bluuebunny/crossref_metadata_2025 huggingface dataset:
Computer Simulation to Estimate the Effectiveness of Carotid Endarterectomy
Authors: Lavender Michael , Craig Neil , Kerr Ron , Howel Denise
Published: January 2017

Objectives:

To investigate the benefit of carotid endarterectomy relative to medical treatment, by comparing the outcome for different groups of patients following transient ischaemic attacks.

Methods:

A Markov model was used to describe the survival and quality of life of patients treated for a transient ischaemic attack. The benefit is measured in terms of quality adjusted life months (QALMs). The outcome was estimated using a computer simulation with parameters based on published studies on the probability of events following treatment. The benefit of carotid endarterectomy was explored using a baseline set of parameters and a sensitivity analysis.

Results:

The baseline scenario of a 65-year-old male patient with the model factors set at an intermediate level showed a benefit for surgery of 3 QALMs compared with medical treatment alone. The sensitivity analysis showed that the most favourable combination of factors had a benefit of 13.4 QALMs and the least favourable a loss of 2 QALMs. Of all 128 factor combinations, 79.9% showed a benefit for surgery, 5.5% showed equal benefit, and 15.6% showed a benefit for medical treatment.

Conclusions:

Computer simulations have the potential for deriving estimates of benefit for different patient groups from the results of clinical trials. Combined with reliable information on costs, the technique could also demonstrate variations in cost-effectiveness for these groups. For patients following a transient ischaemic attack, the results from this simulation and limited cost information suggest that carotid endarterectomy is unlikely to be a cost-effective intervention in the UK for many patient groups despite a reduction in the risk of stroke.
The Importance of Laboratory Data for Comparing Outcomes and Detecting ‘outlier’ Wards in the Treatment of Patients with Pneumonia
Authors: Maor Yasmin , Rubin Haya R. , Gabbai Uri , Mozes Benjamin
Published: January 2017

Objectives:

To evaluate whether routine laboratory data can improve the ability to compare risk-adjusted outcomes of different medical wards, and to detect ‘outlier’ wards with significantly better or worse outcome.

Methods:

Patient data were taken from the Combined Patient Database Systematic Management and Research Tool, a database created by merging different computerized sources at a tertiary care hospital. All patients admitted to internal wards with the diagnosis of pneumonia during the years 1991–1995 were included ( n = 2734). The outcome variable was mortality 30 days post-admission. We used three comorbidity measures based on ICD-9-CM codes as possible predictors of mortality: secondary diagnoses; the Health Care Financing Administration severity index; and the Charlson comorbidity index. Models were created using logistic regression. To each model, laboratory data gathered in the first 48 hours after admission were added. To identify ‘outlier’ services we determined whether the patients' ward was an independent predictor of mortality. The area under the receiver operator curve (ROC) of the models was used for comparisons.

Results:

The area under the ROC was 0.65–0.72 for the models based on age and comorbid diagnoses. The addition of laboratory data improved markedly the discriminatory ability of each of the models, as reflected by an increase in the area under the ROC to 0.83–0.84. An ‘outlier’ ward with a higher risk-adjusted mortality rate was identified only by the models that included laboratory data.

Conclusion:

Basic, automated, routinely gathered laboratory data added significantly to the discriminatory power of risk models based on administrative data with abstracted diagnoses. Addition of laboratory data improved the ability to identify providers with possible exceptional quality of care.
A Review of the Use of Health Status Measures in Economic Evaluation
Authors: Brazier John , Deverill Mark , Green Colin
Published: January 2017

Objective:

To review the use of measures of health status in the assessment of benefits in economic evaluation, whether or not the measures were designed for this purpose.

Methods:

The review was based on a systematic search of the literature. It provides a comprehensive assessment of the evidence where it exists and a balanced overview of opinion otherwise.

Results:

Over 3000 papers were identified, of which 632 were found to be relevant. The review provides a set of recommendations. These include: a checklist of questions for selecting a measure for use in economic evaluation; a list of circumstances in which non-preference-based measures can be used; and recommendations surrounding the use of health state valuation techniques and multi-attribute utility scales.

Conclusion:

These recommendations should help to identify poor economic evaluations and hence guard against inefficient conclusions being drawn regarding the provision of health services.
Preoperative Assessment of Small Tumours in Women with Breast Cancer
Authors: Kald B. A. , Boiesen P. , Ronnow K. , Jonsson P. E. , Bisgaard T.
Published: January 2017

Background and Objectives:

In patients with breast cancer, planning of the surgical strategy may rely on preoperative tumour size. The optimal method for assessment of small tumours has not been established. We compared findings from preoperative mammography and ultrasonography with histopathological tumour size in patients treated with breast-conserving surgery.

Material and Methods:

The study was retrospective and the setting a single institution clinic with free referral of patients. The patients were examined before the operation with mammography, ultrasonography, and findings were compared with postoperative histopathological tumour size.

Results:

The study included 131 patients (median age was 59) years with grade I, II, and III cancers in 47, 71 and in 13 patients, respectively. The medium histological tumour size was 14 mm, range 4–45 mm. A wide 95 % confidence interval between histopathological tumour size and preoperative mammography (standard deviation 4.8 mm) and ultrasonography (standard deviation 4.8 mm) was found. The combination of mammography and ultrasonography did not improve the results (standard deviation 4.3 mm). Preoperative mammography tended to over estimate the tumour size compared with histological tumour size whereas preoperative ultrasonography tended to underestimate the tumour size.

