An Investigation into the Decision Makers's Risk Attitude Index Ranking Technique for Fuzzy Critical Path Analysis. ... Nigerian Journal of Technology ... for a benchmark problem, the decision maker's risk attitude index ranking method produces unrealistic results when the decision maker's attitude towards risk was neutral.
Eduardsen, Jonas Strømfeldt; Marinova, Svetla Trifonova
This study examines the risk perception of decision-makers in small and medium sized enterprises (SMEs) and the factors underlying these perceptions in the process of internationalization of their firms. While risk perception has been identified as a potential predictor variable...... in internationalisation research, very little work has been done exploring the factors and processes that shape decision-makers’ perception of risk. A qualitative interview-based approach was adopted by collecting data from thirty-two Danish SMEs operating in four different industries. Findings suggest that while risk...... awareness exists, decision-makers do not perceive internationalisation as risky behaviour. Findings highlight the importance of decision-makers’ background, including cognitive and psychological characteristics, such as self-efficacy and locus of control, and their experiences in explaining risk perceptions...
B. Kaynar; S.I. Birbil (Ilker); J.B.G. Frenk (Hans)
textabstractIn this paper portfolio problems with linear loss functions and multivariate elliptical distributed returns are studied. We consider two risk measures, Value-at-Risk and Conditional-Value-at-Risk, and two types of decision makers, risk neutral and risk averse. For Value-at-Risk, we show
Matte, Simon; Boucher, Marie-Amélie; Boucher, Vincent; Fortier-Filion, Thomas-Charles
A large effort has been made over the past 10 years to promote the operational use of probabilistic or ensemble streamflow forecasts. It has also been suggested in past studies that ensemble forecasts might possess a greater economic value than deterministic forecasts. However, the vast majority of recent hydro-economic literature is based on the cost-loss ratio framework, which might be appealing for its simplicity and intuitiveness. One important drawback of the cost-loss ratio is that it implicitly assumes a risk-neutral decision maker. By definition, a risk-neutral individual is indifferent to forecasts' sharpness: as long as forecasts agree with observations on average, the risk-neutral individual is satisfied. A risk-averse individual, however, is sensitive to the level of precision (sharpness) of forecasts. This person is willing to pay to increase his or her certainty about future events. In fact, this is how insurance companies operate: the probability of seeing one's house burn down is relatively low, so the expected cost related to such event is also low. However, people are willing to buy insurance to avoid the risk, however small, of loosing everything. Similarly, in a context where people's safety and property is at stake, the typical decision maker is more risk-averse than risk-neutral. Consequently, the cost-loss ratio is not the most appropriate tool to assess the economic value of flood forecasts. This presentation describes a more realistic framework for assessing the economic value of such forecasts for flood mitigation purposes. Borrowing from economics, the Constant Absolute Risk Aversion utility function (CARA) is the central tool of this new framework. Utility functions allow explicitly accounting for the level of risk aversion of the decision maker and fully exploiting the information related to ensemble forecasts' uncertainty. Three concurrent ensemble streamflow forecasting systems are compared in terms of quality (comparison with
Geubbels, Eveline L. P. E.; Grobbee, Diederick E.; Vandenbroucke-Grauls, Christina M. J. E.; Wille, Jan C.; de Boer, Annette S.
OBJECTIVE: To develop prognostic models for improved risk adjustment in surgical site infection surveillance for 5 surgical procedures and to compare these models with the National Nosocomial Infection Surveillance system (NNIS) risk index. DESIGN: In a multicenter cohort study, prospective
Jansen, Anika; Pfeifer, Harald; Raecke, Julia
In this paper, we study the relation between decision makers’ preferences and training investments of their firms. First, we develop a theoretical framework, which takes the possibility into account that individual preferences of decision makers may influence firm behavior with respect to training.
Jansen, Anika; Pfeifer, Harald; Raecke, Julia
In this paper, we study the relation between decision makers’ preferences and training investments of their firms. First, we develop a theoretical framework, which takes the possibility into account that individual preferences of decision makers may influence firm behavior with respect to training.
Genther, Dane J; Papel, Ira D
Rhinoplasty often requires the use of grafting material, and the goal of the specific graft dictates the ideal characteristics of the material to be used. An ideal material would be biologically inert, resistant to infection, noncarcinogenic, nondegradable, widely available, cost-effective, readily modifiable, and easily removable, have compatible biomechanical characteristics, retain physical properties over time, and not migrate. Unfortunately, no material currently in existence meets all of these criteria. In modern rhinoplasty, autologous grafts are the gold standard against which all other nasal implants are measured and offer the safest long-term results for most patients. They are easily manipulated, have inherent stability and biomechanical characteristics similar to the native nasal framework, and confer minimal risk of complications. Modern homologous and alloplastic materials have gained considerable support in recent years because they are readily available in endless quantity, do not require a second surgical site for harvest, and are generally considered safe if most circumstances, but they confer additional risk and have biomechanical characteristics different from that of the native nasal framework. To address some of these issues, we provide a contemporary review of autologous, homologous, and alloplastic materials commonly used in rhinoplasty surgery. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Frewer, L.J.; Fischer, A.R.H.; Brink, van den P.J.; Byrne, P.; Brock, T.C.M.; Brown, C.; Crocker, J.; Goerlitz, G.; Hart, A.; Scholderer, J.; Solomon, K.
In the area of risk assessment associated with ecotoxicological and plant protection products, probabilistic risk assessment (PRA) methodologies have been developed that enable quantification of variability and uncertainty. Despite the potential advantages of these new methodologies, end-user and
Matte, Simon; Boucher, Marie-Amélie; Boucher, Vincent; Fortier Filion, Thomas-Charles
A large effort has been made over the past 10 years to promote the operational use of probabilistic or ensemble streamflow forecasts. Numerous studies have shown that ensemble forecasts are of higher quality than deterministic ones. Many studies also conclude that decisions based on ensemble rather than deterministic forecasts lead to better decisions in the context of flood mitigation. Hence, it is believed that ensemble forecasts possess a greater economic and social value for both decision makers and the general population. However, the vast majority of, if not all, existing hydro-economic studies rely on a cost-loss ratio framework that assumes a risk-neutral decision maker. To overcome this important flaw, this study borrows from economics and evaluates the economic value of early warning flood systems using the well-known Constant Absolute Risk Aversion (CARA) utility function, which explicitly accounts for the level of risk aversion of the decision maker. This new framework allows for the full exploitation of the information related to a forecasts' uncertainty, making it especially suited for the economic assessment of ensemble or probabilistic forecasts. Rather than comparing deterministic and ensemble forecasts, this study focuses on comparing different types of ensemble forecasts. There are multiple ways of assessing and representing forecast uncertainty. Consequently, there exist many different means of building an ensemble forecasting system for future streamflow. One such possibility is to dress deterministic forecasts using the statistics of past error forecasts. Such dressing methods are popular among operational agencies because of their simplicity and intuitiveness. Another approach is the use of ensemble meteorological forecasts for precipitation and temperature, which are then provided as inputs to one or many hydrological model(s). In this study, three concurrent ensemble streamflow forecasting systems are compared: simple statistically dressed
Behrens, Thomas; Kendzia, Benjamin; Treppmann, Tabea; Olsson, Ann; Jöckel, Karl-Heinz; Gustavsson, Per; Pohlabeln, Hermann; Ahrens, Wolfgang; Brüske, Irene; Wichmann, Hans-Erich; Merletti, Franco; Mirabelli, Dario; Richiardi, Lorenzo; Simonato, Lorenzo; Zaridze, David; Szeszenia-Dabrowska, Neonila; Rudnai, Peter; Lissowska, Jolanta; Fabianova, Eleonora; Tardón, Adonina; Field, John; Stanescu Dumitru, Rodica; Bencko, Vladimir; Foretova, Lenka; Janout, Vladimir; Siemiatycki, Jack; Parent, Marie-Elise; McLaughlin, John; Demers, Paul; Landi, Maria Teresa; Caporaso, Neil; Kromhout, Hans; Vermeulen, Roel; Peters, Susan; Benhamou, Simone; Stücker, Isabelle; Guida, Florence; Consonni, Dario; Bueno-de-Mesquita, Bas; 't Mannetje, Andrea; Pearce, Neil; Tse, Lap Ah; Yu, Ignatius Tak-sun; Plato, Nils; Boffetta, Paolo; Straif, Kurt; Schüz, Joachim; Pesch, Beate; Brüning, Thomas
Some studies have suggested increased lung cancer risks among bakers, however the results overall were inconsistent. The authors studied lung cancer risks among bakers and baking-related occupations in the SYNERGY pooled case-control database from 16 countries. Occupation in a baking-related job was identified from the subjects' job histories. ORs adjusted for log(age), study centre, smoking behaviour and ever employment in a job with known exposure to occupational lung carcinogens were calculated by unconditional logistic regression. Findings were stratified by sex, histological subtype of lung cancer and smoking status. 19 366 cases (15 606 men) and 23 670 control subjects (18 528 men) were included. 473 cases (415 men, 58 women) and 501 controls (437 men, 64 women) had ever worked in baking or a related job. We did not observe an increased risk for men in baking (OR 1.01; 95% CI 0.86 to 1.18). No linear trends were observed for duration of employment. Some results suggested increased lung cancer risks for women, for example, for working as a baker for >30 years and in never-smokers, but after exclusion of one study these increased risks disappeared. The findings from this study do not suggest increased lung cancer risks in baking-related professions.
Carl van Walraven
Full Text Available Surgical site infections (SSI are an important cause of peri-surgical morbidity with risks that vary extensively between patients and surgeries. Quantifying SSI risk would help identify candidates most likely to benefit from interventions to decrease the risk of SSI.We randomly divided all surgeries recorded in the National Surgical Quality Improvement Program from 2010 into a derivation and validation population. We used multivariate logistic regression to determine the independent association of patient and surgical covariates with the risk of any SSI (including superficial, deep, and organ space SSI within 30 days of surgery. To capture factors particular to specific surgeries, we developed a surgical risk score specific to all surgeries having a common first 3 numbers of their CPT code.Derivation (n = 181 894 and validation (n = 181 146 patients were similar for all demographics, past medical history, and surgical factors. Overall SSI risk was 3.9%. The SSI Risk Score (SSIRS found that risk increased with patient factors (smoking, increased body mass index, certain comorbidities (peripheral vascular disease, metastatic cancer, chronic steroid use, recent sepsis, and operative characteristics (surgical urgency; increased ASA class; longer operation duration; infected wounds; general anaesthesia; performance of more than one procedure; and CPT score. In the validation population, the SSIRS had good discrimination (c-statistic 0.800, 95% CI 0.795-0.805 and calibration.SSIRS can be calculated using patient and surgery information to estimate individual risk of SSI for a broad range of surgery types.
Superficial SSI was the most commonly observed type, 54.8%. Overall HIV prevalence in this study was 16.9% with a 5 times risk of developing SSI. Conclusions: Surgical site infection has remained a major Nosocomial infection in developing countries. Factors shown to be associated with increased risk are wound class, ...
Segers, P.; de Jong, A. P.; Kloek, J. J.; Spanjaard, L.; de Mol, B. A. J. M.
The purpose of this prospective study was to investigate whether a risk control programme based on risk assessment, new treatment modalities and the presence of a surveillance programme reduces the incidence of surgical site infections (SSI). Between January 2001 and December 2003, 167 patients were
Angeles-Garay, Ulises; Morales-Márquez, Lucy Isabel; Sandoval-Balanzarios, Miguel Antonio; Velázquez-García, José Arturo; Maldonado-Torres, Lulia; Méndez-Cano, Andrea Fernanda
The risk factors for surgical site infections in surgery should be measured and monitored from admission to 30 days after the surgical procedure, because 30% of Surgical Site Infection is detected when the patient was discharged. Calculate the Relative Risk of associated factors to surgical site infections in adult with elective surgery. Patients were classified according to the surgery contamination degree; patient with surgery clean was defined as no exposed and patient with clean-contaminated or contaminated surgery was defined exposed. Risk factors for infection were classified as: inherent to the patient, pre-operative, intra-operative and post-operative. Statistical analysis; we realized Student t or Mann-Whitney U, chi square for Relative Risk (RR) and multivariate analysis by Cox proportional hazards. Were monitored up to 30 days after surgery 403 patients (59.8% women), 35 (8.7%) developed surgical site infections. The factors associated in multivariate analysis were: smoking, RR of 3.21, underweight 3.4 hand washing unsuitable techniques 4.61, transfusion during the procedure 3.22, contaminated surgery 60, and intensive care stay 8 to 14 days 11.64, permanence of 1 to 3 days 2.4 and use of catheter 1 to 3 days 2.27. To avoid all risk factors is almost impossible; therefore close monitoring of elective surgery patients can prevent infectious complications.
Mueck, Krislynn M; Kao, Lillian S
Surgical site infections (SSIs) are a significant healthcare quality issue, resulting in increased morbidity, disability, length of stay, resource utilization, and costs. Identification of high-risk patients may improve pre-operative counseling, inform resource utilization, and allow modifications in peri-operative management to optimize outcomes. Review of the pertinent English-language literature. High-risk surgical patients may be identified on the basis of individual risk factors or combinations of factors. In particular, statistical models and risk calculators may be useful in predicting infectious risks, both in general and for SSIs. These models differ in the number of variables; inclusion of pre-operative, intra-operative, or post-operative variables; ease of calculation; and specificity for particular procedures. Furthermore, the models differ in their accuracy in stratifying risk. Biomarkers may be a promising way to identify patients at high risk of infectious complications. Although multiple strategies exist for identifying surgical patients at high risk for SSIs, no one strategy is superior for all patients. Further efforts are necessary to determine if risk stratification in combination with risk modification can reduce SSIs in these patient populations.
Chapman, Andy R; Litton, Edward; Chamberlain, Jenny; Ho, Kwok M
The purpose of this study is to determine whether varying the format used to present prognostic data alters the perception of risk among surrogate decision makers in the intensive care unit (ICU). This was a prospective randomized comparative trial conducted in a 23-bed adult tertiary ICU. Enrolled surrogate decision makers were randomized to 1 of 2 questionnaires, which presented hypothetical ICU scenarios, identical other than the format in which prognostic data were presented (eg, frequencies vs percentages). Participants were asked to rate the risk associated with each prognostic statement. We enrolled 141 surrogate decision makers. The perception of risk varied significantly dependent on the presentation format. For "quantitative data," risks were consistently perceived as higher, when presented as frequencies (eg, 1 in 50) compared with equivalent percentages (eg, 2%). Framing "qualitative data" in terms of chance of "death" rather than "survival" led to a statistically significant increase in perceived risks. Framing "quantitative" data in this way did not significantly affect risk perception. Data format had a significant effect on how surrogate decision makers interpreted risk. Qualitative statements are interpreted widely and affected by framing. Where possible, multiple quantitative formats should be used for presenting prognostic information. Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.
BACKGROUND: Deep vein thrombosis (DVT) is a cause of preventable morbidity and mortality in hospitalized surgical patients. The occurrence of the disease is related to presence of risk factors, which are related primarily to trauma, venous stasis and hyper-coagulability. DVT seems not to be taken seriously by many ...
It is recommended that preoperative hospital stay should be as short as possible and extra care/precautions taken when working on the elderly, using implants or requiring drainage. Keywords: Clean orthopaedic operations, risk factors, surgical site infection. Nigerian Journal of Clinical Practice • Oct-Dec 2013 • Vol 16 ...
Sanz-Reig, J; Salvador Marín, J; Ferrández Martínez, J; Orozco Beltrán, D; Martínez López, J F
To identify pre-operative risk factors for surgical delay of more than 2 days after admission in patients older than 65 years with a hip fracture. A prospective observational study was conducted on 180 hip fractures in patients older than 65 years of age admitted to our hospital from January 2015 to April 2016. The data recorded included, patient demographics, day of admission, pre-fracture comorbidities, mental state, level of mobility and physical function, type of fracture, antiaggregant and anticoagulant medication, pre-operative haemoglobin value, type of treatment, and surgical delay. The mean age of the patients was 83.7 years. The mean Charlson Index was 2.8. The pre-fracture baseline co-morbidities were equal or greater than 2 in 70% of cases. Mean timing of surgery was 3.1 days. At the time of admission, 122 (67.7%) patients were fit for surgery, of which 80 (44.4%) underwent surgery within 2 days. A Charlson index greater than 2, anticoagulant therapy, and admission on Thursday to Saturday, were independently associated with a surgical delay greater than 2 days. The rate of hip fracture patients undergoing surgery within 2 days is low. Risk factors associated to surgical delay are non-modifiable. However, their knowledge should allow the development of protocols that can reduce surgical delay in this group of patients. Copyright © 2017 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.
Kuy, SreyRam; Romero, Ramon A L
The Overton Brooks VA Medical Center Surgical Service had a high mortality. In an effort to reduce surgical mortality, we implemented a series of quality improvement interventions, including utilization of the ACS Surgical Risk Calculator to identify high-risk surgical patients for discussion in a multidisciplinary Pre-Operative Consultation Committee. Retrospective study describing the implementation of a risk stratification intervention incorporating the ACS Surgical Risk Calculator Tool and a multidisciplinary Pre-Operative Consultation Committee to target high-risk patients. Measurement of 30 day surgical mortality and risk adjusted Observed to Expected (O/E) mortality ratio. From May 2013 to September 2014, 614 high-risk patients were selected utilizing the ACS Risk Calculator and presented at the Pre-Operative Consultation Committee. Following implementation of this risk stratification intervention, 30-day mortality decreased by 66% from 0.9% to 0.3%, and risk adjusted O/E mortality ratio decreased from 2.5 to 0.8. Among the high risk patients presented, there was no increase in referrals to other facilities. There was a significant increase in cases requiring further preoperative optimization, from 6.3% at the beginning of the study period to 17.5% at the end of the study period. Implementation of a preoperative risk stratification intervention utilizing the ACS Surgical Risk Calculator along with a multidisciplinary Pre-Operative Consultation Committee can be successfully accomplished, with a significant decrease in 30-day surgical mortality. This is the first published report of utilization of the ACS Risk calculator as part of a systematic quality improvement tool to decrease surgical mortality. Published by Elsevier Inc.
Diaconu, C; Livadariu, Roxana-Maria; Dogaru, C
The aim of this study is to emphasize the importance of knowing the predisposing factors of the occurrence of homolateral upper limb lymphedema after breast cancer surgery. The study included 1104 patients with breast cancer, who were hospitalized in the IIIrd Surgical Clinic, lasi, between 2000 and 2010, for surgical treatment followed by oncological adjuvant therapy. The surgical intervention was conservative in 228 cases and modified radical mastectomy - Madden type - in 876 patients. Periodic clinical follow-ups were done every 3 months during the first postoperative year, every 6 months during the second year and annually thereafter. Early lymphedema occurring in the first 14 postoperative days or between day 14 and day 21 was found in 8 patients. Late lymphedema, occurring up to 12 months or more after surgery, was diagnosed in 41 patients. Medium and severe lymphedema occurred at 42 patients. We evaluated the preexisting risk factors, the risk factors related to the type of surgery and those related to the cancer staging. It's ideal to identify predisposing factors of developing lymphedema related to breast cancer surgery before applying any type of treatment, There are therapeutic methods (general, drug therapy, physiotherapy) and methods related to the surgical act that influences the prophylaxis of lymphedema or have an amazing effect on already occurred lymphedema.
Luana Machado Chianca
Full Text Available Backgound and Objectives: Considering the use of active surveillance assists in infection identification and the need for studies that use Surgical Risk Index (SRI for assessment of Surgical Site Infection (SSI in cesareans, this study aims to determine the incidence of SSI and analyze the applicability of SRI in the prediction of SSI in women in the postpartum period after being submitted to a cesarean section at a university hospital between April 2012 and March of 2013. Methods: Prospective cohort study. Information notifying SSI by active surveillance was collected daily from the medical records. After hospital discharge, the mothers were contacted through telephone calls to identify infection criteria within 30 days after the cesarean. Descriptive and comparative analyses were performed. The chi-square test was used to compare groups. Results: 737 cesareans were performed. Telephone contact was achieved with 507 (68.8% women up to 30 days postpartum, with loss of follow-up of 230 cases (31.2%. The medical consultation in the post-partum period occurred with 188 (37.08% women, with whom telephone contact was obtained, on average, 17.28 days (SD=8.39 after delivery. It was verified that 21 patients met the criteria for SSI, with a 4.14% rate. A total of 12 cases (57.1% were classified as superficial SSI, 5 (23.8% as deep and 4 (19.1% as infection of organs and cavities. The SRI and its risk variables were not associated with SSI in patients submitted to cesarean sections. Conclusion: The SRI and the risk variables included in this index were not associated to SSI in patients submitted to cesarean sections. KEYWORDS: Cesarean Section; Surgical Wound Infection; Epidemiological Surveillance; Infection Control; Risk Index; Disease Notification.
Deepak Prakash Borde
Full Text Available Background and Aims: Safe airway management is the cornerstone of contemporary anaesthesia practice, and difficult intubation (DI remains a major cause of anaesthetic morbidity and mortality. The surgical category, particularly cardiac surgery as a risk factor for DI has not been studied extensively. The aim of this study was to test the hypothesis whether cardiac surgical patients are at increased risk of DI. Methods: During the study, 627 patients (329 cardiac and 298 non-cardiac surgical were enrolled. Pre-operative demographic and other variables associated with DI were assessed. Patients with Cormack Lehane grade III and IV or use of bougie in Cormack grade II were defined as DI. The incidence of anticipated and unanticipated DI was assessed. Factors associated with DI were described using univariate and multivariate logistic regression models. Results: The overall incidence of DI was 122/627 (19.46%. The incidence of DI was higher in cardiac surgery patients (24% as compared to non-cardiac surgery patients (14.4% P = 0.002. On multivariate analysis, factors independently associated with DI were greater age, male sex, higher Mallampati grade, and anticipated DI, but not cardiac surgery. The incidence of unanticipated DI was 48.1% and 53.4% in cardiac and non-cardiac surgery patients, respectively. Conclusion: Although there was a higher incidence of DI in cardiac surgical patients, cardiac surgery is not an independent risk factor for DI. Rather, other factors play more important role. About half of the DI both in cardiac and non-cardiac surgeries were unanticipated.
DeArmond, Sarah; Huang, Yueng-Hsiang; Chen, Peter Y; Courtney, Theodore K
Top-level managers make important decisions about safety-related issues, yet little research has been done involving these individuals. The current study explored corporate financial decisions makers' perceptions of their company's safety and their justifications for these perceptions. This study also explored whether their perceptions and justifications varied as a function of company size or industry injury risk. A total of 404 individuals who were the most senior managers responsible for making decisions about property and casualty risk at their companies participated in this study. The participants took part in a telephone survey. The results suggest that corporate financial decision makers have positive views of safety at their companies relative to safety at other companies within their industries. Further, many believe their company's safety is influenced by the attention/emphasis placed on safety and the selection and training of safety personnel. Participants' perceptions varied somewhat based on the size of their company and the level of injury risk in their industry. While definitive conclusions about corporate financial decision makers' perceptions of safety cannot be reached as a result of this single study, this work does lay groundwork for future research aimed at better understanding the perceptions top-level managers.
Placci, M; Cerbai, M
The food industry is of great importance in Italy; it is second only to the engineering sector, involving about 440,000 workers. However, 90% of the food businesses have less than 10 employees and are exempt from legal obligation to provide a detailed Risk Assessment Document. The aim of the study was to identify the inconveniences and risks present in the workplaces analyzed with particular reference to biomechanical risk of the upper limbs and the lumbar spine. This preliminary study, carried out by using pre-mapping of the inconveniences and risks (5) and the "mini-checklist OCRA" (4), involved 15 small food businesses: ovens for baking bread, pastry shops, pizzerias and the production of "Piadina" (flat bread). Although undoubtedly with differences, confectioners, pasta makers, pizza makers and "piadinari" were exposed to similar risks. By analyzing the final graphs, action areas can be identified on which further risk analysis can be made. Exposure is mainly related to repetitive movements, manual handling of loads and a common occurrence is the risk of allergy to flour dust. There are real peaks in demand from customers, that inevitably increase work demands and consequently biomechanical overload. In future studies it will be interesting to investigate this aspect by studying the variations in work demand and the final exposure index of the working day.
Mitchell, Thomas O; Holihan, Julie L; Askenasy, Erik P; Greenberg, Jacob A; Keith, Jerrod N; Martindale, Robert G; Roth, John Scott; Liang, Mike K
Current risk assessment models for surgical site occurrence (SSO) and surgical site infection (SSI) after open ventral hernia repair (VHR) have limited external validation. Our aim was to determine (1) whether existing models stratify patients into groups by risk and (2) which model best predicts the rate of SSO and SSI. Patients who underwent open VHR and were followed for at least 1 mo were included. Using two data sets-a retrospective multicenter database (Ventral Hernia Outcomes Collaborative) and a single-center prospective database (Prospective)-each patient was assigned a predicted risk with each of the following models: Ventral Hernia Risk Score (VHRS), Ventral Hernia Working Group (VHWG), Centers for Disease Control and Prevention Wound Class, and Hernia Wound Risk Assessment Tool (HW-RAT). Patients in the Prospective database were also assigned a predicted risk from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Areas under the receiver operating characteristic curve (area under the curve [AUC]) were compared to assess the predictive accuracy of the models for SSO and SSI. Pearson's chi-square was used to determine which models were able to risk-stratify patients into groups with significantly differing rates of actual SSO and SSI. The Ventral Hernia Outcomes Collaborative database (n = 795) had an overall SSO and SSI rate of 23% and 17%, respectively. The AUCs were low for SSO (0.56, 0.54, 0.52, and 0.60) and SSI (0.55, 0.53, 0.50, and 0.58). The VHRS (P = 0.01) and HW-RAT (P < 0.01) significantly stratified patients into tiers for SSO, whereas the VHWG (P < 0.05) and HW-RAT (P < 0.05) stratified for SSI. In the Prospective database (n = 88), 14% and 8% developed an SSO and SSI, respectively. The AUCs were low for SSO (0.63, 0.54, 0.50, 0.57, and 0.69) and modest for SSI (0.81, 0.64, 0.55, 0.62, and 0.73). The ACS-NSQIP (P < 0.01) stratified for SSO, whereas the VHRS (P < 0.01) and ACS
Ciccone, Marco M; Loverro, Giuseppe; Scicchitano, Pietro; Loverro, Matteo; Ricci, Gabriella; Scaramuzzi, Francesca; Gesualdo, Michele; Zito, Annapaola; Campagna, Marcello; Moncelli, Michele; Nicolardi, Vittorio; Manca, Fabio; Boninfante, Barbara; Carbonara, Santa; Cortese, Francesca; Todarello, Orlando; Bettocchi, Carlo
To evaluate and stratify early cardiovascular risk of transsexuals who underwent pharmacological and/or surgical gender reassignment. Fifty-six transsexuals were divided into two groups: group 1 - underwent gonadectomy (orchiectomy for transwomen and hystero-annessiectomy for transmen); group 2 - hormone replacement therapy alone. All participants underwent carotid artery intima-media thickness (C-IMT) and flow-mediated vasodilation (FMD) of brachial artery evaluations. FMD was lower in patients who had undergone gonadectomy compared with non-surgically treated patients (Group 1: 5.711 vs Group 2: 7.339, P < 0.0001). Mean C-IMT was higher in group 1 than group 2 (group 1: 0.733 vs group 2: 0.582). The duration of hormone therapy correlates positively with mean C-IMT (B = 0.001) and negatively with FMD (%) (B = - 0.007). Cardiovascular risk, which is expressed in terms of endothelial (FMD) and morphological (C-IMT) dysfunction, increases in subjects undergoing gonadectomy compared with those receiving cross-sex reassignment therapy alone. © 2017 Royal Australasian College of Physicians.
Kuroyanagi, N; Nagao, T; Sakuma, H; Miyachi, H; Ochiai, S; Kimura, Y; Fukano, H; Shimozato, K
Oral and maxillofacial surgery, which involves several sharp instruments and fixation materials, is consistently at a high risk for cross-contamination due to perforated gloves, but it is unclear how often such perforations occur. This study aimed to address this issue. The frequency of the perforation of surgical gloves (n=1436) in 150 oral and maxillofacial surgeries including orthognathic surgery (n=45) was assessed by the hydroinsufflation technique. Orthognathic surgery had the highest perforation rate in at least 1 glove in 1 operation (91.1%), followed by cleft lip and palate surgery (55.0%), excision of oral soft tumour (54.5%) and dental implantation (50.0%). The perforation rate in scrub nurses was 63.4%, followed by 44.4% in surgeons and first assistants, and 16.3% in second assistants. The odds ratio for the perforation rate in orthognathic surgery versus other surgeries was 16.0 (95% confidence interval: 5.3-48.0). The protection rate offered by double gloving in orthognathic surgery was 95.2%. These results suggest that, regardless of the surgical duration and blood loss in all fields of surgery, orthognathic surgery must be categorized in the highest risk group for glove perforation, following gynaecological and open lung surgery, due to the involvement of sharp objects. Copyright © 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Bekelis, Kimon; Coy, Shannon; Simmons, Nathan
The association of surgical duration with the risk of surgical site infection (SSI) has not been quantified in neurosurgery. We investigated the association of operative duration in neurosurgical procedures with the incidence of SSI. We performed a retrospective cohort study involving patients who underwent neurosurgical procedures from 2005 to 2012 and were registered in the American College of Surgeons National Quality Improvement Project registry. To control for confounding, we used multivariable regression models and propensity score conditioning. During the study period there were 94,744 patients who underwent a neurosurgical procedure and met the inclusion criteria. Of these patients, 4.1% developed a postoperative SSI within 30 days. Multivariable logistic regression showed an association between longer operative duration with higher incidence of SSI (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.16-1.20). Compared with procedures of moderate duration (third quintile, 40th-60th percentile), patients undergoing the longest procedures (>80th percentile) had higher odds (OR, 2.07; 95% CI, 1.86-2.31) of developing SSI. The shortest procedures (operative duration was associated with increased incidence of SSI for neurosurgical procedures. These results can be used by neurosurgeons to inform operative management and to stratify patients with regard to SSI risk. Copyright © 2016 Elsevier Inc. All rights reserved.
Vesco, Kimberly K; Marshall, Lynn M; Nelson, Heidi D; Humphrey, Linda; Rizzo, Joanne; Pedula, Kathryn L; Cauley, Jane A; Ensrud, Kristine E; Hochberg, Marc C; Antoniucci, Diana; Hillier, Teresa A
The aim of this study was to determine whether older postmenopausal women with a history of bilateral oophorectomy before natural menopause (surgical menopause) have a higher risk of nonvertebral postmenopausal fracture than women with natural menopause. We used 21 years of prospectively collected incident fracture data from the ongoing Study of Osteoporotic Fractures, a cohort study of community-dwelling women without previous bilateral hip fracture who were 65 years or older at enrollment, to determine the risk of hip, wrist, and any nonvertebral fracture. χ(2) and t tests were used to compare the two groups on important characteristics. Multivariable Cox proportional hazards regression models stratified by baseline oral estrogen use status were used to estimate the risk of fracture. Baseline characteristics differed significantly among the 6,616 women within the Study of Osteoporotic Fractures who underwent either surgical (1,157) or natural (5,459) menopause, including mean age at menopause (44.3 ± 7.4 vs 48.9 ± 4.9 y, P menopause, even among women who had never used oral estrogen (hip fracture: hazard ratio [HR], 0.87; 95% CI, 0.63-1.21; wrist fracture: HR, 1.10; 95% CI, 0.78-1.57; any nonvertebral fracture: HR, 1.11; 95% CI, 0.93-1.32). These data provide some reassurance that the long-term risk of nonvertebral fracture is not substantially increased for postmenopausal women who experienced premenopausal bilateral oophorectomy, compared with postmenopausal women with intact ovaries, even in the absence of postmenopausal estrogen therapy.
Jie, Bin; Jiang, Zhu-Ming; Nolan, Marie T
This multicenter, prospective cohort study evaluated the effect of preoperative nutritional support in abdominal surgical patients at nutritional risk as defined by the Nutritional Risk Screening Tool 2002 (NRS-2002).......This multicenter, prospective cohort study evaluated the effect of preoperative nutritional support in abdominal surgical patients at nutritional risk as defined by the Nutritional Risk Screening Tool 2002 (NRS-2002)....
Heal, Clare F; Buettner, Petra G; Drobetz, Herwig
Surgical site infection (SSI) following minor surgery contributes to patient morbidity and compromises cosmetic outcomes. The purpose of this study was to determine the incidence of and risk factors for SSI after dermatological surgery in general practice. A prospective, observational study which assessed infection among 972 patients was conducted in regional north Queensland, Australia. Consecutive patients presenting for minor skin excisions were invited to participate. Wounds were assessed for SSI at the time of removal of sutures. Infection occurred in 85 of the 972 excisions; thus, the overall incidence of infection was 8.7% (95% confidence interval 6.5-11.0). Excisions in the upper (Prisk factors for wound infection. The length of the excision (Prisk factors for infection. Diabetes was not found to be an independent risk factor for infection (P=0.891). Prophylactic antibiotics are probably prescribed excessively or inappropriately for dermatological surgery, and overall we wish to discourage their use. The results of this study may encourage the more judicial use of prophylactic antibiotics by defining high-risk procedures, such as excisions from the extremities, excision of BCC or SCC, and larger excisions, and patients who are at high risk for infection, such as ex-smokers. © 2012 The International Society of Dermatology.
Full Text Available Current literature on risk factors for surgical site infection (SSI in dermatological surgery in the absence of antibiotic prophylaxis is limited. The aim of this study was to retrospectively evaluate patients presenting for dermatological surgery. A total of 1,977 procedures were reviewed. SSI was clinically suspected in 79 (4.0% patients and confirmed by culture in 38 (1.9%. Using the strictest definition of SSI (clinical symptoms with positive culture significantly higher risk of SSI was found for location on the ear (odds ratio (OR 6.03, 95% confidence interval (95% CI 2.12–17.15, larger defects (OR 1.08 per cm2 increase, 95% CI 1.03–1.14, closure with flaps (OR 6.35, 95% CI 1.33–30.28 and secondary intention (OR 3.01, 95% CI 1.11–8.13. These characteristics were also associated with higher risk of clinically suspected SSI regardless of culture results with slightly lower ORs. In conclusion, the risk of acquiring a SSI is increased in surgeries performed on the ear, in larger wounds and in defects closed with flaps or healed by secondary intention.
Krieger, Yuval; Walfisch, Asnat; Sheiner, Eyal
To identify trends and risk factors for early surgical site infection (SSI) following cesarean delivery (CD). A population-based study comparing characteristics of women who have and have not developed post cesarean SSI was conducted. Deliveries occurred between the years 1988 and 2013 in a tertiary medical center. A multivariable logistic regression model, with backwards elimination, was used to control for confounders. Of the 41 375 cesarean deliveries performed during the study period, 1521 (3.7%) were complicated with SSI. SSI rates significantly deceased over the years, from 7.4% in 1988 to 1.5% in 2012. Using a multivariable regression model, the following independent risk factors for SSI were identified: obesity (OR 2.0; 95% CI, 1.6-2.5); previous CD (OR 1.8; 95% CI, 1.6-2.0); hypertensive disorders (OR 1.4; 95% CI, 1.2-1.6); premature rupture of membranes (OR 1.3; 95% CI, 1.1-1.6); gestational diabetes mellitus (GDM, OR 1.2; 95% CI, 1.1-1.4); and recurrent pregnancy losses (OR 1.2; 95% CI, 1.1-1.5). Independent risk factors for post-cesarean SSI include obesity, GDM, hypertensive disorders of pregnancy, premature rupture of membranes, and recurrent pregnancy losses. Information regarding higher rates of SSI and preventative measures should be provided to these high-risk women prior to surgery.
B. Kaynar; S.I. Birbil (Ilker); J.B.G. Frenk (Hans)
textabstractWe discuss a class of risk measures for portfolio optimization with linear loss functions, where the random returns of financial instruments have a multivariate elliptical distribution. Under this setting we pay special attention to two risk measures, Value-at-Risk and
Nave, Rosella; Isaia, Roberto; Sandri, Laura; Cristiani, Chiara
In the communication chain between scientists and decision makers (end users), scientific outputs, as maps, are a fundamental source of information on hazards zoning and the related at risk areas definition. Anyway the relationship between volcanic phenomena, their probability and potential impact can be complex and the geospatial information not easily decoded or understood by not experts even if decision makers. Focusing on volcanic hazard the goal of MED SUV WP6 Task 3 is to improve the communication efficacy of scientific outputs, to contribute in filling the gap between scientists and decision-makers. Campi Flegrei caldera, in Neapolitan area has been chosen as the pilot research area where to apply an evaluation/validation procedure to provide a robust evaluation of the volcanic maps and its validation resulting from end users response. The selected sample involved are decision makers and officials from Campanian Region Civil Protection and municipalities included in Campi Flegrei RED ZONE, the area exposed to risk from to pyroclastic currents hazard. Semi-structured interviews, with a sample of decision makers and civil protection officials have been conducted to acquire both quantitative and qualitative data. The tested maps have been: the official Campi Flegrei Caldera RED ZONE map, three maps produced by overlapping the Red Zone limit on Orthophoto, DTM and Contour map, as well as other maps included a probabilistic one, showing volcanological data used to border the Red Zone. The outcomes' analysis have assessed level of respondents' understanding of content as displayed, and their needs in representing the complex information embedded in volcanic hazard. The final output has been the development of a leaflet as "guidelines" that can support decision makers and officials in understanding volcanic hazard and risk maps, and also in using them as a communication tool in information program for the population at risk. The same evaluation /validation process
Kirkham, Kyle R.; Wijeysundera, Duminda N.; Pendrith, Ciara; Ng, Ryan; Tu, Jack V.; Laupacis, Andreas; Schull, Michael J.; Levinson, Wendy; Bhatia, R. Sacha
Background: There is concern about increasing utilization of low-value health care services, including preoperative testing for low-risk surgical procedures. We investigated temporal trends, explanatory factors, and institutional and regional variation in the utilization of testing before low-risk procedures. Methods: For this retrospective cohort study, we accessed linked population-based administrative databases from Ontario, Canada. A cohort of 1 546 223 patients 18 years or older underwent a total of 2 224 070 low-risk procedures, including endoscopy and ophthalmologic surgery, from Apr. 1, 2008, to Mar. 31, 2013, at 137 institutions in 14 health regions. We used hierarchical logistic regression models to assess patient- and institution-level factors associated with electrocardiography (ECG), transthoracic echocardiography, cardiac stress test or chest radiography within 60 days before the procedure. Results: Endoscopy, ophthalmologic surgery and other low-risk procedures accounted for 40.1%, 34.2% and 25.7% of procedures, respectively. ECG and chest radiography were conducted before 31.0% (95% confidence interval [CI] 30.9%–31.1%) and 10.8% (95% CI 10.8%–10.8%) of procedures, respectively, whereas the rates of preoperative echocardiography and stress testing were 2.9% (95% CI 2.9%–2.9%) and 2.1% (95% CI 2.1%–2.1%), respectively. Significant variation was present across institutions, with the frequency of preoperative ECG ranging from 3.4% to 88.8%. Receipt of preoperative ECG and radiography were associated with older age (among patients 66–75 years of age, for ECG, adjusted odds ratio [OR] 18.3, 95% CI 17.6–19.0; for radiography, adjusted OR 2.9, 95% CI 2.8–3.0), preoperative anesthesia consultation (for ECG, adjusted OR 8.7, 95% CI 8.5–8.8; for radiography, adjusted OR 2.2, 95% CI 2.1–2.2) and preoperative medical consultation (for ECG, adjusted OR 6.8, 95% CI 6.7–6.9; for radiography, adjusted OR 3.6, 95% CI 3.5–3.6). The median ORs
Uchino, Motoi; Ikeuchi, Hiroki; Matsuoka, Hiroki; Bando, Toshihiro; Ichiki, Kaoru; Nakajima, Kazuhiko; Tomita, Naohiro; Takesue, Yoshio
Preoperative infliximab treatment may influence postoperative infectious complications in patients with Crohn's disease. The aim of this study was to identify predictors of surgical site infection after surgery for Crohn's disease and evaluate the effects of preoperative infliximab administration. We performed a prospective surveillance and review of surgical site infections. This study was conducted in the Surgical Department of Hyogo College of Medicine. A total of 405 consecutive patients with Crohn's disease who underwent abdominal surgery between January 2008 and December 2011 were included. Infection was diagnosed by the infection control team. The possible risk factors were analyzed by using logistic regression analyses to determine their predictive significance. Within the patient population, 20% of patients received infliximab, and 60% had penetrating disease. The median duration from the last infliximab infusion to surgery was 43 days (range, 4-80). The overall incidence of surgical site infection was 27%. The incidence of incisional surgical site infection was 18%, and the organ/space surgical site infection rate was 8%. In the multivariate analysis, proctectomy was the highest risk factor for all surgical site infection (OR, 3.4-11.8; p risk factor for surgical site infection. By contrast, there was a significantly reduced risk of incisional surgical site infection in patients with penetrating disease who received infliximab (OR, 0.1; p risk factor for surgical site infection in patients with Crohn's disease. The administration of preoperative infliximab was not a risk factor for surgical site infection.
BACKGROUND: Surgical Site infections are the second most frequently reported infections of all nosocomial infections among hospital patients. Among surgical patients in obstetrics, Surgical Site Infections were the most common nosocomial infections and the rate is higher in sub-Saharan Africa. There has not been a ...
Lopes, Camila Mendonça de Moraes; Haas, Vanderlei José; Dantas, Rosana Aparecida Spadoti; Oliveira, Cheila Gonçalves de; Galvão, Cristina Maria
to build and validate a scale to assess the risk of surgical positioning injuries in adult patients. methodological research, conducted in two phases: construction and face and content validation of the scale and field research, involving 115 patients. the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning contains seven items, each of which presents five subitems. The scale score ranges between seven and 35 points in which, the higher the score, the higher the patient's risk. The Content Validity Index of the scale corresponded to 0.88. The application of Student's t-test for equality of means revealed the concurrent criterion validity between the scores on the Braden scale and the constructed scale. To assess the predictive criterion validity, the association was tested between the presence of pain deriving from surgical positioning and the development of pressure ulcer, using the score on the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning (pescala de avaliação de risco para lesões decorrentes do posicionamento cirúrgico em pacientes adultos. pesquisa metodológica, conduzida em duas etapas: construção e validação de face e de conteúdo da escala e pesquisa de campo, com a participação de 115 pacientes. a Escala de Avaliação de Risco para o Desenvolvimento de Lesões Decorrentes do Posicionamento Cirúrgico contém sete itens, sendo que cada um apresenta cinco subitens. A pontuação dessa escala varia de sete a 35 pontos, quanto maior o escore maior o risco do paciente. O Índice de Validade de Conteúdo da escala foi de 0,88. Por meio da aplicação do teste t de Student, para igualdade de médias, constatou-se validade de critério concorrente entre os escores da escala de Braden e da escala construída. Para avaliar a validade de critério preditiva testou-se a associação da presença de dor decorrente do posicionamento cirúrgico e o desenvolvimento de úlcera por pressão com o
Keller, Bastiaan Paul Johan Aart
With prevalence figures of 13% for university hospitals and 23% for general hospitals, pressure ulcers are a major health care issue in The Netherlands. Pressure ulcers in surgical patients are frequently encountered, as is illustrated by reported incidence rates up to 66%. The number of patients at risk will probably also grow, due to an ageing population. In an extensive review of literature on pressure ulcers in ICU patients, figures on pressure ulcer prevalence and incidence are presented...
Lai, Qi; Song, Quanwei; Guo, Runsheng; Bi, Haidi; Liu, Xuqiang; Yu, Xiaolong; Zhu, Jianghao; Dai, Min; Zhang, Bin
Currently, many scholars are concerned about the treatment of postoperative infection; however, few have completed multivariate analyses to determine factors that contribute to the risk of infection. Therefore, we conducted a multivariate analysis of a retrospectively collected database to analyze the risk factors for acute surgical site infection following lumbar surgery, including fracture fixation, lumbar fusion, and minimally invasive lumbar surgery. We retrospectively reviewed data from patients who underwent lumbar surgery between 2014 and 2016, including lumbar fusion, internal fracture fixation, and minimally invasive surgery in our hospital's spinal surgery unit. Patient demographics, procedures, and wound infection rates were analyzed using descriptive statistics, and risk factors were analyzed using logistic regression analyses. Twenty-six patients (2.81%) experienced acute surgical site infection following lumbar surgery in our study. The patients' mean body mass index, smoking history, operative time, blood loss, draining time, and drainage volume in the acute surgical site infection group were significantly different from those in the non-acute surgical site infection group (p operative type in the acute surgical site infection group were significantly different than those in the non-acute surgical site infection group (p operative type, operative time, blood loss, and drainage time were independent predictors of acute surgical site infection following lumbar surgery. In order to reduce the risk of infection following lumbar surgery, patients should be evaluated for the risk factors noted above.
H. van Overhagen (H.); H. Meyers (Hjalmar); H.W. Tilanus (Hugo); J. Jeekel (Hans); J.S. Laméris (Johan )
textabstractPurpose: To evaluate percutaneous cholecystostomy in patients with acute cholecystitis and an increased surgical risk. Methods: Thirty-three patients with acute cholecystitis (calculous, n = 22; acalculous, n = 11) underwent percutaneous cholecystostomy by means of a transhepatic (n =
Full Text Available Abstract Background The Sustainably Managing Environmental Health Risk in Ecuador project was launched in 2004 as a partnership linking a large Canadian university with leading Cuban and Mexican institutes to strengthen the capacities of four Ecuadorian universities for leading community-based learning and research in areas as diverse as pesticide poisoning, dengue control, water and sanitation, and disaster preparedness. Methods In implementing curriculum and complementary innovations through application of an ecosystem approach to health, our interdisciplinary international team focused on the question: “Can strengthening of institutional capacities to support a community of practice of researchers, practitioners, policy-makers and communities produce positive health outcomes and improved capacities to sustainably translate knowledge?” To assess progress in achieving desired outcomes, we review results associated with the logic framework analysis used to guide the project, focusing on how a community of practice network has strengthened implementation, including follow-up tracking of program trainees and presentation of two specific case studies. Results By 2009, train-the-trainer project initiation involved 27 participatory action research Master’s theses in 15 communities where 1200 community learners participated in the implementation of associated interventions. This led to establishment of innovative Ecuadorian-led master’s and doctoral programs, and a Population Health Observatory on Collective Health, Environment and Society for the Andean region based at the Universidad Andina Simon Bolivar. Building on this network, numerous initiatives were begun, such as an internationally funded research project to strengthen dengue control in the coastal community of Machala, and establishment of a local community eco-health centre focusing on determinants of health near Cuenca. Discussion Strengthening capabilities for producing and
Tuomi, Taru; Pasanen, Annukka; Leminen, Arto; Bützow, Ralf; Loukovaara, Mikko
The purpose of this study was to determine the incidence of, and risk factors for, surgical site infections in a contemporary cohort of women with endometrial carcinoma. We retrospectively studied 1164 women treated for endometrial carcinoma by hysterectomy at a single institution in 2007-2013. In all, 912 women (78.4%) had minimally invasive hysterectomy. Data on surgical site infections were collected from medical records. Univariate and multivariate analyses were used to identify risk factors for incisional and organ/space infections. Ninety-four women (8.1%) were diagnosed with a surgical site infection. Twenty women (1.7%) had an incisional infection and 74 (6.4%) had an organ/space infection. The associations of 17 clinico-pathologic and surgical variables were tested by univariate analyses. Those variables that were identified as potential risk factors in univariate analyses (p infections as dependent variables. Obesity (body mass index ≥ 30 kg/m(2)), diabetes, and long operative time (>80th centile) were independently associated with a higher risk of incisional infection, whereas minimally invasive surgery was associated with a smaller risk. Smoking, conversion to laparotomy, and lymphadenectomy were associated with a higher risk of organ/space infection. Organ/space infections comprised the majority of surgical site infections. Risk factors for incisional and organ/space infections differed. Minimally invasive hysterectomy was associated with a smaller risk of incisional infections but not of organ/space infections. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology.
Golan, Shay; Adamsky, Melanie A; Johnson, Scott C; Barashi, Nimrod S; Smith, Zachary L; Rodriguez, Maria V; Liao, Chuanhong; Smith, Norm D; Steinberg, Gary D; Shalhav, Arieh L
To evaluate the accuracy of the American College of Surgeons National Surgical Quality Improvement Programs (ACS-NSQIP) surgical risk calculator in patients undergoing radical cystectomy (RC) with urinary diversion. Preoperative characteristics of patients who underwent RC with ileal conduit or orthotropic neobladder (ONB) between 2007 and 2016 were entered into the proprietary online ACS-NSQIP calculator to generate 30-day predicted risk profiles. Predicted and observed outcomes were compared by measuring Brier score (BS) and area under the receiver operating characteristic curve (AUC). Of 954 patients undergoing RC, 609 (64%) received ileal conduit and 345 (36%) received ONB. The calculator underestimated most risks by 10%-81%. The BSs exceeded the acceptable threshold of 0.01 and AUC were less than 0.8 for all outcomes in the overall cohort. The mean (standard deviation) predicted vs. observed length of stay was 9 (1.5) vs. 10.6 (7.4) days (Pearson's r = 0.09). Among patients who received ONB, adequate BS (calculator for cardiac complications (AUC = 0.69) and discharge to rehab center (AUC = 0.75) among patients who underwent RC with ONB. The universal ACS-NSQIP calculator poorly predicts most postoperative complications among patients undergoing RC with urinary diversion. A procedure-specific risk calculator is required to better counsel patients in the preoperative setting and generate realistic quality measures. Copyright © 2018 Elsevier Inc. All rights reserved.
Reardon, Michael J; Van Mieghem, Nicolas M; Popma, Jeffrey J
BACKGROUND: Although transcatheter aortic-valve replacement (TAVR) is an accepted alternative to surgery in patients with severe aortic stenosis who are at high surgical risk, less is known about comparative outcomes among patients with aortic stenosis who are at intermediate surgical risk. METHODS......: We evaluated the clinical outcomes in intermediate-risk patients with severe, symptomatic aortic stenosis in a randomized trial comparing TAVR (performed with the use of a self-expanding prosthesis) with surgical aortic-valve replacement. The primary end point was a composite of death from any cause...... or disabling stroke at 24 months in patients undergoing attempted aortic-valve replacement. We used Bayesian analytical methods (with a margin of 0.07) to evaluate the noninferiority of TAVR as compared with surgical valve replacement. RESULTS: A total of 1746 patients underwent randomization at 87 centers...
Burgess, Jessica R; Smith, Benjamin; Britt, Rebecca; Weireter, Leonard; Polk, Travis
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator has been used to assist surgeons in predicting the risk of postoperative complications. This study aims to determine if the risk calculator accurately predicts complications in acute care surgical patients undergoing laparotomy. A retrospective review was performed on all patients on the acute care surgery service at a tertiary hospital who underwent laparotomy between 2011 and 2012. The preoperative risk factors were used to calculate the estimated risks of postoperative complications in both the original ACS NSQIP calculator and updated calculator (June 2016). The predicted rate of complications was then compared with the actual rate of complications. Ninety-five patients were included. Both risk calculators accurately predicted the risk of pneumonia, cardiac complications, urinary tract infections, venous thromboembolism, renal failure, unplanned returns to operating room, discharge to nursing facility, and mortality. Both calculators underestimated serious complications (26% vs 39%), overall complications (32.4% vs 45.3%), surgical site infections (9.3% vs 20%), and length of stay (9.7 days versus 13.1 days). When patients with prolonged hospitalization were excluded, the updated calculator accurately predicted length of stay. The ACS NSQIP risk calculator underestimates the overall risk of complications, surgical infections, and length of stay. The updated calculator accurately predicts length of stay for patients calculator to predict postoperative risk in this population.
Full Text Available The Makers is the latest novel of the American science fiction writer, blogger and Silicon Valley intellectual Cory Doctorow. Set in the 2010s, the novel describes the possible impact of the present trend towards the migration of modes of production and organization that have emerged online into the sphere of material production. Called New Work, this movement is indebted to a new maker culture that attracts people into a kind of neo-artisan, high tech mode of production. The question is: can a corporate-funded New Work movement be sustainable? Doctorow seems to suggest that a capitalist economy of abundance is unsustainable because it tends to restrict the reach of its value flows to a privileged managerial elite.
Verhoeven, Marieke O; van der Mooren, Marius J; Teerlink, Tom; Verheijen, René H M; Scheffer, Peter G; Kenemans, Peter
To investigate the influence of physiological and surgical menopause on serum concentrations of coronary heart disease (CHD) risk markers and sex hormones. Physiological menopausal transition was investigated in two studies. In a longitudinal study, 16 women were followed from 2 years before until 2 years after physiological menopause. In a case-control study, 27 early postmenopausal women were compared with 27 age-matched late premenopausal women. Surgical menopause was investigated in 11 women undergoing a prophylactic bilateral salpingo-oophorectomy. The following parameters were measured: serum concentrations of estradiol, follicle-stimulating hormone, inhibin A, inhibin B, asymmetric dimethylarginine, lipids, leptin, homocysteine, C-reactive protein, and coenzyme Q10, as well as weight and body mass index. After physiological and surgical menopause, serum estradiol and inhibin A and B decreased, whereas follicle-stimulating hormone increased (all P values menopausal transition. Total and low-density lipoprotein cholesterol increased after surgical menopause (both P values = 0.01). None of the other parameters studied were influenced significantly by the menopausal transition. No difference in change in the various CHD risk markers investigated was observed between physiological and surgical menopause. The CHD risk profile was affected unfavorably by both physiological and surgical menopause. Changes in most CHD risk markers were small, despite the substantial changes in hormonal parameters.
Uppal, Shitanshu; Harris, John; Al-Niaimi, Ahmed; Swenson, Carolyn W; Pearlman, Mark D; Reynolds, R Kevin; Kamdar, Neil; Bazzi, Ali; Campbell, Darrell A; Morgan, Daniel M
To evaluate associations between prophylactic preoperative antibiotic choice and surgical site infection rates after hysterectomy. A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative undergoing hysterectomy from July 2012 to February 2015. The primary outcome was a composite outcome of any surgical site infection (superficial surgical site infections or combined deep organ space surgical site infections). Preoperative antibiotics were categorized based on the recommendations set forth by the American College of Obstetricians and Gynecologists and the Surgical Care Improvement Project. Patients receiving a recommended antibiotic regimen were categorized into those receiving β-lactam antibiotics and those receiving alternatives to β-lactam antibiotics. Patients receiving nonrecommended antibiotics were categorized into those receiving overtreatment (excluded from further analysis) and those receiving nonstandard antibiotics. Multivariable logistic regression models were developed to estimate the independent effect of antibiotic choice. Propensity score matching analysis was performed to validate the results. The study included 21,358 hysterectomies. The overall rate of any surgical site infection was 2.06% (n=441). Unadjusted rates of "any surgical site infection" were 1.8%, 3.1%, and 3.7% for β-lactam, β-lactam alternatives, and nonstandard groups, respectively. After adjusting for patient and operative factors within clusters of hospitals, compared with the β-lactam antibiotics (reference group), the risk of "any surgical site infection" was higher for the group receiving β-lactam alternatives (odds ratio [OR] 1.7, confidence interval [CI] 1.27-2.07) or the nonstandard antibiotics (OR 2.0, CI 1.31-3.1). Compared with women receiving β-lactam antibiotic regimens, there is a higher risk of surgical site infection after hysterectomy among those receiving a recommended β-lactam alternative or nonstandard regimen.
Six independent predictors of peri-operative MACEs were identified in the vascular surgery cohort: age >65 years, a history of ischaemic heart disease, a history of diabetes, chronic β-blockade, prior coronary revascularisation, and the vascular surgical procedure. The risk model derived from these risk factors appeared to ...
Background: There is dilemma as to whether patients infected with the Human Immunodeficiency Virus (HIV) requiring implant orthopaedic surgery are at an increased risk for post-operative surgical site infection (SSI). We conducted a systematic review to determine the effect of HIV on the risk of post-operative SSI and ...
Sep 6, 2012 ... ABSTRACT. Background:There is dilemma as to whether patients infected with the Human Immunodeficiency Virus (HIV) requiring implant orthopaedic surgery are at an increased risk for post-operative surgical site infection (SSI). We conducted a systematic review to determine the effect of HIV on the risk ...
Tully, Hannah M; Kukull, Walter A; Mueller, Beth A
Children with hydrocephalus are at risk for epilepsy both due to their underlying condition and as a consequence of surgical treatment; however, the relative contributions of these factors remain unknown. The authors sought to characterize epilepsy among children with infancy-onset hydrocephalus and to examine the risks of epilepsy associated with hydrocephalus subtype and with factors related to surgical treatment. We conducted a longitudinal cohort study of all children with infancy-onset hydrocephalus treated at a major regional children's hospital during 2002 to 2012, with follow-up to ascertain risk factors and epilepsy outcome through April 2015. Poisson regression was used to calculate adjusted risk ratios and 95% confidence intervals for associations. Among 379 children with hydrocephalus, 86 (23%) developed epilepsy (mean onset age = 2.7 years), almost one fifth of whom had a history of infantile spasms. Relative to spina bifida-associated hydrocephalus, children with other major hydrocephalus subtypes had fourfold higher risks of developing epilepsy. Among children who underwent surgery, surgical infection doubled the risk of epilepsy (risk ratio = 2.0, 95% confidence interval = 1.4 to 3.0). Epilepsy was associated with surgical failure for intracranial reasons but not extracranial reasons (risk ratio = 1.7, 95% confidence interval = 1.1 to 2.7; risk ratio = 1.1, 95% confidence interval = 0.7 to 1.9, respectively). Epilepsy is common among children with hydrocephalus. Compared with children with spina bifida-associated hydrocephalus, children with other major hydrocephalus subtypes have a markedly increased risk of epilepsy. Surgical infection doubles the risk of epilepsy. Copyright © 2016 Elsevier Inc. All rights reserved.
Simonsen, Casper; de Heer, Pieter; Bjerre, Eik D
OBJECTIVE: The aim of the study was to evaluate sarcopenia as a predictor of postoperative risk of major and total complications after surgery for gastrointestinal cancer. BACKGROUND: Sarcopenia is associated with poor survival in gastrointestinal cancer patients, but the role of sarcopenia as pr...... of these findings. Combining assessment of muscle mass with measures of physical function may increase the prognostic value and accuracy in preoperative risk stratification....
Li, Xinli; Nylander, William; Smith, Tracy; Han, Soonhee; Gunnar, William
Surgical site infection (SSI) complicates approximately 2% of surgeries in the Veterans Affairs (VA) hospitals. Surgical site infections are responsible for increased morbidity, length of hospital stay, cost, and mortality. Surgical site infection can be minimized by modifying risk factors. In this study, we identified risk factors and developed accurate predictive surgical specialty-specific SSI risk prediction models for the Veterans Health Administration (VHA) surgery population. In a retrospective observation study, surgical patients who underwent surgery from October 2013 to September 2016 from 136 VA hospitals were included. The Veteran Affairs Surgical Quality Improvement Program (VASQIP) database was used for the pre-operative demographic and clinical characteristics, intra-operative characteristics, and 30-day post-operative outcomes. The study population represents 11 surgical specialties: neurosurgery, urology, podiatry, otolaryngology, general, orthopedic, plastic, thoracic, vascular, cardiac coronary artery bypass graft (CABG), and cardiac valve/other surgery. Multivariable logistic regression models were developed for the 30-day post-operative SSIs. Among 354,528 surgical procedures, 6,538 (1.8%) had SSIs within 30 days. Surgical site infection rates varied among surgical specialty (0.7%-3.0%). Surgical site infection rates were higher in emergency procedures, procedures with long operative duration, greater complexity, and higher relative value units. Other factors associated with increased SSI risk were high level of American Society of Anesthesiologists (ASA) classification (level 4 and 5), dyspnea, open wound/infection, wound classification, ascites, bleeding disorder, chemotherapy, smoking, history of severe chronic obstructive pulmonary disease (COPD), radiotherapy, steroid use for chronic conditions, and weight loss. Each surgical specialty had a distinct combination of risk factors. Accurate SSI risk-predictive surgery specialty
Ketcheson, Felicia; Woolcott, Christy; Allen, Victoria; Langley, Joanne M
The rate of cesarean delivery is increasing in North America. Surgical site infection following this operation can make it difficult to recover, care for a baby and return home. We aimed to determine the incidence of surgical site infection to 30 days following cesarean delivery, associated risk factors and whether risk factors differed for predischarge versus postdischarge infection. We identified a retrospective cohort in Nova Scotia by linking the provincial perinatal database to hospital admissions and physician billings databases to follow women for 30 days after they had given birth by cesarean delivery between Jan. 1, 1997 and Dec. 31, 2012. Logistic regression with generalized estimating equations was used to determine risk factors for infection. A total of 25 123 women had 33 991 cesarean deliveries over the study period. Of the 25 123, 923 had surgical site infections, giving an incidence rate of 2.7% (95% CI 2.54%-2.89%); the incidence decreased over time. Risk factors for infection (adjusted odds ratios ≥ 1.5) were prepregnancy weight 87.0 kg or more, gaining 30.0 kg or more during pregnancy, chorioamnionitis, maternal blood transfusion, anticoagulation therapy, alcohol or drug abuse, second stage of labour before surgery, delivery in 1997-2000 and delivery in a hospital performing 130-1249 cesarean deliveries annually. Women who gave birth earlier in the study period, those who gave birth in a hospital with 130-949 cesarean deliveries per year and those with more than 1 fetus were at a significantly higher risk for surgical site infection before discharge; women who smoked were at significantly higher risk for surgical site infection after discharge. Most risk factors are known before delivery, and some are potentially modifiable. Although the incidence of surgical site infection decreased over time, targeted clinical and infection prevention and control interventions could further reduce the burden of illness associated with this health
Massey, R.; Miller, S.; Heward, A.
The need to engage with Europe's policy makers is more crucial now than ever. MEPs' understanding of the contribution and importance of planetary science to European research, industry, culture, education and job-creation may have major implications for both the direction of research and future funding for Europe's planetary science community. The mid-term review of the European Commission's Seventh Framework Programme is currently in progress and these discussions will feed into the drafting of Framework Eight. With space-going nations around the world redefining priorities, Europe may have an opportunity to take a lead in planetology on a global scale. This should be taken into account when considering planetology within the frameworks of the European Space Policy. This panel discussion, hosted by Dr Robert Massey, Deputy Executive of the Royal Astronomical Session, will look at engaging with policy makers from the point of view of those working in the European Parliament, European Commission, industry, as well as the planetary community.
