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PubMed2006

Brief review: perioperative management of the patient with chronic non-cancer pain.

PURPOSE: Both opioid and non-opioid medications are being utilized increasingly in the treatment of chronic non-cancer pain, and the number of surgical patients receiving large regular doses of opioids is ever-expanding. The perioperative pain control of these patients is often challenging, and is broadening the role of the anesthesiologist as 'perioperative physician'. These patients need to be identified before surgery to plan optimal pain control postoperatively. The purpose of this review is to provide an update on the important considerations in managing the chronic non-cancer pain patient receiving high dose opioids and other adjunctive medications/analgesics. SOURCE: English language articles published between June 1980 and May 2006 were identified by a computerized Medline search using keywords (1/2)chronic pain(1/2), (1/2)opioid dependent(1/2) and (1/2)perioperative(1/2). This same search strategy was repeated and updated using both Medline and Embase. All relevant publications were retrieved and their bibliographies were scanned for additional sources. PRINCIPAL FINDINGS: Although an increasingly common problem for the acute pain service, there is very little published on this topic. Key points include the concept of opioid equivalency, tolerance, the role of adjunctive medications, and the need for good communication between the surgical team, the acute pain service and the patient who is often anxious about the upcoming procedure due to previous unpleasant experiences with poor pain control in hospital. CONCLUSION: Clinical care of the opioid-dependent patient in the perioperative period can be a daunting task. Education to all staff involved in this area needs to be enhanced to improve outcome and patient satisfaction.

Analgesics, Opioid↗
PubMed1991

Wound tensile strength in the hairless guinea pig following irradiation with pure ultraviolet-A light.

Ultraviolet light in the wavelength range of 315-400 nm (UVA) is known to penetrate the epidermis more readily than UVB and to result in significant dermal damage. Fibroblasts within the dermis are responsible for the production of collagen, which is the chief determinant of wound tensile strength during the third week of wound healing. The present study assesses the effects of UV radiation limited to the UVA wavelength on wound tensile strength in the hairless guinea pig. Twenty female hairless guinea pigs were randomly divided into two equal groups (n = 10). Group 1 animals served as controls. Group 2 animals were irradiated with 120 J/cm2 from a pure UVA fluorescent light source every other day for a period of 21.3 weeks (cumulative dose = 8960 J/cm2). Upon completion of the irradiation schedule, a standard 6 cm linear full-thickness surgical wound was created on the dorsum of all animals and allowed to heal for 21 days. The wounds were excised and wound tensile strength was assessed by determining breaking strength and dividing by the breaking-point surface area. Wound tensile strength was significantly lower (p less than 0.0017) in irradiated animals (0.99 +/- 0.12) than in controls (1.54 +/- 0.08). Therefore, UVA at this dose significantly decreased wound tensile strength in this model and raises further concern regarding exposure to this wavelength of ultraviolet radiation.

Animals↗
PubMed1979

A nosocomial outbreak of infections due to multiply resistant Proteus mirabilis: role of intestinal colonization as a major reservoir.

An outbreak of nosocomial infections involving an unusual strain of multiply resistant Proteus mirabilis (phage type 8888) occurred in 15 patients, 14 of whom were in the surgical intensive care unit at that time. No common source of infection was identified, and person-to-person transmission was the most likely mode of spread. Case-control analysis indicated a significantly increased risk infection related to length of hospital stay (P less than 0.005), number of operations (P less than 0.005), proximity to another case (P less than 0.01), number of antibiotics received (P less than 0.02), and use of a respirator (P less than 0.01). Only the number of operations (P less than 0.01) and proximity to another case (P less than 0.05) remained significant risk factors when related parameters were controlled by multivariate analysis. Thirteen of 14 patients prospectively cultured were colonized by the epidemic organism in the intestinal tract, while rectal carriage preceded infection by the same strain in at least four patients. These data suggest that intestinal colonization may have been an important reservoir for this outbreak, and the findings may explain the unduly prolonged course of intrahospital spread as well as the difficulty encountered in the eradication and control of the outbreak.

Cross Infection↗
PubMed2003

Methodologic requirements for assessing surgical procedures in current medical literature.