Conclusion:

In this retrospective study with preoperative evaluation of small breast cancers by mammography and ultrasonography, wide 95 % confidence intervals for the methods were found and they should therefore be used with caution in the planning of the surgical strategy.
Recurrences after Immediate Reconstruction in Breast Cancer
Authors: Mustonen P. , Kataja V. , Berg M. , Pietiläinen T. , Papp A.
Published: January 2017

Aim:

To determine the incidence of and reasons for recurrences after immediate breast reconstruction in breast cancer patients.

Material and Methods:

The data of 79 patients undergoing immediate breast reconstruction between 1998 and 2001 in Kuopio University Hospital were re-examined from both the local cancer register and the patient charts at the end of year 2003.

Results:

There were five local recurrences (6.3 %), one regional recurrence (1.2 %), and three cases (3.8 %) presented bone and/or visceral metastases. All recurrences except one (primary tumor noninvasive) appeared within the first two years after primary therapy. Young age and increasing size of the tumour were risk factors for distant or logoregional metastases.

Conclusion:

Immediate breast reconstruction is a safe procedure in breast cancer patients, but a multidisciplinary team is needed for careful patient selection.
RSA Applications in Monitoring of Fracture Healing in Clinical Trials
Authors: Madanat R. , Moritz N. , Larsson S. , Aro H. T.
Published: January 2017

Radiostereometric analysis (RSA) was originally developed as a method for performing highly accurate three-dimensional measurements in vivo over time from sequential radiographs. Since its introduction over twenty years ago, the RSA method has proven itself as a powerful tool with numerous orthopaedic applications. RSA has been used extensively in studies of prosthetic fixation and has been shown to be the method of choice for these studies. RSA has, however, also been successfully applied to a limited number of studies examining fracture healing, namely in fractures of the radius, ankle, tibial plateau, trochanter and femoral neck, as well as studies of bone healing following spinal fusion and tibial osteotomies. RSA follow-up of a fracture will provide definitive demonstration of the exact time of union, i.e. the achievement of fracture stability. This information can be invaluable in randomized clinical trials of fracture treatment. Phantom model studies have proven useful for effective preoperative planning and interpretation of RSA results. The RSA method is a highly accurate, precise and safe objective method for studying fracture healing in clinical trials. The RSA method may serve as a scientific tool to accurately evaluate the significance of supporting novel biomaterials for the early stability and the rate of healing in fractures.
Fatal Explosion Injuries in Finland: A Twenty-Year Nationwide Survey
Authors: Mäkitie I. , Pihlajamäki H.
Published: January 2017

Background and Aims:

Expanding violence may necessitate treatment of explosion victims, requiring a broadening of existing medical skills and knowlegde of injury mechanisms. The aim of the study was to assess the number, nature and injury pattern of fatal explosion incidents in Finland.

Material and Methods:

Retrospective analysis of explosion-related deaths from January 1985 to December 2004. Death certificates were obtained and reviewed.

Results:

Over the 20-year period from 1985 to 2004, only 61 inviduals died in Finland as a result of unintentional or unspecified explosion related events. A homemade bomb assault for unknown motives killed seven people in a suburb in 2002. The incidence was 5.7 cases per 10 000 000 person-years. Suicides using explosives were slightly more common; on average 4 cases per year (6.7 cases per 10 000 000 person-years). A small increase in the fatality trend was noticeable during the last years of the study period.

Conclusions:

The incidence of fatal explosion injuries is a minor problem, but a small increase can be seen during the last few years. Victims of such injuries required only minimal hospital resources, because in most cases they died at the scene. Our results suggest that efforts to prevent fatalities related to explosives or corresponding devices, or to reduce their number, should focus on prevention of intentions.
Low Maruyama Index Surgery for Gastric Cancer
Authors: Hundahl S. A.
Published: January 2017

Background:

Japanese definitions and treatment guidelines have dominated extent-of-surgery concepts in gastric cancer for over 4 decades, despite the fact that such definitions/guidelines have changed considerably over time, and the fact they have largely failed to improve survival in prospective, randomized clinical trials.

Aim:

To briefly review lessons from previous surgical trials in gastric cancer, and, more specifically, to review data validating the concept of “low Maruyama Index surgery” as a data-driven guide to surgical treatment.

Methods:

Review of results from blinded multivariate analyses of two separate, prospective, randomized clinical trials: a) the Macdonald Trial of adjuvant postoperative chemo-radiation, Intergroup 0116, conducted in North America; and b) the Dutch D1-D2 Trial.

Results:

Blinded univariate and multivariate analysis of both trials establish “Maruyama Index of Unresected Disease” (MI) <5 as a strong independent predictor of better disease-free and overall survival in gastric cancer. Moreover, a strong “dose response” effect for MI versus survival is apparent.