Ferreira, C; Lavinhas, C; Fernandes, L; Camilo, Ma; Ravasco, P
The prevalence of undernutrition among surgical patients is thought to be high, and negatively influencing outcomes. However, recent evidence shows the increase of overweight/obesity in hospitalised patients. A pilot cross-sectional study was conducted in 50 patients of a Surgical Department of the University Hospital of Santa Maria (CHLN) that aimed: 1) to assess nutritional risk and status through validated methods; 2) to explore the presence of overweight/obesity; 3) to evaluate the prevalence of metabolic risk associated with obesity. Nutritional risk was assessed by Malnutrition Universal Screening Tool (MUST), nutritional status by Body Mass Index (BMI), waist circumference (WC), & Subjective Global Assessment (SGA). Statistical significance was set for p nutrition discipline in the medical curricula, limits the multiprofessional management and a better understanding of the more adequate approaches to these patients. Further, the change in the clinical scenario argues for more studies to clarify the prevalence and consequences of sarcopenic obesity in surgical patients.
Full Text Available Aim: to analyze the erbium laser effects in oral surgery in patients with the risk of bleeding. There were selected 2 groups of patients for oral surgery treatment. Materials and methods. The first group included 31 patients with bleeding risk. In this group erbium laser radiation was used for the cut and tooth socket conditioning after tooth extraction. The second (control group of 43 patients without concomitant pathology was determined for conventional surgical treatment. Results. In the first group there was no postoperative bleeding, post-surgical pain and infection were prevented with no need for analgesics, and the wounds epithelization took 1-3 days. It takes less time than in control group. Conclusion. Application of erbium laser is a modern method which can be successfully used in surgical treatment of patients with the risk of bleeding.
Røder, Martin Andreas; Thomsen, Frederik Birkebæk; Christensen, Ib Jarle
OBJECTIVE: The aim of this study was to evaluate the impact of preoperative and surgical parameters, including nerve-sparing technique, on the risk of positive surgical margins (PSM) following radical prostatectomy for clinically localized prostate cancer. MATERIAL AND METHODS: A prospective...... consecutive single-institution Danish cohort of 1148 patients undergoing RP between 1995 and 2011 was investigated. To analyse the impact of covariates on risk of PSM, a multivariate logistic regression model was used, including cT category, biopsy Gleason score, prostate-specific antigen (PSA), percentage...... positive biopsies for cancer (PPB), surgeon and surgical technique. RESULTS: The overall rate of PSM was 31.4%. The risk of PSM depended (p value for Wald χ(2)) on PSA (p
Gong, Shi-Peng; Guo, Hong-Xia; Zhou, Hong-Zhen; Chen, Li; Yu, Yan-Hong
To estimate the incidence of and identify the risk factors for a surgical site infection after a cesarean section. A survey of women who underwent a cesarean section was conducted in eight hospitals in Guangdong Province, China. The rate of surgical site infection was estimated and a nested case control study was then carried out to identify the risk factors. Among 13 798 women surveyed, 96 (0.7%) developed a surgical site infection after a cesarean section. Multivariate logistic regression analysis identified six factors independently associated with an increased risk of surgical site infection, which included obesity, premature rupture of membranes, lower preoperative hemoglobin, prolonged surgery, lack of prophylactic antibiotics and excessive anal examinations performed during hospitalization. Surgical site infection occurs in approximately 0.7% of cesarean section cases in the general obstetric population in China. Obesity, premature rupture of membranes, lower preoperative hemoglobin, prolonged surgery, lack of prophylactic antibiotics and excessive anal examinations during hospitalization are considered to be independent risk factors. © 2012 The Authors. Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology.
Soares, R; Eden, C G
High-risk prostate cancer (HRPC) currently comprises 17-35% of newly diagnosed cases and has the highest rate of metastasis and cancer-related death, making its management a top priority for improving prostate cancer outcomes. The definition of HRPC is not consensual and several risk stratification criteria have been used, which hinders the interpretation of data and the comparison of different studies. All classifications include prostate-specific antigen (PSA) level, biopsy Gleason score and clinical stage as criteria, but others have been added in an attempt to make stratification more accurate and clinically useful, to enable identification of the patients that can be cured by local treatment of the disease. HRPC was traditionally treated with radiotherapy (RT) and/or androgen deprivation therapy (ADT), but radical prostatectomy (RP) has slowly gained more importance in this context. This article aims to discuss the role of surgery in HRPC, highlighting the advantages of RP as primary treatment option: the ability to provide a definitive stage and grade of the cancer; allowing an early detection of treatment failure by having an undetectable PSA as treatment target; providing excellent local control of the disease; reducing the risk of metastatic progression to a greater extent than does RT. We will try to show the benefits and risks of a "surgery first" approach, keeping in mind that, despite the curative intent, a significant number of patients will still need adjuvant or salvage RT and/or ADT.
Okoshi, Kae; Kobayashi, Katsutoshi; Kinoshita, Koichi; Tomizawa, Yasuko; Hasegawa, Suguru; Sakai, Yoshiharu
Although surgical smoke contains potentially hazardous substances, such as cellular material, blood fragments, microorganisms, toxic gases and vapors, many operating rooms (ORs) do not provide protection from exposure to it. This article reviews the hazards of surgical smoke and the means of protecting OR personnel. Our objectives are to promote surgeons' acceptance to adopt measures to minimize the hazards. Depending on its components, surgical smoke can increase the risk of acute and chronic pulmonary conditions, cause acute headaches; irritation and soreness of the eyes, nose and throat; dermatitis and colic. Transmission of infectious disease may occur if bacterial or viral fragments present in the smoke are inhaled. The presence of carcinogens in surgical smoke and their mutagenic effects are also of concern. This review summarizes previously published reports and data regarding the toxic components of surgical smoke, the possible adverse effects on the health of operating room personnel and measures that can be used to minimize exposure to prevent respiratory problems. To reduce the hazards, surgical smoke should be removed by an evacuation system. Surgeons should assess the potential dangers of surgical smoke and encourage the use of evacuation devices to minimize potential health hazards to both themselves and other OR personnel.
Møller, Morten Hylander; Shah, Kamran; Bendix, Jørgen
OBJECTIVE: The overall mortality for patients undergoing surgery for perforated peptic ulcer has increased despite improvements in perioperative monitoring and treatment. The objective of this study was to identify and describe perioperative risk factors in order to identify ways of optimizing...... recorded retrospectively from medical records. Data were analysed using multiple logistic regression analysis. The primary end-point was 30-day mortality. RESULTS: The 30-day mortality rate was 27%. The following variables were independently associated with death within 30 days of surgery: ASA (American...... insufficiency upon admission and insufficient postoperative nutrition have been added to the list of independent risk factors for death within 30 days of surgery in patients with peptic ulcer perforation. Finding that shock upon admission, reduced albumin blood levels upon admission, renal insufficiency upon...
Hunter, Joshua G; Gross, Jonathan M; Dahl, Jason D; Amsdell, Simon L; Gorczyca, John T
Acute septic arthritis in a native joint may require more than one surgical debridement to eradicate the infection. Our objectives were to determine the prevalence of failure of a single surgical debridement for acute septic arthritis, to identify risk factors for failure of a single debridement, and to develop a prognostic probability algorithm to predict failure of a single surgical debridement for acute septic arthritis in adults. We collected initial laboratory and medical comorbidity data of 128 adults (132 native joints) with acute septic arthritis who underwent at least one surgical debridement at our institution between 2000 and 2011. Univariate and logistic regression analyses were used to identify potential risk factors for failure of a single surgical debridement. Stepwise variable selection was used to develop a prediction model and identify probabilities of failure of a single surgical debridement. Of the 128 patients (132 affected joints) who underwent surgical debridement for acute septic arthritis, forty-nine (38%) of the patients (fifty joints) experienced failure of a single debridement and required at least two debridements (range, two to four debridements). Staphylococcus aureus was the most common bacterial isolate (in sixty, or 45%, of the 132 joints). Logistic regression analysis identified five independent clinical predictors for failure of a single surgical debridement: a history of inflammatory arthropathy (odds ratio [OR], 7.3; 95% confidence interval [CI], 2.4 to 22.6; p 85.0 x 10(9) cells/L (OR, 4.7; 95% CI, 1.8 to 17.7; p = 0.002), S. aureus as the bacterial isolate (OR, 4.6; 95% CI, 1.8 to 11.9; p = 0.002), and a history of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; p = 0.04). Most (62%) of the septic joints were managed effectively with a single surgical debridement. Adults with a history of inflammatory arthropathy, involvement of a large joint, a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L, an infection with S. aureus
Kelly, E G; Cashman, J P; Groarke, P J; Morris, S F
Ankle fracture is a common injury and there is an increasingly greater emphasis on operative fixation. The purpose of the study was to determine the complication rate in this cohort of patients and, in doing so, determine risk factors which predispose to surgical site infection. A prospective cohort study was performed at a tertiary referral trauma center examining risk factors for surgical site infection in operatively treated ankle fractures. Univariate and multivariate analysis was performed. Female gender and advancing age were determined to be the risk factors in univariate analysis. Drain usage and peri-operative pyrexia were found to be significant for infection in multivariate analysis. This study allows surgeons to identify those at increased risk of infection and counsel them appropriately. It also allows for a high level of vigilance with regard to soft tissue handling intra-operatively in this higher risk group.
Røder, Martin Andreas; Thomsen, Frederik Birkebæk; Christensen, Ib Jarle
consecutive single-institution Danish cohort of 1148 patients undergoing RP between 1995 and 2011 was investigated. To analyse the impact of covariates on risk of PSM, a multivariate logistic regression model was used, including cT category, biopsy Gleason score, prostate-specific antigen (PSA), percentage...... positive biopsies for cancer (PPB), surgeon and surgical technique. RESULTS: The overall rate of PSM was 31.4%. The risk of PSM depended (p value for Wald χ(2)) on PSA (p PSA, the risk of PSM...... to the referent surgeon. Nerve-sparing surgery increased the risk of PSM by 50% compared to wide resection (OR = 1.5, 95% CI 1.0-2.1, p = 0.03). CONCLUSION: Both preoperative and surgical parameters affect the risk of PSM after radical prostatectomy. Surgeon and high preoperative PSA, PPB and cT category were...
Abalo, Anani; Patassi, Akouda; James, Yaovi Edem; Walla, Atsi; Sangare, Aly; Dossim, Assang
To identify risk factors associated with surgical wound infection in patients infected with human immunodeficiency virus (HIV) undergoing surgery for orthopaedic trauma. Records of 29 male and 7 female HIV-positive patients aged 18 to 47 years who underwent surgery for orthopaedic trauma were reviewed. Data on HIV-specific variables (HIV clinical classification, CD4+ lymphocyte count) and highly active antiretroviral therapy were retrieved, as were data on wound class, fracture type, surgery type, surgical wound infections, and outcomes. Possible risk factors associated with surgical wound infection were analysed. The median follow-up period was 27 (range, 19-41) months. Of the 36 patients, 14 (39%) developed surgical wound infections (4 were deep and 10 superficial). 89% and 67% of them were in HIV clinical category B and in CD4+ T-lymphocyte category 3, respectively. 12 of these infections resolved after debridement and prolonged antibiotic treatment, and 2 developed chronic osteomyelitis. Four of the patients had non-union. Surgical wound infections were associated with HIV clinical category B (pwounds (p=0.003). Identification of risk factors may help minimise morbidity in HIV-positive patients.
Hoberdan Oliveira Pereira
Full Text Available ABSTRACT OBJECTIVE: To analyze infections of the surgical site among patients undergoing clean-wound surgery for correction of femoral fractures. METHODS: This was a historical cohort study developed in a large-sized hospital in Belo Horizonte. Data covering the period from July 2007 to July 2009 were gathered from the records in electronic medical files, relating to the characteristics of the patients, surgical procedures and surgical infections. The risk factors for infection were identified by means of statistical tests on bilateral hypotheses, taking the significance level to be 5%. Continuous variables were evaluated using Student'sttest. Categorical variables were evaluated using the chi-square test, or Fisher's exact test, when necessary. For each factor under analysis, a point estimate and the 95% confidence interval for the relative risk were obtained. In the final stage of the study, multivariate logistic regression analysis was performed. RESULTS: 432 patients who underwent clean-wound surgery for correcting femoral fractures were included in this study. The rate of incidence of surgical site infections was 4.9% and the risk factors identified were the presence of stroke (odds ratio, OR = 5.0 and length of preoperative hospital stay greater than four days (OR = 3.3. CONCLUSION: To prevent surgical site infections in operations for treating femoral fractures, measures involving assessment of patients' clinical conditions by a multiprofessional team, reduction of the length of preoperative hospital stay and prevention of complications resulting from infections will be necessary.
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.
Verhoeven, Marieke O.; van der Mooren, Marius J.; Teerlink, Tom; Verheijen, Rene H. M.; Scheffer, Peter G.; Kenemans, Peter
Objective: To investigate the influence of physiological and surgical menopause oil Serum concentrations of corollary heart disease (CHD) risk markers and sex hormones. Design: Physiological menopausal transition was investigated in two studies. In a longitudinal Study, 16 women were followed from 2
Background and purpose The most common surgical approaches in total hip arthroplasty in Sweden are the posterior and the anterolateral transgluteal approach. Currently, however, there is insufficient evidence to prefer one over the other regarding risk of subsequent surgery. Patients and methods We searched the Swedish Hip Arthroplasty Register between the years 1992 and 2009 to compare the posterior and anterolateral transgluteal approach regarding risk of revision in the 3 most common all-cemented hip prosthesis designs in Sweden. 90,662 total hip replacements met the inclusion criteria. We used Cox regression analysis for estimation of prosthesis survival and relative risk of revision due to dislocation, infection, or aseptic loosening. Results Our results show that for the Lubinus SPII prosthesis and the Spectron EF Primary prosthesis, the anterolateral transgluteal approach gave an increased risk of revision due to aseptic loosening (relative risk (RR) = 1.3, 95% CI: 1.0–1.6 and RR = 1.6, CI: 1.0–2.5) but a reduced risk of revision due to dislocation (RR = 0.7, CI: 0.5–0.8 and RR = 0.3, CI: 0.1–0.4). For the Exeter Polished prosthesis, the surgical approach did not affect the outcome for dislocation or aseptic loosening. The surgical approach had no influence on the risk of revision due to infection in any of these designs. Interpretation This observational study shows that the surgical approach affected the risk of revision due to aseptic loosening and dislocation for 2 of the most commonly used cemented implants in Sweden. Further studies are needed to determine whether these results are generalizable to other implants and to uncemented fixation. PMID:23116440
Full Text Available CONTEXT: Risk factors for failure of trabeculectomy may have a cumulative effect on the outcome. AIMS: To study the effect of preoperative ocular risk factors on the surgical outcome of trabeculectomy augmented with 2 commonly used doses of Mitomycin C. SETTINGS AND DESIGN: In a prospective cohort study, cases were recruited over an 18 month period. 92 eyes of 83 patients with one to three known risk factors for failure of trabeculectomy underwent Mitomycin-C (MMC augmented trabeculectomy. METHODS AND MATERIAL: Trabeculectomy was done with a randomly chosen MMC dose of 0.2 mg/ml or 0.4 mg/ml. All cases were followed up for a period of at least 3 months. Surgical success was defined as the lowering of intraocular pressure (IOP below 21 mmHg during the follow up period. STATISTICAL ANALYSIS USED: Chi square test, paired t test, odds ratio, effect size. RESULTS: Eyes with two or three risk factors (out of aphakic glaucoma, failed trabeculectomy, neovascular glaucoma, post uveitic glaucoma, traumatic glaucoma, adherent leucoma, juvenile glaucoma, prolonged medical therapy, steroid induced glaucoma, post penetrating keratoplasty glaucoma and developmental glaucoma had a significantly poorer surgical success rate (88% and 78% than eyes with one risk factor (100%. 0.4 mg/ml MMC used sub-sclerally had a statistically similar effect on lowering the IOP as 0.2 mg/ml in all groups. The rate of complications was significantly higher in the 0.4 mg/ml subgroup. CONCLUSIONS: The presence of more than one preoperative ocular risk factor, affects the surgical success of MMC augmented trabeculectomy in high-risk cases. Because of the significantly higher rate of complications with the higher dose of MMC, this should be used sparingly, only in cases with more than two risk factors.
Csordas, Adam; Nietlispach, Fabian; Schuetz, Philipp; Huber, Andreas; Müller, Beat; Maisano, Francesco; Taramasso, Maurizio; Moarof, Igal; Obeid, Slayman; Stähli, Barbara E; Cahenzly, Martin; Binder, Ronald K; Liebetrau, Christoph; Möllmann, Helge; Kim, Won-Keun; Hamm, Christian; Lüscher, Thomas F
Conventional surgical risk scores lack accuracy in risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR). Elevated levels of midregional proadrenomedullin (MR-proADM) levels are associated with adverse outcome not only in patients with manifest chronic disease states, but also in the general population. We investigated the predictive value of MR-proADM for mortality in an unselected contemporary TAVR population. We prospectively included 153 patients suffering from severe aortic stenosis who underwent TAVR from September 2013 to August 2014. This population was compared to an external validation cohort of 205 patients with severe aortic stenosis undergoing TAVR. The primary endpoint was all cause mortality. During a median follow-up of 258 days, 17 out of 153 patients who underwent TAVR died (11%). Patients with MR-proADM levels above the 75th percentile (≥ 1.3 nmol/l) had higher mortality (31% vs. 4%, HR 8.9, 95% CI 3.0-26.0, P 6.8) only showed a trend towards higher mortality (18% vs. 9%, HR 2.1, 95% CI 0.8-5.6, P = 0.13). The Harrell's C-statistic was 0.58 (95% CI 0.45-0.82) for the EuroSCORE II, and consideration of baseline MR-proADM levels significantly improved discrimination (AUC = 0.84, 95% CI 0.71-0.92, P = 0.01). In bivariate analysis adjusted for EuroSCORE II, MR-proADM levels ≥1.3 nmol/l persisted as an independent predictor of mortality (HR 9.9, 95% CI (3.1-31.3), P <0.01) and improved the model's net reclassification index (0.89, 95% CI (0.28-1.59). These results were confirmed in the independent validation cohort. Our study identified MR-proADM as a novel predictor of mortality in patients undergoing TAVR. In the future, MR-proADM should be added to the commonly used EuroSCORE II for better risk stratification of patients suffering from severe aortic stenosis.
Full Text Available Conventional surgical risk scores lack accuracy in risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR. Elevated levels of midregional proadrenomedullin (MR-proADM levels are associated with adverse outcome not only in patients with manifest chronic disease states, but also in the general population.We investigated the predictive value of MR-proADM for mortality in an unselected contemporary TAVR population.We prospectively included 153 patients suffering from severe aortic stenosis who underwent TAVR from September 2013 to August 2014. This population was compared to an external validation cohort of 205 patients with severe aortic stenosis undergoing TAVR. The primary endpoint was all cause mortality.During a median follow-up of 258 days, 17 out of 153 patients who underwent TAVR died (11%. Patients with MR-proADM levels above the 75th percentile (≥ 1.3 nmol/l had higher mortality (31% vs. 4%, HR 8.9, 95% CI 3.0-26.0, P 6.8 only showed a trend towards higher mortality (18% vs. 9%, HR 2.1, 95% CI 0.8-5.6, P = 0.13. The Harrell's C-statistic was 0.58 (95% CI 0.45-0.82 for the EuroSCORE II, and consideration of baseline MR-proADM levels significantly improved discrimination (AUC = 0.84, 95% CI 0.71-0.92, P = 0.01. In bivariate analysis adjusted for EuroSCORE II, MR-proADM levels ≥1.3 nmol/l persisted as an independent predictor of mortality (HR 9.9, 95% CI (3.1-31.3, P <0.01 and improved the model's net reclassification index (0.89, 95% CI (0.28-1.59. These results were confirmed in the independent validation cohort.Our study identified MR-proADM as a novel predictor of mortality in patients undergoing TAVR. In the future, MR-proADM should be added to the commonly used EuroSCORE II for better risk stratification of patients suffering from severe aortic stenosis.
Shrestha, S; Shrestha, R; Shrestha, B; Dongol, A
Cesarean Section (CS) is one of the most commonly performed surgical procedures in obstetrical and gynecological department. Surgical site infection (SSI) after a cesarean section increases maternal morbidity prolongs hospital stay and medical costs. The aim of this study was to find out the incidence and associated risk factors of surgical site infection among cesarean section cases. A prospective, descriptive study was conducted at Dhulikhel Hospital, department of Obstetrics and Gynaecology from July 2013 to June 2014. Total of 648 women who underwent surgical procedure for delivery during study period were included in the study. Data was collected from patient using structred pro forma and examination of wound till discharge was done. Data was compared in terms of presence of surgical site infection and study variables. Wound was evaluated for the development of SSI on third day, and fifth post-operative day, and on the day of discharge. Total of 648 cases were studied. The mean age was 24±4.18. Among the studied cases 92% were literate and 8% were illiterate. Antenatal clinic was attended by 97.7%. The incidence rate of surgical site infection was 82 (12.6%). SSI was found to be common in women who had rupture of membrane before surgery (p=0.020), who underwent emergency surgery (p=0.0004), and the women who had vertical skin incision (p=0.0001) and interrupted skin suturing (p=0.0001) during surgery. Surgical site infection following caesarean section is common. Various modifiable risk factors were observed in this study. Development of SSI is related to multifactorial rather than one factor. Development and strict implementation of protocol by all the health care professionals could be effective to minimize and prevent the infection rate after caesarean section.
Full Text Available In the current economic context, decision making requires complex and multiple actions on the part of the policy makers, who are more challenged than in previous situations, due to the crisis that we are facing. Decision problems cannot be solved by focusing on manager’s own experience or intuition, but require constant adaptation of the methods used effectively in the past to new challenges. Thus, a systemic analysis and modeling of arising issues is required, resulting in the stringent use of Decision Support Systems (DSS, as a necessity in a competitive environment. DSS optimize the situation by getting a timely decision because the decision making process must acquire, process and interpret an even larger amount of data in the shortest possible time. A solution for this purpose is the artificial intelligence systems, in this case Decision Support Systems (DSS, used in a wider area due to expansion of all the new information technologies in decisionmaking processes. These substantial cyber innovations have led to a radical shift in the relationship between enterprise success and quality of decisions made by managers.
Moodley, Yoshan; Naidoo, Prebashini; Biccard, Bruce M
Recent evidence suggests that application of the Revised Cardiac Risk Index (RCRI) for peri-operative cardiovascular risk stratification in vascular surgery patients may be inappropriate, necessitating the development of risk indices specific to vascular surgery patients. To identify risk factors for cardiovascular morbidity and mortality in South African patients undergoing major vascular surgery, and to develop an appropriate cardiovascular risk stratification index, the South African Vascular Surgical Cardiac Risk Index (SAVS-CRI), which could be used to predict the risk of peri-operative major adverse cardiovascular events (MACEs) in South African vascular surgery patients. We prospectively collected data related to peri-operative MACE occurrence and established risk factors for peri-operative MACEs from adult patients who underwent elective vascular surgery at a tertiary hospital in Durban, South Africa, between February 2008 and March 2011. We determined independent predictors of peri-operative MACEs in our cohort by binary logistic regression and used the identified predictors to create a risk index that stratified patients into low-, intermediate- or high-risk groups. Six independent predictors of peri-operative MACEs were identified in the vascular surgery cohort: age >65 years, a history of ischaemic heart disease, a history of diabetes, chronic β-blockade, prior coronary revascularisation, and the vascular surgical procedure. The risk model derived from these risk factors appeared to discriminate between the three risk groups more accurately than the RCRI. The RCRI is not appropriate for peri-operative cardiovascular risk stratification in vascular surgery patients. The SAVS-CRI may be preferable for risk stratification in South African vascular surgery patients, although independent validation is required.
Gibney, R.G.; Fache, J.S.; Becker, C.D.; Nichols, D.M.; Cooperberg, P.L.; Stoller, J.L.; Burhenne, H.J.
Surgical cholecystostomy under local infiltration anesthesia was combined with radiologic removal of gallstones in 36 high-risk patients with acute calculous gallbladder disease. At cholecystostomy, the fundus of the gallbladder was sutured to the anterior abdominal wall, permitting early percutaneous stone removal through the short surgical tract. All gallstones were removed in 31 of 36 patients, for an overall success rate of 86%. The success rate was 97% for gallbladder stones, 86% for cystic duct stones, and 63% for common bile duct stones which were removed by traversing the cystic duct. There were no deaths or serious complications
Bish, Ebru K; El-Amine, Hadi; Steighner, Laura A; Slonim, Anthony D
To understand how structural and process elements may affect the risk for surgical site infections (SSIs) in the ambulatory surgery center (ASC) environment, the researchers employed a tool known as socio-technical probabilistic risk assessment (ST-PRA). ST-PRA is particularly helpful for estimating risks in outcomes that are very rare, such as the risk of SSI in ASCs. Study objectives were to (1) identify the risk factors associated with SSIs resulting from procedures performed at ASCs and (2) design an intervention to mitigate the likelihood of SSIs for the most common risk factors that were identified by the ST-PRA for a particular surgical procedure. ST-PRA was used to study the SSI risk in the ASC setting. Both quantitative and qualitative data sources were utilized, and sensitivity analysis was performed to ensure the robustness of the results. The event entitled "fail to protect the patient effectively" accounted for 51.9% of SSIs in the ambulatory care setting. Critical components of this event included several failure risk points related to skin preparation, antibiotic administration, staff training, proper response to glove punctures during surgery, and adherence to surgical preparation rules related to the wearing of jewelry, watches, and artificial nails. Assuming a 75% reduction in noncompliance on any combination of 2 of these 5 components, the risk for an SSI decreased from 0.0044 to between 0.0027 and 0.0035. An intervention that targeted the 5 major components of the major risk point was proposed, and its implications were discussed.
Alonso-Isa, M; Medina-Polo, J; Lara-Isla, A; Pérez-Cadavid, S; Arrébola-Pajares, A; Sopeña-Sutil, R; Benítez-Sala, R; Justo-Quintas, J; Gil-Moradillo, J; Passas-Martínez, J B; Tejido-Sánchez, A
Open surgery continues to have a fundamental role in urology, and one of its main complications is surgical wound infection. Our objective was to analyse surgical wound infection in patients who underwent surgery in our Department of Urology and to assess the risk factors, microorganisms and resistances by type of surgery. This was a prospective observational study that included 940 patients: 370 abdominal/open lumbar surgeries and 570 genitoperineal surgeries. We analysed age, sex, comorbidities, stay and type of surgery, as well as the causal microorganisms and antibiotic resistances. For genitoperineal surgery, we found 15 cases (2.6%) of surgical wound infection associated with previous urinary catheterisation. Most of the isolated microorganisms corresponded to enterobacteriaceae, highlighting the resistance to beta-lactam. In abdominal/lumbar surgery, we found 41 cases (11.1%) of surgical wound infection. The incidence rate was 3.3% in prostate surgery; 9.8% in renal surgery; and 45.0% in cystectomy. Heart disease was associated with a higher incidence rate of surgical wound infection. The most common microorganisms were Enterococcus spp. (27.1%), E.coli (22.9%) and Staphylococcus aureus (14.6%). Enterococcus and beta-lactamase-producing E.coli are resistant to ampicillin in 37.5% and 41.7% of cases, respectively. We found a low incidence rate of surgical wound infection in genitoperineal surgery, compared with renal surgery and cystectomy. The presence of heart disease and carrying a previous urinary catheter are factors associated with surgical wound infection. Enterococcus and E.coli are the most common pathogens, with high rates of resistance. Copyright © 2016 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.
Yurac, Ratko; Zamorano, Juan J; Lira, Fernando; Valiente, Diego; Ballesteros, Vicente; Urzúa, Alejandro
A recurrent lumbar disc herniation (RLDH) is the most prevalent cause for new radicular pain after surgery for disc herniation-induced sciatica. Reported risk factors include age, gender and smoking, while its surgical treatment is associated to a higher rate of complications and costs. The purpose of this study is to identify factors that increase the risk of requiring surgical treatment for a first RLDH in workers' compensation patients. Nested case-control: 109 patients operated for an RLDH (cases) between June 1st 1994 and May 31st 2011 (minimum follow-up 1 year) and 109 randomly selected patients operated for a first disc herniation with no recurrence during the study period (controls). Age, gender, smoking status, type of work and MRI characteristics of the index herniation were statistically evaluated as potential risk factors. Patient's age of less than 35 years (p = 0.001) and a subligamentous herniation (p disc herniation and patient's age inferior to 35 years at the time of the first surgery are risk factors for requiring surgical treatment of a first RLDH among workers' compensation patients.
Romero, Paola Severo; de Souza, Emiliane Nogueira; Rodrigues, Juliane; Moraes, Maria Antonieta
The study aims to verify quality of life of elderly patients submitted to cardiac surgery, and correlating surgical risk to health-related quality of life instrument domains. Prospective cohort study, performed at a cardiology hospital. It included elderly patients who had undergone elective cardiac surgery. Pre- and postoperative quality of life was evaluated by applying the World Health Organization Quality of Life-Old (WHOQOL-OLD) scale and the Short-Form Health Survey (SF-36) questionnaire. Surgical risk was stratified using the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Fifty-four patients, mostly men (64.8%), were included, with a mean age of 69.3 ± 5.7 years. The eight domains of the SF-36 questionnaire, and the four facets presented for the WHOQOL-OLD scale showed improved quality of life 6 months after surgery (P quality of life instruments. The data showed improved quality of life of elderly people submitted to cardiac surgery, unrelated to surgical risk. © 2014 Wiley Publishing Asia Pty Ltd.
Manchanda, Ranjit; Menon, Usha
The number of ovarian cancer cases is predicted to rise by 14% in Europe and 55% worldwide over the next 2 decades. The current absence of a screening program, rising drug/treatment costs, and only marginal improvements in survival seen over the past 30 years suggest the need for maximizing primary surgical prevention to reduce the burden of ovarian cancer. Primary surgical prevention through risk-reducing salpingo-oophorectomy (RRSO) is well established as the most effective method for preventing ovarian cancer. In the UK, it has traditionally been offered to high-risk women (>10% lifetime risk of ovarian cancer) who have completed their family. The cost-effectiveness of RRSO in BRCA1/BRCA2 carriers older than 35 years is well established. Recently, RRSO has been shown to be cost-effective in postmenopausal women at lifetime ovarian cancer risks of 5% or greater and in premenopausal women at lifetime risks greater than 4%. The acceptability, uptake, and satisfaction with RRSO at these intermediate-risk levels remain to be established. Prospective outcome data on risk-reducing salpingectomy and delayed-oophorectomy for preventing ovarian cancer is lacking, and hence, this is best offered for primary prevention within the context and safe environment of a clinical trial. An estimated 63% of ovarian cancers occur in women with greater than 4% lifetime risk and 53% in those with 5% or greater lifetime-risk. Risk-reducing salpingo-oophorectomy can be offered for primary surgical prevention to women at intermediate risk levels (4%-5% to 10%). This includes unaffected women who have completed their family and have RAD51C, RAD51D, or BRIP1 gene mutations; first-degree relatives of women with invasive epithelial ovarian cancer; BRCA mutation-negative women from high-risk breast-and-ovarian cancer or ovarian-cancer-only families. In those with BRCA1, RAD51C/RAD51D/MMR mutations and the occasional families with a history of ovarian cancer in their 40s, surgery needs to be
Girbes, A R
Reducing the risk in high-risk surgical patients is a common effort of surgeons, anesthesiologists and internists. Several definitions of high-risk surgery exist and one should differentiate the risk for the development of shock and multiple organ dysfunction syndrome from explicitly cardiac risk. Insufficient tissue, especially splanchnic, perfusion can lead to a cascade with the liberation of cytokines and adhesion molecules. Ensuring adequate tissue perfusion is therefore of utmost importance. Assessing tissue perfusion and recognizing hypovolemia is, however, a difficult task using only standard clinical signs as blood pressure and heart rate. Several studies where high-risk surgical patients were treated preoperatively with fluid infusions and/or vasoactive drugs, mainly as determined by invasive monitoring, have shown a positive effect on outcome. On the other hand the value of beta-blockade, started preoperatively, in selected patients at high risk for cardiac complications is accumulating and convincing. The author therefore suggests to aim for targets of therapy based on multiple baseline values for each individual patient. The author also calls for stopping the practice, as is still the case in many hospitals, to leave the patients the night before surgery with an overnight fast, without an intravenous infusion with the appropriate amounts of fluids. However, it is concluded that the definition of 'appropriate' is currently still a matter of opinion and not facts.
Althaus, A; Hinrichs-Rocker, A; Chapman, R; Arránz Becker, O; Lefering, R; Simanski, C; Weber, F; Moser, K-H; Joppich, R; Trojan, S; Gutzeit, N; Neugebauer, E
The incidence of chronic post-surgical pain (CPSP) after various common operations is 10% to 50%. Identification of patients at risk of developing chronic pain, and the management and prevention of CPSP remains inadequate. The aim of this study was to develop an easily applicable risk index for the detection of high-risk patients that takes into account the multifactorial aetiology of CPSP. A comprehensive item pool was derived from a systematic literature search. Items that turned out significant in bivariate analyses were then analysed multivariately, using logistic regression analyses. The items that yielded significant predictors in the multivariate analyses were compiled into an index. The cut-off score for a high risk of developing CPSP with an optimal trade-off between sensitivity and specificity was identified. The data of 150 patients who underwent different types of surgery were included in the analyses. Six months after surgery, 43.3% of the patients reported CPSP. Five predictors multivariately contributed to the prediction of CPSP: capacity overload, preoperative pain in the operating field, other chronic preoperative pain, post-surgical acute pain and co-morbid stress symptoms. These results suggest that several easily assessable preoperative and perioperative patient characteristics can predict a patient's risk of developing CPSP. The risk index may help caregivers to tailor individual pain management and to assist high-risk patients with pain coping. © 2011 European Federation of International Association for the Study of Pain Chapters.
Wang, Xiao; Hu, Yanting; Zhao, Binjiang; Su, Yue
Abstract The risk calculator of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) has been shown to be useful in predicting postoperative complications. In this study, we aimed to evaluate the predictive value of the ACS-NSQIP calculator in geriatric patients undergoing lumbar surgery. A total of 242 geriatric patients who underwent lumbar surgery between January 2014 and December 2016 were included. Preoperative clinical information was retrospectivel...
Cohen, Margot E; Salmasian, Hojjat; Li, Jianhua; Liu, Jianfang; Zachariah, Philip; Wright, Jason D; Freedberg, Daniel E
Antibiotic-resistant infections have high rates of morbidity and mortality, and exposure to antibiotics is the crucial risk factor for development of antibiotic resistance. If surgical antibiotic prophylaxis (SAP) increases risk for antibiotic-resistant infections, prophylaxis may cause net harm, even if it decreases overall infection rates. This retrospective cohort study included adults who underwent elective surgical procedures and developed infections within 30 postoperative days. Procedures from multiple disciplines were included if SAP was considered discretionary by current guidelines. Postoperative antibiotic-resistant infections were defined as positive culture results from any site within 30 postoperative days, showing intermediate or nonsusceptibility across 1 or more antibiotic classes. Surgical antibiotic prophylaxis included use of antibiotics within any class and at any dose from 1 hour before first incision until the end of the operation. Among 689 adults with postoperative infections, 338 (49%) had postoperative resistant infections. Use of SAP was not associated with postoperative antibiotic-resistant infections (odds ratio [OR] 0.99; 95% CI 0.67 to 1.46). This result remained robust when the SAP definition was extended to antibiotics given within 4 hours before first incision (OR 0.94; 95% CI 0.63 to 1.40) and when the follow-up window was narrowed to 14 days (OR 0.82; 95% CI 0.50 to 1.34). Previous antibiotic-resistant infections were associated with risk for postoperative antibiotic-resistant infections (OR 1.81; 95% CI 1.16 to 2.83). Use of SAP was not associated with risk for postoperative antibiotic-resistant infections in a large cohort of patients with postoperative infections. This provides important reassurance regarding use of surgical antibiotic prophylaxis. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Costa, L; Cunha, JP; Amado, D; Abegão Pinto, L; Ferreira, J
ABSTRACT Glaucoma is a multifactorial condition under serious influence of many risk factors. The role of diabetes mellitus (DM) in glaucoma etiology or progression remains inconclusive. Although, the diabetic patients have different healing mechanism comparing to the general population and it has a possible-negative role on surgical outcomes. This review article attempts to analyze the association of both diseases, glaucoma and DM, before and after the surgery. The epidemiological studies, b...
Keller, Bastiaan Paul Johan Aart
With prevalence figures of 13% for university hospitals and 23% for general hospitals, pressure ulcers are a major health care issue in The Netherlands. Pressure ulcers in surgical patients are frequently encountered, as is illustrated by reported incidence rates up to 66%. The number of patients at
Daniel Guerron, A; Portenier, Dana D
Bariatric surgery is the most effective way to improve comorbidities related to obesity. Since the introduction of minimally invasive laparoscopic surgery in the bariatric surgery techniques, the number of procedures has increased substantially; advances in techniques and the transition from open to minimally invasive procedures have decreased morbidity and mortality. Multidisciplinary teams in charge of the operative planning, surgical act, and postoperative recovery are determinant in the success of the management of high-risk bariatric patients; careful identification and preoperative management of these higher-risk patients is crucial in decreasing complications after weight loss surgery. Copyright © 2016 Elsevier Inc. All rights reserved.
Mull, Hillary J; Rosen, Amy K; Charns, Martin P; Itani, Kamal M F; Rivard, Peter E
Little is known about patient safety risks in outpatient surgery. Inpatient surgical adverse events (AEs) risk factors include patient- (e.g., advanced age), process- (e.g., inadequate preoperative assessment), or structure-related characteristics (e.g., low surgical volume); however, these factors may differ from outpatient care where surgeries are often elective and in younger/healthier patients. We undertook an exploratory qualitative research project to identify risk factors for AEs in outpatient surgery. We developed a conceptual framework of patient, process, and structure factors associated with surgical AEs on the basis of a literature review. This framework informed our semistructured interview guide with (1) open-ended questions about a specific outpatient AE that the participant experienced and (2) outpatient surgical patient safety risk factors in general. We interviewed nationwide Veterans Health Administration surgical staff. Results were coded on the basis of categories in the conceptual framework, and additional themes were identified using content analysis. Fourteen providers representing diverse surgical roles participated. Ten reported witnessing an AE, and everyone provided input on risk factors in our conceptual framework. We did not find evidence that patient race/age, surgical technique, or surgical volume affected patient safety. Emerging factors included patient compliance, postoperative patient assessments/instruction, operating room equipment needs, and safety culture. Surgical staff are familiar with AEs and patient safety problems in outpatient surgery. Our results show that processes of care undertaken by surgical providers, as opposed to immutable patient characteristics, may affect the occurrence of AEs. The factors we identified may facilitate more targeted research on outpatient surgical AEs.
Tominaga, Hiroyuki; Setoguchi, Takao; Ishidou, Yasuhiro; Nagano, Satoshi; Yamamoto, Takuya; Komiya, Setsuro
This study aimed to identify and compare risk factors for surgical site infection (SSI) and non-surgical site infections (non-SSIs), particularly urinary tract infection (UTI), after spine surgery. We retrospectively reviewed 825 patients (median age 59.0 years (range 33-70 years); 442 males) who underwent spine surgery at Kagoshima University Hospital from January 2009 to December 2014. Patient parameters were compared using the Mann-Whitney U and Fisher's exact tests. Risk factors associated with SSI and UTI were analyzed via the multiple logistic regression analysis. P operation time (P = 0.0019 and 0.0162, respectively) and ASA classification 3 (P = 0.0132 and 0.0356, respectively). The 1 week post-operative C-reactive protein (CRP) level was a risk factor for UTI (P = 0.0299), but not for SSI (P = 0.4996). There was no relationship between SSI and symptomatic UTI after spine surgery. Risk factors for post-operative SSI and UTI were operative time and ASA classification 3; 1 week post-operative CRP was a risk factor for UTI only.
Magalhães, João E; Azevedo-Filho, Hildo R C; Rocha-Filho, Pedro A S
The aim of this study was to assess the risk of headache in patients undergoing surgical treatment of intracranial aneurysms. The risk of the post-craniotomy headache has never been studied. Patients with intracranial aneurysm, who were consecutively admitted to the Hospital da Restauração, Brazil, from May 2009 to October 2010, were interviewed before they underwent surgical or non-surgical treatment of the aneurysms. The patients were followed for 4 months after intervention. The International Headache Society criteria for post-craniotomy headache were used after surgery and adapted for headache after embolization (maximum intensity of pain on the same side of the aneurysm). We also used the Headache Impact Test, the Hospital Anxiety and Depression Scale, and the Epworth Sleepiness Scale. Of 101 patients enrolled, 53 patients underwent craniotomy and 48 patients embolization. The surgery group was younger and had fewer women. The incidence of headache was 28/51 cases (54.9%) after surgery and 12/47 cases (25.5%) after embolization (relative risk = 2.15; 95% confidence interval [CI] 1.24-3.72). The incidence of persistent headache was not different between the 2 groups. The only risk factor for headache after the intervention was craniotomy (odds ratio = 2.6; 95% CI 1.1-6.7) and for persistent headache was anxiety prior to treatment (odds ratio = 8.5; 95% CI 1.7-42.3). The headache after treatment was not associated with the risk of anxiety or depression after the intervention. Patients who underwent craniotomy had an increased risk of headache after treatment of intracranial aneurysms. The incidence of persistent headache after 3 months was higher among patients who had anxiety before the intervention. © 2013 American Headache Society.
Full Text Available Surgical site infections (SSI following total hip arthroplasty (THA have a significantly adverse impact on patient outcomes and pose a great challenge to the treating surgeon. Therefore, timely recognition of those patients at risk for this complication is very important, as it allows for adopting measures to reduce this risk. This review discusses literature reported risk factors for SSI after THA. These can be classified into patient-related factors (age, gender, obesity, comorbidities, history of infection, primary diagnosis, and socioeconomic profile, surgery-related factors (allogeneic blood transfusion, DVT prophylaxis and coagulopathy, duration of surgery, antibiotic prophylaxis, bearing surface and fixation, bilateral procedures, NNIS index score, and anesthesia type, and hospital-related factors (duration of hospitalization, institution and surgeon volume, and admission from a healthcare facility. All these factors are discussed with respect to potential measures that can be taken to reduce their effect and consequently the overall risk for infection.
Beginning RPG Maker VX Ace takes you through the process of using the RPG Maker VX Ace game development engine to create your very own role playing game. The book has been designed with the complete beginner in mind who has little to no experience with the engine. Tutorials and exercises will take you from installing the software to putting the final touches upon your first project. Game design can be quite a daunting challenge, as it generally involves a large amount of programming know-how on top of having to plan everything out that makes a good game what it is. RPG Maker VX Ace
de Pedro-Cuesta, Jesús; Mahillo-Fernández, Ignacio; Rábano, Alberto
Evidence of surgical transmission of sporadic Creutzfeldt-Jakob disease (sCJD) remains debatable in part due to misclassification of exposure levels. In a registry-based case-control study, the authors applied a risk-based classification of surgical interventions to determine the association...
Kasatpibal, Nongyao; Whitney, Joanne D; Dellinger, E Patchen; Nair, Bala G; Pike, Kenneth C
Antibiotic prophylaxis is a key component of the prevention of surgical site infection (SSI). Failure to manage antibiotic prophylaxis effectively may increase the risk of SSI. This study aimed to examine the effects of antibiotic prophylaxis on SSI risk. A retrospective cohort study was conducted among patients having general surgery between May 2012 and June 2015 at the University of Washington Medical Center. Peri-operative data extracted from hospital databases included patient and operation characteristics, intra-operative medication and fluid administration, and survival outcome. The effects of antibiotic prophylaxis and potential factors on SSI risk were estimated using multiple logistic regression and were expressed as risk ratios (RRs). A total of 4,078 patients were eligible for analysis. Of these, 180 had an SSI. Mortality rates within and after 30 days were 0.8% and 0.3%, respectively. Improper antibiotic redosing increased the risk of SSI (RR 4.61; 95% confidence interval [CI] 1.33-15.91). Other risk factors were in-patient status (RR 4.05; 95% CI 1.69-9.66), smoking (RR 1.63; 95% CI 1.03-2.55), emergency surgery (RR 1.97; 95% CI 1.26-3.08), colectomy (RR 3.31; 95% CI 1.19-9.23), pancreatectomy (RR 4.52; 95% CI 1.53-13.39), proctectomy (RR 5.02; 95% CI 1.72-14.67), small bowel surgery (RR 6.16; 95% CI 2.13-17.79), intra-operative blood transfusion >500 mL (RR 2.76; 95% CI 1.45-5.26), and multiple procedures (RR 1.40; 95% CI 1.01-1.95). These data demonstrate that failure to redose prophylactic antibiotic during long operations increases the risk of SSI. Strengthening a collaborative surgical quality improvement program may help to eradicate this risk.
Cheng, Hang; Chen, Brian Po-Han; Soleas, Ireena M; Ferko, Nicole C; Cameron, Chris G; Hinoul, Piet
The incidence of surgical site infection (SSI) across surgical procedures, specialties, and conditions is reported to vary from 0.1% to 50%. Operative duration is often cited as an independent and potentially modifiable risk factor for SSI. The objective of this systematic review was to provide an in-depth understanding of the relation between operating time and SSI. This review included 81 prospective and retrospective studies. Along with study design, likelihood of SSI, mean operative times, time thresholds, effect measures, confidence intervals, and p values were extracted. Three meta-analyses were conducted, whereby odds ratios were pooled by hourly operative time thresholds, increments of increasing operative time, and surgical specialty. Pooled analyses demonstrated that the association between extended operative time and SSI typically remained statistically significant, with close to twice the likelihood of SSI observed across various time thresholds. The likelihood of SSI increased with increasing time increments; for example, a 13%, 17%, and 37% increased likelihood for every 15 min, 30 min, and 60 min of surgery, respectively. On average, across various procedures, the mean operative time was approximately 30 min longer in patients with SSIs compared with those patients without. Prolonged operative time can increase the risk of SSI. Given the importance of SSIs on patient outcomes and health care economics, hospitals should focus efforts to reduce operative time.
Full Text Available Objectives: High preoperative risk precludes decortication and other surgical interventions in some patients with chronic empyema. We manage such patients by converting the chest tube into an "empyema tube," cutting the tube near the skin and securing the end with a sterile clip to allow for open pleural drainage. The patient is followed serially, and the tube gradually withdrawn based on radiological resolution and amount of drainage. Methods: Between 2010 and 2014, patients with chronic empyema and unexpandable lung, deemed high-risk surgical candidates, had staged chest tube removal, and were included for the study. The volume of fluid drained, culture results, duration of drainage, functional status, and comorbidities were recorded. Measurements and Results: Eight patients qualified. All had resolution of infection. The tube was removed after an average of 73.6 ± 49.73 (95% confidence interval [CI] days. The mean duration of antibiotic treatment was 5.37 ± 1.04 (95% CI weeks. None required surgery or experienced complications from an empyema tube. Conclusion: A strategy of empyema tube drainage with staged removal is an option in appropriately selected patients with chronic empyema, unexpandable lung, and poor surgical candidacy.
Hickman, Ronald L; Daly, Barbara J; Douglas, Sara L; Clochesy, John M
Overwhelmed family decision makers of chronically critically ill patients must comprehend vital information to make complex treatment decisions that are consistent with patients' preferences. Exploration of informational coping styles of family decision makers may yield evidence for tailored communication practices supporting the psychological and informational needs of family decision makers. To describe patterns in the demographic characteristics and informational coping styles of family decision makers; to assess differences in informational satisfaction, role stress, and depressive symptoms between family decision makers classified as monitors and as blunters; and to describe the predictive associations between informational coping styles, informational satisfaction, and role stress on depressive symptoms in family decision makers. A secondary data analysis of 210 family decision makers of cognitively impaired patients who required 3 days or more of mechanical ventilation. On enrollment, decision makers completed the abbreviated Miller Behavioral Style Scale to assess informational coping styles, the Critical Care Family Satisfaction Survey's informational subscale to assess informational satisfaction, a single-item measure of role stress, and the Center for Epidemiological Studies Depression scale to assess depressive symptoms. No associations emerged between demographic characteristics and informational coping styles of family decision makers. Monitors had higher depression scores than did blunters. Both information coping style and informational satisfaction influenced depressive symptoms; however, role stress was the most significant predictor. Family decision makers classified as monitors were at higher risk for depression than were those who seem to avoid information. Targeting monitors with additional psychological and informational support may mitigate their psychological impairment.
Johnston, Lily E; Downs, Emily A; Hawkins, Robert B; Quader, Mohammed A; Speir, Alan M; Rich, Jeffrey B; Ghanta, Ravi K; Yarboro, Leora T; Ailawadi, Gorav
Two large, randomized trials are underway evaluating transcatheter aortic valve replacement (AVR) against conventional surgical AVR. We analyzed contemporary, real-world outcomes of surgical AVR in low-risk patients to provide a practical benchmark of outcomes and cost for evaluating current and future transapical AVR technology. From 2010 to 2015, 2,505 isolated AVR operations were performed for severe aortic stenosis at 18 statewide cardiac institutions. Of these, 2,138 patients had a Society of Thoracic Surgeons predicted risk of mortality of less than 4%, and 1,119 met other clinical and hemodynamic criteria as outlined in the PARTNER 3 (The Placement of Transcatheter Aortic Valves) protocol. Patients with endocarditis, end-stage renal disease, ejection fraction of less than 0.45, bicuspid valves, and previous valve replacements were excluded. Outcomes of interest included operative death and postoperative adverse events. The median Society of Thoracic Surgeons predicted risk of mortality for the study-eligible patients was 1.44%, with a median age of 72 years (interquartile range [IQR], 65 to 78 years). Operative mortality was 1.3%, permanent stroke was 1.3%, and pacemaker requirement was 4.2%. The most common adverse events were transfusion of 2 or more units of red blood cells (18%) and atrial fibrillation (28%). The median length of stay was 6 days (IQR, 5 to 8 days). Median total hospital cost was $37,999 (IQR, $30,671 to $46,138). Examination of complications by age younger than 65 vs 65 or older demonstrated a significantly lower need for transfusion (11.2%, p risk patients undergoing surgical AVR in the current era have excellent results. The most common complications were atrial fibrillation and bleeding. These real-world results should provide additional context for upcoming transcatheter clinical trial data. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Neto, José Garcia; de Cleva, Roberto; Zilberstein, Bruno; Gama-Rodrigues, Joaquim José
AIM: To analyze the risk of cardiovascular complications in patients with indication for surgical treatment of Chagasic esophageal achalasia and to correlate the surgical risks with the degree of esophageal dilation, thereby proposing a risk scale index. METHODS: One hundred and twenty-four patients with Chagasic esophageal achalasia, who received surgical treatment at the Hospital das Clinicas of the Federal University of Goiás, were included in this study. The patients were mostly related to the postoperative complications due to the cardiovascular system. All the patients were submitted to: (1) clinical history to define the cardiac functional class (New York Heart Association); (2) conventional 12-lead electrocardiogram at rest; and (3) contrast imaging of the esophagus to determine esophageal dilatation according to Rezende’s classification of Chagasic megaesophagus. RESULTS: An assessment of the functional classification (FC) of heart failure during the preoperative period determined that 67 patients (54.03%) were assigned functional class I (FC I), 46 patients (37.09%) were assigned functional class II (FC II), and 11 patients (8.87%) were assigned functional class III (FC III). None of the patients were assigned to functional class IV (FC IV). There was a positive correlation between the functional class and the postoperative complications (FC I×FC II:P < 0.001; FC I×FC III: P < 0.001). The ECG was normal in 44 patients (35.48%) and presented abnormalities in 80 patients (64.52%). There was a significant statistical correlation between abnormal ECG (arrhythmias and primary change in ventricular repolarization) and postoperative complications (P < 0.001). With regard to the classification of the Chagasic esophageal achalasia, the following distribution was observed: group II, 53 patients (42.74%); group III, 37 patients (29.83%); and group IV, 34 patients (27.41%). There was a positive correlation between the degree of esophageal dilation and the
Goltz, Daniel E; Baumgartner, Billy T; Politzer, Cary S; DiLallo, Marcus; Bolognesi, Michael P; Seyler, Thorsten M
Patient demand and increasing cost awareness have led to the creation of surgical risk calculators that attempt to predict the likelihood of adverse events and to facilitate risk mitigation. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator is an online tool available for a wide variety of surgical procedures, and has not yet been fully evaluated in total joint arthroplasty. A single-center, retrospective review was performed on 909 patients receiving a unilateral primary total knee (496) or hip (413) arthroplasty between January 2012 and December 2014. Patient characteristics were entered into the risk calculator, and predicted outcomes were compared with observed results. Discrimination was evaluated using the receiver-operator area under the curve (AUC) for 90-day readmission, return to operating room (OR), discharge to skilled nursing facility (SNF)/rehab, deep venous thrombosis (DVT), and periprosthetic joint infection (PJI). The risk calculator demonstrated adequate performance in predicting discharge to SNF/rehab (AUC 0.72). Discrimination was relatively limited for DVT (AUC 0.70, P = .2), 90-day readmission (AUC 0.63), PJI (AUC 0.67), and return to OR (AUC 0.59). Risk score differences between those who did and did not experience discharge to SNF/rehab, 90-day readmission, and PJI reached significance (P Calculator has fair utility in predicting discharge to SNF/rehab, but limited usefulness for 90-day readmission, return to OR, DVT, and PJI. Although length of stay predictions are similar to actual outcomes, statistical correlation remains relatively weak. Copyright © 2017 Elsevier Inc. All rights reserved.
Ovaska, Mikko T; Mäkinen, Tatu J; Madanat, Rami; Huotari, Kaisa; Vahlberg, Tero; Hirvensalo, Eero; Lindahl, Jan
Surgical site infection is one of the most common complications following ankle fracture surgery. These infections are associated with substantial morbidity and lead to increased resource utilization. Identification of risk factors is crucial for developing strategies to prevent these complications. We performed an age and sex-matched case-control study to identify patient and surgery-related risk factors for deep surgical site infection following operative ankle fracture treatment. We identified 1923 ankle fracture operations performed in 1915 patients from 2006 through 2009. A total of 131 patients with deep infection were identified and compared with an equal number of uninfected control patients. Risk factors for infection were determined with use of conditional logistic regression analysis. The incidence of deep infection was 6.8%. Univariate analysis showed diabetes (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.0, 4.9), alcohol abuse (OR = 3.8, 95% CI = 1.6, 9.4), fracture-dislocation (OR = 2.0, 95% CI = 1.2, 3.5), and soft-tissue injury (a Tscherne grade of ≥1) (OR = 2.6, 95% CI = 1.3, 5.3) to be significant patient-related risk factors for infection. Surgery-related risk factors were suboptimal timing of prophylactic antibiotics (OR = 1.9, 95% CI = 1.0, 3.4), difficulties encountered during surgery, (OR = 2.1, 95% CI = 1.1, 4.0), wound complications (OR = 4.8, 95% CI = 1.6, 14.0), and fracture malreduction (OR = 3.4, 95% CI = 1.3, 9.2). Independent risk factors for infection identified by multivariable analyses were tobacco use (OR = 3.7, 95% CI = 1.6, 8.5) and a duration of surgery of more than ninety minutes (OR = 2.5, 95% CI = 1.1, 5.7). Cast application in the operating room was independently associated with a decreased infection rate (OR = 0.4, 95% CI = 0.2, 0.8). We identified several modifiable risk factors for deep surgical site infection following operative treatment of ankle fractures.
D. Yu. Pushkar
Full Text Available Objective – to identify the major risk factors leading to worse results of surgical treatment in patients with urethral stricture.Subjects and methods. Two hundred and forty-eight patients with urethral stricture underwent different surgical interventions: internal optical urethrotomy (IOU for strictures of different portions of the urethra in 157 patients (the operation was made once in 121 patients, twice in 24 patients, and thrice or more in 12; replacement urethroplasty using a buccal mucosa graft for strictures of the anterior urethra in 46 patients; Turner-Warwick’s anastomotic urethroplasty modified by Webster for strictures (distraction defects of the posterior urethra in 45 patients. The results of surgical treatment were studied using urethrography, uroflowmetry, urethrocystoscopy, the international prostate symptom score, quality of life (QoL questionnaire, and the international index of erectile function (IIEF questionnaire. The role of risk factors for postoperative recurrent urethral stricture was assessed by univariate and multivariate analyses.Results. The rate of recurrent urethral stricture after IOU was 66.9 % (59.5, 87.5, and 100 % after the first, second, third or more subsequent operations, respectively; 12.1 % after all types of urethroplasty, 15.2 % after augmentation urethroplasty, and 8.9 % after anastomotic urethroplasty. The major risk factors of recurrent urethral stricture after IOU were recognized to be the location of urethral stricture in the penile or bulbomembranous portions, a urethral stricture length of > 1 cm, severe urethral lumen narrowing, and performance of 2 or more operations; those after augmentation urethroplasty were previous ineffective treatment, a stricture length of > 4 cm, lichen sclerosus, and smoking; those after anastomotic urethroplasty were previous ineffective treatment, smoking, and a stricture length of > 4 cm.Conclusion. The results of the investigation have shown that only
D. Yu. Pushkar
Full Text Available Objective – to identify the major risk factors leading to worse results of surgical treatment in patients with urethral stricture.Subjects and methods. Two hundred and forty-eight patients with urethral stricture underwent different surgical interventions: internal optical urethrotomy (IOU for strictures of different portions of the urethra in 157 patients (the operation was made once in 121 patients, twice in 24 patients, and thrice or more in 12; replacement urethroplasty using a buccal mucosa graft for strictures of the anterior urethra in 46 patients; Turner-Warwick’s anastomotic urethroplasty modified by Webster for strictures (distraction defects of the posterior urethra in 45 patients. The results of surgical treatment were studied using urethrography, uroflowmetry, urethrocystoscopy, the international prostate symptom score, quality of life (QoL questionnaire, and the international index of erectile function (IIEF questionnaire. The role of risk factors for postoperative recurrent urethral stricture was assessed by univariate and multivariate analyses.Results. The rate of recurrent urethral stricture after IOU was 66.9 % (59.5, 87.5, and 100 % after the first, second, third or more subsequent operations, respectively; 12.1 % after all types of urethroplasty, 15.2 % after augmentation urethroplasty, and 8.9 % after anastomotic urethroplasty. The major risk factors of recurrent urethral stricture after IOU were recognized to be the location of urethral stricture in the penile or bulbomembranous portions, a urethral stricture length of > 1 cm, severe urethral lumen narrowing, and performance of 2 or more operations; those after augmentation urethroplasty were previous ineffective treatment, a stricture length of > 4 cm, lichen sclerosus, and smoking; those after anastomotic urethroplasty were previous ineffective treatment, smoking, and a stricture length of > 4 cm.Conclusion. The results of the investigation have shown that only
Young, John; Geraci, Travis; Milman, Steven; Maslow, Andrew; Jones, Richard N; Ng, Thomas
To reduce the incidence of urinary tract infection, Surgical Care Improvement Project 9 mandates the removal of urinary catheters within 48 hours postoperatively. In patients with thoracic epidural anesthesia, we sought to determine the rate of catheter reinsertion, the complications of reinsertion, and the factors associated with reinsertion. We conducted a prospective observational study of consecutive patients undergoing major pulmonary or esophageal resection with thoracic epidural analgesia over a 2-year period. As per Surgical Care Improvement Project 9, all urinary catheters were removed within 48 hours postoperatively. Excluded were patients with chronic indwelling catheter, patients with urostomy, and patients requiring continued strict urine output monitoring. Multivariable logistic regression analysis was used to identify independent risk factors for urinary catheter reinsertion. Thirteen patients met exclusion criteria. Of the 275 patients evaluated, 60 (21.8%) required reinsertion of urinary catheter. There was no difference in the urinary tract infection rate between patients requiring reinsertion (1/60 [1.7%]) versus patients not requiring reinsertion (1/215 [0.5%], P = .389). Urethral trauma during reinsertion was seen in 1 of 60 patients (1.7%). After reinsertion, discharge with urinary catheter was required in 4 of 60 patients (6.7%). Multivariable logistic regression analysis found esophagectomy, lower body mass index, and benign prostatic hypertrophy to be independent risk factors associated with catheter reinsertion after early removal in the presence of thoracic epidural analgesia. When applying Surgical Care Improvement Project 9 to patients undergoing thoracic procedures with thoracic epidural analgesia, consideration to delayed removal of urinary catheter may be warranted in patients with multiple risk factors for reinsertion. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
Thomas, S M; Lam, N N; Welk, B K; Nguan, C; Huang, A; Nash, D M; Prasad, G V R; Knoll, G A; Koval, J J; Lentine, K L; Kim, S J; Lok, C E; Garg, A X
A kidney stone in a person with a solitary kidney requires urgent attention, which may result in surgical and/or hospital attention. We conducted a matched retrospective cohort study to determine if living kidney donors compared to healthy nondonors have a higher risk of: (i) kidney stones with surgical intervention, and (ii) hospital encounters for kidney stones. We reviewed all predonation charts for living kidney donations from 1992 to 2009 at five major transplant centers in Ontario, Canada, and linked this information to healthcare databases. We selected nondonors from the healthiest segment of the general population and matched 10 nondonors to every donor. Of the 2019 donors and 20 190 nondonors, none had evidence of kidney stones prior to cohort entry. Median follow-up time was 8.4 years (maximum 19.7 years; loss to follow-up kidney stones with surgical intervention in donors compared to nondonors (8.3 vs. 9.7 events/10 000 person-years; rate ratio 0.85; 95% confidence interval [CI] 0.47-1.53). Similarly there was no difference in the rate of hospital encounters for kidney stones (12.1 vs. 16.1 events/10 000 person-years; rate ratio 0.75; 95% CI 0.45-1.24). These interim results are reassuring for the safety of living kidney donation. © Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.
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.
