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PubMed2006

[Psychological traits, course of surgery and recovery following hernia repair in patients preferring general or local anaesthesia].

OBJECTIVE: This study addresses two questions concerning open inguinal hernia repair patients: (1) are there differences in psychological traits between patients opting for local vs. general anaesthesia and (2) assuming comparable operations, are there any differences between the two groups during surgery and postoperative recovery? METHODS: A total of 69 male patients aged between 18 and 80 took part in the study. After having been briefed about anaesthesia, they opted for either local (n=40) or general anaesthesia (n=29). In order to determine psychological traits, patients filled out questionnaires before the operation [NEO Five-Factor-Inventory (NEO-FFI) and the Stress Coping Questionnaire (SVF)] and the Anaesthesiological Questionnaire (ANP) after the operation. Data about the surgery (duration of anaesthesia and operation, blood pressure and heart rate) and the convalescence period (time spent in recovery room, length of stay in hospital) were also recorded. The patients' information processing skills were measured preoperatively and postoperatively using the "Trail Making Test". RESULTS: Patients preferring local anaesthesia were significantly older than those who chose general anaesthesia. Therefore two similar age groups were formed by using the method of matched samples (n=2x26). Between these groups no significant differences were found with reference to psychological traits, but markedly extraverted patients favoured local anaesthesia. There were no differences in the duration of anaesthesia and surgery. Local anaesthesia patients spent less time in the recovery room and in hospital than general anaesthesia patients. Postoperatively, the cognitive state and the satisfaction with the anaesthesia were comparable between both groups. CONCLUSION: Psychological traits do not have a significant impact on the choice of either local or general anaesthesia. However, highly extraverted patients prefer local anaesthesia while extreme introverts prefer general anaesthesia. Our findings suggest that local anaesthesia will become more widely adopted for the repair of groin hernia. Future studies should focus on optimising the perioperative care for patients who choose local anaesthesia.

Adolescent↗
PubMed1999

Radical nephrectomy and nephroureterectomy in the octogenarian and nonagenarian: comparison of laparoscopic and open approaches.

OBJECTIVES: To retrospectively compare the outcome of laparoscopic and open radical nephrectomy or nephroureterectomy in patients 80 years old or older, inasmuch as the tolerance profile of major laparoscopic renal surgery in comparison to open surgery in the elderly patient has not been previously reported. METHODS: Since September 1997, 11 patients 80 years old or older underwent retroperitoneal laparoscopic radical nephrectomy or nephroureterectomy for cancer. These patients were compared with 6 consecutive patients 80 years old or older who underwent comparable open surgery at our institution since January 1994. No tumor had computed tomographic evidence of lymphatic, vascular, or perirenal extension. RESULTS: Baseline parameters were comparable between the laparoscopic and open groups. The laparoscopic group had a similar median surgical time (210 minutes versus 175 minutes; P = 0.1) and blood loss (150 mL versus 125 mL; P = 0.8) compared with the open group. However, specimen weight was larger in the laparoscopic group (568 g versus 292 g; P = 0.04). Moreover, the laparoscopic group had a quicker resumption of oral intake (less than 1 day versus 4 days; P <0.001), decreased narcotic requirements (14 mg versus 326 mg; P = 0.004), shorter hospital stay (2 days versus 6 days; P <0.001), and faster convalescence (14 days versus 42 days; P <0.001) compared with the open group. CONCLUSIONS: Retroperitoneal laparoscopic radical nephrectomy and nephroureterectomy are well tolerated by the elderly patient. Although our sample size was small, it appears that laparoscopy is an excellent alternative to open surgery for excision of selected renal malignancies in the octogenarian and nonagenarian population.

Aged↗
PubMed2002

A randomized, double-blind, placebo-controlled trial of dexamethasone in severe respiratory syncytial virus (RSV) infection: effects on RSV quantity and clinical outcome.

