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PubMed1985

Early local complications from intestinal stomas.

A retrospective review of 610 consecutive patients with intestinal stomas constructed at Cook County Hospital, Chicago, was carried out to analyze early local complications with respect to stoma type and to compare complication rates by surgical specialty. A total of 197 complications were recognized in 158 patients for a corrected complication rate of 25.9%. Peristomal skin irritation (42.1%) was the most frequently recognized early complication in this study. Ileostomy was associated with the highest morbidity (40%) of any type of stoma. Emergency stoma formation seems to be associated with the highest complication rates, probably because of suboptimal stoma placement. The morbidity of stoma formation seems to be related to the amount of formal training in gastrointestinal tract surgery. Technical guidelines for stoma construction are presented to help minimize these complications.

Adolescent↗
PubMed2000

Nonpenetrating vascular clips for small-caliber anastomosis.

In the search for better anastomosing techniques, an improved vascular stapler device (VCS clip applier system(R)) has been introduced. The system uses nonpenetrating clips to approximate everted vessel walls. The objective of this study was to determine the effects of nonpenetrating vascular clips on endothelial wound healing. Aortic end-to-end anastomoses were performed in male Wistar rats. A comparison was made between clipped (n = 12) and conventional hand-sewn (n = 6) anastomoses. Patency rates were verified at different time intervals (after 1, 4, and 8 weeks), after which the anastomotic sites were removed. Morphological evaluation was carried out using scanning electron microscopy. All rats survived the procedure. Closure with clips took less time than closure with conventional sutures, with decreasing aortic clamping times for the clipped procedures during the course of the experiments. Patency rates were 100% in both the "clipped" and "sutured" groups. Microscopic examination showed favorable endothelial healing at the clipped anastomotic sites, with less inflammatory reaction at 1 week, and a more complete endothelial regeneration at 4 and 8 weeks follow-up, as compared with the sutured anastomoses. The clip applier holds the promise of a useful device in anastomosing small-caliber vessels, since clip closure takes less time than suturing, while patency rates are identical, and morphological results are favorable. Training is mandatory to obtain technical skills and to achieve optimal results.

Anastomosis, Surgical↗
PubMed2000

A human skull cast model for training of intracranial microneurosurgical skills.

Skillful microsurgical techniques such as microvascular anastomosis and repair of nerves require dedicated and extensive laboratory training. Human microneurosurgery poses several additional technical difficulties, as the intracranial procedures are often performed through a narrow operative space at a considerable length, using knee-bend instruments. This article presents a laboratory model to simulate microneurosurgical procedures in humans. A human skull cast model made from plaster is cut such that, when placed on a operating table, it represents a standard position of a pterional approach and that the point of operation is at the same depth as the hypothetical circle of Willis. A standard pterional opening is made in de skull cast and the model is placed over the rat. Subsequently, all surgical procedures starting from tissue preparation to performing an arterial, venous, and/or nerve repair are performed with the cast over the rat using microneurosurgical knee-bent instruments and a surgical microscope. Microsurgical procedures such as end-to-end vessel anastomosis and nerve repair are technically much more challenging and difficult to execute when performed through the pterional opening of the human skull cast than without the cast model. Moreover, the cast model useful in training microsurgical techniques performed with long knee-bend instruments. It is concluded that the skull cast model represents a useful method to train intracranial microneurosurgical blood vessel anastomosis and nerve repair.

Humans↗
PubMed2004

Standardized procedure for measurement of nasal potential difference: an outcome measure in multicenter cystic fibrosis clinical trials.

Patients with cystic fibrosis (CF) can be discriminated from healthy subjects by measurement of the nasal potential difference, which has become a useful outcome measure for therapies directed toward correcting defective electrolyte transport in CF. A standard operating procedure was developed by a CF Foundation clinical trials network, to be followed by all sites performing collaborative studies. Key variables in the measurement included type of voltmeter, exploring probe, reference electrodes, and solutions used to assess both sodium transport and chloride conductance. Eight sites submitted data on 3-8 normal and 4-5 CF subjects. Baseline voltage, an index of sodium transport, was -18.2 +/- 8.3 mV (mean +/- SD) for normals, and -45.3 +/- 11.4 mV for CF patients. There was no CFTR-mediated chloride secretion in CF subjects, as evidenced by the lack of response to perfusion with zero chloride + beta agonist solutions (+3.2 +/- 3.5 mV) vs. that in normals (-23.7 +/- 10.2 mV). The standardized nasal potential difference measurement minimizes variability between operators and study sites. Valid and consistent results can be attained with trained operators and attention to technical details. These data demonstrate the procedure to be sufficient for multicenter studies in the CF Foundation network.

