Ambulatory surgery. Patients and patient education

This article reviews the concept of day surgery and shows how the treatment can be organized pre-, per- and post-operatively. It can be established in a hospital-integrated unit, a unit separate from the hospital, but connected with it, or a satellite ambulatory facility. Because the patient spends only a short time in hospital it is necessary to have structured preparations before admission, for the benefit of both patient and staff. It should be easy to identify patients suitable for day surgery from the waiting lists, and preparations should be directed at treatment by day surgery right from the start. Rules must be worked out for selecting patients, as well as guidelines for information to patients. It is also necessary to plan the operation programme, and to agree how nurses and doctors should take care of the patient during the different steps of treatment.     

Planning and implementation of research projects in psychosomatic medicine

Based on experiences of the author in planning and realization of scientific studies the different phases and steps of research process are discussed. Especially in the phases of reflecting and planning of a study, a lot of essential preliminary tasks are quite often missed. Failures in these initial phases of a scientific study lead to difficulties in collecting and evaluating of data. Important steps in the different phases of a project are reported in an overview. Finally some typical failures and faults in psychosomatic research made by physicians and social scientists are mentioned.     

Inhibition of posterior capsule opacification with an immunotoxin specific for lens epithelial cells: 24 month clinical results

PURPOSE: To assess the safety and effectiveness of an immunotoxin, MDX-RA, designed to inhibit posterior capsule opacification (PCO). SETTING: Eleven private practices in the United States. METHODS: This study comprised 63 eyes of 63 patients having extracapsular cataract extraction by phacoemulsification; these patients were enrolled in a Phase I/II clinical investigation of the immunotoxin MDX-RA. At the close of surgery, 21 patients were treated with placebo, 23 patients with 50 units of the immunotoxin, and 19 patients with 175 units of the immunotoxin as an aqueous solution. The patients were monitored for 24 months after primary cataract surgery using external eye and slitlamp examinations, visual acuity assessment, ophthalmoscopy, pachymetry, tonometry, endothelial cell counts, and lens capsule photography. Posterior capsule opacification, recorded on lens capsule photographs, was graded independently by a committee of 3 cataract surgeons. The incidence of neodymium:YAG (Nd:YAG) capsulotomy was projected from the opacification results. RESULTS: The immunotoxin, at the 50 unit dose, was well tolerated and effective in inhibiting PCO. At the 175 unit dose, there was a trend toward increased postoperative inflammation that was transient with no residua. From 6 to 24 months postoperatively, the 50 unit dose significantly inhibited PCO compared with the placebo (P < .05). This significant reduction in PCO translated into a significantly lower projected need for Nd:YAG capsulotomy in the 50 unit than the placebo group (P < .004). About 60% in the placebo group and 4% in the 50 unit group were projected to need an Nd:YAG capsulotomy by 3 years postoperatively. CONCLUSION: The immunotoxin was well tolerated and was effective in reducing PCO for up to 24 months after cataract surgery. Although these preliminary results are encouraging, a larger study is underway to determine whether the reduction in PCO by the immunotoxin decreases the need for Nd:YAG capsulotomy.     

Ergonomic working conditions for the nursing team in a cardiology unit]

Aiming at finding out the ergonomics conditions of the nursing personnel in a hospital admission unit, the authors utilized as a methodological presupposition the search for a global experienced work situation through the analysis of some elements as: the man (nursing worker); the work activity (prescribed duty, real activities and work position) and the environment (temperature, noise and illumination). The authors selected the Cardiology admission unit for the site of their research. The results verified that the nursing workers the mentioned unit face problems related to salaries, work installations, relationship, work organization, levels of formation and the activities executed. The authors suggested some recommendations.     

