Paediatric day care surgery: a hidden burden for primary care?

The aims of this study were to identify prospectively 'concealed' postoperative problems, to assess the burden of paediatric day care surgery on primary care services and to define a normal recovery period for common children's procedures. At their first postoperative clinic visit, patients and parents were asked directly about postoperative problems, unscheduled contacts with the hospital or other health professionals, and the time taken to resume normal activity and return to school. A total of 651 children, median age 4 years (range 0-16 years) were included. Median time to the first clinic appointment was 42 days (range 4-235 days). There were 100 unscheduled postoperative contacts (15.5% of all episodes) of which 81 were with general practitioners. Most problems recorded were relatively minor, and most requiring major intervention were identified before the child left hospital. There was a very high incidence of wound related problems after circumcision. Most children were 'back to normal' within a few days (median 2 days, range 0-30 days) and back to school within a week (median 6 days, range 1-20 days). There was a high rate of primary care contact despite clear written and verbal advice given in hospital and the offer of open access for any concerns. Recovery from day care surgery was rapid and overall level of patient satisfaction was high.     

Is an authorization for care necessary for the incapacitated adult?

We report the case of a 30-year-old mentally disabled patient who presented for diagnostic colonoscopy. This patient raised the problem of authorization for such a procedure and the related anaesthetic. The French law of 1968 on the protection of severely incapacitated persons does not clearly solve the problem of the consent for procedures with a therapeutic finality. The distinction relies usually on the extent of the planned act, for asking for an agreement of the guardian, judge of guardianship or the family board. In such cases the problem of the practice of an anaesthetic remains unsolved. For scheduled procedures it is recommended to obtain the written consent of the guardian before any medical act.     

Back to the future for wound care?

The European Renaissance was a time of enormous change and rapid progress in the arts, sciences, and medicine. A glimpse of wound care in the last phase of the European Renaissance is provided by the analysis of work by Wilhelm Fabry, the "father of German surgery," as provided in his book De Combustionibus ("Burns") which details his range of treatments for the burn wound, as well as his approach to the later problems of scarring and contracture. We describe some of the historic events which may have stimulated Fabry's writings, in particular, the influences passed down from the medical school of Padua which thereby advanced the cause of wound care and surgery. Finally, we briefly explore the potential of such an approach to the works of our medical forefathers.     

Corticosteroids for septic shock--a standard of care?

Septic shock has a crude mortality rate of 45% and claims thelives of 90 000 people each year in the USA alone.¹ An epidemiologicalstudy from France of over 100 000 intensive care unit (ICU)admissions indicates the incidence of septic shock before orfollowing admission to ICU is rising and now affects almost10% of this patient population.² Given the scale and associatedcosts of this problem,^{3 4} it is not surprising that developingsolutions has been a focus of researchers, clinicians, and thepharmaceutical industry. Despite many past disappointments particularlywith antagonists of endogenous mediators,⁵ some recent approacheshave shown promise in prevention or treatment of sepsis     

A comprehensive multidisciplinary care pathway for hip fractures better outcome than usual care?

IntroductionHip fracture surgery is among the most performed surgical procedures in elderly patients. Mortality rates are high, however, and patients often fail to live independently following a hip fracture. To improve outcome, multidisciplinary care pathways have been initiated, but longer-term results are lacking. Aim of this study was to compare functional outcome and living situation six months after hip fracture treatment with and without a care pathway.Patients and methodsA multicentre prospective controlled trial was conducted with three hospitals: in one hospital patients were treated with a care pathway, in the other hospitals patients received usual care. All patients aged ≥ 60 years with a hip fracture were asked to participate. Besides basic characteristics, health-related quality of life (EQ-5D) and performance scores of activities of daily living (Katz Index and Lawton IADL) were assessed. Differences in scores were analysed using linear regression. Propensity score adjustment was used to correct for differences between the care pathway and the usual care group. Missing data were imputed.ResultsNo differences in rate of return to prefracture ADL level were found between patients in the care pathway group and the usual care group. The percentage of participants in the same situation as before the fracture was the same in both treatment groups (81%). There were no significant differences in quality of life, activities of daily living or mortality (15% vs 10%, p = 0.17), but hospital stay in the care pathway group was significantly shorter (median 7 vs 10 days).DiscussionTreatment of elderly patients with a hip fracture is commonly organised in care pathways. Although short-term advantages are reported, positive effects on longer-term functional results could not be proven in our study. This study confirmed a shorter hospital stay in the care pathway group, which potentially may lead to a reduction in costs.ConclusionsFunctional outcome and living situation six months after a hip fracture is the same for patients treated with or without a care pathway.     

Nursing care for the patient after femoral popliteal bypass grafting

To share my knowledge, regarding the nursing care for the patients after femoral popliteal bypass grafting in Singapore, with my Chinese colleagues who have never been abroad. Methods: From August 1998 to September 2002, five patients (including ! female and 4 male) after femoral popliteal bypass grafting were summarized retrospectively on postoperative care by assessment, nursing implementation and evaluation. Results: All patients were followed up for 3 to 6 months. The results were evaluated as follows : patient‘ s condition and the function of the operated leg were improved; the leg pain was released; the peripheral pulses were present and strong; the color, temperature and sensation of the skin were normal;none of further complications was noted. Conclusion: For Nursing patients after femoral popliteal bypass grafting, the nurses should focus their attention on the circulatory status of the operated leg, anticoagulant therapy and signs of bleeding from the graft site. Meanwhile, provide a quiet ,comfortable and safe environment for the patients. As all of these are the main points of the postoperative care. A good nursing care offered to a patient not only can ease the patient‘s physical suffering, but also can avoid some complications occurring.