Full Text Available Background: Patients with liver cirrhosis have high surgical risks due to malnutrition, impaired immunity, coagulopathy, and encephalopathy. However, there is no information in English literature about the results of liver cirrhotic patients who underwent instrumented lumbar surgery. The purpose of this study is to report the perioperative complications, clinical outcomes and determine the surgical risk factors in cirrhotic patients. Methods: We retrospectively reviewed 29 patients with liver cirrhosis who underwent instrumented lumbar surgery between 1997 and 2009. The hepatic functional reserves of the patients were recorded according to the Child-Turcotte-Pugh scoring system. Besides, fourteen other variables and perioperative complications were also collected. To determine the risks, we divided the patients into two groups according to whether or not perioperative complications developed. Results: Of the 29 patients, 22 (76% belonged to Child class A and 7 (24% belonged to Child class B. Twelve patients developed one or more complications. Patients with Child class B carried a significantly higher incidence of complications than those with Child class A (p = 0.011. In the Child class A group, patients with 6 points had a significantly higher incidence of complications than those with 5 points (p = 0.025. A low level of albumin was significantly associated with higher risk, and a similar trend was also noted for the presence of ascites although statistical difference was not reached. Conclusion: The study concludes that patients with liver cirrhosis who have undergone instrumented lumbar surgery carry a high risk of developing perioperative complications, especially in those with a Child-Turcotte-Pugh score of 6 or more.
Full Text Available Background: Different studies underline the use of pre-operative antibiotic prophylaxis in clean surgeries like herniotomy and inguinal orchiopexy. But, the meta-analyses do not recommend nor discard the use of prophylactic pre-operative antibiotics. The scarcity of controlled clinical trials in paediatric population further vitiates the matter. This study assessed the difference in the rate of early post-operative wound infection cases in children who received single dose of pre-operative antibiotics and children who did not receive antibiotics after inguinal herniotomy and orchiopexy. Materials and Methods: This randomised prospective study was conducted in Paediatric Surgery department of PGIMER Chandigarh. Out of 251 patients, 112 patients were randomised to the case group and 139 were ascribed to the control group. The patients in control group were given a standard regimen of single dose of intravenous antibiotic at the time of induction followed by 3-4 days of oral antibiotic. Case group patients underwent the surgical procedure in similar manner with no antibiotic either at the time of induction or post-operatively. Results: The incidence of surgical site infection in case group was 3.73 % and that in control group was 2.22%. The observed difference in the incidence of surgical site infection was statistically insignificant (P value = 0.7027. The overall infection rate in case and control group was 2.89%. Conclusions: Our preliminary experience suggests that there is no statistically significant difference in the proportion of early post-operative wound infection between the patients who received single dose of pre-operative antibiotics and the patients who received no antibiotics after inguinal herniotomy and orchiopexy. The risk of surgical site infection in paediatric heriotomies does not increase even if the child′s weight is less than his/her expected weight for age.
Full Text Available Aleksandra Kołtuniuk, Joanna Rosińczuk Department of Nervous System Diseases, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland Background: Cardiovascular diseases (CVDs are the leading cause of mortality among adults in Poland. A number of risk factors have significant influence on CVD incidence. Early identification of risk factors related to our lifestyle facilitates taking proper actions aiming at the reduction of their negative impact on health.Aim: The aim of the study was to compare the prevalence of CVD risk factors between patients aged over 65 years and patients of other age groups in surgical wards.Material and methods: The study was conducted for assessment and finding the distribution of major risk factors of CVD among 420 patients aged 18–84 years who were hospitalized in surgical wards. Interview, anthropometric measurements, blood pressure, and fasting blood tests for biochemical analysis were conducted in all subjects. Statistical analysis of the material was performed using Student’s t-test, chi-square test, Fisher’s exact test, Mann–Whitney U-test, and analysis of variance.Results: While abdominal obesity (83.3%, overweight and obesity (68%, hypertension (65.1%, hypercholesterolemia (33.3%, and low level of physical activity (29.1% were the most common CVD risk factors among patients over 65 years old, abdominal obesity (36.2%, overweight and obesity (36.1%, and current smoking were the most common CVD risk factors among patients up to the age of 35. In the age group over 65, the least prevalent risk factors for CVD were diabetes mellitus (14.8%, depressive episodes (13.6%, abuse of alcohol (11.4%, and smoking (7.8%. In the group under 35 years, we have not reported any cases of hypercholesterolemia and a lesser number of patients suffered from diabetes and HTN.Conclusion: Distribution of the major risk factors for CVD is quite high in the adult population, especially in the age group over 65
Avijeet Mukherjee, Naveen N
Full Text Available Background and Objectives: Surgical site infection (SSI is the most common nosocomial infection encountered in post operative surgical wards. The use of prophylactic antibiotic in clean elective surgical cases is still a subject of controversy to surgeons. The objective of the study is to identify the need for using prophylactic antibiotics in clean surgeries, prevalence of organisms in patients who are not given prophylactic antibiotics and to study whether the presence of risk factors increase the incidence of surgical site infection. Methodology: The comparative study consists of 100 cases admitted under two groups of 50 each: Group A was given prophylactic antibiotic and Group B didn’t receive any. All surgeries other than clean surgical cases were excluded from the study. Results: Out of 50 patients in group B who were not given prophylactic antibiotic, 2 patients had more than one risk factor for development of SSI and both of them developed SSI. Of the 50 patients who received prophylactic antibiotic, none developed SSI. The rate of infection in group A was nil and in Group B was 4%. Conclusion: Prophylactic antibiotics are not recommended for clean elective surgical cases as there is no statistically significant change in the infection rate seen in patients not receiving prophylactic antibiotic(P=0.4952. Meticulous surgical technique and correcting risk factors prior to surgery is a must for reducing incidence of SSI.
Bentzen, Eric; Christiansen, John K.; Varnes, Claus J.
/methodology/approach – The present analysis draws on insights from previous research into decision making in product and portfolio management and studies on organizational decision making. The authors frame why the attention of decision makers is so critical in complex situations. Data for this study were collected through direct......Purpose – Managers' attention is a scarce resource in complex innovation settings. Prior research on the factors to which managers pay attention is mostly based on surveys. The present study aims to address the need for knowledge about the behavior of decision makers based on observations from...... portfolio meetings. The study seeks to investigate how managers allocate their attention and the role of different factors for their attention. Observations also make it possible to compare prior research and expectations with the actual observed behavior of decision makers. Design...
Slump, Jelena; Ferguson, Peter C.; Wunder, Jay S.; Griffin, Anthony; Hoekstra, Harald J.; Bagher, Shaghayegh; Zhong, Toni; Hofer, Stefan O. P.; O'Neill, Anne C.
Introduction: The ACS-NSQIP surgical risk calculator is an open-access on-line tool that estimates the risk of adverse post-operative outcomes for a wide range of surgical procedures. Wide surgical resection of soft tissue sarcoma (STS) often requires complex reconstructive procedures that can be
Matsukawa, Hidetoshi; Kamiyama, Hiroyasu; Tsuboi, Toshiyuki; Noda, Kosumo; Ota, Nakao; Miyata, Shiro; Takahashi, Osamu; Tokuda, Sadahisa; Tanikawa, Rokuya
Advanced age is known to be a significant risk factor for the rupture of intracranial aneurysms. The impact of age on outcomes of surgically treated patients with unruptured intracranial aneurysms (UIAs) is less clear. A total of 663 consecutive patients with 823 surgically treated UIAs were evaluated. UIAs, which need bypass surgery including low-flow or high-flow bypass, were defined as complex aneurysms. Aneurysm size was categorized as small (<15 mm), large (15-24 mm), and giant (≥25 mm). In patients without symptoms, a poor outcome is defined as a modified Rankin Scale (mRS) score of 2-6. In those with mRS score higher than 1 as a result of UIA-related symptoms or other comorbidities, a poor outcome is defined as an increase of 1 or more on the mRS. Outcomes were evaluated at the 6-month and 12-month follow-up examinations. The mean age was 62 ± 12 years and 650 UIAs (78%) were observed in women. Previously treated aneurysm (P = 0.009), posterior circulation aneurysm (P < 0.0001), complex aneurysm (P < 0.0001), a larger size (P = 0.011), and perforator territory infarction (P < 0.0001) were related to poor outcome at 6 months, and posterior circulation aneurysm (P < 0.0001), complex aneurysm (P < 0.0001), a larger size (P = 0.035), and perforator territory infarction (P = 0.013) were related to poor outcome at 12 months. Age was not associated with poor outcome in patients with UIAs who undertook direct surgery. Although risks and benefits of aneurysm treatment in older patients should be carefully considered, surgical treatment of UIAs in the elderly should be considered positively. Copyright © 2016 Elsevier Inc. All rights reserved.
Moulton, Laura J; Munoz, Jessian L; Lachiewicz, Mark; Liu, Xiaobo; Goje, Oluwatosin
To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution. This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors. In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6-3.5; p infection control interventions.
FileMaker Pro 9: The Missing Manual is the clear, thorough and accessible guide to the latest version of this popular desktop database program. FileMaker Pro lets you do almost anything with the information you give it. You can print corporate reports, plan your retirement, or run a small country -- if you know what you're doing. This book helps non-technical folks like you get in, get your database built, and get the results you need. Pronto.The new edition gives novices and experienced users the scoop on versions 8.5 and 9. It offers complete coverage of timesaving new features such as the Q
MakerBot Projects Blueprints is a project-based book, with each chapter taking you through the creation of an awesome stand-alone project. MakerBot Project Blueprints is for anyone with an interest in the 3D printing revolution and the slightest bit of computer skills. Whether you own a 3D printer or not you can design for them. All it takes is Blender, a free 3D modeling tool, this book and a little creativity and someday you'll be able to hold something you designed in the computer in your hands.
Sellner, J; Trinka, E
Epilepsy is a frequent complication of central nervous system (CNS) infections. Post-infectious epilepsy is commonly refractory to medical treatment and plays a pivotal role for the poor long-term outcome of CNS infections. To provide an overview of clinical characteristics and risk factors of seizures associated with CNS infections. In addition, to summarize the state of the art of anticonvulsive treatment and the pre-surgical evaluation process in refractory cases. A comprehensive literature search for articles published between January 1970 and December 2011 was carried out. The occurrence of seizures during the acute course of meningitis, encephalitis and brain abscess is the main risk factor for the development of post-infectious epilepsy. There is a shortage of trials evaluating the efficacy of prophylactic and symptomatic treatment during the course of acute infection. Moreover, there are no randomized-controlled trials studying anticonvulsive drugs and their combinations for the management of post-infectious epilepsy. In a selected group of patients, however, medically refractory focal epilepsy is potentially curable by surgery. Further studies are required to improve the pathogenetic understanding of post-infectious epilepsy in order to develop preventive measures as well as to evaluate additional medical and surgical treatment strategies for the patients currently not considered for surgery. © 2012 The Author(s) European Journal of Neurology © 2012 EFNS.
Wideroff, Matthew; Xing, Yunfan; Liao, Junlin; Byrn, John C
Surgical site infections (SSIs) after colectomy for colon cancer (CC), Crohn's disease (CD), and diverticulitis (DD) significantly impact both the immediate postoperative course and long-term disease-specific outcomes. We aim to profile the effect of diagnosis on SSI after segmental colectomy using the National Surgical Quality Improvement Program (NSQIP) data set. NSQIP data from 2006 to 2011 were investigated, and segmental colectomy procedures performed for the diagnoses of Crohn's disease, DD, and colon malignancy were included. SSI complications were compared by diagnosis using univariate and multivariate analysis. We included 35,557 colectomy cases in the analysis. CD had the highest rate of postoperative SSI (17 vs. 13% DD vs. 10% CC; p risk for acquiring at least one SSI (odds ratio (OR) = 1.38, p ≤ 0.001), deep incisional SSI (OR = 1.85, p = 0.03), and organ space SSI (OR = 1.51, p = 0.02). For patients undergoing segmental colectomy in the NSQIP data set, statistically significant increases in SSI are seen in CD, but not DD, when compared to CC, thus confirming CD as an independent risk factor for SSI.
Hasegawa, Takatoshi; Ogiwara, Toshihiro; Nagm, Alhusain; Goto, Tetsuya; Aoyama, Tatsuro; Hongo, Kazuhiro
Entrapment of the temporal horn, known as isolated lateral ventricle (ILV), is a rare type of noncommunicating focal hydrocephalus, and standard treatment has not been established. We report 2 cases of endoscopic surgery for ILV and highlight the anatomic surgical nuances to avoid associated surgical risks. The first patient presented with recurrent ILV following initial shunt placement for ILV, owing to shunt malfunction. In the second patient, ILV recurred secondary to choroid plexus inflammation caused by cryptococcal infection. Endoscopic temporal ventriculocisternostomy was effective in both cases. However, in the second case, the choroidal fissure was fenestrated, which led to cerebral infarction in the territory of the choroidal artery zone, attributed to damage of the branches of the choroidal segment of the anterior choroidal artery. Although endoscopic temporal ventriculocisternostomy is considered a safe and less invasive procedure for treatment of symptomatic ILV, the technique is still associated with risks. To avoid complications, it is necessary to be familiar with the anatomy of the choroidal arteries and the pertinent endoscopic intraventricular orientation. Additionally, sufficient experience is required before it can be recommended as the treatment of choice. Copyright © 2017 Elsevier Inc. All rights reserved.
Lee, Won Jae; Jo, Kyung-Il; Yeon, Je Young; Hong, Seung-Chyul; Kim, Jong-Soo
Chronic subdural hematoma (CSDH) is a rare complication of unruptured aneurysm clipping surgery. The purpose of this study was to identify the incidence and risk factors of postoperative CSDH after surgical clipping for unruptured anterior circulation aneurysms. This retrospective study included 518 patients from a single tertiary institute from January 2008 to December 2013. CSDH was defined as subdural hemorrhage which needed surgical treatment. The degree of brain atrophy was estimated using the bicaudate ratio (BCR) index. We used uni- and multivariate analyses to identify risk factors correlated with CSDH. Sixteen (3.1%) patients experienced postoperative CSDH that required burr hole drainage surgery. In univariate analyses, male gender (p<0.001), size of aneurysm (p=0.030), higher BCR index (p=0.004), and the use of antithrombotic medication (p=0.006) were associated with postoperative CSDH. In multivariate analyses using logistic regression test, male gender [odds ratio (OR) 4.037, range 1.287-12.688], high BCR index (OR 5.376, range 1.170-25.000), and the use of antithrombotic medication (OR 4.854, range 1.658-14.085) were associated with postoperative CSDH (p<0.05). Postoperative subdural fluid collection and arachnoid plasty were not showed statistically significant difference in this study. The incidence of CSDH was 3.1% in unruptured anterior circulation aneurysm surgery. This study shows that male gender, degree of brain atrophy, and the use of antithrombotic medication were associated with postoperative CSDH.
Amaral, Cristina; Guimarães Pereira, Luís; Moreto, Ana; Sá, Ana Carolina; Azevedo, Ana
Venous thromboembolism, risk of which is increased in surgical patients, is a preventable cause of morbidity and death. The primary objective of this study was to estimate the incidence of symptomatic postoperative venous thromboembolism in adults at a tertiary university hospital, overall and by surgical specialty. The secondary objective was to analyze severity of and mortality from thromboembolic events. We performed a retrospective study to identify cases of in-hospital postoperative venous thromboembolism, encoded by the International Classification of Diseases, Ninth Revision, according to the Joint Commission International criteria. Adult patients admitted for surgery in 2008-2012 were included. Among 67 635 hospitalizations, 90 cases of postoperative symptomatic venous thromboembolism were identified, corresponding to an incidence of 1.33/1000 admissions (95% confidence interval [CI] 1.1-1.6/1000). Neurosurgery had the highest risk (4.07/1000), followed by urological surgery and general surgery (p<0.001). There were 50 cases of pulmonary embolism, 11 of which were fatal. Of the 90 cases, 12.2% occurred under neuraxial anesthesia and 55.1% in patients with American Society of Anesthesiology III physical status. At least 37.7% of patients with events received a prophylactic dose of injectable anticoagulant postoperatively. The overall risk decreased from 2008 to 2012. Venous thromboembolism-associated mortality during hospitalization was 21.1% (95% CI 13.6-30.4). The incidence of postoperative symptomatic venous thromboembolism was 1.33/1000. Neurosurgery showed the greatest risk. Mortality was 21.1%. Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.
Slany, E; Reuter, W; Thüsing, C; Schmidt, C E
Medical advances in diagnosis and therapy, especially in medical technology, lead to differenciated and more complex strategies in therapy with higher risks. Patients show higher expectations concerning the results of a therapy and claim more often that a mistake in treatment has been made. This makes patients turn to arbitration boards more often. They may also want to bring civil action against physicians and hospitals, claiming for compensation and damages. Personal liability insurances have to pay more for damages. Medical insurances have more recourse demands due to mistake in treatment. Hospital and especially operative medicine do have high chances of risks and mistakes. The implementation of a modern risk management system in the hospitals is becoming more and more important, for patients as well as for the surgical departments. A structured reporting system of critical incidents can produce indicators of potential sources of mistakes, which appears to be a successful approach to reduce or avoid typical risks and mistakes in medical treatment. Risk management in medical treatment must be more than just a trendy word, because its roots are in the medical principles of "primum nihil nocere". It is a challenge to today's and tomorrow's medicine. This article is a general overview of current strategies for avoiding mistakes: It is meant to be the basis of a new culture of mistake avoidance as a part of a future quality competition.
Wanta, Brendan T; Hanson, Kristine T; Hyder, Joseph A; Stewart, Thomas M; Curry, Timothy B; Berbari, Elie F; Habermann, Elizabeth B; Kor, Daryl J; Brown, Michael J
Whether the fraction of inspired oxygen (F I O 2 ) influences the risk of surgical site infection (SSI) is controversial. The World Health Organization and the World Federation of Societies of Anesthesiologists offer conflicting recommendations. In this study, we evaluate simultaneously three different definitions of F I O 2 exposure and the risk of SSI in a large surgical population. Patients with clean (type 1) surgical incisions who developed superficial and deep organ/space SSI within 30 days after surgery from January 2003 through December 2012 in five surgical specialties were matched to specialty-specific controls. Fraction of inspired oxygen exposure was defined as (1) nadir F I O 2 , (2) percentage of operative time with F I O 2 greater than 50%, and (3) cumulative hyperoxia exposure, calculated as the area under the curve (AUC) of F I O 2 by time for the duration in which F I O 2 greater than 50%. Stratified univariable and multivariable logistic regression models tested associations between F I O 2 and SSI. One thousand two hundred fifty cases of SSI were matched to 3,248 controls. Increased oxygen exposure, by any of the three measures, was not associated with the outcome of any SSI in a multivariable logistic regression model. Elevated body mass index (BMI; 35+ vs. operative oxygen exposure was associated with higher odds of SSI in the neurosurgical and spine populations. Increased intra-operative inspired fraction of oxygen was not associated with a reduction in SSI. These findings do not support the practice of increasing F I O 2 for the purpose of SSI reduction in patients with clean surgical incisions.
Olsen, Margaret A; Butler, Anne M; Willers, Denise M; Devkota, Preetishma; Gross, Gilad A; Fraser, Victoria J
Independent risk factors for surgical site infection (SSI) after cesarean section have not been well documented, despite the large number of cesarean sections performed and the relatively common occurrence of SSI. To determine independent risk factors for SSI after low transverse cesarean section. Retrospective case-control study. Barnes-Jewish Hospital, a 1,250-bed tertiary care hospital. A total of 1,605 women who underwent low transverse cesarean section during the period from July 1999 to June 2001. Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI or wound complication and/or data on antibiotic use during the surgical hospitalization or at readmission to the hospital or emergency department, we identified potential cases of SSI in a cohort of patients who underwent a low transverse cesarean section. Cases of SSI were verified by chart review using the definitions from the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance System. Control patients without SSI or endomyometritis were randomly selected from the population of patients who underwent cesarean section. Independent risk factors for SSI were determined by logistic regression. SSIs were identified in 81 (5.0%) of 1,605 women who underwent low transverse cesarean section. Independent risk factors for SSI included development of subcutaneous hematoma after the procedure (adjusted odds ratio [aOR], 11.6 [95% confidence interval [CI], 4.1-33.2]), operation performed by the university teaching service (aOR, 2.7 [95% CI, 1.4-5.2]), and a higher body mass index at admission (aOR, 1.1 [95% CI, 1.0-1.1]). Cephalosporin therapy before or after the operation was associated with a significantly lower risk of SSI (aOR, 0.2 [95% CI, 0.1-0.5]). Use of staples for skin closure was associated with a marginally increased risk of SSI. These independent risk factors should be incorporated into approaches for the prevention
Full Text Available BACKGROUND: The role of frozen section (FS in intraoperative decision making for surgical staging of endometrial cancer is controversial. Objective of this study is to assess the agreement rate between the FS and paraffin section (PS; and the potential impact of the role of FS in the intra-operative decision making for the complete surgical staging in low risk endometrial cancer. METHODS: This is a retrospective analysis of patients diagnosed with intra-operative FS stage I, grade I or II endometrial cancer from 1995-2004. FS results were compared with final pathology results with regard to tumor grade, depth of myometrial invasion, cervical involvement, lymphovascular invasion, and lymph node involvement. Agreement statistic with kappa was calculated using SPSS statistical software. Categorical variables were tested using chi-square test with p value of ≤0.05 being statistically significant. RESULTS: Of the 457 patients with endometrial cancer, 146 were evaluated by intra-operative FS and met inclusion criteria. FS results were in disagreement with permanent section in 35% for the grade (kappa 0.58, p = 0.003, 28% for depth of myometrial invasion (kappa 0.61, p<0.0001, 13% for cervical involvement (kappa 0.78, p = 0.002, and 32% for lymphovascular invasion (kappa 0.6, p = 0.01. Permanent pathology upstaged 31.9% & 23.2% of FS stage IA, & IB specimen respectively. Lymph node dissection was done in 56.8%. Lymph node metastasis was identified in 8.4%. Use of intraoperative FS would have resulted in suboptimal surgical treatment in 13% stage IA and 6.6% of stage IB patients respectively by foregoing lymphadenectomy. CONCLUSION: A significant number of patients with low risk endometrial cancer by FS were upstaged and upgraded on final pathology. Before placing absolute reliance on intraoperative FS to undertake complete surgical staging, the inherent limitation of the same in predicting final stage and grade highlighted by our data
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...
Bachoura, Abdo; Guitton, Thierry G; Smith, R Malcolm; Vrahas, Mark S; Zurakowski, David; Ring, David
Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization rates, and increase healthcare costs. Additionally, patients with orthopaedic surgical-site infections (SSI) have substantially greater physical limitations and reductions in their health-related quality of life. However, the risk factors for SSI after operative fracture care are unclear. We determined the incidence and quantified modifiable and nonmodifiable risk factors for SSIs in patients with orthopaedic trauma undergoing surgery. We retrospectively indentified, from our prospective trauma database and billing records, 1611 patients who underwent 1783 trauma-related procedures between 2006 and 2008. Medical records were reviewed and demographics, surgery-specific data, and whether the patients had an SSI were recorded. We determined which if any variables predicted SSI. Six factors independently predicted SSI: (1) the use of a drain, OR 2.3, 95% CI (1.3-3.8); (2) number of operations OR 3.4, 95% CI (2.0-6.0); (3) diabetes, OR 2.1, 95% CI (1.2-3.8); (4) congestive heart failure (CHF), OR 2.8, 95% CI (1.3-6.5); (5) site of injury tibial shaft/plateau, OR 2.3, 95% CI (1.3-4.2); and (6) site of injury, elbow, OR 2.2, 95% CI (1.1-4.7). The risk factors for SSIs after skeletal trauma are most strongly determined by nonmodifiable factors: patient infirmity (diabetes and heart failure) and injury complexity (site of injury, number of operations, use of a drain). Level II, prognostic study. See the Guideline for Authors for a complete description of levels of evidence.
Studer, Peter; Räber, Genevieve; Ott, Daniel; Candinas, Daniel; Schnüriger, Beat
Aspiration pneumonia in hospitalized surgical patients has been associated with a mortality of approximately 30%. The aim of this study was to assess pre-, intra- and postoperative risk factors for mortality in patients suffering aspiration pneumonia after abdominal surgery. Retrospective study from 01/2006-12/2012 of patients with clinically and radiologically confirmed aspiration pneumonia after abdominal surgery. A total of 70 patients undergoing abdominal surgery and postoperative aspiration pneumonia were identified. There were 53 (76%) male patients, the mean age was 71 ± 12 years and the mean ASA score was 3 ± 1. The surgical procedures included 32 colorectal or small bowel resections, 10 partial liver resections, 9 gastric surgeries, 8 esophageal resections, 5 pancreatic surgeries, and 6 hernia repairs. Aspiration pneumonia occurred at mean postoperative day 7 ± 10. Overall, 53% (n = 37) of patients required re-intubation, with 4 ± 5 days of additional mechanical ventilation. Mean hospital and ICU length of stay was 32 ± 25 days and 6 ± 9 days, respectively. Overall mortality was 27% (n = 19). Forward logistic regression revealed older age [OR 7.41 (95% CI: 1.29-42.62)], bilateral aspiration pneumonia [OR 7.39 (95% CI: 1.86-29.29)] and intraoperative requirement of blood component transfusion [OR 5.09 (95% CI: 1.34-19.38)] as independent risk factors for mortality (overall R(2) = 0.336). Postoperative aspiration pneumonia remains a severe complication with significant mortality. Increasing age, the need for intraoperative blood component transfusion and bilateral pulmonary infiltrates are independent risk factors for fatal outcome after aspiration pneumonia. Therefore, these patients suffering aspiration pneumonia require special attention and increased monitoring. Copyright © 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Kim, Hyung Sun; Park, Seho; Koo, Ja Seung; Kim, Sanghwa; Kim, Jee Ye; Nam, Sanggeun; Park, Hyung Seok; Kim, Seung Il; Park, Byeong-Woo
Purpose The Ki-67 labelling index is significant for the management of breast cancer. However, the concordance of Ki-67 expression between preoperative biopsy and postoperative surgical specimens has not been well evaluated. This study aimed to find the correlation in Ki-67 expression between biopsy and surgical specimens and to determine the clinicopathological risk factors associated with discordant values. Patients and Methods Ki-67 levels were immunohistochemically measured using paired b...
Full Text Available Surgical site infection (SSI has not been extensively studied in musculoskeletal tumors (MST owing to the rarity of the disease. We analyzed incidence and risk factors of SSI in MST. SSI incidence was evaluated in consecutive 457 MST cases (benign, 310 cases and malignant, 147 cases treated at our institution. A detailed analysis of the clinical background of the patients, pre- and postoperative hematological data, and other factors that might be associated with SSI incidence was performed for malignant MST cases. SSI occurred in 0.32% and 12.2% of benign and malignant MST cases, respectively. The duration of the surgery (P=0.0002 and intraoperative blood loss (P=0.0005 was significantly more in the SSI group than in the non-SSI group. We established the musculoskeletal oncological surgery invasiveness (MOSI index by combining 4 risk factors (blood loss, operation duration, preoperative chemotherapy, and the use of artificial materials. The MOSI index (0–4 points score significantly correlated with the risk of SSI, as demonstrated by an SSI incidence of 38.5% in the group with a high score (3-4 points. The MOSI index score and laboratory data at 1 week after surgery could facilitate risk evaluation and prompt diagnosis of SSI.
Wang, Xiao; Hu, Yanting; Zhao, Binjiang; Su, Yue
The risk calculator of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) has been shown to be useful in predicting postoperative complications. In this study, we aimed to evaluate the predictive value of the ACS-NSQIP calculator in geriatric patients undergoing lumbar surgery.A total of 242 geriatric patients who underwent lumbar surgery between January 2014 and December 2016 were included. Preoperative clinical information was retrospectively reviewed and entered into the ACS-NSQIP calculator. The predictive value of the ACS-NSQIP model was assessed using the Hosmer-Lemeshow test, Brier score (B), and receiver operating characteristics (ROC, also referred C-statistic) curve analysis. Additional risk factors were calculated as surgeon-adjusted risk including previous cardiac event and cerebrovascular disease.Preoperative risk factors including age (P = .004), functional independence (P = 0), American Society of Anesthesiologists class (ASA class, P = 0), dyspnea (P = 0), dialysis (P = .049), previous cardiac event (P = .001), and history of cerebrovascular disease (P = 0) were significantly associated with a greater incidence of postoperative complications. Observed and predicted incidence of postoperative complications was 43.8% and 13.7% (±5.9%) (P calculator is not an accurate tool for the prediction of postoperative complications in geriatric Chinese patients undergoing lumbar surgery.
Assawapalanggool, Srisuda; Kasatpibal, Nongyao; Sirichotiyakul, Supatra; Arora, Rajin; Suntornlimsiri, Watcharin
Cesarean surgical site infections (SSIs) are a major challenge in Thai-Myanmar border hospital settings. This study aimed to examine risk factors for SSIs after cesarean section. This was a prospective cohort study conducted in a Thai-Myanmar border hospital between January 2007 and December 2012. Data were collected from the medical record database by trained infection control nurses. Stepwise multivariable logistic regression was used for risk factor analysis and expressed as a risk ratio (RR). The cesarean SSI rate was 5.9% (293 SSIs in 4,988 cases). Of these, 17.1% were incisional SSIs (10.9% superficial and 6.2% deep incisional SSIs), and 82.9% were organ or space SSIs. Risk factors for cesarean organ-space SSIs included a wound class ≥3 (RR, 4.82; 95% confidence interval [CI], 3.41-6.83), ethnic minority (RR, 2.51; 95% CI, 1.61-3.92), hemoglobin Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Shree, Raj; Park, Seo Young; Beigi, Richard H; Dunn, Shannon L; Krans, Elizabeth E
This study aims to identify risk factors for cesarean delivery (CD) surgical site infection (SSI). study design: Retrospective analysis of 2,739 CDs performed at the University of Pittsburgh in 2011. CD SSIs were defined using National Healthcare Safety Network (NHSN) criteria. Chi-square test and t-test were used for bivariate analyses and multivariate logistic regression was used to identify SSI risk factors. Of 2,739 CDs, 178 (6.5%) were complicated by SSI. Patients with a SSI were more likely to have Medicaid, have resident physicians perform the CD, an American Society of Anesthesiologists (ASA) class of ≥ 3, chorioamnionitis, tobacco use, and labor before CD. In multivariable analysis, labor (odds ratio [OR], 2.35; 95% confidence interval [95% CI], 1.65-3.38), chorioamnionitis (OR, 2.24; 95% CI, 1.25-3.83), resident teaching service (OR, 2.15; 95% CI, 1.54-3.00), tobacco use (OR, 1.70; 95% CI, 1.04-2.70), ASA class ≥ 3 (OR, 1.61; 95% CI, 1.06-2.39), and CDs performed for nonreassuring fetal status (OR, 0.43; 95% CI, 0.26-0.67) were significantly associated with CD SSI. Multiple patient, provider, and procedure-specific risk factors contribute to CD SSI risk which may be targeted in infection-control efforts. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Duperron, C; Moulin, M; Koutlidis, N; Mourey, E; Cormier, L
To evaluate the feasibility of robot-assisted radical prostatectomy (RARP) in high risk prostate cancer (HR). The rate of positive surgical margins (PSM) was compared between anticipated HR cancer according to D'Amico risk classification and discovered postoperative HR cancer. A retrospective study was conducted between 2006 and 2013 on patients who underwent RARP. Before surgery, patients were divided according to the D'Amico risk classification. After surgery, HR was defined as pT3a or pT3b, or Gleason score≥8 or positive lymph nodes. The rate of PSM was compared according to the D'Amico risk classification and postoperative HR. During the study, 485 patients were reviewed. Before surgery, 10 % of cancers were classified as D'Amico 3 (49/485). After surgery, 27.6 % (134/485) were classified as HR. There was a significant difference between the rate of PSM in HR/D'Amico 3 and HR/non D'Amico 3 cancer, respectively 22.9 % and 34.3 % (P<0.001). The RARP is feasible in HR with an average of 30 % of PSM as in open surgery. However, the accurate assessment of preoperative HR will allow a more adapted dissection and a decrease of rate of PSM. So it is necessary to improve the detection of HR and so to select the most suitable cancer for surgery. Level 5. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Hellinger, Walter C; Crook, Julia E; Heckman, Michael G; Diehl, Nancy N; Shalev, Jefree A; Zubair, Abba C; Willingham, Darrin L; Hewitt, Winston R; Grewal, Hani P; Nguyen, Justin H; Hughes, Christopher B
Risk factors for surgical site infection (SSI) after liver transplantation and outcomes associated with these infections have not been assessed using consensus surveillance and optimal analytic methods. A cohort study was performed of patients undergoing first liver transplantation at Mayo Clinic, Jacksonville, Florida, in 2003 and 2004. SSIs were identified by definitions and methods of the National Nosocomial Infections Surveillance System. Measures of known or suspected risk factors for SSI, graft loss, or death were collected on all patients. Associations of SSI with these factors and also with the primary composite endpoint of graft loss or death within 1 year of liver transplantation were examined using Cox proportional hazards models; relative risks (RRs) were estimated along with 95% confidence intervals (CIs). Of 370 patients, 66 (18%) had SSI and 57 (15%) died or sustained graft loss within 1 year after liver transplantation. Donor liver mass-to-recipient body mass ratio of less than 0.01 (RR 2.56; 95% CI 1.17-5.62; P=0.019) and increased operative time (RR 1.19 [1-hr increase]; 95% CI 1.03-1.37; P=0.018) were associated with increased SSI risk. SSI was associated with increased risk of death or graft loss within the first year after liver transplantation (RR 3.06; 95% CI 1.66-5.64; P<0.001). SSI is associated with increased risk of death or graft loss during the first year after liver transplantation. Increased operative time and decreased donor liver-to-recipient body mass ratio showed evidence of association with SSI.
Dicks, Kristen V; Baker, Arthur W; Durkin, Michael J; Anderson, Deverick J; Moehring, Rebekah W; Chen, Luke F; Sexton, Daniel J; Weber, David J; Lewis, Sarah S
To determine the association (1) between shorter operative duration and surgical site infection (SSI) and (2) between surgeon median operative duration and SSI risk among first-time hip and knee arthroplasties. Retrospective cohort study A total of 43 community hospitals located in the southeastern United States. Adults who developed SSIs according to National Healthcare Safety Network criteria within 365 days of first-time knee or hip arthroplasties performed between January 1, 2008 and December 31, 2012. Log-binomial regression models estimated the association (1) between operative duration and SSI outcome and (2) between surgeon median operative duration and SSI outcome. Hip and knee arthroplasties were evaluated in separate models. Each model was adjusted for American Society of Anesthesiology score and patient age. A total of 25,531 hip arthroplasties and 42,187 knee arthroplasties were included in the study. The risk of SSI in knee arthroplasties with an operative duration shorter than the 25th percentile was 0.40 times the risk of SSI in knee arthroplasties with an operative duration between the 25th and 75th percentile (risk ratio [RR], 0.40; 95% confidence interval [CI], 0.38-0.56; Poperative duration did not demonstrate significant association with SSI for hip arthroplasties (RR, 1.04; 95% CI, 0.79-1.37; P=.36). Knee arthroplasty surgeons with shorter median operative durations had a lower risk of SSI than surgeons with typical median operative durations (RR, 0.52; 95% CI, 0.43-0.64; Poperative durations were not associated with a higher SSI risk for knee or hip arthroplasty procedures in our analysis.
Overhagen, Hans van; Meyers, Hjalmar; Tilanus, Hugo W.; Jeekel, Johannes; Lameris, Johan S.
Purpose: To evaluate percutaneous cholecystostomy in patients with acute cholecystitis and an increased surgical risk. Methods: Thirty-three patients with acute cholecystitis (calculous, n= 22; acalculous, n= 11) underwent percutaneous cholecystostomy by means of a transhepatic (n= 21) or transperitoneal (n= 12) access route. Clinical and laboratory parameters were retrospectively studied to determine the benefit from cholecystostomy. Results: All procedures were technically successful. Twenty-two (67%) patients improved clinically within 48 hr; showing a significant decrease in body temperature (n= 13), normalization of the white blood cell count (n= 3), or both (n= 6). There were 6 (18%) minor/moderate complications (transhepatic access, n= 3; transperitoneal access, n= 3). Further treatment for patients with calculous cholecystitis was cholecystectomy (n= 9) and percutaneous and endoscopic stone removal (n= 8). Further treatment for patients with acalculous cholecystitis was cholecystectomy (n= 2) and gallbladder ablation (n= 2). There were 4 deaths (12%) either in hospital or within 30 days of drainage; none of the deaths was procedure-related. Conclusions: Percutaneous cholecystostomy is a safe and effective procedure for patients with acute cholecystitis. For most patients with acalculous cholecystitis percutaneous cholecystostomy may be considered a definitive therapy. In calculous disease this treatment is often only temporizing and a definitive surgical, endoscopic, or radiologic treatment becomes necessary
Full Text Available Abstract Background Using crude mortality and morbidity rates for comparing outcomes can be misleading. The aim of the present study was to compare the outcome of various surgical modalities without and with risk adjustment using Physiologic and Operative Severity Scoring for the enUmeration of Mortality and morbidity (POSSUM score in cases of ileal perforations. Methods Prospective study on 125 patients of ileal perforations. Resection anastamosis (Group I was done in 38 patients, primary repair (Group II in 42 patients and 45 patients had an ileostomy (Group III. The disease severity was assessed in all patients using POSSUM score. The odds of death without and with risk adjustment using POSSUM mortality score were calculated for all groups Results Seventeen patients (14% patients died and 99 (79% developed postoperative complications. Using crude mortality rates Group I appeared to be the best treatment option with only 2 (5% deaths followed by Group II with 5 (12% deaths where as Group III had the worst outcome with 10 deaths (22%. However, Group III (ileostomy patients had higher mean POSSUM mortality and morbidity score (55.55%, 91.33% than Group I (28%, 75.26% and Group II (27%, 73.59%. Taking Group I as the reference (odds ratio, OR1 odds of death were greatest in Group III (OR 5.14, p = 0.043 followed by Group II (OR 2.43, p = 0.306. With risk adjustment using POSSUM mortality score the odds of death decreased in Group III (OR 1.16 p = 0.875. For the whole group, there was a significant association between the POSSUM score and postoperative complications and deaths. Mean POSSUM mortality and morbidity score of those who died (63.40 vs.33.68, p = 0.001 and developed complications (66.32 vs.84.20, p = 0.001 was significantly higher. For every percent increase in severity score the risk of postoperative complications and death increased by 1.10 (p = 0.001 and1.06 (p = 0.001 respectively. Conclusion Despite ileostomy patients having highest
Full Text Available Background: Degenerative lumbar scoliosis surgery can lead to development of adjacent segment degeneration (ASD after lumbar or thoracolumbar fusion. Its incidence, risk factors, morbidity and correlation between radiological and clinical symptoms of ASD have no consensus. We evaluated the correlation between the occurrence of radiologic adjacent segment disease and certain imperative parameters. Materials and Methods: 98 patients who had undergone surgical correction and lumbar/thoracolumbar fusion with pedicle screw instrumentation for degenerative lumbar scoliosis with a minimum 5 year followup were included in the study. We evaluated the correlation between the occurrence of radiologic adjacent segment disease and imperative patient parameters like age at operation, sex, body mass index (BMI, medical comorbidities and bone mineral density (BMD. The radiological parameters taken into consideration were Cobb′s angle, angle type, lumbar lordosis, pelvic incidence, intercristal line, preoperative existence of an ASD on plain radiograph and magnetic resonance imaging (MRI and surgical parameters were number of the fusion level, decompression level, floating OP (interlumbar fusion excluding L5-S1 level and posterolateral lumbar interbody fusion (PLIF. Clinical outcomes were assessed with the Visual Analogue Score (VAS and Oswestry Disability Index (ODI. Results: ASD was present in 44 (44.9% patients at an average period of 48.0 months (range 6-98 months. Factors related to occurrence of ASD were preoperative existence of disc degeneration (as revealed by MRI and age at operation ( P = 0.0001, 0.0364. There were no statistically significant differences between radiological adjacent segment degeneration and clinical results (VAS, P = 0.446; ODI, P = 0.531. Conclusions: Patients over the age of 65 years and with preoperative disc degeneration (as revealed by plain radiograph and MRI were at a higher risk of developing ASD.
Ng, Chye Yew; Gibson, J N Alastair
Presentation and analysis of a patient information sheet. To produce an evidence-based information sheet that will serve as an aide-memoire to the process of taking informed consent prior to spinal surgery. Consent for a surgical intervention is the end of a process of discussion between the surgeon and the patient. It is essential that the patient has been provided with sufficient information to make an informed judgment as to whether the benefits of a proposed procedure will outweigh its risks. We searched MEDLINE, the Cochrane database of systematic reviews and personal libraries for articles reporting complications of the surgical treatment of spinal diseases with particular reference to the most commonly treated conditions. A draft document was drawn up referencing the odds of specific complications. This was circulated to the National Health Service Scotland Central Legal Office for scrutiny and to an English language expert at the University of Edinburgh for translation to lay English. Finally, the document was issued to 50 patients in the outpatient clinic and scored on visual analog scales (VAS) for the ease of understanding, usefulness, and length. The product of this project was a two-page A4 sheet, with the front page outlining information applicable to spinal surgery "in general" and a back page detailing all common risks, relating to a headline procedure, that a Court of Law would expect a surgeon to discuss. The patients' VAS score (0-10) for "ease of understanding" was 8.8 ± 1.3 and for "usefulness" 8.9 ± 1.0 (means ± SD). Forty-three of 50 patients (86%) indicated that the length of the document was "just right" and seven (14%) of them that it was "too long." The ISSiS is user friendly and can be employed as a tool in the process of obtaining consent.
Sharma, Mamta; Fakih, Mohamad G; Berriel-Cass, Dorine; Meisner, Susan; Saravolatz, Louis; Khatib, Riad
Our goals were to evaluate the risk factors predisposing to saphenous vein harvest surgical site infection (HSSI), the microbiology implicated, associated outcomes including 30-day mortality, and identify opportunities for prevention of infection. All patients undergoing coronary artery bypass grafting (CABG) procedures from January 2000 through September 2004 were included. Data were collected on preoperative, intraoperative, and postoperative factors, in addition to microbiology and outcomes. Eighty-six of 3578 (2.4%) patients developed HSSI; 28 (32.6%) of them were classified as deep. The median time to detection was 17 (range, 4-51) days. An organism was identified in 64 (74.4%) cases; of them, a single pathogen was implicated in 50 (78%) cases. Staphylococcus aureus was the most frequently isolated pathogen: 19 (38% [methicillin-susceptible S aureus (MSSA) = 12, methicillin-resistant S aureus (MRSA) = 7]). Gram-negative organisms were recovered in 50% of cases, with Pseudomonas aeruginosa predominating in 11 (22%) because of a single pathogen. Multiple pathogens were identified in 14 (22%) cases. The 30-day mortality was not significantly different in patients with or without HSSI. Multivariate analysis showed age, diabetes mellitus, obesity, congestive heart failure, renal insufficiency, and duration of surgery to be associated with increased risk. Diabetes mellitus, obesity, congestive heart failure, renal insufficiency, and duration of surgery were associated with increased risk for HSSI. S aureus was the most frequently isolated pathogen.
Viqueira, Almudena Quintás; Caravaca, Gil Rodríguez; Quesada Rubio, José Antonio; Francés, Victoria Soler
The objective of the study is to study surgical site infection (SSI) rates and risk factors in a pediatric population. We conducted a prospective cohort study to estimate the SSI rate at a national pediatric referral center, covering all patients managed at the Orthopedic Surgery Department of the Niño Jesús Children's University Teaching Hospital from January 2010 through December 2012. Risk factors and antibiotic prophylaxis were monitored. A comparison between Spanish and US data was performed, with a breakdown by National Nosocomial Infection Surveillance risk indices. We also conducted a comparative study of SSI rates from 2010 to 2012 to assess the impact of the epidemiologic surveillance system. The study population of 1079 patients had a SSI rate of 2.8%. SSI rates were calculated for spinal fusion and other musculoskeletal procedures according to the National Nosocomial Infection Surveillance risk index. In the case of other musculoskeletal procedures, our SSI rates were 0.8 times lower than the overall Spanish rate, but higher than US rates for all risk categories. For spinal fusion procedures, our SSI rates were 1.2 times higher than the Spanish rates and 3.5 times higher than National Nosocomial Infection Surveillance rates. This latter finding should be interpreted with caution because it was based on a small sample. The multivariate analysis indicated that the only predictive factors of SSI were American Society of Anesthesiologists score and age. The surveillance program showed that for clean procedures, SSI incidence decreased from 4% in 2010 to 3.2% in 2011 and to 2.4% in 2012.
Vladimirov, B S; Schiødt, Morten
The aim of this study was to examine if cessation of smoking after surgical excision of oral potentially malignant lesions in smokers reduced the risk of recurrences, development of new lesions or malignancies. 51 patients with oral leukoplakia or erythroplakia were included. They were daily...... carcinomas (p>0.05) in continuing smokers. Multivariate analysis showed continuing smoking to be the most significant factor for occurrence of unfavorable events, OR 23.7. In conclusion, cessation of smoking significantly reduced the risk of unfavorable events after surgical treatment of oral potentially...
Full Text Available The prevalence of aortic stenosis is increasing with aging population. However with multiple co-morbidities and prior procedures in this aging population, more and more patients are being declared unfit for the ‘Gold Standard’ treatment i.e. surgical aortic valve replacement (AVR. Among the patients who are unfit or high risk for aortic valve replacement (AVR by open heart surgery, transcatheter aortic valve implantation (TAVI has been proven to be a valuable alternative improving survival and quality of life. We report first Indian experience of Core Valve (Medtronic Inc. implantation in three high surgical risk patients performed on 22nd and 23rd February 2012.
Kaboré, Boezemwendé; Soudouem, Georges; Seck, Ibrahima; Millogo, Tieba; Evariste Yaméogo, Wambi Maurice; Kouanda, Seni
To identify the risk factors for surgical site infection after cesarean delivery in a rural area in eastern Burkina Faso. A matched case-control study was conducted in Fada N'Gourma Regional Hospital Center and the Diapaga Medical Center with Surgical Antenna using data from 2011-2014. A total of 99 cases of surgical site infection after cesarean delivery were included in the study. Each case was matched with a control patient similar for age, admission date, and facility where the cesarean took place. Risk factors were identified using conditional logistic regression. Multivariate analysis identified hyperthermia at admission (OR 2.37; P=0.035), the presence of caput succedaneum in newborns (OR 7.07; P=0.001), and difficult delivery (OR 3.69; P=0. 019) as risk factors for surgical site infection. Provision of quality prenatal care, use of the partograph during labor, and the responsiveness of health workers during labor can reduce surgical site infection after cesarean delivery. Copyright © 2016. Published by Elsevier Ireland Ltd.
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...
Full Text Available Xiao Wang, Bin Jiang Zhao, Yue Su Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China Purpose: Hip fractures are associated with poor prognosis in elderly patients partly due to the high rate of postoperative complications. This study was aimed to investigate whether the surgical risk calculator is suitable for predicting postoperative complications in elderly Chinese patients with hip fractures.Methods: The incidence of postoperative complications among 410 elderly patients with hip fractures was predicted by the surgical risk calculator and then compared with the actual value. The risk calculator model was evaluated using the following three metrics: Hosmer–Lemeshow test for the goodness-of-fit of the model, receiver operating characteristic curve (ROC (also referred as C-statistic for the predictive specificity and sensitivity, and the Brier’s score test for predictive accuracy.Results: Preoperative risk factors including gender, age, preoperative functional status, American Society of Anesthesiologists grade, hypertension, dyspnea, dialysis, previous cardiovascular history, and cerebrovascular disease were positively correlated with the incidence of postoperative complications in elderly patients with hip fractures. The predicted complication incidence rate was well matched with the actual complication rate by Hosmer–Lemeshow test. The model had high sensitivity and specificity for predicting the mortality rate of these patients with a C-statistic index of 0.931 (95% CI [0.883, 0.980]. The surgical calculator model had an accuracy of 90% for predicting the reoperation rate (Brier’s score <0.01.Conclusions: The surgical risk calculator could be useful for predicting mortality and reoperation in elderly patients with hip fracture. Patients and surgeons may use this simple calculator to better manage the preoperative risks. Keywords: hip fracture, femoral head fracture, elder age, surgical
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.
Burgess, Adam; Horii, Mitsutoshi
This article begins to develop an understanding of surgical mask-wearing in Japan, now a routine practice against a range of health threats. Their usage and associated meanings are explored through surveys conducted in Tokyo with both mask wearers and non-mask wearers. It contests commonly held cultural views of the practice as a fixed and distinctively Japanese collective courtesy to others. A historical analysis suggests that an originally collective, targeted and science-based response to public health threats has dispersed into a generalised practice lacking a clear end or purpose. Developed as part of the biomedical response to the Spanish flu of 1919, the practice resonated with folk assumptions as making a barrier between purity and pollution. But mask-wearing became socially embedded as a general protective practice only from the 1990s through a combination of commercial, corporate and political pressures that responsibilised individual health protection. These developments are usefully understood amidst the uncertainty created by Japan's 'second modernity' and the fracturing of her post-war order. Mask-wearing is only one form of a wider culture of risk; a self-protective risk ritual rather than a selfless collective practice. © 2012 The Authors. Sociology of Health & Illness © 2012 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.
Hayashi, Hiroyuki; Murakami, Hideki; Demura, Satoru; Kato, Satoshi; Yoshioka, Katsuhito; Shinmura, Kazuya; Yokogawa, Noriaki; Ishii, Takayoshi; Fang, Xiang; Shirai, Toshiharu; Tsuchiya, Hiroyuki
Surgical site infection (SSI) associated with instruments remains a serious and common complication in patients who undergo total en bloc spondylectomy (TES). It is very important that the risk factors for SSI are known to prevent it. The purpose of the study was to identify independent risk factors for SSI after TES and evaluate the positive effect of iodine-supported spinal instruments in the prevention of SSI after TES. This is a retrospective clinical study. One hundred twenty-five patients who underwent TES for vertebral tumor were evaluated. Incidence rate of SSI, risk factors for SSI after TES, and safety of iodine-supported spinal instruments were the outcome measures. Risk factors for SSI were analyzed using logistic regression. In recent 69 patients with iodine-supported spinal instruments, the thyroid hormone levels in the blood were examined to confirm if iodine from the implant influenced thyroid function. Postoperative radiological evaluations were performed regularly. The rate of SSI was 6.4% (8/125 patients). By multivariate logistic regression, combined anterior and posterior approach and nonuse of iodine-supported spinal instruments were associated with an increased risk of SSI. The rate of SSI without iodine-supported spinal instruments was 12.5%, whereas the rate with iodine-supported spinal instruments was 1.4%. This difference was statistically significant. There were no detected abnormalities of thyroid gland function with the use of iodine-supported instruments. Among the 69 patients with iodine-supported spinal instruments, 2 patients required additional surgery because of instrument failure. However, there were no obvious involvements with the use of iodine-supported spinal instruments. This study identified combined anterior and posterior approach and nonuse of iodine-supported spinal instruments to be independent risk factors for SSI after TES. Iodine-supported spinal instrument was extremely effective for prevention of SSI in patients
Crowe, Marie; Burrell, Beverly; Whitehead, Lisa
This article is a report of a study that examined how women describe their decisions in relation to the use of menopausal hormone therapy following surgical menopause. Women who have had a surgically induced menopause generally experience more intense menopausal symptoms than natural menopause and are regularly prescribed menopausal hormone therapy. Since 2002 the risks associated with this therapy have been widely reported. This study is a qualitative analysis of semi-structured interviews between March and May 2009 with 30 participants who had experienced surgical menopause and were, or had in the past, taken menopausal hormone therapy. This was a community sample recruited in Christchurch, New Zealand. A risk management theoretical approach underpinned the analysis. The womens' descriptions of managing the risks associated with menopausal therapy fell into two main themes: Life has to go on and Waiting for someone to tell me. All these women had either made an active decision to continue on treatment because of the impact of menopausal symptoms or took their doctor's advice to continue. A less dominant theme but one that was also evident was Relying on my body to get me through in which the women had decided to discontinue treatment because they regarded it as unnatural. The study provided insights into how women utilize an experiential reasoning process to manage the health and lifestyle risks associated with taking menopausal hormone therapy. Nurses need to be aware of how this process influences women's reasoning processes when working with women following surgical menopause. © 2011 Blackwell Publishing Ltd.
Winoker, Jared S; Paulucci, David J; Anastos, Harry; Waingankar, Nikhil; Abaza, Ronney; Eun, Daniel D; Bhandari, Akshay; Hemal, Ashok K; Sfakianos, John P; Badani, Ketan K
We evaluated the predictive value of the ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Program®) surgical risk calculator in a tertiary referral cohort of patients who underwent robot-assisted partial nephrectomy. We queried our prospectively maintained, multi-institutional database of patients treated with robot-assisted partial nephrectomy and input the preoperative details of 300 randomly selected patients into the calculator. Accuracy of the calculator was assessed by the ROC AUC and the Brier score. The observed rate of any complication in our cohort was 14% while the mean predicted rate of any complication using the calculator was 5.42%. The observed rate of serious complications (Clavien score 3 or greater) was 3.67% compared to the predicted rate of 4.89%. Low AUC and high Brier score were calculated for any complication (0.51 and 0.1272) and serious complications (0.55 and 0.0352, respectively). The calculated AUC was low for all outcomes, including venous thromboembolism (0.67), surgical site infection (0.51) and pneumonia (0.44). The ACS NSQIP risk calculator poorly predicted and discriminated which patients would experience complications after robot-assisted partial nephrectomy. These findings suggest the need for a more tailored outcome prediction model to better assist urologists risk stratify patients undergoing robot-assisted partial nephrectomy and counsel them on individual surgical risks. Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
CONCLUSION: Stage did not clearly predict surgical pathologic risk factors, a result of uncertainty of clinical staging. Without surgery, it is impossible to determine the actual limits of the disease with the tests available at this time.
Dobkowski, W B; Murkin, J M
Aprotinin, a naturally occurring serine protease inhibitor, has found widespread application during cardiac surgical procedures as a consequence of its ability to decrease blood loss and transfusion requirements. While its efficacy in a variety of clinical situations associated with increased risk of blood loss has been well established, at the same time, various complications including anaphylaxis, renal insufficiency, graft closure and arterial thromboses have been reported in association with aprotinin administration. In order to more fully evaluate the risks and benefits associated with aprotinin usage, this review first of all examines the hazards associated with transfusion of blood and blood products. Consideration is then given to various alternatives to allogeneic transfusion, including autologous predonation, acute normovolemic hemodilution, perioperative cell salvage and intraoperative plasma sequestration. A critique of other available pharmacological therapies, specifically desmopressin, aminocaproic acid and tranexamic acid, reviewing their modes of action, efficacy and associated complications, is then made. The role of aprotinin in cardiac surgery is then discussed and its pharmacology, including consideration of its antifibrinolytic, platelet preserving and anti-inflammatory effects is reviewed. Finally, an analysis of potential complications associated with aprotinin administration is undertaken. Issues involving its influence on specific measures of anticoagulation, namely partial thromboplastin time and activated clotting time, and issues relating to graft patency, hypothermic circulatory arrest, renal function, and allergic reactions are analysed and interpreted. In summary, this review concludes that most of the risks associated with aprotinin administration primarily involve inadequate anticoagulation and those of developing an allergic reaction, particularly upon aproptinin re-exposure. The benefits of aproptinin to decrease blood loss and
Røder, Martin Andreas; Thomsen, Frederik Birkebæk; Berg, Kasper Drimer
BACKGROUND AND OBJECTIVE: To investigate risk factors associated with positive surgical margins (PSM) and biochemical recurrence (BR) in organ confined tumors (pT2) after radical prostatectomy (RP) for localized prostate cancer (PCa). METHODS: Between 1995 and 2011, 1,649 patients underwent RP...... trended (P = 0.08) to increase the risk of BR compared to PSM and non-NS surgery. CONCLUSION: Several factors influence the risk of pT2 PSMs in radical prostatectomy. In our cohort pT2 PSM is associated with NS surgery and trend to increase risk of BR compared to non-NS surgery. The optimal selection...
Schmidt, Ryan; Ratto, Matt
As a result of consumer-level 3D printers' increasing availability and affordability, the audience for 3D-design tools has grown considerably. However, current tools are ill-suited for these users. They have steep learning curves and don't take into account that the end goal is a physical object, not a digital model. A new class of "maker"-level design tools is needed to accompany this new commodity hardware. However, recent examples of such tools achieve accessibility primarily by constraining functionality. In contrast, the meshmixer project is building tools that provide accessibility and expressive power by leveraging recent computer graphics research in geometry processing. The project members have had positive experiences with several 3D-design-to-print workshops and are exploring several design-to-fabricate problems. This article is part of a special issue on 3D printing.
Sabouri Kashani Ahmad
Full Text Available Abstract Background Abdominal surgical site infections are among the most common complications of inpatient admissions and have serious consequences for outcomes and costs. Different risk factors may be involved, including age, sex, nutrition and immunity, prophylactic antibiotics, operation type and duration, type of shaving, and secondary infections. This study aimed to determine the risk factors affecting abdominal surgical site infections and their incidence at Imam Khomeini, a major referral teaching hospital in Iran. Methods Patients (n = 802 who had undergone abdominal surgery were studied and the relationships among variables were analyzed by Student's t and Chi-square tests. The subjects were followed for 30 days and by a 20-item questionnaire. Data were collected through pre- and post-operative examinations and telephone follow-ups. Results Of the 802 patients, 139 suffered from SSI (17.4%. In 40.8% of the cases, the wound was dirty infected. The average age for the patients was 46.7 years. The operations were elective in 75.7% of the cases and 24.7% were urgent. The average duration of the operation was 2.24 hours, the average duration of pre-operative hospital stay 4.31 days and the average length of (pre- and post-operation hospital stay 11.2 days. Three quarters of the cases were shaved 12 hours before the operation. The increased operation time, increased bed stay, electivity of the operation, septicity of the wound, type of incision, the administration of prophylactic antibiotic, type of operation, background disease, and the increased time lapse between shaving and operation all significantly associated with SSI with a p-value less than 0.001. Conclusion In view of the high rate of SSI reported here (17.4% compared with the 14% quoted in literature, this study suggests that by reducing the average operation time to less than 2 hours, the average preoperative stay to 4 days and the overall stay to less than 11 days, and
Full Text Available Aim. To analyze tears in sterile surgical gloves used by surgeons in the operating theatre of the Trauma and Orthopedic Surgery Department, Copernicus Memorial Hospital, Łódź, Poland Materials and Method. This study analyzes tears in sterile surgical gloves used by surgeons by ICD-9 and ICD-10 codes. 1,404 gloves were collected from 581 surgical procedures. All gloves were tested immediately following surgery using the test method described in Standard EN455–1 (each glove was inflated with 1,000 ± 50 ml of water and observed for leaks for 2–3 min.. Results. Analysis of tears took into consideration the role of medical personnel (operator, first assistant, second assistant during surgical procedure, the type of procedure according to ICD-9 and ICD-10 codes, and the elective or emergency nature of the procedure. The results of the study show that these factors have a significant influence on the risk of glove tears. Significant differences were observed in tear frequency and tear location depending on the function performed by the surgeon during the procedure. Conclusion. The study proved that the role performed by the surgeon during the procedure (operator, first assistant, second assistant has a significant influence on the risk of glove tearing. The role in the procedure determines exposure to glove tears. Implementing a double gloving procedure in surgical procedures or using single gloves characterized by higher tear resistance should be considered.
Thorlund, Jonas Bloch; Juhl, Carsten Bogh; Ingelsrud, Lina Holm
investigated exercise versus surgery (k=2) or the effect of surgery in addition to exercise (k=5) for degenerative meniscal tears. There was moderate level of evidence for exercise improving self-reported pain (Effect Size (ES)-0.51, 95% CI -1.16 to 0.13) and function (ES -0.06, 95% CI -0.23 to 0.......11) to the same extent as surgery, and improving muscle strength to a greater extent than surgery (ES -0.45, 95% CI -0.62 to -0.29). High-quality evidence showed no clinically relevant effect of surgery in addition to exercise on pain (ES 0.18, 95% 0.05 to 0.32) and function (ES, 0.13 95% CI -0.03 to 0.......28) for patients with degenerative meniscal tears. No randomised trials comparing non-surgical treatments with surgery in patients younger than 40 years of age or patients with traumatic meniscal tears were identified. Diagnosis of meniscal tears is challenging as all clinical diagnostic tests have high risk...
Brunsting, Julie Y; Pille, Frederik J; Oosterlinck, Maarten; Haspeslagh, Maarten; Wilderjans, Hans C
To determine the incidence of infection and associated risk factors, after elective arthroscopy. Retrospective case study. Horses (n=1079) undergoing elective arthroscopy. Medical records of all horses that underwent elective arthroscopy between 2006 and 2013 were reviewed. Age, gender, breed, surgeon, number of joints operated, total anesthetic time, perioperative antimicrobial administration, and the presence and size of osteochondral fragments/subchondral lesions were recorded. For each operated joint, the development of postoperative infection (surgical site infection [SSI] and/or septic arthritis) and long-term outcome (>6 months) were recorded. Multivariate logistic regression was used to test for association between the independent variables and the dependent outcomes. A total of 1741 joints in 1079 horses underwent arthroscopy. SSI without septic arthritis occurred in 1 fetlock joint (0.14%), 1 tibiotarsal joint (0.19%), and 6 femoropatellar joints (1.67%). Thirteen joints (0.75%) were diagnosed with septic arthritis, including 1 fetlock joint (0.14%), 4 tibiotarsal joints (0.74%), and 8 femoropatellar joints (2.23%). The probability of postoperative SSI was higher when large lesions (>40 mm long) were treated, compared to medium (20-40 mm, P = .005) and small (septic arthritis (P septic arthritis rate (P = .028). Septic arthritis after elective arthroscopy was more likely in the presence of SSI and younger age. Horses with large lesions were at risk for SSI, which translated into a higher incidence of postoperative septic arthritis after femoropatellar arthroscopy. © 2017 The American College of Veterinary Surgeons.