Forty-one previously healthy children <2 years of age who required mechanical ventilation for respiratory syncytial virus (RSV) infection were randomized to receive dexamethasone (0.5 mg/kg; n=22) or saline placebo (n=19) intravenously every 12 h for 4 days. RSV quantity was measured by quantitative plaque assay in fresh tracheal and nasal aspirates obtained at intervals of 24+/-3 h on days 0, 1, 2, 5, and 7 following entry. Analysis by linear mixed-effects modeling demonstrated a significantly greater decline in mean tracheal RSV quantity in the placebo group than in the dexamethasone group from day 0 to day 1 (0.82 vs. 0.21 log pfu/mL; P=.01) and from day 0 to day 2 (1.45 vs. 0.53 log pfu/mL; P=.03). No differences were found between groups in nasal RSV quantity, white blood cell counts in tracheal or nasal aspirates, serum neutralizing antibody titers during convalescence, or duration of mechanical ventilation, intensive care unit stay, or hospital stay.

Antibodies, Viral↗
PubMed1994

Laparoscopic radical nephrectomy for renal cell carcinoma: early experience.

We developed a laparoscopic radical nephrectomy for malignant disease of the kidney and successfully performed the operation in six patients between July 1992 and October 1993. This procedure is basically derived from that of Clayman and associates. A CO2 pneumoperitoneum is induced, and five trocars are introduced into the abdominal cavity through the lateral abdominal wall. The kidney is removed en bloc together with the adrenal gland, perirenal fatty tissue, and Gerota's fascia. The free kidney is put into a laparoscopy sack, and the sack is pulled out through a 5- to 6-cm incision in the abdominal wall without morcellation to allow complete pathologic examination. By this procedure, right nephrectomy was performed in four patients and left nephrectomy in two patients. The mean operative time was 6 hours and 13 minutes, and the mean blood loss was 430 mL. There were no severe complications. The average hospital stay was 11 days, and the average time to full convalescence was 21 days. Pathologic examination revealed renal cell carcinoma in five patients and nephroblastoma in one. Of the patients with renal cell carcinoma, the stage was pT1pN0pM0 in three patients and pT2pN0pM0 in two. There has been no recurrent disease in these six patients with a mean follow-up period of 9.5 months.

Adult↗
PubMed1991

Pelviscopic surgery: a key for conserving fertility.

As a result of experience with more than 16,000 pelviscopic operative procedures performed at the Kiel University Women's Clinic from 1971 to 1988 which in this time had been adapted and used around the world, it may be said that the pelviscopic operative techniques, based completely on the laparotomy techniques which employ the microscissors, needles and suture material, is superior for many of the classical gynecological indications to operation. Minimally invasive surgery reduces hospitalization for even the most difficult cases to approximately 3 days. Convalescence is also reduced to approximately 1 week. Postoperative complaints are few, particularly when the primary exudate is removed through an abdominal drain. Late complications are practically unknown. It must be said that even the most minimal of operative procedures can produce late postoperative complaints or can be ascribed as the source of late postoperative complaints. Experiences gathered from around the world with endoscopically guided intraabdominal surgery have shown that for some gynecological procedures laparotomy is now indicated only in the rare case. The leading example of this switch can be seen in the operative treatment of the ectopic pregnancy. Following closely are operations to correct sterility such as salpingolysis, ovariolysis, fimbrioplasty, and salpingostomy. Finally pelviscopic treatment is increasing for all benign ovarian tumors, and the enucleation of myomas of up to 400 grams in weight. Endoscopically guided intraabdominal surgery also has a place in the field of general abdominal surgery--that of treatment of chronic abdominal adhesions. These procedures in the future should basically commence with endoscopic adhesiolysis, the patient having had the proper preoperative bowel preparation. Because of this minimally invasive technique the surgeon will only rarely be forced to perform laparotomy. In the case of abdominal adhesions a prerequisite for pelviscopic treatment is the visually controlled perforation of the peritoneum. Endoscopic surgery, in contrast to open laparoscopy, has a large periumbilical radius of action and produces no postoperative scars. In Kiel operative pelviscopy has replaced 80% of the classic gynecological laparotomies. The recurrence rate of adhesions is 84% with laparotomy compared with a recurrence rate of less than 40% with postendoscopic adhesiolysis. Forty to sixty percent of the patients who underwent pelviscopic adhesiolysis are complaint-free; this is a result not attained with classical abdominal surgery. Adhesiolysis per laparotomy is now limited to the emergency situation, as in the cases of ileus, for example. Endoscopically guided intraabdominal surgery has now improved the quality of life for surgical patients.

