The exogenous sources and controls of microorganisms in the operating room.
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Air Microbiology↗
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Biosynthesis and control of mosquito gut proteases.
Earlier investigations of the proteases that digest the blood meal in mosquitoes identified the midgut epithelial cells as the source of the main blood digesting protease, trypsin. Surgical manipulations and cytoimmunochemical studies indicated that trypsin in the mosquito is not stored in the epithelial cells as an inactive enzyme, but is synthesized, activated and released into the gut lumen after the blood meal. Using molecular biology techniques the major trypsin genes have been sequenced and some information on the transcription factors that regulate the induction of the genes have been reported. Although all the hormone(s) and the factors that are responsible for the induction of trypsin biosynthesis are not known, the termination of trypsin biosynthesis is controlled by a decapeptide hormone; trypsin modulating oostatic factor (TMOF) that is secreted by the mosquito ovary. Genetic engineering and expression of TMOF in bacteria, yeast and algae is emerging as a potential future larval control of mosquitoes in the field.
Aedes↗
Governing time in operating rooms.
AIM: This paper examines how time is controlled and governed in operating rooms through interpersonal communication between nurses and doctors. BACKGROUND: Time is a valuable commodity in organizations with improvements often directed towards maximizing efficiencies. As a consequence, time can be a source of tension and interpersonal conflict as individuals compete for control of its use. METHODS: The data in this paper emanate from an ethnographic study that explored a range of communication practices in operating room nursing. Participants comprised 11 operating room nurses. Data were collected over two years in three different institutional settings and involved participant observation, interviews and the keeping of a personal diary. A deconstructive analysis of the data was undertaken. RESULTS: Results are discussed in terms of the practices, in which clinicians are engaged in, to govern and control their use of time. The four practices presented in this paper include; questioning judgment and timing, controlling speed, estimating surgeons' use of time and coping with different perceptions of time. CONCLUSIONS: Time and speed were hotly contested by nurses. They used their personal knowledge of individual surgeon's habits of time to govern and control practice. Nurses thought about surgeons in terms of time and developed commonly accepted understandings about the length of surgical procedures. They used this knowledge to manage the scheduling of operations in the departments and to control the workflow in individual operating rooms. Knowledge of individual surgeons was a source of power for operating room nurses. RELEVANCE TO CLINICAL PRACTICE: Nurses have more power in the operating room than might be imagined but they exercise this power in subtle ways. If operating rooms are to work effectively, the operating room team must understand each others' work better.
Adaptation, Psychological↗
The minimally invasive surgical suite enters the 21st century. A discussion of critical design elements.
Most minimally invasive surgical procedures are now performed in operating rooms that were originally designed for traditional open surgery. Laparoscopic instrumentation such as insufflators, light sources, and camera control units must be placed on one or more equipment carts. After the cart has been moved into place, insufflation tubing, video cables, light cords, cautery lines, and foot controls must be positioned and connected. This cart-based paradigm restricts the ergonomic configuration of the operating room and creates potential mechanical, electrical, and biological hazards to the patient and operating room staff. In order to decrease clutter, ease personnel movement, improve ergonomics, maintain the sterile field, and facilitate the use of advanced imaging, communication, and display devices, an appropriately designed operating environment is essential. Herein we detail both the theoretical and practical aspects of the design and describe the implementation and utilization of such a suite in our hospital. These design elements may prove to be critical to the next generation of minimally invasive surgical suites and will facilitate future advanced laparoscopic procedures.
Accident Prevention↗
Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application.
OBJECTIVES: Fournier's gangrene (FG) is an abrupt, rapidly progressive, gangrenous infection of the external genitalia, perineum or abdominal wall and is a real urologic emergency. In this study, the risk factors of FG and the effects of enzymatic debridements on wound healing were investigated. PATIENTS AND METHODS: We reviewed the records of 34 patients with FG to investigate the possible correlation between clinical outcome and infection focus, patient age, number of types of bacteria cultured, delay until presentation, predisposing diseases or accompanying conditions such as diabetes, neurologic deficit, chronic alcoholism and renal failure. Broad-spectrum triple antimicrobial therapy, aggressive and frequent surgical debridement, and if necessary urinary and colonic diversions were performed to control the infection. The effects of enzymatic debridements with topical lyophilized collagenase applications on the wound healing after the control of active infection were evaluated. RESULTS: The average age of the patients was 55 years. The sources of infections were urogenital in 12 (35.3%), anorectal in 10 (29.4%), dermal in 10 (29.4%) and undetermined in 2 (5.8%) of the patients. The average presentation time was 4.4 days and the number of isolated bacteria was 3.05 per case. The number of isolated bacteria and surgical debridements, the duration of hospital stay and the rate of mortality in patients with anorectal foci were higher than those of the patients with urogenital or dermal foci (p < 0.05). Diabetes, uremia and advanced age did not significantly affect the number of surgical debridements, the duration of hospital stay and control of active infection. Mortality was increased in chronic alcoholism, a finding of undetermined significance. Enzymatic debridements decreased the duration of hospital stay (p < 0.05). Five patients (14.7%) died despite prompt medical and surgical preventive measures. CONCLUSION: Chronic alcoholism, anorectal infection foci, neurological deficit and delayed presentation were found as risk factors in FG. Diabetes and advanced age did not affect the progression of disease in our cases. Enzymatic debridements decrease the number of surgical debridements and the duration of hospital stay.
