Rørbye, Christina; Nørgaard, Mogens; Nilas, Lisbeth
BACKGROUND: The aim of the study was to compare satisfaction with medical and surgical abortion and to identify potential confounders affecting satisfaction. METHODS: 1033 women with gestational age (GA) ...) or a surgical abortion (vacuum aspiration in general anaesthesia). The procedure was determined either by randomization (n = 111) or by choice (n = 922). Data on satisfaction, side effects and expectations were collected from questionnaires 2 and 8 weeks after termination. RESULTS: More women were very...... satisfied or satisfied after a surgical than a medical abortion both after choosing method (92% vs 82%, P
Rørbye, Christina; Nørgaard, Mogens; Nilas, Lisbeth
) or a surgical abortion (vacuum aspiration in general anaesthesia). The procedure was determined either by randomization (n = 111) or by choice (n = 922). Data on satisfaction, side effects and expectations were collected from questionnaires 2 and 8 weeks after termination. RESULTS: More women were very.......05. Satisfaction with the medical procedure was inversely correlated with GA and the intensity of pain, nausea, vomiting and dizziness, while satisfaction with the surgical procedure was unaffected by these side effects. Fewer women with a failed medical than a failed surgical abortion were satisfied (17% vs 62......BACKGROUND: The aim of the study was to compare satisfaction with medical and surgical abortion and to identify potential confounders affecting satisfaction. METHODS: 1033 women with gestational age (GA)
Bosscher, M. R. F.; van Leeuwen, Barbara; Hoekstra, Harald
An oncologic emergency is defined as an acute, potentially life threatening condition in a cancer patient that has developed as a result of the malignant disease or its treatment. Many oncologic emergencies are signs of advanced, end-stage malignant disease. Oncologic emergencies can be divided into
Cohen-Bittan, Judith; Lazareth, Helene; Zerah, Lorene; Forest, Anne; Boddaert, Jacques
Surgical emergencies represent a diverse combination of common and particularly severe pathologies in elderly patients. This severity is due in part to concurrent comorbidities and sometimes atypical clinical presentations, causing delay in diagnosis and treatment.
Bosscher, M. R. F.; van Leeuwen, B. L.; Hoekstra, H. J.
Cancer patients can experience problems related to their disease or treatment. This study evaluated reasons for presentation at the emergency room (ER) and outcome of surgical oncology patients. A retrospective chart review for all surgical oncology patients who presented at the ER of the UMCG for
Full Text Available Objective. Over the past decade, multiple factors have changed the pattern of neonatal surgical emergencies. An increase in prenatal screenings and the development of neonatal tertiary care centres have changed the clinical approach to these kids. Materials and methods. Between 1995 to 2011 were retrospectively reviewed 34 patients with diagnosis of uncommon rare neonatal surgical emergencies at our institute. We analyzed: sex, gestational age, weight at birth, primary pathology, prenatal diagnosis, associated anomalies, age and weight at surgery, clinical presentation, start of oral feeding and hospitalization. The follow-up was performed at 6,12, 24 and 36 months. Results. There were 21 male and 13 female. The gestational age ranged between 28 and 36 weeks. The weight at birth ranged between 700 and 1400 grams. Oral feeding was started between 4th and 10th postoperative day. The average hospitalization was about 70.47 days. To date, all patients have finished the followup. They are healthy. Conclusion. The outcome of the patients with uncommon surgical emergencies is different based on the etiology. Overall survival is generally good but is influenced by the associated anomalies.
Reid, Lindsay A; Dunn, Mark; Mckeown, Dermot W; Oglesby, Angela J
To determine the frequency of and primary indication for surgical airway during emergency department intubation. Prospectively collected data from all intubations performed in the emergency department from January 1999 to July 2007 were analysed to ascertain the frequency of surgical airway access. Original data were collected on a structured proforma, entered into a regional database and analysed. Patient records were then reviewed to determine the primary indication for a surgical airway. Emergency department intubation was undertaken in 2524 patients. Of these, only five patients (0.2%) required a surgical airway. The most common indication for a surgical airway was trauma in four of the five patients. Two patients had attempted rapid sequence induction before surgical airway. Two patients had gaseous inductions and one patient received no drugs. In all five patients, surgical airway was performed secondary to failed endotracheal intubation attempt(s) and was never the primary technique used. In our emergency department, surgical airway is an uncommon procedure. The rate of 0.2% is significantly lower than rates quoted in other studies. The most common indication for surgical airway was severe facial or neck trauma. Our emergency department has a joint protocol for emergency intubation agreed by the Departments of Emergency Medicine, Anaesthesia and Critical Care at the Edinburgh Royal Infirmary. We believe that the low surgical airway rate is secondary to this collaborative approach. The identified low rate of emergency department surgical airway has implications for training and maintenance of skills for emergency medicine trainees and physicians.
Background: Surgical site infection (SSI) following emergency laparotomy results in significant morbidity. This study determined microbial pattern and duration of antimicrobial therapy following emergency laparotomy at Kenyatta National Hospital (KNH). Objectives: To determine microbial profile and duration of ...
Dec 1, 2009 ... ABSTRACT. Anaesthesia for surgical procedures carries some risks. These risks are accentuated when the surgical operation is performed as an emergency procedure. The value of emergency in risk stratification underscores its relevance in clinical anaesthesia. Limited time for evaluation of patient ...
Marianne R F Bosscher
Full Text Available For some oncologic emergencies, surgical interventions are necessary for dissolution or temporary relieve. In the absence of guidelines, the most optimal method for decision making would be in a multidisciplinary cancer conference (MCC. In an acute setting, the opportunity for multidisciplinary discussion is often not available. In this study, the management and short term outcome of patients after surgical oncologic emergency consultation was analyzed.A prospective registration and follow up of adult patients with surgical oncologic emergencies between 01-11-2013 and 30-04-2014. The follow up period was 30 days.In total, 207 patients with surgical oncologic emergencies were included. Postoperative wound infections, malignant obstruction, and clinical deterioration due to progressive disease were the most frequent conditions for surgical oncologic emergency consultation. During the follow up period, 40% of patients underwent surgery. The median number of involved medical specialties was two. Only 30% of all patients were discussed in a MCC within 30 days after emergency consultation, and only 41% of the patients who underwent surgery were discussed in a MCC. For 79% of these patients, the surgical procedure was performed before the MCC. Mortality within 30 days was 13%.In most cases, surgery occurred without discussing the patient in a MCC, regardless of the fact that multiple medical specialties were involved in the treatment process. There is a need for prognostic aids and acute oncology pathways with structural multidisciplinary management. These will provide in faster institution of the most appropriate personalized cancer care, and prevent unnecessary investigations or invasive therapy.
Rosenstock, C V; Nørskov, A K; Wetterslev, J
BACKGROUND: The emergency surgical airway (ESA) is the final option in difficult airway management. We identified ESA procedures registered in the Danish Anaesthesia Database (DAD) and described the performed airway management. METHODS: We extracted a cohort of 452 461 adult patients undergoing...
Bosscher, Marianne R. F.; van Leeuwen, Barbara L.; Hoekstra, Harald J.
OBJECTIVES: For some oncologic emergencies, surgical interventions are necessary for dissolution or temporary relieve. In the absence of guidelines, the most optimal method for decision making would be in a multidisciplinary cancer conference (MCC). In an acute setting, the opportunity for
In observational studies on causal associations, comparison groups (e.g. groups of treated and untreated subjects) are likely to differ on prognostic characteristics. Such incomparability will bias the association under study, which is referred to as confounding. The studies presented in this thesis
Background: Pediatric surgical emergencies are associated with higher morbidity and mortality. The aim of this study is to describe the epidemiology of non-trauma related pediatric abdominal surgical emergencies in our centre and determine the indicators for survival in a cohort of patients. Patients and Methods: A ...
Background: Abdominal emergency surgery consists a significant number of paediatric emergencies done in our environment. Paucity of paediatric surgeons has led to majority of these cases being done by general surgeons. Aim:To compare results obtained by the general surgeons with that of the paediatric surgeons at ...
Gobeze, Abera A; Kebede, Zelalem; Berhan, Yifru; Ghosh, Biku
Serious shortage of gynecologists and surgeons for several decades leading to a three-year masters level training was initiated in 2009. However, systematic analysis was not done to assess the graduates' performance. The purpose of this study was to assess improvement in access to emergency surgical and obstetrical care services. Both quantitative and qualitative methods were employed to assess the competence of emergency surgical officers (ESOs) in their decision making and surgical skills in eight hospitals between 2012 and 2014. Anesthesia time, post-operative hospital stay and change in hemoglobin level were, among others, used as proxy indicators of their surgical skills. A total of 4075 obstetric and surgical operations was performed in the study hospitals. Of which, 93% were done on emergency base. Of the total emergency procedures, 3570(94%) were done by ESOs. Nearly two-thirds (63%) of all the emergency operations were cesarean sections, which were done by ESOs. Out of 239 uterine ruptures, hysterectomy was done for 58%. The proportion of cesarean and instrumental deliveries over the total deliveries were 13% and 0.7%, respectively. Explorative laparotomies and appendectomies were the majority of the non-obstetric emergency operations. Interviewed staff in the respective hospitals stated that ESOs' clinical decision making, surgical skill and commitment to discharge their responsibilities were in the best possible. The study showed that deployment of ESOs made the emergency surgery services accessible to the majority, and their clinical decision making and surgical skills were remarkable.
Fifty-six (56) patients with 60 episodes of priapism treated surgically over a 14 year period were studied. The aim was to determine whether this condition is a surgical emergency or not. The mean age of the patients was 23.6+8.7 years. All the patients who had their priapism relieved within 24 hours (one day) of onset were ...
Background : Acute abdominal conditions are a common reason for emergency admission of children. Little is available in the literature about such conditions in our subregion, especially Ghana. Objective : The aim of this study was to investigate the range of emergency abdominal surgical conditions amongst children in ...
Paediatric surgical abdominal emergencies in a north central Nigerian centre. ... The causes of PSAEs vary worldwide, and the management is challenging, often with unimaginably poor outcome if not carefully handled. The aim of this ... Keywords: abdominal emergencies, acute abdomen, children, morbidity, mortality ...
Jawaid, Masood; Raza, Syed Muhammad; Alam, Shams Nadeem; Manzar, S
To examine the on-call emergency workload of a general surgical team at a tertiary care teaching hospital to guide planning and provision of better surgical services. During six months period from August to January 2007; all emergency calls attended by general surgical team of Surgical Unit II in Accident and Emergency department (A and E) and in other units of Civil, Hospital Karachi, Pakistan were prospectively recorded. Data recorded includes timing of call, diagnosis, operation performed and outcome apart from demography. Total 456 patients (326 males and 130 females) were attended by on-call general surgery team during 30 emergency days. Most of the calls, 191 (41.9%) were received from 8 am to 5 pm. 224 (49.1%) calls were of abdominal pain, with acute appendicitis being the most common specific pathology in 41 (9.0%) patients. Total 73 (16.0%) calls were received for trauma. Total 131 (28.7%) patients were admitted in the surgical unit for urgent operation or observation while 212 (46.5%) patients were discharged from A and E. 92 (20.1%) patients were referred to other units with medical referral accounts for 45 (9.8%) patients. Total 104 (22.8%) emergency surgeries were done and the most common procedure performed was appendicectomy in 34 (32.7%) patients. Major workload of on-call surgical emergency team is dealing with the acute conditions of abdomen. However, significant proportion of patients are suffering from other conditions including trauma that require a holistic approach to care and a wide range of skills and experience. These results have important implications in future healthcare planning and for the better training of general surgical residents.
Full Text Available Background: To examine the on-call emergency workload of a general surgical team at a tertiary care teaching hospital to guide planning and provision of better surgical services. Patients and Methods: During six months period from August to January 2007; all emergency calls attended by general surgical team of Surgical Unit II in Accident and Emergency department (A and E and in other units of Civil, Hospital Karachi, Pakistan were prospectively recorded. Data recorded includes timing of call, diagnosis, operation performed and outcome apart from demography. Results: Total 456 patients (326 males and 130 females were attended by on-call general surgery team during 30 emergency days. Most of the calls, 191 (41.9% were received from 8 am to 5 pm. 224 (49.1% calls were of abdominal pain, with acute appendicitis being the most common specific pathology in 41 (9.0% patients. Total 73 (16.0% calls were received for trauma. Total 131 (28.7% patients were admitted in the surgical unit for urgent operation or observation while 212 (46.5% patients were discharged from A and E. 92 (20.1% patients were referred to other units with medical referral accounts for 45 (9.8% patients. Total 104 (22.8% emergency surgeries were done and the most common procedure performed was appendicectomy in 34 (32.7% patients. Conclusion: Major workload of on-call surgical emergency team is dealing with the acute conditions of abdomen. However, significant proportion of patients are suffering from other conditions including trauma that require a holistic approach to care and a wide range of skills and experience. These results have important implications in future healthcare planning and for the better training of general surgical residents.
Suh, C. O.; Oh, K. K.; Park, C. Y. [Yonsei University, Medical College, Seoul (Korea, Republic of)
Most pathologic conditions requiring emergent operation in neonate are congenital anomalies and delayed diagnosis and associated anomaly are important factors which have contributed to the high mortality rate of congenital anomalies. To prevent this delay, early recognition of the danger signals, adequate roentagenologic examination and accurate diagnosis should be made. Furthermore radiologists should be aware of developing mechanism, clinical manifestations and roentgenographic findings of those neonatal emergencies. 135 cases of neonatal emergencies were analyzed at this point of view, which verified by surgery and pathologic examination at Yonsei University College of Medicine, Severance Hospital since 1968. Embryology and characteristic roentgenographic pictures of each disease were discussed. The conclusions are as follows; 1. Most cases (110/135) presented intestinal obstruction. Imperforate anus (29 cases) was most common disease which followed by infantile hypertrophic pyloric stenosis (25 cases), small bowel atresia and stenosis (18 cases), congenital megacolon (15 cases) and esophageal atresia (14 cases). 2. Clinical Type and time of occurrence of symptoms and signs were so characteristic that these were helpful for differential diagnosis. 3. In infantile hypertrophic pyloric stenosis, confirmative diagnosis could be made in plain abdominal film, when 'Caterpillar sign' was seen. 4. When small bowel obstruction was suspected in plain abdominal film, barium enema examination was more helpful than upper G-I study. When microcolon was found, lower small bowel obstruction was highly suggested. 5. Diagnosis of midgut malrotation was possible in larger cases (4/7). Upper G-I examination was more valuable than barium enema study, because duodenal obstruction due to Ladd's band was common problem in neonate. 6. In neonatal period, diagnosis of aganglionosis could be made with the finding of barium stasis on 24-48 hours delay film, even though no
Khalid, Sadaf; Bhatti, Afsar Ali; Burhanulhuq
Audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the review of change. Objective of this study was to report the patterns of admissions in our surgical emergency and the comparison of results with the available data. All the patients presented in the surgical emergency of Unit III from April to December 2014. Detail of all surgical patients admitted during the period was recorded from the emergency entry register maintained by the staff nurse. Demographic data, mode of admission, diagnosis and outcomes were recorded on a pro forma. Total number of patients were 11140, out of which 5998 (53.8%) were males and 5142 (46%) were females, mostly were between 18-56 years of age. Emergency surgeries were performed in 650 of our cases whereas the rest of the patients were managed conservatively, treated at minor operation theatre (MOT), referred to their concerned emergencies or discharged. The most common presentation was road traffic accidents followed by trauma, urological emergencies and intestinal obstruction. Overall mortality was estimated as 1.5%. Surgical audit should be made a regular practice to serve as an important and effective tool of accountibilty on clinical outcomes and self evaluation and in improving the quality of our health care system.
Full Text Available A trichobezoar is a mass of undigested hair in the proximal gastrointestinal tract. It is a rare condition seen in young females with psychiatric disorders of trichotillomania and trichophagia or mental retardation. We present a case of an intellectually impaired 14-year-old girl with a gastric trichobezoar discovered during an emergency laparotomy. We will discuss the limited but salient findings on history and examination. Through a review of the literature, imaging modalities and treatment options for the early versus late stage of trichobezoar presentations will be identified. Through our case, subsequent holistic management will also be highlighted to prevent recurrence.
Background: Serious shortage of gynecologists and surgeons for several decades leading to a three-year masters level training was initiated in 2009. However, systematic analysis was not done to assess the graduates' performance. The purpose of this study was to assess improvement in access to emergency surgical ...
BACKGROUND:Gastric ulcer perforation is a rare surgical emergency.Posterior gastric ulcer is even rarer and usually has a delayed presentation with attendant greater morbidity and mortality. AIM:To report a case of posterior perforation of gastric ulcer and review the literature. CASE REPORT:A 65yr old driver was seen in ...
Ectopic gestation is the commonest indication for emergency exploratory laparotomy in our centre and should be considered in the diagnosis of acute abdomen in females. Early elective surgery for external hernia and prompt surgical treatment of acute appendicitis may decrease the burden of intestinal obstruction and ...
The proportion of cesarean and instrumental deliveries over the total deliveries were 13% and 0.7%, respectively. Explorative laparotomies and appendectomies were the majority of the non-obstetric emergency operations. Interviewed staff in the respective hospitals stated that ESOs' clinical decision making, surgical skill ...
Becher, Robert D; Hoth, J Jason; Miller, Preston R; Meredith, J Wayne; Chang, Michael C
Acute care surgeons are uniquely aware of the importance of systemic inflammatory response and its influence on postoperative outcomes; concepts like damage control have evolved from this experience. For surgeons whose practice is mostly elective, the significance of such systemic inflammation may be underappreciated. This study sought to determine the influence of preoperative systemic inflammation on postoperative outcome in patients requiring emergent colon surgery. Emergent colorectal operations were identified in the American College of Surgeons National Surgical Quality Improvement Program 2008 dataset. Four groups were defined by the presence and magnitude of the inflammatory response before operation: no inflammation, systemic inflammatory response syndrome (SIRS), sepsis, or severe sepsis/septic shock. Thirty-day survival was analyzed by Kaplan-Meier method. A total of 3,305 patients were identified. Thirty-day survival was significantly different (p emergency surgical patients. In SIRS or sepsis patients, operations surgical intervention and suggest a potential role for damage control operations in emergency general surgery. II, prognostic study.
Heaney, R M; Reynolds, I; Ryan, R S; Khan, I; Khan, W; Waldron, R; Barry, K
Financial sustainability is an area of sharp ongoing focus across the broad spectrum of the Irish Health Service. Recent attention has been drawn to the financial implications of non-operative surgical admissions, suggesting that some of these may be unnecessary. In this study, we aim to determine the volume of emergency surgical admissions to Mayo University Hospital (MUH), in particular, to identify the scale of non-operative admissions and to assess the wider inherent implications for acute hospital services. An electronic handover system for emergency surgical admissions was introduced in MUH in September 2014. All surgical admissions from September 1st 2014 to August 31st 2015 were identified from this prospectively maintained database. HIPE (Hospital Inpatient Enquiry) data were not used in this study. Theatre logbooks confirmed those patients who required operative intervention. 1466 patients were admitted as emergencies during the study period. 58 % (850) were male and median age was 48 years (0-100). Average length of stay was 5 days (range 1-125). 327 patients (22.3 %) required operative intervention. The most commonly performed procedure was appendicectomy (52.5 %). 48 (3.3 %) patients were transferred to other hospitals. 131 (8.9 %) admissions related to the acute urological conditions. Of the 1466 admissions, 546 underwent a CT scan, while 342 patients proceeded to ultrasound. Almost 80 % of all surgical emergency admissions were discharged without undergoing a formal operative procedure while generating a significant workload for the radiology department. Changes in working practices and hospital network structures will be required to reduce the burden of non-operative emergency admissions.
Schepin, V O; Mirgorodskaya, O V
The article presents the results of providing emergency surgical care in case of acute diseases of abdominal organs and extra uterine pregnancy to population of the Russian Federation in 2000-2010. The analysis also considered time between onset of disease and delivery of patient to hospital, structure of diagnosis, operative activity and indicators of lethality. The preventability of lethal outcome under acute diseases of abdominal organs at the expense of hospitalization is calculated.
Qureshi, Adnan; Smith, Andy; Wright, Frances; Brenneman, Fred; Rizoli, Sandro; Hsieh, Taulee; Tien, Homer C
This study evaluated how implementation of an acute care emergency surgery service (ACCESS) affected key determinants of emergency department (ED) length of stay, and particularly, surgical decision time. Also, we analyzed how ACCESS affected ED overcrowding. We conducted a before and after study of all ED patients referred to ACCESS from January 1, 2007 to June 30, 2009. ACCESS was implemented on July 1, 2008. The primary outcome was surgical decision time; the secondary outcome was a measure of overall ED overcrowding: "time-to-stretcher" for all ED patients. The control groups were patients referred to internal medicine or urology. Patients with appendicitis were studied in order to analyze the impact on patient outcomes and to determine barriers to efficient ED patient flow. Of 2,510 patients, 1,448 patients were pre-ACCESS, and 1,062 were after ACCESS implementation. Implementation of ACCESS was associated with a 15% reduction in surgical decision time (12.6 hours vs 10.8 hours, p < 0.01). During the same period, there were no significant changes in decision time for our control groups. Also, the mean time-to-stretcher for all ED patients decreased by 20%. In patients with appendicitis, we found that patient flow could be further improved by a timely request for surgical consultation and expedited imaging. Finally, we found that patients with nonperforated appendicitis with a fecalith on CT imaging were more likely to suffer perforation while waiting for surgery. ACCESS reduced surgical decision time for surgical patients. Also, ACCESS improved overall ED crowding, as measured by time-to-stretcher for ED patients. Further improvements could be made by improving time to imaging. Patients referred for nonperforated appendicitis with a fecalith on CT should have expedited surgery. Copyright © 2011. Published by Elsevier Inc.
Alcón, Amalia; Villalonga, Antonio; Sabaté, Sergi; Canet, Jaume; Ortiz, Montserrat; Marco, Joan
The aim of this arm of the ANESCAT 2003 study was to describe the use of emergency anesthesia in surgical specialties in Catalonia, Spain. The data analyzed came from a prospective study of the anesthetic procedures performed in 131 hospitals in Catalonia on 14 randomly chosen days in 2003. Emergency anesthetic procedures for surgery (excluding obstetrics and nonsurgical procedures) were selected and the following variables analyzed: type of hospital, patient characteristics, procedure, anesthetic technique, time used, postoperative care, and type of emergency (deferrable or not). Data are expressed as medians (10th-90th percentile) and extrapolated to the population of Catalonia. Out of 23,136 anesthetic procedures recorded, 2,088 (corresponding to an estimated 54,437 anesthetic procedures in Catalonia annually) were associated with surgical emergencies; that figure represents 9% of all anesthetic procedures and 11.5% of anesthetic procedures performed for surgery. The emergency was deferrable in 51% of cases (an estimated 26,906 anesthetic procedures annually). A total of 81.2% of the emergency procedures were performed in hospitals belonging to the public system and 18.8% in private hospitals. Procedures performed from Monday to Friday accounted for 80.6% of emergency procedures. Procedures performed between the hours of 08:00 and 16:00 accounted for 46.5% of the total and 8.1% were performed between 00:00 and 08:00. Sixty percent of deferrable procedures were undertaken between 08:00 and 16:00. Men accounted for 52.4% of all patients, the median age was 51 (15-83) years, and 15.3% of patients were severely ill (American Society of Anesthesiologists physical status class 4). Taken together, orthopedic surgery and traumatology, and general and digestive surgery accounted for 74.4% of the anesthesia practice considered. General anesthesia was used in 51% of cases and regional anesthesia in 38%. The length of anesthesia was greater in deferrable emergencies (90
Rabie, Mohammad E.; Al-Tayeb, Abdul-Rehman E.; Zafer, Mubarak H.; Seikha, Anwar A.
Hemophiliacs are subjected to develop episodes of spontaneous bleeding at different sites of the body, primarily the knees. On occasions such episodes affect the abdomen. The picture engendered in such cases may mimic that of an abdominal emergency requiring surgical intervention.Such ill advised and unwarranted intervention may end with the patient's death.With the proper emloyment of radiology, the correct diagonosis may be reached and consequently, conservative treatment, in which factor VIII plays the major role, instituted. Here we describe the clinical course of two patients with hemophilia A who suffered bleeding in the abdomen and were treated conservatively with a successfull outcome. (author)
Peters, J.; Bruijstens, L.; Ploeg, J. van der; Tan, E.; Hoogerwerf, N.; Edwards, M.J.
BACKGROUND: Airway management is essential in critically ill or injured patients. In a "can't intubate, can't oxygenate" scenario, an emergency surgical airway (ESA), similar to a cricothyroidotomy, is the final step in airway management. This procedure is infrequently performed in the prehospital
Kang, Hee Seung; Cha, Yong Sung; Park, Kyung Hye; Hwang, Sung Oh
Early identification of patients with acute diverticulitis who require emergent surgical intervention in the emergency department (ED) is important to the physician. Although computed tomography (CT) has an important role in evaluating the severity of diverticulitis, its findings alone may not predict the need for emergent surgical intervention in all patients with acute diverticulitis in the ED. Serum inflammation markers may help to differentiate severity of acute diverticulitis and predict the need for surgical intervention in clinical practice. No information is currently available on the clinical usefulness of the delta neutrophil index (DNI), with respect to the prediction of emergent surgical intervention in patients with acute diverticulitis at the ED. This was a retrospective observational study of consecutive adult patients with acute diverticulitis confirmed by CT in the ED, between January 2014 and December 2016. Recruited patients were divided into two groups: emergent surgical intervention and no surgical intervention. The following laboratory serum parameters were examined in the ED: DNI value, C-reactive protein (CRP) levels, white blood cell count, neutrophil count, and neutrophil-to-lymphocyte ratio (NLR). The patients were also examined for the presence or absence of complications by CT. A total of 132 patients were finally included in the study, with the emergent surgical intervention group constituting 52 patients. The median DNI value, CRP levels, neutrophil count, and NLR were significantly higher in the emergent surgical intervention group than in the no surgical intervention group. The area under the curve for predicting emergent surgical intervention, using the DNI was significantly higher than that of CRP levels, neutrophil count, or NLR. Moreover, the combination of initial DNI and CT was most powerful diagnostic modality. DNI values measured at the ED combined with CT were good predictors for emergent surgical intervention in acute
Genser, L; Vons, C
The performance of emergency abdominal surgery in an outpatient setting is increasingly the order of the day in France. This review evaluates the feasibility and reliability of ambulatory surgical treatment of the most common abdominal emergencies: appendectomy for acute appendicitis and cholecystectomy for acute complications of gallstone disease (acute cholecystitis and gallstone pancreatitis). This study evaluates surgical procedures performed on an ambulatory basis according to the international definition (admission in the morning, discharge in the evening with a hospital stay of less than 12 hours). Just as for elective surgery, eligibility of patients for an ambulatory approach depends on the capacities of the surgical and anesthesia team: to manage the risks, particularly the risk of deferring surgery until the morning); to prevent or treat post-operative symptoms like pain, nausea, vomiting, re-ambulation in order to permit rapid post-operative discharge. Recent studies have shown that appendectomy for non-complicated acute appendicitis can be deferred for up to 12 hours without any increase in danger. Many other studies have shown that early discharge after appendectomy for acute non-complicated appendicitis is feasible and safe. Nonetheless, there is only one published series of truly ambulatory appendectomies. The results were excellent. Patients who presented in the afternoon were brought back for operation the following morning. The appropriate timing for performance of cholecystectomy in patients with acute calculous cholecystitis or gallstone pancreatitis has not been well defined, but is always somewhat delayed relative to the onset of symptoms. To minimize operative complications, cholecystectomy for acute calculous cholecystitis should probably be performed between 24 and 72 hours after diagnosis. Cholecystectomy for gallstone pancreatitis should probably not be delayed longer than a week; the need to keep the patient hospitalized during the
Kummerow Broman, Kristy; Phillips, Sharon; Hayes, Rachel M; Ehrenfeld, Jesse M; Holzman, Michael D; Sharp, Kenneth; Kripalani, Sunil; Poulose, Benjamin K
There is a perception among surgeons that hospitals disproportionately transfer unfavorably insured patients for emergency surgical care. Emergency medical condition (EMC) designation mandates referral center acceptance of patients for whom transfer is requested. We sought to understand whether unfavorably insured patients are more likely to be designated as EMCs. A retrospective cohort study was performed on patient transfers from a large network of acute care facilities to emergency surgery services at a tertiary referral center from 2009-2013. Insurance was categorized as favorable (commercial or Medicare) or unfavorable (Medicaid or uninsured). The primary outcome, transfer designation as EMC or non-EMC, was evaluated using multivariable logistic regression. A secondary analysis evaluated uninsured patients only. There were 1295 patient transfers in the study period. Twenty percent had unfavorable insurance. Favorably insured patients were older with fewer nonwhite, more comorbidities, greater illness severity, and more likely transferred for care continuity. More unfavorably insured patients were designated as EMCs (90% versus 84%, P < 0.01). In adjusted models, there was no association between unfavorable insurance and EMC transfer (odds ratio [OR], 1.61; 95% confidence interval [CI], 0.98-2.69). Uninsured patients were more likely to be designated as EMCs (OR, 2.27; CI, 1.08-4.77). The finding that uninsured patients were more likely to be designated as EMCs suggests nonclinical variation that may be mitigated by clearer definitions and increased interfacility coordination to identify patients requiring transfer for EMCs. Published by Elsevier Inc.
Cesaretti, Manuela; Dioguardi Burgio, Marco; Zarzavadjian Le Bian, Alban
With an increasing number of liver transplantation (LT) and an enhanced overall survival, LT recipients are more likely to be admitted in emergency departments of general hospitals. Yet, in LT recipients, common but also benign symptoms may reveal a LT-related (or not) severe condition. To improve management of LT recipients by emergency physicians and general surgeons and potentially improve long-term outcomes, a clinical review was performed. Overall, CT scan and blood tests should be systematically performed. Immunosuppressive side effects should be excluded using blood tests. LT-related complications are more likely to occur during the first three months after LT, including mainly bile leak, arterial aneurysm, and pseudoaneurysm. Patients should be referred in emergency to tertiary centers. Non-LT-related complications and common abdominal conditions may also be diagnosed in LT recipients. Except in case of diffuse peritonitis or in hemodynamically unstable patients when surgical procedure should be performed, most conditions should be reassessed regarding the immunosuppressive treatment and the adhesive abdominal cavity. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
A 46-year-old man who underwent a vasectomy at his general practitioner presented to the emergency department at a regional hospital with a 6 h history of scrotal swelling and skin discolouration. He was haemodynamically stable on admission, with a large, dark red swelling in his scrotum. The patient was admitted to an acute surgical unit for exploration of his scrotum. Bilateral transverse incisions were made in the patient's groin, and approximately 600 mL of blood was drained from the patient's scrotum. Postoperatively, the patient performed well, and was discharged home on oral antibiotics and analgesia. The patient's scrotum healed well, and after 2 months of follow-up, he was discharged.
Ertugrul, Bulent M; Yildirim, Ayse; Ay, Pinar; Oncu, Serkan; Cagatay, Atahan; Cakar, Nahit; Ertekin, Cemalettin; Ozsut, Halit; Eraksoy, Haluk; Calangu, Semra
To investigate the incidence, risk factors and the etiology of ventilator-associated pneumonia (VAP) in surgical emergency intensive care unit (ICU) patients. We conducted this prospective cohort study in the surgical emergency ICU of Istanbul Medical Faculty between December 1999 and May 2001. We included 100 mechanically ventilated patients in this study. We diagnosed VAP according to the current diagnostic criteria. We identified the etiology of VAP cases by both quantitative cultures of endotracheal aspiration and blood cultures. To analyze the predisposing factors for the development of VAP, we recorded the following variables: age, gender, acute physiology and chronic health evaluation (APACHE) II score, Glasgow coma scale (GCS), sequential organ failure assessment (SOFA) score, serum albumin level, duration of mechanical ventilation (MV) prior to the development of VAP, and underlying diseases. We determined the VAP incidence rate as 28%. We found the APACHE II score and the duration of MV to be statistically significant variables for the development of VAP. There were no significant differences regarding age, gender, GCS, SOFA score, albumin level, or underlying diseases for the development of VAP. The isolated bacteria among VAP cases were as follows: Staphylococcus aureus (n=12, 43%), Acinetobacter spp. (n=6, 21%), coagulase-negative Staphylococci (n=4, 15%), Pseudomonas aeruginosa (n=3, 10.7%) and Klebsiella pneumoniae (n=3, 10.7%). Ventilator-associated pneumonia is a common infection, and certain interventions might affect the incidence of VAP. The ICU clinicians should be aware of the risk factors for VAP, which could prove useful in identifying patients at high risk for VAP, and modifying patient care to minimize the risk of VAP.
Full Text Available Introduction. We report the management of a septic Open Abdomen (OA patient by the help of negative pressure therapy (NPT and abdominal reapproximation anchor (ABRA system in pregnant woman with spontaneous jejunal perforation after emergent cesarean section (C/S with confounding factor of mild acute pancreatitis (AP. Presentation of Case. A 29-year-old and 34-week pregnant woman with AP underwent C/S. She was arrested after anesthesia induction and responded to cardiopulmonary resuscitation (CPR. There were only ash-colored serosanguinous fluid within abdomen during C/S. After C/S, she was transferred to intensive care unit (ICU with vasopressor support. On postoperative 1st day, she underwent reoperation due to fecal fluid coming near the drainage. Leakage point could not be identified exactly and operation had to be deliberately abbreviated due to hemodynamic instability. NPT was applied. Two days later source control was provided by conversion of enteroatmospheric fistula (EAF to jejunostomy. ABRA was added and OA was closed. No hernia developed at 10-month follow-up period. Conclusion. NPT application in septic OA patient may gain time to patient until adequate source control could be achieved. Using ABRA in conjunction with NPT increases the fascial closure rate in infected OA patient.
Yetisir, Fahri; Sarer, Akgün Ebru; Acar, Hasan Zafer; Osmanoglu, Gokhan; Özer, Mehmet; Yaylak, Faik
Introduction. We report the management of a septic Open Abdomen (OA) patient by the help of negative pressure therapy (NPT) and abdominal reapproximation anchor (ABRA) system in pregnant woman with spontaneous jejunal perforation after emergent cesarean section (C/S) with confounding factor of mild acute pancreatitis (AP). Presentation of Case. A 29-year-old and 34-week pregnant woman with AP underwent C/S. She was arrested after anesthesia induction and responded to cardiopulmonary resuscitation (CPR). There were only ash-colored serosanguinous fluid within abdomen during C/S. After C/S, she was transferred to intensive care unit (ICU) with vasopressor support. On postoperative 1st day, she underwent reoperation due to fecal fluid coming near the drainage. Leakage point could not be identified exactly and operation had to be deliberately abbreviated due to hemodynamic instability. NPT was applied. Two days later source control was provided by conversion of enteroatmospheric fistula (EAF) to jejunostomy. ABRA was added and OA was closed. No hernia developed at 10-month follow-up period. Conclusion. NPT application in septic OA patient may gain time to patient until adequate source control could be achieved. Using ABRA in conjunction with NPT increases the fascial closure rate in infected OA patient.
MacColl, Jono N.; Illing, Sam; Sleigh, Jamie W.
The re-establishment of conscious awareness after discontinuing general anesthesia has often been assumed to be the inverse of loss of consciousness. This is despite the obvious asymmetry in the initiation and termination of natural sleep. In order to characterize the restoration of consciousness after surgery, we recorded frontal electroencephalograph (EEG) from 100 patients in the operating room during maintenance and emergence from general anesthesia. We have defined, for the first time, 4 steady-state patterns of anesthetic maintenance based on the relative EEG power in the slow-wave (anesthesia. Unlike single-drug experiments performed in healthy volunteers, we found that surgical patients exhibited greater electroencephalographic heterogeneity while re-establishing conscious awareness after drug discontinuation. Moreover, these emergence patterns could be broadly grouped according to the duration and rapidity of transitions amongst these slow-wave dominated brain states that precede awakening. Most patients progressed gradually from a pattern characterized by strong peaks of delta (0.5–4 Hz) and alpha/spindle (8–14 Hz) power (‘Slow-Wave Anesthesia’) to a state marked by low delta-spindle power (‘Non Slow-Wave Anesthesia’) before awakening. However, 31% of patients transitioned abruptly from Slow-Wave Anesthesia to waking; they were also more likely to express pain in the post-operative period. Our results, based on sleep-staging classification, provide the first systematized nomenclature for tracking brain states under general anesthesia from maintenance to emergence, and suggest that these transitions may correlate with post-operative outcomes such as pain. PMID:25264892
Khan, Salma; Zafar, Hasnain; Zafar, Syed Nabeel; Haroon, Naveed
Outcomes of surgical emergencies are associated with promptness of the appropriate surgical intervention. However, delayed presentation of surgical patients is common in most developing countries. Delays commonly occur due to transfer of patients between facilities. The aim of the present study was to assess the effect of delays in treatment caused by inter-facility transfers of patients presenting with surgical emergencies as measured by objective and subjective parameters. We prospectively collected data on all patients presenting with an acute surgical emergency at Aga Khan University Hospital (AKUH). Information regarding demographics, social class, reason and number of transfers, and distance traveled were collected. Patients were categorized into two groups, those transferred to AKUH from another facility (transferred) and direct arrivals (non-transfers). Differences between presenting physiological parameters, vital statistics, and management were tested between the two groups by the chi square and t tests. Ninety-nine patients were included, 49 (49.5 %) patients having been transferred from another facility. The most common reason for transfer was "lack of satisfactory surgical care." There were significant differences in presenting pulse, oxygen saturation, respiratory rate, fluid for resuscitation, glasgow coma scale, and revised trauma score (all p values surgical emergencies is common. These patients arrive with deranged physiology which requires complex and prolonged hospital care. Patients who cannot afford treatment are most vulnerable to transfers and delays.
Schultz, Helen; Qvist, Niels; Backer Mogensen, Christian
To investigate the experiences of patients with acute abdominal pain at discharge from an emergency department observation unit compared with discharge from a surgical assessment unit.......To investigate the experiences of patients with acute abdominal pain at discharge from an emergency department observation unit compared with discharge from a surgical assessment unit....
Hee Seung Kang
Full Text Available Early identification of patients with acute diverticulitis who require emergent surgical intervention in the emergency department (ED is important to the physician. Although computed tomography (CT has an important role in evaluating the severity of diverticulitis, its findings alone may not predict the need for emergent surgical intervention in all patients with acute diverticulitis in the ED. Serum inflammation markers may help to differentiate severity of acute diverticulitis and predict the need for surgical intervention in clinical practice. No information is currently available on the clinical usefulness of the delta neutrophil index (DNI, with respect to the prediction of emergent surgical intervention in patients with acute diverticulitis at the ED.This was a retrospective observational study of consecutive adult patients with acute diverticulitis confirmed by CT in the ED, between January 2014 and December 2016. Recruited patients were divided into two groups: emergent surgical intervention and no surgical intervention. The following laboratory serum parameters were examined in the ED: DNI value, C-reactive protein (CRP levels, white blood cell count, neutrophil count, and neutrophil-to-lymphocyte ratio (NLR. The patients were also examined for the presence or absence of complications by CT.A total of 132 patients were finally included in the study, with the emergent surgical intervention group constituting 52 patients. The median DNI value, CRP levels, neutrophil count, and NLR were significantly higher in the emergent surgical intervention group than in the no surgical intervention group. The area under the curve for predicting emergent surgical intervention, using the DNI was significantly higher than that of CRP levels, neutrophil count, or NLR. Moreover, the combination of initial DNI and CT was most powerful diagnostic modality.DNI values measured at the ED combined with CT were good predictors for emergent surgical intervention
Feb 8, 2010 ... Methods: Details of all children (except infants) operated for an acute surgical abdominal condition over a 5-year period were entered ... high morbidity and mortality in TP is attributable to ignorance, poor sanitation and delay in reporting to hospital ..... Loeb M. Risk factors for enteric perforation in patients.
Villodre, Celia; Rebasa, Pere; Estrada, José Luís; Zaragoza, Carmen; Zapater, Pedro; Mena, Luís; Lluís, Félix
In a previous study, we found that Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) overpredicts morbidity risk in emergency gastrointestinal surgery. Our aim was to find a POSSUM equation adjustment. A prospective observational study was performed on 2,361 patients presenting with a community-acquired gastrointestinal surgical emergency. The first 1,000 surgeries constituted the development cohort, the second 1,000 events were the first validation intramural cohort, and the remaining 361 cases belonged to a second validation extramural cohort. (1) A modified POSSUM equation was obtained. (2) Logistic regression was used to yield a statistically significant equation that included age, hemoglobin, white cell count, sodium and operative severity. (3) A chi-square automatic interaction detector decision tree analysis yielded a statistically significant equation with 4 variables, namely cardiac failure, sodium, operative severity, and peritoneal soiling. A modified POSSUM equation and a simplified scoring system (aLicante sUrgical Community Emergencies New Tool for the enUmeration of Morbidities [LUCENTUM]) are described. Both tools significantly improve prediction of surgical morbidity in community-acquired gastrointestinal surgical emergencies. Copyright © 2016 Elsevier Inc. All rights reserved.
Bosscher, Marianne Roberta Frederiek
Oncologic emergencies are acute, potentially life threatening conditions that have developed as a result of malignant disease or cancer treatment. The clinical outcome of patients with symptoms caused by malignant disease is often poor and short term mortality is high. In an emergency situation,
Lowe, Penelope; Naseem, Salma; Bailey, Charles
A 38-year-old healthy Caucasian man presented to the surgical team with a punctured wound on the right side of his scalp. He had been on a month's holiday to Uganda and South Africa. He recalls a painful swelling progressively increasing over 2 weeks. This was associated with sharp shooting pains and swelling on the right side of the face. He sought medical opinion while on holiday. Broad spectrum oral antibiotics were advised. The condition did not settle with the treatment so he consulted his general practitioner (GP) on return. The GP referred him to the surgical team for management of a scalp wound. On examination, a live pulsating larva was seen within a painful 1.5×2 cm puncture wound on the right side of the scalp. The larva was removed. Microbiology identified the larva as Cordylobia anthropophaga. No further treatment was advised. To our knowledge, the patient remains well to date.
Nardi, Marco; Casini, Giamberto; Guidi, Gianluca; Figus, Michele
There is general consensus that surgery gives a better intraocular pressure (IOP) control than medical therapy, but surgery may be affected by complications and failures, and for this reason nowadays, it is reserved to advanced or clearly progressive glaucoma. In recent years, there have been a lot of efforts to enhance safety and efficacy of conventional surgery as to find new techniques more safer and more effective. Actually, this is a field in rapid evolution, and we have a great number of innovative procedures, often working on complete different basis. These procedures are classified according to their mechanism of action and the type of surgical approach, in order to clearly understand of what we are speaking about. From a general point of view, surgical procedures may be divided in procedures that increase outflow and procedures that reduce aqueous production: most of these procedures can be performed with an ab externo or an ab interno approach. The ab interno approach has great advantages and enormous potential of development; probably, its diffusion will be facilitated by the development of new devices for angle visualization. Nevertheless, it is important to remember that actually none of the new procedures has been validated in large controlled clinical trials and none of the new procedures is indicated when IOP target is very low. © 2015 Elsevier B.V. All rights reserved.
Symons, N R A; Moorthy, K; Almoudaris, A M; Bottle, A; Aylin, P; Vincent, C A; Faiz, O D
There is increasing evidence of variable standards of care for patients undergoing emergency general surgery in the National Health Service (NHS). The aim of this study was to quantify and explore variability in mortality amongst high-risk emergency general surgery admissions to English NHS hospital Trusts. The Hospital Episode Statistics (HES) database was used to identify high-risk emergency general surgery diagnoses (greater than 5 per cent national 30-day mortality rate). Adults admitted to English NHS Trusts with these diagnoses between 2000 and 2009 were included in the study. Thirty-day in-hospital mortality was adjusted for patient and hospital factors. Trusts were grouped into high- and low-mortality outliers, and resource availability was compared between high- and low-mortality outlier institutions. Some 367 796 patients admitted to 145 hospital Trusts were included in the study; the 30-day mortality rate was 15·6 per cent (institutional range 9·2-18·2 per cent). Fourteen and 24 hospital Trusts were identified as high- and low-mortality outlier institutions respectively. Intensive care and high-dependency bed resources, as well as greater institutional use of computed tomography (CT), were independent predictors of reduced mortality (P emergency general surgery patients. Equitable access to essential hospital resources may reduce variability in outcomes. © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.
McIntyre, Thomas; Hughes, Christopher D; Pauyo, Thierry; Sullivan, Stephen R; Rogers, Selwyn O; Raymonville, Maxi; Meara, John G
The earthquake that struck Haiti on 12 January 2010 caused significant devastation to both the country and the existing healthcare infrastructure in both urban and rural areas. Most hospital and health care facilities in Port-au-Prince and the surrounding areas were significantly damaged or destroyed. Consequently, large groups of Haitians fled Port-au-Prince for rural areas to seek emergency medical and surgical care. In partnership with the Haitian Ministry of Health, Partners in Health (PIH) and Zanmi Lasante (ZL) have developed and maintained a network of regional and district hospitals in rural Haiti for over twenty-five years. This PIH/ZL system was ideally situated to accommodate the increased need for emergent surgical care in the immediate quake aftermath. The goal of the present study was to provide a cross-sectional assessment of surgical need and care delivery across PIH/ZL facilities after the earthquake in Haiti. We conducted a retrospective review of hospital case logs and operative records over the course of three weeks immediately following the earthquake. Roughly 3,000 patients were seen at PIH/ZL sites by a combination of Haitian and international surgical teams. During that period 513 emergency surgical cases were logged. Other than wound debridement, the most commonly performed procedure was fixation of long bone fractures, which constituted approximately one third of all surgical procedures. There was a significant demand for emergent surgical care after the earthquake in Haiti. The PIH/ZL hospital system played a critical role in addressing this acutely increased burden of surgical disease, and it allowed for large numbers of Haitians to receive needed surgical services. Our experiences reinforce that access to essential surgery is an essential pillar in public health.
Emergency cricothyroidotomy is a potentially life-saving procedure in the \\'cannot intubate cannot ventilate (CICV)\\' scenario. Although surgical cricothyroidotomy remains the technique recommended in many \\'CICV\\' algorithms, the insertion of a tracheostomy as a cannula over a trocar, or using the Seldinger method, may have advantages as they are more familiar to the anaesthetist. We compared the utility of three cuffed cricothyroidotomy devices: cuffed Melker®, Quicktrach 2®, and PCK® devices, with surgical cricothyroidotomy.
Velmahos George C
Full Text Available Abstract The era of the acute care surgeon has arrived and this "new" specialty will be expected to provide trauma care, emergency surgery, and surgical critical care to a variety of patients arriving at their institution. With the exception of practicing bariatric surgeons, many general surgeons have limited experience caring for obese patients. Obese patients manifest unique physiology and pathophysiology, which can influence a surgeon's decision-making process. Following trauma, obese patients sustain different injuries than lean patients and have worse outcomes. Emergency surgery diseases may be difficult to diagnose in the obese patient and obesity is associated with increased complications in the postoperative patient. Caring for an obese patient in the surgical ICU presents a distinctive challenge and may require alterations in care. The following review should act as an overview of the pathophysiology of obesity and how obesity modifies the care of trauma, emergency surgery, and surgical critical care patients.
Moug, S J; Stechman, M; McCarthy, K; Pearce, L; Myint, P K; Hewitt, J
Older patients (>65 years of age) admitted as general surgical emergencies increasingly require improved recognition of their specific needs relative to younger patients. Two such needs are frailty and cognitive impairment. These are evolving research areas that the emergency surgeon increasingly requires knowledge of to improve short- and long-term patient outcomes. This paper reviews the evidence for frailty and cognitive impairment in the acute surgical setting by defining frailty and cognitive impairment, introducing methods of diagnosis, discussing the influence on prognosis and proposing strategies to improve older patient outcomes. Frailty is present in 25% of the older surgical population. Using frailty-scoring tools, frailty was associated with a significantly longer hospital stay and higher mortality at 30 and 90 days after admission to an acute surgical unit. Cognitive impairment is present in a high number of older acute surgical patients (approximately 70%), whilst acute onset cognitive impairment, termed delirium, is documented in 18%. However, patients with delirium had significantly longer hospital stays and higher in-hospital mortality than those with cognitive impairment. Improved knowledge of frailty and delirium by the emergency surgeon allows the specialised needs of older surgical patients to be taken into account. Early recognition, and consideration of minimally invasive surgery or radiological intervention alongside potentially transferable successful elective interventions such as comprehensive geriatric assessment, may help to improve short- and long-term patient outcomes in this vulnerable population.
Loveday, Jonathan; Sachdev, Sonal P; Cherian, Meena N; Katayama, Francisco; Akhtaruzzaman, A K M; Thomas, Joe; Huda, N; Faragher, E Brian; Johnson, Walter D
Evaluate the capacity of government-run hospitals in Bangladesh to provide emergency and essential surgical, obstetric and anaesthetic services. Cross-sectional survey of 240 Bangladeshi Government healthcare facilities using the World Health Organisation Situational Analysis Tool to Assess Emergency and Essential Surgical Care (SAT). This tool evaluates the ability of a healthcare facility to provide basic surgical, obstetric and anaesthetic care based on 108 queries that detail the infrastructure and population demographics, human resources, surgical interventions and reason for referral, and available surgical equipment and supplies. For this survey, the Bangladeshi Ministry of Health sent the SAT to sub-district, district/general and teaching hospitals throughout the country in April 2013. Responses were received from 240 healthcare facilities (49.5% response rate): 218 sub-district and 22 district/general hospitals. At the sub-district level, caesarean section was offered by 55% of facilities, laparotomy by 7% and open fracture repair by 8%. At the district/general hospital level, 95% offered caesarean section, 86% offered laparotomy and 77% offered open fracture treatment. Availability of anaesthesia services, general equipment and supplies reflected this trend, where district/general hospitals were better equipped than sub-district hospitals, though equipment and infrastructure shortages persist. There has been overall impressive progress by the Bangladeshi Government in providing essential surgical services. Areas for improvement remain across all key areas, including infrastructure, human resources, surgical interventions offered and available equipment. Investment in surgical services offers a cost-effective opportunity to continue to improve the health of the Bangladeshi population and move the country towards universal healthcare coverage.
Bosscher, Marianne R F; Bastiaannet, Esther; van Leeuwen, Barbara L; Hoekstra, Harald J
The clinical outcome of patients with oncologic emergencies is often poor and mortality is high. It is important to determine which patients may benefit from invasive treatment, and for whom conservative treatment and/or palliative care would be appropriate. In this study, prognostic factors for clinical outcome are identified in order to facilitate the decision-making process for patients with surgical oncologic emergencies. This was a prospective registration study for patients over 18 years of age, who were consulted for surgical oncologic emergencies between November 2013 and April 2014. Multiple variables were registered upon emergency consultation, and the follow-up period was 90 days. Multivariate logistic regression analysis was performed to identify factors associated with 30- and 90-day mortality. During the study period, 207 patients experienced surgical oncologic emergencies-101 (48.8 %) men and 106 (51.2 %) women, with a median age of 64 years (range 19-92). The 30-day mortality was 12.6 % and 90-day mortality was 21.7 %. Factors significantly associated with 30-day mortality were palliative intent of cancer treatment prior to emergency consultation (p = 0.006), Eastern Cooperative Oncology Group performance score (ECOG-PS) >0 (p for trend: p = 0.03), and raised lactate dehydrogenase (LDH) (p surgical oncologic emergencies. Additional measurements of HGS, LDH, and albumin levels can serve as objective parameters to support the clinical assessment of individual prognosis.
Mentula, Panu J; Leppäniemi, Ari K
Patients undergoing emergency surgery have a high risk for surgical complications and death. The Clavien-Dindo classification has been developed and validated in elective general surgical patients, but has not been validated in emergency surgical patients. The aim of the current study was to evaluate the Clavien-Dindo classification of surgical complications in emergency surgical patients and to study preoperative factors for risk stratification that should be included into a database of surgical complications. A cohort of 444 consecutive patients having emergency general surgery during a three-month period was retrospectively analyzed. Surgical complications were classified according to the Clavien-Dindo classification. Preoperative risk factors for complications were studied using logistic regression analysis. Preoperatively 37 (8.3%) patients had organ dysfunctions. Emergency surgical patients required a new definition for Grade IV complications (organ dysfunctions). Only new onset organ dysfunctions or complications that significantly contributed to worsening of pre-operative organ dysfunctions were classified as grade IV complications. Postoperative complications developed in 115 (25.9%) patients, and 14 (3.2%) patients developed grade IV complication. Charlson comorbidity index, preoperative organ dysfunction and the type of surgery predicted postoperative complications. The Clavien-Dindo classification of surgical complications can be used in emergency surgical patients but preoperative organ dysfunctions should be taken into account when defining postoperative grade IV complications. For risk stratification patients' comorbidities, preoperative organ dysfunctions and the type of surgery should be taken into consideration.
Thomsen, Thordis; Vester-Andersen, Morten; Nielsen, Martin Vedel
AIMS AND OBJECTIVES: To elicit knowledge of patient experiences of postoperative intermediate care in an intensive care unit and standard postoperative care in a surgical ward after emergency abdominal surgery. BACKGROUND: Emergency abdominal surgery is common, but little is known about how...... postoperative intermediate care after emergency abdominal surgery, the InCare trial. DESIGN: A qualitative study with individual semi-structured interviews. METHODS: We analysed interviews using Systematic Text Condensation. RESULTS: Eighteen patients (nine intervention/nine controls) were strategically sampled...... from the InCare trial. Data analysis resulted in three distinct descriptions of intermediate care; two of standard surgical ward care. Intermediate care was described as 'luxury service' or 'a life saver.' The latter description was prevalent among patients with a perceived complicated disease course...
Stokes, Matthew A R; Guest, Glenn D; Mamadi, Perista; Seta, Westin; Yaubihi, Noel; Karawiga, Grace; Naidi, Billy; Watters, David A K
Timely access to emergency and essential surgical care (EESC) and anaesthesia in low- and middle-income countries (LMICs) prevents premature death, minimises lifelong disability and reduces their economic impact on families and communities. Papua New Guinea is one of the poorest countries in the Pacific region, and provides much of its surgical care at a district hospital level. We aimed to evaluate the surgical capacity of a district hospital in PNG and estimate the effectiveness of surgical interventions provided. We performed a prospective study to calculate the number of DALYs averted for 465 patients treated with surgical care over a 3-month period (Sep-Nov 2013) in Alotau Hospital, Milne Bay Province, PNG (pop 210,000). Data were also collected on infrastructure, workforce, interventions provided and equipment available using the World Health Organization's Integrated Management of Emergency and Essential Surgical Care Toolkit, a survey to assess EESC and surgical capacity. We also performed a retrospective one-year audit of surgical, obstetric and anaesthetic care to provide context with regards to annual disease burden treated and surgical activity. EESC was provided by 11 Surgeons/Anaesthetists/Obstetricians (SAO) providers, equating to 5.7 per 100,000 population (including 4 nurse anaesthetists). They performed 783/100,000 procedures annually. Over the 3-month prospective study period, 4954 DALYs were averted by 465 surgical interventions, 52 % of which were elective. This equates to 18,330 DALYs averted annually or, approximately 18 % of the published but estimated disease burden in the Province in the 2013 Global Burden of Disease Study. The overall peri-operative mortality rate was 1.29 %, with 0.41 % for elective procedures and 2.25 % for emergencies. Much of the burden of surgical disease in Papua New Guinea presenting to Alotau General Hospital serving Milne Bay Province can be effectively treated by a small team providing emergency and
Hasan, Wael; Leonard, David; Russell, John
Objectives. To review the current protocols used for management of Ludwig's angina and to assess the efficacy of conservative measures in these cases. Methods. A retrospective review of patients who were admitted to our institution for management of Ludwig's angina between 2003 and 2010. Results. Two patients were identified. Both were managed successfully with conservative measures and close airway observation. None needed an emergency intubation or surgical tracheostomy. There were no morta...
De Plecker, E; Zachariah, R; Kumar, A M V; Trelles, M; Caluwaerts, S; van den Boogaard, W; Manirampa, J; Tayler-Smith, K; Manzi, M; Nanan-N'zeth, K; Duchenne, B; Ndelema, B; Etienne, W; Alders, P; Veerman, R; Van den Bergh, R
In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes. A retrospective analysis of EmOC data (2011 and 2012). A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by 'general practitioners with surgical skills' and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died. Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.
E De Plecker
Full Text Available In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC, we assessed the a characteristics of women at risk of, or with an obstetric complication and their types b the number and type of obstetric surgical procedures and anaesthesia performed c human resource cadres who performed surgery and anaesthesia and d hospital exit outcomes.A retrospective analysis of EmOC data (2011 and 2012.A total of 6084 women were referred for EmOC of whom 2534(42% underwent a major surgical procedure while 1345(22% required a minor procedure (36% women did not require any surgical procedure. All cases with uterine rupture(73 and extra-uterine pregnancy(10 and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61% and normal delivery (34%. A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65% required spinal and 578(23% required general anaesthesia; 2341(92% procedures were performed by 'general practitioners with surgical skills' and in 2451(96% cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97% were discharged, 21(0.8% were referred to tertiary care and 2(0.1% died.Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.
Moroz, Leslie; DiNapoli, Marianne; D'Alton, Mary; Gyamfi-Bannerman, Cynthia
The purpose of this study was to determine whether surgical speed is associated with maternal outcomes in women who have a history of previous cesarean delivery (CD) and who require emergent delivery. This is a secondary analysis of a multicenter, prospective observational study of women with a history of previous CD. Women who attempted a vaginal birth after CD and required emergent CD were dichotomized into those with a skin incision-to-fetal delivery time of ≤2 min (I-D ≤2) or >2 min (I-D >2), based on the mode I-D. Rates of composite maternal complications and specific surgical complications were compared. Seven hundred ninety-three women had an emergency repeat CD: 108 women (13.6%) had I-D ≤2, and 685 women (86.4%) had I-D >2. The composite of maternal morbidity occurred in 36% of women with I-D≤2 and 23% with I-D>2 (P cesarean delivery, surgical speed was associated with an increased risk for maternal complications. Copyright © 2015 Elsevier Inc. All rights reserved.
Dreyer, Jacob; Hannay, Jonathan; Lane, Robert
In Africa surgical trainees (residents) are often 'at the coalface' in managing surgical emergencies. A practical course on management of surgical emergencies was developed, as requested and guided by the learning needs of surgical trainees in East/Central Africa, to teach structured thinking processes in surgical emergencies; to thoroughly assess participants' knowledge, technical and non-technical skills; and to correlate assessment scores with participants' feedback on course quality. Curriculum design was aimed at learners' needs, as guided by local trainers and previous teaching. A 5-day course was developed on emergencies in critical care and trauma, general surgery, orthopaedics, obstetrics and urology; delivered through lectures, tutorials and practical sessions, with individual mentoring. Participants' knowledge was assessed through end-of-course tests and, with their practical and non-technical skills, evaluated formatively. Opportunity for immediate detailed feedback was provided, and for follow-up 6 months later. All participants completed the course successfully, passed knowledge tests, and received satisfactory scores in continuous assessment. There was good correlation between formative and summative assessment scores. Candidates rated course content, delivery and usefulness very highly; 'open text' noted no such previous training. After six months 90 % of course participants indicated that the course had significantly improved their ability to manage surgical emergencies. An intensive course on management of surgical emergencies can be effectively delivered by a small core faculty for each specialty. Feedback from participants and local faculty indicated that this course filled a specific learning niche. Effective assessment can be based on continuous evaluation during course participation.
