Traumatic lacunar infarction in basal ganglion in children

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What about sentinel node practice in early-staged cutaneous melanoma in France in 2003?

AIM: The aim of this study was to establish the status of sentinel lymph node (SLN) biopsy procedure in cutaneous melanoma in France in 2002. MATERIAL AND METHODS: This study was based upon the statistics of the main French melanoma centers. A short questionnary was sent to Head Physician by email. The authors asked for the global attitude as far as SLN was concerned, number of cutaneous melanoma diagnosed during year 2002 and of SLN procedures performed, critters of inclusion and postoperative management in each case. Abstension could be argued in a free item. Answers were sent back by email. RESULTS: The authors collected 22 answers coming from overall territory; 64% performed SLN procedure (14 centers), 36% applied "wait and watch" policy. Staffs performing SLN diagnosed a mean of 101 (8-400) melanoma and biopsied a mean of 21 (0-53) sentinel nodes. The others diagnosed a mean of 151 (15-250) melanoma. Patients were enrolled for Breslow thickness upper to 1.5 mm in 71%, to 1 mm in 29%. Ulceration was a critter of inclusion in 93% (21 staffs), 100% enrolled patients whose tumor presented signs of regression. SLN was performed for primary sites located overall body in 71%, only in limbs and trunk in 29%. Positive node lead to regional lymph node clearance, then observation or interferon protocol. Negative node lead to "wait and watch policy" in 14%, different interferon protocols according to Breslow thickness in 86%. CONCLUSION: SLN procedure is not homogenous in France. France is divided as far as SLN is concerned. If 64% are performing SLN, more than 50% of the new melanoma are not included in the trial.     

A population-based study on trend in incidence of distal radial fractures in adults in Taiwan in 2000�C2007

Summary  

This population-based study was conducted using claims data obtained from the National Health Insurance to investigate the trend in incidence of distal radial fractures in adults in Taiwan from 2000 to 2007. Our results revealed an increasing trend, particularly among women >50 years of age.     

Dantrolenbevorratung in Anästhesie und Intensivmedizin in Deutschland

Background

A malignant hyperthermia (MH) crisis is a potentially fatal complication in anesthesia and intensive care units (ICU). Rapid administration and adequate dosage of dantrolene is the only known effective pharmacological and causal treatment of an MH crisis. International anesthesiology societies recommend an initial dose of 2.0–2.5?mg/kg body weight (BW). The necessary total dosage should be titrated up to 10?mg/kg BW depending on the effectiveness.

Objective

The goal of this study was an analysis of the stocking situation of dantrolene in Germany. A national survey was conducted amongst members of the German Society of Anaesthesia and Intensive Care (DGAI).

Material and methods

A questionnaire consisting of 19 items was posted online to all DGAI members from 2 September to 30 September 2015. The questionnaire dealt with characterization of the participants, the administration of triggering substances in the operating room and in the ICU of the respective hospitals. The main part covered the amount of stocked dantrolene, the place of storage and emergency availability of stocked dantrolene from elsewhere.

Results

The questionnaire was posted online to 12,415 DGAI members with a response rate of 13.5% (n = 1673). The highest response rate was from 259 directors and heads of anesthesiology units representing 28.3%. In total 93,7% of participants use volatile anesthetics and 82,3% use succinylcholine. In the event of an MH-crisis 40.4% of participants have 36 or more vials of dantrolene available within 5?min, 27.4% have only 24 vials and 18.7% only have 12 vials. Of the anesthesiologists in outpatient surgery 70.6% have a dantrolene stock of less than 36 vials. In those cases with insufficient dantrolene stock, 35.5% of hospitals have no agreement with neighboring hospitals. In the ICU setting, 51.8% of responding participants indicated the use of volatile anesthetics, but only 25.7% stock dantrolene in the ICU. For succinylcholine, 77.3% stated using the drug in the ICU, and 26.0% have a dantrolene stock in the ICU.