Adolescent↗
[Intraoperative brachytherapy in the management of keloids. Apropos of 114 cases] .
PURPOSE: Keloid scars are unsightly, especially when located on the face or bare zones. The purpose of this study was to evaluate the therapeutic results of intraoperative brachytherapy in the management of keloids. MATERIAL AND METHODS: This retrospective study was based on the study of 82 patients with keloids treated in Salah Azaiz Institute (Tunisia) between 1982 and 1994 (65 women and 17 men). The mean age of patients was 23.4 years (+/- 8.4). A total of 114 lesions have been treated with surgical resection and intraoperative brachytherapy using an iridium source placed under the surgical scar. The length of iridium was chosen with the result that the radioactive thread exceeded 5 mm on each side of the surgical scar. The iridium source was loaded less than six hours after resection. Average iridium activity was 1.5 +/- 0.3 mCi/cm. Average iridium length was 56.8 +/- 34 mm. The referred isodose chosen for the target volume included the surgical scar and a margin of 5 mm around the iridium source, which was placed under the surgical scar. The average administered dose was 20.4 Gy (+/- 3.2 Gy). RESULTS: The 2-year local control rate was 87% for the whole group of lesions treated (n = 114). Local control rate of keloids processed by resection and intraoperative brachytherapy as the first treatment (59 cases) was 96% at two years. This rate was better than the local control of lesions that had been previously treated with anterior surgical resection (84% in 55 cases). For the latter group, lesions treated with a dose of more than 20 Gy had better local control, but the difference was not statistically significant (87 vs. 65% at two years, P = 0.41). CONCLUSION: Intraoperative brachytherapy is effective for improving local control of keloids and preventing a recurrence. A rigorous technique and an adequate dose according to previous surgical treatment allows very good results.
Adult↗
Intraoperative angiography.
The thromboendarterectomy can be improved with intraoperative angiography, sources of error may be considerably reduced. The control possibilities of intraoperative angiography offer advantages also for the various bypass operations as surgical errors can be found and corrected during the operation.
Aged↗
Torrential rectal bleeding. An unusual presentation of colonic carcinoma.
A case of torrential rectal bleeding due to a colonic carcinoma is reported. The clinical diagnosis was confirmed by angiography, which showed an abnormal circulatory pattern at the hepatic flexure of the colon. Resection of the tumour controlled the bleeding. Dealing with this clinical problem requires a systematized approach. Angiographic demonstration of the source of the bleeding allows definitive surgical management.
Adenocarcinoma↗
Management of sepsis.
Severe sepsis remains a common cause of death in surgical patients. Eradication of the septic source and supportive care has long been the mainstay of treatment. In recent years, however, early goal-directed therapy, tighter glucose control, administration of drotrecogin alfa (activated), and steroid replacement have produced improved morbidity and mortality. In the future, a better understanding of the pathophysiology of sepsis and clinical studies may further improve outcomes from severe sepsis.
Critical Care↗
Postoperative radiotherapy after pneumonectomy: impact of modern treatment facilities.
PURPOSE: The present study was undertaken to see how modern treatment facilities, computed tomography (CT)-based treatment planning and linear accelerator, have modified the results of postoperative irradiation after a pneumonectomy for lung cancer. METHODS AND MATERIALS: Between 1970-1985, 103 patients were treated in our department after a pneumonectomy: 50 patients with a T1T2N0 tumor and 53 patients with a T3, N1 or N2 tumor. Three groups were considered: 27 patients had only surgical resection, 51 patients were irradiated postoperatively with a Co60 source, and 25 patients were treated using those modern facilities. RESULTS: The 5-year survival varies from 4% to 31% according to the tumor extent but also to the radiation technique. Patients treated with a Co60 source had a dismal 5-year survival rate (8%) whereas patients treated with the modern facilities had a 5-year survival rate of 30% similar to the 31% of the control surgical group including less advanced tumors. CONCLUSION: Linear accelerator and computed tomography-based treatment planning improved the accuracy of postoperative thoracic irradiation and allow to deliver high doses to the mediastinum even after a pneumonectomy.