Full Text Available Background: Since the introduction of nerve-sparing radical prostatectomy (NSRP, there have been concerns about the increased risks of positive surgical margins (PSM and biochemical progression (BP. We examined the relationship of NSRP with PSM and BP using a large, mature dataset. Materials and Methods: Patients who underwent RP for clinically localized prostate cancer at our center between 1997 and 2008 were identified. Patients who received neoadjuvant therapy were excluded. We examined the relation of NSRP to the rate of PSM and BP in univariate and multivariate analyses adjusting for clinical and pathological variables including age, pretreatment prostate-specific antigen (PSA levels and doubling time, and pathological stage and grade. Results: In total, 856 patients were included, 70.9% underwent NSRP and 29.1% had non-NSRP. PSM rates were 13.5% in the NSRP group compared to 17.7% in non-NSRP (P=0.11. In a multivariate analysis, non-NSRP was preformed in patients with a higher pathological stage (HR 1.95, 95% CI 1.25-3.04, P=0.003 and a higher baseline PSA level (HR 1.04, 95% CI 1.01-1.08, P=0.005. With a median follow-up of 41 months, BP-free survival was 88% for non-NSRP compared to 92% for the NSRP group (log rank P=0.018; this difference was not significant in a multivariate Cox regression analysis (HR 0.54, 95% CI 0.28-1.06, P=0.09. Conclusion: When used in properly selected patients, NSRP does not seem to increase the risk of PSM and disease progression. The most effective way of resolving this issue is through a randomized clinical trial; however, such a trial is not feasible.
Dalam Tugas Akhir ini dibahas mengenai perancangan game Role Playing Game (RPG) menggunakan RPG Maker VX. Software RPG Maker VX ini digunakan untuk mempermudah dalam pembuatan perangkat lunak game atau software game. Objektif utama adalah mengembangkan permainan atau game menggunakan RPG Maker VX sehingga menghasilkan perangkat lunak game atau software game yang berbasis RPG. 072406137
Valero-Elizondo, Javier; Kim, Yuhree; Prescott, Jason D.; Margonis, Georgios A.; Tran, Thuy B.; Postlewait, Lauren M.; Maithel, Shishir K.; Wang, Tracy S.; Glenn, Jason A.; Hatzaras, Ioannis; Shenoy, Rivfka; Phay, John E.; Keplinger, Kara; Fields, Ryan C.; Jin, Linda X.; Weber, Sharon M.; Salem, Ahmed; Sicklick, Jason K.; Gad, Shady; Yopp, Adam C.; Mansour, John C.; Duh, Quan-Yang; Seiser, Natalie; Solorzano, Carmen C.; Kiernan, Colleen M.; Votanopoulos, Konstantinos I.; Levine, Edward A.; Poultsides, George A.
Background Adrenocortical carcinoma (ACC) is a rare disease with a poor prognosis. Given the lack of data on readmission after resection of ACC, the objective of the current study was to define the incidence of readmission, as well as identify risk factors associated with readmission among patients with ACC who underwent surgical resection. Methods Two hundred nine patients who underwent resection of ACC between January 1993 and December 2014 at 1 of 13 major centers in the USA were identified. Demographic and clinicopathological data were collected and analyzed relative to readmission. Results Median patient age was 52 years, and 62 % of the patients were female. Median tumor size was 12 cm, and the majority of patients had an American Society of Anesthesiologists (ASA) class of 3–4 (n=85, 56 %). The overall incidence of readmission within 90 days from surgery was 18 % (n=38). Factors associated with readmission included high ASA class (odds ratio (OR), 4.88 (95 % confidence interval (CI), 1.75–13.61); P=0.002), metastatic disease on presentation (OR, 2.98 (95 % CI, 1.37–6.46); P=0.006), EBL (>700 mL: OR, 2.75 (95 % CI, 1.16–6.51); P=0.02), complication (OR, 1.91 (95 % CI, 1.20–3.05); P=0.007), and prolonged length of stay (LOS; ≥9 days: OR, 4.12 (95 % CI, 1.88–9.01); P<0.001). On multivariate logistic regression, a high ASA class (OR, 4.01 (95 % CI, 1.44–11.17); P=0.008) and metastatic disease on presentation (OR, 3.44 (95 % CI, 1.34–8.84); P=0.01) remained independently associated with higher odds of readmission. Conclusion Readmission following surgery for ACC was common as one in five patients experienced a readmission. Patients with a high ASA class and metastatic disease on presentation were over four and three times more likely to be readmitted after surgical treatment for ACC, respectively. PMID:26286367
Klingelhöffer, Christoph; Zeman, Florian; Meier, Johannes; Reichert, Torsten Eugen; Ettl, Tobias
Surgical treatment of the medication-related osteonecrosis of the jaw (MRONJ) is still challenging. We examined the outcome of the resection of osteonecrotic lesions and the influence of potential risk factors on the operative success. Seventy six surgical interventions on 40 patients were evaluated in a prospective design with a mean follow-up of 55 weeks. Primary endpoints were: (i) maintenance of the mucosal closure and (ii) decrease of MRONJ stage. Influential variables included preoperative duration, location and diameter of MRONJ, duration and change of antiresorptive therapy, presence of actinomyces species. Only in 27.6% of cases long-term maintenance of the mucosal closure was achieved. However, stage II patients decreased to stage I in 81% after surgery (p < 0.01) and stage III patients improved in 83% of cases (OR = 8.08; p = 0.07). Stage I patients profited only in 38% by surgical intervention. MRONJ recurrence after surgery was associated with extended preoperative MRONJ duration (p = 0.015). There was no significance of further influential variables, but MRONJ of the upper jaw seems prognostically more favorable. Advanced stages of MRONJ benefit from surgical treatment, whereas stage I diseases may also be treated conservatively. An early intervention reduces the risk of recurrence. Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Full Text Available Abstract Background Surgical site infections (SSI are one of the most common healthcare associated infections in the low-middle income countries. Data on incidence and risk factors for SSI following surgeries in general and Obstetric and Gynecological surgeries in particular are scare. This study set out to identify risk factors for SSI in patients undergoing Obstetric and Gynecological surgeries in an Indian rural hospital. Methods Patients who underwent a surgical procedure between September 2010 to February 2013 in the 60-bedded ward of Obstetric and Gynecology department were included. Surveillance for SSI was based on the Centre for Disease Control (CDC definition and methodology. Incidence and risk factors for SSI, including those for specific procedure, were calculated from data collected on daily ward rounds. Results A total of 1173 patients underwent a surgical procedure during the study period. The incidence of SSI in the cohort was 7.84% (95% CI 6.30–9.38. Majority of SSI were superficial. Obstetric surgeries had a lower SSI incidence compared to gynecological surgeries (1.2% versus 10.3% respectively. The risk factors for SSI identified in the multivariate logistic regression model were age (OR 1.03, vaginal examination (OR 1.31; presence of vaginal discharge (OR 4.04; medical disease (OR 5.76; American Society of Anesthesia score greater than 3 (OR 12.8; concurrent surgical procedure (OR 3.26; each increase in hour of surgery, after the first hour, doubled the risk of SSI; inappropriate antibiotic prophylaxis increased the risk of SSI by nearly 5 times. Each day increase in stay in the hospital after the surgery increased the risk of contacting an SSI by 5%. Conclusions Incidence and risk factors from prospective SSI surveillance can be reported simultaneously for the Obstetric and Gynecological surgeries and can be part of routine practice in resource-constrained settings. The incidence of SSI was lower for Obstetric surgeries
Juan C Ortiz
intraluminal stent implantation is an alternative. Objective: to analyze the impact of percutaneous implantation of aortic stents in high-risk surgical patients with a minimum of one y ear follow-up. Method: Descriptive study conducted from December 2005 to March 2010 which included 125 patients with thoracic or abdominal aortic aneurysm, meeting surgical criteria by its diameter and that were rejected from surgery due to their high risk. The outcomes were intraoperative death from any cause and aneurysm-related at one, six and twelve months. Complications were defined as vascular occurred during the first thirty days. Results: Abdominal aneurysm was more frequent (70.4%. The overall mortality at 25.7 months follow-up was 14.8%. Of this percentage, 5.2% died from causes related to the aneurysm. One patient died during surgery. 4.3% were reoperated for leaks. There was higher aneurysm-related mortality in the thoracic (14.7 vs. 1.2% p = 0.003 and a trend in those of larger diameter (6.9 vs. 5.7 cm p = 0.210. There was no association between mortality and diabetes mellitus, smoking, heart disease, hypertension or dyslipidemia. Conclusions: aneurysm-related mortality in patients undergoing aortic stent graft is low. Mortality was associated with thoracic aneurysm and to its greater diameter. Complications did not imply an increase in mortality. In conclusion, in patients with aortic aneurysm and high surgical risk rejected for open surgery, percutaneous approach is a safe and effective treatment in a medium-term follow-up.
Lucas, Laura S; Witter, Frank R
It's common practice to use a preparation containing chlorhexidine to prepare the surgical site before cesarean birth. We observed an interaction between ultrasound gel, used for electronic fetal heart monitoring before birth, and chlorhexidine. This interaction creates the potential for surgical site infection. Using isopropyl alcohol to thoroughly remove all gel before application of chlorhexidine was associated with reduced rates of postsurgical infection at our institution. © 2014 AWHONN.
Wang X; Zhao BJ; Su Y
Xiao Wang, Bin Jiang Zhao, Yue Su Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China Purpose: Hip fractures are associated with poor prognosis in elderly patients partly due to the high rate of postoperative complications. This study was aimed to investigate whether the surgical risk calculator is suitable for predicting postoperative complications in elderly Chinese patients with hip fractures.Methods: The incidence of postoperative complica...
Inoue, Tadahisa; Okumura, Fumihiro; Kachi, Kenta; Fukusada, Shigeki; Iwasaki, Hiroyasu; Ozeki, Takanori; Suzuki, Yuta; Anbe, Kaiki; Nishie, Hirotada; Mizushima, Takashi; Sano, Hitoshi
Recently, endoscopic gallbladder stenting (EGBS) has been performed to prevent recurrences in high-risk surgical patients with cholecystitis. However, evidence regarding the long-term outcomes of EGBS is sparse. We investigated the cholecystitis recurrence rate in high-risk surgical patients with acute calculous cholecystitis and compared the cholecystitis recurrence rates in patients in whom EGBS was performed with those in patients who were observed after percutaneous drainage. We studied 64 consecutive high-risk surgical patients with acute calculous cholecystitis who required gallbladder decompression between 2007 and 2014. We divided the patient cohort into patients who underwent observation after percutaneous drainage between 2007 and 2011 (OAPD group) and those who underwent EGBS between 2012 and 2014 (EGBS group), and we compared the groups. The technical success rate of EGBS was 82.9% based on the intention-to-treat analysis. The cholecystitis recurrence rates were 17.2% in the OAPD group and 0% in the EGBS group, a difference that was significant (P = .043). There was also a significant difference between the groups with respect to the time to recurrent cholecystitis, which was determined by using Kaplan-Meier analysis (P = .015). The overall biliary event rates were 24.1% in the OAPD group and 9.1% in the EGBS group, and no significant difference was noted (P = .207). EGBS reduced the recurrence of cholecystitis in high-risk surgical patients with calculous cholecystitis. However, stent-related adverse events may occur, and modifications are necessary to reduce these. Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
Ogihara, Satoshi; Yamazaki, Takashi; Maruyama, Toru; Oka, Hiroyuki; Miyoshi, Kota; Azuma, Seiichi; Yamada, Takashi; Murakami, Motoaki; Kawamura, Naohiro; Hara, Nobuhiro; Terayama, Sei; Morii, Jiro; Kato, So; Tanaka, Sakae
Surgical site infection is a serious and significant complication after spinal surgery and is associated with high morbidity rates, high healthcare costs and poor patient outcomes. Accurate identification of risk factors is essential for developing strategies to prevent devastating infections. The purpose of this study was to identify independent risk factors for surgical site infection among posterior thoracic and/or lumbar spinal surgery in adult patients using a prospective multicenter surveillance research method. From July 2010 to June 2012, we performed a prospective surveillance study in adult patients who had developed surgical site infection after undergoing thoracic and/or lumbar posterior spinal surgery at 11 participating hospitals. Detailed preoperative and operative patient characteristics were prospectively recorded using a standardized data collection format. Surgical site infection was based on the definition established by the Centers for Disease Control and Prevention. A total of 2,736 consecutive adult patients were enrolled, of which 24 (0.9%) developed postoperative deep surgical site infection. Multivariate regression analysis indicated four independent risk factors. Preoperative steroid therapy (P = 0.001), spinal trauma (P = 0.048) and gender (male) (P = 0.02) were statistically significant independent patient-related risk factors, whereas an operating time ≥3 h (P operating time ≥3 h were independent risk factors for deep surgical site infection after thoracic and/or lumbar spinal surgery in adult patients. Identification of these risk factors can be used to develop protocols aimed at decreasing the risk of surgical site infection.
Kim, Young Hwan [Keimyung University, College of Medicine, Daegu (Korea, Republic of); Kim, Yong Joo [Andong General Hospital, Andong (Korea, Republic of); Shin, Tae Beom [Gyeonsang National University, College of Medicine, Jinju (Korea, Republic of)
To evaluate the technical feasibility and clinical efficacy of percutaneous transhepatic cholecystolithotomy under fluoroscopic guidance in high-risk surgical patients with acute cholecystitis. Sixty-three consecutive patients of high surgical risk with acute calculous cholecystitis underwent percutaneous transhepatic gallstone removal under conscious sedation. The stones were extracted through the 12-Fr sheath using a Wittich nitinol stone basket under fluoroscopic guidance on three days after performing a percutaneous cholecystostomy. Large or hard stones were fragmented using either the snare guide wire technique or the metallic cannula technique. Gallstones were successfully removed from 59 of the 63 patients (94%). Reasons for stone removal failure included the inability to grasp a large stone in two patients, and the loss of tract during the procedure in two patients with a contracted gallbladder. The mean hospitalization duration was 7.3 days for acute cholecystitis patients and 9.4 days for gallbladder empyema patients. Bile peritonitis requiring percutaneous drainage developed in two patients. No symptomatic recurrence occurred during follow-up (mean, 608.3 days). Fluoroscopy-guided percutaneous gallstone removal using a 12-Fr sheath is technically feasible and clinically effective in high-risk surgical patients with acute cholecystitis
Farret, Túlio Cícero Franco; Dallé, Jessica; Monteiro, Vinícius da Silva; Riche, Cezar Vinícius Würdig; Antonello, Vicente Sperb
The present study evaluated patients with diagnosis of surgical site infection (SSI) following cesarean section and their controls to determinate risk factors and impact of antibiotic prophylaxis on this condition. All cesareans performed from January 2009 to December 2012 were evaluated for SSI, based on criteria established by CDC/NHSN. Control patients were determined after inclusion of case patients. Medical records of case and control patients were reviewed and compared regarding sociodemographic and clinical characteristics. Our study demonstrated an association following univariate analysis between post-cesarean SSI and number of internal vaginal examinations, time of membrane rupture, emergency cesarean and improper use of antibiotic prophylaxis. This same situation did not repeat itself in multivariate analysis with adjustment for risk factors, especially with regard to antibiotic prophylaxis, considering the emergency cesarean factor only. The authors of the present study not only question surgical antimicrobial prophylaxis use based on data presented here and in literature, but suggest that the prophylaxis is perhaps indicated primarily in selected groups of patients undergoing cesarean section. Further research with greater number of patients and evaluated risk factors are fundamental for better understanding of the causes and evolution of surgical site infection after cesarean delivery. Copyright © 2014. Published by Elsevier Editora Ltda.
Nicksa, Grace A; Anderson, Cristan; Fidler, Richard; Stewart, Lygia
The Accreditation Council for Graduate Medical Education core competencies stress nontechnical skills that can be difficult to evaluate and teach to surgical residents. During emergencies, surgeons work in interprofessional teams and are required to perform certain procedures. To obtain proficiency in these skills, residents must be trained. To educate surgical residents in leadership, teamwork, effective communication, and infrequently performed emergency surgical procedures with the use of interprofessional simulations. SimMan 3GS was used to simulate high-risk clinical scenarios (15-20 minutes), followed by debriefings with real-time feedback (30 minutes). A modified Oxford Non-Technical Skills scale (score range, 1-4) was used to assess surgical resident performance during the first half of the academic year (July-December 2012) and the second half of the academic year (January-June 2013). Anonymous online surveys were used to solicit participant feedback. Simulations were conducted in the operating room, intensive care unit, emergency department, ward, and simulation center. A total of 43 surgical residents (postgraduate years [PGYs] 1 and 2) participated in interdisciplinary clinical scenarios, with other health care professionals (nursing, anesthesia, critical care, medicine, respiratory therapy, and pharmacy; mean number of nonsurgical participants/session: 4, range 0-9). Thirty seven surgical residents responded to the survey. Simulation of high-risk clinical scenarios: postoperative pulmonary embolus, pneumothorax, myocardial infarction, gastrointestinal bleeding, anaphylaxis with a difficult airway, and pulseless electrical activity arrest. Evaluation of resident skills: communication, leadership, teamwork, problem solving, situation awareness, and confidence in performing emergency procedures (eg, cricothyroidotomy). A total of 31 of 35 (89%) of the residents responding found the sessions useful. Additionally, 28 of 33 (85%) reported improved confidence
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.
Taylor, Frederick L; Abern, Michael R; Levine, Laurence A
Surgical therapy remains the gold standard treatment for Peyronie's Disease (PD). Surgical options include plication, grafting, and placement of inflatable penile prosthesis (IPP). Postoperative erectile dysfunction (ED) is a potential complication for PD surgery without IPP. We present our large series follow-up to evaluate preoperative risk factors for postoperative ED. The aim of this study is to evaluate preoperative risk factors for the development of ED following surgical correction of PD taking into account the degree of curvature, graft size, surgical approach, hypertension, hyperlipidemia, diabetes, smoking history, preoperative use of phosphodiesterase 5 inhibitors (PDE5), and preoperative duplex ultrasound findings including peak systolic and end diastolic velocities and resistive index. We identified 218 men undergoing either tunica albuginea plication (TAP) or partial plaque excision with pericardial grafting for PD following a previously published algorithm between November 1992 and April 2007. Preoperative and postoperative erectile function, curvature characteristics, presence of vascular risk factors, and duplex ultrasound findings were available on 109 patients. Our primary outcome measure is the development of ED after surgery for PD. Ten percent of TAP and 21% of plaque excision with grafting patients developed postoperative ED. Neither curve direction (P = 0.76), graft area (P = 0.78), surgical approach (P = 0.12), chronic hypertension (P = 0.51), hyperlipidemia (P = 0.87), diabetes (P = 0.69), nor smoking history (P = 0.99) were significant predictors of postoperative ED. No combination of risk factors was found to be predictive of postoperative ED. Preoperative use of PDE5 was not a significant predictor of postoperative ED (P = 0.33). Neither peak systolic, end diastolic, nor resistive index were significant predictors of ED (P = 0.28, 0.28, and 0.25, respectively). This long-term follow-up of a large published series suggests that neither
Bahl, Manisha; Barzilay, Regina; Yedidia, Adam B; Locascio, Nicholas J; Yu, Lili; Lehman, Constance D
Purpose To develop a machine learning model that allows high-risk breast lesions (HRLs) diagnosed with image-guided needle biopsy that require surgical excision to be distinguished from HRLs that are at low risk for upgrade to cancer at surgery and thus could be surveilled. Materials and Methods Consecutive patients with biopsy-proven HRLs who underwent surgery or at least 2 years of imaging follow-up from June 2006 to April 2015 were identified. A random forest machine learning model was developed to identify HRLs at low risk for upgrade to cancer. Traditional features such as age and HRL histologic results were used in the model, as were text features from the biopsy pathologic report. Results One thousand six HRLs were identified, with a cancer upgrade rate of 11.4% (115 of 1006). A machine learning random forest model was developed with 671 HRLs and tested with an independent set of 335 HRLs. Among the most important traditional features were age and HRL histologic results (eg, atypical ductal hyperplasia). An important text feature from the pathologic reports was "severely atypical." Instead of surgical excision of all HRLs, if those categorized with the model to be at low risk for upgrade were surveilled and the remainder were excised, then 97.4% (37 of 38) of malignancies would have been diagnosed at surgery, and 30.6% (91 of 297) of surgeries of benign lesions could have been avoided. Conclusion This study provides proof of concept that a machine learning model can be applied to predict the risk of upgrade of HRLs to cancer. Use of this model could decrease unnecessary surgery by nearly one-third and could help guide clinical decision making with regard to surveillance versus surgical excision of HRLs. © RSNA, 2017.
McMillan, Matthew T; Allegrini, Valentina; Asbun, Horacio J; Ball, Chad G; Bassi, Claudio; Beane, Joal D; Behrman, Stephen W; Berger, Adam C; Bloomston, Mark; Callery, Mark P; Christein, John D; Dickson, Euan; Dixon, Elijah; Drebin, Jeffrey A; Fernandez-Del Castillo, Carlos; Fisher, William E; Fong, Zhi Ven; Haverick, Ericka; Hollis, Robert H; House, Michael G; Hughes, Steven J; Jamieson, Nigel B; Kent, Tara S; Kowalsky, Stacy J; Kunstman, John W; Malleo, Giuseppe; McElhany, Amy L; Salem, Ronald R; Soares, Kevin C; Sprys, Michael H; Valero, Vicente; Watkins, Ammara A; Wolfgang, Christopher L; Zureikat, Amer H; Vollmer, Charles M
This multicenter study sought to evaluate the accuracy of the American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) surgical risk calculator for predicting outcomes after pancreatoduodenectomy (PD) and to determine whether incorporating other factors improves its predictive capacity. The ACS-NSQIP surgical risk calculator has been proposed as a decision-support tool to predict complication risk after various operations. Although it considers 21 preoperative factors, it does not include procedure-specific variables, which have demonstrated a strong predictive capacity for the most common and morbid complication after PD - clinically relevant pancreatic fistula (CR-POPF). The validated Fistula Risk Score (FRS) intraoperatively predicts the occurrence of CR-POPF and serious complications after PD. This study of 1480 PDs involved 47 surgeons at 17 high-volume institutions. Patient complication risk was calculated using both the universal calculator and a procedure-specific model that incorporated the FRS and surgeon/institutional factors. The performance of each model was compared using the c-statistic and Brier score. The FRS was significantly associated with 30-day mortality, 90-day mortality, serious complications, and reoperation (all P calculator for 30-day mortality (c-statistic: 0.79 vs 0.68; Brier score: 0.020 vs 0.021), 90-day mortality, serious complications, and reoperation. Neither surgeon experience nor institutional volume significantly predicted mortality; however, surgeons with a career PD volume >450 were less likely to have serious complications (P < 0.001) or perform reoperations (P < 0.001). Procedure-specific complication risk influences outcomes after pancreatoduodenectomy; therefore, risk adjustment for performance assessment and comparative research should consider these preoperative and intraoperative factors along with conventional ACS-NSQIP preoperative variables.
Mohamed Mohamed Elawdy
Conclusions: In our present series, bladder cancer recurrence of urothelial malignancy occurred in nearly half of the patients after surgical management of UTUC. Ureteric tumour was the only identifiable risk factor, thus patients with ureteric tumours may benefit from prophylactic intravesical chemoimmunotherapy. Bladder recurrence does not appear to affect the cancer-specific survival after surgical management of UTUC.
Lawaetz, Mads; Homøe, Preben
OBJECTIVE: The purpose of this study was to examine which factors are associated with inadequate surgical margins and to assess the postoperative consequences. STUDY DESIGN: A retrospective cohort of 110 patients with oral squamous cell carcinoma treated with surgery during a 2-year period...... was examined. Clinical, histopathologic, and operative variables were related to the surgical margin status. Furthermore postoperative treatment data were compared with margin status. RESULTS: Univariate statistically significant associations were found between the tumor site in the floor of mouth, more...
Li, Guowei; Cook, Deborah J; Levine, Mitchell A H; Guyatt, Gordon; Crowther, Mark; Heels-Ansdell, Diane; Holbrook, Anne; Lamontagne, Francois; Walter, Stephen D; Ferguson, Niall D; Finfer, Simon; Arabi, Yaseen M; Bellomo, Rinaldo; Cooper, D Jamie; Thabane, Lehana
Failure to recognize the presence of competing risk or to account for it may result in misleading conclusions. We aimed to perform a competing risk analysis to assess the efficacy of the low molecular weight heparin dalteparin versus unfractionated heparin (UFH) in venous thromboembolism (VTE) in medical-surgical critically ill patients, taking death as a competing risk.This was a secondary analysis of a prospective randomized study of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT) database. A total of 3746 medical-surgical critically ill patients from 67 intensive care units (ICUs) in 6 countries receiving either subcutaneous UFH 5000 IU twice daily (n = 1873) or dalteparin 5000 IU once daily plus once-daily placebo (n = 1873) were included for analysis.A total of 205 incident proximal leg deep vein thromboses (PLDVT) were reported during follow-up, among which 96 were in the dalteparin group and 109 were in the UFH group. No significant treatment effect of dalteparin on PLDVT compared with UFH was observed in either the competing risk analysis or standard survival analysis (also known as cause-specific analysis) using multivariable models adjusted for APACHE II score, history of VTE, need for vasopressors, and end-stage renal disease: sub-hazard ratio (SHR) = 0.92, 95% confidence interval (CI): 0.70-1.21, P-value = 0.56 for the competing risk analysis; hazard ratio (HR) = 0.92, 95% CI: 0.68-1.23, P-value = 0.57 for cause-specific analysis. Dalteparin was associated with a significant reduction in risk of pulmonary embolism (PE): SHR = 0.54, 95% CI: 0.31-0.94, P-value = 0.02 for the competing risk analysis; HR = 0.51, 95% CI: 0.30-0.88, P-value = 0.01 for the cause-specific analysis. Two additional sensitivity analyses using the treatment variable as a time-dependent covariate and using as-treated and per-protocol approaches demonstrated similar findings.This competing risk analysis yields no
Kao, S S; Frauenfelder, C; Wong, D; Edwards, S; Krishnan, S; Ooi, E H
Appropriate selection of tongue cancer patients considering surgery is critical in ensuring optimal outcomes. The American College of Surgeons' National Surgical Quality Improvement Program ('ACS-NSQIP') risk calculator was developed to assess patients' 30-day post-operative risk, providing surgeons with information to guide decision making. A retrospective review of 30-day actual mortality and morbidity of tongue cancer patients was undertaken to investigate the validity of this tool for South Australian patients treated from 2005 to 2015. One hundred and twenty patients had undergone glossectomy. Predicted length of stay using the risk calculator was significantly different from actual length of stay. Predicted mortality and other complications were found to be similar to actual outcomes. The American College of Surgeons' National Surgical Quality Improvement Program risk calculator was found to be effective in predicting post-operative complication rates in South Australian tongue cancer patients. However, significant discrepancies in predicted and actual length of stay may limit its use in this population.
Bakkour, W; Purssell, H; Chinoy, H; Griffiths, C E M; Warren, R B
There is limited evidence as to whether biologic therapy should be stopped or continued in patients with psoriasis and/or psoriatic arthritis (PsA) who are undergoing surgical procedures. Current guidelines of care recommend a planned break from biologic therapy in those undergoing major surgical procedures. To audit current practice of managing biologic therapy peri-operatively in a tertiary referral psoriasis clinic against guidelines of care and to investigate the effects of continuing/stopping biologic therapy in psoriasis and PsA patients. A retrospective audit of psoriasis and PsA patients who had a surgical procedure whilst on biologic therapy. A proforma was used to collect information on the biologics used, whether they were stopped peri-operatively and whether patients developed post-operative complications and/or disease flare. A total of 42 patients who had 77 procedures were identified. Procedures ranged from skin surgery to orthopaedic and cardiothoracic surgery. Biologic therapy was continued in the majority of procedures (76%). There was no significant difference in post-operative risk of infection and delayed wound healing between those patients who continued and those who stopped biologic therapy, including those undergoing major surgery. Interrupting biologic therapy peri-operatively was associated with a significant (P = 0.003) risk of flare of psoriasis or PsA. Continuing biologic therapy in psoriasis and PsA patients peri-operatively did not increase the risk of post-operative complications. Interrupting biologic therapy peri-operatively significantly increased the risk of disease flare. This study is limited by cohort size and requires replication, ideally in a prospective randomized controlled manner. © 2015 European Academy of Dermatology and Venereology.
After major operations, hypoxaemia is common in the late postoperative period in the surgical ward. Recent studies of humans after major operations showed that such hypoxaemia may be related to the development of myocardial ischaemia and cardiac arrhythmias, even in patients with no preoperative ...
signs or symptoms of coronary artery disease. Experimental studies have shown an adverse effect of tissue hypoxia on wound healing and on resistance to bacterial wound infections. Finally, mental confusion and surgical delirium may be related to inadequate arterial oxygenation during the late...
Mallee, Wouter H.; Weel, Hanneke; van Dijk, C. Niek; van Tulder, Maurits W.; Kerkhoffs, Gino M.; Lin, Chung-Wei Christine
To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal. Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and retrospective
Kortram, Kirsten; van Ramshorst, Bert; Bollen, Thomas L.; Besselink, Marc G. H.; Gouma, Dirk J.; Karsten, Tom; Kruyt, Philip M.; Nieuwenhuijzen, Grard A. P.; Kelder, Johannes C.; Tromp, Ellen; Boerma, Djamila
Background: Laparoscopic cholecystectomy in acute calculous cholecystitis in high risk patients can lead to significant morbidity and mortality. Percutaneous cholecystostomy may be an alternative treatment option but the current literature does not provide the surgical community with evidence based
Steinberg, James P; Braun, Barbara I; Hellinger, Walter C; Kusek, Linda; Bozikis, Michele R; Bush, Andrew J; Dellinger, E Patchen; Burke, John P; Simmons, Bryan; Kritchevsky, Stephen B
The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP). National AMP guidelines should be supported by evidence from large contemporary data sets. Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac, hip/knee arthroplasty, and hysterectomy cases. Surgical site infections (SSIs) were ascertained through routine surveillance, using National Nosocomial Infections Surveillance system methodology. The association between the prophylaxis timing and the occurrence of SSI was assessed using conditional logistic regression (conditioning on hospital). One-hundred thirteen SSI were detected in 109 patients. SSI risk increased incrementally as the interval of time between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 0.04). When antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded, the infection risk following administration of antibiotic within 30 minutes prior to incision was 1.6% compared with 2.4% associated with administration of antibiotic between 31 to 60 minutes prior to surgery (OR: 1.74; 95% confidence interval, 0.98-3.04). The infection risk increased as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision. Intraoperative redosing (performed in only 21% of long operations) appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 3.08 with no redosing; 95% confidence interval 0.74-12.90), but only when the preoperative dose was given correctly. These data from a large multicenter collaborative study confirm and extend previous observations and show a consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision.
Zhu, M.; Chiarella, C.; He, X.Z.; Wang, D.
The market maker plays an important role in price formation, but his/her behavior and stabilizing impact on the market are relatively unclear, in particular in speculative markets. This paper develops a financial market model that examines the impact on market stability of the market maker, who acts
Cleary Kevin; Mann Bhupinder; Emerton Mark; Patel Bhavesh; Mirza Saqeb B; Noble Douglas J; Panesar Sukhmeet S; Sheikh Aziz; Bhandari Mohit
Abstract Background Surgical procedures are now very common, with estimates ranging from 4% of the general population having an operation per annum in economically-developing countries; this rising to 8% in economically-developed countries. Whilst these surgical procedures typically result in considerable improvements to health outcomes, it is increasingly appreciated that surgery is a high risk industry. Tools developed in the aviation industry are beginning to be used to minimise the risk o...
Full Text Available Aim: In association with increasing life expectancy, the number of elderly individuals undergoing coronary bypass grafting (CABG and additional cardiac surgical procedures are increasing. In this study, we evaluated the effects of additional cardiac procedures and preoperative risk factors for postoperative mortality and morbidity in patients 80 years of age and older. Methods: The records of 29 patients aged 80 years and older (82.86±2.91 who had undergone coronary bypass surgery in the department of cardiac surgery between September 2009 and June 2012, were retrospectively reviewed. The subjects were divided into two groups: group 1 included the patients who had undergone CABG, group 2 consisted of those who had undergone CABG and additional cardiac procedures. Results: The mean age of the patients [14 male (48.3% 15 female (51.7%] was 82.86±2.91 years. The left internal thoracic artery was harvested for all patients. The mean number of graft per patient was 3.07±0.95. Carotid endarterectomy was performed in 3 patients before CABG. CABG and aortic valve replacement were performed in 1 patient. CABG, mitral valve replacement ant tricuspid plasty were performed in another patient. Furthermore, in one patient, abdominal aortic graft replacement due to ruptured abdominal aortic aneurysm and CABG was performed at the same session. The mean EuroSCORE was 5.06±5.16. Postoperative 30 days mortality was 6.8%, and the mean length of stay in hospital was 10.45±8.18 days. Conclusion: Coronary bypass surgery is an acceptable treatment method in patients 80 years of age and older. Although additional cardiac procedures may increase sugical risks, they can be successfully performed. (The Medical Bulletin of Haseki 2014; 52: 14-8
Johnson, Matthew D., E-mail: Matthewjohnson@beaumont.edu [Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan (United States); Avkshtol, Vladimir [Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan (United States); Baschnagel, Andrew M. [Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (United States); Meyer, Kurt; Ye, Hong; Grills, Inga S.; Chen, Peter Y.; Maitz, Ann [Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan (United States); Olson, Rick E.; Pieper, Daniel R. [Department of Neurosurgery, William Beaumont Hospital, Royal Oak, Michigan (United States); Krauss, Daniel J. [Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan (United States)
Purpose: Recent prospective data have shown that patients with solitary or oligometastatic disease to the brain may be treated with upfront stereotactic radiosurgery (SRS) with deferral of whole-brain radiation therapy (WBRT). This has been extrapolated to the treatment of patients with resected lesions. The aim of this study was to assess the risk of leptomeningeal disease (LMD) in patients treated with SRS to the postsurgical resection cavity for brain metastases compared with patients treated with SRS to intact metastases. Methods and Materials: Four hundred sixty-five patients treated with SRS without upfront WBRT at a single institution were identified; 330 of these with at least 3 months' follow-up were included in this analysis. One hundred twelve patients had undergone surgical resection of at least 1 lesion before SRS compared with 218 treated for intact metastases. Time to LMD and overall survival (OS) time were estimated from date of radiosurgery, and LMD was analyzed by the use of cumulative incidence method with death as a competing risk. Univariate and multivariate analyses were performed with competing risk regression to determine whether various clinical factors predicted for LMD. Results: With a median follow-up time of 9.0 months, 39 patients (12%) experienced LMD at a median of 6.0 months after SRS. At 1 year, the cumulative incidence of LMD, with death as a competing risk, was 5.2% for the patients without surgical resection versus 16.9% for those treated with surgery (Gray test, P<.01). On multivariate analysis, prior surgical resection (P<.01) and breast cancer primary (P=.03) were significant predictors of LMD development. The median OS times for patients undergoing surgery compared with SRS alone were 12.9 and 10.6 months, respectively (log-rank P=.06). Conclusions: In patients undergoing SRS with deferral of upfront WBRT for intracranial metastatic disease, prior surgical resection and breast cancer primary are associated with an
Shao, Jiashen; Chang, Hengrui; Zhu, Yanbin; Chen, Wei; Zheng, Zhanle; Zhang, Huixin; Zhang, Yingze
This study aimed to quantitatively summarize the risk factors associated with surgical site infection after open reduction and internal fixation of tibial plateau fracture. Medline, Embase, CNKI, Wanfang database and Cochrane central database were searched for relevant original studies from database inception to October 2016. Eligible studies had to meet quality assessment criteria according to the Newcastle-Ottawa Scale, and had to evaluate the risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture. Stata 11.0 software was used for this meta-analysis. Eight studies involving 2214 cases of tibial plateau fracture treated by open reduction and internal fixation and 219 cases of surgical site infection were included in this meta-analysis. The following parameters were identified as significant risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture (p operative time (OR 2.15; 95% CI 1.53-3.02), tobacco use (OR 2.13; 95% CI 1.13-3.99), and external fixation (OR 2.07; 95% CI 1.05-4.09). Other factors, including male sex, were not identified as risk factors for surgical site infection. Patients with the abovementioned medical conditions are at risk of surgical site infection after open reduction and internal fixation of tibial plateau fracture. Surgeons should be cognizant of these risks and give relevant preoperative advice. Copyright © 2017. Published by Elsevier Ltd.
Oplinger, James; Lande, Micah; Jordan, Shawn; Camarena, Leonor
This study examines the emergence of leadership characteristics within a new organizational community of individuals: the Maker community. The Maker community is a group of individuals that classify themselves as "Makers" and have become innovators and entrepreneurs through the creation of technological gadgets, artistic projects, and…
Zijlstra, Wierd P; De Hartog, Bas; Van Steenbergen, Liza N; Scheurs, B Willem; Nelissen, Rob G H H
Background and purpose - Recurrent dislocation is the commonest cause of early revision of a total hip arthropasty (THA). We examined the effect of femoral head size and surgical approach on revision rate for dislocation, and for other reasons, after total hip arthroplasty (THA). Patients and methods - We analyzed data on 166,231 primary THAs and 3,754 subsequent revision THAs performed between 2007 and 2015, registered in the Dutch Arthroplasty Register (LROI). Revision rate for dislocation, and for all other causes, were calculated by competing-risk analysis at 6-year follow-up. Multivariable Cox proportional hazard regression ratios (HRs) were used for comparisons. Results - Posterolateral approach was associated with higher dislocation revision risk (HR =1) than straight lateral, anterolateral, and anterior approaches (HR =0.5-0.6). However, the risk of revision for all other reasons (especially stem loosening) was higher with anterior and anterolateral approaches (HR =1.2) and lowest with posterolateral approach (HR =1). For all approaches, 32-mm heads reduced the risk of revision for dislocation compared to 22- to 28-mm heads (HR =1 and 1.6, respectively), while the risk of revision for other causes remained unchanged. 36-mm heads increasingly reduced the risk of revision for dislocation but only with the posterolateral approach (HR =0.6), while the risk of revision for other reasons was unchanged. With the anterior approach, 36-mm heads increased the risk of revision for other reasons (HR =1.5). Interpretation - Compared to the posterolateral approach, direct anterior and anterolateral approaches reduce the risk of revision for dislocation, but at the cost of more stem revisions and other revisions. For all approaches, there is benefit in using 32-mm heads instead of 22- to 28-mm heads. For the posterolateral approach, 36-mm heads can safely further reduce the risk of revision for dislocation.
Zeev Blumenfeld M.D.
Full Text Available Background Medical termination of pregnancy [TOP] during the early first trimester is commonly used. However, treatment failure which warrants surgical intervention occurs in small proportion of patients. Our objective was to examine the effectiveness and predictive value of sonographic measurement of endometrial thickness during a follow up visit after medical abortion as an accurate predictor of the necessity of curettage for completion of pregnancy termination. Methods Women who opted for medical TOP where treated by single dose of RU486 followed by a single dose of misoprostol. Endometrial thickness was evaluated by transvaginal U.S. at 14 days after misoprostol tretament. The data was collected prospectively for this cohort study which includes all the women undergoing medical abortion in the first seven weeks of gestation. Results In 34.7% of the patients the endometrial width was > 11 mm on the follow-up visit. Surgical intervention was performed in 18% of these patients, for a failure rate of the medical termination of pregnancy [TOP] of 6.25%, as compared with no failure rate in those with endometrium 12 mm the failure was 5.9%. In cases where the endometrium was 12-13 mm the failure rate was 27.3%, and if >13 mm the failure was 18.9%. When the endometrium was 13-14 mm the failure rate was 10%, and when >14 mm the failure was 23.7%. Half of the 18 patients who had undergone dilatation and curettage [D&C] for completion of the TOP, had endometrium > 14 mm, one to two weeks after the medical abortion. Conclusion Measurement of endometrial width after medical TOP is beneficial in segregating patient to low or high risk for surgical treatment of retained product of conception [POC]. Using a cutoff of 11 mm during the follow-up visit after medical TOP, 18% of the patients may need dilatation and curettage to complete the pregnancy termination, and if it is >14 mm, half of them may need surgical intervention. There is no difference between 11
Gorgun, E; Benlice, C; Hammel, J; Hull, T; Stocchi, L
The aim of the present study was to create a unique risk adjustment model for surgical site infection (SSI) in patients who underwent colorectal surgery (CRS) at the Cleveland Clinic (CC) with inherent high risk factors by using a nationwide database. The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who underwent CRS between 2005 and 2010. Initially, CC cases were identified from all NSQIP data according to case identifier and separated from the other NSQIP centers. Demographics, comorbidities, and outcomes were compared. Logistic regression analyses were used to assess the association between SSI and center-related factors. A total of 70,536 patients met the inclusion criteria and underwent CRS, 1090 patients (1.5%) at the CC and 69,446 patients (98.5%) at other centers. Male gender, work-relative value unit, diagnosis of inflammatory bowel disease, pouch formation, open surgery, steroid use, and preoperative radiotherapy rates were significantly higher in the CC cases. Overall morbidity and individual postoperative complication rates were found to be similar in the CC and other centers except for the following: organ-space SSI and sepsis rates (higher in the CC cases); and pneumonia and ventilator dependency rates (higher in the other centers). After covariate adjustment, the estimated degree of difference between the CC and other institutions with respect to organ-space SSI was reduced (OR 1.38, 95% CI 1.08-1.77). The unique risk adjustment strategy may provide center-specific comprehensive analysis, especially for hospitals that perform inherently high-risk procedures. Higher surgical complexity may be the reason for increased SSI rates in the NSQIP at tertiary care centers.
Shinkawa, Hiroji; Takemura, Shigekazu; Uenishi, Takahiro; Sakae, Masayuki; Ohata, Kazunori; Urata, Yorihisa; Kaneda, Kazuhisa; Nozawa, Akinori; Kubo, Shoji
Malnutrition has been considered a risk factor for the development of a surgical site infection (SSI). The aim of this study was to determine the relationship between preoperative nutritional screening scores and the development of SSI after pancreaticoduodenectomy. We examined 64 patients who had undergone pancreaticoduodenectomy. Their clinical data, nutritional risk index (NRI), and nutritional risk screening 2002 (NRS-2002) score were recorded. SSIs were diagnosed according to the definitions of wound infection established by the Center for Disease Control and Prevention and were confirmed by a microbiological examination. Data were analyzed using the Fisher exact probability method and a multivariate logistic regression analysis. SSIs developed in 21 patients (33 %). Eleven patients had wound infections, and 14 patients had an intra-abdominal abscess. A univariate analysis of perioperative factors revealed that a pancreatic fistula, the NRS-2002, and the NRI were significantly associated with the development of SSI (p NRI were independent risk factors for SSI. By analyzing the pre- and intra-operative factors after excluding the 11 patients with pancreatic fistulas, the NRI was still an independent risk factor for SSI. The present study showed the NRI to be an independent factor for predicting the risk of SSI after pancreaticoduodenectomy.
Sosa-Montemayor, F.; Jaramillo, O.A. [Centro de Investigacion en Energia, Universidad Nacional Autonoma de Mexico, Privada Xochicalco S/N, Temixco, Morelos CP 62580 (Mexico); del Rio, J.A. [Centro Morelense de Innovacion y Tranferencia Tecnologica, CCyTEM, Camino Temixco a Emiliano Zapata, Km 0.3, Colonia Emiliano Zapata, Morelos CP 62760 (Mexico)
In this paper we present a novel solar concentrating application, a coffee brewing system using a satellite TV mini-Dish concentrator coupled to a stovetop espresso coffee maker. We present a theoretical model for the thermal behavior of the water in the lower chamber of the coffee maker. We validate the model obtaining good agreement with the experimental results. Our findings indicate that the coffee brewing system works, it takes 30-50 min to complete its task. The model and our practical experience encourage us to improve the concentration device in order to obtain a useful solar coffee maker, using the theoretical model as a safe guide to achieve this. (author)
Sosa-Montemayor, F.; Jaramillo, O.A.; Rio, J.A. del
In this paper we present a novel solar concentrating application, a coffee brewing system using a satellite TV mini-Dish concentrator coupled to a stovetop espresso coffee maker. We present a theoretical model for the thermal behavior of the water in the lower chamber of the coffee maker. We validate the model obtaining good agreement with the experimental results. Our findings indicate that the coffee brewing system works, it takes 30-50 min to complete its task. The model and our practical experience encourage us to improve the concentration device in order to obtain a useful solar coffee maker, using the theoretical model as a safe guide to achieve this.
Munro, Sarah; Kornelsen, Jude; Corbett, Kitty; Wilcox, Elizabeth; Bansback, Nick; Janssen, Patricia
Repeat cesarean delivery is the single largest contributor to the escalating cesarean rate worldwide. Approximately 80 percent of women with a past cesarean are candidates for vaginal birth after a cesarean (VBAC), but in Canada less than one-third plan VBAC. Emerging evidence suggests that these trends may be due in part to nonclinical factors, including care provider practice patterns and delays in access to surgical and anesthesia services. This study sought to explore maternity care providers' and decision makers' attitudes toward and experiences with providing and planning services for women with a previous cesarean. In-depth, semi-structured interviews were conducted with family physicians, midwives, obstetricians, nurses, anesthetists, and health service decision makers recruited from three rural and two urban Canadian communities. Constructivist grounded theory informed iterative data collection and analysis. Analysis of interviews (n = 35) revealed that the factors influencing decisions resulted from interactions between the clinical, organizational, and policy levels of the health care system. Physicians acted as information providers of clinical risks and benefits, with limited discussion of patient preferences. Decision makers serving large hospitals revealed concerns related to liability and patient safety. These stemmed from competing access to surgical resources. To facilitate women's increased access to planned VBAC, it is necessary to address the barriers perceived by care providers and decision makers. Strategies to mitigate concerns include initiating decision support immediately after the primary cesarean, addressing the social risks that influence women's preferences, and managing perceptions of patient and litigation risks through shared decision making. © 2016 Wiley Periodicals, Inc.
FileMaker Pro, famed for power and ease of use, has added a suite of new features that can seriously boost your database productivity. This tutorial helps you take full advantage of the fresh stuff. It focuses on FileMaker's terrific new tool for integrating the Web with your databases: the Web Viewer. Step-by-step instructions help you create a Web Viewer from one of FileMaker's templates or a totally custom version of your own. But the tutorial doesn't stop there. It goes on to cover Object Naming, including FileMaker's rules for Object Names and how to use them in scripts; new scripts; ne
Tag på ekspedition under havets overflade med Nordsøen Movie Maker, hvor din tur i Nordsøen Oceanarium får et helt nyt virtuelt lag. Rejs ud til de syv destinationer og hold øje med de unikke ‘moviespots‘ i nærheden af akvarierne. Her kan du med Nordsøen Movie Maker filme og dokumentere dine...... oplevelser med legesyge sæler, susende hvirvelstrømme og gigantiske klumpfisk. Nordsøen Movie Maker giver filmen et ekstra virtuelt lag, og via augmented reality bliver der tilføjet seje og morsomme, animerede specialeffekter. 1) Download app’en 2) Find et moviespot ved ekspeditionsposterne i Nordsøen......! Nordsøen Movie Maker er udviklet i et samarbejde mellem Nordsøen Oceanarium, Aalborg Universitet - Center for Interaktive Digitale Medier samt Huge Lawn - Miracle Apps....
Maria Eleni Megalomystaka
Full Text Available The purpose of this study was to investigate the measures implemented to manage risks at work in the surgical clinic of a public hospital in Northern Greece, in relation to the requirements of the standard OHSAS 18001: 1999, and to refer to an integrated program to manage those risks. The right to safe and high-quality patient care and management of adverse events is part of the quality system and must be pursued by every health organization. In recent years, in Greece, there are measures taken by the country to align with European Union directives on matters related to safety in the workplace. In this direction, this hospital takes the initiative to reduce accidents and improve working conditions. The ELOT 1801 is a model for the management of health and safety, it is compatible and has technical equivalence with the corresponding BSI-OHSAS 18001: 1999. Since the relevant investigation found that the implementation of policy on health and safety in the surgical clinic under hospital study showed that there is a will by the authorities to adopt and implement procedures that contribute to the proper management and reduction of upcoming events. However, improvement actions are related to staff training can be made in the provision of health services, while considered necessary staffing the department with personnel and equipping adequate consumables.
Roumbelaki, Maria; Kritsotakis, Evangelos I; Tsioutis, Constantinos; Tzilepi, Penelope; Gikas, Achilleas
In this first attempt to implement a standardized surveillance system of surgical site infections (SSI) in a Greek hospital, our objective was to identify areas for improvement by comparing main epidemiologic and microbiologic features of SSI with international data. The National Nosocomial Infections Surveillance (NNIS) system protocols were employed to prospectively collect data for patients in 8 surgical wards who underwent surgery during a 9-month period. SSI rates were benchmarked with international data using standardized infection ratios. Risk factors were evaluated by multivariate logistic regression. A total of 129 SSI was identified in 2420 operations (5.3%), of which 47.3% developed after discharge. SSI rates were higher for 2 of 20 operation categories compared with Spanish and Italian data and for 12 of 20 categories compared with NNIS data. Gram-positive microorganisms accounted for 52.1% of SSI isolates, and Enterococci were predominant. Alarming resistance patterns for Enterococcus faecium and Acinetobacter baumannii were recorded. Potentially modifiable risk factors for SSI included multiple procedures, extended duration of operation, and antibiotic prophylaxis. SSI was associated with prolongation of postoperative stay but not with mortality. Comparisons of surveillance data in our hospital with international benchmarks provided useful information for infection control interventions to reduce the incidence of SSI.
Macdonald, Marilyn; Lang, Ariella; MacDonald, Jo-Anne
The purpose of this qualitative interpretive design was to explore the perspectives of researchers, health care providers, policy makers, and decision makers on key risks, concerns, and emerging issues related to home care safety that would inform a line of research inquiry. Defining safety specifically in this home care context has yet to be…
Kovacs, Judit; Moraru, Liviu; Antal, Krisztina; Cioc, Adrian; Voidazan, Septimiu; Szabo, Attila
Background In the last year there has been an increasing interest for using frailty scales for risk stratification of elderly patients undergoing major surgery. We planned to compare two frailty scales with risk scales already used in cardiac surgery, to study which of these scores have better prognostic value predicting postoperative outcome in open heart surgery. Methods We conducted a prospective clinical trial, including 57 patients over 65 years. We calculated Cardiac Anesthesia Risk Eva...
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.
Celik, F.; Bounif, F.; Fliers, J. M.; Kersten, B. E.; van Dielen, F. M. H.; Cense, H. A.; Brandjes, D. P. M.; van Wagensveld, B. A.; Janssen, I. M. C.; van de Laar, A. W. J. M.; Gerdes, V. E. A.
Studies suggest that postoperative complications are a risk factor for venous thromboembolism (VTE) after bariatric surgery. Knowledge of factors associated with a higher risk of VTE after bariatric surgery may be essential to select patients who may benefit from either prolonged or intensified
Kigera, James W. M.; Straetemans, Masja; Vuhaka, Simplice K.; Nagel, Ingeborg M.; Naddumba, Edward K.; Boer, Kimberly
Background: There is dilemma as to whether patients infected with the Human Immunodeficiency Virus (HIV) requiring implant orthopaedic surgery are at an increased risk for post-operative surgical site infection (SSI). We conducted a systematic review to determine the effect of HIV on the risk of
Aygören-Pürsün, E; Martinez Saguer, I; Kreuz, W; Klingebiel, T; Schwabe, D
Background Hereditary angioedema (HAE), caused by deficiency in C1-inhibitor (C1-INH), leads to unpredictable edema of subcutaneous tissues with potentially fatal complications. As surgery can be a trigger for edema episodes, current guidelines recommend preoperative prophylaxis with C1-INH or attenuated androgens in patients with HAE undergoing surgery. However, the risk of an HAE attack in patients without prophylaxis has not been quantified. Objectives This analysis examined rates of perioperative edema in patients with HAE not receiving prophylaxis. Methods This was a retrospective analysis of records of randomly selected patients with HAE type I or II treated at the Frankfurt Comprehensive Care Centre. These were examined for information about surgical procedures and the presence of perioperative angioedema. Results A total of 331 patients were included; 247 underwent 700 invasive procedures. Of these procedures, 335 were conducted in 144 patients who had not received prophylaxis at the time of surgery. Categories representing significant numbers of procedures were abdominal (n = 113), ENT (n = 71), and gynecological (n = 58) procedures. The rate of documented angioedema without prophylaxis across all procedures was 5.7%; in 24.8% of procedures, the presence of perioperative angioedema could not be excluded, leading to a maximum potential risk of 30.5%. Predictors of perioperative angioedema could not be identified. Conclusion The risk of perioperative angioedema in patients with HAE type I or II without prophylaxis undergoing surgical procedures ranged from 5.7% to 30.5% (CI 3.5–35.7%). The unpredictability of HAE episodes supports current international treatment recommendations to consider short-term prophylaxis for all HAE patients undergoing surgery. PMID:23968383
Papini, Enrico; Guglielmi, Rinaldo; Gharib, Hossein; Hosseim, Gharib; Misischi, Irene; Graziano, Filomena; Chianelli, Marco; Crescenzi, Anna; Bianchini, Antonio; Valle, Dario; Bizzarri, Giancarlo
Incidental papillary thyroid microcarcinoma (PTMC), a frequent clinical problem, is usually associated with a favorable outcome. During long-term follow-up, only a minority of cases show aggressive behavior with either lymph node or distant metastases. Recently, we had an opportunity to evaluate the efficacy of nonsurgical, ultrasound (US)-guided percutaneous laser ablation (PLA) for local treatment of PTMC in an otherwise inoperable patient. Neck US examination revealed an incidental, solitary, 8 × 7 × 7 mm hypoechoic nodule with microcalcifications of the right thyroid lobe. The patient suffered from decompensated liver cirrhosis, renal failure, and recent surgery followed by external beam radiation therapy for breast cancer. Cytologic diagnosis showed papillary thyroid carcinoma, but the patient declined surgery because of high risk of thyroid surgery. After local anesthesia with 2% xylocaine, PLA was performed according to the previously reported procedure with an Nd:YAG laser. The procedure was well tolerated, without side effects, and the patient required no analgesics. US-guided fine-needle aspiration biopsy and core-needle biopsy were performed at 1 and 12 months after PLA, which demonstrated necrotic material and inflammatory cells with no viable neoplastic cell. At the 24 months US follow-up examination, the area of necrosis further decreased, demonstrating a 4 × 4 mm hypoechoic zone and a small hyperechoic area due to fibrotic changes. A fine-needle aspiration biopsy confirmed the absence of malignant cells. Laser-induced thermal ablation was a safe and effective ablative treatment for a patient with PTMC confined to the thyroid gland who was at high surgical risk. This approach should be considered only in elderly patients and/or in those with comorbidities that might expose the patients to an undue high surgical risk and only after the evaluation by neck US, computed tomography, magnetic resonance imaging, or positron emission tomography
Vano, J. A.
Being trained as a scientist provides many valuable tools needed to address society's most pressing environmental issues. It does not, however, provide training on one of the most critical for translating science into action: the ability to engage decision makers. Engagement means different things to different people and what is appropriate for one project might not be for another. However, recent reports have emphasized that for research to be most useful to decision making, engagement should happen at the beginning and throughout the research process. There are an increasing number of boundary organizations (e.g., NOAA's Regional Integrated Sciences and Assessment program, U.S. Department of the Interior's Climate Science Centers) where engagement is encouraged and rewarded, and scientists are learning, often through trial and error, how to effectively include decision makers (a.k.a. stakeholders, practitioners, resource managers) in their research process. This presentation highlights best practices and practices to avoid when scientists engage decision makers, a list compiled through the personal experiences of both scientists and decision makers and a literature review, and how this collective knowledge could be shared, such as through a recent session and role-playing exercise given at the Northwest Climate Science Center's Climate Boot Camp. These ideas are presented in an effort to facilitate conversations about how the science community (e.g., AGU researchers) can become better prepared for effective collaborations with decision makers that will ultimately result in more actionable science.
Scrascia, Giuseppe; Guida, Pietro; Caparrotti, Sergio Maria; Capone, Giuseppe; Contini, Marco; Cassese, Mauro; Fanelli, Vitantonio; Martinelli, Gianluca; Mazzei, Valerio; Zaccaria, Salvatore; Paparella, Domenico
Anemia is a risk factor for adverse events after cardiac operations. We evaluated the incremental value of preoperative anemia over the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II to predict hospital death after cardiac operations. Data for 4,594 consecutive adults (1,548 women [33.7%]), aged 67 ± 11 years, who underwent cardiac operations from January 2011 to July 2013 were extracted from the Regional Cardiac Surgery Registry of Puglia. The last preoperative hemoglobin value was used, according to World Health Organization criteria, to classify anemia as mild (hemoglobin 11.0 to 12.9 g/dL in men and 11.0 to 11.9 g/dL in women) in 1,021 patients (22.2%) and as moderate to severe (hemoglobin anemia, with model discrimination quantified by C statistic and risk classification by the use of net reclassification improvement (NRI). Overall expected and observed mortality rates were 4.4% and 5.9%. Anemia was significantly associated with a mortality rate of 3.4% in patients without anemia, 7.7% in mild anemia, and 15.7% in moderate to severe anemia (p anemia was analyzed with EuroSCORE II, the model improved in discrimination (C statistic = 0.852 vs 0.860; p = 0.007) and reclassification (category free-NRI, 0.592; p anemia has strong association with operative death in cardiac surgical patients. Anemia provides significant incremental value over the EuroSCORE II and should be considered for assessment of cardiac surgical risk. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Thygesen, Torben Henrik; Jensen, Allan Bardow; Norholt, SE
PURPOSE: Data on intraoperative risk factors for long-term postoperative complications after Le Fort I osteotomy (LFO) are limited. The aim of this study was to describe prospectively the overall postoperative changes in maxillary nerve function after LFO, and to correlate these changes with a nu......PURPOSE: Data on intraoperative risk factors for long-term postoperative complications after Le Fort I osteotomy (LFO) are limited. The aim of this study was to describe prospectively the overall postoperative changes in maxillary nerve function after LFO, and to correlate these changes...
Zhu, Mei; Chiarella, Carl; He, Xue-Zhong; Wang, Duo
The market maker plays an important role in price formation, but his/her behavior and stabilizing impact on the market are relatively unclear, in particular in speculative markets. This paper develops a financial market model that examines the impact on market stability of the market maker, who acts as both a liquidity provider and an active investor in a market consisting of two types of boundedly rational speculative investors-the fundamentalists and trend followers. We show that the market maker does not necessarily stabilize the market when he/she actively manages the inventory to maximize profits, and that rather the market maker’s impact depends on the behavior of the speculators. Numerical simulations show that the model is able to generate outcomes for asset returns and market inventories that are consistent with empirical findings.
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. ...
Kruser, Jacqueline M; Pecanac, Kristen E; Brasel, Karen J; Cooper, Zara; Steffens, Nicole M; McKneally, Martin F; Schwarze, Margaret L
To examine how surgeons use the "fix-it" model to communicate with patients before high-risk operations. The "fix-it" model characterizes disease as an isolated abnormality that can be restored to normal form and function through medical intervention. This mental model is familiar to patients and physicians, but it is ineffective for chronic conditions and treatments that cannot achieve normalcy. Overuse may lead to permissive decision making favoring intervention. Efforts to improve surgical decision making will need to consider how mental models function in clinical practice, including "fix-it." We observed surgeons who routinely perform high-risk surgery during preoperative discussions with patients. We used qualitative content analysis to explore the use of "fix-it" in 48 audio-recorded conversations. Surgeons used the "fix-it" model for 2 separate purposes during preoperative conversations: (1) as an explanatory tool to facilitate patient understanding of disease and surgery, and (2) as a deliberation framework to assist in decision making. Although surgeons commonly used "fix-it" as an explanatory model, surgeons explicitly discussed limitations of the "fix-it" model as an independent rationale for operating as they deliberated about the value of surgery. Although the use of "fix-it" is familiar for explaining medical information to patients, surgeons recognize that the model can be problematic for determining the value of an operation. Whether patients can transition between understanding how their disease is fixed with surgery to a subsequent deliberation about whether they should have surgery is unclear and may have broader implications for surgical decision making.
Swinbourne, F; Jeffery, N; Tivers, M S; Artingstall, R; Bird, F; Charlesworth, T; Doran, I; Freeman, A; Hall, J; Hattersley, R; Henken, J; Hughes, J; de la Puerta, B; Rutherford, L; Ryan, T; Williams, H; Woods, S; Nicholson, I
The objectives of this study were to: (1) document the incidence of surgical site dehiscence after full-thickness gastrointestinal biopsy in dogs and cats and (2) identify potential risk factors. Data relating to dogs and cats undergoing full-thickness gastrointestinal biopsy were reviewed retrospectively following submission of a completed questionnaire by 12 referral institutions. Outcome measures were definite dehiscence, possible dehiscence (clinical records suggestive of dehiscence but not confirmed), suspected dehiscence (definite and possible combined) and death within 14 days. Logistic regression was planned for analysis of association of dehiscence with low preoperative serum albumin, biopsy through neoplastic tissue, biopsy alongside another major abdominal surgical procedure and biopsy of the colon. Of 172 cats, two (1·2%) had definite dehiscence, and four (2·3%) had possible dehiscence. Low preoperative serum albumin was significantly associated with definite dehiscence in univariable analysis and with suspected dehiscence and death within 14 days in univariable analysis, but all odds ratios had wide 95% confidence intervals. A histopathological diagnosis of neoplasia was significantly associated with death within 14 days in univariable analysis. Of 195 dogs, two (1·0%) had definite dehiscence, and three (1·5%) had possible dehiscence. In dogs, there was no association between any outcome measure and the putative risk factors. Incidence of dehiscence following full-thickness gastrointestinal biopsy was low in this study. When determining the appropriateness of biopsy in individual cases, this information should be balanced against the potentially life-threatening consequences of dehiscence. © 2017 British Small Animal Veterinary Association.
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.
Bing, Mette Hornum; Gimbel, Helga; Greisen, Susanne
urethral pressure, and bladder-neck immobility were related to poorer outcome of surgery. CONCLUSIONS: This study summarized the available evidence regarding preoperative clinical risk factors and urodynamic parameters indicating decreased or adverse outcome of surgery, and this report also provides...