Conclusion

Almost all anesthesiologists participating in the online survey use volatile anesthethics and/or succinylcholine. Whereas almost all participants have access to dantrolene, more than half of the units have a stock of dantolene, which is less than that recommended by the DGAI. In the case of low dantrolene stock, only 61% of anesthesia departments have access to additional dantrolene within a time frame of 15min?. The results of this online survey demonstrate that the stock of dantrolene may be insufficient in some German hospitals and anesthesiology practices.

     

Assistentensprecher in Orthopädie und Unfallchirurgie in Deutschland

In most German hospitals there are resident representatives to stand in for the rights and interests of residents. The precise number of representatives in orthopaedic and trauma surgery is unknown, as well as the field of duty and the rights of this position.     

The primary determinants of radiation use during fixation of proximal femur fractures

Objectives

To establish the primary determinants of operative radiation use during fixation of proximal femur fractures.

Design

Retrospective cohort study.

Setting

Level I trauma centre.

Cohort

205 patients treated surgically for subtrochanteric and intertrochanteric femoral fractures.

Main outcome measures

Fluoroscopy time, dose-area-product (DAP).

Results

Longer fluoroscopy time was correlated with higher body mass index (p = 0.04), subtrochanteric fracture (p < 0.001), attending surgeon (p = 0.001), and implant type (p < 0.001). Increased DAP was associated with higher body mass index (p < 0.001), subtrochanteric fracture (p = 0.002), attending surgeon (p = 0.003), lateral body position (p < 0.001), and implant type (p = 0.05).

Conclusion

The strongest determinants of radiation use during surgical fixation of intertrochanteric and subtrochanteric femur fractures were location of fracture, patient body position, patient body mass index, and the use of cephalomedullary devices. Surgeon style, presumably as it relates to teaching efforts, seems to strongly influence radiation use.     

Circulational heat dissipation of upper airway: Canine model of inhalational thermal injury

Background

The upper airway has powerful heat-absorbing ability, in which the blood circulation may play an important role.

Objective

This study aimed to explore the circulational heat-dissipating ability, and to investigate the contribution of blood circulation to the heat-absorbing ability of upper airway.

Methods

18 adult, male Beagle dogs were divided into three groups to inhale thermal dry air of 70–80 °C, 150–160 °C or 310–320 °C for 20 min. Blood temperatures and blood flow rates of bilateral common jugular veins (CJVs) were measured. Dogs’ breathing rates and air temperatures in middle trachea were also measured. According to the formula “Q = c·m·ΔT”, the heat dissipated by blood (Q_-blood) and the heat release by air (Q_-air) were calculated out. The contribution of circulational heat dissipation to the heat-absorbing ability of upper airway was defined as “C_-blood”.

Results

The blood temperature rise of CJV was 2.24 ± 0.60 °C. The blood flow rate of CJV was 44.5 ± 5.9 ml/min. The air temperature in middle trachea was 63.5 ± 18.9 °C. The mean breathing rate was 51.8 ± 7.5/min. The calculated “Q_-blood” and “Q_-air” were 13197.3 ± 4408.6 J and 33540.2 ± 24578.7 J, and the “C_-blood” was 55.2 ± 25.0% (21.7–88.8%).

Conclusion

Circulational heat dissipation plays an important role in the heat-absorbing process of upper airway when inhaled air is less than 160 °C. However, for air higher than 160 °C, some other mechanism might be dominant in the upper airway's heat-absorbing ability.     

“Trap-door” and “clamshell” surgical approaches for the management of pediatric tumors of the cervicothoracic junction and mediastinum

Background/Purpose

For pediatric tumors of the cervicothoracic junction, an isolated cervical or thoracic surgical approach provides insufficient exposure for achieving complete resection. We retrospectively examined “trap-door” and “clamshell” pediatric thoracotomies as a surgical approach to these tumors.

Methods

We searched our database for pediatric patients with cervicothoracic tumors who underwent clamshell or trap-door thoracotomy between 1991 and 2013, reviewing tumor characteristics, surgical technique, completeness of resection, morbidity, and outcome.