Combined Modality Therapy↗
Simultaneous microsurgical spermatic vein ligation and sclerotherapy. a combined procedure for the treatment of recurrent or persistent varicocele.
OBJECTIVES: Microsurgical ligation as well as antegrade sclerotherapy have been established in varicocele treatment. The aim of this study was to evaluate whether a combination of microsurgery and sclerotherapy can provide a safe and effective treatment of varicocele recurrence or persistence. METHODS: Nine patients with recurrent or persistent varicoceles were operated by means of the combination method. Under microscopic control varix veins were ligated selectively preserving lymphatics and arteries. Ectopic veins as a possible source for varicocele persistence or recurrence were also ligated. Finally, an intraoperative venography with subsequent sclerotherapy was performed through one of the dissected veins. RESULTS: Despite difficult anatomical situations after previous surgical interventions, the operations were performed successfully without any complications. Clinical controls showed varicocele disappearance without damage of the testis. No varicocele recurrence or persistence was observed. CONCLUSIONS: This method combines the advantages of both methods. Precision of the microsurgical technique is combined with velocity of sclerotherapy. Thus, it may represent an interesting alternative to conventional operation methods especially in the treatment of recurrent or persistent varicoceles.
Combined Modality Therapy↗
Interstitial laserthermia in neurosurgery.
Deep-seated brain tumor is difficult to treat surgically. Hyperthermia using various energy sources has been tried, but has failed to gain wide use because of equipment problems and poor temperature control. It is possible now to use Nd:YAG laser with a stable low-energy supply as an energy source for laser hyperthermia (laserthermia). Animal study and clinical study were done using SLT CL50, Computer-control Laserthermia System to treat deep-seated brain tumors. Experimental study revealed that laserthermia produced minimal edema, temperature control was satisfactory, and blood-brain barrier opened up for 6 days following laserthermia. Five patients with brain tumors were treated with laserthermia. Follow-up CT scan revealed disappearance of tumor in 4 patients and decrease in volume in 1 patient. Long-term neurological follow up revealed no deterioration. Laserthermia using Nd:YAG laser is safe and easy to use and it is beneficial to treat deep-seated brain tumors.
Adult↗
Teaching principles of cardiovascular function in a medical student laboratory.
We describe an animal laboratory using anesthetized swine to demonstrate the regulation of arterial blood pressure to second-year medical students at Saint Louis University School of Medicine (St. Louis, MO). The laboratory is designed to illustrate basic pharmacological and physiological concepts learned in the classroom. The specific learning objectives covered in this lab include maintenance of anesthesia, basic surgical technique including cannulation of blood vessels, understanding the measurement and significance of basic physiological parameters, premortem examination of in situ heart and lungs, direct cardiac massage and induction of ventricular fibrillation, understanding the fundamentals of the baroreceptor reflex, and cardiovascular responses to various pharmacological agents. Pharmacologic agents used include epinephrine, norepinephrine, isoproterenol, atropine, prazosin, propranolol, acetylcholine, nitroprusside, and angiotensin II. The laboratory demonstration has proven effective in reinforcing the fundamental principles of cardiovascular physiology and autonomic pharmacology. By the completion of this experiment, students are expected to be able to: 1) describe the basics of maintenance of anesthesia in a live animal; 2) describe basic surgical technique; 3) observe the procedure for proper cannulation of blood vessels; 4) describe the proper method of controlling hemorrhage from a bleeding source; 5) describe the measurement and recording of four physiological parameters: mean arterial pressure from a pressure transducer, heart rate from an ECG, hindquarters resistance from Doppler measurement of femoral arterial blood flow, and cardiac contractility by calculating dP/dt from left ventricular pressure measured with a Millar transducer; 6) perform a premortem exam of the heart and lungs and appreciate the in situ cardiothoracic anatomy of the living animal; 7) assist in the induction of ventricular fibrillation and perform direct cardiac massage; 8) characterize the autonomic responses activated by the baroreceptor reflex; 9) describe the effects of the adrenergic agonists epinephrine, norepinephrine, and isoproterenol on cardiovascular parameters and construct a dose response curve for each agent; 10) describe the effects of the adrenergic antagonists propranolol and prazosin on cardiovascular parameters and explain how they affect cardiovascular responses to adrenergic agonists; 11) describe the difference between endothelium-dependent and endothelium-independent vasodilation using acetylcholine, nitroprusside, and atropine; 12) observe the pressor response of angiotensin II and describe why this response is not blocked by pretreatment with prazosin; and 13) participate in the collection and analysis of experimental data and the presentation of results.
Animals↗
Recent trends in surgical treatment of localized prostate cancer.