Itatsu, Keita; Sugawara, Gen; Kaneoka, Yuji; Kato, Takehito; Takeuchi, Eiji; Kanai, Michio; Hasegawa, Hiroshi; Arai, Toshiyuki; Yokoyama, Yukihiro; Nagino, Masato
An incisional surgical site infection (I-SSI) is a frequently observed complication following colorectal surgery. Intraoperative wound management is one of the most important factors that determine the incidence of postoperative I-SSI. The purpose of this study was to assess the impact of the methods used for intraoperative wound management on the incidence of I-SSI following elective surgery for colorectal cancer. Between November 2009 and February 2011, the data of 1,980 consecutive patients who underwent elective colorectal resection for colorectal cancer were prospectively collected from 19 affiliated hospitals. The incidence of and risk factors for I-SSI were investigated. Overall, 233 I-SSIs were identified (11.7 %). Forty-two possible risk factors were analyzed. Using a multivariate analysis, the independent risk factors for I-SSI were identified to be a high body mass index, previous laparotomy, chronic liver disease, wound length, contaminated wound class, creation or closure of an ostomy, right hemicolectomy procedure, the suture material used for fascial closure and the incidence of organ/space SSI. To prevent I-SSI following elective colorectal surgery, it is crucial to avoid making large incisions and reduce fecal contamination whenever possible. A high quality randomized control trial is necessary to confirm the definitive intraoperative procedure(s) that can minimize the incidence of I-SSI.
Ahmed, Armin; Baronia, Arvind Kumar; Azim, Afzal; Marak, Rungmei S K; Yadav, Reema; Sharma, Preeti; Gurjar, Mohan; Poddar, Banani; Singh, Ratender Kumar
The aim of this study was to conduct external validation of risk prediction scores for invasive candidiasis. We conducted a prospective observational study in a 12-bedded adult medical/surgical Intensive Care Unit (ICU) to evaluate Candida score >3, colonization index (CI) >0.5, corrected CI >0.4 (CCI), and Ostrosky's clinical prediction rule (CPR). Patients' characteristics and risk factors for invasive candidiasis were noted. Patients were divided into two groups; invasive candidiasis and no-invasive candidiasis. Of 198 patients, 17 developed invasive candidiasis. Discriminatory power (area under receiver operator curve [AUROC]) for Candida score, CI, CCI, and CPR were 0.66, 0.67, 0.63, and 0.62, respectively. A large number of patients in the no-invasive candidiasis group (114 out of 181) were exposed to antifungal agents during their stay in ICU. Subgroup analysis was carried out after excluding such patients from no-invasive candidiasis group. AUROC of Candida score, CI, CCI, and CPR were 0.7, 0.7, 0.65, and 0.72, respectively, and positive predictive values (PPVs) were in the range of 25%-47%, along with negative predictive values (NPVs) in the range of 84%-96% in the subgroup analysis. Currently available risk prediction scores have good NPV but poor PPV. They are useful for selecting patients who are not likely to benefit from antifungal therapy.
There still exist today uncertainties and misunderstandings in our interpretation of panel makers' marks from early 17th century Antwerp. In the future, panel marks and the panels on which they can be found will certainly render much more information concerning the technology of that time. Still...... more can be added to our comprehension of the way the panel makers worked in Antwerp. In the following paper I shall give a brief summary of the present state of research, as well as outline the complicated task of interpreting these marks and their use as a dating tool. The ready-made supports...
Guy, Tatiana Valentine; Wolpert, David H
Prescriptive Bayesian decision making has reached a high level of maturity and is well-supported algorithmically. However, experimental data shows that real decision makers choose such Bayes-optimal decisions surprisingly infrequently, often making decisions that are badly sub-optimal. So prevalent is such imperfect decision-making that it should be accepted as an inherent feature of real decision makers living within interacting societies. To date such societies have been investigated from an economic and gametheoretic perspective, and even to a degree from a physics perspective. However, lit
Keller, Deborah S; Kroll, Donald; Papaconstantinou, Harry T; Ellis, C Neal
To identify patients with a high risk of 30-day mortality after elective surgery, who may benefit from referral for tertiary care, an institution-specific process using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) Risk Calculator was developed. The goal was to develop and validate the methodology. Our hypothesis was that the process could optimize referrals and reduce mortality. A VASQIP risk score was calculated for all patients undergoing elective noncardiac surgery at a single Veterans Affairs (VA) facility. After statistical analysis, a VASQIP risk score of 3.3% predicted mortality was selected as the institutional threshold for referral to a tertiary care center. The model predicted that 16% of patients would require referral, and 30-day mortality would be reduced by 73% at the referring institution. The main outcomes measures were the actual vs predicted referrals and mortality rates at the referring and receiving facilities. The validation included 565 patients; 90 (16%) had VASQIP risk scores greater than 3.3% and were identified for referral; 60 consented. In these patients, there were 16 (27%) predicted mortalities, but only 4 actual deaths (p = 0.007) at the receiving institution. When referral was not indicated, the model predicted 4 mortalities (1%), but no actual deaths (p = 0.1241). These data validate this methodology to identify patients for referral to a higher level of care, reducing mortality at the referring institutions and significantly improving patient outcomes. This methodology can help guide decisions on referrals and optimize patient care. Further application and studies are warranted. Copyright © 2017 American College of Surgeons. All rights reserved.
Jeremy YC Teoh
Full Text Available We investigated the cardiovascular thrombotic risk after surgical castration (SC versus gonadotropin-releasing hormone agonists (GnRHa in Chinese men with prostate cancer. All Chinese prostate cancer patients who were treated with SC or GnRHa from year 2000 to 2009 were reviewed and compared. The primary outcome was any new-onset of cardiovascular thrombotic events after SC or GnRHa, which was defined as any event of acute myocardial infarction or ischemic stroke. The risk of new-onset cardiovascular thrombotic event was compared between the SC group and the GnRHa group using Kaplan-Meier method. Multivariate Cox regression analysis was performed to adjust for other potential confounding factors. A total of 684 Chinese patients was included in our study, including 387 patients in the SC group and 297 patients in the GnRHa group. The mean age in the SC group (75.3 ± 7.5 years was significantly higher than the GnRHa group (71.8 ± 8.3 years (P < 0.001. There was increased risk of new cardiovascular thrombotic events in the SC group when compared to the GnRHa group upon Kaplan-Meier analysis (P = 0.014. Upon multivariate Cox regression analysis, age (hazard ratio [HR] 1.072, 95% confidence interval [CI] 1.04-1.11, P< 0.001, hyperlipidemia (HR 2.455, 95% CI 1.53-3.93, P< 0.001, and SC (HR 1.648, 95% CI 1.05-2.59, P= 0.031 were significant risk factors of cardiovascular thrombotic events. In conclusion, SC was associated with increased risk of cardiovascular thrombotic events when compared to GnRHa. This is an important aspect to consider while deciding on the method of androgen deprivation therapy, especially in elderly men with known history of hyperlipidemia.
Eton, Vic; Sinyavskaya, Liliya; Langlois, Yves; Morin, Jean François; Suissa, Samy; Brassard, Paul
Median sternotomy, the most common means of accessing the heart for cardiac procedures, is associated with higher risk of surgical site infections (SSIs). A limited number of studies reporting the impact of medication use prior to cardiac surgery on the subsequent risk of SSIs usually focused on antibacterial prophylaxis. The objective of the current study was to evaluate the effect of medications prescribed commonly to cardiac patients on the risk of incident SSIs. The study analyzed data on consecutive cardiac surgery patients undergoing median sternotomy at a McGill University teaching hospital between April 1, 2011 and October 31, 2013. Exposure of interest was use of medications for heart disease and cardiovascular conditions in the seven days prior to surgery and those for comorbid conditions. The main outcome was SSIs occurring within 90 d after surgery. Univariate and multivariate logistic regression (adjusted odds ratio [AOR]) was used to evaluate the effect. The cohort included 1,077 cardiac surgery patients, 79 of whom experienced SSIs within 90 d of surgery. The rates for sternal site infections and harvest site infections were 5.8 (95% confidence interval [CI]: 4.4-7.3) and 2.5 (95% CI: 1.4-3.7) per 100 procedures, respectively. The risk of SSI was increased with the pre-operative use of immunosuppressors/steroids (AOR 3.47, 95% CI: 1.27-9.52) and α-blockers (AOR 3.74, 95% CI: 1.21-1.47). Our findings support the effect of immunosuppressors/steroids on the risk of SSIs and add evidence to the previously reported association between the use of anti-hypertensive medications and subsequent development of infection/sepsis.
Lappen, Justin R; Sheyn, David; Hackney, David N
By increasing intraabdominal pressure, pregnancy may increase the risk of abdominal hernia recurrence. Current data are limited to studies with small sample size and thus the impact of pregnancy on recurrence is unclear. The objective of this analysis was to evaluate the impact of pregnancy on clinically significant abdominal hernia recurrence in a large multicenter cohort. A multiinstitution deidentified electronic health record database, EPM: Explore (Explorys Inc, Cleveland, OH) was utilized to perform a retrospective cohort study of women aged 18-45 years with a history of an abdominal hernia repair from 1999 through 2013. Abdominal hernia was defined to include ventral and incisional hernias, and other types were excluded. The presence or absence of a pregnancy following primary hernia repair was elucidated from the database. Subjects were excluded if a hernia repair occurred during pregnancy. The rate of hernia recurrence, defined as reoperation, was calculated. The association between pregnancy and hernia recurrence was evaluated with logistic regression, both unadjusted and adjusted for diabetes, obesity (body mass index >30 kg/m(2)), tobacco abuse, and wound complication at the time of initial hernia repair. A total of 11,020 women with a history of hernia repair were identified, of whom 840 had a subsequent pregnancy. Overall, 915 women in the cohort had a hernia recurrence (8.3%). Women with a history of pregnancy following primary hernia repair were more likely to have a body mass index >30 kg/m(2), a history of tobacco abuse, and a wound complication at the time of primary repair. In an unadjusted analysis, pregnancy was associated with an increase in the risk of hernia recurrence (13.1% vs 7.1%, odds ratio, 1.96, 95% confidence interval, 1.60-2.42). The association between pregnancy and hernia recurrence was attenuated but persisted after adjusting for confounding factors (adjusted odds ratio, 1.73, 95% confidence interval, 1.40-2.14). Pregnancy is
Van Belleghem, Y; Caes, F; Maene, L; Van Overbeke, H; Moerman, A; Van Nooten, G
In a retrospective study, we compared two groups of consecutive patients operated by the same team during the year 2000 for coronary artery disease with the use of extracorporeal circulation (group 1, n=230) or on the beating heart using the Octopus II plus stabiliser (group 2, n=228). High-risk patients were identified by a EuroSCORE plus 6. EuroSCORE definitions and predicted risk models were utilized to compare the variables of the groups. There were no significant differences between the preoperative variables of the groups in age, gender, left ventricular function, diabetes and peripheral vascular and renal disease as is indicated by the Euroscore (resp. 4.7/5.1 p=0.107). Calcification of the ascending aorta and chronic obstructive lung disease were statistically significant more prevalent in the beating heart group. No differences in preoperative variables in the high-risk patients group (Euroscore 8.5/8.1 p=0.356) except for calcification of the ascending aorta. All patients underwent a full revascularisation through a midline sternotomy. Significant more distal anastomoses were performed in group 1 (3.7 per patient (1-6)) with regard to group 2 (2.9 per patient (1-6)). Anesthesia, postoperative treatment and follow up were equal for both groups. A significant lower incidence of atrial fibrillation (p=0.010), shorter ICU stay (p=0.031) and renal insufficiency (p=0.033) was reported in group 2. In the low risk group, we could not diagnose any difference between the two groups, except for atrial fibrillation. The benefits of the beating heart surgery however were more pronounced in the high-risk patient as is indicated by a significant reduction of the ICU stay by 1 day (3.5d/2.5d (p=0.028)), better preservation of the renal function (p=0.017) and a significant reduction of the length of hospital stay by more than two days (p=0.040). A lower incidence of atrial fibrillation, however not significant. In our experience, beating heart surgery is a safe
Lin, Shih-Yi; Lin, Cheng-Li; Liu, Jiung-Hsiun; Wang, I-Kuan; Hsu, Wu-Huei; Chen, Chao-Jung; Ting, I-Wen; Wu, I-Ting; Sung, Fung-Chang; Huang, Chiu-Ching; Chang, Yen-Jung
It is well known that patients with diabetes have higher extent and severity of periodontitis, but the backward relationship is little investigated. The relationship between periodontitis needing dental surgery and subsequent type 2 diabetes mellitus (DMT2) in those individuals without diabetes was assessed. This is a retrospective cohort study using data from the national health insurance system of Taiwan. The periodontitis cohort involved 22,299 patients, excluding those with diabetes already or those diagnosed with diabetes within 1 year from baseline. Each study participant was randomly frequency matched by age, sex, and index year with one individual from the general population without periodontitis. Cox proportional hazards regression analysis was used to estimate the influence of periodontitis on the risk of diabetes. The mean follow-up period is 5.47 ± 3.54 years. Overall, the subsequent incidence of DMT2 was 1.24-fold higher in the periodontitis cohort than in the control cohort, with an adjusted hazard ratio of 1.19 (95% confidence interval = 1.10 to 1.29) after controlling for sex, age, and comorbidities. This is the largest nation-based study examining the risk of diabetes in Asian patients with periodontitis. Those patients with periodontitis needing dental surgery have increased risk of future diabetes within 2 years compared with those participants with periodontitis not requiring dental surgery.
In early February, 2009, the Maine Department of Transportation (MaineDOT) installed a Monroe Slurry : Maker on one of its 2009 Volvo Wheelers (see Photos 1 and 2). This truck was equipped with a : Henderson Utility Body. An 18 gallon per minute spoo...
Full Text Available IntroductionAn analysis of the factors contributing to the risk of repeat ventilation tube placement among patients undergoing ventilation tube placement with adenoidectomy and patients undergoing ventilation tube placement only.MethodologyWe conducted a retrospective review of the medical records of 66 patients ages 3 to 10 who underwent ventilation tube placement only or adenoidectomy plus ventilation tube placement at Otorhinolaryngology and Head and Neck Surgery Clinic between January 2011 and January 2013.ResultsThe analysis revealed no significant relationships between the risk factors evaluated and the need for repeated ventilation tube placement. A repeat ventilation tube placement procedure was required in 7.7% of patients in the age 6-10 age group. This rate of incidence was significant relative to the other age groups evaluated.ConclusionsAdenoidectomy during the initial ventilation tube placement procedure may reduce the need for repeat ventilation tube placement in patients of 6 to 10 years of age with otitis media.
Vemulapalli, Sreekanth; Lippmann, Steven J; Krucoff, Mitchell; Hernandez, Adrian F; Curtis, Lesley H; Foster, Elyse; Qasim, Atif; Wang, Andrew; Glower, Donald D; Feldman, Ted; Hammill, Bradley G
MitraClip is an approved therapy for mitral regurgitation (MR); however, health care resource utilization pre- and post-MitraClip remains understudied. Patients with functional and degenerative MR at high surgical risk in the EVEREST II High-Risk Registry and REALISM Continued-Access Study were linked to Medicare data. Pre- and post-MitraClip all-cause death, stroke, myocardial infarction, heart failure (HF), and bleeding hospitalizations were identified. Inpatient costs, adjusted to 2010 US dollars, were calculated, and event rate ratios and cost ratios were estimated with multivariable modeling. Among 403 linked patients, the mean age was 80 years, 60% were male, mean baseline left ventricular ejection fraction was 49.6%, 83.3% were New York Heart Association class III/IV, 78.2% were MR grade 3+/4+, and 63.3% had functional MR. All-cause hospitalization decreased from 1,854 to 1,435/1,000 person-years (Pproviders seeking to reduce HF hospitalizations and associated Medicare costs may consider MitraClip among appropriate patients likely to survive 1 year. Copyright © 2017 Elsevier Inc. All rights reserved.
Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs); however, SSI after hepatobiliary and pancreatic surgery (HBPS) has not been well investigated in a large cohort of patients. This study analyzed the factors associated with SSI following HBPS in Japan, using a Japanese national database. Data on HBPS performed between 2012 and 2014 were extracted from a national monitoring system for HAI: The Japan Nosocomial Infections Surveillance. Using multivariate logistic regression, I assessed the factors associated with SSI. The cumulative incidence of SSI following HBPS was 15.6% (2873/18,398). The incidence of SSI after pancreatoduodenectomy was 28.0%, which was significantly higher than that after liver resection and other types of HBPS (8.8 and 15.5%, respectively). Among the four traditional risk factors, the American Society of Anesthesiologists score was ineffective for predicting SSI in the final model of all three types of surgery. Additional risk factors were identified, including age and male gender. The incidence of and factors associated with SSI after the three types of HBPS analyzed differed significantly. To accurately compare hospital performance in relation to SSI following HBPS, the operative procedure category in the surveillance system must be divided into three types.
Linzey, Joseph R; Wilson, Thomas J; Sullivan, Stephen E; Thompson, B Gregory; Pandey, Aditya S
Frontotemporal craniotomies are commonly performed for a variety of neurosurgical pathologies. Infections related to craniotomies cause significant morbidity. We hypothesized that the risk of cranial surgical site infections (SSIs) may be increased in patients whose frontal sinuses are breached during craniotomy. To compare the rate of cranial SSIs in patients undergoing frontotemporal craniotomies with and without frontal sinus breach (FSB). We performed a retrospective analysis of all patients undergoing frontotemporal craniotomies for the management of cerebral aneurysms from 2005 to 2014. This study included 862 patients undergoing 910 craniotomies. Primary outcome of interest was occurrence of a cranial SSI. Standard statistical methods were utilized to explore associations between a variety of variables including FSB, cranial SSI, and infections requiring reoperation. Of the 910 craniotomies, 141 (15.5%) involved FSB. Of those involving FSB, 22 (15.6%) developed a cranial SSI, compared to only 56 of the 769 without FSB (7.3%; P = .001). Cranial SSI requiring reoperation was much more likely in patients with FSB compared to those without a breach (7.8% vs 1.6%; P craniotomies are at significantly greater risk of serious cranial SSIs if the frontal sinus has been breached. Copyright © 2017 by the Congress of Neurological Surgeons
van den Akker, Petronella A J; Zusterzeel, Petra L M; Aalders, Anette L; Snijders, Marc P L M; Samlal, Rahul A K; Vollebergh, Jos H A; Kluivers, Kirsten B; Massuger, Leon F A G
To evaluate the importance of the risk of malignancy index (RMI) in the decision to perform frozen section analysis among women with ovarian tumors. A retrospective study was conducted in 11 centers in the Netherlands. Women who underwent surgical treatment of an ovarian mass with unknown histology between January 2005 and September 2009 were included. The RMI was calculated retrospectively. Frozen section analysis and RMI values were assessed for patients with benign, borderline, and malignant ovarian tumors on final histopathology. Overall, 670 women were included. Frozen sections were performed in 323 (48.2%) patients, of whom 206 (63.8%) were diagnosed with benign ovarian tumors, 55 (17.0%) with borderline tumors, and 62 (19.2%) with malignant tumors. Overall, 109 (16.3%) women had an RMI below 20, 106 (97.2%) of whom had benign histology results. Among 235 patients with an RMI over 100, 3 (1.3%) postmenopausal women had malignancies that were missed because frozen sections were not performed. Women with an RMI below 20 have a low risk of malignancy and therefore do not require frozen section analysis. Postmenopausal women with an RMI greater than 100 should be referred to centers where frozen sections can be performed, and proper facilities and expertise are available to perform staging procedures if necessary. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Nuttall, Gregory; Burckhardt, Jennifer; Hadley, Anita; Kane, Sarah; Kor, Daryl; Marienau, Mary Shirk; Schroeder, Darrell R; Handlogten, Kathryn; Wilson, Gregory; Oliver, William C
Prior research has provided inconsistent data regarding the risk factors associated with complications from arterial cannulation. The goal of this study was to clearly define the incidence and risks factors associated with arterial cannulation complications. After obtaining institutional review board approval, all patients requiring arterial line placement with documentation were included in this retrospective study between January 1, 2006, and December 31, 2012. Leveraging two robust data warehouses, the Perioperative DataMart and the Mayo Clinic Life Silences System, the authors cross-matched arterial line cannulation with a documented vascular consult, neurologic consult, infection, or return to surgery within 30 days in order to identify the initial patient population. A total of 62,626 arterial lines were placed in 57,787 patients, and 90.1% of the catheters placed were 20-gauge catheters. The radial artery was cannulated in 94.5% of patients. A total of 21 patients were identified as having experienced vascular complications or nerve injuries, resulting in a complication rate of 3.4 per 10,000 (95% CI, 2.1 to 5.1). Cardiac surgery had the largest number of catheters placed (n = 15,419) with 12 complications (complication rate = 7.8 per 10,000; 95% CI, 4.0 to 13.6). The rate of complications differed significantly (P < 0.001) across the three most common catheter sizes (2.7 per 10,000 [95% CI, 1.5 to 4.4] for 20 gauge, 17.2 per 10,000 [95% CI, 4.7 to 43.9] for 18 gauge, and 9.4 per 10,000 [95% CI, 1.1 to 34.1] for 5 French). In a large retrospective study, the authors document a very low rate of complications with arterial line placement.
Souwer, Esteban T D; Verweij, Norbert M; van den Bos, Frederiek; Bastiaannet, Esther; Slangen, Rob M E; Steup, Willem H; Hamaker, Marije E; Portielje, Johanna E A
Older patients are at risk for adverse outcomes after surgical treatment of cancer. Identifying patients at risk could affect treatment decisions and prevent functional decline. Screening tools are available to select patients for Geriatric Assessment. Until now their predictive value for adverse outcomes in older colorectal cancer patients has not been investigated. To study the predictive value of the Geriatric 8 (G8) and Identification of Seniors at Risk for Hospitalized Patients (ISAR-HP) screening tools for adverse outcomes after elective colorectal surgery in patients older than 70years. Primary outcomes were 30-day complication rates, secondary outcomes were the length of hospital stay and six-month mortality. Multicentre cohort study from two hospitals in the Netherlands. Frail was defined as a G8 ≤14 and/or ISAR-HP ≥2. Odds ratio (OR) is given with 95% CI. Overall, 139 patients (52%) out of 268 patients were included; 32 patients (23%) were ISAR-HP-frail, 68 (50%) were G8-frail, 20 were frail on both screening tools. Median age was 77.7years. ISAR-HP frail patients were at risk for 30-day complications OR 2.4 (CI 1.1-5.4, p=0.03), readmission OR 3.4 (1.1-11.0), cardiopulmonary complications OR 5.9 (1.6-22.6), longer hospital stay (10.3 versus 8.9day) and six-months mortality OR 4.9 (1.1-23.4). When ISAR-HP and G8 were combined OR increased for readmission, 30-day and six-months mortality. G8 alone had no predictive value. ISAR-HP-frail patients are at risk for adverse outcomes after colorectal surgery. ISAR-HP combined with G8 has the strongest predictive value for complications and mortality. Patients screening frail on ISAR-HP are at increased risk for morbidity and mortality. Screening results of G8 alone was not predictive for postoperative outcomes. Predictive value increased when G8 and ISAR-HP were combined. Copyright © 2017 Elsevier Inc. All rights reserved.
Roder, Martin Andreas; Kawa, Sandra; Scheike, Thomas
BACKGROUND AND OBJECTIVE: To investigate how location of positive surgical margins (PSM) in pT2 tumors affect the risk of biochemical recurrence (BR). METHODS: The study includes 1,133 consecutive patients from 1995 until end of 2011, who had organ-confined disease (pT2) following RP. The locatio...
Mallee, W.H.; Weel, H.; van Dijk, C.N.; van Tulder, M.W.; Kerkhoffs, G.M.; Lin, C.W.C.
Aim To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal. Methods Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and
Kyo Chul Koo
Conclusions: RALP-PLND is a feasible option for VHPCa in elderly patients with satisfactory oncologic outcomes; however, functional outcomes were not as favorable. Patients who are unable to accept the risk of adjuvant therapy and its side effects or incontinence should be deterred from surgical treatment, and other options such as radiation therapy could be an alternative.
Huppes, Tsjester; Hermans, Hanneke; Ensink, Jos M
BACKGROUND: Implants are often used to improve the cosmetic appearance of horses after enucleation of the eye. When surgical site infection (SSI) occurs, the implant will almost always be lost. The aim of this study is to collect data on the risk factors for SSIs and report long-term follow-up
Vallejo, Manuel C; Attaallah, Ahmed F; Shapiro, Robert E; Elzamzamy, Osama M; Mueller, Michael G; Eller, Warren S
We aimed to determine the incidence of surgical site infection (SSI) after cesarean delivery (CD) and identify the risk factors in a rural population. We identified 218 SSI patients by International Classification of Disease codes and matched them with 3131 parturients (control) from the electronic record database in a time-matched retrospective quality assurance analysis. The incidence of SSI after CD was 7.0 %. Risk factors included higher body mass index (BMI) [40.30 ± 10.60 kg/m 2 SSI (95 % CI 38.73-41.87) vs 34.05 ± 8.24 kg/m 2 control (95 % CI 33.75-34.35, P < 0.001)], years of education [13.28 ± 2.44 years SSI (95 % CI 12.9-13.66) vs 14.07 ± 2.81 years control (95 % CI 13.96-14.18, P < 0.001)], number of prior births [2 (1-9) SSI vs 1 (1-11) control (P < 0.001)], tobacco use (OR 1.49; 95 % CI 1.06-2.09, P = 0.03), prior diagnosis of hypertension (OR 1.80; 95 % CI 1.34-2.42, P < 0.001), gestational diabetes (OR 1.59; 95 % CI 1.18-2.13, P = 0.003), and an emergency/STAT CD (OR 1.6; 95 % CI 1.1-2.3, P = 0.01). Risk factors for SSI after CD included higher BMI, less years of education, higher prior births, tobacco use, prior diagnosis of hypertension, gestational diabetes, and emergency/STAT CD. The presence of ruptured membranes was protective against SSI.
Denys Yemshanov; Frank H Koch; Mark Ducey
Uncertainty is inherent in model-based forecasts of ecological invasions. In this chapter, we explore how the perceptions of that uncertainty can be incorporated into the pest risk assessment process. Uncertainty changes a decision makerâs perceptions of risk; therefore, the direct incorporation of uncertainty may provide a more appropriate depiction of risk. Our...
Weil, Brent R; Andreoli, Sharon P; Billmire, Deborah F
Children with hemolytic uremic syndrome (HUS) frequently develop acute kidney injury (AKI) requiring renal replacement therapy (RRT). Peritoneal dialysis (PD) is commonly used. Despite high rates of thrombocytopenia, there is concern that platelet transfusions may worsen HUS by exacerbating microthrombi formation. We evaluated bleeding risk for PD catheter placement with or without central venous catheter (CVC) placement in children with HUS. Records from 1998 to 2007 were searched. Data regarding patient demographics, PD catheter placement, CVC placement, occurrence of procedure-associated bleeding, and time from insertion to removal of PD catheter were collected. Patients were stratified according to those who received and those who did not receive platelet transfusions. Seventy-three patients were identified. Twenty-two (30%) patients received platelet transfusion while 51 (70%) did not. Mean preoperative platelet counts were 37,600+/-21,900/mm(3) in patients receiving transfusions and 64,800 +/- 38,800/mm(3) in patients not receiving transfusions. Sixty-seven children (92%) also underwent CVC placement. There were no bleeding complications related to these procedures in either group. No differences in time to removal of the PD catheter were detected. Although caution and sound clinical judgment must be exercised, our findings suggest that PD catheter and CVC placement can be accomplished safely in most children with HUS, without need for platelet transfusion in spite of the associated thrombocytopenia.
Carraro, Alessandro; Ricchiuti, Giorgio
In this paper, we develop a heterogeneous agents model of asset price and inventory with a market maker who considers the excess demand of two groups of agents that employ the same trading rule (i.e. fundamentalists) with different beliefs on the fundamental value. The dynamics of our model is driven by a bi-dimensional discrete non-linear map. We show that the market maker has a destabilizing role when she actively manages the inventory. Moreover, inventory share and the distance between agents’ beliefs strongly influence the results: market instability and periodic, or even, chaotic price fluctuations can be generated. Finally, we show through simulations that endogenous fluctuations of the fractions of agents may trigger instability for a larger set of parameters.
Beveridge, Andrew; Dudek, Andrzej; Frieze, Alan; Muller, Tobias; Stojakovic, Milos
In a Maker-Breaker game on a graph G, Breaker and Maker alternately claim edges of G. Maker wins if, after all edges have been claimed, the graph induced by his edges has some desired property. We consider four Maker-Breaker games played on random geometric graphs. For each of our four games we show
Botti Benevides, Alessander; Masolo, Claudio
In the last decade, the debate about the ontological foundations of reified temporal logics (RTLs) has been relatively quiet, even though we think some problems still exist. In this paper, we identify some of these problems and propose (partial) solutions to them in a FOL framework. States are here characterized (at the syntactic level) as truth-makers of propositions-they reify true propositions-and events are built from states. These choices make the event-state distinction much crisper tha...
Since the late 1990s, there has been huge growth in new do-it-yourself (DIY) and maker communities, reflecting the democratisation of technology. Such practitioners have tended to reject pervasive and ubiquitous technologies and ‘virtualness’, and have moved towards working directly with materials through arts and crafts approaches. Running alongside the growth of digital technologies and culture, a counter-culture took hold, built on grassroots initiatives that had ‘much in common with punk ...
Figuerola-Tejerina, A; Bustamante, E; Tamayo, E; Mestres, C A; Bustamante-Munguira, J
Surgical site infection (SSI) is a major infectious complication that increases mortality, morbidity, and healthcare costs. There are scores attempting to classify patients for calculating SSI risk. Our objectives were to validate the Australian Clinical Risk Index (ACRI) in a European population after cardiac surgery, comparing it against the National Nosocomial Infections Surveillance-derived risk index (NNIS) and analyzing the predictive power of ACRI for SSI in valvular patients. All the patients that who underwent cardiac surgery in a tertiary university hospital between 2011 and 2015 were analyzed. The patients were divided into valvular and coronary groups, excluding mixed patients. The ACRI score was validated in both groups and its ability to predict SSI was compared to the NNIS risk index. We analyzed 1,657 procedures. In the valvular patient group (n: 1119), a correlation between the ACRI score and SSI development (p < 0.05) was found; there was no such correlation with the NNIS index. The area under the receiver-operating characteristic curve (AUC) was 0.64 (confidence interval [CI] 95%, 0.5-0.7) for ACRI and 0.62 (95% CI, 0.5-0.7) for NNIS. In the coronary group (n: 281), there was a correlation between ACRI and SSI but no between NNIS and SSI. The ACRI AUC was 0.70 (95% CI, 0.5-0.8) and the NNIS AUC was 0.60 (95% CI, 0.4-0.7). The ACRI score has insufficient predictive power, although it predicts SSI development better than the NNIS index, fundamentally in coronary artery bypass grafting (CABG). Further studies analyzing determining factors are needed.
Bakkaloglu, Huseyin; Yanar, Hakan; Guloglu, Recep; Taviloglu, Korhan; Tunca, Fatih; Aksoy, Murat; Ertekin, Cemalettin; Poyanli, Arzu
AIM: To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia. METHODS: The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases. RESULTS: Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 × 103 ± 1.3 × 103 μg/L vs 13 × 103 ± 1 × 103 μg/L, P < 0.05 for 24 h after PC; 13.7 × 103 ± 1.3 × 103 μg/L vs 8.3 × 103 ± 1.2 × 103 μg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2 ± 18.5 mg/L vs 27.3 ± 10.4 mg/L, P < 0.05 for 24 h after PC; 51.2 ± 18.5 mg/L vs 5.4 ± 1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38 ± 0.35°C vs 37.3 ± 0.32°C, P < 0.05 for 24 h after PC; 38 ± 0.35°C vs 36.9 ± 0.15°C, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recovered with medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter. CONCLUSION: As an alternative to surgery, percutan-eous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low
Riley, Donna M.; McNair, Lisa D.; Masters, S.
Some have hailed the emergence of maker spaces as an opportunity to broaden participation of underrepresented groups in science, technology, engineering, and math (STEM) education, engaging participants in open, creative, and supportive spaces for learning and applying practical STEM knowledge. Others have questioned the potential of these spaces, as many maker and hacker spaces seem to be enacting certain norms that are more conducive to participation of white, male, middle-class, able-bodie...
López, Fernando J García; Ruiz-Tovar, María; Almazán-Isla, Javier; Alcalde-Cabero, Enrique; Calero, Miguel; de Pedro-Cuesta, Jesús
Sporadic Creutzfeldt-Jakob disease (sCJD) is potentially transmissible to humans. This study aimed to summarise and rate the quality of the evidence of the association between surgery and sCJD. Firstly, we conducted systematic reviews and meta-analyses of case-control studies with major surgical procedures as exposures under study. To assess quality of evidence, we used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Secondly, we conducted a systematic review of sCJD case reports after sharing neurosurgical instruments. Thirteen case-control studies met the inclusion criteria for the systematic review of case-control studies. sCJD was positively associated with heart surgery, heart and vascular surgery and eye surgery, negatively associated with tonsillectomy and appendectomy, and not associated with neurosurgery or unspecified major surgery. The overall quality of evidence was rated as very low. A single case-control study with a low risk of bias found a strong association between surgery conducted more than 20 years before disease onset and sCJD. Seven cases were described as potentially transmitted by reused neurosurgical instruments. The association between surgery and sCJD remains uncertain. Measures currently recommended for preventing sCJD transmission should be strongly maintained. Future studies should focus on the potential association between sCJD and surgery undergone a long time previously.
Jerome, Mairin A; Gillenwater, Justin; Laub, Donald R; Osler, Turner; Allan, Anna Y; Restrepo, Carolina; Campbell, Alex
To compare anthropometric z-scores with incidence of post-operative complications for patients undergoing primary cleft lip or palate repair. This was a retrospective observational analysis of patients from a surgical center in Assam, India, and includes a cohort from a single surgical mission completed before the opening of the center. Patients included in the study underwent surgery during an Operation Smile mission before the opening of Operation Smile's Guwahati Comprehensive Cleft Care Center in Guwahati, India. The remaining cohort received treatment at the center. All patients received preoperative assessment and screening; surgery; and postoperative care, education, and follow-up. Our sample size included 1941 patients and consisted of all patients with complete information in the database who returned for follow-up after receiving primary cleft lip repair or primary cleft palate repair between January 2011 and April 2013. Preoperative anthropometric measurements. Postoperative complications. Anthropometric z-scores were not a significant predictor of adverse surgical outcomes in the group analyzed. Palate surgery had increased risk of complication versus lip repair, with an overall odds ratio of 5.66 (P < .001) for all patients aged 3 to 228 months. Anthropometric z-scores were not correlated with increased risk of surgical complications, possibly because patients were well screened for malnutrition before surgery at this center. Primary palate repair is associated with an approximate fivefold increased risk of developing postoperative complication(s) compared with primary lip repair.
Canaz, Emel; Ozyurek, Eser Sefik; Erdem, Baki; Aldikactioglu Talmac, Merve; Yildiz Ozaydin, Ipek; Akbayir, Ozgur; Numanoglu, Ceyhun; Ulker, Volkan
Determining the risk factors associated with parametrial involvement (PMI) is of paramount importance to decrease the multimodality treatment in early-stage cervical cancer. We investigated the preoperatively assessable clinical and pathological risk factors associated with PMI in surgically treated stage IB1-IIA2 cervical cancer. A retrospective cohort study of women underwent Querleu-Morrow type C hysterectomy for cervical cancer stage IB1-IIA2 from 2001 to 2015. All patients underwent clinical staging examination under anesthesia by the same gynecological oncologists during the study period. Evaluated variables were age, menopausal status, body mass index, smoking status, FIGO (International Federation of Obstetrics and Gynecology) stage, clinically measured maximal tumor diameter, clinical presentation (exophytic or endophytic tumor), histological type, tumor grade, lymphovascular space invasion, clinical and pathological vaginal invasion, and uterine body involvement. Endophytic clinical presentation was defined for ulcerative tumors and barrel-shaped morphology. Two-dimensional transvaginal ultrasonography was used to measure tumor dimensions. Of 127 eligible women, 37 (29.1%) had PMI. On univariate analysis, endophytic clinical presentation (P = 0.01), larger tumor size (P PMI. In multivariate analysis endophytic clinical presentation (odds ratio, 11.34; 95% confidence interval, 1.34-95.85; P = 0.02) and larger tumor size (odds ratio, 32.31; 95% confidence interval, 2.46-423.83; P = 0.008) were the independent risk factors for PMI. Threshold of 31 mm in tumor size predicted PMI with 71% sensitivity and 75% specificity. We identified 18 patients with tumor size of more than 30 mm and endophytic presentation; 14 (77.7%) of these had PMI. Endophytic clinical presentation and larger clinical tumor size (>3 cm) are independent risk factors for PMI in stage IB-IIA cervical cancer. Approximately 78% of the patients with a tumor size of more than 3 cm and endophytic
Qiao, Jun; Xiao, Lingyan; Sun, Xu; Shi, Benlong; Liu, Zhen; Xu, Leilei; Zhu, Zezhang; Qian, Bangping; Qiu, Yong
To investigate incidence, risk factors, and complications of vertebral subluxation (VS) during three-column osteotomy in surgical correction of adult spine deformity. Adult spine deformity patients who underwent three-column osteotomies including VCR, PSO, and other modified types from March 2000 to December 2014 in our center were retrospectively reviewed. The following parameters were measured pre- and postoperatively: Cobb angle of main curve, global kyphosis, sagittal vertical axis, and kyphosis flexibility. Radiographic parameters between groups (VCR vs. PSO and subluxation vs. non-subluxation) were compared. 171 ASD patients were recruited, 18 of which (10.5%) developed sagittal vertebral subluxation at the osteotomy site. 5 of 18 patients (27.8%) developed neurological complications after surgery. For these five patients, two patients got partial recovery, and three got complete recovery at 2-year follow-up. 116 patients underwent PSO, 12 of which (10.3%) developed sagittal vertebral subluxation. In 55 patients receiving VCR, 6 (10.9%) developed sagittal vertebral subluxation. No significant difference was noted between the two groups (P > 0.05). The mean age of VS group was larger than that of non-VS group (46.2 vs. 34.2, P < 0.05). VS group had less kyphosis flexibility (11 vs. 23%, P < 0.05). More patients in VS group had preoperative sagittal VS as compared to non-VS group (77.8 vs. 20.9%, P < 0.05). VS group had more neurological complications than non-VS group (25 vs. 5.4%, P < 0.05). VS occurred in one-tenth of patients receiving three-column osteotomies, one-fourth of which would develop neurological deficits. Older age, rigid kyphosis, and the pre-existence of VS were risk factors for developing VS.
Yassa, Rafik Rd; Khalfaoui, Mahdi Y; Veravalli, Karunakar; Evans, D Alun
The aims of the current study were to determine whether pre-operative urinary tract infections in patients presenting acutely with neck of femur fractures resulted in a delay to surgery and whether such patients were at increased risk of developing post-operative surgical site infections. A retrospective review of all patients presenting with a neck of femur fracture, at a single centre over a one-year period. The hospital hip fracture database was used as the main source of data. UK University Teaching Hospital. All patients ( n = 460) presenting across a single year study period with a confirmed hip fracture. The presence of pre-operative urinary tract infection, the timing of surgical intervention, the occurrence of post-operative surgical site infection and the pathogens identified. A total of 367 patients were operated upon within 24 hours of admission. Urinary infections were the least common cause of delay. A total of 99 patients (21.5%) had pre-operative urinary tract infection. Post-operatively, a total of 57 (12.4%) patients developed a surgical site infection. Among the latter, 31 (54.4%) did not have a pre-operative urinary infection, 23 (40.4%) patients had a pre-operative urinary tract infection, 2 had chronic leg ulcers and one patient had a pre-operative chest infection. Statistically, there was a strong relationship between pre-operative urinary tract infection and the development of post-operative surgical site infection ( p -value: 0.0005). The results of our study indicate that pre-operative urinary tract infection has a high prevalence amongst those presenting with neck of femur fractures, and this is a risk factor for the later development of post-operative surgical site infection.
Aleksey Sergeevih Voynov
Full Text Available Purpose: identify the most important features in the process of making political decisions that affect the effectiveness of problem-solving situationsScientific novelty: as a result of the analysis identified the problematic features of major importance for the efficiency of the development and adoption of the most rational solution to a problem situation.Results: the analysis of the most significant features affecting the quality of decisions among them the interest of the person making decisions in the search for causes of the problem situation; decisions from the influence of the immediate environment; populism in decision making, creating a visibility problem-solving; decision making based on personal emotional factor face decision-makers; the perception of the population face decision-makers in relation to the current problem situation and possible ways of its resolution.Defined facts influencing the process of political decision-making such as: corruption, the struggle for influence on the process of political decision-making, lack of qualified specialists, staff shortage, including arose as the result of substitution of notions of "succession" to "nepotism".
Health programs are shaped by the decisions made in budget processes, so how budget-makers view health programs is an important part of making health policy. Budgeting in any country involves its own policy community, with key players including budgeting professionals and political authorities. This article reviews the typical pressures on and attitudes of these actors when they address health policy choices. The worldview of budget professionals includes attitudes that are congenial to particular policy perspectives, such as the desire to select packages of programs that maximize population health. The pressures on political authorities, however, are very different: most importantly, public demand for health care services is stronger than for virtually any other government activity. The norms and procedures of budgeting also tend to discourage adoption of some of the more enthusiastically promoted health policy reforms. Therefore talk about rationalizing systems is not matched by action; and action is better explained by the need to minimize blame. The budget-maker's perspective provides insight about key controversies in healthcare policy such as decentralization, competition, health service systems as opposed to health insurance systems, and dedicated vs. general revenue finance. It also explains the frequency of various "gaming" behaviors. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Full Text Available Eli Heckscher was not only author of extensive investigations into economic history. He was also skillful in depicting phenomena in small format in encyclopædias, journals and newspapers. This article presents Heckscher as portrait maker of economic scholars. In these portraits—what he emphasized, what he praised, what he criticized—one can discern the stance of the portrait maker himself. Overall, his portraits are permeated by admiration of sharp theoretical analyses and massive economic historical investigations. He admires the founding fathers of political economy, Adam Smith and David Ricardo, stresses continuity in the development of economic thought, praises humble innovators like David Davidson, Knut Wicksell and Alfred Marshall and denounces (what he perceives as pretentious innovators like Gustav Cassel and John Maynard Keynes. He is critical towards economists who attempt to break out of the classical and neoclassical tradition, especially representatives of the German historical school, and what he judges to be a new type of mercantilism, represented by Bertil Ohlin and Keynes. At the same time he appreciates voluminous and solid investigations into economic history, even if performed without theoretical beacons, by scholars like William Cunningham, William Ashley, John Clapham, Marc Bloch, Richard Ehrenberg and Werner Sombart.
Iskenderov, B G; Sisina, O N; Budagovskaia, Z M
to determine the frequency and risk factors of acute renal lesions (ARL) and their prognostic significance in patients with chronic renal disease (CRD) undergoing surgical intervention. The study included 1122 patients (586 men and 536 women) aged 32-68 (mean 62.3 ± 5.2) years who underwent correction of valvular defects, aortocoronary bypass surgery or their combination). Initial glomerular filtration rate was higher than 90 ml/min/l.73 m2 in 656 patients (group 1) and 89-60 ml/min/l/73 m2 in 470 ones (group 2). ARL were diagnosed based on the serum creatinine level using RIFLE criteria. In the early postoperative period, ARL were diagnosed in 23.9% of the patients in group I and 38.7% of those in group 2 (p < 0.001). Intra-hospital lethality in group 1 was 4.9% (14.1% in patients with ARL) and 12.1% in group 2 (18.1% iin patients with ARL). In group 2, 47.9% of the patients with ARL experienced regress of renal dysfunction during 12 months compared with 56.9% ones without ARL. The progress of CRD was documented in 11% of group 2 patients with ARL and in (4.5% without AR (p = 0.013). 5.7% of the patients in group 1 developed CRD after ARL. 4.9% of the patients in group 2 needed programmed hemodialysis. The development of ARL in patients with CRD is associated with unfvouravle cardiovascular prognosis following cardiosurgery.
Petrinec, Amy B; Mazanec, Polly M; Burant, Christopher J; Hoffer, Alan; Daly, Barbara J
To assess the coping strategies used by family decision makers of adult critical care patients during and after the critical care experience and the relationship of coping strategies to posttraumatic stress symptoms experienced 60 days after hospitalization. A single-group descriptive longitudinal correlational study. Medical, surgical, and neurological ICUs in a large tertiary care university hospital. Consecutive family decision makers of adult critical care patients from August 2012 to November 2013. Study inclusion occurred after the patient's fifth day in the ICU. None. Family decision makers of incapacitated adult ICU patients completed the Brief COPE instrument assessing coping strategy use 5 days after ICU admission and 30 days after hospital discharge or death of the patient and completed the Impact of Event Scale-Revised assessing posttraumatic stress symptoms 60 days after hospital discharge. Seventy-seven family decision makers of the eligible 176 completed all data collection time points of this study. The use of problem-focused (p=0.01) and emotion-focused (pcoping decreased over time while avoidant coping (p=0.20) use remained stable. Coping strategies 30 days after hospitalization (R2=0.50, pcoping strategies 5 days after ICU admission (R2=0.30, p=0.001) controlling for patient and decision-maker characteristics. The role of decision maker for a parent and patient death were the only noncoping predictors of posttraumatic stress symptoms. Avoidant coping use 30 days after hospitalization mediated the relationship between patient death and later posttraumatic stress symptom severity. Coping strategy use is a significant predictor of posttraumatic stress symptom severity 60 days after hospitalization in family decision makers of ICU patients.
Munkholm-Larsen, Stine; Wan, Benjamin; Tian, David H
BACKGROUND: MitraClip implantation has emerged as a viable option in high surgical risk patients with severe mitral regurgitation (MR). We performed the present systematic review to assess the safety and efficacy of the MitraClip system for high surgical risk candidates with severe organic and....../or functional MR. METHODS: Six electronic databases were searched for original published studies from January 2000 to March 2013. Two reviewers independently appraised studies, using a standard form, and extracted data on methodology, quality criteria, and outcome measures. All data were extracted and tabulated...... with the most complete dataset were included for quality appraisal and data extraction. All 12 studies were prospective observational studies. Immediate procedural success ranged from 72-100%; 30 day mortality ranged from 0-7.8%. There was a significant improvement in haemodynamic profile and functional status...
Humphrey H.T. Ko
Full Text Available Introduction The repurposing of non-antibiotic drugs as adjuvant antibiotics may help break antimicrobial resistance (AMR. Statins are commonly prescribed worldwide to lower cholesterol. They also possess qualities of AMR “breakers”, namely direct antibacterial activity, synergism with antibiotics, and ability to stimulate the host immune system. However, statins’ role as AMR breakers may be limited. Their current extensive use for cardiovascular protection might result in selective pressures for resistance, ironically causing statins to be AMR “makers” instead. This review examines statins’ potential as AMR breakers, probable AMR makers, and identifies knowledge gaps in a statin-bacteria-human-environment continuum. The most suitable statin for repurposing is identified, and a mechanism of antibacterial action is postulated based on structure-activity relationship analysis. Methods A literature search using keywords “statin” or “statins” combined with “minimum inhibitory concentration” (MIC was performed in six databases on 7th April 2017. After screening 793 abstracts, 16 relevant studies were identified. Unrelated studies on drug interactions; antifungal or antiviral properties of statins; and antibacterial properties of mevastatin, cerivastatin, antibiotics, or natural products were excluded. Studies involving only statins currently registered for human use were included. Results Against Gram-positive bacteria, simvastatin generally exerted the greatest antibacterial activity (lowest MIC compared to atorvastatin, rosuvastatin, and fluvastatin. Against Gram-negative bacteria, atorvastatin generally exhibited similar or slightly better activity compared to simvastatin, but both were more potent than rosuvastatin and fluvastatin. Discussion Statins may serve as AMR breakers by working synergistically with existing topical antibiotics, attenuating virulence factors, boosting human immunity, or aiding in wound healing. It
Full Text Available Stefano Angioni,1 Alessandro Pontis,1 Federica Sedda,1 Theodoros Zampetoglou,2 Vito Cela,3 Liliana Mereu,4 Pietro Litta51Department of Surgical Sciences, University of Cagliari, Cagliari, Italy; 2Obstetrics and Gynecology, Iaso Thessalia Hospital, Larissa, Greece; 3Department of Obstetrics and Gynecology, University of Pisa, Pisa, 4Ospedale S Chiara, Trento, 5Department of Obstetrics and Gynecology, University of Padua, Padua, ItalyAbstract: Bilateral salpingo-oophorectomy (BSO in carriers of BRCA1 and BRCA2 mutations is widely recommended as part of a risk-reduction strategy for ovarian or breast cancer due to an underlying genetic predisposition. BSO is also performed as a therapeutic intervention for patients with hormone-positive premenopausal breast cancer. BSO may be performed via a minimally invasive approach with the use of three to four 5 mm and/or 12 mm ports inserted through a skin incision. To further reduce the morbidity associated with the placement of multiple port sites and to improve cosmetic outcomes, single-port laparoscopy has been developed with a single access point from the umbilicus. The purpose of this study was to evaluate the surgical outcomes associated with reducing the risks of salpingo-oophorectomy performed in a single port, while comparing multiport laparoscopy in women with a high risk for ovarian cancer. Single-port laparoscopy–BSO is feasible and safe, with favorable surgical and cosmetic outcomes when compared to conventional laparoscopy.Keywords: prophylactic salpingectomy, single-port access laparoscopy, BRCA carriers
Langley, David; Zirngibl, M.; Sbeih, J.; Devoldere, B.
Maker technologies, including collaborative digital fabrication tools like 3-D printers, enable entrepreneurial opportunities and new business models. To date, relatively few highly successful maker startups have emerged, possibly due to the dominant mindset of the makers being one of cooperation
how to use special operations forces properly. The literature review recognizes numerous factors that decision makers and senior level commanders... decision makers continued negotiations to buy more time for the preparation of the operation. In Operation Thunderbolt, the decision makers initially...approved the continuation of the negotiation process to buy more time for planning like in previous case studies. However, the Russian decision
Kigera, James W M; Straetemans, Masja; Vuhaka, Simplice K; Nagel, Ingeborg M; Naddumba, Edward K; Boer, Kimberly
There is dilemma as to whether patients infected with the Human Immunodeficiency Virus (HIV) requiring implant orthopaedic surgery are at an increased risk for post-operative surgical site infection (SSI). We conducted a systematic review to determine the effect of HIV on the risk of post-operative SSI and sought to determine if this risk is altered by antibiotic use beyond 24 hours. We searched electronic databases, manually searched citations from relevant articles, and reviewed conference proceedings. The risk of postoperative SSI was pooled using Mantel-Haenszel method. We identified 18 cohort studies with 16 mainly small studies, addressing the subject. The pooled risk ratio of infection in the HIV patients when compared to non-HIV patients was 1.8 (95% Confidence Interval [CI] 1.3-2.4), in studies in Africa this was 2.3 (95% CI 1.5-3.5). In a sensitivity analysis the risk ratio was reduced to 1.4 (95% CI 0.5-3.8). The risk ratio of infection in patients receiving prolonged antibiotics compared to patients receiving antibiotics for up to 24 hours was 0.7 (95% CI 0.1-4.2). The results may indicate an increased risk in HIV infected patients but these results are not robust and inconclusive after conducting the sensitivity analysis removing poor quality studies. There is need for larger good quality studies to provide conclusive evidence. To better develop surgical protocols, further studies should determine the effect of reduced CD4 counts, viral load suppression and prolonged antibiotics on the risk for infection.
Tice, Jeffrey A; Sellke, Frank W; Schaff, Hartzell V
The California Technology Assessment Forum is dedicated to assessment and public reporting of syntheses of available data on medical technologies. In this assessment, transcatheter aortic valve replacement (TAVR) was evaluated for patients with severe aortic stenosis (AS) who are at high risk for complications. In this assessment, 5 criteria were used: Regulatory approval, sufficient scientific evidence to allow conclusions on effectiveness, evidence that the technology improves net health outcomes, evidence that the technology is as beneficial as established methods, and availability of the technology outside investigational settings. In this assessment, all 5 criteria were judged to have been met. The primary benefit of TAVR is the ability to treat AS in patients who would otherwise be ineligible for surgical aortic valve replacement. It may also be useful for patients at high surgical risk by potentially reducing periprocedural complications and avoiding the morbidity and recovery from undergoing heart surgery. Potential harms include the need for conversion to an open procedure, perioperative death, myocardial infarction, stroke, bleeding, valve embolization, aortic regurgitation, heart block that requires a permanent pacemaker, renal failure, pulmonary failure, and major vascular complications such as cardiac perforation or arterial dissection. Potential long-term harms include death, stroke, valve failure or clotting, and endocarditis. As highlighted at the February 2012 California Technology Assessment Forum meeting, the dispersion of this technology to new centers across the United States must proceed with careful thought given to training and proctoring multidisciplinary teams to become new centers of excellence. TAVR is a potentially lifesaving procedure that may improve quality of life for patients at high risk for surgical AVR. However, attention needs to be paid to appropriate patient selection, their preoperative evaluation, surgical techniques, and
Gomez Hoyos, Juan Fernando; Celis Mejia, Jorge Ignacio; Yepes Sanchez, Carlos Jaime; Duque Botero, Julieta
Carotid endarterectomy success in symptomatic or asymptomatic patients has been demonstrated in NASCET and ACAS studies. Although, some patients with carotid stenosis have frequently other pathologies which increase risk in endarterectomy or other surgeries like coronary bypass and aortic-iliac reconstruction. Other patients have lesions such as post surgical restenosis, fibromuscular dysplasia, radiation stenosis or tumoral disease, or stenotic lesions above jaw angle. The main objectives of this work are: to demonstrate, upon the results, that multidisciplinary management of 1 patient with symptomatic or not carotid critical stenosis. Let to select, with strict clinical criteria, those doing well with endovascular therapy. To evaluate implantation technique, peryoperatory morbidity and mortality and permeability time with implanted dispositive. In this study, the preliminary experience of the neurovascular group at the Clinica Cardiovascular Santa Maria in Medellin is presented, during an 18 months period of multidisciplinary management in 15 patients, 7 men and 8 women with critical carotid stenosis. 18 procedures were performed and 21 stents were implanted. The mean age was 66 years. All patients had 70% or greater stenotic lesions, and 93.3% were symptomatic. Twelve (80%) had contraindications to perform surgery. one asymptomatic patient (6.6%) was referred with procedure indications and two (13.3%) requested the stent implantation as their own election. the patient with fibromuscular dysplasia was treated with Wallstent (number 4) and the remaining patients were treated with Palmaz stent. technical success was 100%, 3 patients had pacemaker rhythm, one patient (6.6%) presented extra-pyramidal syndrome which responded to medical treatment in 24 hours. one patient developed right side hemiparesis with total recovery in 4 hours. One patient with a critical left carotid artery stenosis presented right side hemiparesis (3/5) and aphasia, nine months later paresis
Chenier, Tracey S; Whitehead, Ashley E
The purpose of this study was to determine foaling rates in mares presented for medical or surgical treatment of colic, and to examine risk factors associated with abortion following colic. A retrospective analysis of 153 medical records found that mares treated surgically for colic (P = 0.0007) were 3.5 times more likely to have a negative pregnancy outcome than were mares treated medically for colic. Anesthetic time (P = 0.01) and intra-operative hypotension (P = 0.03) were significantly associated with negative pregnancy outcome. Mares with an anesthetic time > or = 3 h were 6 times more likely to abort. Signs of endotoxemia (P = 0.30), hypoxia (P = 0.89), flunixin meglumine administration (P = 0.13), mucous membrane color at the time of presentation (P = 0.82) and capillary refill time (P = 0.76) were not associated with pregnancy outcome. There was no difference in the foaling rate for mares that had received progestin supplementation versus those that had not (P = 0.42). In this study, the significant risk factors for abortion were surgically treated colic, long anesthetic time, and intraoperative hypotension.
Mayer, Erik K; Sevdalis, Nick; Rout, Shantanu; Caris, Jochem; Russ, Stephanie; Mansell, Jenny; Davies, Rachel; Skapinakis, Petros; Vincent, Charles; Athanasiou, Thanos; Moorthy, Krishna; Darzi, Ara
To evaluate impact of WHO checklist compliance on risk-adjusted clinical outcomes, including the influence of checklist components (Sign-in, Time-out, Sign-out) on outcomes. There remain unanswered questions surrounding surgical checklists as a quality and safety tool, such as the impact in cases of differing complexity and the extent of checklist implementation. Data were collected from surgical admissions (6714 patients) from March 2010 to June 2011 at 5 academic and community hospitals. The primary endpoint was any complication, including mortality, occurring before hospital discharge. Checklist usage was recorded as checklist completed in full/partly. Multilevel modeling was performed to investigate the association between complications/mortality and checklist completion. Significant variability in checklist usage was found: although at least 1 of the 3 components was completed in 96.7% of cases, the entire checklist was only completed in 62.1% of cases. Checklist completion did not affect mortality reduction, but significantly lowered risk of postoperative complication (16.9% vs. 11.2%), and was largely noticed when all 3 components of the checklist had been completed (odds ratio = 0.57, 95% confidence interval: 0.37-0.87, P checklist was implemented. Checklist implementation was associated with reduced case-mix-adjusted complications after surgery and was most significant when all 3 components of the checklist were completed. Full, as opposed to partial, checklist completion provides a health policy opportunity to improve checklist impact on surgical safety and quality of care.
Gaeta, G B; Stroffolini, T; Taliani, G; Ippolito, F M; Giusti, G; De Bac, C
The study was carried out to evaluate the risk factors associated with chronic hepatitis C virus (HCV) infection. This case-control study used multiple logistic regression analysis to determine risk factors associated with HCV infection. Study participants were followed at 10 liver or gastroenterologic units and included 294 subjects with chronic HCV infection and 295 age and sex matched anti-HCV-negative controls. The use of glass syringes and surgical procedures was reported by as many as 77.6% and 73.8% of cases, respectively; blood transfusion was recorded in nearly a quarter of cases; 10.2% of cases, but none of the controls, reported past or current intravenous drug use. Multiple logistic regression analysis showed that blood transfusion, being the sexual partner of an intravenous drug user, and surgery all were independent predictors of the likelihood of HCV infection. These findings indicate that, besides the well-known sources of infection, such as blood transfusion and intravenous drug use, surgical procedures may play an important role in the spread of HCV infection in Italy. Given that a large proportion of the general population undergoes surgery, a rational and relatively inexpensive policy for the prevention of HCV infection must focus on implementing efficient procedures for the sterilization of instruments and the use of disposable materials in surgical units.
Yu, Lulu; Kronen, Ryan J; Simon, Laura E; Stoll, Carolyn R T; Colditz, Graham A; Tuuli, Methodius G
The objective of the study was to assess the effect of prophylactic negative-pressure wound therapy on surgical site infections and other wound complications in women after cesarean delivery. We searched Ovid Medline, Embase, SCOPUS, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. We included randomized controlled trials and observational studies comparing prophylactic negative-pressure wound therapy with standard wound dressing for cesarean delivery. The primary outcome was surgical site infection after cesarean delivery. Secondary outcomes were composite wound complications, wound dehiscence, wound seroma, endometritis, and hospital readmission. Heterogeneity was assessed using Higgin's I 2 . Relative risks with 95% confidence intervals were calculated using random-effects models. Six randomized controlled trials and 3 cohort studies in high-risk mostly obese women met inclusion criteria and were included in the meta-analysis. Six were full-text articles, 2 published abstracts, and 1 report of trial results in ClinicalTrials.gov. Studies were also heterogeneous in the patients included and type of negative-pressure wound therapy device. The risk of surgical site infection was significantly lower with the use of prophylactic negative-pressure wound therapy compared with standard wound dressing (7 studies: pooled risk ratio, 0.45; 95% confidence interval, 0.31-0.66; adjusted risk ratio, -6.0%, 95% confidence interval, -10.0% to -3.0%; number needed to treat, 17, 95% confidence interval, 10-34). There was no evidence of significant statistical heterogeneity (I 2 = 9.9%) or publication bias (Egger P = .532). Of the secondary outcomes, only composite wound complications were significantly reduced in patients receiving prophylactic negative-pressure wound therapy compared with standard dressing (9 studies: pooled risk ratio, 0.68, 95% confidence interval, 0.49-0.94). Studies on the effectiveness of prophylactic negative-pressure wound therapy at
Chen, Ko-Ting; Lee, Shih-Tseng; Wu, Chieh-Tsai
A subset of surgically treated patients with traumatic brain injury (TBI) cannot be stabilized by initial surgery. Mobile computed tomography (CT) provides real-time information for diagnosis in these TBI surgically high-risk (TBI-SHR) patients. The objective of this study was to analyze a 5-year series of TBI-SHR patients to evaluate the impact of intraoperative mobile CT (imCT) on prognosis. Of 1017 surgically treated patients with TBI retrospectively reviewed over a 5-year period (2009-2013), 59 patients required second operations within 72 hours of their initial surgery because of progressive or delayed hematomas (TBI-SHR group). Their clinical, radiographic, and intraoperative findings were compared among 19 patients who received imCT versus 40 patients who received fixed-unit CT. Our TBI-SHR group accounted for 5.8% of all surgically treated patients with TBI. The use of imCT led to a change in surgical plan in 56% of patients with TBI intraoperatively. Younger patients (≤55 years; P 20 mm Hg or acute brain swelling after adequate decompression (P = 0.003 and 0.004, respectively) significantly benefited from imCT in the TBI-SHR group. imCT also provided a quicker diagnosis (P < 0.001), led to a trend toward shorter intensive care unit stays (P = 0.077), and was associated with better neurologic outcomes at discharge days (P = 0.044). The use of imCT is associated with better neurologic outcomes at discharge days compared with the use of fixed-unit CT in TBI-SHR patients. Copyright © 2016 Elsevier Inc. All rights reserved.