Crandall, Marie L; Agarwal, Suresh; Muskat, Peter; Ross, Steven; Savage, Stephanie; Schuster, Kevin; Tominaga, Gail T; Shafi, Shahid
Emergent general surgical diseases encompass a broad spectrum of anatomy and pathophysiology, creating challenges for outcomes assessment, research, and surgical training. The goal of this study was to measure anatomic disease severity for eight emergent general surgical diseases using the uniform grading system of the American Association for the Surgery of Trauma (AAST). The Committee on Patient Assessment and Outcomes of AAST applied the previously developed uniform grading system to eight emergent general surgical diseases using a consensus of experts. It was then reviewed and approved by the Board of Managers of AAST. Severity grades for eight commonly encountered emergent general surgical conditions were created: breast abscess, esophageal perforation, infectious colitis, pelvic inflammatory disease, perirectal abscess, pleural space infections, soft tissue infections, and surgical site infections. The range of grades from I through V, reflect progression from mild disease, limited to within the organ itself, to widespread severe disease. This article provides a uniform grading system for measuring anatomic severity of eight emergent general surgical diseases. Consistent adoption of these grades could improve standardization for quality assurance, outcomes research, and surgical training.
Full Text Available Objectives. To review the current protocols used for management of Ludwig's angina and to assess the efficacy of conservative measures in these cases. Methods. A retrospective review of patients who were admitted to our institution for management of Ludwig's angina between 2003 and 2010. Results. Two patients were identified. Both were managed successfully with conservative measures and close airway observation. None needed an emergency intubation or surgical tracheostomy. There were no mortalities, and both had a short hospital stay. Conclusion. Recently, management of Ludwig's angina has evolved from aggressive airway management into a more conservative one. This is based on close airway observation on a specialised airway unit and a serial clinical airway assessment. Improved imaging modalities, antibiotic therapy, surgical skills, and clinical experience are the key factors behind this change in practice.
Hasan, Wael; Leonard, David; Russell, John
Objectives. To review the current protocols used for management of Ludwig's angina and to assess the efficacy of conservative measures in these cases. Methods. A retrospective review of patients who were admitted to our institution for management of Ludwig's angina between 2003 and 2010. Results. Two patients were identified. Both were managed successfully with conservative measures and close airway observation. None needed an emergency intubation or surgical tracheostomy. There were no mortalities, and both had a short hospital stay. Conclusion. Recently, management of Ludwig's angina has evolved from aggressive airway management into a more conservative one. This is based on close airway observation on a specialised airway unit and a serial clinical airway assessment. Improved imaging modalities, antibiotic therapy, surgical skills, and clinical experience are the key factors behind this change in practice. PMID:21760800
Hasan, Wael; Leonard, David; Russell, John
Objectives. To review the current protocols used for management of Ludwig's angina and to assess the efficacy of conservative measures in these cases. Methods. A retrospective review of patients who were admitted to our institution for management of Ludwig's angina between 2003 and 2010. Results. Two patients were identified. Both were managed successfully with conservative measures and close airway observation. None needed an emergency intubation or surgical tracheostomy. There were no mortalities, and both had a short hospital stay. Conclusion. Recently, management of Ludwig's angina has evolved from aggressive airway management into a more conservative one. This is based on close airway observation on a specialised airway unit and a serial clinical airway assessment. Improved imaging modalities, antibiotic therapy, surgical skills, and clinical experience are the key factors behind this change in practice.
Henry, Jaymie A; Orgoi, Sergelen; Govind, Salik; Price, Raymond R; Lundeg, Ganbold; Kehrer, Beat
Provision of surgical care continues to receive little attention and funding despite the growing burden of surgical disease worldwide. In 2004, The World Health Organization (WHO) established the Emergency and Essential Surgical Care (EESC) program, which was designed to strengthen surgical services at the first-referral hospital. There are limited data documenting the implementation and scale-up of such services. We describe the nationwide implementation of the EESC program in Mongolia over a 6 year period. Surgical services were increased in rural areas of Mongolia using the WHO Integrated Management of Emergency and Essential Surgical Care (IMEESC) toolkit from 2004 to 2010. Fund of knowledge tests and program evaluation was done to measure uptake, response, and perceived importance of the program. Two years after the pilot sites were launched, programmatic impact on short-term process measures was evaluated using the WHO Monitoring and Evaluation form. The program was implemented in 14 aimags/provinces (66.67 %) and 178 soum hospitals (52.66 %). Fund of knowledge scores increased from 47.72 % (95 % confidence interval (CI) 40.7-54.7) to 77.9 % (95 % CI 70.1-85.7, p = 0.0001) after the training program. 1 year post-training, there was a 57.1 % increase in the availability of emergency rooms, 59.1 % increase in the supply of emergency kits, a 73.64 % increase in the recording of emergency care cases, and a 46.66 % increase in the provision of facility and instrument usage instructions at the pilot sites. The EESC program was successfully implemented and scaled up at a national level with improvements in short-term process measures.
Johnston, Maximilian J; King, Dominic; Arora, Sonal; Behar, Nebil; Athanasiou, Thanos; Sevdalis, Nick; Darzi, Ara
Outdated communication technologies in healthcare can place patient safety at risk. This study aimed to evaluate implementation of the WhatsApp messaging service within emergency surgical teams. A prospective mixed-methods study was conducted in a London hospital. All emergency surgery team members (n = 40) used WhatsApp for communication for 19 weeks. The initiator and receiver of communication were compared for response times and communication types. Safety events were reported using direct quotations. More than 1,100 hours of communication pertaining to 636 patients were recorded, generating 1,495 communication events. The attending initiated the most instruction-giving communication, whereas interns asked the most clinical questions (P communication compared to the intern and attending (P communication technology. This study lays the foundations for quality improvement innovations delivered over smartphones. Copyright © 2015 Elsevier Inc. All rights reserved.
Full Text Available Abstract Background Hospitals have a critically important role in the management of mass causality incidents (MCI, yet there is little information to assist emergency planners. A significantly limiting factor of a hospital's capability to treat those affected is its surgical capacity. We therefore intended to provide data about the duration and predictors of life saving operations. Methods The data of 20,815 predominantly blunt trauma patients recorded in the Trauma Registry of the German-Trauma-Society was retrospectively analyzed to calculate the duration of life-saving operations as well as their predictors. Inclusion criteria were an ISS ≥ 16 and the performance of relevant ICPM-coded procedures within 6 h of admission. Results From 1,228 patients fulfilling the inclusion criteria 1,793 operations could be identified as life-saving operations. Acute injuries to the abdomen accounted for 54.1% followed by head injuries (26.3%, pelvic injuries (11.5%, thoracic injuries (5.0% and major amputations (3.1%. The mean cut to suture time was 130 min (IQR 65-165 min. Logistic regression revealed 8 variables associated with an emergency operation: AIS of abdomen ≥ 3 (OR 4,00, ISS ≥ 35 (OR 2,94, hemoglobin level ≤ 8 mg/dL (OR 1,40, pulse rate on hospital admission 120/min (OR 1,39, blood pressure on hospital admission Conclusions The mean operation time of 130 min calculated for emergency life-saving surgical operations provides a realistic guideline for the prospective treatment capacity which can be estimated and projected into an actual incident admission capacity. Knowledge of predictive factors for life-saving emergency operations helps to identify those patients that need most urgent operative treatment in case of blunt MCI.
Chun, Stephen G; Pedro, Patrick; Yu, Mihae; Takanishi, Danny M
Retroperitoneal hemorrhagic bleeding is a known manifestation of Type-IV Ehlers-Danlos Syndrome that is caused by loss-of-function mutations of the pro-alpha-1 chains of type III pro-collagen (COL3A1) resulting in vascular fragility. A number of previous reports describe futile surgical intervention for retroperitoneal bleeding in Type-IV Ehlers-Danlos Syndrome with high post-operative mortality, although the rarity of retroperitoneal bleeding associated with Type-IV Ehlers-Danlos Syndrome precludes an evidence-based approach to clinical management. We report a 23-year-old male with history of Type-IV Ehlers-Danlos Syndrome who presented with severe abdominal pain and tachycardia following an episode of vomiting. Further work-up of his abdominal pain revealed massive retroperitoneal bleeding by CT-scan of the abdomen. Given numerous cases of catastrophic injury caused by surgical intervention in Type-IV Ehlers-Danlos Syndrome, the patient was treated non-operatively, and the patient made a full recovery. This case suggests that even in cases of large retroperitoneal hemorrhages associated with Ehlers-Danlos Syndrome, it may not truly represent a surgical emergency. PMID:21966332
Ahmed, Hesham M; Gale, Stephen C; Tinti, Meredith S; Shiroff, Adam M; Macias, Aitor C; Rhodes, Stancie C; Defreese, Marissa A; Gracias, Vicente H
Emergency general surgery (EGS) is increasingly being provided by academic trauma surgeons in an acute care surgery model. Our tertiary care hospital recently changed from a model where all staff surgeons (private, subspecialty academic, and trauma academic) were assigned EGS call to one in which an emergency surgery service (ESS), staffed by academic trauma faculty, cares for all EGS patients. In the previous model, many surgeries were "not covered" by residents because of work-hour restrictions, conflicting needs, or private surgeon preference. The ESS was separate from the trauma service. We hypothesize that by creating a separate ESS, residents can accumulate needed and concentrated operative experience in a well-supervised academic environment. A prospectively accrued EGS database was retrospectively queried for the 18-month period: July 2010 to June 2011. The Accreditation Council for Graduate Medical Education (ACGME) databases were queried for operative numbers for our residency program and for national resident data for 2 years before and after creating the ESS. The ACGME operative requirements were tabulated from online sources. ACGME requirements were compared with surgical cases performed. During the 18-month period, 816 ESS operations were performed. Of these, 307 (38%) were laparoscopy. Laparoscopic cholecystectomy and appendectomy were most common (138 and 145, respectively) plus 24 additional laparoscopic surgeries. Each resident performed, on average, 34 basic laparoscopic cases during their 2-month rotation, which is 56% of their ACGME basic laparoscopic requirement. A diverse mixture of 70 other general surgical operations was recorded for the remaining 509 surgical cases, including reoperative surgery, complex laparoscopy, multispecialty procedures, and seldom-performed operations such as surgery for perforated ulcer disease. Before the ESS, the classes of 2008 and 2009 reported that only 48% and 50% of cases were performed at the main academic
Moore, An'Nita; Fisher, Kathleen
Healthcare information technology in US hospitals and ambulatory care centers continues to expand, and nurses are expected to effectively and efficiently utilize this technology. Researchers suggest that clinical information systems have expanded the realm of nursing to integrate technology as an element as important in nursing practice as the patient or population being served. This study sought to explore how medical surgical nurses make use of healthcare information technology in their current clinical practice and to examine the influence of healthcare information technology on nurses' clinical decision making. A total of eight medical surgical nurses participated in the study, four novice and four experienced. A conventional content analysis was utilized that allowed for a thematic interpretation of participant data. Five themes emerged: (1) healthcare information technology as a care coordination partner, (2) healthcare information technology as a change agent in the care delivery environment, (3) healthcare information technology-unable to meet all the needs, of all the people, all the time, (4) curiosity about healthcare information technology-what other bells and whistles exist, and (5) Big Brother is watching. The results of this study indicate that a new care partnership has emerged as the provision of nursing care is no longer supplied by a single practitioner but rather by a paired team, consisting of nurses and technology, working collaboratively in an interdependent relationship to achieve established goals.
Dumont, Frédéric; Mazouni, Chafika; Bitsakou, Georgina; Morice, Philippe; Goéré, Diane; Honoré, Charles; Elias, Dominique
The purpose of the study was to propose a clinical decision-making tool for predicting mortality in patients undergoing emergency abdominal surgery with a palliative intent in the oncology setting. Identification of all emergency surgical procedures performed in a Department of Oncologic Surgery in a Comprehensive Cancer Center between January 2008 and January 2013. Multivariate logistic and Cox regression models were used to identify factors predicitve of mortality at 3 months and survival probabilities. Models were internally validated using bootstrapping and calibration. The mortality rates were 30% at 1 month, 46.7% at 3 months and 83.3% at the end of the study. One model based on the albumin level and the P-POSSUM score (AUC: 0.725) adequately predicted mortality at 3 months. A survival nomogram predicted mortality with a concordance index (CI) of 0.718, using the following factors: WHO performance status (P = 0.02), albumin level (P surgical decision making should be based on the use of these tools. © 2014 Wiley Periodicals, Inc.
Romics, Laszlo Jr
OBJECTIVE: To outline the emerging significance of Toll-like receptor (TLR) signaling pathways in surgical diseases. DATA SOURCES: A systematic review of the literature was undertaken by searching the MEDLINE database for the period 1966 to 2005 without language restriction. STUDY SELECTION: Original or review articles that described experimental data on the activation of TLR signaling pathways in surgically relevant diseases were selected for inclusion in this review. DATA EXTRACTION: Data were obtained from peer-reviewed articles and references. DATA SYNTHESIS: The role of TLRs in the recognition of pathogens renders them a key figure in the activation of both innate and adaptive immune responses during sepsis. However, emerging evidence points to fundamentally important roles in ulcerative colitis, Crohn disease, and Helicobacter pylori infection in the gastrointestinal tract and in the development of atherosclerotic plaques in the cardiovascular system. Furthermore, recent studies suggest that the regulation of the TLR pathway fulfills a central role in anticancer immunotherapy and in organ rejection after transplantation. CONCLUSION: Given the clinical significance of TLR pathways, the targeting of individual molecular components is likely to offer a broad range of future therapeutic modalities.
Chawla, Kashmira S; Rutkow, Lainie; Garber, Kent; Kushner, Adam L; Stewart, Barclay T
Access to quality and timely emergency and essential surgical care and anesthesia (EESCA) is an integral component of the right to health as reinforced by the ratification of the World Health Assembly Resolution 68.15. However, this resolution is merely a guideline and has not been able to bolster the necessary political will to promote EESCA. Our objective was to evaluate international treaties, which carry legal obligations, for EESCA-related text, and develop a human rights-based framework to support EESCA advancement and advocacy. We conducted a comprehensive review of all the UN Treaty Collection-Certified True Copies (CTCs) of multilateral treaties database from December 2015 to April 2016. The relevant text was manually searched to abstract and analyze to identify major themes supporting a human rights-based approach to EESCA. Multiple treaties in the UN database addressed EESCA in the areas of human rights, refugees and stateless persons, health, penal matters, and disarmament. A total of 13 treaties containing 23 articles had language that endorsed aspects of EESCA. The three major themes, supported by the phraseology in the treaties, included: (1) equal access to EESCA (eight articles); (2) timely care of injured and those with emergency surgical conditions (eight articles); and (3) protection, rehabilitation, psychosocial support, and social security (seven articles). A number of United Nations multilateral treaties support available and equitable EESCA. These findings can be used to galvanize support and encourage signatory Member States to promote and implement EESCA development initiatives.
Wong, Michael Kien Yee; Sivasegaran, Daveraj; Choo, Candy Suet Cheng; Nah, Shireen Anne
This study evaluates usage patterns of online health information in parents with children undergoing elective or emergency surgical procedures. We prospectively surveyed parents of children admitted to our institution for common emergency (appendicectomy, abscess drainage, gonadal torsion) or elective (herniotomy, orchidopexy) operations between March and September 2016. Each completed an anonymized modification of a previously published survey comprising 19 questions on demographic data, Internet usage, and review of Internet resources. Chi-square tests were used for categorical data with p information in elective ( n = 27; 54%) and emergency groups ( n = 24;70.6%) than general practitioners or other health care workers. When condition-specific online information was sought, more than 95% felt that the information concurred with the doctor's. Most common reasons were for more information on the condition ( n = 56; 90.3%) and on medical treatment ( n = 52; 83.9%). Eighteen (18/62; 29%) parents reported excessively technical information. No significant difference in behavior was found comparing elective and emergency groups. Approximately one quarter of parents do not access condition-specific online medical information despite high Internet penetration rates. More than half depend on friends and family for additional information, reflecting societal and cultural norms in our population. Surgeons must incorporate awareness of these behaviors during counselling. Georg Thieme Verlag KG Stuttgart · New York.
Ozdemir, B A; Sinha, S; Karthikesalingam, A; Poloniecki, J D; Pearse, R M; Grocott, M P W; Thompson, M M; Holt, P J E
Variations in patient outcomes between providers have been described for emergency admissions, including general surgery. The aim of this study was to investigate whether differences in modifiable hospital structures and processes were associated with variance in mortality, amongst patients admitted for emergency colorectal laparotomy, peptic ulcer surgery, appendicectomy, hernia repair and pancreatitis. Adult emergency admissions in the English NHS were extracted from the Hospital Episode Statistics between April 2005 and March 2010. The association between mortality and structure and process measures including medical and nursing staffing levels, critical care and operating theatre availability, radiology utilization, teaching hospital status and weekend admissions were investigated. There were 294 602 emergency admissions to 156 NHS Trusts (hospital systems) with a 30-day mortality of 4.2%. Trust-level mortality rates for this cohort ranged from 1.6 to 8.0%. The lowest mortality rates were observed in Trusts with higher levels of medical and nursing staffing, and a greater number of operating theatres and critical care beds relative to provider size. Higher mortality rates were seen in patients admitted to hospital at weekends [OR 1.11 (95% CI 1.06-1.17) Psurgical doctors [1.07 (1.01-1.13) P=0.019] and with lower nursing staff ratios [1.07 (1.01-1.13) P=0.024]. Significant differences between Trusts were identified in staffing and other infrastructure resources for patients admitted with an emergency general surgical diagnosis. Associations between these factors and mortality rates suggest that potentially modifiable factors exist that relate to patient outcomes, and warrant further investigation. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: email@example.com.
Leodoro, Basil M; Beasley, Spencer W; Maoate, Kiki
Conventional surgical aid to emerging countries often does little to build capacity or infrastructure. An evolving model in the South Pacific has been designed to promote local expertise by training local surgeons to a high standard and helping establish sustainable pediatric surgical services in those regions. This review identifies the key elements required to improve and expand local specialist pediatric surgical capacity in Vanuatu. It highlights some of the challenges that face external agencies in helping to create sufficient local infrastructure to achieve these goals and describes how the impediments can be overcome. We conducted a review of the program that provides a sustainable pediatric surgical service to the small and poor Pacific nation of Vanuatu through the involvement and support of the Pacific Island Project administered by the Royal Australasian College of Surgeons. A needs assessment must be done from the recipient's perspective and can be achieved by collaboration between an external agency and existing local surgeons. The key to a sustainable service is identifying and training high quality young indigenous doctors early and providing mentorship and support, including after their return. A sustainable and viable service requires an adequately resourced position for the new surgeons(s) within a framework of a long term strategic plan for the specialty and adequate infrastructure in place on their return. Development of rapport with government and influencing strategic health priorities is a prerequisite of a new national specialty service. (1) Establishing long term viable pediatric surgical capability can only be achieved through the local health system with local leadership and ownership. (2) Internal capability includes governance, alignment with ministry of health priorities and policies, and effective clinical leadership. (3) Selection of person(s) to be trained is best done early, and he/she must be supported throughout training and
Reynolds, Joshua C; Menegazzi, James J; Yealy, Donald M
A journal impact factor represents the mean number of citations per article published. Designed as one tool to measure the relative importance of a journal, impact factors are often incorporated into academic evaluation of investigators. The authors sought to determine how impact factors of emergency medicine (EM) journals compare to journals from other medical and surgical specialties and if any change has taken place over time. The 2010 impact factors and 5-year impact factors for each journal indexed by the Thomson Reuters ISI Web of Knowledge Journal Citation Reports (JCR) were collected, and EM, medical, and surgical specialties were evaluated. The maximum, median, and interquartile range (IQR) of the current impact factor and 5-year impact factor in each journal category were determined, and specialties were ranked according to the summary statistics. The "top three" impact factor journals for each specialty were analyzed, and growth trends from 2001 through 2010 were examined with random effects linear regression. Data from 2,287 journals in 31 specialties were examined. There were 23 EM journals with a current maximum impact factor of 4.177, median of 1.269, and IQR of 0.400 to 2.176. Of 23 EM journals, 57% had a 5-year impact factor available, with a maximum of 4.531, median of 1.325, and IQR of 0.741 to 2.435. The top three EM journals had a mean standard deviation (±SD) impact factor of 3.801 (±0.621) and median of 4.142 and a mean (±SD) 5-year impact factor of 3.788 (±1.091) and median of 4.297, with a growth trend of 0.211 (95% confidence interval [CI] = 0.177 to 0.245; p journals ranked no higher than 24th among 31 specialties. Emergency medicine journals rank low in impact factor summary statistics and growth trends among 31 medical and surgical specialties. © 2012 by the Society for Academic Emergency Medicine.
The confounding effect of the development of idiopathic orthostatic edema and thyrotoxcosis on weight fluctuation related to effects on free water clearance in a woman with long-standing surgically induced panhypopituitarism and diabetes insipidus.
Check, J H; Weidner, J
To evaluate the effect of idiopathic orthostatic edema and the effect of thyrotoxicosis on weight fluctuation and fluid retention in the presence of surgically induced panhypopituitarism and diabetes insipidus controlled with hormone replacement. Dextroamphetamine sulfate was used for weight gain when no other etiologic factor was found. Methimazole was used when weight loss occurred when serum T4 and free T4 indicated thyrotoxicosis. Sympathomimetic amine therapy very effectively controlled the weight gain and methimazole controlled the weight loss. Hypopituitarism and diabetes insipidus controlled with hormone replacement do not protect against fluid retention from idiopathic edema.
Sand, Michael; Bechara, Falk-Georges; Sand, Daniel; Mann, Benno
In-flight medical and surgical emergencies (IMEs) onboard commercial aircrafts occur quite commonly. However, little epidemiological research exists concerning these incidents. Thirty-two European airlines were asked to provide anonymous data on medical flight reports of IMEs for the years 2002 to 2007. The total number of incidents was correlated to revenue passenger kilometers (rpk). Additionally, on-board births and deaths, flight diversions, flight routes (continental/intercontinental) and involvement of a physician or medical professional in providing therapy were analysed. Only four airlines, of which two participated in this study, were able to provide the necessary data. A total of 10,189 cases of IMEs were analysed. Syncope was the most common medical condition reported (5307 cases, 53.5%) followed by gastrointestinal disorders (926 cases, 8.9%) and cardiac conditions (509 cases, 4.9%). The most common surgical conditions were thrombosis (47 cases, 0.5%) and appendicitis (27 cases, 0.25%). In 2.8% of all IMEs, an aircraft diversion was performed. In 86% of cases, a physician or medical professional was involved in providing therapy. A mean (standard deviation) of 14 (+/- 2.3, 10.8 to 16.6 interquartile range) IMEs per billion rpk was calculated. The study demonstrates that although aviation is regulated by a variety of national and international laws, standardised documentation of IMEs is inadequate and needs further development.
Symons, Nicholas R A; Moorthy, Krishna; Vincent, Charles A
Emergency general surgery (EGS) is responsible for 80-90% of surgical in-hospital deaths and the early management of these unwell patients is critical to improving outcomes. Unfortunately care for EGS patients is often fragmented and important care processes are frequently omitted. This study aimed to define a group of important processes during EGS admission and assess their reliability. Literature review and semi-structured interviews were used to define a draft list of processes, which was refined and validated using the Delphi consensus methodology. A prospective cohort study of the 22 included processes was performed in 315 patients across 5 acute hospitals. Prospective study of the 22 selected processes demonstrated omission of 1130/5668 (19.9%) processes. Only 6 (1.9%) patients had all relevant processes performed correctly. Administration of oxygen to hypoxic patients (82/129, 64%), consultant review (202/313, 65%) and administration of antibiotics within 3 h for patients with severe sepsis (41/60, 68%) were performed particularly poorly. There were significant differences in the mean number of omissions per patient between hospitals ( F = 11.008, p surgical team and the implementation of multiple interventions to improve the effectiveness of the admission phase of care. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Dresser, Caleb; Periyanayagam, Usha; Dreifuss, Brad; Wangoda, Robert; Luyimbaazi, Julius; Bisanzo, Mark
Acute surgical care services in rural Sub-Saharan Africa suffer from human resource and systemic constraints. Developing emergency care systems and task sharing aspects of acute surgical care addresses many of these issues. This paper investigates the degree to which specialized non-physicians practicing in a dedicated Emergency Department contribute to the effective and efficient management of acute surgical patients. This is a retrospective review of an electronic quality assurance database of patients presenting to an Emergency Department in rural Uganda staffed by non-physician clinicians trained in emergency care. Relevant de-identified clinical data on patients admitted directly to the operating theater from 2011 to 2014 were analyzed in Microsoft Excel. Overall, 112 Emergency Department patients were included in the analysis and 96% received some form of laboratory testing, imaging, medication, or procedure in the ED, prior to surgery. 72% of surgical patients referred by ED received preoperative antibiotics, and preoperative fluid resuscitation was initiated in 65%. Disposition to operating theater was accomplished within 3 h of presentation for 73% of patients. 79% were successfully followed up to assess outcomes at 72 h. 92% of those with successful follow-up reported improvement in their clinical condition. The confirmed mortality rate was 5%. Specialized non-physician clinicians practicing in a dedicated Emergency Department can perform resuscitation, bedside imaging and laboratory studies to aid in diagnosis of acute surgical patients and arrange transfer to an operating theater in an efficient fashion. This model has the potential to sustainably address structural and human resources problems inherent to Sub-Saharan Africa's current acute surgical care model and will benefit from further study and expansion.
McCulloch, Peter; Kreckler, Simon; New, Steve; Sheena, Yezen; Handa, Ashok; Catchpole, Ken
Emergency surgical patients are at high risk for harm because of errors in care. Quality improvement methods that involve process redesign, such as “Lean,” appear to improve service reliability and efficiency in healthcare. Interrupted time series. The emergency general surgery ward of a university hospital in the United Kingdom. Seven safety relevant care processes. A Lean intervention targeting five of the seven care processes relevant to patient safety. 969 patients were admitted during the four month study period before the introduction of the Lean intervention (May to August 2007), and 1114 were admitted during the four month period after completion of the intervention (May to August 2008). Compliance with the five process measures targeted for Lean intervention (but not the two that were not) improved significantly (relative improvement 28% to 149%; PLean can substantially and simultaneously improve compliance with a bundle of safety related processes. Given the interconnected nature of hospital care, this strategy might not translate into improvements in safety outcomes unless a system-wide approach is adopted to remove barriers to change.
Abebe, Engida; Teshome, Henok; Bekele, Mahteme
Referral is part of patient care when done appropriately. Common reasons for referral include seeking expert advice, technical examination and/or intervention, care beyond the facility’s capacity. Objectives: Determine the rate, reason for and type of cases referred among patients seen at surgical Emergency Room of SPHMMC during May to July 2015. Cross sectional study was done at St. Paul’s Hospital Millennium Medical College Emergency Room, including all surgical patients seen in three months period. Data was collected from the individual patient’s medical records, records of the ER and the liaison office and Interns morning reporting book. Data was analyzed with SPSS version 20. Total of 2,492 patients were seen. The mean number of patients seen per day was 27.7 with a range from 13 to 51. Trauma made 70% (1746) of all cases seen. Cases that needed admission made 30.1% (755), but only 49.5 % (374) of them were admitted. The overall referral rate was 15.3%. The referral rate in patients who needed admission was 50.5 % (381). Trauma made 77.4% (295) of the referrals, mainly orthopedic, 54.6% (161) and neuro-traumas, 38% (112). Among non trauma cases acute abdominal conditions tops, 75% (56). Lack of inpatient beds was the main reason for referral 65.6% (250). Specialist care need was the reason for referral in 34.5% (131) of cases. Among patients referred only 14.4% (55) left the hospital at the time of referrals. Four percent (13) of the kept patients died in the ER waiting for referrals. The rate of referral from St. Paul’s Hospital Millennium Medical College Emergency Room is high. It is higher in trauma cases, specifically orthopedic and neuro-traumas. Main reason for referrals was lack of bed. The capacity of the hospital and other hospitals in AA in absorbing traumas, specifically orthopedic and neurotraumas need to be evaluated and necessary policy adjustments should be implemented. Further study at each hospital and the whole city gives better
Ferrah, Noha; Stephan, Karen; Lovell, Janaka; Ibrahim, Joseph; Beiles, Barry
Adequate surgical care of patients and concurrent training of residents is achieved in elective procedures through careful case selection and adequate supervision. Whether this applies when trainees are involved in emergency operations remains equivocal. The aim of this study was therefore to compare the risk of post-operative complications following emergency procedures performed by senior operators compared with supervised trainees. This is a retrospective cohort study examining in-hospital deaths of patients across all surgical specialties who underwent emergency surgery in Australian public hospitals reported to the national surgical mortality audit between 2009 and 2015. Multivariable logistic regression was used to explore whether there was an association between the level of operator experience (senior operator vs trainee) and the occurrence of post-operative surgical complications following an emergency procedure. Our population consisted of 6920 patients. There were notable differences between the trainees and senior operator groups; trainees more often operated on patients aged over 80 years, with cardiovascular and neurological risk factors. Senior operators more often operated on very young and obese patients with advanced malignancy and hepatic disease. Supervised trainees had a lower rate of post-operative complications compared with senior operators; 18% (n = 396) and 25% (n = 1210), respectively (p emergency operations, provided that cases are judiciously selected.
Vester-Andersen, Morten; Lundstrøm, Lars Hyldborg; Buck, David Levarett; Møller, Morten Hylander
In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing emergency abdominal surgery in general. All in-patients aged ≥ 18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including surgical delay and 90-day mortality were collected. The crude and adjusted association between surgical delay by hour and 90-day mortality was assessed by binary logistic regression. A total of 2803 patients were included. Median age (interquartile range [IQR]) was 66 (51-78) years, and 515 patients (18.4%) died within 90 days of surgery. Over the first 24 h after hospital admission, each hour of surgical delay beyond hospital admission was associated with a median (IQR) decrease in 90-day survival of 2.2% (1.9-3.3%). No statistically significant association between surgical delay by hour and 90-day mortality was shown; crude and adjusted odds ratio with 95% confidence interval 1.016 (1.004-1.027) and 1.003 (0.989-1.017), respectively. Sensitivity analyses confirmed the primary finding. In the present population-based cohort study of high-risk patients undergoing emergency abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted.
Su, H Y; Wang, M J; Li, Y H; Tang, C N; Tsai, M J
To investigate the clinical predictors and the aetiologies for surgery in patients with Naja atra (Taiwan or Chinese cobra) envenomation. This case series was conducted in the only tertiary care centre in eastern Taiwan. Patients who presented to the emergency department with Naja atra bite between January 2008 and September 2014 were included. Clinical information was collected and compared between surgical and non-surgical patients. A total of 28 patients with Naja atra envenomation presented to the emergency department during the study period. Of these, 60.7% (n=17) required surgery. Necrotising fasciitis (76.5%) was the main finding in surgery. Comparisons between surgical and non-surgical patients showed skin ecchymosis (odds ratio=34.36; 95% confidence interval, 2.20-536.08; P=0.012) and a high total dose of antivenin (≥6 vials; odds ratio=14.59; 95% confidence interval, 1.10-192.72; P=0.042) to be the most significant predictors of surgery. The rate of bacterial isolation from the surgical wound was 88.2%. Morganella morganii (76.5%), Enterococcus faecalis (58.8%), and Bacteroides fragilis (29.4%) were the most common pathogens involved. Bacterial susceptibility testing indicated that combined broad-spectrum antibiotics were needed to cover mixed aerobic and anaerobic bacterial infection. Patients with Naja atra envenomation who present with skin ecchymosis or the need for a high dose of antivenin may require early surgical assessment. Combined broad-spectrum antibiotics are mandatory.
Vester-Andersen, Morten; Lundstrøm, Lars Hyldborg; Buck, David Levarett
OBJECTIVE: In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing ...... abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted.......OBJECTIVE: In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing...... emergency abdominal surgery in general. MATERIAL AND METHODS: All in-patients aged ≥18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including...
Álvarez Llano, Laura; Rey Valcárcel, Cristina; Mohamed Al-Lal, Yusef; Sánchez Rodríguez, Teresa; García Marín, Andrés; Pérez Díaz, María Dolores; Turégano Fuentes, Fernando
Drug trafficking by means of introducing packets of illegal substances in body cavities carries a risk of suffering from a gastrointestinal obstruction and/or severe poisoning in the person who transports them. Spain is considered as the port of entry to Europe for drugs, and some Spanish hospitals have experience in managing these types of patients. Two hospitals in Madrid, including the Gregorio Marañón University General Hospital (HGUGM), received these potential patients from the Madrid Barajas airport. To analyse the results of the conservative treatment and the need for surgery in "body-packers". A retrospective, observational study of patients diagnosed as a body-packer between January 2000 and December 2008. Those with gastrointestinal symptoms, signs of poisoning, or positive for drugs of abuse, were admitted to the Custodial Unit of our hospital. The conservative treatment consisted of digestive rest and imaging studies until expulsion from the body. Asymptomatic patients were discharged from the Emergency Department. A total of 549 patients, with a median age of 31 years, and of whom 81% were males, were hospitalised during this period. Less than half (40%) showed positive for drugs in the urine, with cocaine in 80% of the cases. Of the 549 patients with initial conservative treatment, 27 (4.9%) had serious complications (16, bowel obstruction, and 11 with signs of poisoning). Of these, 23 required surgery (the 16 obstructions and 7 of the poisonings); 2 were successfully treated in ICU, and 2 died before surgery (0.4%) of the cases. The most frequent surgical treatment was enterotomy and/or gastrostomy to extract the packets. Thirteen (56%) of those operated on had associated morbidity (11 abdominal infections and 2 nosocomial infections). Conservative treatment is safe in 95% of the patients. A small percentage required surgical treatment, basically for gastrointestinal obstruction or severe poisoning. Copyright © 2011 AEC. Published by Elsevier
Cihoric, Mirjana; Toft Tengberg, Line; Bay-Nielsen, Morten
BACKGROUND: With current literature quoting mortality rates up to 45%, emergency high-risk abdominal surgery has, compared with elective surgery, a significantly greater risk of death and major complications. The Surgical Apgar Score (SAS) is predictive of outcome in elective surgery, but has never...
M. Fernanda Bellolio
Full Text Available Introduction: Compassion fatigue (CF is the emotional and physical burden felt by those helping others in distress, leading to a reduced capacity and interest in being empathetic towards future suffering. Emergency care providers are at an increased risk of CF secondary to their first responder roles and exposure to traumatic events. We aimed to investigate the current state of compassion fatigue among emergency medicine (EM resident physicians, including an assessment of contributing factors. Methods: We distributed a validated electronic questionnaire consisting of the Professional Quality of Life Scale with subscales for the three components of CF (compassion satisfaction, burnout and secondary traumatic stress, with each category scored independently. We collected data pertaining to day- versus night-shift distribution, hourly workload and child dependents. We included residents in EM, neurology, orthopedics, family medicine, pediatrics, obstetrics, and general surgery. Results: We surveyed 255 residents, with a response rate of 75%. Of the 188 resident respondents, 18% worked a majority of their clinical shifts overnight, and 32% had child dependents. Burnout scores for residents who worked greater than 80 hours per week, or primarily worked overnight shifts, were higher than residents who worked less than 80 hours (mean score 25.0 vs 21.5; p=0.013, or did not work overnight (mean score 23.5 vs 21.3; p=0.022. EM residents had similar scores in all three components of CF when compared to other specialties. Secondary traumatic stress scores for residents who worked greater than 80 hours were higher than residents who worked less than 80 hours (mean score 22.2 vs 19.5; p=0.048, and those with child dependents had higher secondary traumatic stress than those without children (mean score 21.0 vs 19.1; p=0.012. Conclusion: CF scores in EM residents are similar to residents in other surgical and medical specialties. Residents working primarily
Chianakwana, Gabriel U; Ihegihu, Chima C; Okafor, Pius I S; Anyanwu, Stanley N C; Mbonu, Okechukwu O
The goal of this study was to examine the adult surgical emergencies seen at the Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, with a view to proffering preventive solutions where appropriate and improving outcome. From the register of patients seen at the Casualty department and from the operations register in the main operation room of NAUTH, names and hospital numbers of adult patients treated as emergencies over a 5-year period, from 7 September 1998 to 6 September 2003, were obtained. The hospital folders were then retrieved from the Records Department. From each folder, the following details about each patient were extracted: age, sex, diagnosis at presentation, causative factors, treatment given, and outcome. A total of 902 adult patients were treated during the period. The commonest emergency operation was appendectomy for acute appendicitis in 139 patients (97 women and 42 men), followed closely by road traffic accidents (RTAs) involving 137 patients (103 men and 34 women). Gunshot injuries, which resulted mainly from armed robbery attacks, accounted for 127 cases. More men (113) sustained gunshot injuries than women (14). Of the 92 cases of acute intestinal obstruction seen, 62 occurred in women and 30 in men. Some 126 men presented with acute urinary retention, and two others presented with priapism. Governments at various levels should provide modern diagnostic tools for the accurate preoperative diagnosis of surgical emergencies in hospitals. Governments should also inculcate strict discipline into drivers using the highways, particularly in relation to abuse of alcohol and drugs. Good roads and adequate security should be provided for the people. The need for Pre-Hospital Care for the efficient evacuation of accident victims is emphasized. These measures will help to improve the management and outcome of surgical emergencies, and decrease the number of surgical emergencies resulting from RTAs and gunshot wounds.
Inaba, Kenji; Okoye, Obi; Aksoy, Hande; Skiada, Dimitra; Ault, Glenn; Sener, Stephen; Lam, Lydia; Benjamin, Elizabeth; Demetriades, Demetrios
To prospectively evaluate the ability of radio frequency detection (RFD) system-embedded sponges to mitigate the incidence of retained surgical sponges (RSS) after emergency surgery. Emergency surgery patients are at high risk for retained foreign bodies. All emergent trauma and nontrauma cavitary operations over a 5-year period (January 2010-December 2014) were prospectively enrolled. For damage-control procedures, only the definitive closure was included. RFD sponges were used exclusively throughout the study period. Before closure, the sponge and instrument count was followed by RFD scanning and x-ray evaluation for retained sponges. RSS and near-misses averted using the RFD system were analyzed. In all, 2051 patients [median (range)], aged 41 (1-101) years, 72.2% male, 46.8% trauma patients, underwent 2148 operations (1824 laparotomy, 100 thoracotomy, 30 sternotomy, and 97 combined). RFD detected retained sponges in 11 (0.5%) patients (81.8%laparotomy, 18.2% sternotomy) before cavitary closure. All postclosure x-rays were negative. No retained sponges were missed by the RFD system. Body mass index was 29 (23-43), estimated blood loss 1.0 L (0-23), and operating room time 160 minutes (71-869). Procedures started after 18:00 to 06:00 hours in 45.5% of the patients. The sponge count was incorrect in 36.4%, not performed due to time constraints in 45.5%, and correct in 18.2%. The additional cost of using RFD-embedded disposables was $0.17 for a 4X18 laparotomy sponge and $0.46 for a 10 pack of 12ply, 4X8. Emergent surgical procedures are high-risk for retained sponges, even when sponge counts are performed and found to be correct. Implementation of a RFD system was effective in preventing this complication and should be considered for emergent operations in an effort to improve patient safety.
Hall, Nigel; Durell, Jonathan; Drewett, Melanie; Paramanantham, Kujan; Burge, David
Objective: identify the proportion of infants born at <26 completed weeks gestation that require emergency laparotomy and review the surgical pathology, incidence of subsequent surgical procedures, and outcomeDesign: retrospective cohort review Setting: tertiary neonatal surgical unitPatients: all infants born at < 26 weeks gestation in a neonatal network over an 8 year periodResults: Of 381 infants, laparotomy was indicated in 61 (16%) and performed in 57. Surgical pathology encounter...
Benjamin B. Albert
Full Text Available Marine oils gained prominence following the report that Greenland Inuits who consumed a high-fat diet rich in long-chain n-3 polyunsaturated fatty acids (PUFAs also had low rates of cardiovascular disease. Marine n-3 PUFAs have since become a billion dollar industry, which will continue to grow based on current trends. However, recent systematic reviews question the health benefits of marine oil supplements, particularly in the prevention of cardiovascular disease. Marine oils constitute an extremely complex dietary intervention for a number of reasons: i the many chemical compounds they contain; ii the many biological processes affected by n-3 PUFAs; iii their tendency to deteriorate and form potentially toxic primary and secondary oxidation products; and iv inaccuracy in the labelling of consumer products. These complexities may confound the clinical literature, limiting the ability to make substantive conclusions for some key health outcomes. Thus, there is a pressing need for clinical trials using marine oils whose composition has been independently verified and demonstrated to be minimally oxidised. Without such data, it is premature to conclude that n-3 PUFA rich supplements are ineffective.
Groenwold, Rolf H. H.; Hak, Eelko; Hoes, Arno W.
PURPOSE: In observational studies on influenza vaccine effectiveness, confounding variables such as individual chronic diseases often are pooled before inclusion into a multivariable regression model. It has been suggested, however, that the pooling of confounders induces residual confounding,
Mouton, J; Houdre, H; Beccari, R; Tarissi, N; Autran, M; Auquit-Auckbur, I
The SHAM Insurance Company in Lyon, France, estimated that inadequate hand wound exploration in the emergency room (ER) accounted for 10% of all ER-related personal injury claims in 2013. The objective of this study was to conduct a critical analysis of 80 claims that were related to hand wound management in the ER and led to compensation by SHAM. Eighty claims filed between 2007 and 2010 were anonymised then included into the study. To be eligible, claims had to be filed with SHAM, related to the ER management of a hand wound in an adult, and closed at the time of the study. Claims related to surgery were excluded. For each claim, we recorded 104 items (e.g., epidemiology, treatments offered, and impact on social and occupational activities) and analysed. Of the 70 patients, 60% were manual workers. The advice of a surgeon was sought in 16% of cases. The most common wound sites were the thumb (33%) and index finger (17%). Among the missed lesions, most involved tendons (74%) or nerves (29%). Many patients had more than one reason for filing a claim. The main reasons were inadequate wound exploration (97%), stiffness (49%), and dysaesthesia (41%). One third of patients were unable to return to their previous job. Mean sick-leave duration was 148 days and mean time from discharge to best outcome was 4.19%. Most claims (79%) were settled directly with the insurance company, 16% after involvement of a public mediator, and 12% in court. The mean compensatory damages award was 4595Euros. Inadequate surgical exploration of hand wounds is common in the ER, carries a risk of lasting and sometimes severe residual impairment, and generates considerable societal costs. IV. Copyright Â© 2016. Published by Elsevier Masson SAS.
Determine the usefulness of a Moodle-type education platform for knowledge development with residents in the medical and surgical emergencies (MSE) specialty. This quasi-experimental study compared the departmental evaluations of MSE residents in two Mexican hospital units after they did their academic work using different educational strategies. The control group used a traditional format (classroom-style teaching with guided discussion), while the comparison group had access to a variety of resources (forums, chat, wikis, downloaded files) on a Moodle-type platform. Nonparametric statistics were used. The study was conducted during the 2010 - 2011 and 2011 - 2012 academic years. Three versions of the course were made available online, geared to the academic level of the residents (first, second, or third year). There were statistically significant differences in the mid-year evaluations, and improvements were even greater in the evaluations at the end of the academic year, especially for the third-year residents. In both academic years, the mid-year evaluations reported that only one resident in the control group performed within the average range, while the majority were in the lower range. The resources most used with the platform Moodle were downloaded files (77%) and the forum (63%). Still, 46.4% of the residents said that they encountered some type of limitation when they used the platform, the main one being lack of time (76.9%). The Moodle-type education platform appears to be useful and to offer greater opportunities for knowledge development compared with the traditional strategies. It is recommended that educational strategies based on Moodle-type platforms be implemented for MSE and other medical specialties.
The rupture of the biceps tendon has either thraumatic or spontaneous degenerative etiology. Degenerative tears can occur during physiological abduction of shoulder, just it has been verified in woman affected by arthromyalgic chronic pain, due to arthrosis, or lifting light weight, like the second case showed Clinical suspect has been confirmed by ultrasound in emergency, validating surgical decision, that's the only treatment for this kind of pathology (arthroscopic or wide open surgery).
Jaramov, N; Sokolov, M; Angelov, K; Toshev, S; Petrov, B
estimating the prevalence of colonic diverticulosis and its complications studied at the clinic for 10-years period as well as the approaches for its operative treatment and analysis of the subsequent results. CASES AND APPROACHES: During the period 1998-2008 56 patients were hospitalized (31 women and 25 men) at the Surgical department of the University hospital "Alexandrovska". They had different forms of colonic diverticulosis. The average age of the patients was 66.7. The retrospective analysis divides the patients into three clinical groups: 1st group--peritonitis and pericolic abscess caused by diverticulosis--present in 49 patients. 2nd group--chronic non-specific inflammatory infiltrate and fistula--present in 5 patients. 3rd group--severe haemorrhage and anaemic syndrome--present in 2 patients Mortality-rate is 12.5% (7 patients). 10 patients with complications were registered--5 with suppuration of the surgical wound and 5 with pneumonia and pleural effusion. Colonic diverticulosis is a disease of great surgical interest because of its complicated forms requiring conventional or surgical treatment. Various forms of peritonitis which are part of the emergency surgical abdomen domain are relatively frequent complication of the gastrointestinal (in particular of the colon) diverticulosis. They are difficult to diagnose in the pre-operative period and its not easy to take a decision about the particular operative approach. All that is related with the relatively high morbidity and mortality.
Merchant, Amina; Hendel, Simon; Shockley, Ross; Schlesinger, Joseph; Vansell, Hilary; McQueen, Kelly
Since 2007, observations reveal that low- and middle-income countries (LICs and LMICs) experience similar surgical access and safety issues, though the etiology of these challenges varies by country. The collective voice of surveys completed to date has pushed the agenda for the inclusion of safe surgery and anesthesia within global health discussions. Comparison of four countries across the world shows similar basic progress as well as ongoing surgical and anesthesia needs in resource-challenged countries. By studying these common needs, a comprehensive plan to provide infrastructure and personnel support can work in multiple austere settings. A standardized survey tool published, designed, and developed initially by the Harvard Humanitarian Initiative and modified at Vanderbilt University was completed in Guatemala, Guyana, Laos, and Mozambique. The survey assessed eight key areas of essential surgical care: access to and availability of surgical services, access to human resources, essential infrastructure (including access to water, electricity, sanitation, blood products, and essential medicines including supplemental oxygen), surgical outcomes, operating room information and procedures, equipment, International Organization, and Non-Government Organization provision of surgical care. These results were compared and contrasted to evaluate resource challenges and assets in each country. A total of 49 hospitals were surveyed in this comparison cohort. The results reveal common needs for emergency and essential surgery in each country, but some differences in human and capital resources exist. While minimal resources exist, all surgical sites provided running water, electricity, and oxygen-assets not seen in previous surveys as recent as 2011. The most basic needs to provide essential surgery are now present in LICs and LMICs. Many more resources are needed to ensure access to safe surgery and anesthesia. The next steps to provide essential surgery must include
Sharma, Rohit; Reddy, Subhash; Thoman, David; Grotts, Jonathan; Ferrigno, Lisa
Small bowel obstruction (SBO) is commonly encountered by surgeons and has traditionally been handled via an open approach, especially when small bowel resection (SBR) is indicated, although recent series have shown improved outcomes with a laparoscopic approach. In this retrospective study, we sought to evaluate outcomes and identify risk factors for adverse events after emergency SBR for SBO with an emphasis on surgical approach. In this retrospective review using American College of Surgeons National Surgical Quality Improvement Program data, 1750 patients were identified who had emergency SBR with the principal diagnosis of SBO from 2006 to 2011. Mortality and postoperative adverse events were evaluated. Of 1750 patients who had emergency SBR, 51 (2.9%) had laparoscopic bowel resection (LBR). There was no difference in surgery duration (open bowel resection [OBR] versus LBR, 100 minutes versus 92 minutes; P=.38). Compared with the LBR group, the OBR group had a higher rate of baseline cardiac comorbidities and postoperative complications, and their length of stay was longer (10 versus 8 days; P70 years, pulmonary, renal, neurological, and cardiac comorbidities, preoperative sepsis, steroid use, and body mass index of surgical problem.
Cooper, Zara; Koritsanszky, Luca A; Cauley, Christy E; Frydman, Julia L; Bernacki, Rachelle E; Mosenthal, Anne C; Gawande, Atul A; Block, Susan D
To address the need for improved communication practices to facilitate goal-concordant care in seriously ill, older patients with surgical emergencies. Improved communication is increasingly recognized as a central element in providing goal-concordant care and reducing health care utilization and costs among seriously ill older patients. Given high rates of surgery in the last weeks of life, high risk of poor outcomes after emergency operations in these patients, and barriers to quality communication in the acute setting, we sought to create a framework to support surgeons in communicating with seriously ill, older patients with surgical emergencies. An interdisciplinary panel of 23 national leaders was convened for a 1-day conference at Harvard Medical School to provide input on concept, content, format, and usability of a communication framework. A prototype framework was created. Participants supported the concept of a structured approach to communication in these scenarios, and delineated 9 key elements of a framework: (1) formulating prognosis, (2) creating a personal connection, (3) disclosing information regarding the acute problem in the context of the underlying illness, (4) establishing a shared understanding of the patient's condition, (5) allowing silence and dealing with emotion, (6) describing surgical and palliative treatment options, (7) eliciting patient's goals and priorities, (8) making a treatment recommendation, and (9) affirming ongoing support for the patient and family. Communication with seriously ill patients in the acute setting is difficult. The proposed communication framework may assist surgeons in delivering goal-concordant care for high-risk patients.
Anantha, Ram Venkatesh; Parry, Neil; Vogt, Kelly; Jain, Vipan; Crawford, Silvie; Leslie, Ken
Background Acute care surgical services provide comprehensive emergency general surgical care while potentially using health care resources more efficiently. We assessed the volume and distribution of emergency general surgery (EGS) procedures before and after the implementation of the Acute Care and Emergency Surgery Service (ACCESS) at a Canadian tertiary care hospital and its effect on surgeon billings. Methods This single-centre retrospective case–control study compared adult patients who underwent EGS procedures between July and December 2009 (pre-ACCESS), to those who had surgery between July and December 2010 (post-ACCESS). Case distribution was compared between day (7 am to 3 pm), evening (3 pm to 11 pm) and night (11 pm to 7 am). Frequencies were compared using the χ2 test. Results Pre-ACCESS, 366 EGS procedures were performed: 24% during the day, 55% in the evening and 21% at night. Post-ACCESS, 463 operations were performed: 55% during the day, 36% in the evening and 9% at night. Reductions in night-time and evening EGS were 57% and 36% respectively (p laparotomies and cholecystectomies all declined by $67 190, $125 215, $66 362, and $84 913, respectively (p < 0.001). Conclusion Acute care surgical services have dramatically shifted EGS from nighttime to daytime. Cost-modelling analysis demonstrates that these services have cost-savings potential for the health care system without reducing overall surgeon billing. PMID:24666462
Berlin, Ana; Hwang, Franchesca; Singh, Ranbir; Pentakota, Sri Ram; Singh, Roshansa; Chernock, Brad; Mosenthal, Anne C
When patients with dementia develop acute surgical abdomen, patients, surrogates, and surgeons need accurate prognostic information to facilitate goal-concordant decision making. Palliative care can assist with communication, symptom management, and family and caregiver support in this population. We aimed to characterize outcomes and patterns of palliative care utilization among patients with dementia, presenting with abdominal surgical emergency. We retrospectively queried the National Inpatient Sample for patients aged >50 years with dementia and acute abdominal emergency who were admitted nonelectively 2009-2013, utilizing ICD-9-CM codes for dementia and surgical indication. We characterized outcomes and identified predictors of palliative care utilization. Among 15,209 patients, in-hospital mortality was 10.2%, the nonroutine discharge rate was 67.2%, and 7.5% received palliative care. Patients treated operatively were less likely to receive palliative care than those who did not undergo operation (adjusted OR = 0.50; 95% CI 0.41-0.62). Only 6.4% of patients discharged nonroutinely received palliative care. Patients with dementia and acute abdominal emergency have considerable in-hospital mortality, a high frequency of nonroutine discharge, and low palliative care utilization. In this group, we discovered a large gap in palliative care utilization, particularly among those treated operatively and those who are discharged nonroutinely. Copyright © 2017 Elsevier Inc. All rights reserved.
Full Text Available Background: Patients who undergo emergency colorectal cancer surgery has poor outcome compared to elective surgery, both in terms of morbidity and mortality. Approximately 15 to 30% of colorectal cancers present as an emergency, most often as obstruction or perforation. Objective: To compare surgical outcome and clinical profiles of emergency and elective cases for colorectal cancer. Methods: Retrospective analysis of 34 cases who underwent surgery for colorectal cancer between December 2011 to January 2013was carried out and their surgical outcomes, clinical presentation, demographic profile were analyzed. Results: The total numbers of patients included in this study were 34. Out of which 52.94 %( n=18 were emergency cases and 47.05 %( n=16 were elective. Male female ratio was 3:1 in emergency cases and 2.6:1 in elective cases. Per rectal bleeding (56% and altered bowel habit (31.25% was predominant clinical presentation in elective cases whereas intestinal obstruction (55.55% and peritonitis (22.22% were predominant clinical presentation in emergency cases. In emergency cases most of the tumors were located in left side (77.77% and in elective cases rectum was common site (37.5%. Left hemicolectomy was the commonest surgery performed (72.22% in emergency set up. In elective cases, right hemicolectomy, left hemicolectomy, APR and LAR was done in 31.25%, 31.25%, 25% and 25% cases respectively. In the emergency group 11.11% (n=2 developed enterocutaneous fistula and early mortality within 30 days was observed in 5% (n=1 of emergency cases only. Conclusion: In emergency conditions, colorectal cancer presented with intestinal obstruction where as elective cases presented with per rectal bleeding and altered bowel habits. Compared with the elective patients, the emergency patients had higher rate of morbidity and mortality. Because of higher incidence of colorectal cancer in our institution, in all emergency cases who presents with features of
Ponce, Brent A; Menendez, Mariano E; Oladeji, Lasun O; Fryberger, Charles T; Dantuluri, Phani K
The authors describe the first surgical case adopting the combination of real-time augmented reality and wearable computing devices such as Google Glass (Google Inc, Mountain View, California). A 66-year-old man presented to their institution for a total shoulder replacement after 5 years of progressive right shoulder pain and decreased range of motion. Throughout the surgical procedure, Google Glass was integrated with the Virtual Interactive Presence and Augmented Reality system (University of Alabama at Birmingham, Birmingham, Alabama), enabling the local surgeon to interact with the remote surgeon within the local surgical field. Surgery was well tolerated by the patient and early surgical results were encouraging, with an improvement of shoulder pain and greater range of motion. The combination of real-time augmented reality and wearable computing devices such as Google Glass holds much promise in the field of surgery. Copyright 2014, SLACK Incorporated.
Hewitt, Jonathan; McCormack, Caroline; Tay, Hui Sian; Greig, Matthew; Law, Jennifer; Tay, Adam; Asnan, Nurwasimah Hj; Carter, Ben; Myint, Phyo Kyaw; Pearce, Lyndsay; Moug, Susan J; McCarthy, Kathryn; Stechman, Michael J
Multimorbidity is the presence of 2 or more medical conditions. This increasingly used assessment has not been assessed in a surgical population. The objectives of this study were to assess the prevalence of multimorbidity and its association with common outcome measures. A cross-sectional observational study. A UK-based multicentre study, included participants between July and October 2014. Consecutive emergency (non-elective) general surgical patients admitted to hospital, aged over 65 years. The outcome measures were (1) the prevalence of multimorbidity and (2) the association between multimorbidity and frailty; the rate and severity of surgery; length of hospital stay; readmission to hospital within 30 days of discharge; and death at 30 and 90 days. Data were collected on 413 participants aged 65-98 years (median 77 years, (IQR (70-84)). 51.6% (212/413) participants were women. Multimorbidity was present in 74% (95% CI 69.7% to 78.2%) of the population and increased with age (pemergency general surgical population had 2 or more chronic medical conditions. It was strongly associated with age and frailty, and was not a barrier to surgical intervention. Multimorbidity showed no associations across a range of outcome measures, as it is currently defined. Multimorbidity should not be relied on as a useful clinical tool in guidelines or policies for older emergency surgical patients. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Cihoric, Mirjana; Toft Tengberg, Line; Bay-Nielsen, Morten; Bang Foss, Nicolai
With current literature quoting mortality rates up to 45%, emergency high-risk abdominal surgery has, compared with elective surgery, a significantly greater risk of death and major complications. The Surgical Apgar Score (SAS) is predictive of outcome in elective surgery, but has never been validated exclusively in an emergency setting. A consecutive prospective single-center cohort study of 355 adults undergoing emergency high-risk abdominal surgery between June 2013 and May 2014 is presented. The primary outcome measure was 30-day mortality. Secondary outcome measures were postoperative major complications, defined according to the Clavien-Dindo scale as well as the American College of Surgeons' National Surgical Quality Improvement Program guidelines, and intensive care unit admission. The SAS was calculated postoperatively. Cochran-Armitage test for trend was used to evaluate the incidence of both outcomes. Area under the curve was used to demonstrate the scores' discriminatory power. One hundred eighty-one (51.0%) patients developed minor or no complications. The overall incidence of major complications was 32.7% and the overall death rate was 16.3%. Risk of major complications, death, and intensive care unit admission increased significantly with decreasing SAS (P high-risk abdominal surgery. Despite its predictive value, the SAS cannot in its current version be recommended as a standalone prognostic tool in an emergency setting.
