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PubMed1989

CO2 laser for otosclerosis: safe energy parameters.

Safe energy parameters for each Sharplan CO2 laser model (734, 1040, 1100A) were established in the laboratory. Ultrasensitive pyroelectric detectors analyzed the precise energy package delivered to the operative field with each of these power setting. Subsequently, 0.6-mm stapedotomy and stapedectomy revisions were performed under simulated operating room conditions while measuring temperature changes in the vestibule with a thermocouple. Table I illustrates safe energy settings for each of the Sharplan CO2 models tested. These power settings produced no more than 0.3 degrees C temperature rise in the vestibule during stapedotomy, and no more than 0.5 degrees C during stapedectomy revision. Following these guidelines, the CO2 laser was then employed to perform stapedotomy and stapedectomy revisions in otosclerosis patients. In over 200 consecutive operations performed under local anesthesia with the CO2 laser, no patient became dizzy intraoperatively while the CO2 laser was applied to the stapes footplate or the oval window neomembrane, confirming the lack of significant caloric effect to the inner ear at these energy settings. More importantly, no patient has yet experienced significant sensorineural hearing loss in the speech range.

Carbon Dioxide↗
PubMed1983

Regional management of liver metastases. II.

Metastatic cancer of the liver has a dominant influence upon survival despite the presence of metastasis in other sites. For patients with untreated liver metastases, the median survival after diagnosis is 75 days, and only 7% survived 1 year. Prognosis of hepatic metastasis is related to the extent of liver involvement, and various staging systems have been proposed (Table I.1). Hepatic metastases are quite resistant to conventional systemic chemotherapy. Surgical resection is the treatment of choice whenever possible, but the resectability rate is rather low and the surgical mortality relatively high. Patients with solitary metastasis and those with primary in the colon, especially females, have had the best results. Regional chemotherapy to the liver has the advantages of achieving higher local concentrations of drug, prolonging the contact of drug and tumor cells, and reducing systemic toxicity. Infusion catheter can be placed either percutaneously or directly at the time of celiotomy. Many reports show that hepatic IA infusion of chemotherapeutic agents (5FU or FUDR) can give favorable response in 55%-80% of the cases and can prolong survival in comparison with untreated patients or patients receiving systemic chemotherapy (Tables I.2 and I.3). Some investigators have added one or more other agents to improve the therapeutic results. For instance, patients who were refractory to 5FU or MMC given as a single IV drug responded to the combination infusion therapy. Evidence from animal and human studies have demonstrated that both primary and metastatic tumors in the liver receive their blood supply almost exclusively from the hepatic arterial system, whereas normal liver tissue has a double supply: the hepatic artery and the portal vein. Thus, deliberate ligation of the hepatic artery has been used as a treatment of metastatic tumors of the liver. From 1966 to 1981, some 518 patients were reported to have undergone this operation as compared to 2327 patients treated with hepatic IA infusion chemotherapy (Table I.4). Although selective necrosis of tumor nodules has been demonstrated after HAL, there is always a shell of viable malignant cells left at the periphery. Thus, several series have administered chemotherapeutic agents either to the distal hepatic artery or to branches of the portal vein to prevent tumor regrowth. Currently there is no definite evidence that HAL with added infusion chemotherapy to the liver gives better response and/or survival results than infusion chemotherapy via the hepatic artery only and/or via the portal vein branches. The availability of a totally implantable infusion pump represents a remarkable advance in long-term i

Hepatic Artery↗
PubMed1989

Single-stage surgery for cholesteatoma: an actuarial analysis.

Single-stage surgery was used for 215 operations for cholesteatoma. The results were analyzed using months at risk (actuarial) statistics. The methods of data collection and of creating a life-table for cholesteatoma follow-up are described. Ninety-one canal-down procedures are compared with 124 canal-up procedures as to the recidivism rate as well as hearing results. The actuarial tables showed a 45% cumulative success rate for canal-up procedures versus a 90% rate for canal-down operations. The successful canal-up procedures demonstrated slightly better hearing results, however. These success rates seemed to be comparable to those using planned staged surgery. It was concluded that, if single-stage canal-up procedures were used with larger mastoids and canal-down procedures with smaller mastoids, 80% of patients could be controlled without either residual or recurrent disease appearing. For the others, it was felt safe to wait for the disease to reappear rather than to do planned two-stage procedures for all patients. It was further urged that actuarial statistics be employed when reporting the results of surgery for cholesteatoma.