Abdomen↗
PubMed2000

Laparoscopic nephroureterectomy for upper tract transitional cell cancer: the Washington University experience.

PURPOSE: Laparoscopic nephroureterectomy has only recently been done to treat patients with upper tract transitional cell carcinoma. We retrospectively evaluated our experience with and long-term followup of laparoscopic nephroureterectomy, compared our results to those of contemporary series of open nephroureterectomy and reviewed the literature. MATERIALS AND METHODS: We reviewed the charts of and followed up by telephone 25 patients who underwent laparoscopic nephroureterectomy between May 1991 and June 1998, and 17 who underwent open nephroureterectomy between March 1990 and January 1997. Demographic, perioperative and followup data were compared. We performed a MEDLINE search and reviewed the literature on laparoscopic nephroureterectomy for upper tract transitional cell carcinoma. RESULTS: Laparoscopic nephroureterectomy required twice the operating time of open nephroureterectomy (7.7 versus 3.9 hours). However, patients who underwent the laparoscopic procedure had a 74% decrease in analgesia requirements (37 versus 144 mg. morphine sulfate equivalent), a 63% shorter hospital stay (3.6 versus 9.6 days) and a 72% more rapid convalescence (2.8 versus 10 weeks). Subsequent bladder transitional cell carcinoma and overall cancer specific survival were similar at a mean followup of 2 years. There was no sign of trocar site or peritoneal seeding after laparoscopic nephroureterectomy. CONCLUSIONS: Although laparoscopic nephroureterectomy is a longer operation, it has the same efficacy and is better tolerated by patients than open nephroureterectomy for upper tract transitional cell carcinoma. As operating time decreases due to surgeon experience and the recent development of hand assisted laparoscopy, laparoscopic nephroureterectomy may soon become the procedure of choice for the ablative management of upper tract transitional cell carcinoma.

Adult↗
PubMed2001

[Postoperative pain in prosthetic inguinal hernioplasty. Predictive factors and effects on patient recovery].

BACKGROUND: Tension free hernioplasty under local anaesthesia in day care basis is now the gold standard for inguinal hernia surgery, but a severe postoperative pain may affect convalescence and return to work, so minimizing economic benefits of day hospital. METHODS: To evaluate the incidence and predisposing factors of severe postoperative pain the authors examined 100 patients (96 men and 4 women, min. age 16 yrs, max 91 yrs, median age 53 yrs) operated from January 1999 to January 2000; in all cases a tension free hernioplasty under local anesthesia was performed. RESULTS: Good results were obtained in 83% of patients for intraoperative comfort, in 91% for postoperative pain, in 86% for immediate postoperative walking and in 93% for walking in the first week. Postoperative pain (first 24 hours) was strictly correlated to intraoperative pain, while a difficult postoperative walking was predictive for a difficult walking in the first week. CONCLUSIONS: Tension free hernioplasty allows a good functional recovery to daily activities since the first postoperative week; with an even more accurate patients selection and aggressive postoperative analgesia in pain risk patients better results will be achievable.

Adolescent↗
PubMed2003

[Determination of energy expenditure in the clinical setting].

A patient's nutritional support is a critical part of his general health care scheme. It aims to prevent or correct malnutrition, reduce morbidity, length of hospital stay and treatment costs. It equally optimises the patient's convalescence and quality of life. An optimal support requires the nutritional evaluation of the patient which includes determination of the energy expenditure. Once the energy needs have been evaluated, the clinician is then able to treat any nutritional deficiencies. This article therefore looks at the different methods available for predicting and measuring energy expenditure. The clinical limitations of these techniques and particular cases encountered (intensive care unit, anorexia and severe obesity, geriatrics, HIV infection, etc) will also be discussed.

Critical Care↗
PubMed2004

Interleukin-6 (IL-6) and tumour necrosis factor-alpha in open and laparoscopic cholecystectomy.