Conclusions:

In contrast to surgery focused on achievement of a particular Japanese-defined D-level, “low Maruyama Index surgery” is associated with increased disease-free and overall survival. Further, the dose-response effect suggests MI can be used to quantify the adequacy of lymphadenectomy for a given patient. Low MI surgery can be pro-spectively planned by using the Maruyama Computer Program pre-operatively or intra-operatively.
Immunonutrition in Elective Gastrointestinal Surgery Patients
Authors: Helminen H. , Raitanen M. , Kellosalo J.
Published: January 2017

Background:

Previous trials have shown that perioperative immunonutrition could protect patients from infectious complications after gastrointestinal cancer operations. The purpose of this study was to determine whether perioperative immunonutrition decreases postoperative morbidity, especially infection complications, mortality and length of hospital stay in patients undergoing major gastrointestinal tract surgery.

Methods:

One hundred patients with a planned elective operation for benign or malignant gastrointestinal illness were randomized into two groups: group 1) oral supplementation for five days before and five days after surgery with 900 mL/day of a formula enriched with arginine, gamma-3-fatty acid and RNA + liquid diet ad libitum on one and two postoperative day and then solid food (immunonutrition group; n = 50) or group 2) no artificial nutrition before and after surgery, on one and two postoperative day intravenous solution of 5% glucose and electrolytes and then normal diet (conventional group; n = 50).

Results:

The groups were comparable for all key baseline and surgical characteristics. There were nine (18%) infectious complications in both groups. Overall complication rates were 28% (n = 14) in the immunonutrition group and 24% (n = 12) in the conventional group. No significant difference between the groups was found in complication rates, mortality or length of hospital stay.

Conclusion:

Routine perioperative immunonutrition to the patients undergoing major gastrointestinal surgery is not beneficial.
A 19-Year Review of Paediatric Patients with Acute Scrotum
Authors: Mäkelä E. , Lahdes-Vasama T. , Rajakorpi H. , Wikström S.
Published: January 2017

Background and Aims:

The aim of the study was to compare incidence, symptoms and signs of spermatic cord torsion to those of other conditions causing acute scrotum.

Material and Methods:

Records of 388 consecutive boys under 17 years of age treated for acute scrotum at The Hospital for Children and Adolescents in Helsinki in 1977–1995 were reviewed. During the period studied all patients with acute scrotum underwent urgent surgery to ensure accurate diagnosis and treatment. The duration and characteristics of the symptoms, clinical findings prior to operation and the age of the patients were registered.

Results:

Scrotal explorations revealed 100 cases (26%) of spermatic cord torsion (SCT), 174 cases (45%) of torsion of the testicular appendage (AT), 38 cases (10%) of epididymitis (ED), 32 cases (8%) of incarcerated inquinal hernias and 44 (11%) other conditions. During the first year of life SCT was the most common cause of acute scrotum, another peak incidence being in adolescence. Almost half of the boys with AT were nine to 12 years of age (median 11). Except for infants, the patients' acute symptoms were pain (SCT 88%, AT 94%, ED 76%). Swelling in the hemiscrotum was found in 44% of SCT, in 39% of AT and in 88% of ED cases. Epididymitis was also accompanied by erythema (37%), but infrequently with fever (in 16%). Erythema was found also in AT (32%), but the “blue dot sign” was found positive in only 17 (10%) of the boys with AT. Three quarters of the boys who were operated on within six hours from onset of symptoms had testicle torsion. All testicles were saved when detorsion was performed within six hours, but salvage was possible in only half of the cases when symptoms had lasted more than six but less than 12 hours.

Conclusions:

The high probability of SCT among those admitted to an emergency department within six hours from the onset of the symptoms justifies immediate surgical exploration.
Arthroscopic Anterior Cruciate Ligament Reconstruction Using a Hamstring Graft with Interference Screw Fixation
Authors: Moisala A.-S. , Järvelä T. , Honkonen S. , Paakkala A. , Kannus P. , Järvinen M.
Published: January 2017

Background and Aims:

This study assessed the clinical and radiographic results 3 to 8 years after an arthroscopic ACL reconstruction using a hamstring graft with interference screw fxation on femoral and tibial sites.

Material and Methods:

Seventy-six of 100 patients, who underwent an arthroscopic ACL reconstruction, could be re-examined with a mean follow-up of 5 years.

Results:

The mean Tegner activity score was 4 (scale: 0 to 10) before surgery, and 5 at the follow-up. Fifty-four patients (78%) achieved a satisfactory result in the IKDC rating. The mean Lysholm score was 85 (scale: 0 to 100), the score being better in patients without meniscal resection than those with (P = 0.04). The mean side-to-side difference in anterior-posterior knee laxity was 1.8 mm, and 62 patients (90%) had good stability. Sixty-four patients (93%) had normal range of motion of the knee. Twelve patients (46 %) with meniscal resection had osteoarthritic changes, compared with only 8 of those (20 %) without meniscal resection (P = 0.03).