Full Text Available Abstract Background Subspecialisation within general surgery has today reached further than ever. However, on-call time, an unchanged need for broad surgical skills are required to meet the demands of acute surgical disease and trauma. The introduction of a new subspecialty in North America that deals solely with acute care surgery and trauma is an attempt to offer properly trained surgeons also during on-call time. To find out whether such a subspecialty could be helpful in Sweden we analyzed our workload for emergency surgery and trauma. Methods Linköping University Hospital serves a population of 257 000. Data from 2010 for all patients, diagnoses, times and types of operations, surgeons involved, duration of stay, types of injury and deaths regarding emergency procedures were extracted from a prospectively-collected database and analyzed. Results There were 2362 admissions, 1559 emergency interventions; 835 were mainly abdominal operations, and 724 diagnostic or therapeutic endoscopies. Of the 1559 emergency interventions, 641 (41.1% were made outside office hours, and of 453 minor or intermediate procedures (including appendicectomy, cholecystectomy, or proctological procedures 276 (60.9% were done during the evenings or at night. Two hundred and fifty-four patients were admitted with trauma and 29 (11.4% required operation, of whom general surgeons operated on eight (3.1%. Thirteen consultants and 11 senior registrars were involved in 138 bowel resections and 164 cholecystectomies chosen as index operations for standard emergency surgery. The median (range number of such operations done by each consultant was 6 (3–17 and 6 (1–22. Corresponding figures for senior registrars were 7 (0–11 and 8 (1–39. Conclusion There was an uneven distribution of exposure to acute surgical problems and trauma among general surgeons. Some were exposed to only a few standard emergency interventions and most surgeons did not operate on a single patient
al-Ayoubi, Fawzi; Eriksson, Helen; Myrelid, Pär; Wallon, Conny; Andersson, Peter
Subspecialisation within general surgery has today reached further than ever. However, on-call time, an unchanged need for broad surgical skills are required to meet the demands of acute surgical disease and trauma. The introduction of a new subspecialty in North America that deals solely with acute care surgery and trauma is an attempt to offer properly trained surgeons also during on-call time. To find out whether such a subspecialty could be helpful in Sweden we analyzed our workload for emergency surgery and trauma. Linköping University Hospital serves a population of 257 000. Data from 2010 for all patients, diagnoses, times and types of operations, surgeons involved, duration of stay, types of injury and deaths regarding emergency procedures were extracted from a prospectively-collected database and analyzed. There were 2362 admissions, 1559 emergency interventions; 835 were mainly abdominal operations, and 724 diagnostic or therapeutic endoscopies. Of the 1559 emergency interventions, 641 (41.1%) were made outside office hours, and of 453 minor or intermediate procedures (including appendicectomy, cholecystectomy, or proctological procedures) 276 (60.9%) were done during the evenings or at night. Two hundred and fifty-four patients were admitted with trauma and 29 (11.4%) required operation, of whom general surgeons operated on eight (3.1%). Thirteen consultants and 11 senior registrars were involved in 138 bowel resections and 164 cholecystectomies chosen as index operations for standard emergency surgery. The median (range) number of such operations done by each consultant was 6 (3-17) and 6 (1-22). Corresponding figures for senior registrars were 7 (0-11) and 8 (1-39). There was an uneven distribution of exposure to acute surgical problems and trauma among general surgeons. Some were exposed to only a few standard emergency interventions and most surgeons did not operate on a single patient with trauma. Further centralization of trauma care, long
Adebiyi Gbadebo Adesiyun
Full Text Available The finding of intraperitoneal foreign body complicating surgical intervention broadly remains as an issue of safety in the operative room, a source of emotive concern for the patient, and an upsetting but equally embarrassing situation to the surgeon and the team. However, in the media world, it is a source of sumptuous and captivating headline on the newspaper and to the legal profession, an attractive case to prosecute. A middle age teacher presented with secondary infertility. She had emergency laparotomy fifteen years ago for ruptured tubal ectopic pregnancy in a private hospital and postoperative period was uneventful. Amongst other investigations to find out the cause of infertility, she had hysterosalpingography and a radio-opaque clamp was visualized on the films. She was counselled and had laparotomy. A pair of surgical Kocher clamps was retrieved buried in the mesentery.
Pakula, Andrea; Skinner, Ruby
Acute care surgeons care for the entire breadth of the American adult population, including obese patients. As the population gets heavier, more patients will present to acute case surgeons with nonbariatric surgical emergencies. Do these surgeons need bariatric training to properly care for obese population? To evaluate our experience in obese population requiring acute surgery and compare outcomes based on surgeon expertise in bariatric surgery. Community teaching hospital, United States. Retrospective review of obese patients requiring acute surgical intervention. Surgeons were classified as bariatric surgeons (B, n = 2) versus nonbariatric surgeons (NB, n = 4). Demographic characteristics, co-morbidities, and outcomes based on surgeon training were compared. Two hundred three patients comprised the cohort. The mean body mass index was 37 ±6 kg/m 2 . The majority of procedures were laparoscopic (cholecystectomies n = 75, appendectomies n = 45). The remaining nonroutine laparoscopic cases were intestinal obstructions (n = 9), incarcerated hernias (n = 17), traumatic injuries (n = 48), and intestinal ischemia or perforation (n = 9). Bariatric surgeons performed 35% of cases, and risk profiles were similar between groups. Operative times were similar for cholecystectomies and appendectomies. Bariatric surgeons performed more nonroutine cases laparoscopically (7% B versus 2% NB, P = .001). Surgical site infections were low (2% B versus 4% NB, P = .4). Hospital length of stay was higher in the NB group at 9 ± 9 days versus 5 ± 4 days for B (P = .05). Mortality was 5%. Acute surgical procedures were performed in obese patients. Bariatric expertise favorably affected length of stay and the application of laparoscopy. Bariatric expertise may improve outcomes in nonbariatric emergencies, but further study is warranted. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
Leppäniemi, A; Jousela, I
Emergency surgery is associated with night-time procedures and disruption of elective surgery. An analysis was undertaken of the effect of classifying emergency operations uniformly with a three-tier urgency colour code and the use of dedicated daytime operating rooms. Observed changes from 2001 to 2012 in the number, timing and ability to meet the urgency-designated colour code deadline were retrieved from the computer-based operating theatre organization system for all emergency operations. The number of emergency operations performed annually ranged from 3330 to 4341, with an increasing trend. The proportion of night-time emergency operations decreased from 27.4 per cent (2563 of 9347) before to 23.5 per cent (7731 of 32,959) after introduction of the colour coding system in 2004 (χ2 = 61.94, 1 d.f., P emergency operation theatre was 85.4 per cent. The structural separation of elective and emergency surgery, the use of dedicated daytime operating theatres and the implementation of a universal classification of emergency operations reduced night-time surgery, improved the efficiency of operating theatre utilization during daytime, shortened preoperative delay in patients requiring urgent surgery, and enabled monitoring and corrective actions for providing emergency surgery services. © 2013 BJS Society Ltd. Published by John Wiley & Sons Ltd.
Buddingh, K. Tim; Wieselmann, Eva; Heineman, Erik; Broens, Paul M. A.
Objective: The aim of this study was to describe the discharge diagnoses of children receiving surgical consultation for acute abdominal pain according to age and sex. Methods: Retrospective chart review. Results: Nine hundred forty-one children were included. Appendicitis was confirmed in 31% of
Kiermeier, Andreas; Babidge, Wendy J; McCulloch, Glenn A J; Maddern, Guy J; Watters, David A; Aitken, R James
The Western Australian Audit of Surgical Mortality was established in 2002. A 10-year analysis suggested it was the primary driver in the subsequent fall in surgeon-related mortality. Between 2004 and 2010 the Royal Australasian College of Surgeons established mortality audits in other states. The aim of this study was to examine national data from the Australian Institute of Health and Welfare (AIHW) to determine if a similar fall in mortality was observed across Australia. The AIHW collects procedure and outcome data for all surgical admissions. AIHW data from 2005/2006 to 2012/2013 was used to assess changes in surgical mortality. Over the 8 years surgical admissions increased by 23%, while mortality fell by 18% and the mortality per admission fell by 33% (P audit was associated with a sharp decline in perioperative mortality. In the absence of any influences from other changes in clinical governance or new quality programmes it is probable it had a causal effect. The reduced mortality was most evident in high-risk patients. This study adds to the evidence that national audits are associated with improved outcomes. © 2017 Royal Australasian College of Surgeons.
Smith, Christopher; Craig, Paul; Taleb, Shayandokht; Young, Shamar; Golzarian, Jafar
Lower urinary tract symptoms (LUTS) are one of the most common health issues in men and pose a significant economic challenge in healthcare. Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment for medically refractive LUTS secondary to benign prostatic hyperplasia. The institution of medical therapy and the development of several minimally invasive surgical therapies (MISTs) began in the 1980's and 1990's. Together, these therapies brought about a change in the natural course of the disease, stimulating investigation into the economic consequences of various management approaches. TURP has been observed to have higher complication rates, but better efficacy and lower retreatment rates compared to MISTs. Staying abreast of the evolving understanding of LUTS and the alternative treatment options is imperative for radiologists.
Van Praet, Karel M; Stamm, Christof; Starck, Christoph T; Sündermann, Simon; Meyer, Alexander; Montagner, Matteo; Nazari Shafti, Timo Z; Unbehaun, Axel; Jacobs, Stephan; Falk, Volkmar; Kempfert, Jörg
Tricuspid valve regurgitation (TR) is frequently encountered and is most often functional (FTR) in nature. Surgical tricuspid valve (TV) treatment is well established in specialized centers. While transcatheter therapy for other valve disease is well established, interventional treatment of TV disease is still in its early stages. With the increasing adoption of catheter-based treatments, there is a growing interest in and need for interventional treatments for TR. An extensive literature search was methodologically performed aiming for an integrative review paper. Areas covered: This review will discuss the current surgical treatment modalities and emerging transcatheter interventions in the management of TR. Furthermore, this review will describe the pathophysiology of functional tricuspid regurgitation (FTR), and the new 2017 ESC/EACTS guidelines for the management of TR. Finally, a five-year view into the future will be stated. Expert commentary: At their center, the authors have an aggressive approach for the treatment of FTR owing to its significant impact on perioperative as well as late postoperative morbidity and mortality. The authors perform TV ring annuloplasty when substantial annular dilation (≥45mm) is observed. In the future, percutaneous TV technologies might become an alternative option to treat TR patients with high surgical risk selectively.
Hanoon P Pokharel
Conclusions:Women present with wide range of complaints and conditions in the admission room of Obstetrics and Gynecology department of BPKIHS. Skilled clinicians, immediate investigation facilities and experienced specialty Obstetrical and Gynaecological surgeons are the main backbone of the emergency case management and saving lives. Study indicates there is need of some prospective study to establish the causes of rising trend in Ectopic Pregnancies. Keywords: ectopic pregnancy; emergency; gynaecological; obstetrics.
Wood, Fiona; Martin, Sean Michael; Carson-Stevens, Andrew; Elwyn, Glyn; Precious, Elizabeth; Kinnersley, Paul
The need to involve patients more in decisions about their care, the ethical imperative and concerns about ligation and complaints has highlighted the issue of informed consent and how it is obtained. In order for a patient to make an informed decision about their treatment, they need appropriate discussion of the risks and benefits of the treatment. To explore doctors' perspectives of gaining informed consent for routine surgical procedures. Qualitative study using semi-structured interviews selected by purposive sampling. Data were analysed thematically. Twenty doctors in two teaching hospitals in the UK. Doctors described that while consent could be taken over a series of consultations, it was common for consent to be taken immediately prior to surgery. Juniors were often taking consent when they were unfamiliar with the procedure. Doctors used a range of communication techniques to inform patients about the procedure and its risks including quantifying risks, personalizing risk, simplification of language and use of drawings. Barriers to effective consent taking were reported to be shortage of time, clinician inexperience and patients' reluctance to be involved. Current consent processes do not appear to be ideal for many doctors. In particular, junior doctors are often not confident taking consent for surgical procedures and require more support to undertake this task. This might include written information for junior staff, observation by senior colleagues when undertaking the task and ward-based communication skills teaching on consent taking. © 2014 John Wiley & Sons Ltd.
Wisely, Jessica C; Barclay, Karen L
Enhanced Recovery After Surgery (ERAS) programmes have been used in elective surgery since the 1990s to optimize peri-operative care, reducing post-operative complications, length of stay and overall costs. Following the local introduction of an ERAS programme for colorectal elective patients, it was suggested an increase in the use of ERAS-type principles in emergency patients may have occurred. The aims of this study were to determine whether management changes could be demonstrated and if there was a difference in outcomes. A retrospective cohort study comparing emergency patients undergoing major abdominal surgery October 2008 to May 2010 (pre-ERAS) and January 2011 to December 2012 (post-ERAS) was performed. Details collected included admission and operative details, post-operative management and outcomes. A total of 370 patients were studied. Baseline variables were comparable. Post-ERAS, intra-operative (P emergency patients following the introduction of such a programme in elective patients. The lack of increased complications in the second period suggests the use of ERAS principles is not harmful. The wider application of ERAS principles could improve outcomes in emergency surgery and deserves further study. © 2016 Royal Australasian College of Surgeons.
Backer Mogensen, Christian; Olsen, Inger; Thisted, Anette Rehn
Pharmacists' advice may reduce medication errors in the emergency department (ED). However, pharmacists' recommendations are of little value if not acknowledged by physicians. The aim of the present study was to analyze how often and which categories of pharmacist recommendations were taken...
Sudhansu Sekhar Mishra
Full Text Available Head injuries following fall of heavy objects are not very uncommon in developing countries. However, compound depressed skull fracture with superior sagittal sinus (SSS laceration caused by a flying asbestos fragment in a stormy afternoon is an unusual mode of head injury. We report such an unusual case of compound depressed skull fracture by an asbestos fragment injuring the middle third of SSS and its successful surgical management in a 14-year-old child. The role of computed tomography (CT scan of head with 3D reconstruction is highlighted. Early steps taken in this case to check the profuse bleeding, which helped save the life of this boy is interesting to note.
Klos, Dušan; Orság, Jiří; Loveček, Martin; Skalický, Pavel; Havlík, Roman; Zadražil, Josef; Neoral, Čestmír
Acute pancreatitis is a rare but frequently fatal complication in patients following kidney transplantation. The first case of acute pancreatitis in patients following a kidney transplant was described by Starzl in 1964. The incidence of acute pancreatitis is stated at between 1 and 5%. The mortality rate amongst these patients reaches as high as 50-100%. Here we present a case of acute pancreatic abscess in a caucasian female - shortly following a kidney transplant complicated by the development of acute rejection, in which immunosuppressant therapy is a potential etiological agent. Emergency surgical treatment was indicated, which included drainage of the abscesses irrigation of the abdominal cavity. Immunosuppressive medication was considered a possible etiological factor, and as a result administration of tacrolimus and mycophenolate mofetil was discontinued. This was successful and three months later, diagnostic rebiopsy of the graft was performed without signs of rejection. The etiology of this illness is multifactorial. The clinical manifestation of acute pancreatitis in patients following kidney transplantation is the same as in the remainder of the population. However, in patients following transplantation with long-term immunosuppression, it usually manifests a more rapid development and a more severe, frequently fatal course. With regard to the patient's comorbidities, early surgical therapy was indicated - drainage and closed lavage and immunosuppressive medication as a suspected tobe ethiological factor was discontinued. This course of treatment led to a complete recovery with preservation of good function of the cadaverous kidney.
Guterman, S; Mandelbrot, L; Keita, H; Bretagnol, F; Calabrese, D; Msika, S
To assess complications and outcomes of pregnancies following laparoscopic abdominal surgery during the second and third trimesters of pregnancy. Retrospective single-center study of 23 cases of laparoscopic surgery in the second or third trimesters of pregnancy between January 2005 and May 2016. The laparoscopies were performed between 15 and 33 weeks of gestation, a mean of 23 weeks+2 days, with 6 cases in the 3rd trimester. The operations were: 11 cholecystectomies, 6 appendectomies, 1 intestinal occlusion (volvulus on a gastric band), 3 adnexal torsions, 1 ovarian cyst and 1 paratubal cyst with torsion. No secondary laparotomy was required. The postoperative courses were favorable in most cases. However, 3 appendectomies were complicated, one by chorioamnionitis and miscarriage at 20½ weeks of gestation and 2 by right iliac fossa abscesses requiring percutaneous radiological drainage, one of these women delivered a healthy term baby and the other had chorioamnionitis and preterm delivery at 34 weeks, followed by neonatal death. Laparoscopy can be safely performed for surgical indications in the second and third trimesters of pregnancy. In case of abdominal symptoms, a timely diagnosis is required to decide whether or not to operate and imaging should not be withheld particularly in case of suspected appendicitis which has a high risk of complications. Copyright © 2017. Published by Elsevier Masson SAS.
Full Text Available Supracondylar humeral fractures (SCHF are the most common elbow fractures in children, representing 3% of all paediatric fractures. Treatment options for SCHF in children are based on the Gartland classification. Treatment of non-displaced fractures (type I is non-operative. Plaster immobilization for 3 to 4 weeks is recommended, depending on the age of the child and fracture healing. Treatments of displaced supracondylar fractures (type II and III of the humerus in children are still undefined in clinical practice. Because of divided opinions, the aim of this study was to evaluate whether delayed or immediate surgical treatment has an advantage in the treatment of supracondylar fractures in children. This is a prospective – retrospective clinical study. This study included 64 patients from 5 to 15 years old; 47 (73.4% were boys and 17 (26.6% were girls. The most common age range (59.4% in this study was 5-8 years old. All patients were diagnosed with supracondylar fractures at the Institute for Orthopaedic Surgery “Banjica”. We analysed 17 parameters, which were obtained either from direct patient interviews or from their medical history. All patients were divided into two groups with matched characteristics. Group I consisted of 26 patients who had immediate operations. Group II consisted of 38 patients who had delayed operations.
Talbot, Lindsay J; Sinyard, Robert D; Rialon, Kristy L; Englum, Brian R; Tracy, Elizabeth T; Rice, Henry E; Adibe, Obinna O
Neonates after emergent enterostomy creation frequently require reversal at low weight because of complications including cholestasis, dehydration, dumping, failure to thrive, and failure to achieve enteral independence. We investigated whether stoma reversal at low weight (stoma type, reversal indication, operative details, and complications were examined. Patients were categorized by weight at reversal of less than 2kg, 2.01-2.5kg, 2.51-3.5kg, and greater than 3.5kg. Data were analyzed using univariable and multivariable regression with significance level of pstoma reversal may be acceptable when required for progression of neonatal care. Level III, Treatment Study (Retrospective comparative study). Copyright © 2017. Published by Elsevier Inc.
Groenwold, Rolf H. H.; Hoes, Arno W.; Hak, Eelko
We conducted a systematic literature search in Medline to assess the proportion of observational intervention studies appreciating confounding bias in peer-reviewed medical literature from 1985 through 2005. This study shows only 9% of all papers on observational intervention studies published in
Bovolato, Francesca Elisa; Isabella, Giambattista; Rampazzo, Debora; Guglielmi, Cosimo; Gerosa, Gino; Iliceto, Sabino; Bilato, Claudio
We report a case of acute coronary syndrome in a patient with suspect Marfan syndrome, 25 days after emergent modified Bentall-De Bono intervention for acute type I peripartum aortic dissection. She was admitted to our intensive care unit because of unstable angina, caused by critical blood flow reduction in a large portion of the myocardium, according to the severity of the symptoms and the electrocardiographic alterations. Coronary angiography showed a sub-occlusive stenosis of the left main coronary artery as a result of the dissection extension to the coronary ostium. Because of the high risk related to heart surgery, the patient was successfully treated by unprotected angioplasty and drug-eluting stent positioning. Short- and mid-term outcomes were favourable. Subsequent tests confirmed the diagnosis of Marfan syndrome. After 2 years of follow-up, the patient remains asymptomatic and in good health. To our knowledge, this is the first report of a successful percutaneous intervention of the left main coronary artery in a patient with Marfan syndrome who had already undergone ascending aortic root and valve replacement by the Bentall-De Bono procedure for acute dissection.
Pelavski, Andrés D; Lacasta, Albert; de Miguel, Marcos; Rochera, Maria I; Roca, Marius
Although longevity is becoming frequent, there are no scores to assess nonagenarians undergoing emergency surgery. The aim of this prospective observational study was to determine 30-day mortality and the individual performance of the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) and other scores in predicting their risk for death. A total of 126 patients were included (2006-2011) and followed for 30 days. Patients risk for death was calculated using different scores. The accuracy of each score was assessed with exponential and linear methods and using the area under the receiver operating characteristic curve. Overall mortality was 34.9%. The POSSUM, with a modification in the age category, had an area under the curve of .71 and ratios of observed to predicted deaths of 1.07 and 1.22, respectively, in the linear and exponential analysis. In a population with as high a risk as nonagenarians, the age-modified POSSUM proved accurate to audit surgery and assess mortality risk. Copyright © 2013 Elsevier Inc. All rights reserved.
Full Text Available Introduction. Transverse colon volvulus is an uncommon cause of bowel obstruction in general. Predisposing factors are mental retardation, dysmotility disorders, chronic constipation and congenital megacolon. Case report. We presented transverse colon volvulus in a 16-year-old boy with cerebral palsy. Chronic constipation in neurologicaly impaired patient was a risk factor predisposing to volvulus. The patient was admitted to the hospital with enormous abdominal distension and acute respiratory insufficiency. A boy was emergently taken to the operating room for exploratory laparotomy. During the surgery, a 360º clockwise volvulus of the transverse colon was found. After reduction of volvulus, an enormous transverse colon was resected and colostomy was formed. In the postoperative period, despite the good functioning of stoma and intraabdominal normotension, numerous and long lasting respiratory problems developed. The patient was discharged from our institution after 8 months. Conclusion. Though very rare in pediatric group, the possibility of a transverse colon volvulus must be considered in the differential diagnosis of acute large bowel obstruction.
Burkle, Frederick M; Nickerson, Jason W; von Schreeb, Johan; Redmond, Anthony D; McQueen, Kelly A; Norton, Ian; Roy, Nobhojit
Following large-scale disasters and major complex emergencies, especially in resource-poor settings, emergency surgery is practiced by Foreign Medical Teams (FMTs) sent by governmental and non-governmental organizations (NGOs). These surgical experiences have not yielded an appropriate standardized collection of data and reporting to meet standards required by national authorities, the World Health Organization, and the Inter-Agency Standing Committee's Global Health Cluster. Utilizing the 2011 International Data Collection guidelines for surgery initiated by Médecins Sans Frontières, the authors of this paper developed an individual patient-centric form and an International Standard Reporting Template for Surgical Care to record data for victims of a disaster as well as the co-existing burden of surgical disease within the affected community. The data includes surgical patient outcomes and perioperative mortality, along with referrals for rehabilitation, mental health and psychosocial care. The purpose of the standard data format is fourfold: (1) to ensure that all surgical providers, especially from indigenous first responder teams and others performing emergency surgery, from national and international (Foreign) medical teams, contribute relevant and purposeful reporting; (2) to provide universally acceptable forms that meet the minimal needs of both national authorities and the Health Cluster; (3) to increase transparency and accountability, contributing to improved humanitarian coordination; and (4) to facilitate a comprehensive review of services provided to those affected by the crisis.
Lupattelli, Tommaso; Garaci, Francesco Giuseppe; Basile, Antonio; Minnella, Daniela Paola; Casini, Andrea; Clerissi, Jacques
Mycotic false aneurysm caused by local arterial injury from attempted intravenous injections in drug addicts remains a challenging clinical problem. The continued increase in drug abuse has resulted in an increased incidence of this problem, particularly in high-volume urban centres. In the drug-abusing population, mycotic arterial pseudoaneurysms most often occur because of missed venous injection and are typically seen in the groin, axilla, and antecubital fossa. Mycotic aneurysms may lead to life-threatening haemorrhage, limb loss, sepsis, and even death. Any soft-tissue swelling in the vicinity of a major artery in an intravenous drug abuser should be suspected of being a false aneurysm until proven otherwise and should prompt immediate referral to a vascular surgeon for investigation and management. We report a case of rupturing mycotic pseudoaneurysm of the left common femoral artery treated by surgical resection followed by vessel reconstruction with autologous material. Unfortunately, at the time of discharge a sudden leakage from the vein graft anastomosis occurred, with subsequent massive bleeding, and required emergent endovascular covered stenting. To the best of our knowledge, this is the first reported case of femoral artery bleeding in a drug abuser treated by stent graft placement.
McLean, Ross C; McCallum, Iain J D; Dixon, Steve; O'Loughlin, Paul
Life expectancies in the UK are increasing and with this there is an increasing elderly population with more complex co-morbidity. Emergency surgery in the elderly is challenging in terms of decision making, managing co-morbidity and post-operative rehabilitation with high morbidity and mortality. To optimise service design and development, it is important to understand the changing pattern of emergency surgical care for this group. After obtaining necessary approvals, we approached each hospital trust in the North of England for details of every emergency admission under a general surgeon from 2000 to 2014. Data for each admission included demographics, co-morbidities, diagnoses, procedures undertaken and outcomes. There were 105 002 elderly (≥70 years) emergency general surgical admissions, and mean age and co-morbidity (defined by Charlson index scores) increased (both p emergency general surgery in the elderly is becoming more complex. This challenge is already being addressed with improvements in outcomes. The data presented here reinforces the need for new models of care with increased multidisciplinary geriatric care input into elderly surgical patient care in the perioperative period. Copyright © 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Groenwold, Rolf H H; Sterne, Jonathan A C; Lawlor, Debbie A; Moons, Karel G M; Hoes, Arno W; Tilling, Kate
Observational studies are prone to (unmeasured) confounding. Sensitivity analysis of unmeasured confounding typically focuses on a single unmeasured confounder. The purpose of this study was to assess the impact of multiple (possibly weak) unmeasured confounders. Simulation studies were performed based on parameters estimated from the British Women's Heart and Health Study, including 28 measured confounders and assuming no effect of ascorbic acid intake on mortality. In addition, 25, 50, or 100 unmeasured confounders were simulated, with various mutual correlations and correlations with measured confounders. The correlated unmeasured confounders did not need to be strongly associated with exposure and outcome to substantially bias the exposure-outcome association at interest, provided that there are sufficiently many unmeasured confounders. Correlations between unmeasured confounders, in addition to the strength of their relationship with exposure and outcome, are key drivers of the magnitude of unmeasured confounding and should be considered in sensitivity analyses. However, if the unmeasured confounders are correlated with measured confounders, the bias yielded by unmeasured confounders is partly removed through adjustment for the measured confounders. Discussions of the potential impact of unmeasured confounding in observational studies, and sensitivity analyses to examine this, should focus on the potential for the joint effect of multiple unmeasured confounders to bias results. Copyright © 2016 Elsevier Inc. All rights reserved.
Prados-Frutos, Juan Carlos; Salinas-Goodier, Carmen; Manchón, Ángel; Rojo, Rosa
The aim of this study was to investigate the prevalence and length of the anterior loop (AL), the distance from this landmark to the alveolar crest and its relation with the shape of the foramen and emergency pattern in the Spanish population on helical computed tomography scan (helical CT scan) through tridimensional reconstructions. Helical CT scan images of 41 patients aged 65 or older were analyzed. A total of 82 human hemi-mandibles were examined in this study. A tridimensional reconstruction of each mandible and Inferior Alveolar Nerve canal was created in AMIRA ® software (AMIRA, Mercury Computer Systems, Berlin, Germany). Prevalence, length and distance between the AL, mental foramen and alveolar ridge were measured. This retrospective observational study was performed according to the STROBE guidelines. Prevalence of the AL was 53.7 % (n = 44) and the mean length was 1.3 ± 0.64 mm. The mean distance from the highest point of the loop to the alveolar ridge was 13.4 ± 2.8 mm. The mean diameter of the mental foramen was 3.5 ± 0.65 mm and the proportion of the oval-shaped was 62.2 % (n = 51) and round-shaped was 37.8 % (n = 31). The study found that patients with type 1 pattern emergency pattern had a higher prevalence of the AL (p = 0.03). Prevalence, location and length of the anterior loop can be overlooked if only two-dimensional pre-surgical studies are performed. Therefore, three-dimensional imaging and modeling of anatomic structures should be used for the pre-operative examination of the interforaminal area. Given the wide variability of the emergency pattern of the mental nerve and the prevalence and location of the anterior loop, it should be studied in every patient individually.
Shah, Adil A; Shakoor, Amarah; Zogg, Cheryl K; Oyetunji, Tolulope; Ashfaq, Awais; Garvey, Erin M; Latif, Asad; Riviello, Robert; Qureshi, Faisal G; Mateen, Arif; Haider, Adil H; Zafar, Hasnain
Whether adult general surgeons should handle pediatric emergencies is controversial. In many resource-limited settings, pediatric surgeons are not available. The study examined differences in surgical outcomes among children/adolescents managed by pediatric and adult general surgery teams for emergency general surgical (EGS) conditions at a university-hospital in South Asia. Pediatric patients (surgery. The overall probability of developing a complication was 1.8%; 0.9% died (all adult general surgery). Patients managed by adult general surgery had higher risk-adjusted odds of developing complications (OR [95%CI]: 5.42 [2.10-14.00]) and longer average LOS (7.98 vs. 5.61 days, p surgery. Pediatric patients had better post-operative outcomes under pediatric surgical supervision, suggesting that, where possible in resource-constrained settings, resources should be allocated to promote development and staffing of pediatric surgical specialties parallel to adult general surgical teams. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Nwazue, Victor C; Raj, Satish R
Most patients who present to a cardiologist with syncope have vasovagal (reflex) syncope. A busy syncope practice often also sees patients with postural tachycardia syndrome, often presenting with severe recurrent presyncope. Recognition of this syncope confounder might be difficult without adequate knowledge of their presentation, and this can adversely affect optimal management. Postural tachycardia syndrome can often be differentiated from vasovagal syncope by its hemodynamic pattern during tilt table test and differing clinical characteristics. This article reviews the presentation of postural tachycardia syndrome and its putative pathophysiology and presents an approach to nonpharmacologic and pharmacologic management. Copyright © 2013 Elsevier Inc. All rights reserved.
Lebeau, R; Diané, B; Kassi, A B F; Yénon, K S; Kouassi, J C
The purpose of this retrospective report is to describe etiologies and therapeutic outcomes of nontraumatic abdominal surgical emergencies in elderly patients. The charts of patients aged 60 years or more who underwent emergency surgery for nontraumatic abdominal disorders at a Teaching Hospital in Abidjan, Cote d'Ivoire from August 1998 to July 2008 were reviewed. Demographic data, clinical findings, operative protocols, and postoperative outcomes were noted. A total of 137 patients with a mean age of 68.3 years (range, 60-93 years) underwent emergency surgery for nontraumatic abdominal disorders during the study period. The underlying etiologies were strangulated hernia (n = 40), abdominal parietal abscess (n = 6), bowel obstruction (n = 32), acute diffuse peritonitis (n = 29), acute appendicitis (n = 23), acute cholecystitis (n = 6) and massive rectorragy from colonic diverticulitis (n = 1). Coexisting medical problems (n = 84) were noted in 69 patients. Surgical procedures were tailored to operative findings. Twenty-seven patients were admitted to the intensive care unit in the immediate postoperative period. Mean hospital stay was 7.7 days (range, 2-23 days). Surgical complications included wound infection (n = 14), stoma-related complications (n = 7), digestive fistula (n = 4), scrotal hematoma (n = 5) and postoperative evisceration (n = 2). The mortality rate was 10.21% (n = 14) mainly due to postoperative peritonitis. The findings of this study indicated that most nontraumatic abdominal surgical emergencies in elderly patients were related to complications of neglected or undiagnosed preexisting disease. Prognosis was related to the stage of the disorder, initial surgical management, and deterioration of the coexisting medical problems.
Vanderweele, Tyler J; Arah, Onyebuchi A
Uncontrolled confounding in observational studies gives rise to biased effect estimates. Sensitivity analysis techniques can be useful in assessing the magnitude of these biases. In this paper, we use the potential outcomes framework to derive a general class of sensitivity-analysis formulas for outcomes, treatments, and measured and unmeasured confounding variables that may be categorical or continuous. We give results for additive, risk-ratio and odds-ratio scales. We show that these results encompass a number of more specific sensitivity-analysis methods in the statistics and epidemiology literature. The applicability, usefulness, and limits of the bias-adjustment formulas are discussed. We illustrate the sensitivity-analysis techniques that follow from our results by applying them to 3 different studies. The bias formulas are particularly simple and easy to use in settings in which the unmeasured confounding variable is binary with constant effect on the outcome across treatment levels.
Powell-Bowns, M; Wilson, M S J; Mustafa, A
To determine whether pregnancy status, gynaecological history, date of last menstrual period and contraceptive use are documented in emergency female admissions of reproductive age admitted to general surgery. This is a retrospective study. This study was conducted in the United Kingdom. Females of reproductive age (12-50 years) admitted as an emergency to general surgery with abdominal pain were considered in this study. Retrospective analysis of medical notes of emergency female admissions with abdominal pain between January and September 2012. We recorded whether a pregnancy test result was documented (cycle 1). Results were analysed and a prompt added to the medical clerk-in document. We re-audited (cycle 2) between January and June 2013 looking for improvement. Documented pregnancy status within 24 h of admission and prior to any surgical intervention. 100 case notes were reviewed in stage 1. 30 patients (30 %) had a documented pregnancy status. 32 (32 %), 25 (25 %) and 29 (29 %) had a documented gynaecology history, contraceptive use and date of last menstrual period (LMP), respectively. 24 patients underwent emergency surgery, 6 (25 %) had a documented pregnancy status prior to surgery. Of 50 patients reviewed in stage 2, 37 (75.0 %) had a documented pregnancy status (p surgical admission document has significantly improved the documentation of pregnancy status and gynaecological history in our female patients, particularly in those who require surgical intervention. A number of patient safety concerns were addressed locally, but require a coordinated, interdisciplinary discussion and a national guideline. A minimum standard of care, in females of reproductive age, should include mandatory objective documentation of pregnancy status, whether or not they require surgical intervention.
Full Text Available In the 21st century, natural disasters and emergencies occur frequently worldwide, which leads to the loss of hundreds of thousands of lives as well as the direct and indirect economic losses. China has a vast territory frequently struck by natural disasters. However, the reality is not optimistic. Poor organization and management during the rescue actions, the lack of large-scale, systematic medical rescue equipment were all great barriers to the outcomes. Mobile hospitals are expected to provide better health care. We were inspired by the concept of mobile hospital. Chongqing Emergency Medical Center, has set up trauma care system since 1988, in which prehospital care, intensive care, and in-hospital treatment is fully integrated. As a major advantage, such a system provided assurance of “golden hour” rescue treatment. Providing mobile intensive care and prehospital surgical service for severe trauma patients could reduce mortality significantly. Based on the civilian experiences in Chongqing Emergency Medical Center, the mobile emergency (surgical hospital was developed.
Kasotakis, George; Lakha, Aliya; Sarkar, Beda; Kunitake, Hiroko; Kissane-Lee, Nicole; Dechert, Tracey; McAneny, David; Burke, Peter; Doherty, Gerard
To identify whether resident involvement affects clinically relevant outcomes in emergency general surgery. Previous research has demonstrated a significant impact of trainee participation on outcomes in a broad surgical patient population. We identified 141,010 patients who underwent emergency general surgery procedures in the 2005-2010 Surgeons National Surgical Quality Improvement Program database. Because of the nonrandom assignment of complex cases to resident participation, patients were matched (1:1) on known risk factors [age, sex, inpatient status, preexisting comorbidities (obesity, diabetes, smoking, alcohol, steroid use, coronary artery disease, chronic renal failure, pulmonary disease)] and preoperatively calculated probability for morbidity and mortality. Clinically relevant outcomes were compared with a t or χ test. The impact of resident participation on outcomes was assessed with multivariable regression modeling, adjusting for risk factors and operative time. The most common procedures in the matched cohort (n = 83,790) were appendectomy (39.9%), exploratory laparotomy (8.8%), and adhesiolysis (6.6%). Trainee participation is independently associated with intra- and postoperative events, wound, pulmonary, and venous thromboembolic complications, and urinary tract infections. Trainee participation is associated with adverse outcomes in emergency general surgery procedures.
Conclusions: With regard to the patient's comorbidities, early surgical therapy was indicated – drainage and closed lavage and immunosuppressive medication as a suspected tobe ethiological factor was discontinued. This course of treatment led to a complete recovery with preservation of good function of the cadaverous kidney.
Kouo-Ngamby, Marquise; Dissak-Delon, Fanny Nadia; Feldhaus, Isabelle; Juillard, Catherine; Stevens, Kent A; Ekeke-Monono, Martin
As the overwhelming surgical burden of injury and disease steadily increases, disproportionately affecting low- and middle-income countries, adequate surgical and trauma care systems are essential. Yet, little is known about the emergency and essential surgical care (EESC) capacity of facilities in many African countries. The objective of this study was to assess the EESC capacity in different types of hospitals across Cameroon. This cross-sectional survey used the WHO Tool for Situational Analysis to Assess EESC, investigating four key areas: infrastructure, human resources, interventions, and equipment and supplies. Twelve hospitals were surveyed between August and September 2009. Facilities were conveniently sampled based on proximity to road traffic and sociodemographic composition of population served in four regions of Cameroon. To complete the survey, investigators interviewed heads of facilities, medical advisors, and nursing officers and consulted hospital records and statistics at each facility. Seven district hospitals, two regional hospitals, two general hospitals, and one missionary hospital completed the survey. Infrastructure for EESC was generally inadequate with the largest gaps in availability of oxygen concentrator supply, an on-site blood bank, and pain relief management guidelines. Human resources were scarce with a combined total of six qualified surgeons, seven qualified obstetrician/gynecologists, and no anesthesiologists at district, regional, and missionary hospitals. Of 35 surgical interventions, 16 were provided by all hospitals. District hospitals reported referring patients for 22 interventions. Only nine of the 67 pieces of equipment were available at all hospitals for all patients all of the time. Severe shortages highlighted by this survey demonstrate the significant gaps in capacity of hospitals to deliver EESC and effectively address the increasing surgical burden of disease and injury in Cameroon. This data provides a foundation
Chung, P J; Lee, J S; Tam, S; Schwartzman, A; Bernstein, M O; Dresner, L; Alfonso, A; Sugiyama, G
Anterior abdominal wall hernias are among the most commonly encountered surgical disease. We sought to identify risk factors that are associated with 30-day postoperative mortality following emergent abdominal wall hernia repair using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. A retrospective analysis of data from the ACS NSQIP from 2005 to 2010 was performed. Patients were selected using Current Procedural Terminology (CPT) and International Classification of Disease 9 Clinical Modification (ICD9) codes for the repair of inguinal, femoral, umbilical, epigastric, ventral, or incisional hernias that were incarcerated, obstructed, strangulated, or gangrenous. Only emergent cases occurring within two days of admission and admitted as inpatients were included. Univariate and multivariable analysis was performed. A risk score was also created. There were 4298 cases of emergent anterior abdominal wall hernia surgery. The most common was inguinal (25.3 %), followed by incisional (23.8 %), umbilical (23.5 %), ventral (12.1 %), femoral (8.8 %), and epigastric (6.5 %) hernias. Multivariable analysis demonstrated six statistically significant predictors of short-term mortality, including history of congestive heart failure (CHF) [odds ratio (OR) 8.24, 95 % confidence interval (CI) 4.05-16.75), age (OR 5.52, 95 % CI 3.48-8.77), history of peripheral vascular disease (PVD) (OR 4.98, 95 % CI 2.08-11.92), presence of ascites (OR 3.16, 95 % CI 1.64-6.08), preoperative blood urea nitrogen (OR 1.35, 95 % CI 1.22-1.49), and preoperative white blood cell count (OR 1.22, 95 % CI 1.02-1.45). The C-statistic for the risk model was 0.858. We present a large study on short-term mortality following emergent anterior abdominal wall hernia repairs based on the ACS NSQIP with a derived risk model that demonstrates excellent discriminative ability.
The epidemiological concept of confounding has had a convoluted history. It was first expressed as an issue of group non-comparability, later as an uncontrolled fallacy, then as a controllable fallacy named confounding, and, more recently, as an issue of group non-comparability in the distribution of potential outcome types. This latest development synthesised the apparent disconnect between phases of the history of confounding. Group non-comparability is the essence of confounding, and the statistical fallacy its consequence. This essay discusses how confounding was perceived in the 18th and 19th centuries, reviews how the concept evolved across the 20th century and finally describes the modern definition of confounding.
Scarborough, John E; Pappas, Theodore N; Bennett, Kyla M; Lagoo-Deenadayalan, Sandhya
To describe the outcomes of elderly patients with do-not-resuscitate (DNR) status who undergo emergency general surgery and to improve understanding of the relationship between preoperative DNR status and postoperative mortality. Preoperative DNR status has previously been shown to predict increased postoperative mortality, although the reasons for this association are not well understood. Patients 65 years or older undergoing emergency operation for 1 of 10 common general surgical diagnoses were extracted from the 2005-2010 National Surgical Quality Improvement database. Propensity score techniques were used to match patients with and without preoperative DNR orders on indication for procedure, patient demographics, comorbid disease burden, acute physical status at the time of operation, and procedure complexity. The postoperative outcomes of this matched cohort were then compared. A total of 25,558 patients were included for analysis (DNR, n =1061; non-DNR, n =24,497). DNR patients seemed to be more acutely and chronically ill than non-DNR patients in the overall study sample but did not seem to be treated less aggressively before or during their operations. Propensity-matching techniques resulted in the creation of a cohort of DNR and non-DNR patients who were well matched for all preoperative and intraoperative variables. DNR patients from the matched cohort had a significantly higher postoperative mortality rate than non-DNR patients (36.9% vs 22.3%, P Emergency general surgery in elderly patients with preoperative DNR orders is associated with significant rates of postoperative morbidity and mortality. One reason for the excess mortality in these patients, relative to otherwise similar patients who do not have preoperative DNR orders, may be their greater reluctance to pursue aggressive management of major complications in the postoperative period.
Sheppard, L.; Burnett, R.T.; Szpiro, A.A.; Kim, J.Y.; Jerrett, M.; Pope, C.; Brunekreef, B.|info:eu-repo/dai/nl/067548180
Studies in air pollution epidemiology may suffer from some specific forms of confounding and exposure measurement error. This contribution discusses these, mostly in the framework of cohort studies. Evaluation of potential confounding is critical in studies of the health effects of air pollution.
Marshall, J R; Hastrup, J L; Ross, J S
Confounding in epidemiology, and the limits of standard methods of control for an imperfectly measured confounder, have been understood for some time. However, most treatments of this problem are based on the assumption that errors of measurement in confounding and confounded variables are independent. This paper considers the situation in which a strong risk factor (confounder) and an inconsequential but suspected risk factor (confounded) are each measured with errors that are correlated; the situation appears especially likely to occur in the field of nutritional epidemiology. Error correlation appears to add little to measurement error as a source of bias in estimating the impact of a strong risk factor: it can add to, diminish, or reverse the bias induced by measurement error in estimating the impact of the inconsequential risk factor. Correlation of measurement errors can add to the difficulty involved in evaluating structures in which confounding and measurement error are present. In its presence, observed correlations among risk factors can be greater than, less than, or even opposite to the true correlations. Interpretation of multivariate epidemiologic structures in which confounding is likely requires evaluation of measurement error structures, including correlations among measurement errors.
Full Text Available Abstract An alcoholic 50-year-old male patient with a history of schizophrenia sustained stab wounds into both ventricles and left lung, and survived following an emergency department thoracotomy. The EDT wound, however became infected requiring serial debridements of soft tissue, rib cartilage and sternum. Regional flap options such as pectoralis major and latissimus dorsi muscle flaps could not be employed due to inadequate reach of these flaps. Additionally, bilateral transection of the internal mammary arteries during emergency thoracotomy eliminated the use of rectus abdominis muscles as pedicled flaps based on the superior epigastric vasculature. Therefore, the EDT wound was reconstructed by using the right rectus abdominis muscle as a free flap. The deep inferior epigastric vessels of the flap were anastomosed to the right internal mammary vessels proximal to their transection level in the third-forth intercostal space. The flap healed with no further wound complications.
Capoccia, Laura; Sbarigia, Enrico; Speziale, Francesco; Toni, Danilo; Biello, Antonella; Montelione, Nunzio; Fiorani, Paolo
The purpose of this study was to examine the safety of emergency carotid endarterectomy (CEA) in patients with carotid stenosis and unstable neurological symptoms. This prospective, single-center study involved patients with stroke in evolution (SIE) or fluctuating stroke or crescendo transient ischemic attack (cTIA) related to a carotid stenosis ≥ 50% who underwent emergency surgery. Preoperative workup included National Institute of Health Stroke Scale (NIHSS) neurological assessment on admission, immediately before surgery and at discharge, carotid duplex scan, brain contrast-enhanced head computed tomography (CT) or magnetic resonance imaging (MRI). End points were perioperative (30-day) neurological mortality, NIHSS score variation, and hemorrhagic or ischemic stroke recurrence. Patients were evaluated according to clinical presentation (SIE or cTIA), timing of surgery, and presence of brain infarction on neuroimaging. Between January 2005 and December 2009, 48 patients were submitted to emergency surgery. CEAs were performed from 1 to 24 hours from onset of symptoms (mean, 10.16 ± 7.75). Twenty-six patients presented an SIE with a worsening NIHSS score between admission and surgery, and 22 presented ≥ 3 cTIAs with a normal NIHSS score (= 0) immediately before surgery. An ischemic brain lesion was detected in four patients with SIE and eight patients with cTIA. All patients with cTIA presented a persistent NIHSS normal score before and after surgery. Twenty-five patients with SIE presented an NIHSS score improvement after surgery. Mean NIHSS score was 5.30 ± 2.81 before surgery and 0.54 ± 0.77 at discharge in the SIE group (P hemorrhagic transformation of an undetected brain ischemic lesion after surgery, with progressive neurological deterioration and death (2%). Due to the absence of randomized controlled trials of CEA for neurologically unstable patients, data currently available do not support a policy of emergency CEA in those patients. Our results
Vanderweele, Tyler J; Ko, Yi-An; Mukherjee, Bhramar
We show that, in the presence of uncontrolled environmental confounding, joint tests for the presence of a main genetic effect and gene-environment interaction will be biased if the genetic and environmental factors are correlated, even if there is no effect of either the genetic factor or the environmental factor on the disease. When environmental confounding is ignored, such tests will in fact reject the joint null of no genetic effect with a probability that tends to 1 as the sample size increases. This problem with the joint test vanishes under gene-environment independence, but it still persists if estimating the gene-environment interaction parameter itself is of interest. Uncontrolled environmental confounding will bias estimates of gene-environment interaction parameters even under gene-environment independence, but it will not do so if the unmeasured confounding variable itself does not interact with the genetic factor. Under gene-environment independence, if the interaction parameter without controlling for the environmental confounder is nonzero, then there is gene-environment interaction either between the genetic factor and the environmental factor of interest or between the genetic factor and the unmeasured environmental confounder. We evaluate several recently proposed joint tests in a simulation study and discuss the implications of these results for the conduct of gene-environment interaction studies.
Marshall, J R; Hastrup, J L
Greenland first documented (Am J Epidemiol 1980; 112:564-9) that error in the measurement of a confounder could resonate--that it could bias estimates of other study variables, and that the bias could persist even with statistical adjustment for the confounder as measured. An important question is raised by this finding: can such bias be more than trivial within the bounds of realistic data configurations? The authors examine several situations involving dichotomous and continuous data in which a confounder and a null variable are measured with error, and they assess the extent of resultant bias in estimates of the effect of the null variable. They show that, with continuous variables, measurement error amounting to 40% of observed variance in the confounder could cause the observed impact of the null study variable to appear to alter risk by as much as 30%. Similarly, they show, with dichotomous independent variables, that 15% measurement error in the form of misclassification could lead the null study variable to appear to alter risk by as much as 50%. Such bias would result only from strong confounding. Measurement error would obscure the evidence that strong confounding is a likely problem. These results support the need for every epidemiologic inquiry to include evaluations of measurement error in each variable considered.
Reis, Phillipe Geraldo Teixeira de Abreu; Driessen, Anna Luiza; da Costa, Ana Claudia Brenner Affonso; Nasr, Adonis; Collaço, Iwan Augusto; Tomasich, Flávio Daniel Saavedra
To evaluate the accidents with biological material among medical students interning in a trauma emergency room and identify key related situations, attributed causes and prevention. we conducted a study with a quantitative approach. Data were collected through a questionnaire applied via internet, with closed, multiple-choice questions regarding accidents with biological material. The sample comprised 100 students. thirty-two had accidents with biological material. Higher-risk activities were local anesthesia (39.47%), suture (18.42%) and needle recapping (15.79%). The main routes of exposure to biological material were the eyes or mucosa, with 34%, and syringe needle puncture, with 45%. After contamination, only 52% reported the accident to the responsible department. The main causes of accidents and routes of exposure found may be attributed to several factors, such as lack of training and failure to use personal protective equipment. Educational and preventive actions are extremely important to reduce the incidence of accidents with biological materials and improve the conduct of post-exposure. It is important to understand the main causes attributed and situations related, so as general and effective measures can be applied.
Schuld, Jochen; Slotta, Jan E; Schuld, Simone; Kollmar, Otto; Schilling, Martin K; Richter, Sven
The influence of superstition, moon calendars, and popular belief on evidence-based medicine is stunning. More than 40% of medical staff is convinced that lunar phases can affect human behavior. The idea that Friday the 13th is associated with adverse events and bad luck is deep-rooted in the population of Western industrial countries. The aim of the present study was to test the hypothesis that these myths are transferable to real-life surgery. We analyzed the extent to which moon phases, zodiac signs, and Friday the 13th influence blood loss, emergency frequency, and intestinal perforations by evaluating the operation records of all 27,914 consecutive patients of our institution undergoing general, visceral, or vascular surgery between August 2001 and August 2010. Dates of surgery were allocated to lunar phases and to zodiac signs, as well as to Friday the 13th. A total of 111 lunar cycles and 15 Fridays the 13th occurred within the 3,281-day observation period. Patients' characteristics did not differ in lunar phases, zodiac signs, or Fridays the 13th. Full moon phases, the presence of Friday the 13th, and zodiac signs influenced neither intraoperative blood loss nor emergency frequency. No statistical peaks regarding perforated aortic aneurysms and gastrointestinal perforations were found on full moon or Friday the 13th. Scientific analysis of our data does not support the belief that moon phases, zodiac signs, or Friday 13th influence surgical blood loss and emergency frequency. Our data indicate that such beliefs are myths far beyond reality.
Suction curettage; Surgical abortion; Elective abortion - surgical; Therapeutic abortion - surgical ... Surgical abortion involves dilating the opening to the uterus (cervix) and placing a small suction tube into the uterus. ...
Marchesi, M; Marchesi, A; Calori, G M; Cireni, L V; Sileo, G; Merzagora, I; Zoia, R; Vaienti, L; Morini, O
Acute compartment syndrome (ACS) is a clinical condition with potentially dramatic consequences, therefore, it is important to recognise and treat it early. Good management of ACS minimises or avoids the sequelae associated with a late diagnosis, and may also reduce the risk of malpractice claims. The aim of this article was to evaluate different errors ascribed to the surgeon and to identify how the damage was evaluated. A total of 66 completed and closed ACS cases were selected. The following were analysed for each case: clinical management before and after diagnosis of ACS, imputed errors, professional fault, damage evaluation and quantification. Particular attention was paid to distinguishing between impairment because of primary injury and iatrogenic impairment. Statistical analyses were performed using Fisher's exact test and Pearson's correlation. The most common presenting symptom was pain. Delay in the diagnosis, and hence delay in decompression, was common in the study. A total of 48 out of 66 cases resolved with the verdict of iatrogenic damage, which varied from 12% to 75% of global capability of the person. A total of $394,780 out of $574,680 (average payment) derived from a medical error. ACS is a clinical emergency that requires continuous clinical surveillance from both medical and nursing staff. The related damage should be evaluated in two parts: damage deriving from the trauma, so that it is considered inevitable and independent from the surgeon's conduct, and damage deriving from a surgeon's error, which is eligible for an indemnity payment. Copyright © 2014 Elsevier Ltd. All rights reserved.
Wackym, P Ashley; Mackay-Promitas, Heather T; Demirel, Shaban; Gianoli, Gerard J; Gizzi, Martin S; Carter, Dale M; Siker, David A
Patients with third window syndrome and superior semicircular canal dehiscence (SSCD) symptoms whose surgical outcomes placed them as outliers were systematically studied to determine comorbidities that were responsible for their poor outcomes due to these confounding factors. Observational analytic case-control study in a tertiary referral center. Twelve adult patients with clinical SSCD syndrome underwent surgical management and had outcomes that did not resolve all of their subjective symptoms. In addition to one of the neurotologists, 2 neurologists (one specializing in migraine and the other a neuro-ophthalmologist), and a psychologist clinician-investigator completed comprehensive evaluations. Neuropsychology test batteries included: the Millon Behavioral Medicine Diagnostic; Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Screener (GAD-7); Adverse Childhood Experiences Scale; the Wide Range Assessment of Memory and Learning, including the 3 domains of verbal memory, visual memory, and attention/concentration; Wechsler Adult Intelligence Scale; and the Delis-Kaplan Executive Function System. The control cohort was comprised of 17 participants who previously underwent surgery for third window syndrome that resulted in the expected outcomes of resolution of their third window syndrome symptoms and cognitive dysfunction. There was a high rate of psychological comorbidity (n = 6) in the outlier cohort; multiple traumatic brain injuries were also a confounding element (n = 10). One patient had elevated cerebrospinal fluid (CSF) pressure requiring ventriculoperitoneal shunting to control the recurrence of dehiscence and one patient with a drug-induced Parkinson-like syndrome and idiopathic progressive neurological degenerative process. Components of the Millon Behavioral Medicine Diagnostic, PHQ-9 and GAD-7 results suggest that these instruments would be useful as screening tools preoperatively to identify psychological comorbidities
Kernodle, D S; Barg, N L; Kaiser, A B
By use of techniques that have been developed to detect small numbers of methicillin-resistant staphylococci, we cultured samples from the nares and subclavian and inguinal areas of 29 patients before and after cardiac surgery and 10 patients before and after coronary angioplasty. Methicillin-resistant coagulase-negative staphylococci were recovered before the surgical or angioplasty procedure from 74% of patients. The quantitative recovery of methicillin-resistant isolates before cardiac surgery or coronary angioplasty was compared with the number of methicillin-resistant staphylococci detected at the same site 3 days after the procedure. In cardiac surgery patients (who received antibiotic prophylaxis), 17 of the 28 sites (61%) in which low-level colonization with methicillin-resistant strains was detected preoperatively contained high levels of methicillin-resistant staphylococci postoperatively. In contrast, coronary angioplasty patients (who did not receive antibiotic prophylaxis) did not have any of the 14 sites containing low levels of methicillin-resistant strains before angioplasty emerge to harbor high levels of methicillin-resistant staphylococci after angioplasty. Methicillin-resistant coagulase-negative staphylococci from each site in which high levels of methicillin-resistant staphylococci emerged postoperatively were paired with preoperative isolates from the same site. Identical antibiograms and plasmid profile patterns were demonstrated for seven of the pre- and postoperative isolate pairs, suggesting that the high levels of methicillin-resistant coagulase-negative staphylococci detected on the skin or in the nares after cardiac surgery were derived from methicillin-resistant organisms present at the site preoperatively in much smaller numbers. Images PMID:2966607
Effectiveness of Specimen Collection Technology in the Reduction of Collection Turnaround Time and Mislabeled Specimens in Emergency, Medical-Surgical, Critical Care, and Maternal Child Health Departments.
Saathoff, April M; MacDonald, Ryan; Krenzischek, Erundina
The objective of this study was to evaluate the impact of specimen collection technology implementation featuring computerized provider order entry, positive patient identification, bedside specimen label printing, and barcode scanning on the reduction of mislabeled specimens and collection turnaround times in the emergency, medical-surgical, critical care, and maternal child health departments at a community teaching hospital. A quantitative analysis of a nonrandomized, pre-post intervention study design evaluated the statistical significance of reduction of mislabeled specimen percentages and collection turnaround times affected by the implementation of specimen collection technology. Mislabeled specimen percentages in all areas decreased from an average of 0.020% preimplementation to an average of 0.003% postimplementation, with a P Collection turnaround times longer than 60 minutes decreased after the implementation of specimen collection technology by an average of 27%, with a P collection and identification errors are a significant problem in healthcare, contributing to incorrect diagnoses, delayed care, lack of essential treatments, and patient injury or death. Collection errors can also contribute to an increased length of stay, increased healthcare costs, and decreased patient satisfaction. Specimen collection technology has structures in place to prevent collection errors and improve the overall efficiency of the specimen collection process.
Tørring, Marie Louise; Vedsted, Peter; Frydenberg, Morten
) Clarify which factors are considered confounders or intermediate variables in the literature. 2) Assess how and to what extent these factors bias survival estimates. CONSIDERATIONS: As illustrated in Figure 1, symptoms of cancer may alert patients, GP's, and hospital doctors differently and influence both...
Sheppard, Lianne; Burnett, Richard T; Szpiro, Adam A; Kim, Sun-Young; Jerrett, Michael; Pope, C Arden; Brunekreef, Bert
Studies in air pollution epidemiology may suffer from some specific forms of confounding and exposure measurement error. This contribution discusses these, mostly in the framework of cohort studies. Evaluation of potential confounding is critical in studies of the health effects of air pollution. The association between long-term exposure to ambient air pollution and mortality has been investigated using cohort studies in which subjects are followed over time with respect to their vital status. In such studies, control for individual-level confounders such as smoking is important, as is control for area-level confounders such as neighborhood socio-economic status. In addition, there may be spatial dependencies in the survival data that need to be addressed. These issues are illustrated using the American Cancer Society Cancer Prevention II cohort. Exposure measurement error is a challenge in epidemiology because inference about health effects can be incorrect when the measured or predicted exposure used in the analysis is different from the underlying true exposure. Air pollution epidemiology rarely if ever uses personal measurements of exposure for reasons of cost and feasibility. Exposure measurement error in air pollution epidemiology comes in various dominant forms, which are different for time-series and cohort studies. The challenges are reviewed and a number of suggested solutions are discussed for both study domains.
To support their hypothesis, the authors point to an inverse correlation between latitude and the incidence of civil conflict and crime. This observation cannot be accepted as evidence for the hypothesis, because of a weighty confounding variable: the historical geography of colonialism and its effects on the fragility of nations.
Karp, Natasha A; Segonds-Pichon, Anne; Gerdin, Anna-Karin B; Ramírez-Solis, Ramiro; White, Jacqueline K
Scientists aspire to measure cause and effect. Unfortunately confounding variables, ones that are associated with both the probable cause and the outcome, can lead to an association that is true but potentially misleading. For example, altered body weight is often observed in a gene knockout; however, many other variables, such as lean mass, will also change as the body weight changes. This leaves the researcher asking whether the change in that variable is expected for that change in weight. Ratio correction, which is often referred to as normalization, is a method used commonly to remove the effect of a confounding variable. Although ratio correction is used widely in biological research, it is not the method recommended in the statistical literature to address confounding factors; instead regression methods such as the analysis of covariance (ANCOVA) are proposed. This method examines the difference in means after adjusting for the confounding relationship. Using real data, this manuscript demonstrates how the ratio correction approach is flawed and can result in erroneous calls of significance leading to inappropriate biological conclusions. This arises as some of the underlying assumptions are not met. The manuscript goes on to demonstrate that researchers should use ANCOVA, and discusses how graphical tools can be used readily to judge the robustness of this method. This study is therefore a clear example of why assumption testing is an important component of a study and thus why it is included in the Animal Research: Reporting of In Vivo Experiment (ARRIVE) guidelines.
Choi, Anna L; Mogensen, Ulla Brasch; Bjerve, Kristian S
BACKGROUND: Methylmercury, a worldwide contaminant of fish and seafood, can cause adverse effects on the developing nervous system. However, long-chain n-3 polyunsaturated fatty acids in seafood provide beneficial effects on brain development. Negative confounding will likely result in underestim...
Bruning, O.; Rodenburg, W.; Wackers, P.F.K.; van Oostrom, C.; Jonker, M.J.; Dekker, R.J.; Rauwerda, H.; Ensink, W.A.; de Vries, A; Breit, T.M.
CONFOUNDING FACTORS: In transcriptomics experimentation, confounding factors frequently exist alongside the intended experimental factors and can severely influence the outcome of a transcriptome analysis. Confounding factors are regularly discussed in methodological literature, but their actual,
Karp, Natasha A; Segonds-Pichon, Anne; Gerdin, Anna-Karin B; Ramírez-Solis, Ramiro; White, Jacqueline K
Scientists aspire to measure cause and effect. Unfortunately confounding variables, ones that are associated with both the probable cause and the outcome, can lead to an association that is true but potentially misleading. For example, altered body weight is often observed in a gene knockout, however many other variables, such as lean mass, will also change as the body weight changes. This leaves the researcher asking whether the change in that variable is expected for that change in weight. ...
