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At least 1,063 records · Page 59Linked to original sources
PubMed2005

Initial experience with eversion carotid endarterectomy: absence of a learning curve for the first 100 patients.

OBJECTIVE: Eversion carotid endarterectomy (CEA) has been touted as superior to standard CEA with patch closure because of allegedly lower restenosis rates and greater technical ease of performance. The purpose of this study was to evaluate the early experience of one vascular surgeon beginning to use this technique. METHODS: This was a retrospective study in an academic vascular surgical practice. The first 100 patients undergoing CEA via the eversion technique were compared with 100 contemporaneous patients who had standard CEA with patch closure. Residual (first examination within 3 months) or recurrent postoperative duplex scan stenosis, perioperative neurologic deficit, and mortality were analyzed by cumulative sum failure and Kaplan-Meier life-table analysis. RESULTS: Operative indications were not significantly different between eversion and standard CEA patients (63% vs 60% asymptomatic, 10% vs 7% stroke, 4% vs 5% amaurosis, and 23% vs 28% transient ischemia). Intraoperative shunting was more commonly used during eversion CEA (87% vs 59%; P < .01). Perioperative neurologic deficits included amaurosis (n = 1) after eversion CEA and transient cerebral ischemia (n = 1) and retinal infarction (n = 1) after standard CEA, with one cardiac death each. By 36 months, one other patient in each group had experienced a transient ischemic event, but there were no strokes. Four carotids occluded within 36 months of eversion CEA, compared with one occlusion after standard CEA (not significant). Patients undergoing eversion CEA showed no difference in critical (>80%) residual or recurrent stenosis rates. However, after eversion CEA, a greater degree of greater than 50% recurrent stenosis was observed at 36 months (38% vs 6%; P < .001) despite similar residual stenosis rates. Cumulative sum failure analysis showed no plateau among patients undergoing eversion CEA, thus indicating the absence of a learning curve, at least within the first 100 patients. CONCLUSIONS: Despite enthusiasm by advocates for eversion CEA, the recurrent greater than 50% stenosis rate remained high for the first 100 patients who underwent this technique, with no evidence of a learning curve. This observation implies that vascular surgeons considering adoption of this technique should monitor their own early results carefully.

Aged↗
PubMed2000

Distal polytetrafluoroethylene bypasses in patients older than 75 years.

HYPOTHESIS: Polytetrafluoroethylene (PTFE) alone is justified for infrapopliteal arterial grafting in elderly patients with critical ischemia of the lower limbs who lack a suitable, autogenous saphenous vein. DESIGN: A consecutive sample clinical study with a mean follow-up of 16 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Thirty-one patients older than 75 years with critical ischemia of the lower limbs received 34 PTFE bypass grafts to the infrapopliteal arteries: 12 patients to the anterior tibial, 8 to the peroneal, 8 to the posterior tibial, and 2 to the dorsalis pedis artery. MAIN OUTCOME MEASURES: Cumulative survival, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Operative mortality rate was 3%. Cumulative survival rate was 80% at 2 years (SE, 9.2%) and 43% at 3 years (SE, 11.4%). Cumulative primary patency rate was 67% at 2 years (SE 9.1%), and 61% at 3 years (SE, 12.7%). Cumulative limb salvage rate was 77% at 2 years (SE, 8.7%) and 70% at 3 years (SE, 12.8%). CONCLUSION: Polytetrafluoroethylene alone is justified as graft material for infrapopliteal bypass grafts in elderly patients with critical ischemia of the lower limbs and without a suitable autogenous saphenous vein.

Aged↗
PubMed1994

Intraoperative pressure sore prevention: an analysis of bedding materials.

The relationship between operating room (OR) table surfaces and skin integrity was examined. Preoperatively, patients (N = 505) were rated for pressure sore potential (Hemphill); postoperatively, skin condition was assessed. Skin changes were more likely with a standard mattress only or with surgery longer than 2.5 hr. The overlay was more effective than the foam and gel or standard foam mattresses for preventing pressure sore formation. Factors predictive of pressure sore development included surgery of 2.5+ hr, 40+ years, vascular disease, and a preoperative Hemphill value of 4+. Patient characteristics, surgical experience variables, and OR table surfaces are determinants in pressure sore development.