Actuarial Analysis↗
PubMed1991

[Peroperative monitoring of early auditory evoked potentials in microsurgical vascular decompression for trigeminal neuralgia or hemifacial spasm].

Intra-operative B.A.E.P. monitoring have been performed in two series of patients who underwent Microsurgical Vascular Decompression (M.V.D.) of the Vth and VIIth cranial nerves in the posterior fossa. The first series consisted of 17 patients among the 400 operated on for Trigeminal Neuralgia (T.N.), the second one also of 17 patients among the 25 treated for Hemifacial spasm (H.S.), over the last four years. The equal number of recorded patients in the two groups is totally fortuitous. The aim of the work was to correlate the electrophysiological changes: 1) to the surgical manoeuvres potentially responsible for B.A.E.P. alterations, in order to modify the M.V.D. technique, so as to minimize the risks of hearing loss, 2) to the eventual post-operative auditory disturbances, in order to define prognostic criteria from B.A.E.P. monitoring. I. Intra-operative B.A.E.P. modifications were graded into 4 categories, according to their degree of severity (table II): minimal changes (category 1), increase in latency returning to normal (2) or without normalization (2a) before end of surgery, abolition or partial decrease of responses returning to normal (3) or without complete normalization (3a) before end of surgery, total B.A.E.P. loss lasting through the entire procedure (4). Patients operated on for H.S. had more often significant B.A.E.P. changes than those with T.N., respectively 10 and 6 for categories 3a and 4 together. Auditory function was at risk mainly during cerebellar retraction (especially if cerebello-pontine angle was approached laterally) and during vascular manipulation of the labyrinthine artery (which can generat vasospasm).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1998

Musculoskeletal, visual and psychosocial stress in VDU operators before and after multidisciplinary ergonomic interventions.

The study has a parallel group design with two intervention groups (T and S) and one control group (C) of VDU operators. Three serial interventions were carried out in the T and S groups, first a new lighting system, then new workplaces and last an optometric examination and corrections if needed. The new lighting gave significantly increased illuminance levels, increased luminances of the room surfaces and better luminance distribution. The two intervention groups reported significant improvement of the lighting conditions, as well as of the visual conditions and significantly reduced visual discomfort and glare. Significant reduction of headache was found in one of the intervention groups. Optometric corrections reduced the visual discomfort in both the intervention groups. When looking at those given new corrections, a significant reduction was found in the T group and a clear tendency was also found in the S group. The C group reported no improvements for any of these health outcomes. The workplace intervention gave the operator the possibility to support the whole forearm and hand on the table top. Before the intervention there were no significant differences between the three groups regarding shoulder pain and static trapezius electromyographic (EMG) load. Two years after the intervention, a significant reduction of shoulder pain was reported in the T and S groups in parallel with a significant reduction in static trapezius load, while no such reduction was found in the C group. At the same time, both static trapezius load and shoulder pain were significantly lower in the T and S groups compared with the C group. Pain in the forearm and hand showed no significant changes in any of the groups during the study period. However, there seem to be a relationship between pain in the forearm and hand and the time the operator used the mouse. The C group reported significantly higher intensity of pain and used the mouse significantly more than the S group.

Back Pain↗
PubMed1998

Computer mouse position as a determinant of posture, muscular load and perceived exertion.

OBJECTIVES: This study concerned the influence of 6 positions of the computer mouse on the work table on posture, muscular load, and perceived exertion during text editing. METHODS: An optoelectronic 3-dimensional motion analysis system was used to register the postures of 10 men and 10 women using video display units. Muscular load was also registered (with electromyography), as was perceived exertion (with rating scales). RESULTS: A neutral posture with a relaxed and supported arm showed the least perceived exertion, and the electromyographic results showed low activity in both trapezius muscles in this position. Short operators (all women) showed a numerically higher activity in the 4 examined muscles than the tall operators (all men, except 1). This finding could be related to lower muscle force among women and to anthropometric differences, which also influence biomechanic load moments. Narrow-shouldered operators (8 women and 1 man) and short operators worked with larger outward rotation and abduction of the shoulder in a position of the mouse lateral to the keyboard than the broad-shouldered (7 men and 2 women) and tall operators did. Arm support markedly reduced muscle load in the neck-shoulder region among the operators. CONCLUSIONS: The operators using video display units in this study preferred to use the mouse on a table in a close to relaxed, neutral posture of the arm in combination with arm support. Short and narrow-shouldered operators worked in more strenuous postures of the arm when the mouse was located lateral to the keyboard.