Prostate cancer and its various forms of treatment remain a source of significant controversy and morbidity despite recent advances. In response, there is an increasing trend toward the development of treatments aimed at cancer prevention and at maximizing the preservation of function without sacrificing cancer control. This article reviews the current prostate cancer literature and reports on improvements in existing surgical treatments and developing technologies aimed toward achieving these goals. Specific therapies addressed include improvements in surgical techniques, laparoscopy, robotics, cryosurgical and thermal ablation, and high-intensity focused ultrasound.
Humans↗
[Placebo effect in research related to surgery and technical procedures].
BACKGROUND: Development of new technology has led to the introduction of many new high-tech surgical treatment modalities. It has been claimed that the use of high-tech medicine is a potent inductor of placebo effect; in fact, many new treatment modalities have been established before they have been evaluated in placebo-controlled trials. However, there are several ways to minimize the confounding effects of placebo in surgical trials. MATERIAL AND METHODS: This is a review based on a thoroughly performed search on Medline of Norwegian and English language publications published up until August 2000. RESULTS: Several studies have demonstrated that surgical treatment induces significant placebo effect. To minimize the confounding effects of placebo in trials evaluating new surgical modalities, it is important to use adequate blinding, neutral patient information, objective end-points, and correction for estimated placebo effects. The use of placebo surgery has been a source of lively controversy; many consider it ethically unacceptable.
Clinical Trials as Topic↗
Infection control update: beware of the ragwheel.
Previously, concern about infection control in dentistry emphasized the handpiece, operator safety, barrier technique, and patient protection in the dental operatory. As current knowledge of infection control increases an expanded understanding of other sources of disease transmission is indicated. Often overlooked is the dental laboratory of which particular interest focuses on the lathes used in preparing prosthetic appliances, castings, orthodontic appliances, and surgical stents. Specifically, the potential threat of the ragwheel to the patient and operator is significant. Ragwheels and pumice samples were collected and cultured, the results of which mandate the need for infection control guidelines for the dental laboratory.
Bacteria, Aerobic↗
Infection control update: beware of the ragwheel.
Previously, concern about infection control in dentistry emphasized the handpiece, operator safety, barrier technique, and patient protection in the dental operatory. As current knowledge of infection control increases an expanded understanding of other sources of disease transmission is indicated. Often overlooked is the dental laboratory of which particular interest focuses on the lathes used in preparing prosthetic appliances, castings, orthodontic appliances, and surgical stents. Specifically, the potential threat of the ragwheel to the patient and operator is significant. Ragwheels and pumice samples were collected and cultured, the results of which mandate the need for infection control guidelines for the dental laboratory.
Colony Count, Microbial↗
Natural history of residual air spaces after pulmonary resection.
It is emphasized that a decision for or against surgical intervention in the management of residual spaces, irrespective of cause, will not be required for several months after their occurrence in most cases. The stresses associated with the critical period of disability occasioned by a prolonged air leak, even if not voluminous, may preclude premature surgical intervention. The indications for initial surgical resection and the diseases for which it was required often are sufficiently debilitating to the patient to produce a protracted period of convalescence, necessitating prolonged observation before a decision for aggressive surgical therapy is mandated or indicated. In our experience, these pleural spaces are not a major threat to the health of the patient. In many cases, the concern over them and the fear that more egregious postoperative problems will ensue have resulted in premature and overzealous treatment that may lead to iatrogenic complications. If, instead, they are left alone and followed with judicious observation based on appropriate clinical, physiologic, and radiologic criteria, a more favorable outcome will result. Haste in arriving at a decision to intervene surgically therefore is not warranted. Many factors must be taken into account before surgical treatment is considered. The age of the patient, his or her ventilatory status, condition of the underlying lung, prospect for physical activity with gainful employment and accompanying quality of life, underlying disease (tuberculosis or cancer) for which even a curative resection may have been done, problems in maintaining drainage (including convenience or discomfort), or adverse metabolic effects of chronic infection are just a few considerations. More recently, economic factors attendant upon managed care programs mandate cost-effective therapies to reduce duration of hospital stay and to decrease resource utilization associated with repetitive surgical procedures and returns to the operating room, protracted use of expensive antimicrobial drugs, and increased outpatient visits and home services. Certainly, prevention of and avoidance of unwarranted interventions for intrathoracic spaces will assist in accomplishing these goals. Finally, it is apparent that patients can live in relatively good health for long periods of time with persisting vented or unvented spaces in association with air leak from alveolar seepage sources, and even with the presence of well-drained and controlled empyemas. The most important aspect of management is delineation of spaces that can be observed safely versus those that require surgical intervention. This discussion provides a basis for making that distinction. The algorithm illustrated in Figure 13 summarizes this management.
Humans↗