Adult↗
PubMed2005

[Clinical risk management. Implementation of an anonymous error registration system in the anesthesia department of a university hospital].

BACKGROUND: The main goal of a medical risk management system is reduction of treatment errors and the primary focus is patient safety. MATERIALS AND METHODS: A task force on risk management in anaesthesia was established in the department of Anaesthesiology and Intensive Care at the University Hospital Dresden with the aim to implement a critical incident reporting system (CIRS) followed by a structured analysis. The theoretical basic principles and tools for the incident analysis are presented. RESULTS: The task force developed a machine-readable, structured, anonymous questionnaire, which was implemented in clinical practice after a primary test period. CONCLUSIONS: Prerequisites for the implementation of an effective CIRS are support from the department head, anonymity, independence of the task force from the department head and competence of the task force to initiate changes and improvements. CIRS is a powerful tool to register and analyse critical incidents and may influence the following domains: education and training (human factors), medical equipment (technical factors), quality of working processes and departmental communication (organisational factors).

Anesthesia Department, Hospital↗
PubMed1998

[The status of neurologic intensive care in Germany. Current data].

In 1994 this journal published the results of a survey undertaken on behalf of the Working Association for Neurological Intensive Care Medicine (ANIM) in the winter of 1992/93. In the winter of 1996/97 a continuation of this analysis was performed. With the help of a questionnaire the data of 62 intensive care units with a total of 420 beds were established. This is 11 intensive care units and 83 beds more than 1992/93. The intensive care units were again classified into three groups (ventilation units, monitoring units, interdisciplinary units) relating to their equipment and structure. The questions concerned structural organisation, such as the number of beds, type of clinic, number and training of physicians and nurses, technical equipment and availability of large and high-tech apparatus or access to other facilities, such as neurosurgery. Of great interest were data about whether and to what extent special measures of intensive medicine can be taken on the one hand and performance parameter data e.g. days of ventilation and duration of in-patient treatment on the other hand. Detailed data were provided concerning the frequency of each diagnosis of patients treated in those intensive care units. Evaluating the data a positive development in the last four years of the neurological intensive care can be found in most of the areas investigated. It has also been found that neurological intensive care in the new lander has reached equal standard both in quality and quantity. Now a single physician is responsible for 2,3 beds compared to 3,6. Today 78 per cent of the beds in ventilation units are equipped with a ventilator. The overall time of ventilation increased to 48 per cent. Overall there are, however, considerable differences between individual units as well as regions. The data presented can serve as a means to monitor the quality of neurological intensive care.

Equipment and Supplies, Hospital↗
PubMed1993

Laparoscopic approaches to the common bile duct stone: transcystic bile duct exploration, choledochotomy and stone fragmentation.

It has been illustrated that a convergence of new technologies, including advanced laparoscopic techniques, flexible video endoscopy, coaxial balloon dilators and biliary lithotripsy, has allowed the modern laparoscopic surgeon to address a pressing issue: how to deal with choledocholithiasis. A variety of techniques and methods have been described; each has their advocates, philosophical advantages and potential drawbacks. The definitive decision as to which technique is the best awaits the results of future prospective studies. Until then, the three techniques outlined will allow the majority of surgeons to extend the advantages of minimally invasive surgery to patients with choledocholithiasis. There is no doubt that this is desirable. These procedures, however, are not without their failure rate and complications, and they remain technically demanding. Increased education and training of surgeons is needed and further improvement of existing technology is demanded. This includes improved fibreoptic choledochoscopes with better optics, more flexibility and larger working channels; better stone baskets and better mechanical graspers, and safer and more effective stone lithotriptors. Other questions remain unanswered, such as the relative and absolute contraindications to performing laparoscopic common duct explorations. Can patients with multiple common duct stones or very small ducts be safely handled using these methods? Is there a size of common duct stone that is safe to leave behind, and are there safe antegrade methods of treating distal duct stenosis? The new interest in avoiding the placement of T-tubes for common duct drainage also needs close scrutiny. All these questions need well-constructed studies to answer them; but in the meantime, laparoscopic common duct exploration is undoubtedly here to stay, and this new approach to an old problem is inducing biliary surgeons to question many traditionally held dicta, which can in the long run only be in the patients' best interest.