Habiba, Samer; Nygaard, Øystein P; Brox, Jens I; Hellum, Christian; Austevoll, Ivar M; Solberg, Tore K
There are no previous studies evaluating risk factors for surgical site infections (SSIs) and the effectiveness of prophylactic antibiotic treatment (PAT), specifically for patients operated on for lumbar disc herniation. This observational multicentre study comprises a cohort of 1,772 consecutive patients operated on for lumbar disc herniation without laminectomy or fusion at 23 different surgical units in Norway. The patients were interviewed about SSIs according to a standardised questionnaire at 3 months' follow-up. Three months after surgery, 2.3% of the patients had an SSI. Only no PAT (OR = 5.3, 95% CI = 2.2-12.7, pdisc herniation. Senior surgeons assisting inexperienced colleagues to avoid prolonged duration of surgery could also reduce the occurrence of SSI.
Nicola Di Daniele
Full Text Available A 30-year-old woman with severe hypertension was admitted to the hospital with a history of headache, palpitations, and diaphoresis following sexual intercourse. Twenty-four hour urinary excretion of free catecholamines and metabolites was markedly increased as was serum chromogranin A. Computed tomography scan revealed a large mass in the left adnex site and magnetic resonance imaging confirmed the computer tomography finding, suggesting the presence of extra-adrenal sympathetic paraganglioma. I-metaiodobenzyl guanidine scintigram revealed an increased uptake in the same area. Transcatheter arterial embolization of the mass resulted in marked decreases in blood pressure and urinary excretion of free catecholamines and metabolites. Surgical excision of the mass was then accomplished without complication. Preoperative embolization is a useful and safe procedure which may reduce the risk of catecholamines release at the time of surgical excision in large pelvic extra-adrenal sympathetic paraganglioma.
Di Daniele, Nicola; Canale, Maria Paola; Tesauro, Manfredi; Rovella, Valentina; Gandini, Roberto; Schillaci, Orazio; Cadeddu, Federica; Milito, Giovanni
A 30-year-old woman with severe hypertension was admitted to the hospital with a history of headache, palpitations, and diaphoresis following sexual intercourse. Twenty-four hour urinary excretion of free catecholamines and metabolites was markedly increased as was serum chromogranin A. Computed tomography scan revealed a large mass in the left adnex site and magnetic resonance imaging confirmed the computer tomography finding, suggesting the presence of extra-adrenal sympathetic paraganglioma. I-metaiodobenzyl guanidine scintigram revealed an increased uptake in the same area. Transcatheter arterial embolization of the mass resulted in marked decreases in blood pressure and urinary excretion of free catecholamines and metabolites. Surgical excision of the mass was then accomplished without complication. Preoperative embolization is a useful and safe procedure which may reduce the risk of catecholamines release at the time of surgical excision in large pelvic extra-adrenal sympathetic paraganglioma. PMID:22988529
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Cohen, R.L.; Lichter, S.R.
In October 1980, the authors surveyed selected scientific experts, decision-makers in financial and regulatory communities and Congress, and directors of major activist groups for national environmental organizations. Questions concerned policy preferences for and general attitudes toward nuclear energy, problems, energy resources, and considerations important to most influential groups in nuclear development. The survey revealed, surprisingly, that most regulators, congressional leaders, outside experts, and financiers are as united in their support of nuclear energy development as are industry executives, Three Mile Island notwithstanding. The antinuclear perspective is represented almost entirely by the heads of activist groups and a few scattered allies in Congress, the Environmental Protection Agency, and the Department of Energy. A relatively few dissenters have played a major role in blocking nuclear development. Implications for the regulatory process from these survey results are that cost-benefit analyses and empirical findings on nuclear power issues will not convince activists and their followers; it appears that they have acquired a kind of veto over nuclear development. Through actively political behavior in the contest for nuclear energy's future, and through sympathetic media, activists have won the American public to their side. 7 tables
Sadek, Betro T.; Shenouda, Mina N.; Abi Raad, Rita F. [Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (United States); Niemierko, Andrzej [Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (United States); Statistics Section, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (United States); Keruakous, Amany R. [Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (United States); Goldberg, Saveli I. [Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (United States); Statistics Section, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (United States); Taghian, Alphonse G., E-mail: email@example.com [Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (United States)
Purpose: To compare the outcome of patients with invasive breast cancer both with and without lobular carcinoma in situ (LCIS)-positive/close surgical margins after breast-conserving treatment. Methods and Materials: We retrospectively studied 2358 patients with T1-T2 invasive breast cancer treated with lumpectomy and radiation therapy from January 1980 to December 2009. Median age was 57 years (range, 24-91 years). There were 82 patients (3.5%) with positive/close LCIS margins (<0.2 cm) and 2232 patients (95.7%) with negative margins. A total of 1789 patients (76%) had negative lymph nodes. Patients who received neoadjuvant chemotherapy were excluded. A total of 1783 patients (76%) received adjuvant systemic therapy. Multivariable analysis (MVA) was performed using Cox's proportional hazards model. Results: The 5-year cumulative incidence of locoregional recurrence (LRR) was 3.2% (95% confidence interval [CI] 2.5%-4.1%) for the 2232 patients with LCIS-negative surgical margins (median follow-up 104 months) and 2.8% (95% CI 0.7%-10.8%) for the 82 patients with LCIS-positive/close surgical margins (median follow-up 90 months). This was not statistically significant (P=.5). On MVA, LCIS-positive margins after the final surgery were not associated with increased risk of LRR (hazard ratio [HR] 3.4, 95% CI 0.5-24.5, P=.2). Statistically significant prognostic variables on Cox's MVA for risk of LRR included systemic therapy (HR 0.5, 95% CI 0.33-0.75, P=.001), number of positive lymph nodes (HR 1.11, 95% CI 1.05-1.18, P=.001), menopausal status (HR 0.96, 95% CI 0.95-0.98, P=.001), and histopathologic grade (grade 3 vs grade 1/2) (HR 2.6, 95% CI 1.4-4.7, P=.003). Conclusion: Our results suggest that the presence of LCIS at the surgical margin after lumpectomy does not increase the risk of LRR or the final outcome. These findings suggest that re-excision or mastectomy in patients with LCIS-positive/close final surgical margins is unnecessary.
Cortes, Dina; Thorup, Jørgen Mogens; Petersen, Bodil Laub
We investigated whether or not surgical strategy has an impact on the risk of invasive testicular neoplasia in cases of cryptorchidism. We made a database study of the incidence of testicular neoplasia at surgery for cryptorchidism in childhood, and evaluated if such abnormalities were found...... in special categories of patients, and also of the incidence of testicular neoplasia after orchiopexy with a simultaneous testicular biopsy in childhood. At surgery for cryptorchidism the risk of testicular neoplasia was 7/182 (4%) in cases with intra-abdominal testis, abnormal external genitalia other than......, p neoplasia was 7/830 (1%). The relative risk of testicular neoplasia was about 4. Conclusion: Based on our data and the literature we recommend: 1) Taking a testicular biopsy at surgery for cryptorchidism in childhood in intra-abdominally placed...
Cuthbertson, Brian H; Campbell, Marion K; Stott, Stephen A; Vale, Luke; Norrie, John; Kinsella, John; Cook, Jonathan; Brittenden, Julie; Grant, Adrian
Patients undergoing major elective or urgent surgery are at high risk of death or significant morbidity. Measures to reduce this morbidity and mortality include pre-operative optimisation and use of higher levels of dependency care after surgery. We propose a pragmatic multi-centre randomised controlled trial of level of dependency and pre-operative fluid therapy in high-risk surgical patients undergoing major elective surgery. A multi-centre randomised controlled trial with a 2 * 2 factorial design. The first randomisation is to pre-operative fluid therapy or standard regimen and the second randomisation is to routine intensive care versus high dependency care during the early post-operative period. We intend to recruit 204 patients undergoing major elective and urgent abdominal and thoraco-abdominal surgery who fulfil high-risk surgical criteria. The primary outcome for the comparison of level of care is cost-effectiveness at six months and for the comparison of fluid optimisation is the number of hospital days after surgery. We believe that the results of this study will be invaluable in determining the future care and clinical resource utilisation for this group of patients and thus will have a major impact on clinical practice. Trial registration number - ISRCTN32188676.
Full Text Available Abstract Background Patients undergoing major elective or urgent surgery are at high risk of death or significant morbidity. Measures to reduce this morbidity and mortality include pre-operative optimisation and use of higher levels of dependency care after surgery. We propose a pragmatic multi-centre randomised controlled trial of level of dependency and pre-operative fluid therapy in high-risk surgical patients undergoing major elective surgery. Methods/Design A multi-centre randomised controlled trial with a 2 * 2 factorial design. The first randomisation is to pre-operative fluid therapy or standard regimen and the second randomisation is to routine intensive care versus high dependency care during the early post-operative period. We intend to recruit 204 patients undergoing major elective and urgent abdominal and thoraco-abdominal surgery who fulfil high-risk surgical criteria. The primary outcome for the comparison of level of care is cost-effectiveness at six months and for the comparison of fluid optimisation is the number of hospital days after surgery. Discussion We believe that the results of this study will be invaluable in determining the future care and clinical resource utilisation for this group of patients and thus will have a major impact on clinical practice. Trial Registration Trial registration number - ISRCTN32188676
Osterhoff, Georg; Burla, Laurin; Werner, Clément M L; Jentzsch, Thorsten; Wanner, Guido A; Simmen, Hans-Peter; Sprengel, Kai
Surgical site infections (SSIs) increase morbidity and mortality rates and generate additional cost for the healthcare system. Pre-operative blood transfusion and the subcutaneous fat thickness (SFT) have been described as risk factors for SSI in other surgical areas. The purpose of this study was to assess the impact of pre-operative blood transfusion and the SFT on the occurrence of SSI in posterior thoracic spine surgery. In total, 244 patients (median age 55 y; 97 female) who underwent posterior thoracic spine fusions from 2008 to 2012 were reviewed retrospectively. Patient-specific characteristics, pre-operative hemoglobin concentration/hematocrit values, the amount of blood transfused, and the occurrence of a post-operative SSI were documented. The SFT was measured on pre-operative computed tomography scans. Surgical site infection was observed in 26 patients (11%). The SFT was 13 mm in patients without SSI and 14 mm in those with infection (p=0.195). The odds ratio for patients with pre-operative blood transfusion to present with SSI was 3.1 (confidence interval [CI] 1.4-7.2) and 2.7 (CI 1.1-6.4) when adjusted for age. There was no difference between the groups with regard to pre-operative hemoglobin concentration (p=0.519) or hematocrit (p=0.908). The SFT did not differ in the two groups. Allogeneic red blood cell transfusion within 48 h prior to surgery was an independent risk factor for SSI after posterior fusion for the fixation of thoracic spine instabilities. Pre-operative blood transfusion tripled the risk, whereas SFT had no influence on the occurrence of SSI.
Iqbal, H J; Ponniah, N; Long, S; Rath, N; Kent, M
The primary aim of this study was to determine whether orthopaedic trauma patients receive appropriate antibiotic prophylaxis keeping in view the results of their MRSA screening. The secondary aim was to analyse the risk of developing MRSA surgical site infection with and without appropriate antibiotic prophylaxis in those colonized with MRSA. We reviewed 400 consecutive orthopaedic trauma patient episodes. Preoperative MRSA screening results, operative procedures, prophylactic antibiotics and postoperative course were explored. In addition to these consecutive patients, the hospital MRSA database over the previous 5 years identified 27 MRSA colonized acute trauma patients requiring surgery. Of the 400 consecutive patient episodes, 395(98.7%) had MRSA screening performed on admission. However, in 236 (59.0%) cases, the results were not available before the surgery. Seven patient episodes (1.8%) had positive MRSA colonization. Analysis of 27 MRSA colonized patients revealed that 20(74%) patients did not have the screening results available before the surgery. Only 5(18.5%) received Teicoplanin and 22(81.4%) received cefuroxime for antibiotic prophylaxis before their surgery. Of those receiving cefuroxime, five (22.73%) patients developed postoperative MRSA surgical site infection (SSI) but none of those (0%) receiving Teicoplanin had MRSA SSI. The absolute risk reduction for SSI with Teicoplanin as antibiotic prophylaxis was 22.73% (CI=5.22%-40.24%) and NNT (Number Needed to Treat) was 5 (CI=2.5-19.2) CONCLUSION: Lack of available screening results before the surgery may lead to inadequate antibiotic prophylaxis increasing the risk of MRSA surgical site infection. Glycopeptide (e.g.Teicoplanin) prophylaxis should be considered when there is history of MRSA colonization or MRSA screening results are not available before the surgery. Copyright © 2017. Published by Elsevier Ltd.
Yassa, Rafik RD; Khalfaoui, Mahdi Y; Veravalli, Karunakar; Evans, D Alun
Objective The aims of the current study were to determine whether pre-operative urinary tract infections in patients presenting acutely with neck of femur fractures resulted in a delay to surgery and whether such patients were at increased risk of developing post-operative surgical site infections. Design A retrospective review of all patients presenting with a neck of femur fracture, at a single centre over a one-year period. The hospital hip fracture database was used as the main source of ...
Serrano, O K; Bangdiwala, A S; Vock, D M; Berglund, D; Dunn, T B; Finger, E B; Pruett, T L; Matas, A J; Kandaswamy, R
The United Network for Organ Sharing recommends that fellowship-trained surgeons participate in 15 laparoscopic donor nephrectomy (LDN) procedures to be considered proficient. The American Society of Transplant Surgeons (ASTS) mandates 12 LDNs during an abdominal transplant surgery fellowship. We performed a retrospective intraoperative case analysis to create a risk-adjusted cumulative summation (RACUSUM) model to assess the learning curve of novice transplant surgery fellows (TSFs). Between January 2000 and December 2014, 30 novice TSFs participated in the organ procurement rotation of our ASTS-approved abdominal transplant surgery fellowship. Measures of surgical performance included intraoperative time, estimated blood loss, and incidence of intraoperative complications. The performance of senior TSFs was used to benchmark novice TSF performance. Scores were tabulated in a learning curve model, adjusting for case complexity and prior TSF case volume. Rates of adverse surgical events were significantly higher for novice TSFs than for senior TSFs. In univariable analysis, multiple renal arteries, high BMI, prior abdominal surgery, male donor, and nephrolithiasis were correlated with higher incidence of adverse surgical events. Based on the RACUSUM model, high intraoperative time is mitigated after 28 procedures, incidence of intraoperative complications tends to diminish after 24 procedures, and improvement in estimated blood loss did not remain consistent. TSFs exhibit a tipping point in LDN performance by 24-28 cases and proficiency by 35-38 cases. © 2016 The American Society of Transplantation and the American Society of Transplant Surgeons.
Huo, Michael H; Muntz, James
Prophylaxis against venous thromboembolism (VTE) is routinely administered during the hospital stay in at-risk surgical and medical patients. However, in high-risk groups, the risk of deep-vein thrombosis or pulmonary embolism may persist for several weeks after discharge. The standard duration of thromboprophylaxis (6-14 days) may not provide adequate protection against such events. This article reviews published data on the efficacy and safety profile of extended-duration thromboprophylaxis in patients at high risk for VTE, the potential cost-effectiveness of such treatment, and practical aspects of ensuring an effective transition from the inpatient to the outpatient setting. MEDLINE and the Cochrane Database of Systematic Reviews were searched through January 2009 for relevant English-language reports of clinical trials, abstracts, and case reports. The search terms included, but were not limited to, venous thromboembolism, pulmonary embolism, anticoagulation, thromboprophylaxis, prolonged duration, and extended duration. The reference lists of the identified articles were reviewed for additional relevant publications. Congress Web sites were also consulted. The principal criteria for inclusion of a study were that it have a prospective, randomized design and include a control group. Case series and retrospective analyses were excluded. Studies have found that extended-duration thromboprophylaxis (28-45 days) with low-molecular-weight heparins (LMWHs) can reduce the risk of VTE in high-risk patients. In separate meta-analyses, extended-duration thromboprophylaxis with LMWH was associated with significant reductions in the likelihood of symptomatic VTE compared with standard-duration thromboprophylaxis in patients undergoing major orthopedic surgery (odds ratio [OR] = 0.38; 95% CI, 0.24-0.61) or major abdominal or pelvic surgery (Peto OR = 0.22; 95% CI, 0.06-0.80). There was large heterogeneity in the reported rates of major and minor bleeding. The occurrence of
Godt, Sue; Mhatre, Sharmila; Schryer-Roy, Anne-Marie
windows of opportunity.Vibrant West African-led collaborations amongst researchers, decision-makers and civil society, which are effectively supported by national, regional and global funding, need to foster, strengthen and use locally-generated evidence to ensure that efforts to strengthen health systems and improve regional health outcomes are successful. The solutions are clearly not to be found in the 'travelling models' of standardised interventions.
Full Text Available Health Impact Assessment is defined as ‘the combination of procedures, methods and tools through which it is possible to evaluate a policy, a program or a development plan concerning possible effects on public health and their distribution in the general population’. In a constructive debate this definition points out some interesting observations: - health is not the result of health policies alone, but it is often defined by the attention given to it in other contexts; - health is however the result of policies and it therefore must deserve the attention of Decision Makers; - health must not be taken into consideration without taking into account an evaluation of its distribution and its determinants within a population. Particular attention must therefore be paid into inequalities; - following the Council of the European Union recent conclusions on Health in All Policies we have to consider that everyday environments such as day-care centers, schools,workplaces,neighborhoods and the commute between them have significant effects on health and that health, in turn, has an effect on the economy by enabling active and productive participation in working life. In the past 20 years huge progress has been achieved in the epidemiological contest to define risks. Nowadays, it is known that a low cultural level lowers the capacity to respond to prevention, that elevated pollution levels do represent a health risk, and that the scarce social relationships that elderly people have in our society have strong consequences on their health and their quality of life.
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.
Full Text Available Introduction:Anal condylomata acuminata was a well-known disease in ancient times but in recent years there has been a rapidly increasing number of people who suffer from this disease. The main cause of this disease is infection of human papilloma virus (HPV which occurs through sexual contact.Currently there are three different ways to treat anal condylomata. Small changes of anal condylomata can be treated with local therapeutic agents, but the best results of treatment of extensive changes are obtained by surgical techniques.Material/Methods:The study group consisted of 30 patients with diagnosed extensive anal condylomata who underwent surgery in Mikolaj Pirogow High Specialized Hospital in Lodz. The survey was conducted from 2007 to 2011. Patients had been directed to the surgical ward by general surgeons and practitioners, proctologists and urologists. The diagnosis was made after proctological assessment in the knee-chest position.Results:All patients underwent surgery and had complete macroscopic electroexcision of anal condylomata. In the research group there was no mortality. Postoperative complications occurred in 4 (13.3�20patients – postoperative bleeding. Strong pain was present in 14 (46.7�20patients but only in the postoperative period. During postoperative follow-up there was no observed infection in the anal region or recurrence of disease. In the operated group there were no observed cosmetic deformations of the anus and/or the anal canal, narrow anal canal or functional fecal incontinence symptoms.Conclusions:Surgical treatment of anal condylomata is an effective and safe method for the patient. In our research there were no serious postoperative complications or recurrence of the disease during the follow-up period.
Simit H Kumar
Full Text Available Introduction: The production of Metallo-β-lactamases (MBLs is one of the resistance mechanisms of Pseudomonas aeruginosa and Acinetobacter species. There is not much Indian data on the prevalence of MBLs in burns and surgical wards. Materials and Methods: A total of 145 non-duplicate isolates of carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter species, isolated from pus/wound swabs and endotracheal secretions from burns and surgical wards, were tested for MBL production by modified ethylene diamine tetra acetic acid (EDTA disc synergy and double disc synergy tests. Results: Prevalence of MBLs was 26.9% by both the above tests. All MBL-positive isolates were multidrug resistant. Only 6.06% (2/33 P.aeruginosa and 16.67% (1/06 Acinetobacter species were susceptible to piperacillin-tazobactam and netilmycin, respectively. These patients had multiple risk factors like >8 days hospital stay, catheterization, IV lines, previous antibiotic use, mechanical ventilation, etc. Graft application and surgical intervention were significant risk factors in MBL-positive patients. Overall mortality in MBL-positive patients was 34.21%. Conclusion: Emergence of MBL-producing Pseudomonas aeruginosa and Acinetobacter species in this hospital is alarming, which reflect excessive use of carbapenems and at the same time, pose a therapeutic challenge to clinicians as well as to microbiologists. Therefore, a strict antibiotic policy and implementation of proper infection control practices will go a long way to prevent further spread of MBLs. Detection of MBLs should also become mandatory in all hospitals.
Guo, Jiao; Pan, Ling-Hui; Li, Yun-Xi; Yang, Xiang-Di; Li, Le-Qun; Zhang, Chun-Yan; Zhong, Jian-Hong
Surgical site infection (SSI) is the third most frequent type of nosocomial infections. Triclosan-coated sutures are often used to reduce the risk of SSI, but studies examining this have given conflicting results. Therefore, this meta-analysis was performed to assess the efficacy of triclosan-coated sutures for reducing risk of SSI in adults. PubMed, EMBASE, Google Scholar, and ClinicalTrials.gov were searched to identify randomized clinical trials evaluating triclosan-coated sutures for preventing SSI on patients 18 y or older. Thirteen randomized clinical trials involving 5256 participants were included. Triclosan-coated sutures were associated with lower risk of SSI than uncoated sutures across all surgeries (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.65-0.88, P triclosan-coated sutures in abdominal surgeries (RR 0.70, 95% CI 0.50-0.99, P = 0.04) and group with prophylactic antibiotic (RR 0.79, 95% CI 0.63-0.99, P = 0.04). However, such risk reduction was not observed in cardiac surgeries, breast surgeries, or group without prophylactic antibiotic. Triclosan-coated sutures can decrease the incidence of SSI in abdominal surgeries and might not interfere with wound healing process. Nevertheless, further studies are needed to examine whether triclosan-coated sutures are effective at preventing SSI in non-abdominal surgeries and to further study the interaction of antibiotic prophylaxis with triclosan-coated sutures. Copyright © 2016 Elsevier Inc. All rights reserved.
Chivukula, V. Keshav; McGah, Patrick; Prisco, Anthony; Beckman, Jennifer; Mokadam, Nanush; Mahr, Claudius; Aliseda, Alberto
Flow in the aortic vasculature may impact stroke risk in patients with left ventricular assist devices (LVAD) due to severely altered hemodynamics. Patient-specific 3D models of the aortic arch and great vessels were created with an LVAD outflow graft at 45, 60 and 90° from centerline of the ascending aorta, in order to understand the effect of surgical placement on hemodynamics and thrombotic risk. Intermittent aortic valve opening (once every five cardiac cycles) was simulated and the impact of this residual native output investigated for the potential to wash out stagnant flow in the aortic root region. Unsteady CFD simulations with patient-specific boundary conditions were performed. Particle tracking for 10 cardiac cycles was used to determine platelet residence times and shear stress histories. Thrombosis risk was assessed by a combination of Eulerian and Lagrangian metrics and a newly developed thrombogenic potential metric. Results show a strong influence of LVAD outflow graft angle on hemodynamics in the ascending aorta and consequently on stroke risk, with a highly positive impact of aortic valve opening, even at low frequencies. Optimization of LVAD implantation and management strategies based on patient-specific simulations to minimize stroke risk will be presented
Peppler, Kylie; Bender, Sophia
The maker movement consists of a growing culture of hands-on making, creating, designing, and innovating. A hallmark of the maker movement is its do-it-yourself (or do-it-with-others) mindset that brings individuals together around a range of activities, both high- and low-tech, all involving some form of creation or repair. The movement's…
Geelhoed, Willem; Zimmermann, Frank
Dutch criminal law does not provide for criminal liability for a political decision-maker who decides to build a bridge, if thereafter the project runs out of control or the bridge appears not to justify the funds spent on the project. This is most probably even the case if the decision-maker knew
... vessel has an emergency squad when operating, has a manual fire alarm system, or is an ocean-going... ALARM SYSTEMS AND EQUIPMENT General Emergency Alarm Systems § 113.25-5 Location of contact makers. (a... miscellaneous vessel must have a manually operated contact maker for the general emergency alarm system: (1) In...
Stuiver, M. M.; Westerduin, E.; ter Meulen, S.; Vincent, A. D.; Nieweg, O. E.; Wouters, M. W. J. M.
Wound complications occur frequently after inguinal lymph node dissection (ILND) in melanoma patients. Evidence on risk factors for complications is scarce and inconsistent. This study assessed wound complication rates after ILND and investigated associated risk factors, in the melanoma unit of a
Full Text Available Abstract Background Surgical procedures are now very common, with estimates ranging from 4% of the general population having an operation per annum in economically-developing countries; this rising to 8% in economically-developed countries. Whilst these surgical procedures typically result in considerable improvements to health outcomes, it is increasingly appreciated that surgery is a high risk industry. Tools developed in the aviation industry are beginning to be used to minimise the risk of errors in surgery. One such tool is the World Health Organization's (WHO surgery checklist. The National Patient Safety Agency (NPSA manages the largest database of patient safety incidents (PSIs in the world, already having received over three million reports of episodes of care that could or did result in iatrogenic harm. The aim of this study was to estimate how many incidents of wrong site surgery in orthopaedics that have been reported to the NPSA could have been prevented by the WHO surgical checklist. Methods The National Reporting and Learning Service (NRLS database was searched between 1st January 2008- 31st December 2008 to identify all incidents classified as wrong site surgery in orthopaedics. These incidents were broken down into the different types of wrong site surgery. A Likert-scale from 1-5 was used to assess the preventability of these cases if the checklist was used. Results 133/316 (42% incidents satisfied the inclusion criteria. A large proportion of cases, 183/316 were misclassified. Furthermore, there were fewer cases of actual harm [9% (12/133] versus 'near-misses' [121/133 (91%]. Subsequent analysis revealed a smaller proportion of 'near-misses' being prevented by the checklist than the proportion of incidents that resulted in actual harm; 18/121 [14.9% (95% CI 8.5 - 21.2%] versus 10/12 [83.3% (95%CI 62.2 - 104.4%] respectively. Summatively, the checklist could have been prevented 28/133 [21.1% (95%CI 14.1 - 28.0%] patient safety
Jbilou, Jalila; Landry, Réjean; Amara, Nabil; El Adlouni, Salaheddine
engaging in activities of research acquisition, the administrative position (being a manager), the preference for applied research results as source of information, the degree of novelty of research results, and the gender. Modern Canadian healthcare organizations need contemporary decision makers who use ICT and develop OI, if performance is the target. Our results let us suggest that the isolated administrative agents profile is no more effective in a dynamic and changing world. Contemporary decision makers need to be more active intellectually and to take risks in their decisions. Relying exclusively on research results and on their social network is no more helpful for a real shift. Moreover, the traditional factors, i.e. organization size, time, experience ... are no more effective, especially when we consider combined roles. We propose some practical and theoretical recommendations to support these changes.
De Zotti, R; Larese, F; Bovenzi, M; Negro, C; Molinari, S
A survey was carried out on respiratory symptoms and skin prick test response to common allergens (atopy), storage mites, and occupational allergens among 226 bakers and pastry makers from 105 small businesses in northern Italy. Atopy was present in 54 workers (23.4%); 40 workers (17.7%) were skin positive to at least one storage mite, 27 (11.9%) to wheat flour and 17 (7.5%) to alpha-amylase. Work related asthma was reported by 11 (4.9%) workers and rhinoconjunctivitis by 31 (17.7%); 22 workers (10.2%) complained of chronic bronchitis. The distribution of skin prick test results among bakers and among 119 white collar workers did not indicate (by logistic analysis) an increased risk for bakers to skin sensitisation to common allergens, storage mite, or to a group of five flours. Sensitisation to wheat flour, on the other hand, was present only among exposed workers. Skin sensitisation to occupational allergens was significantly associated with atopy (p < 0.001), smoking habit (p = 0.015), and work seniority (p = 0.027). The risk of work related symptoms was associated with sensitisation to wheat or alpha-amylase, and with atopy, but not with sensitisation to storage mites, work seniority, or smoking habit. The results of the study indicate that there is still a significant risk of allergic respiratory disease among Italian bakers. Not only wheat allergens, but also alpha-amylase must be considered as causative agents, although sensitisation to storage mites is not important in the occupational allergic response. Atopy must be regarded as an important predisposing factor for skin sensitisation to occupational allergens and for the onset of symptoms at work. The data confirm that for effective prevention, greater care should be taken not only in limiting environmental exposure, but also in identifying susceptible people.
Ohya, Junichi; Chikuda, Hirotaka; Oichi, Takeshi; Kato, So; Matsui, Hiroki; Horiguchi, Hiromasa; Tanaka, Sakae; Yasunaga, Hideo
A retrospective study of data abstracted from the Diagnosis Procedure Combination (DPC) database, a national representative database in Japan. The aim of this study was to examine seasonal variations in the risk of reoperation for surgical site infection (SSI) following spinal fusion surgery. Although higher rates of infection in the summer than in other seasons were thought to be caused by increasing inexperience of new staff, high temperature, and high humidity, no studies have examined seasonal variations in the risk of SSI following spinal fusion surgery in the country where medical staff rotation timing is not in summer season. In Japan, medical staff rotation starts in April. We retrospectively extracted the data of patients who were admitted between July 2010 and March 2013 from the DPC database. Patients were included if they were aged 20 years or older and underwent elective spinal fusion surgery. The primary outcome was reoperation for SSI during hospitalization. We performed multivariate analysis to clarify the risk factors of primary outcome with adjustment for patient background characteristics. We identified 47,252 eligible patients (23,659 male, 23,593 female). The mean age of the patients was 65.4 years (range, 20-101 yrs). Overall, reoperation for SSI occurred in 0.93% of the patients during hospitalization. The risk of reoperation for SSI was significantly higher in April (vs. February; odds ratio, 1.93; 95% confidence interval, 1.09-3.43, P = 0.03) as well as other known risk factors. In subgroup analysis with stratification for type of hospital, month of surgery was identified as an independent risk factor of reoperation for SSI among cases in an academic hospital, although there was no seasonal variation among those in a nonacademic hospital. This study showed that month of surgery is a risk factor of reoperation for SSI following elective spinal fusion surgery, nevertheless, in the country where medical staff rotation timing is not in
Gravante, Gianpiero; Yahia, Shuker
Numerous drugs, largely used in the wards or at home, have a significant influence on patients with untreated diverticular disease. The consequences can be disastrous, may require an emergency operation, postoperative intensive care, and overall influence the patient’s length of stay and the final outcomes. Bearing these considerations in mind the routine or chronic administration of pain-killers, steroids and non-steroidal anti-inflammatory should be balanced in patients with known diverticular disease as it normally happens with other conditions potentially affected by these drugs (i.e., peptic ulcer disease or chronic obstructive pulmonary disease). This is even more important in the old and frail patient where an eventual surgical treatment may not always be possible. PMID:24106394
Marang-van de Mheen, Perla J; van Duijn-Bakker, Nanny; Kievit, Job
Previous research has shown that sicker patients are less satisfied with their healthcare, but specific effects of adverse health outcomes have not been investigated. The present study aimed to assess whether patients who experience adverse outcomes, in hospital or after discharge, differ in their evaluation of quality of care compared with patients without adverse outcomes. In hospital adverse outcomes were prospectively recorded by surgeons and surgical residents as part of routine care. Four weeks after discharge, patients were interviewed by telephone about the occurrence of post-discharge adverse outcomes, and their overall evaluation of quality of hospital care and specific suggestions for improvements in the healthcare provided. Of 2145 surgical patients admitted to the Leiden University Medical Center in 2003, 1876 (88%) agreed to be interviewed. Overall evaluation was less favourable by patients who experienced post-discharge adverse outcomes only (average 19% lower). These patients were also more often dissatisfied (OR 2.02, 95% CI 1.24 to 3.31) than patients without adverse outcomes, and they more often suggested that improvements were needed in medical care (OR 2.07, 1.45 to 2.95) and that patients were discharged too early (OR 3.26, 1.72 to 6.20). The effect of in hospital adverse outcomes alone was not statistically significant. Patients with both in hospital and post-discharge adverse outcomes also found the quality of care to be lower (on average 33% lower) than patients without adverse outcomes. Post-discharge adverse outcomes negatively influence patients' overall evaluation of quality of care and are perceived as being discharged too early, suggesting that patients need better information at discharge.
Nie, Wanpin; Wang, Yan; Yao, Kai; Wang, Zheng; Wu, Hao
Open surgical repair (OSR) is a conventional surgical method used in the repair a ruptured abdominal aortic aneurysm (AAA); however, OSR results in high perioperative mortality rates. The level of serum angiotensin-converting enzyme 2 (ACE2) has been reported to be an independent risk factor for postoperative in-hospital mortality following major cardiopulmonary surgery. In the present study, the association of serum ACE2 levels with postoperative in-hospital mortality was investigated in patients undergoing OSR for ruptured AAA. The study enrolled 84 consecutive patients underwent OSR for ruptured AAA and were subsequently treated in the intensive care unit. Patients who succumbed postoperatively during hospitalization were defined as non-survivors. Serum ACE2 levels were measured in all patients prior to and following the surgery using ELISA kits. The results indicated that non-survivors showed significantly lower mean preoperative and postoperative serum ACE2 levels when compared with those in survivors. Multivariate logistic regression analysis also showed that, subsequent to adjusting for potential confounders, the serum ACE2 level on preoperative day 1 showed a significant negative association with the postoperative in-hospital mortality. This was confirmed by multivariate hazard ratio analysis, which showed that, subsequent to adjusting for the various potential confounders, the risk of postoperative in-hospital mortality remained significantly higher in the two lowest serum ACE2 level quartiles compared with that in the highest quartile on preoperative day 1. In conclusion, the present study provided the first evidence supporting that the serum ACE2 level is an independent risk factor for the in-hospital mortality following OSR for ruptured AAA. Furthermore, low serum ACE2 levels on preoperative day 1 were found to be associated with increased postoperative in-hospital mortality. Therefore, the serum ACE2 level on preoperative day 1 may be a potential
Appiah, Duke; Schreiner, Pamela J; Bower, Julie K; Sternfeld, Barbara; Lewis, Cora E; Wellons, Melissa F
In the present study, we compared changes in risk factors for cardiovascular disease (CVD) before and after natural menopause (NM), hysterectomy with at least 1 ovary conserved (HOC), or hysterectomy with bilateral oophorectomy (HBSO). Data were obtained from women 18-30 years of age who were enrolled in the Coronary Artery Risk Development in Young Adults Study (1985-2011). Piecewise linear mixed models were used to examine changes in CVD risk factors from baseline to the index visit (the first visit after the date of NM or hysterectomy) and after index visit until the end of follow-up. During 25 years of follow-up, 1,045 women reached menopause (for NM, n = 588; for HOC, n = 304; and for HBSO, n = 153). At baseline, women with either type of hysterectomy had less favorable values for CVD risk factors. When comparing the annual rates of change of all CVD risk factors from baseline until the index visit to those from the index visit to the end of follow-up, we saw a small increase in rate of change for high-density lipoprotein cholesterol (β = 0.28 mg/dL; P = 0.002) and a decrease for triglycerides (β =-0.006 mg/dL; P = 0.027) for all groups. Hysterectomy was not associated with risk factors for CVD after accounting for baseline values. However, antecedent young-adult levels of CVD risk factors were strong predictors of levels of postmenopausal risk factors. © 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.
Chen, Yingtai; Chu, Yunmian; Che, Xu; Lan, Zhongmin; Zhang, Jianwei; Wang, Chengfeng
To investigate the value of Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and a modification of the POSSUM system (P-P0SSUM) scoring system in predicting the surgical operative risk of pancreaticoduodenectomy for periampullary tumors. POSSUM and P-POSSUM scoring systems were used to retrospectively evaluate the clinical data of 432 patients with periampullar tumors who underwent pancreaticoduodenectomy in the Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences from January 1985 to December 2010. The predictive occurrence of postoperative complications and mortality rate were calculated according to the formula. ROC curve analysis and different group of risk factors were used to determine the discrimination ability of the two score systems, and to determine their predictive efficacy by comparing the actual and predictive complications and mortality rates, using Hosmer-Lemeshow test to determine the goodness of fit of the two scoring systems. The average physiological score of the 432 patients was 16.1 ± 3.5, and the average surgical severity score was 19.6 ± 2.7. ROC curve analysis showed that the area under ROC curve for mortality predicted by POSSUM and P-POSSUM were 0.893 and 0.888, showing a non-significant difference (P > 0.05) between them. The area under ROC curve for operative complications predicted by POSSUM scoring system was 0.575. The POSSUM score system was most accurate for the prediction of complication rates of 20%-40%, showing the O/E value of 0.81. Compared with the POSSUM score system, P-POSSUM had better ability in the prediction of postoperative mortality, when the predicted value of mortality was greater than 15%, the predictive result was more accurate, and the O/E value was 1.00. POSSUM and P-POSSUM scoring system have good value in predicting the mortality of patients with periampullary tumors undergoing pancreaticoduodenectomy, but a poorer value of
Full Text Available The assessment of nutritional intakes during hospitalization is crucial, as it is known that nutritional status tends to worsen during the hospital stay, and this can lead to the negative consequences of malnutrition. International guidelines recommend the use of parenteral nutrition (PN in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. However, to date, there are no published data regarding either energy intake or objective measurements associated with it in this patient population. The aim of the present exploratory methodological study was to evaluate whether phase angle (PhA and handgrip strength normalized for skeletal muscle mass (HG/SMM are sensitive early markers of energy intake in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. We evaluated 30 eligible patients, who were treated with personalized dietary modifications and supplemental PN for at least one week during hospitalization. In a liner regression model adjusted for age, gender, basal protein intake and the basal value of each variable, a trend toward improvement of PhA and preservation of HG/SMM was observed in patients satisfying the estimated calorie requirements (N = 20, while a significant deterioration of these parameters occurred in those who were not able to reach the target (N = 10. The mean adjusted difference and 95% CI were +1.4° (0.5–2.3 (p = 0.005 for PhA and +0.23 (0.20–0.43 (p = 0.033 for HG/SMM. A significant correlation between PhA and HG/SMM variations was also observed (r = 0.56 (95% CI, 0.23–0.77; p = 0.0023. PhA and HG/SMM were able to distinguish between hypophagic, non-surgical patients at nutritional risk who satisfied their estimated caloric requirements and those who did not after a one-week personalized nutritional support. Clinical studies are warranted, in order to verify these preliminary observations and to validate the role of Ph
This hands-on, friendly guide shows you how to harness FileMaker's power to make your information work for you. With a few mouse clicks, the FileMaker Pro 11 database helps you create and print corporate reports, manage a mailing list, or run your entire business. FileMaker Pro 11: The Missing Manual helps you get started, build your database, and produce results, whether you're running a business, pursuing a hobby, or planning your retirement. It's a thorough, accessible guide for new, non-technical users, as well as those with more experience. Start up: Get your first database up and runnin
Sara Sabouri Rad
Full Text Available Squamous cell carcinoma (SCC is the second most common type of skin cancer with potential risks for metastasis and recurrence if left untreated or incompletely excised. This case series study was designed to determine the frequency of incompletely excised SCCs and the related risk factors. A total of 273 SCCs (253 patients excised in Razi dermatology hospital of Tehran from 2006-2008, were evaluated and were analyzed by Chi-square or t-test. The incidence of incomplete excision was 17.58 % and deep margin involvement was observed in 73% of lesions. Risk factors associated with incomplete excision of SCCs were being female, location of the tumors (in particular the lesions on lateral canthus, upper lip, foot, forehead, cheek, neck, nose and ear, large lesions and grafting method of repair. There was no statistically significant difference for the age, degree of histological differentiation, childhood history of radiotherapy for tinea capitis and the type of anesthesia. More care should be taken for high risk SCCs as complete excision avoids potential risk of recurrence and metastasis.
Bach, N; Tuomilehto, H; Gauthier, C; Papadakis, A; Remise, C; Lavigne, F; Lavigne, G J; Huynh, N
Maxillary transverse deficiencies (MTD) cause malocclusions. Rapid maxillary expansion treatment is commonly used treatment for correcting such deficiencies and has been found to be effective in improving respiration and sleep architecture in children with obstructive sleep apnoea (OSA). However, thus far, the effect of surgically assisted rapid maxillary expansion (SARME) treatment on sleep architecture and breathing of normal subjects has not been assessed. We hypothesised that sleep quality will improve after maxillary expansion treatment. The objective of this study is to access the effect of maxillary expansion treatment on sleep structure and respiratory functions in healthy young adults with severe MTD. This is a prospective and exploratory clinical study. Twenty-eight consecutive young adult patients (15 males and 13 females, mean age 20·6 ± 5·8 years) presenting with severe MTD at the orthodontic examination were recruited into the study. All the participants underwent a standardised SARME procedure (mean expansion 6·5 ± 1·8 and 8·2 ± 1·8 mm, intercanine and intermolar distance, respectively) to correct malocclusion caused by MTD. An overnight in-laboratory polysomnography, before and after the treatment, was performed. The mean follow-up time was 9 months. The main outcome parameters were the changes in sleep architecture, including sleep stages, arousals, slow-wave activity (SWA) and respiratory variables. Before surgery, young adult patients with MTD presented no evidence of sleep breathing problems. At baseline sleep recording, 7 of 28 (25%) had apnoea-hypopnoea index (AHI) ≥ 5 events per hour. No negative effect of the SARME was observed in questionnaires or sleep laboratory parameters. In the patients with a higher baseline AHI (AHI ≥ 5 h of sleep), we observed a reduction in AHI after surgical treatment (P = 0·028). SARME did not have a negative effect on any sleep or respiration parameters in healthy young individuals
Sarkut, Pinar; Kilicturgay, Sadik; Aktas, Hikmet; Ozen, Yilmaz; Kaya, Ekrem
Laparoscopic cholecystectomy (LC) is the gold standard for the treatment of symptomatic gallbladder stones. As infections are rare in uncomplicated LC, it is widely accepted that prophylactic antibiotics need not be administered, and guidelines do not support routine antibiotic prophylaxis during elective LC. However, routine antibiotic prophylaxis for elective LC is still popular in many clinical settings. We investigated this situation in our department. This randomized double-blind controlled study included 570 patients who underwent LC between March 2007 and February 2010. The exclusion criteria were antibiotic intake before surgery, steroid treatment, and the presence of pancreatitis, cholangitis, obstructive jaundice, cephalosporin allergy, or pregnancy. The patients were randomized into three groups. Group 1 (n = 193) received physiologic saline as placebo, Group 2 (n = 191) received a first-generation cephalosporin (cefazolin; 1 g), and Group 3 (n = 186) received a second-generation cephalosporin (cefuroksim aksetil; 750 mg). Bile and epigastric and umbilical port tissue samples were harvested for culture. All patients were observed until the end of the fourth week after surgery. Patient age, sex, weight, American Society of Anesthesiologists (ASA) score, diabetes mellitus, smoking history, history of biliary colic in the past month, length of the hospital stay before the operation, operational findings (acute or chronic cholecystitis), operation duration, use of drainage, type of prophylaxis administered if any, culture results, surgical site infection (SSI) development, and time to SSI development along with associated treatments were evaluated. There was no statistically significant difference between the groups with respect to any of the demographic and clinical features analyzed in this study. The SSI rate was 1.2% in total, and in Groups 1, 2, and 3, it was 1.5%, 1.04%, and 1.07%, respectively. There was no statistical difference
Yang, Ching-Hsiang; Chew, Khong-Yik; Solomkin, Joseph S; Lin, Pao-Yuan; Chiang, Yuan-Cheng; Kuo, Yur-Ren
Salivary contamination of surgical wounds in clean-contaminated head and neck surgery with free flap reconstruction remains a major cause of infection and leads to significant morbidity. This study investigates the correlation between intraoral flora and surgical site infections (SSIs) among high-risk head and neck cancer patients undergoing resection and free flap reconstruction. One hundred twenty-nine patients were identified as being at high risk for infective complications based on cancer stage, tumor size, comorbid factors, and extent of reconstruction. All patients had intraoral swab cultures before surgery. Patients with culture-confirmed SSI after surgery were chosen for analysis, using the κ index and its 95% confidence interval for concordance analysis. All patients received clindamycin and gentamicin for antibiotic prophylaxis for 5 days. Antibiotic susceptibility testing of all isolates was obtained and analyzed. Thirty-seven patients experienced SSI, or an infection rate of 28.3%, occurring at a mean of 9.3 postoperative days. The overall concordance between oral flora and SSI was fair to moderate (κ index of 0.25), but detailed analysis shows a higher concordance for known and opportunistic pathogens, such as Pseudomonas aeruginosa and Enterococcus faecalis, compared to typical oral commensals. Antibiotic susceptibility tests show rapid and significant increases in resistance to clindamycin, indicating a need for a more effective alternative. Predicting pathogens in SSI using preoperative oral swabs did not demonstrate a good concordance in general for patients undergoing clean-contaminated head and neck surgery, although concordance for certain pathogenic species seem to be higher than for typical intraoral commensals. The rapid development of resistance to clindamycin precludes its use as a prophylactic agent.
Montes, Claudia V; Vilar-Compte, Diana; Velazquez, Consuelo; Golzarri, Maria Fernanda; Cornejo-Juarez, Patricia; Larson, Elaine L
Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli are of increasing concern as a cause of healthcare-associated infections. Using a matched case-control design, demographics, antibiotic use, and relevant surgical data were obtained for 173 cases (ESBL E. coli surgical site infections, [SSI]) and 173 controls (antibiotic-susceptible E. coli SSI) in an oncology hospital in Mexico City. Conditional logistic regression modeling was used to calculate odds ratios (OR). The mean age of patients was 53.6 years, 214 (62%) were female. Demographics and comorbidities were similar between groups. Although antibiotic prophylaxis was common among both cases and controls (84% and 89%), more than one-half of cases (53%) were given prophylaxis outside the recommended window or were exposed for more than 24 h in comparison to 29% of controls. Patients who received untimely (OR=3.13, 95% confidence interval [CI] 1.5-6.4) and discontinued inappropriately (OR 6.38, 95% CI=2.5-16.2) prophylaxis were more likely to develop an ESBL SSI. In addition, patients with an organ/space infection compared with superficial had a higher rate of a resistant infection (OR 4.2, 95% CI 1.3-13.9). Among patients not given timely or appropriately discontinued prophylaxis, post-operative cephalosporin use (OR 3.3, 95% CI 1.4-7.7) was associated with ESBL E. coli SSIs. The appropriate timing and duration of perioperative antimicrobial prophylaxis were associated with lower risk of ESBL E. coli in SSIs. Even though compliance to antimicrobial prophylaxis guidelines is of the utmost importance, reduced exposure to cephalosporins may also potentially decrease the risk of ESBL SSI.
Ramonell, Kimberly M; Fang, Shuyang; Perez, Sebastian D; Srinivasan, Jahnavi K; Sullivan, Patrick S; Galloway, John R; Staley, Charles A; Lin, Edward; Sharma, Jyotirmay; Sweeney, John F; Shaffer, Virginia O
Postoperative acute renal failure is a major cause of morbidity and mortality in colon and rectal surgery. Our objective was to identify preoperative risk factors that predispose patients to postoperative renal failure and renal insufficiency, and subsequently develop a risk calculator. Using the National Surgical Quality Improvement Program Participant Use Files database, all patients who underwent colorectal surgery in 2009 were selected (n = 21,720). We identified renal complications during the 30-day period after surgery. Using multivariate logistic regression analysis, a predictive model was developed. The overall incidence of renal complications among colorectal surgery patients was 1.6 per cent. Significant predictors include male gender (adjusted odds ratio [OR]: 1.8), dependent functional status (OR: 1.5), preoperative dyspnea (OR: 1.5), hypertension (OR: 1.6), preoperative acute renal failure (OR: 2.0), American Society of Anesthesiologists class ≥3 (OR: 2.2), preoperative creatinine >1.2 mg/dL (OR: 2.8), albumin discrimination (area under the curve: 0.76). Using this model, a risk calculator was developed with excellent predictive ability for postoperative renal complications in colorectal patients and can be used to aid clinical decision-making, patient counseling, and further research on measures to improve patient care.
Diwakar D. Balachandran
Full Text Available Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA by classifying patients as low risk (LR if STOP-BANG score < 3 or high risk (HR if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS in the postanesthesia care unit (PACU. Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93% in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%, over the age of 50 (90.1%, and had BMI < 30 kg/m2 (88.4%. STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P=0.008. Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.
McCaskill-Stevens, Worta; Wilson, John W; Cook, Elise D; Edwards, Cora L; Gibson, Regina V; McElwain, Diane L; Figueroa-Moseley, Colmar D; Paskett, Electra D; Roberson, Noma L; Wickerham, D Lawrence; Wolmark, Norman
One of the first chemoprevention trials conducted in the western hemisphere, the National Surgical Adjuvant Breast and Bowel Project's (NSABP) Breast Cancer Prevention Trial (BCPT), demonstrated the need to evaluate all aspects of recruitment in real time and to implement strategies to enroll racial and ethnic minority women. The purpose of this report is to review various patient recruitment efforts the NSABP developed to enhance the participation of racial and ethnic minority women in the Study of Tamoxifen and Raloxifene (STAR) trial and to describe the role that the recruitment process played in the implementation and understanding of breast cancer risk assessment in minority communities. The NSABP STAR trial was a randomized, double-blinded study comparing the use of tamoxifen 20 mg/day to raloxifene 60 mg/day, for a 5-year period, to reduce the risk of developing invasive breast cancer. Eligible postmenopausal women were required to have a 5-year predicted breast cancer risk of 1.66% based on the modified Gail Model. For the current report, eligibility and enrollment data were tabulated by race/ethnicity for women who submitted STAR risk assessment forms (RAFs). A total of 184,460 RAFs were received, 145,550 (78.9%) from white women and 38,910 (21.1%) from minority women. Of the latter group, 21,444 (11.6%) were from African Americans/blacks, 7913 (4.5%) from Hispanics/Latinas, and 9553 (5.2%) from other racial or ethnic groups. The percentages of risk-eligible women among African Americans, Hispanics/Latinas, others, and whites were 14.2%, 23.3%, 13.7%, and 57.4%, respectively. Programs targeting minority enrollment submitted large numbers of RAFs, but the eligibility rates of the women referred from those groups tended to be lower than the rates among women referred outside of those programs. The average number of completed risk assessments increased among minority women over the course of the recruitment period compared to those from whites. We have not
Nielsen, Thomas Dyhre; Jensen, Finn Verner
When modeling a decision problem using the influence diagram framework, thequantitative part rests on two principal components: probabilities forrepresenting the decision maker's uncertainty about the domain andutilities for representing preferences. Over the last decade, several methodshave been...
Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions.
Davenport, Daniel L; Henderson, William G; Mosca, Cecilia L; Khuri, Shukri F; Mentzer, Robert M
Since the Institute of Medicine patient safety reports, a number of survey-based measures of organizational climate safety factors (OCSFs) have been developed. The goal of this study was to measure the impact of OCSFs on risk-adjusted surgical morbidity and mortality. Surveys were administered to staff on general/vascular surgery services during a year. Surveys included multiitem scales measuring OCSFs. Additionally, perceived levels of communication and collaboration with coworkers were assessed. The National Surgical Quality Improvement Program was used to assess risk-adjusted morbidity and mortality. Correlations between outcomes and OCSFs were calculated and between outcomes and communication/collaboration with attending and resident doctors, nurses, and other providers. Fifty-two sites participated in the survey: 44 Veterans Affairs and 8 academic medical centers. A total of 6,083 surveys were returned, for a response rate of 52%. The OCSF measures of teamwork climate, safety climate, working conditions, recognition of stress effects, job satisfaction, and burnout demonstrated internal validity but did not correlate with risk-adjusted outcomes. Reported levels of communication/collaboration with attending and resident doctors correlated with risk-adjusted morbidity. Survey-based teamwork, safety climate, and working conditions scales are not confirmed to measure organizational factors that influence risk-adjusted surgical outcomes. Reported communication/collaboration with attending and resident doctors on surgical services influenced patient morbidity. This suggests the importance of doctors' coordination and decision-making roles on surgical teams in providing high-quality and safe care. We propose risk-adjusted morbidity as an effective measure of surgical patient safety.
Lobo, Suzana M; Lobo, Francisco R; Polachini, Carlos A; Patini, Daniela S; Yamamoto, Adriana E; de Oliveira, Neymar E; Serrano, Patricia; Sanches, Helder S; Spegiorin, Marco A; Queiroz, Marcio M; Christiano, Antonio C; Savieiro, Elisangela F; Alvarez, Paula A; Teixeira, Silvia P; Cunrath, Geni S
Introduction Preventing perioperative tissue oxygen debt contributes to a better postoperative recovery. Whether the beneficial effects of fluids and inotropes during optimization of the oxygen delivery index (DO2I) in high-risk patients submitted to major surgeries are due to fluids, to inotropes, or to the combination of the two is not known. We aimed to investigate the effect of DO2I optimization with fluids or with fluids and dobutamine on the 60-day hospital mortality and incidence of complications. Methods A randomized and controlled trial was performed in 50 high-risk patients (elderly with coexistent pathologies) undergoing major elective surgery. Therapy consisted of pulmonary artery catheter-guided hemodynamic optimization during the operation and 24 hours postoperatively using either fluids alone (n = 25) or fluids and dobutamine (n = 25), aiming to achieve supranormal values (DO2I > 600 ml/minute/m2). Results The cardiovascular depression was an important component in the perioperative period in this group of patients. Cardiovascular complications in the postoperative period occurred significantly more frequently in the volume group (13/25, 52%) than in the dobutamine group (4/25, 16%) (relative risk, 3.25; 95% confidence interval, 1.22–8.60; P < 0.05). The 60-day mortality rates were 28% in the volume group and 8% in the dobutamine group (relative risk, 3.00; 95% confidence interval, 0.67–13.46; not significant). Conclusion In patients with high risk of perioperative death, pulmonary artery catheter-guided hemodynamic optimization using dobutamine determines better outcomes, whereas fluids alone increase the incidence of postoperative complications. PMID:16696864
Tongyoo, Assanee; Chatthamrak, Putipan; Sriussadaporn, Ekkapak; Limpavitayaporn, Palin; Mingmalairak, Chatchai
The surgical site infection (SSI) is a common complication of abdominal operation. It relates to increased hospital stay, increased healthcare cost, and decreased patient's quality of life. Obesity, usually defined by BMI, is known as one of the risks of SSI. However, the thickness of subcutaneous layers of abdominal wall might be an important local factor affecting the rate of SSI after the abdominal operations. The objective of this study is to assess the importance of the abdominal wall thickness on incisional SSI rate. The subjects of the present study were patients who had undergone major abdominal operations at Thammasat University Hospital between June 2013 and May 2014, and had been investigated with CT scans before their operations. The demographic data and clinical information of these patients were recorded. The thickness ofsubcutaneous fatty tissue from skin down to the most superficial layer of abdominal wall muscle at the surgical site was measured on CT images. The wound infectious complication was reviewed and categorized as superficial and deep incisional SSIfollowing the definition from Centersfor Disease Control and Prevention (CDC) guidelines. The significance ofeach potentialfactors on SSI rates was determined separately with student t-test for quantitative data and χ2-test for categorical data. Then all factors, which had p operative CTscans. Post-operative SSI was 25.2% (35/139), superficial and deep types in 27 and 8 patients, respectively. The comparison of abdominal wall thickness between patients with and without infection was significantly different (20.0 ± 8.4 mm and 16.0 ± 7.2 mm, respectively). When the thickness at 20 mm was used as the cut-off value, 43 of 139 patients had abdominal wall thickness ≥ 20 mm. The incidence of SSI of the thickness ±20 mm group was 37.2% (16/43) and of the less thickness group was 19.8% (19/96), with p operation. However, only abdominal wall thickness and wound classification were still significant
SHARP , David
International audience; Effective collaboration between instrument makers, musicians and acousticians can be of great benefit to all parties, leading to improved instrument designs, greater understanding of an instruments playing characteristics, and an improved knowledge of the physical processes that occur within an instrument. As a working relationship develops between an instrument maker, a musician and an acoustician, the trust that builds up can facilitate increasingly more detailed in...
Brown, Molly E.; Escobar, Vanessa M.; Lovell, Heather
This chapter will describe the challenges that earth scientists face in developing science data products relevant to decision maker and policy needs, and will describe strategies that can improve the two-way communication between the scientist and the policy maker. Climate change policy and decision making happens at a variety of scales - from local government implementing solar homes policies to international negotiations through the United Nations Framework Convention on Climate Change. Scientists can work to provide data at these different scales, but if they are not aware of the needs of decision makers or understand what challenges the policy maker is facing, they are likely to be less successful in influencing policy makers as they wished. This is because the science questions they are addressing may be compelling, but not relevant to the challenges that are at the forefront of policy concerns. In this chapter we examine case studies of science-policy partnerships, and the strategies each partnership uses to engage the scientist at a variety of scales. We examine three case studies: the global Carbon Monitoring System pilot project developed by NASA, a forest biomass mapping effort for Silvacarbon project, and a forest canopy cover project being conducted for forest management in Maryland. In each of these case studies, relationships between scientists and policy makers were critical for ensuring the focus of the science as well as the success of the decision-making.
MacNeela, Pádraig; Scott, P Anne; Treacy, Margaret; Hyde, Abbey; O'Mahony, Rebecca
Psychiatric patients are liable to stereotyping by healthcare providers. We explored attitudes toward caring for psychiatric patients among 13 nurses working in general hospitals in Ireland. Participants thought aloud in response to a simulated patient case and described a critical incident of a patient for whom they had cared. Two attitudinal orientations were identified that correspond to stereotypical depictions of risk and vulnerability. The nurses described psychosocial care strategies that were pragmatic rather than authentically person-centered, with particular associations between risk-oriented attitudes and directive nursing care. Nurses had expectations likely to impede relationship building and collaborative care. Implications arising include the need for improved knowledge about psychiatric conditions and for access to professional development in targeted therapeutic communication skills. Copyright © 2012 Wiley Periodicals, Inc.
Background In health services research, there is a growing view that partnerships between researchers and decision-makers (i.e., collaborative research teams) will enhance the effective translation and use of research results into policy and practice. For this reason, there is an increasing expectation by health research funding agencies that health system managers, policy-makers, practitioners and clinicians will be members of funded research teams. While this view has merit to improve the uptake of research findings, the practical challenges of building and sustaining collaborative research teams with members from both inside and outside the research setting requires consideration. A small body of literature has discussed issues that may arise when conducting research in one’s own setting; however, there is a lack of clear guidance to deal with practical challenges that may arise in research teams that include team members who have links with the organization/community being studied (i.e., are “insiders”). Discussion In this article, we discuss a researcher-decision-maker partnership that investigated practice in primary care networks in Alberta. Specifically, we report on processes to guide the role clarification of insider team members where research activities may pose potential risk to participants or the team members (e.g., access to raw data). Summary These guiding principles could provide a useful discussion point for researchers and decision-makers engaged in health services research. PMID:22928979
Full Text Available Abstract Background In health services research, there is a growing view that partnerships between researchers and decision-makers (i.e., collaborative research teams will enhance the effective translation and use of research results into policy and practice. For this reason, there is an increasing expectation by health research funding agencies that health system managers, policy-makers, practitioners and clinicians will be members of funded research teams. While this view has merit to improve the uptake of research findings, the practical challenges of building and sustaining collaborative research teams with members from both inside and outside the research setting requires consideration. A small body of literature has discussed issues that may arise when conducting research in one’s own setting; however, there is a lack of clear guidance to deal with practical challenges that may arise in research teams that include team members who have links with the organization/community being studied (i.e., are “insiders”. Discussion In this article, we discuss a researcher-decision-maker partnership that investigated practice in primary care networks in Alberta. Specifically, we report on processes to guide the role clarification of insider team members where research activities may pose potential risk to participants or the team members (e.g., access to raw data. Summary These guiding principles could provide a useful discussion point for researchers and decision-makers engaged in health services research.
Schwenk, W; Hoffmann, P C
Preoperative evaluation of patient risk is an essential component of patient preparation before surgery. Guidelines provide evidence-based algorithms for preoperative assessment of cardiac risk; however, even experienced physicians correctly apply evidence-based algorithms in only 50% of all cases or less. A checklist system for guideline-based cardiopulmonary risk evaluation in adult patients undergoing abdominal or visceral surgery (CAVE checklists) was created to assist in preoperative cardiopulmonary risk assessment and increase correct application of evidence-based algorithms before elective visceral surgery. International guidelines were transformed into a checklist system. These checklists were than evaluated in a department of general and visceral surgery. The main goal was to determine whether preoperative examinations, such as electrocardiograph (ECG), chest-x-ray, spirometry and advanced assessment by a cardiologist, are performed according to evidence-based guidelines. The frequency of recommended as well as unnecessary and missed examinations was assessed. In this study 541 patients with a median age of 64.5 years (interquartile range: 52-73 years) were examined using the checklist system. Of the patients 90.4% underwent ECG and 98.5% chest-X-ray as recommended in the guidelines. Spirometry was not recommended in any patient and not performed in any case. Advanced assessment by a cardiologist was performed in 45.5% of cases as recommended in the guidelines. When guidelines did not recommend ECG, x‑ray, spirometry or advanced cardiac assessment, 69.4%, 99.6%, 99.3% and 99.8% of patients, respectively, actually did not receive these examinations. Only 2.8% of all patients did not receive an examination that was recommended by the guidelines: 1.5% ECG, 0.2% x‑ray and 1.1% advanced cardiological assessment. None of these patients suffered from postoperative cardiopulmonary complications. These simple checklists are easy to use and provide a
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.
Kaplan, Uri; Penner, Scott; Farrokhyar, Forough; Andruszkiewicz, Nicole; Breau, Ruth; Gmora, Scott; Hong, Dennis; Anvari, Mehran
Older age (> 60) has been considered a relative contraindication for bariatric surgery due to increased complication risk. This study examined the risks and benefits of bariatric surgery for patients older than 60 years in Canadian population. This was a retrospective cohort study of the Ontario Bariatric Registry: a database recording peri-operative and post-operative outcomes of publicly funded bariatric surgeries across the province. Patients who completed 1 year follow-up, who underwent laparoscopic gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between January 2010 and May 2013, were divided into older (> 60) and younger (> 60) cohorts, and outcomes were compared. Between January 2010 and May 2013, 3166 registry patients underwent LRYGB or LSG and completed 1-year follow-up. Of these, 204 (6.5%) were older than 60 years, with 175 (85.8%) undergoing LRYGB and 29 (14.2%) LSG. Demographics were similar, except for a higher number of males in the older group (59 (28.9%) versus 452 (15.3%) (p < 0.001)). No significant difference in complication rate was noted (15% for younger cohort versus 13.8% (p = 0.889)). The average percentage of excess weight loss was significantly higher in the younger population (60.72% versus 56.25% (p < 0.05)) overall, however not significantly in the LSG group. Reduction in medication use post-surgery for management of co-morbidities was significantly higher in the older patients (- 0.91 versus - 2.03 (p < 0.001)). The older cohort who underwent LRYGB or LSG was at no greater risk for intra-operative and post-operative complications and showed greater reduction in medication use post-surgery when compared to the younger cohort.
