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PubMed1998

Management of rhinosinusitis in children: consensus meeting, Brussels, Belgium, September 13, 1996.

OBJECTIVES: To (1) provide definitions for the different forms of pediatric rhinosinusitis, with an enumeration of the main symptoms and signs; (2) provide indications for microbiological, allergic, and immunologic assessment as well as for imaging studies; (3) suggest standard medical management with judicious use of antimicrobial agents; and (4) discuss indications for surgery. DATA SOURCES: Clinical studies and literature data relevant to the different topics of pediatric rhinosinusitis. CONCLUSIONS: Rhinosinusitis in children is a multifactorial disease in which the importance of several predisposing factors changes with increasing age. Continued study to obtain a better understanding of the disease and carefully controlled comparative evaluations of medical and surgical therapies are suggested.

Child, Preschool↗

PubMed1979

Uncontrollable postpartum bleeding: a new approach to hemostasis through angiographic arterial embolization.

A case of severe postpartum hemorrhage is reported. Three separate surgical procedures failed to reveal the source of bleeding, and standard surgical techniques, including bilateral ligation of the hypogastric arteries, were unsuccessful in producing hemostasis. However, angiography successfully identified the specific bleeding vessel, and transcatheter embolization with Gelfoam fragments quickly and effectively stopped the hemorrhage. The authors consider angiographic embolization to be an effective alternative approach to the control of pelvic hemorrhage and recommend that the technique be considered prior to surgical intervention.

Adult↗

PubMed1992

The incidence of surgical glove perforation during obstetric and gynaecological surgical procedures.

The increasing prevalence of diseases such as AIDS and hepatitis B makes safe surgical techniques more important than ever before. Intact surgical gloves act as a barrier against these infections and a study was therefore done to determine the incidence of surgical glove perforation during obstetric and gynaecological surgical procedures. Surgical gloves were collected and tested for perforations following 353 consecutive obstetric and gynaecological operations. Forty pairs of new unused surgical gloves were tested for perforations in the same way. Whereas none of the 40 control pairs of gloves was found to be perforated, 22%-24% of used gloves were perforated. The experience of the surgeon had no influence on the incidence of glove perforation (P = 0.997; chi 2-test). Left-hand gloves were more frequently perforated than right-hand gloves, but this difference was not statistically significant (P = 0.075: chi 2-test). These findings must be a source of concern to all those practising obstetrics and gynaecology and measures are therefore suggested to decrease the risk of HIV or hepatitis B transmission during operations.

Equipment Failure↗

PubMed1995

Potential dangers of oxygen supplementation during facial surgery.

The use of local anesthesia and intravenous sedation has made same-day outpatient surgery a viable option for many aesthetic and reconstructive procedures. These procedures often include the use of supplemental oxygen. Oxygen-enriched environments increase the combustibility of most materials, and "oxygen pooling" has been suspected to play an integral role in intraoperative fires. A personal experience with an intraoperative explosion and fire during a cosmetic blepharoplasty compelled us to explore the potential danger inherent in the use of supplemental oxygen as well as potential strategies to minimize that danger. This study systematically examines the microenvironment created by the use of oxygen both in the operative field and beneath the surgical drapes under conditions simulating routine facial surgery and various recommended modifications of its delivery. With the use of oxygen supplementation, oxygen concentration beneath the drapes was found to be consistently elevated when compared with ambient air (20.9 percent) and reached levels as high as 53.5 percent. Oxygen concentration in the operative environment was mildly but not significantly elevated. Although criteria for the use of oxygen supplementation are not clear, when administration is deemed necessary, the use of a posterior pharyngeal catheter for its delivery had no advantage over nasal prongs. However, appropriate alternatives include the use of "open face" draping techniques, the use of compressed air beneath the drapes as a substitute for oxygen supplementation in unsedated patients, and cessation of oxygen supplementation for 60 seconds prior to the use of a possible ignition source with oxygen flow rates of less than 3 liters per minute.

Accidents↗

PubMed2002

Unplanned admission to Siriraj post-anesthetic intensive care unit.