Injury to the human body alters normal physiology across several systems and these alterations are proportional to the extent of the injury. Physiological response to minimally invasive surgery appears to be different than those of traditional open surgery. Acute phase protein response appears to be one example. The important cytokines that are known as major mediators of acute phase response are interleukin-6 and TNF-alpha. Thirty patients were studied in which 14 underwent open cholecystectomy and 16 laparoscopic cholecystectomy. Three blood samples were taken from each patient, one pre-operatively and 2 post operatively at 4 and 24 hours. Interleukin-6 and Tumour Necrosis Factor-alpha (TNF-alpha) were raised significantly in post operative blood sample in both groups but the rise was much more in open group than laparoscopic group. This suggest less stress response in laparoscopic group which also showed a direct effect on patient convalescence in terms of less pain, less analgesic requirement and shorter hospital stay

Acute-Phase Reaction↗
PubMed1993

Control of early postoperative pain with bupivacaine in pediatric tonsillectomy.

Early postoperative pain following pediatric tonsillectomy remains a significant obstacle to speedy recovery and smooth convalescence. Inadequate analgesia causes poor oral intake and occasionally requires overnight hospitalization in same day surgery practices. Several otolaryngologists anecdotally support intraoperative infiltration with a long-acting amide anesthetic, bupivacaine hydrochloride, for postoperative pain control. However, no previous study supports these claims. At the National Naval Medical Center, a prospective, randomized, double-blinded study was undertaken in fifty patients, ages 3 to 16 years old. After tonsil resection, either 0.5% bupivacaine or saline was injected into each fossa. We asked the parents three questions. First, what was the level of pain at 2, 6 and 10 hours postoperatively? Second, what was the amount of oral intake during the first 10 hours after surgery? And third, how many doses of oral acetaminophen elixir were administered over the first 10 postoperative hours? Bupivacaine administration caused no adverse effects. There was no difference in perceived pain level between bupivacaine and saline groups at 2, 6 and 10 hours. Oral intake levels over the first 10 hours were similar. Although bupivacaine group patients received fewer doses of oral acetaminophen, the difference between groups was not statistically significant. We conclude that bupivacaine is a safe medication for infiltration, but offers no advantage over saline in the control of early postoperative pain in pediatric tonsillectomy.

Bupivacaine↗
PubMed1996

Laparoscopically assisted vaginal hysterectomy. Single-surgeon technique with minimal assistance.

OBJECTIVE: To prospectively evaluate parameters of surgical outcome of a novel technique of laparoscopically assisted vaginal hysterectomy performed by a single surgeon with minimal surgical help from an inexperienced assistant. STUDY DESIGN: Four women who had indications for hysterectomy but relative contraindications to the strictly vaginal approach were consecutively entered into the study. The hysterectomy was accomplished with the Endo GIA 30, O'Connor-O'Sullivan self-retaining vaginal retractor, the ligature vaginal hysterectomy technique and one surgical assistant. RESULTS: The average operative time was 133 minutes (range, 105-167). Blood loss averaged 288 mL (range, 150-350). The average length of hospitalization was 62 hours (range, 36-72). The average time of convalescence was two weeks (range, one to three). CONCLUSION: Preliminary results from a series of four patients suggest that this procedure may be a viable and safe alternative for the single surgeon.

Adult↗
PubMed1979

Recognition of a new serogroup of Legionnaires disease bacterium.

A strain of the Legionnaires disease bacterium (LDB) that was isolated by Joseph E. McDade from a postmortem lung specimen of a patient with fatal atypical pneumonia at the Veterans Administration Hospital in Togus, Maine was serologically different from 16 other strains of LDB that had been isolated previously from patients in other geographic locations. The serological differences of the Togus isolate were shown in results of direct and indirect fluorescent antibody staining and of immunoelectrophoresis with soluble antigen extracts. Seroconversion for the Togus strain of LDB in acute- and convalescent-phase sera from a second patient with atypical pneumonia at the Veterans Administration Hospital in Togus indicated that this patient had been infected with an LDB that was serologically similar or identical to the Togus isolate. The Togus serogroup of LDB should be considered when performing serological tests for Legionnaires disease.