Liu, Jingwei; Hu, Shuang
Confounding of three binary-variables counterfactual model is discussed in this paper. According to the effect between the control variable and the covariate variable, we investigate three counterfactual models: the control variable is independent of the covariate variable, the control variable has the effect on the covariate variable and the covariate variable affects the control variable. Using the ancillary information based on conditional independence hypotheses, the sufficient conditions...
The demands to make data available are growing ever louder, including open data initiatives and "data monetization". But the problem of doing so without disclosing confidential information is a subtle and difficult one. Is "private data release" an oxymoron? This paper (accompanying an invited talk) aims to delve into the motivations of data release, explore the challenges, and outline some of the current statistical approaches developed in response to this confounding problem.
Full Text Available Several studies have reported an increased risk of wheezing in the children of mothers who used paracetamol during pregnancy. We evaluated to what extent this association is explained by confounding.We investigated the association between maternal paracetamol use in the first and third trimester of pregnancy and ever wheezing or recurrent wheezing/asthma in infants in the NINFEA cohort study. Risks ratios (RR and 95% confidence intervals (CI were estimated after adjustment for confounders, including maternal infections and antibiotic use during pregnancy.The prevalence of maternal paracetamol use was 30.6% during the first and 36.7% during the third trimester of pregnancy. The prevalence of ever wheezing and recurrent wheezing/asthma was 16.9% and 5.6%, respectively. After full adjustment, the RR for ever wheezing decreased from 1.25 [1.07-1.47] to 1.10 [0.94-1.30] in the first, and from 1.26 [1.08-1.47] to 1.10 [0.93-1.29] in the third trimester. A similar pattern was observed for recurrent wheezing/asthma. Duration of maternal paracetamol use was not associated with either outcome. Further analyses on paracetamol use for three non-infectious disorders (sciatica, migraine, and headache revealed no increased risk of wheezing in children.The association between maternal paracetamol use during pregnancy and infant wheezing is mainly, if not completely explained by confounding.
World Health Assembly Resolution WHA68.15: "Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage"—Addressing the Public Health Gaps Arising from Lack of Safe, Affordable and Accessible Surgical and Anesthetic Services.
Price, Raymond; Makasa, Emmanuel; Hollands, Michael
On May 22 2015, the 68th World Health Assembly (WHA) adopted resolution WHA68.15, "Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage (UHC)." For the first time, governments worldwide acknowledged and recognized surgery and anesthesia as key components of UHC and health systems strengthening. The resolution details and outlines the highest level of political commitments to address the public health gaps arising from lack of safe, affordable, and accessible surgical and anesthetic services in an integrated approach. This article reviews the background of resolution WHA68.15 and discusses how it can be of use to surgeons, anesthetists, advanced practice clinicians, nurses, and others caring for the surgical patients, especially in low- and middle-income countries.
McCandless, Lawrence C; Gustafson, Paul
Bias from unmeasured confounding is a persistent concern in observational studies, and sensitivity analysis has been proposed as a solution. In the recent years, probabilistic sensitivity analysis using either Monte Carlo sensitivity analysis (MCSA) or Bayesian sensitivity analysis (BSA) has emerged as a practical analytic strategy when there are multiple bias parameters inputs. BSA uses Bayes theorem to formally combine evidence from the prior distribution and the data. In contrast, MCSA samples bias parameters directly from the prior distribution. Intuitively, one would think that BSA and MCSA ought to give similar results. Both methods use similar models and the same (prior) probability distributions for the bias parameters. In this paper, we illustrate the surprising finding that BSA and MCSA can give very different results. Specifically, we demonstrate that MCSA can give inaccurate uncertainty assessments (e.g. 95% intervals) that do not reflect the data's influence on uncertainty about unmeasured confounding. Using a data example from epidemiology and simulation studies, we show that certain combinations of data and prior distributions can result in dramatic prior-to-posterior changes in uncertainty about the bias parameters. This occurs because the application of Bayes theorem in a non-identifiable model can sometimes rule out certain patterns of unmeasured confounding that are not compatible with the data. Consequently, the MCSA approach may give 95% intervals that are either too wide or too narrow and that do not have 95% frequentist coverage probability. Based on our findings, we recommend that analysts use BSA for probabilistic sensitivity analysis. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.
Julius H Bourke
Full Text Available Pharmacological Magnetic Resonance Imaging (phMRI is a variant of conventional MRI that adds pharmacological manipulations in order to study the effects of drugs, or uses pharmacological probes to investigate basic or applied (e.g. clinical neuroscience questions. Issues that may confound the interpretation of results from various types of phMRI studies are briefly discussed, and a set of methodological strategies that can mitigate these problems are described. These include strategies that can be employed at every stage of investigation, from study design to interpretation of resulting data, and additional techniques suited for use with clinical populations are also featured. Pharmacological MRI is a challenging area of research that has both significant advantages and formidable difficulties, however with due consideration and use of these strategies many of the key obstacles can be overcome.
Basu, N. B.; Van Meter, K. J.
Watersheds have been shown to demonstrate a range of both chemostatic and chemodynamic responses to changes in discharge based on land use, solute species, and hydrologic regime as well as the presence or absence of large solute mass stores within the watershed. The dynamics of solute export, as captured by concentration-discharge patterns, can be described mathematically based on a power-law concentration-discharge relationship of the form , where a purely chemostatic system is characterized by a b value equal to 0. In practice, catchments across a range of land uses and geologic conditions may exhibit a distribution of solute export behaviors, and such dynamics can be grouped into different regimes as a function of differences in b values. It is our hypothesis that different solute export regimes are created primarily as a function of solute mass stores in different compartments of the landscape, e.g. the vadose zone or groundwater, and that these regimes may vary temporally based on the triggering of these compartments as a function of stochastic forcing within and between years. In the present work, we synthesize both high and low temporal resolution concentration data for a range of geogenic and anthropogenic solutes to better our understanding of the variations in concentration-discharge relationships as a function of land use, climate and solute type. We then develop a parsimonious model to explain these patterns as a function not only of solute mass stores, but also of the triggering of fast and slow transport pathways across a range of precipitation dynamics. Specifically, we have developed a modeling framework to address the following questions: (1) How do C-Q relationships vary across climate and land-use gradients? (2) Is there any seasonality to C-Q patterns? (3) Can C-Q patterns be explained as a function of the activation of fast and slow hydrologic pathways in response to stochastic, hydro-climatic forcing? (4) How do these interactions lead to the development of hot spots and hot moments in catchment biogeochemical processing?
Gros, Ethan; Udpa, Lalita; Smith, James A.; Wachs, Katelyn
Determining Confounding Sensitivities In Eddy Current Thin Film Measurements Ethan Gros, Lalita Udpa, Electrical Engineering, Michigan State University, East Lansing MI 48824 James A. Smith, Experiment Analysis, Idaho National Laboratory, Idaho Falls ID 83415 Eddy current (EC) techniques are widely used in industry to measure the thickness of non-conductive films on a metal substrate. This is done using a system whereby a coil carrying a high-frequency alternating current is used to create an alternating magnetic field at the surface of the instrument's probe. When the probe is brought near a conductive surface, the alternating magnetic field will induce ECs in the conductor. The substrate characteristics and the distance of the probe from the substrate (the coating thickness) affect the magnitude of the ECs. The induced currents load the probe coil affecting the terminal impedance of the coil. The measured probe impedance is related to the lift off between coil and conductor as well as conductivity of the test sample. For a known conductivity sample, the probe impedance can be converted into an equivalent film thickness value. The EC measurement can be confounded by a number of measurement parameters. It is the goal of this research to determine which physical properties of the measurement set-up and sample can adversely affect the thickness measurement. The eddy current testing is performed using a commercially available, hand held eddy current probe (ETA3.3H spring loaded eddy probe running at 8 MHz) that comes with a stand to hold the probe. The stand holds the probe and adjusts the probe on the z-axis to help position the probe in the correct area as well as make precise measurements. The signal from the probe is sent to a hand held readout, where the results are recorded directly in terms of liftoff or film thickness. Understanding the effect of certain factors on the measurements of film thickness, will help to evaluate how accurate the ETA3.3H spring
Kernodle, D S; Barg, N L; Kaiser, A B
By use of techniques that have been developed to detect small numbers of methicillin-resistant staphylococci, we cultured samples from the nares and subclavian and inguinal areas of 29 patients before and after cardiac surgery and 10 patients before and after coronary angioplasty. Methicillin-resistant coagulase-negative staphylococci were recovered before the surgical or angioplasty procedure from 74% of patients. The quantitative recovery of methicillin-resistant isolates before cardiac sur...
Pouwels, Koen B.; Widyakusuma, Niken N.; Groenwold, Rolf H H; Hak, Eelko
Objectives Poor quality of reporting of confounding has been observed in observational studies prior the STrenghtening the Reporting of Observational studies in Epidemiology (STROBE) statement, a reporting guideline for observational studies. We assessed whether the reporting of confounding improved
Pouwels, Koen B; Widyakusuma, Niken N; Groenwold, Rolf Hh; Hak, Eelko
Objectives: Poor quality of reporting of confounding has been observed in observational studies prior the STrenghtening the Reporting of Observational studies in Epidemiology (STROBE) statement, a reporting guideline for observational studies. We assessed whether the reporting of confounding
Identifying Opportunities for Virtual Reality Simulation in Surgical Education: A Review of the Proceedings from the Innovation, Design, and Emerging Alliances in Surgery (IDEAS) Conference: VR Surgery.
Olasky, Jaisa; Sankaranarayanan, Ganesh; Seymour, Neal E; Magee, J Harvey; Enquobahrie, Andinet; Lin, Ming C; Aggarwal, Rajesh; Brunt, L Michael; Schwaitzberg, Steven D; Cao, Caroline G L; De, Suvranu; Jones, Daniel B
To conduct a review of the state of virtual reality (VR) simulation technology, to identify areas of surgical education that have the greatest potential to benefit from it, and to identify challenges to implementation. Simulation is an increasingly important part of surgical training. VR is a developing platform for using simulation to teach technical skills, behavioral skills, and entire procedures to trainees and practicing surgeons worldwide. Questions exist regarding the science behind the technology and most effective usage of VR simulation. A symposium was held to address these issues. Engineers, educators, and surgeons held a conference in November 2013 both to review the background science behind simulation technology and to create guidelines for its use in teaching and credentialing trainees and surgeons in practice. Several technologic challenges were identified that must be overcome in order for VR simulation to be useful in surgery. Specific areas of student, resident, and practicing surgeon training and testing that would likely benefit from VR were identified: technical skills, team training and decision-making skills, and patient safety, such as in use of electrosurgical equipment. VR simulation has the potential to become an essential piece of surgical education curriculum but depends heavily on the establishment of an agreed upon set of goals. Researchers and clinicians must collaborate to allocate funding toward projects that help achieve these goals. The recommendations outlined here should guide further study and implementation of VR simulation. © The Author(s) 2015.
Jan 6, 2010 ... A good way to describe the first surgical audits is that they were 'polite, restrained discussions'. This was the situation before the development of quality assurance in the business world. As this slowly infiltrated into the medical profession the discussions changed to more cri- teria based surgical audits.
Intravenous infusion of ketamine-propofol can be an alternative to intravenous infusion of fentanyl-propofol for deep sedation and analgesia in paediatric patients undergoing emergency short surgical procedures
Samit Kumar Khutia
Full Text Available Background: Paediatric patients often present with different painful conditions that require immediate surgical interventions. Despite a plethora of articles on the ketamine-propofol combination, comprehensive evidence regarding the suitable sedoanalgesia regime is lacking due to heterogeneity in study designs. Methods: This prospective, randomized, double-blind, active-controlled trial was conducted in 100 children, of age 3-14 years, American Society of Anesthesiologist physical status IE-IIE, posted for emergency short surgical procedures. Patients were randomly allocated to receive either 2 mL of normal saline (pre-induction plus calculated volume of drug from the 11 mL of ketamine-propofol solution for induction (group PK, n=50 or fentanyl 1.5 μg/kg diluted to 2 mL with normal saline (pre-induction plus calculated volume of drug from the 11 mL of propofol solution for induction (group PF, n=50. In both the groups, the initial bolus propofol 1 mg/kg i.v. (assuming the syringes contained only propofol, for simplicity was followed by adjusted infusion to achieve a Ramsay Sedation Scale score of six. Mean arterial pressure (MAP was the primary outcome measurement. Results: Data from 48 patients in group PK and 44 patients in group PF were available for analysis. Hypotension was found in seven patients (14.6% in group PK compared with 17 (38.6% patients in group PF (P=0.009. Intraoperative MAP was significantly lower in group PF than group PK when compared with baseline. Conclusion: The combination of low-dose ketamine and propofol is more effective and a safer sedoanalgesia regimen than the propofol-fentanyl combination in paediatric emergency short surgical procedures in terms of haemodynamic stability and lesser incidence of apnoea.
Howards, Penelope P
Confounding is an important source of bias, but it is often misunderstood. We consider how confounding occurs and how to address confounding using examples. Study results are confounded when the effect of the exposure on the outcome, mixes with the effects of other risk and protective factors for the outcome. This problem arises when these factors are present to different degrees among the exposed and unexposed study participants, but not all differences between the groups result in confounding. Thinking about an ideal study where all of the population of interest is exposed in one universe and is unexposed in a parallel universe helps to distinguish confounders from other differences. In an actual study, an observed unexposed population is chosen to stand in for the unobserved parallel universe. Differences between this substitute population and the parallel universe result in confounding. Confounding by identified factors can be addressed analytically and through study design, but only randomization has the potential to address confounding by unmeasured factors. Nevertheless, a given randomized study may still be confounded. Confounded study results can lead to incorrect conclusions about the effect of the exposure of interest on the outcome. © 2018 Nordic Federation of Societies of Obstetrics and Gynecology.
Howards, Penelope P
Confounding biases study results when the effect of the exposure on the outcome mixes with the effects of other risk and protective factors for the outcome that are present differentially by exposure status. However, not all differences between the exposed and unexposed group cause confounding. Thus, sources of confounding must be identified before they can be addressed. Confounding is absent in an ideal study where all of the population of interest is exposed in one universe and is unexposed in a parallel universe. In an actual study, an observed unexposed population represents the unobserved parallel universe. Thinking about differences between this substitute population and the unexposed parallel universe helps identify sources of confounding. These differences can then be represented in a diagram that shows how risk and protective factors for the outcome are related to the exposure. Sources of confounding identified in the diagram should be addressed analytically and through study design. However, treating all factors that differ by exposure status as confounders without considering the structure of their relation to the exposure can introduce bias. For example, conditions affected by the exposure are not confounders. There are also special types of confounding, such as time-varying confounding and unfixable confounding. It is important to evaluate carefully whether factors of interest contribute to confounding because bias can be introduced both by ignoring potential confounders and by adjusting for factors that are not confounders. The resulting bias can result in misleading conclusions about the effect of the exposure of interest on the outcome. © 2018 Nordic Federation of Societies of Obstetrics and Gynecology.
Gabriel, Rodney A; A'Court, Alison M; Schmidt, Ulrich H; Dutton, Richard P; Urman, Richard D
There is a lack of large, multi-institutional studies analyzing the association of timing of emergency surgery with death occurring either intraoperatively or in the recovery room setting. The primary objective of this study was to determine if time of day for emergency surgeries was associated with mortality. Retrospective analysis. U.S. healthcare facilities. Adult patients undergoing emergency surgery and general anesthesia. No intervention. Utilizing the National Anesthesia Clinical Outcomes Registry database, all emergency non-cardiac, non-obstetric surgeries undergoing general anesthesia occurring between 2010 and 2015 in the United States were identified. We performed mixed effects logistic regression to determine the effect of time of day with mortality occurring during the intraoperative and immediate postoperative period. There were 46,196 cases that were eligible for this analysis, in which 24,247 and 21,949 occurred during day and after-hours shifts, respectively. The overall morality rate was 0.28%. Mortality rates were 0.17% and 0.41% in the day and after-hour shifts, respectively. There was no statistically significant association of time of day with mortality (odds ratio 1.31, 95% CI 0.90-1.92, p = 0.16). American Society of Anesthesiologists physical status classification, age, and operative body part were all associated with mortality. Although, theoretically, health care providers working after-hour shifts may be impacted by sleep deprivation and/or limited resources, we found that time of day was not associated with increased risk of mortality during the intraoperative and immediate postoperative period in emergency surgery. Copyright © 2018 Elsevier Inc. All rights reserved.
General anaesthesia was indicated in seven (41.2%) of emergency ophthalmic surgical procedures as compared to 16 (5.9%) of elective ophthalmic procedures P<0.0001. Conclusion: General anaesthesia was more commonly employed in children, eye wall repairs and emergency ophthalmic surgical procedures.
Hale, Diane F; Sexton, Justin C; Benavides, Linda C; Benavides, Jerry M; Lundy, Jonathan B
The deployment of surgical assets has been driven by mission demands throughout years of military operations in Iraq and Afghanistan. The transition to the highly expeditious Golden Hour Offset Surgical Transport Team (GHOST- T) now offers highly mobile surgical assets in nontraditional operating rooms; the content of the surgical instrument sets has also transformed to accommodate this change. The 102nd Forward Surgical Team (FST) was attached to Special Operations assigned to southern Afghanistan from June 2015 to March 2016. The focus was to decrease overall size and weight of FST instrument sets without decreasing surgical capability of the GHOST-T. Each instrument set was evaluated and modified to include essential instruments to perform damage control surgery. The overall number of main instrument sets was decreased from eight to four; simplified augmentation sets have been added, which expand the capabilities of any main set. The overall size was decreased by 40% and overall weight decreased by 58%. The cardiothoracic, thoracotomy, and emergency thoracotomy trays were condensed to thoracic set. The orthopedic and amputation sets were replaced with an augmentation set of a prepackaged orthopedic external fixator set). An augmentation set to the major or minor basic sets, specifically for vascular injuries, was created. Through the reorganization of conventional FST surgical instrument sets to maintain damage control capabilities and mobility, the 102nd GHOST-T reduced surgical equipment volume and weight, providing a lesson learned for future surgical teams operating in austere environments. 2017.
Koopowitz, Harold; Hawkins, Bradford A
Most organisms face similar problems with respect to their conservation in the face of global climate change. Here, we examine probable effects of climate change on the hyperdiverse plant family Orchidaceae. In the 20th century, the major concerns for orchid conservation revolved around unsustainable harvest for the orchid trade and, more importantly, land conversion from natural ecosystems to those unable to support wild orchid populations. Land conversion included logging, fire regimes and forest conversions to agricultural systems. Although those forms of degradation continue, an additional suite of threats has emerged, fueled by global climate change. Global climate change involves more than responses of orchid populations to increases in ambient temperature. Increasing temperature induces secondary effects that can be more significant than simple changes in temperature. Among these new threats are extended and prolonged fire seasons, rising sea levels, increases in cyclonic storms, seasonal climate shifts, changes in orthographic wind dew point and increased drought. The long-term outlook for orchid biodiversity in the wild is dismal, as it is for many animal groups, and we need to start rethinking strategies for conservation in a rapidly changing world. © 2012 ISZS, Blackwell Publishing and IOZ/CAS.
SURGICAL ANATOMY. Rare high origin of the radial artery: a bilateral, symmetrical ease. I. O. ()koro and B. C. J iburum. Department of Anatomy, College of Medicine, lrno State University, Owerri, Nigeria. Reprint requests to: Dr I. O. 0k0r0, Department of Anatomy, [mo State University, P. M. B. 2000. Owerri, Nigeria.
Conclusion:Foraminotomy with or without discectomy is a simple posterior surgical approach to T B spine with good neurological outcome. It is adapted to our ... of the spine also referred to as. (HIV/AIDS) further challenge the outcome. These .... treatment; or for spinal cord or nerve root from 2 weeks depending on patient ...
Epidemiology of dietary components and disease risk limits interpretability due to potential residual confounding by correlated dietary components. Dietary pattern analyses by factor analysis or partial least squares may overcome this limitation. To examine confounding by dietary pattern as well as ...
Epidemiology of dietary components and disease risk limits interpretability due to potential residual confounding by correlated dietary components. Dietary pattern analyses by factor analysis or partial least squares may overcome the limitation. To examine confounding by dietary pattern as well as ...
Groenwold, R H H; Hak, E; Hoes, A W
OBJECTIVE: In nonrandomized intervention studies unequal distribution of patient characteristics in the groups under study may hinder comparability of prognosis and therefore lead to confounding bias. Our objective was to review methods to control for observed confounding, as well as unobserved
Budtz-Jørgensen, Esben; Keiding, Niels; Grandjean, Philippe
PURPOSE: The purpose of the study is to compare different approaches to the identification of confounders needed for analyzing observational data. Whereas standard analysis usually is conducted as if the confounders were known a priori, selection uncertainty also must be taken into account. METHODS......: Confounders were selected by using backward elimination (BE), change in estimate (CIE) method, Akaike information criterion, Bayesian information criterion (BIC), and an empirical approach using a priori information. A modified ridge regression estimator, which shrinks effects of confounders toward zero, also...... of mercury effects on confounder-sensitive neurobehavioral outcomes were calculated for each selection procedure. RESULTS: The full model and the empirical a priori model showed approximately the same precision, and these methods were (slightly) inferior to only modified ridge regression. Lower precisions...
Haskins, Ivy N; Maluso, Patrick J; Schroeder, Mary E; Amdur, Richard L; Vaziri, Khashayar; Agarwal, Samir; Sarani, Babak
The complex nature of current morbidity and mortality predictor models do not lend themselves to clinical application at the bedside of patients undergoing emergency general surgery (EGS). Our aim was to develop a simplified risk calculator for prediction of early postoperative mortality after EGS. EGS cases other than appendectomy and cholecystectomy were identified within the American College of Surgeons National Surgery Quality Improvement Program database from 2005 to 2014. Seventy-five percent of the cases were selected at random for model development, whereas 25% of the cases were used for model testing. Stepwise logistic regression was performed for creation of a 30-day mortality risk calculator. Model accuracy and reproducibility was investigated using the concordance index (c statistic) and Pearson correlations. A total of 79,835 patients met inclusion criteria. Overall, 30-day mortality was 12.6%. A simplified risk model formula was derived from five readily available preoperative variables as follows: 0.034*age + 0.8*nonindependent status + 0.88*sepsis + 1.1 (if bun ≥ 29) or 0.57 (if bun ≥18 and < 29) + 1.16 (if albumin < 2.7), or 0.61 (if albumin ≥ 2.7 and < 3.4). The risk of 30-day mortality was stratified into deciles. The risk of 30-day mortality ranged from 2% for patients in the lowest risk level to 31% for patients in the highest risk level. The c statistic was 0.83 in both the derivation and testing samples. Five readily available preoperative variables can be used to predict the 30-day mortality risk for patients undergoing EGS. Further studies are needed to validate this risk calculator and to determine its bedside applicability. Prognostic/epidemiological study, level III.
Azarmehr, Iman; Stokbro, Kasper; Bell, R. Bryan
body removal, respectively. The average technical system accuracy and intraoperative precision reported were less than 1 mm and 1 to 2 mm, respectively. In general, SN is reported to be a useful tool for surgical planning, execution, evaluation, and research. The largest numbers of studies and patients......Purpose: This systematic review investigates the most common indications, treatments, and outcomes of surgical navigation (SN) published from 2010 to 2015. The evolution of SN and its application in oral and maxillofacial surgery have rapidly developed over recent years, and therapeutic indications...... surgery, skull-base surgery, and foreign body removal were the areas of interests. Results: The search generated 13 articles dealing with traumatology; 5, 6, 2, and 0 studies were found that dealt with the topics of orthognathic surgery, cancer and reconstruction surgery, skull-base surgery, and foreign...
Root canal treatment usually fails because infection remains within the root canal. An orthograde attempt at re-treatment should always be considered first. However, when surgery is indicated, modern microtechniques coupled with surgical magnification will lead to a better prognosis. Careful management of the hard and soft tissues is essential, specially designed ultrasonic tips should be used for root end preparation which should ideally be sealed with MTA. All cases should be followed up until healing is seen, or failure accepted, and should form a part of clinical audit.
Anorectal emergencies refer to anorectal disorders presenting with some alarming symptoms such as acute anal pain and bleeding which might require an immediate management. This article deals with the diagnosis and management of common anorectal emergencies such as acutely thrombosed external hemorrhoid, thrombosed or strangulated internal hemorrhoid, bleeding hemorrhoid, bleeding anorectal varices, anal fissure, irreducible or strangulated rectal prolapse, anorectal abscess, perineal necrotizing fasciitis (Fournier gangrene), retained anorectal foreign bodies and obstructing rectal cancer. Sexually transmitted diseases as anorectal non-surgical emergencies and some anorectal emergencies in neonates are also discussed. The last part of this review dedicates to the management of early complications following common anorectal procedures that may present as an emergency including acute urinary retention, bleeding, fecal impaction and anorectal sepsis. Although many of anorectal disorders presenting in an emergency setting are not life-threatening and may be successfully treated in an outpatient clinic, an accurate diagnosis and proper management remains a challenging problem for clinicians. A detailed history taking and a careful physical examination, including digital rectal examination and anoscopy, is essential for correct diagnosis and plan of treatment. In some cases, some imaging examinations, such as endoanal ultrasonography and computerized tomography scan of whole abdomen, are required. If in doubt, the attending physicians should not hesitate to consult an expert e.g., colorectal surgeon about the diagnosis, proper management and appropriate follow-up. PMID:27468181
Ehret, Totta; Torelli, Francesca; Klotz, Christian; Pedersen, Amy B; Seeber, Frank
Rodents, in particular Mus musculus , have a long and invaluable history as models for human diseases in biomedical research, although their translational value has been challenged in a number of cases. We provide some examples in which rodents have been suboptimal as models for human biology and discuss confounders which influence experiments and may explain some of the misleading results. Infections of rodents with protozoan parasites are no exception in requiring close consideration upon model choice. We focus on the significant differences between inbred, outbred and wild animals, and the importance of factors such as microbiota, which are gaining attention as crucial variables in infection experiments. Frequently, mouse or rat models are chosen for convenience, e.g., availability in the institution rather than on an unbiased evaluation of whether they provide the answer to a given question. Apart from a general discussion on translational success or failure, we provide examples where infections with single-celled parasites in a chosen lab rodent gave contradictory or misleading results, and when possible discuss the reason for this. We present emerging alternatives to traditional rodent models, such as humanized mice and organoid primary cell cultures. So-called recombinant inbred strains such as the Collaborative Cross collection are also a potential solution for certain challenges. In addition, we emphasize the advantages of using wild rodents for certain immunological, ecological, and/or behavioral questions. The experimental challenges (e.g., availability of species-specific reagents) that come with the use of such non-model systems are also discussed. Our intention is to foster critical judgment of both traditional and newly available translational rodent models for research on parasitic protozoa that can complement the existing mouse and rat models.
Ehret, Totta; Torelli, Francesca; Klotz, Christian; Pedersen, Amy B.; Seeber, Frank
Rodents, in particular Mus musculus, have a long and invaluable history as models for human diseases in biomedical research, although their translational value has been challenged in a number of cases. We provide some examples in which rodents have been suboptimal as models for human biology and discuss confounders which influence experiments and may explain some of the misleading results. Infections of rodents with protozoan parasites are no exception in requiring close consideration upon model choice. We focus on the significant differences between inbred, outbred and wild animals, and the importance of factors such as microbiota, which are gaining attention as crucial variables in infection experiments. Frequently, mouse or rat models are chosen for convenience, e.g., availability in the institution rather than on an unbiased evaluation of whether they provide the answer to a given question. Apart from a general discussion on translational success or failure, we provide examples where infections with single-celled parasites in a chosen lab rodent gave contradictory or misleading results, and when possible discuss the reason for this. We present emerging alternatives to traditional rodent models, such as humanized mice and organoid primary cell cultures. So-called recombinant inbred strains such as the Collaborative Cross collection are also a potential solution for certain challenges. In addition, we emphasize the advantages of using wild rodents for certain immunological, ecological, and/or behavioral questions. The experimental challenges (e.g., availability of species-specific reagents) that come with the use of such non-model systems are also discussed. Our intention is to foster critical judgment of both traditional and newly available translational rodent models for research on parasitic protozoa that can complement the existing mouse and rat models. PMID:28638807
Groenwold, R H H; Hoes, A W; Nichol, K L; Hak, E
BACKGROUND: The validity of non-randomized studies using healthcare databases is often challenged because they lack information on potentially important confounders, such as functional health status and socioeconomic status. In a study quantifying the effects of influenza vaccination among
Valente, Matthew J; Pelham, William E; Smyth, Heather; MacKinnon, David P
Psychology researchers are often interested in mechanisms underlying how randomized interventions affect outcomes such as substance use and mental health. Mediation analysis is a common statistical method for investigating psychological mechanisms that has benefited from exciting new methodological improvements over the last 2 decades. One of the most important new developments is methodology for estimating causal mediated effects using the potential outcomes framework for causal inference. Potential outcomes-based methods developed in epidemiology and statistics have important implications for understanding psychological mechanisms. We aim to provide a concise introduction to and illustration of these new methods and emphasize the importance of confounder adjustment. First, we review the traditional regression approach for estimating mediated effects. Second, we describe the potential outcomes framework. Third, we define what a confounder is and how the presence of a confounder can provide misleading evidence regarding mechanisms of interventions. Fourth, we describe experimental designs that can help rule out confounder bias. Fifth, we describe new statistical approaches to adjust for measured confounders of the mediator-outcome relation and sensitivity analyses to probe effects of unmeasured confounders on the mediated effect. All approaches are illustrated with application to a real counseling intervention dataset. Counseling psychologists interested in understanding the causal mechanisms of their interventions can benefit from incorporating the most up-to-date techniques into their mediation analyses. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
Tétreault, Louis-François; Perron, Stéphane; Smargiassi, Audrey
This review assessed the confounding effect of one traffic-related exposure (noise or air pollutants) on the association between the other exposure and cardiovascular outcomes. A systematic review was conducted with the databases Medline and Embase. The confounding effects in studies were assessed by using change in the estimate with a 10 % cutoff point. The influence on the change in the estimate of the quality of the studies, the exposure assessment methods and the correlation between road noise and air pollutions were also assessed. Nine publications were identified. For most studies, the specified confounders produced changes in estimates noise and pollutants, the quality of the study and of the exposure assessment do not seem to influence the confounding effects. Results from this review suggest that confounding of cardiovascular effects by noise or air pollutants is low, though with further improvements in exposure assessment, the situation may change. More studies using pollution indicators specific to road traffic are needed to properly assess if noise and air pollution are subjected to confounding.
Danny Kurniawan Darianto
Full Text Available A patient undergoing surgery faces great physiologic and psychologic stress. so nutritional demands are greatly increased during this period and deficiencies can easily develop. If these deficiencies are allowed to develop and are not in screening, serious malnutrition and clinical problem can occur. Therefore careful attention must be given to a patient's nutritional status in preparation of surgery, as well as to the individual nutritional needs. If these needs are met, complications are less likely developing. Natural resources provide for rapid recovery. Proper nutrition can speed healing in surgical patients with major trauma, severe malnutition, burns, and other severe illnesses. New techniques for tube feeding, intravenous nutrition for patients with serious weight loss due to gastrointestinal disorders, and use of supplements can hasten wound healing and shorten recovery times.
Jun 15, 1974 ... outlined. A systematic classification is presented and a plea made for certain routines in diagnosis and early management of the newborn. S. Air. Med. J., 48, 1255 (1974). ... (45/min) is the result of a relatively high metabolic rate requiring rapid .... environmental temperature during transfer. The posture.
Jun 15, 1974 ... malities of the upper gastro-intestinal tract. If hydramnios is present one should be on the lookout for any abnor- mality of this kind the day the child is born. Premature rupture of membranes, if associated with signs of infection in th~ mother, should arouse a suspicion of intra-uterine infection with pneumonia.
Benin Journal of Postgraduate Medicine. Journal Home · ABOUT THIS JOURNAL · Advanced Search · Current Issue · Archives · Journal Home > Vol 11, No 1 (2009) >. Log in or Register to get access to full text downloads.
Stewart, Lowan H; Trunkey, Donald; Rebagliati, G Steve
Recent events, including the development of space tourism and commercial spaceflight, have increased the need for specialists in space medicine. With increased duration of missions and distance from Earth, medical and surgical events will become inevitable. Ground-based medical support will no longer be adequate when return to Earth is not an option. Pending the inclusion of sub-specialists, clinical skills and medical expertise will be required that go beyond those of current physician-astronauts, yet are well within the scope of Emergency Medicine. Emergency physicians have the necessary broad knowledge base as well as proficiency in basic surgical skills and management of the critically ill and injured. Space medicine shares many attributes with extreme conditions and environments that many emergency physicians already specialize in. This article is an introduction to space medicine, and a review of current issues in the emergent management of medical and surgical disease during spaceflight.
Yu, Yuanyuan; Li, Hongkai; Sun, Xiaoru; Su, Ping; Wang, Tingting; Liu, Yi; Yuan, Zhongshang; Liu, Yanxun; Xue, Fuzhong
Confounders can produce spurious associations between exposure and outcome in observational studies. For majority of epidemiologists, adjusting for confounders using logistic regression model is their habitual method, though it has some problems in accuracy and precision. It is, therefore, important to highlight the problems of logistic regression and search the alternative method. Four causal diagram models were defined to summarize confounding equivalence. Both theoretical proofs and simulation studies were performed to verify whether conditioning on different confounding equivalence sets had the same bias-reducing potential and then to select the optimum adjusting strategy, in which logistic regression model and inverse probability weighting based marginal structural model (IPW-based-MSM) were compared. The "do-calculus" was used to calculate the true causal effect of exposure on outcome, then the bias and standard error were used to evaluate the performances of different strategies. Adjusting for different sets of confounding equivalence, as judged by identical Markov boundaries, produced different bias-reducing potential in the logistic regression model. For the sets satisfied G-admissibility, adjusting for the set including all the confounders reduced the equivalent bias to the one containing the parent nodes of the outcome, while the bias after adjusting for the parent nodes of exposure was not equivalent to them. In addition, all causal effect estimations through logistic regression were biased, although the estimation after adjusting for the parent nodes of exposure was nearest to the true causal effect. However, conditioning on different confounding equivalence sets had the same bias-reducing potential under IPW-based-MSM. Compared with logistic regression, the IPW-based-MSM could obtain unbiased causal effect estimation when the adjusted confounders satisfied G-admissibility and the optimal strategy was to adjust for the parent nodes of outcome, which
Full Text Available Abstract Background Confounders can produce spurious associations between exposure and outcome in observational studies. For majority of epidemiologists, adjusting for confounders using logistic regression model is their habitual method, though it has some problems in accuracy and precision. It is, therefore, important to highlight the problems of logistic regression and search the alternative method. Methods Four causal diagram models were defined to summarize confounding equivalence. Both theoretical proofs and simulation studies were performed to verify whether conditioning on different confounding equivalence sets had the same bias-reducing potential and then to select the optimum adjusting strategy, in which logistic regression model and inverse probability weighting based marginal structural model (IPW-based-MSM were compared. The “do-calculus” was used to calculate the true causal effect of exposure on outcome, then the bias and standard error were used to evaluate the performances of different strategies. Results Adjusting for different sets of confounding equivalence, as judged by identical Markov boundaries, produced different bias-reducing potential in the logistic regression model. For the sets satisfied G-admissibility, adjusting for the set including all the confounders reduced the equivalent bias to the one containing the parent nodes of the outcome, while the bias after adjusting for the parent nodes of exposure was not equivalent to them. In addition, all causal effect estimations through logistic regression were biased, although the estimation after adjusting for the parent nodes of exposure was nearest to the true causal effect. However, conditioning on different confounding equivalence sets had the same bias-reducing potential under IPW-based-MSM. Compared with logistic regression, the IPW-based-MSM could obtain unbiased causal effect estimation when the adjusted confounders satisfied G-admissibility and the optimal
Gustafson, Paul; Greenland, Sander
Greenland (2000, Biometrics 56, 915-921) describes the use of random coefficient regression to adjust for residual confounding in a particular setting. We examine this setting further, giving theoretical and empirical results concerning the frequentist and Bayesian performance of random coefficient regression. Particularly, we compare estimators based on this adjustment for residual confounding to estimators based on the assumption of no residual confounding. This devolves to comparing an estimator from a nonidentified but more realistic model to an estimator from a less realistic but identified model. The approach described by Gustafson (2005, Statistical Science 20, 111-140) is used to quantify the performance of a Bayesian estimator arising from a nonidentified model. From both theoretical calculations and simulations we find support for the idea that superior performance can be obtained by replacing unrealistic identifying constraints with priors that allow modest departures from those constraints. In terms of point-estimator bias this superiority arises when the extent of residual confounding is substantial, but the advantage is much broader in terms of interval estimation. The benefit from modeling residual confounding is maintained when the prior distributions employed only roughly correspond to reality, for the standard identifying constraints are equivalent to priors that typically correspond much worse.
Full Text Available Propensity score (PS methodology is a common approach to control for confounding in nonexperimental studies of treatment effects using health care utilization databases. This methodology offers researchers many advantages compared with conventional multivariate models: it directly focuses on the determinants of treatment choice, facilitating the understanding of the clinical decision-making process by the researcher; it allows for graphical comparisons of the distribution of propensity scores and truncation of subjects without overlapping PS indicating a lack of equipoise; it allows transparent assessment of the confounder balance achieved by the PS at baseline; and it offers a straightforward approach to reduce the dimensionality of sometimes large arrays of potential confounders in utilization databases, directly addressing the “curse of dimensionality” in the context of rare events. This article provides an overview of the use of propensity score methodology for pharmacoepidemiologic research with large health care utilization databases, covering recent discussions on covariate selection, the role of automated techniques for addressing unmeasurable confounding via proxies, strategies to maximize clinical equipoise at baseline, and the potential of machine-learning algorithms for optimized propensity score estimation. The appendix discusses the available software packages for PS methodology. Propensity scores are a frequently used and versatile tool for transparent and comprehensive adjustment of confounding in pharmacoepidemiology with large health care databases.
Ananth, Cande V; Schisterman, Enrique F
Prospective and retrospective cohorts and case-control studies are some of the most important study designs in epidemiology because, under certain assumptions, they can mimic a randomized trial when done well. These assumptions include, but are not limited to, properly accounting for 2 important sources of bias: confounding and selection bias. While not adjusting the causal association for an intermediate variable will yield an unbiased estimate of the exposure-outcome's total causal effect, it is often that obstetricians will want to adjust for an intermediate variable to assess if the intermediate is the underlying driver of the association. Such a practice must be weighed in light of the underlying research question and whether such an adjustment is necessary should be carefully considered. Gestational age is, by far, the most commonly encountered variable in obstetrics that is often mislabeled as a confounder when, in fact, it may be an intermediate. If, indeed, gestational age is an intermediate but if mistakenly labeled as a confounding variable and consequently adjusted in an analysis, the conclusions can be unexpected. The implications of this overadjustment of an intermediate as though it were a confounder can render an otherwise persuasive study downright meaningless. This commentary provides an exposition of confounding bias, collider stratification, and selection biases, with applications in obstetrics and perinatal epidemiology. Copyright © 2017 Elsevier Inc. All rights reserved.
Lee, Paul H.
Purpose: Some confounders are nonlinearly associated with dependent variables, but they are often adjusted using a linear term. The purpose of this study was to examine the error of mis-specifying the nonlinear confounding effect. Methods: We carried out a simulation study to investigate the effect of adjusting for a nonlinear confounder in the…
Full Text Available The methods of the analysis of research data including the concomitant variables (confounders associated with both the response and the current factor are considered. There are two usual ways to take into account such variables: the first, at the stage of planning the experiment and the second, in analyzing the received data. Despite the equal effectiveness of these approaches, there exists strong reason to restrict the usage of regression method to accounting for confounders by ANCOVA. Authors consider the standardization by stratification as a reliable method to account for the effect of confounding factors as opposed to the widely-implemented application of logistic regression and the covariance analysis. The program for the automation of standardization procedure is proposed, it is available at the site of the Institute of Industrial Ecology.
The World Health Organization (WHO) recognizes the challenges and benefits of a competency-based approach to surgical services in its publication, Global Initiative for Emergency and Essential Surgical Care, which provides critical guidance on how to strengthen health systems to take on the burden of surgical problems ...
Litjens, G.; Huisman, H.; Elliott, R.; Shih, N.; Feldman, M.; Viswanath, S.; Fütterer, J.; Bomers, J.; Madabhushi, A.
Laser interstitial thermotherapy (LITT) is a relatively new focal therapy technique for the ablation of localized prostate cancer. However, very little is known about the specific effects of LITT within the ablation zone and the surrounding normal tissue regions. For instance, it is important to be able to assess the extent of residual cancer within the prostate following LITT, which may be masked by thermally induced benign necrotic changes. Fortunately LITT is MRI compatible and hence this allows for quantitatively assessing LITT induced changes via multi-parametric MRI. Of course definite validation of any LITT induced changes on MRI requires confirmation via histopathology. The aim of this study was to quantitatively assess and distinguish the imaging characteristics of prostate cancer and benign confounding treatment changes following LITTon 3 Tesla multi-parametric MRI by carefully mapping the treatment related changes from the ex vivo surgically resected histopathologic specimens onto the pre-operative in vivo imaging. A better understanding of the imaging characteristics of residual disease and successfully ablated tissue might lead to improved treatment monitoring and as such patient prognosis. A unique clinical trial at the Radboud University Medical Center, in which 3 patients underwent a prostatectomy after LITT treatment, yielded ex-vivo histopathologic specimens along with pre- and post-LITT MRI. Using this data we (1) identified the computer extracted MRI signatures associated with treatment effects including benign necrotic changes and residual disease and (2) subsequently evaluated the computer extracted MRI features previously identified in distinguishing LITT induced changes in the ablated area relative to the residual disease. Towards this end first a pathologist annotated the ablated area and the residual disease on the ex-vivo histology and then we transferred the annotations to the post-LITT MRI using semi-automatic elastic registration. The
Dydykin, Sergey; Kapitonova, Marina
Traditional department-based surgical interest groups in Russian medical schools are useful tools for student-based selection of specialty training. They also form a nucleus for initiating research activities among undergraduate students. In Russia, the Departments of Topographical Anatomy and Operative Surgery play an important role in initiating student-led research and providing learners with advanced, practical surgical skills. In tandem with department-led activities, student surgical interest groups prepare learners through surgical competitions, known as "Surgical Olympiads," which have been conducted in many Russian centers on a regular basis since 1988. Surgical Olympiads stimulate student interest in the development of surgical skills before graduation and encourage students to choose surgery as their postgraduate specialty. Many of the participants in these surgical Olympiads have become highly qualified specialists in general surgery, orthopedic surgery, neurosurgery, urology, gynecology, and emergency medicine. The present article emphasizes the role of student interest groups and surgical Olympiads in clinical anatomical and surgical undergraduate training in Russia. © 2015 American Association of Anatomists.
Alfredo Castro Díaz
Full Text Available The objective has been to create a Protocol of Structured Presurgical Visit applicable to the patients who are undergoing an emergency surgery, to provide the user and his family all the necessary cares on the basis of those nursing diagnosis that prevail in all the cases of surgical emergency interventions. The used method has been an analysis of the emergency surgical interventions more prevalent from February 2007 until October 2008 in our area (a regional hospital, and statistic of those nursing diagnosis that more frequently appeared in these interventions, the previous moment to the intervention and in addition common to all of them. The results were the following ones: the more frequent emergency operations were: Caesarean, ginecological curettage, laparotomy, help in risk childbirth, orthopaedic surgery and appendectomy. The more frequent nursing diagnosis in all the emergency operations at the previous moment of the intervention were: risk of falls, pain, anxiety, deficit of knowledge, risk of infection, movement stress syndrome, risk of hemorrhage, cutaneous integrity deterioration. The conclusion is that users present at the previous moment to an emergency operation several problems, which force to the emergency surgical ward nurse to the introduction of the nursing methodology, in order to identify the problems, to mark results and to indicate the interventions to achieve those results, besides in a humanitarian way and with quality. This can be obtained by performing a Structured Emergency Presurgical Visit.
Bijwaard, G.E.; Myrskylä, M.; Tynelius, P.; Rasmussen, F.
For many causes of death a negative educational gradient has been found. This association may be partly explained by confounding factors that affect both education attainment and mortality. We correct the cause-speciﬁc educational gradient for observed individual background and unobserved family
Pouwels, Koen B; Widyakusuma, Niken N; Groenwold, Rolf H H; Hak, Eelko
Poor quality of reporting of confounding has been observed in observational studies prior the STrenghtening the Reporting of Observational studies in Epidemiology (STROBE) statement, a reporting guideline for observational studies. We assessed whether the reporting of confounding improved after the STROBE statement. We searched MEDLINE for all articles about observational cohort and case-control studies on interventions with a hypothesized beneficial effect in five general medical and five epidemiologic journals published between January 2010 and December 2012. We abstracted data for the baseline period before the publication of the STROBE statement (January 2004-April 2007) from a prior study. Six relevant items related to confounding were scored for each article. A comparison of the median number of items reported in both periods was made. In total, 174 articles published before and 220 articles published after the STROBE statement were included. The median number reported items was similar before and after the publication of the STROBE statement [median, 4; interquartile range [IQR], 3-5 vs. median, 4; IQR, 3.75-5]. However, the distribution of the number of reported items shifted somewhat to the right (P = 0.01). Although the quality of reporting of confounding improved in certain aspects, the overall quality remains suboptimal. Copyright © 2016 Elsevier Inc. All rights reserved.
Lynch, Jamie L; von Hippel, Paul T
There is a positive gradient associating educational attainment with health, yet the explanation for this gradient is not clear. Does higher education improve health (causation)? Do the healthy become highly educated (selection)? Or do good health and high educational attainment both result from advantages established early in the life course (confounding)? This study evaluates these competing explanations by tracking changes in educational attainment and Self-rated Health (SRH) from age 15 to age 31 in the National Longitudinal Study of Youth, 1997 cohort. Ordinal logistic regression confirms that high-SRH adolescents are more likely to become highly educated. This is partly because adolescent SRH is associated with early advantages including adolescents' academic performance, college plans, and family background (confounding); however, net of these confounders adolescent SRH still predicts adult educational attainment (selection). Fixed-effects longitudinal regression shows that educational attainment has little causal effect on SRH at age 31. Completion of a high school diploma or associate's degree has no effect on SRH, while completion of a bachelor's or graduate degree have effects that, though significant, are quite small (less than 0.1 points on a 5-point scale). While it is possible that educational attainment would have greater effect on health at older ages, at age 31 what we see is a health gradient in education, shaped primarily by selection and confounding rather than by a causal effect of education on health. Copyright © 2016 Elsevier Ltd. All rights reserved.
Kuramoto, S. Janet; Stuart, Elizabeth A.
Despite that randomization is the gold standard for estimating causal relationships, many questions in prevention science are left to be answered through non-experimental studies often because randomization is either infeasible or unethical. While methods such as propensity score matching can adjust for observed confounding, unobserved confounding is the Achilles heel of most non-experimental studies. This paper describes and illustrates seven sensitivity analysis techniques that assess the sensitivity of study results to an unobserved confounder. These methods were categorized into two groups to reflect differences in their conceptualization of sensitivity analysis, as well as their targets of interest. As a motivating example we examine the sensitivity of the association between maternal suicide and offspring’s risk for suicide attempt hospitalization. While inferences differed slightly depending on the type of sensitivity analysis conducted, overall the association between maternal suicide and offspring’s hospitalization for suicide attempt was found to be relatively robust to an unobserved confounder. The ease of implementation and the insight these analyses provide underscores sensitivity analysis techniques as an important tool for non-experimental studies. The implementation of sensitivity analysis can help increase confidence in results from non-experimental studies and better inform prevention researchers and policymakers regarding potential intervention targets. PMID:23408282
Liu, Weiwei; Kuramoto, S Janet; Stuart, Elizabeth A
Despite the fact that randomization is the gold standard for estimating causal relationships, many questions in prevention science are often left to be answered through nonexperimental studies because randomization is either infeasible or unethical. While methods such as propensity score matching can adjust for observed confounding, unobserved confounding is the Achilles heel of most nonexperimental studies. This paper describes and illustrates seven sensitivity analysis techniques that assess the sensitivity of study results to an unobserved confounder. These methods were categorized into two groups to reflect differences in their conceptualization of sensitivity analysis, as well as their targets of interest. As a motivating example, we examine the sensitivity of the association between maternal suicide and offspring's risk for suicide attempt hospitalization. While inferences differed slightly depending on the type of sensitivity analysis conducted, overall, the association between maternal suicide and offspring's hospitalization for suicide attempt was found to be relatively robust to an unobserved confounder. The ease of implementation and the insight these analyses provide underscores sensitivity analysis techniques as an important tool for nonexperimental studies. The implementation of sensitivity analysis can help increase confidence in results from nonexperimental studies and better inform prevention researchers and policy makers regarding potential intervention targets.
van der Meer, Hedwig A.; Speksnijder, Caroline M.; Engelbert, Raoul; Lobbezoo, Frank; Nijhuis – van der Sanden, Maria W G; Visscher, Corine M.
OBJECTIVES:: The objective of this observational study was to establish the possible presence of confounders on the association between temporomandibular disorders (TMD) and headaches in a patient population from a TMD and Orofacial Pain Clinic. METHODS:: Several subtypes of headaches were
Meer, H.A. van der; Speksnijder, C.M.; Engelbert, R.H.; Lobbezoo, F.; Nijhuis-Van der Sanden, M.W.G.; Visscher, C.M.
OBJECTIVES: The objective of this observational study was to establish the possible presence of confounders on the association between temporomandibular disorders (TMD) and headaches in a patient population from a TMD and Orofacial Pain Clinic. MATERIALS AND METHODS: Several subtypes of headaches
McGrath, Leah J; Ellis, Alan R; Brookhart, M Alan
Nonexperimental studies of preventive interventions are often biased because of the healthy-user effect and, in frail populations, because of confounding by functional status. Bias is evident when estimating influenza vaccine effectiveness, even after adjustment for claims-based indicators of illness. We explored bias reduction methods while estimating vaccine effectiveness in a cohort of adult hemodialysis patients. Using the United States Renal Data System and linked data from a commercial dialysis provider, we estimated vaccine effectiveness using a Cox proportional hazards marginal structural model of all-cause mortality before and during 3 influenza seasons in 2005/2006 through 2007/2008. To improve confounding control, we added frailty indicators to the model, measured time-varying confounders at different time intervals, and restricted the sample in multiple ways. Crude and baseline-adjusted marginal structural models remained strongly biased. Restricting to a healthier population removed some unmeasured confounding; however, this reduced the sample size, resulting in wide confidence intervals. We estimated an influenza vaccine effectiveness of 9% (hazard ratio = 0.91, 95% confidence interval: 0.72, 1.15) when bias was minimized through cohort restriction. In this study, the healthy-user bias could not be controlled through statistical adjustment; however, sample restriction reduced much of the bias. © The Author 2015. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Pouwels, Koen B.; Hak, Eelko
Background: Previously, poor quality of reporting of confounding in articles on observational medical interventions has been observed in a systematic review. Included articles were published before the STROBE statement and it was suggested that this statement could have a considerable impact on the
Bulik-Sullivan, Brendan K.; Loh, Po-Ru; Finucane, Hilary K.; Ripke, Stephan; Yang, Jian; Patterson, Nick; Daly, Mark J.; Price, Alkes L.; Neale, Benjamin M.; Corvin, Aiden; Walters, James T. R.; Farh, Kai-How; Holmans, Peter A.; Lee, Phil; Bulik-Sullivan, Brendan; Collier, David A.; Huang, Hailiang; Pers, Tune H.; Agartz, Ingrid; Agerbo, Esben; Albus, Margot; Alexander, Madeline; Amin, Farooq; Bacanu, Silviu A.; Begemann, Martin; Belliveau, Richard A.; Bene, Judit; Bergen, Sarah E.; Bevilacqua, Elizabeth; Bigdeli, Tim B.; Black, Donald W.; Bruggeman, Richard; Buccola, Nancy G.; Buckner, Randy L.; Byerley, William; Cahn, Wiepke; Cai, Guiqing; Cairns, Murray J.; Campion, Dominique; Cantor, Rita M.; Carr, Vaughan J.; Carrera, Noa; Catts, Stanley V.; Chambert, Kimberly D.; Chan, Raymond C. K.; Chen, Ronald Y. L.; Chen, Eric Y. H.; Cheng, Wei; Cheung, Eric F. C.; Chong, Siow Ann; Cloninger, C. Robert; Cohen, David; Cohen, Nadine; Cormican, Paul; Craddock, Nick; Crespo-Facorro, Benedicto; Crowley, James J.; Curtis, David; Davidson, Michael; Davis, Kenneth L.; Degenhardt, Franziska; del Favero, Jurgen; DeLisi, Lynn E.; Demontis, Ditte; Dikeos, Dimitris; Dinan, Timothy; Djurovic, Srdjan; Donohoe, Gary; Drapeau, Elodie; Duan, Jubao; Dudbridge, Frank; Durmishi, Naser; Eichhammer, Peter; Eriksson, Johan; Escott-Price, Valentina; Essioux, Laurent; Fanous, Ayman H.; Farrell, Martilias S.; Frank, Josef; Franke, Lude; Freedman, Robert; Freimer, Nelson B.; Friedl, Marion; Friedman, Joseph I.; Fromer, Menachem; Genovese, Giulio; Georgieva, Lyudmila; Gershon, Elliot S.; Giegling, Ina; Giusti-Rodríguez, Paola; Godard, Stephanie; Goldstein, Jacqueline I.; Golimbet, Vera; Gopal, Srihari; Gratten, Jacob; de Haan, Lieuwe; Hammer, Christian; Hamshere, Marian L.; Hansen, Mark; Hansen, Thomas; Haroutunian, Vahram; Hartmann, Annette M.; Henskens, Frans A.; Herms, Stefan; Hirschhorn, Joel N.; Hoffmann, Per; Hofman, Andrea; Hollegaard, Mads V.; Hougaard, David M.; Ikeda, Masashi; Joa, Inge; Julià, Antonio; Kahn, René S.; Kalaydjieva, Luba; Karachanak-Yankova, Sena; Karjalainen, Juha; Kavanagh, David; Keller, Matthew C.; Kelly, Brian J.; Kennedy, James L.; Khrunin, Andrey; Kim, Yunjung; Klovins, Janis; Knowles, James A.; Konte, Bettina; Kucinskas, Vaidutis; Kucinskiene, Zita Ausrele; Kuzelova-Ptackova, Hana; Kähler, Anna K.; Laurent, Claudine; Keong, Jimmy Lee Chee; Lee, S. Hong; Legge, Sophie E.; Lerer, Bernard; Li, Miaoxin; Li, Tao; Liang, Kung-Yee; Lieberman, Jeffrey; Limborska, Svetlana; Loughland, Carmel M.; Lubinski, Jan; Lönnqvist, Jouko; Macek, Milan; Magnusson, Patrik K. E.; Maher, Brion S.; Maier, Wolfgang; Mallet, Jacques; Marsal, Sara; Mattheisen, Manuel; Mattingsdal, Morten; McCarley, Robert W.; McDonald, Colm; McIntosh, Andrew M.; Meier, Sandra; Meijer, Carin J.; Melegh, Bela; Melle, Ingrid; Mesholam-Gately, Raquelle I.; Metspalu, Andres; Michie, Patricia T.; Milani, Lili; Milanova, Vihra; Mokrab, Younes; Morris, Derek W.; Mors, Ole; Murphy, Kieran C.; Murray, Robin M.; Myin-Germeys, Inez; Müller-Myhsok, Bertram; Nelis, Mari; Nenadic, Igor; Nertney, Deborah A.; Nestadt, Gerald; Nicodemus, Kristin K.; Nikitina-Zake, Liene; Nisenbaum, Laura; Nordin, Annelie; O'Callaghan, Eadbhard; O'Dushlaine, Colm; O'Neill, F. Anthony; Oh, Sang-Yun; Olincy, Ann; Olsen, Line; van Os, Jim; Pantelis, Christos; Papadimitriou, George N.; Papiol, Sergi; Parkhomenko, Elena; Pato, Michele T.; Paunio, Tiina; Pejovic-Milovancevic, Milica; Perkins, Diana O.; Pietiläinen, Olli; Pimm, Jonathan; Pocklington, Andrew J.; Powell, John; Price, Alkes; Pulver, Ann E.; Purcell, Shaun M.; Quested, Digby; Rasmussen, Henrik B.; Reichenberg, Abraham; Reimers, Mark A.; Richards, Alexander L.; Roffman, Joshua L.; Roussos, Panos; Ruderfer, Douglas M.; Salomaa, Veikko; Sanders, Alan R.; Schall, Ulrich; Schubert, Christian R.; Schulze, Thomas G.; Schwab, Sibylle G.; Scolnick, Edward M.; Scott, Rodney J.; Seidman, Larry J.; Shi, Jianxin; Sigurdsson, Engilbert; Silagadze, Teimuraz; Silverman, Jeremy M.; Sim, Kang; Slominsky, Petr; Smoller, Jordan W.; So, Hon-Cheong; Spencer, Chris C. A.; Stahl, Eli A.; Stefansson, Hreinn; Steinberg, Stacy; Stogmann, Elisabeth; Straub, Richard E.; Strengman, Eric; Strohmaier, Jana; Stroup, T. Scott; Subramaniam, Mythily; Suvisaari, Jaana; Svrakic, Dragan M.; Szatkiewicz, Jin P.; Söderman, Erik; Thirumalai, Srinivas; Toncheva, Draga; Tooney, Paul A.; Tosato, Sarah; Veijola, Juha; Waddington, John; Walsh, Dermot; Wang, Dai; Wang, Qiang; Webb, Bradley T.; Weiser, Mark; Wildenauer, Dieter D.; Williams, Nigel M.; Williams, Stephanie; Witt, Stephanie H.; Wolen, Aaron R.; Wong, Emily H. M.; Wormley, Brandon K.; Wu, Jing Qin; Xi, Hualin Simon; Zai, Clement C.; Zheng, Xuebin; Zimprich, Fritz; Wray, Naomi R.; Stefansson, Kari; Visscher, Peter M.; Adolfsson, Rolf; Andreassen, Ole A.; Blackwood, Douglas H. R.; Bramon, Elvira; Buxbaum, Joseph D.; Børglum, Anders D.; Cichon, Sven; Darvasi, Ariel; Domenici, Enrico; Ehrenreich, Hannelore; Esko, Tõnu; Gejman, Pablo V.; Gill, Michael; Gurling, Hugh; Hultman, Christina M.; Iwata, Nakao; Jablensky, Assen V.; Jönsson, Erik G.; Kendler, Kenneth S.; Kirov, George; Knight, Jo; Lencz, Todd; Levinson, Douglas F.; Li, Qingqin S.; Liu, Jianjun; Malhotra, Anil K.; McCarroll, Steven A.; McQuillin, Andrew; Moran, Jennifer L.; Mortensen, Preben B.; Mowry, Bryan J.; Nöthen, Markus M.; Ophoff, Roel A.; Owen, Michael J.; Palotie, Aarno; Pato, Carlos N.; Petryshen, Tracey L.; Posthuma, Danielle; Rietschel, Marcella; Riley, Brien P.; Rujescu, Dan; Sham, Pak C.; Sklar, Pamela; St Clair, David; Weinberger, Daniel R.; Wendland, Jens R.; Werge, Thomas; Sullivan, Patrick F.; O'Donovan, Michael C.