OBJECTIVE: Notice of all surgical patients who need access to Siriraj post-anesthetic intensive care unit (ICU) must be given to the ICU in advance by the surgical team. However, there are some patients who present unexpectedly, and we would like to evaluate this unplanned ICU admission as a quality control. PATIENTS AND METHOD: We performed a self-reported study of the patients who were categorized as unplanned for ICU admission over a six-month period from June 1st to November 30th, 2001. We attempted to quantify these patients into small groups in order to learn what the reasons were, where they came from, and how big the anesthesia-related reasons can be. RESULTS: There were 520 admissions to the ICU during study period, and of those 80 were unplanned patients. The major source of these patients is from the operating theaters, followed by the recovery rooms and surgical wards. There were 65 patients admitted because of the cardiopulmonary problems, while 13 patients were admitted for close observations; surgical complications made up another 8 patients. Overall there were 36 unplanned patients because of anesthesia-associated complications. CONCLUSION: These results indicate that the patients who are admitted to the post-anesthetic ICU without prior planning can provide insights of ICU resource management, and the standards of perioperative management in the operating theatres. It definitely offers an opportunity to implement changes in our anesthetic practice. We will continue to monitor the impact of this important indicator.

Adult↗

PubMedDate not supplied

Biorheological features of some soft tissues under a surgical tissue expansion procedure.

The aim of this study was to investigate the effects of a surgical tissue expansion procedure on the biomechanical features of the expanded soft tissues. In this procedure a silicone balloon "expander" is surgically inserted into a tissue and inflated. The tissue mass increases under the stretch of the expander. The increased tissue can then be used as an autologous source for the surgical reconstruction of organs. In this article, dog saphenous neurovascular bundle was used. Expanded saphenous nerves, arteries and veins were harvested and their biomechanical features and ultrastructural, histological changes were studied. The stress relaxation features, the continuous spectrum of relaxation time, and the stress-strain relationship of expanded and control specimens were measured. Results show that within two or three weeks after placement of the expanders, the biomechanical properties of expanded saphenous nerves, arteries and veins began to deviate from those of their controls, and the differences between them were proportional to the volume of inflation; but when the expanding period was 15 weeks or longer, the properties of expanded specimens and their controls became close again. Histological study showed that the content of collagenous fibers in blood vessel walls decreased after expansion. The content of elastic fibers in blood vessel walls first increased, then returned to normal, and finally decreased. Ultrastructural studies showed that when elongated by 25-40%, the expanded nerves had well preserved axons and showed fewer smooth myelin sheaths only in the middle and distal part of the expansion.

Animals↗

PubMed1998

Repair of craniotomy defects using bone marrow stromal cells.

BACKGROUND: Techniques used to repair craniofacial skeletal defects parallel the accepted surgical therapies for bone loss elsewhere in the skeleton and include the use of autogenous bone and alloplastic materials. Transplantation of a bone marrow stromal cell population that contains osteogenic progenitor cells may be an additional modality for the generation of new bone. METHODS: Full thickness osseous defects (5 mm) were prepared in the cranium of immunocompromised mice and were treated with gelatin sponges containing murine alloplastic bone marrow stromal cells derived from transgenic mice carrying a type I collagen-chloramphenicol acetyltransferase reporter gene to follow the fate of the transplanted cells. Control surgical sites were treated with spleen stromal cells or gelatin sponges alone, or were left untreated. The surgical defects were analyzed histologically for percent closure of the defect at 2, 3, 4, 6, and 12 weeks. RESULTS: Cultured bone marrow stromal cells transplanted within gelatin sponges resulted in osteogenesis that repaired greater than 99.0+/-2.20% of the original surgical defect within 2 weeks. In contrast, cranial defects treated with splenic fibroblasts, vehicle alone, or sham-operated controls resulted in minimal repair that was limited to the surgical margins. Bone marrow stromal cells carrying the collagen transgene were immunodetected only in the newly formed bone and thus confirmed the donor origin of the transplanted cells. CONCLUSIONS: These studies demonstrate that mitotically expanded bone marrow cells can serve as an abundant source of osteoprogenitor cells that are capable of repairing craniofacial skeletal defects in mice without the addition of growth or morphogenetic factors.

Animals↗

PubMed2026

Hypervirulent Klebsiella pneumoniae ST23 causing pyogenic liver abscess and metastatic endogenous endophthalmitis in Europe: a case report.