Endoscopy, Digestive System↗
PubMed2005

Hospital-wide first-responder automated external defibrillator programme: 1 year experience.

The first year experience with a hospital-wide first-responder automated external defibrillator (AED) programme implemented in a 683-bed University Hospital is reported. Throughout the hospital, 14 "AED access spots" were identified which could be easily reached from all wards and diagnostic rooms within 30s. AEDs were installed (Lifepak 500; Medtronik PhysioControl Corp., Redmond, USA, equipped with a Biolog 3000i portable ECG monitor; Micromedical Industries Ltd., Labrador, Australia). Within 3 months, 120 medical officers, 750 nurses, and 50 administrative or technical staff underwent a 2h training programme. An AED was applied and activated by nurses/medical staff before the cardiac arrest team arrived in 27 of 33 cases (81.8%) of witnessed cardiac arrest. The median time from onset of the emergency call to the activation of the AED (record of ECG) was on average 2.1 min (range 1.0--4.5 min). In 18 of 27 cases in which the AED was installed promptly, the primary arrest rhythm was either VT or VF, and the AED delivered a shock. For this subgroup, the rate of return of spontaneous circulation and the rate of discharge at home were 88.9 and 55.6%, respectively. This encourages us to extend the concept of first-responder AED-defibrillation throughout our hospital.

Adult↗
PubMed1999

Telemedicine and endovascular aortic grafting.

Endovascular aortic grafting represents a minimally invasive approach to aortic aneurysm repair. The technique requires a variety of new skills and extensive training. Telemedicine enhances mentoring and technical support for surgeons performing the technique.

Aortic Aneurysm↗
PubMed2003

Making waves: systems change on behalf of youth with HIV/AIDS.

PURPOSE: To document the effects of five Special Projects of National Significance (SPNS), funded by the Health Resources and Services Administration (HRSA), on HIV care, related service systems, policy, planning, and funding for youth with HIV/AIDS. METHODS: Literature on services and systems integration and technology transfer is used as a conceptual framework for the examination of HIV-informed, youth-specific changes at the local, state, and national levels. The Principal Investigators for each project and/or the Project Evaluators were interviewed several times to capture "snapshots" of evolving results from the Projects' varied activities in New York City; Newark, New Jersey; Chicago; and Miami. Some changes were consciously targeted, and others occurred serendipitously. This work covers the funding period from 1996 through 2000. RESULTS AND CONCLUSIONS: There were many "ripple" effects that emanated from these Projects' presence and activities. Important lessons were learned about why systems change is necessary to effectively serve youth with HIV, how to make constructive changes happen, and how to sustain changes once they are achieved. Successful strategies included, but were not limited to, consensus-building among stakeholders, participatory planning and decision-making, collaborative referral and linkage agreements, staff sharing, co-locating services, providing technical assistance, consultation, cross-training, and engaging consumers as partners in communicating new technologies and in advocating for change.

Adolescent↗
PubMed2000

The relationship between coaching behaviours and sport anxiety in athletes.

Previous research has identified the relationship between athlete sport anxiety and various sport outcomes (e.g., performance and dropout). For the majority of athletes involved in sport, the coach is an influential element of the competitive experience. Two hundred and twenty-eight athletes from 15 sports, completed the Sport Anxiety Scale (SAS) and the Coaching Behavior Scale for Sport (CBS-S). The predictive ability of athletes' perceived frequency of seven coaching behaviours (physical training, mental preparation, goal setting, technical skills, competition strategies, personal rapport and negative personal rapport) on four forms of sport anxiety (total anxiety, somatic anxiety, concentration disruption and worry) was examined. Results indicate that negative personal rapport was a significant predictor of all measured forms of sport anxiety while competition strategies was a significant predictor for total anxiety, concentration disruption, and worry. Other behaviours were not significant. The findings suggest that negative rapport between coach and athlete is an important contributor to athlete anxiety. In addition, behaviours that the coach demonstrates relative to competition can be influential in reducing athlete anxiety.

Adolescent↗
PubMedDate not supplied

Civilian exposure to toxic agents: emergency medical response.