Cavernous malformations: from frame-based to frameless stereotactic localization

AIM: To determine the change in use of a day surgery unit over a 21-year period. DESIGN: Retrospective analysis. SETTING: The day surgery unit within a central London dental hospital. MATERIALS: The operating and anaesthetic records of surgical activity in 1973, 1983, 1993 and 1994. RESULTS: A six-fold increase in the total number of dentoalveolar procedures performed was demonstrated during the period studied. However, these procedures represented only 77.6% of surgical activity in 1994 compared with 98.9% in 1973. CONCLUSIONS: Day case surgery appears to be advantageous to patients, clinicians, hospital managers and purchasing authorities. The development of more specialist day case services and facilities within "dental centres' is proposed as a means of ensuring that the specialty is able to adapt to the changing patterns of health care in the future.     

Loss of cardiopulmonary function in lung-resection surgery and post-operative complications

The items, mentioned as postoperative complications in lung-resection surgery in the newest reports, are much the same to those in patients undergone general surgery. Dealing with perioperative complications in lung-resection surgery, it must be taken into account that lung resection always results in, more or less, loss of cardiopulmonary function and that most perioperative complications are caused by accidental circumstances. Perioperative risk must be assessed based upon the predicted postoperative cardio-pulmonary function, but not the frequency of perioperative complications. The role of unilateral pulmonary artery occlusion test and exercise test in lung-resection surgery, and their pathophysiological implications are discussed.     

IgM myeloma: case report with immunophenotypic profile

STUDY OBJECTIVE: To determine how and why cholesterol concentrations decrease after surgery, and the effect of the administration of nutritional support. DESIGN: Prospective, observational study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS: 213 consecutive patients admitted to a surgical intensive care unit after major surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Serum concentrations of cholesterol, serum albumin and total protein. The initial portion of this study demonstrated that serum concentrations of cholesterol, like those of serum albumin and total protein, decreased by approximately 30% immediately following surgery. These changes were directly related to changes in hematocrit and inversely correlated with the volume of perioperative intravenous (IV)fluid, the degree of positive fluid balance, and the estimated blood loss. The study's second phase examined the 19 patients who received at least 10 days of nutritional support. After 1 week of feeding, serum total protein concentrations increased significantly, but did not return to preoperative levels. Serum concentrations of cholesterol, which were markedly decreased prior to nutritional repletion, increased significantly after 9 days of treatment. The changes in serum cholesterol concentration were negatively correlated (r = -0.32) with the daily intake of IV fluid. CONCLUSION: Serum cholesterol concentrations, like those of serum albumin and total protein, are markedly reduced immediately following major abdominal surgery, often to levels reported in malnutrition. Dilution by IV fluid and redistribution into an expanded extracellular fluid space are likely the major causes of these decreases. Serum cholesterol concentrations are therefore not useful in the nutritional assessment of patients in the immediate postoperative period.     

Iatrogenic provocation in female genital tuberculosis free of symptoms

Clinical symptoms of the disease are: sterility, relapsing, adnexitis, chronic peritonitis or perimetritis, primary or secundary lack of menstruation, even spontaneous abortion with fever and tubal pregnancy. Any kind of physicotherapy causing hyperaemia or congestion, surgery or sexual hormontherapy may enhance local exacerbation even spread of the disease. Congestion may further enhance the growth of bacteria by supplying more oxygen, and the sex hormones are incorporated by them. These circumstances influence the pathogenesis in a particular manner. The iatrogen provocation can prevented by profilactic antituberculous care. Lack of the mentioned prevention results to local progression, exsudat, fistulas, severe adhaesions, which cannot be solved by surgery. The iatrogen damages can only be prevented if gynecologists and phthysiologists cooperate.     

Comparative study of three methods of evaluation of the corneal endothelium in pseudophakic patients: fluorophotometry, specular microscopy and pachymetry