INTRODUCTION AND IMPORTANCE: Pyogenic liver abscess (PLA) has traditionally been considered prevalent in Asia. However, its incidence is increasing in Europe. Klebsiella pneumoniae (Kp) has emerged as the leading causative pathogen, and hypervirulent strains pose a higher risk of invasive disease and metastatic complications, such as endogenous endophthalmitis (EE). CASE PRESENTATION: The case describes a 77-year-old woman who presented with fever and right upper quadrant abdominal pain. She was diagnosed with a second episode of PLA within 3 months, caused by Kp. Despite prompt antimicrobial therapy and percutaneous transhepatic drainage, the patient developed acute vision loss in the left eye during hospitalization. Ophthalmologic assessment confirmed EE secondary to bacteremia. Whole-genome sequencing identified the isolate as hypervirulent Kp (hvKp) sequence type 23 (ST23). While the liver abscess resolved following treatment, the patient sustained permanent loss of vision in the affected eye despite aggressive medical and surgical management. CLINICAL DISCUSSION: This case illustrates the invasive nature of hvKp and its potential for recurrence and metastatic complications. Improved recognition through targeted virulence testing is essential to avoid underdiagnosis. CONCLUSION: This case highlights the aggressive nature of hvKp. Early recognition of systemic and ocular symptoms, prompt ophthalmologic evaluation, and timely source control are essential. Optimal management requires multidisciplinary collaboration and the use of molecular diagnostics, including whole-genome sequencing, to identify hypervirulent lineages and support surveillance.

Klebsiella pneumoniae↗

PubMed2004

Renal cell cancer in presacral ectopic kidney: preoperative diagnostic imaging compared to surgical findings.

The occurrence of renal cell carcinoma is an exceptional phenomenon in an ectopic kidney. We describe a patient with renal cell cancer of the pelvic kidney who underwent radical nephrectomy at our institute. Preoperatively the patient underwent paramagnetic medium-enhanced magnetic resonance that provided an accurate description of the ectopic renal vessels. During surgery the anatomy of the vessels appeared exactly as described by the MR examination. Histological examination revealed a pT2N0GIV renal cell cancer. Nine months later the patient underwent control examinations, and no delayed complications had occurred. In our experience magnetic resonance provided an exact description of the ectopic kidney vascularization as confirmed by the surgical findings. Preoperative knowledge is important both for the surgeon during the dissection of the vessels and to plan correct lymphadenectomy on the basis of the vessel source identified at imaging.

Carcinoma, Renal Cell↗

PubMedDate not supplied

Pulp response to the combined effects of cavity preparation and periodontal ligament injection.

Thirteen random-source dogs provided 54 experimental and 50 control teeth. Controls received either a periodontal ligament (PDL) injection only, or no injection, with deep cavities prepared and restored. Experimental teeth received both a PDL injection and the deep cavity preparation and were then restored with an IRM base and acid-etched composite. Teeth were surgically removed for observation periods of one and 18 weeks and prepared for histologic evaluation. Results indicated that, in this model system, there was little additive effect to the pulpal reaction due to the PDL injection. Controls that were prepared had essentially the same pulpal response as did the experimental teeth (PDL injection/preparation). In both experimental and control pulps, the effects were primarily related to the depth of the cavity preparation.

Anesthesia, Dental↗

PubMed1998

Silent infection in clotted hemodialysis access grafts.

Thrombotic and infectious complications are frequent causes of hemodialysis vascular access failure and contribute considerably to the cost of care for chronic hemodialysis patients. Although there is clear indication for removal of patent grafts in unresolved bacteremia, there are no guidelines for the management of clotted nonfunctioning grafts. To evaluate for the existence and clinical relevance of silent infection in clotted nonfunctioning hemodialysis grafts, a study was conducted with a series of 20 hemodialysis patients who presented with fever (15 patients), or fever and clinical signs of sepsis (five patients), in whom the source of infection was not immediately localized to any organ system. Comparison was made with 21 asymptomatic patients with clotted grafts who served as control subjects. All patients and control subjects came from a pool of 115 chronic hemodialysis patients in an outpatient hemodialysis unit in the Houston metropolitan area, who were on hemodialysis for a period of time ranging from 3 to 15 yr. Indium scans were performed, followed by removal of the clotted grafts in all patients and control subjects. Bacterial cultures of the recovered surgical material and blood were done concomitantly in all study participants. Indium scans showed positive uptake in or around the clotted grafts in all of the patients and in 15 of the control subjects. Purulent material was found in the grafts in all patients and in 13 of 15 indium scan-positive control subjects. When positive, blood culture pathogens were identical to those cultured from the graft material in all instances. The predominant pathogens were Staphylococcus aureus, followed by Staphylococcus epidermidis. There was no evidence of graft infection in the control subjects if indium scan was negative. Chart review dating back to the start of dialysis revealed five past infectious episodes in the patient group, compared with four in the control group. These findings suggest that clotted nonfunctioning grafts are frequent harbingers of infection. They should be suspected as the source of infection in every hemodialysis patient that presents with fever, even in the absence of clinical signs of graft site infection.