Even though, in theory, a new surgical technique should traverse all the stages established for drugs before being introduced into medical practice, it is suspected that many surgical procedures are utilized without having rigorously evaluated their efficacy and safety. With the aim of identifying the methodologic aspects currently employed for assessing new surgical procedures, a descriptive bibliographic study was carried out. Altogether, 75 journal articles published from 1996 to 1998 were reviewed. The papers must have come from studies carried out with the expressed objective of evaluating a surgical procedure and were selected through MEDLINE or directly from six prestigious medical journals (three specifically surgical and three general). Of the reviewed articles, 47% were retrospective studies, and the rest were prospective studies. More than 40% of the retrospective studies omitted some basic methodologic features, namely a description of the patients' source or a definition of the inclusion criteria. Among the 41 prospective articles, only 35 used a control group and 15 did not employ random allocation. Other basic issues, such as the sample size or inclusion of prognostic factors in the analysis, were present in fewer than 50% of the articles. It seems there is consensus about admitting that rigorous assessment of new surgical treatments should be an unavoidable condition before introducing such treatment into practice. The facts demonstrate that this principle is not being followed.

Bibliometrics↗
PubMed2003

Decontamination and control of infection in theatre.

Decontamination covers all aspects of reprocessing of reusable equipment. It is understandable that patient well-being is perceived to take precedence over infection control. Unfortunately the spread of infection is based on the opportunity for organisms able to move from a controlled area to the patient or staff. Continued vigilance and adherence to good practice is essential to combat the ever-present problem. This article covers the problem of local decontamination within the theatre complex, and sources of potential infection are identified and discussed.

Air Conditioning↗
PubMedDate not supplied

Demographic factors that influence human disc cell proliferation in vitro.

BACKGROUND CONTEXT: Although previous work has shown that greater age, greater disc degeneration, female gender, and surgical derivation of disc tissue had deleterious effects on cell proliferative potential, relatively little is known about the association between disc cell proliferation in vitro and clinical donor characteristics. PURPOSE: To identify the relationships between donor characteristic and the in vitro proliferative potential of human disc cells from the annulus. STUDY DESIGN/SETTING: Studies were approved by the human subjects Institutional Review Board. Donor data included donor source, ethnicity, age, gender, smoking history, height, weight, number of years of back pain, and Thompson score. Cells cultured from the annulus were tested for proliferation. PATIENT SAMPLE: There were two study populations: 1) Comparison Group (32 control donors and 33 control surgical subjects; 60 Caucasians, 5 African-Americans). Cell proliferation, age, Thompson score, height, weight, and smoking history were statistically analyzed for control donors versus control surgical group. No significant differences were present, and these two groups were pooled to form the Comparison Group. 2) Nineteen subjects from the United Arab Emirates who underwent disc surgery. OUTCOME MEASURES: Linear models were fit to the data to determine the best prediction of cell proliferation as the outcome variable; multiple R-squared was used to determine model goodness of fit. METHODS: Control donor specimens were obtained from the National Cancer Institute Cooperative Human Tissue Network, and control donor surgical specimens from disc surgeries. A standardized cell proliferation assay was used to evaluate monolayer and three-dimensional agarose cell proliferation. Data were expressed as mean cpm[(3)H]-thymidine per microgram deoxyribonucleic acid+/-SEM. Standard statistical methods used the SAS system for data analysis. RESULTS: No differences were present in the Comparison Group versus the Middle Eastern group for mean Thompson score (both averaged grade III), mean age (44.3 vs. 43.0 years, respectively), gender, height, weight, length of time with back pain (1.9 years vs. 2.1 years respectively), or smoking history. Three-dimensional proliferation in agarose was not significantly different for the two groups. Monolayer proliferation, however, was significantly different (17,434+/-2,929 vs. 6,693+/-2,103, respectively), p=.019. Linear regression models were fit to the data to determine the best prediction using proliferation as the outcome variable. In the Middle Eastern group, monolayer cell proliferation bore a significant negative correlation to age (p=.02, r=-.32), whereas the Comparison Group showed no such relationship. The following equation was derived to fit these data: Log(10) of proliferation (cpm/mug deoxyribonucleic acid)=10.915-0.7919 (Middle Eastern ethnicity)-0.0296 (Age). The r(2) for this equation is 0.203 (ie, 20.3% of the change in proliferation is explained by age and Middle Eastern ethnicity). Middle Eastern ethnicity and age were significant in this equation (p=.04 and .0003, respectively). CONCLUSIONS: Studies have shown that familial history, age, and smoking are important risk factors for disc degeneration in Arabic pedigrees. It is interesting that our present findings also point to age and familial history as important significant factors influencing monolayer proliferation. Further research is needed to identify the cellular basis for this influence on cellular proliferative capacity.

Adult↗
PubMed2006

Cytokeratin 19 fragments in patients with acute lung injury: a preliminary observation.