Antigens, Bacterial↗
PubMed1995

New threats to the control of methicillin-resistant Staphylococcus aureus.

Several countries have achieved considerable success in the control of epidemic methicillin-resistant Staphylococcus aureus (MRSA). However, in several hospitals in the UK, MRSA strains of enhanced epidemicity, notably EMRSA-16, are becoming endemic. Our inability to eliminate the cause of a single-strain outbreak is unfamiliar and unnerving. Factors in 'market-led' health care delivery that hinder control of MRSA include a shortage of inpatient beds, patients moving from ward to ward, and more mixed-specialty wards. Increasing use of day treatments leaves an inpatient hospital population with more risk factors for infection. Early discharge of infected patients to convalescent homes, or to homes for the elderly, has created a new reservoir of infected and colonized patients. The emergence of high-level mupirocin resistance may soon also contribute to failure of control. The transfer of vancomycin resistance from Enterococcus faecium to a laboratory strain of S. aureus suggests that, especially in hospitals with both vancomycin-resistant enterococci and MRSA, there is the opportunity for the emergence of vancomycin-resistant MRSA for which there may be no effective antimicrobial prophylaxis or treatment. It is increasingly important to persuade hospital managers that even partial control of MRSA, whilst expensive, is still cost-effective and is a quality issue for individual hospitals. The control of EMRSA-16 in one hospital has recently been estimated to have saved more than 629,000 pounds extra costs. MRSA continues to be at the forefront of those organisms that seriously challenge modern technological medicine and surgery.

Anti-Bacterial Agents↗
PubMed1983

Management of enteric fever with amdinocillin.

Twenty-six patients with enteric fever treated with amdinocillin and/or its pivaloyloxymethyl ester in 1975 to 1978 were compared with 21 patients with enteric fever treated with trimethoprim-sulfamethoxazole in 1972 to 1974. Diagnosis was based on clinical illness and isolation of Salmonella typhi or S. paratyphi A/B from blood cultures or stool cultures. The dosage of pivamdinocillin in adults was 400 to 800 mg, every 6 hours, for 10 to 16 days; dosage in children was half this amount for 11 to 15 days. Of the 21 patients treated with trimethoprim-sulfamethoxazole, 18 (86 percent) showed a satisfactory clinical response; 13 of these 18 had negative stools immediately after therapy, and two more were negative at the time of discharge (total: 83 percent). Mean hospital stay of these patients was 34.5 days. Of the 26 patients treated with amdinocillin, 23 showed a satisfactory clinical response; 20 of those responding clinically were still excreting the causative organism at the end of therapy; seven of the group remained as convalescent patients who continued to excrete the causative organism in feces at the time of discharge. Mean hospital stay was 43 days. The results of initial trials of amdinocillin and ampicillin in combination suggest that such therapy may be preferable to use of amdinocillin alone, although the excretion of the causative organism during convalescence has not been adequately assessed.

Adolescent↗
PubMed2000

Duration of illness in ambulatory children diagnosed with bronchiolitis.

OBJECTIVES: To measure the duration of illness in ambulatory children diagnosed with bronchiolitis and to examine clinical predictors of duration of illness. DESIGN: Validation inception cohort study. Duration of follow up was 28 days. SETTING: A primary-level ambulatory department of a public sector children's hospital in Cape Town, South Africa. PATIENTS: One hundred eighty-one children aged 2 to 23 months who went to the hospital as their first contact for that episode of illness, and had a clinical diagnosis of bronchiolitis were enrolled consecutively on weekday mornings if their guardian stated that they were contactable by telephone. MAIN OUTCOME MEASURE: Resolution of symptoms, as judged by the guardian, measured by twice-weekly telephone interviews. RESULTS: Median duration of illness (calculated as the reported duration of symptoms before initial hospital visit plus the time from first consultation to recovery) was 12 days (95% confidence interval, 11-14 days). After 21 days, 18% were still ill and after 28 days, 9% were still ill. Sixty-two patients (34.2%) had unscheduled consultations within 28 days, a median of 13 days after the first consultation. There was no association of duration of illness with age, sex, z score for weight for age, or respiratory rate. CONCLUSIONS: Ambulatory children diagnosed with bronchiolitis recover with few complications, but the resolution of symptoms may take several weeks. Providing parents with this information could help reduce the high rate of unscheduled return visits as observed in this cohort.