Civilian populations are at risk from exposure to toxic materials as a result of accidental or deliberate exposure. In addition to industrial hazards, toxic agents designed for use in warfare now are a potential hazard in everyday life through terrorist action. Civil emergency medical responders should be able to adapt their plans for dealing with casualties from hazardous materials (HazMat) to deal with the new threat. Chemical and biological warfare (CBW) and HazMat agents can be viewed as a continuous spectrum. Each of these hazards is characterized by qualities of toxicity, latency of action, persistency, and transmissibility. The incident and medical responses to release of any agent is determined by these characteristics. Chemical and biological wardare agents usually are classified as weapons of mass destruction, but strictly, they are agents of mass injury. The relationship between mass injury and major loss of life depends very much on the protection, organization, and emergency care provided. Detection of a civil toxic agent release where signs and symptoms in casualties may be the first indicator of exposure is different from the military situation where intelligence information and tuned detection systems generally will be available. It is important that emergency medical care should be given in the context of a specific action plan. Within an organized and protected perimeter, triage and decontamination (if the agent is persistent) can proceed while emergency medical care is provided at the same time. The provision of advanced life support (TOXALS) in this zone by protected and trained medical responders now is technically feasible using specially designed ventilation equipment. Leaving life support until after decontamination may have fatal consequences. Casualties from terrorist attacks also may suffer physical as well as toxic trauma and the medical response also should be capable of dealing with mixed injuries.

Biological Warfare↗
PubMed2001

Epidemiology of contact allergy in adults.

BACKGROUND: We aimed to determine the prevalence of contact sensitization in the general population and to investigate associations with important sociodemographic and medical characteristics. METHODS: Within a population-based nested, case-control study in Germany, we performed patch tests with 25 standard allergens in 1141 adults (50.4% female, age median 50 years). Additional information was obtained by a dermatologic examination, a standardized interview, and blood analysis. RESULTS: At least one positive reaction was exhibited by 40.0% of the subjects, with reactions most frequently observed to fragrance mix (15.9%), nickel (13.1%), thimerosal (4.7%), and balsam of Peru (3.8%). Women were sensitized more often than men (50.2% vs 29.9%, OR 2.36, CI 1.84-3.03), and this was also significant for fragrance mix, nickel, turpentine, cobalt chloride, and thimerosal. Contact sensitization was more frequent in subjects who reported adverse skin reactions (53.8% vs. 32.6%; OR 2.41, CI 1.85-3.14), and this was particularly true for sensitization to nickel (45.5% vs 8.8%, OR 8.64, CI 5.67-13.17) and fragrance mix (29.0% vs 14.0%, OR 2.51, CI 1.60-3.91) and the corresponding intolerance of fashion jewelry and fragrances. Contact sensitization decreased with increasing degree of occupational training (unskilled 45.9%, apprenticeship 40.1%, technical college 40.4%, and school of engineering 12.5%; P=0.023; trend test P=0.042). Significant associations of contact sensitization and presence of allergen-specific IgE antibodies, atopic eczema, or psoriasis were not observed. Frequency estimates for the general adult population based on these findings were 28.0% for overall contact sensitization and 11.4% for fragrance mix, 9.9% for nickel, and 3.2% for thimerosal. CONCLUSIONS: It is concluded that contact allergy is influenced by sociodemographic parameters and plays an important role in the general population.

Adult↗
PubMed1998

The clinical skills of community psychiatric nurses working with patients who have severe and enduring mental health problems: an empirical analysis.

This study describes the use of reliable scales to rate the clinical skills of mental health nurses when working with individuals and families with severe mental health problems. The Cognitive Therapy Scale and the Schizophrenia Family Work Scale were adapted for the study and were shown to have good inter-rater reliability when assessing audio-taped interviews carried out by mental health nurses during their usual course of work with patients with severe mental health problems and their families. The sample of mental health nurses studied were shown to have significantly better general therapy skills than specific cognitive therapy technical skills. The implications for training are discussed.

Clinical Competence↗
PubMed1999

Experience of social support in rehabilitation: a phenomenological study.

The progressive muscular weakness brought on by muscular dystrophy causes the sufferer many problems in everyday life. Earlier studies in Sweden have shown that adults with hereditary muscular dystrophy often have difficulty in gaining access to rehabilitation. For this reason a special rehabilitation programme was drawn up and carried out, extending over a period of 18 months. The purpose of the study is to describe the participants' experience of social support in connection with the programme. Thirty-seven participants (21 women and 16 men) were interviewed. The analytical method was phenomenological, incorporating validation by independent judges. Nine overall themes emerged from the interviews: psychosocial support, meeting other people with muscular dystrophy, knowledge and learning, adjustment in daily life, coping with illness-related problems, adjustment at work, management of physical disability, medical examination and treatment, and involvement of relatives. The results indicate that the participants encountered staff with a sense of commitment and felt themselves to be 'seen and confirmed'. From the discussions and the contact with others in the same situation there arises a sense of affinity and a better understanding of one's own situation. There was appreciation of the education about the disease, its hereditary aspect, technical aids, grants and physical training. Hardly any of the participants spoke of knowing such things before. In conclusion there was approval of the received support, and recognition that persons with muscular dystrophy should be given access to recurrent rehabilitation.