OBJECTIVE: Cytokeratin 19 (CK19) is a specific cytoskeletal structure for alveolar epithelium. We hypothesized that the levels of CK19 fragments in bronchoalveolar lavage (BAL) fluid could serve as an index of epithelial injury and as a prognosis marker in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). The aims of our study were, in patients with ALI/ARDS: (1) to measure CK19 fragments concentrations in BAL fluid, (2) to assess its prognostic value, and (3) to identify the cellular source of CK19 in the alveolar space. DESIGN: Prospective preliminary study. SETTING: University hospital surgical ICU. PATIENTS: Twenty-two mechanically ventilated patients with ALI/ARDS and 10 non-ventilated control patients. Plasma samples were obtained for 11 ALI/ARDS patients. MEASUREMENTS AND RESULTS: The concentration of BAL CK19 fragments was higher in patients (median 4916 pg/ml, 25th-75th percentile 2717-10533) than in controls (2208 pg/ml. 767-3923; p =0.05), and higher in 10 non-survivors (7051 pg/ml, 4372-13371) than in 12 survivors (2888 pg/ml, 1315-5639; p =0.03 among ALI/ARDS patients). BAL CK19 fragment concentration did not correlate with simplified acute physiologic score, lung injury score or PaO(2)/FIO(2) ratio, but correlated positively with BAL albumin concentration (p =0.002) and with number of BAL macrophages (p=0.0001). Plasma CK19 fragment concentrations were 10 times lower than those in BAL. Immunohistochemical staining for CK19 showed a strong labelling of injured detached epithelial cells and hyperplastic epithelium in ALI/ARDS lung samples. CONCLUSION: CK19 fragment concentrations were found to be elevated in BAL fluid in ALI/ARDS patients compared with control subjects. High BAL CK19 fragment levels were associated with a poor prognosis.

Bronchoalveolar Lavage Fluid↗
PubMed2004

Rehabilitative approaches to Parkinson's disease.

Many sources of disability impact on quality of life and some are likely to remain relatively refractory to pharmacological or surgical treatment. Rehabilitative approaches may help despite the paucity of randomized control studies. There is increasing evidence from neuroscience, reviewed here, that supports current rehabilitative approaches and most importantly, can be the basis for future rehabilitative approaches. Parkinson's disease is complex and the disabilities not absolute but relative. These disabilities can be affected by the environment or context in which the motor activities occur. These observations can be exploited and argue for the potential of rehabilitative approaches.

Animals↗
PubMedDate not supplied

Severe hemorrhagic complications in pancreatitis.

Severe bleeding may complicate the course of either acute or chronic pancreatitis, the latter being more frequently involved. Pseudocysts, severe inflammation, regional necrosis and infection may cause major vessel erosion with or without pseudoaneurysm formation which eventually may result in severe bleeding into the gastrointestinal tract, retroperitoneum and peritoneal cavity. The AA report their experience on 8 cases and analyze the data of a comprehensive review of 389 cases of massive bleeding reported in the literature during the last 100 years until December 1993. Mortality rate seems to be related to the etiology of the bleeding along with its localization and the underlying anatomo-pathologic findings. In patients with chronic pancreatitis it is 22% while in patients with acute pancreatitis or chronic pancreatitis with acute exacerbation it is 60.4% and 57.1% respectively. Splenic, gastroduodenal and superior pancreaticoduodenal arteries are the most commonly involved vessels being associated respectively with a mortality rate of 20.5%, 27.9% and 46.1%. Massive haemorrhage complicating infected necrosis or abscesses implies a worse prognosis when compared to severe bleeding associated with pseudocyst with or without pseudoaneurysm. The increasing use of diagnostic and interventional radiology appears to be the way forward to improve survival rates. Awareness of high risk predisposing condition, activism in achieving an early identification of the bleeding sources, and eventually its angiographic control are essential guidelines for successful approach to the most unpredictable complication of pancreatitis. When embolization fails or is followed by recurrence of hemorrhage, definitive surgical procedures should be immediately instituted.

Abscess↗
PubMed1982

A case-control study of cholecystectomy and right-side colon cancer: the influence of alternative data sources and differential interview participation proportions on odds ratio estimates.

