What patients think of day-surgery proctology.
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Adolescent↗
Biomedical subjects
T A Cook
Publications and source records attributed to T A Cook.
Protocol violation in deep vein thrombosis prophylaxis.
This study aimed to determine how closely deep vein thrombosis (DVT) prophylactic policies are adhered to in routine general surgical practice, to identify reasons for policy violations and to assess the effects of policy modification. Eight adult patients, sixty of whom had undergone an operation, under the care of six general surgeons, each with their own written DVT protocol, were studied on one weekday. Thirty patients (50%) did not receive DVT prophylaxis according to the policy of the relevant consultant. Most violations occurred for unacceptable reasons, mainly starting low-dose subcutaneous heparin or using thromboembolic stockings postoperatively. However, 43% of protocol violations occurred for acceptable clinical reasons. Following the initial study, a uniform departmental DVT prophylaxis policy was introduced. Nursing and medical staff were thoroughly appraised of the new policy. In a repeat study of 75 patients 1 year later, there were 15 protocol violations among 58 patients who had undergone an operation (27%). However, there were no violations for acceptable reasons. The number of unacceptable protocol violations in the two studies was similar (24/60 and 17/56). The number of patients at moderate or high DVT risk who received no preoperative prophylaxis was the same in both studies (8/48 in both audits). DVT protocol violations are common in routine general surgical practice. Policy modification and unification results in fewer violations, but made little impact on the level of thromboprophylactic care.
Adolescent↗
Cartilage viability with interpolated skin flaps: an experimental study.
Although composite cartilage grafts are often used in conjunction with a midline forehead flap to repair full-thickness nasal defects, the timing of pedicle division, which optimizes cartilage viability, has yet to be determined. A rabbit animal model was designed to investigate this question. The skin flap pedicle was divided at 0 days, 4 days, 3 weeks, 6 weeks, and 10 weeks in each of five groups of five animals. Although early pedicle division led to partial skin flap necrosis, the cartilage grafts tolerated this ischemic period better. Cartilage viability was approximately 70% and did not differ significantly between the five groups. It is concluded that a larger composite graft and better definition of the skin flap's critical period are needed to determine optimum timing for pedicle division in this animal model.
Analysis of Variance↗
Quality of life changes after angioplasty for claudication: medium-term results affected by comorbid conditions.
Rapid improvements in walking distance and quality of life have been identified in patients with intermittent claudication following percutaneous transluminal angioplasty, but the medium-term results are less well defined. The aim of this study was to assess quality of life and walking distance in the medium term. Walking distance was assessed before percutaneous transluminal angioplasty and at 6 weeks and 1 year after the procedure using a previously validated questionnaire. At the same time, quality of life was assessed using a EuroQol questionnaire and a visual analogue scoring system. Twenty-four patients (12 men, 12 women, mean age 65 years) underwent successful percutaneous transluminal angioplasty (five iliac, 17 femoropopliteal, two both). Significant improvements in walking distance and quality of life were demonstrated following percutaneous transluminal angioplasty. These were maintained at 1 year, although perceived health state deteriorated. During the study period, six patients developed other serious comorbidities. Development of comorbid conditions may affect the medium-term outcome of quality of life studies in patients treated for intermittent claudication. Data from such studies should therefore be interpreted with care.
Aged↗
Reconstructive rhinoplasty.
Reconstructive rhinoplasty for larger nasal defects requires a three-dimensional perspective using many of the aesthetic and functional techniques commonly employed in rhinoplasty. There are numerous ways of addressing a deficiency of the internal lining and each technique is detailed. Structural grafting is imperative in order to resist the contracture and collapse of the reconstructive nose. These grafts are also used to enhance contour and definition. Resurfacing of large cutaneous defects is frequently achieved through the midline forehead flap. There are many subtle maneuvers which can significantly impact the final aesthetic outcome and these are discussed below. This article highlights the three-layered approach to subtotal and total reconstructive rhinoplasty.
Adult↗
Varicose vein clinics: modelling the effects of seasonal variation in referrals.
Data have been collected prospectively on patients referred to a specialist varicose vein clinic between January 1991 and December 1994. A seasonal variation in referral pattern of patients is demonstrated, with more patients being referred in the summer months. Similar fluctuations are seen in the number of patients waiting for first appointment, and the average waiting time for first appointment. Such fluctuations in referral patterns can lead to difficulties in planning. A computer model has been constructed and used to predict future referrals and the effects of seasonal variations upon waiting times for appointments and on efficiency of clinic usage. The computer model accurately predicts numbers of future referrals. The average waiting time for first appointment could be kept constant by arranging more varicose vein clinics in summer than in winter but keeping the overall number of clinics during the year constant. The computer model could be important in planning of specialist clinics, and may play a role when negotiating future contracts. If flexibility can be achieved by exchanging clinics with different seasonal patterns, it may be possible to reduce waiting times within existing resources.