Conclusions:

This medium-term follow-up study showed that good stability and function and normal range of motion of the knee can be achieved in majority of the patients who have undergone an ACL reconstruction with a hamstring graft and interference screw fixation.
Management of Severe Sepsis of Abdominal Origin
Authors: Pieracci F. M. , Barie P. S.
Published: January 2017

Severe sepsis is a life-threatening condition that may occur as a sequela of intra-abdominal infections (IAIs) of all types. Diagnosis of IAIs is predicated upon the combination of physical examination and imaging techniques. Diffuse peritonitis usually requires urgent surgical intervention. In the absence of diffuse peritonitis, abdominal computed tomography remains the most useful test for the diagnosis of IAIs, and is essential to both guide therapeutic interventions and evaluate suspected treatment failure in the critically ill patient. Parameters most consistently associated with poor outcomes in patients with IAIs include increased illness severity, failed source control, inadequate empiric antimicrobial therapy, and healthcare-acquired, as opposed to community-acquired infection. Whereas community-acquired IAI is characterized predominantly by enteric gram-negative bacilli and anaerobes that are susceptible to narrow-spectrum agents, healthcare-acquired IAI (e.g., anastomotic dehiscence, postoperative organ-space surgical site infection) frequently involves at least one multi-drug resistant pathogen, necessitating broad-spectrum therapy guided by both culture results and local antibiograms. The cornerstone of effective treatment for abdominal sepsis is early and adequate source control, which is supplemented by antibiotic therapy, restoration of a functional gastrointestinal tract (if possible), and support of organ dysfunction. Furthermore, mitigation of deranged immune and coagulation responses via therapy with recombinant human activated protein C may improve survival significantly in severe cases complicated by septic shock and multiple organ dysfunction syndrome.
Ten-Year Outcomes after Endovascular Aneurysm Repair (Evar) and Magnitude of Additional Procedures
Authors: Väärämäki S. , Pimenoff G. , Heikkinen M. , Suominen V. , Saarinen J. , Zeitlin R. , Salenius J.
Published: January 2017

Background and Aims:

With any new technology complications are possible, and problems with first-generation aortic stentgrafts have been extensively reported. The long-term outcome of this patient population and the magnitude of additional secondary procedures are, however, less well covered.

Materials and Methods:

Between February 1997 and November 1999, 48 patients (44 men and 4 women; mean age 70 years; range 54–85) with AAA (average 57mm, range 40–90mm) were treated with a Vanguard® endoprosthesis. Stentgrafts were sized by CT and angiography-based measurements. Results were continuously assessed using contrast-enhanced CT before discharge, 1, 3, 6 and 12 months after the procedure and thereafter annually. Since 2001 plain abdominal X-rays have been performed annually.

Results:

The technical implant success rate was 100%. Median follow-up was 91 months (range 7.6–120 months). None of the patients was lost during this period. Hospital mortality was 0%. There were 25 subsequent deaths (52%), the most common cause being coronary artery disease. There were ten late conversions to open surgical repair, including three emergency operations: two due to rupture and one to thrombosis. EVAR-related complications were encountered in 43 patients (90%): 12 primary endoleaks (all type II), 36 late endoleaks (16 type I, 2 type II and 18 type III), 22 migrations, 25 row separations, 20 thromboses, one endotension and 3 ruptures of the AAA. Secondary procedures were required in 39 patients (81%): 1 re-endografting by aortoiliac bifurcated graft and 3 with a uni-iliac graft; 33 limb graft repairs were performed and 19 infrarenal cuffs were placed. There were 4 late embolizations and 4 attempts, and 6 thrombolyses, four of which were successful. Further, 9 femoro-femoral crossover by-pass and 2 axillo-femoral by-pass operations and 2 amputations were carried out during the follow-up. Only one patient was alive without complications.

Conclusions:

The impact of long-term follow-up of patients treated with the new technology was emphasized in this patient population. A careful surveillance protocol and active endovascular treatment of complications can yield acceptable results and low AAA rupture and aneurysm mortality rates, also with the first-generation endovascular graft. A new technology, however, may involve unpredictable problems which can magnify the workload and incur high costs over several years after the initial procedure.
Interplay between Coagulation and Inflammation in Open and Endovascular Abdominal Aortic Aneurysm Repair — Impact of Intra-Aneurysmal Thrombus
Authors: Aho P.-S. , Niemi T. , Piilonen A. , Lassila R. , Renkonen R. , Lepäntalo M.
Published: January 2017

Aims:

Our aim was to compare hemostatic and inflammatory mechanisms in abdominal aortic aneurysm (AAA) patients after open surgery (OPEN) and endovascular AAA repair (ENDO).

Subjects and Methods:

From the 32 consecutive AAA patients recruited, 17 represented ENDO and 15 OPEN. The intra-aneurysmal thrombus was removed during OPEN, but stayed intact after ENDO. The pre-operative volume of the intra-aneurysmal thrombus was calculated from computed tomography images. Markers of coagulation and inflammation were studied pre-operatively, at one, two, three, four and seven days and at three months postoperatively.

Results:

Preoperative upregulation of F 1 + 2, TAT and D-dimer was evident in both groups. The volume of intra-aneurysmal thrombus correlated with CRP (β=0.62, p=0.001), IL-6 (β=0.60, p=0.001) and PAI-1 ag (β=0.51, p=0.007). Surgery further enhanced inflammation, coagulation and fibrinolysis. IL-6 increased in both groups, but the increases of CRP and PIIINP were higher in the OPEN group. Postoperative CRP correlated with the intra-aneurysmal thrombus volume in the ENDO group. At three months D-dimer (p<0.05) was higher than pre-operatively in the ENDO, in contrast to the OPEN group.