Activities of Daily Living↗
PubMed2006

Oropharyngeal aspiration of a silica suspension produces a superior model of silicosis in the mouse when compared to intratracheal instillation.

Instillation of crystalline silica into the lungs of mice is a common experimental model of pulmonary fibrosis. Typically, a suspension of silica in saline is injected into the trachea via intubation or surgical tracheostomy. These techniques require a high degree of technical skill, have a lengthy training period, and can suffer from a high failure rate. In oropharyngeal aspiration, a droplet of liquid is placed in the animal's mouth while simultaneously holding its tongue (to block the swallow reflex) and pinching its nose shut, forcing it to breathe through its mouth, aspirating the liquid. To determine whether oropharyngeal aspiration (OA) could replace intratracheal instillation (IT) in a model of silica-induced fibrosis, a comparison was performed. Crystalline silica was introduced into the lungs of male C57BL/6 mice by the IT or OA procedure, and the resulting inflammation and fibrosis was assessed after 3 weeks. IT and OA instillation of silica both resulted in neutrophilic inflammation and fibrotic changes, including interstitial fibrosis and dense fibrotic foci. Mice treated via IT demonstrated a few large lesions proximal to conducting airways with little involvement of the distal parenchyma and large interanimal variability. In contrast, OA resulted in a diffuse pathology with numerous fibrotic foci distributed throughout the lung parenchyma, which is more representative of human fibrotic lung disease. OA- but not IT-treated mice exhibited significantly increased lung collagen content. Furthermore, the interanimal variability within the OA group was significantly less than in the IT group. Oropharyngeal aspiration should be considered as an alternative to intratracheal instillation of silica and other particulates in studies of respiratory toxicity and lung disease.

Administration, Inhalation↗
PubMedDate not supplied

Mini-knemometry: an accurate technique for lower leg length measurements in early childhood.

A novel miniaturization of knemometry for accurate measurements of the lower leg length in prematures, newborns and infants (mini-knemometry), is presented. The study was performed in four healthy neonates, born at term, and one infant, born in the 34th week of gestation, measured daily for periods of 40 days; and in two monozygotic healthy twin sisters, born in the 32nd week of gestation, measured daily for periods of 58 days. Each of the 316 measurements consisted of four independent subsequent estimations of the distance between heel and knee, which are grasped by two metallic holders under light compression of 2.0-3.0 N. After an initial training of 1 week the technical error is 144 microns. Lower leg growth is non-linear (p < 0.001) with periods of stunted, and periods of accelerated, growth velocity.

Anthropometry↗
PubMed1999

Modern treatments of menorrhagia attributable to dysfunctional uterine bleeding.

Menorrhagia (excessive uterine bleeding) affects some 20 percent of the women of reproductive age worldwide. The following review describes known and theorized etiologies of the disorder, followed by a discussion of treatment options that are currently in use as well as those on the horizon. There is much interest internationally in decreasing hysterectomy rates, particularly for those women with abnormal bleeding and anatomically normal uteri. It is these women who are the focus of this paper. Pharmacotherapy and surgery are the mainstay treatments for such patients with menorrhagia secondary to dysfunctional uterine bleeding. Most commonly, hormonal and nonhormonal medications are followed by dilatation and curettage, and ultimately, in many cases, hysterectomy. Endometrial ablation techniques have been evolving since the 1980s in response to the need for an efficacious, safer, and more cost-effective alternatives to hysterectomy. Hysteroscopic ablation achieves these goals but is difficult technically and requires significant additional training even for otherwise skilled and experienced gynecologists. The current decade has seen the development of many innovative approaches to performing endometrial ablation. These methods are intended to be much simpler to perform with less risk than electrosurgical or laser endometrial ablation. The final section of this article presents the published data to date on these new technologies, which should (in their refined state) revolutionize the treatment of menorrhagia secondary to dysfunctional uterine bleeding.

Endometrium↗