Ambulatory Care Facilities↗
The liposhaver in facial plastic surgery. A multi-institutional experience.
OBJECTIVE: To report a multi-institutional clinical experience with the liposhaver in facial plastic surgery. DESIGN: Nonrandomized, nonblinded, multi-institutional evaluation of the liposhaver in a clinical setting in patients presenting for cosmetic facial liposuction. INTERVENTIONS: Cosmetic facial surgery with the liposhaver was performed in 19 patients (21 procedures) who underwent submental lipectomy, facelift with defatting beneath the facelift flap, and/or correction of deep nasolabial folds. Standardized preoperative and postoperative photographs were obtained. Fat obtained from the abdomen of 1 patient was also studied histologically. This fat was excised sharply and was then liposhaved at varying oscillation speeds. OUTCOME MEASURES: Subjective evaluation by the operating surgeons. RESULTS: The liposhaver was used successfully in all cases. The fat was cleanly shaved and the contour results were even, without dimpling or asymmetry. Operative time was comparable to that for conventional liposuction. Preferred cannula sizes and settings were determined. There were no cases of facial nerve injury, no evidence of increased bleeding intraoperatively, and no hematomas in the immediate postoperative period. One patient developed a small hematoma on postoperative day 5 that was effectively treated with needle aspiration and a pressure dressing. Histologic evaluation of liposhaved abdominal fat showed normal fat cells and well-preserved architecture. CONCLUSIONS: The liposhaver offers a precise alterative to conventional liposuction. It may be less traumatic because it requires low suction pressures and does not rely on the potentially bruising, vigorous, back-and-forth motion for fat extraction typical of conventional liposuction.
Adipose Tissue↗
Use of covered expandable metal stents in the treatment of oesophageal carcinoma and tracheo-oesophageal fistula.
Palliation for malignant dysphagia has relied on oesophageal dilatation, insertion of rigid prostheses and laser treatment. All three methods have substantial risk of perforation. Displacement of the tube is also well described. Seventeen expandable polyethylene-covered metal stents were inserted in 15 patients with oesophageal carcinoma; there were 11 men and four women, of median age 70 years. Thirteen stents were inserted for dysphagia and four for tracheo-oesophageal fistula (TOF). Stents were inserted endoscopically under fluorosopic control. Seven patients died from their disease a median of 5 (range 1-11) months after stent insertion. Median follow-up in the remainder is 6 (range 1-11) months. Median dysphagia scores before and after insertion were 3 (range 2-4) and 1 (range 1-2) respectively. Stent insertion provided cure of symptoms in patients with TOF. Median hospital stay following insertion was 2 (range 1-20) nights. There were no deaths and no perforations associated with the procedure. Two patients complained of retrosternal chest pain for 2 days after stent insertion. One patient presented with dysphagia related to later stent migration. There has been no deterioration in symptoms of dysphagia in the remainder. Expandable oesophageal stents offer a safe alternative to traditional methods of palliative treatment for oesophageal carcinoma. In the long term they may provide a cost-effective alternative to standard treatments.
Aged↗
Port-site metastases in patients undergoing laparoscopy for gastrointestinal malignancy.
Laparoscopic colonic resection and laparoscopy for the assessment of malignant disease have been advocated. Metastatic deposits at port sites are recognized but the incidence of these is poorly defined. Forty-six patients, of median age 65 (range 19-90) years, with gastrointestinal malignancy underwent laparoscopy. Eighteen patients died a median of 4 (range 1-28) months after laparoscopy, four following colonic resection and 14 with gastro-oesophageal malignancy; ten had undergone resection. Median follow-up of the 28 survivors is 8 (range 2-39) months. Five of the 46 patients developed port-site recurrence giving an early incidence of port-site recurrence in this cohort of patients of 11 per cent. Five of 20 patients with tumour involving serosal surfaces developed port-site recurrence compared with none of 26 without serosal involvement (P = 0.022, Fisher's exact test). Port-site recurrence may be related to serosal involvement with tumour.
Adult↗
A prospective study to define the optimum rescreening interval for small abdominal aortic aneurysm.