Results

Trap-door (n = 13) and clamshell (n = 4) thoracotomies were performed for neuroblastoma (n = 9), non-rhabdomyosarcoma soft tissue sarcoma (n = 4), germ cell tumor (n = 2), rhabdomyosarcoma (n = 1), and neuroendocrine small cell carcinoma (n = 1). Fourteen of these cervicothoracic tumors were primary, and three were metastatic. Gross total resection was achieved in 15 patients (94%). Operative complications included vocal cord paralysis (n = 2), mild upper-extremity neuropraxia (n = 2), and hemidiaphragm paralysis (n = 1), All but one involved encased nerves. Overall survival was 61% for the series and 80% for patients with primary tumors. Eleven (73%) of 15 patients who underwent gross total resection had no evidence of recurrence. Three patients with metastatic disease died of distant progression within 1.3 years.

Conclusions

Gross total resection of primary cervicothoracic tumors can be accomplished with specialized exposure in pediatric patients with minimal morbidity.     

Utilisation d’un fibroscope à usage unique pour la formation sur labyrinthe à l’intubation sous fibroscope

Goal of the study

To evaluate a single-use fiberscope, the Ascope-Trainer™, for the training in the intubation under fiberscope.

Type of study

Prospective randomized study approved by the local ethic committee.

Methodology

After evaluation of their level of expertise, “experienced” or “novices” in intubation under fiberscope, the doctors attending the Training for Referents in Difficult Airway Management performed a test on labyrinth with a standard fiberscope (T1). After they were assigned to two groups, training with the Ascope-Trainer™ (group A, n = 35) or with a classic fiberscope (group C, n = 29), they trained during 15 minutes and performed a new test (T2). An analysis of variance was used to compare means. A goal for the training was determined according to the “experienced” doctors’ mean T1. A test of Khi² was used for the comparison of the number of participants having reached this goal as well as the progress in both groups A and C.

Results

The T1 in the “experienced” group was 76 ± 31 s and the training improved significantly T2 (53 ± 17 s). Considering the novices, T2 was significantly lower than T1 in the group A (77 ± 38 s versus 135 ± 68 s) as well as in C (64 ± 28 s versus 122 ± 60 s), and the proportion of the novices having reached the goal of training was comparable in both groups.

Conclusions

Because its use is similar to the standard fiberscope, the Ascope-Trainer™ may be interesting for this type of training.     

Gender and Age Differences in the Perception of Bother and Health Care Seeking for Lower Urinary Tract Symptoms: Results from the Hospitalised and Outpatients’ Profile and Expectations Study

Background

Few comparisons have been made of health care seeking behaviour for lower urinary tract symptoms (LUTS) between men and women, as well as trends across age groups.

Objective

To investigate the bother from LUTS and effect on health care seeking in both men and women of different age groups and in comparison between the two genders.

Design, setting, and participants

A representative cross section of each of 13 clinics of a general academic hospital, with equal numbers of subjects recruited in each of six design cells that were defined by age (18–40, 41–60, 61–80 yr) and gender.

Intervention

A 2-h in-person interview, conducted by a trained psychologist/interviewer in a clinic office.

Measurements

Severity of LUTS was measured by the International Prostate Symptom Score (IPSS). Treatment seeking was measured by a single item. A bother question was modified to assess overall bother. Impact on quality of life (QoL) was measured by the IPSS QoL question.

Results and limitations

The final study sample comprised 415 patients. More women than men reported the presence of LUTS (85.5% vs 75.2%; p = 0.01). LUTS were more bothersome in women (25.4% of women vs 17.6% of men with bother “some” or “a lot”; p = 0.02). Severity of LUTS increased with age in both genders (men: p < 0.001; women: p = 0.03). Bother from LUTS increased as severity of symptoms increased in both genders (p < 0.001) but was associated with age only in men (p < 0.001). QoL showed similar results as bother. Although men and women had equal prevalence of treatment seeking (27.9% vs 23.7%; p = 0.40), men, but not women, were more likely to seek treatment as age (p < 0.01) and severity of LUTS (p < 0.001) increased. In multivariate logistic regressions, only bother from LUTS was associated with treatment seeking in women, compared with bother, age, and the presence of voiding symptoms in men.