BACKGROUND: At present, three techniques, based on different methodological suppositions, are used indiscriminately for the study of the corneal endothelium. These are pachymetry, specular microscopy and fluorophotometry. The purpose of this work was to study the corneal endothelium of pseudophakic patients with the three techniques mentioned. On the basis of the results obtained, we discuss the relations between them and their practical clinical utility. METHODS: One hundred and fourteen eyes of pseudophakic patients were studied using the three corneal endothelial evaluation techniques, both in the immediate pre-operative period and 1 year after surgery. RESULTS: Statistically significant relations exist between the number of endothelial cells and the fluorophotometric endothelial permeability coefficient (Kc.ca) 12 months after surgery, between the increase in corneal thickness in the first week after the operation and the Kc.ca 12 months after surgery, and between fluctuations of the corneal thickness greater than 30 microns and both the endothelial cell count and the Kc.ca 12 months after surgery. There are no significant relationships among the pre-operative values obtained with the three methods. CONCLUSION: The results show how the parameters measured with the functional techniques (fluorophotometry, pachymetry) generally become normal after the surgical trauma, while the endothelial cell count remains irreversibly altered. The results obtained with different techniques are more closely related in more pathological endothelia, while no relation among them are shown in the study of normal endothelia. It is also shown how pachymetry is a good clinical predictor, in the immediate post-operative period, of the long-term status of the corneal endothelium.     

Home medical equipment suppliers: a critical home care partner. Interview by Sarah F Zarbock

Conventional management of gastroesophageal reflux (GER) and hiatus hernia in children affected with encephalopathy can deteriorate their pulmonary function, already compromised by their leaning position and their spine deformations. The results after laparoscopic surgery for GER in 6 encephalopathy children are reviewed; their ages ranged from 9 to 14 years, their accompanying diseases were: spastic tetraparesia, hydrocephalus, scoliosis, epilepsy and Reye's syndrome. The laparoscopy procedures followed the same surgical steps as open surgery; the surgical time was 3 to 5 hours; the average hospital stay was 3 days. Oral intake started 8 hours after surgery. The successful results of these first cases in this group of patients with neurologic anomalies, suggest that laparoscopic Nissen funduplication is the treatment of choice for GER and hiatus hernia.     

150 t VD/VOD超纯铁素体不锈钢的开发

蒂森克虏伯AST厂采用新单罐150 t VD/VOD,通过EAF-AOD-VOD三步工艺试制了409LI、439M、460LI以及470LI等4个级别不含Ni和Mo的超纯铁素体不锈钢。生产实践表明,采用EAF-AOD-VOD三步工艺比EAF-VOD两步工艺明显减少处理时间,实现了低成本生产超纯铁素体不锈钢的工艺目标,所生产的新一代超纯铁素体不锈钢AST460LI(%:≤0.010C、21.0～21.4Cr、≤0.002S、0.10～0.20Ti)和AST470LI(%:≤0.007C、23.8～24.2Cr、≤0.002S、0.10～0.20Ti)的耐蚀性和耐高温性能均优于标准奥氏体不锈钢304(%:≤0.08C、8.0～11.5Ni、18.0～20.0Cr)和316(%:≤0.08C、10.0～14.0Ni、16.0～18.0Cr、2.0～3.0Mo)。     

Audiometric bone conduction

Audiometric bone conduction test data are obtained with a unit that permits comparison with a recognized standard because the unit can be calibrated to operate within specified limits. Proper calibration of the unit is necessary if the equipment is to be accurate. Two procedures can be helpful in determining the need for calibration: the average loss method and the input voltage measurement method. Neither should supplant calibration, but each offers a means of checking the output of the unit. Confidence in auditory test data is increased when there is a high degree of consistency among the various tests; the availability of several different tests in the audiometric series can be used to an advantage then in a determination of consistency. An additional opportunity to ascertain the existence of consistency is present when tuning fork tests are employed as part of the total evaluation. The use of a masking stimulus in the nontest ear simultaneously with the presentation of the test tone to the test ear can be extremely useful in defining the type as well as the extent of the hearing loss. Presentation of the test tone and the masking stimulus in controlled discrete steps is the key to the interpretation of masking results.     