A prospective study of 99 patients with small abdominal aortic aneurysms was undertaken using serial ultrasound to assess the optimum screening interval. Fifty-three patients had aneurysms measuring 2.5-3.9 cm and 46 patients aneurysms of 4.0-4.9 cm. Aneurysms measuring 2.5-3.9 cm were screened annually and those > 4.0 cm every 6 months. There were eight deaths in the 2.5-3.9 cm group, none attributable to a ruptured aneurysm and five patients have had their aneurysm repaired. Nine patients died in the 4.0-4.9 cm group, one with a ruptured aneurysm measuring 5.6 cm at her previous screening visit and who was unfit for operation. No other patient had an aneurysm which ruptured between scans. There were seven elective repairs in this group. No patient died following elective operation in either group. The mean growth rate of aneurysms in the 2.5-3.9 cm group was 2.2 mm in the first year, 2.8 mm in the second and 1.8 mm in the third. Corresponding growth rates in the 4.0-4.9 cm group were 2.7 mm, 4.2 mm and 2.2 mm. This study supports a policy of annual screening for aneurysms measuring 2.5-3.9 cm and 6-monthly screening for those > or = 4.0 cm.
Aged↗
Inhibition of GABA-gated chloride channels in brain by the arachidonic acid metabolite, thromboxane A2.
Previously, we showed that arachidonic acid and prostaglandin metabolites inhibited GABAA responses in rat cerebral cortex. Thromboxane A2 (TXA2), a metabolite of arachidonic acid, has potent actions on blood vessels and platelets, but its actions on neurons are not known. Here, we examined the effects of several TXA2 analogs on the functional and binding characteristics of GABAA receptors in rat brain. The stable analogs of TXA2, pinane and carbocyclic TXA2, and the TXA2 agonist, U-46619, inhibited muscimol-induced 36Cl- uptake in cerebral cortical synaptoneurosomes. Carbocyclic TXA2 decreased the maximal response to muscimol, consistent with a non-competitive interaction. The TXA2 antagonist, SQ 25,548, did not block the effects of either arachidonic acid or carbocyclic TXA2. Neither the biologically inactive metabolite of TXA2, TXB2, nor carbacyclin, a stable analog of prostacyclin (prostaglandin I2) had an effect on GABAA responses. Thus the pharmacology differs from that in vascular smooth muscle and platelets. To determine if GABAA receptors were sensitive to the thromboxanes, the effect of pinane TXA2 on the binding of [35S]t-butylbicyclophosphorothionate ([35S]TBPS) to GABA-gated Cl- channels was measured using receptor autoradiography. Pinane TXA2 inhibited [35S]TBPS binding in a regionally selective and non-competitive manner; the greatest inhibition was in the cerebral cortex, hippocampus and striatum, areas which are selectively vulnerable to cerebral ischemia. We conclude that TXA2 can interact with neuronal membranes to inhibit GABA receptor function, independent of its actions on the cerebrovasculature and on glial cells. This may be important during pathologic states such as ischemia, when TXA2 accumulates in extracellular spaces.
Animals↗
Quality of life following percutaneous transluminal angioplasty for claudication.
OBJECTIVE: To determine quality of life in claudicants before and after percutaneous transluminal angioplasty (PTA). DESIGN: Prospective study using EuroQuol questionnaire and visual analogue scales. SETTING: District general hospital. MATERIAL: Twenty-nine patients undergoing successful PTA. RESULTS: Before PTA patients showed a significantly lower EuroQuol score compared with the normal population. There was also marked impairment of patients usual activities, mobility and perceived health state. Following successful PTA the EuroQuol score, perceived health state, mobility, usual activities, pain and discomfort and mental state were all significantly improved. CONCLUSIONS: Intermittent claudication impairs quality of life. Following successful PTA there is significant improvement in symptoms and in general health.
Aged↗
Popliteal artery entrapment caused by bony exostosis.
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Adult↗
Rejuvenation of the aging forehead and brow.
Rejuvenation of the aging upper face can transform tired and angry features into youthful-appearing ones. This article presents the principles for analyzing and treating the aging forehead and brow. The esthetic dimensions and proportions of the brow and forehead are discussed, in context with the corresponding surgical anatomy. The goals of facial rejuvenation surgery as it relates to the upper third of the face are addressed. Various approaches, including their advantages and disadvantages, are presented. The appropriate approach is selected to eliminate unsightly features that are in need of correction while minimizing hairline shifts and forehead scarring and anesthesia. Following the principles and techniques illustrated in this article, the facial plastic surgeon may confidently treat the signs and complaints of the aging upper face.
Aged↗
The rat ventral island flap: a comparison of the effects of reduction in arterial inflow and venous outflow.