Conclusions

In our hospital-based sample, differences in LUTS frequency, bother, and health care seeking profiles between men and women suggest a different perception and response to LUTS between the two genders.     

The relationship between reticulated platelets,intestinal alkaline phosphatase,and necrotizing enterocolitis

Background

Necrotizing enterocolitis (NEC) affects up to 10% of extremely-low-birthweight infants, with a 30% mortality rate. Currently, no biomarker reliably facilitates early diagnosis. Since thrombocytopenia and bowel ischemia are consistent findings in advanced NEC, we prospectively investigated two potential biomarkers: reticulated platelets (RP) and intestinal alkaline phosphatase (iAP).

Methods

Infants born ≤ 32 weeks and/or ≤ 1500 g were prospectively enrolled from 2009 to 2012. Starting within 72 hours of birth, 5 weekly whole blood specimens were collected to measure RP and serum iAP. Additional specimens were obtained at NEC onset (Bell stage II or III) and 24 hours later. Dichotomous cut-points were calculated for both biomarkers. Non-parametric (Mann-Whitney) and Chi-square tests were used to test differences between groups. Differences in Kaplan-Meier curves were examined by log-rank test. The Cox proportional hazards model estimated hazard ratios.

Results

A total of 177 infants were enrolled in the study, 15 (8.5%) of which developed NEC (40% required surgery and 20% died). 14 (93%) NEC infants had “low” (≤ 2.3%) reticulated platelets, and 9 (60%) had “high” iAP (> 0 U/L) in at least one sample before onset. Infants with “low” RP were significantly more likely to develop NEC [HR = 11.0 (1.4–83); P = 0.02]. Infants with “high” iAP were at increased risk for NEC, although not significant [HR = 5.2 (0.7–42); P = 0.12]. Median iAP levels were significantly higher at week 4 preceding the average time to NEC onset by one week (35.7 ± 17.3 days; P = 0.02).

Conclusion

Decreased RP serves as a sensitive marker for NEC onset, thereby enabling early preventative strategies. iAP overexpression may signal NEC development.     

Brachial cuff measurements of blood pressure during passive leg raising for fluid responsiveness prediction

Objective

The passive leg raising maneuver (PLR) for fluid responsiveness testing relies on cardiac output (CO) measurements or invasive measurements of arterial pressure (AP) whereas the initial hemodynamic management during shock is often based solely on brachial cuff measurements. We assessed PLR-induced changes in noninvasive oscillometric readings to predict fluid responsiveness.

Study design

Multicentre interventional study.

Patients and methods

In ICU sedated patients with circulatory failure, AP (invasive and noninvasive readings) and CO measurements were performed before, during PLR (trunk supine, not modified) and after 500-mL volume expansion. Areas under the ROC curves (AUC) were determined for fluid responsiveness (> 10% volume expansion-induced increase in CO) prediction.

Results

In 112 patients (19% with arrhythmia), changes in noninvasive systolic AP during PLR (noninvasiveΔ_PLRSAP) only predicted fluid responsiveness (cutoff 17%, n = 21, positive likelihood ratio [LR] of 26 [18–38]), not unresponsiveness. If PLR-induced change in central venous pressure (CVP) was at least of 2 mmHg (n = 60), suggesting that PLR succeeded in altering cardiac preload, noninvasiveΔ_PLRSAP performance was good: AUC of 0.94 [0.85–0.98], positive and negative LRs of 5.7 [4.6–6.8] and 0.07 [0.009–0.5], respectively, for a cutoff of 9%. Of note, invasive AP-derived indices did not outperform noninvasiveΔ_PLRSAP.

