for enhanced psychosocial intervention for donors. We sought to explore donor reactions by assessing psychosocial issues after donation. A descriptive review of donors was undertaken. The overall incidence of psychosocial issues after donation was examined by using a uniform interview questionnaire and by anecdotal case studies. Responses tend to indicate a general positive reaction to donation; yet, findings suggest a need for more preparation in the predonor stage, 100% social work follow-up after donation to provide needed support services, and inclusion of the donor as a critical partner in organ transplant treatment. A more extensive study drawing on the questionnaire may offer a standardized approach to the treatment of organ donors.
Research to Practice: A National Consensus Conference
Authors: Metzger Robert A. , Taylor Gloria J. , McGaw Lin J. , Delmonico Francis L. , Prottas Jeffrey M. ,   for the UNOS Research to Practice Steering Committee
Published: January 2017

Purpose

To gain consensus on aspects of the process of gaining consent for organ donation that should be mainstream daily practice.

Methods

A 3-day consensus conference of transplant professionals that provided a forum for research and innovative ideas about gaining consent for organ donation. Four work groups were assembled to address issues of gaining consent from organ and tissue donors: (1) demystifying first-person consent (donor authorization): is it a matter of law?, (2) recovery coordinators: getting from green to great, (3) maximizing the process: old views and new, and (4) donor family support: mother or smother?

Results

Participants reached a consensus about major consent-related practices, identified areas of practice variance, and defined topics in need of further research.

Conclusions

The conference participants agreed that (1) the primary role of the organ procurement organization is to recover organs for transplantation from deceased donors and to facilitate distribution of those organs to the appropriate recipients; (2) early referral of potential donors from the hospital to the organ procurement organization is desirable; (3) a score less than 5 on the Glasgow Coma Scale should initiate end-of-life discussions with family members; a procurement coordinator from the organ procurement organization who is physically housed within the hospital is the most successful model for accommodating early referral of potential donors and optimizing family support practices; and (3) a decedent's right to donate should take precedence in the donation process and such designation by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death.