The relative importance of reduced arterial inflow versus reduced venous outflow in determining flap necrosis remains undefined, even though this is critically important in understanding the effects of pharmacologic agents on flap survival. By means of a rat bipedicled ventral island flap, the amount of random flap necrosis was examined in four experimental groups: (1) unilateral arteriovenous ligation (n = 19), (2) unilateral vein ligation (n = 20), (3) unilateral artery ligation (n = 20), and (4) alternate side vein and artery ligation (n = 18). No necrosis occurred on the side of the vein ligation in groups 2 and 4, indicating that independently reducing venous outflow does not cause flap necrosis. A predictable necrosis occurred ipsilateral to artery ligation in groups 1 (37.63 +/- 17.34 percent), 3 (32.74 +/- 17.32 percent), and 4 (15.70 +/- 9.86 percent). These data indicate that the rat ventral island flap is more sensitive to a decrease in arterial inflow than to a decrease in venous outflow. This model may therefore be useful in clarifying the effect and determining the mechanism of action of pharmacologic agents that alter flap survival.
Abdomen↗
Upregulation of dynamin II expression during the acquisition of a mature pancreatic acinar cell phenotype.
Members of the dynamin superfamily are GTPases which have been shown to support receptor-mediated endocytosis in vivo and bind to growth factor receptor-associated proteins in vitro. In acinar cells of the pancreas, receptor-mediated endocytosis is very important for the recycling of membranes after secretory granule release. Therefore, characterization of the molecular machinery responsible for this process is critical for a better understanding of this phenomenon. In this study we sought to determine the expression pattern of the endocytic GTPase dynamin II during pancreatic acinar cell differentiation in developing rat embryos and in dexamethasone-treated AR42J cells using Western blot, Northern blot, and immunocytochemical analyses. During pancreatic development, dynamin immunoreactivity is almost undetectable until day E17 but undergoes significant upregulation in acinar cells starting at E18. In addition, the levels of dynamin mRNA and protein in AR42J cells increase approximately threefold during dexamethasone-induced acinar differentiation. The increase in dynamin levels that occurs in both embryonic pancreatic cells and dexamethasone-treated AR42J cells correlates with the establishment of a more differentiated acinar phenotype. Therefore, these results suggest a potential role for dynamin in supporting receptor-mediated endocytosis in mature pancreatic acinar cells.
Animals↗
Magnetic resonance imaging in the management of diabetic foot infection.
A prospective study was carried out of 22 patients admitted with 25 diabetic foot infections. All had cellulitis, 12 had discharging ulcers and eight had digital gangrene. In one case magnetic resonance imaging (MRI) was unhelpful owing to patient movement. Thirteen scans suggested deep-seated infection, including abscess (ten), osteomyelitis (seven) and ankle effusion (one). Overall, imaging provided a specificity of 77 per cent, a positive predictive value of 77 per cent, a sensitivity of 91 per cent and a negative predictive value of 91 per cent. MRI is valuable in determining the presence and extent of infection, which allows appropriate planning of surgical intervention.
Adult↗
Autologous free dermal fat graft. Reconstruction of facial contour defects.
OBJECTIVE: To examine the use of autologous free dermal fat grafts (FDFGs) in the reconstruction of soft-tissue facial contour defects, an 8-year, retrospective, computerized medical chart review was conducted for 21 patients who underwent reconstruction with FDFGs. SETTING: Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Oregon Health Sciences University, Portland, or affiliated hospitals. PATIENTS: Twenty-one patients identified in the chart review were included in the retrospective evaluation. Follow-up periods ranged from 11 to 94 months. Five patients were unavailable for follow-up at the chart review, but all five had satisfactory results at their last evaluation. DESIGN: Soft-tissue augmentation was performed using autologous FDFGs harvested from the abdomen following in situ de-epithelialization with a high-speed dermabrader. Facial contour defects resulted from tumor extirpation, congenital deformity, trauma, or degenerative disease. MAIN OUTCOME MEASURES: Outcome was considered satisfactory when the patient and the surgeon were pleased with the long-term results at the last evaluation. RESULTS: Complications, including graft resorption (five patients) and epithelial cyst formation (two patients), were observed in seven patients and resulted in an unsatisfactory outcome. The remaining 14 patients demonstrated satisfactory results as determined by the patient and the surgeon at the last evaluation. CONCLUSIONS: Successful long-term augmentation of facial contour defects may be achieved with autologous FDFGs in an appropriate patient population. Careful patient selection and proper surgical technique are essential for satisfactory long-term results. Guidelines are provided for the augmentation of facial contour defects with autologous FDFGs.
Adipose Tissue↗