Adult↗

PubMed1993

Pulmonary artery catheterization. Can there be an integrated strategy for guideline development and research promotion?

OBJECTIVES: To review the evidence regarding indications for pulmonary artery catheterization (PAC) in critically ill patients, and to propose a guideline-generating process that would encourage randomized controlled trials of PAC. DATA SOURCES: Computerized and manual search for randomized trials involving PAC as an integral part of the protocol, published as of October 1992. Manual search for guidelines endorsed by specialty societies and/or proposed by expert panels following an explicit group process. DATA SYNTHESIS: Four trials suggest benefit from PAC for pre- or perioperative management of high-risk surgical patients. Two others indicate that PAC for low-risk aortic aneurysm surgery confers no advantages. Use of PAC to guide therapy aimed at improved mixed venous oxygen saturation was beneficial compared with usual care with PAC in two small trials among patients with septic shock and severe trauma. Other PAC indications are either untested or inadequately tested by small trials. Large trials are needed, but trials to date have been impeded by clinicians' uncertainty about PAC and unwillingness to randomize critically ill patients. No published guidelines for PAC have used a formal group process and/or a hierarchical review of evidence to demarcate proven from unproven indications. CONCLUSIONS: We propose a research-promoting expert panel on indications for PAC. Aided by a critical literature review, experts would rate case scenarios on the need for routine PAC with or without a specified intervention strategy. Future trials should test indications where there is either consensus about the uncertainty of need for PAC, or interpanelist disagreement owing to inconclusive evidence. This process could facilitate practice guideline development, utilization management, and large trials of PAC and related interventions.

Cardiac Catheterization↗

PubMed1979

Studies in burns, XVI: The effect of surgical trauma on metabolic heat production.

As part of an ongoing study of the naturally-occurring skin lipid ethyl linoleate as an adjunct for reducing post-burn hypermetabolism and hyperevaporation, we have conducted a series of evaluations of metabolic heat production (M) using a clinical partitional calorimeter. In this article, we describe the metabolic chamber and its use in evaluating the change in M in pre- and postoperative patients. We determined that dry heat losses (radiation and convection) comprise the major components of heat loss in the "normal" and traumatized individual with intact skin. In the post-operative state, metabolic heat production increases significantly above the preoperative levels, the percentage of change being accurately described by a first order exponential equation. In the postoperative patient, possibly because of a physiologic shift in source of metabolic substrate, stored heat increases significantly. These data may be useful in allowing approximate correction of the metabolic heat equation when studying the burn patient where no "control" is attainable and where some approximation of the contribution of "pure" trauma must be made.

Adult↗

PubMed1994

Meta-analysis of highly selective vagotomy versus truncal vagotomy and pyloroplasty in the surgical treatment of uncomplicated duodenal ulcer.

OBJECTIVE: To compare critically by meta-analysis the postoperative outcomes after truncal vagotomy and pyloroplasty (TVP) and after highly selective vagotomy (HSV). DATA SOURCES: A search was conducted on MEDLINE with the keywords "peptic ulcer" and "vagotomy". Bibliographics of the articles retrieved and review articles pertaining to the subject were scanned further. STUDY SELECTION: Included were only published prospective, randomized controlled trials comparing TVP and HSV in the English-language literature up to April 1991. Twelve studies were found. DATA EXTRACTION: Two authors, working independently, abstracted raw data on mortality, recurrence, dumping, diarrhea and postoperative Visick grading. DATA SYNTHESIS: A ratio greater than 1.0 indicates a higher proportion occurring with TVP and less than 1.0 a higher proportion with HSV. [Table: See Text] CONCLUSION: The results suggest that the likelihood of adverse long-term sequelae is higher with TVP whereas the likelihood of recurrence is higher with HSV.

Confidence Intervals↗

PubMed2003

Fluid resuscitation strategies in the Israeli army.