Both polygenicity (many small genetic effects) and confounding biases, such as cryptic relatedness and population stratification, can yield an inflated distribution of test statistics in genome-wide association studies (GWAS). However, current methods cannot distinguish between inflation from a true
Jackson, D.; White, I.; Kostis, J.B.
One difficulty in performing meta-analyses of observational cohort studies is that the availability of confounders may vary between cohorts, so that some cohorts provide fully adjusted analyses while others only provide partially adjusted analyses. Commonly, analyses of the association between an...
Hallager, Dennis Winge; Hansen, Lars Valentin; Dragsted, Casper Rokkjær
hoc analyses were performed for each SRS-Schwab modifier. Age, history of spine surgery, and aetiology of spinal deformity were considered potential confounders and their influence on the association between SRS-Schwab modifiers and aggregated Oswestry Disability Index (ODI) scores was evaluated...
Willeberg, Preben; Nielsen, Liza Rosenbaum; Salman, Mo
We estimated the effects of confounder adjustment as a part of the underlying quantitative risk assessments on the performance of a hypothetical example of a risk-based surveillance system, in which a single risk factor would be used to identify high risk sampling units for testing. The differences...
Reveiz, Ludovic; Haby, Michelle M; Martínez-Vega, Ruth; Pinzón-Flores, Carlos E; Elias, Vanessa; Smith, Emma; Pinart, Mariona; Broutet, Nathalie; Becerra-Posada, Francisco; Aldighieri, Sylvain; Van Kerkhove, Maria D
Given the severity and impact of the current Zika virus (ZIKV) outbreak in the Americas, numerous countries have rushed to develop research studies to assess ZIKV and its potential health consequences. In an effort to ensure that studies are comprehensive, both internally and externally valid, and with reliable results, the World Health Organization, the Pan American Health Organization, Institut Pasteur, the networks of Fiocruz, the Consortia for the Standardization of Influenza Seroepidemiology (CONSISE) and the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) have generated six standardized clinical and epidemiological research protocols and questionnaires to address key public health questions on ZIKV. We conducted a systematic search of ongoing study protocols related to ZIKV research. We analyzed the content of protocols of 32 cohort studies and 13 case control studies for systematic bias that could produce erroneous results. Additionally we aimed to characterize the risks of bias and confounding in observational studies related to ZIKV and to propose ways to minimize them, including the use of six newly standardized research protocols. Observational studies of ZIKV face an array of challenges, including measurement of exposure and outcomes (microcephaly and Guillain-Barré Syndrome). Potential confounders need to be measured where known and controlled for in the analysis. Selection bias due to non-random selection is a significant issue, particularly in the case-control design, and losses to follow-up is equally important for the cohort design. Observational research seeking to answer key questions on the ZIKV should consider these restrictions and take precautions to minimize bias in an effort to provide reliable and valid results. Utilization of the standardized research protocols developed by the WHO, PAHO, Institut Pasteur, and CONSISE will harmonize the key methodological aspects of each study design to minimize bias at
Full Text Available Given the severity and impact of the current Zika virus (ZIKV outbreak in the Americas, numerous countries have rushed to develop research studies to assess ZIKV and its potential health consequences. In an effort to ensure that studies are comprehensive, both internally and externally valid, and with reliable results, the World Health Organization, the Pan American Health Organization, Institut Pasteur, the networks of Fiocruz, the Consortia for the Standardization of Influenza Seroepidemiology (CONSISE and the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC have generated six standardized clinical and epidemiological research protocols and questionnaires to address key public health questions on ZIKV.We conducted a systematic search of ongoing study protocols related to ZIKV research. We analyzed the content of protocols of 32 cohort studies and 13 case control studies for systematic bias that could produce erroneous results. Additionally we aimed to characterize the risks of bias and confounding in observational studies related to ZIKV and to propose ways to minimize them, including the use of six newly standardized research protocols.Observational studies of ZIKV face an array of challenges, including measurement of exposure and outcomes (microcephaly and Guillain-Barré Syndrome. Potential confounders need to be measured where known and controlled for in the analysis. Selection bias due to non-random selection is a significant issue, particularly in the case-control design, and losses to follow-up is equally important for the cohort design.Observational research seeking to answer key questions on the ZIKV should consider these restrictions and take precautions to minimize bias in an effort to provide reliable and valid results. Utilization of the standardized research protocols developed by the WHO, PAHO, Institut Pasteur, and CONSISE will harmonize the key methodological aspects of each study design to
Musiienko, Anton M; Shakerian, Rose; Gorelik, Alexandra; Thomson, Benjamin N J; Skandarajah, Anita R
The acute surgical unit (ASU) is a recently established model of care in Australasia and worldwide. Limited data are available regarding its effect on the management of small bowel obstruction. We compared the management of small bowel obstruction before and after introduction of ASU at a major tertiary referral centre. We hypothesized that introduction of ASU would correlate with improved patient outcomes. A retrospective review of prospectively maintained databases was performed over two separate 2-year periods, before and after the introduction of ASU. Data collected included demographics, co-morbidity status, use of water-soluble contrast agent and computed tomography. Outcome measures included surgical intervention, time to surgery, hospital length of stay, complications, 30-day readmissions, use of total parenteral nutrition, intensive care unit admissions and overall mortality. Total emergency admissions to the ASU increased from 2640 to 4575 between the two time periods. A total of 481 cases were identified (225 prior and 256 after introduction of ASU). Mortality decreased from 5.8% to 2.0% (P = 0.03), which remained significant after controlling for confounders with multivariate analysis (odds ratio = 0.24, 95% confidence interval 0.08-0.73, P = 0.012). The proportion of surgically managed patients increased (20.9% versus 32.0%, P = 0.003) and more operations were performed within 5 days from presentation (76.6% versus 91.5%, P = 0.02). Fewer patients received water-soluble contrast agent (27.1% versus 18.4%, P = 0.02), but more patients were investigated with a computed tomography (70.7% versus 79.7%, P = 0.02). The ASU model of care resulted in decreased mortality, shorter time to intervention and increased surgical management. Overall complications rate and length of stay did not change. © 2015 Royal Australasian College of Surgeons.
Eliyas, S; Vere, J; Ali, Z; Harris, I
Non-surgical endodontic retreatment is the treatment of choice for endodontically treated teeth with recurrent or residual disease in the majority of cases. In some cases, surgical endodontic treatment is indicated. Successful micro-surgical endodontic treatment depends on the accuracy of diagnosis, appropriate case selection, the quality of the surgical skills, and the application of the most appropriate haemostatic agents and biomaterials. This article describes the armamentarium and technical procedures involved in performing micro-surgical endodontics to a high standard.
Hedley-Whyte, John; Milamed, Debra R
The planning for surgery in war was revisited in 1937 when Ian Fraser was elected a member of the Surgical Travellers. At their 1938 Surgical Travellers meeting in Vienna, Ian and Eleanor Fraser were evicted from their hotel room by the Nazis. The 1939 meeting in Belfast discussed the organization of surgery and the conduct of Emergency Medical Service Hospitals in the United Kingdom; the vast majority were to be under civilian government and military control. From 1943 lengthy and informative organizational meetings were held at least monthly under the chairmanship of Sir Alexander Hood, KBE, Head of the RAMC. Surgical Consultants, now Major Generals, Brigadiers or Full Colonels in the British and U.S. Armies stationed in the UK, prepared for the invasion of Europe. The allocation of medical, surgical, nursing and auxiliary responsibilities was delineated. Liaison with the RAF and US Army Air Force was close as it was with the proposed leaders, Ulstermen Brooke and Montgomery. Montgomery chose Arthur Porritt as Surgeon in Chief to Supreme Headquarters Allied Expeditionary Force (SHAEF), and Eisenhower, General Albert W. Kenner. Just after D-Day, Porritt met Ian Fraser, who had waded in on Arromanches Beach. The triage and evacuation plans for Allied casualties had been controversial, particularly as regards Landing Ship Tanks (LSTs). The dispute with the Hood-selected surgeons on one side, against medical and surgical deployment of LSTs, and Admiral Ernest King and Winston Churchill on the other, favouring LST use for surgery and evacuation. King and Churchill were correct but total Allied air superiority allowed wide use of many of the Allies' Dakotas; 10,000 DC-3s were eventually in service. Supported by forty Allied combat planes to each Luftwaffe, the dispute about Landing Ship Tank use in about a fortnight became moot. The multifaceted role of the Princess Royal in the Emergency Medical Services of the United Kingdom and her close liaison with the Consultant
Based upon a review of published clinical observations regarding syphilitic amyotrophic lateral sclerosis (ALS), I hypothesize that syphilis is actually a confounding factor, not a causative factor, in syphilitic ALS. Moreover, I propose that the successful treatment of ALS symptoms in patients with syphilitic ALS using penicillin G and hydrocortisone is an indirect consequence of the treatment regimen and is not due to the treatment of syphilis. Specifically, I propose that the observed effect is due to the various pharmacological activities of penicillin G ( e.g ., a GABA receptor antagonist) and/or the multifaceted pharmacological activity of hydrocortisone. The notion that syphilis may be a confounding factor in syphilitic ALS is highly relevant, as it suggests that treating ALS patients with penicillin G and hydrocortisone-regardless of whether they present with syphilitic ALS or non-syphilitic ALS-may be effective at treating this rapidly progressive, highly devastating disease.
Blanes-Vidal, Victoria; Schwartz, Joel
Whether or not wind turbines pose a risk to human health is a matter of heated debate. Personal reactions to other environmental exposures occurring in the same settings as wind turbines may be responsible of the reported symptoms. However, these have not been accounted for in previous studies. We investigated whether there is an association between residential proximity to wind turbines and idiopathic symptoms, after controlling for personal reactions to other environmental co-exposures. We assessed wind turbine exposures in 454 residences as the distance to the closest wind turbine (Dw) and number of wind turbines turbines and agricultural odor exposure, we did not observe a significant relationship between residential proximity to wind turbines and symptoms and the parameter estimates were attenuated toward zero. Wind turbines-health associations can be confounded by personal reactions to other environmental co-exposures. Isolated associations reported in the literature may be due to confounding bias. Copyright © 2016 Elsevier Inc. All rights reserved.
Kriebel, David; Zeka, Ariana; Eisen, Ellen A; Wegman, David H
Uncontrolled confounding by personal exposures like smoking can limit the inferential power of occupational cohort studies. We developed and demonstrate a refinement of an existing type of sensitivity analysis, indirect adjustment, for evaluating the potential magnitude of confounding by alcohol and tobacco. Results of a large retrospective cohort study of laryngeal cancer and exposure to metalworking fluids (MWF) are used to illustrate the methods. Data on smoking and drinking habits representative of the study cohort were obtained from a sample of US manufacturing workers from the 1977 National Health Interview Survey (NHIS). Two different mechanisms were assumed to affect the distribution of confounding factors between MWF exposure groups: socially determined and chance differences. Chance variation was investigated with Monte Carlo sampling from the NHIS survey distribution of smoking and drinking. An upper bound on systematic differences in smoking and drinking was set by assuming that differences between exposure groups within the same unionized blue collar workforce were very unlikely to be larger than differences between blue and white collar manufacturing workers in the NHIS data. Under plausibly large differences in smoking and drinking habits among MWF exposure groups occurring by either mechanism, the exposure-risk association was unlikely to have been over- or under-estimated by as much as 20%. When comparing exposure groups within the same working population, it is unlikely that either systematic or chance differences in smoking and drinking habits will cause as much as a 20% change in the relative risk in large studies. While this study focused on an occupational exposure and laryngeal cancer, there are many situations in which epidemiologists are concerned that unmeasured 'lifestyle factors' may differ among exposure groups, and it would appear that the likely confounding effect of such differences will often be modest.
Kriegbaum, Margit; Hendriksen, C.; Vass, Mikkel
% confidence intervals (CI). Results When covariates were entered one at a time, the changes in HR estimates showed that psychiatric disease, socioeconomic position and substance abuse reduced the excess risk by 17–36% in the low user group and by 45–52% in the high user group. Somatic disease, intelligence...... point at psychiatric disease, substance abuse and socioeconomic position as potential confounding factors partly explaining the association between use of hypnotics and all-cause mortality....
FRANK, DEBORAH A.; AUGUSTYN, MARILYN; ZUCKERMAN, BARRY S.
Complex methodologic challenges face researchers studying the effects of prenatal cocaine exposure on infant outcome. These include unavoidable imprecision in ascertaining the gestational timing and dose of cocaine to which the fetus was exposed and difficulties in identifying and quantifying the confounding, mediating, and moderating variables. Review of research on neonatal behavioral and cranial ultrasound findings following in utero cocaine exposure is used to illustrate these issues. We ...
Willeberg, Preben; Nielsen, Liza Rosenbaum; Salman, Mo
We estimated the effects of confounder adjustment as a part of the underlying quantitative risk assessments on the performance of a hypothetical example of a risk-based surveillance system, in which a single risk factor would be used to identify high risk sampling units for testing. The differences...... considered for their appropriateness, if the risk estimates are to be used for informing risk-based surveillance systems....
Fritz, Matthew S; Kenny, David A; MacKinnon, David P
Mediation analysis requires a number of strong assumptions be met in order to make valid causal inferences. Failing to account for violations of these assumptions, such as not modeling measurement error or omitting a common cause of the effects in the model, can bias the parameter estimates of the mediated effect. When the independent variable is perfectly reliable, for example when participants are randomly assigned to levels of treatment, measurement error in the mediator tends to underestimate the mediated effect, while the omission of a confounding variable of the mediator-to-outcome relation tends to overestimate the mediated effect. Violations of these two assumptions often co-occur, however, in which case the mediated effect could be overestimated, underestimated, or even, in very rare circumstances, unbiased. To explore the combined effect of measurement error and omitted confounders in the same model, the effect of each violation on the single-mediator model is first examined individually. Then the combined effect of having measurement error and omitted confounders in the same model is discussed. Throughout, an empirical example is provided to illustrate the effect of violating these assumptions on the mediated effect.
Johanna M Walz
Full Text Available Vascular endothelial growth factor-A (VEGF-A is intensively investigated in various medical fields. However, comparing VEGF-A measurements is difficult because sample acquisition and pre-analytic procedures differ between studies. We therefore investigated which variables act as confounders of VEGF-A measurements.Following a standardized protocol, blood was taken at three clinical sites from six healthy participants (one male and one female participant at each center twice one week apart. The following pre-analytical parameters were varied in order to analyze their impact on VEGF-A measurements: analyzing center, anticoagulant (EDTA vs. PECT / CTAD, cannula (butterfly vs. neonatal, type of centrifuge (swing-out vs. fixed-angle, time before and after centrifugation, filling level (completely filled vs. half-filled tubes and analyzing method (ELISA vs. multiplex bead array. Additionally, intrapersonal variations over time and sex differences were explored. Statistical analysis was performed using a linear regression model.The following parameters were identified as statistically significant independent confounders of VEGF-A measurements: analyzing center, anticoagulant, centrifuge, analyzing method and sex of the proband. The following parameters were no significant confounders in our data set: intrapersonal variation over one week, cannula, time before and after centrifugation and filling level of collection tubes.VEGF-A measurement results can be affected significantly by the identified pre-analytical parameters. We recommend the use of CTAD anticoagulant, a standardized type of centrifuge and one central laboratory using the same analyzing method for all samples.
Fritz, Matthew S.; Kenny, David A.; MacKinnon, David P.
Mediation analysis requires a number of strong assumptions be met in order to make valid causal inferences. Failing to account for violations of these assumptions, such as not modeling measurement error or omitting a common cause of the effects in the model, can bias the parameter estimates of the mediated effect. When the independent variable is perfectly reliable, for example when participants are randomly assigned to levels of treatment, measurement error in the mediator tends to underestimate the mediated effect, while the omission of a confounding variable of the mediator to outcome relation tends to overestimate the mediated effect. Violations of these two assumptions often co-occur, however, in which case the mediated effect could be overestimated, underestimated, or even, in very rare circumstances, unbiased. In order to explore the combined effect of measurement error and omitted confounders in the same model, the impact of each violation on the single-mediator model is first examined individually. Then the combined effect of having measurement error and omitted confounders in the same model is discussed. Throughout, an empirical example is provided to illustrate the effect of violating these assumptions on the mediated effect. PMID:27739903
Walz, Johanna M; Boehringer, Daniel; Deissler, Heidrun L; Faerber, Lothar; Goepfert, Jens C; Heiduschka, Peter; Kleeberger, Susannah M; Klettner, Alexa; Krohne, Tim U; Schneiderhan-Marra, Nicole; Ziemssen, Focke; Stahl, Andreas
Vascular endothelial growth factor-A (VEGF-A) is intensively investigated in various medical fields. However, comparing VEGF-A measurements is difficult because sample acquisition and pre-analytic procedures differ between studies. We therefore investigated which variables act as confounders of VEGF-A measurements. Following a standardized protocol, blood was taken at three clinical sites from six healthy participants (one male and one female participant at each center) twice one week apart. The following pre-analytical parameters were varied in order to analyze their impact on VEGF-A measurements: analyzing center, anticoagulant (EDTA vs. PECT / CTAD), cannula (butterfly vs. neonatal), type of centrifuge (swing-out vs. fixed-angle), time before and after centrifugation, filling level (completely filled vs. half-filled tubes) and analyzing method (ELISA vs. multiplex bead array). Additionally, intrapersonal variations over time and sex differences were explored. Statistical analysis was performed using a linear regression model. The following parameters were identified as statistically significant independent confounders of VEGF-A measurements: analyzing center, anticoagulant, centrifuge, analyzing method and sex of the proband. The following parameters were no significant confounders in our data set: intrapersonal variation over one week, cannula, time before and after centrifugation and filling level of collection tubes. VEGF-A measurement results can be affected significantly by the identified pre-analytical parameters. We recommend the use of CTAD anticoagulant, a standardized type of centrifuge and one central laboratory using the same analyzing method for all samples.
Loeys, Tom; Talloen, Wouter; Goubert, Liesbet; Moerkerke, Beatrijs; Vansteelandt, Stijn
It is well known from the mediation analysis literature that the identification of direct and indirect effects relies on strong no unmeasured confounding assumptions of no unmeasured confounding. Even in randomized studies the mediator may still be correlated with unobserved prognostic variables that affect the outcome, in which case the mediator's role in the causal process may not be inferred without bias. In the behavioural and social science literature very little attention has been given so far to the causal assumptions required for moderated mediation analysis. In this paper we focus on the index for moderated mediation, which measures by how much the mediated effect is larger or smaller for varying levels of the moderator. We show that in linear models this index can be estimated without bias in the presence of unmeasured common causes of the moderator, mediator and outcome under certain conditions. Importantly, one can thus use the test for moderated mediation to support evidence for mediation under less stringent confounding conditions. We illustrate our findings with data from a randomized experiment assessing the impact of being primed with social deception upon observer responses to others' pain, and from an observational study of individuals who ended a romantic relationship assessing the effect of attachment anxiety during the relationship on mental distress 2 years after the break-up. © 2016 The British Psychological Society.
Ibrahim, Andrew M; Dimick, Justin B
Surgeons are increasingly under pressure to measure and improve their quality. While there is broad consensus that we ought to track surgical quality, there is far less agreement about which metrics matter most. This article reviews the important statistical concepts of case mix and chance as they apply to understanding the observed wide variation in surgical quality. We then discuss the benefits and drawbacks of current measurement strategies through the framework of structure, process, and outcomes approaches. Finally, we describe emerging new metrics, such as video evaluation and network optimization, that are likely to take on an increasingly important role in the future of measuring surgical quality.
Barnes, R W
Surgeons choose their profession with a strong desire to excel at manual therapeutic skills. Although we mime our mentors, we have often received the torch of technique in the absence of a systematic program to optimally develop our manual dexterity. The operating room is the ultimate arena to refine one's technical ability, but a surgical skills laboratory should assume increasing importance in introducing the trainee to the many nuances of the fine manual motor skills necessary for optimal surgical technique. Surgical educators should address the science of surgical handicraft in a manner similar to the science of preoperative and postoperative surgical principles that have been espoused over the past 40 years. Although it has been euphemistically said that "you can teach a monkey to operate," few of us have broken the process down into the basic elements to accomplish such a goal. In view of the increasing complexity of operations and equipment, the constraints on animal laboratories and teaching caseloads, and the mounting economic and medico-legal pressures, the development of optimal surgical skills should be a major objective of every surgical training program. By developing novel programs and scientifically evaluating the results of such endeavors, surgical faculties may find increased academic rewards for being a good teacher.
Voutilainen, Ari; Pitkäaho, Taina; Kvist, Tarja; Vehviläinen-Julkunen, Katri
To study the effects of scale type (visual analogue scale vs. Likert), item order (systematic vs. random), item non-response and patient-related characteristics (age, gender, subjective health, need for assistance with filling out the questionnaire and length of stay) on the results of patient satisfaction surveys. Although patient satisfaction is one of the most intensely studied issues in the health sciences, research information about the effects of possible instrument-related confounding factors on patient satisfaction surveys is scant. A quasi-experimental design was employed. A non-randomized sample of 150 surgical patients was gathered to minimize possible alterations in care quality. Data were collected in May-September 2014 from one tertiary hospital in Finland using the Revised Humane Caring Scale instrument. New versions of the instrument were created for the present purposes. In these versions, items were either in a visual analogue format or Likert-scaled, in systematic or random order. The data were analysed using an analysis of covariance and a paired samples t-test. The visual analogue scale items were less vulnerable to bias from confounding factors than were the Likert-scaled items. The visual analogue scale also avoided the ceiling effect better than Likert and the time needed to complete the visual analogue scale questionnaire was 28% shorter than that needed to complete the Likert-scaled questionnaire. The present results supported the use of visual analogue scale rather than Likert scaling in patient satisfaction surveys and stressed the need to account for as many potential confounding factors as possible. © 2015 John Wiley & Sons Ltd.
Sabry Mohamed Amin
Conclusions: In our study both dexmedetomidine and esmolol were effective in reducing MABP, and lowering the heart rate providing dry surgical field and ensured good surgical condition during cochlear implant surgery in pediatric patients.
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Questions of mediation are often of interest in reasoning about mechanisms, and methods have been developed to address these questions. However, these methods make strong assumptions about the absence of confounding. Even if exposure is randomized, there may be mediator-outcome confounding variables. Inference about direct and indirect effects is particularly challenging if these mediator-outcome confounders are affected by the exposure because in this case these effects are not identified irrespective of whether data is available on these exposure-induced mediator-outcome confounders. In this paper, we provide a sensitivity analysis technique for natural direct and indirect effects that is applicable even if there are mediator-outcome confounders affected by the exposure. We give techniques for both the difference and risk ratio scales and compare the technique to other possible approaches. PMID:25580387
Bjorn T Adalsteinsson
Full Text Available Epigenetic studies are commonly conducted on DNA from tissue samples. However, tissues are ensembles of cells that may each have their own epigenetic profile, and therefore inter-individual cellular heterogeneity may compromise these studies. Here, we explore the potential for such confounding on DNA methylation measurement outcomes when using DNA from whole blood. DNA methylation was measured using pyrosequencing-based methodology in whole blood (n = 50-179 and in two white blood cell fractions (n = 20, isolated using density gradient centrifugation, in four CGIs (CpG Islands located in genes HHEX (10 CpG sites assayed, KCNJ11 (8 CpGs, KCNQ1 (4 CpGs and PM20D1 (7 CpGs. Cellular heterogeneity (variation in proportional white blood cell counts of neutrophils, lymphocytes, monocytes, eosinophils and basophils, counted by an automated cell counter explained up to 40% (p<0.0001 of the inter-individual variation in whole blood DNA methylation levels in the HHEX CGI, but not a significant proportion of the variation in the other three CGIs tested. DNA methylation levels in the two cell fractions, polymorphonuclear and mononuclear cells, differed significantly in the HHEX CGI; specifically the average absolute difference ranged between 3.4-15.7 percentage points per CpG site. In the other three CGIs tested, methylation levels in the two fractions did not differ significantly, and/or the difference was more moderate. In the examined CGIs, methylation levels were highly correlated between cell fractions. In summary, our analysis detects region-specific differential DNA methylation between white blood cell subtypes, which can confound the outcome of whole blood DNA methylation measurements. Finally, by demonstrating the high correlation between methylation levels in cell fractions, our results suggest a possibility to use a proportional number of a single white blood cell type to correct for this confounding effect in analyses.
Full Text Available Background and objective: Evaluation is an integral part of education in German medical schools. According to the quality standards set by the German Society for Evaluation, evaluation tools must provide an accurate and fair appraisal of teaching quality. Thus, data collection tools must be highly reliable and valid. This review summarises the current literature on evaluation of medical education with regard to the possible dimensions of teaching quality, the psychometric properties of survey instruments and potential confounding factors.Methods: We searched Pubmed, PsycINFO and PSYNDEX for literature on evaluation in medical education and included studies published up until June 30, 2011 as well as articles identified in the “grey literature”. Results are presented as a narrative review.Results: We identified four dimensions of teaching quality: structure, process, teacher characteristics, and outcome. Student ratings are predominantly used to address the first three dimensions, and a number of reliable tools are available for this purpose. However, potential confounders of student ratings pose a threat to the validity of these instruments. Outcome is usually operationalised in terms of student performance on examinations, but methodological problems may limit the usability of these data for evaluation purposes. In addition, not all examinations at German medical schools meet current quality standards.Conclusion: The choice of tools for evaluating medical education should be guided by the dimension that is targeted by the evaluation. Likewise, evaluation results can only be interpreted within the context of the construct addressed by the data collection tool that was used as well as its specific confounding factors.
Strachan, Eric; Poeschla, Brian; Dansie, Elizabeth; Succop, Annemarie; Chopko, Laura; Afari, Niloofar
Pain is a complex phenomenon influenced by context and person-specific factors. Affective dimensions of pain involve both enduring personality traits and fleeting emotional states. We examined how personality traits and emotional states are linked with clinical and evoked pain in a twin sample. 99 female twin pairs were evaluated for clinical and evoked pain using the McGill Pain Questionnaire (MPQ) and dolorimetry, and completed the 120-item International Personality Item Pool (IPIP), the Positive and Negative Affect Scale (PANAS), and ratings of stress and mood. Using a co-twin control design we examined a) the relationship of personality traits and emotional states with clinical and evoked pain and b) whether genetics and common environment (i.e. familial factors) may account for the associations. Neuroticism was associated with the sensory component of the MPQ; this relationship was not confounded by familial factors. None of the emotional state measures was associated with the MPQ. PANAS negative affect was associated with lower evoked pressure pain threshold and tolerance; these associations were confounded by familial factors. There were no associations between IPIP traits and evoked pain. A relationship exists between neuroticism and clinical pain that is not confounded by familial factors. There is no similar relationship between negative emotional states and clinical pain. In contrast, the relationship between negative emotional states and evoked pain is strong while the relationship with enduring personality traits is weak. The relationship between negative emotional states and evoked pain appears to be non-causal and due to familial factors. Copyright © 2014 Elsevier Inc. All rights reserved.
Sinclair, Thomas R; Manandhar, Anju; Shekoofa, Avat; Rosas-Anderson, Pablo; Bagherzadi, Laleh; Schoppach, Remy; Sadok, Walid; Rufty, Thomas W
Theoretical derivation predicted growth retardation due to pot water limitations, i.e., pot binding. Experimental observations were consistent with these limitations. Combined, these results indicate a need for caution in high-throughput screening and phenotyping. Pot experiments are a mainstay in many plant studies, including the current emphasis on developing high-throughput, phenotyping systems. Pot studies can be vulnerable to decreased physiological activity of the plants particularly when pot volume is small, i.e., "pot binding". It is necessary to understand the conditions under which pot binding may exist to avoid the confounding influence of pot binding in interpreting experimental results. In this paper, a derivation is offered that gives well-defined conditions for the occurrence of pot binding based on restricted water availability. These results showed that not only are pot volume and plant size important variables, but the potting media is critical. Artificial potting mixtures used in many studies, including many high-throughput phenotyping systems, are particularly susceptible to the confounding influences of pot binding. Experimental studies for several crop species are presented that clearly show the existence of thresholds of plant leaf area at which various pot sizes and potting media result in the induction of pot binding even though there may be no immediate, visual plant symptoms. The derivation and experimental results showed that pot binding can readily occur in plant experiments if care is not given to have sufficiently large pots, suitable potting media, and maintenance of pot water status. Clear guidelines are provided for avoiding the confounding effects of water-limited pot binding in studying plant phenotype.
Full Text Available Background: Failure to account for the etiological diversity that typically occurs in psychiatric cohorts may increase the potential for confounding, as a proportion of genetic variance will be specific to exposures that have variable distribution in cases. This study investigated whether minimizing the potential for such confounding strengthened the evidence for a genetic candidate currently unsupported at the genome-wide level.Methods: 291 first-episode psychosis cases from South London UK, and 218 unaffected controls were evaluated for a functional polymorphism at the rs1360780 locus in FKBP5. The relationship between FKBP5 and psychosis was modelled using logistic regression. Cannabis use (Cannabis Experiences Questionnaire and parental separation (Childhood Experience of Care and Abuse Questionnaire were modelled as confounders in the analysis.Results: Association at rs1360780 was not detected until the effects of the two environmental factors had been adjusted for in the model (OR=2.81, 95% CI 1.23-6.43, p=0.02. A statistical interaction between rs1360780 and parental separation was confirmed by stratified tests (OR=2.8, p=0.02 vs. OR=0.89, p=0.80. The genetic main effect was directionally-consistent with findings in other (stress-related clinical phenotypes. Moreover, the variation in effect magnitude was explained by the level of power associated with different cannabis constructs used in the model (r=0.95.Conclusions: Our results suggest that the extent to which genetic variants in FKBP5 can influence susceptibility to psychosis may depend on the other etiological factors involved. This finding requires further validation in other large independent cohorts. Potentially this work could have translational implications, as the ability to discriminate between genetic etiologies, based on a case-by-case understanding of exposure history would confer an important clinical advantage that would benefit the delivery of personalizable treatment
Budtz-Jørgensen, Esben; Keiding, Niels; Grandjean, Philippe
Non-differential measurement error in the exposure variable is known to attenuate the dose-response relationship. The amount of attenuation introduced in a given situation is not only a function of the precision of the exposure measurement but also depends on the conditional variance of the true...... exposure given the other independent variables. In addition, confounder effects may also be affected by the exposure measurement error. These difficulties in statistical model development are illustrated by examples from a epidemiological study performed in the Faroe Islands to investigate the adverse...
Skuladottir, Margret; Ramel, Alfons; Rytter, Dorte; Haug, Line Småstuen; Sabaredzovic, Azemira; Bech, Bodil Hammer; Henriksen, Tine Brink; Olsen, Sjurdur F.; Halldorsson, Thorhallur I.
Background: Perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) have consistently been associated with higher cholesterol levels in cross sectional studies. Concerns have, however, been raised about potential confounding by diet and clinical relevance. Objective: To examine the association between concentrations of PFOS and PFOA and total cholesterol in serum during pregnancy taking into considerations confounding by diet. Methods: 854 Danish women who gave birth in 1988–89 and provided a blood sample and reported their diet in week 30 of gestation. Results: Mean serum PFOS, PFOA and total cholesterol concentrations were 22.3 ng/mL, 4.1 ng/mL and 7.3 mmol/L, respectively. Maternal diet was a significant predictor of serum PFOS and PFOA concentrations. In particular intake of meat and meat products was positively associated while intake of vegetables was inversely associated (P for trend <0.01) with relative difference between the highest and lowest quartile in PFOS and PFOA concentrations ranging between 6% and 25% of mean values. After adjustment for dietary factors both PFOA and PFOS were positively and similarly associated with serum cholesterol (P for trend ≤0.01). For example, the mean increase in serum cholesterol was 0.39 mmol/L (95%CI: 0.09, 0.68) when comparing women in the highest to lowest quintile of PFOA concentrations. In comparison the mean increase in serum cholesterol was 0.61 mmol/L (95%CI: 0.17, 1.05) when comparing women in the highest to lowest quintile of saturated fat intake. Conclusion: In this study associations between PFOS and PFOA with serum cholesterol appeared unrelated to dietary intake and were similar in magnitude as the associations between saturated fat intake and serum cholesterol. - Highlights: • PFOS and PFOA have consistently been linked with raised serum cholesterol • Clinical relevance remains uncertain and confounding by diet has been suggested • The aim of this study was to address these issues in
Mashhood Ahmed Sheikh
Full Text Available The life course perspective, the risky families model, and stress-and-coping models provide the rationale for assessing the role of smoking as a mediator in the association between childhood adversity and anxious and depressive symptomatology (ADS in adulthood. However, no previous study has assessed the independent mediating role of smoking in the association between childhood adversity and ADS in adulthood. Moreover, the importance of mediator-response confounding variables has rarely been demonstrated empirically in social and psychiatric epidemiology. The aim of this paper was to (i assess the mediating role of smoking in adulthood in the association between childhood adversity and ADS in adulthood, and (ii assess the change in estimates due to different mediator-response confounding factors (education, alcohol intake, and social support. The present analysis used data collected from 1994 to 2008 within the framework of the Tromsø Study (N = 4,530, a representative prospective cohort study of men and women. Seven childhood adversities (low mother's education, low father's education, low financial conditions, exposure to passive smoke, psychological abuse, physical abuse, and substance abuse distress were used to create a childhood adversity score. Smoking status was measured at a mean age of 54.7 years (Tromsø IV, and ADS in adulthood was measured at a mean age of 61.7 years (Tromsø V. Mediation analysis was used to assess the indirect effect and the proportion of mediated effect (% of childhood adversity on ADS in adulthood via smoking in adulthood. The test-retest reliability of smoking was good (Kappa: 0.67, 95% CI: 0.63; 0.71 in this sample. Childhood adversity was associated with a 10% increased risk of smoking in adulthood (Relative risk: 1.10, 95% CI: 1.03; 1.18, and both childhood adversity and smoking in adulthood were associated with greater levels of ADS in adulthood (p < 0.001. Smoking in adulthood did not significantly
Kvam, Paul H.; Martz, Harry F.
We consider redundant systems of identical components for which reliability is assessed statistically using only demand-based failures and successes. Direct assessment of system reliability can lead to gross errors in estimation if there exist external events in the working environment that cause two or more components in the system to fail in the same demand period which have not been included in the reliability model. We develop a simple Bayesian model for estimating component reliability and the corresponding probability of common cause failure in operating systems for which the data is confounded; that is, the common cause failures cannot be distinguished from multiple independent component failures in the narrative event descriptions
Gustafson, R; Källmén, H
40 and 48 subjects participated in two separate experiments aimed at reproducing the subliminal psychodynamic activation (SPA) phenomenon and taking into account the major methodological critique by Fudin (1986, 1990). Subjects were first exposed either to a full or one of all possible partial symbiotic messages and then to their anagram equivalents. Confounding and irrelevant influences were controlled; the results indicate that only the full symbiotic message improved motor performance. This strongly suggests that subjects encode the meaning of the full message and supports an interpretation in terms of an alleviation of an internal symbiotic conflict leading to a state of calmness conducive to improved motor performance.
Ota, D; Loftin, B; Saito, T; Lea, R; Keller, J
Virtual reality (VR) is an emerging technology that can teach surgeons new procedures and can determine their level of competence before they operate on patients. Also VR allows the trainee to return to the same procedure or task several times later as a refresher course. Laparoscopic surgery is a new operative technique which requires the surgeon to observe the operation on a video-monitor and requires the acquisition of new skills. VR simulation could duplicate the operative field and thereby enhance training and reduce the need for expensive animal training models. Our preliminary experience has shown that we have the technology to model tissues and laparoscopic instruments and to develop in real time a VR learning environment for surgeons. Another basic need is to measure competence. Surgical training is an apprenticeship requiring close supervision and 5-7 years of training. Technical competence is judged by the mentor and has always been subjective. If VR surgical simulators are to play an important role in the future, quantitative measurement of competence would have to be part of the system. Because surgical competence is "vague" and is characterized by such terms as "too long, too short" or "too close, too far," it is possible that the principles of fuzzy logic could be used to measure competence in a VR surgical simulator. Because a surgical procedure consists of a series of tasks and each task is a series of steps, we will plan to create two important tasks in a VR simulator and validate their use. These tasks consist of laparoscopic knot tying and laparoscopic suturing. Our hypothesis is that VR in combination with fuzzy logic can educate surgeons and determine when they are competent to perform these procedures on patients.
Lindmark, Anita; de Luna, Xavier; Eriksson, Marie
To estimate direct and indirect effects of an exposure on an outcome from observed data, strong assumptions about unconfoundedness are required. Since these assumptions cannot be tested using the observed data, a mediation analysis should always be accompanied by a sensitivity analysis of the resulting estimates. In this article, we propose a sensitivity analysis method for parametric estimation of direct and indirect effects when the exposure, mediator, and outcome are all binary. The sensitivity parameters consist of the correlations between the error terms of the exposure, mediator, and outcome models. These correlations are incorporated into the estimation of the model parameters and identification sets are then obtained for the direct and indirect effects for a range of plausible correlation values. We take the sampling variability into account through the construction of uncertainty intervals. The proposed method is able to assess sensitivity to both mediator-outcome confounding and confounding involving the exposure. To illustrate the method, we apply it to a mediation study based on the data from the Swedish Stroke Register (Riksstroke). An R package that implements the proposed method is available. Copyright © 2018 John Wiley & Sons, Ltd.
Ornö, A K; Dietz, H P
A Valsalva maneuver is used clinically and on imaging in order to determine female pelvic organ prolapse. We have examined the potential confounding effect of levator co-activation at the time of a Valsalva maneuver and the impact of repetition with biofeedback instruction. Fifty nulliparous women at 36-38 weeks' gestation received 3D/4D translabial ultrasound investigation in the dorsal resting position after bladder emptying. Valsalva maneuvers were recorded initially and after repeated attempts with visual biofeedback both during the maneuver and after, with the operator demonstrating findings on the ultrasound monitor, in order to abolish levator co-activation. Offline analysis was subsequently undertaken. Significant differences between first and optimal Valsalva maneuver were found for bladder neck position, bladder neck descent, hiatal sagittal diameter and hiatal area on Valsalva. In a minority of women (22/50) we observed a reduction in the sagittal hiatal diameter on first Valsalva maneuver, indicating levator co-activation. A reduction in sagittal diameter was seen in only 11/50 after instruction. Levator co-activation was associated with significantly lower bladder neck descent. The Valsalva maneuver is frequently accompanied by a pelvic floor muscle contraction. Levator co-activation may be a substantial confounder, reducing pelvic organ descent. Without repetition and digital, auditory or visual biofeedback, women may not perform a correct Valsalva maneuver. Biofeedback markedly reduces the likelihood of levator co-activation but does not abolish it completely. Copyright 2007 ISUOG. Published by John Wiley & Sons, Ltd.
VanderWeele, Tyler J.; Robinson, Whitney R.
We consider several possible interpretations of the “effect of race” when regressions are run with race as an exposure variable, controlling also for various confounding and mediating variables. When adjustment is made for socioeconomic status early in a person’s life, we discuss under what contexts the regression coefficients for race can be interpreted as corresponding to the extent to which a racial inequality would remain if various socioeconomic distributions early in life across racial groups could be equalized. When adjustment is also made for adult socioeconomic status, we note how the overall racial inequality can be decomposed into the portion that would be eliminated by equalizing adult socioeconomic status across racial groups and the portion of the inequality that would remain even if adult socioeconomic status across racial groups were equalized. We also discuss a stronger interpretation of the “effect of race” (stronger in terms of assumptions) involving the joint effects of race-associated physical phenotype (e.g. skin color), parental physical phenotype, genetic background and cultural context when such variables are thought to be hypothetically manipulable and if adequate control for confounding were possible. We discuss some of the challenges with such an interpretation. Further discussion is given as to how the use of selected populations in examining racial disparities can additionally complicate the interpretation of the effects. PMID:24887159
VanderWeele, Tyler J; Robinson, Whitney R
We consider several possible interpretations of the "effect of race" when regressions are run with race as an exposure variable, controlling also for various confounding and mediating variables. When adjustment is made for socioeconomic status early in a person's life, we discuss under what contexts the regression coefficients for race can be interpreted as corresponding to the extent to which a racial inequality would remain if various socioeconomic distributions early in life across racial groups could be equalized. When adjustment is also made for adult socioeconomic status, we note how the overall racial inequality can be decomposed into the portion that would be eliminated by equalizing adult socioeconomic status across racial groups and the portion of the inequality that would remain even if adult socioeconomic status across racial groups were equalized. We also discuss a stronger interpretation of the effect of race (stronger in terms of assumptions) involving the joint effects of race-associated physical phenotype (eg, skin color), parental physical phenotype, genetic background, and cultural context when such variables are thought to be hypothetically manipulable and if adequate control for confounding were possible. We discuss some of the challenges with such an interpretation. Further discussion is given as to how the use of selected populations in examining racial disparities can additionally complicate the interpretation of the effects.
Christofaro, Diego Giulliano Destro; De Andrade, Selma Maffei; Cardoso, Jefferson Rosa; Mesas, Arthur Eumann; Codogno, Jamile Sanches; Fernandes, Rômulo Araújo
The aim of this study was to determine whether high blood pressure (HBP) is associated with sedentary behavior in young people even after controlling for potential confounders (gender, age, socioeconomic level, tobacco, alcohol, obesity and physical activity). In this epidemiological study, 1231 adolescents were evaluated. Blood pressure was measured with an oscillometric device and waist circumference with an inextensible tape. Sedentary behavior (watching television, computer use and playing video games) and physical activity were assessed by a questionnaire. We used mean and standard deviation to describe the statistical analysis, and the association between HBP and sedentary behavior was assessed by the chi-squared test. Binary logistic regression was used to observe the magnitude of association and cluster analyses (sedentary behavior and abdominal obesity; sedentary behavior and physical inactivity). HBP was associated with sedentary behaviors [odds ratio (OR) = 2.21, 95% confidence interval (CI) = 1.41-3.96], even after controlling for various confounders (OR = 1.68, CI = 1.03-2.75). In cluster analysis the combination of sedentary behavior and elevated abdominal obesity contributed significantly to an increased likelihood of having HBP (OR = 13.51, CI 7.21-23.97). Sedentary behavior was associated with HBP, and excess fat in the abdominal region contributed to the modulation of this association.
Minguez, Laëtitia; Buronfosse, Thierry; Beisel, Jean-Nicolas; Giambérini, Laure
Biological responses measured in aquatic organisms to monitor environmental pollution could be also affected by different biotic and abiotic factors. Among these environmental factors, parasitism has often been neglected even if infection by parasites is very frequent. In the present field investigation, the parasite infra-communities and zebra mussel biological responses were studied up- and downstream a waste water treatment plant in northeast France. In both sites, mussels were infected by ciliates and/or intracellular bacteria, but prevalence rates and infection intensities were different according to the habitat. Concerning the biological responses differences were observed related to the site quality and the infection status. Parasitism affects both systems but seemed to depend mainly on environmental conditions. The influence of parasites is not constant, but remains important to consider it as a potential confounding factor in ecotoxicological studies. This study also emphasizes the interesting use of integrative indexes to synthesize data set. Highlights: ► Study of potential bias associated with the use of infected zebra mussels in ecotoxicological studies. ► Presence of infected mussels on banks and channels, up- and downstream a waste water treatment plant. ► Parasitism influence on biological responses dependent of mussel population history. ► Integrative index, an interesting tool to synthesize the set of biological data. - Parasitism influence on the host physiology would be strongly dependent on environmental conditions but remains a potential confounding factor in ecotoxicological studies.
The emergence of HIV and AIDS has changed the pattern of many diseases including surgical ones. Some of the .... Symmetrical lymphadenopathy occurring even in adults,. More visceral disease as manifested by oral ... othenvise exposure of the empyema cavity to the atmospheric pressure will certainly lead to collapse.
Full Text Available Abstract Background Automated classification of histopathology involves identification of multiple classes, including benign, cancerous, and confounder categories. The confounder tissue classes can often mimic and share attributes with both the diseased and normal tissue classes, and can be particularly difficult to identify, both manually and by automated classifiers. In the case of prostate cancer, they may be several confounding tissue types present in a biopsy sample, posing as major sources of diagnostic error for pathologists. Two common multi-class approaches are one-shot classification (OSC, where all classes are identified simultaneously, and one-versus-all (OVA, where a “target” class is distinguished from all “non-target” classes. OSC is typically unable to handle discrimination of classes of varying similarity (e.g. with images of prostate atrophy and high grade cancer, while OVA forces several heterogeneous classes into a single “non-target” class. In this work, we present a cascaded (CAS approach to classifying prostate biopsy tissue samples, where images from different classes are grouped to maximize intra-group homogeneity while maximizing inter-group heterogeneity. Results We apply the CAS approach to categorize 2000 tissue samples taken from 214 patient studies into seven classes: epithelium, stroma, atrophy, prostatic intraepithelial neoplasia (PIN, and prostate cancer Gleason grades 3, 4, and 5. A series of increasingly granular binary classifiers are used to split the different tissue classes until the images have been categorized into a single unique class. Our automatically-extracted image feature set includes architectural features based on location of the nuclei within the tissue sample as well as texture features extracted on a per-pixel level. The CAS strategy yields a positive predictive value (PPV of 0.86 in classifying the 2000 tissue images into one of 7 classes, compared with the OVA (0.77 PPV and OSC
Dvir, Danny; Webb, John; Brecker, Stephen
Transcatheter aortic valve-in-valve implantation is an emerging therapeutic alternative for patients with a failed surgical bioprosthesis and may obviate the need for reoperation. We evaluated the clinical results of this technique using a large, worldwide registry....
Ahmed Abdulrahman Elassal
Conclusion: Surgical pulmonary embolectomy is a rescue operation in high-risk PE. It could save patients with preoperative cardiac arrest. Early diagnosis, interdisciplinary team action, appropriate and emergent treatment strategy are necessary for favorable outcome.
... The Marfan Foundation Marfan & Related Disorders What is Marfan Syndrome? What are Related Disorders? What are the Signs? ... Emergencies Eye Emergencies Lung Emergencies Surgeries Eye Emergencies Marfan syndrome significantly increases your risk of retinal detachment, a ...
E. Y. Dyakonova
Full Text Available Hemorrhagic vasculitis is a hematological disorder, which is often accompanied by abdominal pain syndrome and blood in stool, which is why it requires differential diagnosis with acute surgical pathology. The article presents clinical follow-up of a patient with hemorrhagic vasculitis complicated by intestinal intussusception and developed mesenteric thrombosis, which required emergency surgical intervention.
Roig, José V; Sánchez-Guillén, Luis; García-Armengol, Juan J
Diverticulitis is a common condition in industrialized countries and an important cause of hospital admissions. Its growing trend is a challenge for the surgeons who perform emergency surgery, because approximately 15-25% of the patients will require surgery, being the surgical management of complicated acute diverticulitis controversial. The past decade has seen a paradigm shift in the treatment of sigmoid diverticulitis based on new epidemiological studies and refinement of surgical techniques that has produced a reassessment of our guidelines. CT imaging and sepsis scores allows to stratify the patients and better define the therapeutic strategies in each case. Special considerations must also be made for patients with a high surgical risk, such as immunosuppressed ones. The recommendations to perform surgery after two episodes of uncomplicated diverticulitis have been re-evaluated and the belief that new episodes may be complicated and associated with high morbidity and mortality has been rejected, since the clinical manifestations of this disease are usually defined by the first attack. In complicated cases, more patients can be treated with resection and primary anastomosis with or without an associated stoma, whose reversal rate is much higher than that of a Hartmann's procedure. Likewise, laparoscopic surgery performing a peritoneal lavage and drainage without associated resection may have an increasing role in the management of these patients, although with controversial results, having become laparoscopic colon resection the approach of choice for the treatment of this pathology in elective settings.
De la Salle, Barbara
The complete blood count (CBC) is one of the most frequently requested tests in laboratory medicine, performed in a range of healthcare situations. The provision of an ideal assay material for external quality assessment is confounded by the fragility of the cellular components of blood, the lack of commutability of stabilised whole blood material and the lack of certified reference materials and methods to which CBC results can be traced. The choice of assay material between fresh blood, extended life assay material and fully stabilised, commercially prepared, whole blood material depends upon the scope and objectives of the EQA scheme. The introduction of new technologies in blood counting and the wider clinical application of parameters from the extended CBC will bring additional challenges for the EQA provider.
Meier, S M; Plessen, K J; Verhulst, F
investigation. Method We conducted a nationwide cohort study including 957635 individuals born in Denmark between 1991 and 2007. Data on MSDP and diagnoses of depression or anxiety disorders were derived from national registers and patients were followed up from the age of 5 years to the end of 2012. Hazard...... rate ratios (HRRs) were estimated using stratified Cox regression models. Sibling data were used to disentangle individual- and familial-level effects of MSDP and to control for unmeasured familial confounding. Results At the population level, offspring exposed to MSDP were at increased risk for both...... for MSDP (depression: HRR 1.11, 95% CI 0.94-1.30; anxiety disorders: HRR 0.94, 95% CI 0.80-1.11) or comparing differentially exposed siblings (depression: HRR 1.18, 95% CI 0.75-1.89; anxiety disorders: HRR 0.87, 95% CI 0.55-1.36). Conclusions The results suggest that familial background factors account...
Minguez, Laëtitia; Buronfosse, Thierry; Beisel, Jean-Nicolas; Giambérini, Laure
Biological responses measured in aquatic organisms to monitor environmental pollution could be also affected by different biotic and abiotic factors. Among these environmental factors, parasitism has often been neglected even if infection by parasites is very frequent. In the present field investigation, the parasite infra-communities and zebra mussel biological responses were studied up- and downstream a waste water treatment plant in northeast France. In both sites, mussels were infected by ciliates and/or intracellular bacteria, but prevalence rates and infection intensities were different according to the habitat. Concerning the biological responses differences were observed related to the site quality and the infection status. Parasitism affects both systems but seemed to depend mainly on environmental conditions. The influence of parasites is not constant, but remains important to consider it as a potential confounding factor in ecotoxicological studies. This study also emphasizes the interesting use of integrative indexes to synthesize data set. Copyright © 2011 Elsevier Ltd. All rights reserved.
Leenaars, C.H.; Dematteis, M.; Joosten, R.N.J.M.; Eggels, L.; Sandberg, H.; Schirris, M.; Feenstra, M.G.P.; van Someren, E.J.W.
The function of sleep in physiology, behaviour and cognition has become a primary focus of neuroscience. Its study inevitably includes experimental sleep deprivation designs. However, concerns exist regarding confounds like stress, increased locomotor activity levels, and decreased motivation to
Greenland, Sander; Mansournia, Mohammad Ali
We describe how ordinary interpretations of causal models and causal graphs fail to capture important distinctions among ignorable allocation mechanisms for subject selection or allocation. We illustrate these limitations in the case of random confounding and designs that prevent such confounding. In many experimental designs individual treatment allocations are dependent, and explicit population models are needed to show this dependency. In particular, certain designs impose unfaithful covariate-treatment distributions to prevent random confounding, yet ordinary causal graphs cannot discriminate between these unconfounded designs and confounded studies. Causal models for populations are better suited for displaying these phenomena than are individual-level models, because they allow representation of allocation dependencies as well as outcome dependencies across individuals. Nonetheless, even with this extension, ordinary graphical models still fail to capture distinctions between hypothetical superpopulations (sampling distributions) and observed populations (actual distributions), although potential-outcome models can be adapted to show these distinctions and their consequences.
Thygesen, Lau Caspar; Pottegård, Anton; Ersbøll, Annette Kjaer
- and sex-matched (1:8) population controls (n = 759 334). Long-term benzodiazepine use was defined as ≥500 defined daily doses 1-5 years prior to the index date. We implemented propensity score (PS) calibration using external information on confounders available from a survey of the Danish population. Two...... PSs were used: The error-prone PS using register-based confounders and the calibrated PS based on both register- and survey-based confounders, retrieved from the Health Interview Survey. RESULTS: Register-based data showed that cancer cases had more diagnoses, higher comorbidity score and more co......% confidence interval 1.00-1.19) and for smoking-related cancers from 1.20 to 1.10 (95% confidence interval 1.00-1.21). CONCLUSION: We conclude that the increased risk observed in the solely register-based study could partly be attributed to unmeasured confounding....
Chapman, Benjamin; Fiscella, Kevin; Duberstein, Paul; Kawachi, Ichiro; Muennig, Peter
IQ is thought to explain social gradients in mortality. IQ scores are based roughly equally on Verbal IQ (VIQ) and Performance IQ tests. VIQ tests, however, are suspected to confound true verbal ability with socioeconomic status (SES), raising the possibility that associations between SES and IQ scores might be overestimated. We examined, first, whether two of the most common types of VIQ tests exhibited differential item functioning (DIF) favouring persons of higher SES and/or majority race/ethnicity. Second, we assessed what impact, if any, this had on estimates of the extent to which VIQ explains social gradients in mortality. Data from the General Social Survey-National Death Index cohort, a US population representative dataset, was used. Item response theory models queried social-factor DIF on the Thorndike Verbal Intelligence Scale and Wechsler Adult Intelligence Scales, Revised Similarities test. Cox models examined mortality associations among SES and VIQ scores corrected and uncorrected for DIF. When uncorrected for DIF, VIQ was correlated with income, education, occupational prestige and race, with correlation coefficients ranging between |0.12| and |0.43|. After correcting for DIF, correlations ranged from |0.06| to |0.16|. Uncorrected VIQ scores explained 11-40% of the Relative Index of Inequalities in mortality for social factors, while DIF-corrected scores explained 2-29%. Two of the common forms of VIQ tests appear confound verbal intelligence with SES. Since these tests appear in most IQ batteries, circumspection may be warranted in estimating the amount of social inequalities in mortality attributable to IQ. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Schmidt, Amand F; Klungel, Olaf H; Groenwold, Rolf H H
Postlaunch data on medical treatments can be analyzed to explore adverse events or relative effectiveness in real-life settings. These analyses are often complicated by the number of potential confounders and the possibility of model misspecification. We conducted a simulation study to compare the performance of logistic regression, propensity score, disease risk score, and stabilized inverse probability weighting methods to adjust for confounding. Model misspecification was induced in the independent derivation dataset. We evaluated performance using relative bias confidence interval coverage of the true effect, among other metrics. At low events per coefficient (1.0 and 0.5), the logistic regression estimates had a large relative bias (greater than -100%). Bias of the disease risk score estimates was at most 13.48% and 18.83%. For the propensity score model, this was 8.74% and >100%, respectively. At events per coefficient of 1.0 and 0.5, inverse probability weighting frequently failed or reduced to a crude regression, resulting in biases of -8.49% and 24.55%. Coverage of logistic regression estimates became less than the nominal level at events per coefficient ≤5. For the disease risk score, inverse probability weighting, and propensity score, coverage became less than nominal at events per coefficient ≤2.5, ≤1.0, and ≤1.0, respectively. Bias of misspecified disease risk score models was 16.55%. In settings with low events/exposed subjects per coefficient, disease risk score methods can be useful alternatives to logistic regression models, especially when propensity score models cannot be used. Despite better performance of disease risk score methods than logistic regression and propensity score models in small events per coefficient settings, bias, and coverage still deviated from nominal.
Torkildsen, Oivind; Aarseth, Jan; Benjaminsen, Espen; Celius, Elisabeth; Holmøy, Trygve; Kampman, Margitta T; Løken-Amsrud, Kristin; Midgard, Rune; Myhr, Kjell-Morten; Riise, Trond; Grytten, Nina
A month of birth effect on multiple sclerosis (MS) risk has been reported from different countries. Recent critics have suggested that this finding is caused by confounding and that adequately adjusting for year and place of birth would markedly reduce this effect. All inhabitants in Norway are registered in the Norwegian Population Registry (Statistics Norway), making this an ideal area for performing adjusted analyses. Using the entire Norwegian population born between 1930 and 1979 (n = 2,899,260), we calculated the excess between observed and expected number of births for each month for 6649 Norwegian MS patients, 5711 mothers, 5247 fathers, and 8956 unaffected siblings. The analyses were adjusted for year of birth and place of birth according to the 19 counties in Norway. An unadjusted analysis revealed 13% fewer MS births than expected in February (P = 0.0015; Bonferroni corrected P = 0.018), 10% more in April (P = 0.0083; Bonferroni corrected P = 0.0996) and 15% more in December (P = 0.00058; Bonferroni corrected P = 0.007). Adjustments for both year and place of birth significantly altered our results for February and December, but even after these adjustments there were still 10% more MS births than expected in April (P = 0.00796; Bonferroni corrected P = 0.096). MS patients had a higher incidence of April births than their siblings (Fisher-exact test; P = 0.011), mothers (Fisher-exact test; P = 0.004), and fathers (Fisher-exact test; P = 0.011) without MS. Adjustments for confounding significantly affected our results. However, even after adjustments, there appears to be a persistent higher than expected frequency of April births in the MS population.
Torkildsen, Øivind; Aarseth, Jan; Benjaminsen, Espen; Celius, Elisabeth; Holmøy, Trygve; Kampman, Margitta T; Løken-Amsrud, Kristin; Midgard, Rune; Myhr, Kjell-Morten; Riise, Trond; Grytten, Nina
A month of birth effect on multiple sclerosis (MS) risk has been reported from different countries. Recent critics have suggested that this finding is caused by confounding and that adequately adjusting for year and place of birth would markedly reduce this effect. All inhabitants in Norway are registered in the Norwegian Population Registry (Statistics Norway), making this an ideal area for performing adjusted analyses. Using the entire Norwegian population born between 1930 and 1979 (n = 2,899,260), we calculated the excess between observed and expected number of births for each month for 6649 Norwegian MS patients, 5711 mothers, 5247 fathers, and 8956 unaffected siblings. The analyses were adjusted for year of birth and place of birth according to the 19 counties in Norway. An unadjusted analysis revealed 13% fewer MS births than expected in February (P = 0.0015; Bonferroni corrected P = 0.018), 10% more in April (P = 0.0083; Bonferroni corrected P = 0.0996) and 15% more in December (P = 0.00058; Bonferroni corrected P = 0.007). Adjustments for both year and place of birth significantly altered our results for February and December, but even after these adjustments there were still 10% more MS births than expected in April (P = 0.00796; Bonferroni corrected P = 0.096). MS patients had a higher incidence of April births than their siblings (Fisher-exact test; P = 0.011), mothers (Fisher-exact test; P = 0.004), and fathers (Fisher-exact test; P = 0.011) without MS. Adjustments for confounding significantly affected our results. However, even after adjustments, there appears to be a persistent higher than expected frequency of April births in the MS population. PMID:25356394
Hecksteden, Anne; Leidinger, Petra; Backes, Christina; Rheinheimer, Stefanie; Pfeiffer, Mark; Ferrauti, Alexander; Kellmann, Michael; Sedaghat-Hamedani, Farbod; Meder, Benjamin; Meese, Eckart; Meyer, Tim; Keller, Andreas
The dependency of miRNA abundance from physiological processes such as exercises remains partially understood. We set out to analyze the effect of physical exercises on miRNA profiles in blood and plasma of endurance and strength athletes in a systematic manner and correlated differentially abundant miRNAs in athletes to disease miRNAs biomarkers towards a better understanding of how physical exercise may confound disease diagnosis by miRNAs. We profiled blood and plasma of 29 athletes before and after exercise. With four samples analyzed for each individual we analyzed 116 full miRNomes. The study set-up enabled paired analyses of individuals. Affected miRNAs were investigated for known disease associations using network analysis. MiRNA patterns in blood and plasma of endurance and strength athletes vary significantly with differences in blood outreaching variations in plasma. We found only moderate differences between the miRNA levels before training and the RNA levels after training as compared to the more obvious variations found between strength athletes and endurance athletes. We observed significant variations in the abundance of miR-140-3p that is a known circulating disease markers (raw and adjusted p value of 5 × 10(-12) and 4 × 10(-7)). Similarly, the levels of miR-140-5p and miR-650, both of which have been reported as makers for a wide range of human pathologies significantly depend on the training mode. Among the most affected disease categories we found acute myocardial infarction. MiRNAs, which are up-regulated in endurance athletes inhibit VEGFA as shown by systems biology analysis of experimentally validated target genes. We provide evidence that the mode and the extent of training are important confounding factors for a miRNA based disease diagnosis.