Adult↗
PubMed1983

Complications of pediatric percutaneous renal procedures: incidence and observations.

Successful definitive (complete) percutaneous renal procedures in the pediatric age group were performed in 97 per cent of antegrade pyelograms, in 94 per cent of ureteral perfusions (Whitaker test), in 98 per cent of nephrostomies, and 100 per cent of both retroperitoneal fluid drainages and renal aspiration biopsies. Significant complications, or those necessitating specific treatment or prolonged hospitalization, were 1.1 per cent. 0.7 per cent, 15.2 per cent, 0 per cent, and 0 per cent, respectively, for the above procedures. Not surprisingly, certain operators are more adept than others at successfully performing procedures and at avoiding some but not all complications (see Tables 2 and 3). Proper training, experience, and adherence to basic principles are important. However, there were no deaths, no kidneys lost, and no transfusions or operations required as a result of any complication from the pediatric percutaneous renal procedures; correction of any existing blood coagulation disorder is necessary prior to their performance to avoid potentially fatal hemorrhage.

Biopsy, Needle↗
PubMedDate not supplied

St. Louis system has Corporate Ethics Committee. Sisters of Mercy Health System has developed an approach for assisting in the integration of ethics and operations.

Despite the relatively recent advent of organizational ethics committees--created to address operational concerns that are not always appropriate for a clinical ethics committee to take on--there remain impediments (such as time constraints, limited ethical expertise, lack of senior leaders at the table, and waning interest of members) to the impact such a group might have. Committed to addressing operational concerns in a meaningful and "value-added" way, and mindful of the challenges that can limit the effectiveness of organizational ethics committees, the St. Louis-based Sisters of Mercy Health System developed an approach that has proven successful. Without changing the committee's goals-education, policy, and consultation-Mercy's renewed Corporate Ethics Committee was restructured to include ethical experts, people knowledgeable about particular issues, and people with authority.

Ethics Committees↗
PubMed1982

Cancer, chemotherapy and anaesthesia.

The main principle in anaesthetic management of cancer patients is caution in dosage because of the possibility of decreased cardiac and respiratory reserve, and possible obscured hepatic and renal impairment. The anaesthetic problems which should be anticipated in cancer patients who are on therapy are discussed and summarised in Table III. An understanding of these problems ensures greater safety during operation and quicker recovery in the postoperative period.

Anesthesia, General↗
PubMed2006

Utility of surgery for ruptured abdominal aortic aneurysm.

Our aim was to assess the utility of surgery for ruptured abdominal aortic aneurysm (RAAA) using the number of quality-adjusted life years (QALYs) in a retrospective study with cross-sectional quality-of-life (QoL) evaluation. During a 7-year period up to 2002, 242 of 269 (90%) patients with RAAA underwent surgery. Survivors were sent the EQ-5D self-administered questionnaire to assess their long-term outcome. EQ-5D single index values were calculated for each survivor and combined with age- and sex-adjusted Finnish life tables to obtain QALY estimates. Total hospital mortality (90-day) and operative mortality (30-day) were 140 of 269 (52.0%) and 106 of 242 (43.8%), respectively. Of the 129 surviving patients, 111 were available for QoL evaluation. The response rate was 85%. The mean (range) number of QALYs after RAAA was 4.1 (0-30.9) for all and 8.5 (0.2-30.9) for hospital survivors. Young age and low Glasgow Aneurysm Score were associated with a high number of QALYs irrespective of the statistical method used for analysis. Successful repair of RAAA was able to lend considerable benefit as measured by QALYs.

Adult↗
PubMed1983

Renal cell carcinoma: the Ochsner Medical Institution experience (1945-1978).

We reviewed 161 patients operated upon for renal cell carcinoma between 1945 and 1978. Life table and survival analyses were computed to compare the effects of stage, tumor differentiation, cell type, surgical technique, renal vein involvement and sex on the years of survival. Patients with stage I and well differentiated tumors had the best prognosis. All patients surviving 10 years or more had well differentiated tumors. The type of nephrectomy did not affect survival and lymphadenectomy was only of value in staging the disease. The stage and differentiation of the tumor were more important to outcome than choice of therapy.

Adenocarcinoma↗
PubMed1998

Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures.