Conclusion:

Preoperatively both prothrombotic and fibrinolytic mechanisms are activated in patients with AAA. Intraluminal thrombus induces prothrombotic and inflammatory interactions, which persist after endovascular aortic aneurysm repair.
Evolution of the Therapeutic Approach of Visceral Artery Aneurysms
Authors: Ruiz-Tovar J. , Martínez-Molina E. , Morales V. , Sanjuanbenito A. , Lobo E.
Published: January 2017

Introduction:

Visceral artery aneurysms are an infrequent entity. Most of them are asymptomatic, but when they present as a rupture, a high mortality is associated.

Material and Methods:

We review our experience of 18 cases between 1988 and 2006.

Results:

9 males and 9 females with a mean age of 66,5 years are analyzed. Aneurysms were located in splenic artery (9), hepatic artery (2), superior mesenteric artery (2), celiac trunk (3), inferior mesenteric artery (1) and gastroduodenal artery (1). Three of them were associated with abdominal aorta aneurysms. Fourteen patients were asymptomatic, three presented abdominal pain and one case presented with rupture and intraperitoneal bleeding. Surgical treatment was performed in thirteen of the patients and endovascular in five. Two cases of endovascular treatment failed and surgery was necessary. Postsurgical mortality was 0 and complications appeared in 2 patients. Mean hospital stay after surgical treatment was 11 days and 3 days after endovascular one. None of the patients presented recurrences, and one has chronic mesenteric ischemia as sequelae of surgical treatment of a superior mesenteric artery aneurysm.

Conclusion:

Visceral artery aneurysms must be treated if it is feasible, due to the potential risk of rupture. Endovascular treatment associates lower morbimortality rates and shorter hospital stay than surgical one, but nowadays many aneurysms are not suitable for this management. Endovascular treatment is a technically difficult approach, that requires a specific training and the first cases represent a learning curve.
Retrospective Review of 234 Scaphoid Fractures and Nonunions Treated with Arthroscopy for Union and Complications
Authors: Slade J. F. , Gillon T.
Published: January 2017

The purpose of this paper is to retrospectively review 234 consecutive cases of scaphoid fractures and nonunions treated using arthroscopy with the dorsal percutaneous implantation of a headless compression screw for healing and complications. Solid union of fracture is determined by CT scan. We identified 126 acute injuries, including 65 proximal pole fractures; 67 grossly displaced fractures; 12 trans-scaphoid perilunate dislocations including four trans-scaphoid trans-capitate fractures; and ten combined scaphoid and distal radius fractures. 108 scaphoid nonunions were identified. 98 were correctly aligned and ten had a humpback deformity which was correctable using arthroscopic assisted reduction techniques at the time of surgery. 82 presented with a fracture gap 2mm or greater requiring percutaneous bone grafting. 12 cases of avascular necrosis (AVN) were identified by MRI. 20 nonunions had surgery performed at other institutions. The mean time to surgery for the nonunions was 20 months.

99% union rate of acute scaphoid fractures was obtained by 12 weeks, as determined by CT scan. Two complications were identified (3%). One case of delayed healing was identified. This delayed union was treated with percutaneous bone grafting and continued on to heal uneventfully. The other complication was a case of volar trans-scaphoid peri-lunate dislocation. While the fracture healed, the patient developed a traumatic dislocation requiring a capitate-lunate arthrodesis. Treatment of scaphoid nonunions resulted in ten cases of delayed healing, which were treated with repeat percutaneous bone grafting. This represented a 9% complication rate. Of the ten cases of delayed unions that were re-bone grafted, four failed to heal by nine months. This resulted in a 96% union rate of our nonunion group by nine months. When acute fracture healing was compared to nonunions the average healing of acute fractures as determined by CT scanning measuring trabecular bridging was 12 weeks, while the average healing of nonunions was 22 weeks. We conclude that the dorsal percutaneous treatment of scaphoid fractures and nonunions using arthroscopy is safe and effective. CT scans to evaluate scaphoid healing by measuring trabecular bridging at the fracture site was determined to be an excellent modality to evaluate scaphoid healing. While not witnessed in this series, the potential for complications requires proper training.
Wrist Instability
Authors: Carlsen B. T. , Shin A. Y.
Published: January 2017

The topic of wrist or carpal instability has been a source of confusion and miscommunication for decades. The terminology can often be difficult to understand and one surgeon's concept of instability may be completely different from another's. This is by no means a comprehensive review of carpal instability, which has often been the focus of numerous multi-volume textbooks. The purpose of this paper is to detail the basics of carpal instability, the anatomy, pathomechanics, terminology and basic principles of treatment.
Expertise and Skill in Minimally Invasive Surgery
Authors: Silvennoinen M. , Mecklin J.-P. , Saariluoma P. , Antikainen T.
Published: January 2017

New attitudes to medical ethics and demands for efficiency have brought increased attention to surgical skills and training. It is important to characterize the expertise and skill involved in the multidimensional surgical profession. At a time of change, there is a need to discuss the nature of surgical expertise, and also the prospects for resident training, with special reference to new minimally invasive techniques (MIS).