Burgert, O.; Neumuth, T.; Gessat, M.; Jacobs, S.; Lemke, H. U.
The generation, storage, transfer, and representation of image data in radiology are standardized by DICOM. To cover the needs of image guided surgery or computer assisted surgery in general one needs to handle patient information besides image data. A large number of objects must be defined in DICOM to address the needs of surgery. We propose an analysis process based on Surgical Workflows that helps to identify these objects together with use cases and requirements motivating for their specification. As the first result we confirmed the need for the specification of representation and transfer of geometric models. The analysis of Surgical Workflows has shown that geometric models are widely used to represent planned procedure steps, surgical tools, anatomical structures, or prosthesis in the context of surgical planning, image guided surgery, augmented reality, and simulation. By now, the models are stored and transferred in several file formats bare of contextual information. The standardization of data types including contextual information and specifications for handling of geometric models allows a broader usage of such models. This paper explains the specification process leading to Geometry Mesh Service Object Pair classes. This process can be a template for the definition of further DICOM classes.
... emergency medical or surgical treatment together with any necessary attendant or attendants and (b) any... 14 Aeronautics and Space 4 2010-01-01 2010-01-01 false Emergency transportation. 206.1 Section 206... EXEMPTIONS § 206.1 Emergency transportation. Notwithstanding the provisions of section 41101 of the Statute...
A medical record is presented on the basis of selected linguistic pearls collected over the years from surgical case records Udgivelsesdato: 2008/12/15......A medical record is presented on the basis of selected linguistic pearls collected over the years from surgical case records Udgivelsesdato: 2008/12/15...
In the Netherlands, each year over 1700 patients die from preventable surgical errors. Numerous initiatives to improve surgical practice have had some impact, but problems persist. Despite the introduction of checklists and protocols, patient safety in surgery remains a continuing challenge. This is
the spinal cord. In this article, the reader is referred back to this illustration to understand the surgical techniques used to manage pain. Pain is caused by ... Injured dorsal root neurons discharge at higher frequencies and more spontaneously than normally. Surgical techniques. The physician should ensure that treat-.
the development of SSI. Complications associated with surgical site infections7. • Longer hospital stay with risk of acquiring other hospital acquired infections like pneumonia. • Require more surgical procedures. • Risk for development of resistance to antibiotics. • Risk for development of necrotizing fasciitis with skin loss.
Full Text Available Abstract Acute abdominal pain is a leading symptom in many surgical emergency patients. Laparoscopy allows for accurate diagnosis and immediate therapy of many intraabdominal pathologies. The guidelines of the EAES (European Association for Endoscopic Surgery provides scientifically founded recommendations about the role of laparoscopy in the different situations. Generally, laparoscopy is well suited for the therapy of the majority of diseases that cause acute abdominal pain.
Risi, D.; Alessi, G.; Meli, C.; Marzano, M.; Fiori, E.; Caterino, S.
From February 1986 to March 1988 113 abdominal US exams were performed in emergency situation to evaluate the accuracy of this methodology: 13 were blunt traumas, 18 post-operative complications. A real-time scanner with a linear probe of 5 MHz was employed. The results were confirmed by surgical and/or clinical and instrumental evaluation. In 81% of the examinations, ultrasonography allowed a diagnosis to be made. Gallbladder and biliary pathologies were the most common findings. The results (sensibility 96%, specificity 88%, accuracy 95%) confirm the affidability of ultrasonography in abdominal emergencies, as shown in literature
Lech, Christie; Swaminathan, Anand
This article discusses abdominal aortic emergencies. There is a common thread of risk factors and causes of these diseases, including age, male gender, hypertension, dyslipidemia, and connective tissue disorders. The most common presenting symptom of these disorders is pain, usually in the chest, flank, abdomen, or back. Computed tomography scan is the gold standard for diagnosis of pathologic conditions of the aorta in the hemodynamically stable patient. Treatment consists of a combination of blood pressure and heart rate control and, in many cases, emergent surgical intervention. Copyright © 2017 Elsevier Inc. All rights reserved.
Bouyou, J; Gaujoux, S; Marcellin, L; Leconte, M; Goffinet, F; Chapron, C; Dousset, B
Abdominal emergencies during pregnancy (excluding obstetrical emergencies) occur in one out of 500-700 pregnancies and may involve gastrointestinal, gynecologic, urologic, vascular and traumatic etiologies; surgery is necessary in 0.2-2% of cases. Since these emergencies are relatively rare, patients should be referred to specialized centers where surgical, obstetrical and neonatal cares are available, particularly because surgical intervention increases the risk of premature labor. Clinical presentations may be atypical and misleading because of pregnancy-associated anatomical and physiologic alterations, which often result in diagnostic uncertainty and therapeutic delay with increased risks of maternal and infant morbidity. The most common abdominal emergencies are acute appendicitis (best treated by laparoscopic appendectomy), acute calculous cholecystitis (best treated by laparoscopic cholecystectomy from the first trimester through the early part of the third trimester) and intestinal obstruction (where medical treatment is the first-line approach, just as in the non-pregnant patient). Acute pancreatitis is rare, usually resulting from trans-ampullary passage of gallstones; it usually resolves with medical treatment but an elevated risk of recurrent episodes justifies laparoscopic cholecystectomy in the 2nd trimester and endoscopic sphincterotomy in the 3rd trimester. The aim of the present work is to review pregnancy-induced anatomical and physiological modifications, to describe the main abdominal emergencies during pregnancy, their specific features and their diagnostic and therapeutic management. Copyright © 2015. Published by Elsevier Masson SAS.
Full Text Available BACKGROUND: Research has consistently found lower cognitive ability to be related to increased risk for violent and other antisocial behaviour. Since this association has remained when adjusting for childhood socioeconomic position, ethnicity, and parental characteristics, it is often assumed to be causal, potentially mediated through school adjustment problems and conduct disorder. Socioeconomic differences are notoriously difficult to quantify, however, and it is possible that the association between intelligence and delinquency suffer substantial residual confounding. METHODS: We linked longitudinal Swedish total population registers to study the association of general cognitive ability (intelligence at age 18 (the Conscript Register, 1980-1993 with the incidence proportion of violent criminal convictions (the Crime Register, 1973-2009, among all men born in Sweden 1961-1975 (N = 700,514. Using probit regression, we controlled for measured childhood socioeconomic variables, and further employed sibling comparisons (family pedigree data from the Multi-Generation Register to adjust for shared familial characteristics. RESULTS: Cognitive ability in early adulthood was inversely associated to having been convicted of a violent crime (β = -0.19, 95% CI: -0.19; -0.18, the association remained when adjusting for childhood socioeconomic factors (β = -0.18, 95% CI: -0.18; -0.17. The association was somewhat lower within half-brothers raised apart (β = -0.16, 95% CI: -0.18; -0.14, within half-brothers raised together (β = -0.13, 95% CI: (-0.15; -0.11, and lower still in full-brother pairs (β = -0.10, 95% CI: -0.11; -0.09. The attenuation among half-brothers raised together and full brothers was too strong to be attributed solely to attenuation from measurement error. DISCUSSION: Our results suggest that the association between general cognitive ability and violent criminality is confounded partly by factors shared by
Schoolmaster, Donald R.; Grace, James B.; Schweiger, E. William; Mitchell, Brian R.; Guntenspergen, Glenn R.
The development of multimetric indices (MMIs) as a means of providing integrative measures of ecosystem condition is becoming widespread. An increasingly recognized problem for the interpretability of MMIs is controlling for the potentially confounding influences of environmental covariates. Most common approaches to handling covariates are based on simple notions of statistical control, leaving the causal implications of covariates and their adjustment unstated. In this paper, we use graphical models to examine some of the potential impacts of environmental covariates on the observed signals between human disturbance and potential response metrics. Using simulations based on various causal networks, we show how environmental covariates can both obscure and exaggerate the effects of human disturbance on individual metrics. We then examine from a causal interpretation standpoint the common practice of adjusting ecological metrics for environmental influences using only the set of sites deemed to be in reference condition. We present and examine the performance of an alternative approach to metric adjustment that uses the whole set of sites and models both environmental and human disturbance effects simultaneously. The findings from our analyses indicate that failing to model and adjust metrics can result in a systematic bias towards those metrics in which environmental covariates function to artificially strengthen the metric–disturbance relationship resulting in MMIs that do not accurately measure impacts of human disturbance. We also find that a “whole-set modeling approach” requires fewer assumptions and is more efficient with the given information than the more commonly applied “reference-set” approach.
With the recent interest in the study of occupational exposures, the impact of certain selective biases in the groups studied is a matter of some concern. In this paper, data from the Hanford nuclear facility population (southeastern Washington State, 1947-1976), which includes many radiation workers, are used to illustrate a method for examining the effect on mortality of such potentially confounding variables as calendar year, length of time since entering the industry, employment status, length of employment, job category, and initial employment year. The analysis, which is based on the Mantel-Haenszel procedure as adapted for a prospective study, differs from most previous studies of occupational variables which have relied primarily on comparing standardized mortality ratios (utilizing an external control) for various subgroups of the population. Results of this analysis confirm other studies in that reduced death rates are observed for early years of follow-up and for those with higher socioeconomic status (as indicated by job category). In addition, workers employed less than two years and especially terminated workers are found to have elevated death rates as compared with the remainder of the study population. It is important that such correlations be taken into account in planning and interpreting analyses of the effects of occupational exposure
Carr, R.S.; Biedenbach, J.M.; Nipper, M.
The influence of potentially confounding factors has been identified as a concern for interpreting sea urchin porewater toxicity test data. The results from >40 sediment-quality assessment surveys using early-life stages of the sea urchin Arbacia punctulata were compiled and examined to determine acceptable ranges of natural variables such as pH, ammonia, and dissolved organic carbon on the fertilization and embryological development endpoints. In addition, laboratory experiments were also conducted with A. punctulata and compared with information from the literature. Pore water with pH as low as 6.9 is an unlikely contributor to toxicity for the fertilization and embryological development tests with A. punctulata. Other species of sea urchin have narrower pH tolerance ranges. Ammonia is rarely a contributing factor in pore water toxicity tests using the fertilization endpoint, but the embryological development endpoint may be influenced by ammonia concentrations commonly found in porewater samples. Therefore, ammonia needs to be considered when interpreting results for the embryological development test. Humic acid does not affect sea urchin fertilization at saturation concentrations, but it could have an effect on the embryological development endpoint at near-saturation concentrations. There was no correlation between sediment total organic carbon concentrations and porewater dissolved organic carbon concentrations. Because of the potential for many varying substances to activate parthenogenesis in sea urchin eggs, it is recommended that a no-sperm control be included with every fertilization test treatment. ?? 2006 Springer Science+Business Media, Inc.
Full Text Available Ya-Wen Jan1,2, Chien-Ming Yang1,3, Yu-Shu Huang4,51Department of Psychology, National Cheng-Chi University, Taipei; 2Sleep Center of Taipei Medical University Hospital, Taipei; 3The Research Center for Mind Brain and Learning, National Cheng-Chi University, Taipei; 4Department of Child Psychiatry and Sleep Center, Chang Gung Memorial Hospital, Taoyuan; 5College of Medicine, Chang Gung University, Taoyuan, TaiwanAbstract: Sleep problems are commonly reported in children with attention-deficit/hyperactivity disorder (ADHD symptoms. Research data regarding the complex and reciprocal relationship between ADHD and sleep disturbances has now accumulated. This paper is focused on the types of sleep problems that are associated with ADHD symptomatology, and attempts to untangle confounding factors and overlapping symptoms. The goal is also to present an updated overview of the pathophysiology of and treatment strategies for sleep problems in children with ADHD. The review also points out that future research will be needed to clarify further the other psychiatric comorbidities and side effects of medication in order to improve treatment outcomes and prevent misdiagnosis in clinical practice.Keywords: attention-deficit/hyperactivity disorder, sleep, children
Full Text Available The increasing usage of smart phones has compelled mobile technology to become a universal part of everyday life. From wearable gadgets to sophisticated implantable medical devices, the advent of mobile technology has completely transformed the healthcare delivery scenario. Self-report measures enabled by mobile technology are increasingly becoming a more time and cost efficient method of assessing real world health outcomes. But, amidst all the optimism, there are concerns also on adopting this technology as regulations and ethical considerations on privacy legislations of end users are unclear. In general, the healthcare industry functions on some stringent regulations and compliances to ensure the safety and protection of patient information. A couple of the most common regulations are Health Insurance Portability Accountability Act (HIPPA and Health Information Technology for Economic and Clinical Health (HITECH. To harness the true potential of mobile technology to empower stakeholders and provide them a common platform which seamlessly integrates healthcare delivery and research, it is imperative that challenges and drawbacks in the sphere are identified and addressed. In this age of information and technology, no stones should be left unturned to ensure that the human race has access to the best healthcare services without an intrusion into his/her confidentiality. This article is an overview of the role of tracking and self-monitoring devices in data collection for real world evidence/observational studies in context to feasibility, confounders and ethical considerations.
Jones, Andrew; Button, Emily; Rose, Abigail K; Robinson, Eric; Christiansen, Paul; Di Lemma, Lisa; Field, Matt
Motivation to drink alcohol can be measured in the laboratory using an ad-libitum 'taste test', in which participants rate the taste of alcoholic drinks whilst their intake is covertly monitored. Little is known about the construct validity of this paradigm. The objective of this study was to investigate variables that may compromise the validity of this paradigm and its construct validity. We re-analysed data from 12 studies from our laboratory that incorporated an ad-libitum taste test. We considered time of day and participants' awareness of the purpose of the taste test as potential confounding variables. We examined whether gender, typical alcohol consumption, subjective craving, scores on the Alcohol Use Disorders Identification Test and perceived pleasantness of the drinks predicted ad-libitum consumption (construct validity). We included 762 participants (462 female). Participant awareness and time of day were not related to ad-libitum alcohol consumption. Males drank significantly more alcohol than females (p alcohol consumption (p = 0.04), craving (p alcohol consumption. The construct validity of the taste test was supported by relationships between ad-libitum consumption and typical alcohol consumption, craving and pleasantness ratings of the drinks. The ad-libitum taste test is a valid method for the assessment of alcohol intake in the laboratory.
Full Text Available Most conventional measures of information processing speed require motor responses to facilitate performance. However, although not often addressed clinically, motor impairment, whether due to age or acquired brain injury, would be expected to confound the outcome measure of such tasks. The current study recruited 29 patients (20 stroke and 9 transient ischemic attack with documented reduction in dexterity of the dominant hand, and 29 controls, to investigate the extent to which 3 commonly used processing speed measures with varying motor demands (a Visuo-Motor Reaction Time task, and the Wechsler Adult Intelligence Scale-IV Symbol Search and Coding subtests may be measuring motor-related speed more so than cognitive speed. Analyses include correlations between indices of cognitive and motor speed obtained from two other tasks (Inspection Time and Pegboard task, respectively with the three speed measures, followed by hierarchical regressions to determine the relative contribution of cognitive and motor speed indices toward task performance. Results revealed that speed outcomes on tasks with relatively high motor demands, such as Coding, were largely reflecting motor speed in individuals with reduced dominant hand dexterity. Thus, findings indicate the importance of employing measures with minimal motor requirements, especially when the assessment of speed is aimed at understanding cognitive rather than physical function.
Patrick, Emily; Ada, Louise
To compare the Tardieu Scale as a clinical measure of spasticity after stroke with the Ashworth Scale. Cross-sectional study. Sixteen people, living in the community three years after their stroke. The Ashworth Scale and Tardieu Scale as well as laboratory measures of spasticity (stretch-induced electromyographic (EMG) activity) and contracture (maximum passive joint excursion) were collected from the affected elbow flexors and extensors and ankle plantarflexors and dorsiflexors by three examiners who were blinded to the results of the other measures. The percentage exact agreement (PEA) between the Tardieu Scale and a laboratory measure of spasticity was 100% for both the elbow flexors and ankle plantarflexors. This was significantly (P= 0.02) greater than the PEA of 63% for both muscles between the Ashworth Scale and the same laboratory measure of spasticity. For contracture, the PEA between the Tardieu Scale and a laboratory measure was 94% for both the elbow flexors and the ankle plantarflexors. Pearson correlation coefficients between the Tardieu Scale and laboratory measures of spasticity were 0.86 for the elbow flexors and 0.62 for the ankle plantarflexors and between the Tardieu Scale and laboratory measures of contracture were 0.89 for the elbow flexors and 0.84 for the ankle plantarflexors. In all cases that spasticity was overestimated by the Ashworth Scale, participants had a contracture. These findings suggest that the Tardieu Scale differentiates spasticity from contracture whereas the Ashworth Scale is confounded by it.
Auther, A M; Cadenhead, K S; Carrión, R E; Addington, J; Bearden, C E; Cannon, T D; McGlashan, T H; Perkins, D O; Seidman, L; Tsuang, M; Walker, E F; Woods, S W; Cornblatt, B A
Cannabis use has been examined as a predictor of psychosis in clinical high-risk (CHR) samples, but little is known about the impact of other substances on this relationship. Substance use was assessed in a large sample of CHR participants (N = 370, mean age = 18.3) enrolled in the multisite North American Prodrome Longitudinal Study Phase 1 project. Three hundred and forty-one participants with cannabis use data were divided into groups: No Use (NU, N = 211); Cannabis Use without impairment (CU, N = 63); Cannabis Abuse/Dependence (CA/CD, N = 67). Participants (N = 283) were followed for ≥2 years to determine psychosis conversion. Alcohol (45.3%) and cannabis (38.1%) were the most common substances. Cannabis use groups did not differ on baseline attenuated positive symptoms. Seventy-nine of 283 participants with cannabis and follow-up data converted to psychosis. Survival analysis revealed significant differences between conversion rates in the CA/CD group compared with the No Use (P = 0.031) and CU group (P = 0.027). CA/CD also significantly predicted psychosis in a regression analysis, but adjusting for alcohol use weakened this relationship. The cannabis misuse and psychosis association was confounded by alcohol use. Non-impairing cannabis use was not related to psychosis. Results highlight the need to control for other substance use, so as to not overstate the cannabis/psychosis connection. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Singh, Komal Manpreet; Phung, Yume T.; Kohla, Mohamed S.; Lan, Billy Y-A; Chan, Sharon; Suen, Diana L.; Murad, Sahar; Rheault, Shana; Davidson, Peter; Evans, Jennifer; Singh, Manpreet; Dohil, Sofie; Osorio, Robert W.; Wakil, Adil E.; Page, Kimberly; Feng, Sandy; Cooper, Stewart L.
Killer cell immunoglobulin-like receptors (KIR) are encoded by highly polymorphic genes that regulate the activation of natural killer (NK) cells and other lymphocyte subsets, and likely play key roles in innate and adaptive immunity. Association studies increasingly implicate KIR in disease predisposition and outcome but could be confounded by unknown KIR genetic structure in heterogeneous populations. To examine this we characterized the diversity of 16 KIR genes in 712 Northern Californians (NC) stratified by selfassigned ethnicities, and compared the profiles of KIR polymorphism with other US and global populations using a reference database. Sixty-eight distinct KIR genotypes were characterized: 58 in 457 Caucasians (NCC); 17 in 47 African Americans (NCAA); 21 in 80 Asians (NCA); 20 in 74 Hispanics (NCH) and 18 in 54 “other” ethnicities (NCO). KIR genotype patterns and frequencies in the 4 defined ethnicities were compared with each other and with 34 global populations by phylogenetic analysis. Although there were no population-specific genotypes, the KIR genotype frequency patterns faithfully traced the ancestry of NCC, NCAA and NCA but not of NCH whose ancestries are known to be more heterogeneous. KIR genotype frequencies can therefore track ethnic ancestries in modern urban populations. Our data emphasize the importance of selecting ethnically matched controls in KIR based studies to avert spurious associations. PMID:21898189
Lardner, Bjorn; Rodda, Gordon H.; Yackel Adams, Amy A.; Savidge, Julie A.; Reed, Robert N.
Transect surveys without some means of estimating detection probabilities generate population size indices prone to bias because survey conditions differ in time and space. Knowing what causes such bias can help guide the collection of relevant survey covariates, correct the survey data, anticipate situations where bias might be unacceptably large, and elucidate the ecology of target species. We used negative binomial regression to evaluate confounding variables for gecko (primarily Hemidactylus frenatus and Lepidodactylus lugubris) counts on 220-m-long transects surveyed at night, primarily for snakes, on 9,475 occasions. Searchers differed in gecko detection rates by up to a factor of six. The worst and best headlamps differed by a factor of at least two. Strong winds had a negative effect potentially as large as those of searchers or headlamps. More geckos were seen during wet weather conditions, but the effect size was small. Compared with a detection nadir during waxing gibbous (nearly full) moons above the horizon, we saw 28% more geckos during waning crescent moons below the horizon. A sine function suggested that we saw 24% more geckos at the end of the wet season than at the end of the dry season. Fluctuations on a longer timescale also were verified. Disturbingly, corrected data exhibited strong short-term fluctuations that covariates apparently failed to capture. Although some biases can be addressed with measured covariates, others will be difficult to eliminate as a significant source of error in longterm monitoring programs.
Weise, Lutz M; Harter, Patrick N; Eibach, Sebastian; Braczynski, Anne K; Dunst, Maika; Rieger, Johannes; Bähr, Oliver; Hattingen, Elke; Steinbach, Joachim P; Plate, Karl H; Seifert, Volker; Mittelbronn, Michel
In nonresectable glioblastoma (GBM), stereotactic biopsies are performed to retrieve tissue for diagnostic purposes. The analysis of O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation adds prognostic and predictive information. The aim of the study was to detect confounding factors that limit the number of conclusive MGMT promoter methylation results. We analyzed 71 consecutive GBM patients undergoing stereotactic biopsy on whom MGMT analysis was performed by methylation-specific polymerase chain reaction. Specimens were correlated to imaging by coregistration and prospective documentation of biopsy localization. Our findings were validated in an additional 62 GBM stereotactic biopsies. Our results demonstrate that the best MGMT promoter methylation results were obtained from samples (n = 71) taken in a tangential manner from tumor areas showing contrast enhancement in magnetic resonance imaging. In the additional validation series of 62 stereotactically biopsied GBM, we were able to increase the rate of conclusive MGMT promoter methylation results from 76.1 to 85.48% by strictly planning the route of biopsy in a tangential manner if possible. These results underline that within the contrast-enhanced tumor part, choosing the trajectory in a tangential manner increases the diagnostic yield for conclusive MGMT promoter methylation analyses in stereotactic biopsies as a basis for patient stratification and individualized therapy.
Kreisel, Stefan H; Blahak, Christian; Bäzner, Hansjörg; Hennerici, Michael G
Causal experimental evidence that physical activity prevents disability in older people is sparse. Being physically active has nonetheless been shown to be associated with disability-free survival in observational studies. Observational studies are, however, prone to bias introduced by time-dependent confounding. Time-dependent confounding occurs when an exposure (e.g. being physically active at some time-point) potentially affects the future status of a confounder (such as depression sometime later), and both variables have an effect on latter outcome (i.e. disability). "Conventional" analysis with e.g. Cox-regression is the mainstay when analyzing longitudinal observational studies. Unfortunately, it does not provide unbiased estimates in the presence of time-dependent confounding. Marginal structural models (MSM) - a relatively new class of causal models - have the potential to adequately account for time-dependent confounding. Here we analyze the effect of older people being physically active on disability, in a large long-term observational study. We address time-dependent confounding by using marginal structural models and provide a non-technical practical demonstration of how to implement this type of modeling. Data is from 639 elderly individuals ascertained in the European multi-center Leukoaraiosis and Disability study (LADIS), followed-up yearly over a period of three years. We estimated the effect of self-reported physical activity on the probability to transit to instrumental disability in the presence of a large set of potential confounders. We compare the results of "conventional" modeling approaches to those estimated using marginal structural models, highlighting discrepancies. A "conventional" Cox-regression-like adjustment for salient baseline confounders signals a significant risk reduction under physical activity for later instrumental disability (OR 0.62, 95% CI 0.44-0.90). However, given MSM estimation, the effect is attenuated towards null
Vercler, Christian J
The encounter between a patient and her surgeon is unique for several reasons. The surgeon inflicts pain upon a patient for the patient's own good. An operative intervention is irreducibly personal, such that the decisions about and performance of operations are inseparable from the idiosyncrasies of the individual surgeon. Furthermore, there is a chasm of knowledge between the patient and surgeon that is difficult to cross. Hence, training in the discipline of surgery includes the inculcation of certain virtues and practices to safeguard against abuses of this relationship and to make sure that the best interests of the patient are prioritized. The stories in this issue are evidence that in contemporary practice this is not quite enough, as surgeons reflect on instances they felt were ethically challenging. Common themes include the difficulty in communicating surgical uncertainty, patient-surgeon relationships, ethical issues in surgical training, and the impact of the technological imperative on caring for dying patients.
... the uterus CHOICES FOR EMERGENCY CONTRACEPTION Two emergency contraceptive pills may be bought without a prescription. Plan ... to provide ongoing birth control. MORE ABOUT EMERGENCY CONTRACEPTIVE PILLS Women of any age can buy Plan ...
... The Marfan Foundation Marfan & Related Disorders What is Marfan Syndrome? What are Related Disorders? What are the Signs? ... Emergencies Lung Emergencies Surgeries Lung Emergencies People with Marfan syndrome can be at increased risk of sudden lung ...
DeBowes, Linda J
Preemptive and postoperative pain management is part of patient care when performing extractions. Simple extractions can become complicated when tooth roots are fractured. Adequate lighting,magnification, and surgical techniques are important when per-forming surgical (complicated) extractions. Radiographs should be taken before extractions and also during the procedure to assist with difficult extractions. Adequate flap design and bone removal are necessary when performing surgical extractions. Complications, including ocular trauma, jaw fracture, and soft tissue trauma, are avoided or minimized with proper patient selection and technique.
Thukral, Inderpreet S.; Von Ehr, James; Walsh, Steven Thomas; Groen, Arend J.; van der Sijde, Peter; Adham, Khairul Akmaliah
Academics and practitioners alike have long understood the benefits, if not the risks, of both emerging markets and emerging technologies.Yet it is only recently that foresighted firms have embraced emerging technologies and emerging markets through entrepreneurial activity. Emerging technologies
Nestel, Debra; Harlim, Jennifer; Bryant, Melanie; Rampersad, Rajay; Hunter-Smith, David; Spychal, Bob
The landscape of surgical training is changing. The anticipated increase in the numbers of surgical trainees and the shift to competency-based surgical training places pressures on an already stretched health service. With these pressures in mind, we explored trainers' and trainees' experiences of surgical training in a less traditional rotation, an outer metropolitan hospital. We considered practice-based learning theories to make meaning of surgical training in this setting, in particular Actor-network theory. We adopted a qualitative approach and purposively sampled surgical trainers and trainees to participate in individual interviews and focus groups respectively. Transcripts were made and thematically analysed. Institutional human research ethics approval was obtained. Four surgical trainers and fourteen trainees participated. Almost without exception, participants' report training needs to be well met. Emergent inter-related themes were: learning as social activity; learning and programmatic factors; learning and physical infrastructure; and, learning and organizational structure. This outer metropolitan hospital is suited to the provision of surgical training with the current rotational system for trainees. The setting offers experiences that enable consolidation of learning providing a rich and varied overall surgical training program. Although relational elements of learning were paramount they occurred within a complex environment. Actor-network theory was used to give meaning to emergent themes acknowledging that actors (both people and objects) and their interactions combine to influence training quality, shifting the focus of responsibility for learning away from individuals to the complex interactions in which they work and learn.
U.S. Department of Health & Human Services — The Ambulatory Surgical Center Quality Reporting (ASCQR) Program seeks to make care safer and more efficient through quality reporting. ASCs eligible for this...
U.S. Department of Health & Human Services — The Ambulatory Surgical Center Quality Reporting (ASCQR) Program seeks to make care safer and more efficient through quality reporting. ASCs eligible for this...
... NICHD Research Information Find a Study More Information Preeclampsia and Eclampsia About NICHD Research Information Find a ... Treatments Share Facebook Twitter Pinterest Email Print Surgical Treatments for Fibroids If you have moderate or severe ...
U.S. Department of Health & Human Services — The Ambulatory Surgical Center Quality Reporting (ASCQR) Program seeks to make care safer and more efficient through quality reporting. ASCs eligible for this...
Ungeheuer, E; Schröder, D; Lüders, K
The standard of today in surgical treatment of the duodenal and gastric ulcer in Germany is shown. Positive and negative aspects of the different methods are discussed. Special technics are recommended for the different types of gastroduodenal ulcera.
Satava, R M
Technological change, decreased financial support for medical education, and social oversight (in the form of the "To Err Is Human" report, HIPPA, and reduced work hours) are forcing a rethinking of the traditional model of surgical education to improve patient safety. New approaches to evaluating surgical competence, such as objective assessment, in combination with new technologies, such as the Internet and surgical simulators, provide the tools to effect a revolution in surgical education and training. Competency based upon quantifiable criteria measures must replace the traditional subjective assessment. The implementation requires accurately defining the elements of training, establishing new quantifiable metrics, stringently measuring performance against criterion, and reporting outcomes throughout the career of a surgeon.
Federal Laboratory Consortium — The Surgical Critical Care Initiative (SC2i) is a USU research program established in October 2013 to develop, translate, and validate biology-driven critical care....
Yu, Menggang; Xie, Dawei; Wang, Xingmei; Weiner, Mark G; Tannen, Richard L
The purpose of this study was to evaluate a statistical method, prior event rate ratio (PERR) adjustment, and an alternative, PERR-ALT, both of which have the potential to overcome "unmeasured confounding," both analytically and via simulation. Formulae were derived for the target estimates of both PERR methods, which were compared with results from simulations to ensure their validity. In addition to the theoretical insights gained, relative biases of both PERR methods for estimating exposure effects were also investigated via simulation studies and compared empirically with electronic medical record database study results. Theoretical derivations closely matched simulated results. In simulation studies, both PERR methods significantly reduce bias from unmeasured confounding compared with the standard Cox model. When there is no interaction between unmeasured confounders and time intervals, the estimate from PERR-ALT is unbiased, whereas the estimate from PERR has well-controlled relative bias. When interactions exist, relative biases tend to increase but not greatly, especially when the exposure effect is relatively large in comparison with the interaction effects. When the event rate is low and the sample size is limited, PERR is more computationally stable than PERR-ALT. In empiric study comparisons with randomized controlled trials, both PERR methods show potential to reduce bias from the standard Cox model similarly when unmeasured confounding is present. Extensive simulation studies and theoretical derivation show that PERR-based methods may reduce bias from unmeasured confounders when the exposure effect is relatively large in comparison with confounder-exposure interaction. The rare study event situation warrants further investigation. Copyright © 2012 John Wiley & Sons, Ltd.
Matthew J Mellon
Full Text Available Since its first description in 1992, laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal conditions. The benefits of a minimally invasive approach to adrenal resection such as decreased hospital stay, shorter recovery time and improved patient satisfaction are widely accepted. However, as this procedure becomes more widespread, critical steps of the operation must be maintained to ensure expected outcomes and success. This article reviews the surgical techniques for the laparoscopic adrenalectomy.
R. F. Wright
Full Text Available The RAIN and CLIMEX experiments at Risdalsheia, southernmost Norway, together cover 17 years (1984-2000 of whole-catchment manipulation of acid deposition and climate. A 1200 m2 roof placed over the forest canopy at KIM catchment excluded about 80% of ambient acid deposition; clean rain was sprinkled under the roof. A climate change treatment (3.7°C increase in air temperature and increase in air carbon dioxide concentrations to 560 ppmv was superimposed on the clean rain treatment for four years (1995-1998. Sea-salt inputs and temperature are climate-related factors that influence water chemistry and can confound long-term trends caused by changes in deposition of sulphur and nitrogen. The RAIN and CLIMEX experiments at Risdalsheia provided direct experimental data that allow quantitative assessment of these factors. Run-off chemistry responded rapidly to the decreased acid deposition. Sulphate concentrations decreased by 50% within three years; nitrate and ammonium concentrations decreased to new steady-state levels within the first year. Acid neutralising capacity increased and hydrogen ion and inorganic aluminium decreased. Similar recovery from acidification was also observed at the reference catchment, ROLF, in response to the general 50% reduction in sulphate deposition over southern Norway in the late 1980s and 1990s. Variations in sea-salt deposition caused large variations in run-off chemistry at the reference catchment ROLF and the year-to-year noise in acid neutralising capacity was as large as the overall trend over the period. These variations were absent at KIM catchment because the sea-salt inputs were held constant over the entire 17 years of the clean rain treatment. The climate change experiment at KIM catchment resulted in increased leaching of inorganic nitrogen, probably due to increased mineralisation and nitrification rates in the soils. Keywords: acid deposition, global change, water, soil, catchment, experiment, Norway.
Mike S Fowler
Full Text Available The colour of environmental variability influences the size of population fluctuations when filtered through density dependent dynamics, driving extinction risk through dynamical resonance. Slow fluctuations (low frequencies dominate in red environments, rapid fluctuations (high frequencies in blue environments and white environments are purely random (no frequencies dominate. Two methods are commonly employed to generate the coloured spatial and/or temporal stochastic (environmental series used in combination with population (dynamical feedback models: autoregressive [AR(1] and sinusoidal (1/f models. We show that changing environmental colour from white to red with 1/f models, and from white to red or blue with AR(1 models, generates coloured environmental series that are not normally distributed at finite time-scales, potentially confounding comparison with normally distributed white noise models. Increasing variability of sample Skewness and Kurtosis and decreasing mean Kurtosis of these series alter the frequency distribution shape of the realised values of the coloured stochastic processes. These changes in distribution shape alter patterns in the probability of single and series of extreme conditions. We show that the reduced extinction risk for undercompensating (slow growing populations in red environments previously predicted with traditional 1/f methods is an artefact of changes in the distribution shapes of the environmental series. This is demonstrated by comparison with coloured series controlled to be normally distributed using spectral mimicry. Changes in the distribution shape that arise using traditional methods lead to underestimation of extinction risk in normally distributed, red 1/f environments. AR(1 methods also underestimate extinction risks in traditionally generated red environments. This work synthesises previous results and provides further insight into the processes driving extinction risk in model populations. We
Stokke, Thomas M; Hasselberg, Nina E; Smedsrud, Marit K; Sarvari, Sebastian I; Haugaa, Kristina H; Smiseth, Otto A; Edvardsen, Thor; Remme, Espen W
Preserved left ventricular (LV) ejection fraction (EF) and reduced myocardial strain are reported in patients with hypertrophic cardiomyopathy, ischemic heart disease, diabetes mellitus, and more. The authors performed a combined mathematical and echocardiographic study to understand the inconsistencies between EF and strains. An analytical equation showing the relationship between EF and the 4 parameters, global longitudinal strain (GLS), global circumferential strain (GCS), wall thickness, and short-axis diameter, was derived from an elliptical LV model. The equation was validated by measuring the 4 parameters by echocardiography in 100 subjects with EF ranging from 16% to 72% and comparing model-predicted EF with measured EF. The effect of the different parameters on EF was explored in the model and compared with findings in the patients. Calculated EF had very good agreement with measured EF (r = 0.95). The model showed that GCS contributes more than twice as much to EF than GLS. A significant reduction of GLS could be compensated by a small increase of GCS or wall thickness or reduced diameter. The model further demonstrated how EF can be maintained in ventricles with increased wall thickness or reduced diameter, despite reductions in both longitudinal and circumferential shortening. This was consistent with similar EF in 20 control subjects and 20 hypertrophic cardiomyopathy patients with increased wall thickness and reductions in both circumferential and longitudinal shortening (all p < 0.01). Reduced deformation despite preserved EF can be explained through geometric factors. Due to geometric confounders, strain better reflects systolic function in patients with preserved EF. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.
Jerrett, Michael; Buzzelli, Michael; Burnett, Richard T; DeLuca, Patrick F
Scientists and policymakers have shown growing interest in the health effects of chronic air pollution exposure. In this study, we use geostatistical techniques in combination with small-area data to address a central research question: "Does chronic exposure to particulate air pollution significantly associate with mortality when the effects of other social, demographic, and lifestyle confounders are taken into account?" Our analysis relies on age-standardized mortality ratios for census tracts (CTs) of Hamilton (average population of 3419 persons), social and demographic data from the 1991 Census of Canada, smoking variables extracted from secondary surveys, and total suspended particulate (TSP) data from 23 monitoring stations operated by the Ministry of the Environment. Air pollution data are interpolated with a geostatistical procedure known as "kriging". This method translates fixed-site pollution monitoring observations into a continuous surface, which was overlaid onto the population-weighted centroids of the CTs. Our results show substantively large and statistically significant health effects for women and men. Evaluated over the inter-quartile range of the data, we found the relative risk of premature mortality for TSP exposure to be 1.19 (95% CI: 1.13-1.26) for women and 1.30 (95% CI: 1.24-1.37) for men. We also tested associations with cardio-respiratory and cancer mortality. We found positive, significant associations between particulate exposure and these causes of death in most models. Inclusion of socioeconomic, demographic, and lifestyle reduced but did not eliminate the health effects of exposure to particulate air pollution. Overall our results suggest that intra-urban variations in particulate air pollution significantly associate with premature, all-cause, cardio-respiratory, and cancer mortality in small areas of Hamilton.
Full Text Available Tuberculosis (TB is one of the major health problems that our country is facing today. Despite active interventions by our government, control of TB still remains to be achieved. The emergence and exponential growth of the human immunodeficiency virus and drug-resistant strains threaten to further complicate the TB situation in our country. Even in this era of advanced chemotherapy, many lives are lost every day in our country. Tuberculosis of the urinary tract, despite being one of the commonest forms of extra-pulmonary TB, is generally overlooked. Most patients present with vague lower urinary symptoms typical of urinary tract infection. In this article, we shall highlight the various issues related to the surgical management of renal and ureteral tuberculosis.
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Akbar, M.; Naveed, D.; Akbar, I.; Khattak, I.; Zafar, A.; Haider, I.Z.; Akbar, K.
Background: Acute intestinal obstruction due to tuberculosis is a common surgical problem in our community. Emergency surgery is usually required and surgical procedure depends upon the location and extent of the disease. The aim of this study was to determine the commonly involved region of intestine and different surgical procedures tailored. Methods: Thirty patients operated upon for acute intestinal obstruction in emergency with operative and histopathological findings suggestive of tuberculosis were included in the study. Demographic profile, operative findings, details of surgical procedure, complications and post-op hospital stay were recorded. The patients were followed for 6 months. Results: Intestinal tuberculosis is more common in young female, with male to female ratio of 1:1.5. Stricture of the small bowel was found in 50% of the cases. The next common finding was ileocaecal tuberculosis found in 40% of patients. Strictruplasty was performed in 11 (36.33%). The right hemicolectomy, limited ileocaecal resection and segmental bowel resection with end to end anastomosis were performed in four patients each. Other procedures were release of adhesions and bands in 4 patients, ileotransverse bypass in 1 patient and loop ileiostomy in 2 patients. Major complication in 10 patient and mortality rate was 10%. Conclusion: Because of non-specific clinical features, ignorance and malpractice intestinal tuberculosis presents late. Ileocecal tuberculosis is becoming less common as compared to small bowel strictures. Less radical surgery gives better results. Post operative complications and mortality are related to the perforation of the intestine at the time of surgery. (author)
A retrospective study of post surgical complications was conducted on records of students' Large Animal Surgical Laboratories in the Faculty of Veterinary Medicine (F.V.M.), Ahmadu Bello University (A.B.U), Zaria from 1989 to 1993. Three hundred and eleven surgical complications were recorded from five surgical ...
Strak, Maciej; Janssen, Nicole; Beelen, Rob; Schmitz, Oliver; Karssenberg, Derek; Houthuijs, Danny; van den Brink, Carolien; Dijst, Martin; Brunekreef, Bert; Hoek, Gerard
Cohorts based on administrative data have size advantages over individual cohorts in investigating air pollution risks, but often lack in-depth information on individual risk factors related to lifestyle. If there is a correlation between lifestyle and air pollution, omitted lifestyle variables may result in biased air pollution risk estimates. Correlations between lifestyle and air pollution can be induced by socio-economic status affecting both lifestyle and air pollution exposure. Our overall aim was to assess potential confounding by missing lifestyle factors on air pollution mortality risk estimates. The first aim was to assess associations between long-term exposure to several air pollutants and lifestyle factors. The second aim was to assess whether these associations were sensitive to adjustment for individual and area-level socioeconomic status (SES), and whether they differed between subgroups of the population. Using the obtained air pollution-lifestyle associations and indirect adjustment methods, our third aim was to investigate the potential bias due to missing lifestyle information on air pollution mortality risk estimates in administrative cohorts. We used a recent Dutch national health survey of 387,195 adults to investigate the associations of PM 10 , PM 2.5 , PM 2.5-10 , PM 2.5 absorbance, OP DTT, OP ESR and NO 2 annual average concentrations at the residential address from land use regression models with individual smoking habits, alcohol consumption, physical activity and body mass index. We assessed the associations with and without adjustment for neighborhood and individual SES characteristics typically available in administrative data cohorts. We illustrated the effect of including lifestyle information on the air pollution mortality risk estimates in administrative cohort studies using a published indirect adjustment method. Current smoking and alcohol consumption were generally positively associated with air pollution. Physical activity
Maria Joao Leitao
Full Text Available Core cerebrospinal fluid (CSF biomarkers-Aβ42, Tau and pTau–have been recently incorporated in the revised criteria for Alzheimer’s disease (AD. However, their widespread clinical application lacks standardization. Pre-analytical sample handling and storage play an important role in the reliable measurement of these biomarkers across laboratories. In this study, we aim to surpass the efforts from previous studies, by employing a multicentre approach to assess the impact of less studied CSF pre-analytical confounders in AD-biomarkers quantification. Four different centres participated in this study and followed the same established protocol. CSF samples were analysed for three biomarkers (Aβ42, Tau and pTau and tested for different spinning conditions (temperature: Room temperature (RT vs. 4oC; speed: 500g vs. 2000g vs. 3000g, storage volume variations (25%, 50% and 75% of tube total volume as well as freezing-thaw cycles (up to 5 cyles. The influence of sample routine parameters, inter-centre variability and relative value of each biomarker (reported as normal/abnormal, was analysed. Centrifugation conditions did not influence biomarkers levels, except for samples with a high CSF total protein content, where either non centrifugation or centrifugation at RT, compared to 4ºC, led to higher Aβ42 levels. Reducing CSF storage volume from 75% to 50% of total tube capacity, decreased Aβ42 concentration (within analytical CV of the assay, whereas no change in Tau or pTau was observed. Moreover, the concentration of Tau and pTau appears to be stable up to 5 freeze-thaw cycles, whereas Aβ42 levels decrease if CSF is freeze-thawed more than 3 times. This systematic study reinforces the need for CSF centrifugation at 4ºC prior to storage and highlights the influence of storage conditions in Aβ42 levels. This study contributes to the establishment of harmonized standard operating procedures that will help reducing inter-lab variability of CSF
This paper presents findings of an audit of emergency surgical and anaesthetic services provided at the main theatre of the Ahmadu Bello University Teaching Hospital, Kaduna (ABUTHK) in year 2001. Our focus was to survey emergency surgical and anaesthetic services over a twelve-month period in order to evaluate the ...
Boef, Anna G C; Dekkers, Olaf M; Vandenbroucke, Jan P; le Cessie, Saskia
Instrumental variable (IV) analysis is promising for estimation of therapeutic effects from observational data as it can circumvent unmeasured confounding. However, even if IV assumptions hold, IV analyses will not necessarily provide an estimate closer to the true effect than conventional analyses as this depends on the estimates' bias and variance. We investigated how estimates from standard regression (ordinary least squares [OLS]) and IV (two-stage least squares) regression compare on mean squared error (MSE). We derived an equation for approximation of the threshold sample size, above which IV estimates have a smaller MSE than OLS estimates. Next, we performed simulations, varying sample size, instrument strength, and level of unmeasured confounding. IV assumptions were fulfilled by design. Although biased, OLS estimates were closer on average to the true effect than IV estimates at small sample sizes because of their smaller variance. The threshold sample size above which IV analysis outperforms OLS regression depends on instrument strength and strength of unmeasured confounding but will usually be large given the typical moderate instrument strength in medical research. IV methods are of most value in large studies if considerable unmeasured confounding is likely and a strong and plausible instrument is available. Copyright © 2014 Elsevier Inc. All rights reserved.
Bijwaard, G.E.; Myrskylä, M.; Tynelius, P.; Rasmussen, F.
A negative educational gradient has been found for many causes of death. This association may be partly explained by confounding factors that affect both educational attainment and mortality. We correct the cause-specific educational gradient for observed individual background and unobserved family
Miller, M; Swanson, S A; Azrael, D
Despite the magnitude and consistency of risk estimates in the peer-reviewed literature linking firearm availability and suicide, inferring causality has been questioned on the theoretical basis that existing studies may have failed to account for the possibility that members of households with firearms differ from members of households without firearms in important ways related to suicide risk. The current bias analysis directly addresses this concern by describing the salient characteristics that such an unmeasured confounder would need to possess in order to yield the associations between firearm availability and suicide observed in the literature when, in fact, the causal effect is null. Four US studies, published between 1992 and 2003, met our eligibility criteria. We find that any such unmeasured confounder would need to possess an untenable combination of characteristics, such as being not only 1) as potent a suicide risk factor as the psychiatric disorders most tightly linked to suicide (e.g., major depressive and substance use disorders) but also 2) an order of magnitude more imbalanced across households with versus without firearms than is any known risk factor. No such confounder has been found or even suggested. The current study strongly suggests that unmeasured confounding alone is unlikely to explain the association between firearms and suicide. © The Author 2016. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: email@example.com.
McAdams, Tom A; Neiderhiser, Jenae M; Rijsdijk, Fruhling V; Narusyte, Jurgita; Lichtenstein, Paul; Eley, Thalia C
Parental psychopathology, parenting style, and the quality of intrafamilial relationships are all associated with child mental health outcomes. However, most research can say little about the causal pathways underlying these associations. This is because most studies are not genetically informative and are therefore not able to account for the possibility that associations are confounded by gene-environment correlation. That is, biological parents not only provide a rearing environment for their child, but also contribute 50% of their genes. Any associations between parental phenotype and child phenotype are therefore potentially confounded. One technique for disentangling genetic from environmental effects is the children-of-twins (COT) method. This involves using data sets comprising twin parents and their children to distinguish genetic from environmental associations between parent and child phenotypes. The COT technique has grown in popularity in the last decade, and we predict that this surge in popularity will continue. In the present article we explain the COT method for those unfamiliar with its use. We present the logic underlying this approach, discuss strengths and weaknesses, and highlight important methodological considerations for researchers interested in the COT method. We also cover variations on basic COT approaches, including the extended-COT method, capable of distinguishing forms of gene-environment correlation. We then present a systematic review of all the behavioral COT studies published to date. These studies cover such diverse phenotypes as psychosis, substance abuse, internalizing, externalizing, parenting, and marital difficulties. In reviewing this literature, we highlight past applications, identify emergent patterns, and suggest avenues for future research. PsycINFO Database Record (c) 2014 APA, all rights reserved.
Northern Uganda to offer free surgical services and to teach basic surgical skills to up-country doctors. The team, consisting of 10 surgeons in various specialities, two anaesthetists and two surgical residents, saw 500 patients, of whom 272 had surgery. This was the frrst such surgical camp organised by the Ugandan.
Cevidanes, Lucia; Tucker, Scott; Styner, Martin; Kim, Hyungmin; Chapuis, Jonas; Reyes, Mauricio; Proffit, William; Turvey, Timothy; Jaskolka, Michael
This paper discusses the development of methods for computer-aided jaw surgery. Computer-aided jaw surgery allows us to incorporate the high level of precision necessary for transferring virtual plans into the operating room. We also present a complete computer-aided surgery (CAS) system developed in close collaboration with surgeons. Surgery planning and simulation include construction of 3D surface models from Cone-beam CT (CBCT), dynamic cephalometry, semi-automatic mirroring, interactive cutting of bone and bony segment repositioning. A virtual setup can be used to manufacture positioning splints for intra-operative guidance. The system provides further intra-operative assistance with the help of a computer display showing jaw positions and 3D positioning guides updated in real-time during the surgical procedure. The CAS system aids in dealing with complex cases with benefits for the patient, with surgical practice, and for orthodontic finishing. Advanced software tools for diagnosis and treatment planning allow preparation of detailed operative plans, osteotomy repositioning, bone reconstructions, surgical resident training and assessing the difficulties of the surgical procedures prior to the surgery. CAS has the potential to make the elaboration of the surgical plan a more flexible process, increase the level of detail and accuracy of the plan, yield higher operative precision and control, and enhance documentation of cases. Supported by NIDCR DE017727, and DE018962 PMID:20816308
Zhang, Henry T; McGrath, Leah J; Wyss, Richard; Ellis, Alan R; Stürmer, Til
To improve control of confounding by frailty when estimating the effect of influenza vaccination on all-cause mortality by controlling for a published set of claims-based predictors of dependency in activities of daily living (ADL). Using Medicare claims data, a cohort of beneficiaries >65 years of age was followed from September 1, 2007, to April 12, 2008, with covariates assessed in the 6 months before follow-up. We estimated Cox proportional hazards models of all-cause mortality, with influenza vaccination as a time-varying exposure. We controlled for common demographics, comorbidities, and health care utilization variables and then added 20 ADL dependency predictors. To gauge residual confounding, we estimated pre-influenza season hazard ratios (HRs) between September 1, 2007 and January 5, 2008, which should be 1.0 in the absence of bias. A cohort of 2 235 140 beneficiaries was created, with a median follow-up of 224 days. Overall, 52% were vaccinated and 4% died during follow-up. During the pre-influenza season period, controlling for demographics, comorbidities, and health care use resulted in a HR of 0.66 (0.64, 0.67). Adding the ADL dependency predictors moved the HR to 0.68 (0.67, 0.70). Controlling for demographics and ADL dependency predictors alone resulted in a HR of 0.68 (0.66, 0.70). Results were consistent with those in the literature, with significant uncontrolled confounding after adjustment for demographics, comorbidities, and health care use. Adding ADL dependency predictors moved HRs slightly closer to the null. Of the comorbidities, health care use variables, and ADL dependency predictors, the last set reduced confounding most. However, substantial uncontrolled confounding remained. Copyright © 2017 John Wiley & Sons, Ltd.
Park, Jessica J.; Chen, Ming-Hui; Loffredo, Marian; D’Amico, Anthony V.
Purpose: Prostate-specific antigen (PSA) velocity, like PSA level, can be confounded. In this study, we estimated the impact that confounding factors could have on correctly identifying a patient with a PSA velocity >2 ng/ml/y. Methods and Materials: Between 2006 and 2010, a total of 50 men with newly diagnosed PC comprised the study cohort. We calculated and compared the false-positive and false-negative PSA velocity >2 ng/ml/y rates for all men and those with low-risk disease using two approaches to calculate PSA velocity. First, we used PSA values obtained within 18 months of diagnosis; second, we used values within 18 months of diagnosis, substituting the prebiopsy PSA for a repeat, nonconfounded PSA that was obtained using the same assay and without confounders. Results: Using PSA levels pre-biopsy, 46% of all men had a PSA velocity >2 ng/ml/y; whereas this value declined to 32% when substituting the last prebiopsy PSA for a repeat, nonconfounded PSA using the same assay and without confounders. The false-positive rate for PSA velocity >2 ng/ml/y was 43% as compared with a false-negative rate of PSA velocity >2 ng/ml/y of 11% (p = 0.0008) in the overall cohort. These respective values in the low-risk subgroup were 60% and 16.7% (p = 0.09). Conclusion: This study provides evidence to explain the discordance in cancer-specific outcomes among groups investigating the prognostic significance of PSA velocity >2 ng/ml/y, and highlights the importance of patient education on potential confounders of the PSA test before obtaining PSA levels.
... to a doctor to have an IUD inserted. Emergency contraceptive pills can be very effective if they are ... use. Some women feel nauseous after they take emergency contraceptive pills. This feeling should go away in about ...
... Week National Prescription Drug Take-Back Day Emergency Checklist If someone may have been poisoned, call the ... visit to the emergency room. Below is a checklist to help you in the event of a ...
The concept of emergence appears in various places within the literature on expertise and expert practice. Here, I examine some of these applications of emergence in the light of two prominent accounts of emergence from the philosophy of science and philosophy of mind. I evaluate these accounts with respect to several specific contexts in which…
Full Text Available Context: Surgery for the rheumatoid cervical spine has been shown to stabilize the unstable spine; arrest/improve the progression of neurological deficit, help neck pain, and possibly decelerate the degenerative disease process. Operative intervention for the rheumatoid spine has significantly changed over the last 30 years. Aims: The purpose of this study was to review all cases of cervical rheumatoid spine requiring surgical intervention in a single unit over the last 30 years. Materials and Methods: A prospectively-maintained spine database was retrospectively searched for all cases of rheumatoid spine, leading to a review of indications, imaging, Ranawat and Myelopathy Disability Index measures, surgical morbidity, and survival curve analysis. Results: A total of 224 cases were identified between 1981 and 2011. Dividing the data into three time-epochs, there has been a significant increase in the ratio of segment-saving Goel-Harms C1-C2: Occipitocervical fixation (OCF surgery and survival has increased between 1981 and 2011 from 30% to 51%. Patients undergoing C1-C2 fixation were comparatively less myelopathic and in a better Ranawat class preoperatively, but postoperative outcome measures were well-preserved with favorable mortality rates over mean 39.6 months of follow-up. However, 11% of cases required OCF at mean 28 months post-C1-C2 fixation, largely due to instrumentation failure (80%. Conclusion: We present the largest series of surgically managed rheumatoid spines, revealing comparative data on OCF and C1-C2 fixation. Although survival has improved over the last 30 years, there have been changes in medical, surgical and perioperative management over that period of time too confounding the interpretation; however, the analysis presented suggests that rheumatoid patients presenting early in the disease process may benefit from C1 to C2 fixation, albeit with a proportion requiring OCF at a later time.
Full Text Available Late complications after surgical repair of aortic coarctation are not uncommon. Among these complications pseudoaneurysms are the most frequent complications, occurring between 3 and 38%. Reoperation in these patients is associated with high morbidity and mortality. In the last decade, endovascular techniques emerged as an alternative to conventional surgery with excellent results. We report the case of two patients who presented with pseudoaneurysms after surgical correction for aortic coarctation, which were treated by endovascular means.
Rabellino, M.; Zander, T.; González, G.; Baldi, S.; Cheves, H.; Estigarribia, A.; Llorens, R.; Carreira, J. M.; Maynar, M.
Late complications after surgical repair of aortic coarctation are not uncommon. Among these complications pseudoaneurysms are the most frequent complications, occurring between 3 and 38%. Reoperation in these patients is associated with high morbidity and mortality. In the last decade, endovascular techniques emerged as an alternative to conventional surgery with excellent results. We report the case of two patients who presented with pseudoaneurysms after surgical correction for aortic coar...
Email: firstname.lastname@example.org. Snoring is now seen as one end of sleep-related breathing disorder resulting ultimately in obstructive sleep apnea. Uvulopalatopharyngoplasty (UPPP) is the first surgical procedure specifically designed to alleviate the abnormalities, although the use of laser appears to be the new trend.
1 Dept.of Veterinary Surgery and Medicine 2Veterinary Teaching Hospital Ahmadu Bello University. Zaria .... unnecessary suffering., Administration of poisons .... way that humans are. Vivisection/ Surgical Training And Research. Animal model use: In both the human and veterinary medical practice, there continue to be ...
Toledo-Pereyra, Luis H
Joseph Lister (1827-1912), renowned British surgeon-scientist, introduced to the world the use and appreciation of the antiseptic method for the prevention of wound sepsis. Armed with the ideas of Louis Pasteur (1822-1895) regarding the role of microorganisms in infections or the so-called germ theory of disease, he advanced the surgical field by using antiseptics, such as carbolic acid, in the treatment of contaminated wounds. These developments constituted a real surgical revolution. No breakthrough before Lister's, except perhaps the discovery of anesthesia, had contributed to such an incredible advancement in relationship to the surgical arena. After 1867, the year in which Lister published his remarkable paper in Lancet, it was possible to appropriately treat or prevent wound infections with the use of antiseptics at the site of the operated wound. Lister's method was complicated but produced its desired effect--to diminish wound morbidity and patient mortality. His contribution was secured for future generations and a surgical revolution had begun!
Eika, Berit; Langebæk, Rikke; Jensen, A.L.
The surgical educational environment is potentially stressful and this can negatively affect students' learning. The aim of this study was to investigate whether veterinary students' level of anxiety is higher in a surgical course than in a non-surgical course and if pre-surgical training...... in a Surgical Skills Lab (SSL) has an anxiety reducing effect. Investigations were carried out as a comparative study and a parallel group study. Potential participants were fourth-year veterinary students who attended a surgical course (Basic Surgical Skills) and a non-surgical course (Clinical Examination...... Skills); both courses were offered in multiple classes (with a total of 171 students in 2009 and 156 students in 2010). All classes in 2009 participated in the SSL stage of the Basic Surgical Skills course before performing live-animal surgery, and one class (28 students) in 2010 did not. Two validated...
Tisherman, Samuel A; Kaplan, Lewis; Gracias, Vicente H; Beilman, Gregory J; Toevs, Christine; Byrnes, Matthew C; Coopersmith, Craig M
Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few. Recommendations are made for broadening the multidisciplinary training and practice opportunities in surgical critical care for intensivists from all base specialties and for maintaining the intensivist model within acute care surgery practice. Support from academic and administrative leadership, as well as national organizations, will be needed.
Petrucci, Andrea M; Chand, Manish; Wexner, Steven D
The role of social media (SoMe) in surgical education is emerging as a tool that augments and complements traditional learning. As SoMe usage has steadily increased in our personal and professional lives, it is no surprise that it has permeated into surgical education. Different SoMe sites offer distinct platforms from which knowledge can be transmitted, while catering to various learning styles. The purpose of this review is to outline the various SoMe platforms and their use in surgical education. Moreover, it will discuss their effectiveness in teaching and learning surgical knowledge and skills as well as other potential roles SoMe has to offer to improve surgical education.