Adolescent↗
PubMed1979

Cranioplasty technical note.

A modification of Galicich and Hovind's method of cranioplasty is described. The prosthesis is not made on a side-table in the operation theatre. Steel wire mesh is fastened to the edge of the bone defect with stainless wires passed through drill holes. Acrylic mixture is then poured over the mesh and is cooled with saline. The technique has its main advantage in simplicity, and the result is cosmetically and functionally satisfactory.

Acrylic Resins↗
PubMed1997

[The trochanteric flip osteotomy.].

GOAL OF SURGERY: Easy access to the posterior, superior and anterior joint capsule through an osteotomy which reduces the risk of complications and the incidence of non-union. INDICATIONS: Hip joint revision with or without intertrochanteric osteotomy, periarticular ossifications, difficult total hip procedures, exchange procedures. CONTRAINDICATIONS: Absolute: None Relative: Distal transfer of the trochanter. PREOPERATIVE WORK UP: Radiographs in 2 planes (anterior-posterior pelvis+"false profile" hip). POSITIONING AND ANAESTHESIA: Lateral decubitus. General anaesthesia. SURGICAL TECHNIQUE: In lateral decubitus the greater trochanter will be osteotomized from posterior leaving a 1 to 1.5 cm thick bony wafer uniting the insertion of the gluteus medius and minimus with the origin of the vastus lateralis. The trochanteric crest remains untouched. After refixation with nonresorbable sutures #3 the fragment is not subjected to a unidirectional tension by the abductors which could interfere with the consolidation. POSTOPERATIVE MANAGEMENT: Bed rest with lower limb in neutral position. Mobilization with 2 canes on the 2nd postoperative day. The timing of partial weight bearing depends on the type of surgery. Abductor exercises after 6 weeks. POSSIBLE COMPLICATIONS: Bony wafer too thin or too thick. Inadequate refixation. Delayed consolidation. Cranial migration of the greater trochanter. RESULTS: Between 1991 and 1994 41 patients were operated. Diagnoses, see Table 1. Method of refixation: see Table 2. After 21+/-9 months 39 patients could be reexamined clinically, and radiological after 17+/-11 months: 38 osteotomies consolidated. Cranial migration varied between 0 and 8 mm. 25 patients were free of symptoms, 12 had slight and 2 moderate pain over the trochanter. Avulsion of wire cerclage: 2, foreign body irritation: 2 necessitating implant removal.

English Abstract↗
PubMed1995

The responsive workbench: a virtual working environment for physicians.

The paper describes the concept of the Responsive Workbench (RW). This virtual environment was designed to support end users working on desks, workbenches, and tables as physicians, architects and scientists with an adequate human-machine interface. We attempt to construct a task-driven interface for this class of users by working in an interdisciplinary team from the beginning. The system is explained and evaluated along three medical applications: medical education, a cardiological tutorial with a simulation system for ultrasonographic examinations of the heart and surgery planning. Virtual objects are located on a real "workbench". The objects, displayed as computer generated stereoscopic images are projected onto the surface of a table. The participants operate within a non-immersive virtual environment. A "guide" uses the virtual environment while several observers can also watch events by using shutter glasses. Depending on the application, various input and output modules can be integrated, such as motion, gesture and speech recognition systems which characterize the general trend away from the classical multimedia desktop interface. The RW is compared with other common virtual reality systems as head mounted displays. First experiences of the collaborators are drawn and future enhancements are proposed.

Computer Graphics↗
PubMedDate not supplied

Predictors of emergency department visit disposition for patients with chronic obstructive pulmonary disease.