In this paper, we selectively review knowledge on surgical expertise and the specific demands placed on a skilled MIS surgeon. In addition, the review contains a selection of studies from those areas that have been seen as important for the future of training in surgery.
Effectiveness of Superficial Venous Surgery in Terms of Quality-Adjusted Life Years and Costs
Authors: Eskelinen E. , Räsänen P. , Albäck A. , Lepäntalo M. , Eskelinen A. , Peltonen M. , Roine R. P.
Published: January 2017

Aims:

To assess the impact of superficial venous surgery (SVS) on health-related quality of life (HRQoL) and to explore the cost-utility of venous surgery.

Material and Methods:

143 patients (110 female and 33 male) enrolled for SVS between 2003 and 2005 in Helsinki University Central Hospital filled in the 15D survey before and six months after operation. Direct hospital costs were obtained from a patient administration database and were examined from the perspective of secondary care provider.

Results:

After SVS, the HRQoL score improved in 71% of the patients, and the mean score increased from 0.919 (on a0–1 scale) preoperatively to 0.933 postoperatively at 6 months (p < 0.001). Patients with a clinically important result from SVS (≥ 0.03 increase in the HRQoL score) had significantly worse HRQoL at baseline. At 6 months postoperatively, the mean (SD) hospital costs were 1637€ (693) and the mean quality-adjusted life year (QALY) gain 0.504 (1.674), respectively. Thus, the mean cost per QALY gained during a 6-month period was 3248€ for SVS.

Conclusions:

Superficial venous surgery improves HRQoL, and is a cost-effective treatment of symptomatic superficial venous insufficiency.
Development of an Educational Booklet for Children of Adult Liver Transplant Recipients
Authors: Bufton Sally
Published: January 2017

Educating family members of transplant recipients has long been recognized as an important factor in preparation for organ transplantation. This preparation may help the family come to terms with potential complications, the possibility of extended hospitalization, and the psychological changes that their loved ones might experience. Although education of a spouse or essential others may take place, children of an organ recipient may be unintentionally overlooked in the teaching process. This article describes how an educational booklet for children of adults undergoing liver transplantaion was developed and introduced into a liver transplant unit.
Interdisciplinary Approach to the Management of Intestinal Transplant Recipients: Evaluation, Discharge, and Lifetime Management
Authors: Samela Kate , Fennelly Erin , Brosnan Mary , Robinson Jill
Published: January 2017

Patients suffering from intestinal failure present unique and difficult challenges to the transplant team. Augmenting the need for interdisciplinary teamwork is the higher incidence of death on the intestinal transplant waiting list. Successful management of this population requires an interdisciplinary approach at each stage of care, beginning with evaluation and continuing through discharge and lifetime management. A close relationship between patients, their caregivers, and all members of the transplant team is an essential component to successful lifetime management. Open communication between team members and unlimited accessibility to each other enables work flow to be managed efficiently, and enables the provision of optimal care. In this article, we describe the functions of the nonphysician clinical personnel needed to manage the intestinal transplant patient—beginning at the evaluation through lifetime follow-up care. The goal of each professional is the same: to restore the patient to the best quality of life possible.
Dollars and Sense of Successful Rehabilitation
Authors: Callahan Mary Beth
Published: January 2017

Improving employment outcomes for transplant recipients can positively contribute to a patient's identity, self-esteem, and quality of life. Placing a dollar figure on the costs associated with advanced medical procedures is much easier than placing a dollar figure on the benefits resulting from being employed after transplantation. This article outlines the work of the Life Options Rehabilitation Advisory Council and how it has assisted people with kidney disease—those on dialysis and those who received transplants—to achieve life goals and provide long-term access to employer group health plans. A review of current work incentives includes the Ticket to Work and the Work Incentives Improvement Act, Medicaid Buy-in Programs, and other work incentives related to the Social Security system. Effective rehabilitation outcomes can be enhanced in the transplant population through knowledge of work incentives and awareness of obstacles that are perceived by rehabilitation agencies in working with this group.
Transfer versus Transition: Success in Pediatric Transplantation Brings the Welcome Challenge of Transition
Authors: Stabile Laura , Rosser Lynette , Porterfield Karen M. , McCauley Sonia , Levenson Cecile , Haglund Jeneva , Christman Karen
Published: January 2017

Context

Increasing success with solid organ transplantation in children has increased the numbers of adolescents and young adults who are at an age to transfer to adult healthcare.

Objective

To determine the nature of transfer/transition of adolescents and young adults to adult healthcare.

Design

Using a qualitative approach, 24 young adults provided answers to 12 questions about their transfer to adult healthcare. Responses were compared to identify themes.

Setting

Subjects had been pediatric patients at Children's Hospital of Pittsburgh. Most were transferred to the University of Pittsburgh Medical Center.

Patients

The subjects had received, or were on the list to receive, solid organ transplants and had been transferred within 18 months of the study.