Vedula, S Swaroop; Hager, Gregory D
Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care with the goal of maximizing quality and value of care. While innovations in diagnostic and therapeutic technologies have driven past improvements in quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytic techniques, and translation or integration of research findings into patient care. We foresee the emergence of Surgical/Interventional Data Science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model and quantify the pathways or processes within the context of patient health states or outcomes, and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data is pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care including prevention, diagnosis, intervention, or post-operative recovery. Existing literature already provides preliminary results suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from pre-, intra-, and post-operative contexts, how it could support intra-operative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot
Vedula S. Swaroop
Full Text Available Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care, with the goal of maximizing the quality and value of care. Whereas innovations in diagnostic and therapeutic technologies have driven past improvements in the quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytical techniques, and translation or integration of research findings into patient care. We foresee the emergence of surgical/interventional data science (SDS as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model, and quantify the pathways or processes within the context of patient health states or outcomes and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data are pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care, including prevention, diagnosis, intervention, or postoperative recovery. The existing literature already provides preliminary results, suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from preoperative, intraoperative, and postoperative contexts, how it could support intraoperative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective
Marvel, Kate; Pincus, Robert; Schmidt, Gavin A.; Miller, Ron L.
An emerging literature suggests that estimates of equilibrium climate sensitivity (ECS) derived from recent observations and energy balance models are biased low because models project more positive climate feedback in the far future. Here we use simulations from the Coupled Model Intercomparison Project Phase 5 (CMIP5) to show that across models, ECS inferred from the recent historical period (1979-2005) is indeed almost uniformly lower than that inferred from simulations subject to abrupt increases in CO2 radiative forcing. However, ECS inferred from simulations in which sea surface temperatures are prescribed according to observations is lower still. ECS inferred from simulations with prescribed sea surface temperatures is strongly linked to changes to tropical marine low clouds. However, feedbacks from these clouds are a weak constraint on long-term model ECS. One interpretation is that observations of recent climate changes constitute a poor direct proxy for long-term sensitivity.
Summary: Salivary alpha-amylase: More than an enzyme - Investigating confounders of stress-induced and basal amylase activity (Dipl.-Psych. Jana Strahler) The hypothalamus-pituitary-adrenal (HPA) axis and the autonomic nervous system (ANS) are two of the major systems playing a role in the adaptation of organisms to developmental changes that threaten homeostasis. The HPA system involves the secretion of glucocorticoids, including cortisol, into the circulatory system. Numerous studies hav...
Harris-Adamson, Carisa; Eisen, Ellen A; Neophytou, Andreas; Kapellusch, Jay; Garg, Arun; Hegmann, Kurt T; Thiese, Matthew S; Dale, Ann Marie; Evanoff, Bradley; Bao, Stephen; Silverstein, Barbara; Gerr, Fred; Burt, Susan; Rempel, David
Between 2001 and 2010, six research groups conducted coordinated prospective studies of carpal tunnel syndrome (CTS) incidence among US workers from various industries to estimate exposure-response relationships. This analysis examined the presence and magnitude of confounding between biomechanical and workplace psychosocial factors and incidence of dominant-hand CTS. 1605 participants, without CTS at enrolment, were followed for up to 3.5 years (2471 person-years). Demographic information, medical history and workplace psychosocial stress measures were collected at baseline. Individual workplace biomechanical exposures were collected for each task and combined across the workweek using time-weighted averaging (TWA). CTS case criteria were based on symptoms and results of electrophysiological testing. HRs were estimated with Cox proportional hazard models. Confounding was assessed using causal diagrams and an empirical criterion of 10% or greater change in effect estimate magnitude. There were 109 incident CTS cases (IR=4.41/100 person-years; 6.7% cumulative incidence). The relationships between CTS and forceful repetition rate, % time forceful hand exertion and the Threshold Limit Value for Hand Activity Level (TLV-HAL) were slightly confounded by decision latitude with effect estimates being attenuated towards the null (10-14% change) after adjustment. The risk of CTS among participants reporting high job strain was attenuated towards the null by 14% after adjusting for the HAL Scale or the % time forceful hand exertions. Although attenuation of the relationships between CTS and some biomechanical and work psychosocial exposures was observed after adjusting for confounding, the magnitudes were small and confirmed biomechanical and work psychosocial exposures as independent risk factors for incident CTS. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
de Vocht, Frank; Lee, Brian
Studies have suggested that residential exposure to extremely low frequency (50 Hz) electromagnetic fields (ELF-EMF) from high voltage cables, overhead power lines, electricity substations or towers are associated with reduced birth weight and may be associated with adverse birth outcomes or even miscarriages. We previously conducted a study of 140,356 singleton live births between 2004 and 2008 in Northwest England, which suggested that close residential proximity (≤ 50 m) to ELF-EMF sources was associated with reduced average birth weight of 212 g (95%CI: -395 to -29 g) but not with statistically significant increased risks for other adverse perinatal outcomes. However, the cohort was limited by missing data for most potentially confounding variables including maternal smoking during pregnancy, which was only available for a small subgroup, while also residual confounding could not be excluded. This study, using the same cohort, was conducted to minimize the effects of these problems using multiple imputation to address missing data and propensity score matching to minimize residual confounding. Missing data were imputed using multiple imputation using chained equations to generate five datasets. For each dataset 115 exposed women (residing ≤ 50 m from a residential ELF-EMF source) were propensity score matched to 1150 unexposed women. After doubly robust confounder adjustment, close proximity to a residential ELF-EMF source remained associated with a reduction in birth weight of -116 g (95% confidence interval: -224:-7 g). No effect was found for proximity ≤ 100 m compared to women living further away. These results indicate that although the effect size was about half of the effect previously reported, close maternal residential proximity to sources of ELF-EMF remained associated with suboptimal fetal growth. Copyright © 2014 Elsevier Ltd. All rights reserved.
Posma, Joram M; Garcia-Perez, Isabel; Ebbels, Timothy M D; Lindon, John C; Stamler, Jeremiah; Elliott, Paul; Holmes, Elaine; Nicholson, Jeremy K
Metabolism is altered by genetics, diet, disease status, environment, and many other factors. Modeling either one of these is often done without considering the effects of the other covariates. Attributing differences in metabolic profile to one of these factors needs to be done while controlling for the metabolic influence of the rest. We describe here a data analysis framework and novel confounder-adjustment algorithm for multivariate analysis of metabolic profiling data. Using simulated data, we show that similar numbers of true associations and significantly less false positives are found compared to other commonly used methods. Covariate-adjusted projections to latent structures (CA-PLS) are exemplified here using a large-scale metabolic phenotyping study of two Chinese populations at different risks for cardiovascular disease. Using CA-PLS, we find that some previously reported differences are actually associated with external factors and discover a number of previously unreported biomarkers linked to different metabolic pathways. CA-PLS can be applied to any multivariate data where confounding may be an issue and the confounder-adjustment procedure is translatable to other multivariate regression techniques.
An updated version of the mitochondrial free radical theory of aging (MFRTA) and longevity is reviewed. Key aspects of the theory are emphasized. Another main focus concerns common misconceptions that can mislead investigators from other specialties, even to wrongly discard the theory. Those different issues include (i) the main reactive oxygen species (ROS)-generating site in the respiratory chain in relation to aging and longevity: complex I; (ii) the close vicinity or even contact between that site and the mitochondrial DNA, in relation to the lack of local efficacy of antioxidants and to sub-cellular compartmentation; (iii) the relationship between mitochondrial ROS production and oxygen consumption; (iv) recent criticisms on the MFRTA; (v) the widespread assumption that ROS are simple "by-products" of the mitochondrial respiratory chain; (vi) the unnecessary postulation of "vicious cycle" hypotheses of mitochondrial ROS generation which are not central to the free radical theory of aging; and (vii) the role of DNA repair concerning endogenous versus exogenous damage. After considering the large body of data already available, two general characteristics responsible for the high maintenance degree of long-lived animals emerge: (i) a low generation rate of endogenous damage: and (ii) the possession of tissue macromolecules that are highly resistant to oxidative modification.
Kinjal Shankar Majumdar
Full Text Available Introduction We present our experience in the management of parapharyngeal tumours. A conservative trans-cervical approach was found to be feasible and effective in majority of the cases over radical ones, which may be required in malignancies and skull-base involvement. Methods Fifteen patients with parapharyngeal tumours treated surgically in the Department of ENT, Nilratan Sircar Medical College in last 3 years were included in the study. 80% of the cases were benign, most common being Schwannoma. Most important investigation was found to be MRI. Conclusion The study gives an overview regarding the surgical approach, based upon the extent and histology of the tumour. Trans-cervical approachwas found to be the most effective.
Kinjal Shankar Majumdar
Introduction We present our experience in the management of parapharyngeal tumours. A conservative trans-cervical approach was found to be feasible and effective in majority of the cases over radical ones, which may be required in malignancies and skull-base involvement. Methods Fifteen patients with parapharyngeal tumours treated surgically in the Department of ENT, Nilratan Sircar Medical College in last 3 years were included in the study. 80% of the cases were benign, mos...
Emergency dental problems can result from trauma, dental pathology, or from dental treatment itself. While the physician can treat many instances of dental trauma, the patient should see a dentist as soon as possible so that teeth can be saved. Emergency treatment of dental pathology usually involves relief of pain and/or swelling. Bleeding is the most frequent post-treatment emergency. The physician should be able to make the patient comfortable until definitive dental treatment can be avail...
Torres-Landa, Samuel; Kannan, Umashankkar; Guajardo, Isabella; Pickett-Blakely, Octavia E; Dempsey, Daniel T; Williams, Noel N; Dumon, Kristoffel R
Obesity is a spreading epidemic associated with significant morbidity and mortality with a prevalence of over 36% worldwide. In the face of a growing epidemic, increasing medical costs, and the disappointing limitations of medical and lifestyle modification bariatric surgery was found to consistently lead to significant weight loss and improvement in obesity-associated comorbidities when compared to non-surgical interventions. Bariatric procedures fall within three basic categories: restrictive procedures, malabsorptive procedures, and procedures that combine both restrictive and malabsorptive mechanisms. Four major procedures are currently performed (most often laparoscopically): Roux-en-Y gastric bypass, biliopancreatic diversion with duodenal switch, adjustable gastric banding, and sleeve gastrectomy. Although the laparoscopic Roux-en-Y gastric bypass was the most frequently performed bariatric procedure, the laparoscopic sleeve gastrectomy has since become the most popular. Bariatric surgery currently has similar mortality rates to standard general surgical operations. Morevoer, bariatric surgery reduces mortality by the improvement and remission of obesity-related comorbidities. Newer minimally-invasive weight loss procedures and endoscopic methods continue to evolve as we expand our understanding of the intricacies of obesity and the effects of currently available surgical treatments.
Haidegger, Tamás; Benyó, Zoltán
Surgical robotics is one of the most dynamically advancing areas of biomedical engineering. In the past few decades, computer-integrated interventional medicine has gained significance internationally in the field of surgical procedures. More recently, mechatronic devices have been used for nephrectomy, cholecystectomy, as well as in orthopedics and radiosurgery. Estimates show that 70% of the radical prostatectomies were performed with the da Vinci robot in the United States last year. Robot-aided procedures offer remarkable advantages in neurosurgery both for the patient and the surgeon, making microsurgery and Minimally Invasive Surgery a reality, and even complete teleoperation accessible. This paper introduces surgical robotic systems developed primarily for brain and spine applications, besides, it focuses on the different research strategies applied to provide smarter, better and more advanced tools to surgeons. A new system is discussed in details that we have developed together with the Johns Hopkins University in Baltimore. This cooperatively-controlled system can assist with skull base drilling to improve the safety and quality of neurosurgery while reducing the operating time. The paper presents the entire system, the preliminary results of phantom and cadaver tests and our efforts to improve the accuracy of the components. An effective optical tracking based patient motion compensation method has been implemented and tested. The results verify the effectiveness of the system and allow for further research.
Pacheco, Karin A
Surgical implants have a wide array of therapeutic uses, most commonly in joint replacements, but also in repair of pes excavatum and spinal disorders, in cardiac devices (stents, patches, pacers, valves), in gynecological implants, and in dentistry. Many of the metals used are immunologically active, as are the methacrylates and epoxies used in conjunction with several of these devices. Allergic responses to surgical components can present atypically as failure of the device, with nonspecific symptoms of localized pain, swelling, warmth, loosening, instability, itching, or burning; localized rash is infrequent. Identification of the specific metal and cement components used in a particular implant can be difficult, but is crucial to guide testing and interpretation of results. Nickel, cobalt, and chromium remain the most common metals implicated in implant failure due to metal sensitization; methacrylate-based cements are also important contributors. This review will provide a guide on how to assess and interpret the clinical history, identify the components used in surgery, test for sensitization, and provide advice on possible solutions. Data on the pathways of metal-induced immune stimulation are included. In this setting, the allergist, the dermatologist, or both have the potential to significantly improve surgical outcomes and patient care. Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Jutkowitz, L Ari
The emergency clinician is frequently called on to manage problems relating to the female reproductive tract. Because owners sel-dom have the medical knowledge needed to differentiate normal from abnormal reproductive behaviors, they frequently look to the emergency veterinarian for guidance and information during and after parturition. For this reason, it is essential that the veterinarian have a good understanding of the normal reproductive cycle as well as the common emergencies that may occur. This article reviews the events surrounding normal parturition in the dog and cat and the reproductive emergencies seen most commonly in practice.
Wang, Chunyou; Gou, Shanmiao
Severe acute pancreatitis (SAP) is hard to treat for the abrupt onset, critical condition and complicated pathophysiology. Historically, the treatment strategy of SAP hovered between surgical intervention and conservative treatment. At the turn of the 20(th) century, SAP was reported to be cured by surgical intervention in a series cases, which lead to the dominance of surgical intervention in SAP treatment. Subsequently, SAP was documented to respond to nonoperative therapy. A wave of conservatism emerged, and surgical intervention for SAP was rarely practiced for the next 3 decades. However, surgeons refined the indications and considered new approaches for surgical treatment in 1960s because of the poor outcomes of conservation, and surgical interventions was mainly performed at early stage of SAP. However, a series of prospective studies showed that conservative treatment of patients with sterile pancreatic necrosis is superior to surgical intervention, and that delayed intervention provide improved outcomes in 1990s, which changed the treatment concept of SAP again. The modern treatment concept formed during the progression: organ supportive care dominates in the early stage of the disease, and surgical intervention should be performed at late stage with proper indications. Despite the advances in treatment, the morbidity of SAP is still 5%-20%, which suggests the pancreatic surgeons' exploration in the future.
Full Text Available The presented work is an alternative to established measurement systems in surgical navigation. The system is based on camera based tracking of QR code markers. The application uses a single video camera, integrated in a surgical lamp, that captures the QR markers attached to surgical instruments and to the patient.
The Nigerian Journal of Surgical Research is a publication of the Surgical Research Society with main office in Zaria, Nigeria. Zaria is home to Ahmadu Bello University (ABU), a premier university in Nigeria. The aim of The Nigerian Journal of Surgical Research is to cover developments and advances in the broad field of ...
Waltz, Paul K; Zuckerbraun, Brian S
Surgical site infection (SSI) contributes significantly to surgical morbidity. Patient factors and operative factors contribute to the risk of development of SSI. This review focuses on understanding operative characteristics that are associated with an increased risk of SSI. Much attention has been given to protocol care to reduce SSI, such as hair removal, skin preparation, and pre-operative antibiotic agents. Even with this, the appropriate antibiotic and re-dosing regimens often remain a challenge. Other operative factors such as blood loss/transfusion, emergency/urgent cases, duration of the operation, type of anesthesia, and resident involvement are also potentially modifiable to reduce the risk of SSI. Data are reviewed to highlight the increased risk associated with such factors. Strategies to reduce risk, such as operative care bundles, have significant promise to reduce the incidence of SSI for any given procedure.
Fuerst, H.; Schildberg, F.W.
Purpose: To summarize current knowledge on surgical therapy in patients with inflammatory bowel disease (Crohn's disease, ulcerative colitis and diverticulitis). Material and methods: To discuss surgical indications and strategies, we reviewed major peer review publications of the last 10 years, and we also analysed data from patients with Crohn's disease who were treated in our institution between 1978 and 1994. Results: With Crohn's disease (305 patients), emergency surgery should be avoided as much as possible, since morbidity (50% vs 8.8%) and mortality (11% vs 0.6%) rise significantly in comparison to elective procedures. With ulcerative colitis, operative therapy is indicated in patients with secondary malignoma, and urgent surgery is requested in cases with associated perforation, toxic megacolon or massive bleeding. With diverticulitis, the first episode should be managed conservatively. Surgery is indicated in patients with recurrent episodes or with secondary complications. (orig.) [de
Dinscore, Amanda; Andres, Amy
This article determines the extent of the online availability and quality of surgical videos for the educational benefit of the surgical community. A comprehensive survey was performed that compared a number of online sites providing surgical videos according to their content, production quality, authority, audience, navigability, and other features. Methods for evaluating video content are discussed as well as possible future directions and emerging trends. Surgical videos are a valuable tool for demonstrating and teaching surgical technique and, despite room for growth in this area, advances in streaming video technology have made providing and accessing these resources easier than ever before.
Kuhls, Deborah A; Risucci, Donald A; Bowyer, Mark W; Luchette, Fred A
Surgical education is changing owing to workforce and economic demands. Simulation and other technical teaching methods are used to acquire skills transferable to the operating room. Operative management of traumatic injuries has declined, making it difficult to acquire and maintain competence. The ASSET course was developed by the Committee on Trauma's Surgical Skills Committee to fill a surgical skills need in resident and fellow education. Using a human cadaver, standardized rapid exposure of vital structures in the extremities, neck, thorax, abdomen, retroperitoneum, and pelvis is taught. A retrospective analysis of 79 participants in four ASSET courses was performed. Operative experience data were collected, and self-efficacy questionnaires (SEQs) were administered before and after the course. Course evaluations and instructor evaluation data were analyzed. Student's and paired samples t tests as well as analysis of variance and Spearman ρ correlation coefficient analysis were performed using α at p ASSET course would teach new surgical techniques and that learner self-assessed ability would improve. Participants included 27 PGY-4, 20 PGY-5, 24 PGY-6 or PGY-7 and PGY-8 at other levels of training. Self-assessed confidence improved in all body regions (p knowledge rated at 4.8 and learning new techniques at 4.72. A standardized cadaver-based surgical exposures course offered to senior surgical residents adds new surgical skills and improves participant self-assessed ability to perform emergent surgical exposure of vital structures.
pain/distension and/or vomiting as chief complaint. Fourteen (63.7%) of patients with perforated ... Teaching Hospital, Ilorin and bPaediatric Surgery Unit, Department of Surgery,. Obafemi Awolowo University Teaching ... paediatric unit, 7% to the neonatal intensive care unit, 5% to the inpatient ward, 7% to the accident and ...
Background: Aspegillus is an important pathogen in patients with impaired host defences. These mycelial fungi can cause local as well disseminated disease. Two forms of pulmonary aspergillosis are frequently seen : 1. pulmonary or brochial aspergilloma (fungus ball) due to secondary invasion of a a tuberculous cavity ...
Sep 5, 2016 ... Specifically, the most common obstetric causes of mortality (obstructed labor, obstetric hemorrhage and ectopic pregnancy), causes of acute abdomen and trauma are rampant. (4). ..... maternal and neonatal health interventions through task shifting (Optimize4MNH), 2012. Accessed on. January. 27 from:.
Garcia-Aymerich, J.; Lange, P.; Serra, I.
this type of confounding. We sought to assess the presence of time-dependent confounding in the association between physical activity and COPD development and course by comparing risk estimates between standard statistical methods and MSMs. METHODS: By using the population-based cohort Copenhagen City Heart...
Burne, Rebecca M; Abrahamowicz, Michal
Unmeasured confounding remains an important problem in observational studies, including pharmacoepidemiological studies of large administrative databases. Several recently developed methods utilize smaller validation samples, with information on additional confounders, to control for confounders unmeasured in the main, larger database. However, up-to-date applications of these methods to survival analyses seem to be limited to propensity score calibration, which relies on a strong surrogacy assumption. We propose a new method, specifically designed for time-to-event analyses, which uses martingale residuals, in addition to measured covariates, to enhance imputation of the unmeasured confounders in the main database. The method is applicable for analyses with both time-invariant data and time-varying exposure/confounders. In simulations, our method consistently eliminated bias because of unmeasured confounding, regardless of surrogacy violation and other relevant design parameters, and almost always yielded lower mean squared errors than other methods applicable for survival analyses, outperforming propensity score calibration in several scenarios. We apply the method to a real-life pharmacoepidemiological database study of the association between glucocorticoid therapy and risk of type II diabetes mellitus in patients with rheumatoid arthritis, with additional potential confounders available in an external validation sample. Compared with conventional analyses, which adjust only for confounders measured in the main database, our estimates suggest a considerably weaker association. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.
Full Text Available Introduction. The Royal College of Surgeons in England published guidelines in 2008 outlining the information that should be documented at each surgery. St. James’s Hospital uses a standard operation sheet for all surgical procedures and these were examined to assess documentation standards. Objectives. To retrospectively audit the hand written orthopaedic operative notes according to established guidelines. Methods. A total of 63 operation notes over seven months were audited in terms of date and time of surgery, surgeon, procedure, elective or emergency indication, operative diagnosis, incision details, signature, closure details, tourniquet time, postop instructions, complications, prosthesis, and serial numbers. Results. A consultant performed 71.4% of procedures; however, 85.7% of the operative notes were written by the registrar. The date and time of surgery, name of surgeon, procedure name, and signature were documented in all cases. The operative diagnosis and postoperative instructions were frequently not documented in the designated location. Incision details were included in 81.7% and prosthesis details in only 30% while the tourniquet time was not documented in any. Conclusion. Completion and documentation of operative procedures were excellent in some areas; improvement is needed in documenting tourniquet time, prosthesis and incision details, and the location of operative diagnosis and postoperative instructions.
Greenberg, Simon L L; Huang, Johnson; Chang, Robert S K; Ananda, Subramaniam N
Ludwig's angina (LA) is a dangerous surgical condition that can cause severe airway compromise and death. There is controversy regarding the best way to manage the airway of patients with LA. Options range from conservative management involving close observation and i.v. antibiotics to airway intervention, including tracheostomy and endotracheal intubation using fibre-optic nasoendoscopy. We present evidence supporting a role for conservative airway management in a select subset of patients. This paper reviews 9 years' experience of treating patients with LA at Liverpool Hospital. Twenty-one out of 29 (72%) of our patients were treated conservatively following initial clinical assessment. One of these patients subsequently deteriorated requiring emergency intubation. Of those treated non-conservatively at initial presentation, seven patients were able to be intubated using fibre-optic nasoendoscopy and one patient required tracheostomy under local anaesthesia. A general discussion of issues related to the management of LA is presented. Based on our experience we conclude that there is a subset of patients with LA who can be managed safely with conservative management.
Ohfuji, Satoko; Okada, Kenji; Nakano, Takashi; Ito, Hiroaki; Hara, Megumi; Kuroki, Haruo; Hirota, Yoshio
When using a case-control study design to examine vaccine effectiveness, both the selection of control subjects and the consideration of potential confounders must be the important issues to ensure accurate results. In this report, we described our experience from a case-control study conducted to evaluate the effectiveness of acellular pertussis vaccine combined with diphtheria-tetanus toxoids (DTaP vaccine). Newly diagnosed pertussis cases and age- and sex-matched friend-controls were enrolled, and the history of DTaP vaccination was compared between groups. Logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) of vaccination for development of pertussis. After adjustment for potential confounders, four doses of DTaP vaccination showed a lower OR for pediatrician-diagnosed pertussis (OR=0.11, 95% CI, 0.01-0.99). In addition, the decreasing OR of four doses vaccination was more pronounced for laboratory-confirmed pertussis (OR=0.07, 95%CI, 0.01-0.82). Besides, positive association with pertussis was observed in subjects with a history of steroid treatment (OR=5.67) and those with a recent contact with a lasting cough (OR=4.12). When using a case-control study to evaluate the effectiveness of vaccines, particularly those for uncommon infectious diseases such as pertussis, the use of friend-controls may be optimal due to the fact that they shared a similar experience for exposure to the pathogen as the cases. In addition, to assess vaccine effectiveness as accurately as possible, the effects of confounding should be adequately controlled with a matching or analysis technique. Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.
Fuertes, Elaine; Standl, Marie; Markevych, Iana; Bischof, Wolfgang; Heinrich, Joachim
Pet ownership is consistently associated with higher indoor endotoxin concentrations, but may also be related to the amount of greenspace around the home. This study examined whether the association between pet ownership and higher indoor endotoxin concentrations is confounded or modified by residential greenspace. Information on pet ownership was collected at the time of recruitment of the German LISA birth cohort. Endotoxin levels were measured in settled house dust sampled from mothers' mattresses (N=1197) and living room floors (N=390). Greenspace around the home was assessed as the mean Normalized Difference Vegetation Index in 100m, 500m and 1000m buffers around the home, and as the distance to the nearest urban and natural green space. Linear regression models assessed cross-sectional associations between pet ownership and log-transformed endotoxin levels, adjusted for known predictors of endotoxin levels. Confounding by greenspace was assessed by additionally adjusting the models for each greenspace variable. Effect modification was assessed by including interaction terms between pet ownership and each greenspace variable, and by model stratification. Dog and cat ownership were associated with higher endotoxin levels in mothers' mattresses, whereas only dog ownership was associated with endotoxin levels in the floor samples. All associations were highly robust to further adjustment for greenspace, and there was little evidence to suggest any effect modification (interaction terms had p-values >0.05). Residential greenspace did not confound or modify the association between pet ownership and indoor endotoxin levels. Studies should continue investigating whether pets influence the indoor environment only by their presence, or also by acting as transmission vectors of the outdoors. Copyright © 2018 Elsevier B.V. All rights reserved.
Full Text Available Although researchers have recently demonstrated a relationship between oral health and arterial sclerosis, the genetic contribution to this relationship has been ignored even though genetic factors are expected to have some effect on various diseases. The aim of this study was to evaluate oral health as a significant risk factor related to arterial sclerosis after eliminating genetic confounding through study of older Japanese twins.Medical and dental surveys were conducted individually for 106 Japanese twin pairs over the age of 50 years. Maximal carotid intima-media thickness (IMT-Cmax was measured as a surrogate marker of arterial sclerosis. IMT-Cmax > 1.0 mm was diagnosed as arterial sclerosis. All of the twins were examined for the number of remaining teeth, masticatory performance, and periodontal status. We evaluated each measurement related with IMT-Cmax and arterial sclerosis using generalized estimating equations analysis adjusted for potential risk factors. For non-smoking monozygotic twins, a regression analysis using a "between within" model was conducted to evaluate the relationship between IMT-Cmax and the number of teeth as the environmental factor controlling genetic and familial confounding.We examined 91 monozygotic and 15 dizygotic twin pairs (males: 42, females: 64 with a mean (± standard deviation age of 67.4 ± 10.0 years. Out of all of the oral health-related measurements collected, only the number of teeth was significantly related to arterial sclerosis (odds ratio: 0.72, 95% confidence interval: 0.52-0.99 per five teeth. Regression analysis showed a significant association between the IMT-Cmax and the number of teeth as an environmental factor (p = 0.037.Analysis of monozygotic twins older than 50 years of age showed that having fewer teeth could be a significant environmental factor related to arterial sclerosis, even after controlling for genetic and familial confounding.
Christie Y Jeon
Full Text Available The impact of glucose control on surgical-site infection (SSI and death remains unclear. We examined how pre- and post-operative glucose levels and their variability are associated with the risk of SSI or in-hospital death.This retrospective cohort study employed data on 13,800 hospitalized patients who underwent a surgical procedure at a large referral hospital in New York between 2006 and 2008. Over 20 different sources of electronic data were used to analyze how thirty-day risk of SSI and in-hospital death varies by glucose levels and variability. Maximum pre- and post-operative glucose levels were determined for 72 hours before and after the operation and glucose variability was defined as the coefficient of variation of the glucose measurements. We employed logistic regression to model the risk of SSI or death against glucose variables and the following potential confounders: age, sex, body mass index, duration of operation, diabetes status, procedure classification, physical status, emergency status, and blood transfusion.While association of pre- and post-operative hyperglycemia with SSI were apparent in the crude analysis, multivariate results showed that SSI risk did not vary significantly with glucose levels. On the other hand, in-hospital deaths were associated with pre-operative hypoglycemia (OR = 5.09, 95% CI (1.80, 14.4 and glucose variability (OR = 1.14, 95% CI (1.03, 1.27 for 10% increase in coefficient of variation.In-hospital deaths occurred more often among those with pre-operative hypoglycemia and higher glucose variability. These findings warrant further investigation to determine whether stabilization of glucose and prevention of hypoglycemia could reduce post-operative deaths.
Jeon, Christie Y; Furuya, E Yoko; Berman, Mitchell F; Larson, Elaine L
The impact of glucose control on surgical-site infection (SSI) and death remains unclear. We examined how pre- and post-operative glucose levels and their variability are associated with the risk of SSI or in-hospital death. This retrospective cohort study employed data on 13,800 hospitalized patients who underwent a surgical procedure at a large referral hospital in New York between 2006 and 2008. Over 20 different sources of electronic data were used to analyze how thirty-day risk of SSI and in-hospital death varies by glucose levels and variability. Maximum pre- and post-operative glucose levels were determined for 72 hours before and after the operation and glucose variability was defined as the coefficient of variation of the glucose measurements. We employed logistic regression to model the risk of SSI or death against glucose variables and the following potential confounders: age, sex, body mass index, duration of operation, diabetes status, procedure classification, physical status, emergency status, and blood transfusion. While association of pre- and post-operative hyperglycemia with SSI were apparent in the crude analysis, multivariate results showed that SSI risk did not vary significantly with glucose levels. On the other hand, in-hospital deaths were associated with pre-operative hypoglycemia (OR = 5.09, 95% CI (1.80, 14.4)) and glucose variability (OR = 1.14, 95% CI (1.03, 1.27) for 10% increase in coefficient of variation). In-hospital deaths occurred more often among those with pre-operative hypoglycemia and higher glucose variability. These findings warrant further investigation to determine whether stabilization of glucose and prevention of hypoglycemia could reduce post-operative deaths.
Cichosz, Simon Lebech; Frystyk, Jan; Tarnow, Lise
BACKGROUND: We have recently shown how the combination of information from continuous glucose monitor (CGM) and heart rate variability (HRV) measurements can be used to construct an algorithm for prediction of hypoglycemia in both bedbound and active patients with type 1 diabetes (T1D). Questions...... remain on how cardiovascular autonomic neuropathy (CAN) influences these measurable changes. This study aims to examine if changes in HRV during hypoglycemia are confounded by the presence of CAN. METHODS: Twenty-one adults (hereof 13 men) with T1D prone to hypoglycemia were recruited and monitored...
Shen, Tianjie; Sie, Kathleen C Y
Most speech disorders of childhood are treated with speech therapy. However, two conditions, ankyloglossia and velopharyngeal dysfunction, may be amenable to surgical intervention. It is important for surgeons to work with experienced speech language pathologists to diagnose the speech disorder. Children with articulation disorders related to ankyloglossia may benefit from frenuloplasty. Children with velopharyngeal dysfunction should have standardized clinical evaluation and instrumental asseessment of velopharyngeal function. Surgeons should develop a treatment protocol to optimize speech outcomes while minimizing morbidity. Copyright © 2014 Elsevier Inc. All rights reserved.
Levi-Mazloum, Niels Donald; Prag, Jørgen Brorson; Jensen, J S
Mycoplasma hominis and Ureaplasma urealyticum are common inhabitants of the human genital tract. Evidence for an aetiological role in pyelonephritis, pelvic inflammatory disease, post-abortion and post-partum fever has been presented. There are sporadic reports of Mycoplasma causing serious extra...... extragenital infection such as septicemia, septic arthritis, neonatal meningitis and encephalitis. We review 38 cases of surgical infections with Mycoplasma.......Mycoplasma hominis and Ureaplasma urealyticum are common inhabitants of the human genital tract. Evidence for an aetiological role in pyelonephritis, pelvic inflammatory disease, post-abortion and post-partum fever has been presented. There are sporadic reports of Mycoplasma causing serious...
A state of the art of surgical method of abortion focusing on safety and practical aspects. A systematic review of French-speaking or English-speaking evidence-based literature about surgical methods of abortion was performed using Pubmed, Cochrane and international recommendations. Surgical abortion is efficient and safe regardless of gestational age, even before 7 weeks gestation (EL2). A systematic prophylactic antibiotics should be preferred to a targeted antibiotic prophylaxis (grade A). In women under 25 years, doxycycline is preferred (grade C) due to the high prevalence of Chlamydia trachomatis. Systematic cervical preparation is recommended for reducing the incidence of complications from vacuum aspiration (grade A). Misoprostol is a first-line agent (grade A). When misoprostol is used before a vacuum aspiration, a dose of 400 mcg is recommended. The choice of vaginal route or sublingual administration should be left to the woman: (i) the vaginal route 3 hours before the procedure has a good efficiency/safety ratio (grade A); (ii) the sublingual administration 1 to 3 hours before the procedure has a higher efficiency (EL1). The patient should be warned of more common gastrointestinal side effects. The addition of mifepristone 200mg 24 to 48hours before the procedure is interesting for pregnancies between 12 and 14 weeks gestations (EL2). The systematic use of nonsteroidal anti-inflammatory drugs is recommended for limiting the operative and postoperative pain (grade B). Routine vaginal application of an antiseptic prior to the procedure cannot be recommended (grade B). The type of anesthesia (general or local) should be left up to the woman after explanation of the benefit-risk ratio (grade B). Paracervical local anesthesia (PLA) is recommended before performing a vacuum aspiration under local anesthesia (grade A). The electric or manual vacuum methods are very effective, safe and acceptable to women (grade A). Before 9 weeks gestation
... non-Federal facility: (1) Medical or surgical conditions which would constitute an emergency in the... 32 National Defense 5 2010-07-01 2010-07-01 false Emergency care requirements. 732.16 Section 732... MEDICAL AND DENTAL CARE Medical and Dental Care From Nonnaval Sources § 732.16 Emergency care requirements...
Davies, Sarah Rachael; Selin, Cynthia; Rodegher, Sandra
The Emerge event, held in Tempe, AZ in March 2012, brought together a range of scientists, artists, futurists, engineers and students in order to experiment with innovative methods for thinking about the future. These methodological techniques were tested through nine workshops, each of which made...... use of a different format; Emerge as a whole, then, offered an opportunity to study a diverse set of future-oriented engagement practices. We conducted an event ethnography, in which a team of 11 researchers collaboratively developed accounts of the practices at play within Emerge and its workshops...
47.5%of patients had resection and primary anastomosis while 24.0% had manual reduction at laparotomy. Conclusion: Intussusception is one of the most common paediatric surgical emergencies at Harare Central Hospital. The age and sex of patients are the same as those found in literature. In contrast with previous data ...
The mean duration of admission was 3.1 (3) days. 157 patients (89.2%) were discharged to the wards while 19 patients (10.8%) died in the ICU. Significant predictors of mortality were oliguria and use of Vaso-active support. Conclusion: Ninety percent (90%) of ICU deaths in general surgery occur in risk emergency surgical ...
The digestive system and genitourinary systems were the most commonly affected systems. Emergency admission accounted for 18.1% of all surgical admissions while elective admissions accounted for the rest. Conclusion: More detailed research on the pattern of admissions is important in planning and should be carried ...
Acute appendicitis is the most common cause of acute surgical abdomen requiring emergency surgery both in developed and developing countries. Appendicectomies in patients presenting with clinically suspected acute appendicitis show a diversity of pathologies. The aim of this study is to evaluate the frequency and ...
Full Text Available Commercial surgical robots have been in clinical use since the mid-1990s, supporting surgeons in various tasks. In the past decades, many systems emerged as research platforms, and a few entered the global market. This paper summarizes the currently available surgical systems and research directions in the broader field of surgical robotics. The widely deployed teleoperated manipulators aim to enhance human cognitive and physical skills and provide smart tools for surgeons, while image-guided robotics focus on surpassing human limitations by introducing automated targeting and treatment delivery methods. Both concepts are discussed based on prototypes and commercial systems. Through concrete examples the possible future development paths of surgical robots are illustrated. While research efforts are taking different approaches to improve the capacity of such systems, the aim of this survey is to assess their maturity from the commercialization point of view.
Antiel, Ryan M; Thompson, Scott M; Camp, Christopher L; Thompson, Geoffrey B; Farley, David R
Along with a decline in interest in general surgery among United States medical school graduates, reports indicate a decrease in the amount of time students are spending on their surgical clerkship. In an effort to offer early exposure to general surgery as well as to equip students with the basic surgical skills that will enhance their third-year clerkship experience, we developed a preclinical surgical experience. Students were surveyed to determine whether the surgical selective changed student level of comfort with basic surgical skills. Surveys were administered, preexperience and postexperience to the medical students enrolled in the surgery selective. The students were asked to rate their comfort level with 12 unique surgical skills. Comfort with the task was evaluated using a 10-point Likert scale. Analyses were conducted to evaluate the impact of the surgical experience on student comfort levels with the surgical skills. The self-reported comfort levels of students increased significantly after the experience in all 12 areas. The greatest change in comfort level (greater than or equal to mean difference of 4) occurred in the surgical technique categories: knot tying (mean difference: 4.9, p < 0.0001), suturing (mean difference: 4.85, p < 0.0001), correctly making an incision (mean difference: 4.95, p < 0.0001), using a needle driver (mean difference: 5.35, p < 0.0001), holding pickups (mean difference: 4.6, p < 0.0001), use of laparoscopic instruments (mean difference: 4.8, p < 0.0001), and use of surgical simulators (mean difference: 6.0, p < 0.0001). Our preclinical surgical experience serves as a model of an effective modality providing early exposure to general surgery. The experience provides trainees with basic surgical skills well before they begin their third-year clerkships. Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
... directly) to the person's skin and use a fan to lower body temperature. Place cold compresses on ... RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 9th ed. Philadelphia, PA: Elsevier; ...
... from an explosion, blow to the head, flying, scuba diving, falling while water skiing, or being slapped on ... Byyny RL, Shockley LW. Scuba diving and dysbarism. In: Marx JA, ... Rosen's Emergency Medicine: Concepts and Clinical Practice . 8th ...
This paper describes emergency triage. It presents the reasons for implementation of triage and its benefits. Focuses on the Manchester triage system, which is formally validated triage model in Slovenia.
The aim of Journal of Surgical Technique and Case Report is to advance surgical knowledge and practice by promoting the reporting of innovative and reproducible surgical techniques and illustrative surgical cases on various surgical disciplines. The journal encourages authoritative synthesis of current surgical literature ...
Full Text Available Our goal was to test the hypothesis that inter-individual genomic copy number variation in control samples is a confounding factor in the non-invasive prenatal detection of fetal microdeletions via the sequence-based analysis of maternal plasma DNA. The database of genomic variants (DGV was used to determine the "Genomic Variants Frequency" (GVF for each 50kb region in the human genome. Whole genome sequencing of fifteen karyotypically normal maternal plasma and six CVS DNA controls samples was performed. The coefficient of variation of relative read counts (cv.RTC for these samples was determined for each 50kb region. Maternal plasma from two pregnancies affected with a chromosome 5p microdeletion was also sequenced, and analyzed using the GCREM algorithm. We found strong correlation between high variance in read counts and GVF amongst controls. Consequently we were unable to confirm the presence of the microdeletion via sequencing of maternal plasma samples obtained from two sequential affected pregnancies. Caution should be exercised when performing NIPT for microdeletions. It is vital to develop our understanding of the factors that impact the sensitivity and specificity of these approaches. In particular, benign copy number variation amongst controls is a major confounder, and their effects should be corrected bioinformatically.
Turner, W C; Cizauskas, C A; Getz, W M
Estimates of parasite intensity within host populations are essential for many studies of host-parasite relationships. Here we evaluated the seasonal, age- and sex-related variability in faecal water content for two wild ungulate species, springbok (Antidorcas marsupialis) and plains zebra (Equus quagga). We then assessed whether or not faecal water content biased conclusions regarding differences in strongyle infection rates by season, age or sex. There was evidence of significant variation in faecal water content by season and age for both species, and by sex in springbok. Analyses of faecal egg counts demonstrated that sex was a near-significant factor in explaining variation in strongyle parasite infection rates in zebra (P = 0.055) and springbok (P = 0.052) using wet-weight faecal samples. However, once these intensity estimates were re-scaled by the percent of dry matter in the faeces, sex was no longer a significant factor (zebra, P = 0.268; springbok, P = 0.234). These results demonstrate that variation in faecal water content may confound analyses and could produce spurious conclusions, as was the case with host sex as a factor in the analysis. We thus recommend that researchers assess whether water variation could be a confounding factor when designing and performing research using faecal indices of parasite intensity.
Liang, Wenbin; Chikritzhs, Tanya
Experimental studies suggest that alcohol can lead to aggression in laboratory settings; however, it is impossible to test the causal relationship between alcohol use and real-life violence among humans in randomized clinical trials. Objectives. (i) To examine the relationship between heavy alcohol use and assaults in a population based study; (ii) to demonstrate the proxy outcome method, as a means of controlling the effects of unknown/unmeasured confounders in observational studies. This study used data collected from three waves of the National Survey on Drug Use and Health (NSDUH). The effects of heavy alcohol use on assault were measured using multivariable logistic regressions in conjunction with the proxy outcome method. Application of the proxy outcome method indicated that effect sizes of heavy alcohol use on the risk of assault were overestimated in the standard models. After adjusting for the effects of unknown/unmeasured confounders, the risk of assault remained 43% and 63% higher (P alcohol use and risk of violence remained significant. These findings support the hypothesis that heavy alcohol use can cause violence.
O'Connell, Elaine Finbarr
I argue that emotion is an ontologically emergent and sui generis. I argue that emotion meets both of two individually necessary and jointly sufficient conditions for ontological emergence. These are, (i) that emotion necessarily has constituent parts to which it cannot be reduced, and (ii) that emotion has a causal effect on its constituent parts (i.e. emotion demonstrates downward causation).\\ud \\ud I argue that emotion is partly cognitive, partly constituted by feelings and partly perceptu...
M.P. Simón Díaz
Full Text Available Dermatologic emergencies represent about 8–20% of the diseases seen in the Emergency Department of hospitals. It is often a challenge for primary care physicians to differentiate mundane skin ailments from more serious, life threatening conditions that require immediate intervention. In this review we included the following conditions: Stevens-Johnson syndrome/toxic epidermal necrosis, pemphigus vulgaris, toxic shock syndrome, fasciitis necrotising, angioedema/urticaria, meningococcemia, Lyme disease and Rocky Mountain spotted fever.
Oyetunji, Tolulope A; Gonzalez, Dani O; Gonzalez, Katherine W; Nwomeh, Benedict C; St Peter, Shawn D
Surgical wound classification has emerged as a measure of surgical quality of care, but scant data exist in the era of minimally invasive procedures, especially in children. The aim of this study is to examine the surgical site infection (SSI) rate by wound classification during common pediatric surgical procedures. A retrospective analysis of the 2013 Pediatric-National Surgical Quality Improvement Program (Peds-NSQIP) dataset was conducted. Patients undergoing pyloromyotomy, cholecystectomy, ostomy reversal, and appendectomy were included. Wound classification, SSI rate, reoperation, and readmission were analyzed. A total of 10,424 records were included. Pyloromyotomy, a clean case, had a 0.7% SSI rate, while ostomy reversal, a clean contaminated case, had an SSI in 6.9% of cases. Appendectomy for nonperforated acute appendicitis and laparoscopic cholecystectomy for cholecystitis, both contaminated cases, had SSI rates of 2.1% and 40% for dirty cases. Reoperations and readmission rates ranged from wound classifications systems do not reflect surgical risk in children and remain questionable tools for benchmarking surgical care in children. Role of readmissions and reoperations as quality of care indices needs further investigation. Copyright © 2016 Elsevier Inc. All rights reserved.
Mitra, Niloy J.
Emergence refers to the unique human ability to aggregate information from seemingly meaningless pieces, and to perceive a whole that is meaningful. This special skill of humans can constitute an effective scheme to tell humans and machines apart. This paper presents a synthesis technique to generate images of 3D objects that are detectable by humans, but difficult for an automatic algorithm to recognize. The technique allows generating an infinite number of images with emerging figures. Our algorithm is designed so that locally the synthesized images divulge little useful information or cues to assist any segmentation or recognition procedure. Therefore, as we demonstrate, computer vision algorithms are incapable of effectively processing such images. However, when a human observer is presented with an emergence image, synthesized using an object she is familiar with, the figure emerges when observed as a whole. We can control the difficulty level of perceiving the emergence effect through a limited set of parameters. A procedure that synthesizes emergence images can be an effective tool for exploring and understanding the factors affecting computer vision techniques. © 2009 ACM.
IN URGENT NEED OF A DOCTOR GENEVA EMERGENCY SERVICES GENEVA AND VAUD 144 FIRE BRIGADE 118 POLICE 117 CERN FIREMEN 767-44-44 ANTI-POISONS CENTRE Open 24h/24h 01-251-51-51 Patient not fit to be moved, call family doctor, or: GP AT HOME, open 24h/24h 748-49-50 Association Of Geneva Doctors Emergency Doctors at home 07h-23h 322 20 20 Patient fit to be moved: HOPITAL CANTONAL CENTRAL 24 Micheli-du-Crest 372-33-11 ou 382-33-11 EMERGENCIES 382-33-11 ou 372-33-11 CHILDREN'S HOSPITAL 6 rue Willy-Donzé 372-33-11 MATERNITY 32 bvd.de la Cluse 382-68-16 ou 382-33-11 OPHTHALMOLOGY 22 Alcide Jentzer 382-33-11 ou 372-33-11 MEDICAL CENTRE CORNAVIN 1-3 rue du Jura 345 45 50 HOPITAL DE LA TOUR Meyrin EMERGENCIES 719-61-11 URGENCES PEDIATRIQUES 719-61-00 LA TOUR MEDICAL CENTRE 719-74-00 European Emergency Call 112 FRANCE EMERGENCY SERVICES 15 FIRE BRIGADE 18 POLICE 17 CERN FIREMEN AT HOME 00-41-22-767-44-44 ANTI-POISONS CENTRE Open 24h/24h 04-72-11-69-11 All doctors ...
Hechenbleikner, Elizabeth M; Hobson, Deborah B; Bennett, Jennifer L; Wick, Elizabeth C
Surgical site infections are a potentially preventable patient harm. Emerging evidence suggests that the implementation of evidence-based process measures for infection reduction is highly variable. The purpose of this work was to develop an auditing tool to assess compliance with infection-related process measures and establish a system for identifying and addressing defects in measure implementation. This was a retrospective cohort study using electronic medical records. We used the auditing tool to assess compliance with 10 process measures in a sample of colorectal surgery patients with and without postoperative infections at an academic medical center (January 2012 to March 2013). We investigated 59 patients with surgical site infections and 49 patients without surgical site infections. First, overall compliance rates for the 10 process measures were compared between patients with infection vs patients without infection to assess if compliance was lower among patients with surgical site infections. Then, because of the burden of data collection, the tool was used exclusively to evaluate quarterly compliance rates among patients with infection. The results were reviewed, and the key factors contributing to noncompliance were identified and addressed. Ninety percent of process measures had lower compliance rates among patients with infection. Detailed review of infection cases identified many defects that improved following the implementation of system-level changes: correct cefotetan redosing (education of anesthesia personnel), temperature at surgical incision >36.0°C (flags used to identify patients for preoperative warming), and the use of preoperative mechanical bowel preparation with oral antibiotics (laxative solutions and antibiotics distributed in clinic before surgery). Quarterly compliance improved for 80% of process measures by the end of the study period. This study was conducted on a small surgical cohort within a select subspecialty. The
Sameh Ibrahim Sersar
Full Text Available Introduction and Aim: Emergency thoracotomy is performed either immediately at the scene of injury, in the emergency department or in the operating room. It aims to evacuate the pericardial tamponade, control the haemorrhage, to ease the open cardiac massage and to cross-clamp the descending thoracic aorta to redistribute blood flow and maybe to limit sub-diaphragmatic haemorrhage, bleeding and iatrogenic injury are the common risk factors. We aimed to review our experience in the field of emergency thoracotomies, identify the predictors of death, analyze the early results, detect the risk factors and asses the mortalities and their risk factors. Patients and Methods: Our hospital records of 197 patients who underwent emergency thoracotomy were reviewed. We retrospectively analyzed a piece of the extensive experience of the Mansoura University Hospitals and Mansoura Emergency Hospital; Egypt and Saudi German Hospitals; Jeddah in the last 12 years in the management of trauma cases for whom emergency thoracotomy. The aim was to analyse the early results of such cases and to detect the risk factors of dismal prognosis. Results: Our series included 197 cases of emergency thoractomies in Mansoura; Egypt and SGH; Jeddah; KSA in the last 12 years. The mean age of the victims was 28 years and ranged between 5 and 62 years. Of the 197 patients with emergency thoracotomy, the indications were both penetrating and blunt chest trauma, iatrogenic and postoperative hemodynamito a surgical cause. The commonest indication was stab heart followed by traumatic diaphragmatic ruptures. Conclusion: The results of emergency thoracotomy in our series were cooping with the results of other reports, mainly due to our aggressive measures to achieve rapid stabilization of the hemodynamic condition. We emphasize the importance of emergency medicine education programs on rapid diagnosis of traumatic injuries with early intervention, and adequate hemodynamic and respiratory
Liu, Tianyi; Nie, Xiaolu; Wu, Zehao; Zhang, Ying; Feng, Guoshuang; Cai, Siyu; Lv, Yaqi; Peng, Xiaoxia
Different confounder adjustment strategies were used to estimate odds ratios (ORs) in case-control study, i.e. how many confounders original studies adjusted and what the variables are. This secondary data analysis is aimed to detect whether there are potential biases caused by difference of confounding factor adjustment strategies in case-control study, and whether such bias would impact the summary effect size of meta-analysis. We included all meta-analyses that focused on the association between breast cancer and passive smoking among non-smoking women, as well as each original case-control studies included in these meta-analyses. The relative deviations (RDs) of each original study were calculated to detect how magnitude the adjustment would impact the estimation of ORs, compared with crude ORs. At the same time, a scatter diagram was sketched to describe the distribution of adjusted ORs with different number of adjusted confounders. Substantial inconsistency existed in meta-analysis of case-control studies, which would influence the precision of the summary effect size. First, mixed unadjusted and adjusted ORs were used to combine individual OR in majority of meta-analysis. Second, original studies with different adjustment strategies of confounders were combined, i.e. the number of adjusted confounders and different factors being adjusted in each original study. Third, adjustment did not make the effect size of original studies trend to constringency, which suggested that model fitting might have failed to correct the systematic error caused by confounding. The heterogeneity of confounder adjustment strategies in case-control studies may lead to further bias for summary effect size in meta-analyses, especially for weak or medium associations so that the direction of causal inference would be even reversed. Therefore, further methodological researches are needed, referring to the assessment of confounder adjustment strategies, as well as how to take this kind
Full Text Available While contemporary periodontics has witnessed the continued emergence of sophisticated techniques to resolve esthetic concerns through various periodontal procedures, frequently the early stages of periodontal diseases are best treated with non-surgical periodontal therapy. This short communication presents a case of reactive positioning of pathologically migrated anterior tooth following non-surgical periodontal therapy.
We report on 2 patients with surgical site infections following the inadvertent use of Teflon felt for haemostasis in elective and emergency surgery. CT scanning was superior to plain radiography in demonstrating the foreign bodies to enable planning of further surgical treatment.
Fencl, Jennifer L
Research conducted during the past four decades has demonstrated that surgical smoke generated from the use of energy-generating devices in surgery contains toxic and biohazardous substances that present risks to perioperative team members and patients. Despite the increase in information available, however, perioperative personnel continue to demonstrate a lack of knowledge of these hazards and lack of compliance with recommendations for evacuating smoke during surgical procedures. The new AORN "Guideline for surgical smoke safety" provides guidance on surgical smoke management. This article focuses on key points of the guideline to help perioperative personnel promote smoke-free work environments; evacuate surgical smoke; and develop education programs and competency verification tools, policies and procedures, and quality improvement initiatives related to controlling surgical smoke. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Full Text Available Scar formation is an inevitable consequence of wound healing from either a traumatic or a surgical intervention. The aesthetic appearance of a scar is the most important criteria to judge the surgical outcome. An understanding of the anatomy and wound healing along with experience, meticulous planning and technique can reduce complications and improve the surgical outcome. Scar revision does not erase a scar but helps to make it less noticeable and more acceptable. Both surgical and non-surgical techniques, used either alone or in combination can be used for revising a scar. In planning a scar revision surgeon should decide on when to act and the type of technique to use for scar revision to get an aesthetically pleasing outcome. This review article provides overview of methods applied for facial scar revision. This predominantly covers surgical methods.
Marcelo Augusto Fontenelle Ribeiro Junior
Full Text Available AIMS: Spontaneous ruptured hepatocellular adenoma (SRHA is a rare life-threatening condition that may require surgical treatment to control hemorrhaging and also stabilize the patient. We report a series of emergency surgeries performed at our institution for this condition. METHODS: We reviewed medical records and radiology files of 28 patients (from 1989 to 2006 with a proven diagnosis of hepatocellular adenoma (HA. Three (10.7% of 28 patients had spontaneous ruptured hepatocellular adenoma, two of which were associated with intrahepatic hemorrhage while one had intraperitoneal bleeding. Two patients were female and one was male. Both female patients had a background history of oral contraceptive use. Sudden abdominal pain associated with hemodynamic instability occurred in all patients who suffered from spontaneous ruptured hepatocellular adenoma. The mean age was 41.6 years old. The preoperative assessment included liver function tests, ultrasonography and computed tomography. RESULTS: The surgical approaches were as follows: right hemihepatectomy for controlling intraperitoneal bleeding, and right extended hepatectomy and non-anatomic resection of the liver for intrahepatic hemorrhage. There were no deaths, and the postoperative complications were bile leakage and wound infection (re-operation, as well as intraperitoneal abscess (re-operation and pleural effusion. CONCLUSION: Spontaneous ruptured hepatocellular adenoma may be treated by surgery for controlling hemorrhages and stabilizing the patient, and the decision to operate depends upon both the patient's condition and the expertise of the surgical team.
Patrick J Stokes
Full Text Available Background Establishment of the Acute Surgical Unit (ASU has redefined the approach to emergency surgery in Australia with quantitative data showing improvement in patient outcomes. However, as qualitative data regarding the ASU remains scarce, we sought to determine the impact of the ASU on overall surgeon job satisfaction. Aims The aim of this paper was to specifically address the impact of the ASU on consultant surgeons overall job satisfaction. Methods We designed a 34 – item questionnaire with consultant general surgeons addressing important aspects of the ASU. Themes included on – call rostering and workload, academic pursuits, surgical training, work – life balance and overall job satisfaction. Results We received responses from 88 surgeons currently working on ASU units, responding correctly and in full to the survey. Overall, our surveyed cohort reported better on – call rostering, improved surgical training and higher levels of job satisfaction and overall work – life balance with ASU implementation. Conclusion Preliminary qualitative results indicate that the ASU may improve on – call rostering, work – life balance and overall job satisfaction.
Are, C; Berman, R S; Wyld, L; Cummings, C; Lecoq, C; Audisio, R A
The significant global variations in surgical oncology training paradigms can have a detrimental effect on tackling the rising global cancer burden. While some variations in training are essential to account for the differences in types of cancer and biology, the fundamental principles of providing care to a cancer patient remain the same. The development of a global curriculum in surgical oncology with incorporated essential standards could be very useful in building an adequately trained surgical oncology workforce, which in turn could help in tackling the rising global cancer burden. The leaders of the Society of Surgical Oncology and European Society of Surgical Oncology convened a global curriculum committee to develop a global curriculum in surgical oncology. A global curriculum in surgical oncology was developed to incorporate the required domains considered to be essential in training a surgical oncologist. The curriculum was constructed in a modular fashion to permit flexibility to suit the needs of the different regions of the world. Similarly, recognizing the various sociocultural, financial and cultural influences across the world, the proposed curriculum is aspirational and not mandatory in intent. A global curriculum was developed which may be considered as a foundational scaffolding for training surgical oncologists worldwide. It is envisioned that this initial global curriculum will provide a flexible and modular scaffolding that can be tailored by individual countries or regions to train surgical oncologists in a way that is appropriate for practice in their local environment. Copyright © 2016 Society of Surgical Oncology, European Society of Surgical Oncology. Published by Elsevier Ltd.. All rights reserved.
Omeje, IC; Poruban, R; ?ag?t, M; Nos?l, M; Hra?ka, V
Coarctation of the aorta accounts for about 8% of all congenital heart diseases. Since the first successful case of surgical treatment in 1944 by Crafoord and Nylin1 in Sweden, several surgical techniques have been employed in the treatment of this anomaly. This article reviews by illustration the various surgical options in coarctation of the aorta with emphasis on our preferred technique – the extended resection and end-to-end anastomosis. Why the extended resection technique? Our exper...
Słowińska, Iwona; Słowiński, Radosław; Rutkowska-Sak, Lidia
Gout is an inflammatory joint disease associated with deposition of monosodium urate crystals in the bones forming the joints, in periarticular tissues and in other organs. The disease is one of the most frequent causes of disability. This paper presents the case of a 57-year-old male patient treated for generalised gout. A "clinical mask" suggesting another disease was the cause of making the correct diagnosis only six years after the occurrence of the first manifestations. The patient, with high values of inflammatory markers, severe pain and advanced joint destruction, was given an aggressive anti-inflammatory treatment. The unsatisfactory effect of the conservative treatment forced the authors to perform surgical resection of the gouty nodules in the hands. After several operations the function of the hand joints operated on, appearance of the hands and the quality of the patient's life improved significantly.
Di Leo, Alberto; Piffer, Silvano; Ricci, Francesco; Manzi, Alberto; Poggi, Elena; Porretto, Vincenzo; Fambri, Paolo; Piccini, Giannina; Patrizia, Trentini; Fabbri, Luca; Busetti, Rosanna
Surgical site infection (SSI) remains a major cause of morbidity and death. This study analyzed the results of surveillance to evaluate the incidence, risk factors, and characteristics of SSI in patients who underwent an operation in a typical Italian surgical ward. A group of 1,281 patients operated on from August 2005 to December 2007 underwent prospective and direct observation of incisions by a surgeon according to the U.S. Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance (NNIS) method. The minimum follow-up was 30 days. A locally-modified risk index score (LRI) based on the NNIS was calculated for each patient, using as a cut point the 75(th) percentile of the duration of surgery (in minutes) for that particular procedure. Seventy-six patients were affected by incision site infection, and the SSI rate was 5.9%. Thirty-four (2.6% of the series) were superficial incisional, 32 (2.5%) deep incisional, and 10 (0.8%) organ/space SSIs. An increasing value of the LRI was significantly (p or=2, respectively. Obesity (body mass index >30 kg/m(2)), diabetes mellitus, and emergency surgery were associated with a higher risk of infection by multivariable analysis independent of the LRI. The NNIS method can be useful for SSI surveillance and monitoring in single surgical wards. Longer operations, diabetes mellitus, and obesity increase the risk of SSI, as does performance of surgery in an emergency situation.