One hundred fifty patients with right-side colon cancer (i.e., patients with adenocarcinoma of the cecum or ascending colon) were compared to 150 matched left-side colon cancer controls (i.e., patients with adenocarcinoma of the descending or sigmoid colon) and to 123 neighborhood controls, Pittsburgh, Pennsylvania, Standard Metropolitan Statistical Area, 1975-1978. The gastrointestinal surgical history was ascertained for all study subjects so that the presence or absence of a history of cholecystectomy could be noted. Cholecystectomy history was obtained through telephone interviews and whenever possible subsequently validated from operative and pathology reports at time of cholecystectomy. Cholecystectomy history for the colon cancer patients was also abstracted from hospital records at time of colon cancer diagnosis with an attempt to confirm the gallbladder's status through operative reports, cholecystograms, and physical examinations. Hospital records and interviews for the colon cancer patients appeared to provide accurate exposure history. Point estimates of the odds ratios and confidence intervals for intra- and inter-data source comparisons (i.e., hospital records, interviews, and hospital records and interviews combined) were comparable with similar measures of effect. Consistent odds ratio estimates appeared in both left-side colon cancer controls (1.9) and neighborhood controls (1.89). The authors suggest that changes in bile acid metabolism following cholecystectomy may be associated an increased risk of right-side colon cancer.

Adenocarcinoma↗
PubMed2004

Collateral brain damage, a potential source of cognitive impairment after selective surgery for control of mesial temporal lobe epilepsy.

BACKGROUND: Highly selective epilepsy surgery in temporal lobe epilepsy is intended to achieve seizure freedom at a lower cognitive risk than standard en bloc resections, but bears the risk of collateral cortical damage resulting from the surgical approach. OBJECTIVE: To investigate cortical damage associated with selective amygdalo-hippocampectomy (SAH). METHODS: 34 epileptic patients were evaluated. They were randomly assigned to SAH using either a sylvian (9 left/10 right) or a transcortical surgical approach (5 left/10 right). Postoperative MRI signal intensity changes adjacent to the approach were correlated with performance changes in serial word and design list learning. RESULTS: Losses in verbal learning and recognition memory were positively related to signal intensity changes, independent of the side of the resection, the surgical approach, or the extent of the mesial resection. Losses in consolidation/retrieval (memory) were greater after left sided surgery. Losses in design learning were related to right sided surgery and signal intensity changes. Seizure outcome (85% seizure-free) did not differ depending on the side or type of surgery. CONCLUSIONS: Collateral damage to cortical tissues adjacent to the surgical approach contributes to postoperative verbal and figural memory outcome after SAH. Controlling for collateral damage may clarify the controversial memory outcomes after SAH reported by different surgical centres.

Amygdala↗
PubMed1998

[Transplantation of autologous submandibular glands in very severe keratoconjunctivitis sicca. 2 year outcome].

INTRODUCTION: The conservative treatment of the most severe cases of keratoconjunctivitis sicca (KCS) can be sometimes frustrating. Especially with an underlying autoimmunologic disorder, even the application of artificial tears as often as every 5 min may not prevent further damage to the ocular surface. A microvascular transplantation of the autologous submandibular gland (SG) can be performed by a maxillo-facial surgeon as an alternative approach for those cases. We report 2 years of ophthalmological experience with the results of this procedure. MATERIAL AND METHODS: To date 27 operations have been performed in 23 patients. The SG was moved from its natural site into the temporal fossa. The secretory duct was implanted into the conjunctival fornix and the gland's vessels connected to the temporal artery and vein. A complete ophthalmological examination has been performed in 25 eyes of 21 patients up to 1 year and in 11 eyes of 9 patients 2 years after surgery. RESULTS: Three months and 1 year postoperatively 19 of 25, and 2 years postoperatively 8 of 11 transplants remained vital. The baseline secretion increased in patients with a vital transplant from an average of 1.6 +/- 1.3 mm before the operation to 16.2 +/- 11.3 mm after 3 months and 20.6 +/- 10.6 mm after 1 year. Ten of 19 vital grafts were reduced 1 year after transplantation in a minor second procedure to control an increasing epiphora. Subsequently baseline secretion was reduced to 13.6 +/- 8.2 mm 2 years after transplantation. Patients with a vital graft reported in 84% of cases (16 of 19) at 3 months, and 79% at 1 year (15 of 19) and 2 years (7 of 8), a strong relief of dry eye symptoms. In 58% (3 months), 79% (1 year) and 63% (2 years) of the eyes with a vital transplant all artificial tear substitution could be stopped. Break-up time increased significantly, resulting in reduced bengal rose staining. CONCLUSION: The transfer of the autologous SG into the temporal fossa can be used to provide patients with very severe KCS with a continuous, endogenous source of ocular lubrication. Despite surgical denervation the graft maintains a sufficient baseline secretion over a period of years. Subjective symptoms and the application of pharmaceutical lubricating substances are reduced to a large extent. If epiphora occurs, it can be controlled by surgically reducing the transplant. The influence of SG saliva on the ocular surface is the object of ongoing studies.

Adult↗
PubMed1988

Acute effects of hypophysectomy and administration of pancreatic and thyroid hormones on circulating concentrations of somatomedin-C in young chickens: relationship between growth hormone and somatomedin-C.