STUDY OBJECTIVES: The study objective was to validate among patients with chronic obstructive pulmonary disease (COPD) clinical predictors of emergency department (ED) disposition (admission vs discharge) found in a previous study. We hypothesized that the initial heart rate (HR) at presentation and the number of nebulizer treatments would predict visit disposition adequately and that existing triage criteria would not. METHODS: In this correlational study, all ED visits to a university medical center related to a diagnosis of COPD over a 2-year period were identified and reviewed retrospectively (N = 114 patients and 226 visits). Associations of clinical predictors with visit disposition was by contingency table or receiver operating characteristic curve analysis. RESULTS: The overall admission rate was 60.2%. An initial HR slightly greater than normal limits (HR >/= 106 vs HR </= 105 beats/min) predicted visit disposition; receiver operating characteristic area under curve (95% confidence interval) = .67 (.60-.73); sensitivity = .61 (.52-.69); and specificity = .68 (.57-.77). Likelihood ratios for positive and negative tests were 1.93 and 0.57, corresponding to posterior probabilities of admission = .74 and .46, respectively. Triage classification did not adequately predict visit disposition. Patients receiving three or more nebulized bronchodilator treatments were more likely to be admitted than those receiving fewer treatments, but this predictor had low sensitivity and was no more discriminating than the initial HR. Women were more likely than men to be admitted, odds ratio = 2.66 (1.54-4.61), but there were few clinically meaningful differences between sexes. CONCLUSIONS: The initial HR on arrival predicted disposition of ED visits for patients with COPD with operating characteristics that were superior to the existing triage criteria. Triage of patients with COPD could be improved simply, and at no additional expense, by recognizing that almost any degree of tachycardia in a patient with COPD substantially increases the likelihood of admission.

Aged↗
PubMed2003

[Emergency ultrasound for blunt abdominal trauma--meta-analysis update 2003].

Emergency ultrasound has established itself as a key procedure of primary diagnostic work-up for blunt abdominal and multiple trauma. However, in a systematic review published in 2001 ultrasonography turned out to provide an unexpectedly low sensitivity. We conducted an update of this analysis to investigate if test characteristics will be maintained including recent studies. Prospective trials published between January 1957 and January 2003 were identified using the Medline/Oldmedline, Embase and Cochrane Controlled Trials Register databases. The searching strategy comprised a manual search as well as a search along the world-wide web. Qualitative rating was carried out by two investigators using criteria proposed by the Centre for Evidence-Based Medicine, Oxford. We investigated a composite endpoint (i. e., free fluid and/or organ laceration) as well as the single criteria organ injury and free intraabdominal fluid collections. After calculation of two-by-two-tables, Summary Receiver Operating Characteristics (SROC) and Q* values were determined together with their 95% confidence intervals. The Q* value was proposed as the point of intersection where sensitivity equals specificity. In addition, a random effects model was employed to compute common positive and negative likelihood ratios (LR). By assessing the title and/or abstract, 349 of 957 papers contained potentially valid information for the purpose of this review. A total of 67 studies were deemed eligible, nine of which had to be excluded from meta-analysis because of dual publication. This left 58 trials allocating 16,361 subjects for statistical analysis. Despite a trend towards improved study designs observed during the past decade, the included trials were of average methodological quality. Two-thirds of all investigations fulfilled two or less of the six possible quality criteria. The diagnostic reference standard was applied independently in only 40% of all protocols. With regard to the composite endpoint and the sonographic depiction of free fluid, the Q* value was estimated at 0.91, whereas Q* equaled 0.90 for the detection of organ injury. Q* values subsequently decreased with improving study quality and fell clearly below 0.80 in methodologically proper studies. Accounting for a negative LR of 0.23 (composite endpoint) and an assumed prevalence of 35% of intraabdominal injury, a post-test probability of 11% will remain in case of a negative sonogram. In pediatric trauma, ultrasound showed even worse test characteristics (negative LR = 0.43). Thus, in case of a 35% prevalence, the post-test probability has to estimated at 19%. Emergency ultrasound provides high specificity but insufficient sensitivity to reliably rule out intraabdominal injury.