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 ...
Risk factors for unplanned readmission within 30 days after pediatric neurosurgery: a nationwide analysis of 9799 procedures from the American College of Surgeons National Surgical Quality Improvement Program.
Sherrod, Brandon A; Johnston, James M; Rocque, Brandon G
OBJECTIVE Hospital readmission rate is increasingly used as a quality outcome measure after surgery. The purpose of this study was to establish, using a national database, the baseline readmission rates and risk factors for patient readmission after pediatric neurosurgical procedures. METHODS The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database was queried for pediatric patients treated by a neurosurgeon between 2012 and 2013. Procedures were categorized by current procedural terminology (CPT) code. Patient demographics, comorbidities, preoperative laboratory values, operative variables, and postoperative complications were analyzed via univariate and multivariate techniques to find associations with unplanned readmissions within 30 days of the primary procedure. RESULTS A total of 9799 cases met the inclusion criteria, 1098 (11.2%) of which had an unplanned readmission within 30 days. Readmission occurred 14.0 ± 7.7 days postoperatively (mean ± standard deviation). The 4 procedures with the highest unplanned readmission rates were CSF shunt revision (17.3%; CPT codes 62225 and 62230), repair of myelomeningocele > 5 cm in diameter (15.4%), CSF shunt creation (14.1%), and craniectomy for infratentorial tumor excision (13.9%). The lowest unplanned readmission rates were for spine (6.5%), craniotomy for craniosynostosis (2.1%), and skin lesion (1.0%) procedures. On multivariate regression analysis, the odds of readmission were greatest in patients experiencing postoperative surgical site infection (SSI; deep, organ/space, superficial SSI, and wound disruption: OR > 12 and p 10 days (OR 1.411, p = 0.010), oxygen supplementation (OR 1.645, p = 0.010), nutritional support (OR 1.403, p = 0.009), seizure disorder (OR 1.250, p = 0.021), and longer operative time (per hour increase, OR 1.059, p = 0.029). CONCLUSIONS This study may aid in identifying patients at risk for unplanned readmission following pediatric neurosurgery
Straub, B; Bouletreau, P; Breton, P
Orthodontic preparation for orthognathic surgery requires correcting mal-occlusions and coordination of arcades. In addition to improving the aesthetics, these treatments can ensure the achievement and sustainability of prosthetics and/or implants. Nevertheless, periodontal structures are easily damaged. Orthodontic displacement can only be applied in the absence of inflammation or weakened periodontal structure. An early detection of periodontal risk should be achievable by prescribers of a surgical-orthodontic treatment. Simplified periodontal examination, with easily detectable warning signs, will help to identify the periodontal risk. Although periodontal treatment follows current "non invasive" trend, some procedures remain necessary to prevent and/or remedy periodontal defects or diseases, such as mineral periodontal reinforcement corticotomy. It is essential that the patient meets all the practitioners to plan and assess the extent of the constraints necessary to optimize results, before starting orthodontic treatment combined with orthognathic surgery. Any periodontal complication (even minor) will be considered as a failure, regardless of good aesthetic and functional results. Copyright © 2014 Elsevier Masson SAS. All rights reserved.
Gokhale, Priyanka; Lappen, Justin R; Waters, Jonathan H; Perriera, Lisa K
The primary objective of this study was to assess the risk of perioperative anesthesia-related complications in a cohort of obese and non-obese women undergoing outpatient surgical abortion under IV sedation without tracheal intubation. We performed a retrospective cohort study of all surgical abortions through 22 6/7 weeks' gestation at an outpatient clinic from 2012 to 2013. Women receiving IV sedation were included. Obesity status was defined by the World Health Organization criteria. The primary outcome was the rate of perioperative anesthesia complications defined as tracheal intubation, pulmonary aspiration, hospital transfer for an anesthesia indication, or anesthesia-related adverse events (persistent hypoxemia and allergic reaction). The use of opioid reversal (naloxone) was assessed as a secondary outcome measure. Multivariate analysis for the secondary outcome measure was performed with adjustment for confounding factors. During the study period, 9348 abortions were performed. Of the 5579 patients who received IV sedation, 1438 (25.8%) were obese, 1707 (30.6%) were in the second trimester, and 851 (15.3%) were ≥17 weeks' gestation. No patients experienced a primary outcome measure. Based on the upper 95% confidence interval (CI) for the sample size, the maximal risk of an anesthesia-related complication is 1 in 1860 procedures. Naloxone use occurred in 13 (0.2%) patients and was not more frequent among obese patients (0.14% vs 0.27%; 95% CI of odds ratio [OR], 0.12-2.36; P = 0.54) or procedures at ≥17 weeks' gestation (0.47% vs 0.19%; 95% CI of OR, 0.76-8.06; P = 0.12). These negative findings should be interpreted with caution, given the limitations of the sample size to assess these secondary outcome measures. Naloxone use was associated with fentanyl doses >200 μg (0.82% vs 0.13%; P = 0.002), an association that remained significant when we controlled for confounding factors (adjusted OR, 5.51; 95% CI, 1.61-18.91). Further analysis revealed that
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 ...
Zhou, Zhen-Yu; Liu, Ya-Ke; Chen, Hong-Lin; Liu, Fan
Patients with diabetes have a high risk of surgical site infection (SSI) after ankle surgery. The aim of the present study was to investigate the efficacy of vacuum-assisted closure (VAC) in the prevention of SSI after ankle surgery compared with the efficacy of standard moist wound care (SMWC). A retrospective study was performed of unstable ankle fractures for surgical fixation in patients with diabetes from January 2012 to December 2014. VAC and SMWC were used for surgical incision coverage. The primary outcome was the incidence of SSI, and the secondary outcomes were the length of hospital stay and crude hospital costs. The data from 76 patients were analyzed, with 22 (28.95%) in the VAC group and 54 (71.05%) in the SMWC group. The incidence of SSI was 4.6% in the VAC group compared with 27.8% in the SMWC group (chi-square 5.076; p = .024), and the crude odds ratio for SSI in the VAC group was 0.124 (95% confidence interval 0.002 to 0.938). The length of hospital stay was lower in the VAC group than in the SMWC group (12.6 ± 2.7 days and 15.2 ± 3.5 days, respectively; t = 3.122, p = .003). The crude hospital costs were also lower in the VAC group than in the SMWC group (Chinese yuan 8643.2 ± 1195.3 and 9456.2 ± 1106.3, respectively; t = 2.839, p = .006). After logistic regression analysis, the adjusted odds ratio for the total SSI rate comparing VAC and SMWC was 0.324 (95% confidence interval 0.092 to 0.804; p = .021). Compared with SMWC, VAC can decrease the SSI rate after ankle surgery in patients with diabetes. This finding should be confirmed by prospective, randomized controlled clinical trials. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Asghar, All; Hashmi, Madiha; Rashid, Saima; Khan, Fazal Hameed
Sepsis is amongst the leading causes of admission to the intensive care units and is associated with a high mortality. However, data from developing countries is scares. Aim of conducting this study was to determine the incidence, outcome and risk factors for sepsis on admission to surgical intensive care unit (SICU) of a teaching hospital in Pakistan. Two year retrospective observational study included all consecutive adult admissions to the surgical intensive care unit (SICU) of a University Hospital, from January 2012 to December 2013. Two hundred and twenty-nine patients met the inclusion criteria. Average age of the patients was 46.35 ± 18.23 years (16-85), mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 15.92 ± 8.13 and males were 67.6%. Median length of ICU stay was 4 [IQR 5]. 43% patients fulfilled the criteria of sepsis at the time of admission to the SICU and incidence of severe sepsis/septic shock was 35%. Abdominal sepsis was the most frequent source of infection (57.5%). The overall intensive care unit mortality was 32.31% but the mortality of sepsis-group was 51.15% as compared to 17.7% of the non- sepsis group. Stepwise logistic regression model showed that increasing age, female gender, non-operative admission, admission under general surgery and co-morbidities like ischaemic heart disease and chronic kidney disease were significant predictors of sepsis. The incidence of sepsis and severe sepsis/septic shock, on admission to SICU is high and mortality of the sepsis group is nearly three times the mortality of the non-sepsis group.
Asghar, A.; Hashmi, M.; Rashid, S.; Khan, F.H.
Background: Sepsis is amongst the leading causes of admission to the intensive care units and is associated with a high mortality. However, data from developing countries is scarse. Aim of conducting this study was to determine the incidence, outcome and risk factors for sepsis on admission to surgical intensive care unit (SICU) of a teaching hospital in Pakistan. Methods: Two year retrospective observational study included all consecutive adult admissions to the surgical intensive care unit (SICU) of a University Hospital, from January 2012 to December 2013. Results: Two hundred and twenty-nine patients met the inclusion criteria. Average age of the patients was 46.35±18.23 years (16-85), mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 15.92±8.13 and males were 67.6 percentage. Median length of ICU stay was 4 [IQR 5]. 43 percentage patients fulfilled the criteria of sepsis at the time of admission to the SICU and incidence of severe sepsis/septic shock was 35 percentage. Abdominal sepsis was the most frequent source of infection (57.5 percentage). The overall intensive care unit mortality was 32.31 percentage but the mortality of sepsis-group was 51.15 percentage as compared to 17.7 percentage of the non-sepsis group. Stepwise logistic regression model showed that increasing age, female gender, non-operative admission, admission under general surgery and co-morbidities like ischaemic heart disease and chronic kidney disease were significant predictors of sepsis. Conclusion: The incidence of sepsis and severe sepsis/septic shock, on admission to SICU is high and mortality of the sepsis group is nearly three times the mortality of the non-sepsis group. (author)
Hourieh, Shamshiri-Milani; Abolghasem, Pourreza; Feizollah, Akbari
Unsafe and illegal abortions are the third leading cause of maternal death. It affects physical, emotional and social health of women and their families. Abortion is a multi-dimensional phenomenon with several social, legal, and religious implications. The views of policy-makers affect the approach to abortion in every society. Understanding the attitudes and knowledge of high-ranking decision makers towards abortion was the purpose of this study. A qualitative research was implemented by carrying out individual interviews with 29 out of a selection of 80 presidents of medical sciences universities, senior executive managers in the legal system, forensic medicine and decision-makers in the health system and a number of top Muslim clerics, using a semi-structured questionnaire for data gathering. Content analysis revealed the results. There were considerable unwillingness and reluctance among the interviewees to participate in the study. The majority of participants fairly knew about the prevalence of illegal abortions and their complications. There was strong agreement on abortion when health of the mother or the fetus was at risk. Abortion for reproductive health reasons was supported by a minority of the respondents. The majority of them disagreed with abortion when pregnancy was the result of a rape, temporary marriage or out of wedlock affairs. Making decision for abortion by the pregnant mother, as a matter of her right, did not gain too much approval. It seemed that physical health of the mother or the fetus was of more importance to the respondents than their mental or social health. The mother's hardship was not any indication for induced abortion in the viewpoints of the interviewed policy-makers. Strengthening family planning programs, making appropriate laws in lines with religious orders and advocacy programs targeting decision makers are determined as strategies for improving women's health rights.
Yukalov, V. I.; Yukalova, E. P.; Sornette, D.
We suggest a model of a multi-agent society of decision makers taking decisions being based on two criteria, one is the utility of the prospects and the other is the attractiveness of the considered prospects. The model is the generalization of quantum decision theory, developed earlier for single decision makers realizing one-step decisions, in two principal aspects. First, several decision makers are considered simultaneously, who interact with each other through information exchange. Second, a multistep procedure is treated, when the agents exchange information many times. Several decision makers exchanging information and forming their judgment, using quantum rules, form a kind of a quantum information network, where collective decisions develop in time as a result of information exchange. In addition to characterizing collective decisions that arise in human societies, such networks can describe dynamical processes occurring in artificial quantum intelligence composed of several parts or in a cluster of quantum computers. The practical usage of the theory is illustrated on the dynamic disjunction effect for which three quantitative predictions are made: (i) the probabilistic behavior of decision makers at the initial stage of the process is described; (ii) the decrease of the difference between the initial prospect probabilities and the related utility factors is proved; (iii) the existence of a common consensus after multiple exchange of information is predicted. The predicted numerical values are in very good agreement with empirical data.
Nascimento, Susana; Pólvora, Alexandre
Supported by easier and cheaper access to tools and expanding communities, maker cultures are pointing towards the ideas of (almost) everyone designing, creating, producing and distributing renewed, new and improved products, machines, things or artefacts. A careful analysis of the assumptions and challenges of maker cultures emphasizes the relevance of what may be called technological action, that is, active and critical interventions regarding the purposes and applications of technologies within ordinary lives, thus countering the deterministic trends of current directions of technology. In such transformative potential, we will explore a set of elements what is and could be technological action through snapshots of maker cultures based on the empirical research conducted in three particular contexts: the Fab Lab Network, Maker Media core outputs and initiatives such as Maker Faires, and the Open Source Hardware Association (OSHWA). Elements such as control and empowerment through material engagement, openness and sharing, and social, cultural, political and ethical values of the common good in topics such as diversity, sustainability and transparency, are critically analysed.
Vitale, Michael G; Riedel, Matthew D; Glotzbecker, Michael P; Matsumoto, Hiroko; Roye, David P; Akbarnia, Behrooz A; Anderson, Richard C E; Brockmeyer, Douglas L; Emans, John B; Erickson, Mark; Flynn, John M; Lenke, Lawrence G; Lewis, Stephen J; Luhmann, Scott J; McLeod, Lisa M; Newton, Peter O; Nyquist, Ann-Christine; Richards, B Stephens; Shah, Suken A; Skaggs, David L; Smith, John T; Sponseller, Paul D; Sucato, Daniel J; Zeller, Reinhard D; Saiman, Lisa
Perioperative surgical site infection (SSI) after pediatric spine fusion is a recognized complication with rates between 0.5% and 1.6% in adolescent idiopathic scoliosis and up to 22% in "high risk" patients. Significant variation in the approach to infection prophylaxis has been well documented. The purpose of this initiative is to develop a consensus-based "Best Practice" Guideline (BPG), informed by both the available evidence in the literature and expert opinion, for high-risk pediatric patients undergoing spine fusion. For the purpose of this effort, high risk was defined as anything other than a primary fusion in a patient with idiopathic scoliosis without significant comorbidities. The ultimate goal of this initiative is to decrease the wide variability in SSI prevention strategies in this area, ultimately leading to improved patient outcomes and reduced health care costs. An expert panel composed of 20 pediatric spine surgeons and 3 infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine surgery, was developed. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were as follows: (1) surveyed for current practices; (2) presented with a detailed systematic review of the relevant literature; (3) given the opportunity to voice opinion collectively; and (4) asked to vote regarding preferences privately. Round 1 was conducted using an electronic survey. Initial results were compiled and discussed face-to-face. Round 2 was conducted using the Audience Response System, allowing participants to vote for (strongly support or support) or against inclusion of each intervention. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. Repeat voting for consensus was performed. Consensus was reached to support 14 SSI prevention strategies and all participants agreed to implement the BPG in their
Shimohata, Keiko; Hasegawa, Kazuhiro; Onodera, Osamu; Nishizawa, Masatoyo; Shimohata, Takayoshi
To clarify the clinical features and risk factors of cervicogenic headache (CEH; as diagnosed according to the International Classification of Headache Disorders-Third Edition beta) in patients with cervical spine disorders requiring surgery. CEH is caused by cervical spine disorders. The pathogenic mechanism of CEH is hypothesized to involve a convergence of the upper cervical afferents from the C1, C2, and C3 spinal nerves and the trigeminal afferents in the trigeminocervical nucleus of the upper cervical cord. According to this hypothesis, functional convergence of the upper cervical and trigeminal sensory pathways allows the bidirectional (afferent and efferent) referral of pain to the occipital, frontal, temporal, and/or orbital regions. Previous prospective studies have reported an 86-88% prevalence of headache in patients with cervical myelopathy or radiculopathy requiring anterior cervical surgery; however, these studies did not diagnose headache according to the International Classification of Headache Disorders criteria. Therefore, a better understanding of the prevalence rate, clinical features, risk factors, and treatment responsiveness of CEH in patients with cervical spine disorders requiring surgery is necessary. We performed a single hospital-based prospective cross-sectional study and enrolled 70 consecutive patients with cervical spine disorders such as cervical spondylotic myelopathy, ossification of the posterior longitudinal ligament, cervical spondylotic radiculopathy, and cervical spondylotic myeloradiculopathy who had been scheduled to undergo anterior cervical fusion or dorsal cervical laminoplasty between June 2014 and December 2015. Headache was diagnosed preoperatively according to the International Classification of Headache Disorders-Third Edition beta. The Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire, Neck Disability Index, and a 0-100 mm visual analog scale (VAS) were used to evaluate clinical
Percutaneous implantation of the CoreValve aortic valve prosthesis in patients at high risk or rejected for surgical valve replacement: Clinical evaluation and feasibility of the procedure in the first 30 patients in the AMC-UvA
Baan, J.; Yong, Z. Y.; Koch, K. T.; Henriques, J. P. S.; Bouma, B. J.; de Hert, S. G.; van der Meulen, J.; Tijssen, J. G. P.; Piek, J. J.; de Mol, B. A. J. M.
Objective. To report the feasibility, safety and efficacy of percutaneous aortic valve implantation (PAVI) with the CoreValve self-expanding aortic valve bioprosthesis in elderly patients with aortic valve stenosis who are rejected for surgery or have a high surgical risk.Methods. PAVI using the
Novais, Eduardo N; Potter, Gorden D; Sierra, Rafael J; Kim, Young-Jo; Clohisy, John C; Schoenecker, Perry L; Trousdale, Robert T; Carry, Patrick M; Millis, Michael B
The Bernese periacetabular osteotomy (PAO) is frequently used to treat symptomatic acetabular dysplasia in the adolescent age group. Despite encouraging results, factors predictive of the development of postoperative complications remain poorly understood. The purpose of this study was to investigate whether obesity is a risk factor for complications following PAO in adolescents. A retrospective cohort study design was used to collect data from 3 different institutions. Children and adolescents (below 19 y of age) who underwent PAO and were followed for minimum of 12 months were included. Obesity was defined as a body mass index ≥95 percentile. The modified Clavien-Dindo classification was used to grade complications. A logistic regression analysis was used to identify factors related to the development of a complication that required treatment outside of routine postoperative care (complication grades II to V). Changes in radiographic parameters including Tönnis acetabular roof angle, anterior center-edge angle, and lateral center-edge angle among obese versus nonobese subjects were also evaluated. The mean age at surgery among the 84 adolescents included in the study was 16.5 years (range, 12 to 19 y). A total of 11% of the population was considered obese. Obesity (P=0.0047) was the only variable significantly associated with the development of a complication. After controlling for study site, the odds of an obese subject developing a complication were 10 [95% confidence interval (CI), 1.89-59.8] times the odds of a nonobese subject developing a complication. There was no difference in the magnitude of change in anterior center-edge angle (P=0.1251), lateral center-edge angle (P=0.9774), or Tönnis (P=0.5770) angular correction that was achieved among the obese versus nonobese subjects following surgery. The Bernese PAO allows for adequate radiographic correction of acetabular dysplasia among obese and nonobese adolescents. However, the hip preservation
Al-Temimi, Mohammed H; Chandrasekaran, Bindupriya; Phelan, Michael J; Pigazzi, Alessio; Mills, Steven D; Stamos, Michael J; Carmichael, Joseph C
Motor peripheral nerve injury is a rare but serious event after colorectal surgery, and a nationwide study of this complication is lacking. The purpose of this study was to report the incidence, trends, and risk factors of motor peripheral nerve injury during colorectal surgery. The National Surgical Quality Improvement Program database was surveyed for motor peripheral nerve injury complicating colorectal procedures. Risk factors for this complication were identified using logistic regression analysis. The study used a national database. Patients undergoing colorectal resection between 2005 and 2013 were included. The incidence, trends, and risk factors for motor peripheral nerve injury complicating colorectal procedures were measured. We identified 186,936 colorectal cases, of which 50,470 (27%) were performed laparoscopically. Motor peripheral nerve injury occurred in 122 patients (0.065%). Injury rates declined over the study period, from 0.025% in 2006 to nerve injury were younger (mean ± SD; 54.02 ± 15.41 y vs 61.56 ± 15.95 y; p Nerve injury was also associated with longer operative times (277.16 ± 169.79 min vs 176.69 ± 104.80 min; p nerve injury (OR = 1.04 (95% CI, 1.03-1.04)), whereas increasing age was associated with a protective effect (OR = 0.80 (95% CI, 0.71-0.90)). This study was limited by its retrospective nature. Motor peripheral nerve injury during colorectal procedures is uncommon (0.065%), and its rate declined significantly over the study period. Prolonged operative time is the strongest predictor of motor peripheral nerve injury during colorectal procedures. Instituting and documenting measures to prevent nerve injury is imperative; however, special attention to this complication is necessary when surgeons contemplate long colorectal procedures.
Verwilghen, Denis; Singh, Ameet
A diverse array of pathogen-related, patient-related, and caretaker-related issues influence risk and prevention of surgical site infections (SSIs). The entire surgical team involved in health care settings in which surgical procedures are performed play a pivotal role in the prevention of SSIs. ...
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...
Isgren, C M; Salem, S E; Archer, D C; Worsman, F C F; Townsend, N B
Surgical site infection (SSI) is an important cause of post operative morbidity following laparotomy. To investigate risk factors for SSI, including effect of season and surgery performed outside normal working hours, and to report bacterial isolates and antimicrobial resistance patterns. Retrospective cohort study. Data were obtained from horses that had undergone exploratory laparotomy over a 3-year period (2010-2013) in a UK hospital population. SSI was defined as any purulent or serous discharge from the laparotomy incision of >24 h duration that developed during hospitalisation. Multivariable logistic regression was used to identify associations between pre-, intra- and post operative variables and altered likelihood of SSI. Surgical site infection developed in 73/287 (25.4%) horses during hospitalisation. Horses of greater bodyweight (odds ratio [OR] 1.002, 95% confidence interval [CI] 1.0002-1.005, P = 0.03), increased packed cell volume (≥48%) on admission (OR 3.03, 95% CI 1.32-6.94, P = 0.01), small intestinal resection (OR 2.27, 95% CI 1.15-4.46, P = 0.02) and post operative colic (OR 2.86, 95% CI 1.41-5.79, P = 0.003) were significantly associated with increased likelihood of SSI in a multivariable model. SSI was also significantly more likely to occur during winter (OR 3.84, 95% CI 1.38-10.70, P = 0.01) and summer (OR 5.63, 95% CI 2.07-15.3, P = 0.001) months in the model. Three-layer closure of the incision was protective (OR 0.31, 95% CI 0.16-0.58, P<0.001) compared to 2-layer closure. There was no effect of surgery being performed outside normal working hours (P = 0.5). The most common bacterial isolates were Escherichia coli (59.5%), Enterococcus spp. (42.4%) and Staphylococcus spp. (25.4%). Penicillin resistant isolates accounted for 92% (96/104) of isolates while 18% (21/119) of isolates were gentamicin resistant. Laparotomy during winter and summer months was associated with increased likelihood of SSI but there was no effect of surgery
Sherrod, Brandon A.; Arynchyna, Anastasia A.; Johnston, James M.; Rozzelle, Curtis J.; Blount, Jeffrey P.; Oakes, W. Jerry; Rocque, Brandon G.
Objective Surgical site infection (SSI) following CSF shunt operations has been well studied, yet risk factors for nonshunt pediatric neurosurgery are less well understood. The purpose of this study was to determine SSI rates and risk factors following nonshunt pediatric neurosurgery using a nationwide patient cohort and an institutional dataset specifically for better understanding SSI. Methods The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS NSQIP-P) database for the years 2012–2014, including all neurosurgical procedures performed on pediatric patients except CSF shunts and hematoma evacuations. SSI included deep (intracranial abscesses, meningitis, osteomyelitis, and ventriculitis) and superficial wound infections. The authors performed univariate analyses of SSI association with procedure, demographic, comorbidity, operative, and hospital variables, with subsequent multivariate logistic regression analysis to determine independent risk factors for SSI within 30 days of the index procedure. A similar analysis was performed using a detailed institutional infection database from Children’s Hospital of Alabama (COA). Results A total of 9296 nonshunt procedures were identified in NSQIP-P with an overall 30-day SSI rate of 2.7%. The 30-day SSI rate in the COA institutional database was similar (3.3% of 1103 procedures, p = 0.325). Postoperative time to SSI in NSQIP-P and COA was 14.6 ± 6.8 days and 14.8 ± 7.3 days, respectively (mean ± SD). Myelomeningocele (4.3% in NSQIP-P, 6.3% in COA), spine (3.5%, 4.9%), and epilepsy (3.4%, 3.1%) procedure categoriess had the highest SSI rates by procedure category in both NSQIP-P and COA. Independent SSI risk factors in NSQIP-P included postoperative pneumonia (OR 4.761, 95% CI 1.269–17.857, p = 0.021), immune disease/immunosuppressant use (OR 3.671, 95% CI 1.371–9.827, p = 0.010), cerebral palsy (OR 2.835, 95% CI 1.463–5.494, p = 0.002), emergency
Sherrod, Brandon A; Arynchyna, Anastasia A; Johnston, James M; Rozzelle, Curtis J; Blount, Jeffrey P; Oakes, W Jerry; Rocque, Brandon G
OBJECTIVE Surgical site infection (SSI) following CSF shunt operations has been well studied, yet risk factors for nonshunt pediatric neurosurgery are less well understood. The purpose of this study was to determine SSI rates and risk factors following nonshunt pediatric neurosurgery using a nationwide patient cohort and an institutional data set specifically for better understanding SSI. METHODS The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) database for the years 2012-2014, including all neurosurgical procedures performed on pediatric patients except CSF shunts and hematoma evacuations. SSI included deep (intracranial abscesses, meningitis, osteomyelitis, and ventriculitis) and superficial wound infections. The authors performed univariate analyses of SSI association with procedure, demographic, comorbidity, operative, and hospital variables, with subsequent multivariate logistic regression analysis to determine independent risk factors for SSI within 30 days of the index procedure. A similar analysis was performed using a detailed institutional infection database from Children's of Alabama (COA). RESULTS A total of 9296 nonshunt procedures were identified in NSQIP-P with an overall 30-day SSI rate of 2.7%. The 30-day SSI rate in the COA institutional database was similar (3.3% of 1103 procedures, p = 0.325). Postoperative time to SSI in NSQIP-P and COA was 14.6 ± 6.8 days and 14.8 ± 7.3 days, respectively (mean ± SD). Myelomeningocele (4.3% in NSQIP-P, 6.3% in COA), spine (3.5%, 4.9%), and epilepsy (3.4%, 3.1%) procedure categories had the highest SSI rates by procedure category in both NSQIP-P and COA. Independent SSI risk factors in NSQIP-P included postoperative pneumonia (OR 4.761, 95% CI 1.269-17.857, p = 0.021), immune disease/immunosuppressant use (OR 3.671, 95% CI 1.371-9.827, p = 0.010), cerebral palsy (OR 2.835, 95% CI 1.463-5.494, p = 0.002), emergency operation (OR 1
Christensen, Morten; Frigaard, Peter
An absorbing wave maker operated by means of on-line signals from digital FIR filters is presented. Surface elevations are measured in two positions in front of the wave maker. The reflected wave train is seperated by the sum of the incident and reflected wave trains by means of digital filtering...... and subsequent superposition of the measured surface elevations. The motion of the wave paddle required to absorb reflected waves is determined and added to the original wave paddle control signal. Irregular wave tests involving test structures with different degrees of reflection show that excellent absorption...
Bell, Trudy E.
A history of lesser-known telescope makers. The following makers, owners, dealers and firms are discussed: Henry Fitz, William S. Van Duzee, Lewis M. Rutherford, Charles A. Spencer, A. K. Eaton, John Byrne, Robert B. Tolles, Buff and Berger of Boston, Fauth and Co., George N. Saegmuller, E. Kubel (Kübel), Chester S. Lyman, Stackpole and Brother, William Wurdemann (Würdemann), William J. Young, Gundlach of Rochester, William Kahler, Stendicke of NYC, Walther of Philadelphia, Worcester R. Warner, Ambrose Swasey, William T. Gregg, Phelps and Gurley of Troy, H. G. Sedgewick, Benjamin Pike, William Mogey, David Mogey, and James A. Queen.
This case study of climate change communications assesses the salient means of communication and the message adopted by regional political decision makers on the German Baltic coast. Realizing that cultural factors and local values (and not simply knowledge) are significant influences in explaining attitudes towards climate change, this analysis draws from the records of regional weather, from scientists with a specific focus on the region, from the political decision makers for that region, and the media message reaching the decision makers, ensuring all elements of the analysis are drawn from the same socioeconomic, geophysical, political and cultural context. This is important as the social dynamics surrounding the trust in science is of critical importance and, as such, all elements of the case study are specifically contained within a common context. If the utility of climate change knowledge is to prompt well conceived adaptation/mitigation strategies then the political decision process, or at least the perceptions shaping it, can best be understood by locating it within the world view of the decision makers involved in the production process. Using the results of two survey questionnaires, one of regional climate scientists and one of regional political decision makers, ten years of local weather records, and a summary of the message from mass media circulation, the discord in perceptions of regional climate change are quantitatively explored. The conclusions drawn from the analysis include, compared to the scientific assessment: The decision makers' perceptions of recent past differ from actual observations. The decision makers' perceptions of the future differ from scientific assessments. The decision makers tend to over estimate the magnitude of regional climate change and its impacts. The decision makers tend to over estimate the sense of immediacy for adaptation measures. The conclusions drawn suggest that in the regional political realm, it is often a
[Percutaneous transfemoral valvuloplasty in patients with calcified aortic stenosis and significantly increased surgical risk: clinical course and value of Doppler sonography in assessment of therapeutic success].
Kücherer, H; Katus, H; Dietz, R; Rauch, B; Kübler, W
Percutaneous transluminal valvuloplasty (PTV) was performed in 24 patients (aged 67-86 years, mean: 76 +/- 5.7 years) with calcific aortic stenosis and high operative risk. The gradient between maximal left ventricular and aortic pressures (peak-to-peak gradient, PPPG) could be reduced by 52% from 73 +/- 21 to 34 +/- 12 mmHg (p less than 0.001). Peak pressure gradient (PPG), as assessed by continuous wave Doppler, could be reduced from 80 +/- 28 to 58 +/- 21 mmHg (p less than 0.001). Aortic valve area (AVA) as determined by Doppler and two dimensional echocardiography increased significantly from 0.39 +/- 0.14 to 0.61 +/- 0.3 cm2 (p less than 0.05). Clinical symptoms were found to be improved in 5 of 8 patients with impaired ejection fraction and in 11 of 16 patients with normal ejection fraction during the first week after PTV. Complications due to the procedure were surgical revision of femoral artery puncture site in one patient and hemodynamic relevant pericardial effusion in another patient. Transmitral early (E) and late (L) diastolic filling integrals were measured by pulsed Doppler: the ratio E/L decreased significantly after PTV from 0.9 +/- 0.5 to 0.63 +/- 0.31 (p less than 0.03) indicating further reduction of left ventricular early diastolic filling. Ejection fraction, stroke volume and cardiac output did not significantly change immediately after PTV.(ABSTRACT TRUNCATED AT 250 WORDS)
Moreno-Vicente, Javier; Schiavone-Mussano, Rocío; Clemente-Salas, Enrique; Marí-Roig, Antoni; Jané-Salas, Enric
Background Coronectomy is the surgical removal of the crown of the tooth deliberately leaving part of its roots. This is done with the hope of eliminating the pathology caused, and since the roots are still intact, the integrity of the inferior alveolar nerve is preserved. Objectives The aim is to carry out a systematic review in order to be able to provide results and conclusions with the greatest scientific evidence possible. Material and Methods A literature review is carried out through the following search engines: Pubmed MEDLINE, Scielo, Cochrane library and EMI. The level of evidence criteria from the Agency for Healthcare Research and Quality was applied, and the clinical trials’ level of quality was analyzed by means of the JADAD criteria. Results The following articles were obtained which represents a total of 17: 1 systematic review, 2 randomized clinical trials and 2 non-randomized clinical trials, 3 cohort studies, 2 retrospective studies, 3 case studies and 4 literature reviews. Conclusions Coronectomy is an adequate preventative technique in protecting the inferior alveolar nerve, which is an alternative to the conventional extraction of third molars, which unlike the former technique, presents a high risk of injury to the inferior alveolar nerve. However, there is a need for new clinical studies, with a greater number of samples and with a longer follow-up period in order to detect potential adverse effects of the retained roots. Key words: Coronectomy, inferior alveolar nerve, nerve injury, wisdom tooth removal, paresthesia, and systematic review. PMID:25858081
Pérez Gladish, Blanca María; Arenas Parra, María del Mar; Bilbao Terol, Amelia María; Rodríguez Uria, María Victoria
This study attempts to apply a management science technique to improve the efficiency of Hospital Administration. We aim to design the performance of the surgical services at a Public Hospital that allows the Decision-Maker to plan surgical scheduling over one year in order to reduce waiting lists. Real decision problems usually involve several objectives that have parameters which are often given by the decision maker in an imprecise way. It is possible to handle these kinds of problems ...
Jordá Aragón, Carlos; Peñalver Cuesta, Juan Carlos; Mancheño Franch, Nuria; de Aguiar Quevedo, Karol; Vera Sempere, Francisco; Padilla Alarcón, José
Survival studies of non-small cell lung cancer (NSCLC) are usually based on the Kaplan-Meier method. However, other factors not covered by this method may modify the observation of the event of interest. There are models of cumulative incidence (CI), that take into account these competing risks, enabling more accurate survival estimates and evaluation of the risk of death from other causes. We aimed to evaluate these models in resected early-stage NSCLC patients. This study included 263 patients with resected NSCLC whose diameter was ≤ 3 cm without node involvement (N0). Demographic, clinical, morphopathological and surgical variables, TNM classification and long-term evolution were analysed. To analyse CI, death by another cause was considered to be competitive event. For the univariate analysis, Gray's method was used, while Fine and Gray's method was employed for the multivariate analysis. Mortality by NSCLC was 19.4% at 5 years and 14.3% by another cause. Both curves crossed at 6.3 years, and probability of death by another cause became greater from this point. In multivariate analysis, cancer mortality was conditioned by visceral pleural invasion (VPI) (P=.001) and vascular invasion (P=.020), with age>50 years (P=.034), smoking (P=.009) and the Charlson index ≥ 2 (P=.000) being by no cancer. By the method of CI, VPI and vascular invasion conditioned cancer death in NSCLC >3 cm, while non-tumor causes of long-term death were determined. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.
The adventures of Coco Nut, a coconut which has fallen from a palm tree in Florida, are illustrated in this booklet for elementary school students. His fall into a canal and ensuing encounters with dead and alive fish and a gadget maker (industry) are used to portray the effects of water pollution. What man can do to stop such pollution and…
Lille, Benjamin; Romero, Margarida
Creativity is a key competence in 21st century education. Among the active learning pedagogies which aims to develop creativity, learning by making is an emerging approach in which the students are engaged in the co-creation of a shared artefact. In this study, we aim to analyse the creativity competency through a maker-based projects.…
Stoyanov, S.; Aroyo, L.M.; Kommers, Petrus A.M.; Ivanov, Ivan
This paper focuses on the purposes, theoretical model, and functionality of the SMILE (Solution Mapping Intelligent Learning Environment) Maker--a World Wide Web-based problem-solving tool. From an instructional design point of view, an attempt to establish a balance between
An evidence to policy self-assessment questionnaire was used to assess the capacity of forty MNCH policy makers to acquire, assess, adapt and apply research evidence for policy making. Results: Low mean ratings were observed ranging from 2.68-3.53 on a scale of 5 for knowledge about initiating/conducting research ...
Jan 1, 2009 ... For the International Development Research Centre ( IDRC ) and its partners, the link between research and policy is of paramount importance in their goal to improve social, economic, and environmental conditions in developing countries. Collaboration between researchers and decision-makers, ...
Sep 3, 2017 ... research and capacity to assess authenticity, validity, reliability, relevance and applicability of research evidence and for organiza- ... Conclusion: There is need to institute policy makers' capacity development programmes to improve evidence-informed poli- ..... designing of research methodology; writing of ...
Sep 17, 2008 ... described by the above framework – and, in particular, the workings of the bureaucracy – would appear to constitute the major challenge facing high-level technical professionals and decision-makers in the provision and sustainability of water services. More generally, the investigation established that for ...
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.
Rijken, Conny; Pijnenburg, Annick
Human trafficking is one of the largest criminal enterprises in the world. It is a multi-billiondollar crime of global scale. This is because human trafficking as a criminal enterprise continues to evolve as a high profit-low risk business for perpetrators and challenges policy makers, law
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.
Vilain, Katherine R; Magnuson, Elizabeth A; Li, Haiyan; Clark, Wayne M; Begg, Richard J; Sam, Albert D; Sternbergh, W Charles; Weaver, Fred A; Gray, William A; Voeks, Jenifer H; Brott, Thomas G; Cohen, David J
from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00004732.
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.
Full Text Available Published data suggests that wedge resection for stage I NSCLC results in improved overall survival compared to stereotactic body radiation therapy (SBRT. We report CyberKnife outcomes for high-risk surgical patients with biopsy-proven stage I NSCLC. PET/CT imaging was completed for staging. Three-to-five gold fiducial markers were implanted in or near tumors to serve as targeting references. Gross tumor volumes (GTVs were contoured using lung windows; the margins were expanded by 5 mm to establish the planning treatment volume (PTV. Treatment plans were designed using hundreds of pencil beams. Doses delivered to the PTV ranged from 42-60 Gy in 3 fractions. The 30-Gy isodose contour extended at least 1cm from the GTV to eradicate microscopic disease. Treatments were delivered using the CyberKnife system with tumor tracking. Examination and PET/CT imaging occurred at 3-month follow-up intervals. Forty patients (median age 76 with a median maximum tumor diameter of 2.6 cm (range, 1.4-5.0 cm and a mean post-bronchodilator percent predicted forced expiratory volume in 1 second (FEV1 of 57% (range, 21 - 111% were treated. A mean dose of 50 Gy was delivered to the PTV over 3 to 13 days (median, 7 days. The 30-Gy isodose contour extended a mean 1.9 cm from the GTV. At a median 44 months (range, 12 -72 months follow-up, the 3-year Kaplan-Meier locoregional control and overall survival estimates compare favorably with contemporary wedge resection outcomes at 91% and 75% , respectively. CyberKnife is an effective treatment approach for stage I NSCLC that is similar to wedge resection, eradicating tumors with 1 to 2 cm margins in order to preserve lung function. Prospective randomized trials comparing CyberKnife with wedge resection are necessary to confirm equivalence.
Full Text Available Abstract Background With an ever-increasing elderly population, orthopaedic surgeons are faced with treating a high number of fragility fractures. Biomechanical tests have demonstrated the potential role of osteoporosis in the increased risk of fracture fixation complications, yet this has not been sufficiently proven in clinical practice. Based on this knowledge, two clinical studies were designed to investigate the influence of local bone quality on the occurrence of complications in elderly patients with distal radius and proximal humerus fractures treated by open reduction and internal fixation. Methods/Design The studies were planned using a prospective multicentre open cohort design and included patients between 50 and 90 years of age. Distal radius and proximal humerus fractures were treated with locking compression 2.4 mm and proximal humerus internal locking plates, respectively. Follow-up examinations were planned for 6 weeks, 3 and 12 months as well as a telephone interview at 6 months. The primary outcome focuses on the occurrence of at least one local bone quality related complication. Local bone quality is determined by measuring bone mineral density and bone mineral content at the contralateral radius. Primary complications are categorised according to predefined factors directly related to the bone/fracture or the implant/surgical technique. Secondary outcomes include the documentation of soft tissue/wound or general/systemic complications, clinical assessment of range of motion, and patient-rated evaluations of upper limb function and quality of life using both objective and subjective measures. Discussion The prospective multicentre open cohort studies will determine the value of local bone quality as measured by bone mineral density and content, and compare the quality of local bone of patients who experience a complication (cases following surgery with that of patients who do not (controls. These measurements are novel and
Wang, Tao; Chen, Tao; Zou, Shu; Lin, Ning; Liang, Hong-yin; Yan, Hong-tao; Li, Nan-lin; Liu, Li-ye; Luo, Hao; Chen, Qi; Liu, Wei-hui; Tang, Li-jun
technique for the management of small stones (less than 15 mm) in high-risk surgical patients.
The Power Makers - the producers of our electricity - must meet the demands of their customers while also addressing the threat of climate change. There are widely differing views about solutions to electricity generation in an emission constrained world. Some see the problem as relatively straight forward, requiring deep cuts in emissions now by improving energy efficiency, energy conservation and using only renewable resources. Many electricity industry engineers and scientists see the problem as being much more involved. The Power Makers ’ Challenge: and the need for Fission Energy looks at why using only conventional renewable energy sources is not quite as simple as it seems. Following a general introduction to electricity and its distribution, the author quantifies the reductions needed in greenhouse gas emissions from the power sector in the face of ever increasing world demands for electricity. It provides some much needed background on the many energy sources available for producing electricity ...
Full Text Available This study examines the recognition and use of critical success factors by market makers in electronic marketplaces. A content analysis of e-marketplace websites enabled an examination of how these factors have been incorporated into marketplace sites. Evidence of market makers’ awareness of the success factors was found in all the sites although there remain questions and issues to be addressed. Awareness of the need for critical mass and privacy were very evident, but the key factors of security, technological infrastructure and neutrality were identified as areas of concern. Evidence of an awareness of the importance of trust by market makers was found, but more effective signalling of trust to buyers and sellers within the marketplaces is required.
Šmíd, Martin; Kopa, Miloš
Roč. 53, č. 5 (2017), s. 922-958 ISSN 0023-5954 R&D Projects: GA ČR(CZ) GBP402/12/G097 Institutional support: RVO:67985556 Keywords : market maker * optimal decision * price and inventory * high frequency data * dynamic model Subject RIV: BB - Applied Statistics, Operational Research OBOR OECD: Statistics and probability Impact factor: 0.379, year: 2016 http://www.library.utia.cas.cz/separaty/2017/E/smid-0483753.pdf
Lieberman, Heather D; Fogelman, Joshua P; Ramsay, David L; Cohen, David E
Allergy to colophony is well noted in the literature, however, there have been few case reports of allergic contact dermatitis to propolis in musicians and instrument makers. We report a case of a stringed instrument craftsman who developed allergic contact dermatitis to propolis, a component of Italian varnish. A review of the components, applications, and the clinical manifestations of hypersensitivity reactions to propolis are presented.
Game merupakan salah satu industri di dunia saat ini. Perkembangan game begitu pesat dengan jenis yang beragam, mulai dari game yang hanya dapat dimainkan oleh satu orang saja hingga game yang dapat dimainkan oleh beberapa orang sekaligus. RPG maker VX merupakan perangkat lunak yang digunakan untuk membuat sebuah game ber-genre RPG. Tujuan tugas akhir ini adalah untuk membuat sebuah game bertema wirausaha namun dengan gaya bermain RPG (Role Playing Game). 092406213
Scientists can and should inform public policy decisions in the Arctic. But the pace of climate change in the polar world has been occurring far more quickly than most scientists have been able to predict. This creates problems for decision-makers who recognize that difficult management decisions have to be made in matters pertaining to wildlife management, cultural integrity and economic development. With sea ice melting, glaciers receding, permafrost thawing, forest fires intensifying, and disease and invasive species rapidly moving north, the challenge for scientists to provide climate policy makers with a strong scientific base has been daunting. Clashing as this data sometimes does with the “traditional knowledge” of indigenous peoples in the north, it can also become very political. As a result the need to effectively communicate complex data is more imperative now than ever before. Here, the author describes how the work of scientists can often be misinterpreted or exploited in ways that were not intended. Examples include the inappropriate use of scientific data in decision-making on polar bears, caribou and other wildlife populations; the use of scientific data to debunk the fact that greenhouse gases are driving climate change, and the use of scientific data to position one scientist against another when there is no inherent conflict. This work will highlight the need for climate policy makers to increase support for scientists working in the Arctic, as well as illustrate why it is important to find new and more effective ways of communicating scientific data. Strategies that might be considered by granting agencies, scientists and climate policy decision-makers will also be discussed.
This Guide comes from the activities of the Arts and Humanities Research Council Video Games Research Networking Scheme project, Creative Territories (2014-15). The project looked at the recent emergence of small and independent game maker collectives. The aims were to get some bearings on these as part of the growth of indie games production and to consider how to support them as valuable components in the long term sustainability of this important breeding ground of video game creativity wh...
Strategic Issues in Information Technology: International Implications for Decision Makers presents the significant development of information technology in the output of components, computers, and communication equipment and systems. This book discusses the integration of information technology into factories and offices to increase productivity.Organized into six parts encompassing 12 chapters, this book begins with an overview of the advancement towards an automated interpretation communication system to achieve real international communication. This text then examines the main determining
Kwan, Phoenix; Birmingham, Amanda
High-throughput screening (HTS) is a common technique for both drug discovery and basic research, but researchers often struggle with how best to derive hits from HTS data. While a wide range of hit identification techniques exist, little information is available about their sensitivity and specificity, especially in comparison to each other. To address this, we have developed the open-source NoiseMaker software tool for generation of realistically noisy virtual screens. By applying potential hit identification methods to NoiseMaker-simulated data and determining how many of the pre-defined true hits are recovered (as well as how many known non-hits are misidentified as hits), one can draw conclusions about the likely performance of these techniques on real data containing unknown true hits. Such simulations apply to a range of screens, such as those using small molecules, siRNAs, shRNAs, miRNA mimics or inhibitors, or gene over-expression; we demonstrate this utility by using it to explain apparently conflicting reports about the performance of the B score hit identification method. NoiseMaker is written in C#, an ECMA and ISO standard language with compilers for multiple operating systems. Source code, a Windows installer and complete unit tests are available at http://sourceforge.net/projects/noisemaker. Full documentation and support are provided via an extensive help file and tool-tips, and the developers welcome user suggestions.
No clinical effect of prosthesis-patient mismatch after transcatheter versus surgical aortic valve replacement in intermediate- and low-risk patients with severe aortic valve stenosis at mid-term follow-up
Thyregod, Hans Gustav Hørsted; Steinbrüchel, Daniel Andreas; Ihlemann, Nikolaj
OBJECTIVES: Prosthesis-patient mismatch (PPM) after surgical aortic valve replacement (SAVR) for severe aortic valve stenosis (AVS) is common, but less common after transcatheter aortic valve replacement (TAVR) in patients considered at high risk for death after surgery. The objectives of this st......OBJECTIVES: Prosthesis-patient mismatch (PPM) after surgical aortic valve replacement (SAVR) for severe aortic valve stenosis (AVS) is common, but less common after transcatheter aortic valve replacement (TAVR) in patients considered at high risk for death after surgery. The objectives...... for TAVR, and younger age and higher body mass index for SAVR. At 2 years, there were numerical but no statistically significant differences between both TAVR and SAVR patients with severe and no severe PPM for MACCE (0.0 vs 12.8% for TAVR; P = 0.13, and 13.5 vs 7.0% for SAVR; P = 0.27), number of cardiac...
Møller, Henrik; Riaz, Sharma P; Holmberg, Lars
calendar year, and patients were assigned to a hospital volume quintile on the basis of the volume of their hospital. Hospitals with large lung cancer surgical resection volumes were less restrictive in their selection of patients for surgical management and provided a higher resection rate...... for this analysis was based on cancer registration and hospital discharge data and comprised information on 15,738 non-small-cell lung cancer patients resident and diagnosed in England in 2006-2010 and treated by surgical resection. The number of lung cancer resections was computed for each hospital in each......It is debated whether treating cancer patients in high-volume surgical centres can lead to improvement in outcomes, such as shorter length of hospital stay, decreased frequency and severity of post-operative complications, decreased re-admission, and decreased mortality. The dataset...
Suefuji, Masaki; Heinze, Jürgen
Socially parasitic ants of the formicoxenine genus Myrmoxenus exhibit considerable diversity in colony structure and life history. While some species are active slave-makers with many workers and others are workerless 'murder-parasites,' Myrmoxenus kraussei is considered as a 'degenerate slave-maker' because of its very low worker numbers. Here, we document that Temnothorax recedens host workers in single colonies of M. kraussei from Lago di Garda, Italy, exhibit significantly more genetic diversity than workers in unparasitized colonies. This raises the possibility that, despite its low worker numbers, M. kraussei may actively engage in slave raids in nature. © 2014 International Society of Zoological Sciences, Institute of Zoology/Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd.
Background The development of pediatric surgical care in Africa has suffered from the neglect of health policy makers, yet surgery remains an essential component of basic healthcare and an important means of providing preventive and curative treatment. The purpose of this report is to highlight the problem of childhood ...
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.
Cost-effectiveness of transcatheter aortic valve replacement compared with surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results of the PARTNER (Placement of Aortic Transcatheter Valves) trial (Cohort A).
Reynolds, Matthew R; Magnuson, Elizabeth A; Lei, Yang; Wang, Kaijun; Vilain, Katherine; Li, Haiyan; Walczak, Joshua; Pinto, Duane S; Thourani, Vinod H; Svensson, Lars G; Mack, Michael J; Miller, D Craig; Satler, Lowell E; Bavaria, Joseph; Smith, Craig R; Leon, Martin B; Cohen, David J
The aim of this study was to evaluate the cost-effectiveness of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (AVR) for patients with severe aortic stenosis and high surgical risk. TAVR is an alternative to AVR for patients with severe aortic stenosis and high surgical risk. We performed a formal economic analysis based on cost, quality of life, and survival data collected in the PARTNER A (Placement of Aortic Transcatheter Valves) trial in which patients with severe aortic stenosis and high surgical risk were randomized to TAVR or AVR. Cumulative 12-month costs (assessed from a U.S. societal perspective) and quality-adjusted life-years (QALYs) were compared separately for the transfemoral (TF) and transapical (TA) cohorts. Although 12-month costs and QALYs were similar for TAVR and AVR in the overall population, there were important differences when results were stratified by access site. In the TF cohort, total 12-month costs were slightly lower with TAVR and QALYs were slightly higher such that TF-TAVR was economically dominant compared with AVR in the base case and economically attractive (incremental cost-effectiveness ratio economically dominated by AVR in the base case and economically attractive in only 7.1% of replicates. In the PARTNER trial, TAVR was an economically attractive strategy compared with AVR for patients suitable for TF access. Future studies are necessary to determine whether improved experience and outcomes with TA-TAVR can improve its cost-effectiveness relative to AVR. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Brown, Lucy; Duthie, Lyndsay
Lucy Brown and Lyndsay Duthie are award-winning television programme-makers (having worked for BBC, ITV, Channel 4, SKY) and they run Film and TV production programmes. Their presentation will explore how to create compelling reality TV, like the Kardashians, going behind the scenes to reveal the mechanics of the format, the casting and the key ingredients that make up a successful reality format.\\ud \\ud Brown and Duthie have writen a book called The TV Studio Production Handbook, designed to...
Zugno, Marco; Morales González, Juan Miguel; Pinson, Pierre
We consider the problem of a wind power producer trading energy in short-term electricity markets. The producer is a price-taker in the day-ahead market, but a price-maker in the balancing market, and aims at optimizing its expected revenues from these market floors. The problem is formulated...... or median forecast of wind power distribution. Finally, sensitivity analyses are carried out to assess the impact on the offering strategy of the producer's penetration in the market, of the correlation between wind power production and residual system deviation, and of the shape of the forecast...
Grunert, Klaus G.; Trondsen, Torbjørn; Campos, Emilio Gonzalo
Purpose: This study determines whether predictions about different degrees of market orientation in two cross-border value chains also appear in the mental models of decision makers at two levels of these value chains. Design: The laddering method elicits mental models of actors in two value chains......: Norwegian salmon exported to Japan and Danish pork exported to Japan. The analysis of the mental models centers on potential overlap and linkages between actors in the value chain, including elements in the mental models that may relate to the actors' market orientation. Findings: In both value chains...
Full Text Available No abstract available. Article truncated at 150 words. Two years after high generic drug prices became a public controversy, Reuters is reporting that 20 states filed a lawsuit Thursday against Mylan, Teva Pharmaceuticals and four other generic drug makers (1. The suit alleges the companies conspired to fix prices or allocated markets to prop up prices. The civil lawsuit, led by antitrust investigators in Connecticut, comes one day after the U.S. Department of Justice filed criminal charges against two former executives of the generic drug maker, Heritage. The states attorneys general asked the court to order the companies to disgorge ill-gotten gains, which were not defined, pay attorneys' fees and stop collusion. Of the states in the Southwest only Nevada is participating in the lawsuit. The cases are part of a broader generic drug pricing probe that remains under way at the state and federal level, as well as in the U.S. Congress. In 2014, media reports of …
Johnson, Fred A.; Eaton, Mitchell J.; Williams, James H.; Jensen, Gitte H.; Madsen, Jesper
Traditional conservation curricula and training typically emphasizes only one part of systematic decision making (i.e., the science), at the expense of preparing conservation practitioners with critical skills in values-setting, working with decision makers and stakeholders, and effective problem framing. In this article we describe how the application of decision science is relevant to conservation problems and suggest how current and future conservation practitioners can be trained to be better decision makers. Though decision-analytic approaches vary considerably, they all involve: (1) properly formulating the decision problem; (2) specifying feasible alternative actions; and (3) selecting criteria for evaluating potential outcomes. Two approaches are available for providing training in decision science, with each serving different needs. Formal education is useful for providing simple, well-defined problems that allow demonstrations of the structure, axioms and general characteristics of a decision-analytic approach. In contrast, practical training can offer complex, realistic decision problems requiring more careful structuring and analysis than those used for formal training purposes. Ultimately, the kinds and degree of training necessary depend on the role conservation practitioners play in a decision-making process. Those attempting to facilitate decision-making processes will need advanced training in both technical aspects of decision science and in facilitation techniques, as well as opportunities to apprentice under decision analysts/consultants. Our primary goal should be an attempt to ingrain a discipline for applying clarity of thought to all decisions.
Santa Maria Victoria
Full Text Available Several factors increase the risk of insicional hernias post-kidney transplantation and different surgical techniques exist for solving this problem. A retrospective study analyzing the risk factors for developing an insicional hernia and eventroplasties made in the kidney transplants performed between 2006-2013 was performed. The incidence of hernias was 12.7%. All elements studied were statistically independent of the appearance of hernias, probably by influence when combined together and not each separately. Consistent with the literature in which patients did not mesh was used or an absorbable mesh used had a recurrence of 100%. It should be more study of the risk factors that influence the development of post-transplant hernias because of the contradictions that arise from the literature. Post-transplant renal ventral hernia repair is safe and effective provided it is carried out for non-resorbable mesh. The risk of post-surgical infections does not appear to be affected by the use of mesh when the necessary precautions are taken, and if it does not change the prognosis.
Alp, E.; Bijl, D.; Bleichrodt, R.P.; Hansson, B.M.; Voss, A.
Gaseous byproducts produced during electrocautery, laser surgery or the use of ultrasonic scalpels are usually referred to as 'surgical smoke'. This smoke, produced with or without a heating process, contains bio-aerosols with viable and non-viable cellular material that subsequently poses a risk of
for ophthalmic surgical procedures (1-7). Regional anaesthetic techniques eliminate the need for some routine investigations like chest X-ray, ECG,as well as risk associated with general anaesthesia (8) they are more tolerable for elderly patients, ill patients, they are cheaper and generally more useful for ambulatory ...
Weijers, M.; Snow, G.B.; Bezemer, DP; Wal, van der J.E.; Waal, van der I.
0.5 cm, the difference being not statistically significant. Apparently, the presence of tumour cells within a distance of less than 0.5 cm, but not into the deep surgical margin, does not necessarily seem to require additional treatment. The pattern of invasion and the presence or absence of
also dictates to the surgeon about the implant body placement that offers the best ... surgical template. The requirements are more relevant than the. Surgical Templates for Dental Implant Positioning;. Current Knowledge and Clinical Perspectives. Mohammed Zaheer Kola ..... A risk of damage to vital anatomical structures.
Optimisation of surgical care means weighing the risk of treatment related morbidity against the patients’ potential benefits of a surgical intervention. The first part of this thesis focusses on the anaemic patient undergoing colorectal surgery. Hypothesizing that a more profound haemoglobin
Full Text Available Abstract Background The Contextualized Health Research Synthesis Program (CHRSP, developed in 2007 by the Newfoundland and Labrador Centre for Applied Health Research, produces contextualized knowledge syntheses for health-system decision makers. The program provides timely, relevant, and easy-to-understand scientific evidence; optimizes evidence uptake; and, most importantly, attunes research questions and evidence to the specific context in which knowledge users must apply the findings. Methods As an integrated knowledge translation (KT method, CHRSP: Involves intensive partnerships with senior healthcare decision makers who propose priority research topics and participate on research teams; Considers local context both in framing the research question and in reporting the findings; Makes economical use of resources by utilizing a limited number of staff; Uses a combination of external and local experts; and Works quickly by synthesizing high-level systematic review evidence rather than primary studies. Although it was developed in the Canadian province of Newfoundland and Labrador, the CHRSP methodology is adaptable to a variety of settings with distinctive features, such as those in rural, remote, and small-town locations. Results CHRSP has published 25 syntheses on priority topics chosen by the provincial healthcare system, including: Clinical and cost-effectiveness: telehealth, rural renal dialysis, point-of-care testing; Community-based health services: helping seniors age in place, supporting seniors with dementia, residential treatment centers for at-risk youth; Healthcare organization/service delivery: reducing acute-care length of stay, promoting flu vaccination among health workers, safe patient handling, age-friendly acute care; and Health promotion: diabetes prevention, promoting healthy dietary habits. These studies have been used by decision makers to inform local policy and practice decisions. Conclusions By asking the health
Palko, S.; Glieca, M.; Dombrowski, A.
Following numerous national and international studies conducted on the overall impact of the 1986 Chernobyl nuclear power plant disaster, decision-makers of the affected countries have oriented their efforts on environmental clean-up and population safety. They have focused on activities leading to a better understanding of radionuclide contamination and to the development of effective environmental rehabilitation programs. Initial developments involved the use of domestic USSR technologies consisting of mainframe IBM computers and DEC minicomputers. Later, personal computers with imported software packages were introduced into the decision-making process. Following the breakup of the former USSR, the Ministry of Chernobyl was created in Ukraine in 1991. One of the Ministry's mandate was the elimination of the environmental after-effects of the Chernobyl disaster
Cushing, J.B.; Wilson, T.; Brandt, L.; Gregg, V.; Spengler, S.; Borning, A.; Delcambre, L.; Bowker, G.; Frame, M.; Fulop, J.; Hert, C.; Hovy, E.; Jones, J.; Landis, E.; Schnase, J.L.; Schweik, C.; Sonntag, W.; ,
Resource managers often face significant information technology (IT) problems when integrating ecological or environmental information to make decisions. At a workshop sponsored by the NSF and USGS in December 2004, university researchers, natural resource managers, and information managers met to articulate IT problems facing ecology and environmental decision makers. Decision making IT problems were identified in five areas: 1) policy, 2) data presentation, 3) data gaps, 4) tools, and 5) indicators. To alleviate those problems, workshop participants recommended specific informatics research in modeling and simulation, data quality, information integration and ontologies, and social and human aspects. This paper reports the workshop findings, and briefly compares these with research that traditionally falls under the emerging eco-informatics rubric. ?? Springer-Verlag Berlin Heidelberg 2005.
Ogawa, I.; Hernandes Tabares, R.
The aim of this work is to present a simplified model that could help the nuclear industry to keep the expertise of safeguards professionals in touch with the state of the art, and also to have available information in the Portal of Knowledge Management. It can also provide indicators and general data for decision makers. Authors have developed the concept based on their own experience through systems running in hydroelectric and gas fired plants, and one exclusive system that manage all courses in one University. It is under development a Portal of Knowledge Management for NPP dealing with information obtained of Strategic Plans, Budgets and Economics, Operation Performance, Maintenance and Surveillance Plans, Training and Education Programs, QA Programs, Operational Experience, Safety Culture, and Engineering of Human Factors. This model will provide indicators for decision makers. Training and education module is prepared according to profile of each individual and his attributes, tasks and capabilities, and training and education programmes. The system could apply self-assessment questionnaires; immersive learning using media (video) classes, and test applications using questions randomly selected from data bank, as well as could make applications to certificate people. All these data are analyzed and generate indicators about strongest and weakness points. Managers could have indication of individual's deficiency even though in training programmes on a real time basis. Another tool that could be applied to the model is the remote operation of supervision equipment. The model is developed using web-based tools, like ASP.NET encrypted by 128 bits, and web site https. Finally, it is important to stress that the model can be customized according to industry preference. (author)
Liu, Jinding; Xiao, Huamei; Huang, Shuiqing; Li, Fei
Insects are one of the largest classes of animals on Earth and constitute more than half of all living species. The i5k initiative has begun sequencing of more than 5,000 insect genomes, which should greatly help in exploring insect resource and pest control. Insect genome annotation remains challenging because many insects have high levels of heterozygosity. To improve the quality of insect genome annotation, we developed a pipeline, named Optimized Maker-Based Insect Genome Annotation (OMIGA), to predict protein-coding genes from insect genomes. We first mapped RNA-Seq reads to genomic scaffolds to determine transcribed regions using Bowtie, and the putative transcripts were assembled using Cufflink. We then selected highly reliable transcripts with intact coding sequences to train de novo gene prediction software, including Augustus. The re-trained software was used to predict genes from insect genomes. Exonerate was used to refine gene structure and to determine near exact exon/intron boundary in the genome. Finally, we used the software Maker to integrate data from RNA-Seq, de novo gene prediction, and protein alignment to produce an official gene set. The OMIGA pipeline was used to annotate the draft genome of an important insect pest, Chilo suppressalis, yielding 12,548 genes. Different strategies were compared, which demonstrated that OMIGA had the best performance. In summary, we present a comprehensive pipeline for identifying genes in insect genomes that can be widely used to improve the annotation quality in insects. OMIGA is provided at http://ento.njau.edu.cn/omiga.html .