Results

Twenty-four of 37 potential subjects completed interviews. Those who participated were enthusiastic about making a contribution to the transfer process. Most subjects cited difficulty leaving the pediatric system. Challenges included abrupt transfers, insufficient communication between pediatric and adult specialty providers, and becoming “lost to follow-up.” However, there was a consistent, clear statement that subjects preferred being treated as adults. They liked healthcare staff addressing them instead of their parents, being spoken to in an adult manner, and being responsible for their own care. Suggestions for improvement included early introduction of the concept of transition to adult care, providing written material about the transition process, and use of pediatric/adult social work collaboration to provide support for young adults in transition.
Informed Consent
Authors: Zink Sheldon , Wertlieb Stacey , Kimberly Laura
Published: January 2017

In the last half century, informed consent has become a central tenet of all research involving human subjects. However, even after the worldwide adoption of regulations aimed at ensuring the protection of subjects, some abuses continue. The installation of oversight bodies, such as institutional review boards, has prevented the bulk of deliberate mistreatment; however, unintentional coercion is still a problem. Informed consent is not limited to obtaining a signature on a consent form, but a process of decision making designed to protect the rights of patients and subjects. It is a constant, ongoing exchange of information between researcher and subject. Although research is invaluable to the advancement of medicine and transplantation, researchers have the responsibility to protect their subjects' rights and autonomy. This paper provides an overview of informed consent, principles behind the process, and implications of current regulations to assist readers in their endeavor for sound and ethical research.
Subcapsular Hematoma Evacuation as a Method of Evaluating Injured Kidneys for Transplant
Authors: Yushkov Yuriy , Hoffman Allison , Giudice Anthony
Published: January 2017

Background

Approximately one-third of organ donors in the United States are trauma victims. In general, kidneys with large subcapsular hematomas are not used for transplant because of the possibility of significant parenchymal injury. A large subcapsular renal hematoma may cause scarring resulting in renal parenchymal compression and development of the Page syndrome.

Objective

To elucidate a successful method of evaluating kidneys subject to trauma, while also possibly preventing further damage and improving their function.

Design

Data were collected from the donor kidney pool of the New York Organ Donor Network from January 2006 through July 2007. Four kidneys during that period were determined to have significant subcapsular hematomas. Surgical intervention was undertaken and outcomes after transplantation were reviewed.

Main Outcome Measures

Four of the kidneys underwent a surgical procedure to drain the subcapsular hematoma allowing assessment of the underlying renal parenchyma. All 4 of these kidneys were deemed transplantable. After transplantation, 3 of the 4 kidneys had immediate function and did not require dialysis. The remaining kidney was removed as a result of primary nonfunction.

Conclusion

The described surgical intervention allows the transplant surgeon to accurately assess the extent of damage to a traumatized kidney while possibly preventing further damage to the kidney.
Short-Term Impact of an Educational Program Promoting Live Donor Kidney Transplantation in Dialysis Centers
Authors: Pradel Françoise G. , Suwannaprom Puckwipa , Mullins C. Daniel , Sadler John , Bartlett Stephen T.
Published: January 2017

Context

Given the shortage of kidneys available for transplantation, a community-based intervention trial was implemented to assess the impact of an educational program on patients' access to live donor kidney transplantation (LDKT).

Objective

To compare the short-term impact of a basic intervention and an enhanced intervention on patients' readiness to pursue LDKT.

Design

Baseline data and data from 1 week after interventions were analyzed.

Participants

214 transplant-eligible hemodialysis patients attending 14 dialysis facilities in Maryland, Virginia, and Pennsylvania.

Interventions

In the basic intervention, 107 patients watched a 10-minute videotape on the experience of recipients and live donors of a kidney. In the enhanced intervention, 107 patients watched the same videotape and had a discussion with a health educator on the risks and benefits of LDKT, who could be a donor, and how to address the barriers they were encountering when seeking a live kidney donor.

Main outcome measure

Patient reported whether they were considering LDKT, had talked with family or friends about LDKT, and had asked someone for a kidney.

Results

Over half of transplant-eligible patients were not pursuing LDKT at baseline (64% in the basic intervention group, 61% in the enhanced intervention group). One week after the intervention, the odds of considering LDKT were higher among African Americans (odds ratio [OR], 2.28; confidence interval [CI], 1.22–4.25), younger patients (OR, 0.94; CI, 0.91–0.97), and patients who spent less time on dialysis (OR, 0.90; CI, 0.83–0.97). The odds of asking for a kidney were higher among African Americans (OR, 4.94; CI, 2.54–9.60) and patients who perceived they were in poor to fair health (OR, 3.30; CI, 1.12–9.67).

Conclusions

Although both interventions helped patients consider LDKT and ask for a kidney, more time and expanded educational content might be needed to facilitate patients' discussion about LDKT with their loved ones.
Participation in School: School Assistants Creating Opportunities and Obstacles for Pupils with Disabilities
Authors: Hemmingsson Helena , Borell Lena , Gustavsson Anders
Published: January 2017

This study addresses how help is provided for pupils with physical disabilities and how school assistants influence their participation in school. Data were collected through field observations and interviews with seven pupils between 7 and 15 years old and with each pupil's teacher and assistant. The analysis resulted in a description of features that influenced how help was provided and the consequences in school for the pupil with disabilities. A major finding was that the assistants could both facilitate and hinder participation. We concluded that an awareness of the priority the pupils place on social participation with their peers is needed to ensure effective and flexible support is made available to pupils with disabilities.
The Role of Sensory Processing in the Everyday Lives of Older Adults
Authors: Pohl Patricia S. , Dunn Winnie , Brown Catana
Published: January 2017