Abdominal Injuries↗
PubMed1981

Clinical and morphological investigations on ependymomas and their tissue cultures.

A morphological investigation was carried out on 56 ependymomas cultivated in vitro as short-term cultures in roller tubes. The tumours had been histologically classified as cellular and fibrillary ependymomas, subependymomas, myxopapillary and malignant ependymomas (Table 1). A very good growth was detected in 32 cases, most of them being cellular and malignant ependymomas (Table 2). The prevailing growth pattern was epithelial in type, i.e. proliferating cells forming a carpet. In some cases, in the first stages of growth elongated bipolar cells did appear, but they evolved later as flattened epithelial elements. In four cases, a mixed proliferation of piloid astrocytes and ependymal cells was seen; these tumours were regarded as mixed gliomas. In 46 cases an exact evaluation of the history was possible. Although no correlation could be found between histology and survival time (Table 4), the longest survival was observed in spinal tumours (Table 3). Tumours in children had a slightly worse prognosis in comparison with adults (Table 5). A radical removal of the tumour was generally followed by a longer survival time (Table 6), although the operative procedure employed did not seem to influence the development of recurrences (Table 7).

Adult↗
PubMed1980

Unfavourable radiological signs in fractures of the calcaneum.

Although 28 radiological signs in both primary and late radiographs were analysed for 67 patients with 86 fractures of the calcaneum. The fracture type is correlated with the clinical late result in Table 1. The radiological signs which predict or correlate with a poor late result are presented in Table 2. The operative reduction is mainly directed to improve the architecture of the posterior talocalcaneal joint: in our series the improvement was observed in half of the postoperative radiographs. However, this improvement was not usually followed by a favourable late result; mainly because the operated patients had also the most severe injuries.

Adolescent↗
PubMed2001

Timing of postoperative adjustment in adjustable suture strabismus surgery.

PURPOSE: The use of adjustable sutures in strabismus surgery has increased the rate of surgical success. Little data are available on the optimum timing for postoperative adjustment after strabismus surgery. We wanted to compare 2 common practices of adjustable suture technique after strabismus surgery. METHODS: Two comparable groups of 40 patients each, who had strabismus surgery with adjustable suture technique, were prospectively studied. Group A had early adjustment the same day of the surgery about 6 hours after the operation, and group B had late adjustment the next day about 24 hours after the operation. Subjective scoring tables were used to evaluate the pain felt by the patient before, during, and after the adjustment and any difficulties of the adjustment process. Requirements of postoperative pain medications and final alignment 6 weeks after surgery were also compared. RESULTS: Despite adequate statistical power, no significant differences were found between the groups regarding pain before, during, and after adjustment, difficulties performing the adjustment, and final alignment after 6 weeks (P > .05). Both adjustment schedules were equally associated with mild to moderate pain before, during, and after the adjustment. In the first 24 hours after surgery, no overall difference in the use of pain medications was found. Nausea and vomiting in the first 24 postoperative hours were more common in the early adjustment group (P = .02). CONCLUSION: The surgeon can feel free to choose the timing for postoperative adjustment. However, when performing an early adjustment, the surgeon should be especially prepared to control nausea and vomiting.

Adult↗
PubMed2006

Serum S-100B concentration provides additional information fot the indication of computed tomography in patients after minor head injury: a prospective multicenter study.