The short-term control of plasma concentrations of somatomedin C (SmC) in young chicks was examined by either surgical removal of the pituitary gland or by the administration of hormones which affect plasma concentrations of growth hormone (GH). As expected, removal of the source of GH by hypophysectomy reduced plasma concentration of GH, these being suppressed by 95.7% within 1 hour. Hypophysectomy was rapidly followed by reductions in the plasma concentration of SmC. For instance, plasma concentrations of SmC were decreased to 53% of pretreatment one hour following hypophysectomy. This suggests both that SmC has a short half life and that the release of SmC into the circulation is tightly coupled to the presence of pituitary hormone(s), presumably including GH. Sham surgery also decreased plasma concentrations of GH but were without effect on plasma concentrations of SmC. The short term control of plasma concentrations of SmC was also examined by the acute administration of hormones, which affect GH secretion in vivo. Injections of thyroxine or triiodothyronine decreased the plasma concentration of GH but were without effect on the plasma concentration of SmC. On the other hand, the administration of either glucagon or insulin decreased the plasma concentration of both GH and SmC. The present data suggest that plasma concentrations of SmC do not simply reflect the GH status in young chickens.

Animals↗
PubMed1995

[A 100-year-old transatlantic contribution to anesthesiologic quality control].

Aspects of quality assurance or control in anaesthesia were already discussed at the end of the last century. The reports "Zur Narkotisirungs-Statistik" given by the Berlin surgeon Gurlt between 1891 and 1895 are published examples. Answers in questionnaires and additional comments--mainly from German surgical hospital departments--were the main sources of these reports. However, every year some answers also came from foreign countries. In his fifth report Gurlt published in 1895 the full text of a contribution given by Prince from Chicago, Illinois, USA. That report--given here once again in the original form--allows an insight into the practice of anaesthesia in North America in those days. Many of these statements and recommendations are still relevant; they are now essentials of the so-called "quality assurance" or "quality control".

Anesthesia, General↗
PubMed2005

Major vessel involvement in Behçet disease.

PURPOSE OF REVIEW: Large vessel vasculitis occurs in a subgroup of patients with Behçet disease at high risk for disease-related morbidity and mortality. Recognition of patients at risk, early detection of vasculitis, and the need for aggressive treatment are essential for optimal care of these patients. The authors review the clinical spectrum and management of large vessel problems in Behçet disease, highlighting contributions over the past year. RECENT FINDINGS: Vasculo-Behçet patients are at risk for multiple vessel-related complications including thromboses, stenoses, occlusions, and aneurysms. A number of factors may contribute to thrombosis in individual cases, but the primary reason for clot seems to reside in the inflammatory process in the arterial wall, still incompletely understood. An appreciation for the challenges in the perioperative period requires the joint efforts of physicians and surgeons, and fuels the study of alternate, less invasive procedures for Behçet patients. SUMMARY: Because of earlier recognition, aggressive medical treatment, and novel surgical procedures, the morbidity and mortality of large vessel vasculitis in Behçet disease are beginning to change. In the absence of controlled treatment studies, reports of clinical experience remain an important source of information for clinicians. Identification of patients at risk for vascular complications remains a priority.

Aneurysm↗
PubMed1992

Circulating endothelial cells in surgical patients.

The circulating endothelial cells (CEC) in healthy volunteers and surgical patients before and after operations were counted. The results showed that CEC counts of the patients were much higher than those of the volunteers. After operation, however, patients' CEC counts returned to control levels. It is suggested that detection of CEC may be useful for quantitatively evaluation of the injury to blood vessels in surgical patients. The operation may not only remove the source of injury, it also eliminates the injured microvascular bed which may be important to maintain homeostasis. Another possible interpretation of the results may be related to time lag and mental stress.

Blood Cell Count↗
PubMed1995

An outbreak of post-operative endophthalmitis in Lampang Hospital.

An outbreak of post-operative endophthalmitis involving 48 patients from October 1991 to October 1992 in Lampang Hospital was reported. There were 3 waves of clustered cases, i.e. from October 1991 to January 1992, April-June 1992, and August-October 1992. Investigation revealed several risk factors: defects in sterilization of surgical instruments, poor operating room hygiene, contaminated tap water and the use of multiple-dose fluids and medication. Bacteria isolated from vitreous fluid showed different bacteria, indicating multiple sources of infection or failure of asepsis. Each episode of infection was brought under control by removing the risk factors and emphasis on aseptic techniques. The value of an effective survey programme for the detection of post-operative endophthatmitis was emphasized.

Adult↗