This study investigated whether there are age-related differences in sensory processing within daily life. Participants included 404 community-dwelling adults divided into three age groups: 19 to 34 years old (127 individuals), 35 to 64 years old (126 individuals), and 65 years and older (151 individuals). Each participant completed the Adolescent/Adult Sensory Profile. There was a difference in sensory processing between the three groups (p = .000), with the older adults noticing sensory input less than the young and middle aged adults (p = .002 for both groups). Both middle aged and older adults engaged in less sensory seeking behaviors than did young adults (p = .012 and p = .000, respectively). In an additional analysis, the older group was subdivided into four age groups (65 to 69 years, 70 to 74 years, 75 to 79 years, and 80 years and older). There was an age-related difference between the four groups (p = .000). Those 75 to 79 years old and those 80 years and older noticed sensory input less than did those younger than 70 years (p = .002 and p = .001, respectively). Those 80 years and older were also less apt to seek sensory experiences than were those younger than 70 years (p = .011). The authors propose hypotheses about the meaning of these findings and provide recommendations for the application of this knowledge to support older adults to age in place successfully.
Embolisation of Orbital Varix via the Superficial Temporal Vein
Authors: Mavilio N. , Pau A. , Pisani R. , Casasco A. , Rosa M.
Published: January 2017

A case of orbital varix is presented, in which the lesion was successfully treated by means of embolisation with Guglielmi detachable coils, via the superficial temporal vein. Reports of endovascular treatment via transvenous route of orbital varix are lacking, only one case having previously been presented in the literature. We stress endovascular management for such an entity.
Iatrogenic Rupture of a Cerebral Aneurysm on the Feeding Artery of an Arteriovenous Malformation
Authors: Guzman R. , Remonda L. , Lövblad K.O. , Barth A. , Schroth G.
Published: January 2017

We present the case of a patient with acute onset of headache who showed a flow-related acutely ruptured aneurysm on the feeding artery of an AVM in the angiogram. Rerupture of the aneurysm occurred during angiography after endovascular treatment with a Guglielmi detachable coil. The possible mechanisms leading to rupture of the aneurysm are discussed.
Recovery of Third Nerve Palsy after Endovascular Packing of Internal Carotid-Posterior Communicating Artery Aneurysms
Authors: Mavilio N. , Pisani R. , Rivano C. , Testa V. , Spaziante R. , Rosa M.
Published: January 2017

Endovascular packing of intracranial aneurysm with preservation of the parent vessel has become in many cases a valid alternative to surgical clipping. Regression of oculomotor disorders after clipping of internal carotid-posterior communicating artery (ICA-PCoA) aneurysms has been well assessed. This report focuses on the reversal of third nerve palsy after endovascular packing of ICA-PCoA aneurysms. To this end, clinical appearances, neuroradiological features, and endovascular interventional procedures of six treated patient are reported and discussed in the light of the very few previous case observations found in the literature. Results indicate that endovascular packing of ICA-PCoA aneurysms may produce effective recovery of correlated third nerve dysfunction.
Role of Multimodality Intraoperative Neurophysiological Monitoring during Embolisation of a Spinal Cord Arteriovenous Malformation
Authors: Sala F. , Niimi Y. , Berenstein A. , Deletis V.
Published: January 2017

The decision whether or not to embolise during endovascular procedures for arteriovenous malformations (AVMs) of the spinal cord under general anesthesia, relies primarily on neurophysiological results of provocative tests with Lidocaine and short-acting barbiturates. Because of the complex haemodynamics of spinal AVMs, when either sensory (CSEPs) or muscle motor evoked potentials (mMEPs) are used independently, they can mislead the interpretation of provocative tests. This report illustrates the specific but complementary role played by provocative tests using CSEPs and mMEPs during embolisation of a low thoracic spinal cord AVM.

We present the case of a 46 year old male with six year history of right lower extremity weakness. At that time, Magnetic Resonance (MR) imaging of the spine disclosed an intramedullary AVM at T11. He remained neurologically stable up to seven months before admission, when he developed sudden onset of low back pain, followed by progressive paraparesis, numbness in lower extremities, urinary retention and fecal incontinence. A new MR imaging study indicated venous thrombosis of the AVM.

A two-stage embolisation was performed. During the first procedure, after provocative tests did not affect either CSEPs or mMEPs, an embolisation was performed through a sulco-commisure feeder from the anterior spinal artery (ASA) at T9. Conversely, provocative tests with Lidocaine performed from a right posterior spinal artery (PSA) feeder to the AVM nidus resulted in a significant (>50%) decrease of CSEPs, while mMEPs remained unchanged. The repeatedly positive tests warranted further investigation of the vascular anatomy which disclosed a normal right PSA distal to the nidus; the distal normal PSA was protected with coils. A repeated Lidocaine test was negative and the posterior feeder was embolised with no subsequent changes in CSEPs or mMEPs. After the procedure, the patient experienced only a mild transitory increase in right leg numbness, but no additional motor deficits. Five days later, the embolisation through the ASA feeder at T9 was completed on the basis of negative provocative tests. No additional neurological deficits were observed.

Favoring either CSEPs or MEPs during endovascular procedures in the spinal cord is not justified by a solid scientific background. This case report illustrates that monitoring both CSEPs and mMEPs combined with provocative tests allows the safest and most effective embolisation of spinal cord AVMs under general anesthesia.