Ninety percent of patients with minor head injury (MHI) who have cranial computed tomography (CCT) under the present clinical decision rules have normal scans. Serum concentrations of the astroglial protein S-100B were recently found to provide useful information, but these studies were too small to provide a statistically safe basis for changing the present rule. We have investigated whether S-100B concentrations in patients with MHI can provide additional information to improve indication of the need for an initial CCT scan. One thousand three hundred nine patients with MHI were enrolled in this prospective, multicenter study. All had a CCT scan to confirm diagnosis in accordance with the present clinical decision rules. S-100B was measured in serum samples obtained upon admission. Data were analyzed using contingency table and receiver operating characteristic curve and compared with those for healthy donors (n = 540) and with those for patients with moderate to severe head injury (n = 55). Of the 1309 patients studied, 93 exhibited trauma-relevant intracerebral lesions on the CCT scan (CCT+). With a cutoff limit of 0.10-microg/L S-100B (95th percentile of values in healthy volunteers), CCT+ patients were identified with a sensitivity level of 99% (95% confidence interval, 96% - 100%) and a specificity level of 30% (95% confidence interval, 29% - 31%). Adding the measurement of S-100B concentration to the clinical decision rules for a CCT scan in patients with MHI could allow a 30% reduction in scans. A prospective study of the clinical value of S-100B measurement in such patients is now under way.

Adult↗
PubMed1988

Primary anastomosis in emergency distal colonic surgery after on-table colonic lavage.

The traditional operative management of emergency distal colon pathology has involved staged procedures, but recently Hartmann's operation has gained popularity. The indications for primary anastomosis without covering colostomy have remained controversial, but the technique of on-table lavage has extended the use of this approach in the acute setting. A series of seven patients having this procedure for diverticular abscess (three), obstructing colonic carcinoma (one), perforating colonic carcinoma (one) and sigmoid volvulus (two) is presented. The saline irrigation is introduced by a Foley catheter inserted via the appendix stump and the effluent is diverted from the proximal colon by anaesthetic scavenger tubing. The lavage is continued until the effluent is clear and anastomosis performed with one-layer interrupted absorbable sutures. There were no deaths in the series; one patient developed a wound infection and average hospitalization was 16 days (range: 6-31 days). Immediate anastomosis in selected cases of emergency distal colonic pathology is thus feasible and safe following on-table colonic lavage.

Acute Disease↗
PubMed2003

Midterm clinical and echocardiographic results with patch glue repair of left ventricular free wall rupture.

BACKGROUND: Left ventricular free wall rupture (LVFWR) is a dramatic complication after myocardial infarction. We present our mid-term clinical and echocardiographic results of LVFWR with an epicardial patch without cardiopulmonary bypass. METHODS: From February 1993 to May 2001, 17 patients underwent surgery for LVFWR. The mean age+/-SD of 12 males and 5 females was 68+/-10 years. All patients presented for emergency surgery with cardiac tamponade confirmed on echocardiography. After opening the chest and identification of the site of rupture, a Goretex patch was fashioned and applied with enbucrilate surgical glue. RESULTS: Effective control of bleeding was achieved in all cases. There were no on-table deaths. The operative (30 day) mortality was 23.5% (4/17). One death occurred because of patch failure, two because of cardiogenic shock, and one from pneumonia. On follow-up at a median of 2.2 years (interquartile range, 1.1 to 4.3 years), two further deaths occurred, one from myocardial infarction and another of undetermined etiology. Echocardiography did not reveal any evidence of restriction to left ventricular free wall motion. CONCLUSIONS: Patch glue repair is expedient, simple and effective; with no adverse effects on mid-term ventricular dynamics. In view of superior published results to infarctectomy and repair with extra corporeal circulation, it should be considered to be the initial procedure of choice for the surgical repair of LVFWR.

Aged↗
PubMed2006

Concordane of OSTA and lumbar spine BMD by DXA in identifying risk of osteoporosis.