Medical training in the Israel Defense Forces (IDF) is currently based on the principles of the Advanced Trauma Life Support course of the American College of Surgeons termed Military Trauma Life Support. The Advanced Trauma Life Support guidelines provide a systematic standardized approach to the treatment of trauma casualties that has been very successful in civilian trauma. On the battlefield, however, these guidelines have been modified according to the combat environment. The factors that influence these changes are tactical considerations, availability and level of training of medical personal, direct enemy fire, medical equipment limitations, means of transportation of casualties, and the variable transportation time from the front line to the first medical echelon. The basic strategy of the IDF is to bring the military physician or paramedic and airlifted surgical units as close as possible to the front line, to minimize evacuation time. Also, evacuation helicopters that land in the combat zone close to the front line, sometimes under direct fire, usually have a military physician on board. The dilemma of "scoop and run" or "stay and stabilize" in hemorrhagic shock has been solved in the IDF toward early rapid evacuation of casualties to a surgical unit. Immediately after airway and breathing have been secured, if evacuation time is less than 1 hour, the intravenous line and fluid resuscitation is started en route to the medical facility. When evacuation time is longer than 1 hour, an intravenous line is always started before evacuation. In controlled hemorrhagic shock, where the source of bleeding has been controlled and evacuation time is less than 1 hour, fluid resuscitation with lactated Ringer's solution or normal saline is started, to achieve normalization of hemodynamic parameters. When evacuation time exceeds 60 minutes, colloids such as Hemaccel or hydroxyethyl starch are added. In uncontrolled hemorrhagic shock, where internal bleeding has temporarily stopped because of hypotension, vasoconstriction, and thrombus formation, aggressive fluid resuscitation with lactated Ringer's solution to achieve normal hemodynamic parameters is prohibited, because it may induce internal rebleeding and hemodynamic decompensation. When evacuation time exceeds 60 minutes, the use of crystalloids and colloids is indicated. If brain injury is suspected, fluid resuscitation should be aimed toward normalization of hemodynamic parameters.

Fluid Therapy↗

PubMed2004

Histological findings in experimental macular surgery with indocyanine green.

PURPOSE: To analyze the effect of different concentrations and application intervals of indocyanine green (ICG) on the retina in an experimental setting of macular surgery. METHODS: Twenty-one porcine eyes were used within 5 hours after enucleation. The eyes were hemisected and the vitreous removed. Different doses of ICG (up to 1 mg) were applied over the trephined macula, and the remainder of the eyecup was filled with a balanced salt solution (BSS). Both the ICG solution and the BSS were drained after 30 or 60 seconds and the complete eyecup irrigated and filled with fresh BSS. The posterior pole was then illuminated with a standard surgical light pipe and light source at maximum power for 3 minutes. Both the ICG-treated retina and the nontreated surrounding retina were processed for histology. RESULTS: Exposure of the retina at different concentrations of ICG either for 30 or 60 seconds, followed by illumination, caused no histologically detectable damage compared with the controls. No microarchitectural disorganization or cellular disruption was detected. The vitreoretinal interface seemed unaffected. CONCLUSIONS: Previously described severe damage to the inner retina of human donor eyes could not be found with even higher doses of ICG in this porcine model. Although differences within the species may contribute to these contradictory results, it is conceivable that the postmortem time and the vitality of the tissue influence the outcome in this ex vivo system.

Animals↗

PubMed1989

Adult-onset macular degeneration in the Cayo Santiago macaques.

Since 1985 a group from the University of Florida has examined 136 rhesus monkeys from the Cayo Santiago colony. From the sample, 97 are older than nine years (approximately 30 human years) and 39 are younger. Drusen were found in 17% of the younger eyes and in 46% of the older eyes. All animals over 25 years of age had drusen in the central fundus. The incidence of drusen varied from 19-77% between five social groups. Incidence reported in random-source colonies in the continental U.S.A. is about six percent. Compared to near-age matched controls without drusen, selected rhesus exhibited visual resolution losses amounting to two Snellen-lines or more. The end-stage disciform changes and ultrastructural similarities are comparable with human macular disease. Future prospective studies may include therapies, surgical intervention, environmental manipulation and genetic research.

Academies and Institutes↗

PubMed1977

[Hemorrhage complications of acute pancreatitis (author's transl)].

The authors report 11 cases of hemorrhage due to vascular ulcerations arising early or late in the course of acute pancreatitis. The seriousness of these hemorrhages, the difficulties of their therapy are pointed out. In all cases, bleeding should be controlled by surgery. Therefore, attention is drawn to the need for prompt laparotomy in all the shocked patients who failed to respond to conservative measures, for in such cases, a fatal outcome may rapidly occur. The respective advantages and inconveniences of the 2 main surgical treatments, ligation of bleeding vessels or pancreatectomy removing the source of bleeding, are discussed, basing on the presently reported cases and the data of the literature.

Acute Disease↗