Spontaneous ambulatory activity as a quantifiable outcome measure for osteoarthritis of the knee

OBJECTIVE: Quantifiable outcome measures for disabling diseases such as osteoarthritis (OA) of the knee are necessary in order to compare the impact of different interventions competing for financial resources. Current subjective and questionnaire data are not satisfactory for such study. In this study, we examine the potential of the direct measurement of ambulatory activity as such a measure. POPULATION: Patients with X-ray evidence of OA of the knee recruited to studies of anti-inflammatory agents (n = 29). Patients with OA of the knee awaiting knee replacement surgery (n = 28). METHODS: Comparison of various standard measures with total energy output data from an activity monitor. RESULTS: Spearman rho correlations of ambulatory energy output (number of steps x average amplitude of steps) correlated with other measures. Correlation with physician's opinion was greater than with patient's opinion (r = 0.4 and 0.2, respectively). There was no correlation with visual analogue pain scale or OA severity index. Correlation with scales of the Nottingham Health Profile questionnaire were not significant either for mobility (r = - 0.15) or for pain (r = - 0.13). There was, however, a significant correlation between poor sleep and increased activity (r = 0.34, P < 0.05). Correlation with Kellgren X-ray grade was significant (r = - 0.45, P = 0.01). Patients recruited to anti-inflammatory studies were 69% more active than those awaiting replacement surgery. CONCLUSION: The monitoring of ambulatory activity shows some construct and discriminant validity, and is worthy of further study.     

Transit compartments versus gamma distribution function to model signal transduction processes in pharmacodynamics

Delayed effects for pharmacodynamic responses can be observed for many signal transduction processes. Three approaches are summarized in this report to describe such effects caused by cascading steps: stochastic process model, gamma distribution function, and transit compartment model. The gamma distribution function, a probability density function of the waiting time for the final step in a stochastic process model, is a function of time with two variables: number of compartments N, and the expected number of compartments occurring per unit time k. The parameter k is equal to 1/tau, where tau is the mean transit time in the stochastic process model. Effects of N and k on the gamma distribution function were examined. The transit compartment model can link the pharmacokinetic profile of the tested compound, receptor occupancy, and cascade steps for the signal transduction process. Time delays are described by numbers of steps, the mean transit time tau, and the amplification or suppression of the process as characterized by a power coefficient gamma. The effects of N, tau, and gamma on signal transduction profiles are shown. The gamma distribution function can be utilized to estimate N and k values when the final response profile is available, but it is less flexible than transit compartments when dose-response relationships, receptor dynamics, and efficiency of the transduction process are of concern. The transit compartment model is useful in pharmacokinetic/pharmacodynamic modeling to describe precursor/product relationships in signal transduction process.     

Membranoproliferative glomerulonephritis associated with HCV infection in native kidneys and renal allograft

STUDY OBJECTIVE: We sought to test the assumption that an emergency department observation unit can be funded through the reallocation of resources made available through the unit's impact in reducing inpatient admissions and facilitating bed closures. METHODS: We conducted our study in a tertiary care center ED with 46,000 visits annually. For a 3-month period, all patients admitted to the hospital through the ED were screened by an emergency physician for suitability for admission to an observation unit. Any patient in the hospital for 3 days or less who did not undergo surgery or other inpatient procedure, and who was admitted through the ED, was considered a candidate for the observation unit. RESULTS: Of 1,840 admissions, 147 patients met the admission criteria. Only 48 (32.2%) could have been treated in an observation unit, and these patients were not admitted to any single unit in high frequency. The potential savings from inpatient bed closures would only have amounted to 1.68 full-time equivalents-not enough to staff a 4-bed observation unit, which would require 5 full-time equivalents. CONCLUSION: Because of the diffuse and inconsistent effect such a unit had on inpatient bed use, funding for an ED observation unit at our institution could not be justified on the basis of the closure of inpatient beds and transfer of resources.     

Recent advances in antireflux surgery for gastroesophageal reflux diseases--from open surgery to laparoscopic surgery

Gastroesophageal reflux diseases (GERD) are common in the western countries and have been well studied about diagnosis and treatment. Nissen technique (a complete wrap) and Toupet technique (a partial wrap) are usually transabdominal fundoplication. Hill technique is a transabdominal posterior gastropexy. Allison technique is a transthoracic reduction method of the herniated cardia back into the abdomen, but is not frequently employed today. Belsey Mark VI technique is a transthroacic anterior plication. Collis gastroplasty is an esophageal lenghening technique and is used with standard repairs (Nissen, Belsey, and Hill). Good result rate of above mentioned surgery are about 90%. Recently, laparoscopic Nissen/Toupet technique are a standard antireflex surgery because of minimal invasiveness and more than 90% of good results. After introducing laparoscopic surgery the indication of antireflex surgery for GERD can be changed because of quality of life of patients and medicoeconomical reasons.     