Conclusion

Regardless of CVP (i.e., during “blind PLR”), noninvasiveΔ_PLRSAP more than 17% reliably identified fluid responders. During “CVP-guided PLR”, in case of sufficient change in CVP, noninvasiveΔ_PLRSAP performed better (cutoff of 9%). These findings, in sedated patients who had already undergone volume expansion and/or catecholamines, have to be verified during the early phase of circulatory failure (before an arterial line and/or a CO measuring device is placed).     

Avaliação do clube de revista de anestesiologia por meio de mudanças semânticas

Background and objectives

The interactive approach of a journal club has been described in the medical education literature. The aim of this investigation is to present an assessment of journal club as a tool to address the question whether residents read more and critically.

Methods

This study reports the performance of medical residents in anesthesiology from the Clinics Hospital – University of São Paulo Medical School. All medical residents were invited to answer five questions derived from discussed papers. The answer sheet consisted of an affirmative statement with a Likert type scale (totally disagree–disagree–not sure–agree–totally agree), each related to one of the chosen articles. The results were evaluated by means of item analysis – difficulty index and discrimination power.

Results

Residents filled one hundred and seventy three evaluations in the months of December 2011 (n = 51), July 2012 (n = 66) and December 2012 (n = 56). The first exam presented all items with straight statement, second and third exams presented mixed items. Separating “totally agree” from “agree” increased the difficulty indices, but did not improve the discrimination power.

Conclusions

The use of a journal club assessment with straight and inverted statements and by means of five points scale for agreement has been shown to increase its item difficulty and discrimination power. This may reflect involvement either with the reading or the discussion during the journal meeting.     

Évaluation du stress chez le personnel des urgences : enquête dans un service d’urgences tunisien

Objectives

The objectives of this work were to make an inventory of the stress level, to detect various stressors and to describe the working conditions as perceived by staff to pinpoint the factors that might be changed.

Study design

This survey was conducted from July to August 2012 in all sectors of the emergency department. We used the Karasek model. Collected data were demographic and professional.

Results

We included 107 participants, which represent 61.5% of the whole staff. The median age of participants was 30 years with a male predominance (66%). Scores found place our sample in the dial of “job strain”. Only 17.8% of participants were found to be active. No significant correlation between gender, marital status, seniority and emergency risk of developing stress state was found. Age under 30 years (P = 0.04) and low social support by supervisors (P = 0.02) were predictive of developing stress. Job satisfaction was lower among paramedics. In multivariate analysis, they were much more sensitive to psychological demands that the doctors.

Conclusion

This study could be used to show the importance of preventing this emotional exhaustion in order to improve the quality of health care providers but also the care given in this service.     

Effectiveness of a topical local anaesthetic spray as analgesia for dressing changes: A double-blinded randomised pilot trial comparing an emulsion with an aqueous lidocaine formulation

Background

Partial thickness skin graft wounds are painful. Topically applied lidocaine has been used for analgesia in several clinical trials. This study compared the effectiveness of two different formulations of topical local anaesthetic for dressing changes of partial thickness skin graft donor sites.

Methods

A double-blind randomised controlled, pilot trial was conducted in 29 patients undergoing split thickness skin graft surgery. Subjects were randomised to either a 3% lidocaine emulsion formulation “Treatment E” (NOPAYNE™) or a 4% aqueous solution “Treatment A” (Xylocaine™). Subjects received one spray per 3 cm² of donor site area followed by up to two further spays as required. Endpoints included pain intensity measured by the numerical rating scale (NRS) up to 1 h after dressing change commencement, sting sensation, overall satisfaction and lidocaine plasma concentration.

Results

The 60 min pain scores for E and A were 1.3 ± 0.3 (mean ± SEM) and 1.8 ± 0.4 (p = 0.98) respectively. Nearly 90% of patients were very satisfied with their treatment. The mean plasma concentrations of lidocaine for A and E were 0.132 mg/l and 0.040 mg/l respectively (p = 0.069).

Conclusion

The topical local anaesthetic formulations achieved low pain scores during dressing changes. The safety profile was potentially improved with the emulsion formulation of lidocaine.