Moore, Gabriel; Redman, Sally; Rudge, Sian; Haynes, Abby
Rapid reviews are increasingly used by policy agencies to access relevant research in short timeframes. Despite the growing number of programmes, little is known about how rapid reviews are used by health policy agencies. This study examined whether and how rapid reviews commissioned using a knowledge brokering programme were used by Australian policy-makers. This study used interview data to examine the use of 139 rapid reviews by health policy agencies that were commissioned between 2006 and 2015. Transcripts were coded to identify how rapid reviews were used, the type of policy processes in which they were used, what evidence of use was provided and what reasons were given when rapid reviews were not used. Fisher's exact test was used to assess variation between types of agencies. Overall, 89% of commissioned rapid reviews were used by the commissioning agencies and 338 separate instances of use were identified, namely, on average, three uses per review. Policy-makers used reviews primarily to determine the details of a policy or programme, identify priorities for future action or investment, negotiate interjurisdictional decisions, evaluate alternative solutions for a policy problem, and communicate information to stakeholders. Some variation in use was observed across agencies. Reasons for non-use were related to changes in organisational structures, resources or key personnel in the commissioning agencies, or changes in the broader political environment. This study found that almost all rapid reviews had been used by the agencies who commissioned them, primarily in policy and programme development, agenda-setting, and to communicate information to stakeholders. Reviews were used mostly in instrumental and conceptual ways and there was little evidence of symbolic use. Variations in use were identified across agencies. The findings suggest that commissioned rapid reviews are an effective means of providing timely relevant research for use in policy processes
Comer, Amber R; Slaven, James E; Montz, Annie; Burke, Emily; Inger, Lev; Torke, Alexia
Without advanced preparation of legal documents, state law determines who may serve as a surrogate decision maker for patients in hospitals. To examine the relationship characteristics associated with traditional versus nontraditional health care surrogates who are making medical decisions for patients in hospitals. Secondary analysis of a baseline cross-sectional survey of a larger prospective observational study. In total, 364 patient/surrogate dyads consisting of patients aged 65 years and older admitted to the medical or medical intensive care unit services who lacked decision-making capacity based on a physician assessment and also had a surrogate available. This study of surrogate decision makers for hospitalized older adults found that the relationships of nontraditional surrogates such as, nieces, nephews, and friends serving in the surrogate role is nearly identical to those of traditional, first degree relatives serving as a surrogate. Over two-thirds (71.2%) of nontraditional surrogates saw the patient in-person at least weekly compared with 80.8% of legal surrogates (P-value, 0.9023). Almost all traditional and nontraditional surrogates discussed the patient's medical preferences with the patient (96.9% of legal surrogates and 89.2% of nontraditional surrogates; P=0.0510). This study shows that both traditional and nontraditional surrogates, who are a patient's primary care giver have similar relationships with patients. The findings of this study suggest that requiring family members such as grandchildren to take the extra step of formal appointment through a legal channel may not be necessary to protect patients. Therefore, broader state laws expanding the list of surrogates authorized by state statute to include more nontraditional surrogates may be necessary.
Giannakopoulos, C.; Hatzaki, M.; Kostopoulou, E.; Varotsos, K.
Analysing climate change and its impact needs a production of relevant elements for policy making that can be very different from the parameters considered by climate experts. In the framework of EU project CIRCE, a more realistic approach to match stakeholders and policy-makers demands is attempted. For this reason, within CIRCE selected case studies have been chosen that will provide assessments that can be integrated in practical decision making. In this work, an integrated assessment of climate change impacts on several sectors for the urban site of Athens in Greece is presented. The Athens urban case study has been chosen since it provides excellent opportunities for using an integrated approach across multiple temporal and spatial scales and sectors. In the spatial dimension, work extends from the inner city boundaries to the surrounding mountains and forests. In the temporal dimension, research ranges from the current observed time period (using available meteorological and sector data) to future time periods using data from several climate change projections. In addition, a multi-sector approach to climate change impacts is adopted. Impacts sectors covered range from direct climate impacts on natural ecosystems (such as flash floods, air pollution and forest fire risk) to indirect impacts resulting from combined climate-social-economic linkages (such as energy demand, tourism and health). Discussion of impact sector risks and adaptation measures are also exploited. Case-study work on impact sector risk to climate change is of particular interest to relevant policy makers and stakeholders, communication with who is ensured through a series of briefing notes and information sheets and through regional workshops.
Hsu, Yu-Chang; Ching, Yu-Hui; Baldwin, Sally
This research explored how K-16 educators learned physical computing, and developed as maker-educators in an online graduate course. With peer support and instructor guidance, these educators designed maker projects using Scratch and Makey Makey, and developed educational maker proposals with plans of teaching the topics of their choice in STEAM…
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.
Department of Veterans Affairs — The Surgery Risk Assessment (SRA) database is part of the VA Surgical Quality Improvement Program (VASQIP). This database contains assessments of selected surgical...
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
Webb, Erik Karl; Tidwell, Vincent Carroll
This document outlines ways to more effectively communicate with U.S. Federal decision makers by outlining the structure, authority, and motivations of various Federal groups, how to find the trusted advisors, and how to structure communication. All three branches of Federal governments have decision makers engaged in resolving major policy issues. The Legislative Branch (Congress) negotiates the authority and the resources that can be used by the Executive Branch. The Executive Branch has some latitude in implementation and prioritizing resources. The Judicial Branch resolves disputes. The goal of all decision makers is to choose and implement the option that best fits the needs and wants of the community. However, understanding the risk of technical, political and/or financial infeasibility and possible unintended consequences is extremely difficult. Primarily, decision makers are supported in their deliberations by trusted advisors who engage in the analysis of options as well as the day-to-day tasks associated with multi-party negotiations. In the best case, the trusted advisors use many sources of information to inform the process including the opinion of experts and if possible predictive analysis from which they can evaluate the projected consequences of their decisions. The paper covers the following: (1) Understanding Executive and Legislative decision makers - What can these decision makers do? (2) Finding the target audience - Who are the internal and external trusted advisors? (3) Packaging the message - How do we parse and integrate information, and how do we use computer simulation or models in policy communication?
Weller, N.; Farooque, M.; Sittenfeld, D.
Public engagement around climate resilience efforts can foster learning for both public audiences and decision makers. On the one hand, public audiences learn about environmental hazards and strategies to increase community resilience through effective public engagement. On the other, decision makers and scientists learn about community members' values and priorities and their relation to environmental hazards and resilience strategies. Evidence from other public engagement efforts involving decision makers suggests that decision maker involvement results in reflection by officials on their own values, capacities, and roles. However, few public engagement exercises evaluate impacts on decision makers. As part of the Science Center Public Forums project, which aims to conduct public forums in eight cities across the country on resiliency to drought, heat, extreme precipitation, and sea level rise, we sought to 1) build partnerships with local decision makers and scientists around public forums and 2) explore how decision makers and scientists interacted with the planning and undertaking of those public forums. We held workshops with decision makers and scientists to inform forum content and identify local resilience issues. We will conduct interviews with local decision makers regarding their involvement in forum planning, their reflections and takeaways from the forum itself, and their perspectives on the value of public engagement for policy making. We will present our model of engagement with decision makers, initial findings from interviews, and lessons learned from connecting decision makers and scientists to public engagement efforts.
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.
outcomes could help residency programs and policy makers in structuring more efficient training. Keywords: surgical education, fatigue, simulator, sleep deprivation, duty hours
Jones, A. D.; Jagannathan, K.; Calvin, K. V.; Lamarque, J. F.; Ullrich, P. A.
There is a growing need for information about future climate conditions to support adaptation planning across a wide range of sectors and stakeholder communities. However, our principal tools for understanding future climate - global Earth system models - were not developed with these user needs in mind, nor have we developed transparent methods for evaluating and communicating the credibility of various climate information products with respect to the climate characteristics that matter most to decision-makers. Several recent community engagements have identified a need for "co-production" of knowledge among stakeholders and scientists. Here we highlight some of the barriers to communication and collaboration that must be overcome to improve the dialogue among researchers and climate adaptation practitioners in a meaningful way. Solutions to this challenge are two-fold: 1) new institutional arrangements and collaborative mechanisms designed to improve coordination and understanding among communities, and 2) a research agenda that explicitly incorporates stakeholder needs into model evaluation, development, and experimental design. We contrast the information content in global-scale model evaluation exercises with that required for in specific decision contexts, such as long-term agricultural management decisions. Finally, we present a vision for advancing the science of model evaluation in the context of predicting decision-relevant hydroclimate regime shifts in North America.
Full Text Available Ecological assessments and monitoring programs often rely on indicators to evaluate environmental conditions. Such indicators are frequently developed by scientists, expressed in technical language, and target aspects of the environment that scientists consider useful. Yet setting environmental policy priorities and making environmental decisions requires both effective communication of environmental information to decision makers and consideration of what members of the public value about ecosystems. However, the complexity of ecological issues, and the ways in which they are often communicated, make it difficult for these parties to fully engage such a dialogue. This paper describes our efforts to develop a process for translating the indicators of regional ecological condition used by the U.S. Environmental Protection Agency into common language for communication with public and decision-making audiences. A series of small-group sessions revealed that people did not want to know what these indicators measured, or how measurements were performed. Rather, respondents wanted to know what such measurements can tell them about environmental conditions. Most positively received were descriptions of the kinds of information that various combinations of indicators provide about broad ecological conditions. Descriptions that respondents found most appealing contained general reference to both the set of indicators from which the information was drawn and aspects of the environment valued by society to which the information could be applied. These findings can assist with future efforts to communicate scientific information to nontechnical audiences, and to represent societal values in ecological programs by improving scientist-public communication.
During the Industrial Revolution, it became clear that wood was unsuited as an energy source for industrial production, especially iron smelting. However, the transition to coal was the effort of decades. Similarly, the transition from coal to oil was neither a smooth nor rapid process. The transition to an energy and materials production regime based on renewable resources can similarly be expected to be fraught with many setbacks and obstacles, technically and politically. Those earlier transitions, however, were not complicated by the so-called grand challenges faced today. Above energy security and food and water security lurks climate change. Some events of 2015 have politically legitimised climate change and its mitigation, and 2016 saw the world finally sworn to action. The bioeconomy holds some of the answers to the economic challenges thrown up by mitigating climate change while maintaining growth and societal wellbeing. For bioeconomy policy makers, the future is complex and multi-faceted. The issues start in regions and extend to global reach. It is hard to quantify what is going to be the most difficult of challenges. However, one of the visions for the bioeconomy, that of distributed manufacturing in small- and medium-scale integrated biorefineries flies in the face of the current reality of massive fossil fuel and petrochemical economies of scale, married to gargantuan fossil fuel consumption subsidies. Copyright © 2017 Elsevier B.V. All rights reserved.
Grant, T R; Ellinas, E H; Kula, A O; Muravyeva, M Y
Parturients with abnormally adherent placentas present anesthetic challenges that include risk-stratification, management planning and resource utilization. The labor and delivery unit may be remote from the main operating room services. Division chiefs of North American obstetric anesthesiology services were surveyed about their practices and management of parturients with an abnormally adherent placenta. Eighty-four of 122 chiefs, representing 103 hospital sites, responded to the survey (response rate 69%). Sixty-one percent of respondents agreed that women with preoperative placental imaging that was "suspicious" of placenta accreta represented a lower risk category; all other suggested descriptions fell into a higher risk category. Seventy-nine percent of respondents indicated that lower risk cases were managed on the labor and delivery unit, while 71% indicated that higher risk cases would be managed in the main operating room. Institutions where all cases were managed on the labor and delivery unit had better access to human and technical resources, were less remote from their main operating areas, and promoted neuraxial rather than general anesthesia, even for parturients perceived to be at higher risk. Obstetric anesthesia leaders identified patients at lower clinical risk and those less likely to require greater resources. Additional resources were available in institutions where all abnormal placentation cases were managed on the labor and delivery unit. Practitioners should consider risk-stratification and resource availability when planning high-risk cases. Copyright © 2018 Elsevier Ltd. All rights reserved.
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.
American Pediatric Surgical Association Search for: Login Resources + For Members For Professionals For Training Program Directors For Media For ... Surgical Outcomes Surveys & Results Publications Continuing Education + ExPERT Pediatric Surgery NaT Annual Meeting CME MOC Requirements Residents / ...
Policy-makers today have almost infinite climate-relevant scientific and other information available to them. The problem for climate change decision-making isn't missing science or inadequate knowledge of climate risks; the problem is that the "right" climate change actionable knowledge isn't getting to the right decision-maker, or is getting there too early or too late to effectively influence her decision-making. Actionable knowledge is not one-size-fit-all, and for a given decision-maker might involve scientific, economic, or risk-based information. Simply producing more and more information as we are today is not the solution, and actually makes it harder for individual decision-makers to access "their" actionable knowledge. The Climatographers began building the Climate Web five years ago to test the hypothesis that a knowledge management system could help navigate the gap between infinite information and individual actionable knowledge. Today the Climate Web's more than 1,500 index terms allow instant access to almost any climate change topic. It is a curated public-access knowledgebase of more than 1,000 books, 2,000 videos, 15,000 reports and articles, 25,000 news stories, and 3,000 websites. But it is also much more, linking together tens of thousands of individually extracted ideas and graphics, and providing Deep Dives into more than 100 key topics from changing probability distributions of extreme events to climate communications best practices to cognitive dissonance in climate change decision-making. The public-access Climate Web is uniquely able to support cross-silo learning, collaboration, and actionable knowledge dissemination. The presentation will use the Climate Web to demonstrate why knowledge management should be seen as a critical component of science and policy-making collaborations.
Gromov, Kirill; Greene, Meridith E; Huddleston, James I
BACKGROUND: Persistent acetabular dysplasia (AD) after periacetabular osteotomy has been hypothesized to increase the risk for malpositioning of the acetabular component. In this study, we investigate whether AD is an independent risk factor for cup malpositioning during primary total hip arthrop...
Tae, Chung Hyun; Pouw, Roos E.; Duits, Lucas C.; Sung, Young Kyung; Min, Byung-Hoon; Lee, Jun Haeng; Rhee, Poong-Lyul; Kim, Kyoung-Mee; Bergman, Jacques J. G. H. M.; Kim, Jae J.
Although endoscopic resection (ER) for early gastric cancers (EGCs) has become popular with the development of endoscopic instruments and skillful endoscopists, the risk of lymph node metastasis (LNM) is still an obstacle in performing ER. In this study, we aimed to identify the risk factors of LNM
Idblan Carvalho de Albuquerque
Full Text Available Apesar dos avanços na compreensão da doença de Crohn, os fatores determinantes da recidiva no pós-operatório permanecem especulativos. O objetivo deste estudo foi analisar retrospectivamente os fatores preditivos da recidiva na doença de Crohn no pós-operatório. Métodos: foram analisados 45 pacientes com diagnóstico de doença de Crohn, submetidos ao tratamento cirúrgico, avaliando recidiva da doença e fatores como idade, sexo, raça, tabagismo, localização, padrão anatomo-clínico, indicação cirúrgica, tipo de anastomose. Resultados: em 67,7% dos pacientes houve recidiva da doença sendo a causa mais freqüente a forma fistulizante; 64,6% foram operados três vezes ou mais (p=0,002. Doentes com quadro de perfuração apresentaram maior número de reoperações, três ou mais operações, em 63,6% (p=0,003. Conclusões: Quadro de perfuração e forma fistulizante da doença determinaram maior número de recidiva nos pacientes estudados.Despite the advances in the understanding of Crohn's disease, the determinants of surgical recurrence remain speculative. The aim of this study was to examine retrospectively the factors affecting post-operative recurrence of Crohn's disease. Methods: The following factors were investigated in 45 patients submitted to surgery for Crohn's disease: age, sex, race, smoking, anatomical site of involvement, type (inflammatory, fibrostenotic, or fistulizing, indication for surgery and anastomotic technique. Results: Recurrence occurred in 67,7% patients. Patients fistulizing Crohn's disease had undergone three or more surgical procedures, 64,6% (p=0, 002. Perforating indication for initial surgeryPatients with perforation presented the greatest number of reoperations, three or more surgical procedures in 63,6% (p=0,003. Conclusions: Perforationg and fistulizing type in Crohn's disease estabilished the major cause of recurrence in the patients studied.
Ebner, Natalie C; Kamin, Hayley; Diaz, Vanessa; Cohen, Ronald A; MacDonald, Kai
Aging is associated with well-recognized alterations in brain function, some of which are reflected in cognitive decline. While less appreciated, there is also considerable evidence of socioemotional changes later in life, some of which are beneficial. In this review, we examine age-related changes and individual differences in four neuroendocrine systems-cortisol, estrogen, testosterone, and oxytocin-as "difference makers" in these processes. This suite of interrelated hormonal systems actively coordinates regulatory processes in brain and behavior throughout development, and their level and function fluctuate during the aging process. Despite these facts, their specific impact in cognitive and socioemotional aging has received relatively limited study. It is known that chronically elevated levels of the stress hormone cortisol exert neurotoxic effects on the aging brain with negative impacts on cognition and socioemotional functioning. In contrast, the sex hormones estrogen and testosterone appear to have neuroprotective effects in cognitive aging, but may decrease prosociality. Higher levels of the neuropeptide oxytocin benefit socioemotional functioning, but little is known about the effects of oxytocin on cognition or about age-related changes in the oxytocin system. In this paper, we will review the role of these hormones in the context of cognitive and socioemotional aging. In particular, we address the aforementioned gap in the literature by: (1) examining both singular actions and interrelations of these four hormonal systems; (2) exploring their correlations and causal relationships with aspects of cognitive and socioemotional aging; and (3) considering multilevel internal and external influences on these hormone systems within the framework of explanatory pluralism. We conclude with a discussion of promising future research directions.
Full Text Available Due to its complexity, the evolution of cities is something that is difficult to predict and planning new developments for cities is therefore a difficult task. This complexity can be identified on two levels: on a micro level, it emerges from the multiple relations between the many components and actors in cities, whereas on a macro level it stems from the geographical, social and economic relations between cities. However, many of these relations can be measured. The design of plans for cities can only be improved if designers are able to address measurements of some of the relationships between the components of cities during the design process. These measurements are called urban indicators. By calculating such measurements, designers can grasp the meaning of the changes being proposed, not just as simple alternative layouts, but also in terms of the changes in indicators adding a qualitative perception. This thesis presents a method and a set of tools to generate alternative solutions for an urban context. The method proposes the use of a combined set of design patterns encoding typical design moves used by urban designers. The combination of patterns generates different layouts which can be adjusted by manipulating several parameters in relation to updated urban indicators. The patterns were developed from observation of typical urban design procedures, first encoded as discursive grammars and later translated into parametric design patterns. The CItyMaker method and tools allows the designer to compose a design solution from a set of programmatic premises and fine-tune it by pulling parameters whilst checking the changes in urban indicators. These tools improve the designer’s awareness of the consequences of their design moves.
Full Text Available Due to its complexity, the evolution of cities is something that is difficult to predict and planning new developments for cities is therefore a difficult task. This complexity can be identified on two levels: on a micro level, it emerges from the multiple relations between the many components and actors in cities, whereas on a macro level it stems from the geographical, social and economic relations between cities. However, many of these relations can be measured. The design of plans for cities can only be improved if designers are able to address measurements of some of the relationships between the components of cities during the design process. These measurements are called urban indicators. By calculating such measurements, designers can grasp the meaning of the changes being proposed, not just as simple alternative layouts, but also in terms of the changes in indicators adding a qualitative perception.This thesis presents a method and a set of tools to generate alternative solutions for an urban context. The method proposes the use of a combined set of design patterns encoding typical design moves used by urban designers. The combination of patterns generates different layouts which can be adjusted by manipulating several parameters in relation to updated urban indicators. The patterns were developed from observation of typical urban design procedures, first encoded as discursive grammars and later translated into parametric design patterns. The CItyMaker method and tools allows the designer to compose a design solution from a set of programmatic premises and fine-tune it by pulling parameters whilst checking the changes in urban indicators. These tools improve the designer’s awareness of the consequences of their design moves.
Full Text Available Aging is associated with well-recognized alterations in brain function, some of which are reflected in cognitive decline. While less appreciated, there is also considerable evidence of socioemotional changes later in life, some of which are beneficial. In this review, we examine age-related changes and individual differences in four neuroendocrine systems—cortisol, estrogen, testosterone, and oxytocin—as difference makers in these processes. This suite of interrelated hormonal systems actively coordinates regulatory processes in brain and behavior throughout development, and their level and function fluctuate during the aging process. Despite these facts, their specific impact in cognitive and socioemotional aging has received relatively limited study. It is known that chronically elevated levels of the stress hormone cortisol exert neurotoxic effects on the aging brain with negative impacts on cognition and socioemotional functioning. In contrast, the sex hormones estrogen and testosterone appear to have neuroprotective effects in cognitive aging, but may decrease prosociality. Higher levels of the neuropeptide oxytocin benefit socioemotional functioning, but little is known about the effects of oxytocin on cognition or about age-related changes in the oxytocin system. In this paper, we will review the role of these hormones in the context of cognitive and socioemotional aging. In particular, we address the aforementioned gap in the literature by: 1 examining both singular actions and interrelations of these four hormonal systems; 2 exploring their correlations and causal relationships with aspects of cognitive and socioemotional aging; and 3 considering multilevel internal and external influences on these hormone systems within the framework of explanatory pluralism. We conclude with a discussion of promising future research directions.
Jones, L.; Bwarie, J.; Pearce, I.
The gap between science and decision making in our society can be large and multi-faceted, involving communication, process, cultural and even subconscious differences. In sweeping generalization, scientists reject anecdotes, focus on uncertainty and details, and expect conflict as part of the scientific process, while non-scientists respond to stories, want certainty and the big picture, and see conflict as a reason to reject the message. Bridging this gap often requires ongoing collaboration to find the intersection of three independent domains: what science can provide, the technical information decision makers need to make the most effective choices and what information decision makers need to motivate action. For ten years, the USGS has experimented with improving the usefulness of its science through the SAFRR (Science Application for Risk Reduction) Project and its predecessor, the Multi Hazards Demonstration Project in Southern California. Through leading and participating in these activities, we have recognized 3 steps that have been essential to successful partnerships between scientists and decision makers. First, determining what makes for a successful product cannot be done in isolation by either scientists or users. The users may want something science cannot produce (e.g., accurate short-term earthquake predictions), while the scientists can fail to see that the product they know how to make may not be relevant to the decisions that need to be made. Real discussions with real exchange and absorption of information on both sides makes for the most useful products. Second, most scientific results need work beyond what belongs in a journal to create a product that can be used. This is not just a different style of communication, but analyses that focus on the community's local questions rather than on scientific advances. Third, probabilities of natural hazards almost never motivate action to mitigate. The probabilities are usually low on human time
Full Text Available Members of the South African Risk and Vulnerability Atlas were involved in a meeting aimed at the development of a toolkit towards improved integration of climate change into local government's integrated development planning (IDP) process....
Eduardo Keller Saadi
the definitive repair is indicated to improve the disease's natural history. However many factors are responsible for a still high surgical mortality in this condition. In the present study the surgical experience in the correction of CAVSD is reviewed in order to identify potential statistically important risk factors for operative death. Between January 1974 and December 1990,52 patients with complete atrioventricular septal defects underwent definitive surgical repair at The Royal Brompton and National Heart and Lung Institute. They were retrospectively studied and the following variables analysed: age, weight, sex, year of the operation, Down's syndrome, atrioventricular valve regurgitation, previous pulmonary artery banding, associated anomalies, systolic pulmonary artery pressure, double "mitral" valve orifice, Rastelli's classification, circulatory arrest, and the surgical technique (1 x 2 patches. All this variables were studied by the univariate analysis and, to determine which factors were independently responsible for the operative risk, multivariate analysis with logistic regression was applied. Multivariate analysis showed that the low weight at operation an 1 patch technique significantly increased surgical mortality.
Landis, Wayne G
...) in the performance of regional-scale ecological risk assessments. The initial chapters present the methodology and the critical nature of the interaction between risk assessors and decision makers...
Pilleri, Annarita; Scorcu, Giampaolo
The role of age in the risk stratification of patients candidate for non-cardiac surgery is still today an unresolved issue. European guidelines, in contrast to American guidelines, do not attribute to age an independent role in increasing the risk, and the indices for assessment of perioperative cardiovascular risk are based on studies that were carried out on middle-aged subgroups of the population without specific attention to the elderly patient. While the indices of geriatric assessment have still not yet gained a standardized role in the risk stratification of patients candidate to non-cardiac surgery, their need is becoming increasingly urgent considering the epidemiological impact of elderly patients with multi-comorbidities who more and more in the future will undergo such interventions. The European guidelines themselves identify an "evidence gap" concerning frailty which requires a deeper evaluation. The aim of the multicenter observational study VALUTA-75 is to verify if the indices of risk stratification routinely used by the cardiologist integrated with those of physical and cognitive performance of specific geriatric pertinence can improve the ability to predict perioperative cardiovascular and non cardiovascular events, with the scope of improving the therapeutic process.
Court, C; Mansour, E; Bouthors, C
Thoracic disc herniation is rare and mainly occurs between T8 and L1. The herniation is calcified in 40% of cases and is labeled as giant when it occupies more than 40% of the spinal canal. A surgical procedure is indicated when the patient has severe back pain, stubborn intercostal neuralgia or neurological deficits. Selection of the surgical approach is essential. Mid-line calcified hernias are approached from a transthoracic incision, while lateralized soft hernias can be approached from a posterolateral incision. The complication rate for transthoracic approaches is higher than that of posterolateral approaches; however, the former are performed in more complex herniation cases. The thoracoscopic approach is less invasive but has a lengthy learning curve. Retropleural mini-thoracotomy is a potential compromise solution. Fusion is recommended in cases of multilevel herniation, herniation in the context of Scheuermann's disease, when more than 50% bone is resected from the vertebral body, in patients with preoperative back pain or herniation at the thoracolumbar junction. Along with complications specific to the surgical approach, the surgical risks are neurological worsening, dural breach and subarachnoid-pleural fistulas. Giant calcified herniated discs are the largest contributor to myelopathy, intradural extension and postoperative complications. Some of the technical means that can be used to prevent complications are explored, along with how to address these complications. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Ersboll, Mads; Samad, Zainab; Al Enezi, Fawaz
significantly over time (P = 0.009) with the most substantial increase occurring from 2010 and onward. Median age upon referral (P period among patients with a finding of severe AS. Among patients...... with a finding of severe AS, the proportion of patients aged older than 80 years increased to 51.0% in the most recent time period (2010-2012) compared with 32.6% in the preceding time period (P ... risk at referral. Health-care resource planning should account for an increasing number of patients in need of high-risk aortic valve replacements in the near future....
Prosthetic vascular grafts are frequently used to reconstruct (part) of the aorta. Every surgical procedure caries a certain risk for infection and when a prosthetic aortic graft is implanted, this may lead to an aortic graft infection (AGI). Endovascular techniques have gradually replaced open surgical reconstructions as first line of treatment for aorto-iliac diseases. Nowadays, open reconstructions are primarily reserved for patients unsuitable for endovascular reconstructions or for redo ...
Li, Chun-Chang; Fu, Ju-Peng; Chang, Shun-Cheng; Chen, Tim-Mo; Chen, Shyi-Gen
Gynecomastia is defined as the benign enlargement of the male breast. Multiple surgical options have been used to improve outcomes. The aim of this study was to analyze the surgical approaches to the treatment of gynecomastia and their outcomes over a 10-year period. All patients undergoing surgical correction of gynecomastia in our department between 2000 and 2010 were included for retrospective evaluation. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and revision rate. The surgical result was evaluated with self-assessment questionnaires. A total of 41 patients with 75 operations were included. Techniques included subcutaneous mastectomy alone or with additional ultrasound-assisted liposuction (UAL) and isolated UAL. The surgical revision rate for all patients was 4.8%. The skin-sparing procedure gave good surgical results in grade IIb and grade III gynecomastia with low revision and complication rates. The self-assessment report revealed a good level of overall satisfaction and improvement in self-confidence (average scores 9.4 and 9.2, respectively, on a 10-point scale). The treatment of gynecomastia requires an individualized approach. Subcutaneous mastectomy combined with UAL could be used as the first choice for surgical treatment of grade II and III gynecomastia.
Shoji, Kristin; Heng, Marilyn; Harris, Mitchel B; Appleton, Paul T; Vrahas, Mark S; Weaver, Michael J
To determine whether time from injury to fixation of diaphyseal humeral fractures and nonunions is associated with the risk of iatrogenic radial nerve palsy. Retrospective review. Two Level 1 trauma centers. Between 2001 and 2015, 325 patients who had documented intact radial nerve function preoperatively were treated with fixation of a humerus fracture or humerus nonunion. Open reduction and internal fixation. Development of an iatrogenic radial nerve injury. Those with an injury were followed to either resolution of the nerve palsy or definitive treatment. The risk of iatrogenic radial nerve palsy was 7.7% (25/325). Time to surgery was not significantly associated with iatrogenic radial nerve palsy. In a multiple variable analysis, when comparing patients treated within 4 weeks to those treated 4-8 weeks (P = 0.41), 8-12 weeks (P = 0.94), and over 12 weeks (0.20), there were no significant associations. Independent risk factors for iatrogenic radial nerve palsy included distal location of fracture (P = 0.04, odds ratio 3.71) and previous fixation (P = 0.03, odds ratio 3.80). Of the 25 iatrogenic nerve injuries, 22 recovered fully with expectant management, 1 was lost to follow-up, and 2 required either nerve graft or tendon transfers. Time from injury to surgery does not seem to be a risk factor for developing an iatrogenic radial nerve palsy when treating diaphyseal humerus fractures. Patients with distal fractures, and those with previous fracture implants, are at increased risk of iatrogenic radial nerve palsy. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Gram, S.; Jacobsen, Soeren
The Green paper - A European Strategy for Sustainable, Competitive and Secure Energy, 2006 states that Europe has a rising dependency on imported energy reserves, which are concentrated in a few countries. The Rising gas and oil prices along with demands on lower emissions of CO2 adds pressure on the need for a new energy future for Europe. EU has since 1990 planned to become world leader in the renewable energy field. Therefore the EU member states have agreed that by 2010 21% of the consumed electricity and 5,75% of the consumed gasoline and diesel should originate from renewable energy sources. If the EU countries are to reach their goals, a commitment on several levels to develop and install energy from sustainable energy sources is needed. The purpose of this catalogue is to offer planners and decision-makers in EU states an inspirational tool to be used during local or regional transition towards sustainable energy technologies. The catalogue can also be used by everyone else who needs an overview of the sustainable energy technologies and their current development level and future potential, among others educational use is relevant. The catalogue provides an introduction to the following technologies that are already or are estimated to become central to a development with renewable energy in EU: Technologies for wind energy, wave energy, geothermal energy, bioenergy, solar energy, hydropower and fuel cells. The catalogue also includes a section about energy systems, which also includes a part about technologies for efficient use of energy. The catalogue could have included a few other technologies as e.g. heating pumps, but due to the size of the catalogue a priority was necessary. The catalogue does not claim to give all answers or to be complete regarding all details about the individual technologies; even so it offers information, which cannot easily be looked up on the Internet. In the back of the catalogue, under 'References and links' there
Miller, Megan E; Siegler, Mark; Angelos, Peter
Innovation is responsible for most advances in the field of surgery. Innovative approaches to solving clinical problems have significantly decreased morbidity and mortality for many surgical procedures, and have led to improved patient outcomes. While innovation is motivated by the surgeon's expectation that the new approach will be beneficial to patients, not all innovations are successful or result in improved patient care. The ethical dilemma of surgical innovation lies in the uncertainty of whether a particular innovation will prove to be a "good thing." This uncertainty creates challenges for surgeons, patients, and the healthcare system. By its very nature, innovation introduces a potential risk to patient safety, a risk that may not be fully known, and it simultaneously fosters an optimism bias. These factors increase the complexity of informed consent and shared decision making for the surgeon and the patient. Innovative procedures and their associated technology raise issues of cost and resource distribution in the contemporary, financially conscious, healthcare environment. Surgeons and institutions must identify and address conflicts of interest created by the development and application of an innovation, always preserving the best interest of the patient above the academic or financial rewards of success. Potential strategies to address the challenges inherent in surgical innovation include collecting and reporting objective outcomes data, enhancing the informed consent process, and adhering to the principles of disclosure and professionalism. As surgeons, we must encourage creativity and innovation while maintaining our ethical awareness and responsibility to patients.
Schwartz, Jamie; Goss, Selena; Facchin, Federico; Manizate, Fotini; Gendics, Cynthia; Braitman, Elissa; Lantis, John
Surgical site infections (SSI) are a known complication of surgery. Silver-containing wound treatments are popular, despite the lack of evidence of SSI reduction. A two-armed study was conducted between July 2007 and November 2008 to evaluate the efficacy and ease of use of a postoperative silver dressing. In the first arm of the study, patients undergoing clean general, vascular, orthopedic, and neurosurgical procedures were allocated to receive a postoperative silver dressing (POSD) or a standard dressing of nonstick gauze under a fluid occlusive dressing. Outcome variables included the incidence of antibiotic initiation for SSI, clinical signs of infection, and leukocyte counts. The second arm of the study was a prospective case series designed to evaluate the performance and handling characteristics of the POSD. Onehundred- ninety-nine (199) patients (mean age 59.2 [range 21-94] years) were enrolled in the first arm of the study. Three out of 99 (3%) patients in the POSD and six out of 100 (6%) control group patients received antibiotic therapy for SSI (P = 0.498). Differences in the percentage of patients with clinical signs of infection following surgery also were not statistically significant (POSD: n = 24, 24.2%; control: n = 30, 30%; P = 0.426). In the second arm, 34 out of 36 patients rated the study dressing easy to apply in (94%), and no pain on removal was noted in 38 out of 57 (66.7%) assessments. No patients in the dressing performance cohort developed an SSI. Prospective, randomized, controlled clinical studies with large sample sizes are warranted to evaluate the efficacy and cost-effectiveness of the POSD.
Smith, Andrew C
Full Text Available Internet of Things (IoT) advocates promise huge benefits but what technical challenges does the maker community face in order to participate in this new technological wave? We report on our experience in incorporating a maker community friendly...
Cohen, Jonathan; Jones, W. Monty; Smith, Shaunna; Calandra, Brendan
Maker culture is part of a burgeoning movement in which individuals leverage modern digital technologies to produce and share physical artifacts with a broader community. Certain components of the maker movement, if properly leveraged, hold promise for transforming formal education in a variety of contexts. The authors here work towards a…
Kafai, Yasmin B.; Fields, Deborah A.; Searle, Kristin A.
Electronic textiles are a part of the increasingly popular maker movement that champions existing do-it-yourself activities. As making activities broaden from Maker Faires and fabrication spaces in children's museums, science centers, and community organizations to school classrooms, they provide new opportunities for learning while challenging…
Geer, Brandon Terrell
Success Maker is an educational software that differentiates and personalizes K-8 reading and math. Limited research has been conducted on the impact of Success Maker on Grade 4 math state tests. At the research site, located in southeastern United States, 33.7% of fourth grade students did not pass the Palmetto Assessment of State Standards…
Woods, Jeffrey G.
Purpose: The purpose of this paper is to develop a conceptual model that uses dialectical inquiry (DI) to create cognitive conflict in strategic decision-makers for the purpose of improving strategic decisions. Activation of the dialectical learning process using DI requires strategic decision-makers to integrate conflicting information causing…
Soulat, C; Gelly, M
While medical abortion is now available in non hospital facilities, abortions by vacuum aspiration remain illegal in non hospital settings. It is therefore important to assess through the literature the real risks associated with this method. All the most recent and large-scale studies showed that legal abortion by vacuum aspiration is an extremely safe procedure. It is less risky than other medical or surgical procedures performed outside the hospital. According to the studies, the death rate varies from 0 to 0.7 per 100,000 abortions, and is smaller when the procedure is done under local anesthesia than general anesthesia. The overall early complication rate (hemorrhage, uterine perforation, cervical injury) is between 0.01 and 1.16%. Complications are not more frequent than with medical abortions. In view of these low complication rates, surgical abortion by vacuum aspiration could be performed outside the hospital setting in France, as it is the case in many other countries.
Portie Felix, Antonio; Navarro Sanchez, Gustavo; Hernandez Solar, Abel; Grass Baldoquin, Jorge Alberto; Domloge Fernandez, Joana
The obesity is the chronic non-communicable disease with a higher rate of growth in past 20 years. It is a risk factor for type 2 diabetes mellitus, high blood pressure, cardiovascular and respiratory affections, infertility, sexual and functional impotence, metabolic syndrome, load joint disorders and some types of cancer (breast, colon, prostate). The metabolic bariatric surgery is the surgical treatment more effective for the morbid obesity at long -and medium- term and not the pharmacologic treatment and the isolated diets. The aim of present historical review of the international literature on the evolution of surgical techniques of the bariatric surgery (malabsorption techniques, gastric restrictive techniques and mixed techniques), is to make available to those interested in this subject, a valuable therapeutic tool to be rationally used. (author)
Barrett, Kali A; Ferguson, Niall D; Athaide, Valerie; Cook, Deborah J; Friedrich, Jan O; McDonald, Ellen; Pinto, Ruxandra; Smith, Orla M; Stevenson, James; Scales, Damon C
To examine the attitudes and preferences of surrogate decision makers (SDMs) regarding their involvement in the consent to research process for ICU patients. We presented 136 SDMs of critically ill patients in five ICUs with four hypothetical research scenarios: baseline interventional study of a placebo controlled RCT; study with higher risk of treatment complication; study comparing two accepted treatments; study with shorter enrolment window. For each we asked SDMs if they would want to be involved in the consent to research decision, and to rate the acceptability of their comfort with, and their sense of burden with their involvement. Participants were screened for symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale. For the baseline scenario, most SDMs wished to be involved in research decision making (90 %; 95 % CI 84-95 %); responses varied little across study permutations. The majority considered their involvement to be acceptable (85 %; 95 % CI 77-90 %), whereas, a small minority rated it as being unacceptable (2 %; 95 % CI 1-6 %). Many were comfortable with being involved (50 %; 95 % CI 41-59 %), but the number decreased when risk of harm was higher (34 %; 95 % CI 26-43 %) or enrolment window was shorter (41 %; 95 % CI 33-50 %). A majority (62 %) reported symptoms of anxiety and many (38 %) had symptoms of depression. Most of the interviewed SDMs wished to be involved in research decision making for critically ill and incapable loved ones. Variability existed, however, in their desire to be involved when decisions were time-sensitive or perceived risk was greater.
Mark P. Lachiewicz
Full Text Available The development of surgical site infection (SSI remains the most common complication of gynecologic surgical procedures and results in significant patient morbidity. Gynecologic procedures pose a unique challenge in that potential pathogenic microorganisms from the skin or vagina and endocervix may migrate to operative sites and can result in vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscesses. Multiple host and surgical risk factors have been identified as risks that increase infectious sequelae after pelvic surgery. This paper will review these risk factors as many are modifiable and care should be taken to address such factors in order to decrease the chance of infection. We will also review the definitions, microbiology, pathogenesis, diagnosis, and management of pelvic SSIs after gynecologic surgery.
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.
Full Text Available BACKGROUND: Thoracic surgeries including thoracotomy and VATS are some of the highest risk procedures that often lead to CPSP, with or without a neuropathic component. This retrospective study aims to determine retrospectively the prevalence of CPSP following thoracic surgery, its predicting risk factors, the incidence of neuropathic component, and its impact on quality of life. METHODS: Patients who underwent thoracic surgeries including thoracotomy and VATS between 01/2010 and 12/2011 at the First Affiliated Hospital, School of Medicine, Zhejiang University were first contacted and screened for CPSP following thoracic surgery via phone interview. Patients who developed CPSP were then mailed with a battery of questionnaires, including a questionnaire referenced to Maguire's research, a validated Chinese version of the ID pain questionnaire, and a SF-36 Health Survey. Logistic regression analyses were subsequently performed to identify risk factors for CPSP following thoracic surgery and its neuropathic component. RESULTS: The point prevalence of CPSP following thoracic surgery was 24.9% (320/1284 patients, and the point prevalence of neuropathic component of CPSP was 32.5% (86/265 patients. CPSP following thoracic surgery did not improve significantly with time. Multiple predictive factors were identified for CPSP following thoracic surgery, including age<60 years old, female gender, prolonged duration of post-operative chest tube drainage (≥ 4 days, options of post-operative pain management, and pre-existing hypertension. Furthermore, patients who experienced CPSP following thoracic surgery were found to have significantly decreased physical function and worse quality of life, especially those with neuropathic component. CONCLUSIONS: Our study demonstrated that nearly 1 out of 4 patients underwent thoracic surgery might develop CPSP, and one third of them accompanied with a neuropathic component. Early prevention as well as aggressive
Williams, Stephen B; Davis, John W; Wang, Xuemei; Achim, Mary F; Zurita-Saavedra, Amado; Matin, Surena F; Pisters, Louis L; Ward, John F; Pettaway, Curtis A; Chapin, Brian F
Multimodality therapies for men with high- and very high-risk prostate cancer, including neoadjuvant systemic therapy followed by subsequent radical prostatectomy (RP) are being increasingly explored despite the lack of adequate morbidity data. We analyzed the data from 215 consecutive patients with high- and very high-risk prostate cancer who were previously untreated or had received neoadjuvant systemic therapy. All patients underwent RP with extended pelvic lymph node dissection from 2006 to 2010 at a single tertiary care academic center. All complications within 90 days of surgery were defined and categorized by a 5-grade and 10-domain modification of the Clavien system. Univariable and multivariable logistic regression analyses were used to identify preoperative predictors for complications. Of the 215 patients, 29% experienced a complication of any grade ≤ 90 days after surgery; 6% experienced grade ≥ 3, with no significant difference between either cohort (P = .50). On multivariate analysis, open RP (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.11-3.90; P = .02) and preoperative hemoglobin (OR, 1.98; 95% CI, 1.05-3.72; P = .03) were independent predictors of the occurrence of any grade complication. For major complications (Clavien ≥ 3), a Charlson comorbidity index of 6 to 7 versus 3 to 5 (OR, 5.45; 95% CI, 1.57-18.98; P = .008) and the most recent year of surgery (OR, 4.73; 95% CI, 1.36-16.39; P = .01) were significant predictors on multivariable analysis. The use of neoadjuvant systemic therapy did not appear to increase the risk of perioperative complications. These findings support current clinical trials, which might elucidate the oncologic benefit of this multimodality approach. Copyright © 2016 Elsevier Inc. All rights reserved.
Bertl, Kristina; Bruckmann, Corinna; Isberg, Per-Erik; Klinge, Björn; Gotfredsen, Klaus; Stavropoulos, Andreas
To evaluate the effect of hyaluronan (HY) application as monotherapy or as adjunct to non-surgical and/or surgical periodontal therapy. Literature search was performed according to PRISMA guidelines with the following main eligibility criteria: (a) English or German language; (b) pre-clinical in vivo or human controlled trials; (c) effect size of HY evaluated histologically or clinically. Two pre-clinical in vivo studies on surgical treatment and 12 clinical trials on non-surgical and/or surgical treatment were included. Most of the studies were highly heterogeneous, regarding with HY product used and application mode, and of high risk of bias, thus not allowing meta-analysis. The majority of clinical studies described a beneficial, occasionally statistically significant, effect of HY on bleeding on probing (BoP) and pocket depth (PD) reduction (2.28-19.5% and 0.2-0.9 mm, respectively), comparing to controls; no adverse effects were reported. Hyaluronan application as adjunct to non-surgical and surgical periodontal treatment seems to have a beneficial, generally moderate, effect on surrogate outcome variables of periodontal inflammation, i.e., BoP and residual PD, and appears to be safe. The large heterogeneity of included studies, does not allow recommendations on the mode of application or effect size of HY as adjunct to non-surgical and surgical periodontal treatment. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
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-.
Determining Surgical Complications in the Overweight (DISCOVER): a multicentre observational cohort study to evaluate the role of obesity as a risk factor for postoperative complications in general surgery.
Nepogodiev, Dmitri; Chapman, Stephen J; Glasbey, James; Kelly, Michael; Khatri, Chetan; Drake, Thomas M; Kong, Chia Yew; Mitchell, Harriet; Harrison, Ewen M; Fitzgerald, J Edward; Bhangu, Aneel
Obesity is increasingly prevalent among patients undergoing surgery. Conflicting evidence exists regarding the impact of obesity on postoperative complications. This multicentre study aims to determine whether obesity is associated with increased postoperative complications following general surgery. This prospective, multicentre cohort study will be performed utilising a collaborative methodology. Consecutive adults undergoing open or laparoscopic, elective or emergency, gastrointestinal, bariatric or hepatobiliary surgery will be included. Day case patients will be excluded. The primary end point will be the overall 30-day major complication rate (Clavien-Dindo grade III-V complications). Data will be collected to risk-adjust outcomes for potential confounding factors, such as preoperative cardiac risk. This study will be disseminated through structured medical student networks using established collaborative methodology. The study will be powered to detect a two-percentage point increase in the major postoperative complication rate in obese versus non-obese patients. Following appropriate assessment, an exemption from full ethics committee review has been received, and the study will be registered as a clinical audit or service evaluation at each participating hospital. Dissemination will take place through national and local research collaborative networks. 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.
Long-term Outcomes and Risk Factors for Reoperation After Surgical Treatment for Gastrointestinal Crohn Disease According to Anti-tumor Necrosis Factor-α Antibody Use: 35 Years of Experience at a Single Institute in Korea.
Lee, Sang Mok; Han, Eon Chul; Ryoo, Seung-Bum; Oh, Heung-Kwon; Choe, Eun Kyung; Moon, Sang Hui; Kim, Joo Sung; Jung, Hyun Chae; Park, Kyu Joo
Crohn disease is characterized by high rates of recurrence and reoperations. However, few studies have investigated long-term surgical outcomes in Asian populations. We investigated risk factors for reoperation, particularly those associated with anti-tumor necrosis factor-α (anti-TNF-α) antibody use, and long-term follow-up results. We reviewed the records of 148 patients (100 males and 48 females) who underwent surgery for gastrointestinal Crohn disease and retrospectively analyzed long-term outcomes and risk factors. The mean age at diagnosis was 28.8 years. Thirty-eight patients (25.7%) received monoclonal antibody treatment before reoperation. A small bowel and colon resection was most commonly performed (83 patients, 56.1%). The median follow-up was 149 months, during which 47 patients underwent reoperation. The median interval between the primary and the secondary surgeries was 65 months, with accumulated reoperation rates of 16.5%, 31.8%, and 57.2% after 5, 10, and 15 years, respectively. Obstruction was the most common indication for reoperation (37 patients, 25.0%). In a multivariable analysis, age Crohn diseases. Younger age at primary operation, penetrating behavior, and no azathioprine use were significant factors associated with reoperation for gastrointestinal Crohn disease.
Risk of surgical site infection, acute kidney injury, and Clostridium difficile infection following antibiotic prophylaxis with vancomycin plus a beta-lactam versus either drug alone: A national propensity-score-adjusted retrospective cohort study.
Full Text Available The optimal regimen for perioperative antimicrobial prophylaxis is controversial. Use of combination prophylaxis with a beta-lactam plus vancomycin is increasing; however, the relative risks and benefits associated with this strategy are unknown. Thus, we sought to compare postoperative outcomes following administration of 2 antimicrobials versus a single agent for the prevention of surgical site infections (SSIs. Potential harms associated with combination regimens, including acute kidney injury (AKI and Clostridium difficile infection (CDI, were also considered.Using a multicenter, national Veterans Affairs (VA cohort, all patients who underwent cardiac, orthopedic joint replacement, vascular, colorectal, and hysterectomy procedures during the period from 1 October 2008 to 30 September 2013 and who received planned manual review of perioperative antimicrobial prophylaxis regimen and manual review for the 30-day incidence of SSI were included. Using a propensity-adjusted log-binomial regression model stratified by type of surgical procedure, the association between receipt of 2 antimicrobials (vancomycin plus a beta-lactam versus either single agent alone (vancomycin or a beta-lactam and SSI was evaluated. Measures of association were adjusted for age, diabetes, smoking, American Society of Anesthesiologists score, preoperative methicillin-resistant Staphylococcus aureus (MRSA status, and receipt of mupirocin. The 7-day incidence of postoperative AKI and 90-day incidence of CDI were also measured. In all, 70,101 procedures (52,504 beta-lactam only, 5,089 vancomycin only, and 12,508 combination with 2,466 (3.5% SSIs from 109 medical centers were included. Among cardiac surgery patients, combination prophylaxis was associated with a lower incidence of SSI (66/6,953, 0.95% than single-agent prophylaxis (190/12,834, 1.48%; crude risk ratio [RR] 0.64, 95% CI 0.49, 0.85; adjusted RR 0.61, 95% CI 0.46, 0.83. After adjusting for SSI risk, no
Risk of surgical site infection, acute kidney injury, and Clostridium difficile infection following antibiotic prophylaxis with vancomycin plus a beta-lactam versus either drug alone: A national propensity-score-adjusted retrospective cohort study.
Branch-Elliman, Westyn; Ripollone, John E; O'Brien, William J; Itani, Kamal M F; Schweizer, Marin L; Perencevich, Eli; Strymish, Judith; Gupta, Kalpana
The optimal regimen for perioperative antimicrobial prophylaxis is controversial. Use of combination prophylaxis with a beta-lactam plus vancomycin is increasing; however, the relative risks and benefits associated with this strategy are unknown. Thus, we sought to compare postoperative outcomes following administration of 2 antimicrobials versus a single agent for the prevention of surgical site infections (SSIs). Potential harms associated with combination regimens, including acute kidney injury (AKI) and Clostridium difficile infection (CDI), were also considered. Using a multicenter, national Veterans Affairs (VA) cohort, all patients who underwent cardiac, orthopedic joint replacement, vascular, colorectal, and hysterectomy procedures during the period from 1 October 2008 to 30 September 2013 and who received planned manual review of perioperative antimicrobial prophylaxis regimen and manual review for the 30-day incidence of SSI were included. Using a propensity-adjusted log-binomial regression model stratified by type of surgical procedure, the association between receipt of 2 antimicrobials (vancomycin plus a beta-lactam) versus either single agent alone (vancomycin or a beta-lactam) and SSI was evaluated. Measures of association were adjusted for age, diabetes, smoking, American Society of Anesthesiologists score, preoperative methicillin-resistant Staphylococcus aureus (MRSA) status, and receipt of mupirocin. The 7-day incidence of postoperative AKI and 90-day incidence of CDI were also measured. In all, 70,101 procedures (52,504 beta-lactam only, 5,089 vancomycin only, and 12,508 combination) with 2,466 (3.5%) SSIs from 109 medical centers were included. Among cardiac surgery patients, combination prophylaxis was associated with a lower incidence of SSI (66/6,953, 0.95%) than single-agent prophylaxis (190/12,834, 1.48%; crude risk ratio [RR] 0.64, 95% CI 0.49, 0.85; adjusted RR 0.61, 95% CI 0.46, 0.83). After adjusting for SSI risk, no association
Pawils, S; Boettcher, A; Metzner, F; Plaumann, M; Walter, U
Representatives of the statutory health insurance (n=46) and policy makers at the local, federal and state level (n=136) were interviewed in 2 nationwide online surveys about the significance and degree of implementation of prevention. The group comparison between the decision-makers shows significant differences in terms of attitudes towards health prevention. The political leaders are demanding an improvement of the GKV-benefit package and the obstacles require the cooperation of urgent attention. © Georg Thieme Verlag KG Stuttgart · New York.
Mehta, Sangeeta; Quittnat Pelletier, Friederike; Brown, Maedean; Ethier, Cheryl; Wells, David; Burry, Lisa; MacDonald, Rod
Consent for research participation in the intensive care unit (ICU) is often obtained from a substitute decision maker (SDM). In this study we explored SDMs' reasons for declining or providing consent for research studies for critically ill adult family members. Two questionnaires were developed, one directed at SDMs who agreed to have their relative participate in a research study (AGREE group), and another for SDMs who declined participation (DECLINE group). The questionnaires explored SDMs' opinions about research in general, timing of research approach, the informed consent process, and reasons for agreeing or declining participation. Ninety-six SDMs completed the questionnaire (68 AGREE, 27 DECLINE). There were no differences between AGREE and DECLINE groups with respect to SDM demographics, perceived severity of illness of the patient, or the research study approach. The most common reasons for providing consent were potential for research to help others (91%), research is important for medical progress (88%), and trust in the medical team (87%). The most common reasons for declining consent were SDM was too anxious to consider research (67%), fear that patient would receive experimental treatment (37%), and concern about risks of the study (33%). SDMs who agree to have a relative participate in an ICU research study are motivated by the potential benefit to the patient and altruism. SDMs who decline research participation, while not generally opposed to research, are fearful of study-related harm or discomfort for the patient, and are too anxious to consider a research study at that time.
Sullivan, T. J.; Chino, M.; Ehrhardt, J.; Shershakov, V.
This paper discusses a collaborative project (1) to demonstrate the feasibility and benefit of a system seeking early review, in a 'quasi peer review' mode, of nuclear accident plume and dose assessment predictions by four major international nuclear accident emergency response systems before release of calculations to respective national authorities followed by (2) sharing these results with responsible national/international authorities, (3) development of an affordable/accessible system to distribute results to countries without prediction capabilities and (4) utilisation for exercises and collaboration studies. The project exploits Internet browser technology and low-cost PC hardware, incorporates an Internet node, with access control, for depositing a minimal set of XML-based graphics files for presentation in an identical map format. Side-by-side viewing and tele-video conferencing will permit rapid evaluation, data elaboration and recalculation (if necessary) and should produce strong consensus among decision makers. Successful completion affords easy utilisation by national/international organisations and non-nuclear states at risk of trans-boundary incursion. (authors)
Epileptic Seizures in Patients Following Surgical Treatment of Acute Subdural Hematoma-Incidence, Risk Factors, Patient Outcome, and Development of New Scoring System for Prophylactic Antiepileptic Treatment (GATE-24 score).
Won, Sae-Yeon; Dubinski, Daniel; Herrmann, Eva; Cuca, Colleen; Strzelczyk, Adam; Seifert, Volker; Konczalla, Juergen; Freiman, Thomas M
Clinically evident or subclinical seizures are common manifestations in acute subdural hematoma (aSDH); however, there is a paucity of research investigating the relationship between seizures and aSDH. The purpose of this study is 2-fold: determine incidence and predictors of seizures and then establish a guideline in patients with aSDH to standardize the decision for prophylactic antiepileptic treatment. The author analyzed 139 patients with aSDH treated from 2007 until 2015. Baseline characteristics and clinical findings including Glasgow Coma Scale (GCS) at admission, 24 hours after operation, timing of operation, anticoagulation, and Glasgow Outcome Scale at hospital discharge and after 3 months were analyzed. Multivariate logistic regression analysis was performed to detect independent predictors of seizures, and a scoring system was developed. Of 139 patients, overall incidence of seizures was 38%, preoperatively 16% and postoperatively 24%. Ninety percent of patients with preoperative seizures were seizure free after operation for 3 months. Independent predictors of seizures were GCS <9 (odds ratio [OR] 3.3), operation after 24 hours (OR 2.0), and anticoagulation (OR 2.2). Patients with seizures had a significantly higher rate of unfavorable outcome at hospital discharge (P = 0.001) and in 3-month follow-up (P = 0.002). Furthermore, a score system (GATE-24) was developed. In patients with GCS <14, anticoagulation, or surgical treatment 24 hours after onset, a prophylactic antiepileptic treatment is recommended. Occurrence of seizures affected severity and outcomes after surgical treatment of aSDH. Therefore seizure prophylaxis should be considered in high-risk patients on the basis of the GATE-24 score to promote better clinical outcome. Copyright © 2017 Elsevier Inc. All rights reserved.
Full Text Available Currently, few studies deal with evaluation of data mining plans in context of solvng organizational problems. A successful data miner is searching to solve a fully defined business problem. To make the data mining (DM results actionable, the data miner must explain them to the business insider. The interaction process between the business insiders and data miners is actually a knowledge-sharing process. In this study through representing a framwork, influence of organizational decision makers on data mining process and results investigated. By investigating research literature, the critical success factors of data mining plans was identified and the role of organizational decision makers in each step of data mining was investigated. Then, the conceptual framework of influence of organizational decision makers on data mining process achievement was designed. By getting expert opinions, the proposed framework was analyzed and evantually designed the final framework of influence of organizational decision makers on data mining process achievement. Analysis of experts opinions showed that by knowledge sharing of data ming results with decision makers, "learning", "action or internalization" and "enforcing/unlearning" will become as critical success factors. Also, results of examining importance of decision makers' feedback on data mining steps showed that getting feedback from decision makers could have most influence on "knowledge extraction and representing model" step and least on "data cleaning and preprocessing" step.
De Backer, Ole; Götberg, Matthias; Ihlberg, Leo
BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis (AS) who are ineligible or at high risk for conventional valvular surgery. In Northwestern Europe, the TAVR technology is also......)-defined device success was obtained in 97.4%. A Lotus Valve was successfully implanted in all patients. There was no valve migration, embolization, ectopic valve deployment, or TAV-in-TAV deployment. The VARC-defined combined safety rate at 30days was 92.2%, with a mortality rate of 1.9% and stroke rate of 3.......2%. The clinical efficacy rate after 30days was 91.6% - only one patient had moderate aortic regurgitation. When considering only those patients in the late experience group (N=79), the combined safety and clinical efficacy rates were 93.7% and 92.4%, respectively. The pacemaker implantation rate was 27...
Large, Thomas M; Alton, Timothy B; Patton, Daniel J; Beingessner, Daphne
We hypothesized that internal fixation procedures performed on trauma intensive care unit (ICU) patients with systemic infections, some also febrile, would be at increased risk for deep infection. A total of 128 patients (mean age, 37.4 years; mean Injury Severity Score [ISS], 34.7) admitted to the ICU with 179 femur or tibia fractures developed systemic infections. Systemic infections included sepsis, pneumonia, urinary tract infections, abdominal infections, and wound infections remote to the fracture. Of the fractures, 33 open and 146 closed underwent 150 intramedullary and 29 plate fixation procedures. Data were gathered regarding antibiotic use, systemic infection timing in relation to the date of fixation, and whether fever (>38.2°C) was present within 24 hours of fixation. Patients were followed up for a mean of 491 days. Twenty-eight procedures were performed a mean of 4.7 days after the diagnosis of a systemic infection, and 151 were performed a mean of 9.3 days before the diagnosis. Forty-five procedures were performed in patients who were febrile within 24 hours. Of the 179 procedures, 10 (5.6%) developed a deep infection. Four patients' implant infection was potentially hematogenously seeded with the same organism as their systemic infection. Neither the timing of the systemic infection in relation to the fixation procedure nor the presence of fever within 24 hours of fixation, days of preoperative antibiotics, location of the fracture, type of fixation (intramedullary nail vs. plate fixation), or type of systemic infection was significantly associated with the development of an infection. The only significant risk factor for developing an orthopedic infection was an open fracture (p close conjunction to the diagnosis of systemic infection led to a 5.6% infection rate, which compares favorably with historic infection rates for fixation of open or closed tibia and femur fractures. Therapeutic, level IV.
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.
Lee, Yu L; Kilic, Gokhan; Phelps, John Y
Surgical robotics instructors provide an essential service in improving the competency of novice gynecologic surgeons learning robotic surgery and advancing surgical skills on behalf of patients. However, despite best intentions, robotics instructors and the gynecologists who use their services expose themselves to liability. The fear of litigation in the event of a surgical complication may reduce the availability and utility of robotics instructors. A better understanding of the principles of duty of care and the physician-patient relationship, and their potential applicability in a court of law likely will help to dismantle some concerns and uncertainties about liability. This commentary is not meant to discourage current and future surgical instructors but to raise awareness of liability issues among robotics instructors and their students and to recommend certain preventive measures to curb potential liability risks. Published by Elsevier Inc.
Frewer, Lynn J.; Fischer, Arnout R. H.; van den Brink, Paul J.
community regarding the reliability and utility of the outputs. Training in interpretation of outputs is therefore highly relevant to regulatory acceptance. In other end-user sectors, a positive attitude toward PRA, "hands on" experience, and perceived capability of actually performing PRA is an important...
Throughout his career, Lavoisier paid particular attention to the apparatuses he intended to use in his experimental pursuits. Lavoisier engaged many instrument makers in Paris, the French provinces, and abroad, and he made several efforts, more or less successful, to design a new environment for chemical experimentation. In addition to working with famous instrument makers such as Fortin, Mégnié, and Ramsden, Lavoisier had his instruments made by more than seventy other different makers. In this essay, I outline their contributions and make a preliminary attempt to establish their role in the design of Lavoisier's instruments and in the changes that occurred in chemical experimentation.
Düring, Marten; Bixler, Matthias; Kronenwett, Michael; Stark, Martin
Este artículo explora la aplicabilidad del programa informático VennMaker para la investigación histórica. El artículo se apoya en dos casos de estudio de investigaciones históricas actuales orientadas a estudiar las redes y que cubren diferentes periodos de tiempo y distintas fuentes. La mayor ventaja de VennMaker es que invierte el proceso de recolección de datos. Mientras que los programas tradicionales utilizan datos pre-codificados para producir el mapa de una red, VennMaker genera los d...
Full Text Available When we mention about surgical treatment of any tumor residing on the skin independent of its benign or malignant nature, the first method we recall is excision. Elliptical excision is the mainstay of the dermatologic surgery. Each excision ends with a defect for which we are responsible to repair functionally and cosmetically. The diameter of the tumor we excised and the safety margin used for excision determine the diameter of the final defect. After achieving tumor free lateral and deep margins with the appropriate surgical method, we decide between the repair options of second intention healing, primary repair, flaps, full or split thickness grafts, considering the diameter and the anatomic localization of the defect, for the best functional and cosmetic result for that specific defect. This review overviews not only the most common dermatologic surgical methods, but also Mohs surgery which is a method rarely used in our country, although it is the treatment of cho