Ambulatory Care↗
PubMed1997

Practical aspects of out-of-hospital transfusion.

Out-of-hospital transfusion (OOHT) occurs in nontraditional settings, such as a patient's home, a physician's office, or a convalescent facility. Requests to issue components for OOHT present new challenges to some blood centers and transfusion services that are accustomed to issuing blood for use only in the hospital setting. Concerns about patient safety, a paucity of practical information on establishing programs, and a lack of specific practice guidelines may discourage some organizations from offering these services. Participation in OOHT programs, however, may present new patient care and customer service opportunities to blood centers and transfusion services. The purpose of this article is to familiarize readers with the essential elements for establishing a safe program. Relevant regulatory, legal, and financial issues are also addressed.

Ambulatory Care↗
PubMed2005

[A case of primary HIV infection presenting as meningoencephalitis].

A 23-year-old man presented with disturbance of consciousness and convulsion. Two weeks prior to his admission, he had general arthralgia, retro-orbital pain, and body temperature increase to 40 degrees C. These symptoms persisted for two weeks. He was admitted to the hospital because of general convulsion, followed by disturbance of consciousness. On admission, he was deeply lethargic. Cerebrospinal fluid obtained on admission showed pleocytosis (247/mm3) and an increased level of protein. Electroencephalogram obtained on admission disclosed diffuse slow waves. Enhanced cranial MR image did not show any abnormal lesions in the cerebral parenchyma. The patient was diagnosed as having meningoencephalitis and the treatment consisting of aciclovir, CTRX, and methylprednisolone was undertaken. A test for human immunodeficiency virus (HIV) antibody was found to be positive on the second day of hospitalization. A Western blot was positive with bands at gp160 and P24 confirming HIV infection. Antibody titers of paired acute and convalescent sera including HSV, EBV, CMV, mumps, measles, and Japanese encephalitis did not show any significant increase. The patient became alert on the 3rd day of hospitalization. Electroencephalogram obtained on the 10th day of hospitalization was normal. Western blot, which was obtained 4 months later, was positive with bands at gp120, p68, p55, p52, gp41, p40, p34, p18, including gp160 and P24. He was diagnosed as having primary HIV infection. Meningoencephalitis was attributed to acute primary HIV infection. Acute HIV infection should be considered as an etiology of meningoencephalitis.

Acyclovir↗
PubMed2004

Experiences of elderly patients regarding independent community living after discharge from hospital: a longitudinal study.

OBJECTIVE: To describe the reported experiences of elderly patients regarding their transition from an acute hospital to independent community living. DESIGN: Observational longitudinal study based on semi-structured interviews conducted monthly for 6 months following discharge from hospital. SETTING: Four South Australian acute hospitals. Patients. One hundred elderly patients who faced a long-term change in health status and/or in their ability to manage practical aspects of daily living. MAIN OUTCOME MEASURES: Experiences in managing change in health status, social circumstances and independent community living. RESULTS: Few patients believed that discharge plans made in hospital had assisted their return to independent community living. Discharge planning addressed mainly formal health services rather than practical aspects of daily living. Many patients implemented innovative solutions when formal services were unavailable or inadequate. Pain, tiredness, loss of mobility, and grief over loss of previous abilities were frequent, long lasting sequelae to illness, and few discharge plans prepared patients to deal with this. CONCLUSIONS: Elderly patients who have left hospital to face a permanent change in health status often regret that they have not been better prepared for what lies ahead in terms of more specific information about their condition, linked with practical discharge plans that prepare them for their period of convalescence. We suggest that the underlying problem is a disjunction between the multiple systems involved in hospital discharge planning, primary medical care, disability-oriented community health services, and informal community services.

Activities of Daily Living↗