A study of acute, dorsally displaced, unstable (high-energy) fractures of the distal radius was conducted to determine the safety and efficacy of a new low-profile plate for unstable distal radius fractures. Thirteen surgeons in 11 US cities participated in the study. A minimum follow-up period of 1 year was required to be included in the study. Seventy-three fractures in 71 patients met this criterion. Each fracture was treated according to a prospective protocol. An autogenous bone graft was used in 64 fractures. All procedures were completed using a radiolucent sterile traction table. No external fixators were used either during or after the operation. After bone grafting and while in traction, a fracture reduction clamp with a template preshaped to the normal contour of the dorsal radial metaphysis molded the fracture into reduction and then allowed precision drilling of the holes for the plate. Active wrist motion began at an average of 14 days. Satisfactory open reduction was obtained in 93% of the fractures and maintained in 88%. Ninety-five percent of the fractures demonstrated good or excellent outcomes using a standardized evaluation. Eighty-one percent of the outcomes were rated as excellent. This initial report demonstrates that the method is a safe and effective treatment for acute, unstable, dorsally displaced fractures of the distal radius.

Adolescent↗
PubMed2002

Does radical surgery to the axilla give a survival advantage in more severe breast cancer?

There is some evidence that more radical treatment of the axilla may improve survival in node-positive disease, but there are concerns about the resultant morbidity from axillary surgery and radiotherapy. The aim of this study was to compare the outcome of axillary node clearance with axillary sampling in similar patients by comparing loco-regional recurrence and overall survival. Patients with invasive breast cancer undergoing axillary surgery between 1986 and 1997 were included. The axillary procedure performed in these patients was either an axillary sample or a level III axillary clearance. To compare like with, the patients were separated into good, moderate and poor prognostic groups by the Nottingham Prognostic Index (NPI) and overall survival was compared by a Kaplan-Meier life table analysis and the log rank test. 734 consecutive patients with operable invasive breast cancer were treated by axillary clearance n=350 or sampling n=384. The mean follow-up in the clearance group was 65 months versus 66 months in the sampled group. Local recurrence in the clearance group was 11% versus 6% in the sampled group, regional recurrence 2% versus 3% and distant metastasis 28% versus 13%. Kaplan-Meier analysis of the three prognostic groups for the clearance versus sampled groups showed no differences in the absolute survival (log rank: P=0.3, P=0.8 and P=0.6 for the good, moderate and poor prognostic groups, respectively). A conservative surgical approach to the axilla did not significantly increase the incidence of local or regional recurrence and the expected survival benefit from a radical axillary clearance was not apparent.

Axilla↗
PubMedDate not supplied

Postoperative pain guidelines.

BACKGROUND AND OBJECTIVES: Postoperative pain is the expected but nonetheless undesirable byproduct of all surgical procedures. Humanitarian concerns and recent quasi-governmental regulations have heightened awareness about the importance of treating postoperative pain. This guideline builds upon the foundation created by the Agency for Health Care Policy and Research guideline published in 1993, highlights changes that have occurred over the past 10 years, and makes recommendations based on the current scientific evidence. In addition, it takes advantage of the versatile information management inherent in a web-based format to make the information readily available. METHODS: A multidisciplinary group of physicians, dentists, nurses, pharmacists, physical therapists, psychologists, and ethicists from the Veterans Health Administration (VHA) and Department of Defense (DoD) in conjunction with the VHA Office of Quality and Performance and a consultant group developed a postoperative pain algorithm and supporting documentation. The guideline structure and content were determined by a standardized rating of the evidence gleaned from comprehensive electronic searches. RESULTS: An interactive electronic and traditional "paper" guideline with a pre- and postoperative algorithm was developed. A table, which provides a menu of analgesic choices organized by specific operation, was constructed. Preferences for particular analgesic techniques and classes of medications were identified. A postoperative pain interactive pharmacopoeia and printable patient educational materials were also provided. The guideline may be reviewed at the following website: www.oqp.med.va.gov/cpg/cpg.htm. CONCLUSIONS: This postoperative pain guideline provides readily accessible information and evidence-based guidance to a variety of providers. It highlights deficiencies in our understanding of the pain and recovery processes and how they might guide our choices of postoperative analgesic techniques. In combination with the powerful system-wide data collection capabilities of the VHA, there may be improved understanding of what techniques are useful. Finally, it may lead to the development of reliable, individualized analgesic plans for specific surgical procedures that incorporate the full range of pharmacologic and nonpharmacologic techniques.

Algorithms↗