OBJECTIVE: To investigate the accuracy of Osteoporosis Self-assessment Tool for Asians (OSTA) in identifying the risk of osteoporosis in postmenopausal women. To validate use of OSTA risk index by comparing it with the bone mineral density (BMD) of lumbar spine measured by dual energy X-ray absorptiometry (DXA). METHODS: The data of lumbar spine BMD (LS BMD) measurements by DXA of 218 postmenopausal women of Han nationality in Sichuan province were compared with OSTA risk index. The concordance of OSTA and LS BMD were calculated and analyzed by fourfold table and receiver operating characteristic (ROC) curve. RESULTS: The prevalence of osteoporosis in these women was 40.4% and 61.5%, with the LS BMD T score cutoffs -2.5 and -2.0, respectively. The sensitivity, specificity, and accuracy of OSTA risk index compared with T score cutoff -2.5 of LS BMD were 59.1%, 56.9% and 57.8%, respectively, while they were 57.5%, 63.1%, 59.6% by T score cutoff -2.0. CONCLUSION: For identifying risk of osteoporosis, the concurrence was lower than those reported studies when comparing LS BMD measurements to OSTA risk index in Chinese Han nationality postmenopausal women of Sichuan province. Physicians should identify women who need BMD measurement according to more factors rather than age and body weight.

Journal Article↗
PubMed1993

Nonoperative management of cubital tunnel syndrome: an 8-year prospective study.

This study reports the results of a prospective trial of nonoperative management of the cubital tunnel syndrome in 128 patients. Forty-three of the patients had bilateral ulnar nerve compression. At study's end, information was available on 94% of patients and 164 managed extremities, at a mean of 58.6 months of follow-up. We scored the degree of severity of cubital tunnel syndrome numerically, based on concepts of the pathophysiology of chronic nerve compression. For statistical purposes, a successful outcome of the nonoperative regimen was not having an operation. Life-table analysis demonstrated that 89% of patients with symptoms only, 67% of patients with abnormal sensorimotor thresholds, and 38% of patients with abnormal sensorimotor innervated density did not have surgery. These differences were significant (p < 0.001) by both parametric and nonparametric analysis. A history of elbow injury significantly worsened outcome (p < 0.02), but the results of the pretreatment electrodiagnosis did not. We conclude that a strict nonoperative regimen be supervised in the initial management of the cubital tunnel syndrome.

Adolescent↗
PubMed1996

Radiographic skills learning: procedure simulation using adaptive hypermedia.

The design and development of a simulation tool supporting learning of radiographic skills is reported. This tool has by textual, graphical and iconic resources, organized according to a building-block, adaptive hypermedia approach, which is described and supported by an image base of radiographs. It offers interactive user-controlled simulation of radiographic imaging procedures. The development is based on a commercially available environment (Toolbook 3.0, Asymetrix Corporation). The core of the system is an attributed precedence (priority) graph, which represents a task outline (concept and resources structure), which is dynamically adjusted to selected procedures. The user interface imitates a conventional radiography system, i.e. operating console, tube, table, patient and cassette. System parameters, such as patient positioning, focus-to-patient distance, magnification, field dimensions, tube voltage and mAs are under user control. Their effects on image quality are presented, by means of an image base acquired under controlled exposure conditions. Innovative use of hypermedia, computer based learning and simulation principles and technology in the development of this tool resulted in an enhanced interactive environment providing radiographic parameter control and visualization of parameter effects on image quality.

Computer Simulation↗
PubMed2002

Optical propagation within a three-dimensional shadowed atmosphere-ocean field: application to large deployment structures.

Estimation of optical shadowing effects that occur on in situ submerged radiance and irradiance measurements conducted in the proximity of a large and complex three-dimensional deployment structure is addressed by use of Monte Carlo simulations. We have applied backward Monte Carlo techniques and variance reduction schemes in three-dimensional radiative transfer computations of in-water light field perturbations by taking into account relevant geometric, environmental, and optical parameters that describe a realistic atmosphere-ocean system. Significant parameters, determined by a sensitivity analysis study, have then been systematically varied for the computation of an extensive set of correction factors, included in look-up tables designed for operational removal of tower-shading uncertainties, which typically induce an approximately 1-10% decrease in absolute radiometric data values near a specific oceanographic tower located in the northern Adriatic Sea. In principle, the proposed correction methodology can be transferred to other deployment systems, instrument casings, and measurement sites if a comprehensive description is provided for the system parameters and their variability.

Journal Article↗