A retrospective audit of blood loss in total hip joint replacement surgery at Middlemore Hospital

AIMS: To quantify the level of inappropriate red cell transfusion in primary and complex hip replacement surgery. METHODS: Data extraction was by retrospective review of patients records. Calculation of total red cell volume loss was by use of pre and postoperative (day 7) haematocrit levels, patient weight and number of units transfused. Transfusion was accepted as justified only if instituted for a 30% red cell volume loss or loss sufficient to drop the haematocrit below 0.28. RESULTS: Of 104 patients having primary hip joint replacement, 58 were transfused with a total of 157 units of red cells; 37 (24%) of these units were given inappropriately. Of 38 patients having complex hip replacement operations, 32 were transfused with a total of 139 units of red cells; 12 (9%) of these were given inappropriately. CONCLUSIONS: Inappropriate transfusion occurs in hip replacement surgery. A concurrent audit of red cell usage is required to better define the magnitude of the problem. Two unit transfusion is commonly given when one unit would have been sufficient.     

Routine pulmonary artery catheterization does not reduce morbidity and mortality of elective vascular surgery: results of a prospective, randomized trial

OBJECTIVE: The authors determined whether the preoperative placement of a pulmonary artery catheter (PAC) with optimization of hemodynamics results in outcome improvement after elective vascular surgery. SUMMARY BACKGROUND DATA: The PAC commonly is used not only in patients who are critically ill, but also perioperatively in major elective surgery. Few prospective studies exist documenting its usefulness. METHODS: One hundred four consecutive patients were randomized to have a PAC placed the morning of operation (group I) or to have a PAC placed only if clinically indicated (group II). Group I patients were resuscitated to preestablished endpoints before surgery and kept at these points both intraoperatively and postoperatively. Group II patients received standard care. RESULTS: There was one death in each group. An intraoperative or postoperative complication developed in 13 patients in group I versus 7 patients in group II (p = not significant). Group I patients received more fluid than did group II patients (5137 +/- 315 mL vs. 3789 +/- 306 mL; p < 0.003). There was no significant difference in either overall or surgical intensive care unit length of stay. Only one patient in group II required a postoperative PAC. CONCLUSIONS: Routine PAC use in elective vascular surgery increases the volume of fluid given to patients without demonstrable improvement in morbidity or mortality.     

Universal calibration of surgical instruments for spinal stereotaxy

PURPOSE: To describe new software applications and interchangeable instrumentation enabling the use of standard surgical instruments with image-guided systems for stereotactic spinal procedures. CONCEPT: The ability to adapt essentially any surgical instrument for stereotactic procedures will improve the safety and accuracy of image-guided spinal surgery. RATIONALE: Using universal dynamic registration hardware and software, standard surgical instruments are adapted for real-time image-guided surgery. The Radionics Optical Tracking System (Radionics, Inc., Burlington, MA) has custom software applications and universal hardware adaptation devices for spinal stereotaxy that allows the use of standard instruments for intraoperative guidance. An array of light-emitting diodes can be attached to essentially any rigid instrument with a definable tip and can then be calibrated to the system for intraoperative use. Stereotactic guidance of a drill, tap, and screwdriver may improve screw placement accuracy in spinal surgery because every step of the procedure can be monitored in real time. DISCUSSION: Most stereotactic systems have only a standard probe or limited instruments for localization, targeting, and tracking a procedure. The surgeon then resumes the operation using standard surgical instruments without the benefit of image guidance for the key steps of the procedure. Because each surgical step for screw placement in the spine has a potential for error, use of multiple instruments that can be interchanged for real-time image-guided spinal surgery may increase the accuracy and safety of spinal instrumentation procedures. These techniques can also be applied to intracranial image-guided surgery.