Atsuko Koyama; Laura Hagopian; Judith Linden
Emergency post-coital contraception (EC) is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD) and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method), and less commonly, mifepristone. Some options are available over-the-counter, while others...
Di Pasquale, LisaMarie; Ferneini, Elie M
Fire in the operating room is a life-threatening emergency that demands quick, efficient intervention. Because the circumstances surrounding fires are generally well-understood, virtually every operating room fire is preventable. Before every operating room case, thorough preprocedure "time outs" should address each team members' awareness of specific fire risks and agreement regarding fire concerns and emergency actions. Fire prevention centers on 3 constituent parts of the fire triad necessary for fire formation. Regular fire drills should guide policies and procedures to prevent surgical fires. Delivering optimal patient care in emergent situations requires surgical team training, practicing emergency roles, and specific actions. Copyright © 2016 Elsevier Inc. All rights reserved.
Full Text Available In recent years, the surprising progress made in other areas of hematology (advances in the understanding of leukemogenesis, improved transplant techniques has been conspicuously absent in the management of hematologic emergencies. And yet, every step toward greater knowledge, every new treatment option will be of little value unless we are able to manage the acute complications of hematologic diseases. These complications are better defined as hematologic emergencies, and they are characterized by a high rate of mortality. This review is based on a search of the literature that was initially confined to articles published in the journal Hematology from 2000 to 2009. The search was then extended to the Cochrane Library and to Pub Med in February 2010 with the following Keywords emergencies; urgencies; hematology. The same key words were employed in a search of the archives of Blood and the New England Journal of Medicine from 2000 to 2010. The results confirm that hematologic emergencies can be caused by hematologic malignancies as well as by non-neoplastic hematologic diseases. Within the former category; this review examines the causes; manifestations; treatment and prevention of disseminated intravascular coagulation; superior vena caval syndrome; spinal cord compression; tumor lysis syndrome; hyperleukocytosis; and hypercalcemia. We also review emergency situations associated with non-neoplatic haematological diseases; such as thrombotic thrombocytopenic purpura; drug-induced hemolytic anemia; and acute sickle-cell crisis.
Scarabino, T.; Hospital of Andria; Salvolini, U.; Jinkins, J.R.
The book is directed at emergency radiologists and neuroradiologists. It aims at providing exhaustive information that will help the reader understand the clinical problems in the full range of neurological emergencies and to select the methodological and technical options that will ensure prompt and effective response and correct interpretation of the clinical findings. The various chapters address the most common neuroradiological emergencies, summarize their fundamental physiopathological features, describe the main semiological and differential diagnostic features, and provide operative suggestions for the selection of the appropriate techniques to be applied in a sequential order. The book addresses the application of state-of-the-art techniques and their implications for clinical practice (particularly the contributions of standard and functional MRI and of spiral and multislice CT). The illustrations provide not only training but also reference material for routine clinical work. (orig.)
The nuclear activities are exercised so as to prevent the accidents. They are subjected to a rule whom application is controlled by the Asn. The risk of grave accident is so limited to a very low level of probability. He cannot be however completely pushed aside. The expression ' radiological emergency situation ' indicates a situation which ensues from an incident or of an accident risking to lead to an emission of radioactive materials or a level of radioactivity susceptible to strike a blow at the public health. The term ' nuclear crisis ' is used for the events which can lead to a radiological emergency situation on a nuclear basic installation or during a transport of radioactive materials. The preparation and the management of emergency situations, that they are of natural, accidental or terrorist origin, became a major concern of our society. We propose you of to know more about it in this file. (N.C.)
Scarabino, T. [Scientific Inst. ' Casa Sollievo della Sofferenza' , San Giovanni Rotondo (Italy). Dept. of Neuroradiology]|[Hospital of Andria (Italy). Dept. of Radiology, ASL BA/1; Salvolini, U. [Ancona Univ. (Italy). Neuroradiology and Dept. of Radiology; Jinkins, J.R. (eds.) [New York State Univ., Brooklyn, NY (United States). Dept. of Radiology, Downstate Medical Center
The book is directed at emergency radiologists and neuroradiologists. It aims at providing exhaustive information that will help the reader understand the clinical problems in the full range of neurological emergencies and to select the methodological and technical options that will ensure prompt and effective response and correct interpretation of the clinical findings. The various chapters address the most common neuroradiological emergencies, summarize their fundamental physiopathological features, describe the main semiological and differential diagnostic features, and provide operative suggestions for the selection of the appropriate techniques to be applied in a sequential order. The book addresses the application of state-of-the-art techniques and their implications for clinical practice (particularly the contributions of standard and functional MRI and of spiral and multislice CT). The illustrations provide not only training but also reference material for routine clinical work. (orig.)
Background: Surgical abdominal emergencies constitute an entity of pathologies requiring immediate medical and surgical management in most of the cases. There is little information regarding the clinical spectrum of disease in these patients and the outcome after admission to hospital. This study was conducted at Kigali ...
Full Text Available Emergency contraception refers to any device or drug that is used as an emergency procedure to prevent pregnancy after unprotected sexual intercourse.The first method of emergency contraception was high dose of estrogen. Concern about side effects led to subsequent development of the so-called Yuzpe regimen which combined ethinil estradiol with levonorgestrel and levonorgestrel alone. Less convenient to use is the copper intauterine contraceptive device.It is known that in some women sexual steroids may inhibit or delay ovulation and may interfere with ovum and sperm transport and implantation. Copper intrauterine device causes a foreign-body effect on the endometrium and a direct toxic effect to sperm and blastocyst.The Yuzpe regimen reduces the risk of pregnancy after a single act of sexual intercourse by about 75% and the levonorgestrel alone by about 85%. The copper intrauterine device is an extremely effective method for selected patients.Nausea and vomiting are common among women using the Yuzpe regimen and considerably less common among women using levonorgestrel alone regimen.Emergency contraception is relatively safe with no contraindications except pregnancy. It is ineffective if a woman is pregnant. There is no need for a medical hystory or a phisical examination before providing emergency contraceptive pills. They are taken long before organogenesis starts, so they should not have a teratogenic effect.Counseling should include information about correct use of the method, possible side effects and her preferences for regular contraception.Unintended pregnancy is a great problem. Several safe, effective and inexpensive methods of emergency contraception are available including Yuzpe regimen, levonorges-trel-only regimen and copper intrauterine device.
Full Text Available The emerging markets are winning the currency war, because at this very moment its the battle of global financial institutions , as to who is more vulnerable and more exposed to the debt crisis and have their hands in more risky assets. US and Euro with their intertwining the financial stuff of the nation, the banks and the corporations are in a deep mess. One goes down, takes the other ones too. Right now , they all are struggling and getting beaten up , while the emerging markets are quiet and not really expressing their stands on the current situation except are reacting by all only putting their own houses in order.
This leaflet, which is in the form of a fold-up chart, has panels of text which summarize the emergencies that could arise and the countermeasures and emergency plans that have been prepared should nuclear accident occur or affect the United Kingdom. The levels of radiation doses at which various measures would be introduced are outlined. The detection and monitoring programmes that would operate is illustrated. The role of NRPB and the responsible government departments are set out together with an explanation of how the National Arrangements for Incidents involving Radioactivity would be coordinated. (UK)
Chaibub Neto, Elias
Clinical trials traditionally employ blinding as a design mechanism to reduce the influence of placebo effects. In practice, however, it can be difficult or impossible to blind study participants and unblinded trials are common in medical research. Here we show how instrumental variables can be used to quantify and disentangle treatment and placebo effects in randomized clinical trials comparing control and active treatments in the presence of confounders. The key idea is to use randomization to separately manipulate treatment assignment and psychological encouragement conversations/interactions that increase the participants’ desire for improved symptoms. The proposed approach is able to improve the estimation of treatment effects in blinded studies and, most importantly, opens the doors to account for placebo effects in unblinded trials.
Fleischhauer, Monika; Enge, Sören; Miller, Robert; Strobel, Alexander; Strobel, Anja
Meta-analytic data highlight the value of the Implicit Association Test (IAT) as an indirect measure of personality. Based on evidence suggesting that confounding factors such as cognitive abilities contribute to the IAT effect, this study provides a first investigation of whether basic personality traits explain unwanted variance in the IAT. In a gender-balanced sample of 204 volunteers, the Big-Five dimensions were assessed via self-report, peer-report, and IAT. By means of structural equation modeling (SEM), latent Big-Five personality factors (based on self- and peer-report) were estimated and their predictive value for unwanted variance in the IAT was examined. In a first analysis, unwanted variance was defined in the sense of method-specific variance which may result from differences in task demands between the two IAT block conditions and which can be mirrored by the absolute size of the IAT effects. In a second analysis, unwanted variance was examined in a broader sense defined as those systematic variance components in the raw IAT scores that are not explained by the latent implicit personality factors. In contrast to the absolute IAT scores, this also considers biases associated with the direction of IAT effects (i.e., whether they are positive or negative in sign), biases that might result, for example, from the IAT's stimulus or category features. None of the explicit Big-Five factors was predictive for method-specific variance in the IATs (first analysis). However, when considering unwanted variance that goes beyond pure method-specific variance (second analysis), a substantial effect of neuroticism occurred that may have been driven by the affective valence of IAT attribute categories and the facilitated processing of negative stimuli, typically associated with neuroticism. The findings thus point to the necessity of using attribute category labels and stimuli of similar affective valence in personality IATs to avoid confounding due to recoding.
Full Text Available Meta-analytic data highlight the value of the Implicit Association Test (IAT as an indirect measure of personality. Based on evidence suggesting that confounding factors such as cognitive abilities contribute to the IAT effect, this study provides a first investigation of whether basic personality traits explain unwanted variance in the IAT. In a gender-balanced sample of 204 volunteers, the Big-Five dimensions were assessed via self-report, peer-report, and IAT. By means of structural equation modeling, latent Big-Five personality factors (based on self- and peer-report were estimated and their predictive value for unwanted variance in the IAT was examined. In a first analysis, unwanted variance was defined in the sense of method-specific variance which may result from differences in task demands between the two IAT block conditions and which can be mirrored by the absolute size of the IAT effects. In a second analysis, unwanted variance was examined in a broader sense defined as those systematic variance components in the raw IAT scores that are not explained by the latent implicit personality factors. In contrast to the absolute IAT scores, this also considers biases associated with the direction of IAT effects (i.e., whether they are positive or negative in sign, biases that might result, for example, from the IAT’s stimulus or category features. None of the explicit Big-Five factors was predictive for method-specific variance in the IATs (first analysis. However, when considering unwanted variance that goes beyond pure method-specific variance (second analysis, a substantial effect of neuroticism occurred that may have been driven by the affective valence of IAT attribute categories and the facilitated processing of negative stimuli, typically associated with neuroticism. The findings thus point to the necessity of using attribute category labels and stimuli of similar affective valence in personality IATs to avoid confounding due to
Bijwaard, Govert E; Myrskylä, Mikko; Tynelius, Per; Rasmussen, Finn
A negative educational gradient has been found for many causes of death. This association may be partly explained by confounding factors that affect both educational attainment and mortality. We correct the cause-specific educational gradient for observed individual background and unobserved family factors using an innovative method based on months lost due to a specific cause of death re-weighted by the probability of attaining a higher educational level. We use data on men with brothers from the Swedish Military Conscription Registry (1951-1983), linked to administrative registers. This dataset of some 700,000 men allows us to distinguish between five education levels and many causes of death. The empirical results reveal that raising the educational level from primary to tertiary would result in an additional 20 months of survival between ages 18 and 63. This improvement in mortality is mainly attributable to fewer deaths from external causes. The highly educated gain more than nine months due to the reduction in deaths from external causes, but gain only two months due to the reduction in cancer mortality and four months due to the reduction in cardiovascular mortality. Ignoring confounding would lead to an underestimation of the gains by educational attainment, especially for the less educated. Our results imply that if the education distribution of 50,000 Swedish men from the 1951 cohort were replaced with that of the corresponding 1983 cohort, 22% of the person-years that were lost to death between ages 18 and 63 would have been saved for this cohort. Copyright © 2017 Elsevier Ltd. All rights reserved.
Knowlden, Adam P; Burns, Maranda; Harcrow, Andy; Shewmake, Meghan E
Poor sleep quality is a significant public health problem. The role of nutrition in predicting sleep quality is a relatively unexplored area of inquiry. The purpose of this study was to evaluate the capacity of 10 food choice categories, sleep confounding beverages, and psychological distress to predict the sleep quality of college students. A logistic regression model comprising 10 food choice variables (healthy proteins, unhealthy proteins, healthy dairy, unhealthy dairy, healthy grains, unhealthy grains, healthy fruits and vegetables, unhealthy empty calories, healthy beverages, unhealthy beverages), sleep confounding beverages (caffeinated/alcoholic beverages), as well as psychological distress (low, moderate, serious distress) was computed to determine the capacity of the variables to predict sleep quality (good/poor). The odds of poor sleep quality were 32.4% lower for each unit of increased frequency of healthy proteins consumed (pfrequency of healthy dairy food choices consumed (p=0.024; OR=0.859), 13.1% higher for each unit of increased frequency of empty calorie food choices consumed (p=0.003; OR=1.131), and 107.3% higher for those classified in the moderate psychological distress (p=0.016; OR=2.073). Collectively, healthy proteins, healthy dairy, unhealthy empty calories, and moderate psychological distress were moderately predictive of sleep quality in the sample (Nagelkerke R2=23.8%). Results of the study suggested higher frequency of consumption of healthy protein and healthy dairy food choices reduced the odds of poor sleep quality, while higher consumption of empty calories and moderate psychological distress increased the odds of poor sleep quality.
Bertin, Angeline; Gouin, Nicolas; Baumel, Alex; Gianoli, Ernesto; Serratosa, Juan; Osorio, Rodomiro; Manel, Stephanie
Positive species-genetic diversity correlations (SGDCs) are often thought to result from the parallel influence of neutral processes on genetic and species diversity. Yet, confounding effects of non-neutral mechanisms have not been explored. Here, we investigate the impact of non-neutral genetic diversity on SGDCs in high Andean wetlands. We compare correlations between plant species diversity and genetic diversity (GD) calculated with and without loci potentially under selection (outlier loci). The study system includes 2188 specimens from five species (three common aquatic macroinvertebrate and two dominant plant species) that were genotyped for 396 amplified fragment length polymorphism loci. We also appraise the importance of neutral processes on SGDCs by investigating the influence of habitat fragmentation features. Significant positive SGDCs were detected for all five species (mean SGDC = 0.52 ± 0.05). While only a few outlier loci were detected in each species, they resulted in significant decreases in GD and in SGDCs. This supports the hypothesis that neutral processes drive species-genetic diversity relationships in high Andean wetlands. Unexpectedly, the effects on genetic diversity GD of the habitat fragmentation characteristics in this study increased with the presence of outlier loci in two species. Overall, our results reveal pitfalls in using habitat features to infer processes driving SGDCs and show that a few loci potentially under selection are enough to cause a significant downward bias in SGDC. Investigating confounding effects of outlier loci thus represents a useful approach to evidence the contribution of neutral processes on species-genetic diversity relationships. © 2016 John Wiley & Sons Ltd.
Motosugi, Utaroh; Hernando, Diego; Wiens, Curtis; Bannas, Peter; Reeder, Scott B
To determine whether high signal-to-noise ratio (SNR) acquisitions improve the repeatability of liver proton density fat fraction (PDFF) measurements using confounder-corrected chemical shift-encoded magnetic resonance (MR) imaging (CSE-MRI). Eleven fat-water phantoms were scanned with 8 different protocols with varying SNR. After repositioning the phantoms, the same scans were repeated to evaluate the test-retest repeatability. Next, an in vivo study was performed with 20 volunteers and 28 patients scheduled for liver magnetic resonance imaging (MRI). Two CSE-MRI protocols with standard- and high-SNR were repeated to assess test-retest repeatability. MR spectroscopy (MRS)-based PDFF was acquired as a standard of reference. The standard deviation (SD) of the difference (Δ) of PDFF measured in the two repeated scans was defined to ascertain repeatability. The correlation between PDFF of CSE-MRI and MRS was calculated to assess accuracy. The SD of Δ and correlation coefficients of the two protocols (standard- and high-SNR) were compared using F-test and t-test, respectively. Two reconstruction algorithms (complex-based and magnitude-based) were used for both the phantom and in vivo experiments. The phantom study demonstrated that higher SNR improved the repeatability for both complex- and magnitude-based reconstruction. Similarly, the in vivo study demonstrated that the repeatability of the high-SNR protocol (SD of Δ = 0.53 for complex- and = 0.85 for magnitude-based fit) was significantly higher than using the standard-SNR protocol (0.77 for complex, P < 0.001; and 0.94 for magnitude-based fit, P = 0.003). No significant difference was observed in the accuracy between standard- and high-SNR protocols. Higher SNR improves the repeatability of fat quantification using confounder-corrected CSE-MRI.
Checkoway, H; Heyer, N J; Demers, P A; Gibbs, G W
OBJECTIVE: To evaluate the potential for confounding from asbestos exposure, primarily chrysotile, on the relation between crystalline silica and mortality from lung cancer among diatomaceous earth (diatomite) workers. METHODS: A reanalysis of a cohort mortality study of diatomite workers was performed to take into account quantitative estimates of asbestos exposure. The reanalysis was limited to a subset of the original cohort, comprising 2266 white men for whom asbestos exposure could be reconstructed with greatest confidence. Comparisons between mortality from lung cancer (standardised mortality ratios (SMR)) were made between rates for 1942-87 for United States white men, and workers cross classified according to cumulative exposures to crystalline silica and asbestos. Comparisons of internal rates, involving Poisson regression modeling, were conducted for exposure to crystalline silica, with and without adjustment for asbestos exposure. Exposures were lagged by 15 years to take into account disease latency. RESULTS: There was an overall excess of lung cancer (SMR 1.41; 52 observed). The SMRs for four categories of increasing crystalline silica among the workers not exposed to asbestos were 1.13, 0.87, 2.14, 2.00. An SMR of 8.31 (three observed) was found for workers with the highest cumulative exposure to both dusts. Internal analysis, after adjustment for asbestos exposure, yielded rate ratios for categories of exposure to crystalline silica: 1.00 (reference), 1.37, 1.80, and 1.79. CONCLUSIONS: Asbestos exposure was not an important confounder of the association between crystalline silica and mortality from lung cancer in this cohort. Although based on a small number of deaths from lung cancer, the data suggest possible synergy between these exposures. An extended follow up of this cohort is in progress and should enable better assessments of independent and combined effects on risk of lung cancer. PMID:8882123
Wilkening, Jennifer L; Ray, Chris; Varner, Johanna
Measurement of stress hormone metabolites in fecal samples has become a common method to assess physiological stress in wildlife populations. Glucocorticoid metabolite (GCM) measurements can be collected noninvasively, and studies relating this stress metric to anthropogenic disturbance are increasing. However, environmental characteristics (e.g., temperature) can alter measured GCM concentration when fecal samples cannot be collected immediately after defecation. This effect can confound efforts to separate environmental factors causing predeposition physiological stress in an individual from those acting on a fecal sample postdeposition. We used fecal samples from American pikas (Ochotona princeps) to examine the influence of environmental conditions on GCM concentration by (1) comparing GCM concentration measured in freshly collected control samples to those placed in natural habitats for timed exposure, and (2) relating GCM concentration in samples collected noninvasively throughout the western United States to local environmental characteristics measured before and after deposition. Our timed-exposure trials clarified the spatial scale at which exposure to environmental factors postdeposition influences GCM concentration in pika feces. Also, fecal samples collected from occupied pika habitats throughout the species' range revealed significant relationships between GCM and metrics of climate during the postdeposition period (maximum temperature, minimum temperature, and precipitation during the month of sample collection). Conversely, we found no such relationships between GCM and metrics of climate during the predeposition period (prior to the month of sample collection). Together, these results indicate that noninvasive measurement of physiological stress in pikas across the western US may be confounded by climatic conditions in the postdeposition environment when samples cannot be collected immediately after defecation. Our results reiterate the importance
Mellert, F; Preusse, C J; Haushofer, M; Winkler, K; Nill, C; Pfeiffer, D; Redel, D; Lüderitz, B; Welz, A
Transcatheter occlusion of uncomplicated atrial septum defects (ASD) is recognized as an effective and minimally invasive method. Sometimes, serious early and late complications require surgical intervention. We therefore investigated reasons and outcomes of the secondary surgical approach. 5 patients (aged 5-73 yrs) were admitted to our institution for device explantation and surgical ASD closure. ASDOS devices (A devices) had to be explanted in 4 patients and a SIDERIS "buttoned" occluder (S device) had to be explanted in 1 patient. The period from transcatheter implantation to surgical explantation ranged from 1 hour to 3 years. 3 patients (60 %) had to be operated in an emergency setting. In our youngest patient (5 yrs), the A device separated and embolized into the aorta and pulmonary artery. A pregnant women who needed emergent cesarean section developed hemopericard and tamponade due to atrial perforation by a fractured leg of an A device. In another A device, a suspect endocarditis caused membrane perforation. Malpositioning of an S device was the reason for operation. All patients recovered well without neurological symptoms. Transcatheter closure of uncomplicated ASD is a feasible alternative but surgical stand-by is essential. Nevertheless more complicated ASD should be operated, especially since the cosmetically satisfactory techniques of minimal invasive heart surgery are available.
Shah, Adil A; Haider, Adil H; Riviello, Robert; Zogg, Cheryl K; Zafar, Syed Nabeel; Latif, Asad; Rios Diaz, Arturo J; Rehman, Zia; Zafar, Hasnain
Geriatric patients remain largely unstudied in low-middle income health care settings. The purpose of this study was to compare the epidemiology and outcomes of older versus younger adults with emergency general surgical conditions in South Asia. Discharge data from March 2009 to April 2014 were obtained for all adult patients (≥16 years) with an International Classification of Diseases, 9th revision, Clinical Modification diagnosis codes consistent with an emergency general surgery condition as defined by the American Association for the Surgery of Trauma. Multivariable regression analyses compared patients >65 years of age with patients ≤65 years for differences in all-cause mortality, major complications, and duration of hospital stay. Models were adjusted for potential confounding owing to patient demographic and clinical case-mix data with propensity scores. We included 13,893 patients; patients >65 years constituted 15% (n = 2,123) of the cohort. Relative to younger patients, older adults were more likely to present with a number of emergency general surgery conditions, including gastrointestinal bleeding (odds ratio OR [95% CI], 2.63[1.99-3.46]), resuscitation (2.17 [1.67-2.80]), and peptic ulcer disease (2.09 [1.40-3.10]). They had an 89% greater risk-adjusted odds (1.89 [1.55-2.29]) of complications and a 63% greater odds (1.63 [1.21-2.20]) of mortality. Restricted to patients undergoing operative interventions, older adults had 95% greater odds (1.95 [1.29-2.94]) of complications and 117% greater odds (2.17 [1.62-2.91]) of mortality. Understanding unique needs of geriatric patients is critical to enhancing the management and prioritization of appropriate care in developing settings. Copyright © 2015 Elsevier Inc. All rights reserved.
Hunte, Haslyn ER; King, Katherine; Hicken, Margaret; Lee, Hedwig; Lewis, Ten? T
Background Research suggests that reports of interpersonal discrimination result in poor mental health. Because personality characteristics may either confound or mediate the link between these reports and mental health, there is a need to disentangle its role in order to better understand the nature of discrimination-mental health association. We examined whether hostility, anger repression and expression, pessimism, optimism, and self-esteem served as confounders in the association between ...
Luiz Carlos Almeida da Silva
Full Text Available ABSTRACT OBJECTIVE: To evaluate the clinical results of surgical treatment of intraarticular fractures of the calcaneus, comparing the use of calcaneal plate and flat plate. METHODS: This was a retrospective study assessing the postoperative results of 25 patients between 2013 and 2015. Patients undergoing surgical treatment of intraarticular fractures of the calcaneus without concomitant surgical lesions were included. Patients who did not complete appropriate follow-up after surgery were excluded from the study. RESULTS: The unavailability of calcaneal plates at resource-limited settings, associated with the availability and lower cost of flat plates, may have been a confounding factor in the present study. However, there was no statistical difference between the outcomes of fractures treated with calcaneal plates or flat plates. CONCLUSION: Statistical inference shows that, when calcaneal plates are not available, it is possible to use flat plates with similar clinical outcomes.
Van Goethem, Bart
In this thesis some recent technological developments in human surgery are evaluated for their potential use in veterinary medicine by introducing them as surgical innovations for canine gonadectomy. Barbed sutures achieve wound apposition without surgical knot tying and thus avoid knot-associated
Broekman, Marike L.|info:eu-repo/dai/nl/343152347; Carrière, Michelle E.; Bredenoord, Annelien L.|info:eu-repo/dai/nl/240834666
The aim of the present article was to systematically review the ethics of surgical innovation and introduce the components of the learning health care system to guide future research and debate on surgical innovation. Although the call for evidence-based practice in surgery is increasingly high on
'To sleep: perchance to dream', is the frequent mantra of the surgical resident. However, unlike. Hamlet, there is no ensuing speculation as to what dreams may come as there are seldom any!! Surgical residency has been both vilified and immortalized, but the fact remains that it is one of the most challenging, provocative ...
The trends of RPC work in the area of preparedness for nuclear and radiological accidents are listed. RPC in cooperation with Swedish Government developed the project on preparation for iodine prophylaxis in case of accident at Ignalina NPP and arranged seminar on emergency preparedness issues in 2001.
Bertelsen, Olav Wedege; Breinbjerg, Morten; Pold, Søren
The authors examine how materiality emerges from complex chains of mediation in creative software use. The primarily theoretical argument is inspired and illustrated by interviews with two composers of electronic music. The authors argue that computer mediated activity should not primarily...
Blom, H.A.P.; Everdij, M.H.C.; Bouarfa, S.; Cook, A; Rivas, D
In complexity science a property or behaviour of a system is called emergent if it is not a property or behaviour of the constituting elements of the system, though results from the interactions between its constituting elements. In the socio-technical air transportation system these interactions
Munk, Louise; Andersen, Lars Peter Holst; Gögenur, Ismail
Emergence delirium (ED) is a well-known phenomenon in the postoperative period. However, the literature concerning this clinical problem is limited. This review evaluates the literature with respect to epidemiology and risk factors. Treatment strategies are discussed. The review concludes...
Patel, Shaili K; Kacheriwala, Samir M; Duttaroy, Dipesh D
The objective of this study was to conduct an audit of Surgical Intensive Care Unit (SICU) for identifying the admission risk factors and evaluating the outcomes of postoperative surgical patients. This was a prospective, observational study. This study was conducted at SICU of a 1500-bedded tertiary care university hospital in Western India. Two hundred and forty patients admitted to the SICU postoperatively over a period of 15 months. Planned and unplanned postoperative SICU admission rate was 4.45% and 0.09% of the 5284 patients operated. Indications for planned admissions included preoperative medical illnesses, anticipated blood loss, and anticipated mechanical ventilation while unpredicted intraoperative hypotension was the principal cause of unplanned admittance. Univariate analysis for two groups of the American Society of Anesthesiologists (ASA) physical status indicated that advanced age, high American College of Cardiology/American Heart Association (ACC/AHA) surgical risk, emergency surgery, planned admissions, and mortality were related to high ASA class. Analysis for ACC/AHA surgical risk showed association of high ACC/AHA surgical risk with advanced age, male gender, high ASA physical status, emergency surgery, planned admissions, and mortality. High mortality was observed in patients with SICU stay of >7 days (75.86%) and readmitted cases (72.73%). The need for postoperative critical care is significantly higher in males, elderly, patients with poor preoperative risk stratification scores, preexisting medical illness, major intraoperative hemorrhage, hypotension requiring inotropic support, perioperative respiratory problems and patients undergoing abdominal, trauma, and emergent surgeries. A larger study inclusive of other surgical subspecialties would aid in optimal decision-making for admissions to the SICU.
Peponis, Thomas; Bohnen, Jordan D; Sangji, Naveen F; Nandan, Anirudh R; Han, Kelsey; Lee, Jarone; Yeh, D Dante; de Moya, Marc A; Velmahos, George C; Chang, David C; Kaafarani, Haytham M A
The emergency surgery score is a mortality-risk calculator for emergency general operation patients. We sought to examine whether the emergency surgery score predicts 30-day morbidity and mortality in a high-risk group of patients undergoing emergent laparotomy. Using the 2011-2012 American College of Surgeons National Surgical Quality Improvement Program database, we identified all patients who underwent emergent laparotomy using (1) the American College of Surgeons National Surgical Quality Improvement Program definition of "emergent," and (2) all Current Procedural Terminology codes denoting a laparotomy, excluding aortic aneurysm rupture. Multivariable logistic regression analyses were performed to measure the correlation (c-statistic) between the emergency surgery score and (1) 30-day mortality, and (2) 30-day morbidity after emergent laparotomy. As sensitivity analyses, the correlation between the emergency surgery score and 30-day mortality was also evaluated in prespecified subgroups based on Current Procedural Terminology codes. A total of 26,410 emergent laparotomy patients were included. Thirty-day mortality and morbidity were 10.2% and 43.8%, respectively. The emergency surgery score correlated well with mortality (c-statistic = 0.84); scores of 1, 11, and 22 correlated with mortalities of 0.4%, 39%, and 100%, respectively. Similarly, the emergency surgery score correlated well with morbidity (c-statistic = 0.74); scores of 0, 7, and 11 correlated with complication rates of 13%, 58%, and 79%, respectively. The morbidity rates plateaued for scores higher than 11. Sensitivity analyses demonstrated that the emergency surgery score effectively predicts mortality in patients undergoing emergent (1) splenic, (2) gastroduodenal, (3) intestinal, (4) hepatobiliary, or (5) incarcerated ventral hernia operation. The emergency surgery score accurately predicts outcomes in all types of emergent laparotomy patients and may prove valuable as a bedside decision
Nawka, Tadeus; Hosemann, Werner
Surgical procedures for voice restoration serve to improve oral communication by better vocal function. They comprise of phonomicrosurgery, with direct and indirect access to the larynx; laryngoplasty; laryngeal injections; and surgical laryngeal reinnervation. The basis for modern surgical techniques for voice disorders is the knowledge about the ultrastructure of the vocal folds and the increasing experience of surgeons in voice surgery, while facing high social and professional demands on the voice. Vocal activity limitation and participation restriction has become more important in the artistic and social areas. A number of surgical methods that have been developed worldwide for this reason, are presented in this article. Functional oriented surgery has to meet high standards. The diagnostics of vocal function has to be multi-dimensional in order to determine the indication and the appropriate surgical intervention. PMID:22073062
Full Text Available Calcaneal malunion is a common complication after conservative treatment or incorrect surgical treatment of calcaneal fracture. The typical pathoanatomies of calcaneal malunion are subtalar joint incongruity, loss of calcaneal height, arch collapse, varus or valgus deformity of the calcaneus, heel widening and so on. Calcaneal malunion often needs to be treated surgically. The classification of calcaneal malunion and the detailed clinical and radiographical assessment play important roles for surgical option. The main surgical methods include in situ subtalar arthrodesis, reconstruction of calcaneal thalamus and subtalar arthrodesis, calcaneal osteotomy with subtalar arthrodesis, corrective calcaneal osteotomy without subtalar arthrodesis. Each option has its different indications, advantages and disadvantages. Thus, the surgical treatment should be individualised.
Koyama, Atsuko; Hagopian, Laura; Linden, Judith
Emergency post-coital contraception (EC) is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD) and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method), and less commonly, mifepristone. Some options are available over-the-counter, while others require provider prescription or placement. There are no absolute contraindications to the use of emergency contraceptive pills, with the exception of ulipristal acetate and mifepristone. This article reviews the mechanisms of action, efficacy, safety, side effects, clinical considerations, and patient preferences with respect to EC usage. The decision of which regimen to use is influenced by local availability, cost, and patient preference. PMID:24453516
Full Text Available Emergency post-coital contraception (EC is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method, and less commonly, mifepristone. Some options are available over-the-counter, while others require provider prescription or placement. There are no absolute contraindications to the use of emergency contraceptive pills, with the exception of ulipristal acetate and mifepristone. This article reviews the mechanisms of action, efficacy, safety, side effects, clinical considerations, and patient preferences with respect to EC usage. The decision of which regimen to use is influenced by local availability, cost, and patient preference.
Full Text Available Colorectal surgery carries significant morbidity and mortality, which is associated with an enormous use of healthcare resources. Patients with pre-existing morbidities, and those undergoing emergency colorectal surgery due to complications such as perforation, obstruction, or ischemia / infarction are at an increased risk for adverse outcomes. Fluid therapy in emergency colorectal surgical patients can be challenging as hypovolemic and septic shock may coexist. Abdominal sepsis is a serious complication and may be diagnosed during pre-, intra-, or postoperative periods. Early suspicion and recognition of medical and / or surgical complications are essential. The critical care management of complicated colorectal surgical patients require collaborative and multidisciplinary efforts.
Procacciante, F; Picozzi, P; Fantini, A; Pacifici, M; Di Nardo, A; Ribotta, G; Delle Fave, G; Catani, M; Ruggeri, S; Romeo, F
This paper reports a case of pancreatic VIPoma with widespread hepatic metastasis which was treated for approximately 2 years with a synthetic somatostatin analog (SMS 201/995). The treatment of choice in cases in which the tumour was fully removable is surgical resection. This occurred rarely since approximately 80% of VIPomas are malignant and are operated late when local infiltration is already widespread; in addition, 50% of cases are already metastasised at diagnosis. In this case, due to the infiltration of the superior mesenteric artery by the primary tumour it was necessary to carry out a left pancreasectomy which included two-thirds of the neoplastic mass. This was justified by slow tumour growth and also facilitated control of diarrhea and ensured a greater efficacy of possible postoperative chemotherapy. The use of synthetic somatostatin analog (SMS 201/995) enabled diarrhea to be satisfactorily controlled and is therefore specifically indicated for this type of tumour. NSE serum assay (neuron specific enolase) allowed the evolution of disease to be monitored during follow-up.
Miller, Quintessa; Moulton, Michael J; Pratt, Jerry
A case report is presented of a 66-year-old white woman with a 3-month history of atypical chest pain and shortness of breath. A lateral chest radiograph demonstrated an anterior mediastinal density. A subsequent computed tomography (CT) scan revealed a mass in the right anterolateral mediastinum. Fine-needle aspiration (FNA) revealed tumor cells positive for cytokeratin and negative for leukocyte common antigen. The differential diagnosis at that time included thymoma versus thymic carcinoid. She underwent a median sternotomy with complete thymectomy. The pathology revealed a large thymoma with microinvasion into the surrounding adipose tissue. She had an uneventful postoperative course and later underwent adjuvant radiation therapy. Surgical treatment of thymoma is discussed, with emphasis on diagnosis and treatment. Although some patients may present with symptoms caused by involvement of surrounding structures, most thymomas are discovered incidentally on chest radiograph. Various diagnostic procedures can aid the surgeon in ruling out other neoplasms, such as lymphoma or germ cell tumors. Prognosis is not based on histology, but on the tumor's gross characteristics at operation. Benign tumors are noninvasive and encapsulated. All patients with potentially resectable lesions should undergo en-bloc excision. Radiation or chemotherapy should be instituted in more advanced tumors.
Xará, Daniela; Silva, Acácio; Mendonça, Júlia; Abelha, Fernando
To evaluate the frequency, determinants, and outcome of inadequate emergence after elective surgery in the Postanesthesia Care Unit (PACU). Prospective observational study. 12-bed PACU of a tertiary-care hospital in a major metropolitan area. 266 adult patients admitted to the PACU. To evaluate inadequate emergence, the Richmond Agitation and Sedation Scale (RASS) was administered to patients 10 minutes after their admission to the PACU. Demographic data, perioperative variables, and postoperative length of stay (LOS) in the PACU and the hospital were recorded. 40 (15%) patients showed symptoms of inadequate emergence: 17 patients (6.4%) screened positive for emergence delirium and 23 patients (8.6%) showed hypoactive emergence. Determinants of emergence delirium were longer duration of preoperative fasting (P = 0.001), higher visual analog scale (VAS) scores for pain (P = 0.002), and major surgical risk (P = 0.001); these patients had a higher frequency of postoperative delirium (P = 0.017) and had higher nausea VAS score 6 hours after surgery (P = 0.001). Determinants of hypoactive emergence were duration of surgery (P = 0.003), amount of crystalloids administered during surgery (P = 0.002), residual neuromuscular block (P < 0.001), high-risk surgery (P = 0.002), and lower core temperature on PACU admission (P = 0.028); these patients also had more frequent residual neuromuscular block (P < 0.001) postoperative delirium (P < 0.001), and more frequent adverse respiratory events (P = 0.02). Patients with hypoactive emergence had longer PACU and hospital LOS. Preventable determinants for emergence delirium were higher postoperative pain scores and longer fasting times. Hypoactive emergence was associated with longer postoperative PACU and hospital LOSs. © 2013 Elsevier Inc. All rights reserved.
Knowlton, Lisa Marie; Chackungal, Smita; Dahn, Bernice; LeBrun, Drake; Nickerson, Jason; McQueen, Kelly
There is a significant burden of disease in low-income countries that can benefit from surgical intervention. The goal of this survey was to evaluate the current ability of the Liberian health care system to provide safe surgical care and to identify unmet needs in regard to trained personnel, equipment, infrastructure, and outcomes measurement. A comprehensive survey tool was developed to assess physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, equipment and medications, and the capacity of the surgical system to collect and evaluate surgical outcomes at district-level hospitals in Africa. This tool was implemented in a sampling of 11 county hospitals in Liberia (January 2011). Data were obtained from the Ministry of Health and by direct government-affiliated hospital site visits. The total catchment area of the 11 hospitals surveyed was 2,313,429--equivalent to roughly 67 % of the population of Liberia (3,476,608). There were 13 major operating rooms and 34 (1.5 per 100,000 population) physicians delivering surgical, obstetric, or anesthesia care including 2 (0.1 per 100,000 population) who had completed formal postgraduate training programs in these specialty areas. The total number of surgical cases for 2010 was 7,654, with approximately 43 % of them being elective procedures. Among the facilities that tracked outcomes in 2010, a total of 11 intraoperative deaths (145 per 100,000 operative cases) were recorded for 2009. The 30-day postoperative mortality at hospitals providing data was 44 (1,359 per 100,000 operative cases). Metrics were also used to evaluate surgical output, safety of anesthesia, and the burden of obstetric disease. A significant volume of surgical care is being delivered at county hospitals throughout Liberia. The density and quality of appropriately trained personnel and infrastructure remain critically low. There is strong evidence for continued development of emergency and
) and books (e.g. Goldstein 2007; Benito and Narula 2007). This paper takes stock of the mounting trend of outward FDI from emerging economies, with special focus on a group of five countries, which are becoming increasingly economically and politically influential, viz. the ‘BRICS' countries. An ‘S......' is appended here to the conventional acronym of ‘BRIC' (Brazil, Russia, India, China) to include the largest economy on the African continent, South Africa. The five BRICS countries produced some USD25 billion of outward FDI flows in 2004, corresponding to some 3 percent of world FDI flows and well over half...... (61 percent) of total developing country outflows. OFDI from the BRICS countries has grown rapidly over the last few years, while still remaining modest compared to many developed countries. Following a brief discussion of FDI and emerging economies in general the article proceeds to hypothesise...
Suleiman Hussein Suleiman
Full Text Available Surgical intervention is an integral component in the diagnosis and management of mycetoma. Surgical treatment is indicated for small, localised lesions and massive lesions to reduce the mycetoma load and to enable better response to medical therapy. It is also a life-saving procedure in patients with massive disease and sepsis. Surgical options for mycetoma treatment range from a wide local surgical excision to repetitive debridement excisions to amputation of the affected part. Adequate anaesthesia, a bloodless field, wide local excision with adequate safety margins in a suitable surgical facility, and expert surgeons are mandatory to achieve the best surgical outcome. Surgical intervention in mycetoma is associated with considerable morbidity, deformities, and disabilities, particularly in advanced disease. These complications can be reduced by educating patients to seek medical advice earlier when the lesion is small, localised, and amenable to surgery. There is no evidence for mycetoma hospital cross infection. This communication is based on the authors' experience in managing over 7,200 mycetoma patients treated at the Mycetoma Research Centre, University of Khartoum, Sudan.
Miguel S. Guerra
Full Text Available While the prevalence of bronchiectasis has decreased significantly over recent decades in developed countries, resection for bronchiectasis still plays an important part in thoracic surgery practice in some countries, such as Portugal. Between 1994 and 2004, 51 patients (29 female and 22 male with a mean age of 38.6 years (range 4â65 years underwent pulmonary resection for bronchiectasis. Mean duration of symptoms was 4.8 years. Surgery was indicated because of unsuccessful medical therapy in 25 patients (49.1%, haemoptysis in 12 (23.5%, lung mass in 9 (17.6% and lung abscess in 5 (9.8%. The surgical treatment was pulmonectomy in 7 patients, bilobectomy in 3, lobectomy in 36 and segmentectomy in 5. There was no operative mortality. Complications occurred in 8 patients and the morbidity rate was 15.7%. Follow-up was complete in 45 (88.2% patients with a mean of 3.4 years. Overall, 35 (77.7% patients were asymptomatic after surgery, symptoms were improved in 7 (15.6%, and unchanged or worse in 3 (6.7%. Unsuccessful medical therapy was still our main indication for surgery of bronchiectasis, despite aggressive antibiotic therapy. Surgical resection was performed with acceptable morbidity and morbidity and markedly improved symptoms in the majority of patients. Resumo: A prevalÃªncia das bronquiectasias diminuiu significativamente nas Ãºltimas dÃ©cadas, principalmente nos paÃses desenvolvidos. Contudo, a ressecÃ§Ã£o cirÃºrgica Ã© ainda a alternativa terapÃªutica para um nÃºmero significativo de doentes em alguns paÃses, tais como Portugal. Entre 1994 e 2004, operÃ¡mos 51 doentes com bronquiectasias (29 mulheres e 22 homens, com idades compreendidas entre os 4 e os 65 anos (mÃ©dia= 38,6 anos. A duraÃ§Ã£o mÃ©dia dos sintomas foi de 4,8 anos e a indicaÃ§Ã£o cirÃºrgica foi: insucesso do tratamento mÃ©dico (49,1%, hemoptises (23,5%, massa pulmonar (17,6% e abcesso (9,8%. Foram realizadas 7 pneumectomias, 3
de Vries, Eefje N.; Eikens-Jansen, Manon P.; Hamersma, Alice M.; Smorenburg, Susanne M.; Gouma, Dirk J.; Boermeester, Marja A.
Objective: To assess what proportion of surgical malpractice claims might be prevented by the use of a surgical safety checklist. Background: Surgical disciplines are overrepresented in the distribution of adverse events. The recently described multidisciplinary SURgical PAtient Safety System
Schwaller, Pedro; Weiler, Andreas
In this work, we propose a novel search strategy for new physics at the LHC that utilizes calorimeter jets that (i) are composed dominantly of displaced tracks and (ii) have many different vertices within the jet cone. Such emerging jet signatures are smoking guns for models with a composite dark sector where a parton shower in the dark sector is followed by displaced decays of dark pions back to SM jets. No current LHC searches are sensitive to this type of phenomenology. We perform a detailed simulation for a benchmark signal with two regular and two emerging jets, and present and implement strategies to suppress QCD backgrounds by up to six orders of magnitude. At the 14 TeV LHC, this signature can be probed with mediator masses as large as 1.5 TeV for a range of dark pion lifetimes, and the reach is increased further at the high-luminosity LHC. The emerging jet search is also sensitive to a broad class of long-lived phenomena, and we show this for a supersymmetric model with R-parity violation. Possibilit...
Lopes, Antonio Alberto; Tong, Lin; Thumma, Jyothi; Li, Yun; Fuller, Douglas S.; Morgenstern, Hal; Bommer, Jürgen; Kerr, Peter G; Tentori, Francesca; Akiba, Takashi; Gillespie, Brenda; Robinson, Bruce M.; Port, Friedrich K; Pisoni, Ronald L.
residual confounding. Conclusions Longer survival and better nutritional status were observed for MHD patients prescribed PBs and in facilities with greater percentage PB prescription. Understanding the mechanisms for explaining this effect and ruling out possible residual confounding require additional research. PMID:22385781
Aarabi, Ardalan; Osharina, Victoria; Wallois, Fabrice
Slow and rapid event-related designs are used in fMRI and functional near-infrared spectroscopy (fNIRS) experiments to temporally characterize the brain hemodynamic response to discrete events. Conventional averaging (CA) and the deconvolution method (DM) are the two techniques commonly used to estimate the Hemodynamic Response Function (HRF) profile in event-related designs. In this study, we conducted a series of simulations using synthetic and real NIRS data to examine the effect of the main confounding factors, including event sequence timing parameters, different types of noise, signal-to-noise ratio (SNR), temporal autocorrelation and temporal filtering on the performance of these techniques in slow and rapid event-related designs. We also compared systematic errors in the estimates of the fitted HRF amplitude, latency and duration for both techniques. We further compared the performance of deconvolution methods based on Finite Impulse Response (FIR) basis functions and gamma basis sets. Our results demonstrate that DM was much less sensitive to confounding factors than CA. Event timing was the main parameter largely affecting the accuracy of CA. In slow event-related designs, deconvolution methods provided similar results to those obtained by CA. In rapid event-related designs, our results showed that DM outperformed CA for all SNR, especially above -5 dB regardless of the event sequence timing and the dynamics of background NIRS activity. Our results also show that periodic low-frequency systemic hemodynamic fluctuations as well as phase-locked noise can markedly obscure hemodynamic evoked responses. Temporal autocorrelation also affected the performance of both techniques by inducing distortions in the time profile of the estimated hemodynamic response with inflated t-statistics, especially at low SNRs. We also found that high-pass temporal filtering could substantially affect the performance of both techniques by removing the low-frequency components of
Ide, Takeshi; Kinugawa, Yoshitaka; Nobae, Yuichi; Suzuki, Toshihiro; Tanaka, Yoshiyuki; Toda, Ikuko; Tsubota, Kazuo
Background: Blue light has more energy than longer wavelength light and can penetrate the eye to reach the retina. When surgeons use magnifying loupes under intensive surgical shadowless lamps for better view of the surgical field, the total luminance is about 200 times brighter than that of typical office lighting. In this study, the effects of 2 types of shadowless lamps were compared. Moreover, the effect of various eyeglasses, which support magnifying loupes, on both the light energy and ...
During the Great War, the French surgeon Alexis Carrel, in collaboration with the English chemist Henry Dakin, devised an antiseptic treatment for infected wounds. This paper focuses on Carrel's attempt to standardise knowledge of infected wounds and their treatment, and looks closely at the vision of surgical skill he espoused and its difference from those associated with the doctrines of scientific management. Examining contemporary claims that the Carrel-Dakin method increased rather than diminished demands on surgical work, this paper further shows how debates about antiseptic wound treatment opened up a critical space for considering the nature of skill as a vital dynamic in surgical innovation and practice.
Muff, Christine; Dragano, N; Jöckel, K-H; Moebus, S; Möhlenkamp, S; Erbel, R; Mann, K; Siegrist, J
As smoking and unhealthy diet are more prevalent in lower socioeconomic groups, this study aims at exploring whether associations between smoking and fruit and vegetable consumption are confounded by socioeconomic conditions or if smoking is independently associated with consumption. Cross-sectional analyses of 4,814 middle-aged participants from the Heinz Nixdorf recall study, a population-based cohort study in Germany. Fruit and vegetable consumption was assessed by a food frequency questionnaire. Education and income were used as indicators for socioeconomic groups. Logistic regression models were run to estimate odds ratios for consumption by smoking status. Smoking is associated with poor consumption of fruits and raw vegetables/salad in both genders, and with poor consumption of boiled vegetables and fruit/vegetable juice in men. Importantly, poor consumption is related to smoking independently of people's socioeconomic conditions. The findings imply that smokers in all socioeconomic groups are at higher risk for unhealthy intake of fruits and vegetables. Public health interventions targeted to smokers should include dietary instructions.
Full Text Available Brain-derived neurotrophic factor (BDNF plays a role in the maintenance and function of neurons. Although persons with Alzheimer's disease have lower cortical levels of BDNF, evidence regarding the association between circulating BDNF and cognitive function is conflicting. We sought to determine the correlates of BDNF level and whether BDNF level was prospectively associated with cognitive decline in healthy older adults. We measured serum BDNF near baseline in 912 individuals. Cognitive status was assessed repeatedly with the modified Mini-Mental Status Examination and the Digit Symbol Substitution test over the next 10 years. We evaluated the association between BDNF and cognitive decline with longitudinal models. We also assessed the association between BDNF level and demographics, comorbidities and health behaviors. We found an association between serum BDNF and several characteristics that are also associated with dementia (race and depression, suggesting that future studies should control for these potential confounders. We did not find evidence of a longitudinal association between serum BDNF and subsequent cognitive test trajectories in older adults, although we did identify a potential trend toward a cross-sectional association. Our results suggest that serum BDNF may have limited utility as a biomarker of prospective cognitive decline.
Olesen, Charlotte; de Vries, Corinne S; Thrane, Nana; MacDonald, Tom M; Larsen, Helle; Sørensen, Henrik Toft
Aims The diabetogenic effect of diuretics, as well as the indication for prescribing them, may impact on fetal growth. We analysed whether the purchase of prescription drugs for diuretics during pregnancy was associated with measures of fetal growth. Methods During 1991–98 all women who purchased prescription drugs for diuretics during pregnancy were identified in the Northern Jutland Prescription Database (NJDP), Denmark, and in the Medicines Monitoring Unit's Database (MEMO), Scotland. Information on birth weight and gestational age was obtained from the Danish Birth Registry, the Danish Hospital Discharge Registry and the Scottish Tayside Neonatal Database. Information on diabetes, hypertension and prepregnancy weight were obtained by hospital record review in a sample of women in the Danish cohort. Women who did not purchase prescription diuretics during pregnancy were used as a reference group in both cohorts. Results Danish women who purchased prescription loop diuretics during pregnancy gave birth to infants with higher birth weights than women who did not use diuretics; mean difference 104.7 g (95% CI; 2.6, 206.9). However, the high prevalence of diabetes (10.3%) among Danish women who purchased prescription loop diuretics during pregnancy might explain this result. Both the Danish and the Scottish women who purchased prescription diuretics during their pregnancy were at increased risk of preterm delivery (diuretics during pregnancy was associated with differences in birth weight and incidence of preterm delivery. Confounding by indication may explain the findings. PMID:11259987
Blocker, Tomica D.; Ophir, Alexander G.
Contaminants, like pesticides, polychlorinated biphenyls (PCBs), dioxins and metals, are persistent and ubiquitous and are known to threaten the environment. Traditionally, scientists have considered the direct physiological risks that these contaminants pose. However, scientists have just begun to integrate ethology and toxicology to investigate the effects that contaminants have on behavior. This review considers the potential for contaminant effects on mating behavior. Here we assess the growing body of research concerning disruptions in sexual differentiation, courtship, sexual receptivity, arousal, and mating. We discuss the implications of these disruptions on conservation efforts and highlight the importance of recognizing the potential for environmental stressors to affect behavioral experimentation. More specifically, we consider the negative implications for anthropogenic contaminants to affect the immediate behavior of animals, and their potential to have cascading and/or long-term effects on the behavioral ecology and evolution of populations. Overall, we aim to raise awareness of the confounding influence that contaminants can have, and promote caution when interpreting results where the potential for cryptic affects are possible. PMID:24244068
Full Text Available We used Support Vector Machine (SVM to perform multivariate pattern classification based on brain activation during emotional processing in healthy participants with subclinical depressive symptoms. Six-hundred undergraduate students completed the Beck Depression Inventory II (BDI-II. Two groups were subsequently formed: (i subclinical (mild mood disturbance (n = 17 and (ii no mood disturbance (n = 17. Participants also completed a self-report questionnaire on subclinical psychotic symptoms, the Community Assessment of Psychic Experiences Questionnaire (CAPE positive subscale. The functional magnetic resonance imaging (fMRI paradigm entailed passive viewing of negative emotional and neutral scenes. The pattern of brain activity during emotional processing allowed correct group classification with an overall accuracy of 77% (p = 0.002, within a network of regions including the amygdala, insula, anterior cingulate cortex and medial prefrontal cortex. However, further analysis suggested that the classification accuracy could also be explained by subclinical psychotic symptom scores (correlation with SVM weights r = 0.459, p = 0.006. Psychosis proneness may thus be a confounding factor for neuroimaging studies in subclinical depression.
Gualniera, Patrizia; Scurria, Serena
Retained surgical sponge events continue to occur despite the implementation of preventive surgical count policies, procedures, and adjunct technologies to manual counting. Such intraoperative mistakes can cause chronic nonspecific symptoms during the early postoperative period. When discovered years after surgery, they raise thorny medicolegal questions. We describe two cases from our practice that illustrate the need to identify the responsibility of the surgical team, as delineated in ministerial directives and the current legal framework, as well as the difficulty in evaluating clinical actions taken at different times and in different settings, with regard to the permanent health damage incurred by sponge retention. Finally, we discuss prevention actions operating room staff should take to reduce the risk of retained surgical sponges. Copyright © 2018 Elsevier B.V. All rights reserved.
Full Text Available In recent years, there has been a worldwide increase in childhood obesity. At present, pediatric surgeons manage a greater number of pediatric patients who are significantly overweight. Little data exist regarding the surgical challenges of obese children. This review study was designed to examine the relationship of obesity to surgical comorbidities, postoperative complications, and perioperative outcome in children, and to pediatric trauma. Obesity seems to be an independent risk factor in surgical-related pediatric morbidity and should be considered an important variable when looking at surgical outcomes in the pediatric population. Identification by and awareness among pediatric surgeons, of increased risk factors for peri/postoperative complications, will be crucial in optimizing the hospital stay and outcome of these children.
Soler, Luc; Marescaux, Jacques
Technological innovations of the twentieth century have provided medicine and surgery with new tools for education and therapy definition. Thus, by combining Medical Imaging and Virtual Reality, patient-specific applications providing preoperative surgical simulation have become possible.
Gundel, Ossian; Gundersen, Sofie Kirchhoff; Dahl, Rikke Maria
. The aim of this study was to investigate the diagnostic timing of surgical site infections and pulmonary complications after laparotomy. MATERIAL AND METHODS: This is a secondary analysis of the PROXI trial which was a randomized clinical trial conducted in 1400 patients undergoing elective or emergent......BACKGROUND: Surgical site infection (SSI) and other postoperative complications are associated with high costs, morbidity, secondary surgery, and mortality. Many studies have identified factors that may prevent SSI and pulmonary complications, but it is important to know when they in fact occur...... laparotomy. Patients were randomly allocated to either 80% or 30% perioperative inspiratory oxygen fraction. RESULTS: SSI or pulmonary complications were diagnosed in 24.2% (95% CI: 22.0%-26.5%) of the patients at a median of 9 days [IQR: 5-15] after surgery. Most common was surgical site infection (19...
Background Research suggests that reports of interpersonal discrimination result in poor mental health. Because personality characteristics may either confound or mediate the link between these reports and mental health, there is a need to disentangle its role in order to better understand the nature of discrimination-mental health association. We examined whether hostility, anger repression and expression, pessimism, optimism, and self-esteem served as confounders in the association between perceived interpersonal discrimination and CESD-based depressive symptoms in a race/ethnic heterogeneous probability-based sample of community-dwelling adults. Methods We employed a series of ordinary least squares regression analyses to examine the potential confounding effect of hostility, anger repression and expression, pessimism, optimism, and self-esteem between interpersonal discrimination and depressive symptoms. Results Hostility, anger repression, pessimism and self-esteem were significant as possible confounders of the relationship between interpersonal discrimination and depressive symptoms, together accounting for approximately 38% of the total association (beta: 0.1892, p interpersonal discrimination remained a positive predictor of depressive symptoms (beta: 0.1176, p personality characteristics in the association between reports of interpersonal discrimination and mental health, our results suggest that personality-related characteristics may serve as potential confounders. Nevertheless, our results also suggest that, net of these characteristics, reports of interpersonal discrimination are associated with poor mental health. PMID:24256578
Hunte, Haslyn E R; King, Katherine; Hicken, Margaret; Lee, Hedwig; Lewis, Tené T
Research suggests that reports of interpersonal discrimination result in poor mental health. Because personality characteristics may either confound or mediate the link between these reports and mental health, there is a need to disentangle its role in order to better understand the nature of discrimination-mental health association. We examined whether hostility, anger repression and expression, pessimism, optimism, and self-esteem served as confounders in the association between perceived interpersonal discrimination and CESD-based depressive symptoms in a race/ethnic heterogeneous probability-based sample of community-dwelling adults. We employed a series of ordinary least squares regression analyses to examine the potential confounding effect of hostility, anger repression and expression, pessimism, optimism, and self-esteem between interpersonal discrimination and depressive symptoms. Hostility, anger repression, pessimism and self-esteem were significant as possible confounders of the relationship between interpersonal discrimination and depressive symptoms, together accounting for approximately 38% of the total association (beta: 0.1892, p discrimination remained a positive predictor of depressive symptoms (beta: 0.1176, p discrimination and mental health, our results suggest that personality-related characteristics may serve as potential confounders. Nevertheless, our results also suggest that, net of these characteristics, reports of interpersonal discrimination are associated with poor mental health.
Full text: There are numerous conditions that affect mainly or exclusively the pediatric population. These constitute true emergencies, related to patient's health. Delay in diagnosis and treatment of abdominal non-traumatic emergencies may result in rapid deterioration, peritonitis, sepsis, even death or in severe complications with subsequent morbidity. Abdominal emergencies in children mostly present with pain, tenderness, occasionally coupled by vomiting, fever, abdominal distension, and failure to pass meconium or stools. Diarrhea, blood per rectum, abnormal laboratory tests and lethargy may also be manifestations of acute abdominal conditions. Abdominal emergencies have a different aetiology, depending on age and whether the pain is acute or chronic. Symptoms have to be matched with age and gender. Newborns up to 1 months of age may have congenital diseases: atresia, low obstruction including Hirschsprung's disease, meconium ileus. Meconium plug is one of the commonest cause of low obstruction in newborns that may also develop necrotizing enterocolitis, incarcerated inguinal hernia and mid-gut volvulus. Past the immediate postnatal period, any duodenal obstruction should be considered midgut volvulus until proven otherwise and patients should undergo ultrasonography and/or properly performed upper GI contrast study that records the exact position of the deduno-jejunal junction. Infants 6 months-2 years carry the risk of intussusception, mid-gut volvulus, perforation, acute pyelonephritis. Preschool and school-aged children 2-12 years carry the risk of appendicitis, genito-urinary abnormalities including torsion, urachal abnormalities, haemolytic uremic syndrome and Henoch-Schonlein purpura. Children above 12 years suffer from the same conditions as in adults. Most conditions may affect any age despite age predilection. Abdominal solid organ ultrasonography (US) coupled with gastrointestinal ultrasonography is the principle imaging modality in radiosensitive
Stoneham, M; Murray, D; Foss, N
undertaken on elderly patients with limited physiological reserve. National audits have reported variations in care quality, data that are increasingly being used to drive quality improvement through professional guidance. Given that the number of elderly patients presenting for emergency surgery is likely...... to rise as the population ages, this review summarises the evidence on which such guidance is based, and provides information about how anaesthetists might participate in audit and research aimed at improving local and national outcomes for these most vulnerable of patients....